Endoscopic Ultrasonography E-Book

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 1156

Veröffentlichungsjahr: 2016

Beschreibung

Year on year, there continue to be dramatic changes in endoscopic ultrasonography (EUS) since it was first introduced 30 years ago. Advances in technology have meant that as well as being used in the diagnosis of gastrointestinal disorders, EUS is now one of the primary diagnostic and therapeutic modalities used in GI endoscopy.

Back and improved for a new edition, Endoscopic Ultrasonography is the market-leading book covering the topic.  Written by leading experts in the field, it provides a technical how-to approach to learning this advanced endoscopic procedure. The highly-acclaimed authors provide step-by-step guidance to the fundamentals of EUS, giving clear instructions on the instruments involved, the correct sedation procedures to follow and how EUS should be performed safely and effectively.

Every chapter discusses a specific aspect of EUS as it relates to a particular gastrointestinal disorder or organ system.   Brand new to this edition are:

1)                  Seven new chapters on the hottest topics in EUS: Learning Anatomy for EUS; Elastography; Lung Cancer; Autoimmune Pancreatitis; EUS for Liver Disease; Biliary Access; Pancreatic Fluid Collection Drainage

2)                  A complete update of all previous chapters to reflect the most current clinical recommendations

3)                  A host of new color images in every chapter 

 Endoscopic Ultrasonography 3^rd edition is the ideal tool to consult to improve EUS skills and improve patient management, and an essential purchase for all gastroenterologists and endoscopists.

Leseprobe

Table of contents

Cover

Title page

Copyright

List of contributors

Preface

Acknowledgments

Chapter 1: Endoscopic ultrasonography at the beginning: a personal history

Reference

Chapter 2: Basic principles and fundamentals of EUS imaging

How US images are made

How transducer properties affect the image

Attenuation and tissue penetration

How tissue properties affect images: the GI wall

Detection of tissue movement: doppler imaging

New techniques in EUS imaging

Imaging artifacts

Conclusion

References

Chapter 3: Learning EUS anatomy

General principles of EUS

Echo endoscopes

Regional anatomy

Approach to understanding EUS anatomy

Conclusion

Reference

Chapter 4: EUS instruments, room setup, and assistants

EUS instruments and other equipment

Room setup

EUS assistants

Conclusion

References

Chapter 5: EUS procedure: consent and sedation

Consent

Sedation

Conclusion

References

Chapter 6: The EUS report

Roles of the endoscopic report

Evolution of the medical report

Standard terminology and structured reporting

Free text and conventional reports

Databases

Commercial software for EUS reporting

The EUS report

Disease-specific information

Conclusion

References

Chapter 7: Radial EUS: normal anatomy

Normal gut wall anatomy

Examination technique

Mediastinum

Pancreaticobiliary stations

Rectum

Conclusion

References

Chapter 8: Linear-array EUS: normal anatomy

Performing the examination

The linear esophagus

The linear stomach

The linear duodenum

The linear rectum

Conclusion

References

Chapter 9: EUS elastography

Technical aspects and methodology of elastography

Qualitative EUS elastography

Quantitative EUS elastography

Clinical applications of EUS elastography

Conclusion

References

Chapter 10: Fundamentals of EUS FNA

Pre-procedural fundamentals

Intraprocedural fundamentals

Post-procedural fundamentals

Safety of EUS FNA

Conclusion

References

Chapter 11: EUS FNA cytology: material preparation and interpretation

Technical preparation and quality of EUS biopsy material

Technical quality of EUS biopsy material

Molecular analysis

Quality of interpretation

Integration of pathologic and clinical information

References

Chapter 12: High-frequency ultrasound probes

High-frequency ultrasonography

Intraductal ultrasonography

Complications

The future

Conclusion

References

Chapter 13: EUS: applications in the mediastinum

Mediastinal cysts

Rationale for EUS

Cross-sectional and functional imaging: how does EUS stack up?

Medical mediastinoscopy

Endobronchial ultrasonography

EUS in early NSCLC

Failed bronchoscopy and EUS rescue

EUS and MS

Getting the examination done

Which lymph nodes for FNA?

FNA: how and how much?

