Abstracts

Conclusions: EUS-FNA is useful for diagnosis of malignant lymphoma. One of theproblems in EUS-FNA examination was the limited amount of specimens collectedby EUS-FNA, especially in case of diagnosis for follicular lymphomas. Developmentof new device that can gather enough specimens for diagnosis of malignantlymphoma including follicular lymphoma is needed.

Echo-endoscopic analysis of variceal hemodynamics in patient

with isolated gastric varicesHidemichi ImamuraBackground /Aim: Massive hemorrhage of isolated gastric varices (GV) is a life-threatening event in patients with portal hypertension. To stanch the gastricvariceal bleeding, endoscopic injection sclerotherapy (EIS) using immediate tissue-adhesive substances, super glue, is considered effective treatment. Until now, wehave performed EIS using 62.5%/75% cyanoacrylate mixed contrast medium to 150or more patients. However, leakage of injected CA to systemic circulation throughthe gastro-renal shunt was occurred in some patients with large GV. Although it wasthought that large GV had high blood flow volume (BFV), there was no data ofrelationship between GV diameter and BFV. The aim of this study was to investigateBFV of GV in variety of GV size using echo-endoscope.Patients /Methods: Nineteen patients who had isolated GV in the period from Nov.2004 to Apr. 2008 were enrolled in this study. We had used echo-endoscope withcurved linear array (GF-UCT240-AL5,Tokyo, Olympus, Japan) or with electronicradial array (GF-UE260-AL5, Olympus, Japan). The variceal diameter and BFV weremeasured five times in each patient, definite data was fixed with the use of averageexcluding the maximum/minimum diameter and FV. Assessment of variceal form(F1:small varix, F2: medium varix, F3: large/timorous varix) was according toJapanese society of portal hypertention. EIS was performed using cyanoacrylate inall cases.Results: 1) Form and the diameter of GV: F2 was 5.0 mm, and F3 was 5.8 mm inmean diameter of EV. 2) BFV and diameter of GV: BFV was in range of 15-686.3 ml/min (2.3-7.6 mm in diameter), 1751.5 ml/min (9 mm in diameter). BFV wasinterrelated with GV diameter. 3) therapeutic results: GV was completely eradicatedin all cases. However, in a case that diameter was 9 mm, injected cyanoacrylateflowed out the systemic circulation.Conclusions: BFV of isolated GV was correlated with its size. Our results suggestedthat the estimation of BFV by endoscopic findings would be possible in isolated GVcase. In addition, care should be exercised in the case of 9mm in diameter and/ormore than 1700 ml/min in BFV, in performing EIS for GVs using super glue.

Can contrast-enhanced endoscopic ultrasonography with

Sonazoid increase the accuracy of preoperative T-staging for

pancreatico-biliary tumor? An ongoing studyH. Imazu, H. Tajiri, Y. Uchiyama, H. KakutaniBackground: Several reports have showed EUS is highly accurate for local staging ofgastrointestinal tumor. However, EUS has still limited values in staging ofpancreaticobiliary tumor. Sonazoid is a new second generation microbubblecontrast agent for ultrasonography which was recently developed in Japan. There isno report of clinical utility of EUS with Sonazoid for pancreaticobiliary tumor.Study aim: To prospectively evaluate the diagnostic role of contrast-enhancedharmonic imaging EUS with Sonazoid (EH-EUS) in preoperative T-staging ofpancreaticobiliary tumor.Methods: Thirty consecutive patients with suspected pancreaticobiliary tumorunderwent EH-EUS (Olympus GF UE 260/Aloka-5) by single examiner (H.I). Afterlesions were observed carefully with conventional harmonic imaging EUS (H-EUS),EH-EUS was performed with intravenous injection of 0.015ml/kg of Sonazoid (Dai-ichi Sankyo, Tokyo, Japan). Reviewer was blinded to findings of recorded video ofH-EUS and EH-EUS. Accuracy of HEUS and EH-EUS for T-staging was compared tofindings of surgical specimens as reference standard in patients who underwentsurgery.Results: Fifteen patients underwent surgical resection and were evaluated in thisstudy. Final diagnosis based on histological findings were pancreatic cancer in 5,bile duct cancer in 5, gallbladder cancer in 3 and ampullary cancer in 2. Final T-staging was T1 in one, T2 in 3, T3 in 9 and T4 in 2. Overall accuracy of H-EUS andEH-EUS for T-staging were 60% (9/15) and 86.7% (13/15) respectively. There weredisagreement in 3 cases of bile duct cancer and one case of pancreatic cancer(26.6%) between H-EUS and EH-EUS. Although EH-EUS staged correctly in all ofsuch 4 cases, HEUS over-diagnosed depth of invasion to serosa of bile duct in 2cases of bile duct cancer and invasion to portal vein in one case of pancreatic cancerand one case bile duct cancer. For EH-EUS, we had observed that serosa of bile ductand gall bladder, submucosal layer of duodenum and normal tissue between cancerand large vessels were prominently highlighted with Sonazoid.Conclusion: Depth of invasion of biliary cancer and vascular invasion of pancreaticand biliary cancer could be demonstrated more clearly with EH-EUS as comparedwith H-EUS. EH-EUS might improve the diagnostic capability of preoperative T-staging of pancreaticobiliary cancer. However, further studies are warranted toclarify the clinical impact of EHEUS.

