Case presentationTransylvania GI Oncology 2014

Case 1• F 63 y• Colonoscopy- 2011

– Stenotic ,circuferential neoplasm in the transvers colon 85cm from anal verge.

– Another 2 polips on the descending colon and sigmoid – tatoo– extra-large rectal polip 6/6cm in the rectum – staging by EUS T1??

• Surgical intervention 2011 - left hemicolectomy and transanal polipectomy.

• Delay -Follow up colonoscopy -2014• Sesil rectal tubulo-vilos adenoma 2/2,5cm + 2 small

polips

Case 2• F 64,• Dispepsia, NSAID and warfarine• Moderate anemia and 2-3 episodes of melena• EGD – D2 sesil polip 1,5-2cm – source of bleeding?

(colonoscopy without lesions)• Histology - Tubulo-vilos adenoma with low grade displazia

Case 3

• F 54 -11/2013• Semicircumferential sesil rectal polip 5/5cm• Patology – tubulo-vilos adenom with high grade displazia• EMR – rectal polip without previous EUS staging.

Patology report:• We examen 13 slides of the tissular material• Vilos –adenoma with small tubular component, low and high

grade displazia and with the stalk free of glandular elements.• There are only 2 section (block 5) where you could see a

malignant transformation of tubular adenocarcinoma moderate differentiate with a small mucinous component extracitoplasmic, moderate desmopazia and neutrofilic infilatrate; no angiolimfatic or perineural invasions in those sections. The tumoral islets cell are extend beyond the muscularis mucosae without the possibility to appreciate the real resection margin.

• Conclusion: tubular adenocc G2 – on the vilos adenoma with high grade displazia.

Post EMR - EUS• Impresion:

– Progresion to 25cm from anal verge, no LN at iliac station.– Examination of the ulcer bed, there are image sections which could plead for

muscularis invasion or artefacts produce by inflamatory process after EMR. T1/T2– Two images of rectal LNs with 1cm and 0,4cm in diameter. N1

• Oncologic consult• MRI of the pelvis – second investigation method.

• Pacient follow a neoadjuvant protocol T2N1• After 1month after she finished the neoadjuvant therapy

protocol – colonoscopy with rectum biopty• No histologic signs of disease• Pelvis MRI – no signs of disease in abdomen or pelvis 5/2014

Case 4• B 64• Epigastric pain, heartburn, regurgitations• History of duodenal ulcer – 15y ago• Melena, moderat anemia.• EGD: - atipic gastric ulcer in the prepiloric area• Patology report:– Negativ for cancer

• EUS – radial exam

EUS - radial

Re-biopty the lesion

• Patology report – negativ for cancer.

• Which is the best way to follow?– Re-biopty with jumbo forceps or snare biopty– EUS-FNA?

Case 5

• B 60 y• Moderate dilatation of Wirsung duct• EUS – 7/2013– The pancreatic duct is dilatated on all of his course with a

caliber of 4-5mm.– La nivelul corpului mai multe formatiuni chistice grupate

intr-o formatiune Multiple cystic lesions grouped in the pancreatic body, 1,8/1,2cm – possible seros cyst adenoma. There are also other sections where you could see a comunication with the main pancreatic duct and a small mural nodul – possible IPMN with high risk for neoplazia.

EUS-FNA ???

Case 6

• F 55y• Abdominal pain, cronic constipation• Abdominal CT scan: -duodenal GIST• Recomandation for EUS• 1/2014 – EUS – radial exam

– Normal aspect of the pancreas, PD normal size and no dilatation of the CBD (5mm)

– No suspicions of ampuloma– From the level of D3 in the same plain with aorta and vena cava, on

the oposite site of duodenum circuference, there are 2 lesions, well deliniated , outside of duodenal wall , hipoechoic, inomogenuos with diameters of 1,5cm and 1,8cm.

– Conclusions: Malignant LN. Suspected colon cancer

• Patient had negativ colonoscopy and enteroscopy• Then patient went to abdominal surgery, they extract the

LN. Pathology report said:– LN with a metastasis of a carcinoma type tumor– Low mitotic index and no tumoral necrosis – Ki67

pozitiv 2-3%– IHC – moderate pozitiv for Cromogranin A and intense

pozitiv for sinaptofizin• During abdominal surgery the surgeon said the pancreatic

head and ampulary region seemed a little bit hard ??? Still no decision for whipple resection.

CT scan 5/2014 showed several modification

• Suspected lesion with high contrast acumulation in the areterial tim, 7/14/5mm visible in the pancreatic papila area with the extension in the inferior wall of the pancreatic duct. PD is dilated to 5mm in the pancreatic head with a length of 7,5mm.

• Pancreas divisium• Compared with the CT scaun 12/2012 – progression of

pancreatic atrophy and lipomatos accumulation.

• Surgeon propose a Whipple resetion !!!• She came for a second oppinion – EUS- FNA??

Case 7

• B 79 y• Upper right quadrant pain, hepatic cysts and GB stones.• Transabdominal US – suspicions of pancreatic cystic lesions.• EUS 1/2014

– Multiple cysts with septations in direct contact and PD communications and side branches 2,6/2,2cm, fine wall without evidence of mural nodules.

– High probability of IPMN without clear risk of malignacy transformation.

– PD mild dilatated in the body – 3,8mm– Normal CBD and ampula.

Follow up – EUS or EUS-FNA??