How Good Is EUS to Detect Pancreatic Insulinomas? A Meta-Analysis and Systematic Review

How Good Is EUS to Detect Pancreatic Insulinomas? A Meta-Analysis and Systematic Review

Abstracts retrospectively studied. All patients underwent conventional radial endosonography (frequency 5 MHz). Any suspicious appearing lymph nodes ...

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Abstracts

retrospectively studied. All patients underwent conventional radial endosonography (frequency 5 MHz). Any suspicious appearing lymph nodes were sampled using a linear echoendoscope. Results: Twenty-two patients (Mean age 65 y; 82% Male) with HGD in flat Barrett’s mucosa had EUS examination prior to referral for therapy. 13 (59%) patients had long segment Barrett’s and 7 (32%) patients had multifocal HGD. In 2 patients the latter information was not available. EUS staging reported T0N0 in 20 patients. Two patients had detected lymphadenopathy, however FNA cytology in both patients was negative for malignancy. Of the 12 patients that underwent EMR, 8 had HGD on histological examination, 1 had low grade dysplasia and 2 had nondysplastic Barrett’s. An additional 3 patients underwent esophagectomy, and the surgical pathology revealed HGD with negative LNs. 5 patients underwent radiofrequency ablation without EMR, while 2 patients returned to their primary gastroenterologists for management. Conclusion: Patients with HGD in flat Barrett’s mucosa had no evidence of invasive disease or nodal involvement by conventional EUS  FNA. These findings correlated with pathologic staging in the 15 patients that had surgery or EMR. This study suggests that in patients with flat Barrett’s and HGD, EUS did not affect staging or management and may not be needed in the routine workup in this group of patients.

M1456 Comparison of Catheter-Based Ultrasound Probes Versus Radial Echoendoscopes for Evaluating Dysplastic Nodules in Barrett’s Esophagus Prior to Endoscopic Mucosal Resection Rabindra R. Watson, Kenneth F. Binmoeller, Tonya Kaltenbach, Roy M. Soetikno, Janak N. Shah Background: Endoscopic ultrasound (EUS) is often used to confirm potential resectability prior to endoscopic mucosal resection (EMR) of dysplastic nodules in Barrett’s esophagus (BE). Two main technologies for this application include catheter-based US miniprobes and dedicated echoendoscopes. There are few data comparing these EUS techniques. Aims: To compare catheter-based ultrasound probes to dedicated radial echoendoscopes in identifying focal dysplastic lesions within BE amenable to EMR. Methods: Our center routinely performs EUS prior to EMR to evaluate dysplastic nodules in BE. Use of miniprobe versus echoendoscope is at the discretion of the endoscopist and often based on immediate instrument availability at our high-volume center. We retrospectively identified all patients referred for EMR of dysplastic nodules over a 5-year period. The following data were collected: patient demographics, referral indication, EUS technique and findings, and pathology findings from EMR. Results: A total of 55 patients (mean age 68, male 86%) with BE were referred for potential EMR. Pathology specimens from prior forceps biopsies of the nodules revealed: high-grade dysplasia (75%), suspected carcinoma-in-situ (18%), and indeterminate (7%). EUS exams were performed with radial echoendoscopes (7.5MHz) in 38%, miniprobes (12MHz) in 49%, and both in 13%. EUS revealed invasion depth limited to the mucosal or submucosal layers in all patients. Indeterminate periesophageal lymph nodes (LN) were seen in 11%, all using radial echoendoscopes. Immediate EUS-FNA with onsite cytology revealed benign LN in all cases. All patients underwent EMR based on EUS findings. Final pathology from the miniprobe group included: high grade dysplasia (48%), carcinoma-in-situ (11%), and invasive carcinoma (19%). Pathology from the echoendoscope group included: high grade dysplasia (33%), carcinomain-situ (10%), and invasive carcinoma (14%). Of the 7 evaluated with both modalities, pathology revealed: high grade dysplasia (14%), carcinoma-in-situ (43%), and invasive carcinoma (29%). Three of ten patients with invasive carcinoma had positive submucosal resection margins (two evaluated with miniprobes, 1 with both), and were referred for esophagectomy. Two underwent esophagectomy, revealing adenocarcinoma limited to the submucosa without lymph node involvement. Conclusions: Miniprobes appears comparable to dedicated radial echoendoscopes in identifying dysplastic lesions amenable to EMR. Given start-up cost differences for these technologies, our findings have implications for endoscopic centers with limited resources interested in managing patients with dysplastic BE.

M1457 DNA Mutational Analysis of Pancreatic Cyst Fluid Does Not Change Clinical Management and May Be Misleading Stacie A. Vela, Joseph Romagnuolo, Brenda Hoffman Pancreatic cyst lesions often pose a diagnostic and management dilemma to the gastroenterologist. Many cysts have (variable) malignant potential. Multiple laboratory and radiologic evaluation techniques have been proposed to predict this potential and, in turn, aid in management decisions. These include ultrasound characteristics and cyst fluid analysis such as carcinoembryonic antigen (CEA), cytology, and more recently, DNA mutational analysis (DNA-ma). While DNA-ma appears to be the most promising of those studied, it is expensive, and the added information has not yet proven to change management from that based on radiologic characteristics, cytology and CEA. Aim: To determine if DNA-ma of pancreatic cyst fluid changes clinical management of patients with pancreatic cysts.

