Git j club EUS FNA or cb.

1. Kurdistan Board GEH J ClubKurdistan Board GEH J Club
Supervised by:Supervised by:
Dr. Mohamed AlshekhaniDr. Mohamed Alshekhani
Professor in MedicineProfessor in Medicine
MBChB-CABM-FRCP-EBGH 2016MBChB-CABM-FRCP-EBGH 2016

2. Introduction:Introduction:
 With (EUS) guidance, it is possible to obtain tissue or fluidWith (EUS) guidance, it is possible to obtain tissue or fluid
samples from all lesions at a distance of not >5–6 cm, thesamples from all lesions at a distance of not >5–6 cm, the
distance the echoendoscope can reach.distance the echoendoscope can reach.
 EUS enables a gastroenterologist to sample the masses ofEUS enables a gastroenterologist to sample the masses of
the middle & inferior mediastinum, adjacent to thethe middle & inferior mediastinum, adjacent to the
esophagus; cystic or solid lesions of the pancreas,esophagus; cystic or solid lesions of the pancreas,
adjacent to the stomach / duodenum; perirectal lesions;adjacent to the stomach / duodenum; perirectal lesions;
subepithelial lesions of UGIT; upper abd masses&lesionssubepithelial lesions of UGIT; upper abd masses&lesions
located in the left kidney, left adrenal gland& left lobe oflocated in the left kidney, left adrenal gland& left lobe of
the liver by FNA or core biopsy.the liver by FNA or core biopsy.
 Needles used for EUS sampling include aspirationNeedles used for EUS sampling include aspiration
 (19, 20, 22 Gauge) or core biopsy needles (Pro-Core/(19, 20, 22 Gauge) or core biopsy needles (Pro-Core/
Trucut) (19, 20,22 Gauge).Trucut) (19, 20,22 Gauge).
 The tissue samples obtained by EUS-FNA or ProCoreThe tissue samples obtained by EUS-FNA or ProCore
needle can be handled in two different ways:needle can be handled in two different ways:

3. Introduction:Introduction:
 1.The aspirated cells are smeared on slide for cytopatho or1.The aspirated cells are smeared on slide for cytopatho or
 2. A cell block is prepared by fixing the tissue in formalin2. A cell block is prepared by fixing the tissue in formalin
for histopathology exam.for histopathology exam.
 The quantity/quality of obtained samples determine theThe quantity/quality of obtained samples determine the
preference of the method.preference of the method.
 Both methods are complementary&improve the diagnosticBoth methods are complementary&improve the diagnostic
value of EUS-FNA&if possible, should be applied by everyvalue of EUS-FNA&if possible, should be applied by every
EUS-FNA of solid tumors.EUS-FNA of solid tumors.
 Cell blocks enable the study of tissue architecture, specialCell blocks enable the study of tissue architecture, special
stains,immunohistochemistry, or molecular analyses.stains,immunohistochemistry, or molecular analyses.
 The Trucut needles samples are only used for histopatho.The Trucut needles samples are only used for histopatho.
 The choice of needle depends on type(solid–cystic),The choice of needle depends on type(solid–cystic),
location(mediastinum, pancreatic, subepithelial,location(mediastinum, pancreatic, subepithelial,
etc.)&etc.)&preliminary diagnosis (lymphoma, neuroendocrinepreliminary diagnosis (lymphoma, neuroendocrine
tumor, metastasis, etc.).tumor, metastasis, etc.).

4. Which EUS needle is more effective?:Which EUS needle is more effective?:
 The choice of FNA, Trucut biopsy, or 19 G/22 G/25 G didThe choice of FNA, Trucut biopsy, or 19 G/22 G/25 G did
not change the overall diagnostic rate.not change the overall diagnostic rate.
 The type/ size of EUS needles do not alter the diagnosticThe type/ size of EUS needles do not alter the diagnostic
yield.yield.
 The size of the needle that is independent of the location /The size of the needle that is independent of the location /
type of lesion is not a determining factor in the diagnostictype of lesion is not a determining factor in the diagnostic
yield.yield.
 However, using a 25 G needle, particularly for samplingHowever, using a 25 G needle, particularly for sampling
pancreatic head & uncinate process from the duodenum,pancreatic head & uncinate process from the duodenum,
provides user convenience&device safety.provides user convenience&device safety.
 In particular, FNA of the lymph nodes using a 19 G needleIn particular, FNA of the lymph nodes using a 19 G needle
will increase the blood that obscures cellularwill increase the blood that obscures cellular detail.detail.

