CLAUDIO DE ANGELIS - Paolo BOCUS

IEC
ATLAS OF
ENDOSCOPIC
ULTRASOUND

EDIZIONI MINERVA MEDICA

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 Contents

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

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11 ANORECTUM AND COLON............................................................................................................................... 141

1 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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Figure 2.1 – Fujinon EUS radial scope EG-530UR. Figure 2.2 – Fujinon linear scope EG-530UT.

Figure 2.3 – Olympus radial electronic echoendoscope GF- Figure 2.4 – Olympus mechanical radial echoendoscope
UE160. (GF-UM Q130). Note the bulky motor drive, located in the en-
doscope handle, connected to the trasducer with a wire cable.

Figure 2.5 – Olympus linear echoendoscope UCT180. Figure 2.6 – Pentax radial scope EG.3670URK.

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Figure 2.21 – EUS processor Olympus EU-ME1 that enables

Figure 2.20 – EUS processor Aloka Prosound Alpha 7 for the use of both mechanical and electronic radial echoendo-
radial and linear Olympus electronic. scopes as well as the linear echoendoscopes from Olympus.

Figure 2.22 – Boston Scientific Expect Needles. Figure 2.23 – Boston Scientific Expect Needles.

Figure 2.24 – The new concept Boston Scientifics Expect Figure 2.25 – Cook EchoTip Needles.
Flex 19 gauge needle: a new needle completely made of nitinol,
very flexible and deemed suitable for tissue acquisition even in
the most difficult position of the scope, like mainly the duo-
denum. In the model represented in the figure the needle is
able to exit the sheath even after multiple spiral windings.

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Figure 5.13 – Esophagus, T2 N0 adenocarcinoma, Olympus
radial mechanical UM 160 probe (20 MHz): note a hypoechoic
circumferential thickening (13 mm) of the esophageal wall, with
fusion of mucosa, submucosa and muscularis propria; the ad-
ventitia is preserved; no periesophageal lymph nodes are visible.
Figure 5.15 – Esophagus, T2 N0 adenocarcinoma, Olympus
radial electronic UE 160 probe (6 MHz): note a hypoechoic
circumferential thickening of the esophageal wall, with partial
fusion 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 5.17 – Esophagus, T2 NX adenocarcinoma, Olympus
radial electronic UE 160 (10 MHz): note a hypo-isoechoic
semi-circumferential thickening of the esophageal wall, with
fusion 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 • Esophagus 37
Figure 5.14 – Esophagus, T2 N0 adenocarcinoma, Olympus
radial mechanical UM 160 probe (7.5 MHz): note a hypo-iso-
echoic circumferential thickening of the esophageal wall, with
fusion of mucosa, submucosa and muscularis propria; the ad-
5
ventitia is preserved; no periesophageal lymph nodes are visible.
Figure 5.16 – Esophagus, T2 N1 adenocarcinoma, Olympus
radial mechanical UM 160 probe (7.5 MHz): note a hypo-iso-
echoic circumferential thickening of the esophageal wall, with
fusion 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 5.18 – Esophagus, T2 adenocarcinoma, 3D volume
reconstruction using Olympus dual planner mini-probe (UM-
DP12-25R) and 3D upgrade kit (MAJ-1330).
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 6 • MEDIASTINUM 71

Figure 6.54 – The Olympus linear
array (BF-UC160F-OL8) bronchoscope.
Attached via the instrument port is the
white, single use aspiration needle used
for EBUS-TBNA.
Figure 6.55 – The distal end of the EBUS scope showing the red linear transducer,
the optics, and the 22 gauge needle extended from the scope. The water filled balloon
is inflated in the image to the right.

6
1
1 1
1

1
1
2R

2L
2R

4R
2L

4R 4L

4R 4L

4L 5

10
10
11 - 14
7
11 - 14
7
7

9 9
Figure 6.57 – An ultrasound image of a
8
round, hypoechoic lymph node as seen with a
linear array EBUS. Note the hyperechoic aspi-
Figure 6.56 – The mediastinal regional lymph node map. Stations 5 and 6 ration needle seen in the upper portion of the
are not accessible by EUS or EBUS. node.

BIBLIOGRAPHY ment on interventional pulmonology. European Respi-

Annema JT van Meerbeeck JP. Rintoul RC. Mediastinoscopy
vs Endosonography for Metastatic Nodal staging of lung
Cancer: A Randomized Trial. JAMA 2010;304:2245-52.
Bolliger CT, Mathur PN, Beamis JF et al. European Respira-
tory Society/American Thoracic Society. ERS/ATS state-
ratory Society/American Thoracic Society. Eur Respir J
2002;19:356-73.
Ernst A, Anntham D, Eberhardt R et al. Diagnosis of medi-
astinal adenopathy: real time endobronchial ultrasound
guided transbronchial needle aspiration versus mediasti-
noscopy. Thorac Oncol 2008;3:577-82.

