超声内镜引导下细针穿刺针吸活检在胆囊肿瘤诊断中的应用

Background and study aims: There are very few data on endoscopic ultrasound guided fine-needle aspiration (EUS-FNA) of gallbladder masses. The aim of this study was to assess the utility and safety of EUS-FNA in the evaluation of patients with gallbladder masses. Patients and methods: Six patients who underwent EUS-FNA of gallbladder masses over a 2-year period between 2002 and 2004 were studied retrospectively. Reports of endoscopic ultrasound (EUS) procedures, EUS images, cytology results, and clinical records were reviewed. Abdominal computed tomography (CT) prior to EUS had revealed a definitive gallbladder mass in only one of the six patients and no gallbladder masses were identified in any of the patients who had undergone prior transabdominal ultrasound. Results: At EUS, all the patients were found to have an echo-poor mass arising from the gallbladder wall or within the lumen of the gallbladder. EUS-FNA of the gallbladder masses revealed adenocarcinoma in five patients and benign disease in one patient. After a mean follow-up period of 127 days (range 90 - 187 days), three patients had died, two were undergoing palliative chemoradiotherapy, and one had been confirmed as having chronic cholecystitis at surgery. No complications occurred. Conclusions: In patients with obstructive jaundice and equivocal ultrasound or CT findings, evaluation of the gallbladder for the presence of a primary malignancy by EUS is useful. In patients with gallbladder masses, EUS-FNA can be performed safely and can help to make a definitive diagnosis.

EUS引导下FNA结合流式细胞分析术诊断可疑性或复发性胸内或腹膜后淋巴瘤

Background: Limited data exist on the combined use of EUS guided FNA (EUS-FNA) and flow cytometry (FC) in the diagnosis of lymphoma. The aim of this study was to evaluate the accuracy of EUS-FNA combined with FC in the diagnosis of primary or recurrent lymphoma. Methods: This study was a retrospective analysis of a prospective collection of data over a 3-year period. Over 3 years, 29 patients with lesions (n = 31) suspicious for lymphoma underwent EUS-FNA and FC. Results: Of the 29 patients, 10 patients had lymphoma and 17 patients had nonlymphoma lesions; for two patients, final diagnosis was indeterminate because of insufficient material for FC. The lymphoma cases included non-Hodgkin’s lymphoma (n = 6, including 3 recurrences), mucosa-associated lymphoid tissue (MALT) lymphoma (n = 2), a non-GI lymphoma with mediastinal lymphadenopathy (n = 1), and an uncharacterized lymphoma (n = 1). Of the 31 lesions, 8 were true positive, 18 were true negative, and 3 were false negative; for two lesions, we could not determine the final diagnosis. No false-positive results were encountered. The sensitivity, the specificity, and the accuracy of EUS-FNA combined with FC for diagnosing lymphoma were 72.7% : 95% CI [43.3% , 90.3% ], 100% : 95% CI [82.4% , 100.0% ], and 89.7% : 95% CI [73.6% , 96.4% ], respectively. Limitations to this study include a short duration of follow-up and a lack of a surgical criterion standard. Conclusions: EUS-FNA in combination with FC allows the diagnosis of primary suspected or recurrent lymphoma. It also is an adjunct in staging MALT lymphoma and could direct clinicians toward further investigative procedures.

超声内镜引导细针抽吸对慢性胰腺炎和无慢性胰腺炎患者胰腺肿块的诊断率对比

Background: Evaluation of a focal pancreatic mass in the setting of chronic pancreatitis (CP) is a diagnostic challenge. The objectives of the study were to compare the diagnostic yield and accuracy of EUS-guided FNA (EUS-FNA) in the evaluation of pancreatic-mass lesions in the presence or the absence of CP and to identify predictors of CP before EUS-FNA of pancreatic-mass lesions. Methods: The study design was analysis of data collected prospectively on all patients with solid pancreatic-mass lesions who underwent EUS-FNA at a tertiary referral center. A total of 282 consecutive patients underwent 300 EUS-FNA procedures of pancreatic-mass lesions over a 3 year period. The diagnostic yield and the accuracy of EUS-FNA was compared between patients with and without CP. CP was defined by the presence of more than 4 EUS criteria. Results: Final diagnosis was adenocarcinoma in 210 (70%), benign disease in 64 (21%), other pathology in 19 (6%), and indeterminate in 4 (2%); 3 patients (1%) were lost to follow-up. CP was noted in 75/300 (25%) patients. A lower sensitivity for EUS-FNA was observed in patients with CP than in those without CP (73.9%vs. 91.3%; p = 0.02). While patients with CP had a higher negative predictive value (88.9%vs. 45.5%; p < 0.001), no significant differences were observed for specificity (100%vs. 93.8%), positive predictive value (100%vs. 99.5%), and accuracy (91.5%vs. 91.4%) between those with and without CP. False-negative cytology was encountered in 24 cases: 6/71 (8%) with CP vs. 18/222 (8%) without CP. Patients with CP required more EUS-FNA passes to establish a diagnosis vs. those without CP (median, 5 vs. 2; p < 0.001). On multivariable analysis, age < 50 years (p < 0.001), male gender (p < 0.001), black race (p = 0.001), and the absence of jaundice (p = 0.005) were significantly associated with CP. The impact of EUS-FNA on long-term clinical management was not analyzed. The impact of individual EUS features of CP on sensitivity of EUS-FNA was not evaluated. By protocol, mass lesions that were benign required more passes to definitively exclude malignancy. Conclusions: EUS-FNA has a low sensitivity for pancreatic-mass lesions in the setting of CP. This decreased sensitivity can be overcome by performing more numbers of passes at FNA, which improves diagnostic accuracy. Demographic features and clinical presentation are predictive of underlying CP in patients with pancreatic-mass lesions.

