Endoscopic ultrasonography （EUS） has gained wide acceptance as an important, minimally invasive diagnostic tool in gastroenterology, pulmonology, visceral surgery and oncology. This review focuses on ...data regarding risks and complications of non-interventional diagnostic EUS and EUS-guided fine-needle biopsy （EUS-FNB）. Measures to improve the safety of EUS und EUS-FNB will be discussed. Due to the specific mechanical properties of echoendoscopes in EUS, there is a low but noteworthy risk of perforation. To minimize this risk, endoscopists should be familiar with the specific features of their equipment and their patients’ specific anatomical situations （e.g., tumor stenosis, diverticula）. Most diagnostic EUS complications occur during EUS-FNB. Pain, acute pancreatitis, infection and bleeding are the primary adverse effects, occurring in 1% to 2% ofpatients. Only a few cases of needle tract seeding and peritoneal dissemination have been reported. The mortality associated with EUS and EUS-FNB is 0.02%. The risks associated with EUS-FNB are affected by endoscopist experience and target lesion. EUS-FNB of cystic lesions is associated with an increased risk of infection and hemorrhage. Peri-interventional antibiotics are recommended to prevent cyst infection. Adequate education and training, as well consideration of contraindications, are essential to minimize the risks of EUS and EUS-FNB. Restricting EUS-FNB only to patients in whom the cytopathological results may be expected to change the course of management is the best way of reducing the number of complications.
RECOMMENDATIONS
For routine EUS-guided sampling of solid masses and lymph nodes (LNs) ESGE recommends 25G or 22G needles (high quality evidence, strong recommendation); fine needle aspiration (FNA) ...and fine needle biopsy (FNB) needles are equally recommended (high quality evidence, strong recommendation).
When the primary aim of sampling is to obtain a core tissue specimen, ESGE suggests using 19G FNA or FNB needles or 22G FNB needles (low quality evidence, weak recommendation).
ESGE recommends using 10-mL syringe suction for EUS-guided sampling of solid masses and LNs with 25G or 22G FNA needles (high quality evidence, strong recommendation) and other types of needles (low quality evidence, weak recommendation).
ESGE suggests neutralizing residual negative pressure in the needle before withdrawing the needle from the target lesion (moderate quality evidence, weak recommendation).
ESGE does not recommend for or against using the needle stylet for EUS-guided sampling of solid masses and LNs with FNA needles (high quality evidence, strong recommendation) and suggests using the needle stylet for EUS-guided sampling with FNB needles (low quality evidence, weak recommendation).
ESGE suggests fanning the needle throughout the lesion when sampling solid masses and LNs (moderate quality evidence, weak recommendation).
ESGE equally recommends EUS-guided sampling with or without on-site cytologic evaluation (moderate quality evidence, strong recommendation). When on-site cytologic evaluation is unavailable, ESGE suggests performance of three to four needle passes with an FNA needle or two to three passes with an FNB needle (low quality evidence, weak recommendation).
For diagnostic sampling of pancreatic cystic lesions without a solid component, ESGE suggests emptying the cyst with a single pass of a 22G or 19G needle (low quality evidence, weak recommendation). For pancreatic cystic lesions with a solid component, ESGE suggests sampling of the solid component using the same technique as in the case of other solid lesions (low quality evidence, weak recommendation).
ESGE does not recommend antibiotic prophylaxis for EUS-guided sampling of solid masses or LNs (low quality evidence, strong recommendation), and suggests antibiotic prophylaxis with fluoroquinolones or beta-lactam antibiotics for EUS-guided sampling of cystic lesions (low quality evidence, weak recommendation).
ESGE suggests that evaluation of tissue obtained by EUS-guided sampling should include histologic preparations (e. g., cell blocks and/or formalin-fixed and paraffin-embedded tissue fragments) and should not be limited to smear cytology (low quality evidence, weak recommendation).
MAIN RECOMMENDATIONS
For pancreatic solid lesions, ESGE recommends performing endoscopic ultrasound (EUS)-guided sampling as first-line procedure when a pathological diagnosis is required. ...Alternatively, percutaneous sampling may be considered in metastatic disease.
Strong recommendation, moderate quality evidence.
In the case of negative or inconclusive results and a high degree of suspicion of malignant disease, ESGE suggests re-evaluating the pathology slides, repeating EUS-guided sampling, or surgery.
Weak recommendation, low quality evidence.
