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   2014| January-March  | Volume 3 | Issue 1  
    Online since February 14, 2014

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Basic technique in endoscopic ultrasound-guided fine needle aspiration for solid lesions: What needle is the best?
Jesse Lachter
January-March 2014, 3(1):46-53
DOI:10.4103/2303-9027.124313  PMID:24949410
Basic technique for endoscopic ultrasound (EUS) of solid lesions has developed during 30 years of EUS, as endoscopes and accessory equipment, particularly needles, have been developed. Systematic high-quality examinations require understanding and planning. Needles used for EUS-guided fine needle aspiration (FNA) have gone through many improvements; some 18 characteristics of any needle are presented and these come under consideration whenever choosing the best needle for each procedure. The bright future of EUS and FNA for solid lesions currently still leaves much room for continued developments.
  13,604 1,123 3
How good is fine needle aspiration? What results should you expect?
Pierre Eisendrath, Mostafa Ibrahim
January-March 2014, 3(1):3-11
DOI:10.4103/2303-9027.127122  PMID:24949404
Tissue acquisition plays a key role before treatment decision in most of oncological pathologies but also in several benign diseases. By offering tissue sampling, endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) has become an essential tool in the diagnostic processes. One of the reasons for the success of the technique is related to its excellent diagnostic performance. The diagnostic accuracy of EUS-FNA is above 80% for most of the usual indications. These performances are however dependent on some factors related to both the disease and patient's medical history but also related to medical staff expertise. Endoscopist needs to know how to reach a lesion but also how to efficiently acquire good tissue samples. This review aims to report general recommendations available in the literature for high quality EUS-FNA. Sample processing and sample interpretation also influence diagnostic accuracy of FNA. This paper includes a discussion on sample processing and benefits of the on-site pathology examination. It also provides the results reported in the literature of sample adequacy and diagnostic performance of EUS-FNA for most common indications: Pancreatic diseases, sub-mucosal lesion, mucosal thickenings, lymph nodes, cystic lesion and free fluids.
  6,181 1,007 11
Basic techniques in endoscopic ultrasound-guided fine needle aspiration for solid lesions: Adverse events and avoiding them
Larissa L Fujii, Michael J Levy
January-March 2014, 3(1):35-45
DOI:10.4103/2303-9027.123006  PMID:24949409
Endoscopic ultrasound (EUS) guided fine-needle aspiration (FNA) is often the preferred technique for tissue acquisition in the diagnosis of suspected intrathoracic and intraabdominal pathology. Although EUS FNA is a safe and accurate procedure, it has been associated with a low risk of adverse events. The unique properties of the echoendoscope and its ability to acquire tissue outside of the gastrointestinal lumen impart risks that are not associated with routine endoscopic procedures. In this review, we discuss the risk of perforation related to the echoendoscope itself and adverse events related to FNA of solid masses including infections, bleeding, pancreatitis and pancreatic duct leak, bile duct leak and tumor seeding. We also provide tips on how to avoid the most common adverse events related to EUS-FNA.
  5,859 927 15
Role of high resolution ultrasound/endosonography and elastography in predicting lymph node malignancy
Hussein Hassan Okasha, Mona Mansour, Khaled Ahmed Attia, Hany Mahmoud Khattab, Amr Yahia Sakr, Mohamed Naguib, Wael Aref, Ahmed Abdel-Moaty Al-Naggar, Reem Ezzat
January-March 2014, 3(1):58-62
DOI:10.4103/2303-9027.121252  PMID:24949412
Objective: The objective of this study is to evaluate the role of high resolution ultrasonography (US) and endoscopic ultrasound (EUS)-elastography in predicting malignant lymphadenopathy. Patients and Methods: This prospective study included 88 patients who underwent EUS or US examination of different groups of lymph nodes (LNs). The classification as benign or malignant based on the real time elastography pattern and the B-mode US/EUS images was compared with the final diagnosis obtained by EUS or US guided fine-needle aspiration cytology (FNAC), tru-cut biopsy or excisional biopsy and follow-up in benign lesions not indicated for biopsy for at least 12 months. Results: Regarding the echogenicity, 98.3% of the benign LNs were hyperechoic, 1.7% was hypoechoic while 89.7% of the malignant LNs were hypoechoic, 3.4% were heterogenous and 6.9% were hyperechoic. With cut-off value of 1.93, the sensitivity of longitudinal to transverse ratio was 73% and the specificity was 100%. Score 1 elastography had specificity of 100% in diagnosis of benign LNs, sensitivity was 76.3%, positive predictive value (PPV) was 100%, negative predictive value (NPV) was 84.7% while score 2 had a sensitivity of 60%, specificity of 31.5%, PPV of 15.3%, NPV of 79.3%. Score 3 had a sensitivity of 70.2%, specificity of 100%, PPV of 13.8%, NPV of 100% in detecting malignancy while score 4 had a sensitivity of 85.5%, specificity of 100%, PPV of 100%, NPV of 65.5%. Conclusion: Elastography is a promising diagnostic modality that may complement standard ultrasound and EUS and help guide FNAC during staging of LNs.
