Eus talk.novato.march 2010 converted to ppt

1. Endoscopic Ultrasound (EUS):
from A to Z
Jan 2015
Jason Klapman,MD
Director of Endoscopy
Moffitt Cancer Center

2. • No relevant financial disclosures

3. Objectives
• Describe the main clinical uses of EUS
• Illustrate the role of EUS in the context of
other modalities in the investigation of
pancreatic/biliary disease
• Provide a perspective on how EUS advances
may impact the conventional approach to GI
disorders

4. What is EUS?
• convergence of US and
endoscopy
• US probe at scope tip allows
detailed views of GI tract wall
and adjacent structures
• History: 1st
published reports
in 1980s, increasing clinical use
since 1990s

5. EUS - fine needle aspiration (FNA)
QuickTime™ and a
DV/DVCPRO - NTSC decompressor
are needed to see this picture.
QuickTime™ and a
DV/DVCPRO - NTSC decompressor
are needed to see this picture.

6. EUS allows us to see...
• Esophagus: esophageal wall, mediastinal structures (aorta,
heart, azygous vein, right/left pleura, mediastinal LN, etc.)
• Stomach: gastric wall, pancreas (body/tail), celiac vessels,
liver, GB, spleen, left adrenal, left kidney
• Duodenum: duodenal wall, ampulla, pancreas
(head/uncinate), CBD, GB, portal vein, right kidney
• Rectum: rectal wall, anal sphincter, perirectal structures
(prostate, uterus), iliac vessels

7. EUS: mainstream clinical uses
• Evaluation of GI luminal tract disease:
• GI cancers: esophageal, gastric, rectal
• GI wall submucosal lesions
• Evaluation of pancreatico-biliary disease:
• Known of suspected pancreatic cancer
• Pancreatic cysts
• Biliary stones
• Acute and chronic pancreatitis

8. EUS : normal GI tract wall

9. EUS: roles in esophageal cancer
(1) determine local extent
of tumor (TN stage)
(2) guide treatment based
on tumor stage
(3) assess tumor response to
neoadjuvant tx?
Chak et al., GIE 2002; 55:655

11. Esophageal cancer:
stage-based treatment

12. Esophageal cancer - early stage
tumor stage T2: tumor invades into (but not through) esophageal wall
Patient underwent esophagectomy

13. GE junction cancer: locally advanced
tumor stage T3N1: tumor invades through muscular wall + local LN
Patient underwent preop chemoXRT followed by surgery

14. EUS-FNA of LN in esophageal cancer
•Technically feasible when tumor
not adjacent to LN
•Increases N staging accuracy
over EUS alone: 70 vs. 93%
•Wiersema. GIE 2001;53:751.

15. Esophageal cancer -
local staging accuracy
Local extent
T-stage
Regional LN
N-stage
CT 40-50% 40-70%
PET n/a 40-70%
EUS 80-85% 75-85%
from Rosch T. GIE Clin NA 1995; 5:537
Wiersema M. Gastroenterol 2003; 125:1626
van Vliet. Br J Cancer 2008; 98:547

16. EUS: roles in gastric malignancy
• guide treatment based on tumor stage
• early stage > surgery
• advanced stage > chemo, palliative surgery
• superficial lesions > endoscopic treatment
• tumor staging and follow-up of gastric
lymphoma (MALToma)
• evaluation of suspected linitis plastica

17. EUS: roles in rectal cancer
(1) Guide treatment based on tumor stage
(analogous to esophageal cancer)
(2) Post-operative surveillance:
• q3-6 months for patients that did not
undergo aggressive surgical resection (e.g.
mesorectal excision)

18. Rectal cancer:
stage-based treatment

19. Rectal cancer : early stage lesion
QuickTime™ and a
DV/DVCPRO - NTSC decompressor
are needed to see this picture.

20. Rectal cancer : locally advanced
T4- mass invades through rectal wall into prostate
candidate for neoadjuvant therapy

21. Rectal cancer:
local staging accuracy
Local extent
T-stage
Regional LN
N-stage
MRI 75-85% 60-65%
CT 65-75% 55-65%
EUS 80-95% 70-75%
from Savides T. GIE 2002; 56:S12 and Schwartz DA. GIE 2002; 56:100

22. Summary:
EUS for GI luminal cancers
• Determine local tumor extent (T and N stage)
• Guide treatment based on predicted tumor stage

23. Submucosal lesion at EGD
QuickTime™ and a
DV/DVCPRO - NTSC decompressor
are needed to see this picture.
What is it?
Is it worrisome?
Surgery?
Differential Dx ???

