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Papers by julia leblanc

Research paper thumbnail of Pancreatic Cystic Neuroendocrine Tumors: Preoperative Diagnosis with Endoscopic Ultrasound and Fine-Needle Immunocytology

Journal of Gastrointestinal Surgery, 2008

Background Pancreatic cystic neuroendocrine tumors (CNETs) are rare premalignant conditions. Comp... more Background Pancreatic cystic neuroendocrine tumors (CNETs) are rare premalignant conditions. Computed tomography (CT) occasionally demonstrates the hypervascular border characteristic of NETs. Endoscopic ultrasound (EUS) with fineneedle aspiration and immunocytology may be a more consistent means to establish the diagnosis, but no data on the role of EUS are available. This report represents the largest series of CNETs treated to date, documents the role of EUS in preoperative diagnosis, and describes current management. Methods Retrospective review of our experience with CNETs treated at an academic center between 1999 and 2006. Results Thirteen patients with CNETs were identified. One had symptoms consistent with a functional tumor; the others were nonfunctional. Twelve were detected by CT; only three had peripheral hypervascularity. Nine were studied with preoperative EUS/immunocytology; each of these demonstrated strong staining for chromogranin and synaptophysin. All were resected: four by pancreaticoduodenectomy, one by total pancreatectomy, and one by enucleation. Perioperative morbidity occurred in 39%. Perioperative mortality was 0%. Average follow-up was 3.3+0.5 years. One patient had late hepatic recurrence and ultimately died of disease. Two developed recurrent NET in the context of MEN I and required additional surgery. Twelve are alive with no evidence of disease. Conclusions EUS-guided immunocytology with staining for neuroendocrine markers is an accurate method to establish the diagnosis of CNET preoperatively. Short-and long-term outcomes after resection are excellent.

Research paper thumbnail of Endoscopic Ultrasound: How Does It Aid the Surgeon?

Advances in Surgery, 2007

1. Adv Surg. 2007;41:17-50. Endoscopic ultrasound: how does it aid the surgeon? LeBlanc JK, DeWit... more 1. Adv Surg. 2007;41:17-50. Endoscopic ultrasound: how does it aid the surgeon? LeBlanc JK, DeWitt J, Sherman S. Division of Gastroenterology and Hepatology, Indiana University Medical Center, 550 North University Boulevard, UH 4100, Indianapolis, IN 46202, USA. ...

Research paper thumbnail of Pancreatic Cyst Fluid DNA Analysis Detects Malignant Cysts: Final Report of the PANDA Study

Gastrointestinal Endoscopy, 2007

Gastrointestinal Endoscopy, Volume 65, Issue 5, Pages AB102, April 2007, Authors:Asif Khalid; Syd... more Gastrointestinal Endoscopy, Volume 65, Issue 5, Pages AB102, April 2007, Authors:Asif Khalid; Sydney Finkelstein; Julia K. Leblanc; Neeraj Kaushik; Nuzhat A. Ahmad; William R. Brugge; Steven A. Edmundowicz; Robert H. Hawes; Kevin M. Mcgrath.

Research paper thumbnail of EUS-guided methylene blue pancreatography for minor papilla localization after unsuccessful ERCP

Gastrointestinal Endoscopy, 2004

Research paper thumbnail of Role of Endoscopic Ultrasound in the Diagnosis of Intraductal Papillary Mucinous Neoplasms: Correlation With Surgical Histopathology

Clinical Gastroenterology and Hepatology, 2007

Background & Aims: Intraductal papillary mucinous neoplasms (IPMNs) are precancerous tumors chara... more Background & Aims: Intraductal papillary mucinous neoplasms (IPMNs) are precancerous tumors characterized by dilation of the main pancreatic duct, its side branches, or both. The purpose of this study was to evaluate the role of endoscopic ultrasound (EUS) in differentiating benign and malignant IPMNs. Methods: We identified all patients between July 1996 -November 2005 who underwent preoperative EUS for IPMNs. Malignancy was defined as the presence of invasive carcinoma; all other neoplasms were considered benign. The results of EUS and EUS-guided fine-needle aspiration (EUS-FNA) were compared with corresponding histopathology. Results: Seventy-four patients (38 male; mean age, 65 years) with 21 (28%) malignant and 53 (72%) benign IPMNs were identified. Sixty-five (88%) underwent EUS-FNA. Compared with benign tumors, patients with malignant IPMNs were more likely to be older (P ‫؍‬ .011), present with jaundice (P ‫؍‬ .03) or weight loss (P ‫؍‬ .03), and have EUS features of a dilated main pancreatic duct (P ‫؍‬ .0001), solid lesion (P ‫؍‬ .0001), pancreatic ductal filling defects (P ‫؍‬ .03), or thickened septa within any cyst (P ‫؍‬ .02). The sensitivity, specificity, and accuracy of EUS-FNA for the diagnosis of malignancy were 75% (95% confidence interval [CI], 53%-89%), 91% (95% CI, 79%-97%), and 86% (95% CI, 76%-93%), respectively. Cyst or pancreatic duct fluid carcinoembryonic antigen (CEA) and carbohydrate antigen (CA) 19-9 did not differ between groups. Conclusions: Older age, jaundice and weight loss, and EUS features of a solid lesion, dilated main pancreatic duct, ductal filling defects, and thickened septa are predictive of malignancy in patients with IPMNs. EUS-FNA cytology is helpful, but cyst fluid CEA and CA 19-9 are of limited value to differentiate malignant from benign IPMNs.

Research paper thumbnail of EUS-FNA of Recurrent Postoperative Extraluminal and Metastatic Malignancy

Gastrointestinal Endoscopy, 2003

Background: EUS-guided FNA is safe and accurate for the diagnosis of benign or malignant neoplasi... more Background: EUS-guided FNA is safe and accurate for the diagnosis of benign or malignant neoplasia and lymphadenopathy; however, its role in the diagnosis of recurrent malignancy is not well described. Methods: A prospectively updated EUS-guided FNA cytology database was used to identify patients in whom a diagnosis of postoperative, recurrent, extraluminal, or metastatic malignancy was made over a 5-year period. Only patients with a positive EUS-guided FNA were included in the analysis. All had undergone surgery for the primary malignancy and were in clinical and/or radiographic remission before the initial suspicion of tumor recurrence.

