Atlas de endosonografia.pdf

8/18/2019 Atlas de endosonografia.pdf

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CLAUDIO DE ANGELIS - PAOLO BOCUS

IEC

ATLAS OFENDOSCOPIC

ULTRASOUND

EDIZIONI MINERVA MEDICA


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ISBN: 978-88-7711-761-8

© 2013 – EDIZIONI MINERVA MEDICA S.p.A. – Corso Bramante 83/85 – 10126 urin (Italy) www.minervamedica.it / e-mail : [email protected]

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by anymeans.

ABBREVIATIONS

AA = Ascending Aorta AoA = Aortic Arch AoV = Aortic Valve

AV = Ampulla Vateri AzA = Azygous Arch AzV = Azygous VeinCA = Celiac Artery CBD = Common Bile DuctCC = Common Carotid Artery CD = Cystic DuctCon = Splenoportal ConfluenceDA = Descending Aorta DC = Diaphragmatic CrusDM = Deep Mucosa

ES = External Anal SphincterEso = EsophagusGB = GallbladderGDA = Gastroduodenal Artery HA = Hepatic Artery HV = Hepatic VeinsICA = Internal Carotid Artery IIV = Internal Iliac VesselsIJV = Internal Jugular VeinIS = Internal Anal SphincterIV = Innominate VeinIVC = Inferior Vena Cava

L = Lung LA = Levator AniLA = Left AtriumLAG = Left Adrenal GlandLI = LiverLK = Left kidney LN = Lymph Node(s)LRA = Left Renal Artery LRV = Left Renal VeinLV = Left VentricleMP = Muscularis Propria

MSB = Mainstem Bronchus

MU = Membranous Urethra MV = Mitral ValveO = Ovary

P = ProstatePA = Pulmonary Artery PB = Pancreatic Body PD = Pancreatic DuctPH = Pancreas HeadPl = Pleura PN = Pancreas Neck P = Pancreas ailPV = Portal VeinRA = Right AtriumRAG = Right Adrenal Gland

RK = Right Kidney RV = Right VentricleSA = Splenic Artery Sac = SacrumSC = Subclavian Artery SeV = Seminal VesiclesSM = Submucosa SMA = Sup. Mesenteric Artery SMV = Sup. Mesenteric VeinSp = SpineSpl = Spleen

SV = Splenic VeinSVC = Superior Vena Cava = rachea D = Toracic DuctG = Tymus GlandT = TyroidUB = Urinary BladderUP = Uncinate ProcessUr = Urethra Ut = Uterus V = Vagina

VP = Ventral Pancreas


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After the first pioneering studies in the 80’s brought about by Giancarlo Caletti in Bologna, and by veryfew other researchers in the world, EUS has gradually become a mainstay technique. It is now essential to theclinical practice and the diagnostic and therapeutic work-up of many digestive disorders.

In particular, the last decade has witnessed the definitive consecration of EUS in almost all the main Italianhospitals, where it has entered busy routine clinical practice together with several educational events and sym-posia, dedicated to spread the knowledge of its indications also to non-EUS users.

Te Italian Club of Endosonography (IEC - Italian Endosonography Club) was founded in 2002 with theaim of bringing together the Italian doctors, involved in EUS or willing to approach this technique, in orderto exchange views on EUS-related clinical issues, technical aspects, administrative issues and research projects.eaching of EUS was also included among the main aims of the club.

Trough our association we also aim to promote EUS among colleagues who do not practice it personallybut nevertheless have to deal with it almost on a daily basis (such as internists, surgeons, oncologists), so that

they can refer their patients according to the most appropriate indications. Moreover, the IEC is constantlystriving to promote the utilization of EUS within hospitals, universities and other scientific organizations. TeIEC also promoted relationships and initiated collaboration with international EUS experts, some of whichare also among the contributors of this volume and with Clubs or EUS Groups of interest of other Europeancountries, by founding in 2003, the European Group for Endoscopic UltraSound (EGEUS).

IEC remains strongly committed to advancing and promoting EUS through education and training. Sothe present atlas appears as a natural consequence of these premises and a continuation of the club’s educationalactivities. Te format of the book encompasses essentially bare EUS images with explicative legends, precededby just a more or less brief introduction to each chapter. Te ratio images/text is all in favor of the former, col-lecting the most significant cases seen at our centers. In fact, all the IEC members have had the opportunity tosubmit their own cases to the editors.

