Endoscopy in Gastrointestinal Oncology - Slide 9 - P.G. Arcidiacono - EUS in pancreatobiliary malignancies

EUS
Pancreatic
Cancer
Paolo G. Arcidiacono
Endoscopic Ultrasonography Unit
Gastroenterology and Gastrointestinal Endoscopy Unit
IRCCS San Raffaele Hospital
Vita Salute San Raffaele University
Milan, Italy Endosonography Unit
San Raffaele Scientific Institute

Pancreatic Cancer
The facts:

• The 10th most common malignancy
• 4th largest cancer killer
• American Cancer Society 2006:
– 33730 new diagnosis  32300 deaths

Endosonography Unit

• Survival rates are stage dependent.
• Surgery –the only chance for cure
• Ideal surgical candidate- 5 year
survival rate of 20-30%
• Inability to diagnose pancreatic
cancer early based on symptoms
alone

Endosonography Unit

EUS

Endosonography Unit

Pancreatic Cancer

• High risk population
screening
• Early detection
• Accurate staging

Endosonography Unit

Clinical Suspicion of
Pancreatic neoplasm

MDHCT –
MDHCT doubtful
MDHCT +

Endosonography Unit

EUS vs MDHCT
MDHCT missed 47% lesions < 25 mm and 21% overall
DeWitt J et al. Ann Intern Med 2004

MDHCT missed 60% of lesions < 2 cms
Agarwal B, AM J Gastro 2004

Endosonography Unit

EUS and EUS-FNA
No definite mass on
MDHCT
EUS EUS-FNA
Sensitivit
100 89
y
Specificit
71 100
y
NPV 100 78
PPV 90 100
Accuracy 92 92

Agarwal B, AM J Gastro 2004 Endosonography Unit

EUS in patients with non
specific change of the pancreas
on CT
Author N° Patients FNA Rate of
malignan
Horwhat 69 patients 19/69 cy
8.7%
2009 Enlarged (6/69)
Singh pancreas
107 patients ??? 22%
2008 Enlarged
Ho pancreas
50 patients 11/50 8%
2006 Enlarged 22% 4/50
pancreas
Horwart JD, JOP 2009
Singh S, Dis Dig Sci 2008 Endosonography Unit
Ho S, Clin Gastroenterol Hepatol 2003 San Raffaele Scientific Institute

EUS - negative
Negative predictive value of EUS in
patients with clinical suspicion of
pancreatic cancer

In a follow – up period of 25 months
NO patient developed Cancer

NPV (rule out cancer) 100%

J Klapman et al; Am J Gastro 2005;100;1-4
Endosonography Unit

MDHCT =
positive
• lesion away from
vessels
• lesion adherent to
vessels
• lesion invading vessels

Endosonography Unit

EUS vs MDHCT
Resectability
EUS MDHC EUS +
T MDHCT
Sens 88 90 80

Spec 67 64 93

EUS + MDHCT PPV = 95%

DeWitt J et al. Ann Intern Med 2004
Endosonography Unit

Diagnostic accuracy of EUS for
vascular invasion: meta-
analysis
• 29 studies
• Sensitivity 73%
• Specificity 90%
• Positive likelihood ratio 9.1 (measure of how
well the test identifies the disease)
• Negative likelihood ratio 0.3 (how well the
same test performs in excluding the disease)
 EUS is a better test to identify vascular
invasion rather then excluding it

Puli S.R. et al; GIE 2007;65;788-797 Endosonography Unit

Impact of EUS
1997-2001 2001-2004 P

% EUS 32 47 <0.56

% surgery 45 24 <0.01

HCT used in 92% of patients
J. Lachter et al. Pancreas 2007;35;130-134
Endosonography Unit

FNA or not FNA
?