Research paper thumbnail of Endoscopic ultrasound–guided fine needle aspiration cytology of solid liver lesions: a large single-center experience

American Journal of Gastroenterology, 2003

The aim of this study was to report the sensitivity, cytological diagnoses, endoscopic ultrasound... more The aim of this study was to report the sensitivity, cytological diagnoses, endoscopic ultrasound (EUS) features, complications, clinical impact, and long term follow-up of a large single-center experience with endoscopic ultrasound–guided fine needle aspiration (EUS-FNA) of benign and malignant solid liver lesions.A database of cytologic specimens from EUS-FNA was reviewed to identify all hepatic lesions aspirated between January, 1997, and July, 2002. Procedural indications, prior radiographic data, patient demographics, EUS examination results, complications, and follow-up data were obtained and recorded.EUS-FNA of 77 liver lesions in 77 patients was performed without complications. Of these 77 lesions, 45 (58%) were diagnostic for malignancy, 25 (33%) were benign, and seven (9%) were nondiagnostic. A total of 22 lesions were confirmed as negative for malignancy by follow-up (mean 762 days, range 512–1556 days) or intraoperative examination; however, seven lesions could not be classified as benign or malignant. Depending on the status of the seven unclassified lesions, sensitivity of EUS-FNA for the diagnosis of malignancy ranged from 82 to 94%. When compared with benign lesions, EUS features predictive of malignant hepatic masses were the presence of regular outer margins (60% vs 27%; p = 0.02) and the detection of two or more lesions (38% vs 9%; p = 0.03). Of the 42 patients with malignancy identified by EUS-FNA and other available imaging records, EUS detected the malignancy in 41% of patients with previously negative examinations. For the 45 subjects with cytology positive for malignancy, EUS-FNA changed management in 86% of subjects.EUS-FNA of the liver is a safe and sensitive procedure that can have a significant impact on patient management. Prospective studies comparing the accuracy and complication rate of EUS-FNA and percutaneous fine needle aspiration (P-FNA) for the diagnosis of liver tumors are needed.

Research paper thumbnail of “A Prospective Randomized Trial of 1 Versus 2 Injections During a Single EUS-Guided Celiac Plexus Block (CPB) Procedure for Chronic Pancreatitis Pain: Final Results”

Gastrointestinal Endoscopy, 2008

The efficacy of 1-injection versus a 2-injections method of EUS-guided celiac plexus block (EUS-C... more The efficacy of 1-injection versus a 2-injections method of EUS-guided celiac plexus block (EUS-CPB) in patients with chronic pancreatitis is not known. To compare the clinical effectiveness and safety of EUS-CPB by using 1 versus 2 injections in patients with chronic pancreatitis and pain. The secondary aim is to identify factors that predict responsiveness. A prospective randomized study. EUS-CPB was performed by using bupivacaine and triamcinolone injected into 1 or 2 sites at the level of the celiac trunk during a single EUS-CPB procedure. Duration of pain relief, onset of pain relief, and complications. Fifty [corrected] subjects were enrolled (23 received 1 injection, 27 [corrected] received 2 injections). The median duration of pain relief in the 31 responders was 28 days (range 1-673 days). [corrected] Fifteen [corrected] of 23 (65%) [corrected] subjects who received 1 injection [corrected] had relief from pain compared with 16 of 27 (59%) [corrected] subjects who received 2 injections [corrected] (P = .67). [corrected] The median times to onset in the 1-injection and 2-injections groups were 21 and 14 days, respectively (P = .99). No correlation existed between duration of pain relief and time to onset of pain relief or onset within 24 hours. Age, sex, race, prior EUS-CPB, and smoking or alcohol history did not predict duration of pain relief. Telephone interviewers were not blinded. There was no difference in duration of pain relief or onset of pain relief in subjects with chronic pancreatitis and pain when the same total amount of medication was delivered in 1 or 2 injections during a single EUS-CPB procedure. Both methods were safe.

Research paper thumbnail of EUS-guided FNA of proximal biliary strictures after negative ERCP brush cytology results

Gastrointestinal Endoscopy, 2006

Accurate nonoperative diagnosis of proximal biliary strictures (PBSs) is often difficult.To repor... more Accurate nonoperative diagnosis of proximal biliary strictures (PBSs) is often difficult.To report our experience with EUS-guided FNA (EUS-FNA) of PBSs following negative or unsuccessful results with brush cytology during ERCP.Retrospective cohort study.Single, tertiary referral hospital in Indianapolis, Indiana.Consecutive subjects from January 2001 to November 2004 who underwent EUS-FNA of a PBS documented by ERCP.EUS-FNA of PBS.Performance of EUS-FNA, with the final diagnosis determined by surgical pathology study or the results of EUS-FNA and follow-up.A total of 291 biliary strictures undergoing EUS were identified. Of these, 26 (9%) had PBSs and 2 were excluded. EUS-FNA was not attempted in 1 because no mass was visualized. The second had a PBS seen on magnetic resonance cholangiopancreatography, but no ERCP was performed. Twenty-four patients (14 men; mean age, 68 years) underwent EUS-FNA of a PBS following ERCP brush cytology studies that were either negative/nondiagnostic (20) or unable to be performed (4). EUS visualized a mass in 23 (96%) patients, including 13 in whom previous imaging detected no lesion. EUS-FNA (median, 4 passes; range, 1-11) demonstrated malignancy in 17 of 24 (71%) patients with findings showing adenocarcinoma (15), lymphoma (2), atypical cytology (3), or benign cells (4). No complications were noted. Pathology results from 8 of 24 (33%) patients who underwent surgery showed hilar cholangiocarcinoma (6), gallbladder cancer (1), and a benign, inflammatory stricture (1). The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of EUS-FNA were 77% (95% confidence interval [CI], 54%-92%), 100% (95% CI, 15%-100%), 100% (95% CI, 83%-100%), 29% (95% CI, 4%-71%), and 79% (95% CI, 58%-93%), respectively.Histopathologic correlation of EUS-FNA findings was limited to 8 of 24 (33%) patients who underwent surgery.EUS-FNA is a sensitive method for the diagnosis of PBSs following negative results or unsuccessful ERCP brush cytology. The low negative predictive value does not permit reliable exclusion of malignancy following a negative biopsy.

Research paper thumbnail of Initial Experience with Endoscopic Ultrasound Guided Tru-Cut Biopsy for Known Or Suspected Benign Liver Disease

Gastrointestinal Endoscopy, 2008

Research paper thumbnail of Utility of a repeated EUS at a tertiary-referral center

Gastrointestinal Endoscopy, 2008

The utility of a repeated EUS by experts is not known. To define the utility of a repeated EUS fo... more The utility of a repeated EUS by experts is not known. To define the utility of a repeated EUS for the same indication. A retrospective case series. Tertiary-referral hospital in Indianapolis, Indiana. Consecutive subjects, with and without cancer, who, between January 2000 and September 2006, underwent an initial EUS elsewhere within 6 and 12 weeks of a repeated EUS at our hospital. A repeated EUS. Clinical impact of a repeated EUS. Of 8936 EUS examinations, 73 repeated procedures (0.8%) were identified, and 24 were excluded. The 49 initial EUS procedures (26 men, median age 59 years) were done in Indiana (n = 44) or another state (n = 5) by one of 15 physicians in private practice (n = 48) or at a teaching hospital (n = 1). An EUS-guided FNA (EUS-FNA) was performed during an initial EUS in 21 patients (no biopsy diagnostic for cancer) and was not attempted in 14 patients. The principle indication for a repeated EUS (n = 35) was for an EUS-FNA after the initial tissue sampling was benign, nondiagnostic, or not done. A second EUS had no clinical impact in 18 patients (37%). In the remaining 31 patients (63%), a repeated EUS provided a new or changed clinical diagnosis (n = 12), the initial diagnosis of primary pancreatic cancer (n = 5) or GI stromal tumor (GIST) (n = 1) after a previous nondiagnostic biopsy; or the initial diagnosis of primary (n = 4) or metastatic (n = 2) pancreatic cancer, metastatic esophageal cancer (n = 1), hilar cholangiocarcinoma (n = 1), GIST (n = 1), or pancreatic neuroendocrine tumor (n = 1), or an initial aspiration of a pancreatic cyst (n = 3) after a previous EUS-FNA was not able to be performed. A retrospective design; a small number of nonpancreatic indications. In this study, a repeated EUS at a tertiary-referral center had a clinical impact in 63% of patients when performed by experts for a similar clinical indication.

