Endoscopic UltraSound (EUS) Endoscopic Mucosal Resection (EMR) Moishe Liberman Director C.E.T.O.C.

Transcription

1 Endoscopic UltraSound (EUS) Endoscopic Mucosal Resection (EMR) Moishe Liberman Director C.E.T.O.C. Division of Thoracic Surgery Centre Hospitalier de l Université de Montréal

2 Research Grants: Disclosures Ethicon Endosurgery Boston Scientific Olympus Baxter (in kind support)

3 Outline EUS Tricks for Esophageal Cancer Staging EUS in Lung Cancer EMR Thoracic Interventional Endoscopy in Your Practise

4 EUS Tricks for Esophageal Cancer Staging

5 T Staging TX T0 Tis T1a T1b T2 T3 T4a T4b Primary tumor cannot be assessed No evidence of primary tumor High grade dysplasia (previously CIS) Lamina Propria or Muscularis Mucosa Submucosa Muscularis Propria Adventitia Resectable tumor invading pleura, pericardium or diaphragm Unresectable tumor invading other adjacent structures (aorta, vertebra, trachea) AJCC Cancer Staging Manual, Seventh Edition (2010)

6 Tissue Diagnosis EGD - Increased number of biopsies increases diagnostic accuracy First Biopsy: 93% Four Biopsies: 95% Seven Biopsies: 98% + Brush: 100% EUS for Difficult Cases EMR for Diagnosis Graham DY et al. Gastroenterology 1982;82:228.

7 EUS T1b

8 EUS T2

9 EUS T3

10 EUS T4a

11 Mini-Probe Radial EUS Through the scope High frequency US images MHz Limited tissue penetration Higher tissue resolution No FNA OBSTRUCTING TUMORS Tis, T1 Mechanical Drive unit required

12 Esophageal Dilation for EUS Multi-center Retrospective 272 EUS for esophageal CA Dilation in 77 Successful in 73 1 perforation following dilation 1 perforation without dilation Jacobsen et al. Dig Dis Sci 2007;52:817.

13 N Staging NX N0 N1 N2 N3 Regional LNs cannot be assessed No regional LN metastases Regional LN metastases in 1-2 nodes Regional LN metastases in 3-6 nodes Regional LN metastases in 7 nodes 2R AJCC Cancer Staging Manual, Seventh Edition (2010)

14 Gastro-Hepatic Ligament LN

15 Celiac Axis

16 4L

17 Predicting Malignancy Using Endoluminal Ultrasound Characteristics in Mediastinal Lymph Nodes Prospective clinical trial NCT Ultrasound Criteria Variables Long axis cm Round shape Yes or No Sharp border Yes or No Homogenous pattern Yes or No Low echogenecity Yes or No Sensitivity: 63.2% Specificity: 61.1% Goudie et al Recruiting

18 EUS - M Staging Liver Adrenal +/- Peritoneum +/- Omentum

19 EUS After Chemo/XRT EUS inaccurate for T Staging Fibrotic changes - overstaging Linear EUS and FNA helpful Tmax reduction has been shown to correlate with survival

20 EUS in Stented Patients

21 C.E.T.O.C. Esophageal Cancer Endoscopic Intervention 1. Flexible EGD 2. Radial EUS T Staging 3. Linear EUS N Staging 4. Flexible Bronchoscopy 5. Linear EBUS 6. In Non-Bypassable Tumors Linear EBUS in Esophagus

22 Stenotic Tumors EBUS for EUS EBUS utilized in the esophagus for T and N staging was necessary in 5 cases (11.9%) No tumor was dilated prior to EBUS Endobronchial Ultrasound Added to Endoscopic Ultrasound Improves Staging in Esophageal Cancer. STS 2013 (Annals of Thoracic Surgery in press)

23 EUS T4 EBUS Scope

24 EUS in Lung Cancer

25 Diagnostic Yield of EUS-FNA as a First Test EUS established a tissue diagnosis in 70% of cases when used as the first diagnostic test Singh P, Camazine B, Jadhav Y, et al. American Journal of Respiratory and Critical Care Medicine. 2007;175:

26 Mediastinal Lymph Node Access NODAL BASSIN EBUS EUS CM AM VATS 1 Highest Mediastinal 2 Upper Paratracheal 3 Pre-Vascular Retrotracheal 4 Lower Paratracheal 5 Subaortic (AP Window) 6 Para-Aortic NEW! 7 Subcarinal 8 Paraesophageal 9 Pulmonary Ligament 10 Hilar 11 Interlobar Gastrointestinal Endoscopy 2011;73(5):

27 Endosonography vs SMS Sens NPV Accuracy EBUS 72% ( ) 88% ( ) 91% ( ) EUS 62% ( ) 85% ( ) 88% ( ) EBUS-EUS 91% ( ) 96% ( ) 97% ( ) Endosonographic Mediastinal Lymph Node Staging in Lung Cancer - A Prospective Head-to-Head Comparison with Gold Standard Surgical Staging Techniques. ATS 2013

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29 Endoscopic Mucosal Resection EMR

30 EMR Indications Diagnosis T Staging High Grade Dysplasia Diagnosis Treatment Early Esophageal Cancer Treatment Diameter < 2 cm < 1/3 circumference of esophageal wall Limited to the mucosa T1a no submucosal invasion

31 Endoscopic Mucosal Resection Cap Technique Lift and Cut

32 Endoscopic Mucosal Resection Multi-Band Ligation and Snare Suck-Band-Cut Technique

33 Needle Knife Technique ESD

34 EMR Complications Bleeding: 9-46% Perforation: <1% Stricture

35 EMR Complications

36 Thoracic Interventional Endoscopy in Your Practise

37 Mediastinoscopy vs Mediastinotomy vs EBUS-EUS 100% 90% 80% 70% 60% 50% 40% 30% EBUS-EUS Anterior Mediastinotomy Cervical Mediastinoscopy 20% 10% 0%

38 Mediastinoscopy vs Mediastinotomy vs 600 EBUS-EUS Cervical Mediastinoscopy Anterior Mediastinotomy EBUS-EUS

39 Interventional Thoracic Endoscopy Effect on Volume Interventional Endoscopy

40 1200 Interventional Thoracic Endoscopy Effect on Volume Interventional Endoscopy Overall Thoracic Volume Lobectomy Esophagectomy Airway Surgery

41 Endoscopic UltraSound (EUS) Endoscopic Mucosal Resection (EMR) Moishe Liberman Director C.E.T.O.C. Division of Thoracic Surgery Centre Hospitalier de l Université de Montréal