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CLAUDIO DE ANGELIS - PAOLO BOCUS

IECATLAS OF

ENDOSCOPIC ULTRASOUND

EDIZIONI MINERVA MEDICA

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

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


IEC - ATLAS OF ENDOSCOPIC ULTRASOUND12

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figure 2.3 – Olympus radial electronic echoendoscope GF-UE160.

figure 2.2 – Fujinon linear scope EG-530UT.

figure 2.5 – Olympus linear echoendoscope UCT180.

figure 2.4 – Olympus mechanical radial echoendoscope (GF-UM Q130). Note the bulky motor drive, located in the en-doscope handle, connected to the trasducer with a wire cable.

figure 2.6 – Pentax radial scope EG.3670URK.

figure 2.1 – Fujinon EUS radial scope EG-530UR.



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figure 2.22 – Boston Scientific Expect Needles.

figure 2.25 – Cook EchoTip Needles.figure 2.24 – The new concept Boston Scientifics Expect Flex 19 gauge needle: a new needle completely made of nitinol, very flexible and deemed suitable for tissue acquisition even in the most difficult position of the scope, like mainly the duo-denum. In the model represented in the figure the needle is able to exit the sheath even after multiple spiral windings.

figure 2.23 – Boston Scientific Expect Needles.

figure 2.20 – EUS processor Aloka Prosound Alpha 7 for radial and linear Olympus electronic.

figure 2.21 – EUS processor Olympus EU-ME1 that enables the use of both mechanical and electronic radial echoendo-scopes as well as the linear echoendoscopes from Olympus.


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.


6 • MEDIASTINUM 71

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BIBLIOGRAPHYAnnema JT van Meerbeeck JP. Rintoul RC. Mediastinoscopy

vs Endosonography for Metastatic Nodal staging of lung Cancer: A Randomized Trial. JAMA 2010;304:2245-52.

Bolliger CT, Mathur PN, Beamis JF et al. European Respira-tory Society/American Thoracic Society. ERS/ATS state-

figure 6.57 – An ultrasound image of a round, hypoechoic lymph node as seen with a linear array EBUS. Note the hyperechoic aspi-ration needle seen in the upper portion of the node.

figure 6.54 – The Olympus linear array (BF-UC160F-OL8) bronchoscope. Attached via the instrument port is the white, single use aspiration needle used for EBUS-TBNA.

figure 6.55 – The distal end of the EBUS scope showing the red linear transducer, the optics, and the 22 gauge needle extended from the scope. The water filled balloon is inflated in the image to the right.

ment on interventional pulmonology. European Respi-ratory Society/American Thoracic Society. Eur Respir J 2002;19:356-73.

Ernst A, Anntham D, Eberhardt R et al. Diagnosis of medi-astinal adenopathy: real time endobronchial ultrasound guided transbronchial needle aspiration versus mediasti-noscopy. Thorac Oncol 2008;3:577-82.

figure 6.56 – The mediastinal regional lymph node map. Stations 5 and 6 are not accessible by EUS or EBUS.

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2L

4L

4L

4L

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4R

4R



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Figure 8.92 – Same patient at higher magnification. Cystic space inside the thickened duodenal wall.

Figure 8.94 – Pancreas and duodenal wall. Chronic pancrea-titis. Olympus linear scope. Note the cystic dystrophy of the duodenal wall: the cystic type of the dystrophy of the duodenal wall is characterized by the presence of cystic lesions (>1 cm) within the thickened wall of the second portion of the duo-denum.

Figure 8.93 – Pancreas and duodenal wall. Chronic pan-creatitis. Olympus radial scope. Note the solid type of cystic dystrophy of the duodenal wall: fibrous solid thickening of the wall with small cysts (< 1 cm) inside.

Figure 8.95 – Pancreas and duodenal wall. Chronic pancrea-titis. Olympus linear scope. Note the EUS-FNA needle inside the cystic cavity of the duodenal wall. The cyst is now smaller because some fluid has already been aspirated.

cyst

Figure 8.96 – Pancreas. Complication of chronic pancrea-titis. Olympus linear scope. Pseudocyst. Note the cystic lesion of the pancreas with hyperechogenic material due to debris.

