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 18 November 2017

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Endoscopic ultrasound

Editor: Ian Penman


2. EUS equipment and technique

Anne Marie Lennon & Koji Matsuda

Top of page Synopsis  Next section

This chapter describes the wide range of equipment available for EUS—processors, echoendoscopes, and accessories—and discusses their roles and limitations in EUS procedures.

Top of page Introduction  Previous section Next section

Endoscopic ultrasound (EUS) was initially developed in the early 1980s primarily to overcome the limitations of transabdominal ultrasound in imaging the pancreas. EUS combines endoscopy with high-frequency ultrasound by incorporating a small ultrasonic transducer at or close to the tip of a modified endoscope. EUS transducers can be either single element, where the transducer must be mechanically rotated to produce an image, or phased array, where multiple piezoceramic crystals are stimulated by electronic pulses. Phased arrays can incorporate Doppler ultrasound, which can be used to identify active blood flow. Single-element transducers were initially the mainstay of EUS; however, there is an increasing move towards phased arrays in the newest generation of instruments being developed.

Top of page Radial and linear endosonographic probes  Previous section Next section

Early echoendoscopes used mechanical radial scanning, where the transducer is orientated perpendicular to the shaft of the endoscope and generates a radial image of 360°(Figs 1–3). Some, although not all authors, feel that this type of imaging gives a better overview of the GI wall and paramural structures [1]. More recently, electronic radial instruments have been developed (Fig. 4). At the same time as mechanical radial endoscopes were being developed, curved linear array (CLA) echoendoscopes were also produced. These generate ultrasound images along the long axis of the echoendoscope(Fig. 5), allowing real-time visualization of fine-needle aspiration (FNA) biopsy of lesions. Very few studies have compared the accuracy of these two types of imaging; however, those that have found similar accuracies for pancreatic and esophageal cancer staging [2,3]. Figure 6 lists commonly used echoendoscopes, but a more detailed list of all available instruments can be found in Rosch [1].

Top of page Contrast-enhanced ultrasonography  Previous section Next section

Objects moving towards an US beam augment reflection from their surface, which increases the frequency of the returning wave. Conversely, if the motion is away from the receiver, the received wave has a lower frequency compared with its incident frequency. The importance of this equation is that the velocity of the object is directly related to the change in frequency of the US beam. This is called the Doppler shift effect and can be used to determine if an anechoic structure is a vessel with active blood flow. It is only possible to measure the Doppler effect with phased array transducers.

Contrast-enhanced sonography was initially described using carbon dioxide microbubbles which were infused into the celiac or superior mesenteric artery [4,5]. More recently Levovist, a sonography contrast agent, has been used in Doppler ultrasound studies. However, several limitations of this technique have been found, including blooming artifacts, poor spatial resolution, and low sensitivity to slow flow [6–14]. Coded phase inversion harmonic imaging is a newly available sonographic technique which is based on a combination of phase inversion harmonics and coded technology [15–17]. With the use of a microbubble contrast agent (a suspension of monosaccharide microparticles in sterile water), it depicts signals from microbubbles in very slow flow without Doppler related artifacts, and enables visualization of slow flow in microscopic vessels. A recent study by Kitano et al. [18] identified tumor vessels in 67% of pancreatic ductal carcinomas using contrast-enhanced ultrasonography, although most were relatively hypovascular compared with the surrounding pancreatic tissue. Interestingly, although contrast-enhanced ultrasonography was clearly superior in its sensitivity in identifying pancreatic tumors of 2 cm or less in size compared with contrast-enhanced computed tomography (95% vs. 68%), it was no better than routine endosonography (95% sensitivity). This is an interesting new technique; however, further studies are required to delineate its exact role and potential.

Top of page Catheter-based EUS probes (miniprobes)  Previous section Next section

EUS is typically performed using an echoendoscope. This often entails two procedures: an initial endoscopy to identify the lesion or area of interest, followed by EUS to evaluate it further. EUS probes are larger than regular endoscopes and are not always able to cross tight strictures. Standard echoendoscopes may also have difficulty visualizing small or early lesions due to their relatively low imaging frequency and oblique forward-viewing optics.

