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Endoscopic ultrasound

Editor: Ian Penman

3. EUS for staging gastrointestinal and pancreatic cancer

Thomas J. Savides

Fig. 1 Survival rates for esophageal cancer [1].

Fig. 2 TNM staging of esophageal cancer [1,2].

Fig. 3 Esophageal cancer regional lymph nodes (N-stage) defined by location of esophageal cancer [1,2].

Fig. 4 T2 esophageal carcinoma. The tumor (T) invades into but not beyond the hypoechoic muscularis. AO, aorta; AZ, azygous vein; PL, pleura; LA, left atrium.

Fig. 5 Risk of malignant lymph nodes is associated with esophageal cancer T-stage [43].

Fig. 6 T3 esophageal carcinoma. There is loss of the normal wall layer structure and the circumferential tumor invades into the peri-esophageal fat.

Fig. 7 An enlarged celiac lymph node (CLN) is seen close to the origin of the main celiac trunk. Ao, aorta; CA, celiac axis.

Fig. 8 Early esophageal carcinoma. The tumor (T) is confined to the submucosal (third layer) and does not invade the muscularis propria (T1sm).

Fig. 9 N1 lymph node involvement in esophageal carcinoma. Although < 10 mm in size, the sonographic features are suspicious for malignancy: round shape, hypoechoic nature, and discrete borders.

Fig. 10 A malignant-looking N1 lymph node undergoing EUS-FNA. Cytology confirmed adenocarcinoma.

Fig. 11 T4 esophageal carcinoma. The tumor (T) invades the aorta (Ao) and no clear plane of separation exists between tumor and aortic wall (arrowhead).

Fig. 12 Impact of EUS staging of esophageal cancer on patient management.

Fig. 13 TNM staging system for gastric adenocarcinoma [1,2].

Fig. 14 T4 gastric carcinoma. There is no plane of separation (arrowheads) between the tumor (T) and the pancreatic body (P), indicating likely unresectability.

Fig. 15 Gastric cancer. Small volume malignant ascites (arrowhead) can often be detected at EUS when other imaging techniques fail. T, tumor.

Fig. 16 TNM staging of rectal cancer [1,2].

Fig. 17 Potential impact of EUS staging on rectal cancer management.

Fig. 18 Rectal carcinoma.

Fig. 19 Rectal carcinoma.

Fig. 20 TNM staging of anal cancer [1,2].

Fig. 21 EUS staging of pancreatic cancer [1,2].

Fig. 22 Pancreatic carcinoma. A large hypoechoic mass arising from the pancreatic head obstructs the common bile duct (not seen). There is sludge in the distended gallbladder (GB).

Fig. 23 Pancreatic carcinoma. A 15-mm tumor is identified in the head of pancreas in a patient with pain and weight loss.

Fig. 24 EUS staging of ampullary cancer [1,2].

Fig. 25 Ampullary carcinoma. Linear EUS in a patient with painless biliary dilatation and abnormal liver function tests. A 10-mm ampullary mass obstructs the common bile duct (CBD), and the pancreatic duct (PD) is also dilated.

Fig. 26 EUS staging of extrahepatic bile duct cancer [1,2].

Copyright © Blackwell Publishing, 2005

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Current applications
Therapeutic EUS
Teaching and training EUS
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
   Accuracy and safety
Outstanding issues and future trends
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
Endoscopic and EUS examination
  Origin and development of GISTs
  Molecular biology of GIST: c-kit
  CD34 and other immunohistochemistry
  Clinical features
  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
  Clinical features and diagnosis
  EUS features
  Clinical features and diagnosis
  EUS features
Granular cell tumors
  Clinical features
  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
  Endoscopic and EUS features
  Appendiceal carcinoids
  Ileal carcinoids
  Rectal carcinoids
  Gastric and duodenal carcinoids
Ectopic pancreas ('pancreatic rest')
  Clinical features
  EUS features
Extrinsic compressions
Future trends and outstanding issues
Morbid anatomy
  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
Benign biliary disease
  Choledochal cysts
  Primary sclerosing cholangitis (PSC)
Malignant biliary disease
  Ampullary carcinoma
  Carcinoma of the gallbladder
Benign pancreatic disease
   Acute pancreatitis
   Chronic pancreatitis
   Autoimmune pancreatitis
Cystic lesions of the pancreas
   Serous cystadenoma
   Mucinous cystadenoma
   Solid-cystic pseudopapillary tumor
   Intraductal mucin-producing tumor/neoplasm (IPMT/N)
   Mucinous cyst adenocarcinoma
Solid tumors of the pancreas
   Screening for adenocarcinoma
  Neuroendocrine tumors
Training in pancreatico-biliary EUS
Outstanding issues and future trends
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

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