24. Etiology of submucosal lesions
by EUS
from Chak. GIE 2002; 56:S43

25. EUS: mainstream clinical uses
• Evaluation of GI luminal tract disease:
• GI cancers: esophageal, gastric, rectal
• GI wall submucosal lesions
• Evaluation of pancreatico-biliary
disease:
• Pancreatic cancer
• Pancreatic cysts
• Biliary stones
• Acute and chronic pancreatitis

26. Case:
• 65 year-old male presents with a 20 lb.
unintentional wt loss over 3 mo, and 2 wk hx of
jaundice. He denies abd pain or fevers.TB=12,
DB=8,Alk Phos=650.
• An MRI/MRCP was obtained- moderate CBD
dilation with “fullness” of the pancreatic head, no
definite mass.The patient has done internet
research, and asks if the next step is ERCP ?
What is the role of ERCP in suspected pancreatic CA?
Did the MRI miss a tumor? How often does that occur?
What is the role of EUS?

27. Best test to detect pancreatic cancer?
Sensitivity of CT/MRI vs. EUS
study N MRI CT EUS p significant
Palazzo 1993 64 69% 96% +
Yasuda 1993 29 72% 100% +
Muller 1994 49 83% 69% 94% + (EUS vs CT)
Nakaizumi 1995 232 65% 94% +
Sugiyama 1997 73 81% 96% +
Gress 1999 81 74% 100% +
Mertz 2000 35 53% 93% +
DeWitt 2004 80 86% 98% +
Borbath 2005 59 88% 98% ns

28. Detection of small tumors
< 2.5 - 3cm
study N
sensitivity:
CT EUS
Palazzo 1993 7 14% 100%
Muller 1994 15 53% 93%
DeWitt 2004 19 53% (MDCT) 89%
Main benefit of EUS over CT is detection of small lesions

29. Algorithm for pancreatic
tumor detection
Suspect pancreatic cancer
Non-invasive CT or MRI
“Pancreatic protocol”
Mass present
No mass seen
but high suspicion
EUSEvaluate resectability…

30. What if EUS is “normal” in a patient with
suspected pancreatic cancer?
study N follow-up results
Chak 2003 58 / 80
minimum - 6 mo
mean - 24 mo
no cancer
Chang 2005 155 / 693
8 - 48 mo
mean - 24 mo
no cancer
Gress 2006 21 / 50 median - 27 mo no cancer

31. Main clinical questions after
detection of pancreatic cancer
• Does the mass appear surgically resectable?
• What is the best test to determine
resectability?
• Is a tissue diagnosis needed?
• Best method to collect tissue sample?
• CT-bx? ERCP with brushings? EUS-FNA?

32. Accuracy in assessing resectability in
pancreatic cancer
study N MRI CT EUS p-value
Gress 1999 81 60% 93% <0.001
Ahmad 2000 63 77% 69% ns
Ramsay 2004 27 83% 76% 63% ns
Soriano 2004 62 75% 83% 67% ns
DeWitt 2004 53 77% 77% ns
CT/MRI + EUS may be more accurate than either alone
Ahmad 2000, Soriano 2004

33. • EUS reveals a 3cm mass in the pancreas that abuts the
portal vein- potentially resectable. He is referred to
surgery. The patient has history of CAD. Surgeon & pt.
are reluctant for Whipple unless a dx of tumor is
confirmed. How should this mass be biopsied?
(1)CT guided bx
(2)EUS-FNA
(3)ERCP
(4)Laparoscopic
QuickTime™ and a
DV/DVCPRO - NTSC decompressor
are needed to see this picture.
Case continued...

34. Indications for tissue diagnosis
in suspected pancreatic cancer
Indicated: tissue bx might
impact treatment plan
NOT Indicated: bx will not
impact treatment plan
metastatic cancer
dx for neoadjuvant treatment
confirm dx in high risk pt prior to surgery
questionable lesion on imaging (?focal pancreatitis)
questionable tumor type- lymphoma?
Example: 50 yo with painless jaundice, wt loss, visible
lesion on CT/EUS that appears resectable
bx positive >> resection
bx negative >> resection (assume false neg)

35. Best method for pancreatic tumor biopsy?
EUS-FNA vs. CT/US-FNA
•Horwhat GIE 2006: Single-center, randomized prospective
cross-over study (1997-2002)
•EUS-FNA (n=41) CT/US (n=43)
•Sensitivity for diagnosing panc. cancer higher with EUS:
• EUS-FNA: 84%
• CT / US guided FNA: 62% (p=0.12)
•Unable to reach target enrollment (attributed to increased
referral specifically for EUS-FNA)

36. Complications of tissue sampling
EUS vs. percutaneous-FNA
2% vs. 16% ; p=0.025
Micames GIE 2003

37. Tissue sampling in pancreatic cancer
EUS-FNA or ERCP?
sensitivity
Procedure
related
pancreatitis
EUS-FNA >85% 1-2%
ERCP 40-75% 3-5%
Fritscher-Ravens, AJG 2000
Kochman, JCO 1997
Jacobsen, GIE 2005
Jailwala, GIE 2000
Brugge, GIE 2010
From Brugge NEJM 1999; 341