5. Do aspiration techniqs affect sampling success?Do aspiration techniqs affect sampling success?::
 1. Slow pull technique: the stylet is slowly removed during1. Slow pull technique: the stylet is slowly removed during
the to & fro movement of the needle & sampling isthe to & fro movement of the needle & sampling is
conducted through capillary action (non-aspiration)conducted through capillary action (non-aspiration)
 2.Standard vacuum aspiration:after inserting the needle2.Standard vacuum aspiration:after inserting the needle
into the tissue, the needle stylet is withdrawn &10- or 20-into the tissue, the needle stylet is withdrawn &10- or 20-
mL vacuum syringe attached to the proximal part of themL vacuum syringe attached to the proximal part of the
needle & suction applied&suction should be discontinuedneedle & suction applied&suction should be discontinued
before removing the needle from the tissue.before removing the needle from the tissue.
 The slow pull technique increases the diagnostic yieldThe slow pull technique increases the diagnostic yield
without blood contamination&pulling back the stylet for 10without blood contamination&pulling back the stylet for 10
cm after each pass of the needle is an important point.cm after each pass of the needle is an important point.

6. Rapid on-site cytopathology incrRapid on-site cytopathology incr diagnostic efficacydiagnostic efficacy::
 Rapid on-site cytopathology will increase the diagnosticRapid on-site cytopathology will increase the diagnostic
efficacy to 100% without prolonging the procedure time.efficacy to 100% without prolonging the procedure time.
 To evaluate the adequacy, a cytopathologist examines theTo evaluate the adequacy, a cytopathologist examines the
rapidly stained air-dried smears for the quantity of lesionalrapidly stained air-dried smears for the quantity of lesional
cells&quality of cell preservation.cells&quality of cell preservation.
 Diff-Quik stain is commonly used for this purpose.Diff-Quik stain is commonly used for this purpose.
Hypocellular smears, those with poor cellular preservationHypocellular smears, those with poor cellular preservation
or obscuring blood & clotting artifact are considered “notor obscuring blood & clotting artifact are considered “not
adequate.”adequate.”
 The needle rinse is triaged for ancillary testing & cell blockThe needle rinse is triaged for ancillary testing & cell block
preparation.preparation.
 If the material obtained on the first pass is not adequate, aIf the material obtained on the first pass is not adequate, a
second pass is performed.second pass is performed.

7. Rapid on-site cytopathology incrRapid on-site cytopathology incr diagnostic efficacydiagnostic efficacy::
 In absence of on-site cytopathology:In absence of on-site cytopathology:
 1.A 4–6 passes will increase the diagnostic efficacy,but,1.A 4–6 passes will increase the diagnostic efficacy,but,
using 2ndneedle will increase the cost&extendedusing 2ndneedle will increase the cost&extended
anesthesia times inc risk for complications.anesthesia times inc risk for complications.
 2.Important that even&thin smears should be prepared.2.Important that even&thin smears should be prepared.
 3. Care not to use too much pressure in preparing smears3. Care not to use too much pressure in preparing smears
so that the cells are not crushed.so that the cells are not crushed.
 4. Some of the slides should be air-dried&some should be4. Some of the slides should be air-dried&some should be
immediately fixed in 95% ethanol.immediately fixed in 95% ethanol.
 4.The material for cell block or the tissue obtained by4.The material for cell block or the tissue obtained by
Trucut should be placed in formalin.Trucut should be placed in formalin.
 5.Samples obtained from multiple sites of the lesion rather5.Samples obtained from multiple sites of the lesion rather
than repeatedly from a single spot.than repeatedly from a single spot.
 6. 6. Sampling necrotic areas will decrease diag adequacy,6. 6. Sampling necrotic areas will decrease diag adequacy,
whereas sampling central & peripheral areas enhances it.whereas sampling central & peripheral areas enhances it.

