The value of EUS in neoadjuvant chemotherapy of gastric cancer

The value of EUS in neoadjuvant chemotherapy of gastric cancer

Abstracts A successful EUS-FNA of the pelvic lymph node through the colon Noriaki Matsui, Kazuya Akahoshi, Yasuaki Motomura, Masaru Kubokawa, Naomi H...

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A successful EUS-FNA of the pelvic lymph node through the colon Noriaki Matsui, Kazuya Akahoshi, Yasuaki Motomura, Masaru Kubokawa, Naomi Higuchi, Shingo Endoh In the patient with lymphadenopathy, EUS-FNA is useful when those lymph nodes were located in the mediastinum, perigastric area or perirectum. It is difficult to perform EUS-FNA of the pelvic node with conventional technique using an oblique view linear scope. A newly developed linear EUS scope (EG530UT, FTS, Tokyo) has an oblique view, but good direct visualization is obtained since the angle of the optical device is sharp. We report a successful EUS-FNA of the pelvic lymph node close to the sigmoid colon using a newly developed linear EUS scope. The patient was a 77 years old female who had complained general fatigue and loss of appetite. She was noted to have elevated level of leukocyte (17680/micro L), anemia and hypoglycemia. A CT scan revealed multiple swollen lymph nodes in the paraarortic area and in the pelvis. She was referred to our department to consider any possibility of EUS-FNA to obtain histological evidence. EUS was performed per oral, which was failed to detect any lymph node. EUS with forward-viewing radial echoendoscope (EG530UR, FTS, Tokyo) was then performed per anus and multiple swollen lymph nodes were observed near the sigmoid colon. FTS linear echoendoscope was used to perform EUS FNA. The scope was advanced into the sigmoid colon under the direct visualization. An Olympus 22G needle was used to obtain pathological specimen. The pathological specimen revealed diffuse large B cell lymphoma and the patient was treated with adequate chemotherapy. A good direct visualization is obtained with the newly developed linear scope even in the colon and it is useful for pericolonic lesion.

Impact of staging EUS–FNA on treatment choice in patients with pancreatic lesions Rusmir Mesihovic Background: During the last years, endoscopic ultrasound (EUS) has become an important imaging procedure for diagnosis and management of pancreatic diseases. The clinical interest of EUS is now enhanced by interventional procedures. Fine-needle aspiration biopsy is one of the most important contributions of EUS, in particular for the investigation of patients with pancreatic cancer and cystic tumors. EUS-guided fine-needle aspiration appears to be a safe and reliable technique to obtain tissue from pancreatic masses with a low risk of complications. However, the impact of EUS – FNA confirmation of metastatic disease in patient with pancreatic tumors on treatment choice is the aim of this study. Objective: To determine the impact of pancreatic disease as determined by EUS staging on treatment choice in patients with pancreatic lesions. Design: Retrospective analysis of prospectively collected data. Setting: Tertiary university-based referral center. Patients: Patients with biopsy proven pancreatic adenocarcinoma who underwent staging EUS- FNA. The relationship of EUS nodal status and treatment was evaluated. Main Outcomes Measurements: Impact of EUS-FNA on therapy in patients with pancreatic cancer. Results: Of 22 patients with pancreatic tumor, EUS FNA confirmed metastatic disease in 72,7 % of the patients. Patients who were node positive were more likely to receive chemotherapy and/or radiation therapy and were less likely to undergo surgery compared with patients who were node negative (p ! 0,0001). Limitations: Lack of surgical reference standard in all patients. Conclusions: Patients with node positive pancreatic cancer as detected by EUS FNA are more likely to receive neoadjuvant therapy and less likely to receive surgery. Preoperative EUS - FNA is a minimally invasive technique that provides important prognostic information in patient with pancreatic lesions.

GI applications of the endobronchial ultrasound device: a report of 12 patient cases Faris M. Murad, Kapil Gupta, Rebecca Li, Shawn Mallery Background: EUS with a standard radial or linear echoendoscope may be technically impossible due to the large outer diameter of the scope. This may occur due to the presence of a large cervical osteophyte, luminal stenosis, or altered postoperative anatomy such as Roux-en-Y gastric bypass. The endobronchial ultrasound device (EBUS) utilizes a smaller outer diameter while still providing the ability to perform a good linear examination and obtain tissue through fine needle aspiration (FNA). Objective: To utilize the EBUS device when it was technically impossible to complete a standard EUS examination. Results: The EBUS device was utilized in the GI tract to complete a failed standard EUS examination in 12 cases. The cases included 6 esophageal masses or strictures, 2 cervical osteophytes, 2 pediatric cases, and 2 surgically created 24-French gastrostomy sites in patients with Roux-en-Y gastric bypass. There were a total of 7 cases where FNA was performed. Of these cases, 5 cases resulted in malignant cytology and 2 cases of suspected tuberculous lymphadenitis were nondiagnostic. One therapeutic case was performed following gastric bypass via gastrostomy for


transgastric abscess drainage. Of the 4 remaining cases, 2 of the cases allowed completion of staging while in the other 2 cases limited diagnostic examination was completed.

