ATLAS OF ENDOSCOPIC ULTRASOUND - Minerva Medica

CLAUDIO DE ANGELIS - PAOLO BOCUS

IECATLAS OF

ENDOSCOPIC ULTRASOUND

EDIZIONI MINERVA MEDICA

ATLANTE ENDOSCOPIA IMPAGINATO.indd 1 20/12/12 14:21

ISBN: 978-88-7711-761-8

© 2013 – EDIZIONI MINERVA MEDICA S.p.A. – Corso Bramante 83/85 – 10126 Turin (Italy)www.minervamedica.it / e-mail: [email protected]

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means.

ABBREVIATIONS

AA = Ascending AortaAoA = Aortic ArchAoV = Aortic ValveAV = Ampulla VateriAzA = Azygous ArchAzV = Azygous VeinCA = Celiac ArteryCBD = Common Bile DuctCC = Common Carotid ArteryCD = Cystic DuctCon = Splenoportal ConfluenceDA = Descending AortaDC = Diaphragmatic CrusDM = Deep MucosaES = External Anal SphincterEso = EsophagusGB = GallbladderGDA = Gastroduodenal ArteryHA = Hepatic ArteryHV = Hepatic VeinsICA = Internal Carotid ArteryIIV = Internal Iliac VesselsIJV = Internal Jugular VeinIS = Internal Anal SphincterIV = Innominate VeinIVC = Inferior Vena CavaL = LungLA = Levator AniLA = Left AtriumLAG = Left Adrenal GlandLI = LiverLK = Left kidneyLN = Lymph Node(s)LRA = Left Renal ArteryLRV = Left Renal VeinLV = Left VentricleMP = Muscularis PropriaMSB = Mainstem Bronchus

MU = Membranous UrethraMV = Mitral ValveO = OvaryP = ProstatePA = Pulmonary ArteryPB = Pancreatic BodyPD = Pancreatic DuctPH = Pancreas HeadPl = PleuraPN = Pancreas NeckPT = Pancreas TailPV = Portal VeinRA = Right AtriumRAG = Right Adrenal GlandRK = Right KidneyRV = Right VentricleSA = Splenic ArterySac = SacrumSC = Subclavian ArterySeV = Seminal VesiclesSM = SubmucosaSMA = Sup. Mesenteric ArterySMV = Sup. Mesenteric VeinSp = SpineSpl = SpleenSV = Splenic VeinSVC = Superior Vena CavaT = TracheaTD = Thoracic DuctTG = Thymus GlandTh = ThyroidUB = Urinary BladderUP = Uncinate ProcessUr = UrethraUt = UterusV = VaginaVP = Ventral Pancreas


After the first pioneering studies in the 80’s brought about by Giancarlo Caletti in Bologna, and by very few other researchers in the world, EUS has gradually become a mainstay technique. It is now essential to the clinical practice and the diagnostic and therapeutic work-up of many digestive disorders.

In particular, the last decade has witnessed the definitive consecration of EUS in almost all the main Italian hospitals, where it has entered busy routine clinical practice together with several educational events and sym-posia, dedicated to spread the knowledge of its indications also to non-EUS users.

The Italian Club of Endosonography (IEC - Italian Endosonography Club) was founded in 2002 with the aim of bringing together the Italian doctors, involved in EUS or willing to approach this technique, in order to exchange views on EUS-related clinical issues, technical aspects, administrative issues and research projects. Teaching of EUS was also included among the main aims of the club.

Through our association we also aim to promote EUS among colleagues who do not practice it personally but nevertheless have to deal with it almost on a daily basis (such as internists, surgeons, oncologists), so that they can refer their patients according to the most appropriate indications. Moreover, the IEC is constantly striving to promote the utilization of EUS within hospitals, universities and other scientific organizations. The IEC also promoted relationships and initiated collaboration with international EUS experts, some of which are also among the contributors of this volume and with Clubs or EUS Groups of interest of other European countries, by founding in 2003, the European Group for Endoscopic UltraSound (EGEUS).

IEC remains strongly committed to advancing and promoting EUS through education and training. So the present atlas appears as a natural consequence of these premises and a continuation of the club’s educational activities. The format of the book encompasses essentially bare EUS images with explicative legends, preceded by just a more or less brief introduction to each chapter. The ratio images/text is all in favor of the former, col-lecting the most significant cases seen at our centers. In fact, all the IEC members have had the opportunity to submit their own cases to the editors.

