Endoscopia e lesione solide del pancreas - mcrferrara.org · U.O. di Gastroenterologia ed...
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Endoscopia e lesione solide del pancreas
Carlo FabbriU.O. di Gastroenterologia ed Endoscopia Digestiva
OSPEDALE BELLARIA-MAGGIOREBOLOGNA
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Indicazioni
Tecniche
Complicanze
Indicazioni
Tecniche
Complicanze
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Causes of malignant bile duct strictures
Intrahepatic bile ducts CholangiocarcinomaHepatocellular carcinomaMetastatic disease
Extrahepatic bile duct CholangiocarcinomaPancreatic cancer Ampullary malignancyGallbladder cancerMetastatic disease
Hilar region Cholangiocarcinoma
Bulky porta hepatis lymphadenopathy
Webb,Suanders 2013
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Preprocedural checklist
Lesion resectability and goals of care
Life expectancy given stage of disease and comorbidities
Location and length of the lesion
Plastic versus self-expanding metal stent
Covered versus uncovered
Cost comparisons
Physician comfort level with the procedure
Webb,Suanders 2013
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van der Gaag et al. N Engl J Med 2010;362:129-37
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van der Gaag NA et al. N Engl J Med 2010;362:129-37
Rates of serious complications
-39% (37 patients) in the early-surgery
-74% (75 patients) in the biliary-drainageP<0.001
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Non endoscopic
biliary
imaging
modalities
TC
Laparoscopic
US
MRC
IOC
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Endoscopic
biliary
imaging
modalities
EUS
EUSDirected
ERC
ERC
ERC+Technologies
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Algorithm for Suspected Panc Mass
Mass seen by CT/MRI
Unresectable PC Resectable mass equivocal resectability
EUS
EUS/CT FNAUnresectable PC
resectable PC
Classic symptoms, signs, labs, and imaging consistent for adenocarcinoma
Surgery, if surgeon/patient
comfortable with this approach
EUS-FNA if neoadjuvant therapy
planned
Picture not typical for adenocarcinoma
Increased surgical risk
Patient demands diagnosis
EUS FNA
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Algorithm for Suspected Panc Mass
Mass seen by CT/MRI
Unresectable PC Resectable mass equivocal resectability
EUS
EUS/CT FNAUnresectable PC
resectable PC
Classic symptoms, signs, labs, and imaging consistent for adenocarcinoma
Surgery, if surgeon/patient
comfortable with this approach
EUS-FNA if neoadjuvant therapy
planned
Picture not typical for adenocarcinoma
Increased surgical risk
Patient demands diagnosis
EUS FNA
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Staging of Solid Pancreatic Tumors
Resectability
0
10
20
30
40
50
60
70
80
90
100
CT scan EUS
predictive v
61-86%
•Detection Small P.T. < 2 cm
71-90%
DeWitt J et al. Ann Intern Med 2004;
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0
10
20
30
40
50
60
70
80
90
100
CT scan EUS
predictive v
Unresectability
64-90%70-100%
Staging of Solid Pancreatic Tumors
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Pancreatic Cancer
DYAGNOSTIC ACCURACY
Hunt, ,2002
EUS TC
Detection 97% 73%
Resecability 91% 83%
Vascular
Invasion91% 64%
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Pancreatic Cancer
Sensitivity:50-90%
Specificity: 90-100%
PV/confluence:EUS superiorSMV:Equivalent (~CT)Celiac trunk:Equivalent (~CT)HA, SMA:CT superior
Vascular Invasion
Rosch, 2002
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Three-Dimensional Linear Endoscopic UltrasoundFeasibility of a Novel Technique Applied for the Detection of Vessel Involvement of Pancreatic Masses
Fritscher-Ravens A 2005
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Algorithm for Suspected Panc Mass
Mass seen by CT/MRI
Unresectable PC Resectable mass equivocal resectability
EUS
EUS/CT FNAUnresectable PC
resectable PC
Classic symptoms, signs, labs, and imaging consistent for adenocarcinoma
Surgery, if surgeon/patient
comfortable with this approach
EUS-FNA if neoadjuvant therapy
planned
Picture not typical for adenocarcinoma
Increased surgical risk
Patient demands diagnosis
EUS FNA
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Algorithm for Suspected Panc Mass
Mass seen by CT/MRI
Unresectable PC Resectable mass equivocal resectability
EUS/CT FNA
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To document a diagnosis of malignancy in a patient with an unresectable mass as a prerequisite for adjuvant chemotherapy or radiation therapy
To exclude other tumor types
patients who are reluctant to undergo major surgery without a definitive diagnosis
To document the absence of malignancy when the pretest probability of malignancy is low
……………..Neoadviant therapy
Varadarajulu 2010
Indications for the use of EUS-FNA
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Pancreatic Cancer Clinical Impact of EUS-FNA
99 patients elegible for surgery
Metastatic distant lymph nodes 6
Liver metastasis 4
Malignant ascites 1
Retroperitoneal infiltration 1•
Mortensen MB, et al. Endoscopy 2001.