Research paper thumbnail of Clinical utility of EUS-guided fine-needle aspiration of mediastinal masses in the absence of known pulmonary malignancy

Gastrointestinal Endoscopy, 2002

Background: Mediastinal masses represent a diagnostic challenge because of their proximity to num... more Background: Mediastinal masses represent a diagnostic challenge because of their proximity to numerous critical structures, difficulty of access for tissue sampling, and myriad potential pathologic etiologies. A large, single-center experience with EUS-guided fine-needle aspiration (EUS-FNA) in the diagnosis of non-lung cancer-related mediastinal masses is presented. Methods: An EUS database was reviewed and all cases of mediastinal mass or lymphadenopathy encountered between 1994 and 1999 were included. Final diagnoses were determined by EUS-FNA cytology and clinical follow-up. Results: Forty-nine patients were identified (27 women, 22 men; mean age 58.1 years, range 30-89 years). A malignant process was diagnosed in 22 cases (45%) and a benign process in 24 (49%). The EUS-FNA specimen was nondiagnostic in 3 cases (6%). An accurate diagnosis was made in 46 of the 49 patients (94%). No complication was noted. Conclusions: EUS-FNA is a minimally invasive technique that facilitates detection and tissue sampling of mediastinal masses. It is a safe procedure that can be performed with the patient under conscious sedation in an outpatient setting. (Gastrointest Endosc 2002;56:397-401.)

Research paper thumbnail of Pancreatic Cystic Neuroendocrine Tumors: Preoperative Diagnosis with Endoscopic Ultrasound and Fine-Needle Immunocytology

Journal of Gastrointestinal Surgery, 2008

Background Pancreatic cystic neuroendocrine tumors (CNETs) are rare premalignant conditions. Comp... more Background Pancreatic cystic neuroendocrine tumors (CNETs) are rare premalignant conditions. Computed tomography (CT) occasionally demonstrates the hypervascular border characteristic of NETs. Endoscopic ultrasound (EUS) with fineneedle aspiration and immunocytology may be a more consistent means to establish the diagnosis, but no data on the role of EUS are available. This report represents the largest series of CNETs treated to date, documents the role of EUS in preoperative diagnosis, and describes current management. Methods Retrospective review of our experience with CNETs treated at an academic center between 1999 and 2006. Results Thirteen patients with CNETs were identified. One had symptoms consistent with a functional tumor; the others were nonfunctional. Twelve were detected by CT; only three had peripheral hypervascularity. Nine were studied with preoperative EUS/immunocytology; each of these demonstrated strong staining for chromogranin and synaptophysin. All were resected: four by pancreaticoduodenectomy, one by total pancreatectomy, and one by enucleation. Perioperative morbidity occurred in 39%. Perioperative mortality was 0%. Average follow-up was 3.3+0.5 years. One patient had late hepatic recurrence and ultimately died of disease. Two developed recurrent NET in the context of MEN I and required additional surgery. Twelve are alive with no evidence of disease. Conclusions EUS-guided immunocytology with staining for neuroendocrine markers is an accurate method to establish the diagnosis of CNET preoperatively. Short-and long-term outcomes after resection are excellent.

Research paper thumbnail of Pancreatic cyst fluid DNA analysis in evaluating pancreatic cysts: a report of the PANDA study

Gastrointestinal Endoscopy, 2009

The role of pancreatic cyst fluid DNA analysis in evaluating pancreatic cysts remains unclear. Ou... more The role of pancreatic cyst fluid DNA analysis in evaluating pancreatic cysts remains unclear. Our purpose was to evaluate the utility of a detailed DNA analysis of pancreatic cyst fluid to diagnose mucinous and malignant cysts. Prospective, multicenter study. Patients with pancreatic cysts presenting for EUS evaluation. EUS-guided pancreatic cyst aspirates cytology evaluation, carcinoembryonic antigen (CEA) level determination, and a detailed DNA analysis; incorporating DNA quantification, k-ras mutation and multiple allelic loss analysis, mutational amplitude, and sequence determination. Cyst fluid analysis compared with surgical pathologic or malignant cytologic examination. The study cohort consisted of 113 patients with 40 malignant, 48 premalignant, and 25 benign cysts. Cyst fluid k-ras mutation was helpful in the diagnosis of mucinous cysts (odds ratio 20.9, specificity 96%), whereas receiver-operator characteristic curve analysis indicated optimal cutoff points for allelic loss amplitude (area under the curve [AUC] 0.79; optimal value > 65%) and CEA (AUC 0.74; optimal value >148 ng/mL). Components of DNA analysis detecting malignant cysts included allelic loss amplitude over 82% (AUC 0.9) and high DNA amount (optical density ratio >10, AUC 0.79). The criteria of a high amplitude k-ras mutation followed by allelic loss showed maximum specificity (96%) for malignancy. All malignant cysts with negative cytologic evaluation (10/40) could be diagnosed as malignant by using DNA analysis. Limited follow-up, selection bias. Elevated amounts of pancreatic cyst fluid DNA, high-amplitude mutations, and specific mutation acquisition sequences are indicators of malignancy. The presence of a k-ras mutation is also indicative of a mucinous cyst. DNA analysis should be considered when cyst cytologic examination is negative for malignancy.

Research paper thumbnail of Pancreatic Cyst Fluid DNA Analysis Detects Malignant Cysts: Final Report of the PANDA Study

Gastrointestinal Endoscopy, 2007

Gastrointestinal Endoscopy, Volume 65, Issue 5, Pages AB102, April 2007, Authors:Asif Khalid; Syd... more Gastrointestinal Endoscopy, Volume 65, Issue 5, Pages AB102, April 2007, Authors:Asif Khalid; Sydney Finkelstein; Julia K. Leblanc; Neeraj Kaushik; Nuzhat A. Ahmad; William R. Brugge; Steven A. Edmundowicz; Robert H. Hawes; Kevin M. Mcgrath.

