Endosonography (Series in Radiology)
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Gastrointest Endosc Clin North Am , Z Gastroenterol , Tech Gastrointestinal Endoscopy , Cancer , Gut , Palazzo L, Roseau G, Salmeron M: Endoscopic ultrasonography in the preoperative localization of pancreatic endocrine tumors. Surgery , Am J Roentgenol , Digestion 55 suppl 3 , Gibril F, Jensen RT: Comparative analysis of diagnostic techniques for localization of gastrointestinal neuroendocrine tumors. Yale Biol Med , Ann Intern Med , Rosch T, Lorenz R, Braig C, et al: Preoperative localization of endocrine tumors of the pancreas: Endoscopic ultrasound is superior to transabdominal sonography and computed tomography.
Bansal R, Tierney W, Carpenter S, et al: Cost effectiveness of endoscopic ultrasound for preoperative localization of pancreatic endocrine tumors. Ann Surg , Gastroenterology A, J Ultrasound Med , Langenbecks Arch Surg , Sarr MG, Carpenter HA, Prabhakar LP, et al: Clinical and pathologic correlation of 84 mucinous cystic neoplasms of the pancreas: Can one reliably differentiate benign from malignant or premalignant neoplasms?
Am J Surg Pathol , J Comput Assist Tomogr , French Surgical Association. Sand JA, Hyoty MK, Mattila J, et al: Clinical assessment compared with cyst fluid analysis in the differential diagnosis of cystic lesions in the pancreas. Hammel P, Voitot H, Vilgrain V, et al: Diagnostic value of CA and carcinoembryonic antigen determination in the fluid of pancreatic cystic lesions.
Eur J Gastroenterol Hepatol , Torresan F, Casadei R, Solmi L, et al: The role of ultrasound in the differential diagnosis of serous and mucinous cystic tumours of the pancreas. Gress F, Gottlieb K, Cummings O, et al: Endoscopic ultrasound characteristic of mucinous cystic neoplasms of the pancreas.
Am J Gastroenterol , Sperti C, Pasquali C, Guolo P, et al: Serum tumor markers and cyst fluid analysis are useful for the diagnosis of pancreatic cystic tumors. A prospective study of 28 percutaneous aspirates. Acta Cytol , Fukushima N, Mukai K, Kanai Y, et al: Intraductal papillary tumors and mucinous cystic tumors of the pancreas: Clinicopathologic study of 38 cases. Human Pathol , Ariyama J, Suyama M, Satoh K, et al: Endoscopic ultrasound and intraductal ultrasound in the diagnosis of small pancreatic tumors. Hepatogastroenterology , CA Cancer J Clin , Surg Clin North Am , Gastroenterol Clin North Am , Gastrointest Endosc 52 suppl , Gress F, Savides T, Cummings O, et al: Radial scanning and linear array endosonography for staging pancreatic cancer: A prospective randomized comparison.
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Snady H, Bruckner H, Siegel J, et al: Endoscopic ultrasonographic criteria of vascular invasion by potentially resectable pancreatic tumors. Malden, Massachusetts, Blackwell Science, Vilmann P, Hancke S, Henriksen FW, et al: Endoscopic ultrasonography-guided fine-needle aspiration biopsy of lesions in the upper gastrointestinal tract. Wegener M, Adamek RJ, Wedmann B, et al: Endosonographically guided fine-needle aspiration puncture of paraesophagogastric mass lesions: Preliminary results.
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Chronic Pancreatitis Imaging
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Tumours classed as T3N0 or N1 must be considered non-resectable although it is accepted that the criteria of non-resectabilty are very variable from one surgical team to another. The major problem is the diagnosis of an ADKP that develops on CP because it is very difficult to recognize with certainty the malignant character of a hypoechoic area within CP tissue.
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Positive diagnosis requires a biopsy specimen. For the diagnosis of pancreatic tumours, two studies have demonstrated that EUS is superior to helicoidal CT scan for small tumours measuring less than 25 mm. The first study reported by Midwinter et al. This study showed that EUS is more precise for the diagnosis and the location of small-sized pancreatic tumours less than 25 mm in diameter, and that EUS provides comparable results for diagnosis of invasion of the superior mesenteric or portal veins.
