GRDecember20th2010 - Jacobi Medical Center

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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 precholecystectomy 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
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
H&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

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
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


Significant bleeding


< 1:1000
Infection - rare


< 1:500
Perforation


< 1:100
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
 Pancreatic
lesions
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, paraesophageal, 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 Adenocarcinoma
Invasion 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
 Prevents
cancer staging
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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