CT引导穿刺活检或支气管镜检阴性时应用超声内镜引导下的针吸活检术检查邻近或毗连食管的肺部肿块

Background The accuracy, the safety, and the cost-effectiveness of EUS-guided FNA for screening patients with lung cancer for mediastinal metastasis are well established, but the utility of EUS-guided FNA in evaluating lung mass per se has not been investigated. This study retrospectively evaluated experience with EUS-guided FNA of lung mass lesions after unsuccessful attempts by CT-guided or bronchoscopic tissue sampling to establish a tissue diagnosis. Methods A database was searched for all patients who had EUS-guided FNA of lung mass lesions over a 3-year period. The diagnostic yield and safety of EUS guided FNA were evaluated. Observations Eighteen patients(11 men, 7 women) underwent EUS-guided FNA of lung mass lesions adjacent to or abutting the esophagus. The indication for EUS-guided FNA was evaluation of the mediastinum of patients with lung mass of unclear etiology. EUS-guided FNA yielded tissue for diagnosis in 100% of patients: 15 non-small-cell lung cancer, one small-cell lung cancer, two metastatic lung disease. Ten patients had unresectable disease; in 8, the mass was confined to the lung parenchyma. The mean number of needle passes required to establish a diagnosis was two (range 1-6). No complication was encountered (mean follow-up 141 days; range 72-396 days). Five patients underwent curative surgery, and 13 had palliative chemoradiation. Conclusions In this study, EUS-guided FNA of lung mass was safe, and it established a diagnosis in all patients with accessible lesions.Given these preliminary data, a prospective evaluation of this new indication for EUS-guided FNA is justified.

超声内镜对胰胆管疾病患儿评估的影响

Background: While the role of EUS in the evaluation of pancreaticobiliary (PB) disorders in adults is well established, its utility in children remains unproven. This pros-pective study evaluates the feasibility, the safety, and the impact of EUS in the evaluation of PB disorders in children. Methods: All children (< 18 years)referred for ERCP for evaluation of suspected PB disorders who underwent EUS before scheduled ERCP. The main outcome measure was to evaluate the impact of EUS in the evaluation of PB disorders in children. EUS was considered to have a significant impact if a new diagnosis was established or if the findings altered subsequent management. Results: Fourteen patients (mean age 13 years; range 5- 17 years) underwent 15 EUS procedures over a 3-year period. Main indications were the following: acute or recurrent pancreatitis (6 patients), suspected biliary obstruction (5), and abdominal pain suggestive of PB origin (3). EUS diagnosed chronic pancreatitis (3 patients), idiopathic fibrosing pancreatitis (2), carcinoid tumor (1), pancreatic pse-udocyst (1), pancreas divisum (1), choledocholithiasis (1), duodenal duplication cyst (1), and normal (4). Dia-gnosis of idiopathic fibrosing pancreatitis and carcinoid tumor was established by EUS-guided FNA. The procedure was successful in all patients, and no complications were encountered. EUS had an impact on patient management in 93% of cases: established new diagnosis (10), precluded need for ERCP (9), and provided additional information that facilitated focused endotherapy (4). A limitation was the small number of enrolled patients and absence of long-term clinical follow-up. Conclusions: EUS and EUS-guided FNA are feasible, safe, and have significant impact that alters subsequent management in the majority of children with PB disorders. Further studies and dissemination of information is required to facilitate its increased application in children.

