Endoscopic Ultrasound: Emerging Indications

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Endoscopic UltrasoundEmerging Indications

• Klaus Gottlieb, MD, FACP, FACG
• Spokane, WA

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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
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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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CPBTraditional Technique
Posterior approach
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CPBTraditional 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 DrainageEndoscopic 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 CancerA 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.
• MediastinoscopyInvasive, 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 Dec72(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 Feb57(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
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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 BiopsiesMost 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 [phone]
• Toll free 1-888-PEG-TUBE
• Physician phone consultations Option 1 of the
  menu
• We want to hear from you!