Research paper thumbnail of Role of Endoscopic Ultrasound in the Diagnosis of Intraductal Papillary Mucinous Neoplasms: Correlation With Surgical Histopathology

Clinical Gastroenterology and Hepatology, 2007

Background & Aims: Intraductal papillary mucinous neoplasms (IPMNs) are precancerous tumors chara... more Background & Aims: Intraductal papillary mucinous neoplasms (IPMNs) are precancerous tumors characterized by dilation of the main pancreatic duct, its side branches, or both. The purpose of this study was to evaluate the role of endoscopic ultrasound (EUS) in differentiating benign and malignant IPMNs. Methods: We identified all patients between July 1996 -November 2005 who underwent preoperative EUS for IPMNs. Malignancy was defined as the presence of invasive carcinoma; all other neoplasms were considered benign. The results of EUS and EUS-guided fine-needle aspiration (EUS-FNA) were compared with corresponding histopathology. Results: Seventy-four patients (38 male; mean age, 65 years) with 21 (28%) malignant and 53 (72%) benign IPMNs were identified. Sixty-five (88%) underwent EUS-FNA. Compared with benign tumors, patients with malignant IPMNs were more likely to be older (P ‫؍‬ .011), present with jaundice (P ‫؍‬ .03) or weight loss (P ‫؍‬ .03), and have EUS features of a dilated main pancreatic duct (P ‫؍‬ .0001), solid lesion (P ‫؍‬ .0001), pancreatic ductal filling defects (P ‫؍‬ .03), or thickened septa within any cyst (P ‫؍‬ .02). The sensitivity, specificity, and accuracy of EUS-FNA for the diagnosis of malignancy were 75% (95% confidence interval [CI], 53%-89%), 91% (95% CI, 79%-97%), and 86% (95% CI, 76%-93%), respectively. Cyst or pancreatic duct fluid carcinoembryonic antigen (CEA) and carbohydrate antigen (CA) 19-9 did not differ between groups. Conclusions: Older age, jaundice and weight loss, and EUS features of a solid lesion, dilated main pancreatic duct, ductal filling defects, and thickened septa are predictive of malignancy in patients with IPMNs. EUS-FNA cytology is helpful, but cyst fluid CEA and CA 19-9 are of limited value to differentiate malignant from benign IPMNs.

Research paper thumbnail of Role of endoscopic ultrasound-guided fine-needle aspiration with flow cytometry to diagnose lymphoma: A single center experience

Journal of Gastroenterology and Hepatology, 2009

The use of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) Ϯ flow cytometry (FC) fo... more The use of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) Ϯ flow cytometry (FC) for the diagnosis of suspected lymphoma remains controversial. We report our experience and diagnostic yield for EUS Ϯ FC for suspected lymphoma. Methods: Databases were queried for those who underwent EUS-FNA Ϯ FC for suspected lymphoma. Hospital charts were reviewed to confirm the final cytological diagnosis, follow up and FC results if obtained. The final diagnosis was confirmed by the results of EUS-FNA Ϯ FC, other biopsy and/or follow up. Results: In total, 54 patients underwent EUS-FNA of 72 lesions. The final diagnosis of lymphoma was made in 38 of the 54 (70%) patients, and 33 of the 54 (61%) patients relied on EUS-FNA. Cytopathology in 41 patients using EUS-FNA + FC showed lymphoma in 24 patients, atypical lymphoid cells in six and reactive lymph node in 11. In 9 of the 24 with lymphoma by EUS + FC, the diagnosis was confirmed by another diagnostic modality, like surgery, bone marrow biopsy and computed tomography-guided biopsy. Of the six with atypical lymphoid cells, additional diagnostic methods confirmed lymphoma in three. The remaining 13 of the 54 patients underwent EUS-FNA without FC due to insufficient sample (n = 5) or operator choice (n = 8). Cytopathology in these 13 patients without FC showed lymphoma (9), atypical lymphoid cells (3) and reactive node (1). The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of EUS-FNA for lymphoma in all 54 patients ranged from 80% to 87%, 92% to 93%, 97%, 60% to 75% and 83% to 89%, respectively. Conclusions: EUS-FNA is sensitive and specific for the diagnosis of suspected lymphoma. Confirmatory or further testing should be performed when EUS-FNA with or without FC is indeterminate and or non-diagnostic.

Research paper thumbnail of “A Prospective Randomized Trial of 1 Versus 2 Injections During a Single EUS-Guided Celiac Plexus Block (CPB) Procedure for Chronic Pancreatitis Pain: Final Results”

Gastrointestinal Endoscopy, 2008

The efficacy of 1-injection versus a 2-injections method of EUS-guided celiac plexus block (EUS-C... more The efficacy of 1-injection versus a 2-injections method of EUS-guided celiac plexus block (EUS-CPB) in patients with chronic pancreatitis is not known. To compare the clinical effectiveness and safety of EUS-CPB by using 1 versus 2 injections in patients with chronic pancreatitis and pain. The secondary aim is to identify factors that predict responsiveness. A prospective randomized study. EUS-CPB was performed by using bupivacaine and triamcinolone injected into 1 or 2 sites at the level of the celiac trunk during a single EUS-CPB procedure. Duration of pain relief, onset of pain relief, and complications. Fifty [corrected] subjects were enrolled (23 received 1 injection, 27 [corrected] received 2 injections). The median duration of pain relief in the 31 responders was 28 days (range 1-673 days). [corrected] Fifteen [corrected] of 23 (65%) [corrected] subjects who received 1 injection [corrected] had relief from pain compared with 16 of 27 (59%) [corrected] subjects who received 2 injections [corrected] (P = .67). [corrected] The median times to onset in the 1-injection and 2-injections groups were 21 and 14 days, respectively (P = .99). No correlation existed between duration of pain relief and time to onset of pain relief or onset within 24 hours. Age, sex, race, prior EUS-CPB, and smoking or alcohol history did not predict duration of pain relief. Telephone interviewers were not blinded. There was no difference in duration of pain relief or onset of pain relief in subjects with chronic pancreatitis and pain when the same total amount of medication was delivered in 1 or 2 injections during a single EUS-CPB procedure. Both methods were safe.

Research paper thumbnail of Optimal number of EUS-guided fine needle passes needed to obtain a correct diagnosis

Gastrointestinal Endoscopy, 2004

The immediate assistance of a cytologist during EUS-guided FNA is not universal. The optimal numb... more The immediate assistance of a cytologist during EUS-guided FNA is not universal. The optimal number of fine needle passes during EUS-guided FNA has not been determined in a prospective study. The aim of this study was to determine the optimal number of passes required to obtain a correct diagnosis.Seven or more passes were made with a fine needle into a variety of lesions during EUS-guided FNA. Adequacy of the aspirate, diagnosis, and a “certainty score” were recorded after each pass and interpreted sequentially by a cytopathologist. Surgical histopathology and 1-year clinical follow-up were used as reference standards. The percentage of correctly diagnosed cases was calculated and stratified according to organ, disease group, and EUS characteristics of the lesion.Lesions from 95 patients were categorized into the following locations: pancreas, lymph node, and miscellaneous. The sensitivity and specificity for 7 passes from the pancreas and miscellaneous lesion groups were, respectively, 83% and 100%. The sensitivity and specificity for 5 passes from the lymph node group were, respectively, 77% and 100%.During EUS-guided FNA, at least 7 passes with a fine needle into pancreatic and miscellaneous lesions, and 5 passes into lymph nodes are needed to ensure a high degree of certainty for making a correct diagnosis.