  5,002 684 16
Basic technique in endoscopic ultrasound-guided fine needle aspiration for solid lesions: How many passes?
Maria Chiara Petrone, Paolo Giorgio Arcidiacono
January-March 2014, 3(1):22-27
DOI:10.4103/2303-9027.124310  PMID:24949407
Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) has evolved to become an indispensable tool for tissue acquisition in patients with luminal and extra luminal gastrointestinal cancers. Despite the extensive use of EUS-FNA, there still exists a wide variation in the number of samples required to ensure acquisition of diagnostic material from different kind of lesions. There are several factors that may influence the number of fine needle passes made during EUS-FNA, but the main factor seems to be the presence of a Cytopathologist during the EUS procedure. The diagnostic yield of EUS-FNA with rapid on-site evaluation (ROSE) in most studies exceeds 90%. Nevertheless, ROSE is not available in many centers. Various studies have investigated the adequate number of needle passes that should be performed if ROSE is not used. Differences exist based on the nature of the target lesion: Five to seven passes for pancreatic masses, three passes for lymphnodes, only one pass for pancreatic cystic lesions. Consider using a core biopsy needle or a 19-G FNA needle for histology could improve the diagnostic yield. Even though EUS-FNA is widely available, some patients still do not receive conclusive diagnoses upon initial EUS-FNA. One way to maximize the benefits for patients might be to centralize cases to several well-equipped, high-volume centers with experienced endosonographers that have universal availability of ROSE.
  3,983 885 11
Basic techniques in endoscopic ultrasound-guided fine-needle aspiration: Role of a stylet and suction
Sachin Wani
January-March 2014, 3(1):17-21
DOI:10.4103/2303-9027.123008  PMID:24949406
There are several variables that have been studied to optimize various outcomes of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) such as quality and adequacy of specimens, diagnostic yield of malignancy, accuracy and overall efficiency. Using an evidence-based approach, the objectives of this review are to discuss two key aspects of EUS-FNA: (a) Use of a stylet and (b) use of suction. Level 1 evidence available from randomized controlled trials demonstrates that the use of a stylet during EUS-FNA has no impact on the diagnostic yield of malignancy or the quality of specimens. Air flushing in a slow, controlled fashion is superior to reinsertion of a stylet to express EUS-FNA aspirates. The use of suction should be considered during EUS-FNA of pancreatic masses. However, data from a randomized controlled trial suggest that suction should not be used during EUS-FNA of lymph nodes as it increases bloodiness of specimens obtained and has no impact on the overall diagnostic yield.
  2,931 712 14
Training in endoscopic ultrasound-guided fine needle aspiration
Sarto C Paquin
January-March 2014, 3(1):12-16
DOI:10.4103/2303-9027.127123  PMID:24949405
Like any other technique, fine needle aspiration (FNA) proficiency requires adequate experience. Although this technique is not difficult to master, formal training will allow endosonographers to achieve better results. The following article is derived in two parts: (1) To review current knowledge on endoscopic ultrasound (EUS)-FNA training, discuss the current recommendations on training guidelines, explore other training adjuncts and review the latest studies evaluating the validity of current recommendations; and (2) to provide some basic grounds on the EUS-FNA technique. EUS-FNA can be broken down into a series of steps. Proper execution of each step will make FNA easier and likely increase its diagnostic yield. Adequate positioning of the lesion in regards to the ultrasound probe is a key factor to obtain best results. The following will discuss useful tips in order to achieve maximal success rates.