Te readers will find here a collection of relevant images for the most common but also the less known oreven anecdotal pathologies studied by EUS. Te atlas aims at providing a referral manual, which hopefully will assist all the endosonographers with reference images for almost each pathological condition amenable tobe investigated by our fascinating technique.

We sincerely hope that this textbook will help in their daily practice current and future endosonographers,at last leading to improvement in the practice of EUS and the care of our patients. In order to better achievethese goals a unique collection of online EUS videos will be made available to our readers and it will be con-tinuously updated and enriched with new contents.

While we do hope that the commitment and sacrifices bestowed for the realization of this atlas will beappreciated, we wish you a good reading but mainly a good watching.

C D A - P B

Preface


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Acknowledgements

We would like to thank our families, especially our spouses and our children, for the long time taken away from them in completing this project and mainly for their continuous support and encouragement, particularly in the most difficultmoments when we felt that we would not be able to successfully complete the work.

C. De Angelis, P. Bocus T. Togliani, M. Bruno

EDITORS

CLAUDIO DE A NGELIS, MDP AOLO BOCUS, MD

ASSOCIATES EDITORS

T HOMAS T OGLIANI, MDM AURO BRUNO, MD


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AUTHORSM ARCO BIANCHI Unit of Gastroenterology and Hepatology, San Filippo NeriHospital, Rome, Italy

P AOLO BOCUS High Technology Endoscopy Unit, Veneto Institute of On-cology, IRCCS, Padua, Italy

GIACOMO BONANNO Gastroenterology and Digestive Endoscopy Unit, VittorioEmanuele Hospital, Catania, Italy

M AURO BRUNO GastroHepatology Department, Endoscopy and Endosono-

graphy Center, Azienda Ospedaliera Città della Salute edella Scienza, University of Turin, Italy

ELISABETTA BUSCARINI Gastroenterology and Digestive Endoscopy Unit, MaggioreHospital, Crema, Italy

GIANCARLO C ALETTI Department of Gastroenterology, University of Bologna,Hospital of Imola, Italy

R ENATO C ANNIZZARO

Department of Gastroenterology and Oncology, Centro diRiferimento Oncologico IRCCS, Aviano, Italy

P ATRIZIA C ARUCCI GastroHepatology Department, Endoscopy and Endosono-


CLAUDIO DE A NGELIS GastroHepatology Department, Endoscopy and Endosono-


LEONARDO DE LUCA

Gastrointestinal Unit, Pellegrini Hospital, Naples, Italy C ARLO F ABBRI Department of Surgery, Unit of Gastroenterology and Di-

gestive Endoscopy, Hospital Bellaria-Maggiore, AUSL ofBologna, Italy

T ELEMACO FEDERICI Senior GI Consultant. Gastroenterology Unit, San Camil-lo-Forlanini Hospital, Rome, Italy

PIETRO FUSAROLIDepartment of Gastroenterology, University of Bologna,Hospital of Imola, Italy

M ARGARET M. JOHNSONDivision of Pulmonary Medicine, Mayo Clinic Jacksonville,FL, USA

PHILIP E. LOWMANDivision of Pulmonary Medicine, Mayo Clinic Jacksonville,FL, USA

C ATERINA M ARCHIÒ Azienda Ospedaliera Città della Salute e della Scienza,Department of Medical Sciences, University of Turin, Italy

PIETRO M ARONE Department of Endoscopic Imaging, Istituto dei TumoriFondazione “G. Pascale”, Naples, Italy

V INCENZO N APOLITANO Department of General and Specialistic Surgery, Unit ofSurgical Endoscopy, Second University of Naples, Italy

DONATELLA P ACCHIONI Azienda Ospedaliera Città della Salute e della Scienza,Department of Medical Sciences, University of Turin, Italy

A NTONIO PISANI Department of Gastroenterology, Policlinico University ofBari, Italy

A NNA M ARI A POLIFEMO O.U. of Gastroenterology and Digestive Endoscopy HospitalBellaria-Maggiore Bologna, Italy