The readers will find here a collection of relevant images for the most common but also the less known or even anecdotal pathologies studied by EUS. The atlas aims at providing a referral manual, which hopefully will assist all the endosonographers with reference images for almost each pathological condition amenable to be investigated by our fascinating technique.

We sincerely hope that this textbook will help in their daily practice current and future endosonographers, at last leading to improvement in the practice of EUS and the care of our patients. In order to better achieve these goals a unique collection of online EUS videos will be made available to our readers and it will be con-tinuously updated and enriched with new contents.

While we do hope that the commitment and sacrifices bestowed for the realization of this atlas will be appreciated, we wish you a good reading but mainly a good watching.

Claudio De Angelis - Paolo Bocus

Preface


AcknowledgementsWe would like to thank our families, especially our spouses and our children,for the long time taken away from them in completing this project and mainlyfor their continuous support and encouragement, particularly in the most difficult moments when we felt that we would not be able to successfully complete the work.

C. De Angelis, P. BocusT. Togliani, M. Bruno

EDITORS

Claudio de angelis, MdPaolo BoCus, Md

ASSOCIATES EDITORS ThoMas Togliani, MdMauro Bruno, Md


AuThORS

MarCo BianChi Unit of Gastroenterology and Hepatology, San Filippo Neri Hospital, Rome, Italy

Paolo BoCus High Technology Endoscopy Unit, Veneto Institute of On-cology, IRCCS, Padua, Italy

giaCoMo Bonanno Gastroenterology and Digestive Endoscopy Unit, Vittorio Emanuele Hospital, Catania, Italy

Mauro Bruno GastroHepatology Department, Endoscopy and Endosono-graphy Center, Azienda Ospedaliera Città della Salute e della Scienza, University of Turin, Italy

elisaBeTTa BusCarini Gastroenterology and Digestive Endoscopy Unit, Maggiore Hospital, Crema, Italy

gianCarlo CaleTTi Department of Gastroenterology, University of Bologna, Hospital of Imola, Italy

renaTo Cannizzaro Department of Gastroenterology and Oncology, Centro di Riferimento Oncologico IRCCS, Aviano, Italy

PaTrizia CaruCCi GastroHepatology Department, Endoscopy and Endosono-graphy Center, Azienda Ospedaliera Città della Salute e della Scienza, University of Turin, Italy

Claudio de angelis GastroHepatology Department, Endoscopy and Endosono-graphy Center, Azienda Ospedaliera Città della Salute e della Scienza, University of Turin, Italy

leonardo de luCa Gastrointestinal Unit, Pellegrini Hospital, Naples, Italy

Carlo FaBBri Department of Surgery, Unit of Gastroenterology and Di-gestive Endoscopy, Hospital Bellaria-Maggiore, AUSL of Bologna, Italy

TeleMaCo FederiCi Senior GI Consultant. Gastroenterology Unit, San Camil-lo-Forlanini Hospital, Rome, Italy

PieTro FusaroliDepartment of Gastroenterology, University of Bologna, Hospital of Imola, Italy

MargareT M. JohnsonDivision of Pulmonary Medicine, Mayo Clinic Jacksonville, FL, USA

PhiliP e. lowManDivision of Pulmonary Medicine, Mayo Clinic Jacksonville, FL, USA

CaTerina MarChiò Azienda Ospedaliera Città della Salute e della Scienza, Department of Medical Sciences, University of Turin, Italy

PieTro Marone Department of Endoscopic Imaging, Istituto dei Tumori Fondazione “G. Pascale”, Naples, Italy

VinCenzo naPoliTano Department of General and Specialistic Surgery, Unit of Surgical Endoscopy, Second University of Naples, Italy

donaTella PaCChioni Azienda Ospedaliera Città della Salute e della Scienza, Department of Medical Sciences, University of Turin, Italy

anTonio Pisani Department of Gastroenterology, Policlinico University of Bari, Italy

anna Maria PoliFeMo O.U. of Gastroenterology and Digestive Endoscopy Hospital Bellaria-Maggiore Bologna, Italy