8. Abstract:Abstract:
 EUS enables a gastroenterologist to sample the massesEUS enables a gastroenterologist to sample the masses
of the middle & inferior mediastinum, adjacent to theof the middle & inferior mediastinum, adjacent to the
esophagus; cystic or solid lesions of the pancreas,esophagus; cystic or solid lesions of the pancreas,
adjacent to the stomach / duodenum& perirectal lesions.adjacent to the stomach / duodenum& perirectal lesions.
 Needles used for EUS sampling include aspiration (19,20,Needles used for EUS sampling include aspiration (19,20,
22 Gauge) or core biopsy needles (ProCore /Trucut) (19,22 Gauge) or core biopsy needles (ProCore /Trucut) (19,
20,22 Gauge). The type and size of EUS needles do not20,22 Gauge). The type and size of EUS needles do not
alter the diagnostic results.alter the diagnostic results.
 Rapid on-site cytopathology will increase the diagnosticRapid on-site cytopathology will increase the diagnostic
efficacy to 100% without prolonging the procedure time.efficacy to 100% without prolonging the procedure time.
 Diagnostic efficacy of EUS-guided FNA or core biopsyDiagnostic efficacy of EUS-guided FNA or core biopsy
depends on the experience of an endoscopist &depends on the experience of an endoscopist &
cytopathologist.cytopathologist.
 With experienced endoscopist& cytopathologist, the sizeWith experienced endoscopist& cytopathologist, the size
of the needle does not have significant impact on succes.of the needle does not have significant impact on succes.

9. Abstract:Abstract:
 The choice of the needle size should be based on theThe choice of the needle size should be based on the
type of lesion, location of lesion&preliminary diagnosis. Iftype of lesion, location of lesion&preliminary diagnosis. If
possible, sampling should be conducted in the presencepossible, sampling should be conducted in the presence
of on-site cytopathological evaluation.of on-site cytopathological evaluation.
 If on-site cytopathology is not available, 4–6 passesIf on-site cytopathology is not available, 4–6 passes
should be performed.should be performed.
 The samples should be properly prepared& immediatelyThe samples should be properly prepared& immediately
sent to the cytopathology laboratory.sent to the cytopathology laboratory.

10. EUSEUS
 Originally utilized to ‘clear’ the bile duct pre-Originally utilized to ‘clear’ the bile duct pre-
cholecystectomy in patients with suspectedcholecystectomy in patients with suspected
CBD stonesCBD stones
 Less invasive alternative to ERCPLess invasive alternative to ERCP
 Risks similar to standard EGDRisks similar to standard EGD
 EUS still used for this indicationEUS still used for this indication
 Less than 20% of EUS procedures are performedLess than 20% of EUS procedures are performed
for this indication in established advancedfor this indication in established advanced
endoscopy centerendoscopy center

11. Evolution of EUSEvolution of EUS
 EUS as an imaging studyEUS as an imaging study
 EUS as a means of fluid and tissueEUS as a means of fluid and tissue
acquisitionacquisition
 Cancer stagingCancer staging
 Cyst analysisCyst analysis
 EUS as an interventional/therapeutic modalityEUS as an interventional/therapeutic modality
 NeurolysisNeurolysis
 Transmural cyst drainageTransmural cyst drainage
 Direct access to biliary systemDirect access to biliary system
 More…More…

12. OverviewOverview
 Several illustrative EUS cases from JMCSeveral illustrative EUS cases from JMC
 Basic EUS principlesBasic EUS principles
 What is ‘within reach’ of EUS +/- FNA?What is ‘within reach’ of EUS +/- FNA?
 Brief overview of selected diseasesBrief overview of selected diseases

13. Patient GRPatient GR
 62 y.o. woman with significant weight loss62 y.o. woman with significant weight loss
over the past 6 monthsover the past 6 months
 CT a/p shows a 6 cm intra-abdominal massCT a/p shows a 6 cm intra-abdominal mass
 EGD/EUS/FNA planned to further evaluateEGD/EUS/FNA planned to further evaluate
lesionlesion

18. Endosonographic EvaluationEndosonographic Evaluation
 EGD showed normal gastric mucosa withEGD showed normal gastric mucosa with
evidence of mild external compression vs.evidence of mild external compression vs.
submucosal lesion in the area of the gastricsubmucosal lesion in the area of the gastric
incisuraincisura
 EUSEUS
 Clear demarcation of hypoechoic mass adjacentClear demarcation of hypoechoic mass adjacent
to left lobe of the liverto left lobe of the liver
 FNA was performedFNA was performed