Endosonography Unit

EUS – FNA vs US/TC – FNA
Seeding

Incidence of peritoneal carcinomatosis
C. Micames Gastrointest Endosc 2003

• EUS – FNA 2.2%
• Percutaneous FNA 16.3%
P < 0.025

American Joint Comittee on Cancer
US – FNA preferred sampling technique in pancreatic cance

Endosonography Unit

Prevalence of pancreatic focal
lesions N° pts / %
Prim Pancreatic
ary 56 / 50
Malignancy
Metastatic Tum or 12 / 10.7
Benign Lesions 44 / 39.2

Endosonography Unit
Fritscher-Ravens A, Gastrointest endosc. 2001

Pancreatic Cancer
• Mediastinal Nodes
• Celiac Nodes
• Liver lesions
• Benign or low malignant
potential lesions

Chang 1997 44% avoid 68%
surgery treatment
strategy
Mortensen 30%
2001 treatment
strategy
Fritscher- 21% 44%
Ravens surgical treatment
2002 approach strategy Endosonography Unit

EUS-FNA  CONS

• Endosonographer’s
skills
• On site cytologist

Endosonography Unit

Benchmark
• The diagnostic yield of EUS-FNA of these
lesions has recently been proposed a
benchmark for the technical performance
of the exam.

• In a recent multicenter (21 centers)
retrospective study of 1075 pts, the overall
diagnostic rate of malignacy was 71%, with
a great variability among centers and
endoscopists.
Diagnostic rates less than 52%
(lowest quartile) are considered Endosonography Unit
below the
quality standards San Raffaele Scientific Institute

EUS-FNA  HSR
Overall Endoscopis Endoscopi Endoscopis
(n=206) tA st B (n=98) t C (n=76)
(n=32)
No.of passes 479 69 224 186
Mean (+ SD) 2,3 + 0,9 2.1 + 0.9 2.3 + 0,8 2.4 + 0.9

Adequacy “on-site”:
- not performed 7 (3%) 2 (6%) 5 (5%) ----
- obtained 182 26 (81%) 85 (87%) 71 (93%)
- not obtained (88%) 4 (12%) 8 (8%) 5 (7%)
17 (9%)

Endosonography Unit

Onsite
Pros
• “live” feedback
1. number to Cons
adequacy
2. Inadequate compensation
2. prevents over-
3. Increases time of procedure
biopsy
4. Expert endosonographer +
3. increases
expert cytopathologist
adequacy
outside > 90% adequacy
4. decreases second
look EUS-FNA
5. increases the yield
Endosonography Unit
10 – 15% San Raffaele Scientific Institute

Endosonography Unit

Adequacy %

Blind 152/166 (91.6%)
cytopathologist
cyto - technician 120/166 (72.3%)
team
Pathologist team 104/166 (62.6%)

P value < 0.000 Endosonography Unit

EUS OPEN
QUESTIONS
• Differential diagnosis
– pancreatic cancer  chronic
pancreatitis
– lymph nodes
• Vascular invasion

Endosonography Unit

Tissue
Characterization

Endosonography Unit

EUS – Contrast
Media

PC CP

Sens Spec

EUS 73 83
EUS
Sonovu 91 93
e

Endosonography Unit
M Hocke et al W J Gastro;2006;12;246-250 San Raffaele Scientific Institute
Becker D et al, Gastrointest Endosc 2001;

Parenchimal
flow

Endosonography Unit

Clinical
Presentation
Jaundice No Jaundice

MDHCT EUS EUS-FNA MDHCT EUS EUS-FNA

Sensitivity 67 100 84 88 100 96
Specificit
100 50 100 63 50 100
y
NPV 12 100 22 63 100 89

PPV 100 98 100 88 87 100

Accuracy 68 98 85 82 88 97

8/9 FNA false negative were pts with stents otherwise NPV = 89%
Endosonography Unit
Agarwal B, AM J Gastro 2004 San Raffaele Scientific Institute

Elastograp
hy
Vascular involvement: 100% accuracy

Carrara et al. GUT 2009
Endosonography Unit

Elastography
Lymph nodes
Convention EUS EUS -
al EUS elastograp FNA
Accurac 52,6 hy
88,5 96,4
y

Endosonography Unit
Saftiou et al.; GIE 2007;66;291-300 San Raffaele Scientific Institute

Conclusions
EUS is to be considered for the time being as the most
valuable modality to:
- follow-up high risk patients
- early detection
- local staging
- tissue diagnosis
of pancreatic cancer .

EUS should be done in high volume Centers

Endosonography Unit

Endoscopy in Gastrointestinal Oncology - Slide 9 - P.G. Arcidiacono - EUS in pancreatobiliary malignancies

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