Endoscopic Ultrasound Assessment of the Duodenal Wall Lesions

Subepithelial tumors (SETs) in the upper digestive tract are rare and only 10% of are located in the duodenum. Assessment of lesions protruding from the duodenal wall is difficult. Upper gastrointestinal (GI) endoscopy and computed tomography (CT) are not able to completely distinguish between different tumors and guide their subsequent management. Endoscopic ultrasonography (EUS) has a significant diagnostic yield in this context. EUS is able to accurately diagnose duodenal lesions, perform a biopsy if considered useful, guide the approach for resection and provide appropriate follow-up. SETs reported during upper GI endoscopy are more commonly cysts, polyps, lipomas, Brunner’s gland adenoma, ectopic pancreas, gastrointestinal stromal tumors (GISTs) or neuroendocrine tumors (NETs). In addition, although more rarely, adenocarcinomas and lymphomas can be identified. EUS should be performed for any duodenal lesion larger than 1 cm that lacks the endoscopic characteristics of a cyst or a lipoma

Added value of intravenous contrast-enhanced ultrasound for characterization of cystic pancreatic masses: a prospective study on 37 patients

Abstract The aim of this study was to evaluate the added value of contrast-enhanced ultrasound (CEUS) in the pancreatic cystic mass (PCM) diagnosis by using a qualitative and quantitative analysis in order to make a relevant characterization. Patients and method: Between December 2008 and November 2011, 37 patients with PCM discovered at ultrasound examination were prospectively followed. A qualitative and quantitative CEUS analysis was performed in order to differentiate etiologies of the PCM. In the quantitative analysis several parameters were followed: Peak Intensity (PI), Time to Peak (TTP), maximum ascending gradient (GRAD), Time to maximum gradient (TTG) and Area Under the Curve (AUC). Normalized ratios were also calculated. In all patients a definite cytological or histological diagnosis was obtained. Results: Thirty-seven patients were studied: 12 with pancreatitis-associated pseudocyst and 25 with cystic tumors (10 serous cystic adenoma, 5 mucinous cystic adenoma, 6 cystadenocarcinomas, 2 solid pseudopapillary tumors and 2 intraductal papillary mucinous neoplasms). There was a significant difference of the nAUC and nTTP between pseudocyst and cystic tumors, p=0.03 and p=0.01, respectively. A normalized TTP value above 7 sec was suggestive for the diagnosis of pseudocysts with 79.16 % accuracy. There was a significant difference of nTTP and nTTG between the benign and malignant lesions. nTTP < 9 sec and nTTG < 8.5 sec rules out malignant cysts in almost 90% of cases. Conclusion: The CEUS is useful in the diagnosis of PCM. The quantitative analysis of the enhancement of the cystic wall may discriminate the different types of the PCM

Left atrial geometric and functional remodeling parameters by cardiac magnetic resonance imaging and outcome prediction in patients with severe aortic stenosis

BACKGROUND: Emerging studies are beginning to shape the role of afflicted left atrium’s (LA) function and strain in cardiovascular diseases including aortic stenosis (AS), especially for risk stratification and outcome prediction. Cardiac magnetic resonance imaging (CMR) is becoming increasingly useful in determining parameters of LA, however, in patients with AS, this has not been yet approached. AIMS: The study sought to evaluate the role of CMR in characterizing LA geometry and function in patients with severe AS. METHODS: We prospectively evaluated 70 patients with symptomatic severe AS and 70 controls. LA volumes, function and strain were determined using CMR. A composite outcome (cardiac death, ventricular tachyarrhythmias, and heart failure hospitalization) was evaluated over a median of 13 months. Time-to-event outcomes were analyzed accordingly. RESULTS: Besides increased LA volumes (LAVs) and LA sphericity index (LASI) (P <0.001), LA phasic functions and strain were considerably defective in patients with AS (all P <0.001). LV mass (LVM), end-diastolic and end-systolic volumes were also significantly associated withal LA strain parameters (P <0.001). Regarding outcome prediction, decreased total (LA-et), active (LA-ea) and passive strain (LA-ep), along with enhanced LASI were independently associated with outcome (P <0.001). Time-to-event analysis showed significantly higher risk to reach the composite outcome for LA-et <31.1% [HR=6.981; 95%CI (2.74–17.77),  P <0.001)], LA-ep <14.5% [HR = 2.68; 95% CI (1.00–7.18), P<0.01)], and LA-ea <21.2% [HR = 2.02; 95% CI (1.07–3.83), P <0.03]. CONCLUSION: Patients with severe AS have significantly remodelled LA, with impaired phasic function and strain. Amongst all CMR parameters, LAVmin, LASI, LAPF and LA-ep appear to be independent predictors for outcome

Endoscopic Ultrasound in the Diagnosis and Staging of Pancreatic Cancer

Pancreatic cancer is one of the digestive cancers with the poorest prognosis, so an early and correct diagnosis is of utmost importance. With the development of new therapeutic options an accurate staging is essential. Endoscopic ultrasonography (EUS) has a major role in all stages of the management of these patients. EUS has a high accuracy in the diagnosis of pancreatic adenocarcinoma and the possibility to perform fine-needle aspiration/biopsy (FNA/FNB) increases the diagnostic yield of EUS. There is still no consensus on the several technical aspects of FNA, namely on the rapid on-site evaluation (ROSE), the diameter and type of needle, the number of passes and the use of stylet and suction. Contrast-enhanced EUS (CE-EUS) and EUS elastography (EUS-E) have been used in recent years as an adjunct to EUS-FNA. Given the higher sensitivity of these techniques a negative cytology by EUS-FNA should not exclude malignancy when CE-EUS and/or EUS-E are suggestive of pancreatic neoplasia. EUS remains one of the main methods in the staging of pancreatic adenocarcinoma, namely to further evaluate patients with non-metastatic disease that appears resectable on initial imaging. EUS is crucial for an accurate preoperative evaluation of pancreatic cancer which is essential to choose the correct management strategy. The possibility to obtain samples from suspicious lesions or lymph nodes, by means of EUS-guided fine-needle aspiration as well as the use of contrast-enhanced and elastography, makes EUS an ideal modality for the diagnosis and staging of pancreatic cancer.info:eu-repo/semantics/publishedVersio