Mo1387 Does Real Time Endoscopic Ultrasound Elastography (EUS-E) Predict Pancreatic Cancer?

Abstracts

Mo1387 Does Real Time Endoscopic Ultrasound Elastography (EUS-E) Predict Pancreatic Cancer? Sri Naveen Surapaneni, Michael Maloy, Joanna Linsteadt, Valeska Balderas, Laura Rosenkranz, Sandeep Patel University of Texas Health Science Center, San Antonio, San Antonio, TX Background: Real time Endoscopic Ultrasound Elastography (EUS-E) is a new imaging modality that characterizes abnormalities based on tissue stiffness (elasticity). Prior studies using this technology have been recently conducted in Europe and Asia aiding in the diagnosis of various gastrointestinal and pancreatic diseases. The aim of this study is to evaluate the utility of EUS-E in predicting pancreatic cancer based on quantitative analysis of tissue stiffness (Strain Ratio;SR). Methods: A linear echoendoscope (EG 3870 UTK, Pentax) was used to examine the pancreas with standard B-mode imaging (Hitachi HA 900) in 37 patients with pancreatic abnormalities. Real time tissue elastography was then applied in areas of interest displayed as a color overlay of the real-time B-mode image. Strain, a measure of elasticity, was then determined from two points: A (Area of interest); B (adjacent normal tissue). The ratio of B/A (Strain Ratio) was calculated as a quantitative measure of elasticity. Fine Needle Aspiration (FNA) was performed in all subjects with: (1) A SR in the area of interest ⬎ 25; (2) mass on B-mode EUS or (3) mass on pre-procedure imaging (CT or MRI). Cytology was performed on all the FNA specimens and presence of malignancy evaluated. Patients were considered to have benign disease if the cytology on FNA specimens did not show malignancy or if they did not develop pancreatic cancer at 12 months of clinical follow up. Results: Thirty seven patients (13 males, 24 females, mean age 64 yrs, range 31-86) underwent EUS for evaluation of various pancreatic abnormalities (7 suspected mass on imaging, 6 obstructive jaundice, 19 chronic pancreatitis, 5 others). Sixteen out of 37 patients (43%) had cytological evidence of pancreatic cancer with a mean SR of 41.19 ⫾ 22.36. Twenty one of 37 patients (57%) had benign disease (based on negative cytology and no development of cancer on clinical follow up) with a mean SR of 22.80 ⫾ 28.43. The sensitivity and specificity for predicting pancreatic cancer using a strain ratio of 25 was 88% and 76% respectively. Conclusion: Using EUS Elastography, a Strain Ratio of 25 accurately predicted likelihood of pancreatic cancer. Further research needs to be conducted to improve the sensitivity,specificity and accurancy of predicting pancreatic cancer as well as improving cytological diagnosis using this new modality.

Mo1388 Expression Profile of Vascular Endothelial Growth Factor in Human Pancreatic Cancer Assessed by qRT-PCR in EUS-FNA Samples Dan Ionut Gheonea1,3, Cristina Angelescu2, Tudorel Ciurea1, Mihai Ioana2, Adrian Saftoiu1 1 Gastroenterology, University of Medicine and Pharmacy, Craiova, Romania; 2Molecular Genetics, University of Medicine and Pharmacy, Craiova, Romania; 3University of Medicine and Pharmacy Carol Davila, Bucharest, Romania Background and Aims: Pancreatic adenocarcinoma is the fifth leading cause of cancer death and has the lowest survival rate for any solid cancer. It is characterized by a variety of molecular alterations and superexpression of several mitogenic and angiogenic growths factors and their receptors. Vascular endothelial growth factor (VEGF), secreted by tumor cells, plays a crucial role in primary tumor development and metastatic potential, acting directly on endothelial cells. The aim of our study was to compare the gene expression patterns of VEGF-A (including two of it’s splicing variants) and VEGF-B in malignant and benign pancreatic masses samples by quantitative real-time reverse transcription-polymerase chain reaction (qRT-PCR) in endoscopic ultrasound guided fine needle aspiration (EUS-FNA) specimens. Patients and Method: We analyzed the expression profiles for VEGF-A, VEGF-A121, VEGFA169 and VEGF-B genes in 26 EUS-FNA specimens including pseudotumoral chronic pancreatitis (n⫽8) and pancreatic cancer patients (n⫽16). The final diagnosis was obtained by EUS-FNA cytology analysis, by surgical pathology or by 6 months follow-up. Total RNA was isolated from all the samples. For every sample 100 ng of total RNA were available. The quality of the isolated RNA was evaluated and total RNA was reverse-transcribed into complementary single stranded DNA. qRT-PCR was performed to measure the expression of these selected genes in EUS-FNA specimens. Results: In pancreatic cancer samples we detected a disregulation of expression for the evaluated genes compared to chronic pancreatitis specimens (p⬍0.05). The expression of VEGF isoforms was polymorphic in human pancreatic cancer and in chronic pancreatitis samples. Conclusion: Expression profiling is a useful method to identify potential target genes.Molecular analysis of EUS-FNA samples in pancreatic cancer appears as a valuable strategy for improving our knowledge of molecular mechanism of cancer development, and furthermore for assessment of antiangiogenic treatment response in inoperable patients.