Special topics

Conclusion

References

Chapter 14: EBUS and EUS for lung cancer diagnosis and staging

EBUS for lung cancer staging

EUS for lung cancer staging

Combined procedures (EBUS and EUS) for complete mediastinal staging

Complications of EBUS and EUS

Conclusion

References

Chapter 15: EUS for esophageal cancer

Staging of esophageal cancer

Defining esophageal cancer based on location

T-staging

N-staging

M-staging

Stage-based treatment decisions

EUS staging after neoadjuvant chemoradiotherapy

EUS in obstructing tumors

EUS in superficial cancers

Technical aspects of EUS in esophageal cancer

Radial examination

Linear examination

Conclusion

References

Chapter 16: EUS of the stomach and duodenum

Benign disorders

Malignant disorders

Gastric lymphoma

Benign lesions of the duodenum, ampullary adenomas, and ampullary carcinoma

Conclusion

References

Chapter 17: Gastrointestinal subepithelial masses

Endoscopic findings

EUS imaging techniques

Lesions located in the mucosal layer

Lesions located in the submucosa

Lesions located in the muscularis propria

Extrinsic compression lesions

Comparison of imaging studies for subepithelial masses

Utility of EUS in the management of subepithelial masses

Endoscopic tissue sampling

Conclusion

References

Chapter 18: EUS for the diagnosis and staging of solid pancreatic neoplasms

Pancreatic and peripancreatic anatomy

EUS imaging and the diagnosis of solid pancreatic lesions

EUS and pancreatic cancer staging

Conclusion

References

Chapter 19: EUS for pancreatic cysts

EUS morphology

EUS-guided FNA and cyst fluid analysis

Characteristics of pancreatic cystic lesions

EUS FNA technique

Evolving approaches

Conclusion

References

Chapter 20: The role of EUS in inflammatory diseases of the pancreas

Acute pancreatitis

Recurrent acute pancreatitis

Conclusion

References

Chapter 21: Autoimmune pancreatitis

Classification of AIP

Clinical presentation of AIP

Diagnosis of AIP

Role of other tests in AIP

EUS imaging features of AIP

EUS-guided tissue acquisition

Treatment and outcomes of AIP

Conclusion

References

Chapter 22: EUS for biliary diseases

Common bile duct stones

Acute biliary pancreatitis

Indeterminate biliary strictures

Gallbladder polyps and cancer

EUS-guided biliary drainage

EUS-guided gallbladder drainage

Conclusion

References

Chapter 23: EUS in liver disease

EUS imaging of the liver

Liver parenchymal abnormalities in EUS

Malignant lesions in the liver

Benign lesions in the liver

Cystic liver lesions

Intrahepatic biliary disorders

Biliary adenomas

References

Chapter 24: Colorectal EUS

Instruments for colorectal endosonography

Examination technique

Colorectal cancer staging by EUS

Accuracy of T-staging

Accuracy of N-staging

Fine-needle aspiration

Interobserver variability in rectal cancer staging by EUS

EUS compared to CT and MRI

Three-dimensional EUS for rectal cancer staging

Contrast-enhanced EUS for rectal cancer staging

Clinical impact of EUS staging in rectal cancer

EUS for local recurrence of colorectal carcinoma

Restaging after chemotherapy and radiation

Linitis plastica of the rectum

Anal cancer

Anal sphincter defects

Subepithelial lesions and compression of the colorectal wall

Rectosigmoid and pelvic endometriosis

Perianorectal abscess and fistula

EUS in inflammatory bowel disease beyond imaging for perianal fistulas

EUS-guided drainage of perirectal abscesses

Prostate cancer and rectal EUS

Other pelvic malignancies

Conclusion

References

Chapter 25: Therapeutic EUS for cancer treatment

EUS-guided delivery of antitumor agents

EUS-guided tumor ablation

EUS-guided placement of fiducial markers and brachytherapy

EUS-guided celiac neurolysis

Conclusion

References

Chapter 26: EUS-guided biliary access

Equipment

Indications

Technique

Outcomes

Conclusion

References

Chapter 27: Pancreatic fluid collection drainage

Definitions

Indications and criteria for drainage

Rationale

Technique

Clinical outcomes

Technical proficiency

Technical limitations

Complications

Conclusion

References

Chapter 28: EUS-guided drainage of pelvic fluid collections

Patient preparation

Procedure

Post-procedure care and follow-up

Current evidence

Conclusion

References

Chapter 29: EUS hemostasis

EUS hemostasis of nonvariceal GI bleeding

EUS hemostasis of variceal bleeding

EUS hemostasis of pseudoaneurysms

Conclusion

References

Chapter 30: Training in EUS

Training options

Quality indicators in EUS training

Learning EUS

Practical aspects of EUS learning

Terminology

Hospital privileges

References

Chapter 31: The future of EUS

Instrumentation

Therapeutic accessory devices

Non-GI applications

Expansion of EUS indications

Conclusion

Acknowledgment

References

Index

End User License Agreement

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Guide

Cover

Table of Contents

Preface

Begin Reading

List of Illustrations

Chapter 2: Basic principles and fundamentals of EUS imaging

Figure 2.1 Frequencies of audible sound and US.

