The document discusses innovations in endoscopic ultrasound (EUS) and its applications in oncology, highlighting the development of EUS techniques and the importance of histology for cancer diagnosis. It reviews advancements in contrast-enhanced EUS and elastography, emphasizing their roles in improving diagnostic accuracy and guiding treatment decisions. Additionally, it addresses the challenges and future directions of EUS-based techniques, including the need for adequate tissue samples for molecular analysis.

1. Fabia Attili MD, PhD
Digestive Endoscopy Unit
European Endoscopy Training Centre
Catholic University, Rome
INNOVAZIONI in ECOENDOSCOPIA

2. COS’E’
L’ECOENDOSCOPIA
E’ la combinazione di endoscopia ed ecografia

3. COS’E’L’ECOENDOSCOPIA

4. Strumento radiale
Strumento lineare

5. EUS radiale (imaging) EUS lineare (operativa)

6. 1980 First studies published in the literature
Hisanaga K. AJR 1980; Di Magno EP. Lancet 1980; Strohm WD. Endoscopy
1980
1984-88 Diagnostic EUS: Staging of luminal GI and
pancreatic cancers
Caletti GC. Scand J Gastroenterol 1984; Tanada Y. Scand J Gastroenterol 1984;
Yasuda K. Gastrointest Endosc 1988.
1992 EUS-FNA Vilman
P. Gastrointest Endosc 1992; Wegener M. Ultraschall Med 1992
1970 Development of the technique
1996 Interventional EUS
Wiersema MJ. Gastrointestinal Endoscopy 1996; Gress F. Gastrointestinal
Endoscopy 1996; Giovannini M. Endoscopy 2001
2013 Therapeutic EUS
Endoscopic Ultrasound
Historical Background

7. ECOENDOSCOPIA E ONCOLOGIA
CANCRO
Tipo di neoplasia
Marcatori Prognostitici predittivi
Diagnosi molecolare
Terapie Mirate

8.  The Sample
 The Analytical Technique
Two Ingredients
Cancer Heterogeneity - Moleular
Diagnosis – Target Therapies

9. CITOLOGIA o ISTOLOGIA ???

10. Histology advantages over Cytology
 Future tissue profiling to guide individualized
therapies highly dependent on tissue
availability
 Easier to interpret and to perform
immunohistochemicals studies than cytology
 Cytopathology expertise is not available in
many centers
 The need for cytopathology has limited the
widespread use of EUS throughout the world
Why Histology?

11. Gastrointest Endosc 2005;62:768-74.
Gastrointest Endosc 2004;59:185-90.

12. 19 g
22 g
25 g

14. 2015 : Siamo Pronti per L’istologia??
 19 G/Procore/Flex: very good results but
difficult to use and fear of complications
 22 Procore: too few results to draw
conclusions
 25 Procore: too small to get enough tissue
What we need to search for:
A needle that can be used by the large majority
of endosonographers able to provide the
adequate amount of tissue to perform all the
studies you need

15. 2015 : Siamo pronti per L’istologia??
NO

16. Contrast-enhanced EUS

17.  Signals from microbubbles appear approximately 10 seconds
after infusion and peak 20-30 seconds after infusion
Pancreas head image before
infusion of SonoVue
CH-EUS image 13 sec. after
infusion of contrast agent. Spotty
signals from microbubbles and
fine branching vessels
CH-EUS image 21 sec. After
infusion of contrast agent. Diffuse
parenchymal perfusion of
microbubbles. Bile Duct and MPD
are non-enhanced structures
Kitano, 2015
Contrast-enhanced EUS

18. Hypo-enhancement
Ductal carcinoma, hypoechoic area of
23 mm
Iso-enhancement
Tumor-forming chroning pancreatitis,
hypoechoic area of 22 mm
Hyper-enhancement
Neuroendocrine tumor, hypoechoic area
of 14 mm
Kitano, 2015
Contrast-enhanced EUS

19. CH-EUS for FNA
80-90% of false negative cases in EUS-FNA were correctly
classified by CH-EUS
CH-EUS could help to decide between surgery and follow-
up when then results of FNA are inconclusive
CH-EUS is also useful for identification of the target of
FNA, improving depiction of very small lesions and
identification of avascular sites (necrotic areas and
hemorragic risks)
Contrast-enhanced EUS
Kitano, 2015

20. Elastography
The science of creating
noninvasive images of
mechanical characteristics of
tissues
Real-time elastography during
the endoscopic ultrasound is
the study of tissue stiffness
and orients the diagnosis
towards different pathological
entities
EUS Elastography

21. 2016: siamo Pronti per l’istologia???
22 g core needle
25 g core needle

23. 2016: siamo pronti per l’istologia???
SI !!!!!!

24.  Drainage procedures
 Pancreatobiliary access and
drainage
 Oncologic procedures
 Fine needle injection, implantation and
EUS-guided directed therapies
 Vascular interventions
 Endosurgical interventions
Interventional and Therapeutic EUS