M ASSIMO R AIMONDO

Division of Gastroenterology and Hepatology, Mayo Clinic Jacksonville, Florida, USA

A NNA S APINO Azienda Ospedaliera Città della Salute e della Scienza,Department of Medical Sciences, University of Turin, Italy

Authors and Contributors


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IEC - ATLAS OF ENDOSCOPIC ULTRASOUND VI

ILARIA T ARANTINO Gastroenterology and Digestive Endoscopy Unit, Mediter-ranean Institute for Transplantation and High Specializederapy (ISMETT)/ University of Pittsburgh Medical Cen-ter in Italy, Palermo, Italy

T HOMAS T OGLIANI Endoscopy Unit, “Carlo Poma” Hospital, Mantua, Italy

MICHAEL W ALLACE Division of Gastroenterology and Hepatology, Mayo Clinic

Jacksonville, FL, USA

CONTRIBUTORS

D ANIELA A SSISI O.U. of Gastroenterology and Digestive Endoscopy. Nation-al Institute of Tumors, Regina Elena Institute, Rome, Italy

GIORGIO B ATTAGLIA High Technology Endoscopy Unit, Veneto Institute of On-cology, IRCCS, Padua, Italy

R OSARIO FRANCESCO BRIZZIGastroHepatology Department, Endoscopy and Endosono-


V INCENZO C ANZONIERIDepartment of Pathology, Centro di Riferimento Oncologi-co IRCCS, Aviano, Italy

EMANUELE D ABIZZIGastroenterology and Digestive Endoscopy Unit, SanremoHospital, ASL1 Imperiese, Italy

M ARCO D APERNOGastroenterology Unit, Mauriziano Hospital, Turin, Italy

GIORGIO DE STEFANO Department of Infectious Diseases and Interventional Ul-trasound, Endosonography Center, AORM-Ospedali DeiColli - P.O. D. Cotugno, Naples, Italy

M ARA FORNASARIG

Department of Gastroenterology and Oncology, Centro diRiferimento Oncologico IRCCS, Aviano, Italy

A LDO G ARBARINIEmergency Surgery Department, Digestive Endoscopy Cen-ter, Azienda Ospedaliera Città della Salute e della Scienza,University of Turin, Italy

STEFANIA M AIERODepartment of Gastroenterology and Oncology, Centro diRiferimento Oncologico IRCCS, Aviano, Italy

M ARCELLO M ARTINI

GastroHepatology Department, Endoscopy and Endosono- graphy Center, Azienda Ospedaliera Città della Salute edella Scienza, University of Turin, Italy

EMANUELE MERONI Endoscopic Unit, Fondazione IRCCS Istituto NazionaleTumori, Milan, Italy

SELENE FRANCESCA M ANFRÈGastroHepatology Department, Endoscopy and Endosono-


R INALDO PELLICANOGastroHepatology Department, Azienda Ospedaliera Città della Salute e della Scienza, University of Turin, Italy

D ARIO R EGGIO Liver Transplantation Center, Azienda Ospedaliera Cittàdella Salute e della Scienza, University of Turin, Italy

R ODOLFO R OCCA Gastroenterology Unit, Mauriziano Hospital, Turin, Italy


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Preface ......................................................................................................................................................................... III Authors and Contributors ........................................................................................................................................ V

1 EUS HISTORY ...........................................................................................................................................................1 C. De Angelis, G. Caletti

2 INSTRUMENTS AND ACCESSORIES ....................................................................................................................9 M. Bruno, A.M. Polifemo, C. De Angelis

3 EUS ROOM SETUP ............................................................................................................................................... 21 P. Fusaroli

4 NORMAL GI WALL AND IMAGING ARTIFACTS ............................................................................................. 27 M. Bianchi, A. Pisani With the collaboration of: C. De Angelis

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

With the collaboration of: M. Fornasarig, S. Maiero, V. Canzonieri

8 PANCREAS ............................................................................................................................................................ 87 C. De Angelis, M. Raimondo

With the collaboration of: S.F. Manfrè, R. Pellicano, E. Dabizzi

9 BILE DUCTS ......................................................................................................................................................... 131