Figure 2.2 The basic types of US image. (A) An A-mode image plots the amplitude of a returning echo versus the time at which it returns relative to the transmitted US wave. Because the velocity of sound through soft tissue is relatively constant, the time taken for an echo to return can be converted into the distance or depth within the tissue at which the echo originated. (B) A B-mode image displays the amplitude of an echo as the brightness of a dot. (C) When multiple transducers are used or when a single transducer is moved over an area, the multiple single-line B-mode images can be converted into a rectilinear or compound scan.

Figure 2.3 The resolution in three dimensions (resolution cell) for a pulse of US energy as it propagates from a rectangular-shaped transducer of defined width (w) and height (h). The duration of the pulse, defining the axial or range resolution, stays the same as the wave propagates and is illustrated at three times: , and . Changes in the beam pattern produce changes in the lateral and azimuthal resolutions at the three time points. The near–far field transition point () is the point with the smallest-resolution cell (in this case, illustrated at time ) and offers the best overall resolution. Source: Kimmey MB, Martin RW 1992 [4]. Fundamentals of endosonography. Gastrointest Endosc Clin North Am 2:560, WB Saunders. Reproduced with permission of Elsevier.

Figure 2.4 Effects of US frequency (f) on the beam pattern of a transducer. For the same size transducer, a beam (solid lines) with a higher US frequency () produces a near–far field transition point that is further from the transducer and causes a narrower beam width in the far field. A beam (dashed lines) with a “lower frequency” () is illustrated for comparison. Source: Kimmey MB, Martin RW 1992 [4]. Fundamentals of endosonography. Gastrointest Endosc Clin North Am 2:561, WB Saunders. Reproduced with permission of Elsevier.

Figure 2.5 A duodenal lipoma (L) strongly attenuates the 12.5 MHz US beam, producing an acoustic shadow (arrows) in the tissue deep to the lipoma.

Figure 2.6 Time-varying gain (TVG) compensation. The vertical axis represents the amplitude of the received echoes (A, C) and the control signal (B). (A) US echoes with the same amplitude at the reflection site are received by the transducer as lower-amplitude signals according to how far the reflector is from the transducer, because of attenuation of both the transmitted and the reflected US waves. (B) The received echo can be electronically amplified according to when it is received. As shown by the linear increase, echoes from similar reflectors have the same amplitude at all distances from the transducer. Source: Kimmey MB, Martin RW 1992 [4]. Fundamentals of endosonography. Gastrointest Endosc Clin North Am 2:563, WB Saunders. Reproduced with permission of Elsevier.

Figure 2.7 Fluid within this small pancreatic cyst (C) does not reflect much of the US beam, leading to more echoes being seen in the tissue deep to the cyst (between arrows). This is the through-transmission artifact.

Figure 2.8 The five layers of the normal GI wall, as imaged with most endoscopic ultrasound equipment. From the mucosal surface at the top, layer 1 is produced by the interface between luminal fluid and the mucosal surface. Layer 2 is from the remainder of the mucosa. Layer 3 is from the submucosa and its interface with the muscularis propria. Layer 4 is the remainder of the muscularis propria. Layer 5 is from subserosal fat and connective tissue.

Figure 2.9 High-frequency US transducers may image the GI wall as a nine-layered structure. From the mucosal surface at the top, layer 1 is produced by the interface between luminal fluid and the mucosal surface. Layer 2 is from the remainder of the lamina propria. Layer 3 is from the interface of the lamina propria and the muscularis mucosae. The remainder of the muscularis mucosae is visualized as a hypoechoic fourth layer only if the muscularis mucosae is thicker than the pulse length or axial resolution of the US transducer used. Layer 5 is from the submucosa and its interface with the muscularis propria. Layer 6 is the remainder of the inner circular component of the muscularis propria. The intermuscular connective tissue produces a thin echoic layer 7. The outer longitudinal component of the muscularis propria is responsible for layer 8. Layer 9 is from subserosal fat and connective tissue.

Figure 2.10 The plastic casing (C) around the US transducer produces a strong reverberation of the US beam between the transducer and the casing. This results in a series of circular rings (arrows) of equal spacing and diminishing amplitude around the transducer.

Figure 2.11 Mirror image (M) of the US transducer and water-filled balloon (B), produced by reverberation between the transducer and the air–water interface (arrow) within the gastric lumen.