Catheter- or 'mini' probes have been developed, which overcome some of these problems. They consist of a cable with a mechanical transducer at its end (Fig. 7). The majority of miniprobes use a radial transducer; however, dual-plane reconstruction probes (UM-DP-12-25R, 12 MHz and UM-DP20-25R, 20 MHz; Olympus) are also available and these allow the user to scan simultaneously in both linear and radial planes. The miniprobes come in a variety of diameters and lengths with probes of over 2 m being used for colonic and pancreatico-biliary imaging (Fig. 8). They are also available in a variety of frequencies. The higher the frequency, the greater the image resolution, with up to nine gut-wall layers visualized with high-frequency probes [19,20]. However, this higher resolution comes at the expense of limited depth of penetration, with an average of 1 cm penetration with a 30-MHz probe compared with 2.9 cm for a 12-MHz probe.

Miniprobe technique  Previous section Next section

The miniprobe is inserted down the working channel of a regular endoscope. Air is removed from the lumen, which is then filled with water to allow transmission of the ultrasound. Particular care should be taken in imaging the esophagus, where the head of the bed should be raised to at least 30° to prevent aspiration. A catheter balloon sheath (UM-BS20-26R; Olympus), which consists of a small water-filled balloon that inflates around the transducer tip, can be used in combination with the miniprobe. This improves acoustic coupling and has been shown to improve the clarity of the image and the depth of penetration for esophageal imaging [21,22]. In pancreatico-biliary imaging a catheter balloon sheath is not required as bile and pancreatic juice provide a fluid-filled lumen.

Intraductal ultrasound (IDUS) can be performed either through a percutaneous or retrograde transpapillary route. In the case of a retrograde procedure, an ERCP is performed first and a guidewire is passed proximal to the lesion. A wire-guided probe (Fig. 9) is then advanced under fluoroscopic guidance. Alternatively, a non-wire-guided intraductal ultrasound probe may be used; however, up to 20% of patients will require a sphincterotomy using this technique [23]. The IDUS probe can also be inserted into the pancreatic duct. This can be a more difficult procedure, particularly if the duct is tortuous or not dilated, with intubation rates falling from between 94% and 97% in the head to 89% to 90% in the body, and only 45% in the tail [24,25].

Miniprobes in cancer  Previous section Next section

Miniprobes have been used to stage several cancers, including esophageal, gastric, duodenal, colorectal, ampullary, and pancreatico-biliary. The accuracy of miniprobes for staging cancers varies depending on the organ. Miniprobes provide better visualization and higher T-staging for esophageal cancer than standard EUS probes [26–30]. For gastric cancer, miniprobes have again been shown to be superior in overall staging accuracy compare with standard EUS (72% vs. 65%) [31]. However, miniprobes are less reliable for advanced cancer staging due to limited depth of ultrasound penetration [27]. They have also been shown to be superior to standard EUS in the visualization and diagnosis of ampullary tumors (100% vs. 59.3%) [32] with nodal staging accuracy varying from 66.7% to 93% [32,33].

Other uses of miniprobes  Previous section Next section

Miniprobes have also been used to examine Barrett's esophagus [34,35], achalasia [36–38], esophageal varices [39], MALToma, Menetrier's disease, linitis plastica [40], and inflammatory bowel disease [41–43].

Miniprobe limitations  Previous section Next section

Although miniprobes offer high resolution of small lesions in a single procedure, they do have some disadvantages. These include the limited penetration, which can make lymph node staging difficult. Unless a balloon sheath is used, the lumen needs to be filled with water, which may increase the risk of aspiration. Although the probes are reusable, they have a limited lifetime and undergo image deterioration after a certain number of cases.

Top of page Needles and accessories for EUS  Previous section Next section

Fine-needle aspiration  Previous section Next section

The ability to sample tissue using EUS has greatly increased the sensitivity for diagnosing malignant lesions. It also overcomes some of the limitations of transcutaneous US- and CT-guided needle aspiration, which are limited when the lesions are small or no safe 'skin to lesion' route for the needle can be found. EUS-FNA is now part of the investigative algorithms for patients with pancreatic, esophageal, rectal, and lung cancer [44–46], and also for patients with submucosal tumors.