19. GR-GIST
H&E

20. GR-GIST
C-KIT (CD117)

21. Patient DDPatient DD
 62 y.o. man with history of alcoholism and recurrent62 y.o. man with history of alcoholism and recurrent
pancreatitis since the 1970’s, admitted to an outsidepancreatitis since the 1970’s, admitted to an outside
hospital with jaundicehospital with jaundice
 MRI showed a large pancreatic head massMRI showed a large pancreatic head mass
 ERCP for biliary drainage – failedERCP for biliary drainage – failed
 Complicated by pancreatic tail pseudocyst formationComplicated by pancreatic tail pseudocyst formation
 PTC with internalization - successfulPTC with internalization - successful
 Patient left AMA and came to JMCPatient left AMA and came to JMC
 EUS/FNA performed to obtain diagnosisEUS/FNA performed to obtain diagnosis

26. Endosonographic EvaluationEndosonographic Evaluation
 EUSEUS
 Large ~30mm hypoechoic pancreatic head massLarge ~30mm hypoechoic pancreatic head mass
surrounding the intrapancreatic CBD with PTCsurrounding the intrapancreatic CBD with PTC
drain seen within CBDdrain seen within CBD
 Dilated PD to 5mm with evidence of chronicDilated PD to 5mm with evidence of chronic
pancreatitispancreatitis
 FNA performedFNA performed

27. DD- Pancreas Ca.
Pap stain

28. DD-Pancreas Ca.
Pap stain

29. Patient CEPatient CE
 69 y.o. man with h/o non-small cell lung69 y.o. man with h/o non-small cell lung
cancer s/p LUL resection in 2006 who iscancer s/p LUL resection in 2006 who is
referred after a chest CT showed newreferred after a chest CT showed new
mediastinal lymphadenopathymediastinal lymphadenopathy
 EUS/FNA scheduled to evaluate for recurrentEUS/FNA scheduled to evaluate for recurrent
diseasedisease

40. Endosonographic EvaluationEndosonographic Evaluation
 EUSEUS
 Suspicious lymph nodes in the aortopulmonarySuspicious lymph nodes in the aortopulmonary
window, sized 6-11mmwindow, sized 6-11mm
 Suspicious lymph nodes in the subcarinal space,Suspicious lymph nodes in the subcarinal space,
sized 6-12mmsized 6-12mm
 FNA performedFNA performed

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

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

43. Radial UltrasonographyRadial Ultrasonography
 Oblique-viewing instruments with an ultrasound transducerOblique-viewing instruments with an ultrasound transducer
located at the tiplocated at the tip
 The circumferential ultrasound image is perpendicular to theThe circumferential ultrasound image is perpendicular to the
long axis of the endoscopelong axis of the endoscope

44. Linear UltrasonographyLinear Ultrasonography
 Ultrasound image parallel to the long axis of the endoscopeUltrasound image parallel to the long axis of the endoscope
 Capable of performing real time, ultrasound directed needleCapable of performing real time, ultrasound directed needle
aspiration biopsyaspiration biopsy
 Color Doppler analysisColor Doppler analysis

45. Working End of LinearWorking End of Linear
EchoendoscopeEchoendoscope

46. The Scope of theThe Scope of the
EchoendoscopeEchoendoscope
 What can be assessed by EUS with potentialWhat can be assessed by EUS with potential
FNA?FNA?
 Any structure within several cm of U/L GI tractAny structure within several cm of U/L GI tract
 Ability to see structures measuringAbility to see structures measuring 1 mm1 mm
 Ability to perform FNA upon structures measuringAbility to perform FNA upon structures measuring
3mm3mm
 LimitationsLimitations
 Cannot visualize beyond air-filled structuresCannot visualize beyond air-filled structures
 Cannot biopsy through air-filled structures, bloodCannot biopsy through air-filled structures, blood
vessels, or the heartvessels, or the heart
 Lung that is non-adjacent to esophagus, trachea, aorta,Lung that is non-adjacent to esophagus, trachea, aorta,
pulmonary artery, r/l atriapulmonary artery, r/l atria

47. Risks of EUS FNARisks of EUS FNA
 PancreatitisPancreatitis
 < 1:100< 1:100
 Significant bleedingSignificant bleeding
 < 1:500< 1:500
 PerforationPerforation
 < 1:1000< 1:1000
 Infection - rareInfection - rare
 Antibiotics for transrectal FNA or FNA of cystsAntibiotics for transrectal FNA or FNA of cysts
 Inadequate tissueInadequate tissue
 1:101:10 to 1:5to 1:5
 Can be related to pathology of lesionCan be related to pathology of lesion
 Cholangio, GISTCholangio, GIST