Figure 2.12 Production of a mirror-image artifact by reverberation of echoes from an air–water interface. The air–water interface reflects so strongly that US energy is redirected back to the transducer, just like light is redirected by a mirror. In the illustration at the left, the echoes and result from a double reflection, from the air–water interface and the stomach wall or balloon (or transducer case), respectively. The US processor records the position of the echo according to the time it receives the signal; the double reflection path takes longer and therefore causes the echo to appear further away from the transducer, as if it were a reflection in a mirror (diagram at left). The echoes received by the transducer directly (e.g., and ) are displayed on the image in the expected location. The distance from the transducer to the air–water interface (d) and the distance from the balloon or transducer case to the interface () are also illustrated. (Reproduced from Kimmey MB, Martin RW. Fundamentals of endosonography. Gastrointest Endosc Clin North Am 1992;2:570, with permission from WB Saunders.)

Figure 2.13 Why artifactual layer thickness increases with tangential scanning. (A) Amplitude and spatial duration of the echoes from the interfaces and specular reflectors in the normal GI wall when the US beam is at right angles to the wall. The diagonally-hatched region represents a tissue type with nonspecular echoes (e.g., the submucosa); the remaining echoes are produced by interfaces between tissue layers (specular echoes). The duration of the interface echoes is the same as the duration of the US pulse or the range resolution of the system (illustrated as a black rectangle in the beam). The echoes (displayed at the right) are spatially separated and distinguishable from one another. (B) When the US beam is not perpendicular to the wall, both the lateral and range resolution affect the duration of the echoes from each layer. In the extreme situation illustrated here, echoes from each layer overlap and cannot be distinguished individually. (Reproduced from Kimmey MB, Martin RW. Fundamentals of endosonography. Gastrointest Endosc Clin North Am

1992;2:572,

with permission from WB Saunders.)

Figure 2.14 EUS image of an esophageal cancer (Tj), appearing to show invasion of the descending aorta (Ao) at the arrow. This is an artifact caused by nonperpendicular or tangential scanning. A clue to this is the location of the water-filled balloon (B): the transducer and balloon should be positioned in the center of the esophagus, with the transducer in the center of the balloon to avoid this artifact and avoid tumor over-staging.

Figure 2.15 Pancreatic cyst (C) with apparent echoes (arrows), suggesting a solid component. These echoes are caused by side-lobe artifacts and are recognized because they are not consistently imaged when the transducer is maneuvered into another imaging plane.

Chapter 3: Learning EUS anatomy

Figure 3.1 The major vascular and ductal structures of interest during an EUS exam. Taken from the TolTech dissector program using University of Colorado Visible Human data.

Figure 3.2 (A1, B1) Thoracic transaxial CT images and (A2, B2) corresponding extraesophageal radial-array EUS images taken at the level of (A1, A2) the azygos arch and (B1, B2) the carina. The red circles show the esophagus and the location of an EUS probe. A, aorta; T, trachea; z, Azygos; B, bronchus.

Figure 3.3 (A1) Sagittal CT image of the chest. (A2) The same image, rotated and flipped to put it into an orientation seen during linear-array EUS. (A3) Corresponding EUS image. LA, left atrium; LV, left ventricle; PA, pulmonary artery. The location of the EUS probe is shown by a red spot.

Figure 3.4 Vascular structures of the chest and their relation to the esophagus. Taken from the TolTech dissector program using University of Colorado Visible Human data. (A1) The aortic arch and the proximal branches, as viewed from the left. (A2) The addition of the pulmonary truck and pulmonary arteries, as viewed from the left. (A3) The cavity of the left ventricle and left atrium, separated by the mitral valve, with the pulmonary veins, from the left. (A4) A posterior right view showing the azygos vein, superior vena cava, trachea, and main stem bronchi.

Figure 3.5 Three-dimensional anatomy of the stomach, viewed from the left and right. Taken from the TolTech dissector program using University of Colorado Visible Human data. HA, hepatic artery; SA, splenic artery; Celiac, celiac artery; SMA, superior mesenteric artery; PV, portal vein; SV, splenic vein.

Figure 3.6 Comparison of CT images and correlated EUS images. A: Sagittal CT (1) and linear-array EUS (2) at the level of the celiac artery insertion in the aorta. B: Transaxial CT (1) and radial-array EUS (2) at the level of the celiac artery insertion in the aorta. SMA, superior mesenteric artery.

Figure 3.7 Cross-sections from the University of Colorado Visible Human project, approximating EUS examinations going left from the aorta. (A1–4) Sagittal views, similar to linear-array EUS. (B1–4) Transaxial views, similar to radial-array EUS. (A1) Aorta at celiac and superior mesenteric origins. (A2) Slightly left. (A3) Further left, at the level of the left adrenal gland. (A4) Further left, at the splenic hilum. (B1) Aorta at the level of the celiac artery. (B2) Portal confluence. (B3) Slightly left, at the level of the left adrenal gland. (B4) Slightly left, at the level of the splenic hilum. A, aorta; AD, left adrenal gland; C, celiac artery; P, pancreas; PV, portal vein; SA, splenic artery; SMA, superior mesenteric artery; SV, splenic vein.