Different types of needles  Previous section Next section

An EUS-FNA needle (Fig. 10) is a stainless steel echogenic needle with a bevelled edge. A stainless steel or nitinol stylet is inserted inside the needle, which prevents tissue or blood from clogging the needle while it is being advanced into the lesion (Figs 11–14). These stylets can be either bevelled to fit flush with the needle's tip or they can protrude a short distance from the needle tip with a sharp or a blunt tip. The needles come in a variety of diameters from 18 to 25 G, with 22 G being the most commonly used. The use of larger needles (18 or 19 G) is helpful if viscous fluid or large volumes are being aspirated. Spring-loaded needle designs are also available to help penetrate difficult-to-pierce lesions. There are as yet no studies comparing spring-loaded needles with routine EUS-FNA needles.

FNA technique  Previous section Next section

EUS-FNA is performed using a linear echoendoscope, which allows visualization of the entire needle in real time. The needle is inserted through the instrument channel of the echoendoscope and into the lesion, and the stylet is removed and the needle moved through the lesion with a rapid inward thrust and slower backwards motion. Suction is usually used except when initial aspirates are bloody. In this case the use of suction may decrease the sensitivity [47] of FNA and tissue should be aspirated without suction. Up to 10 back-and-forth movements are usually used [48]; suction is released, the tip of the needle is withdrawn back into the needle sheath, the needle is removed, and the contents are spread thinly on slides for examination by a cytopathologist. The exact number of needle passes required depends on whether a cytopathologist is available at the procedure, and the type of lesion being biopsied. If a cytopathologist is present the number of passes needed will be determined by the adequacy of sample obtained. If a cytopathologist is not available most series suggest that 3–4 passes [49–53] are sufficient to ensure a cellular sample, although up to 10 passes may be required in well-differentiated tumors or solid pancreatic masses [54].

Accuracy and safety  Previous section Next section

The accuracy of EUS-FNA is dependent on the technique used [55,56], the experience of the endosonographer [48,52], and the cytopathologist [54]. Even in the most challenging scenario of hard pancreatic masses, EUS-FNA can provide a cytological diagnosis in 80–94% of pancreatic lesions [57–61].

EUS-FNA has a low complication rate of 1–2% [50,53,62–65], similar to that reported for CT- or US-guided FNA or biopsy [66–69]. The major complications are infection in cystic lesions [50], bleeding [62], pancreatitis [53,70,71], and duodenal perforation [63]. Clinically significant bacteremia after EUS-FNA is rare but, because of the small but documented risk of infecting cystic lesions at EUS-FNA, intravenous broad-spectrum antibiotics are often used with EUS-FNA of cystic lesions [72–74] and puncture of any lesion through the colonic wall [75]. To date two deaths have been reported with EUS-FNA [62,76]. Needle-tract seeding is a potential complication; however, the risk is minimal in EUS-FNA, with only one case reported to date [77], as the needle travels from the gut lumen to the lesion, a pathway that usually does not cross peritoneal or pleural surfaces. In addition, the complete needle tract is usually included should the lesion subsequently undergo resection.

Core tissue biopsies  Previous section Next section

Technique  Previous section Next section

One of the disadvantages of FNA is that tissue architecture is not preserved. This is particularly important for the diagnosis of stromal tumors and lymphomas [78,79]. Core biopsies allow tissue to be obtained with preservation of underlying architecture. A modified Trucut biopsy needle has been developed, consisting of a 20-mm tissue tray, with a 19 G outer cutting sheath and a spring-loaded mechanism built into the handle that automates collection of specimens (Fig. 15). The biopsy needle is prepared before introduction into the endoscope by pulling back the spring handle until it clicks into the 'firing' position. This action draws the outer cutting sheath back and allows the inner needle tissue tray to be advanced. The inner needle remains in the withdrawn position until the specimen is obtained. The sheath assembly is advanced through the echoendoscope and then securely screwed into the accessory port channel with the Luer-lock adapter. The needle assembly is advanced into the lesion under EUS visualization. Once the lesion is entered, the tissue tray is further advanced into the tissue. Once the tray has exited the cutting sheath, the spring is released, which causes the cutting sheath to deploy rapidly over the tissue tray. The needle is withdrawn into the sheath and the entire assembly is removed from the endoscope. Samples up to 20 mm long can often be obtained with this device (Fig. 16).