38. What is the role of ERCP in pancreatic cancer?
• Tumor detection: No role
• ERCP can show dilated ducts
• CT/MRI/EUS more sensitive and
less risky (cholangitis, pancreatitis)
• Tumor staging: No role
• Extent of bile / pancreatic duct
involvement rarely relevant for
consideration of resectability
• Similar info readily available on
CT / MRI
• Tissue diagnosis: possible
• EUS-FNA > ERCP
• Reasonable to perform ERCP
tissue acquisition in those needing
biliary decompression
MAIN ROLE:
Biliary Decompression in surgically
unresectable disease

39. Pre-op ERCP improves serum
bilirubin, but is it needed?
Study type N outcome
Lai 1994
randomized
prospective
43 stent
44 no stent
no diff in periop
morbidity/mortality
Karsten 1996 retrospective
149 stent
57 no stent
no diff in periop
infections
Povoski 1999 retrospective
126 stent
35 no stent
increased infections,
mortality with stent
Sewnath 2001
prospective
not random cohort
232 stent
58 no stent
no diff in periop
morbidity/mortality

40. EUS: mainstream clinical uses
• Evaluation of GI luminal tract disease:
• GI cancers: esophageal, gastric, rectal
• GI wall submucosal lesions
• Evaluation of pancreatico-biliary disease:
• Pancreatic cancer
• Pancreatic cysts
• Biliary stones
• Acute and chronic pancreatitis

41. Pancreatic cysts : etiology

42. Pancreatic cyst dilemma:
benign or potentially malignant?
Lesion EUS appearance
EUS-FNA
viscosity amylase CEA
pseudocyst internal debris low high low
serous
cystadenoma
microcysts low low low
IPMN
dilated PD or side
branches
high high high
mucinous
cystadenoma
macrocystic
sepatated
high low high
IPMN or MCA
with CA
above with mural
nodule, mass
high high or low high

43. Case
The surgical team consults GI on a 45 year-old female with
episodic RUQ pain associated with meals. Abd US reveals
GB stones, otherwise nl biliary system. Two of 3 sets of LFTs
over the last several months were elevated (during episodes
of pain). MRCP showed mildly dilated ducts, no definite
stones. Should an ERCP be performed prior to lap chole...
How accurate is a negative MRCP?
What is the role of EUS in this setting?

44. MRCP, EUS, or ERCP for bile duct stones?
MRCP sensitivity >90%
(for larger stones)
Barish, NEJM 1999
Lower sensitivity for stones <6mm
Scheiman, AJG 2001

45. EUS for CBD stones:
•>90% accuracy rates (even
for smaller stones)
•Cost-effective vs. ERCP, IOC in
patients with low-moderate
suspicion for CBD stones Sahai,
GIE 1999
QuickTime™ and a
DV/DVCPRO - NTSC decompressor
are needed to see this picture.

46. Evaluation of biliary stones:
MRCP EUS ERCP
Indications Low suspicion CBD
stone
Low-mod. suspicion High suspicion,
cholangitis, severe
GS pancreatitis
Detection rate > 90%
(large stones)
> 90% Gold standard
Therapeutic No No, but can do
immediate ERCP
Yes
Approximate Cost
Medicare 2007
$560 $780 $ 780-1530
Risks none <1% 4-10%
++

47. Role of EUS in acute pancreatitis
• detect GB stones missed on other imaging
(acute recurrent pancreatitis)
• detect retained CBD stone in gallstone
pancreatitis
• detect small tumor

48. EUS: criteria for chronic pancreatitis
abnl on ERCP

49. Safety of EUS
From Shah J. GIE Clin N Am 2007

50. New strategy in evaluating pancreatic/biliary
disease : Single-session EUS + ERCP
• Perform EUS > immediate ERCP, if needed
• Optimize care:
• combine high diag yield of EUS with high therapeutic success of ERCP
• minimize risks of unnecessary ERCP
• Limitations
• requires specialized endo unit with fluoro + EUS
• needs endoscopist / assistants trained in both

51. EUS-based approach to ERCP
CPMC experience
• Pts in need of EUS and ERCP are offered
both procedures at one session
• Pts in whom EUS may warrant ERCP are
offered same session ERCP
• All procedures performed in endoscopy
room with fluoro + EUS
• All procedures performed by single
endoscopist experienced in EUS & ERCP

52. EUS-based ERCP:
suspected CBD stones
• EUS “diagnostic cholangiogram”
• stone present > ERCP
• stone absent > no ERCP
• same session (one sedation)
QuickTime™ and a
DV/DVCPRO - NTSC decompressor
are needed to see this picture.

53. EUS-based ERCP:
suspected malignant obstruction
• mass present or not?
• immediate staging information-
resectable?
• tissue sampling (EUS-FNA)
• decide need for ERCP and
appropriate stent type
QuickTime™ and a
DV/DVCPRO - NTSC decompressor
are needed to see this picture.

54. EUS : from A to Z
Summary
• EUS has an established role in evaluating GI tract
cancers, submucosal GI lesions, and a variety of
pancreaticobiliary diseases
• Advances in EUS technology and treatment strategy
are improving the diagnostic and therapeutic approach
for patients with various types of GI disorders
?