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   Table of Contents - Current issue
Coverpage
July-August 2019
Volume 8 | Issue 4
Page Nos. 217-282

Online since Tuesday, August 6, 2019

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EDITORIAL  

EUS: A one-stop shop approach for pancreatic head masses: Dream or reality? p. 217
Alberto Larghi, Mihai Rimbaş, Stefano Francesco Crino, Gianenrico Rizzatti, Antonio Gasbarrini, Guido Costamagna
DOI:10.4103/eus.eus_61_18  PMID:30785119
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REVIEW ARTICLE Top

EUS-guided radiofrequency ablation as an alternative to surgery for pancreatic neuroendocrine neoplasms: Who should we treat? p. 220
Alberto Larghi, Gianenrico Rizzatti, Mihai Rimbaş, Stefano Francesco Crino, Antonio Gasbarrini, Guido Costamagna
DOI:10.4103/eus.eus_28_19  PMID:31249164
Pancreatic neuroendocrine neoplasms (PanNENs) are rare tumors, but their incidental diagnosis has significantly increased due to the widespread use of imaging studies. Therefore, most PanNENs are now diagnosed when completely asymptomatic and in early stages. PanNENs are classified according to their grade (Ki-67 index) and can be functional (F-) or nonfunctional (NF-) depending on the presence or absence of a clinical, hormonal hypersecretion syndrome. The mainstay treatment of PanNENs is a surgery that is mostly curative but also associated with significant short- and long-term adverse events. Therefore, less invasive alternative locoregional treatment modalities are warranted. Recently, few case reports and two case series have described EUS-guided radiofrequency ablation (EUS-RFA) for the treatment of patients with both F-PanNENs and NF-PanNENs. If for F-PanNENs EUS-RFA can very easily become the standard of care, for NF-PanNENEs it is still controversial how to select patients for EUS-RFA. A balance between overtreatment (i.e., RFA/surgery in patients who will not progress) and undertreatment (locoregional treatments in patients with undetected metastases) needs to be found based on solid data. The decision should also take into account patients' comorbidity and risk of postoperative death, life expectancy, tumor location, risk of postoperative fistula and postoperative morbidity, and risk of long-term exocrine and/or endocrine insufficiency. To answer the important question on which a patient should be treated with EUS-RFA, properly designed studies to evaluate the efficacy of this treatment in large cohorts of patients with NF-PanNENs and to establish prognostic factors associated with treatment response are urgently needed.
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TRAINING COURSES Top

EUS of the neck: A comprehensive anatomical reference for the staging of head and neck cancer (with videos) p. 227
Malay Sharma, Amit Pathak, Abid Shoukat, Chittapuram Srinivasan Rameshbabu, Sumit Goyal, Raghav Bansal, Rooby Hamza, Kshitij Charaya
DOI:10.4103/2303-9027.260860  PMID:31249169
The use of EUS has application in the nodal staging of head and neck cancer. The technique and the anatomy of head and neck region using EUS have not been described. EUS from three stations in thoracic esophagus, cervical esophagus, and hypopharynx can allow imaging of head and neck. In this article we describe the normal structures from the three stations. The EUS imaging of head and neck can give relevant and additional information in malignancies of head and neck.
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RAPID COMMUNICATION Top

Changes in tumor vascularity depicted by contrast-enhanced EUS as a predictor of prognosis and treatment efficacy in patients with unresectable pancreatic cancer (PEACE): A study protocol p. 235
Adrian S„ftoiu, Manoop S Bhutani, Takao Itoi, Paolo G Arcidiacono, Erwan Bories, Irina M Cazacu, Alina Constantin, Emmanuel Coronel, Christoph F Dietrich, Dan G Duda, Julio Iglesias Garcia, Michael Hocke, Andre Ignee, Christian Jenssen, Mariana Jinga, Christopher Khor, Kofi W Oppong, Stephen Pereira, Maria Chiara Petrone, Erwin Santo, Andrada Seicean, Dong Wan Seo, Sun Siyu, Peter Vilmann, Irving Waxman, Paul Yeaton
DOI:10.4103/eus.eus_16_19  PMID:31249159
Patients with unresectable pancreatic cancer have a poor prognosis. The analysis of prognostic factors before treatment may be helpful in determining the best therapeutic strategies. The aim of the PEACE study is to assess the vascularity of pancreatic malignant tumors using contrast-enhanced harmonic EUS (CEH-EUS) and to clarify the prognostic value of tumor vascularity in patients with locally advanced and metastatic pancreatic cancer. Hereby, we present the protocol of a prospective, nonrandomized, single-arm, multicenter study aiming to assess changes in tumor vascularity using CEH-EUS before and 2 months after treatment initiation in patients with unresectable, locally advanced/metastatic pancreatic cancer and to examine the correlation between vascular changes and treatment response, progression-free survival, and overall survival.
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ORIGINAL ARTICLES Top

