Endoscopic Ultrasound (EUS): Visualizing Lesions under the Surface
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Endoscopic Ultrasound - SamplingGI Lesions from the Inside Out
Endoscopic Ultrasound (EUS): Visualizing Lesions under the SurfaceKenneth D. Chi, MDAdvocate Lutheran General Hospital
April 5, 2014Spring Educational Conference1IntroductionOutline
1. Basic primer in EUS
How has EUS changed patient care and community referrals?
When do you refer for an EUS? What is appropriate referral?4. When is EUS useful? /What are limitations / Complications?5. Applications of EUS at Lutheran General Hospital6. Future Applications of EUS2What is EUS?Endoscopic Ultrasound has expanded the breadth of GI Endoscopy
Introduced in 1980s: Japan / USA / Germany
Able to visualize pancreas through the stomach wall
Permits detailed imaging of GI wall layers
Enables accurate locoregional tumor staging
3EUS has allowed us to move from the lumen of the GI tract, to the beyond the lumen.Endoscopy vs. EUS
4The EUS Scopes
RadialLinear (FNA)Miniprobe5Radial vs. Linear
Yusuf, et al. Gastrointest Endosc. 2007 Jul;66(1):131-43. 6Basic principles of Ultrasound
Yusuf, et al. Gastrointest Endosc. 2007 Jul;66(1):131-43. Hyper-echoic (bright)Hypo-echoic (dark)An-echoic (black)Iso-echoic (same)7
(mucosa)(muscularis mucosa)(submucosa)(muscularis propria)(adventitia / serosa)8Find a better photo?EUS Fine Needle Aspiration
9Fine Needle Aspiration (FNA)
How EUS has changed patient careEsophageal cancer staging:
EUS results could dramatically change the patients treatment course
??11Role of EUS in Esophageal CaCentral role in initial stagingas outcome is strongly associated with stage
Useful in monitoring disease recurrence
Has complementary role with other imaging:EUS for locoregional stagingCT / PET : eval for mets / stage IV dz 12Comparing CT scan vs. EUS in detecting Lymph NodesSensitivitySpecificityCT29% (17-44)89% (72-98)EUS71% (56-83)79% (59-92)EUS w/FNA83% (70-93)93% (77-99)Vazquez-Sequeiros, E, Clain, JE, Norton, ID, et al, Gastroenterology 2003; 125:1626. ( Lymph node staging in Esophageal Cancer)13Esophageal Cancer Staging AlgorithmPrimary Diagnosis (EGD)CT Scan (+/- PET)UnresectableDiseaseT4 or M1T1 (T2)N0T3 or TxN1T4 or M1EUSStage Dependent TreatmentChemoXRTPalliationSurgicalResectionChemo / XRTResectionResectable Disease14EUS T + N StagingEUS T-stageT1Invasion up to Layer 3 (submucosa)T2Invasion into (but not thru) Layer 4 (musc. Propria)T3Breaks thru musc. propriaT4Invasion into adjacent structures
T1T2T3T412345EUS Layer15Why is T Stage Important?Risk of LN Mets Depth of tumor predicts LN involvement
Rice, TW et. al Ann Thorac Surg. 1998 Mar;65(3):787-92. T StageN1 DiseaseTis0%T111%T243%T3 77%Compared to T1 patient:T2 = 6x more likely to have N1T3 = 23xT4 = 35x
16Utility of EUS in EMR
Clinical impact of EUSShami VM, Villaverde A, Stearns L, Chi KD, Kinney TP, Rogers GB, Dye CE, Waxman I. Endoscopy. 2006 Feb;38(2):157-61. *In this study, EUS/FNA dramatically changed 20% (5/7) patients management course EUSFNAClinical Impact of Conventional Endosonography and Endoscopic Ultrasound-guided Fine-needle Aspiration in the Assessment of Patients with Barrett's Esophagus and High-grade Dysplasia or Intramucosal Carcinoma who have been Referred for Endoscopic Ablation TherapyV. M. Shami1, A. Villaverde1, L. Stearns1, K. D. Chi1, T. P. Kinney1, G. B. Rogers1, C. E. Dye1, I. Waxman11 Study Aims: Endoscopic mucosal resection and photodynamic therapy are exciting, minimally invasive curative techniques that represent an alternative to surgery in patients with Barrett's esophagus and high-grade dysplasia or intramucosal adenocarcinoma. However, there is lack of uniformity regarding which staging method should be used prior to therapy, and some investigators even question whether staging is required prior to ablation. We report our experience with a protocol of conventional endoscopic ultrasound staging prior to endoscopic therapy.
Patients and Methods: A total of 25 consecutive patients with a diagnosis of high-grade dysplasia or intramucosal adenocarcinoma in Barrett's esophagus who had been referred to the University of Chicago for staging in preparation for endoscopic therapy between March 2002 and November 2004 were included in the study. All 25 patients underwent repeat diagnostic endoscopy and conventional endosonography with a radial echo endoscope. Any suspicious lymph nodes that were detected were sampled using endoscopic ultrasound-guided fine-needle aspiration.