Figure 3.8 Cross-sections from the University of Colorado Visible Human project, approximating EUS examinations going right from the aorta. (A1–3) Sagittal views, similar to linear-array EUS. (B1–3) Transaxial views, similar to radial-array EUS. CBD, common bile duct; CYS, cystic duct; GB gallbladder; GDA, gastroduodenal artery; HA, hepatic artery; IVC, inferior vena cava; PD, pancreatic duct; PV, portal vein; SMA, superior mesenteric artery; SV, splenic vein.

Figure 3.9 Three-dimensional anatomy of the duodenum, showing major vessels and ducts. Taken from the TolTech dissector program using University of Colorado Visible Human data. CBD, common bile duct; GDA, gastroduodenal artery; HA, hepatic artery; IVC, inferior vena cava; PD, pancreatic duct; PV, portal vein; SMA, superior mesenteric artery; SV, superior mesenteric vein.

Figure 3.10 Images from the University of Colorado Visible Human data Oblique Maker program, showing (A1,B1) planes placed into three-dimensional models and (A2,B2) the cross-sectional anatomy generated within them. CBD, common bile duct; IVC, inferior vena cava; PD, pancreatic duct; PV, portal vein; SV, splenic vein; SMV, superior mesenteric vein. A is similar to a linear array exam of the ampulla from the proximal duodenum. B is similar to a radial array exam of the ampulla from the proximal duodenum bulb.

Figure 3.11 Cross-sections from the University of Colorado Visible Human project, showing (A1,2) periampullary images and (B1) correlated linear-array and (B2) radial-array EUS. CBD, common bile duct; PD, pancreatic duct; PV, portal vein.

Figure 3.12 Three-dimensional models made from the TolTech dissector program using University of Colorado Visible Human data. The vasculature and ductal structures around the proximal duodenum are shown. CBD, common bile duct; GB, gallbladder; GDA, gastroduodenal artery and superior pancreaticoduodenal artery; HA, common hepatic artery; LHA, left hepatic artery; RHA, right hepatic artery; SA, splenic artery; SMV, superior mesenteric artery.

Figure 3.13 EUS and CT images taken where the duodenum crosses over the vertebral column. This is generally the distal extent of an EUS examination. (A1) Linear-array image, which provides a transaxial view, similar to (A2) a standard transaxial CT. An enlarged lymph node is shown between the aorta and the inferior vena cava. (B1) Radial array image, similar to (B2) a sagittal CT image rotated 90° counterclockwise. IVC, inferior vena cava; RV, left renal vein; SMA, superior mesenteric vein.

Figure 3.14 Sagittal cross-sections from the University of Colorado Visible Human project, showing the (A1) male and (A2) female pelvis. SV, seminal vesicles.

Figure 3.15 (A1, A2, A3) Three-dimensional models made from the TolTech dissector program using University of Colorado Visible Human data and (A4) an EUS image taken from the sigmoid colon showing a sagittal view of the aortic bifurcation over a mass lesion. The internal iliac vessels drape over the rectosigmoid juncture (A1), and the right-sided vessels are generally easier to see than the left-sided, as shown in the posterior anterior image (A3). (A4) Linear-array image taken while doing a guided biopsy of a mass lesion that was found at the iliac bifurcation on CT scan (insert). RI, right iliac artery; LI, left iliac artery; M, mass.

Chapter 4: EUS instruments, room setup, and assistants

Figure 4.1 A linear-array echoendoscope (top) and an electronic radial-array (or transverse array) echoendoscope (bottom). The piezoelectric crystals on the linear-array echoendoscope are arranged along a single curved surface (arrows). On the electronic radial-array echoendoscope, the crystals are arranged as a band around the side of the instrument's tip.

Figure 4.2 A wall-mounted storage system works well for organizing small, EUS-related supplies such as air and suction buttons, balloons, and balloon applicators.

Figure 4.3 The EUS image is fed from the processor to the room's primary monitor to increase options for viewing. Note that the EUS processor is to the right of the endosonographer to improve access to the instrument panel and keyboard.

Figure 4.4 A small worktable in the EUS room provides dedicated workspace for processing of cytology samples. Keeping a microscope and cytology reagents in the EUS room makes it easier for a cytopathologist to simply stop in to help with a case.

Figure 4.5 The endosonographer can maintain control over the image displayed on the room's primary monitor using a switcher box. In this case, the box receives input from both the EUS processor and a video microscope.