Adverse events with lumen-apposing metal stents in endoscopic gallbladder drainage: A systematic review and meta-analysis p. 241
Babu P Mohan, Ravishankar Asokkumar, Mohammed Shakhatreh, Rajat Garg, Suresh Ponnada, Udayakumar Navaneethan, Douglas G Adler
DOI:10.4103/eus.eus_63_18  PMID:31115387
Background: Lumen-apposing metal stents (LAMS) are rapidly being used in endoscopic interventional drainage procedures and have started to replace the self-expanding metal stents (SEMSs). Its use in gallbladder drainage (GBD) is limited by lack of good-quality studies, and data are scarce on its safety. Methods: We conducted a comprehensive search of multiple electronic databases and conference proceedings including PubMed, Embase, and Web of Science databases (from inception through July 2018) to identify studies that reported on the use of LAMS in GBD. The outcomes measured were the pooled rates of all adverse events (AEs), pooled rates of early AEs and pooled rates of delayed AEs. Results: A total of 8 studies (393 patients) were included. The pooled rate of all AEs was 12.7% (95% CI 8.4-18.7, I2= 7.7) compared to 17.5% (95% CI 10.2-28.2, I2= 65.1) with other SEMS, P = 0.39. The rate of early AEs with LAMS in endoscopic ultrasound-GBD (EUS-GBD) was 6.5% (95% CI 4.2-10, I2= 1.2), and the rate of delayed AEs was 8.3% (95% CI 5.8-11.9, I2 = 4.8). The rate of recurrent cholecystitis and/or cholangitis was 4.6% (95% CI 2.6-9.5, I2= 0) and the pooled rate of death was 5% (95% CI 2.6-9.5, I2 = 36.4). Conclusion: We report an overall AE rate of 13% with LAMS in EUS-GBD. Early AE risk appears to be 6.5% and delayed AE risk appears to be 8%. Our results are analyzed out of good-quality studies, with minimal to zero heterogeneity.
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EUS anatomy of the pancreatobiliary system in a swine model: The WISE experience p. 249
Dario Ligresti, Yu-Ting Kuo, Stefano Baraldo, Radhika Chavan, Margaret Geri Keane, Shaimaa Seleem, Dong-Wan Seo
DOI:10.4103/eus.eus_10_19  PMID:31115384
Background and Objectives: EUS training is recognized to have a substantial learning curve. To date, few dedicated training programs for EUS have been described. The swine model has been highlighted as a realistic tool to enhance EUS training. Studies extensively describing EUS swine anatomy are lacking in the current literature. The article aims to describe both radial and linear EUS pancreatobiliary swine anatomy. Materials and Methods: Four live pigs were endoscoped under general anesthesia using both radial and linear array echoendoscopes. Relevant images and videos were recorded. Results: It was possible to effectively image aorta, crus of the diaphragm, celiac trunk, superior mesenteric artery, pancreas, common bile duct, gallbladder, portal vein, kidneys, spleen, and hepatic hilum. Images were comparable to human EUS findings, with some remarkable differences. The pancreas was relatively larger in swine and in contrast to humans has three segments (duodenal, splenic, and connecting lobe). Conclusions: The swine model was a highly realistic teaching model for linear and radial pancreatobiliary EUS and a useful tool for training in the setting of in vivo hands-on sessions.
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The difference in histological yield between 19G EUS-FNA and EUS-fine-needle biopsy needles p. 255
Tiing Leong Ang, James Weiquan Li, Andrew Boon Eu Kwek, Prem Harichander Thurairajah, Lai Mun Wang
DOI:10.4103/eus.eus_12_19  PMID:31115385
Background and Objective: EUS-guided fine-needle biopsy (EUS-FNB) with acquisition of tissue core is possible with the use of 19G fine-needle aspiration (FNA) and dedicated biopsy needles. Published data of direct comparisons between biopsy needles are more limited compared to the abundant data comparing EUS-FNA with EUS-FNB. We performed a retrospective study to determine the difference in histologic yield between 19G FNA needle and EUS-FNB needles in patients with solid masses. Materials and Methods: Consecutive patients who underwent EUS-FNB of solid masses from January 2014 to July 2018 were identified from a database. The difference in histologic yield between needles was analyzed. Results: A total of 159 patients underwent 179 EUS-FNB procedures (median of 2 needle passes [range: 1–4]). The use of 19G FNA, 19G, 20G, and 22G FNB needles allowed acquisition of a histologic core in 67.4% (29/43), 72.5% (29/40), 82.1% (46/56), and 75.9% (22/29), respectively (P = 0.368). A significant difference in the yield of histologic core was detected when 19G FNA needle was compared with 22G Acquire™ FNB needle (67.4% [29/43] vs. 94.1% [16/17], P = 0.032). The presence of histologic core was significantly associated with a positive diagnosis (95.6% vs. 30.2%, P < 0.0001). Conclusion: EUS-FNB with acquisition of histologic core improved the diagnostic yield. Dedicated FNB needles appeared to achieve a higher yield of histologic core compared to 19G FNA needles.