Research paper thumbnail of Initial Experience with Endoscopic Ultrasound Guided Tru-Cut Biopsy for Known Or Suspected Benign Liver Disease

Gastrointestinal Endoscopy, 2008

Research paper thumbnail of Pancreatic Cystic Neuroendocrine Tumors: Preoperative Diagnosis with Endoscopic Ultrasound and Fine-Needle Immunocytology

Journal of Gastrointestinal Surgery, 2008

Background Pancreatic cystic neuroendocrine tumors (CNETs) are rare premalignant conditions. Comp... more Background Pancreatic cystic neuroendocrine tumors (CNETs) are rare premalignant conditions. Computed tomography (CT) occasionally demonstrates the hypervascular border characteristic of NETs. Endoscopic ultrasound (EUS) with fineneedle aspiration and immunocytology may be a more consistent means to establish the diagnosis, but no data on the role of EUS are available. This report represents the largest series of CNETs treated to date, documents the role of EUS in preoperative diagnosis, and describes current management. Methods Retrospective review of our experience with CNETs treated at an academic center between 1999 and 2006. Results Thirteen patients with CNETs were identified. One had symptoms consistent with a functional tumor; the others were nonfunctional. Twelve were detected by CT; only three had peripheral hypervascularity. Nine were studied with preoperative EUS/immunocytology; each of these demonstrated strong staining for chromogranin and synaptophysin. All were resected: four by pancreaticoduodenectomy, one by total pancreatectomy, and one by enucleation. Perioperative morbidity occurred in 39%. Perioperative mortality was 0%. Average follow-up was 3.3+0.5 years. One patient had late hepatic recurrence and ultimately died of disease. Two developed recurrent NET in the context of MEN I and required additional surgery. Twelve are alive with no evidence of disease. Conclusions EUS-guided immunocytology with staining for neuroendocrine markers is an accurate method to establish the diagnosis of CNET preoperatively. Short-and long-term outcomes after resection are excellent.

Research paper thumbnail of Endoscopic Ultrasound: How Does It Aid the Surgeon?

Advances in Surgery, 2007

1. Adv Surg. 2007;41:17-50. Endoscopic ultrasound: how does it aid the surgeon? LeBlanc JK, DeWit... more 1. Adv Surg. 2007;41:17-50. Endoscopic ultrasound: how does it aid the surgeon? LeBlanc JK, DeWitt J, Sherman S. Division of Gastroenterology and Hepatology, Indiana University Medical Center, 550 North University Boulevard, UH 4100, Indianapolis, IN 46202, USA. ...

Research paper thumbnail of Pancreatic Cyst Fluid DNA Analysis Detects Malignant Cysts: Final Report of the PANDA Study

Gastrointestinal Endoscopy, 2007

Gastrointestinal Endoscopy, Volume 65, Issue 5, Pages AB102, April 2007, Authors:Asif Khalid; Syd... more Gastrointestinal Endoscopy, Volume 65, Issue 5, Pages AB102, April 2007, Authors:Asif Khalid; Sydney Finkelstein; Julia K. Leblanc; Neeraj Kaushik; Nuzhat A. Ahmad; William R. Brugge; Steven A. Edmundowicz; Robert H. Hawes; Kevin M. Mcgrath.

Research paper thumbnail of EUS-guided methylene blue pancreatography for minor papilla localization after unsuccessful ERCP

Gastrointestinal Endoscopy, 2004

Research paper thumbnail of Role of Endoscopic Ultrasound in the Diagnosis of Intraductal Papillary Mucinous Neoplasms: Correlation With Surgical Histopathology

Clinical Gastroenterology and Hepatology, 2007

Background & Aims: Intraductal papillary mucinous neoplasms (IPMNs) are precancerous tumors chara... more Background & Aims: Intraductal papillary mucinous neoplasms (IPMNs) are precancerous tumors characterized by dilation of the main pancreatic duct, its side branches, or both. The purpose of this study was to evaluate the role of endoscopic ultrasound (EUS) in differentiating benign and malignant IPMNs. Methods: We identified all patients between July 1996 -November 2005 who underwent preoperative EUS for IPMNs. Malignancy was defined as the presence of invasive carcinoma; all other neoplasms were considered benign. The results of EUS and EUS-guided fine-needle aspiration (EUS-FNA) were compared with corresponding histopathology. Results: Seventy-four patients (38 male; mean age, 65 years) with 21 (28%) malignant and 53 (72%) benign IPMNs were identified. Sixty-five (88%) underwent EUS-FNA. Compared with benign tumors, patients with malignant IPMNs were more likely to be older (P ‫؍‬ .011), present with jaundice (P ‫؍‬ .03) or weight loss (P ‫؍‬ .03), and have EUS features of a dilated main pancreatic duct (P ‫؍‬ .0001), solid lesion (P ‫؍‬ .0001), pancreatic ductal filling defects (P ‫؍‬ .03), or thickened septa within any cyst (P ‫؍‬ .02). The sensitivity, specificity, and accuracy of EUS-FNA for the diagnosis of malignancy were 75% (95% confidence interval [CI], 53%-89%), 91% (95% CI, 79%-97%), and 86% (95% CI, 76%-93%), respectively. Cyst or pancreatic duct fluid carcinoembryonic antigen (CEA) and carbohydrate antigen (CA) 19-9 did not differ between groups. Conclusions: Older age, jaundice and weight loss, and EUS features of a solid lesion, dilated main pancreatic duct, ductal filling defects, and thickened septa are predictive of malignancy in patients with IPMNs. EUS-FNA cytology is helpful, but cyst fluid CEA and CA 19-9 are of limited value to differentiate malignant from benign IPMNs.

Research paper thumbnail of EUS-FNA of Recurrent Postoperative Extraluminal and Metastatic Malignancy

Gastrointestinal Endoscopy, 2003

Background: EUS-guided FNA is safe and accurate for the diagnosis of benign or malignant neoplasi... more Background: EUS-guided FNA is safe and accurate for the diagnosis of benign or malignant neoplasia and lymphadenopathy; however, its role in the diagnosis of recurrent malignancy is not well described. Methods: A prospectively updated EUS-guided FNA cytology database was used to identify patients in whom a diagnosis of postoperative, recurrent, extraluminal, or metastatic malignancy was made over a 5-year period. Only patients with a positive EUS-guided FNA were included in the analysis. All had undergone surgery for the primary malignancy and were in clinical and/or radiographic remission before the initial suspicion of tumor recurrence.