In patients with chronic pancreatitis associated with a pancreatic mass, EUS-guided sampling results that do not confirm cancer should be interpreted with caution.
Strong recommendation, low quality evidence.
For pancreatic cystic lesions (PCLs), ESGE recommends EUS-guided sampling for biochemical analyses plus cytopathological examination if a precise diagnosis may change patient management, except for lesions ≤ 10 mm in diameter with no high risk stigmata. If the volume of PCL aspirate is small, it is recommended that carcinoembryonic antigen (CEA) level determination be done as the first analysis.
Strong recommendation, low quality evidence.
For esophageal cancer, ESGE suggests performing EUS-guided sampling for the assessment of regional lymph nodes (LNs) in T1 (and, depending on local treatment policy, T2) adenocarcinoma and of lesions suspicious for metastasis such as distant LNs, left liver lobe lesions, and suspected peritoneal carcinomatosis.
Weak recommendation, low quality evidence.
For lymphadenopathy of unknown origin, ESGE recommends performing EUS-guided (or alternatively endobronchial ultrasound EBUS-guided) sampling if the pathological result is likely to affect patient management and no superficial lymphadenopathy is easily accessible.
Strong recommendation, moderate quality evidence.
In the case of solid liver masses suspicious for metastasis, ESGE suggests performing EUS-guided sampling if the pathological result is likely to affect patient management, and (i) the lesion is poorly accessible/not detected at percutaneous imaging, or (ii) a sample obtained via the percutaneous route repeatedly yielded an inconclusive result.
Weak recommendation, low quality evidence.
Abstract
The updated version of the EFSUMB guidelines on the application of non-hepatic contrast-enhanced ultrasound (CEUS) deals with the use of microbubble ultrasound contrast outside the liver in ...the many established and emerging applications.
In patients with solid pancreatic lesions (SPLs), the differential diagnosis must be evaluated to determine whether radical surgery, pancreatic parenchyma-saving strategies, or follow-up is ...indicated. Contrast-enhanced (endoscopic) ultrasonography and elastography facilitate the further characterization of SPLs. The majority of cases of pancreatic ductal adenocarcinoma exhibit hypoenhancement with contrast-enhanced ultrasonography. Elastographically soft SPLs are benign with very few exceptions, whereas stiffer SPLs can be malignant or benign. This article reviews the current use of modern ultrasound imaging techniques, including contrast-enhanced ultrasonography and elastography, for the detection and characterization of SPLs. In particular, the unexcelled diagnostic potential of multiparametric endoscopic ultrasonography to detect and characterize small SPLs is highlighted.
Background and Aims Pancreatic ductal adenocarcinoma (PDAC) is typically diagnosed at a late stage. Little is known about the incidental finding of early-stage PDAC. The aim of the current study was ...to determine the etiology of small solid pancreatic lesions (≤15 mm) to optimize clinical management. Methods Inclusion criterion for the retrospective study analysis was the incidental finding of primarily undetermined small solid pancreatic lesions ≤15 mm in 394 asymptomatic patients. Final diagnoses were based on histology or cytology obtained by imaging-guided biopsy (and at least 12-month follow-up) and/or surgery. Contrast-enhanced US or contrast-enhanced EUS were performed in 219 patients. Results The final diagnoses of 394 patients were as follows: 146 PDAC, 156 neuroendocrine tumors, 28 metastases into the pancreas from other primary sites, and 64 various other etiologies. Contrast-enhanced US allowed differential diagnosis of PDAC and non-PDAC in 189 of 219 patients (86%). Conclusions Approximately 40% of patients with small solid pancreatic lesions had very early stage PDAC. Approximately 60% of small solid pancreatic lesions ≤15 mm are not PDAC and, therefore, do not require radical surgery. Without preoperative diagnosis, an unacceptably large proportion of patients would be exposed to radical surgery with significant morbidity and mortality.
Strain Elastography - How To Do It? Dietrich, Christoph F.; Barr, Richard G.; Farrokh, André ...