Figure 4.6 Keeping both wires and their receptacles clearly labeled helps ensure quick and accurate hook-ups after equipment is moved for room cleaning.

Chapter 7: Radial EUS: normal anatomy

Figure 7.1 Radial EUS examination of a normal stomach. The five distinct echogenic layers described in the text are apparent, and are labeled 1–5.

Figure 7.2 The aorta, azygos vein, and thoracic duct all appear from this mediastinal window at the lower esophagus.

Figure 7.3 Mid-mediastinal views, showing the aorta (Ao) and the spine (Sp) at the lower half of the field, and a benign-appearing node in the subcarinal window (SC).

Figure 7.4 Aortopulmonary window (APW) visible just distal to the aortic arch, as seen in a cross-section. Trachea appears anteriorly as alternating hyperchogenic rings.

Figure 7.5 Thyroid gland lobes (arrows) appear as triangular structures separated by the echo-poor cricothyroid cartilage (CT). Sp, spine; a, left carotid artery; v, jugular vein.

Figure 7.6 Celiac artery (Cx), giving origin to the left gastric artery (1) and splenic artery (2).

Figure 7.7 Celiac ganglia (arrow), between the celiac artery (Cx), left adrenal (LA), and aorta (Ao).

Figure 7.8 Radial view of the pancreatic body, tail, and duct. The black splenic vein and portal confluence make up the “clubhead” view. The superior mesenteric artery (SMA) is seen in cross-section underneath the clubhead.

Figure 7.9 Station 1 views. The pancreatic duct (PD) is seen coursing through the pancreatic body. The splenic artery (SA) and splenic vein (SV) are in cross-section, close to the pancreatic parenchyma.

Figure 7.10 Splenules (arrow) are round and have well-defined borders and similar echogenicity to that of the spleen.

Figure 7.11 Radial view of the left adrenal, with classic “gullwing” shape.

Figure 7.12 Apical views of the pancreatic head from the duodenal bulb: the pancreatic duct (PD), common bile duct (CBD), and portal vein (PV) are all seen in alignment with the pancreatic head surrounding the common bile duct and pancreatic duct (stack sign).

Figure 7.13 Aorta (Ao) and inferior vena cava (IVC), examined from the second portion of the duodenum.

Figure 7.14 Radial view of uncinate process. Ventral (V) and dorsal (D) pancreas are seen with different echogenicities, along with the superior mesenteric vein (SMV).

Figure 7.15 Seminal vesicles appear anterior to the EUS probe. Note the normal rectal wall layers seen at the lower half of the screen.

Figure 7.16 Radial EUS views of a normal prostate gland (PS) above the EUS probe in a male approximately above the anal verge. The urethra appears as an anechoic tubular structure in the middle of the gland (arrow).

Figure 7.17 Views of the normal vagina and urinary bladder from the rectum.

Figure 7.18 Hyperechogenic external anal sphincter (EAS) and the hypoechoic internal anal sphincter (IAS), seen between the X marks in a normal female.

Chapter 8: Linear-array EUS: normal anatomy

Figure 8.2 Locations of thoracic nodal groups used in lung cancer staging.

Figure 8.3 (A) View of the aortopulmonary window, with thoracic nodal station 5A nestled between cross-sectional views of the arch of the aorta (aa) and the right pulmonary artery (rpa). (B) View of the azygous vein (az) from the mid-esophagus level. (C) View of the left common carotid artery (lcc) arising out of the arch of the aorta. (D) View of the hepatic veins (hv) draining into the inferior vena cava at the dome of the diaphragm (dia).

Figure 8.1 (A) Home base view of the descending aorta (da) in the mid-esophagus. (B) View of the left atrium (la), with the deeper mitral valve (mv) and left ventricle and the main pulmonary artery (pa). (C) View of the subcarinal region (arrow), with the deeper right pulmonary artery (rpa), ascending aorta (aa), and aortic valve (av). (D) View of the right atrium (ra), with the inferior vena cava (ivc) and superior vena cava (svc) running into it. Unless otherwise stated, all endosonographic images were made using the Olympus GF-UC240P-AL5 ultrasound gastrovideoscope with an Aloka ProSound Alpha 5 ultrasound processor at 7.5 MHz.

Figure 8.4 Endosonographic stations in the stomach.

Figure 8.5 (A) Home base view for the stomach (station 1 in Figure 8.4), with the abdominal aorta (aa) seen in longitudinal section and the crus of the left diaphragm overlying it. (B) View of the left adrenal, made using a Pentax FG36-UX echoendoscope with a Hitachi EUB-525 processor at 7.5 MHz. (C) View of the celiac artery (ca) arising from the abdominal aorta, with the more distal and oblique superior mesenteric artery (sma) (station 2 in Figure 8.4). (D) View of the pancreas body in cross-section, with the splenic artery (sa) and vein (sv) typically seen caudad to it (station 3 in Figure 8.4). Note the very small normal pancreatic duct (pd), also seen in cross-section.

