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Michael J Levy

Publications and source records attributed to Michael J Levy.

At least 19 recordsLinked to original sources
PubMed2006

Preoperative diagnosis of extrapancreatic neural invasion in pancreatic cancer.

BACKGROUND & AIMS: Pancreatic cancer recurs in most patients after resection with curative intent. Recurrence is particularly common in patients with extrapancreatic neural invasion (EPNI), the presence of which correlates with poor prognosis. Macroscopic EPNI may be detected with conventional noninvasive imaging and endoscopic ultrasound (EUS) imaging, but microscopic EPNI has required postoperative pathologic examination of surgical specimens. We report the preoperative diagnosis of cancer infiltration into celiac ganglia. We hypothesized that microscopic pancreatic cancer metastasis to neural ganglia can be detected by EUS-guided biopsy examination. METHODS: We performed a retrospective review of patients with pancreatic cancer undergoing EUS in whom celiac ganglia were sampled to exclude malignant infiltration. RESULTS: Six patients with pancreatic cancer underwent EUS-guided fine-needle aspiration or trucut biopsy examination of presumed celiac ganglia. Metastatic cancer was found in ganglia of 2 patients. Specimen review identified adenocarcinoma and neural tissue in the absence of lymphocytes. At laparoscopy, 1 of the 2 patients with positive celiac biopsy specimens also had several unexpected peritoneal metastatic deposits. The other patient was considered to have locally advanced unresectable disease. Both patients are receiving supportive care. CONCLUSIONS: EPNI may be shown preoperatively in patients with pancreatic cancer using EUS-guided sampling of celiac ganglia. A preoperative diagnosis of EPNI has the potential to improve staging accuracy and patient outcomes.

Adenocarcinoma↗
PubMed2006

Laser assisted hatching in good prognosis patients undergoing in vitro fertilization-embryo transfer: a randomized controlled trial.

OBJECTIVE: To evaluate whether assisted hatching improves clinical outcomes of embryo transfers to good prognosis patients, defined as patients < or =39 years with normal follicle-stimulating hormone (FSH) and E(2) levels, no more than one previous unsuccessful cycle of in vitro fertilization (IVF)-embryo transfer, and good embryo quality. DESIGN: Prospective randomized controlled trial. SETTING: Private assisted reproductive technology (ART) center. PATIENT(S): One hundred ninety-nine good prognosis patients undergoing IVF-embryo transfer. INTERVENTION(S): In vitro fertilization followed by embryo transfer on day 3 after oocyte retrieval with or without assisted hatching using a 1,480-nm wavelength infrared laser. MAIN OUTCOME MEASURE(S): Clinical intrauterine pregnancy, spontaneous pregnancy loss, and live birth. RESULT(S): Rates of clinical intrauterine pregnancy with fetal cardiac activity (53% vs. 54% per cycle), spontaneous pregnancy loss (13% vs. 16% per pregnancy), and live birth (47% vs. 46% per cycle) were very similar between treatment cycles with laser-assisted hatching and control cycles in which embryos were transferred without assisted hatching. There were no significant differences between treatment and control groups in any measured clinical outcome parameters. CONCLUSION(S): Assisted hatching does not improve clinical outcomes among good prognosis patients.

Adult↗
PubMed2006

Relationship between endometrial thickness and embryo implantation, based on 1,294 cycles of in vitro fertilization with transfer of two blastocyst-stage embryos.

OBJECTIVE: To evaluate the relationship between endometrial thickness and clinical outcome of IVF and ET. DESIGN: Retrospective study. SETTING: Private assisted reproductive technology center. PATIENTS: One thousand two hundred and ninety-four infertility patients. INTERVENTIONS: IVF and fresh autologous ET of two blastocyst-stage embryos, including at least one good-quality blastocyst. MAIN OUTCOME MEASURES: Clinical pregnancy rate (PR) and spontaneous abortion rate. RESULTS: Endometrial thickness was greater in cycles resulting in pregnancy than in cycles not resulting in pregnancy (11.9 vs. 11.3 mm, respectively). Clinical pregnancy rates increased gradually from 53% among patients with a lining of <9 mm, to 77% among patients with a lining of > or =16 mm. Multiple logistic regression analysis indicated significant effects of age, embryo quality, and endometrial thickness on both clinical pregnancy rates and live-birth or ongoing pregnancy rates. There was also a marginally significant trend toward decreasing rates of spontaneous pregnancy loss with increasing endometrial thickness. CONCLUSIONS: Clinical pregnancy and live-birth or ongoing pregnancy rates increase significantly with increasing endometrial thickness, independent of the effects of patient age and embryo quality.