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Feasibility of endoscopic ultrasound guided fine needle

aspiration and immune-cytochemistry examination for the

assessment of neoangiogenesis in the patients with lung cancerAna Maria IoncicaPurpose: Endoscopic ultrasound (EUS) - guided fine-needle aspiration (FNA) isa minimally invasive technique, increasingly used for the assessment of digestiveorgans. However, this technique is extremely important to determine the diagnosisand staging of lung cancer by assessing the posterior mediastinal masses. The aimof our study was to assess the feasibility of EUS-FNA with immune-cytochemistry forthe assessment of neo-angiogenesis in patients with lung cancer.Methods: Our study included 20 consecutive patients visualized by endoscopicultrasound at the Research Center of Gastroenterology and Hepatology Craiova,University of Medicine and Pharmacy Craiova. The patients were initially examinedby chest x-ray, computer tomography scans and bronchial endoscopy, withouta tissue confirmation of malignancy. All the patients were assessed by endoscopicultrasound guided fine needle aspiration followed by cytology examination andimuno-cytochemistry.Results: Of the 20 patients included in our study, 15 had a positive FNA, confirmingthe diagnosis of malignancy, the samples being obtained from the lymph nodes atlevel 5 (the aorto-pulmonary window) or level 7 (the subtraheal space), as well asfrom the primary mediastinal tumors. One of the patients could not be assessed byEUS-FNA because of the impossibility of finding a suitable puncture route, withoutinterfering with the main vessels (the aorta, the pulmonary artery). In this patient,the diagnosis was confirmed by EUS-guided FNA of the left adrenal gland. Fourpatients had negative EUS-FNA and the diagnosis was certified by EUS-guidedhistological needle (Trucut). The obtained samples allowed us to accomplishimunocytochemistry / imunohistochemistry for all the patients, in order to assessseveral angiogenesis markers: Vascular Endothelial Growth Factor (VEGF) and itsreceptor (VEGFR-1), Epidermal Growth Factor Receptor (EGFR) and PlateletDerived Growth Factor (PDGF).Conclusion: In conclusion, EUS is highly sensitive for diagnosing lung cancer, whileFNA improves not only the specificity, but also the accuracy. In addition, EUS-FNAallows the assessment of neo-angiogenesis in lung cancer patients before and afterthe tratament, being potentially useful as a minimally invasive method used to tailorantiangiogenic therapy.