MassiMo raiMondo Division of Gastroenterology and Hepatology, Mayo Clinic Jacksonville, Florida, USA

anna saPino Azienda Ospedaliera Città della Salute e della Scienza, Department of Medical Sciences, University of Turin, Italy

Authors and Contributors


IEC - ATLAS OF ENDOSCOPIC ULTRASOUNDVI

ilaria TaranTino Gastroenterology and Digestive Endoscopy Unit, Mediter-ranean Institute for Transplantation and High Specialized Therapy (ISMETT)/ University of Pittsburgh Medical Cen-ter in Italy, Palermo, Italy

ThoMas Togliani Endoscopy Unit, “Carlo Poma” Hospital, Mantua, Italy

MiChael wallaCe Division of Gastroenterology and Hepatology, Mayo Clinic Jacksonville, FL, USA

CONTRIBuTORS

daniela assisi O.U. of Gastroenterology and Digestive Endoscopy. Nation-al Institute of Tumors, Regina Elena Institute, Rome, Italy

giorgio BaTTaglia

High Technology Endoscopy Unit, Veneto Institute of On-cology, IRCCS, Padua, Italy

rosario FranCesCo Brizzi

GastroHepatology Department, Endoscopy and Endosono-graphy Center, Azienda Ospedaliera Città della Salute e della Scienza, University of Turin, Italy

VinCenzo Canzonieri

Department of Pathology, Centro di Riferimento Oncologi-co IRCCS, Aviano, Italy

eManuele daBizzi

Gastroenterology and Digestive Endoscopy Unit, Sanremo Hospital, ASL1 Imperiese, Italy

MarCo daPerno

Gastroenterology Unit, Mauriziano Hospital, Turin, Italy

giorgio de sTeFano Department of Infectious Diseases and Interventional Ul-trasound, Endosonography Center, AORM-Ospedali Dei Colli - P.O. D. Cotugno, Naples, Italy

Mara Fornasarig

Department of Gastroenterology and Oncology, Centro di Riferimento Oncologico IRCCS, Aviano, Italy

aldo garBarini

Emergency Surgery Department, Digestive Endoscopy Cen-ter, Azienda Ospedaliera Città della Salute e della Scienza, University of Turin, Italy

sTeFania Maiero

Department of Gastroenterology and Oncology, Centro di Riferimento Oncologico IRCCS, Aviano, Italy

MarCello MarTini GastroHepatology Department, Endoscopy and Endosono-graphy Center, Azienda Ospedaliera Città della Salute e della Scienza, University of Turin, Italy

eManuele Meroni Endoscopic Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy

selene FranCesCa ManFrè

GastroHepatology Department, Endoscopy and Endosono-graphy Center, Azienda Ospedaliera Città della Salute e della Scienza, University of Turin, Italy

rinaldo PelliCano

GastroHepatology Department, Azienda Ospedaliera Cittàdella Salute e della Scienza, University of Turin, Italy

dario reggio Liver Transplantation Center, Azienda Ospedaliera Città della Salute e della Scienza, University of Turin, Italy

rodolFo roCCa Gastroenterology Unit, Mauriziano Hospital, Turin, Italy


Preface ......................................................................................................................................................................... IIIAuthors and Contributors ........................................................................................................................................ V

1 EuS hISTORY ...........................................................................................................................................................1 C.DeAngelis,G.Caletti

2 INSTRumENTS AND ACCESSORIES ....................................................................................................................9 M.Bruno,A.M.Polifemo,C.DeAngelis

3 EuS ROOm SETuP ............................................................................................................................................... 21 P.Fusaroli

4 NORmAl GI wAll AND ImAGING ARTIfACTS ............................................................................................. 27 M.Bianchi,A.Pisani Withthecollaborationof:C.DeAngelis

5 ESOPhAGuS ......................................................................................................................................................... 33 P.Bocus,T.Togliani

6 mEDIASTINum ..................................................................................................................................................... 57 M.Wallace,V.Napolitano

Endobronchial ultrasound ..................................................................................................................................... 69 P.E.Lowman,M.M.Johnson

7 STOmACh AND DuODENum ............................................................................................................................ 73 R.Cannizzaro,P.Marone

Withthecollaborationof:M.Fornasarig,S.Maiero,V.Canzonieri

8 PANCREAS ............................................................................................................................................................ 87 C.DeAngelis,M.Raimondo