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The second study by Bender et al. EUS confirmed the pancreatic lesion in 33 patients and found a normal pancreas in the 32 others. Finally, another study by Mertz et al. EUS was more sensitive than helicoidal scan for the diagnosis of portal invasion. Summarizing, today EUS is the best exploration for the diagnosis of small-sized pancreatic tumours; it is however still the second intention examination after helicoidal CT scan. The specificity of EUS for the diagnosis of pancreatic tumours is better than other explorations, a specificity that is further improved with adjunction of guided biopsy.
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Endoscopic Ultrasound : Table of Contents
In all these studies, the EUS data have been compared to the results of surgical exploration. Staging of pancreatic cancer. The problem is the interpretation of the loss of the interface between the tumour and the wall of the portal vein. Few studies are to be found in the literature evaluating the performance of EUS in the evaluation of arterial involvement. It would be difficult to assess the superior mesenteric artery with mechanical rotating probes. The last problem is that of nodal extension, particularly in cases with an obstructive jaundice where inflammatory nodes of the hepatic pedicle are frequently encountered.
ESSENTIALS OF DIAGNOSIS
The problem is even more difficult when EUS is performed after insertion of a biliary stent. The development of helicoidal CT scan has modified the data reported in the literature up through Legmann et al. EUS could be more interesting for the diagnostic of distal nodal invasion particularly for celiac nodes for tumours of the head of the pancreas and lomboaortic nodes.
Quite obviously, only guided biopsy can confirm tumour invasion of a LN. Finally, EUS can evidence signs of peritoneal carcinomatosis such as minimal ascitis effusion around the stomach or the duodenum.
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EUS provides also a precise assessment of the left liver and in certain case can evidence small metastasis less than 1 cm that can go unnoticed on CT scan. The development of EUS has enabled us to have a more accurate picture of the spread of pancreatic tumours. Nevertheless, EUS is not able to confirm the malignant or benign character of such pancreatic masses.
Biopsies are performed at the end of US endoscopy examinations, the patient lying down on their left side. Neuroleptanaesthaesia is generally necessary. One to three passages are usually necessary in order to obtain a micro-biopsy.
The micro-biopsies are obtained in the following manner: all of the sample contained within the needle is withdrawn using a foam stylet that is introduced into the needle, the sample is then placed in formaldehyde or cytolit then completely enclosed in paraffin wax.
In contrast to American teams, we do not systematically administer an antibiotic injection after taking a sample. At the end of the examination, it is necessary of monitor patients for at least 3 hours. Biopsies guided by EUS can be done on an outpatient basis in the majority of cases. Our experience is based on around samples we have taken up to now.
Samples have been taken from LN and mediastinal, celiac and pelvic masses, from sub-mucosal membrane tumours, from gastric linitis tumours with negative endoscopic biopsies and from pancreatic tumours. The best results are obtained from LN, anastomotic recurrences of tumours and extrinsic compressions in addition to pancreatic tumours. Furthermore, certain teams recommend the presence of an anatomical pathologist in the theatre in order to ensure the high quality of the sample.
No mention was found in the literature concerning the risk of spreading the cancer with this sampling technique. On the other hand, there was no difference concerning the specificity for these three groups of lesions. This study involved patients; the average diameter of the lesions varied between Concerning the process of diagnosis, it seems to be accepted that an EUSGB is the least aggressive technique five minor complications in samples, three of which were directly attributable to the biopsy: two episodes of fever that responded to antibiotics and one haemorrhage during the biopsy of a pancreatic cyst.
This is because the transgastric or transduodenal route of entry diminishes the risk of spread and for tumours of the head of the pancreas, the biopsy path will be operated at the time of the cephalic duodeno-pancreactectomy. Regarding solid pancreatic masses, what is the impact of EUS on the treatment decided on?