Figure 8.6 (A) Linear view across the mid body of pancreas (p) (station 3 in Figure 8.4), showing the splenic artery (sa) weaving around the pancreas, with the larger and straighter splenic vein (sv) deep to it. Also in view are the left adrenal (la) and the left renal vein (lrv). (B) View of the neck of the pancreas at the level of the portal vein (pv) confluence (station 4 in Figure 8.4). The superior mesenteric vein (smv) merges into the portal vein, with glimpses of the superior mesenteric artery (sma) deep to this. (C) View of the right lateral margin of the pancreatic neck, looking down toward the pancreatic head (arrow). (D) View of the spleen and its hilar vessels (station 5 in Figure 8.4).

Figure 8.7 Fluoroscopic views of a linear echoendoscope maneuvering around the duodenum. (A) On first entering into the duodenal bulb, the scope is typically in a long position, with the tip pointing posteriorly and caudad. (B) View from this first duodenal station, looking down on to the pancreatic head intercepting the gastroduodenal artery (gda), bile duct, hepatic artery (ha), portal vein (pv), and superior mesenteric vein confluence (smv). Also shown are the gallbladder (gb), common hepatic artery (cha), and splenic artery (sa). (C) Second duodenal station, the home base location of the echoendoscope over the ampulla in a short position. Here, the common bile duct (cbd) and pancreatic duct appear within the pancreatic head, with the smv and superior mesenteric artery (sma) deep to them. (D) In the third station of the duodenum, the echoendoscope is deep at the junction between the second and third portions, looking up toward the ventral pancreas and mesenteric root vessels.

Figure 8.8 (A) Linear view from the second duodenal station (Figure 8.7C), where the echoendoscope is placed directly over the ampulla (amp). Usually, the pancreatic duct (pd) is seen first at this level. (B) Slightly more caudad view from above, with the common bile duct (cbd) now seen between the duodenal wall and pancreatic duct. (C) In the third duodenal station (Figure 8.7D), the abdominal aorta (aa) and inferior vena cava (ivc) come into view, either in cross-section or longitudinally. (D) View of mesenteric root vessels (mv) from the proximal third portion of the duodenum (third duodenal station), showing some uncinate pancreatic tissue (p).

Figure 8.9 (A) Linear view from the first duodenal station (Figure 8.7A,B), where the echoendoscope is in a long position inserted deep into the duodenal bulb. From here, the bulk of the pancreatic head is visible, with the pancreatic duct (pd) running deep toward the neck. The common bile duct (cbd) is seen in cross-section, as is the potentially confusing gastroduodenal artery (gda). The portal vein (pv), superior mesenteric vein (smv), splenic vein (sv) confluence is the prominent deep structure. Deep to the portal vein is the hepatic artery (ha). (B) Further counterclockwise rotation from above brings the porta hepatis into view, with the triad of the portal vein, common bile duct, and hepatic artery in cross-section. Notice the large gastroduodenal artery coming off the hepatic artery, which can be mistaken for the common bile duct. (C) Anywhere in the second portion of the duodenum, the right kidney (K) may be seen. (D) Rotation in the duodenal bulb or antrum usually results in views of the gallbladder (gb).

Figure 8.10 (A) Linear view of the male rectum at about 9 cm from the anal verge. The seminal vesicles (sv) are caudad to the prostate (pr). Deep to this is the bladder (B). (B) At the distal end of the prostate, the membranous urethra (mu) and perineal membrane (pm) mark the end of the male pelvis. (C) Linear view of the female rectum at about 9 cm, showing the uterus (ut) and the deeper bladder. (D) At 5–9 cm from the anal verge, the vagina (V) is easy to detect due to the small amount of air within it, producing a bright stripe.

Chapter 9: EUS elastography

Figure 9.1 Qualitative EUS elastography of normal pancreas, showing a specific color distribution.

Figure 9.2 Quantitative EUS elastography based on hue-histogram analysis of normal pancreas. The analysis was performed on a selected area within the ROI. The mean value is shown at the bottom of the image (137.0).

Figure 9.3 Quantitative EUS elastography of a pancreatic solid mass (pancreatic adenocarcinoma) based on: (A) strain ratio (area A representing the pancreatic lesion, area B corresponds to a soft area from the gut wall; the B/A ratio is displayed at the bottom of the image (31.38)); (B) hue histogram (almost the complete lesion is selected for analysis; the mean is shown at the bottom of the image (27.5)). In the qualitative evaluation, the mass presents a clear, heterogeneous, blue-predominant pattern.