Research paper thumbnail of Endoscopic ultrasound–guided fine needle aspiration cytology of solid liver lesions: a large single-center experience

American Journal of Gastroenterology, 2003

The aim of this study was to report the sensitivity, cytological diagnoses, endoscopic ultrasound... more The aim of this study was to report the sensitivity, cytological diagnoses, endoscopic ultrasound (EUS) features, complications, clinical impact, and long term follow-up of a large single-center experience with endoscopic ultrasound–guided fine needle aspiration (EUS-FNA) of benign and malignant solid liver lesions.A database of cytologic specimens from EUS-FNA was reviewed to identify all hepatic lesions aspirated between January, 1997, and July, 2002. Procedural indications, prior radiographic data, patient demographics, EUS examination results, complications, and follow-up data were obtained and recorded.EUS-FNA of 77 liver lesions in 77 patients was performed without complications. Of these 77 lesions, 45 (58%) were diagnostic for malignancy, 25 (33%) were benign, and seven (9%) were nondiagnostic. A total of 22 lesions were confirmed as negative for malignancy by follow-up (mean 762 days, range 512–1556 days) or intraoperative examination; however, seven lesions could not be classified as benign or malignant. Depending on the status of the seven unclassified lesions, sensitivity of EUS-FNA for the diagnosis of malignancy ranged from 82 to 94%. When compared with benign lesions, EUS features predictive of malignant hepatic masses were the presence of regular outer margins (60% vs 27%; p = 0.02) and the detection of two or more lesions (38% vs 9%; p = 0.03). Of the 42 patients with malignancy identified by EUS-FNA and other available imaging records, EUS detected the malignancy in 41% of patients with previously negative examinations. For the 45 subjects with cytology positive for malignancy, EUS-FNA changed management in 86% of subjects.EUS-FNA of the liver is a safe and sensitive procedure that can have a significant impact on patient management. Prospective studies comparing the accuracy and complication rate of EUS-FNA and percutaneous fine needle aspiration (P-FNA) for the diagnosis of liver tumors are needed.

Research paper thumbnail of “A Prospective Randomized Trial of 1 Versus 2 Injections During a Single EUS-Guided Celiac Plexus Block (CPB) Procedure for Chronic Pancreatitis Pain: Final Results”

Gastrointestinal Endoscopy, 2008

The efficacy of 1-injection versus a 2-injections method of EUS-guided celiac plexus block (EUS-C... more The efficacy of 1-injection versus a 2-injections method of EUS-guided celiac plexus block (EUS-CPB) in patients with chronic pancreatitis is not known. To compare the clinical effectiveness and safety of EUS-CPB by using 1 versus 2 injections in patients with chronic pancreatitis and pain. The secondary aim is to identify factors that predict responsiveness. A prospective randomized study. EUS-CPB was performed by using bupivacaine and triamcinolone injected into 1 or 2 sites at the level of the celiac trunk during a single EUS-CPB procedure. Duration of pain relief, onset of pain relief, and complications. Fifty [corrected] subjects were enrolled (23 received 1 injection, 27 [corrected] received 2 injections). The median duration of pain relief in the 31 responders was 28 days (range 1-673 days). [corrected] Fifteen [corrected] of 23 (65%) [corrected] subjects who received 1 injection [corrected] had relief from pain compared with 16 of 27 (59%) [corrected] subjects who received 2 injections [corrected] (P = .67). [corrected] The median times to onset in the 1-injection and 2-injections groups were 21 and 14 days, respectively (P = .99). No correlation existed between duration of pain relief and time to onset of pain relief or onset within 24 hours. Age, sex, race, prior EUS-CPB, and smoking or alcohol history did not predict duration of pain relief. Telephone interviewers were not blinded. There was no difference in duration of pain relief or onset of pain relief in subjects with chronic pancreatitis and pain when the same total amount of medication was delivered in 1 or 2 injections during a single EUS-CPB procedure. Both methods were safe.

Research paper thumbnail of EUS-guided FNA of proximal biliary strictures after negative ERCP brush cytology results

Gastrointestinal Endoscopy, 2006

Accurate nonoperative diagnosis of proximal biliary strictures (PBSs) is often difficult.To repor... more Accurate nonoperative diagnosis of proximal biliary strictures (PBSs) is often difficult.To report our experience with EUS-guided FNA (EUS-FNA) of PBSs following negative or unsuccessful results with brush cytology during ERCP.Retrospective cohort study.Single, tertiary referral hospital in Indianapolis, Indiana.Consecutive subjects from January 2001 to November 2004 who underwent EUS-FNA of a PBS documented by ERCP.EUS-FNA of PBS.Performance of EUS-FNA, with the final diagnosis determined by surgical pathology study or the results of EUS-FNA and follow-up.A total of 291 biliary strictures undergoing EUS were identified. Of these, 26 (9%) had PBSs and 2 were excluded. EUS-FNA was not attempted in 1 because no mass was visualized. The second had a PBS seen on magnetic resonance cholangiopancreatography, but no ERCP was performed. Twenty-four patients (14 men; mean age, 68 years) underwent EUS-FNA of a PBS following ERCP brush cytology studies that were either negative/nondiagnostic (20) or unable to be performed (4). EUS visualized a mass in 23 (96%) patients, including 13 in whom previous imaging detected no lesion. EUS-FNA (median, 4 passes; range, 1-11) demonstrated malignancy in 17 of 24 (71%) patients with findings showing adenocarcinoma (15), lymphoma (2), atypical cytology (3), or benign cells (4). No complications were noted. Pathology results from 8 of 24 (33%) patients who underwent surgery showed hilar cholangiocarcinoma (6), gallbladder cancer (1), and a benign, inflammatory stricture (1). The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of EUS-FNA were 77% (95% confidence interval [CI], 54%-92%), 100% (95% CI, 15%-100%), 100% (95% CI, 83%-100%), 29% (95% CI, 4%-71%), and 79% (95% CI, 58%-93%), respectively.Histopathologic correlation of EUS-FNA findings was limited to 8 of 24 (33%) patients who underwent surgery.EUS-FNA is a sensitive method for the diagnosis of PBSs following negative results or unsuccessful ERCP brush cytology. The low negative predictive value does not permit reliable exclusion of malignancy following a negative biopsy.

Research paper thumbnail of Initial Experience with Endoscopic Ultrasound Guided Tru-Cut Biopsy for Known Or Suspected Benign Liver Disease

Gastrointestinal Endoscopy, 2008

Research paper thumbnail of Utility of a repeated EUS at a tertiary-referral center

Gastrointestinal Endoscopy, 2008

The utility of a repeated EUS by experts is not known. To define the utility of a repeated EUS fo... more The utility of a repeated EUS by experts is not known. To define the utility of a repeated EUS for the same indication. A retrospective case series. Tertiary-referral hospital in Indianapolis, Indiana. Consecutive subjects, with and without cancer, who, between January 2000 and September 2006, underwent an initial EUS elsewhere within 6 and 12 weeks of a repeated EUS at our hospital. A repeated EUS. Clinical impact of a repeated EUS. Of 8936 EUS examinations, 73 repeated procedures (0.8%) were identified, and 24 were excluded. The 49 initial EUS procedures (26 men, median age 59 years) were done in Indiana (n = 44) or another state (n = 5) by one of 15 physicians in private practice (n = 48) or at a teaching hospital (n = 1). An EUS-guided FNA (EUS-FNA) was performed during an initial EUS in 21 patients (no biopsy diagnostic for cancer) and was not attempted in 14 patients. The principle indication for a repeated EUS (n = 35) was for an EUS-FNA after the initial tissue sampling was benign, nondiagnostic, or not done. A second EUS had no clinical impact in 18 patients (37%). In the remaining 31 patients (63%), a repeated EUS provided a new or changed clinical diagnosis (n = 12), the initial diagnosis of primary pancreatic cancer (n = 5) or GI stromal tumor (GIST) (n = 1) after a previous nondiagnostic biopsy; or the initial diagnosis of primary (n = 4) or metastatic (n = 2) pancreatic cancer, metastatic esophageal cancer (n = 1), hilar cholangiocarcinoma (n = 1), GIST (n = 1), or pancreatic neuroendocrine tumor (n = 1), or an initial aspiration of a pancreatic cyst (n = 3) after a previous EUS-FNA was not able to be performed. A retrospective design; a small number of nonpancreatic indications. In this study, a repeated EUS at a tertiary-referral center had a clinical impact in 63% of patients when performed by experts for a similar clinical indication.