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High diagnostic adequacy and accuracy of the new 20G procore needle for EUS-guided tissue acquisition: Results of a large multicentre retrospective study p. 261
Carlo Fabbri, Adele Fornelli, Lorenzo Fuccio, Silvia Giovanelli, Ilaria Tarantino, Filippo Antonini, Rosa Liotta, Leonardo Frazzoni, Paolo Gusella, Marina La Marca, Luca Barresi, Giampiero Macarri, Mario Traina, Dario De Biase, Siro Fiorino, Elio Jovine, Alberto Larghi, Vincenzo Cennamo
DOI:10.4103/eus.eus_14_19  PMID:31115386
Background and Objective: EUS-guided fine-needle biopsy has become the standard for tissue sampling. A new 20G ProCore™ (PC) needle has been developed to overcome the limitations of tissue acquisition of the smaller needles (22G, 25G) and the rigidity of the larger one (19G). The aim of this study is to assess the performance of the 20G PC needle. Materials and Methods: Patients who underwent EUS-guided tissue acquisition with the 20G PC needle of pancreatic and extra-pancreatic mass lesions were retrospectively identified at three Italian centers (Bologna, Fermo, and Palermo). Diagnostic adequacy, accuracy, and tissue core acquisition were the outcome measures. All the cases were performed without rapid on-site evaluation. Results: A total of 384 patients with pancreatic (62.2%) and extra-pancreatic lesions were included in the study. For pancreatic lesions, adequacy, accuracy, sensitivity, and specificity were 92.4%, 91.5%, 90.8%, and 100%, respectively, with a number needed to misdiagnose (NNM) of 11.8. The tissue core was obtained in 72% of cases. Transduodenal approach was performed in 150 pancreatic lesions; adequacy, accuracy, and tissue core acquisition were 88.7%, 90%, and 66%, respectively (NNM 10). For extrapancreatic lesions, adequacy, accuracy, sensitivity, specificity, and tissue core sampling were 95.3%, 95.3%, 92.6%, 100%, and 84.5% (NNM 21.3). Conclusions: The 20G PC needle showed high diagnostic adequacy and accuracy, regardless the access route.
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A prospective comparison of conventional cytology and digital image analysis for the identification of pancreatic malignancy in patients undergoing EUS-FNA p. 269
Fanyang Kong, Xiangyu Kong, Jianwei Zhu, Tao Sun, Yiqi Du, Kaixuan Wang, Zhendong Jin, Zhaoshen Li, Dong Wang
DOI:10.4103/eus.eus_9_19  PMID:31115388
Background and Objectives: Digital image analysis (DIA) has been reported to be a sensitive method to detect pancreatic neoplasms by assessing nuclear DNA content. The aim of the current study was to evaluate the diagnostic performance of DIA for pancreatic malignancy relative to conventional cytology (CC) in patients undergoing EUS-FNA. Patients and Methods: One hundred and forty-two patients with suspected pancreatic malignancy were enrolled prospectively in this study. FNA sample from each patient was evenly divided and assessed by CC and DIA. Findings from histopathology of FNA specimens and a minimum 12-month follow-up were used as the standard. Results: Total 102 out of 142 patients were determined as pancreatic cancer (PC) in this study. The overall sensitivity, specificity, and accuracy of CC were 75%, 85%, and 78%, whereas the sensitivity, specificity, and accuracy of DIA were 84%, 80%, and 83%, respectively. A combination of CC and DIA (CC/DIA) showed greater sensitivity than CC alone (92% vs. 75%, P < 0.01), but the specificity was reduced from 85% to 70% (P = 0.03). Conclusions: In this study, we demonstrated that DIA provided comparable diagnostic performance to CC in detecting PC. This objective diagnostic method, DIA, emerged as an important supplementary tool to endoscopic biopsy and cytology for diagnosing patients undergoing EUS-FNA with suspected pancreatic malignancy.
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IMAGES AND VIDEOS Top

Delayed pancreatic ductal leakage after EUS-FNA for autoimmune pancreatitis p. 277
Satoshi Ikarashi, Atsunori Tsuchiya, Kazunao Hayashi, Shuji Terai
DOI:10.4103/eus.eus_55_18  PMID:30719995
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Antegrade stent deployment using a novel, covered metal stent through EUS-guided hepaticogastrostomy (with video) p. 279
Takeshi Ogura, Nobu Nishioka, Kazuhide Higuchi
DOI:10.4103/eus.eus_5_19  PMID:30880728
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Differentiating intrapancreatic accessory spleen from a pancreatic neuroendocrine tumor or metastasis by the “bridge sign” p. 281
Manoop S Bhutani, Ben S Singh, Irina M Cazacu, Adrian Saftoiu
DOI:10.4103/eus.eus_29_19  PMID:31249165
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