E. Buscarini, I. Tarantino

10 IDUS AND EDUS................................................................................................................................................. 141 M. Bruno, C. De Angelis With the collaboration of: D. Reggio, A. Garbarini

Contents


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111 ANORECTUM AND COLON .............................................................................................................................. 141 T. Federici, G. Bonanno

With the collaboration of: D. Assisi

12 OTHER ORGANS ................................................................................................................................................ 167

P. Carucci, L. De Luca

13 THERAPEUTIC EUS AND NEW APPLICATIONS ............................................................................................ 181 C. De Angelis, C. Fabbri, P. Fusaroli

With the collaboration of: D. Reggio, S.F. Manfrè. R.F. Brizzi, A. Garbarini, R. Rocca

14 THE ROLE OF CYTOPATHOLOGY .................................................................................................................... 207 D. Pacchioni, C. Marchiò, A. Sapino


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5 ESOPHAGUS

P. Bocus, T. Togliani

In the late 80s EUS has been proposed as a newmethod to study the gastroesophageal wall and bilio-pancreatic district, and it soon demonstrated its po-tential in the evaluation of some esophageal diseases;adenocarcinoma and squamous cell carcinoma arethe main indications for esophageal EUS, althoughsubepithelial lesions such as Abrikosoff tumors, leio-myomas, varices, cysts can be easily displayed.

Esophageal cancer is a common tumor and itsincidence is rising in western countries. As far as pa-tient’s prognosis and cost-effectiveness of therapeuticprotocols are strongly related to tumor staging, many

efforts have been made in the last three decades toimprove the diagnostic techniques.

EUS showed the best accuracy for locoregionalstaging of esophageal cancer, as it can precisely deter-mine the degree of parietal infiltration ( parameterof NM classification); it also provides a good visu-alization of periesophageal and celiac lymph nodes,that can be sampled by means of FNA (fine needleaspiration) in the suspect of nodal metastasis (N pa-rameter of NM classification). Some recent soft-

ware applications coupled to EUS miniprobes allow

the three dimensional reconstruction, that permits abetter spatial visualization of the lesions, the innersuperficial rendering and the volume measurements.For a complete distant staging (M parameter of NMclassification) a thoraco-abdominal C/PE scan ismandatory.

In the last years many different multimodal ther-apeutic approaches have been proposed, according tothe initial staging and the surgical risk of the patient:endoscopic resection, surgery, chemo-radiation, adju-vant and neoadjuvant therapy, endoscopic stenting.Te introduction of new neoadjuvant protocols needs

tools able to confirm, before surgery, if a real down-staging has occurred, but traditional radiology seemsto have a limited accuracy in this field. Few datain the literature are available on the role of EUS inthe staging of esophageal cancer after neoadjuvant

therapy; parietal fibrosis of the esophageal wall andthe inflammatory enlargement of periesophageallymph nodes make EUS (like all the other imagingtechniques) less accurate in this particular situation.

o improve EUS accuracy in the evaluation oflymph nodes two promising innovations have beenintroduced: contrast enhanced EUS and EUS-elas-tography. Tese new techniques could find interestingapplications in the study of esophageal cancer, by im-proving the detection of malignancy and targetingFNA in lymph nodes with suspicion of metastasis.

Te examination of the esophagus using a ra-dial probe, which is the most frequently used foresophageal tumor staging, is one of the easiest EUSprocedures to perform, since the esophagus is es-sentially a straight tube requiring little manipula-tion of the echoendoscope. However, examinationof the esophagus cannot be competently performed

without a strong knowledge of the spatial anatomy ofthe mediastinum. EUS staging of esophageal canceris rarely performed with linear echoendoscopes,

which imposes a multi-step 360 degrees rotation toobtain a complete circumferential image of the en-tire esophageal wall; on the contrary, these probes arecrucial for a correct lymph node assessment in thesuspect of node metastasis. Superficial small lesionsor tight neoplastic stenoses can be studied with echo-graphic miniprobes through the operative channel ofa normal gastroscope.

In case of tumor staging the maximum depthof wall infiltration, the presence of extraesophagealinfiltration, the upper and lower edges of the lesion,and the presence of celiac or mediastinal lymph node

metastases should be described in the report.