Figure 8.97 – Pancreas. Complication of chronic pancrea-titis. Image of the content of a pseudocyst, after FNA.



10figure 10.4 – Biliary IDUS is the only diagnostic modality that can reliably recognize the sphincter of Oddi (arrows).

figure 10.2 – Biliary IDUS. Radiological image. The mini-probe is advanced in the dilated opacified CBD alongside the Hydra Jagwire®.

figure 10.6 – Biliary IDUS: a 1 cm reactive lymph node and the portal vein are visible from the upper common bile duct.

figure 10.5 – Biliary IDUS: the portal vein can be observed from the upper common bile duct.

figure 10.3 – Biliary IDUS: the insertion of a miniprobe in the common bile duct can be facilitated by the wire-guided version from Olympus (UM-G20-29R).

figure 10.1 – Biliary IDUS. Radiological image. The mini-probe is entering the opacified dilated common bile duct (CBD). A Hydra Jagwire® (Boston Scientifics) has previously been positioned in the intrahepatic bile ducts.



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figure 13.15 – Same patient. At CH EUS the lesion appears hyperenhanced with homogeneous pattern. This finding is very typical of neuroendocrine tumors. Olympus linear electronic probe.

figure 13.17 – A pancreatic serous cystadenoma. The typical honeycomb pattern is visible. Olympus linear electronic probe.

figure 13.16 – A pancreatic pseudocyst with abundant necrosis inside, seen as echogenic material. CH EUS shows lack of enhancement at the level of the necrotic material thereby allowing differentiation towards cystic neoplasms. Olympus linear electronic probe.

figure 13.18 – Same patient. After infusion of Sonovue, power Doppler shows homogeneous hyperenhancement at the level of the pancreatic cyst. Olympus linear electronic probe.

figure 13.13 – Same patient. After Sonovue infusion, hyper-enhancement is clearly appreciated by e-flow (a dedicated color Doppler analysis for vessels with slow flow). However, artifacts such as ballooning and overpainting hamper a clear apprecia-tion of the lesion. Olympus linear electronic probe.

figure 13.14 – A neuroendocrine tumor (T) is visible in the tail of the pancreas as a small well-demarcated hypoechoic le-sion, with regular margins. Olympus linear electronic probe.

T


13 • THERAPEUTIC EUS AND NEw APPLICATIONS 197

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figure 13.81 – Same patient. Pancreatic Pseudocyst trans-mural drainage (EUS-Guided cystogastrostomy): the radio-logical view of the guide-wire in the cyst.

figure 13.83 – Same patient. Pancreatic Pseudocyst trans-mural drainage (EUS-Guided cystogastrostomy): the posi-tioning of the cystotome.

figure 13.82 – Same patient. Pancreatic Pseudocyst trans-mural drainage (EUS-Guided cystogastrostomy): the endo-scopic view of the guide-wire in the cyst.

figure 13.84 – Same patient. Pancreatic Pseudocyst trans-mural drainage (EUS-Guided cystogastrostomy): the puncture of the gastric wall with cystotome to obtain the passage in the cystic cavity.

figure 13.79 – Same patient. Pancreatic Pseudocyst trans-mural drainage (EUS-Guided cystogastrostomy): EUS-guided injection of contrast through an access needle to obtain cystog-raphy.

figure 13.80 – Same patient. Pancreatic Pseudocyst trans-mural drainage (EUS-Guided cystogastrostomy): EUS vision of the guide-wire positioned in the pseudocyst.



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Figure 14.9 – Poorly differentiated pancreatic ductal adeno-carcinoma. Fragments of carcinoma on a cell block section.

Figure 14.11 – Pancreatic ductal adenocarcinoma. An atyp-ical mitotic figure.

Figure 14.10 – Poorly differentiated pancreatic ductal ad-enocarcinoma. Neoplastic glands are best appreciated at high magnification (higher magnification of image in figure 14.9).

Figure 14.12 – Pancreatic ductal adenocarcinoma. High magnification of neoplastic glands.

Figure 14.7 – Pancreatic ductal adenocarcinoma. Fragment of adenocarcinoma on a cell block section.

Figure 14.8 – Pancreatic ductal adenocarcinoma. Neoplastic glands are best appreciated at high magnification (higher mag-nification of image in figure 14.7).