Endoscopic ultrasound-guided fine needle aspiration for biliary lesions Masanori Nakashima, Ichiro Yasuda, Takuji Iwashita Introduction: Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is a well-established procedure for making a pathological diagnosis of undetermined lesions. The pancreas, gastrointestinal submucosal tumors, as well as the mediastinal and intraabnominal lymph nodes are currently common targets for this procedure, however, so far only a few reports have described the yield of EUSFNA for biliary lesions. Aims: To evaluate the yield of EUS-FNA for biliary lesions. Methods: The data of EUS-FNA for biliary lesions were retrospectively investigated based on information obtained from the database of our institutions. Results: Nine cases underwent EUS-FNA for the treatment of biliary lesions at our institutions between September 2005 and January 2007. They included 7 gall bladder lesions and 2 bile duct lesions. In all cases, the findings obtained before performing EUS-FNA indicated a high suspicion for cancer, and all patients were considered to be inoperable due to involvement of large vessels. A transpapillary biopsy and brush cytology, and/or bile cytology were performed prior to EUS-FNA in all cases, however, no definitive diagnosis could be made. The sampling of pathological materials by EUS-FNA was successful in all cases, and a diagnosis of adenocarcinoma was made in 5 cases and of squamous cell carcinoma in 1 case. In addition, three cases were suspected to have xanthogranulomatous cholecystitis (XGC) based on the histopathological findings. These patients suspected of having XGC underwent a subsequent surgical operation, and all were finally diagnosed to have XGC. The final diagnosis was gall bladder cancer in 4 cases, XGC in 3 cases, and bile duct cancer in 2 cases. Chemotherapy was commenced as previously scheduled in 5 cases, but the treatment strategy was altered in three cases (33%) suspected of having XGC. There were no complications related to the EUS-FNA procedure. Conclusions: EUS-FNA is therefore considered to be a safe and effective modality for the diagnosis of biliary lesions.

A case of small pancreatic acinar cell carcinoma detected by endoscopic ultrasonography (EUS) Naoko Hyodo A 53-year old man was first hospitalized to our hospital due to a severe abdominal pain on October 3, 2006. Acute pancreatitis possibly due to alcoholic drinking was diagnosed on an abdominal CT revealing the swollen pancreatic tail, peri-pancreatic fluid collection and pleural effusion. Magnetic resonance cholangiopancreatography showed no abnormality of the main pancreatic duct (MPD). His hospital course was satisfactory and discharged 2weeks later, but he could not quit alcohol intake. He was second hospitalized due to acute pancreatitis on January 13, 2007, when CT showed slight dilatation of the MPD (3 mm) in the pancreatic body to tail without any space occupying lesions. After intermission of 6 months, he was third hospitalized due to the same reason, when CT showed ill-defined hypoperfusion mass of 1cm at diameter with distal MPD dilatation suggesting MPD obstruction at the pancreatic body. Although radiologist interpreted this lesion as cystic dilatation of the pancreatic branch, we performed EUS to examine the reason of MPD obstruction. EUS defined a low echoic mass lesion of 10 mm at diameter slightly enhanced after the injection of the contrast material (Levovist). Intraductal ultrasonography (IDUS) for MPD showed an irregular low echoic mass adjacent to MPD. The result of endoscopical pancreatic biopsy was atypical cell proliferation showing glandular or solid pattern with high cellurality, suggesting acinar cell carcinoma. Distal pancreatectomy was performed on October 3, 2007. Small nodular lesion of 106 mm in the pancreatic body was histologically and immunohistochemically acinar cell carcinoma with slight venular/peineural and lymphatic permeations. There is no recurrence so far. We emphasize the importance of EUS and IDUS to identify small pancreatic tumor.

The value of EUS in neoadjuvant chemotherapy of gastric cancer Weidong Nian The aim of the present study was to evaluate the role of EUS in preoperative neoadjuvant chemotherapy of gastric cancer. The patient with T or 3 tumors and/or node-positive disease by EUS staging were eligible for entry. Neoadjuvant chemotherapy consisted of two cycles of 5-FU(2400mg/m2), Eloxatin (130mg/m2) and LV (400mg/m2)(Folfox7) one time every three weeks. Before operation, EUS examination was done again. Twenty-five patients were entered into the study (4 with T3N0 disease and 21 with T3N1 disease). Induction chemotherapy was well tolerated with major toxicities being neutropenia and diarrhea. After neoadjuvant chemotherapy, EUS shows that largest diameters of tumors decreased to more than 30% in 17 patients (68%), largest diameters of tumors deceased to less than 30% or no obvious change in 8 patients (32%), no tumors increased the diameters during


chemotherapy and lymph nodes disappeared in 9 patients (operative specimens confirmed). Conclusions: Preoperative neoadjuvant chemotherapy can reduce the tumor size. This can increase the R0 operation rate. EUS can provide direct proof of changes of tumor size and metastasis of local lymph nodes.

