Slide 1. Slide 2. Slide 3 Pancreatic Cancer- Case #1. Endoscopic management of GI malignancy. Endoscopic approaches in GI malignancy- Agenda

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1 Slide 1 A teaching hospital of Harvard Medical School Endoscopic management of GI malignancy Tyler Berzin MD, MS Center for Advanced Endoscopy Division of Gastroenterology Beth Israel Deaconess Medical Center Slide 2 Endoscopic approaches in GI malignancy- Agenda 1: Pancreatic cancer a. Diagnosis- brush cytology vs. EUS/FNA b. Management of biliary strictures (plastic/metal stents) c. Pain control/palliation 2. Esophageal Cancer- does EUS have a role in staging? 3. Luminal stenting for GI malignancy 4. Endoscopy in altered anatomy Slide 3 Pancreatic Cancer- Case #1 65 y.o. M in generally excellent health presents with several weeks of episodic post-prandial abdominal pain and sudden worsening RUQ pain. Evaluated in New Hampshire: Afebrile, benign exam- mild RUQ tenderness ALT 871, AST 297, Tbili 2.9, Lipase 314. RUQ ultrasound shows biliary dilation Initial concern for gallstone blocking the bile duct Patient requested further evaluation at BIDMC

2 Slide 4 Slide 5 Slide 6 CBD stricture PD stricture

3 Slide 7 Slide 8 LFTs normalize and symptoms partially improve after biliary stent placement ERCP brushings show atypical cells CA19-9 = 35ng/dL (0-37) Slide 9 LFTs normalize and symptoms partially improve after biliary stent placement ERCP brushings show atypical cells CA19-9 = 35ng/dL (0-37) What is the next step?

4 Slide 10 CT scan Slide 11 CT scan Slide 12 CT scan cm mass in the pancreatic head with associated double-duct sign. - No celiac/sma involvement - The adjacent portal vein is narrowed just distal to the splenoportal confluence. - No evidence of metastatic disease - Several small peri-pancreatic lymph nodes do not meet size criteria

5 Slide 13 Pancreatic Cancer- Case Summary 65 y.o. M in generally excellent health presents with several weeks of episodic post-prandial abdominal pain and sudden worsening RUQ pain. Found to have double duct sign on ERCP, 3cm pancreatic mass identified on CT scan. Compressing portal vein. Cytology results: ERCP brushing: atypical, likely reactive epithelium Slide 14 Slide 15

6 Slide 16 EUS-FNA positive for: adenocarcinoma Slide 17 Tissue diagnosis for pancreatic cancer Sensitivity of biliary cytology/brush sample during ERCP for pancreatic adenocarcinoma is ~30%. Sensitivity of EUS-FNA for pancreatic adenocarcinoma is ~75-85% (94% if atypical or suspicious findings are included) Fogel EL et al. GIE 2006 Turner BG et al. GIE 2010 Bang JY et al. GIE 2012 Slide 18 With new diagnosis of pancreatic adenocarcinoma causing jaundice, is plastic or metal bile duct stent more appropriate?

7 Slide 19 Plastic vs. Metal Biliary Stent? - Plastic biliary stents: - Metal biliary stents: (SEMS) Slide 20 Plastic vs. Metal Biliary Stent? - Plastic biliary stents: -Cheaper ($80). -Luminal diameter ~3mm. -Typically need replacement Q4-8 weeks because of biliary sludge blockage - Metal biliary stents: - Expensive ($1000) - Luminal diameter = 10mm - No longer permanent ; newer covered/coated stents are removable endoscopically. - Metal stent does not interfere with Whipple resection - May be cost-effective for patients receiving neoadjuvant chemotherapy prior to Whipple (i.e. avoids repeat ERCPs for plastic stent blockage/exchange) Slide 21 Strange-but-true trivia interlude: Inventor of self-expanding metal Wallstent (used in GI/biliary/vascular/urologic interventions):

8 Slide 22 Strange-but-true trivia interlude: Inventor of self-expanding metal Wallstent (used in GI/biliary/vascular/urologic interventions): Hans Wallsten Slide 23 Pancreatic Cancer- Case Summary 65 y.o. M now with new diagnosis of pancreatic cancer, not surgically resectalbe. Started chemotherapy, however having worsening abdominal pain despite opiate pain medications. Additional treatment options for pain relief are considered: Slide 24 Celiac Plexus Neurolysis/Block Wang et al. Abdom Imaging 2006

9 Slide 25 Celiac Plexus Neurolysis/Block Transcutaneous celiac/splanchnic nerve block first proposed by Kappis in 1914 via posterior approach variations of this performed by anesthesiologists and radiologists Therapeutic EUS has become dominant approach due to proximity of celiac ganglion to stomach lumen Wang et al. Abdom Imaging 2006 Slide 26 Slide 27 Celiac Plexus Neurolysis Celiac plexus is located within 2-3cm of posterior gastric walleasily accessed by EUS needle Bupivicaine and ethanol are injected under EUS guidance, adjacent to celiac artery takeoff ~50-75% patients will experience some relief of pain (complete relief of pain achieved in ~10-20%) Leblanc et al. GIE 2011 Kaufman et al. J Clin Gastro 2010

10 Slide 28 Slide 29 Ascunce et al. GIE 2011 Slide 30 EUS-guided Fiducial Placement Fiducials easily placed via 19g EUS needle, in pancreatic tumor or in any area of interest near GI lumen

11 Slide 31 EUS-guided Fiducial Placement Sterile bone wax used to seal fiducial into tip of needle Slide 32 Esophageal Cancer- Case #2 Slide 33 Case #2: Esophageal Cancer 70 y.o. M with history of Barrett s esophagus (last EGD 3 years ago), presents with abdominal pain to ER. Ultimately diagnosed with mild cholecystitis, however, CT scan was obtained, showing mild distal esophageal thickening. Patient denies dysphagia, weight loss- recovering well after CCY. Medical history notable only for hypertension. Referred for EGD.