Accuracy and safety  Previous section Next section

The overall accuracy of EUS core biopsies is 85–94% [80–82]. However, there is substantial variation in the accuracy, depending on whether biopsies are performed through the stomach or through the duodenum. In a study by Gines [82] the diagnostic yield was 57% with a transduodenal approach, compared with 89–100% for transesophageal or transgastric biopsies, which is comparable with findings from other studies [83,84]. The reason for higher failure rate with transduodenal biopsies has not been fully investigated but may be due to the increased angulation of the echoendoscope in the setting of a stiffer 19 G TCB needle. EUS-guided core biopsy is a relatively safe procedure with a complication rate of 2%, which is similar to that of EUS-FNA [85].

Top of page Outstanding issues and future trends  Previous section Next section

Several new imaging techniques are being developed. A curved linear array echoendoscope for endobronchial ultrasound-FNA (EBUS) (Fig. 17) and 360° electronic radial echoendoscopes have been launched recently. Three-dimensional EUS probes and software are being developed to evaluate esophageal, colorectal, and pancreatico-biliary lesions [86,87]. Preliminary results show that this is feasible for pancreatic evaluation and may enhance the evaluation of pancreatic lesions, especially in the setting of established chronic pancreatitis [88]. In animal studies, unresectable pancreatic tumors have been ablated using a modification of the EUS needle as a radiofrequency catheter [89]. EUS can also provide minimally invasive targeted delivery of specific therapies to tumors. EUS-guided FNA has been used to deliver a local immunotherapy (Cytoimplant) in patients with advanced pancreatic carcinoma with no procedure-related complications [90], and has also been used to inject a modified adenovirus into pancreatic adenocarcinomas [91]. Case reports of EUS-guided photodynamic therapy have been reported and studies of EUS-guided brachytherapy are awaited with interest. Finally, a specially designed applicator permeable to sound waves has been developed to apply radiation directly by needles under ultrasound guidance for anal cancer [92]. In a study of 18 patients with anal cancer EUS-guided chemotherapy produced complete initial remission in all patients with 13.9% recurrence at mean follow-up of 44 months [93]. More studies are required to assess these technologies further but they point the way forward for EUS, and hopefully the next few years will see further growth in the field of EUS-guided therapy in a range of gastrointestinal and mediastinal diseases.

Top of page References  Previous section

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Copyright © Blackwell Publishing, 2006

