Endoscopic Ultrasound Emerging Indications

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					Endoscopic Ultrasound:
 Emerging Indications
Klaus Gottlieb, MD, FACP, FACG
         Spokane, WA
           EUS in Spokane
• Started in March
  1999, now in our 5th
  year
• Annually approx. 370
  cases
• Referral corridor
  includes Inland
  Northwest and
  beyond

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Spokane does relative more EUS with FNAs
      and not enough regular EUS


           100
            80

  Spokane 60
  Nation    40
            20
             0
                 EUS            EUS FNA   EUS Rectum


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       EUS still underutilized

• No pharmaceutical company reps pushing
  the “product”
• A lot of community physicians unsure
  about indications
• People often call Radiology Department to
  get info: “Do you do rectal ultrasound”?

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SGNA Members as Information
       Resource




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           EUS-Indications
• 1. Staging of esophageal, gastric and rectal
  cancer
• 2. Evaluation of abnormalities of the
  gastrointestinal wall or adjacent structures
  (submucosal masses, extrinsic compression)
• 3. Evaluation of thickened gastric folds
• 4. Diagnosis (FNA) and staging of pancreatic
  cancer
• 5. Evaluation of pancreatic abnormalities
  (suspected masses, cystic lesions including
  pseudocysts, suspected chronic pancreatitis)
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           EUS-Indications
• 6. Staging of ampullary neoplasms
• 7. Diagnosis and staging of
  cholangiocarcinoma
• 8. Evaluation of suspected
  choledocholithiasis
• 9. Celiac plexus neurolysis for chronic pain
  due to intra-abdominal malignancy or chronic
  pancreatitis
• 10. Evaluation of fecal incontinence with
  endo-anal ultrasound
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         EUS: The standard of care

• The official American Joint Commission on
  Cancer (AJCC) Cancer Staging Handbook
  recognizes the contribution of EUS in its latest
  edition (2002, p 182):
   – “Endoscopic ultrasonography (when done by
     experienced gastroenterologists) also provides
     information helpful for clinical staging and is the
     procedure of choice for performing fine-needle
     aspiration biopsy of the pancreas.”
• EUS now available at both Sacred Heart and
  Deaconess Endoscopy Departments

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       Emerging Indications
• As alternative to ERCP in the diagnosis of
  bile duct stones
• Celiac block for pancreatic cancer pain
• EUS guided Pseudo-Cyst drainage
• EUS guided mediastinal lymph node
  biopsies



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               Gallstone Disease
• To ERCP or to EUS?
• “…the weight of the evidence suggests
  that EUS is similar in detecting common
  bile duct stones.”
 NIH consensus conference: Evidence based assessment of diagnostic modalities for
 bile duct stones

• High probability: ERCP
• Low probability: EUS

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       Emerging Indications
• As alternative to ERCP in the diagnosis of
  bile duct stones
• Celiac block for pancreatic cancer pain
• EUS guided Pseudo-Cyst drainage
• EUS guided mediastinal lymph node
  biopsies



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Celiac Plexus Block




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Celiac Axis Anatomy




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CPB:Traditional Technique




 Posterior approach



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CPB:Traditional Approach




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EUS directed celiac block




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       Emerging Indications
• As alternative to ERCP in the diagnosis of
  bile duct stones
• Celiac block for pancreatic cancer pain
• EUS guided Pseudo-Cyst drainage
• EUS guided mediastinal lymph node
  biopsies



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EUS guided Pseudo-Cyst drainage




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Pseudo-Cyst Drainage:
    Endoscopic View




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       Emerging Indications
• As alternative to ERCP in the diagnosis of
  bile duct stones
• Celiac block for pancreatic cancer pain
• EUS guided Pseudo-Cyst drainage
• EUS guided mediastinal lymph node
  biopsies



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The esophagus: a window into the
         mediastinum




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 Lung Cancer:A Brief Overview
• In the US, lung cancer is the most common cause of
  cancer deaths among both men and women.
• North Americans have the highest rates of lung cancer in
  the world. In 1997, some 178,100 new cases were
  diagnosed and roughly 160,400 deaths occurred from
  the disease.
• The 5-year survival rate for patients with lung cancer is
  only 14%.
• 50 % of lung cancer patients have mediastinal
  lymphadenopathy at the time of diagnosis


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N-Staging
          • N0 absence of any lymph node
            involvement.
          • N1 presence of cancer in the
            hilar lymph nodes.
          • N2 refers to an involvement of
            the mediastinal lymph nodes
            on the cancer side.
          • N3 cancers involve the lymph
            nodes on the other side of the
            chest, or in the supraclavicular
            area.