Te following is a brief description of the anatom-ical landmarks that must be recognized in a standardradial examination of the esophagus.


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while the right lung can be seen in the 9 o’clocklocation. he lungs have a unique EUS image ofhyperechoic rings that represents air within thelung parenchyma. Further withdrawal of the in-strument will image structures surrounding the

mid-esophagus.Keeping the aorta in the 5 o’clock position, thespine is visualized at the 7 o’clock position. Teazygos vein will be seen to the right of the aorta and

will move upwards along the right lung. Te tho-racic duct will appear as a small, round anechoic dotbetween the azygos vein and the aorta. As the scopeis further withdrawn, the azygos vein will be seenmoving forward and merging into the superior venacava. Te aortic arch will be noted on the left as itarises from the aorta and can be seen curving to-

wards the right. Also, the left and right bronchi canbe seen, as small hyperechoic rings that represent car-tilage and air artifacts, at the 1 o’clock and 11 o’clockpositions, respectively.

As the echoendoscope is withdrawn, the left andright bronchi can be observed forming the tracheaat the level of the carina, which is usually about 26to 28 cm from the incisors. Just below this regionlies the subcarina region, where lymph nodes can fre-quently be seen. Tese lymph nodes characteristicallyappear as small hyperechoic structures with indistinctmargins and ovalar or triangular shapes. In cases of

malignant nodes an hypoechoic pattern with moredistinct and sharper borders and a round shape aretypical.

Te proximal or cervical esophagus is enteredupon further withdrawal of the instrument. In thisposition, the blood vessels of the neck come intoview above the aortic arch. Te left subclavian ar-tery can be seen posteriorly while the left commoncarotid artery and sometimes the brachiocephalictrunk are seen anteriorly. Te location of the tra-chea in the mid-plane causes air artifacts, which canhamper imaging at this station. In the neck later-ally to the esophagus the right and the left internalcarotid arteries and internal jugular vein are clearlydisplayed. In some patients, the thyroid gland canbe seen mainly its left lobe, appearing as a hypo-isoechoic structure laterally to the crycoid echos. Afurther withdrawal makes the instrument pass theupper esophageal sphincter (approximately 18 cmfrom the incisors).

During the whole exam overinflation of the bal-loon, oblique scanning of the esophageal wall andlack of complete air suction should be avoided since

they can cause imaging artifacts and misinterpreta-tions of the images.

Once the radial scanning echoendoscope isintroduced into the esophagus, it should be ad-vanced slowly into the stomach just below the gas-troesophageal junction, which is usually approxi-mately 40 cm from the incisors. At the beginningof EUS scanning, the aorta should be positioned atfive o’clock; the image can be adjusted by rotatingthe aorta (either manually or electronically) to thecorrect anatomical position. With this orientation,like in C scan images, the anterior region of the

patient is displayed in the upper part of the screen,the posterior in the lower, the left is on the right,the right is on the left.

With the scope in the stomach, just above theneck of the pancreas, the celiac axis and its mainbranches (the hepatic, the splenic and the left gastricarteries) can be visualized coming out from the aorta(which is located at 5 o’clock position). Between 6o’clock and 12 o’clock position the left lobe of theliver, the inferior vena cava and hepatic veins can beseen.

Te five-layers wall pattern of the esophaguscomes into view as the echoendoscope is slowly with-drawn cephalad; the esophageal wall, whose normalthickness is 3 to 4 mm, is gradually explored up tothe upper esophageal sphincter. During withdrawalof the scope in the thorax the left atrium, the mitralvalve and the pulmonary veins will come into viewbetween 12 o’clock and 3 o’clock position. Upon fur-ther interrogation of this area, the left pulmonary ar-tery can be seen. Te left ventricle, right atrium, andright ventricle are more difficult to image and maynot be seen distinctly in all cases.

As the echoendoscope is further withdrawnthe left lung will appear at the 2 o’clock position

TNM classification of esophageal cancer (7th edition).