EUS characteristics of intraductal papillary mucinous neoplasia (IPMN): series of 10 consecutive cases Hubert Nietsch Background: Intraductal Papillary Mucinous Neoplasie (IPMN) is a well-defined premalignant cystic lesion of the pancreas. Patients are either symptomatic (pancreatitis, steatorrhea, weight loss) or the lesion is found incidentally on abdominal imaging. Methods: We report the utility and characteristics of endoscopic ultrasound (EUS) and fine-needle aspiration (FNA) in a series of 10 consecutive patients over a period of 18 months. Results: 6 males and 4 females (nZ10) with IPMN were identified over an 18-month period in our institution with a mean age of 73.4 years (59-87 years). 7 patients were symptomatic with bouts of pancreatitis, weight loss and steatorrhea. The remainder were incidentally detected on crosssectional imaging for other reasons. All patients underwent EUS and some EUS-FNA by an experienced endosonographer in a highvolume referral center. 8 patients were classified as main-duct-type IPMN (MDTIPMN) with a medium main duct diameter of 8.2 mm (range: 5 to 12 mm) and intraductal nodules ranging from 3 to 12 mm in size. Two of the symptomatic MDTIPMN patients were diagnosed with invasive cancer on EUS-FNA. One underwent curative R0 resection, but the other patient was not an operable candidate due to severe comorbidities. Two further patients with mural nodules O10 mm and main duct dilation O10 mm underwent pylorus-preserving resection and were histologically staged as borderline neoplasia and are considered cured. The remaining 20% of our cohort had branch-duct IPMN (BDT-IPMN) with cystic dilations of side branches ranging from 4 to 10 mm in size and were enrolled in an annual EUS surveillance program. Conclusion: Our case series of 10 consecutive IPMN patients demonstrates the characteristic EUS features of MDT and BDT-IPMN and the utility of EUS-FNA of mural nodules. EUS is a helpful minimally-invasive tool for risk stratification and surveillance in patients with IPMN.

Isolated pancreas metastasis of renal cell carcinoma diagnosed by EUS-FNA Hubert Nietsch Background: Pancreatic metastasis are rare and account for less than 2% of pancreas tumors. Methods: We report two patients with biopsy proven renal cell metastasis to the pancreas after a very long latency period. Both patients underwent EUS with FNA as the primary mode of definitive diagnosis. Results: The first patient is a 82-year old female who underwent a right-sided nephrectomy 18 years prior to her presentation. Her current symptoms were abdominal pain associated with an elevated serum lipase. She was referred for EUS which demonstrated a 28x33 mm slightly hypoechoic round lesion in the head of the pancreas. FNA with a 22G needle (Echotip, Cook) was diagnostic showing metastatic renal cell carcinoma confirmed on immunohistochemistry with CD 10, vimentin/cytokeratin staining. Given her significant co-morbidities (CAD, CHF) the patient opted against surgery and is currently treated with the thyrosin-kinase inhibitor Sunitinib. The second patient is a 80-year old female status post left-sided nephrectomy 34 years ago, who presented with epigastric pain and weight loss. A MRI showed a 35 mm round lesion in the body of the pancreas, which appeared slightly hypoechoic on EUS. An EUS-FNA biopsy was consistent with clear cell carcinoma metastasis. An extended distal pancreatectomy was performed with R0 resection of the tumor metastasis. Conclusion: Both cases demonstrate the typical EUS appearance of renal cell metastasis to the pancreas and the utility of FNA cytology diagnosis. Remarkable is the long latency between primary curative tumor resection and development of metastasis to the pancreas.

Clinical usefulness of the endoscopic ultrasonography for the management of IPMN Masami Ogawa Background and aim: The International Consensus Guidelines for Management of Intraductal Papillary Mucinous Neoplasms and Mucinous Cystic Neoplasms of the Pancreas has been published and are useful for the management of intraductal papillary mucinous neoplasms of the pancreas (IPMN). But some problems are still remains. We evaluated the usefulness of endoscopic ultrasonography (EUS) for the management of IPMN. Method: Twenty-three patients who were underwent surgical resection in our hospital from April 2001 to November 2007 and verified pathologically IPMN. Eighteen of whom were underwent EUS and CT/MRI before operation were included in this study. We classified benign IPMN or malignant IPMN by