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Methods: All patients that had endoscopic ultrasound evaluation and aspiration of a pancreatic cyst with fluid sent for DNA-ma (either at or referred to our institution) were included in the study. The reports from endoscopic ultrasound were reviewed and recommendations were recorded. DNA-ma reports were then evaluated and compared to EUS diagnosis. Management strategy changes, due to these results, were recorded. Results: 14 (50% male) eligible patients were identified. Average age was 67 yrs (50-81). 7% had their EUS done outside our institution. 50% of patients had high risk features on EUS: mural nodules, thick wall, large size (O3 cm), main duct involvement, and/or solid component. Mean CEA was 279.8 ng/dL(!0.51793.7 ng/dL). Diagnoses based on EUS and conventional fluid analysis were IPMN in 79% of the patients, inflammatory in 7% and indeterminate in 14%. All 14 (100%) DNA-ma results indicated benign lesions. This did not change clinical management or follow up interval in any of the patients, including the patients with high risk features. One indeterminate cyst with high risk features underwent surgical resection, despite low CEA and DNA-ma consistent with a serous cystadenoma; final pathology revealed a T2N0 solid pseudopapillary tumor with high grade pancreatic intraepithelial neoplasia. Conclusion: In our series, DNA-ma results did not change clinical management. In at least one case, DNA-ma suggested a benign condition, but surgical follow-up revealed malignancy. While DNA mutational analysis appears to a promising technology, further studies are needed to determine clinical utility beyond conventional tests.

M1458 How Good Is EUS to Detect Pancreatic Insulinomas? A MetaAnalysis and Systematic Review Srinivas R. Puli, Matthew L. Bechtold, Jyotsna Bk Reddy, Srinivas R. Bapoje, Mainor R. Antillon, William R. Brugge Background: The published data on accuracy of Endoscopic Ultrasound to detect pancreatic insulinomas (PI) has been varied. Detection of PI is critical from a therapeutic stand point. Aim: To evaluate the accuracy of EUS in detecting PI. Method: Study Selection Criteria: Only EUS studies confirmed by surgery or appropriate follow-up were selected. Only studies from which a 2 X 2 table could be constructed for true positive, false negative, false positive and true negative values were included. Data collection & extraction: Articles were searched in Medline, Pubmed, Ovid journals, Cumulative index for nursing & allied health literature, International pharmaceutical abstracts, old Medline, Medline nonindexed citations, and Cochrane Central Register of Controlled Trials & Database of Systematic Reviews. Two reviewers independently searched and extracted data. The differences were resolved by mutual agreement. 2 X 2 tables were constructed with the data extracted from each study. Statistical Method: Meta-analysis for the accuracy of EUS was analyzed by calculating pooled estimates of sensitivity, specificity, likelihood ratios, and diagnostic odds ratio. Pooling was conducted by both Mantel-Haenszel method (fixed effects model) and by the DerSimonian Laird method (random effects model). The heterogeneity among studies was tested using Cochran’s Q test based upon inverse variance weights. Results: Initial search identified 2610 reference articles, of these 130 relevant articles were selected and reviewed. Data was extracted from 9 studies (NZ 242) which met the inclusion criteria. Pooled sensitivity of EUS to detect PI was 87.5% (95% CI: 81.2 - 92.3). EUS had a pooled specificity of 97.4% (95% CI: 90.8 - 99.7). The positive likelihood ratio of EUS was 8.2 (95% CI: 3.7 - 18.3) and negative likelihood ratio was 0.17 (95% CI: 0.12 - 0.26). The diagnostic odds ratio, the odds of having anatomic PI in positive as compared to negative EUS studies was 67.6 (95% CI: 22.7 - 200.9). All the pooled estimates calculated by fixed and random effect models were similar. SROC curves showed an area under the curve of 0.94. Egger bias indicator for publication bias gave a value of -0.05 (95% CI Z -4.13 to 4.04, p Z 0.98), indicating no publication bias. The p for chi-squared heterogeneity for all the pooled accuracy estimates was O 0.10. Conclusions: EUS has excellent sensitivity and specificity to detect PI. EUS should be strongly considered for evaluation of PNT.

M1459 PET-CT Versus EUS Lymph Node Detection in Esophageal Cancer Patients: Implications for Dilatation Requirement Craig M. Womeldorph, Richard S. Kwon For the staging of esophageal cancer, endoscopic ultrasound (EUS) is the most sensitive modality to detect local and distant lymph nodes (LN). Dilatation of stenotic cancers to assess the celiac axis is often challenging and has a perforation risk up to 25%. Integrated positron emission tomography computed tomography (PET-CT) has reported incremental improvement for nodal staging over PET and CT alone. The aim of this study is to compare the detection of celiac LN by PET-CT and EUS. We specifically sought to determine whether a negative PET-CT could prevent the risks involved in dilatation at the time of EUS. Aim: To compare the detection of celiac lymph nodes by PET-CT and EUS. Methods: We retrospectively reviewed all staging EUS performed for esophageal carcinoma from January 2005 to December, 2008. Only patients treated with esophageal dilation with concomitant PET-CT reports were included in the analysis. Successful dilatations were defined by passage of the EUS scope into the stomach. Positive celiac LN detection by EUS was

Volume 69, No. 5 : 2009 GASTROINTESTINAL ENDOSCOPY AB247