EUS           Pancreatic            Cancer                Paolo G. Arcidiacono         Endoscopic Ultrasonography UnitGast...
Pancreatic CancerThe facts:• The 10th most common malignancy• 4th largest cancer killer• American Cancer Society 2006:  – ...
• Survival rates are stage dependent.• Surgery –the only chance for cure• Ideal surgical candidate- 5 year  survival rate ...
EUS     Endosonography Unit San Raffaele Scientific Institute
Pancreatic Cancer• High risk population  screening• Early detection• Accurate staging                         Endosonograp...
Clinical Suspicion ofPancreatic neoplasm      MDHCT –    MDHCT doubtful      MDHCT +                     Endosonography Un...
EUS vs MDHCTMDHCT missed 47% lesions < 25 mm and 21% overall                           DeWitt J et al. Ann Intern Med 2004...
EUS and EUS-FNA             No definite mass on                  MDHCT               EUS     EUS-FNASensitivit            ...
EUS in patients with non  specific change of the pancreas               on CTAuthor      N° Patients              FNA     ...
EUS - negative Negative predictive value of EUS in  patients with clinical suspicion of          pancreatic cancerIn a fol...
MDHCT =     positive• lesion away from  vessels• lesion adherent to  vessels• lesion invading vessels                     ...
EUS vs MDHCT   Resectability          EUS   MDHC           EUS +                 T            MDHCT   Sens   88     90    ...
Diagnostic accuracy of EUS for       vascular invasion: meta-               analysis• 29 studies• Sensitivity 73%• Specifi...
Impact of EUS             1997-2001       2001-2004                P  % EUS           32              47              <0.5...
FNA or not FNA        ?                     Endosonography Unit                 San Raffaele Scientific Institute
EUS – FNA vs US/TC – FNA                     Seeding         Incidence of peritoneal carcinomatosis         C. Micames Gas...
Prevalence of pancreatic focal                lesions   N° pts / %    Prim Pancreatic         ary                         ...
Pancreatic Cancer•   Mediastinal Nodes•   Celiac Nodes•   Liver lesions•   Benign or low malignant    potential lesions   ...
EUS-FNA  CONS  • Endosonographer’s    skills  • On site cytologist                             Endosonography Unit       ...
Benchmark• The diagnostic yield of EUS-FNA of these  lesions has recently been proposed a  benchmark for the technical per...
EUS-FNA  HSR                      Overall Endoscopis Endoscopi Endoscopis                      (n=206)     tA     st B (n...
OnsitePros• “live” feedback  1. number to             Cons     adequacy                           2.    Inadequate compens...
Endosonography UnitSan Raffaele Scientific Institute
Adequacy %Blind                152/166 (91.6%)cytopathologist cyto - technician   120/166 (72.3%)teamPathologist team     ...
EUS OPEN           QUESTIONS• Differential diagnosis  – pancreatic cancer  chronic   pancreatitis  – lymph nodes• Vascula...
TissueCharacterization                Endosonography Unit            San Raffaele Scientific Institute
EUS – Contrast     Media         PC      CP         Sens   SpecEUS      73       83EUSSonovu   91       93e               ...
Parenchimal    flow          Endosonography Unit      San Raffaele Scientific Institute
Endosonography UnitSan Raffaele Scientific Institute
Endosonography UnitSan Raffaele Scientific Institute
Endosonography UnitSan Raffaele Scientific Institute
Clinical                     Presentation                      Jaundice                    No Jaundice              MDHCT ...
Endosonography UnitSan Raffaele Scientific Institute
Endosonography UnitSan Raffaele Scientific Institute
Elastograp    hy  Vascular involvement: 100% accuracy             Carrara et al. GUT 2009                                 ...
Elastography          Lymph nodes          Convention    EUS         EUS -            al EUS   elastograp     FNAAccurac  ...
ConclusionsEUS is to be considered for the time being as the most   valuable modality to:- follow-up high risk patients- e...
