role of eus in pancreato- biliary disorders a aljebreen m.d, frcpc gastroenterology division, kkuh,...
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Role of EUS in Role of EUS in pancreato-biliary pancreato-biliary
DisordersDisordersA Aljebreen M.D, FRCPCA Aljebreen M.D, FRCPC
Gastroenterology Division, KKUH, Gastroenterology Division, KKUH, King Saud UniversityKing Saud University
EUS meeting, KFMC, EUS meeting, KFMC,
Dec 16, 2006Dec 16, 2006
ObjectivesObjectives
Role of EUS in Role of EUS in Pancreatic cancersPancreatic cancers Pancreatic neuroendocrine tumorsPancreatic neuroendocrine tumors Pancreatic cystic lesionsPancreatic cystic lesions PancreatitisPancreatitis CholedocholithiasisCholedocholithiasis Periampullary tumorsPeriampullary tumors
Pancreatic cancersPancreatic cancers
Backgrounds
Data indicate that incomplete resection and positive nodes may convey poor long-term survival, equivalent to vascular encasement.
In addition, the increasing use of complementary endoscopic techniques, including duodenal endoprosthetic placement, biliary decompression via ERCP, and EUS placement of celiac neurolysis, obviates the necessity for reliance on surgical
techniques for the palliation of obviously unresectable or incurable malignancies.
Resectability of PC: Backgrounds
An apparent clean surgical resection is needed for potential cure.
During staging, 50% have mets and 30-35% have locally advanced unresectable tumors
15-20% of tumors are resectable. Surgical resection is curative in a
small percentage of patients (15-20% 5-year survival rate of those resected). Niederhuber et al. Cancer 1995; 76: 1671-7.
EUS diagnostic accuracyEUS diagnostic accuracy
Staging sensitivity with EUS has consistently been reported to be over 90%.
EUS is also more accurate in the assessment of vascular invasion that might preclude surgical resection (compared to h-CT/MRI)
Rösch et al. Gastrointest Endosc Clin N Am 1995;5:735-9.Yasuda et al. Endoscopy 1993;25: 151-5.Palazzo et al. Endoscopy 1993;25:143-50.
Brugge et al. GI Endosc 1996;43:561-7.
Mertz et al. GI Endoscopy 2000
35 patients, retrospective
Gress et al. GI Endoscopy Gress et al. GI Endoscopy 19991999
Radiologist DATA?Radiologist DATA?
Data from 30 pts with suspected pancreatic ca a 92% sensitivity & 93% overall accuracy for h-CT a 100% sensitivity & 93% overall accuracy for EUS.
The accuracy in predicting the tumor resectability was 90% for both techniques
Accuracy for predicting unresectability was 100% for helical CT and 86% for EUS (over staging).
Legmann et al. AJR Legmann et al. AJR 19981998
h-CT?
Fine section h-CT: 90% sensitive, Fine section h-CT: 90% sensitive, 90% sensitivity for liver mets, 80-90% sensitivity for liver mets, 80-90% sensitive for vascular invasion90% sensitive for vascular invasion
Specificity of HCT for assessment of Specificity of HCT for assessment of resectability due to vascular invasion resectability due to vascular invasion is close to 100%is close to 100%
MRI has almost the same sen and sp MRI has almost the same sen and sp rates.rates.
What are the remaining indications for EUS in
pancreatic ca?1.1. 10% of PC (20-30% of PC<2cm) are 10% of PC (20-30% of PC<2cm) are
not demonstrated by h-CTnot demonstrated by h-CT Sensitivity of EUS is close to 100%Sensitivity of EUS is close to 100%
2.2. Demonstration of N2-positive nodes Demonstration of N2-positive nodes (celiac, mesentric),+ EUS FNA for (celiac, mesentric),+ EUS FNA for confirmation.confirmation.
3. EUS is the most effective method for biopsy of solid pancreatic masses whatever the size is or the location.
FNA for solid pancreatic mass
All areas of pancreas including uncinate process and tail, diameter >5mm
Low complication rate ~ 1-2% (pancreatitis, haemorrhage)
? Risk of peritoneal seeding
SensitivitSensitivity y
specificityspecificity PPVPPV NPVNPV
75-93%75-93% 95-100%95-100% 100%100% 25-85%25-85%
Vilmann, Wiresma, Giovannini, Chang, Gress, Bhutani, Hawes, Williams, Palazzo
Mallery et al. GI Endoscopy 2002
Suspected pancreatic mass
Ultrasound
H-CT
No MassMass
EUS +/- FNA
Bx (CT, EUS or ERCP)
Palliation (biliary stent/CPN, oncology)
ERCP/Stent
Surgery
Cholangitis OR delayed
resection + jaundice/pruritu
s
Unresectable
Resectable
Unresectable
Resectable
Unresectable
EUS- guided Plexus Block/Neurolysis (CPN)
Technique
Complications Mild complications include
transient diarrhea (4%-15%), transient orthostasis (1%), transient increase in pain (9%).
Major complications (2.5%) retroperitoneal bleeding peripancreatic abscess.
The patients typically receive IV 0.9% saline during the procedure.
They should be monitored for orthostasis for 2 hours after the procedure.
EUS- guided CPN: Results
Wiersema's initial study of EUS-CPN in patients with pancreatic cancer showed a significant reduction in pain that persisted for 20 weeks (2 weeks for chronic pancreatitis).
It reduced pain scores in 78% of patients which is similar to that achieved by surgical and transcutaneous reports (Gunaratnam et al GI Endosc 2001)
Ischia et al. found CPN to be more effective when applied soon after the diagnosis rather than late in the course.