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Figure 8.92 – Same patient at higher magnification. Cystic
space inside the thickened duodenal wall.
cyst
8 Figure 8.94 – Pancreas and duodenal wall. Chronic pancrea-
titis. Olympus linear scope. Note the cystic dystrophy of the
duodenal wall: the cystic type of the dystrophy of the duodenal
wall is characterized by the presence of cystic lesions (>1 cm)
within the thickened wall of the second portion of the duo-
denum.
Figure 8.96 – Pancreas. Complication of chronic pancrea-
titis. Olympus linear scope. Pseudocyst. Note the cystic lesion
of the pancreas with hyperechogenic material due to debris.
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Figure 8.93 – Pancreas and duodenal wall. Chronic pan-
creatitis. Olympus radial scope. Note the solid type of cystic
dystrophy of the duodenal wall: fibrous solid thickening of the
wall with small cysts (< 1 cm) inside.
Figure 8.95 – Pancreas and duodenal wall. Chronic pancrea-
titis. Olympus linear scope. Note the EUS-FNA needle inside
the cystic cavity of the duodenal wall. The cyst is now smaller
because some fluid has already been aspirated.
Figure 8.97 – Pancreas. Complication of chronic pancrea-
titis. Image of the content of a pseudocyst, after FNA.
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Figure 10.1 – Biliary IDUS. Radiological image. The mini- Figure 10.2 – Biliary IDUS. Radiological image. The mini-
probe is entering the opacified dilated common bile duct probe is advanced in the dilated opacified CBD alongside the
(CBD). A Hydra Jagwire® (Boston Scientifics) has previously Hydra Jagwire®.
been positioned in the intrahepatic bile ducts.

Figure 10.3 – Biliary IDUS: the insertion of a miniprobe in Figure 10.4 – Biliary IDUS is the only diagnostic modality
the common bile duct can be facilitated by the wire-guided that can reliably recognize the sphincter of Oddi (arrows).

10
version from Olympus (UM-G20-29R).

Figure 10.5 – Biliary IDUS: the portal vein can be observed Figure 10.6 – Biliary IDUS: a 1 cm reactive lymph node and
from the upper common bile duct. the portal vein are visible from the upper common bile duct.

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Figure 13.13 – Same patient. After Sonovue infusion, hyper-
enhancement is clearly appreciated by e-flow (a dedicated color
Doppler analysis for vessels with slow flow). However, artifacts
such as ballooning and overpainting hamper a clear apprecia-
tion of the lesion. Olympus linear electronic probe.
Figure 13.15 – Same patient. At CH EUS the lesion appears
hyperenhanced with homogeneous pattern. This finding is very
typical of neuroendocrine tumors. Olympus linear electronic
probe.
13
Figure 13.17 – A pancreatic serous cystadenoma. The typical
honeycomb pattern is visible. Olympus linear electronic probe.
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Figure 13.14 – A neuroendocrine tumor (T) is visible in the
tail of the pancreas as a small well-demarcated hypoechoic le-
sion, with regular margins. Olympus linear electronic probe.
Figure 13.16 – A pancreatic pseudocyst with abundant
necrosis inside, seen as echogenic material. CH EUS shows lack
of enhancement at the level of the necrotic material thereby
allowing differentiation towards cystic neoplasms. Olympus
linear electronic probe.
Figure 13.18 – Same patient. After infusion of Sonovue,
power Doppler shows homogeneous hyperenhancement at the
level of the pancreatic cyst. Olympus linear electronic probe.
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Figure 13.79 – Same patient. Pancreatic Pseudocyst trans-
mural drainage (EUS-Guided cystogastrostomy): EUS-guided
injection of contrast through an access needle to obtain cystog-
raphy.
Figure 13.81 – Same patient. Pancreatic Pseudocyst trans-
mural drainage (EUS-Guided cystogastrostomy): the radio-
logical view of the guide-wire in the cyst.
Figure 13.83 – Same patient. Pancreatic Pseudocyst trans-
mural drainage (EUS-Guided cystogastrostomy): the posi-
tioning of the cystotome.
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13 • THERAPEUTIC EUS AND NEW APPLICATIONS 197
Figure 13.80 – Same patient. Pancreatic Pseudocyst trans-
mural drainage (EUS-Guided cystogastrostomy): EUS vision
of the guide-wire positioned in the pseudocyst.
Figure 13.82 – Same patient. Pancreatic Pseudocyst trans-
mural drainage (EUS-Guided cystogastrostomy): the endo-
scopic view of the guide-wire in the cyst.
13
Figure 13.84 – Same patient. Pancreatic Pseudocyst trans-
mural drainage (EUS-Guided cystogastrostomy): the puncture
of the gastric wall with cystotome to obtain the passage in the
cystic cavity.
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Figure 14.7 – Pancreatic ductal adenocarcinoma. Fragment Figure 14.8 – Pancreatic ductal adenocarcinoma. Neoplastic
of adenocarcinoma on a cell block section. glands are best appreciated at high magnification (higher mag-
nification of image in figure 14.7).

Figure 14.9 – Poorly differentiated pancreatic ductal adeno- Figure 14.10 – Poorly differentiated pancreatic ductal ad-
carcinoma. Fragments of carcinoma on a cell block section. enocarcinoma. Neoplastic glands are best appreciated at high
magnification (higher magnification of image in figure 14.9).

14 Figure 14.11 – Pancreatic ductal adenocarcinoma. An atyp-

ical mitotic figure.
Figure 14.12 – Pancreatic ductal adenocarcinoma. High
magnification of neoplastic glands.

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