Results: Baseline pathology in the 25 patients (mean age 70, range 49 - 85) revealed high-grade dysplasia in 12 patients and intramucosal carcinoma in 13 patients. Five patients were found to have submucosal invasion on conventional endosonography. Seven patients had suspicious adenopathy, six regional (N1) and one metastatic to the celiac axis (M1a). Fine-needle aspiration confirmed malignancy in five of these seven patients. Based on these results, five patients (20 %) were deemed to be unsuitable candidates for endoscopic therapy.
Conclusions: By detecting unsuspected malignant lymphadenopathy, conventional endosonography and endoscopic ultrasound with fine-needle aspiration dramatically changed the course of management in 20 % of patients referred for endoscopic therapy of Barrett's esophagus with high-grade dysplasia or intramucosal carcinoma. Based on our results, we believe that conventional endosonography and endoscopic ultrasound with fine-needle aspiration when nodal disease is present should be performed routinely in all patients referred for endoscopic therapy in this setting.
18Cost analysis of EUSImpact of pre-op EUS on Esophageal cancer management and cost
26% of patients undergoing pre-op EUS staging would be spared combined modality therapy who were found to be Stage I or IV.
In other words:Estimated for every 100 pts undergoing pre-op EUS for Esophageal cancer staging:14 pts with Stage I would be spared neo-adjuvant CTX (Total Cost savings $122,192)12 pts with Stage IV would be spared surgery (saving a total of $285,600)Average cost savings $3443 per patient
(Shumaker, et. al Gastrointest Endosc. 2002 Sep;56(3):391-6.)19http://www.medscape.com/viewarticle/460477_5
In today's healthcare scenario of ever-increasing cost and consequent attempts at cost containment, every healthcare intervention has to pass the acid test of cost-effectiveness. This is particularly relevant for newer technologies such as EUS. Over the past decade, clinical studies have proved beyond doubt that EUS is a particularly useful imaging modality in the staging of esophageal cancer, and it is no surprise that outcome studies have started to evaluate the economic aspects of cancer staging by EUS. Using a large national endoscopic database, Shumaker et al.[11*] studied the impact of EUS staging on the cost of esophageal cancer. They estimated that for every 100 patients undergoing preoperative EUS staging for esophageal cancer, 14 patients with Stage I disease would be spared neoadjuvant therapy (saving a total of $122,192), and 12 patients with Stage IV cancer would be spared surgery (saving a total of $285,600), for an average cost savings of $3443 per patient. They concluded that preoperative staging with EUS identified a significant proportion of patients (26% in this series) with Stage I and IV tumors who could be spared combined modality therapy, with an associated potential for cost savings. It should be noted that the authors based their estimate of cost savings on a rather biased assumption that esophageal cancer in all patients who do not undergo EUS staging would be managed with multimodality combination therapy, including surgery. In a cost-minimization analysis, it was shown that EUS-guided FNA for staging of esophageal cancer is less costly than a strategy of CT-guided FNA, particularly in a cohort with a high prevalence of metastatic celiac lymph nodes. Using decision-analysis techniques, Wallace et al.[13**] compared the cost and effectiveness of different strategies for staging of esophageal cancer. Clinical probabilities were obtained from a parallel prospective clinical trial, and cost estimates were derived from the Surveillance, Epidemiology, and End Results (SEER) Medicare linked databases and from other Medicare reimbursement rates. Under baseline assumptions, CT + EUS-FNA was the most inexpensive strategy and offered more quality-adjusted life-years, on average, than all other strategies with the exception of positron emission tomography (PET) + EUS-FNA. The latter was slightly more effective but also more expensive. The marginal cost-effectiveness ratio for PET + EUS-FNA was $60,544 per quality-adjusted life-year. The authors concluded that the combination of PET + EUS-FNA should be the recommended staging procedure for patients with esophageal cancer, unless resources are scarce or PET is unavailable. In these instances, CT + EUSFNA can be considered the preferred strategy. PET has a major advantage in that it can do rapid assessment for distant metastasis by whole-body imaging and has recently been approved for staging of esophageal cancer.
EUS IndicationsQuestion:Are community physicians aware of the indications of EUS?
20Add a cartoon hereEUS IndicationsASGE Recommended Indications for EUSStaging of tumors of GI tract, pancreas, bile ducts, mediastinum
Evaluating abnormalities of the GI-tract wall or adjacent structures
Tissue sampling of lesions within, or adjacent to the wall of the GI tract
Evaluation of abnormalities of pancreas (masses, PC, chronic pancreatitis)
Evaluation of abnormalities of the biliary tree
Providing endoscopic therapy under US guidance21EUS Indications / Limitations1st study to assess knowledge of referring indications of