Ta Infiltration of the lamina propria

T1b Infiltration of the submucosa

T2 Infiltration of the muscularis propria

T3 Infiltration of the adventitia

T4a Infiltration of pleura, pericardium, diaphragm

T4b Infiltration of aorta, vertrebral body, trachea

N0 No regional lymph node metastasis

N1 1-2 regional lymph nodes

N2 3-6 regional lymph nodes

N3 7 or more regional lymph nodes

M1 Distant metastases


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Figure 5.3 – Esophagus, 1a N0 adenocarcinoma, Olympusminiprobe (20 MHz): a small isoechoic thickening (3 mm) ofthe mucosa, with preservation of the other layers is clearly vis-ible.

Figure 5.4 – Esophagus, 1a N0 adenocarcinoma, Olympusradial mechanical UMQ130 probe with the water filled bal-loon (20 MHz): note a small hypoechoic thickening (3 mm) ofthe mucosa, with preservation of the other layers.

Figure 5.5 – Esophagus, 1a N0 adenocarcinoma, Olympusradial mechanical UMQ130 probe (20 MHz): note a hypoe-choic thickening (6 mm) of the mucosa, with preservation ofthe other layers.

Figure 5.1 – Esophagus, normal wall, Olympus radialelectronic GF UE 160 (7.5 MHz): note the normal 5-layersechostructure of the esophageal wall.

Figure 5.2 – Esophagus, normal wall, Olympus radial me-chanical GF UM 160 (20 MHz): note the normal 7-layersechostructure of the esophageal wall which is visible at highfrequencies.

Figure 5.6 – Esophagus, small adenocarcinoma in a segmentof Barrett’s metaplasia, endoscopic view.


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5

Figure 5.12 – Esophagus, 1b N0 adenocarcinoma (samepatient), Olympus radial electronic UE 160 probe (7.5 MHz):note a hypoechoic thickening (12 x 8 mm) of the mucosa, withinitial infiltration of the submucosa; muscularis propria andadventitia are preserved.

Figure 5.8 – Esophagus, 1a N0 adenocarcinoma (same pa-tient), Olympus radia l mechanical UM160 probe (20 MHz):note a small hypoechoic thickening (3 mm) of the mucosa,

with preservation of the other layers.

Figure 5.10 – Esophagus, 1a N0 adenocarcinoma, Alokaminiprobe (15 MHz): note a small hypoechoic thickening (3mm) of the mucosa, with preservation of the other layers

Figure 5.9 – Esophagus, specimen from endoscopic mucosec-tomy (same patient); pathology confirmed EUS staging.

Figure 5.11 – Esophagus, small adenocarcinoma above thecardia, Olympus GF 140.

Figure 5.7 – Esophagus, small adenocarcinoma in a segmentof Barrett’s metaplasia (same patient), NBI view.


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Figure 5.14 – Esophagus, 2 N0 adenocarcinoma, Olympusradial mechanical UM 160 probe (7.5 MHz): note a hypo-iso-echoic circumferential thickening of the esophageal wall, withfusion of mucosa, submucosa and muscularis propria; the ad-

ventitia is preserved; no periesophageal lymph nodes are visible.

Figure 5.15 – Esophagus, 2 N0 adenocarcinoma, Olympusradial electronic UE 160 probe (6 MHz): note a hypoechoiccircumferential thickening of the esophageal wall, with partialfusion 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, 2 N1 adenocarcinoma, Olympusradial mechanical UM 160 probe (7.5 MHz): note a hypo-iso-echoic circumferential thickening of the esophageal wall, withfusion 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, 2 N0 adenocarcinoma, Olympusradial mechanical UM 160 probe (20 MHz): note a hypoechoiccircumferential thickening (13 mm) of the esophageal wall, withfusion of mucosa, submucosa and muscularis propria; the ad-

ventitia is preserved; no periesophageal lymph nodes are visible.

Figure 5.18 – Esophagus, 2 adenocarcinoma, 3D volumereconstruction using Olympus dual planner mini-probe (UM-DP12-25R) and 3D upgrade kit (MAJ-1330).

Figure 5.17 – Esophagus, 2 NX adenocarcinoma, Olympusradial electronic UE 160 (10 MHz): note a hypo-isoechoicsemi-circumferential thickening of the esophageal wall, withfusion of mucosa, submucosa and muscularis propria; the ad-ventitia is preserved; a round hypoechoic 6 x 3 mm periesopha-geal lymph node is visible.