48. Thyroid MassThyroid Mass

49. FNA of Thyroid MassFNA of Thyroid Mass

50. Right Lower Pole Kidney MassRight Lower Pole Kidney Mass

51. EUS in Pre-Malignant DiseaseEUS in Pre-Malignant Disease
 Pancreatic CystsPancreatic Cysts
 PD fluid analysisPD fluid analysis
 Pancreatic screening in high riskPancreatic screening in high risk
populationspopulations
 Chronic pancreatitisChronic pancreatitis
 Family history of pancreatic cancerFamily history of pancreatic cancer
 Cancer syndromesCancer syndromes
 Submucosal lesionsSubmucosal lesions
 Pancreatic restsPancreatic rests

52. Pancreatic Cystic Fluid AnalysisPancreatic Cystic Fluid Analysis
 Incidental pancreatic cysts seen in up to 20%Incidental pancreatic cysts seen in up to 20%
of abdominal CT’s performed for any reasonof abdominal CT’s performed for any reason
 Cystic lesions of the pancreas, even whenCystic lesions of the pancreas, even when
found incidentally, may representfound incidentally, may represent malignantmalignant oror
pre-malignantpre-malignant lesionslesions
 The majority of pancreatic cysts requireThe majority of pancreatic cysts require
evaluation by EUS/FNAevaluation by EUS/FNA
FNA measurement of CEA, amylase, genetic markersFNA measurement of CEA, amylase, genetic markers
Relatively sensitive and specific for differentiatingRelatively sensitive and specific for differentiating
mucinous cysts (IPMN, MCA) from non-mucinous cystsmucinous cysts (IPMN, MCA) from non-mucinous cysts
(SCA, Pseudocyst)(SCA, Pseudocyst)

53. HOP Serous CystadenomaHOP Serous Cystadenoma

54. BOP Serous CystadenomaBOP Serous Cystadenoma

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

56. Patient PSPatient PS
 Media reports state that the actor wasMedia reports state that the actor was
diagnosed with an IPMNdiagnosed with an IPMN
 IPMN is aIPMN is a pre-cancerouspre-cancerous lesionlesion
 Conclusion: the IPMN had already progressedConclusion: the IPMN had already progressed
to adenocarcinoma prior toto adenocarcinoma prior to
diagnosis/resectiondiagnosis/resection
 Resected IPMNs often have foci ofResected IPMNs often have foci of
adenocarcinomaadenocarcinoma
 Lesson: ALL pancreatic cysts need to beLesson: ALL pancreatic cysts need to be
referred for risk stratificationreferred for risk stratification

57. EUS in Malignant DiseaseEUS in Malignant Disease
 Non-small cell lung cancerNon-small cell lung cancer
 Pancreatic cancerPancreatic cancer
 Esophageal and gastric cancerEsophageal and gastric cancer
 CholangiocarcinomaCholangiocarcinoma
 Rectal adenocarcinomaRectal adenocarcinoma
 Metastatic diseaseMetastatic disease
 Lymph nodes: aortopulmonary, subcarinal, para-Lymph nodes: aortopulmonary, subcarinal, para-
esophageal, celiac, intra-abdominalesophageal, celiac, intra-abdominal
 Left lobe of liverLeft lobe of liver
 Left adrenalLeft adrenal
 And beyondAnd beyond – right lobe of liver, right adrenal, ...– right lobe of liver, right adrenal, ...

58. EUS and Lung CancerEUS and Lung Cancer
 ““We really do not need additional proof beforeWe really do not need additional proof before
EUS-FNA is considered the gold standard forEUS-FNA is considered the gold standard for
invasive staging of non-small cell lung cancerinvasive staging of non-small cell lung cancer
and for diagnosis of posterior mediastinaland for diagnosis of posterior mediastinal
lesions; there is little to lose and much tolesions; there is little to lose and much to
gain.”gain.”
 --P. Vilmann and S.S. Larsen, Eur Respir JP. Vilmann and S.S. Larsen, Eur Respir J 20052005; 25:; 25:
400–401400–401