超声内镜引导下细针穿刺抽吸胰腺肿块的主要并发症发生率:一项前瞻性研究

Background:EUS-guided FNA is effective for establishing tissue diagnosis in suspected pancreatic cancer.However,data on the frequency of major complications following EUS-FNA are limited.Objective:To evaluate the frequency of major complications after EUS-FNA of solid pancreatic masses.Design:Prospective cohort study.Setting:Tertiary University based referral center for pancreatico-biliary disorder.Patients:Consecutive patients who underwent EUS-FNA of a solid pancreatic over a 42-month period.All immediate complications were recorded by the endosonographer.Late complications were assessed at 72 hours and at 30-days after the procedure.Main Outcomes Measurements:Major complications were defined as acute pancreatitis,bleeding,infection,perforation,use of reversal medication,hospitalization or death.Results:A total of 355 consecutive patients with a solid pancreatic mass underwent EUS-FNA.Major complications were encountered in 9 patients(2.54%,95%CI 1.17-4.76).Acute pancreatitis occurred in 3 of 355(0.85 %,95%CI 0.17-2.45);2 patients were hospitalized,and 1 patient recovered with outpatient analgesics.Three patients were admitted for severe pain after the procedure;all were treated with analgesics and subsequently discharged with no sequela.Two patients(0.56%,95%CI 0.07-2.02)developed fever and were admitted for intravenous antibiotics;1 patient recovered with intravenous antibiotics and the other required surgical debridement for necrosis.One patient required the use of reversal medication.Overall,1.97%(95%CI 0.80-4.02)of the patients were hospitalized for complications(range 1-16 days).None of the patients experienced clinically significant hemorrhage,perforation,or death.No clear predisposing risk factors were identified.Limitations:Lack of surgical gold standard and referral to a tertiary center.Conclusions:EUS-FNA of solid pancreatic masses infrequently leads to major complications.Our results can be used by endosonographers to counsel patients before EUS-FNA of solid pancreatic masses.

胰腺囊性病变进行超声内镜引导下的细针穿刺活检时,发生急性囊内出血的频率和意义

Background: Complications from EUS guided FNA of cystic lesions of the pancre as are infrequent. Although several studies have evaluated infectious complicati ons of EUS-guided FNA in this setting, the frequency and the clinical significa nce of intracystic hemorrhage have not been determined. This study assessed the frequency of acute intracystic hemorrhage during EUS-guided FNA of pancreatic cystic lesions. The characteristic EUS appearance is described. Methods: EUS-guided FNA of pancreatic cyst lesions was per formed in 50 patients (July 2000 to June 2003). Patients were followed prospecti vely for the development of complications. Observations: Acute intracystic hemor rhage occurred during EUS-guided FNA at the site of aspiration in 3 patients (6 %: 95%confidence interval [1.3%, 16.6%]). Endosonographically, the bleeding manifested as a small hyperechoic area at the puncture site that progressed gradually over a few minutes to involve the majority of the cyst cavity. EUS-guided FNA was terminated when bleeding was observed. One patient was asymptomatic, but two patients experienced abdominal pain transiently. All patients were treated with a short course of orally administered antibiotics and were observed as out patients. Clinical history and laboratory parameters did not predict which patients were at risk for intracystic hemorrhage. Conclusions: Acute intracystic hemo rrhage is a rare complication of EUS-guided FNA; it has a characteristic EUS ap pearance. Recognition of this event is important, because it permits termination of the procedure and thereby minimizes the potential for more serious bleeding.

超声内镜引导胰腺实质性病变的细针穿刺:300例操作经验

Background: The objective of our study was to assess a single operator’s learning curve with regard to the number of passes, the diagnostic accuracy, and the complications associated with EUS-guided FNA (EUS-FNA) of solid pancreatic masses. Methods: The number of passes, the diagnostic accuracy, and the complication rate were prospectively evaluated in 300 consecutive EUS-FNA of solid pancreatic masses performed by a single endosonographer over a 3-year period. The procedures were placed into 3 groups,which contained 100 procedures each. The endosonographer had undergone a third-tier EUS fellowship and had performed 45 supervised pancreatic EUS-FNA during his training. Results: Of the 300 EUS-FNA performed (median age 63 years, 64%men), no statistically significant differences among the 3 groups with regard to age, gender, race, location, or size of the mass were found. Diagnostic accuracy of the EUS-FNA procedure was similar over time (Group 1, 92%; Group 2, 92%; Group 3, 95%). Median number of passes showed a decreasing trend over the 3-year study period, despite an increasing trend of the number of procedures performed (r = -0.14, p = 0.42). The median number of passes was lower for Group 2 (median, 3; p = 0.02) and Group 3 (median, 3; p = 0.003) compared with Group 1 (median, 4). Group 3 (7/100, 7%) was less likely to encounter complications compared with Group 1 (13/100, 13%; p = 0.24) and Group 2 (18/100, 18%; p = 0.03). Frequency of serious complications was similar across the 3 groups (1%-3%). Conclusions: With adequate third-tier training, a newly developed EUS program can achieve safe and accurate results of EUS-FNA of the pancreas. The learning curve, however, needs to continue after the fellowship, because more procedures are needed for one to gain proficiency and efficiency with EUS-FNA.