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
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
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
Overview

  • Several illustrative EUS cases from JMC

  • Basic EUS principles

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

  • Brief overview of selected diseases


Patient gr
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



Endosonographic evaluation
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-GIST

C-KIT (CD117)


Patient dd
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 evaluation1
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


Patient ce
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



Trachea

AP Node

Esophagus


Esophagus

SC Node


Endosonographic evaluation2
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




Radial ultrasonography
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
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



The scope of the 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
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





Eus in pre malignant disease
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
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)




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


Patient ps
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
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
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














Fna of peri pancreatic mass
FNA of Peri-pancreatic Mass

  • Metastatic Leiomyosarcoma










Secondary target acquired carcinoma at fna
…Secondary Target Acquired(Carcinoma at FNA)












T2 gastric adenocarcinoma invasion of muscularis with intact serosa
T2 Gastric AdenocarcinomaInvasion of Muscularis With Intact Serosa





Rectal mass at ct t4 apparent invasion of uterus
Rectal Mass at CT: T4?(Apparent invasion of uterus)





Key points
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
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
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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