Abortion, Spontaneous↗
PubMed2006

IgG4-positive plasma cell infiltration in the diagnosis of autoimmune pancreatitis.

Autoimmune pancreatitis typically produces an enlarged pancreas with narrowing of the pancreatic duct, and can mimic carcinoma. Autoimmune pancreatitis usually responds to corticosteroid treatment, making it important to differentiate from pancreatic ductal adenocarcinoma. Affected patients often have an elevated serum IgG4. It has been proposed that increased numbers of IgG4-positive plasma cells in tissue might be a marker for the condition. We investigated the role of IgG4 staining in the diagnosis of autoimmune pancreatitis, first in resected pancreas specimens (29 autoimmune pancreatitis, nine chronic alcoholic pancreatitis and 25 pancreatic cancer), then in pancreatic needle biopsies. Immunohistochemical stains for IgG4 were scored as none, mild, moderate or marked, according to published criteria. Moderate to marked numbers of IgG4-positive plasma cells were seen in 21/29 autoimmune pancreatitis patients, and were distributed in and around ducts, in interlobular fibrous tissue and in peripancreatic fat. In contrast, eight of nine examples of chronic alcoholic pancreatitis and 22/25 ductal adenocarcinomas had scores of none or mild. When we subdivided autoimmune pancreatitis into the histologic subtypes lymphoplasmacytic sclerosing pancreatitis and idiopathic duct-destructive pancreatitis, 16/17 lymphoplasmacytic sclerosing pancreatitis had moderate to marked staining, compared to five to 12 idiopathic duct-destructive pancreatitis. Needle biopsies from nine patients suspected of having autoimmune pancreatitis had increased numbers of IgG4 cells. We conclude that pancreatic tissue from patients with autoimmune pancreatitis often shows moderate or marked infiltration by IgG4-positive plasma cells (>10/HPF). This is particularly so in the subtype we have designated lymphoplasmacytic sclerosing pancreatitis. We rarely see IgG4 staining in patients with chronic alcoholic pancreatitis and pancreatic ductal adenocarcinoma. IgG4-positive plasma cells are a useful marker for the tissue diagnosis of autoimmune pancreatitis.

Adenocarcinoma↗
PubMed2006

Advanced cytologic techniques for the detection of malignant pancreatobiliary strictures.

BACKGROUND & AIMS: Two advanced cytologic techniques for detecting aneuploidy-digital image analysis (DIA) and fluorescence in situ hybridization (FISH)-have recently been developed to help identify malignant pancreatobiliary strictures. The aim of this study was to assess the clinical utility of cytology, DIA, and FISH for the identification of malignant pancreatobiliary strictures. METHODS: Brush cytologic specimens from 233 consecutive patients undergoing endoscopic retrograde cholangiopancreatography for pancreatobiliary strictures were examined by all 3 (cytology, DIA, and FISH) techniques. Strictures were stratified as proximal (n = 33) or distal (n = 114) based on whether they occurred above or below the cystic duct, respectively. Strictures in patients with primary sclerosing cholangitis (n = 86) were analyzed separately. RESULTS: Despite the stratification, the performances of the tests were similar. Conventional cytology has a low sensitivity (4%-20%) but 100% specificity. Because of the high specificity for cytology, we assessed the performance of the other tests when conventional cytology was negative. In this clinical context, FISH had an increased sensitivity (35%-60%) when assessing for chromosomal gains (polysomy) while preserving the specificity of cytology. The sensitivity and specificity of DIA was intermediate as compared with routine cytology and FISH but was additive to FISH values demonstrating only trisomy of chromosome 7 or chromosome 3. CONCLUSIONS: These findings suggest that FISH and DIA increase the sensitivity for the diagnosis of malignant pancreatobiliary tract strictures over that obtained by conventional cytology while maintaining an acceptable specificity.