Withthecollaborationof:S.F.Manfrè,R.Pellicano,E.Dabizzi

9 BIlE DuCTS ......................................................................................................................................................... 131 E.Buscarini,I.Tarantino

10 IDuS AND EDuS ................................................................................................................................................. 141 M.Bruno,C.DeAngelis Withthecollaborationof:D.Reggio,A.Garbarini

Contents


IEC - ATLAS OF ENDOSCOPIC ULTRASOUNDVIII

1 111 ANORECTum AND COlON .............................................................................................................................. 141 T.Federici,G.Bonanno

Withthecollaborationof:D.Assisi

12 OThER ORGANS ................................................................................................................................................ 167 P.Carucci,L.DeLuca

13 ThERAPEuTIC EuS AND NEw APPlICATIONS ............................................................................................ 181 C.DeAngelis,C.Fabbri,P.Fusaroli Withthecollaborationof:D.Reggio,S.F.Manfrè.R.F.Brizzi,A.Garbarini,R.Rocca

14 ThE ROlE Of CYTOPAThOlOGY ....................................................................................................................207 D.Pacchioni,C.Marchiò,A.Sapino


5 ESOPhAGuSP.Bocus,T.Togliani

In the late 80s EUS has been proposed as a new method to study the gastroesophageal wall and bilio-pancreatic district, and it soon demonstrated its po-tential in the evaluation of some esophageal diseases; adenocarcinoma and squamous cell carcinoma are the main indications for esophageal EUS, although subepithelial lesions such as Abrikosoff tumors, leio-myomas, varices, cysts can be easily displayed.

Esophageal cancer is a common tumor and its incidence is rising in western countries. As far as pa-tient’s prognosis and cost-effectiveness of therapeutic protocols are strongly related to tumor staging, many efforts have been made in the last three decades to improve the diagnostic techniques.

EUS showed the best accuracy for locoregional staging of esophageal cancer, as it can precisely deter-mine the degree of parietal infiltration (T parameter of TNM classification); it also provides a good visu-alization of periesophageal and celiac lymph nodes, that can be sampled by means of FNA (fine needle aspiration) in the suspect of nodal metastasis (N pa-rameter of TNM classification). Some recent soft-ware applications coupled to EUS miniprobes allow the three dimensional reconstruction, that permits a better spatial visualization of the lesions, the inner superficial rendering and the volume measurements. For a complete distant staging (M parameter of TNM classification) a thoraco-abdominal CT/PET scan is mandatory.

In the last years many different multimodal ther-apeutic approaches have been proposed, according to the initial staging and the surgical risk of the patient: endoscopic resection, surgery, chemo-radiation, adju-vant and neoadjuvant therapy, endoscopic stenting. The introduction of new neoadjuvant protocols needs tools able to confirm, before surgery, if a real down-staging has occurred, but traditional radiology seems to have a limited accuracy in this field. Few data in the literature are available on the role of EUS in the staging of esophageal cancer after neoadjuvant

therapy; parietal fibrosis of the esophageal wall and the inflammatory enlargement of periesophageal lymph nodes make EUS (like all the other imaging techniques) less accurate in this particular situation.

To improve EUS accuracy in the evaluation of lymph nodes two promising innovations have been introduced: contrast enhanced EUS and EUS-elas-tography. These new techniques could find interesting applications in the study of esophageal cancer, by im-proving the detection of malignancy and targeting FNA in lymph nodes with suspicion of metastasis.

The examination of the esophagus using a ra-dial probe, which is the most frequently used for esophageal tumor staging, is one of the easiest EUS procedures to perform, since the esophagus is es-sentially a straight tube requiring little manipula-tion of the echoendoscope. However, examination of the esophagus cannot be competently performed without a strong knowledge of the spatial anatomy of the mediastinum. EUS staging of esophageal cancer is rarely performed with linear echoendoscopes, which imposes a multi-step 360 degrees rotation to obtain a complete circumferential image of the en-tire esophageal wall; on the contrary, these probes are crucial for a correct lymph node assessment in the suspect of node metastasis. Superficial small lesions or tight neoplastic stenoses can be studied with echo-graphic miniprobes through the operative channel of a normal gastroscope.

In case of tumor staging the maximum depth of wall infiltration, the presence of extraesophageal infiltration, the upper and lower edges of the lesion, and the presence of celiac or mediastinal lymph node metastases should be described in the report.