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Endoscopy in Gastrointestinal Oncology - Slide 9 - P.G. Arcidiacono - EUS in pancreatobiliary malignancies

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Endoscopy in Gastrointestinal Oncology - Slide 9 - P.G. Arcidiacono - EUS in pancreatobiliary malignancies

  1. 1. EUS Pancreatic Cancer Paolo G. Arcidiacono Endoscopic Ultrasonography UnitGastroenterology and Gastrointestinal Endoscopy Unit IRCCS San Raffaele Hospital Vita Salute San Raffaele University Milan, Italy Endosonography Unit San Raffaele Scientific Institute
  2. 2. Pancreatic CancerThe facts:• The 10th most common malignancy• 4th largest cancer killer• American Cancer Society 2006: – 33730 new diagnosis  32300 deaths Endosonography Unit San Raffaele Scientific Institute
  3. 3. • Survival rates are stage dependent.• Surgery –the only chance for cure• Ideal surgical candidate- 5 year survival rate of 20-30%• Inability to diagnose pancreatic cancer early based on symptoms alone Endosonography Unit San Raffaele Scientific Institute
  4. 4. EUS Endosonography Unit San Raffaele Scientific Institute
  5. 5. Pancreatic Cancer• High risk population screening• Early detection• Accurate staging Endosonography Unit San Raffaele Scientific Institute
  6. 6. Clinical Suspicion ofPancreatic neoplasm MDHCT – MDHCT doubtful MDHCT + Endosonography Unit San Raffaele Scientific Institute
  7. 7. EUS vs MDHCTMDHCT missed 47% lesions < 25 mm and 21% overall DeWitt J et al. Ann Intern Med 2004 MDHCT missed 60% of lesions < 2 cms Agarwal B, AM J Gastro 2004 Endosonography Unit San Raffaele Scientific Institute
  8. 8. EUS and EUS-FNA No definite mass on MDHCT EUS EUS-FNASensitivit 100 89ySpecificit 71 100yNPV 100 78PPV 90 100Accuracy 92 92 Agarwal B, AM J Gastro 2004 Endosonography Unit San Raffaele Scientific Institute
  9. 9. EUS in patients with non specific change of the pancreas on CTAuthor N° Patients FNA Rate of malignanHorwhat 69 patients 19/69 cy 8.7%2009 Enlarged (6/69)Singh pancreas 107 patients ??? 22%2008 EnlargedHo pancreas 50 patients 11/50 8%2006 Enlarged 22% 4/50 pancreas Horwart JD, JOP 2009 Singh S, Dis Dig Sci 2008 Endosonography Unit Ho S, Clin Gastroenterol Hepatol 2003 San Raffaele Scientific Institute
  10. 10. EUS - negative Negative predictive value of EUS in patients with clinical suspicion of pancreatic cancerIn a follow – up period of 25 months NO patient developed Cancer NPV (rule out cancer) 100% J Klapman et al; Am J Gastro 2005;100;1-4 Endosonography Unit San Raffaele Scientific Institute
  11. 11. MDHCT = positive• lesion away from vessels• lesion adherent to vessels• lesion invading vessels Endosonography Unit San Raffaele Scientific Institute
  12. 12. EUS vs MDHCT Resectability EUS MDHC EUS + T MDHCT Sens 88 90 80 Spec 67 64 93EUS + MDHCT PPV = 95%DeWitt J et al. Ann Intern Med 2004 Endosonography Unit San Raffaele Scientific Institute
  13. 13. Diagnostic accuracy of EUS for vascular invasion: meta- analysis• 29 studies• Sensitivity 73%• Specificity 90%• Positive likelihood ratio 9.1 (measure of how well the test identifies the disease)• Negative likelihood ratio 0.3 (how well the same test performs in excluding the disease) EUS is a better test to identify vascular invasion rather then excluding it Puli S.R. et al; GIE 2007;65;788-797 Endosonography Unit San Raffaele Scientific Institute
  14. 14. Impact of EUS 1997-2001 2001-2004 P % EUS 32 47 <0.56 % surgery 45 24 <0.01HCT used in 92% of patients J. Lachter et al. Pancreas 2007;35;130-134 Endosonography Unit San Raffaele Scientific Institute
  15. 15. FNA or not FNA ? Endosonography Unit San Raffaele Scientific Institute
  16. 16. EUS – FNA vs US/TC – FNA Seeding Incidence of peritoneal carcinomatosis C. Micames Gastrointest Endosc 2003 • EUS – FNA 2.2% • Percutaneous FNA 16.3% P < 0.025 American Joint Comittee on CancerUS – FNA preferred sampling technique in pancreatic cance Endosonography Unit San Raffaele Scientific Institute