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                        Modalities
• Bronchoscopy: Good for endobronchial lesions. Subcarinal
  biopsies with Wang needle. Bleeding risk
• CT-guided transthoracic fine needle aspiration (FNA):
  Limited by surrounding vascular structures, size of the targeted
  lesion. Pneumothorax risk.
• Mediastinoscopy:
  Invasive, requires general anesthesia. Subcarinal and subaortic (a-
  p window) nodes inaccessible.
• Thoracoscopic biopsy (video-assisted thoracoscopy)
  Limited to inferior mediastinum.
• EUS-FNA




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The bronchoscope




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Mediastinoscopy




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Mediastinoscopy: Overused, Invasive, Limited
               Applications




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Thoracoscopy: Limited to
  inferior mediastinum




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EUS: No incision, no anesthesia




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EUS: High Yield, Versatile




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Endoscopic ultrasound-guided fine needle aspiration for
staging patients with carcinoma of the lung.


Wallace MB, Silvestri GA, Sahai AV, Hawes RH, Hoffman BJ,
Durkalski V, Hennesey WS, Reed CE.


Endoscopic ultrasound with fine needle aspiration identified and
histologically confirmed mediastinal disease in more than two
thirds of patients with carcinoma of the lung who have abnormal
mediastinal CT scans. Although mediastinal disease was more
likely in patients with an abnormal mediastinal CT, EUS also
detected mediastinal disease in more than one third of patients
with a normal mediastinal CT and deserves further study.
Endoscopic ultrasound should be considered a first line
method of presurgical evaluation of patients with tumors of
the lung.

Ann Thorac Surg 2001 Dec;72(6):1861-7
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Endoscopic ultrasound guided biopsy of mediastinal
lesions has a major impact on patient management.

Larsen SS, Krasnik M, Vilmann P, Jacobsen GK, Pedersen
JH, Faurschou P, Folke K.

EUS-FNA is a safe and sensitive minimally invasive method for
evaluating patients with a solid lesion of the mediastinum
suspected by CT scanning. EUS-FNA has a significant impact
on patient management and should be considered for
diagnosing the spread of cancer to the mediastinum in patients
with lung cancer considered for surgery, as well as for the
primary diagnosis of solid lesions located in the
mediastinum adjacent to the oesophagus.

Thorax 2002 Feb;57(2):98-103


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A mediastinal mass




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Thymoma, Teratoma, Thyroid,
   Terrible Lymphoma ?

                       EUS guided FNA biopsy




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Thyroid Transcription Factor 1   www.gi-guy.com
 Special Stains from the FNA Cell Block

The mediastinal mass was solid and cystic on
EUS. The papillary architecture suggested a
papillary thyroid carcinoma. The Thyroid
Transcription Factor-1 was positive, which can
be positive in thyroid and lung carcinomas. The
thyroglobulin, not shown, was negative. So this
appears to be a metastatic lung carcinoma with
a papillary architecture. A PET scan is planned



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Micropapillary Carcinoma of the
             Lung




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     EUS Mediastinal Biopsies:
         Most frequent indications



• Bronchoscopy negative, but mediastinal
  adenopathy present (diagnosis)
• PET scan equivocal, i.e., “warm” spot in
  the mediastinum (staging)



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                  The Future
• EUS directed local therapy of non-
  resectable pancreatic cancer
       – DAB(389)EGF is a diphtheria toxin fused via a His-Ala
         linker to human epidermal growth factor (EGF),
         selectively toxic to EGFR-overexpressing cells

• EUS directed therapy of GERD
       – Delivery of the Enteryx co-polymer directly into the
         muscularis propria




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               Our Practice
• Dedicated to advanced therapeutic
  endoscopy

    • ERCP
    • EUS
    • Endoscopic Anti-Reflux procedures: Enteryx,
      Stretta
    • Capsule endoscopy (Given M2A)


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          Contact Information
•   Sacred Heart and Deaconess in Spokane
•   On the web at www.gi-guy.com
•   Local number (509) 455-3453
•   Toll free   1-888-PEG-TUBE
•   Physician phone consultations: Option 1 of
    the menu

We want to hear from you!
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