EUS FNA influenced
Management in 12%
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Celiac mesenteric region
Hepatic pedicule
Entire pancreas
Lymph nodes
Aspirate ascitic Fluid
Left liver nodeChang, GUT, 1997
Performance of EUS-FNA: Solid Pancreatic Tumors
CeliacLumboaorticRetroduodenopancreaticSuperior MesentericMediastinal
Linfonodo-mediastinico.avi
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Celiac mesenteric region
Hepatic pedicule
Entire pancreas
Lymph nodes
Aspirate ascitic Fluid
Left liver node
Peritoneal
Carcinomatosis
Performance of EUS-FNA: Solid Pancreatic Tumors
Peter 2009
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Celiac mesenteric region
Hepatic pedicule
Entire pancreas
Lymph nodes
Aspirate ascitic Fluid
Left liver node
Shah,Gatroint Endoscopy 2007
Small metastasisSensibility: 100%
Performance of EUS-FNA: Solid Pancreatic Tumors
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Resectable TumorsShould FNA be performed?
Adenocarcinoma 78,5%
Mucinous cystic neoplasm 5,4%
Metastatic tumor 3,9%
Neuroendocrine tumor 3,8%
Poorly differentiated carcinoma 3,0%
Lymphoma 2,8%
Serous Cystadenoma 1,8%
Solid pseudopapillary tumor 0,8%
Volmar KE, et al. Gastrointest Endosc 2005
503 pts
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Resectable TumorsShould FNA be performed?
Adenocarcinoma 78,5%
Mucinous cystic neoplasm 5,4%
Metastatic tumor 3,9%
Neuroendocrine tumor 3,8%
Poorly differentiated carcinoma 3,0%
Lymphoma 2,8%
Serous Cystadenoma 1,8%
Solid pseudopapillary tumor) 0,8%
Volmar KE, et al. Gastrointest Endosc 2005
Benign lesions
Pseudotumor Chronic pancreatitis
Groove pancreatitis
PAI tipo I e II
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Paranganglioma Gangliocitico Ampollare
Fiscaletti et al 2011
GEP-NETs
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91%% 94%% 98% 72%%
Classif. 1
Classif. 2
Hewitt, GE, 2012
Sensibilità Specificità VPP VPN
85% 98% 99% 64%
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Trends in the use of EUS-FNA in patients with locoregional pancreatic cancer who underwent curative intent surgery
Ngamruengphong 15
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1075 ptz
EUS-guided FNA: a benchmark for quality performance measurement
21 centers/41endoscopist
Savides 2008
85%
52%
85%
61%
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Eloubedi 2007
Pancreatic cancer
Cholangiocarcinoma
Differential Diagnosis
ACCURACY
EUS 78%
IDUS 86%
P<0.002
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Author (yr)No. Pts
Sen (%)
Spe (%)
PPV (%)
NPV (%)
Acc (%)
Saftoiu, ‘08 68 91.4 87.9 88.9 90.6 89.7
Hirche, ‘08 70 41 53 -- -- 45
Giovannini, ‘09 121 92.3 80 93.3 77.4 89.4
Iglesias-Garcia, ‘09 130 100 85.5 90.7 100 94
Iglesias-Garcia, ‘10* 86 100 92.9 96.7 100 97.7
Cancer vs Chronic PancreatitisElastosonography
* Second generation EUS elastography
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Cancer vs Chronic PancreatitisContrast-Enhanced Harmonic EUS
Author (yr)No. Pts
Sen (%)
Spe (%)
PPV (%)
