Endoscopic ultrasound applications in pre malignant and malignant disease
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Endoscopic Ultrasound: Applications in Pre-malignant and Malignant Disease. December 20 th , 2010 Andrew T. Pellecchia, MD Director of Advanced Endoscopy Jacobi Medical Center. EUS. Originally utilized to ‘clear’ the bile duct pre-cholecystectomy in patients with suspected CBD stones

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Endoscopic Ultrasound: Applications in Pre-malignant and Malignant Disease

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Endoscopic Ultrasound:Applications in Pre-malignant and Malignant Disease

December 20th, 2010

Andrew T. Pellecchia, MD

Director of Advanced Endoscopy

Jacobi Medical Center


EUS

  • Originally utilized to ‘clear’ the bile duct pre-cholecystectomy in patients with suspected CBD stones

    • Less invasive alternative to ERCP

    • Risks similar to standard EGD

  • EUS still used for this indication

    • Less than 20% of EUS procedures are performed for this indication in established advanced endoscopy center


Evolution of EUS

  • EUS as an imaging study

  • EUS as a means of fluid and tissue acquisition

    • Cancer staging

    • Cyst analysis

  • EUS as an interventional/therapeutic modality

    • Neurolysis

    • Transmural cyst drainage

    • Direct access to biliary system

    • More…


Overview

  • Several illustrative EUS cases from JMC

  • Basic EUS principles

  • What is ‘within reach’ of EUS +/- FNA?

  • Brief overview of selected diseases


Patient GR

  • 62 y.o. woman with significant weight loss over the past 6 months

  • CT a/p shows a 6 cm intra-abdominal mass

  • EGD/EUS/FNA planned to further evaluate lesion


Mass


Endosonographic Evaluation

  • EGD showed normal gastric mucosa with evidence of mild external compression vs. submucosal lesion in the area of the gastric incisura

  • EUS

    • Clear demarcation of hypoechoic mass adjacent to left lobe of the liver

  • FNA was performed


GR-GISTH&E


GR-GIST

C-KIT (CD117)


Patient DD

  • 62 y.o. man with history of alcoholism and recurrent pancreatitis since the 1970’s, admitted to an outside hospital with jaundice

  • MRI showed a large pancreatic head mass

  • ERCP for biliary drainage – failed

    • Complicated by pancreatic tail pseudocyst formation

  • PTC with internalization - successful

  • Patient left AMA and came to JMC

  • EUS/FNA performed to obtain diagnosis


PTC Drain

Panc Pseudocyst

Panc Mass


Endosonographic Evaluation

  • EUS

    • Large ~30mm hypoechoic pancreatic head mass surrounding the intrapancreatic CBD with PTC drain seen within CBD

    • Dilated PD to 5mm with evidence of chronic pancreatitis

  • FNA performed


DD- Pancreas Ca. Pap stain


DD-Pancreas Ca.

Pap stain


Patient CE

  • 69 y.o. man with h/o non-small cell lung cancer s/p LUL resection in 2006 who is referred after a chest CT showed new mediastinal lymphadenopathy

  • EUS/FNA scheduled to evaluate for recurrent disease


Aorta


Trachea

AP Node

Esophagus


Esophagus

SC Node


Endosonographic Evaluation

  • EUS

    • Suspicious lymph nodes in the aortopulmonary window, sized 6-11mm

    • Suspicious lymph nodes in the subcarinal space, sized 6-12mm

  • FNA performed


CE-Non-small cell ca.

Pap stain


CE-Non-small cell ca.

Pap stain


Radial Ultrasonography

  • Oblique-viewing instruments with an ultrasound transducer located at the tip

  • The circumferential ultrasound image is perpendicular to the long axis of the endoscope


Linear Ultrasonography

  • Ultrasound image parallel to the long axis of the endoscope

  • Capable of performing real time, ultrasound directed needle aspiration biopsy

  • Color Doppler analysis


Working End of Linear Echoendoscope


The Scope of the Echoendoscope

  • What can be assessed by EUS with potential FNA?

