1. Endoscopic Ultrasound: Applications in Pre-malignant and Malignant Disease December 20 th, 2010 Andrew T. Pellecchia, MD Director of Advanced Endoscopy Jacobi Medical Center

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

3. Evolution of EUS  EUS as an imaging study  EUS as a means of fluid and tissue acquisition  Cancer staging  Cyst analysis  EUS as an interventional/therapeutic modality  Neurolysis  Transmural cyst drainage  Direct access to biliary system  More…

4. Overview  Several illustrative EUS cases from JMC  Basic EUS principles  What is ‘within reach’ of EUS +/- FNA?  Brief overview of selected diseases

5. Patient GR  62 y.o. woman with significant weight loss over the past 6 months  CT a/p shows a 6 cm intra-abdominal mass  EGD/EUS/FNA planned to further evaluate lesion

10. Endosonographic Evaluation  EGD showed normal gastric mucosa with evidence of mild external compression vs. submucosal lesion in the area of the gastric incisura  EUS  Clear demarcation of hypoechoic mass adjacent to left lobe of the liver  FNA was performed

11. GR-GIST H&E

12. GR-GIST C-KIT (CD117)

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

18. Endosonographic Evaluation  EUS  Large ~30mm hypoechoic pancreatic head mass surrounding the intrapancreatic CBD with PTC drain seen within CBD  Dilated PD to 5mm with evidence of chronic pancreatitis  FNA performed

19. DD- Pancreas Ca. Pap stain

20. DD-Pancreas Ca. Pap stain

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

32. Endosonographic Evaluation  EUS  Suspicious lymph nodes in the aortopulmonary window, sized 6-11mm  Suspicious lymph nodes in the subcarinal space, sized 6-12mm  FNA performed

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

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

35. Radial Ultrasonography  Oblique-viewing instruments with an ultrasound transducer located at the tip  The circumferential ultrasound image is perpendicular to the long axis of the endoscope

36. Linear Ultrasonography  Ultrasound image parallel to the long axis of the endoscope  Capable of performing real time, ultrasound directed needle aspiration biopsy  Color Doppler analysis

37. Working End of Linear Echoendoscope

38. The Scope of the Echoendoscope  What can be assessed by EUS with potential FNA?  Any structure within several cm of U/L GI tract  Ability to see structures measuring 1 mm  Ability to perform FNA upon structures measuring 3mm  Limitations  Cannot visualize beyond air-filled structures  Cannot biopsy through air-filled structures, blood vessels, or the heart  Lung that is non-adjacent to esophagus, trachea, aorta, pulmonary artery, r/l atria

39. Risks of EUS FNA  Pancreatitis  < 1:100  Significant bleeding  < 1:500  Perforation  < 1:1000  Infection - rare  Antibiotics for transrectal FNA or FNA of cysts  Inadequate tissue  1:10 to 1:5  Can be related to pathology of lesion  Cholangio, GIST

40. Thyroid Mass

41. FNA of Thyroid Mass

42. Right Lower Pole Kidney Mass

43. EUS in Pre-Malignant Disease  Pancreatic Cysts  PD fluid analysis  Pancreatic screening in high risk populations  Chronic pancreatitis  Family history of pancreatic cancer  Cancer syndromes  Submucosal lesions  Pancreatic rests

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

45. HOP Serous Cystadenoma

46. BOP Serous Cystadenoma

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

48. Patient PS  Media reports state that the actor was diagnosed with an IPMN  IPMN is a pre-cancerous lesion  Conclusion: the IPMN had already progressed to adenocarcinoma prior to diagnosis/resection  Resected IPMNs often have foci of adenocarcinoma  Lesson: ALL pancreatic cysts need to be referred for risk stratification

49. EUS in Malignant Disease  Non-small cell lung cancer  Pancreatic cancer  Esophageal and gastric cancer  Cholangiocarcinoma  Rectal adenocarcinoma  Metastatic disease  Lymph nodes: aortopulmonary, subcarinal, para- esophageal, celiac, intra-abdominal  Left lobe of liver  Left adrenal  And beyond – right lobe of liver, right adrenal,...

50. EUS and Lung Cancer  “We really do not need additional proof before EUS-FNA is considered the gold standard for invasive staging of non-small cell lung cancer and for diagnosis of posterior mediastinal lesions; there is little to lose and much to gain.”  -P. Vilmann and S.S. Larsen, Eur Respir J 2005; 25: 400–401

51. EUS and Lung Cancer

52. Lymph Node Stations

53. Normal AP Window

54. LAD at AP Window

55. FNA at AP Window

56. Subcarinal Space

57. LAD in Subcarinal Space

58. Likely Benign Abd LAD

59. Pancreatic Mass

60. Pancreatic Mass at CT

62. 'Pancreatic' Mass at EUS

63. FNA of Peri-pancreatic Mass  Metastatic Leiomyosarcoma

64. Liver Mass

65. FNA of Liver Mass

66. Hyperechoic Liver Masses

67. FNA of Hyperechoic Liver Mass

85. EUS Evaluation of Left Lobe of Liver

86. Abdominal LAD

87. EUS/FNA of Periportal LN

88. Primary Target Fail…

89. …Secondary Target Acquired (Carcinoma at FNA)

90. Normal Left Adrenal

91. Left Adrenal Met in NSCLC

92. Normal GI Wall Layers

93. Normal Esophagus and Cyst

94. Distal Esophageal Lesion

95. Normal Gastric Wall Layers

96. Mucosal Lesion

98. Malt Lymphoma

99. Gastric Lipoma

100. T2 Gastric Adenocarcinoma Invasion of Muscularis With Intact Serosa

101. T3 Gastric Cancer

102. T1 Rectal Cancer by EUS

103. T2 Rectal Cancer

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

105. Further History: Recent IUD Removal (Actinomycosis)

106. Celiac Plexus Neurolysis

107. Celiac Axis

108. Key Points  All patients with pancreatic cysts should have consultation for possible EUS/FNA  EUS/FNA is the standard of care in the loco-regional staging of many cancers  Lung  Esophageal  Gastric  Pancreatic  Cholangiocarcinoma  Rectal adenocarcinoma

109. Key Points, Continued  EUS is minimally invasive  Reduces need for mediastinoscopy, surgical biopsy, bronchoscopy, CT guided biopsy  Reduces morbidity/mortality while reducing health care costs  Appropriate cancer staging  Prevents unnecessary surgical resections  Identifies patients who will benefit from pre-op chemo/xrt

110. Cutting Edge EUS Applications  Role for EUS is expanding  EUS placement of fiducials for radiation therapy  EUS rendezvous procedure for accessing CBD  EUS directed brachytherapy  EUS guided hepaticogastrostomy for malignant CBD obstruction