NPV (%)
Acc (%)
Hocke, ‘06 86 73.2 83,3 -- -- --
Fusaroli, ’10
Hypoenhancing lesion* Hyperenhancing lesion*
Hyperenhancing lesion#
90 96 39 69
64 98 90
78 94 56
93 68 95
82 72 88
Napoleon, ‘10* 35 72 100 100 77 86
Seicean, ‘10* 24 80 91.7 92.8 78 --
Predictors of *Adeno Ca and #NET
Courtesy Dr Fusaroli
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Identified pancreatic tumor
Increased detection ( difficult cases)
Help EUS-FNA
Rule out cancer
Fusaroli 2010
CHE-EUS in pancreatic tumors
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NEDDLES
• 25 G• 22 G• 19 G• Tru-cut• Echo-Brush
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ROSE: the big dilemma
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ROSE: the big dilemma
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Do you have a onsite pathologist?
57
Author No. Diagnostic
Yield
Indeterminate Unsatisfactory
Klapman
Iglesias
Garcia
Alsohaibani
198
182
104
78% vs. 32%,
p=0.001
97% vs. 86%,
p=0.01
77% vs. 53%,
p=0.01
10% vs. 12%,
p=0.9
2.1% vs. 10.3%,
p=0.02
23% vs. 47%,
p=0.001
9% vs. 20%,
p=.003
1 vs. 13%,
p=0.002
0 vs. 17%, p=NS
Diagnostic sensitivity
Onsite cytopathologist
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Survey
Dumonceau. 2012
Available Normal Selected cases
ROSE 28% 15.1%
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22g 19G25g
Technical aspectsNEEDLES
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22 G 25 G
=
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19gFeasibility
65%
Not
relevant
41%
Immuno
Isto
chemistry
91%
Overalldiagnostic
yield
52%
Tecnical aspectsNEEDLES
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19g
Rare Conditions
metastasis
IAP
lymphomas
NET
diffentiation
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Sen Spe PPV NPV Acc
87.5%, 100%, 100%, 41.7%, 88.5%
J.W. Poley1, M.C. Petrone2, J.Iglesias-Garcia3, A. Larghi4, M. Giovannini5, G. Costamagna4, Paolo Arcidiaccono2, E. Bories5, M.J. Bruno1
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Surgical outcomes
6%
20%
0
10
20
30
40
50 Stadio IV Stadio I
Stadio I
Stadio IV
The 5 years survival rate
15%–20%: candidates for pancreatectomy at the time of diagnosis
Groover 2010
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C. Fabbri, C. Luigiano, A. Maimone, I. Tarantino, P. Baccarini, A.Fornelli, R. Liotta, A. Polifemo, L. Barresi, M. Traina, C. Virgilio, V. Cennamo
EUS-FNB of Small Solid Pancreatic Lesions using a 22-Gauge Needle with Side Fenestration
2014
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2013
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2014
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Pancreatic endocrine tumor EUS-guided FNA DNAmicrosatellite loss and mortality
Differentiating neoplastic from benign lesions of thepancreas: translational techniques
Diagnostic approach to pancreatic tumors with thespecimens of endoscopic ultrasound-guided fine needleaspiration
EUS for pancreatic endocrine tumors: do we need toknow our pancreatic endocrine tumor's DNA?
