Endoscopic Ultrasonography Clinical Impact. Giancarlo Caletti. Gastroenterologia Università di Bologna. Caletti
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1 Clinical Impact Giancarlo Gastroenterologia Università di Bologna AUSL di Imola,, Castel S. Pietro Terme (BO)
2 1982
3 Indications Diagnosis of Submucosal Tumors (SMT) Staging of Neoplasms Evaluation of Pancreato-Biliary Region Therapeutic applications??
4 Indications Staging of neoplasms Esophageal cancer Gastric lymphoma Gastric cancer Non small cell lung cancer Rectal cancer
5 Indications Staging of neoplasms Esophageal cancer Extremely useful for staging and triage the initial therapy
6 Staging of neoplasms: More complex Less complex Esophagus / Mediastinum Management plan changes post EUS Surgery to neodjuvant therapy and surgery (n=1) Chemotherapy to surgery (n=1) Clinical follow-up (palliative) to neodjuvant therapy and surgery (n=1) Diagnostic endoscopy to endoscopic mucosal resection (n=1) Imaging follow-up to chemotherapy (n=1) Surgery to radiation and/or chemotherapy (n=3) Surgery to imaging and/or endoscopic follow-up (n=1) Imaging and/or endoscopic follow-up to clinical follow-up (n=3) Number of EUS FNA leading to management change 12/22 (56%) 5/12 (42%) 7/12 (58%) 4/4 (100%) Shah et al. Clin Gastroenterol Hepatol 2004
7 Indications Staging of neoplasms Esophageal cancer T1m, N0 T1sm/T2, N0 T3, N1 Neoadjuvant Ch RX Endoscopy / Surgery Surgery Surgery T4, N1 Palliation
8 Staging of neoplasms: stomach Management plan changes post-eus More complex 9/15 (60%) 2/9 (22%) Imaging follow-up to surgery (n=1) Endoscopic follow-up to endoscopic mucosal resection (n=1) Less complex 7/9 (78%) Surgery to endoscopic mucosal resection (n=1) Surgery to clinical follow-up (n=1) Imaging and/or endoscopic follow-up to clinical follow-up (n=5) Number of EUS FNA leading to a management change 0/1 (0%) Shah et al. Clin Gastroenterol Hepatol 2004
9 Impact of EUS on Surgery in UGI Cancer Treatment decisions were changed in 34% based on EUS results, and the majority of these changes were toward nonsurgical and palliative treatments (85%) Mortensen et al. Surg Endosc 2007
10 Staging of neoplasms: rectal Management plan changes post-eus More complex 4/10 (40%) 2/4 (50%) Surgery alone to neoadjuvant therapy and surgery (n=2) Less complex 2/4 (50%) Surgery to chemotherapy Neoadjuvant therapy and surgery to surgery alone (n=1) Number of EUS FNA leading to management change 1/2 (50%) Shah et al. Clin Gastroenterol Hepatol 2004
11 EUS: T1m
12 Indications for EUS Evaluation of pancreato-biliary region Pancreatic and periampullary cancer Acute Pancreatitis Choledocholithiasis Neuroendocrine tumors Pancreatic cysts Chronic pancreatitis
13 EUS vs MRCP in pancreatobiliary diseases: prospective comparison PPV NPV Malignancy EUS 98% 100% MRCP 96% 97.4% Choledocholithiasis EUS 78% 94% MRCP 92% 91% Fernandez-Esparrach et al. Am J Gastroenterol 2007
14 Pancreatic cancer meta-analysis: analysis: EUS sensitivity for vascular invasion Puli et al. Gastrointest Endosc 2007
15 Pancreatic cancer meta-analysis: analysis: EUS specificity for vascular invasion Puli et al. Gastrointest Endosc 2007
16 Negative predictive value of EUS for Pancreatic Cancer NPV of EUS was 100% Retrospective review of 693 pts. (Jan 1999-Mar 2003) suspected of having PC 155 pts. were found to have a normal pancreas No pts. developed PC during follow up (mean 25 months) No further work-up was required in 88% of pts. In pts. with a clinical suspicion of PC, EUS should be considered as the initial diagnostic modality Klapman et al. Am J Gastroenterol 2005
17 Clinical impact Management plan changes post-eus More complex ERCP to surgery (n=1) Radiology guided biopsy to radiation and/or chemotherapy (n=1) Imaging to surgery (n=2) Imaging to ERCP (n=2) Less complex Surgery to clinical follow-up (n=3) Surgery to radiation and or chemotherapy (n=4) ERCP to clinical follow-up (n=2) ERCP to imaging follow-up (n=3) Radiology guided biopsy examination to imaging follow-up (n=2) Imaging to clinical follow-up (n=1) Number of EUS FNA leading to management change 21/43 (49%) 6/21 (29%) 15/21 (71%) 4/13 (31%) Shah et al. Clin Gastroenterol Hepatol 2004