pathologically and investigated whether the mural nodule or wall thickening of the lesion could detect by EUS and CT/MRI before resection. And more we classified clinical types, main duct type IPMN or brunch duct type IPMN. We measured size of the cystic lesion and height of the mural nodule with brunch type. Result: Six patients (6/18; 33.3%) were malignant IPMN. All of them (6/6; 100%) were detected mural nodule or wall thickening of the lesion before resection by EUS, and four of them (4/6; 66.7%) by CT/MRI. Twelve were benign, seven of them (7/12; 58.3%) were detected by EUS and one (1/12; 8.3%) by CT/MRI. Seven patients were main duct type and five of them (5/7; 71.4%) were malignant. Eleven patients were brunch type. Seven of them were larger than 3cm, but only one patient was malignant. The height of mural nodule was 10mm with malignant, and average height were 5mm (range; 3-6mm) with benign. Conclusion: EUS is a useful tool for demonstrating the mural nodule of IPMN. And guideline recommends resection larger than 3cm of the brunch type, but this study suggests that the brunch type IPMN larger than 3cm are possible to follow-up by using EUS.

Backloaded fiducial placement using a bone wax seal to facilitate EUS-guided fiducial placement David J. Owens, Thomas J. Savides Purpose: Stereotactic body radiation therapy (SBRT) permits the delivery of high energy external radiation to extra-cranial tumors. CyberKnife (Accuray, Sunnyvale, CA) is one delivery system that uses implanted fiducials to accurately target lesions and minimize damage to surrounding normal tissue. Fiducials can be placed surgically or via CT, ultrasound, bronchoscopy or endoscopic ultrasound (EUS). EUS placement is a recognized mode of delivery for fiducials for the treatment of mediastinal and abdominal malignancies. EUS-guided fiducial placement is often complicated by the inability to advance the fiducial through a standard 19g FNA needle when the echo-endoscope tip is angulated. Angulation of the tip is often necessary for visualization of pancreatic tumors. In addition, introduction of air often obscures EUS visualization following fiducial placement and complicates assessment of fiducial adequacy for CyberKnife treatment. We introduce a new technique where the fiducial is backloaded into the 19g needle and held in place with bone wax that allows for easier fiducial delivery and elimination of air introduction. Methods: The 3 mm x 0.8 mm fiducial is backloaded into a 19-gauge EUS FNA needle with the stylet retracted slightly to accommodate the fiducial. The fiducial is secured in place by pressing the needle into sterile bone wax. The needle is then introduced into the working channel. The needle with the backloaded fiducial is advanced into the mass under EUS guidance. Finally, the fiducial is delivered into the desired location by briskly advancing the slightly retracted stylet the remainder of the distance to the hub of the needle handle. Fluroscopy is used to confirm fiducial release into the tumor. Results: Two consecutive patients with inoperable pancreatic adenocarcinoma had successful EUS-guided placement of fiducials with the use of the backloading with bone wax seal technique. Both tumors were located in the pancreatic head and were placed with transduodenal EUS FNI. Three fiducials were released in each patient without difficulty. No complications were noted. Conclusions: The technique of backloading with a bone wax seal for EUS-guided fiducial placement is a simple modification that significantly improves this procedure.

Is EUS a financially viable for community based hospital? Rig Patel, Colm O’loughlin, Naveen Narahari, April Leonard, Tracy Handzel, Heather Patterson Background: EUS is widely available in tertiary centers but is not well established in the community setting. Equipment costs along with concerns of financial reimbursement, has been a deterrent for community hospitals when considering requests for an EUS program. Aim: Evaluate the direct hospital/facility revenue from EUS procedures as well as the indirect collections from other hospital services (OHS) that result from patients being referred from the EUS unit (e.g. referral for surgery, radiology, cancer care etc) at a community based hospital. Methods: At the initiation of the EUS program, data was collected to evaluate several parameters of EUS procedures (including indication, diagnosis, postprocedure clinical plan and a secure patient identifier to allow for analysis of facility charges and collections at that hospital for all subsequent services). Clinical data was collected prospectively and financial data retrospectively. Financial data [charges, payments, variable cost for clinical services (nursing salaries, medications and supplies, excluding endoscopes)] was independently analyzed by one individual using the CCA Trendstar (HBO) database software. Results: Over a 12 month period, 212 patients [mean age 60yrs (range 22:91 yr), M:F,7:9)] underwent EUS (75 with FNA), all were included in analysis. EUS newly diagnosed and/or staged a malignancy in 97 patients. 271 further patient visits to other hospital services (OHS) resulted from referral after EUS. Insurance carriers included 107 (50%) managed care patients and 82 (39%) Medicare patients. To summarize financial data: total charges were $4,028,153 ($1,321,151 for EUS alone and $2,707,002 for OHS), total payments: $1,290,674 ($406,789 for EUS and