Ultrasound international open,
09/2017, Letnik:
3, Številka:
4
Journal Article
Recenzirano
Odprti dostop
Abstract
Tissue stiffness assessed by palpation for diagnosing pathology has been used for thousands of years. Ultrasound elastography has been developed more recently to display similar information ...on tissue stiffness as an image. There are two main types of ultrasound elastography, strain and shear wave. Strain elastography is a qualitative technique and provides information on the relative stiffness between one tissue and another. Shear wave elastography is a quantitative method and provides an estimated value of the tissue stiffness that can be expressed in either the shear wave speed through the tissues in meters/second, or converted to the Young’s modulus making some assumptions and expressed in kPa. Each technique has its advantages and disadvantages and they are often complimentary to each other in clinical practice. This article reviews the principles, technique, and interpretation of strain elastography in various organs. It describes how to optimize technique, while pitfalls and artifacts are also discussed.
Background: Ectopic pancreas (EP) belongs to the most frequent subepithelial lesions (SELs) of the upper gastrointestinal (GI) tract. In the majority of cases, it is detected incidentally. ...Differential diagnosis from mesenchymal subepithelial tumors may be difficult. Methods: Among 24,308 endosonographic examinations and interventions, which were prospectively enrolled in the database of the German Endoscopic Ultrasound (EUS) Registry from January 2009 to August 2013, 575 were performed for suspected SELs of the upper GI tract. Sixty three cases of EP of the upper GI tract (stomach, n = 53; duodenum, n = 10; esophagus, n = 0) were extracted and retrospectively reviewed. Results: In 65.1% of cases, radial echoendoscopes or radial miniprobes were used for examination. Nearly 84% of EP was found in the stomach, 16% in the duodenum, none in the esophagus. In 88.9% of cases, the EUS examination discerned the layer of origin. In 59% of cases EP was described as a heterogeneous, in 28.6% as a homogeneous-hypoechoic and in 7.9% as a homogeneous-echogenic subepithelial mass lesion. Mean diameter was 13.0 mm × 8.1 mm, the mean ratio between long and short axis diameter was 1.75. EUS-guided fine needle aspiration (EUS-FNA) was used to accomplish cytological or histological diagnosis in only 6.3% of cases. Conclusions: EP accounts for 11% of all EUS examinations performed for subepithelial lesions of the upper GI tract and prospectively enrolled in the German EUS registry. Rather than being an eyecatcher, EP is a chameleon with numerous differential diagnoses. In selected cases, EUS-FNA may help clarifying the diagnosis.
Abstract
Different surgical and medical specialists increasingly use head and neck
ultrasound and ultrasound-guided interventions as part of their clinical
practice. We need to ensure high quality ...and standardized practice across
specialties, and this position paper of the European Federation of Societies for
Ultrasound in Medicine and Biology (EFSUMB) describes the training requirements
for head and neck ultrasound. Traditionally, a minimum number of ultrasound
examinations indicates competence, but this is unreliable, and a general shift
towards competence-based training is ongoing. For each EFSUMB level, we will
outline the theoretical knowledge and skills needed for clinical practice. The
recommendations follow the three EFSUMB competency levels for medical ultrasound
practice. Level 1 describes the skills required to perform essential head and
neck ultrasound examinations independently, level 2 includes ultrasound-guided
interventions, while level 3 involves the practice of high-level neck ultrasound
and use of advanced technologies. Our goal is to ensure high quality and
standardized head and neck ultrasound practice performed by different clinical
specialists with these recommendations.
Abstract
Due to the severity of their disease, palliative care patients often present
complex clinical symptoms and complaints like pain, shortness of breath, nausea,
loss of appetite, and fatigue. ...Solely relying on the information available from
the history and physical examination often causes uncertainty among palliative
care physicians regarding treatment decisions during home visits, potentially
leading to unnecessary hospitalizations or transfer to cross-sectional imaging
in radiological practices. A rational approach is essential to avoid diagnostic
aggressiveness while still providing the imaging information required for
optimal palliative care. Bedside use of handheld ultrasound (HHUS) has the
potential to expand the diagnostic and therapeutic spectrum in the case of
symptom exacerbation but is still underutilized. In this review, we evaluate the
potential uses of HHUS in home care settings to provide a more accurate
diagnosis of the most common symptoms in palliative patients and to guide
bedside interventions such as bladder catheterization, thoracentesis,
paracentesis, venous access, and regional anesthesia. Specific training programs
for ultrasound in palliative care are currently not available. Adequate
documentation is warranted but fraught with technological and privacy issues.
Expert supervision and quality assurance are necessary. Despite its limitation
and challenges, we suggest that HHUS leads to improved clinical decision-making,
expedited symptom relief, and reduced complications without burdening of the
patient and costly transfer to hospital or specialty consultations.
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