Endoscopic ultrasonography guided biliary stenting for

malignant biliary obstructionYasutaka Ishii, Keiji Hanada, Tomohiro Iiboshi, Naomichi Hirano,Fumiaki Hino, Makoto OobayashiBackground: Endoscopic biliary drainage (EBD) is usually performed forobstructive jaundice caused by malignant lower biliary obstruction such ascarcinomas in pancreas head, lower bile duct, and papilla of Vater. In cases difficultfor EBD, the standard alternative method is considered to be percutaneoustranshepatic biliary drainage (PTBD). However, there are many problems such ascomplications and the degradation of quality of daily life of the patient. Recentlythere have been some reports on the usefulness of endoscopic ultrasonographyguided biliary stenting (EUS-BS) when EBD is difficult. In this study, we report anddiscuss the result and problem of EUS-BS.Patients and Methods: Between November 2006 and December 2007, EUS-BSwas performed in 5 cases. 4 cases were pancreas head carcinomas, and one wasa Vater carcinoma. EUS examinations were performed using a convex scanningechoendoscope (GFUCT240-AL5; Olympus Optical Co, Tokyo, Japan). Wedemonstrated the dilated common bile duct from duodenal bulb and then,fistula was created by introducing a 19-gauge needle (Echo tip Ultra; Wilson-Cook, Winston-Salem, NC) into common bile duct. A guidewire was introducedthrough the needle and placed at the intrahepatic bile duct. After the fistula wasdilated, a biliary plastic stent was placed.Results: We could place a biliary plastic stent by EUS-BS procedure in 4 cases. Therequired time ranged from 18 to 60 minutes. There were no severe complicationssuch as bleeding or perforation, and no mortality. In one case, we could not placethe plastic stent completely. Therefore, we immediately performed percutaneoustranshepatic gallbladder drainage. A few days later, we succeeded to perform EBDusing a rendezvous method.Conclusion: EUS-BS may be a reasonable, feasible and encouraging treatmentoption in selected patients with malignant biliary obstruction when EBD is notsuccessful.

Comparing the amount of specimens collected by EUS-FNAHideki IshikawaBackground: We had performed EUS-FNA procedures on more than 150 casesbetween May of 1995 and March of 2006 and there were some cases with nodiagnosis because insufficient amount of specimens were collected. We havetherefore adopted the fast diagnostic cytology ‘‘Diff-Quick’’ stain with thepresence of a cyto-pathologist during each procedure since May of 2003 whileseeking to decrease the number of times of puncturing and to improve ofdiagnostic accuracy. The joint study by various institutions aiming to standardizethe use of puncture needles is still in progress in Japan and there have been fewreports on the study of the puncture needles overseas.

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Abstracts

Study objectives: Compare the puncture needles and define differences in theamount of specimens collected.Subjective: 70 cases in which EUS-FNA was used between July of 2004 and March of2006.Methods: !Equipment used for all 70 casesO Echoendoscope - OLYMPUS GF-UC240P, GF-UCT240. Ultrasonograph - ALOKA SSD 5000, Prosound 5500SV, 5. Weused both Wilson-Cook ECHO-TIP 22G and OLYMPUS NA-200H-8022 22Galternately on all of the 70 cases. 12 cases were not diagnosable with 22G thereforewe used ECHO-TIP 19G in addition on those 12 cases. The collected specimenswere weighed on an electric balance scale before they were formalin-fixed.Results: For all the 70 cases, the average times of puncture were three times, thespecimen collection rate was 100%, the diagnostic accuracy was 95.7%. As 12 caseshad no diagnosis with the 22G needles, we used ECHO-TIP 19G needles andsucceeded at collecting sufficient amount of specimens.

