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

slide2
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
slide12
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
slide16
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
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
slide25
Trachea

AP Node

Esophagus

slide30
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)
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
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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