Endoscopic Ultrasound: Applications in Pre-malignant and Malignant Disease

1. Endoscopic Ultrasound:Applications in Pre-malignant and Malignant Disease December 20th, 2010 Andrew T. Pellecchia, MD Director of Advanced Endoscopy Jacobi Medical Center

2. 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

3. 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…

4. Overview • Several illustrative EUS cases from JMC • Basic EUS principles • What is ‘within reach’ of EUS +/- FNA? • Brief overview of selected diseases

5. 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

8. Mass

10. 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

11. GR-GISTH&E

12. GR-GIST C-KIT (CD117)

13. 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

16. PTC Drain Panc Pseudocyst Panc Mass

18. 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

19. DD- Pancreas Ca. Pap stain

20. DD-Pancreas Ca. Pap stain

21. 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

22. Aorta

25. Trachea AP Node Esophagus

30. Esophagus SC Node

32. 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

33. CE-Non-small cell ca. Pap stain

34. CE-Non-small cell ca. Pap stain

35. 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

36. 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

37. Working End of Linear Echoendoscope

38. 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

39. 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

40. Thyroid Mass

41. FNA of Thyroid Mass

42. Right Lower Pole Kidney Mass

43. 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

44. 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)

45. HOP Serous Cystadenoma

46. BOP Serous Cystadenoma

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

48. 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

49. 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, ...

50. 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