18 EUS-Sonovue Sonovue for pancreatic cancer Sonovue: early venous phase Cytology: adenocarcinoma et al. Unsubmitted Data 2007
19 Pancreatic cancer: EUS algorithm Patient with a pancreatic mass by CT/US or suspected pancreatic cancer with negative imaging studies No obvious metastatic disease Obvious metastatic disease (confirm by FNA) EUS staging and FNA No EUS evidence of advanced disease EUS evidence of advanced disease Surgical Neoadjuvant resection Rx and restaging? Palliative therapy (consider EUS guided celiac block)
20 Acute Pancreatitis Determination of Etiology Detection of choledocholithiasis by EUS in AP 100 consecutive pts. with AP Gallbladder stones: EUS more sensitive than US (100% vs. 84%, p<0.005) Choledocholithiasis: EUS ERCP (US) sensitivity 97% 97% (26%) specificity 98% 95% (100%) accuracy 98% 96% (75%) Liu, Gastrointest Endosc 2001
21 Changing trends in ERCP Advent of EUS ERCP diagnostic vs. therapeutic Jamal et al. Am J Gastroenterol 2007
22 Influence of biliary stents on EUS
23 Influence of biliary stents on EUS Overall concordance EUS/gold standard: 11/22 (50%) Surgical T stage T0 T1 T2 T3 T4 EUS T0 (n = 3) T0 (n = 1) T3 (n = 1) T0 (n = 2) T2 (n = 1) T4 (n = 1) T2 (n = 1) T3 (n = 2) T3 (n = 5) T4 (n = 5) % 100 (3/3) 0 (0/2) 25 (1/4) 67 (2/3) 50 (5/10) Fusaroli et al. Endoscopy 2007
24 Acute Pancreatitis: Determination of Etiology Does normal EUS obviate the need for ERCP? Prospective 1-year follow-up study in 238 pts. referred for biliary study with normal EUS [early (1-month) and late (1-year) follow-up details were obtained] 59 (25 %) pts. underwent cholecystectomy,, with (n=31) or without (n=28) IOC,, and 30 (13%) pts. underwent ERCP (13 %) CBD stone was found in 14 (6 %) patients NPV of EUS for CBD stones was 95.4 % Napoleon,, Endoscopy 2003
25 Acute Pancreatitis: Determination of Etiology Idiopathic AP Extensive and invasive evaluations (such as ERCP) are not needed after a single episode of Idiophatic AP. In patients in whom PCa is more likely (>40 yrs, smokers), an evaluation using MRCP, or EUS is preferably to using ERCP initially. Forsmark and Baillie. Gastroenterology 2007
26 EUS first vs. ERCP first for CBD Stones EUS group: 49 successful and 1 failed initial EUS, 15 ERCs for CBD stone tx,, and 6 procedures during f-upf ERC group: 36 successful and 12 failed initial ERCs,, 13 repeat procedures (EUS or ERC) and 2 during f-upf In intermediate probability CBD stones, EUS (with selective ERC in pts. with stones) is safer and not associated with an excess of endoscopic procedures compared with ERC alone Polkowski et al. Endoscopy 2007
27 EUS first vs. ERCP first in Biliary Acute Pancreatitis Occult cholelithiasis (missed by US) is best detected by EUS or MRCP. EUS sensitivity of 90%. Sludge in the gallbladder may form with prolonged fasting and may represent the consequence rather than the cause of pancreatitis. EUS is used to identify patients with biliary AP who have persistent CBD stones and thus select patients for ERCP. Forsmark and Baillie. Gastroenterology 2007
28 EUS first vs. ERCP first in Biliary Acute Pancreatitis In patients with mild or resolved biliary AP who are scheduled for cholecystectomy, in whom a preoperative question exists as to the presence of persistent CBD stones, preoperative EUS or MRCP is appropriate rather than proceeding directly to ERCP. Liu et al. Clin Gastroenterol Hepatol 2005
29 EUS first vs. ERCP first in Biliary Acute Pancreatitis Malignancy is a potential etiology (age>40 yrs). EUS could be used to screen not only for malignancy but also to assess for ampullary masses, pancreatic ductal dilatation, signs of chronic pancreatitis, and microlithiasis. Forsmark and Baillie. Gastroenterology 2007
