Endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) and therapeutic procedures have been performed by a curved linear array (CLA) echoendoscope since the early 1990's. This particular echoendoscope, allowing real time visualization of aspira­tion needles and of other devices, has substantially remained unchanged since its introduction to the market. In a context of rapidly expanding indications for EUS-guided procedures, a dedicated forward view (FV) echoendoscope has been developed and tested under different clinical conditions. The FV echoendoscope is equipped with front endoscopic and EUS view, allowing deployment of needles and other devices through the working channel in straight direction. Several new diagnostic and therapeutic applica­tions may thereby potentially be feasible with the FV echoendoscope and the established ones may prove easier to accomplish. The published literature with the FV echoendoscope has been systematically reviewed and the results are presented analytically and discussed in detail. EUS-FNA and therapeutic procedures, including pancreatic pseudocyst drainage, treatment of gastric fundal varices, celiac plexus neurolysis, and duct drainage were reported. The FV echoendoscope showed some unique advantages, open­ing new possibilities such as EUS-FNA in difficult gastrointestinal tracts and combined endoscopic/EUS treatment with frontal approach. However, no statistically significant evidence of superiority of the FV echoendoscope vs. the CLA echoendoscope was found in pancreatic pseudocyst drainage. No complications specifically attributable to the use of the FV echoendoscope were reported.

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Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is a technique which allows the study of cells obtained through aspiration in different locations near the gastrointestinal tract. EUS-FNA is used to acquire tissue from mucosal/submucosal tumors, as well as peri-intestinal structures including lymph nodes, pancreas, adrenal gland, gallbladder, bile duct, liver, kidney, lung, etc. The pancreas and lymph nodes are still the most common organs targeted in EUS-FNA. The overall accuracy of EUS is supe­rior to computed tomography scan and magnetic resonance imaging for detecting pancreatic lesions. In most cases it is possible to avoid unnecessary surgical interventions in advanced pancreatic cancer, and EUS is considered the preferred method for loco-regional staging of pancreatic cancer. FNA improved the sensitivity and specificity compared to EUS imaging alone in detection of malignant lymph nodes. The negative predictive value of EUS-FNA is relatively low. The presence of a cytopathologist during EUS-FNA improves the diagnostic yield, decreasing unsatisfactory samples or need for additional passes, and consequently the procedural time. The size of the needle is another factor that could modify the diagnostic accuracy of EUS-FNA. Even though the EUS-FNA technique started in early nineteen's, there are many remarkable progresses culminating nowadays with the discovery and performance of needle-based confocal laser endomicroscopy. Last, but not least, identification and quantification of potential molecular markers for pancreatic cancer on cellular samples obtained by EUS-FNA could be a promising approach for the diagno­sis of solid pancreatic masses.

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Objective: Angiogenesis is a crucial event for pancreatic carcinogenesis, and it also plays an important role in chronic pancreatitis. The aim of our study was to evaluate the mRNA expression of vascular endothelial growth factor (VEGF) and epidermal growth factor receptor (EGFR) in chronic inflammatory or malignant pancreatic pathology in order to elucidate the differences in expres­sion patterns and potential clinical implications. Methods: Thirty-five patients who had undergone endoscopic ultrasonography followed by endoscipic ultrasound-guided fine needle aspiration (EUS-FNA) of focal pancreatic masses were included in the study. VEGF and EGFR mRNA expression levels in the samples collected by EUS-FNA were analyzed using quantitative real-time polymerase chain reaction (PCR). Results: VEGF expression was detected in all chronic pancreatitis and adenocarcinoma samples and in only 62.5% of pancreatic neuroendocrine tumors. EGFR expression was detected in only 40% of the chronic pancreatitis cases, 76.9% of adenocarcinomas and in 50% of pancreatic neuroendocrine tumors. Both VEGF and EGFR mRNA levels were significantly higher in pancreatic ductal adenocarcinoma than those in normal tissue. VEGF expression inversely correlated with pancreatic ductal adenocarcinoma size, while EGFR expression was related to local invasiveness of adenocarcinoma. Conclusion: Both VEGF and EGFR mRNA expression in EUS-FNA samples may be used as a diagnostic marker associated with invasiveness in patients with pancreatic adenocarcinoma.