The following is a brief description of the anatom-ical landmarks that must be recognized in a standard radial examination of the esophagus.


IEC - ATLAS OF ENDOSCOPIC ULTRASOUND34

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while the right lung can be seen in the 9 o’clock location. The lungs have a unique EUS image of hyperechoic rings that represents air within the lung parenchyma. Further withdrawal of the in-strument will image structures surrounding the mid-esophagus.

Keeping the aorta in the 5 o’clock position, the spine is visualized at the 7 o’clock position. The azygos vein will be seen to the right of the aorta and will move upwards along the right lung. The tho-racic duct will appear as a small, round anechoic dot between the azygos vein and the aorta. As the scope is further withdrawn, the azygos vein will be seen moving forward and merging into the superior vena cava. The aortic arch will be noted on the left as it arises from the aorta and can be seen curving to-wards the right. Also, the left and right bronchi can be seen, as small hyperechoic rings that represent car-tilage and air artifacts, at the 1 o’clock and 11 o’clock positions, respectively.

As the echoendoscope is withdrawn, the left and right bronchi can be observed forming the trachea at the level of the carina, which is usually about 26 to 28 cm from the incisors. Just below this region lies the subcarina region, where lymph nodes can fre-quently be seen. These lymph nodes characteristically appear as small hyperechoic structures with indistinct margins and ovalar or triangular shapes. In cases of malignant nodes an hypoechoic pattern with more distinct and sharper borders and a round shape are typical.

The proximal or cervical esophagus is entered upon further withdrawal of the instrument. In this position, the blood vessels of the neck come into view above the aortic arch. The left subclavian ar-tery can be seen posteriorly while the left common carotid artery and sometimes the brachiocephalic trunk are seen anteriorly. The location of the tra-chea in the mid-plane causes air artifacts, which can hamper imaging at this station. In the neck later-ally to the esophagus the right and the left internal carotid arteries and internal jugular vein are clearly displayed. In some patients, the thyroid gland can be seen mainly its left lobe, appearing as a hypo-isoechoic structure laterally to the crycoid echos. A further withdrawal makes the instrument pass the upper esophageal sphincter (approximately 18 cm from the incisors).

During the whole exam overinflation of the bal-loon, oblique scanning of the esophageal wall and lack of complete air suction should be avoided since they can cause imaging artifacts and misinterpreta-tions of the images.

Once the radial scanning echoendoscope is introduced into the esophagus, it should be ad-vanced slowly into the stomach just below the gas-troesophageal junction, which is usually approxi-mately 40 cm from the incisors. At the beginning of EUS scanning, the aorta should be positioned at five o’clock; the image can be adjusted by rotating the aorta (either manually or electronically) to the correct anatomical position. With this orientation, like in CT scan images, the anterior region of the patient is displayed in the upper part of the screen, the posterior in the lower, the left is on the right, the right is on the left.

With the scope in the stomach, just above the neck of the pancreas, the celiac axis and its main branches (the hepatic, the splenic and the left gastric arteries) can be visualized coming out from the aorta (which is located at 5 o’clock position). Between 6 o’clock and 12 o’clock position the left lobe of the liver, the inferior vena cava and hepatic veins can be seen.

The five-layers wall pattern of the esophagus comes into view as the echoendoscope is slowly with-drawn cephalad; the esophageal wall, whose normal thickness is 3 to 4 mm, is gradually explored up to the upper esophageal sphincter. During withdrawal of the scope in the thorax the left atrium, the mitral valve and the pulmonary veins will come into view between 12 o’clock and 3 o’clock position. Upon fur-ther interrogation of this area, the left pulmonary ar-tery can be seen. The left ventricle, right atrium, and right ventricle are more difficult to image and may not be seen distinctly in all cases.

As the echoendoscope is further withdrawn the left lung will appear at the 2 o’clock position

TNm classification of esophageal cancer (7th edition).