Adolescent↗
PubMed2006

Diagnosis of autoimmune pancreatitis: the Mayo Clinic experience.

BACKGROUND & AIMS: The Japan Pancreas Society criteria for diagnosis of autoimmune pancreatitis (AIP) mandate presence of characteristic imaging (diffuse pancreatic enlargement with diffusely irregular, narrow pancreatic duct). AIP has unique histologic features associated with infiltration of tissues of affected organs with abundant IgG4-positive cells. We propose expanded diagnostic criteria for AIP with a cohort of histologically confirmed AIP. METHODS: We reviewed the pancreatic imaging findings on computed tomography scans, serum IgG4 levels, other organ involvement, and response to steroids in 29 consecutive patients who met histologic criteria for AIP. RESULTS: Computed tomography scans (n = 22) showed diffuse pancreatic enlargement in 6 (27%) patients; the rest had focal enlargement, distinct mass, normal pancreas, or focal acute pancreatitis. Serum IgG4 level was elevated in 15 of 21 (71%) patients, and other organ involvement (eg, intrahepatic biliary strictures) was noted in 11 of 29 (38%) patients. All 17 patients treated with steroids exhibited resolution/marked improvement of pancreatic/extrapancreatic manifestation. On the basis of this experience we propose that diagnosis of AIP can be made in patients with > or =1 of these criteria: (1) diagnostic histology, (2) characteristic imaging on computed tomography and pancreatography with elevated serum IgG4 level, or (3) response to steroid therapy of pancreatic/extrapancreatic manifestations of AIP. Twenty additional patients met expanded diagnostic criteria for AIP, and their demographic and clinical profile was similar to that of the 29 patients meeting histologic criteria. CONCLUSIONS: AIP defined by histological criteria shows a wide spectrum of radiologic features, with characteristic imaging seen only in a minority. Incorporation of additional features into current diagnostic criteria can identify the full spectrum of clinical presentations of AIP.

Adolescent↗
PubMed2006

A novel endoscopic approach to brachytherapy in the management of Hilar cholangiocarcinoma.

OBJECTIVES: Traditionally, biliary brachytherapy sources are placed percutaneously via transhepatic drains or endoscopically via nasobiliary tubes (NBT). Another ERCP is needed for stent replacement after NBT removal. The aim of this study was to determine the feasibility and safety of endoscopic transpapillary insertion of irradiation sources through 10-Fr stents. METHODS: Medical records of Mayo Clinic Rochester patients undergoing biliary brachytherapy for hilar cholangiocarcinoma (CCA) were reviewed. Patients were part of a treatment protocol with curative intent including external beam radiation therapy (4,500 cGy), radiation sensitization (5-FU), and low dose rate (LDR) brachytherapy (<3,000 cGy) followed by liver transplantation. The 10-Fr biliary stent placed across the malignant biliary stricture was directly cannulated using a radiopaque (192)Ir embedded ribbon within a 300-cm long, 5.1-Fr plastic sheath. After withdrawal of the endoscope, the external end of the brachytherapy catheter was rerouted transnasally and secured. Each patient was hospitalized in a shielded room up to 24 h after which the brachytherapy catheter was removed by hand. RESULTS: Between 1999 and 2004, 32 patients underwent biliary brachytherapy via endoscopically placed 10-Fr plastic stents (mean age 50.6 yr, 69% PSC, bilateral brachytherapy catheters 28.1%). The technical complication observed was immediate brachytherapy catheter displacement (7 of 32, 22%) managed by prompt brachytherapy catheter repositioning. CONCLUSION: LDR biliary brachytherapy administration via endoscopically placed biliary stents is technically feasible and appears reasonably safe in select patients with unresectable perihilar CCA. Unlike NBTs, stents can potentially be placed in bilateral ductal systems to accommodate dual brachytherapy catheters when indicated.

Bile Duct Neoplasms↗
PubMed2006

Routine vs. selective EUS-guided FNA approach for preoperative nodal staging of esophageal carcinoma.