Research paper thumbnail of Clinical utility of EUS-guided fine-needle aspiration of mediastinal masses in the absence of known pulmonary malignancy

Gastrointestinal Endoscopy, 2002

Background: Mediastinal masses represent a diagnostic challenge because of their proximity to num... more Background: Mediastinal masses represent a diagnostic challenge because of their proximity to numerous critical structures, difficulty of access for tissue sampling, and myriad potential pathologic etiologies. A large, single-center experience with EUS-guided fine-needle aspiration (EUS-FNA) in the diagnosis of non-lung cancer-related mediastinal masses is presented. Methods: An EUS database was reviewed and all cases of mediastinal mass or lymphadenopathy encountered between 1994 and 1999 were included. Final diagnoses were determined by EUS-FNA cytology and clinical follow-up. Results: Forty-nine patients were identified (27 women, 22 men; mean age 58.1 years, range 30-89 years). A malignant process was diagnosed in 22 cases (45%) and a benign process in 24 (49%). The EUS-FNA specimen was nondiagnostic in 3 cases (6%). An accurate diagnosis was made in 46 of the 49 patients (94%). No complication was noted. Conclusions: EUS-FNA is a minimally invasive technique that facilitates detection and tissue sampling of mediastinal masses. It is a safe procedure that can be performed with the patient under conscious sedation in an outpatient setting. (Gastrointest Endosc 2002;56:397-401.)

Research paper thumbnail of Pancreatic Cystic Neuroendocrine Tumors: Preoperative Diagnosis with Endoscopic Ultrasound and Fine-Needle Immunocytology

Journal of Gastrointestinal Surgery, 2008

Background Pancreatic cystic neuroendocrine tumors (CNETs) are rare premalignant conditions. Comp... more Background Pancreatic cystic neuroendocrine tumors (CNETs) are rare premalignant conditions. Computed tomography (CT) occasionally demonstrates the hypervascular border characteristic of NETs. Endoscopic ultrasound (EUS) with fineneedle aspiration and immunocytology may be a more consistent means to establish the diagnosis, but no data on the role of EUS are available. This report represents the largest series of CNETs treated to date, documents the role of EUS in preoperative diagnosis, and describes current management. Methods Retrospective review of our experience with CNETs treated at an academic center between 1999 and 2006. Results Thirteen patients with CNETs were identified. One had symptoms consistent with a functional tumor; the others were nonfunctional. Twelve were detected by CT; only three had peripheral hypervascularity. Nine were studied with preoperative EUS/immunocytology; each of these demonstrated strong staining for chromogranin and synaptophysin. All were resected: four by pancreaticoduodenectomy, one by total pancreatectomy, and one by enucleation. Perioperative morbidity occurred in 39%. Perioperative mortality was 0%. Average follow-up was 3.3+0.5 years. One patient had late hepatic recurrence and ultimately died of disease. Two developed recurrent NET in the context of MEN I and required additional surgery. Twelve are alive with no evidence of disease. Conclusions EUS-guided immunocytology with staining for neuroendocrine markers is an accurate method to establish the diagnosis of CNET preoperatively. Short-and long-term outcomes after resection are excellent.

Research paper thumbnail of Pancreatic cyst fluid DNA analysis in evaluating pancreatic cysts: a report of the PANDA study

Gastrointestinal Endoscopy, 2009

The role of pancreatic cyst fluid DNA analysis in evaluating pancreatic cysts remains unclear. Ou... more The role of pancreatic cyst fluid DNA analysis in evaluating pancreatic cysts remains unclear. Our purpose was to evaluate the utility of a detailed DNA analysis of pancreatic cyst fluid to diagnose mucinous and malignant cysts. Prospective, multicenter study. Patients with pancreatic cysts presenting for EUS evaluation. EUS-guided pancreatic cyst aspirates cytology evaluation, carcinoembryonic antigen (CEA) level determination, and a detailed DNA analysis; incorporating DNA quantification, k-ras mutation and multiple allelic loss analysis, mutational amplitude, and sequence determination. Cyst fluid analysis compared with surgical pathologic or malignant cytologic examination. The study cohort consisted of 113 patients with 40 malignant, 48 premalignant, and 25 benign cysts. Cyst fluid k-ras mutation was helpful in the diagnosis of mucinous cysts (odds ratio 20.9, specificity 96%), whereas receiver-operator characteristic curve analysis indicated optimal cutoff points for allelic loss amplitude (area under the curve [AUC] 0.79; optimal value > 65%) and CEA (AUC 0.74; optimal value >148 ng/mL). Components of DNA analysis detecting malignant cysts included allelic loss amplitude over 82% (AUC 0.9) and high DNA amount (optical density ratio >10, AUC 0.79). The criteria of a high amplitude k-ras mutation followed by allelic loss showed maximum specificity (96%) for malignancy. All malignant cysts with negative cytologic evaluation (10/40) could be diagnosed as malignant by using DNA analysis. Limited follow-up, selection bias. Elevated amounts of pancreatic cyst fluid DNA, high-amplitude mutations, and specific mutation acquisition sequences are indicators of malignancy. The presence of a k-ras mutation is also indicative of a mucinous cyst. DNA analysis should be considered when cyst cytologic examination is negative for malignancy.

Research paper thumbnail of Pancreatic Cyst Fluid DNA Analysis Detects Malignant Cysts: Final Report of the PANDA Study

Gastrointestinal Endoscopy, 2007

Gastrointestinal Endoscopy, Volume 65, Issue 5, Pages AB102, April 2007, Authors:Asif Khalid; Syd... more Gastrointestinal Endoscopy, Volume 65, Issue 5, Pages AB102, April 2007, Authors:Asif Khalid; Sydney Finkelstein; Julia K. Leblanc; Neeraj Kaushik; Nuzhat A. Ahmad; William R. Brugge; Steven A. Edmundowicz; Robert H. Hawes; Kevin M. Mcgrath.