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Objective: Dysphagia as a presenting manifestation of tuberculosis is rare and there is paucity of data on the clinical, endoscopic and endosonographic features of these patients. We present our data related to the features over last four years. Methods: We analyzed retrospectively the clinical, endoscopic, radiological, endosonographic and cytological findings in 14 patients (male: 10; mean age: 37.7 ± 10.4 years) with dysphagia due to tuberculosis presenting to us over last 4 years. Results: Nine patients (64.3%) had Grade 1 dysphagia, 4 (28.6%) patients had Grade 2 and 1 patient (7.1%) had Grade 3. Mid esophagus was the commonest site of involvement. Endoscopic findings were extrinsic bulge (50%), linear ulcers (28.6%) and pol­ypoidal ulcerated lesion (7.1%). Endoscopic biopsies were inconclusive. Endoscopic ultrasound (EUS) demonstrated mediastinal lymph nodes being responsible for endoscopic bulge and their infiltration into esophageal wall leading on to ulcers. EUS-guided fine needle aspiration from these nodes established diagnosis in all patients. Conclusion: Dysphagia in tuberculosis is most commonly caused by compression by the surrounding mediastinal lymph nodes. EUS is a useful investigation for assessment of these patients.

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Cholangiocarcinoma is a malignancy that arises from biliary epithelium and is associated with a poor prognosis. Accurate preopera­tive diagnosis and staging of cholangiocarcinoma continues to remain difficult. Endoscopic retrograde cholangiopancreatography (ERCP) is the most commonly performed procedure for cholangiocarcinoma and can provide a tissue diagnosis through brush cytology of the bile duct. However, the sensitivity of biliary brush cytology to diagnose cholangiocarcinoma may be as low as 30%. Endoscopic ultrasound (EUS) is a diagnostic modality which may overcome the limitations of other imaging and biopsy techniques in this setting. EUS can complement the role of ERCP and provide a tissue diagnosis through fine needle aspiration (FNA) and staging through ultrasound imaging. There is currently a paucity of data about the exact role of EUS for the diagnosis of cholan­giocarcinoma in patients with indeterminate extrahepatic biliary strictures. Although multiple studies have shown that EUS is more accurate than ERCP and radiologic imaging for identifying a biliary mass and diagnosing cholangiocarcinoma, the sensitivities are variable. More importantly, the incidence of false negative results is not negligible, though the specificity is close to 100%. There is also controversy regarding the role of EUS-FNA, since even though this may increase diagnosis, it can also lead to tumor seeding.

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The practical use of EUS in small children below the age of 4 years is not described. The aim of the study was to evaluate the fea­sibility, safety, and clinical utility of smaller caliber echo-bronchoscope in the management of gastrointestinal, pancreatobiliary, and mediastinal disease in children below 4 years. Consecutive children of age younger than 4 years where EUS was clinically considered useful were evaluated by echo-bronchoscopes. The findings showed that EUS by echo-bronchoscopes is feasible and safe in young children.

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Endoscopic ultrasound (EUS) features of mediastinal paraganglioma have not been described. In this paper, we report a female patient presented with cough and chest pain without any neuroendocrinal symptoms. Final diagnosis of mediastinal paraganglioma was made on thoracoscopic biopsy and immunohistochemistry after EUS-guided fine needle aspiration. EUS features of mediasti­nal paraganglioma are described.

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Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is an excellent method for primary lung cancer staging. We describe a 66-year-old male who underwent EUS-FNA for the diagnosis of recurrent lung cancer. Two years after initial radiation therapy followed by complete remission, routine follow-up imaging study revealed a mass in the right hilum. Trans-esophageal EUS revealed a 1.3-cm mass and the result of EUS-FNA was consistent with non-small lung cancer. EUS-FNA can play an important role in diagnosis of recurrent lung cancer as well as primary staging avoiding the more invasive diagnostic technique.

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