    • Any structure within several cm of U/L GI tract

    • Ability to see structures measuring 1 mm

    • Ability to perform FNA upon structures measuring 3mm

  • Limitations

    • Cannot visualize beyond air-filled structures

    • Cannot biopsy through air-filled structures, blood vessels, or the heart

      • Lung that is non-adjacent to esophagus, trachea, aorta, pulmonary artery, r/l atria


Risks of EUS FNA

  • Pancreatitis

    • < 1:100

  • Significant bleeding

    • < 1:500

  • Perforation

    • < 1:1000

  • Infection - rare

    • Antibiotics for transrectal FNA or FNA of cysts

  • Inadequate tissue

    • 1:10 to 1:5

    • Can be related to pathology of lesion

      • Cholangio, GIST


Thyroid Mass


FNA of Thyroid Mass


Right Lower Pole Kidney Mass


EUS in Pre-Malignant Disease

  • Pancreatic Cysts

  • PD fluid analysis

  • Pancreatic screening in high risk populations

    • Chronic pancreatitis

    • Family history of pancreatic cancer

    • Cancer syndromes

  • Submucosal lesions

    • Pancreatic rests


Pancreatic Cystic Fluid Analysis

  • Incidental pancreatic cysts seen in up to 20% of abdominal CT’s performed for any reason

  • Cystic lesions of the pancreas, even when found incidentally, may represent malignant or pre-malignant lesions

    • The majority of pancreatic cysts require evaluation by EUS/FNA

      • FNA measurement of CEA, amylase, genetic markers

      • Relatively sensitive and specific for differentiating mucinous cysts (IPMN, MCA) from non-mucinous cysts (SCA, Pseudocyst)


HOP Serous Cystadenoma


BOP Serous Cystadenoma


Oncology Consult?(FNA benign: Island of normal pancreatic tissue within serous cystadenoma)


Patient PS

  • Media reports state that the actor was diagnosed with an IPMN

  • IPMN is a pre-cancerous lesion

  • Conclusion: the IPMN had already progressed to adenocarcinoma prior to diagnosis/resection

    • Resected IPMNs often have foci of adenocarcinoma

  • Lesson: ALL pancreatic cysts need to be referred for risk stratification


EUS in Malignant Disease

  • Non-small cell lung cancer

  • Pancreatic cancer

  • Esophageal and gastric cancer

  • Cholangiocarcinoma

  • Rectal adenocarcinoma

  • Metastatic disease

    • Lymph nodes: aortopulmonary, subcarinal, para-esophageal, celiac, intra-abdominal

    • Left lobe of liver

    • Left adrenal

    • And beyond – right lobe of liver, right adrenal, ...


EUS and Lung Cancer

  • “We really do not need additional proof before EUS-FNA is considered the gold standard for invasive staging of non-small cell lung cancer and for diagnosis of posterior mediastinal lesions; there is little to lose and much to gain.”

  • -P. Vilmann and S.S. Larsen, Eur Respir J 2005; 25: 400–401


EUS and Lung Cancer


Lymph Node Stations


Normal AP Window


LAD at AP Window


FNA at AP Window


Subcarinal Space


LAD in Subcarinal Space


Likely Benign Abd LAD


Pancreatic Mass


Pancreatic Mass at CT


Pancreatic Mass at CT


'Pancreatic' Mass at EUS


FNA of Peri-pancreatic Mass

  • Metastatic Leiomyosarcoma


Liver Mass


FNA of Liver Mass


Hyperechoic Liver Masses


FNA of Hyperechoic Liver Mass


EUS Evaluation of Left Lobe of Liver


Abdominal LAD


EUS/FNA of Periportal LN


Primary Target Fail…


…Secondary Target Acquired(Carcinoma at FNA)


Normal Left Adrenal


Left Adrenal Met in NSCLC


Normal GI Wall Layers


Normal Esophagus and Cyst


Distal Esophageal Lesion


Normal Gastric Wall Layers


Mucosal Lesion


Mucosal Lesion


Malt Lymphoma


Gastric Lipoma


T2 Gastric AdenocarcinomaInvasion of Muscularis With Intact Serosa


T3 Gastric Cancer


T1 Rectal Cancer by EUS


T2 Rectal Cancer


Rectal Mass at CT: T4?(Apparent invasion of uterus)


Further History: Recent IUD Removal(Actinomycosis)


Celiac Plexus Neurolysis


Celiac Axis


Key Points

  • All patients with pancreatic cysts should have consultation for possible EUS/FNA

  • EUS/FNA is the standard of care in the loco-regional staging of many cancers

    • Lung

    • Esophageal

    • Gastric

    • Pancreatic

    • Cholangiocarcinoma

    • Rectal adenocarcinoma


Key Points, Continued

  • EUS is minimally invasive

    • Reduces need for mediastinoscopy, surgical biopsy, bronchoscopy, CT guided biopsy

  • Reduces morbidity/mortality while reducing health care costs

    • Appropriate cancer staging

      • Prevents unnecessary surgical resections

      • Identifies patients who will benefit from pre-op chemo/xrt


Cutting Edge EUS Applications

  • Role for EUS is expanding

    • EUS placement of fiducials for radiation therapy

    • EUS rendezvous procedure for accessing CBD

    • EUS directed brachytherapy

    • EUS guided hepaticogastrostomy for malignant CBD obstruction


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