Usefulness of EUS-guided choledochododenostomy in patients

with endoscopically inaccessible papillaFumihide ItokawaIntroduction: Endoscopic transpapillary biliary drainage is the procedure of firstchoice for biliary decompression in patients with malignant lower bile ductstricture. If impossible, the alternative procedures, i.e., percutaneous transhepaticdrainage or surgery, are chosen usually. Both modalities often carry a highercomplication rate and are more invasive than endoscopic drainage. Recently, EUS-guided biliary drainage has been reported as an alternative biliary drainagetechnique.Aim: The aim of this study is to evaluate the outcome of EUS-guidedtransdunodenal biliary drainage in malignant lower bile duct stricture.Patients and Methods: We encountered four failed ERCP patients with malignantdiseases and obstructive jaundice (Papilla of Vater carcinoma 2, pancreatic cancer2). An echoendoscope with a curved linear array transducer, a 3.7-mm accessorychannel with elevator (GF-UCT2000-OL5, Olympus) was used. Zimmon needle-knife (Wilson-Cook) with electrocoagulation (EndoCut ICC200), or conventional19-gauge FNA needle (Wilson-Cook) was used to perform thechodeochoduodenostomy. Subsequently, a 5-Fr external drainage tube or a 7-Frinternal drainage tube was placed.Results: Eus-guided choledochodudenostomy was performed in all cases withoutserious complications by using Zimmon needle-knife and 19-gauge needle was usedin each 2 cases, and the stent placement was succeeded in 3 of 4 cases. In remainingone case, however, stent could not advance into bile duct after puncture byZimmon needle-knife with electrocoagulatio because of uneven portion betweenbile duct and duodenal wall. Then, only 5-Fr nasobiliary drainage was performed.Stent occulusion occurred due to food impaction in one case, and it was changedto metallic stent.Conclusion: EUS-guided choledochododenostomy in patients with endoscopicallyinaccessible papilla may be very useful as an alternative drainage technique.

Impact of elastography endoscopic ultrasound for diagnosis of

pancreatic massFumihide ItokawaIntroduction: In general, pancreatic ductal cancer (PDC) involves the comparativelymarked fibrosis representing tissue hardness from early stage. The reconstructionof tissue elasticity provides the sonographer with important additional informationwhich can be applied for the diagnosis of these diseases.Aim: The aim of our study was to evaluate the ability of endoscopic ultrasoundelastography to differentiate between benign and malignant pancreatic masses.Patients and Methods: The subjects were 53 patients who performed an endoscopicultrasound (EUS) for pancreas in our hospital from September 2006 to March 2008.The disease were 6 with mass forming pancreatitis (MFP), 5 with chronicpancreatitis (CP), 48 with PDC, 5 with neuroendocrine carcinoma (PNET), 2 withauto immune pancreatitis (AIP), 5 with SCN, 2 with SPN, 1 with Schwanoma, 1 withGIST, 1 with renal cell carcinoma pancreatic metastasis, 4 with IPMN, 1 withmalignant lymphoma and 5 with normal control. A histological diagnosis by surgeryor EUS-FNA was performed for all subjects. The ultrasound was used the HITACHIHI VISION900, and EUS scope was PENTAX EG-3630UR, EG-3670URK and EG-3870UTK. The calculation of tissue elasticity distribution is performed in real-timeand the results are represented in color over the radial B-mode image. Malignanttissue appeared in blue color, fibrosis in blue to green, and normal tissue in greento red. In addition, we performed the quantification by using strain ratio (non massarea/mass area: SR) in order to evaluate the objective hardness as numerical valuebetween mass to non mass area especially to distinguish TFP from PDC.Results: Elastography for all PDCs showed intense blue coloration, which indicatedthat the mass lesions had malignant aspects. While MFP presented the colorationpattern of mixed green, yellow and low intensity of blue. Normal control was an evenapplication of green to red. The mean SR of MFP and PDC were each 23.08 � 12.65and 37.08 � 20.54, respectively, which was significant difference (p?0.05).

S246 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 2 : 2009

Conclusion: EUS elastography is potentially capable of further defining the tissuecharacteristics of benign and malignant lesions. This study suggested that it wasuseful for the quantification by using strain ratio to characterize the tissue hardnessof pancreatic disease and distinguish MFP from PDC.

