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2018| May-June | Volume 7 | Issue 3
Online since
June 25, 2018
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REVIEW ARTICLES
A quarter century of EUS-FNA: Progress, milestones, and future directions
Irina Mihaela Cazacu, Adriana Alexandra Luzuriaga Chavez, Adrian Saftoiu, Peter Vilmann, Manoop S Bhutani
May-June 2018, 7(3):141-160
DOI
:10.4103/eus.eus_19_18
PMID
:29941723
Tissue acquisition using EUS has considerably evolved since the first EUS-FNA was reported 25 years ago. Its introduction was an important breakthrough in the endoscopic field. EUS-FNA has now become a part of the diagnostic and staging algorithm for the evaluation of benign and malignant diseases of the gastrointestinal tract and of the organs in its proximity, including lung diseases. This review aims to present the history of EUS-FNA development and to provide a perspective on the recent developments in procedural techniques and needle technologies that have significantly extended the role of EUS and its clinical applications. There is a bright future ahead for EUS-FNA in the years to come as extensive research is conducted in this field and various technologies are continuously implemented into clinical practice.
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ORIGINAL ARTICLES
Autoimmune pancreatitis: Imaging features
Yi Dong, Mirko D'Onofrio, Michael Hocke, Christian Jenssen, Andrej Potthoff, Nathan Atkinson, Andre Ignee, Christoph F Dietrich
May-June 2018, 7(3):196-203
DOI
:10.4103/eus.eus_23_17
PMID
:28836516
Background and Objectives:
Autoimmune pancreatitis (AIP) remains a difficult disease to diagnose before treatment, particularly if presenting as a focal mass lesion. The purpose of this multicenter retrospective study is to analyze imaging features of histologically confirmed AIP to determine the additional diagnostic value of contrast-enhanced ultrasound (CEUS), contrast-enhanced endoscopic ultrasound (CE-EUS), and elastography to B-mode features.
Patients and Methods:
We report on a retrospective data collection of 60 histologically confirmed cases of AIP in comparison to 16 patients with pancreatic adenocarcinomas (PDAC). All CE (-E) US examinations were assessed by two independent readers in consensus. The role of CEUS and CE-EUS for pancreatic evaluation was defined according to the 2011 European Federation of Societies for Ultrasound in Medicine and Biology guidelines.
Results:
After injection of ultrasound (US) contrast agents, most AIP lesions displayed focal or diffuse isoenhancement (86.6%) in the arterial phase, while most of the PDAC lesions (93.7%) were hypoenhancing (
P
< 0.01). During the late phase, most AIP lesions were hyper-(65%) or iso-enhancing (35%), while most PDAC lesions were hypoenhancing (93.7%). CE-EUS was performed in a subset of ten patients and showed hyperenhancement in all AIP cases. Most focal AIP lesions (
n
= 27, 79.4%) were stiffer than the surrounding pancreatic parenchyma.
Conclusions:
In this study, percutaneous and endoscopic contrast enhanced harmonic US techniques consistently revealed diffuse and focal types of AIP to have features consistent with vascularized lesions. Differentiation from the typically hypovascularized pancreatic adenocarcinoma was possible with CE (-E) US evaluation.
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Assessing tumor angiogenesis in colorectal cancer by quantitative contrast-enhanced endoscopic ultrasound and molecular and immunohistochemical analysis
Elena-Tatiana Cartana, Dan Ionuţ Gheonea, Irina Florina Cherciu, Ioana Streaţa, Constantin-Daniel Uscatu, Elena-Raluca Nicoli, Mihai Ioana, Daniel Pirici, Claudia-Valentina Georgescu, Dragoş-Ovidiu Alexandru, Valeriu Şurlin, Gabriel Gruionu, Adrian Săftoiu
May-June 2018, 7(3):175-183
DOI
:10.4103/eus.eus_7_17
PMID
:28685747
Background and Objectives:
Data on contrast-enhanced endoscopic ultrasound (CE-EUS) for colorectal cancer (CRC) evaluation are scarce. Therefore, we aimed to assess the vascular perfusion pattern in CRC by quantitative CE-EUS and compare it to immunohistochemical and genetic markers of angiogenesis.
Patients and Methods:
We performed a retrospective analysis of CE-EUS examinations of 42 CRC patients, before any therapy. CE-EUS movies were processed using a dedicated software. Ten parameters were automatically generated from the time-intensity curve (TIC) analysis: peak enhancement (PE), rise time (RT), mean transit time, time to peak (TTP), wash-in area under the curve (WiAUC), wash-in rate (WiR), wash-in perfusion index (WiPI), wash-out AUC (WoAUC), and wash-in and wash-out AUC (WiWoAUC). The expression levels of the vascular endothelial growth factor receptor 1 (VEGFR1) and VEGFR2 genes were assessed from biopsy samples harvested during colonoscopy. Microvascular density and vascular area were calculated after CD31 and CD105 immunostaining.