Research paper thumbnail of Role of Endoscopic Ultrasound in the Diagnosis of Intraductal Papillary Mucinous Neoplasms: Correlation With Surgical Histopathology

Clinical Gastroenterology and Hepatology, 2007

Background & Aims: Intraductal papillary mucinous neoplasms (IPMNs) are precancerous tumors chara... more Background & Aims: Intraductal papillary mucinous neoplasms (IPMNs) are precancerous tumors characterized by dilation of the main pancreatic duct, its side branches, or both. The purpose of this study was to evaluate the role of endoscopic ultrasound (EUS) in differentiating benign and malignant IPMNs. Methods: We identified all patients between July 1996 -November 2005 who underwent preoperative EUS for IPMNs. Malignancy was defined as the presence of invasive carcinoma; all other neoplasms were considered benign. The results of EUS and EUS-guided fine-needle aspiration (EUS-FNA) were compared with corresponding histopathology. Results: Seventy-four patients (38 male; mean age, 65 years) with 21 (28%) malignant and 53 (72%) benign IPMNs were identified. Sixty-five (88%) underwent EUS-FNA. Compared with benign tumors, patients with malignant IPMNs were more likely to be older (P ‫؍‬ .011), present with jaundice (P ‫؍‬ .03) or weight loss (P ‫؍‬ .03), and have EUS features of a dilated main pancreatic duct (P ‫؍‬ .0001), solid lesion (P ‫؍‬ .0001), pancreatic ductal filling defects (P ‫؍‬ .03), or thickened septa within any cyst (P ‫؍‬ .02). The sensitivity, specificity, and accuracy of EUS-FNA for the diagnosis of malignancy were 75% (95% confidence interval [CI], 53%-89%), 91% (95% CI, 79%-97%), and 86% (95% CI, 76%-93%), respectively. Cyst or pancreatic duct fluid carcinoembryonic antigen (CEA) and carbohydrate antigen (CA) 19-9 did not differ between groups. Conclusions: Older age, jaundice and weight loss, and EUS features of a solid lesion, dilated main pancreatic duct, ductal filling defects, and thickened septa are predictive of malignancy in patients with IPMNs. EUS-FNA cytology is helpful, but cyst fluid CEA and CA 19-9 are of limited value to differentiate malignant from benign IPMNs.

Research paper thumbnail of Role of endoscopic ultrasound-guided fine-needle aspiration with flow cytometry to diagnose lymphoma: A single center experience

Journal of Gastroenterology and Hepatology, 2009

The use of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) Ϯ flow cytometry (FC) fo... more The use of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) Ϯ flow cytometry (FC) for the diagnosis of suspected lymphoma remains controversial. We report our experience and diagnostic yield for EUS Ϯ FC for suspected lymphoma. Methods: Databases were queried for those who underwent EUS-FNA Ϯ FC for suspected lymphoma. Hospital charts were reviewed to confirm the final cytological diagnosis, follow up and FC results if obtained. The final diagnosis was confirmed by the results of EUS-FNA Ϯ FC, other biopsy and/or follow up. Results: In total, 54 patients underwent EUS-FNA of 72 lesions. The final diagnosis of lymphoma was made in 38 of the 54 (70%) patients, and 33 of the 54 (61%) patients relied on EUS-FNA. Cytopathology in 41 patients using EUS-FNA + FC showed lymphoma in 24 patients, atypical lymphoid cells in six and reactive lymph node in 11. In 9 of the 24 with lymphoma by EUS + FC, the diagnosis was confirmed by another diagnostic modality, like surgery, bone marrow biopsy and computed tomography-guided biopsy. Of the six with atypical lymphoid cells, additional diagnostic methods confirmed lymphoma in three. The remaining 13 of the 54 patients underwent EUS-FNA without FC due to insufficient sample (n = 5) or operator choice (n = 8). Cytopathology in these 13 patients without FC showed lymphoma (9), atypical lymphoid cells (3) and reactive node (1). The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of EUS-FNA for lymphoma in all 54 patients ranged from 80% to 87%, 92% to 93%, 97%, 60% to 75% and 83% to 89%, respectively. Conclusions: EUS-FNA is sensitive and specific for the diagnosis of suspected lymphoma. Confirmatory or further testing should be performed when EUS-FNA with or without FC is indeterminate and or non-diagnostic.

Research paper thumbnail of “A Prospective Randomized Trial of 1 Versus 2 Injections During a Single EUS-Guided Celiac Plexus Block (CPB) Procedure for Chronic Pancreatitis Pain: Final Results”

Gastrointestinal Endoscopy, 2008

The efficacy of 1-injection versus a 2-injections method of EUS-guided celiac plexus block (EUS-C... more The efficacy of 1-injection versus a 2-injections method of EUS-guided celiac plexus block (EUS-CPB) in patients with chronic pancreatitis is not known. To compare the clinical effectiveness and safety of EUS-CPB by using 1 versus 2 injections in patients with chronic pancreatitis and pain. The secondary aim is to identify factors that predict responsiveness. A prospective randomized study. EUS-CPB was performed by using bupivacaine and triamcinolone injected into 1 or 2 sites at the level of the celiac trunk during a single EUS-CPB procedure. Duration of pain relief, onset of pain relief, and complications. Fifty [corrected] subjects were enrolled (23 received 1 injection, 27 [corrected] received 2 injections). The median duration of pain relief in the 31 responders was 28 days (range 1-673 days). [corrected] Fifteen [corrected] of 23 (65%) [corrected] subjects who received 1 injection [corrected] had relief from pain compared with 16 of 27 (59%) [corrected] subjects who received 2 injections [corrected] (P = .67). [corrected] The median times to onset in the 1-injection and 2-injections groups were 21 and 14 days, respectively (P = .99). No correlation existed between duration of pain relief and time to onset of pain relief or onset within 24 hours. Age, sex, race, prior EUS-CPB, and smoking or alcohol history did not predict duration of pain relief. Telephone interviewers were not blinded. There was no difference in duration of pain relief or onset of pain relief in subjects with chronic pancreatitis and pain when the same total amount of medication was delivered in 1 or 2 injections during a single EUS-CPB procedure. Both methods were safe.

Research paper thumbnail of Optimal number of EUS-guided fine needle passes needed to obtain a correct diagnosis

Gastrointestinal Endoscopy, 2004

The immediate assistance of a cytologist during EUS-guided FNA is not universal. The optimal numb... more The immediate assistance of a cytologist during EUS-guided FNA is not universal. The optimal number of fine needle passes during EUS-guided FNA has not been determined in a prospective study. The aim of this study was to determine the optimal number of passes required to obtain a correct diagnosis.Seven or more passes were made with a fine needle into a variety of lesions during EUS-guided FNA. Adequacy of the aspirate, diagnosis, and a “certainty score” were recorded after each pass and interpreted sequentially by a cytopathologist. Surgical histopathology and 1-year clinical follow-up were used as reference standards. The percentage of correctly diagnosed cases was calculated and stratified according to organ, disease group, and EUS characteristics of the lesion.Lesions from 95 patients were categorized into the following locations: pancreas, lymph node, and miscellaneous. The sensitivity and specificity for 7 passes from the pancreas and miscellaneous lesion groups were, respectively, 83% and 100%. The sensitivity and specificity for 5 passes from the lymph node group were, respectively, 77% and 100%.During EUS-guided FNA, at least 7 passes with a fine needle into pancreatic and miscellaneous lesions, and 5 passes into lymph nodes are needed to ensure a high degree of certainty for making a correct diagnosis.

Research paper thumbnail of Initial Experience with Endoscopic Ultrasound Guided Tru-Cut Biopsy for Known Or Suspected Benign Liver Disease

Gastrointestinal Endoscopy, 2008