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Introduction
History
Current applications
Therapeutic EUS
Teaching and training EUS
Synopsis
Introduction
Radial and linear endosonographic probes
Contrast-enhanced ultrasonography
Catheter-based EUS probes (miniprobes)
  Miniprobe technique
  Miniprobes in cancer
  Other uses of miniprobes
  Miniprobe limitations
Needles and accessories for EUS
  Fine-needle aspiration
   Different types of needles
   FNA technique
   Accuracy and safety
  Core tissue biopsies
   Technique
   Accuracy and safety
Outstanding issues and future trends
References
Synopsis
EUS for cancer staging
Esophageal cancer staging with EUS
  Esophageal cancer TNM staging
  Technique for performing EUS staging of esophageal cancer
  EUS of stenotic esophageal tumors
  EUS evaluation of superficial tumors
  EUS evaluation of lymph nodes
  EUS-FNA of peri-esophageal lymph nodes
  Accuracy and limitations of EUS staging of esophageal cancer
  EUS re-staging of esophageal cancer after chemoradiation
  Impact of EUS staging on esophageal cancer management
Gastric cancer staging with EUS
  Gastric cancer TNM staging
  EUS staging of advanced gastric adenocarcinoma
  EUS staging of early gastric adenocarcinoma
  EUS staging of gastric MALT lymphoma
Rectal cancer staging with EUS
  Rectal cancer TNM staging
  Pathologic staging of rectal cancer
  Surgical management of rectal cancer
  Management algorithm for rectal cancer (Fig. 17)
  Technique for performing EUS rectal cancer staging
  EUS staging of rectal cancer
  Accuracy of EUS in staging rectal cancer
  EUS vs. CT and MRI for rectal cancer staging
  EUS/FNA for rectal cancer lymph node staging
  Stenotic rectal tumors
  Rectal EUS staging after radiation therapy
  Colon cancer staging with EUS
Anal cancer staging with EUS
Pancreatic cancer
  Staging of pancreatic cancer
  EUS staging of pancreatic cancer (Figs 12,13)
  Combination of EUS and CT/MRI for pancreatic cancer staging and determining resectability
  EUS-FNA for staging pancreatic cancer
  Recommendations for EUS staging of pancreatic cancer
Ampullary cancer
Extrahepatic bile duct cancer
Future trends and outstanding issues
References
Synopsis
Introduction
Endoscopic and EUS examination
GISTs
  Origin and development of GISTs
  Molecular biology of GIST: c-kit
  CD34 and other immunohistochemistry
  Clinical features
  Pathology
  Predicting malignant behavior: role of molecular markers
  Predicting malignant behavior: role of EUS
  Tissue sampling of GISTs
  EUS-guided fine-needle aspiration
  Therapy: surgery
  Therapy: imatinib
Leiomyomas
  Clinical features and diagnosis
  EUS features
Lipomas
  Clinical features and diagnosis
  EUS features
Granular cell tumors
  Clinical features
  Pathology
  Endoscopic and EUS features
  Treatment of granular cell tumors
Duplication cysts
  Clinical features
  EUS features
  Treatment of duplication cysts
Carcinoid tumors
  Clinical features and pathology
  Biochemistry
  Endoscopic and EUS features
  Appendiceal carcinoids
  Ileal carcinoids
  Rectal carcinoids
  Gastric and duodenal carcinoids
Ectopic pancreas ('pancreatic rest')
  Clinical features
  EUS features
Extrinsic compressions
Varices
Future trends and outstanding issues
References
Synopsis
Morbid anatomy
  Pancreas
  Portal vein
  Common bile duct
Endosonographic anatomy
Performing EUS of the pancreas and biliary tree
  Body and tail of pancreas
   Radial EUS
   Linear EUS
  Head and uncinate process of pancreas
   Radial EUS
   Linear
Benign biliary disease
  Choledocholithiasis
  Choledochal cysts
  Primary sclerosing cholangitis (PSC)
Malignant biliary disease
  Ampullary carcinoma
  Cholangiocarcinoma
  Carcinoma of the gallbladder
Benign pancreatic disease
  Pancreatitis
   Acute pancreatitis
   Chronic pancreatitis
   Autoimmune pancreatitis
Cystic lesions of the pancreas
  Pseudocysts
  Cystadenomas
   Serous cystadenoma
   Mucinous cystadenoma
   Solid-cystic pseudopapillary tumor
   Intraductal mucin-producing tumor/neoplasm (IPMT/N)
   Mucinous cyst adenocarcinoma
Solid tumors of the pancreas
  Adenocarcinoma
   Screening for adenocarcinoma
  Neuroendocrine tumors
  Metastases
Training in pancreatico-biliary EUS
Outstanding issues and future trends
References
Synopsis
Non-invasive imaging modalities
  Chest CT
  Positron emission tomography
Invasive staging
Endoscopic ultrasound-guided fine-needle aspiration
  Accuracy for diagnosing malignancy
  EUS and identification of metastatic disease
  EUS technique
  Limitations of EUS-FNA
Combined minimally invasive staging with endoscopic ultrasound and endobronchial ultrasound
Outstanding issues and future trends
  EUS-FNA and molecular markers in lung cancer
References

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