Endoscopic ultrasound-guided fine needle aspiration for the

splenic tumorTakuji Iwashita, Ichiro Yasuda, Masanori Nakashima, Keisuke Iwata,Tsuyoshi Mukai, Eiichi Tomita, Hisataka MoriwakiIntroduction: Splenic tumor is occasionally found in clinical practice, but thediagnosis is often difficult only by imaging and blood examinations. Pathologicalsampling is required in such cases, but a percutaneous biopsy under the externalultrasound guidance is sometimes difficult because the visualization could beinterfered by gastrointestinal gas, lung, and bones. On the other hand, EUSprovides good image of the spleen through the gastric wall. Therefore, transgastricapproach under EUS guidance seems much easier than percutaneous approach.However, the needle puncture may be risky because the spleen is a blood-richorgan, while using a larger needle is requested for the diagnosis because lymphomais a major possible cause.Aims: To evaluate the yield of EUS-FNA using a 19-gauge needle for splenic tumor.Methods: We reviewed the data of the patients who had undergone EUS-FNA forthe splenic tumor from our database between October 2003 and November 2007.Their follow-up data was also investigated from their medical charts.Results: EUS-FNA had been attempted to five patients with splenic tumors in theperiod. They included a male and 4 females, whose median age was 67 years(range: 50-71 years). The targeted lesion was successfully detected by transgastricscanning, and pathological sample was also successfully obtained using a 19-gaugeneedle in all patients. The median long axis of the punctured tumors was 53 mm(range: 14-70 mm) and the median short axis was 45 mm (range: 11-51 mm). Themean number of passes was 2.0 (range: 1-3 passes). The pathological diagnosisfrom FNA materials was lymphoma in 2, sarcoidosis in 2, and inflammatorypseudotumor in 1 patient. Two patients diagnosed with lymphoma wascommenced chemotherapy, and 2 patients with sarcoidosis have been followedperiodically without any medications. A patient diagnosed with inflammatorypseudotumor underwent splenectomy later, because the spleen was extremelylarge and she complained continuous pain. The final diagnosis from the resectedspecimen was also inflammatory pseudotumor. A patient had mild abdominal painafter EUS-FNA, but bleeding or inflammation was not suspected from blood andimaging tests. Her symptom was resolved spontaneously in a day.Conclusion: EUSFNA using 19-gauge needle is still safe and useful for the diagnosisof splenic tumors.

EUS-guided radioactive seeds implantation of iodine 125 in the

retroperitoneal metastatic adenocarcinoma: a case reportZhendong JinEUS-guided radioactive seeds implantation of iodine 125 combined withchemotherapy were used for the treatment of the retroperitoneal cancer which wasnon-operative, accessed to obtain the local remission in one case of theretroperitoneal metastatic adenocarcinoma. A 61-year-old Chinese womanpresented to Changhai hospital with a one-week history of abdominal distention.MRI scan showed that there were many enlarged lymph nodes which wereintegrated near the hepatic portal and retroperitoneal, considered of lymphoma.The followings were laboratory tests (with normal range in parentheses): white cellcount 8.92 � 109/L (4.0-10.0 � 109/L), hemoglobin 9.0 g/dl (10-15 g/dl), plateletcount 239 � 109/L (100-300 � 109/L), GT 73 U/L (0-45 U/L), and the renal functionwas in the normal range. AFP and CA19-9 were normal, and the level of CEA inserum was 305ng/ml (0-10 ng/ml). The biopsy pathology was proved to bemetastatic adenocarcinoma under the CT-guided puncture. Immunohistochemistrystaining showed that it was metastatic adenocarcinoma, P53 (high level expression),Topo (drug fast gene middle level expression), proliferation of cell activity asmoderate. Twice chemotherapy were performed on the patient and the interval wasone month. The project of the chemotherapy was oxaliplatin200mg (d1),5-Fluorouraci 750 mg (d1-d5) and Calcium Folinate 200 mg (d1-d5). MRI scanshowed that the enlarged lymph nodes which were integrated near the hepaticportal and retroperitoneal were smaller than before. Since then, EUS-guidedradioactive iodine125 seed implantation were performed twice. The seeds wereimplanted into the enlarged lymph nodes using 19T needle. 20 seeds wereimplanted at the first time, 12 seeds in the second, and the total number of theiodine-125 seeds was 32. The interval was 7 days. The implantation of radioactiveseeds was secure for the patient, because there were no significant procedure-related complications which including acute pancreatitis and perforation.Laboratory test about hemogram and hemodiastase were both in the normalrange, and liver function did not change significantly. Two months after theimplantation of radioactive particles, two courses of the same chemotherapy were

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