  2,769 749 2
Clinical, endoscopic and endoscopic ultrasound features of duodenal varices: A report of 10 cases
Surinder Singh Rana, Deepak Kumar Bhasin, Vishal Sharma, Vinita Chaudhary, Ravi Sharma, Kartar Singh
January-March 2014, 3(1):54-57
DOI:10.4103/2303-9027.121243  PMID:24949411
Background: Duodenal varices (DV) although an uncommon cause, are an important cause due to the severe nature of the bleed and associated adverse outcome. Materials and Methods: We retrospectively evaluated patients with DV seen at our institution over past 4 years. Results: A total of 10 patients (nine males; mean age was 35.8 ± 7.68 years) with DV were studied. Five patients had underlying cirrhosis and five had DV because of non-cirrhotic portal hypertension (four patients had extra-hepatic portal venous obstruction and one patient had non-cirrhotic portal fibrosis). Five patients presented with upper gastrointestinal (GI) bleed, whereas in the remaining five patients DV were detected on endoscopy performed for evaluation of portal hypertension. Endoscopy revealed submucosal lesion in nine patients, whereas in one patient an initial endoscopic diagnosis of Dieulafoy's lesion was made. However endoscopic ultrasound (EUS) could clearly identify DV in all patients. Of five patients presenting with upper GI bleed, three had the esophageal varices eradicated and two presented 1 st time with bleed form DV and did not have esophagogastric varices. All patients with acute upper GI bleed were initially treated with intravenous terlipressin followed by glue (n-butyl cyanoacrylate) injection in 4/5 patients with one patient refusing further endoscopic therapy. The variceal obliteration was documented by EUS in all these four patients and there has been no recurrence of bleed in these four patients over a follow-up period of 4-46 months. The five non-bleeding DV were already on beta- blockers and the same were continued. Two of these five patients succumbed to progressive liver failure with none of these five patients having GI bleed on follow-up. Conclusion: EUS is a useful investigational modality for evaluating patients with DV and endoscopic injection of glue is an effective therapy for controlling and preventing recurrence of bleed from DV.
  2,740 470 9
Endoscopic ultrasound for cavernous hemangioma of rectum
Malay Sharma, Almessabi Adulqader, Ruth Shifa
January-March 2014, 3(1):63-65
DOI:10.4103/2303-9027.127127  PMID:24949413
Lower gastrointestinal (GI) bleed due to hemangioma in rectum is an uncommon problem. A 19-year-old female patient presented with history of recurrent episodes of lower GI bleeding 1-2 times/month for last 3 years. At the time of hospitalization her vital signs were normal and rectal examination revealed frank blood. Investigations revealed a hemoglobin level of 8.9 g/dL and normal coagulation parameters. Colonoscopy showed bluish reddish elevated nodular lesions limited to distal rectum. Magnetic resonance imaging and endoscopic ultrasound showed cavernous hemangioma.
  2,135 315 4
Endoscopic ultrasound-guided fine-needle aspiration: Getting to the point
Anand V Sahai
January-March 2014, 3(1):1-2
DOI:10.4103/2303-9027.127118  PMID:24949403
  1,701 481 2
Basic technique for solid lesions: Cytology, core, or both?
Shantel Hébert-Magee
January-March 2014, 3(1):28-34
DOI:10.4103/2303-9027.123010  PMID:24949408
This chapter highlights key fundamentals relevant to post-procurement tissue handling of materials obtains by aspiration and/or biopsy and details the subtle techniques that can significantly impact patient management and practice patterns. A basic knowledge of tissue handling and processing is imperative for endosonographers who attempt to achieve a greater than 95% diagnostic accuracy with their tissue-acquisition procedures.
  1,820 351 9
A rare case of incidental retroperitoneal seminoma diagnosed by endoscopic ultrasound-guided fine-needle aspiration
Nirav Thosani, Keshia Ferguson, Jamie Buryanek, Donald Lesslie, Matthew P Spinn
January-March 2014, 3(1):66-67
DOI:10.4103/2303-9027.127129  PMID:24949414
  1,400 199 1