Mo1389 A Prospective Multicenter Evaluation of a New Side-Hole EUS FNA Needle in Solid Upper Gastrointestinal Lesions Arthur J. Kaffes1, Robert Chen2, William Tam4, Ian D. Norton3, Sarah S. Cho3, Benedict M. Devereaux5, Rhys Vaughan6 1 Royal Prince Alfred Hospital, Camperdown, NSW, Australia; 2 Gastroenterology, St Vincents Hospital, Melbourne, VIC, Australia; 3 Royal North Shore Hospital, Sydney, NSW, Australia; 4Royal Adelaide Hospital, Adelaide, SA, Australia; 5Royal Brisbane Hospital, Brisbane, QLD, Australia; 6Austin Hospital, Melbourne, VIC, Australia Introduction EUS FNA remains a challenge for many providers. Despite excellent results published from expert centers surveys from US centers has suggested a positive FNA results in only 71% of patients. Additionally, many authors have recommended as few as 5 passes are required for pancreatic masses to maximize the diagnostic yield. This is time consuming, and may lend itself to increased complications. Side-hole FNA (SH FNA) was developed recently by author AJK and Olympus Corporation and a pilot study (DDW 2009) demonstrated a possible benefit for solid lesions with an excellent cellular yield with fewer passes. We aim to study this in a prospective fashion at four Australian centers. Methods A prospective evaluation of patients with solid upper gastrointestinal masses referred to four EUS centers in Australia was conducted. SH FNA was performed with full syringe suction applied with all passes. The needle was dried with 4-5 passes of a dry 5ml syringe between passes to maintain a dry needle lumen. The option for changing to standard FNA needles was available if the endosonographer felt it appropriate. The pass that obtained a diagnosis was recorded. Cellular acquisition was also scored. Results A total of 21 patients (13 male), mean age 68 (range 17-88) were evaluated. Indications included pancreatic masses in 16, biliary masses in 2, LN masses in 2 and retroperitoneal mass in 1. All patients (100%) had adequate cellular acquisition to make a diagnosis. In a 10 point visual analog scale (unvalidated) the mean sample rating was 6.4. Eighteen (85.7%) had a diagnosis of malignancy. The 3 non malignant aspirates were confirmed as non malignant clinically and on follow-up. The mean number of passes required to make a diagnosis was 1.6 (range 1-5). Only 1 patient required more than 3 passes including 2 passes with standard FNA, and this patient was finally diagnosed as benign. In malignant cases the mean number of passes was 1.4 (range 1-3). No complications were encountered. A unique feature noted with SH FNA was continuous aspiration during the needle pass via the side hole not typically seen with standard FNA. Conclusion Side hole FNA shows significant promise for faster and easier diagnosis of solid upper gastrointestinal masses. The number of passes needed to achieve a diagnosis is significantly less than the published literature with standard FNA. Randomised studies are required.

Mo1390 EUS Significantly Reduces the Burden of ERCP and Accurately Predicts CBD Stones in Patients With Suspected Biliary Obstruction: Consecutive Analysis of 418 Patients Abdul Zaheer1, Malik M. Anwar2, Claire L. Donohoe1, Sinead O’Keeffe2, Hamid Mushtaq1, T Barry Kelleher2, Eileen Clarke2, Murat Kirca1, Padraic Mac Mathuna2, Dermot O’Toole1 1 Clinical Medicine/Gastroenterology, St James’s University Hospital/ Trinity College Dublin, Dublin, Ireland; 2Clinical Medicine/ Gastroenterology, Mater Misericordiae University Hospital & University College Dublin, Dublin, Ireland Introduction: EUS & MRCP have seen the diagnostic role of ERCP diminish. EUSguided ERCP has been described useful when non-invasive imaging remains inconclusive. Aims: Evaluate outcomes of EUS-guided ERCP in a single endoscopic session and factors predictive of common bile duct (CBD) stones. Methods: From Nov 2007 to May 2010, 418 patients (females n⫽224, mean age 66 yrs) with suspected biliary obstruction were referred for EUS prior to possible ERCP. Pre-referral investigations failed to reveal an underlying cause in 362 pts; 56 had suspected malignancy. EUS to triage patients for ERCP was performed during the same session. Logistic regression was used to identify factors predicting CBD stones and ROC curves using clinical and biological factors established. Diagnostic yield and accuracy of EUS in predicting the need for therapeutic ERCP were assessed. Data were recorded in two groups: 1) where EUS lead to ERCP and 2) ERCP was avoided. Results: Overall, factors predictive of choledocholithiasis were age (p⬍0.001), jaundice (p⬍0.005), biliary colic (p⬍0.001) and cholangitis (p⬍0.001). In predicting choledocholithaisis in the benign cohort: abnormal LFTs give poor AUC (all ⬍ 0.6); a dilated CBD prior to EUS had 66% and 49% PPV and NPV respectively; and an age cut-off of 44 years (AUC 0.7) yielded sensitivity of 85% and specificity of 72%. Group 1: EUS deemed ERCP necessary in 264/412 (64%) revealing: a) choledocholithiasis 151 (57%) - ERCP confirmed stones (100%); b) Pancreatic cancers 37 (14%), EUSFNAB positive in 31 (85%); c) cholangiocarcinoma 28 (11%); d) benign pancreato-biliary disorders 33 (12%); e) ampullary tumours 7 (3%); benign ampullary abnormalities 8 (3%). No EUS-related complications seen however post-ERCP complications occurred in 8 (3%). Combined EUS-ERCP mean time

AB328 GASTROINTESTINAL ENDOSCOPY Volume 73, No. 4S : 2011

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