Results:
Forty-two CE-EUS video sequences were analyzed. We found positive correlations between the parameters PE, WiAUC, WiR, WiPI, WoAUC, WiWoAUC, and N staging (Spearman
r
= 0.437,
r
= 0.336,
r
= 0.462,
r
= 0.437,
r
= 0.358, and
r
= 0.378, respectively,
P
< 0.05), and also between RT and TTP and CD31 vascular area (
r
= 0.415, and
r
= 0.421, respectively,
P
< 0.05). VEGFR1 and VEGFR2 expression did not correlate with any of the TIC parameters.
Conclusions:
CE-EUS with TIC analysis enables minimally invasive assessment of CRC angiogenesis and may provide information regarding the lymph nodes invasion. However, further studies are needed for defining its role in the evaluation of CRC patients.
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EDITORIAL
EUS-guided fine-needle tissue acquisition for solid pancreatic lesions: Finally moving from fine-needle aspiration to fine-needle biopsy?
Mihai Rimbaş, Stefano Francesco Crino, Antonio Gasbarrini, Guido Costamagna, Aldo Scarpa, Alberto Larghi
May-June 2018, 7(3):137-140
DOI
:10.4103/eus.eus_23_18
PMID
:29941722
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ORIGINAL ARTICLES
Canalization technique to obtain deep tissue biopsy of gastrointestinal subepithelial tumors as an alternative to conventional known techniques
Ramón Abad-Belando, Modesto J Varas-Lorenzo, Carlos Pons-Vilardell, Xavier Puig-Torrus, Marta Pla-Alcaraz, Antonio Monleón-Getino, Elena Sánchez-Vizcaíno-Mengual
May-June 2018, 7(3):184-190
DOI
:10.4103/eus.eus_13_17
PMID
:28707653
Background and Objectives:
The most accurate technology to detect and diagnose subepithelial tumors (SETs) is the endoscopic ultrasonography (EUS) combined with puncture techniques, such as the endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA) or the endoscopic ultrasonography-guided fine-needle biopsy. Going further in the improvement of the results of tumor samples obtained endoscopically to diagnose the SETs, the canalization technique guided by miniprobes (MPs) to obtain biopsies of SET could be an alternative to EUS-FNA. The objective of this study is to analyze the results of samples obtained by this procedure.
Materials and Methods:
A multicenter, retrospective study of a review of a database of 32 consecutive patients with a SET in the digestive tract, from 2000 to 2015 was conducted. All patients underwent EUS-performed by MP, to define the size, internal echostructure, and layer of origin of tumor. Once the echostructure was defined, it proceeded to the canalization technique to arrive to the tumor tissue.
Results:
The average diameter of SETs in this series (32 patients) was about 21.6±11 mm (range: 5–41 mm). The diagnostic accuracy was 28/32, 87.50% (Confidence interval 95%: 76.04%–98.99%), and there were no major complications. All procedures were performed on outpatients, none of which required additional hospitalization. The 50% of patients were operated or endoscopically resected and in all cases, the previous pathological diagnosis was confirmed.
Conclusions:
This is a feasible, safe, and effective procedure that allows to access to inside of SET to obtain deep biopsies. Tumor samples obtained by deep biopsy, with prior performing of the canalization technique guided by MP, were sufficient for histopathological and immunohistochemical diagnosis and similar to those obtained with other known methods (FNA Trucut, ProCore
®
, etc.). However, more prospective comparative studies with a larger number of patients and different specialists carrying out the procedure to reach a higher statistical significance are necessary.
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IMAGES AND VIDEOS
Pancreatic cancer: Does it work if EUS and laser ablation get married?
Tian'an Jiang, Zhuang Deng, Ju Li, Guo Tian
May-June 2018, 7(3):207-209
DOI
:10.4103/eus.eus_28_17
PMID
:29749351
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205
EUS of an atypical ectopic pancreas
Alexander Flores, Charilaos Papafragkakis, Angad S Uberoi, Sayam Thaiudom, Manoop S Bhutani
May-June 2018, 7(3):216-217
DOI
:10.4103/eus.eus_111_17
PMID
:29697071
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ORIGINAL ARTICLES
A tertiary care hospital's 10 years' experience with rectal ultrasound in early rectal cancer
Ahmed Akhter, Andrew Walker, Charles P Heise, Gregory D Kennedy, Mark E Benson, Patrick R Pfau, Eric A Johnson, Terrence J Frick, Deepak V Gopal
May-June 2018, 7(3):191-195
DOI
:10.4103/eus.eus_15_17
PMID
:28836512
Background and Objectives:
Rectal endoscopic ultrasound (RUS) has become an essential tool in the management of rectal adenocarcinoma because of the ability to accurately stage lesions. The aim of this study was to identify the staging agreement of early RUS-staged rectal adenocarcinoma with surgical resected pathology and ultimately determine how this impacts the management of early rectal cancer (T1–T2).
Methods:
Retrospective chart review was performed from November 2002 to November 2013 to identify procedure indication, RUS staging data, surgical management, and postoperative surgical pathology data.