Neuroendocrine Pancreatic Neuroendocrine Pancreatic TumorsTumors
Up to 30 % of patients with gastrinomas or Up to 30 % of patients with gastrinomas or insulinomas who undergo surgery fails to have insulinomas who undergo surgery fails to have localization of the tumor during surgerylocalization of the tumor during surgery Rosch Rosch
Gastroenterology 92Gastroenterology 92 A series of 37 patients who had had non-A series of 37 patients who had had non-
diagnostic CT and US proceeded to have pre-op diagnostic CT and US proceeded to have pre-op EUS.EUS.
22 underwent selective angio.22 underwent selective angio. EUS had sensitivity of 82% compared with 27% EUS had sensitivity of 82% compared with 27%
for angio and the specificity of EUS was ~95%.for angio and the specificity of EUS was ~95%. Rosch et al, Rosch et al,
NEJM 92NEJM 92
Pancreatic Cystic neoplasms
DDXDDX Pseudocysts (~90% of PCL) Benign:
*Serous cystadenoma. *Others
Malignant potential: Mucinous cystadenoma (commonest after pseudocysts) Intraductal papillary mucinous tumor (IPMT). Others
Malignant: Cystadenoca Necrotic adenoca
EUS and PCLEUS and PCL
EUS imaging findings are not sufficient to reliably distinguish between benign and those e malignant potential.
The main use of EUS is to guide aspiration of cystic lesion to obtain fluid for cytologic and biochem analysis.
Is it important to differentiate?
EUS alone Cytology CEA>3.1 ng/mL*
CA 19-9 >37 U/mL*
Sensitivity (95% CI)
50% (16-84%)
71% (44-90%)
78% (40-97%)
82% (48-97%)
Specificity (95% CI)
56% (30-80%)
96% (78-99%)
82% (48-97%)
90% (56-98%)
NPV (95% CI) 69% (39-91%)
82% (62-94%)
79% (49-95%)
75% (43-95%)
PPV (95% CI) 36% (11-69%)
92% (64-99.8%)
78% (40-97%)
90% (56-99.8%)
Accuracy (95% CI)
54% (34-74%)
85% (74-96%)
78% (61-95%)
82% (66-98%)
Aljebreen et al (in press)
41 prospective patients
Aim: diagnostic accuracy of EUS/CEA, CA 19-9 & cytology to differentiate benign from malignant/pre-malignant pancreatic cystic lesions
FNA complicationsFNA complications
There is a risk of infecting cyst fluid, There is a risk of infecting cyst fluid, so ABX prophylaxis is advisable.so ABX prophylaxis is advisable.
There is also 1% risk of causing There is also 1% risk of causing acute panc especially for pancreatic acute panc especially for pancreatic head lesions.head lesions.
Bleeding is an uncommon Bleeding is an uncommon complication.complication.
337 patients with cystic lesions underwent prospective EUS and FNA.
116 (mean age 63) underwent surgical resection of the cystic lesion and the histology was used to determine the type of the cyst.
EUS morphology was prospectively collected (microcystic= benign, macrocystic= mucinous, mass=malignant, unilocular=pseudocyst).
W Bruggie, Gastroenterology, 2004
Results Results
CEA provided the greatest accuracy CEA provided the greatest accuracy for mucinous and malignant.for mucinous and malignant.
The optimal diagnostic cut-off for The optimal diagnostic cut-off for CEA was 158 pg/ml (mucinous) and CEA was 158 pg/ml (mucinous) and 1872 pg/ml (malignant).1872 pg/ml (malignant).
CEA negatively correlated with CEA negatively correlated with predicting serous cystadenoma.predicting serous cystadenoma.
Results
The findings of a microcystic morphology was nearly diagnostic of a serous cystadenoma.
Malignant cytology was highly specific but insensitive (17%).
The use of all 3 tests provided the greatest diagnostic accuracy for all types of cyst.
Choledocholithiasis In prospective studies, EUS has demonstrated a
sensitivity of >95% for the detection of choledocholithiasis.
These results compare favorably to ERCP and are superior to conventional ultrasound and clinical history without the inherent risk of post-procedural pancreatitis.
EUS has also been shown to be a cost-effective initial screening study, in lieu of ERCP for patients with a low or intermediate risk of bile duct stones.49
EUS does not have the therapeutic capacity of ERCP and cannot help in stone removal.
The precise clinical role of EUS remains to be defined. Canto et al. GI Endosc 1998;47:439-48.
Biliary cancersBiliary cancers
Cancers of the biliary tract (gall bladder adenocarcinoma and cholangiocarcinoma) have also been staged by EUS with improved staging accuracy compared to other imaging techniques, although the data are considerably limited as compared to pancreatic malignancy.
Tierney et al, GI endoscopy 2001
Cannon et al, GI endoscopy 1999
ConclusionConclusion
EUS has a major role in not only in EUS has a major role in not only in diagnosing and staging pancreatic diagnosing and staging pancreatic tumor but also as a therapeutic toll for tumor but also as a therapeutic toll for patients with pancreatic tu pain.patients with pancreatic tu pain.
EUS has the best diagnostic accuracy EUS has the best diagnostic accuracy in patients with small pancreatic in patients with small pancreatic lesions especially neuroendocrine lesions especially neuroendocrine tumorstumors
EUS is the gold standard in diagnosing EUS is the gold standard in diagnosing pts with chronic pancreatitis.pts with chronic pancreatitis.
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