1. Case presentation Transylvania GI Oncology 2014

2. Case 1 F 63 y Colonoscopy Colonoscopy- 2011 – Stenotic,circuferential neoplasm in the transvers colon 85cm from anal verge. – Another 2 polips on the descending colon and sigmoid – tatoo – extra-large rectal polip 6/6cm in the rectum – staging by EUS T1??

3. Surgical intervention 2011 - left hemicolectomy and transanal polipectomy. Delay -Follow up colonoscopy -2014 Sesil rectal tubulo-vilos adenoma 2/2,5cm + 2 small polips

4. Case 2 F 64, Dispepsia, NSAID and warfarine Moderate anemia and 2-3 episodes of melena EGD – D2 sesil polip 1,5-2cm – source of bleeding? (colonoscopy without lesions) Histology - Tubulo-vilos adenoma with low grade displazia

5. Case 3 F 54 -11/2013 Semicircumferential sesil rectal polip 5/5cm Patology – tubulo-vilos adenom with high grade displazia EMR – rectal polip without previous EUS staging.

6. Patology report: We examen 13 slides of the tissular material Vilos –adenoma with small tubular component, low and high grade displazia and with the stalk free of glandular elements. There are only 2 section (block 5) where you could see a malignant transformation of tubular adenocarcinoma moderate differentiate with a small mucinous component extracitoplasmic, moderate desmopazia and neutrofilic infilatrate; no angiolimfatic or perineural invasions in those sections. The tumoral islets cell are extend beyond the muscularis mucosae without the possibility to appreciate the real resection margin. Conclusion: tubular adenocc G2 – on the vilos adenoma with high grade displazia. Conclusion: tubular adenocc G2 – on the vilos adenoma with high grade displazia.

7. Post EMR - EUS Impresion: – Progresion to 25cm from anal verge, no LN at iliac station. – Examination of the ulcer bed, there are image sections which could plead for muscularis invasion or artefacts produce by inflamatory process after EMR. T1/T2 – Two images of rectal LNs with 1cm and 0,4cm in diameter. N1 Oncologic consult MRI of the pelvis – second investigation method.

8. Pacient follow a neoadjuvant protocol T2N1 After 1month after she finished the neoadjuvant therapy protocol – colonoscopy with rectum biopty No histologic signs of disease Pelvis MRI – no signs of disease in abdomen or pelvis 5/2014

9. Case 4 B 64 Epigastric pain, heartburn, regurgitations History of duodenal ulcer – 15y ago Melena, moderat anemia. EGD: - atipic gastric ulcer in the prepiloric area Patology report: – Negativ for cancer EUS – radial exam

10. EUS - radial

11. Re-biopty the lesion Patology report – negativ for cancer. Which is the best way to follow? – Re-biopty with jumbo forceps or snare biopty – EUS-FNA?

12. Case 5 B 60 y Moderate dilatation of Wirsung duct EUS – 7/2013 – The pancreatic duct is dilatated on all of his course with a caliber of 4-5mm. – La nivelul corpului mai multe formatiuni chistice grupate intr-o formatiune Multiple cystic lesions grouped in the pancreatic body, 1,8/1,2cm – possible seros cyst adenoma. There are also other sections where you could see a comunication with the main pancreatic duct and a small mural nodul – possible IPMN with high risk for neoplazia.

13. EUS-FNA ???

14. Case 6 F 55y Abdominal pain, cronic constipation Abdominal CT scan: -duodenal GIST Recomandation for EUS 1/2014 – EUS – radial exam – Normal aspect of the pancreas, PD normal size and no dilatation of the CBD (5mm) – No suspicions of ampuloma – From the level of D3 in the same plain with aorta and vena cava, on the oposite site of duodenum circuference, there are 2 lesions, well deliniated, outside of duodenal wall, hipoechoic, inomogenuos with diameters of 1,5cm and 1,8cm. – Conclusions: Malignant LN. Suspected colon cancer

16. Patient had negativ colonoscopy and enteroscopy Then patient went to abdominal surgery, they extract the LN. Pathology report said: – LN with a metastasis of a carcinoma type tumor – Low mitotic index and no tumoral necrosis – Ki67 pozitiv 2-3% – IHC – moderate pozitiv for Cromogranin A and intense pozitiv for sinaptofizin During abdominal surgery the surgeon said the pancreatic head and ampulary region seemed a little bit hard ??? Still no decision for whipple resection.

17. CT scan 5/2014 showed several modification Suspected lesion with high contrast acumulation in the areterial tim, 7/14/5mm visible in the pancreatic papila area with the extension in the inferior wall of the pancreatic duct. PD is dilated to 5mm in the pancreatic head with a length of 7,5mm. Pancreas divisium Compared with the CT scaun 12/2012 – progression of pancreatic atrophy and lipomatos accumulation. Surgeon propose a Whipple resetion !!! She came for a second oppinion – EUS- FNA??

18. Case 7 B 79 y Upper right quadrant pain, hepatic cysts and GB stones. Transabdominal US – suspicions of pancreatic cystic lesions. EUS 1/2014 – Multiple cysts with septations in direct contact and PD communications and side branches 2,6/2,2cm, fine wall without evidence of mural nodules. – High probability of IPMN without clear risk of malignacy transformation. – PD mild dilatated in the body – 3,8mm – Normal CBD and ampula.

19. Follow up – EUS or EUS-FNA??