Results:
There were a total of 693 RUS examinations available for review and 282 of these were performed for a new diagnosis of rectal adenocarcinoma. There was staging agreement between RUS and surgical pathology in 19 out of 20 (95%) RUS-staged T1 cases. There was staging agreement between RUS and surgical pathology in 3 out of 9 (33%) RUS-staged T2 cases. There was significantly better staging agreement for RUS-staged T1 lesions compared to RUS staged T2 lesions (
P
= 0.002). Nearly 60% of T1N0 cancers were referred for transanal excisions (TAEs), and 78% of T2N0 cancers underwent low anterior resection.
Conclusions:
This study identified only a small number of T1–T2 adenocarcinomas. There was good staging agreement between RUS and surgical pathology among RUS-staged T1 lesions whereas poor staging agreement among RUS-staged T2 lesions. Although TAE is largely indicated by the staging of a T1 lesion, this approach may be less appropriate for T2 lesions due to high reported local recurrence.
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TRAINING COURSE
Endoscopic ultrasound of the hepatoduodenal ligament and liver hilum
Malay Sharma, Chittapuram Srinivasan Rameshbabu, Christoph F Dietrich, Praveer Rai, Raghav Bansal
May-June 2018, 7(3):168-174
DOI
:10.4103/2303-9027.193584
PMID
:27824022
The
porta hepatis
and hepatoduodenal ligament (HDL) are important anatomical pathways of extension of disease to and from the liver. The imaging of this area is difficult. The role of endoscopic ultrasound (EUS) as an imaging modality for hepatoduodenal ligament has not been established so far. All images in the present study have been generated from a detailed review of real time recordings using the curved linear scanning echoendoscope EG -3830 UT (Pentax Corporation, Tokyo, Japan), coupled with a Hitachi avius and Hitach 7500 processor (Hitachi Aloka Medical, Tokyo Japan). Our image orientation is with the cranial aspect of the patient directed toward the right side of the screen. We have illustrated that with a careful technique, a detailed EUS evaluation of the HDL and hepatic hilum is possible. A thorough understanding of the HDL anatomy by curved linear EUS probe may play a crucial role in the accurate diagnosis of a broad spectrum of pathologic conditions of the
porta hepatis
. EUS examination of the HDL should be a part of the upper abdominal EUS studies. The description and the images described in this article are useful for beginners who want to start imaging of the
porta hepatis
and hepatoduodenal ligament. This information is useful for staging of malignancies involving common bile duct.
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IMAGES AND VIDEOS
Endoscopic ultrasound-guided antegrade metal stent placement using the stent-in-stent technique in a patient with malignant hilar biliary obstruction
Hiroshi Yamauchi, Mitsuhiro Kida, Shiro Miyazawa, Kosuke Okuwaki, Tomohisa Iwai, Hiroshi Imaizumi, Wasaburo Koizumi
May-June 2018, 7(3):204-206
DOI
:10.4103/eus.eus_19_17
PMID
:28836515
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REVIEW ARTICLES
Laparoscopic ultrasonography: The wave of the future in renal cell carcinoma?
Bitian Liu, Yunhong Zhan, Xiaonan Chen, Qingpeng Xie, Bin Wu
May-June 2018, 7(3):161-167
DOI
:10.4103/eus.eus_27_18
PMID
:29941724
Laparoscopic or robotic surgery is the main method of treating renal cell carcinoma (RCC). Laparoscopic surgery can accurately target lesions and shorten patient recovery time. Renal endogenous tumors or inferior vena cava tumor thrombi are very difficult to remove using the laparoscopic approach. The emergence of laparoscopic ultrasonography (LUS) has solved this problem. LUS can assist in the detection of tumor boundaries and the extent of tumor thrombi. The lack of tactile feedback may hinder the development of laparoscopic surgery for the treatment of renal cancer. LUS has become an important tool that has improved the rates of successful surgery. LUS is applied in not only early and locally advanced RCC treatment but also in monitoring ablation therapy, testing renal blood perfusion, and exposing renal pedicles. Sonographic techniques used for LUS include initial B-mode, Doppler, and contrast-enhanced ultrasound (CEUS). Contrast agents applied for CEUS do not induce nephrotoxicity and can display renal perfusion more accurately than the regular color Doppler ultrasound. According to current literature, LUS is a promising technique for the treatment of RCC, especially for endogenous RCC or RCC with thrombosis, and for monitoring the effectiveness of radiofrequency ablation, although further well-designed studies are warranted.
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IMAGES AND VIDEOS
Echinococcosis infection diagnosed based on the histological findings of a lymph node involvement obtained by EUS-FNA
Kentaro Moriichi, Mikihiro Fujiya, Takuma Goto, Toshikatsu Okumura
May-June 2018, 7(3):210-211
DOI
:10.4103/eus.eus_90_17
PMID
:29536956
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Pancreatic ductal adenocarcinoma masquerading as a serous cystic tumor (with videos)
Takeshi Ogura, Miyuki Imanishi, Atsushi Okuda, Tadahiro Yamada, Kazuhide Higuchi
May-June 2018, 7(3):212-213
DOI
:10.4103/eus.eus_92_17
PMID
:29697072
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Unusual filling defect in bile duct
Surinder Singh Rana, Abhishek Mewara, Sonali Guleria, Ravi Sharma
May-June 2018, 7(3):214-215
DOI
:10.4103/eus.eus_95_17
PMID
:29536954
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