12 Slide 34 Slide 35 Biopsy confirms invasive adenocarcinoma Slide 36 What is the optimal approach to esophageal CA staging?

13 Slide 37 T3 N1 (positive FNA) Slide 38 PET CT scan - 2cm exophytic lesion demonstrating FDG-avidity (SUVmax = 6.8). - FDG-avid left supraclavicular lymph node (SUVmax = 4.7). - Possible paraesophageal lymph node (SUVmax = 3.9). PET/CT sensitivity of 51%, spec of 84% for detection of nodal metastases in esophageal CA (van Westreenen et al. J Clin Onc 2004). Slide 39 What is the optimal approach to esophageal CA staging?

14 Slide 40 What is the optimal approach to esophageal CA staging? Slide 41 What is the optimal approach to esophageal CA staging? Radiology GI Nuclear Slide 42 What is the optimal approach to esophageal CA staging? A practical outside in approach: EUS 1. PET-CT to evaluate for distant/metastatic disease if yes treatment for stage IV if no or equivocal FDG avid regions 2. EUS (with 2 specific goals in mind) A. lymph node evaluation/fna B. eval for endoscopic resection (T1a?) * EUS also useful for T staging (~75% accurate, better than any other imaging modality, but far from perfect) Pech et al. Endoscopy 2010

15 Slide 43 Case #3: Esophageal Cancer Slide 44 Case #3: Esophageal Cancer 68 y.o. F with long history of reflux undergoes EGD because of persistent symptoms despite PPI. Approximately 3cm of Barrett s esophagus is noted, and biopsies show high grade dysplasia. Referred to BIDMC for possible radiofrequency ablation Slide 45

16 Slide 46 Biopsy confirms HGD with focus of adenocarcinoma Slide 47 Proposed Algorithm for Suspected Superficial Esophageal Cancer Thosani et al GIE 2012 Slide 48

17 Slide 49 Slide 50 Slide 51

18 Slide 52 Slide 53 EMR specimens confirm T1a (intramucosal) cancer Slide 54 A 4-slide summary of Luminal Stenting Near-complete obstruction due to esophageal CA Self-expanding metal stent placement

19 Slide 55 Common roles for luminal stenting in GI malignancy 1.Esophageal cancer: Symptomatic patients who are not candidates for chemoradiotherapy, or who have recurrent dysphagia following definitive chemoradiotherapy 2.Colon cancer: Symptomatic obstruction in patients with unresectable disease, or, occasionally to decompress colon as a temporary bridge to surgery 3.Pancreatic cancer: Unresectable disease causing duodenal obstruction (may require both biliary and duodenal stenting) Slide 56 Brief Summary of Luminal Stenting Uncovered stents Covered stents Slide 57 Brief Summary of Luminal Stenting Uncovered stents Original type of selfexpanding metal stent SEMS Lower migration risk After several weeks, cannot be removed because of tumor ingrowth Covered stents More recent type of SEMS now much more commonly used Higher migration risk Ease of endoscopic removability?decreased tumor ingrowth * partially covered stents also exist, but are uncommonly used

20 Slide 58 Summary Points: Endoscopic approaches in GI malignancy 1: Pancreatic cancer diagnosis: EUS-FNA much more sensitive than ERCP brush cytology (~80% vs. 30%) 2. Biliary stenting: plastic stents more cost effective for short term stenting but self-expanding metal stents costeffective for patients receiving chemotherapy prior to Whipple (i.e. avoids repeat ERCPs for plastic stent blockage/exchange) 3. Esophageal Cancer: EUS most useful for determining endoscopic resectability in early-stage disease and for lymph node eval/fna after PET-CT Slide 59 Thank Slide 60 Bonus slides: Off-road Endoscopy

21 Slide 61 Failed ERCP in patient with pancreatic cancer/ampullary infiltration Slide 62 PTC/PTBD: Historical back-up plan for failed endoscopic/ercp drainage in patients with malignant jaundice Slide 63 EUS-guided biliary access: Newer,?better back-up planavoids need for external drains 3 sites of EUS-guided biliary access Duodenal obstruction or other tumor invasion

22 Slide 64 Slide 65 Slide 66 Deep Enteroscopy in Patients with Surgically Altered Anatomy

23 Slide 67 Deep Enteroscopy in Patients with Surgically Altered Anatomy Slide 68 Single Balloon Enteroscopy Slide 69

24 Slide 70 Hepaticojejunostomy in biliary limb s/p Whipple