BACKGROUND: EUS-guided FNA (EUS-FNA) is the most accurate method for lymph-node staging of esophageal carcinoma; however, it may not be necessary when EUS features are present that strongly suggest a benign or a malignant origin. AIMS: (1) To identify a combination of EUS criteria that have a sufficient sensitivity and specificity to preclude the need for EUS-FNA and (2) to assess the cost savings derived from a selective EUS-FNA approach. METHODS: A total of 144 patients with esophageal carcinoma were prospectively evaluated with EUS. Accuracy of standard (hypoechoic, smooth border, round, or width > 5 mm) and modified (4 standard plus EUS identified celiac lymph nodes, >5 lymph nodes, or EUS T3/4 tumor) criteria were compared (receiver operating characteristic curves). Resource utilization of two diagnostic strategies, routine (all patients with lymph nodes) and selective EUS-FNA (FNA only in those patients in whom the number of EUS malignant criteria provides a sensitivity and a specificity <100%), were compared. RESULTS: Modified EUS criteria for lymph-node staging were more accurate than standard criteria (area under the curve 0.88 vs. 0.78, respectively). No criterion alone was predictive of malignancy; sensitivity and specificity reached 100% when a cutoff value of >1 and >6 modified criteria were used, respectively. The EUS-FNA selective approach may avoid performing FNA in 61 patients (42%). CONCLUSIONS: Modified EUS lymph-node criteria are more accurate than standard criteria. A selective EUS-FNA approach reduced the cost by avoiding EUS-FNA in 42% of patients with esophageal carcinoma. These results require confirmation in future studies.

Adult↗
PubMed2006

International survey of knowledge of indications for EUS.

BACKGROUND: The knowledge level for EUS indications among gastroenterologists across different locations and practices is not known. The aim of this study was to assess knowledge of EUS indications among a diverse group of gastroenterologists, both nationally and internationally. METHODS: A web-based survey was designed to assess knowledge of EUS with respect to 4 organ systems: esophagus, gastroduodenum, hepatopancreatobiliary, and colorectum. The survey was distributed by electronic mail (e-mail) to members of the American Society for Gastrointestinal Endoscopy. RESULTS: The survey was distributed to 3848 physicians, of whom 2848 had an active e-mail address. There were 323 respondents (11.3%), of whom 210 were U.S. members and 113 international. Overall, the mean score for the different organ systems for all respondents was highest for gastroduodenum (93% correct) and lowest for colorectum (71%) compared with esophagus (79%) and hepatopancreatobiliary (83%) systems. The mean total score was higher for U.S. respondents (84% correct) compared with international respondents (79%, p < 0.0001). Endosonographers fared better than those who were not endosonographers (85% vs. 81%, p = 0.0002). CONCLUSIONS: Knowledge levels of colorectal applications of EUS are poorest among the 4 organ systems studied. Future educational initiatives should focus on applications of EUS in this category. Studies are required to assess the impact of this education on the appropriateness of EUS referral patterns.

Bile Ducts↗
PubMed2006

Endoscopic ultrasound-guided pain control for intra-abdominal cancer.

This article summarizes percutaneous and surgical methods for performing celiac plexus neurolysis and focuses on the technical aspects of endoscopic ultrasound-guided celiac plexus neurolysis. Published literature concerning endoscopic ultrasound-guided celiac plexus neurolysis is reviewed, indications are proposed, and opinions are offered concerning potential future applications and investigational needs as they apply to this technique.

Abdominal Neoplasms↗
PubMed2005

Prospective study of a Trucut needle for performing EUS-guided biopsy with EUS-guided FNA rescue.