59. EUS and Lung CancerEUS and Lung Cancer

60. Lymph Node StationsLymph Node Stations

61. Normal AP WindowNormal AP Window

62. LAD at AP WindowLAD at AP Window

63. FNA at AP WindowFNA at AP Window

64. Subcarinal SpaceSubcarinal Space

65. LAD in Subcarinal SpaceLAD in Subcarinal Space

66. Likely Benign Abd LADLikely Benign Abd LAD

67. Pancreatic MassPancreatic Mass

68. Pancreatic Mass at CTPancreatic Mass at CT

69. Pancreatic Mass at CTPancreatic Mass at CT

70. 'Pancreatic' Mass at EUS'Pancreatic' Mass at EUS

71. FNA of Peri-pancreatic MassFNA of Peri-pancreatic Mass
 Metastatic LeiomyosarcomaMetastatic Leiomyosarcoma

72. Liver MassLiver Mass

73. FNA of Liver MassFNA of Liver Mass

74. Hyperechoic Liver MassesHyperechoic Liver Masses

75. FNA of Hyperechoic Liver MassFNA of Hyperechoic Liver Mass

93. EUS Evaluation of Left Lobe of LiverEUS Evaluation of Left Lobe of Liver

94. Abdominal LADAbdominal LAD

95. EUS/FNA of Periportal LNEUS/FNA of Periportal LN

96. Primary Target Fail…Primary Target Fail…

97. ……Secondary Target AcquiredSecondary Target Acquired
(Carcinoma at FNA)(Carcinoma at FNA)

98. Normal Left AdrenalNormal Left Adrenal

99. Left Adrenal Met in NSCLCLeft Adrenal Met in NSCLC

100. Normal GI Wall LayersNormal GI Wall Layers

101. Normal Esophagus and CystNormal Esophagus and Cyst

102. Distal Esophageal LesionDistal Esophageal Lesion

103. Normal Gastric Wall LayersNormal Gastric Wall Layers

104. Mucosal LesionMucosal Lesion

105. Mucosal LesionMucosal Lesion

106. Malt LymphomaMalt Lymphoma

107. Gastric LipomaGastric Lipoma

108. T2 Gastric AdenocarcinomaT2 Gastric Adenocarcinoma
Invasion of Muscularis With Intact SerosaInvasion of Muscularis With Intact Serosa

109. T3 Gastric CancerT3 Gastric Cancer

110. T1 Rectal Cancer by EUST1 Rectal Cancer by EUS

111. T2 Rectal CancerT2 Rectal Cancer

112. Rectal Mass at CT: T4?Rectal Mass at CT: T4?
(Apparent invasion of uterus)(Apparent invasion of uterus)

113. Further History: Recent IUD RemovalFurther History: Recent IUD Removal
(Actinomycosis)(Actinomycosis)

114. Celiac Plexus NeurolysisCeliac Plexus Neurolysis

115. Celiac AxisCeliac Axis

116. Key PointsKey Points
 All patients with pancreatic cysts should haveAll patients with pancreatic cysts should have
consultation for possible EUS/FNAconsultation for possible EUS/FNA
 EUS/FNA is the standard of care in the loco-regionalEUS/FNA is the standard of care in the loco-regional
staging of many cancersstaging of many cancers
 LungLung
 EsophagealEsophageal
 GastricGastric
 PancreaticPancreatic
 CholangiocarcinomaCholangiocarcinoma
 Rectal adenocarcinomaRectal adenocarcinoma

117. Key Points, ContinuedKey Points, Continued
 EUS is minimally invasiveEUS is minimally invasive
 Reduces need for mediastinoscopy, surgicalReduces need for mediastinoscopy, surgical
biopsy, bronchoscopy, CT guided biopsybiopsy, bronchoscopy, CT guided biopsy
 Reduces morbidity/mortality while reducingReduces morbidity/mortality while reducing
health care costshealth care costs
 Appropriate cancer stagingAppropriate cancer staging
Prevents unnecessary surgical resectionsPrevents unnecessary surgical resections
Identifies patients who will benefit from pre-opIdentifies patients who will benefit from pre-op
chemo/xrtchemo/xrt

118. Cutting Edge EUS ApplicationsCutting Edge EUS Applications
 Role for EUS is expandingRole for EUS is expanding
 EUS placement of fiducials for radiation therapyEUS placement of fiducials for radiation therapy
 EUS rendezvous procedure for accessing CBDEUS rendezvous procedure for accessing CBD
 EUS directed brachytherapyEUS directed brachytherapy
 EUS guided hepaticogastrostomy for malignantEUS guided hepaticogastrostomy for malignant
CBD obstructionCBD obstruction