  17. 17. Prevalence of pancreatic focal lesions N° pts / % Prim Pancreatic ary 56 / 50 Malignancy Metastatic Tum or 12 / 10.7 Benign Lesions 44 / 39.2 Endosonography Unit San Raffaele Scientific InstituteFritscher-Ravens A, Gastrointest endosc. 2001
  18. 18. Pancreatic Cancer• Mediastinal Nodes• Celiac Nodes• Liver lesions• Benign or low malignant potential lesions Chang 1997 44% avoid 68% surgery treatment strategy Mortensen 30% 2001 treatment strategy Fritscher- 21% 44% Ravens surgical treatment 2002 approach strategy Endosonography Unit San Raffaele Scientific Institute
  19. 19. EUS-FNA  CONS • Endosonographer’s skills • On site cytologist Endosonography Unit San Raffaele Scientific Institute
  20. 20. Benchmark• The diagnostic yield of EUS-FNA of these lesions has recently been proposed a benchmark for the technical performance of the exam.• In a recent multicenter (21 centers) retrospective study of 1075 pts, the overall diagnostic rate of malignacy was 71%, with a great variability among centers and endoscopists. Diagnostic rates less than 52% (lowest quartile) are considered Endosonography Unit below the quality standards San Raffaele Scientific Institute
  21. 21. EUS-FNA  HSR Overall Endoscopis Endoscopi Endoscopis (n=206) tA st B (n=98) t C (n=76) (n=32)No.of passes 479 69 224 186Mean (+ SD) 2,3 + 0,9 2.1 + 0.9 2.3 + 0,8 2.4 + 0.9Adequacy “on-site”: - not performed 7 (3%) 2 (6%) 5 (5%) ---- - obtained 182 26 (81%) 85 (87%) 71 (93%) - not obtained (88%) 4 (12%) 8 (8%) 5 (7%) 17 (9%) Endosonography Unit San Raffaele Scientific Institute
  22. 22. OnsitePros• “live” feedback 1. number to Cons adequacy 2. Inadequate compensation 2. prevents over- 3. Increases time of procedure biopsy 4. Expert endosonographer + 3. increases expert cytopathologist adequacy outside > 90% adequacy 4. decreases second look EUS-FNA 5. increases the yield Endosonography Unit 10 – 15% San Raffaele Scientific Institute
  23. 23. Endosonography UnitSan Raffaele Scientific Institute
  24. 24. Adequacy %Blind 152/166 (91.6%)cytopathologist cyto - technician 120/166 (72.3%)teamPathologist team 104/166 (62.6%) P value < 0.000 Endosonography Unit San Raffaele Scientific Institute
  25. 25. EUS OPEN QUESTIONS• Differential diagnosis – pancreatic cancer  chronic pancreatitis – lymph nodes• Vascular invasion Endosonography Unit San Raffaele Scientific Institute
  26. 26. TissueCharacterization Endosonography Unit San Raffaele Scientific Institute
  27. 27. EUS – Contrast Media PC CP Sens SpecEUS 73 83EUSSonovu 91 93e Endosonography Unit M Hocke et al W J Gastro;2006;12;246-250 San Raffaele Scientific Institute Becker D et al, Gastrointest Endosc 2001;
  28. 28. Parenchimal flow Endosonography Unit San Raffaele Scientific Institute
  29. 29. Endosonography UnitSan Raffaele Scientific Institute
  30. 30. Endosonography UnitSan Raffaele Scientific Institute
  31. 31. Endosonography UnitSan Raffaele Scientific Institute
  32. 32. Clinical Presentation Jaundice No Jaundice MDHCT EUS EUS-FNA MDHCT EUS EUS-FNASensitivity 67 100 84 88 100 96Specificit 100 50 100 63 50 100yNPV 12 100 22 63 100 89PPV 100 98 100 88 87 100Accuracy 68 98 85 82 88 97 8/9 FNA false negative were pts with stents otherwise NPV = 89% Endosonography Unit Agarwal B, AM J Gastro 2004 San Raffaele Scientific Institute
  33. 33. Endosonography UnitSan Raffaele Scientific Institute
  34. 34. Endosonography UnitSan Raffaele Scientific Institute
  35. 35. Elastograp hy Vascular involvement: 100% accuracy Carrara et al. GUT 2009 Endosonography Unit San Raffaele Scientific Institute
  36. 36. Elastography Lymph nodes Convention EUS EUS - al EUS elastograp FNAAccurac 52,6 hy 88,5 96,4y Endosonography Unit Saftiou et al.; GIE 2007;66;291-300 San Raffaele Scientific Institute
  37. 37. ConclusionsEUS is to be considered for the time being as the most valuable modality to:- follow-up high risk patients- early detection- local staging- tissue diagnosisof pancreatic cancer . EUS should be done in high volume Centers Endosonography Unit San Raffaele Scientific Institute

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