Ta Infiltration of the lamina propria

T1b Infiltration of the submucosa

T2 Infiltration of the muscularis propria

T3 Infiltration of the adventitia

T4a Infiltration of pleura, pericardium, diaphragm

T4b Infiltration of aorta, vertrebral body, trachea

N0 No regional lymph node metastasis

N1 1-2 regional lymph nodes

N2 3-6 regional lymph nodes

N3 7 or more regional lymph nodes

M1 Distant metastases


5 • ESOPHAGUS 35

5

figure 5.3 – Esophagus, T1a N0 adenocarcinoma, Olympus miniprobe (20 MHz): a small isoechoic thickening (3 mm) of the mucosa, with preservation of the other layers is clearly vis-ible.

figure 5.4 – Esophagus, T1a N0 adenocarcinoma, Olympus radial mechanical UMQ130 probe with the water filled bal-loon (20 MHz): note a small hypoechoic thickening (3 mm) of the mucosa, with preservation of the other layers.

figure 5.5 – Esophagus, T1a N0 adenocarcinoma, Olympus radial mechanical UMQ130 probe (20 MHz): note a hypoe-choic thickening (6 mm) of the mucosa, with preservation of the other layers.

figure 5.1 – Esophagus, normal wall, Olympus radial electronic GF UE 160 (7.5 MHz): note the normal 5-layers echostructure of the esophageal wall.

figure 5.2 – Esophagus, normal wall, Olympus radial me-chanical GF UM 160 (20 MHz): note the normal 7-layers echostructure of the esophageal wall which is visible at high frequencies.

figure 5.6 – Esophagus, small adenocarcinoma in a segment of Barrett’s metaplasia, endoscopic view.



5

figure 5.12 – Esophagus, T1b N0 adenocarcinoma (same patient), Olympus radial electronic UE 160 probe (7.5 MHz): note a hypoechoic thickening (12 x 8 mm) of the mucosa, with initial infiltration of the submucosa; muscularis propria and adventitia are preserved.

figure 5.8 – Esophagus, T1a N0 adenocarcinoma (same pa-tient), Olympus radial mechanical UM160 probe (20 MHz): note a small hypoechoic thickening (3 mm) of the mucosa, with preservation of the other layers.

figure 5.10 – Esophagus, T1a N0 adenocarcinoma, Aloka miniprobe (15 MHz): note a small hypoechoic thickening (3 mm) of the mucosa, with preservation of the other layers

figure 5.9 – Esophagus, specimen from endoscopic mucosec-tomy (same patient); pathology confirmed EUS staging.

figure 5.11 – Esophagus, small adenocarcinoma above the cardia, Olympus GF 140.

figure 5.7 – Esophagus, small adenocarcinoma in a segment of Barrett’s metaplasia (same patient), NBI view.


5 • ESOPHAGUS 37

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figure 5.14 – Esophagus, T2 N0 adenocarcinoma, Olympus radial mechanical UM 160 probe (7.5 MHz): note a hypo-iso-echoic circumferential thickening of the esophageal wall, with fusion of mucosa, submucosa and muscularis propria; the ad-ventitia is preserved; no periesophageal lymph nodes are visible.

figure 5.15 – Esophagus, T2 N0 adenocarcinoma, Olympus radial electronic UE 160 probe (6 MHz): note a hypoechoic circumferential thickening of the esophageal wall, with partial fusion of mucosa, submucosa and muscularis propria; the ad-ventitia is preserved; no periesophageal lymph nodes are visible; the echographic layers, where no fusion occurs, are measured.

figure 5.16 – Esophagus, T2 N1 adenocarcinoma, Olympus radial mechanical UM 160 probe (7.5 MHz): note a hypo-iso-echoic circumferential thickening of the esophageal wall, with fusion of mucosa, submucosa and muscularis propria; the ad-ventitia is preserved; two round isoechoic 15 mm (pathologic) and 5 mm periesophageal lymph nodes are visible.

figure 5.13 – Esophagus, T2 N0 adenocarcinoma, Olympus radial mechanical UM 160 probe (20 MHz): note a hypoechoic circumferential thickening (13 mm) of the esophageal wall, with fusion of mucosa, submucosa and muscularis propria; the ad-ventitia is preserved; no periesophageal lymph nodes are visible.

figure 5.18 – Esophagus, T2 adenocarcinoma, 3D volume reconstruction using Olympus dual planner mini-probe (UM-DP12-25R) and 3D upgrade kit (MAJ-1330).

figure 5.17 – Esophagus, T2 NX adenocarcinoma, Olympus radial electronic UE 160 (10 MHz): note a hypo-isoechoic semi-circumferential thickening of the esophageal wall, with fusion of mucosa, submucosa and muscularis propria; the ad-ventitia is preserved; a round hypoechoic 6 x 3 mm periesopha-geal lymph node is visible.