30 EUS first vs. ERCP first in Biliary Acute Pancreatitis The most accurate method to identify cholelithiasis or coledocholithiasis in a patient with acute pancreatitis is endoscopic ultrasonography. Forsmark and Baillie. Gastroenterology 2007
31 Acute Pancreatitis:Management of Complications Pancreatic Infection: MRI and EUS provide the most reliable information to define the internal character of the collection and gauging its consistency. Pancreatic Fluid Collection and Pseudocyst: Endoscopic treatment, utilizing EUS guidance is becoming much more common. Forsmark and Baillie. Gastroenterology 2007
32 Changing trends in ERCP.Every ERCP should be performed for a solid indication: : it is not a game!.....with the avaliability of less- and non-invasive imaging techniques, such as EUS and MRCP, solely diagnostic ERCP is becoming a rarity...eus is increasingly important in both the diagnosis and staging of biliary and pancreatic cancer, and its therapeutic applications are increasing daily....eus and ERCP are complementary techniques. Baillie and Testoni. Gut 2007
33 Pancreatic Cysts Sahani et al. Radiographics 2005
34 Pancreatic Cysts Cooperative pancreatic cyst study Prospective study; 341 pts. CEA for all mucinous CPTs was significantly higher than CEA for all non-mucinous CPTs (cutoff 192 ng/ml) CA was the second best discriminating marker CONCLUSIONS: the determination of cyst fluid concentration of CEA alone is highly diagnostic and more accurate than any combination testing (p < ) Brugge et al. Gastroenterology 2004
35 Intra Papillary Mucinous Neoplasms: IPMN Callery, Gastroenterology 2006
36 Intra Papillary Mucinous Neoplasms: IPMN Callery, Gastroenterology 2006
37 PC arising in IPMN
38 Intra Papillary Mucinous Neoplasms: IPMN Pathological Diagnosis of Invasive IPMN Malignant cells & ductal structures infiltrating pancreatic parenchyma are required. Perineural, lymphatic,, and vascular invasion are variably seen with Invasive but never with nonivasive IPMN. Acellular pools of mucin alone are inadequate (non Invasive IPMN). Median overall survival is only 23 months for invasive IPMN, compared to 85 months for noninvasive disease. Raut et al. Ann Surg Oncol 2006
39 Intra Papillary Mucinous Neoplasms: IPMN Preoperative imaging, includig EUS Ca 19-9 levels Targeted EUS-FNA Could not reliably discriminate invasive and non invasive IPMN Only Jaundice is predictive of Invasive IPMN Raut et al. Ann Surg Oncol 2006
40 Intra Papillary Mucinous Neoplasms: IPMN- Conclusions A defensive approach is to remove them. But deciding to operate when observation is appropriate is wrong. In the old patients with comorbidity,, a misguided decision to resect can do more harm than good. We still need to learn more about the natural history of IPMN to become confortable with such decisions. Callery, Gastroenterology 2006
41 EUS in Pancreatic Cysts: Algorithm Cystic Lesion in the Pancreas Microcystic (SCA) EUS Other features Follow up High surgical risk Uncertain EUS Asymptomatic Low surgical risk Vegetation/Mass Wirsung dilated Symptomatic EUS-FNA Surgery
42 Avoidance of additional investigations Patients Additional investigations avoided Yes EUS-FNA 69 (30%) 45 (65 %) 33/44 (75%) Lung/mediastinal 10/21 (48%) Pancreaticobiliary 2/3 (67%) esophageal 0/1 gastric EUS without FNA 162 (70%) 70 (43%) 0/1 Lung/mediastinal 31/51 (61%) Pancreaticobiliary 23/72 (32%) esophageal 16/34 (47%) gastric p Value p < 0.08 Possible 5 (7.3%) 33 (20.4%) EUS usefulness No Very Moderately Minimally/ not useful 21 (30.4%) 45 (65.2%) 16 (23.2%) 8 (11.6) 62 (38.3%) 77 (47.5%) 72 (44.4%) 13 (8.1%) p < 0.8 Chong et al. Gastrointest Endosc 2005
43 Conclusions EUS results in a change of management in approximately one half of the patients. Staging with EUS is associated with a recurrence free survival advantage and an overall survival advantage. EUS is deemed useful by referring physicians. EUS is not only accurate but also cost- effective.
44 IV IEC / I EGEUS EUS COURSE Castel S. Pietro June
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