Post on 09-May-2019
transcript
EUS rectal CA staging
Jonathan Myers, DO Eugene Gastroenterology
Consultants
Objectives
• Recognize indications for rectal endoscopic ultrasound (EUS)
• Familiarize common structures and anatomy for rectal EUS
• Understanding rectal cancer staging via rectal EUS
• 63 yo Caucasian male presents with hematochezia. Pt denies f/c/n/v/d/constipation/melena. Pt reports 30lb wt loss, decreased energy, fatigue.
• PMHX: HTN, dyslipidemia, GERD • PSHX: none • MEDS: HCTZ, zocor, OTC omeprazole • SHX: 1 ppd/35 years, occasional ETOH • FHX: no malignancies
LABS
TP-
ALB-
TB-
DB-
AP-
AST-
ALT-
136
3.8
101
29
9
1
86
22.5
7.3
6.5
220
8 4.3 1.2 0.3 77 23 24
MCV – 61.2
RDW – 20.8
Fe – 11
TIBC – 405
Fe Sat – 3 %
Ferritin - 4
• Colonoscopy- large friable mass at in rectum – Biopsies -
adenocarcinoma
• NOW WHAT???
Staging
1. CT scan chest/abdomen/pelvis – Do this first…if lung mass(higher likelihood as
rectal CA goes to lung due to rectal blood supply), liver mass, pelvic mass…then you are staged already
2. Then….if CT scan negative - EUS
But first.... a little more about colorectal cancer
Colorectal Cancer
• 5-6% lifetime risk of colorectal cancer • 3rd most commonly diagnosed cancer • 3rd leading cause of cancer deaths male
and female • 72% colon cancer with 28% rectal cancer
split • 90% of CRC diagnosed age > 50 • 94% of deaths due to CRC age > 50
Colorectal Cancer Oregon
American Cancer Society. Colorectal Cancer Facts & Figures 2011-2013. Atlanta: American Cancer Society, 2011.
• Incidence – Non-Hispanic
• Men 51.5/100,000 • Women 39.2/100,000
– African American • Men 51/100,000 • Women 43/100,000
• Mortality – Non-Hispanic
• Men 19/100,000 • Women 15/100,000
– Data not available for African-American mortality due to < 25 cases or deaths
Awareness • The level of awareness among non-
gastroenterologists of the indications for EUS is unknown. This study assessed knowledge of the indications and the utility of EUS among gastroenterologists and non-gastroenterologists in a large multispecialty academic practice.
• Knowledge of appropriate indications was highest among gastroenterologists (84.3%) compared with internists (68.9%), non-gastroenterologist specialists (65.4%), and surgeons (65.3%) (p < 0.0001)
Yosuf T, Harewood GC, et al. Knowledge of indications for EUS among gastroenterologists and non-gastroenterologists. Gastrointestinal Endoscopy. 60(4):575-9, 2004 Oct
EUS-Indications 1. Staging of esophageal, gastric and rectal cancer 2. Evaluation of abnormalities of the gastrointestinal
wall or adjacent structures (submucosal masses, extrinsic compression)
3. Evaluation of thickened gastric folds 4. Diagnosis (FNA) and staging of pancreatic
cancer 5. Evaluation of pancreatic abnormalities
(suspected masses, cystic lesions including pseudocysts, suspected chronic pancreatitis)
EUS-Indications 6. Staging of ampullary neoplasms 7. Diagnosis and staging of cholangiocarcinoma 8. Evaluation of suspected choledocholithiasis 9. Celiac plexus neurolysis for chronic pain due to
intra-abdominal malignancy or chronic pancreatitis
10. Evaluation of fecal incontinence with endo-anal ultrasound
11. Therapeutic intervention for pancreatic pseudocyst drainage
Type of EUS Radial Echoendoscope Curvilinear (linear)
Echoendoscope
Electronic Radial Array Imaging
Radial Image in rectum Radial Image in stomach
Radial Array Imaging
Advantages: • 360 view • Mucosal cross-
sectional view for easier T-staging
Disadvantages: • No FNA/therapeutic
capabilities • Difficult to learn
Linear Imaging: Pancreatic Mass Example
Curvilinear echoendoscope
Curvilinear echoendoscope
Linear Array Imaging
Advantages: • Better resolution • Fine needle aspiration
(FNA)
Disadvantages: • Difficult to learn • Indirect anatomical
correlation
Mucosal layers
Mucosa
Muscularis mucosa
Submucosa
Muscularis propria
Serosa
• Why does it matter? – Current National Comprehensive Cancer
Network (NCCN) guidelines for Preoperative chemotherapy/radiation therapy
• T3-T4 mucosal staging • N1-N2 disease
EUS in rectal cancer
WHAT STAGE?
T2 – invades into muscularis propria
WHAT STAGE?
T3 – invades through muscularis propria
WHAT STAGE?
T1 – contained within submucosal and muscularis mucosa
WHAT STAGE?
T4 – invades into another organ - prostate
Summary
• Safe – same risk as flexible sigmoidoscopy
• Accurate
• Critical in determining effective treatment plan due to T and N staging