5

figure 5.23 – Esophagus, T3 N1 adenocarcinoma, Ol-ympus radial mechanical UM 160 probe (5 MHz): note a se-vere hypoechoic semi-circumferential thickening (25 mm) of the esophageal wall, with fusion of mucosa, submucosa and muscularis propria; the adventitia is interrupted by tumoral pseudopodia; a ovalar hypoechoic 14 mm (pathologic) per-iesophageal lymph node is visible.

figure 5.24 – Esophagus, T3 N1 adenocarcinoma, Aloka radial mechanical miniprobe (15 MHz): note a stenotic hypoe-choic circumferential thickening of the esophageal wall, with fusion of mucosa, submucosa and muscularis propria; the ad-ventitia is irregular; two ovalar hypoechoic 10 mm periesopha-geal lymph node are visible.

figure 5.22 – Esophagus, T3 N1 adenocarcinoma, Olympus radial mechanical MH 908 “blind Probe” (7.5 MHz): note a hypoechoic circumferential thickening of the esophageal wall, with fusion of mucosa, submucosa and muscularis propria; the adventitia is interrupted; an ovalar hypoechoic 13 mm (patho-logic) periesophageal lymph node is visible.

figure 5.20 – Esophagus, T3 N0 adenocarcinoma, Olympus radial electronic UE 160 probe (5 MHz): note a severe hypoe-choic thickening (27 mm) of the esophageal wall that involves 3/4 of the circumference of the esophagus, with fusion of mu-cosa, submucosa and muscularis propria; the adventitia is ir-regular; no periesophageal lymph nodes are visible.

figure 5.19 – Esophagus, T3 N0 adenocarcinoma, Olympus radial mechanical UM 160 probe (20 MHz): note a hypoe-choic semi-circumferential thickening (14 mm) of the esopha-geal wall, with fusion of mucosa, submucosa and muscularis propria; the adventitia is irregular; no periesophageal lymph nodes are visible.

figure 5.21 – Esophagus, T3 N0 adenocarcinoma, Olympus radial mechanical UM 160 probe (12 MHz): note a moderate hy-poechoic semi-circumferential thickening (8 mm) of the esopha-geal wall, with fusion of mucosa, submucosa and muscularis pro-pria; the adventitia is interrupted by a single thin pseudopodium of tumoral tissue; no periesophageal lymph nodes are visible.

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figure 5.25 – Esophagus, T3 N1 adenocarcinoma (same pa-tient): endoscopic view of the tumoral mass of the lower es-ophagus.

figure 5.26 – Esophagus, T3 adenocarcinoma, Olympus radial mechanical miniprobe (12 MHz); 3D reconstruction with area and volume calculation: note a stenotic hypoechoic circumfer-ential thickening of the esophageal wall, with fusion of mucosa, submucosa and muscularis propria; the adventitia is irregular.

figure 5.27 – Esophagus, T4 N0 adenocarcinoma, Olympus radial mechanical UM 160 probe (7.5 MHz): note a hypoe-choic circumferential thickening (up to 17 mm) of the esopha-geal wall, with fusion of all the layers and infiltration of the right pleura; no periesophageal lymph nodes are visible.

figure 5.28 – Esophagus, T4 N0 adenocarcinoma, Olympus radial mechanical UM 130 probe (7.5 MHz): note a hypoe-choic circumferential thickening (up to 25 mm) of the esopha-geal wall, with fusion of all the layers and infiltration of the tra-chea and right lung; no periesophageal lymph nodes are visible.

figure 5.29 – Esophagus, T4 N0 adenocarcinoma, Olympus radial mechanical UM 130 probe (7.5 MHz): note an isoechoic 3 cm mass of the posterior esophageal wall with infiltration of the descending aorta; no periesophageal lymph nodes are visible.

figure 5.30 – Cardia, T4 N0 adenocarcinoma, Olympus ra-dial electronic UE 160 probe (7.5 MHz): note a hypoechoic circumferential thickening of the GI wall with infiltration of the left diaphragmatic pillar.

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ATLAS OF ENDOSCOPIC ULTRASOUND - Minerva Medica

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