BACKGROUND: EUS-guided FNA (EUS-FNA) is an accurate technique for sampling extraintestinal masses and lymph nodes. The use of a Trucut needle to perform EUS-guided biopsy (EUS-TCB) may improve the results or simplify the procedure. To date, few studies have prospectively assessed the performance and the safety of EUS-TCB. METHODS: Patients with a known or a suspected malignancy referred for a diagnostic and/or staging EUS examination were enrolled in a prospective study. EUS-guided biopsy was performed first with a 19-gauge Trucut needle. If the Trucut failed to obtain an adequate sample or when the "in room" touch preparation was benign, EUS-FNA was performed with a standard 22-gauge FNA needle. The objective of the study was to assess the yield of detection of malignancy and the safety of EUS-TCB in patients with known or suspected malignancies and to investigate if EUS-FNA has a role for rescue in cases of Trucut failure. OBSERVATIONS: Thirty-nine lesions underwent EUS-TCB in 30 patients. Sufficient follow-up was available for all patients. By using EUS-TCB, we were able to obtain a sample for diagnosis in all but 3 patients (one pancreatic mass and two lymph nodes) in which technical problems arose. In these patients, the diagnosis was obtained in two cases by EUS-FNA and in the other one by EUS-TCB from the primary pancreatic tumor. The yield of detection of malignancy for EUS-TCB was 84%. No complications were recorded in any patients at 1 and 7 days of follow-up. The sample size is limited to generalize conclusions. CONCLUSIONS: EUS-TCB is a safe and an accurate procedure to obtain a histologic diagnosis in patients with known or suspected malignancies. EUS-FNA can serve as a rescue technique in cases of Trucut failure.

Adult↗
PubMed2005

Pancreatic neoplasms.

Patients who present with signs and symptoms suggesting a pancreatic neoplasm typically undergo initial imaging with transabdominal ultrasound or CT. When a pancreatic mass or fullness is identified, it may represent an inflammatory mass, benign process, or malignancy. Endoscopic ultrasound (EUS) is performed commonly to further characterize the lesion, obtain a tissue diagnosis, and for staging. This article reviews the role of EUS for the diagnosis and staging of pancreatic tumors.

Adenocarcinoma↗
PubMed2005

Endoscopic ultrasound for luminal malignancies.

Luminal gastrointestinal (GI) tract cancers are responsible for substantial morbidity and mortality. Since the first pairing of ultrasonography with endoscopy in 1980, technologic advances and the increased availability of trained endosonographers have propelled endoscopic ultrasonography (EUS) to the forefront of luminal GI cancer staging. In this article we discuss the role of EUS for evaluating luminal GI cancers.

Endoscopy, Gastrointestinal↗
PubMed2005

EUS features of recurrent transitional cell bladder cancer metastatic to the GI tract.

BACKGROUND: Recurrent transitional cell bladder cancer (TCBC) can metastasize to the GI tract albeit uncommonly. This is the first report of the EUS appearance of metastatic TCBC to the GI tract. In addition to describing the EUS features of recurrent metastatic TCBC, this study determined the number of patients referred for evaluation of a primary GI luminal cancer in which EUS instead established the diagnosis of metastatic recurrent TCBC. METHODS: Patients referred from July 2000 through April 2004 for EUS evaluation of a suspected primary GI luminal cancer were retrospectively reviewed. For patients with an established diagnosis of recurrent metastatic TCBC, EUS images were retrospectively reviewed to identify characteristic features. RESULTS: Of 2216 patients undergoing EUS to evaluate a suspected primary GI luminal cancer, 3 men (0.14%: 95% confidence interval [0.02%, 0.29%]) (mean age 67 years, range 54-74 years) were found instead to have recurrent metastatic TCBC involving the duodenum (n = 1) or rectum (n = 2). The patients presented a mean of 32 months after diagnosis of the primary TCBC with change in bowel habit (n = 1) and symptoms of bowel obstruction (n = 2). In each patient, initial endoscopy revealed circumferential luminal stenosis and mucosal erythema, but mucosal biopsy specimens revealed normal tissue. EUS demonstrated hypoechoic, symmetric, circumferential wall thickening, loss of deep wall layers, and pseudopodia-like extensions into the peri-intestinal tissues. In the two patients with rectal involvement, no evidence of direct infiltration from the bladder bed was seen. EUS-guided FNA was diagnostic of metastatic TCBC in all patients. CONCLUSIONS: Although most cases of hypoechoic bowel-wall thickening and stenosis are from primary GI neoplasia, recurrent TCBC should be considered in patients with a history of this tumor. Correct diagnosis is important, because this allows selection of appropriate therapeutic interventions. Although firm EUS criteria for TCBC cannot be established based on findings in 3 patients, certain features may prove useful. EUS-guided FNA can confirm the diagnosis.

Aged↗