Molecular Techniques
Fasanella 2009
Kalid 2009
Ito 2009
De Witt 2009
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Molecular Techniques
K-ras analysis
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LO SCREENING DEL FUTURO
The MicroRNA(miRNAs) regulate the expression of oncogenes and tumors suppressor
La loro espressione è tessuto specifica e il loro profilo è alterato in tutte le
neoplasie
The miRNAs have characteristic expression profiles in some
carcinomas, and several species are dysregulated in Pancreatic Ductal Adenocarcinoma.
The Near Future
Zhang 2007
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The MiRNA expression have
accurately predicted the
presence of malignancy in 89%
of cancer specimens in the
cellblock
Panarelli 2012
The Near Future
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NET
Istotipo Caratteri lesione Procedura chirugica
Insulinoma < 2 cm, superficiale, No Wirs> 2 cm o coinvolg. Wirsung
EnucleoresezioneResezione
Gastrinoma Qualsiasi localizzazioneLocal. Esclusiva linfonodale
Resezione tipicaExeresi linfonodi
Tumori non funzionanti
< 2 cm, superficiale, No Wirs> 2 cm o coinvolg. Wirsung
EnucleoresezioneResezione tipica
VIPomaGlucagonomaSMSoma
Qualsiasi localizzazione Resezione tipica Falc
oni M
et al. 2
007,
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Simultaneous EUS-FNA Diagnosis and TNM Staging of a PancreaticNeuroendocrine Tumor in a Patient with an Unrecognized MEN Type 1
Francesco Ferrara,1 Carmelo Luigiano,1 Antonella Maimone,1Marco Bassi,1 Anna Maria Polifemo,1 Paola Baccarini,2 Vincenzo
Cennamo,3 Nadia Cremonini,4 and Carlo Fabbri1
Case Reports in Oncological Medicine Volume 2012
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Tattooing before laparoscopic distal pancreatic resection
Lennon 2010
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Pancreatology. 2013 Jul-Aug;13(4):449.Body tattooing: efficacy of a “new” practice.Fornelli A1, Fabbri C, Zanini N, Jovine E.
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Goggins 2011
< 2 cm
Screening PC
SurgeryScreening/Follow up
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Principles of screening
To be considered an important health problem, a disease need not necessary have a high degree of prevalence...
…..but also conditions with serious consequences to the individual may warrant relatively uneconomic screening measures.
Wilson WHO 1968
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Screening pancreatic cancerN. Pt.s Tests Detection Rate Diagnostic Yield Sugery Authors
14
EUS
ERCP
CT
71%
54%
33%
50% 50%
38
EUS ± FNA
ERCP
CT
76%
100%
N/S
5,3% 18%
78EUS ± FNA
CT
ERCP
21%
N/S
N/S
10,2% 8,9%
44 EUS
MRI/MRCP
CT
23%
N/S
N/S
23% 7%
76 EUS ± FNA
MRI/MRCP
33%
23,3 %
0,76% 7,8%
Brentnall 1999
Brentnall 1999
Canto 2012
Langer 2009
Ludwing 2011
Canto 2006
Canto 2004
Brentnall 1999
Poley 2009
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Brentnall
Canto
Canto
Ludwing
Poley
Verna
Kimmey
Canto
Al-Sukhni
LangerGut 2009
Gastroenterology 2012
Gastr Endosc 2002Ann Intern Med 1999
Clin Gastroen Hepatolog 2004
Clin Gastroen Hepatolog 2006
Am J Gastroent 2011
A J Gastroemter 2009
Clinical Cancer Contr 2010
Screening pancreatic cancer
J Gastrointest Surg 2012
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LO SCREENING DEL FUTURO
Riuscire a identificare una lesione pancreatica prima della sua
manifestazione clinica darebbe la possibilità di intervenire in tempo utile.
I miRNA sono piccole molecole di RNA non codificanti che regolano
l’espressione di numerosi geni.
La loro espressione è tessuto specifica e il loro profilo è alterato in tutte
le neoplasie
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Thanks
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Endoscopy could play a new role?
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PHOTODYNAMIC THERAPY
Khorsandi
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RADIOFREQUENCY
ABLATION
Steel
2011
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