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5

Figure 5.23 – Esophagus, 3 N1 adenocarcinoma, Ol-

ympus radial mechanical UM 160 probe (5 MHz): note a se-vere hypoechoic semi-circumferential thickening (25 mm) ofthe esophageal wall, with fusion of mucosa, submucosa andmuscularis propria; the adventitia is interrupted by tumoralpseudopodia; a ovalar hypoechoic 14 mm (pathologic) per-iesophageal lymph node is visible.

Figure 5.24 – Esophagus, 3 N1 adenocarcinoma, Aloka

radial mechanical miniprobe (15 MHz): note a stenotic hypoe-choic circumferential thickening of the esophageal wall, withfusion of mucosa, submucosa and muscularis propria; the ad-ventitia is irregular; two ovalar hypoechoic 10 mm periesopha-geal lymph node are visible.

Figure 5.22 – Esophagus, 3 N1 adenocarcinoma, Olympusradial mechanical MH 908 “blind Probe” (7.5 MHz): note ahypoechoic circumferential thickening of the esophageal wall,

with fusion of mucosa, submucosa and muscularis propria; theadventitia is interrupted; an ovalar hypoechoic 13 mm (patho-logic) periesophageal lymph node is visible.

Figure 5.20 – Esophagus, 3 N0 adenocarcinoma, Olympusradial electronic UE 160 probe (5 MHz): note a severe hypoe-choic thickening (27 mm) of the esophageal wall that involves3/4 of the circumference of the esophagus, with fusion of mu-cosa, submucosa and muscularis propria; the adventitia is ir-regular; no periesophageal lymph nodes are visible.

Figure 5.19 – Esophagus, 3 N0 adenocarcinoma, Olympusradial mechanical UM 160 probe (20 MHz): note a hypoe-choic semi-circumferential thickening (14 mm) of the esopha-geal wall, with fusion of mucosa, submucosa and muscularispropria; the adventitia is irregular; no periesophageal lymphnodes are visible.

Figure 5.21 – Esophagus, 3 N0 adenocarcinoma, Olympusradial mechanical UM 160 probe (12 MHz): note a moderate hy-poechoic semi-circumferential thickening (8 mm) of the esopha-geal wall, with fusion of mucosa, submucosa and muscularis pro-pria; the adventitia is interrupted by a single thin pseudopodiumof tumoral tissue; no periesophageal lymph nodes are visible.

Ln

Ln

Ln


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Figure 5.25 – Esophagus, 3 N1 adenocarcinoma (same pa-tient): endoscopic view of the tumoral mass of the lower es-ophagus.

Figure 5.26 – Esophagus, 3 adenocarcinoma, Olympus radialmechanical miniprobe (12 MHz); 3D reconstruction with areaand volume calculation: note a stenotic hypoechoic circumfer-ential thickening of the esophageal wall, with fusion of mucosa,

submucosa and muscularis propria; the adventitia is irregular.

Figure 5.27 – Esophagus, 4 N0 adenocarcinoma, Olympusradial mechanical UM 160 probe (7.5 MHz): note a hypoe-choic circumferential thickening (up to 17 mm) of the esopha-geal wall, with fusion of all the layers and infiltration of theright pleura; no periesophageal lymph nodes are visible.

Figure 5.28 – Esophagus, 4 N0 adenocarcinoma, Olympusradial mechanical UM 130 probe (7.5 MHz): note a hypoe-choic circumferential thickening (up to 25 mm) of the esopha-geal wall, with fusion of all the layers and infiltration of the tra-chea and right lung; no periesophageal lymph nodes are visible.

Figure 5.29 – Esophagus, 4 N0 adenocarcinoma, Olympusradial mechanical UM 130 probe (7.5 MHz): note an isoechoic3 cm mass of the posterior esophageal wall with infiltrationof the descending aorta; no periesophageal lymph nodes arevisible.

Figure 5.30 – Cardia, 4 N0 adenocarcinoma, Olympus ra-dial electronic UE 160 probe (7.5 MHz): note a hypoechoiccircumferential thickening of the GI wall with infiltration ofthe left diaphragmatic pillar.

DA

DA

Li

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