Figure 9.4 Quantitative EUS elastographic evaluation of a patient with EUS findings related to CP. Strain ratio is shown at the bottom of the image (2.99).

Figure 9.5 Quantitative EUS elastography of a lymph node, showing a predominantly green pattern, corresponding to a reactive lymph node. The strain ratio is shown at the bottom of the image (3.01). In the qualitative evaluation, the lymph node presents a clear, heterogeneous, green-predominant pattern.

Figure 9.6 Qualitative EUS elastography of a solid liver lesion, corresponding to a metastasis from a colon cancer. The lesions present the typical heterogeneous blue predominant patter, clearly differentiated from surrounding tissue.

Chapter 10: Fundamentals of EUS FNA

Figure 10.1 FNA of duodenal wall infiltration in a patient with lymphoma who presented with extensive lymphadenopathy.

Figure 10.2 FNA of a portal hilar lymph node measuring 0.85 cm in a patient with pancreatic adenocarcinoma.

Figure 10.3 FNA of a subcarinal lymph node in a patient with a pancreatic mass.

Figure 10.4 FNA of a pancreatic mass.

Figure 10.5 FNA of liver metastases in a patient with pancreatic adenocarcinoma.

Figure 10.6 (A) FNA of a pancreatic cyst with intracystic solid component. The needle tip is located in the intracystic solid component. (B) Intracystic blood seen after FNA. (C) Intracystic blood seen after FNA.

Figure 10.7 (A) FNA of a pancreatic cyst. (B) FNA of the intracystic solid component of the same cyst.

Chapter 12: High-frequency ultrasound probes

Figure 12.1 HFUS probe through the working channel of a side-view endoscope.

Figure 12.2 Sonographic correlation with wall structure of the gastric wall ().

Figure 12.3 Radiologic images of an IDUS probe in the common bile duct during ERCP.

Figure 12.4 HFUS of (A) normal pancreas and (B) correspondent histopathology.

Figure 12.5 HFUS 3D imaging: reconstructed images.

Chapter 13: EUS: applications in the mediastinum

Figure 13.1 Adrenal metastasis. An nodule in the left wing of the left adrenal gland. PET scan showed avid uptake (SUV 5). EUS FNA confirmed malignant involvement.

Figure 13.2 Bulky N2 disease. EUS FNA confirmed N2 disease in a patient with NSCLC. Surgery was avoided and neoadjuvant therapy was recommended.

Figure 13.3 The Mountain and Dresler regional lymph node classification [11].

Figure 13.4 Normal-appearing “seagull” adrenal gland (curvilinear echoendoscope).

Figure 13.5 Subcarinal mass invading the mediastinum (small-cell lung carcinoma, SCLC). EUS FNA confirmed SCLC and surgical staging was avoided.

Figure 13.6 Renal cell carcinoma metastasis. EUS FNA (with immunostains) diagnosed renal cell carcinoma metastatic to the spine. The lesion was identified slightly above the gastroesophageal (GE) junction. EUS was the only nonsurgical approach used to reach this lesion.

Figure 13.7 Melanoma. EUS FNA, along with immunostains, confirmed recurrent metastatic melanoma to the mediastinum.

Chapter 14: EBUS and EUS for lung cancer diagnosis and staging

Figure 14.1 (A) EBUS scope (Pentax EB 1970 UK). (B) Distal end of the endoscope, demonstrating a linear ultrasound head and side-viewing optique. US, ultrasound transducer.

Figure 14.2 Diagnostic reach of EBUS and EUS. EBUS: Right paratracheal nodes (stations 2R and 4R) and hilar and interlobar nodes (stations 10 L/R and 11L/R) (open balls). EUS: Nodes in the lower mediastinum (stations 8 and 9), left liver lobe, celiac nodes, and left adrenal gland (black balls). EBUS and EUS: Left paratracheal nodes and subcarinal nodes (stations 4L, 2L, and 7, respectively; half-open balls).

Figure 14.3 (A) Schematic drawing of station 4R, located paratracheally to the right. The inferior border of the azygos vein marks the inferior border of station 4R. (B) Corresponding EBUS image, demonstrating station 4R located superior to the azygos vein. (C) EBUS image (ultrasound transducer is positioned paratracheally to the right), showing an isoechogic lymph node that is being sampled by a 22-gauge needle. Left upper corner: endoscopic view demonstrating mucosa of the trachea and the sheet and needle at the 3 o'clock position. The endobronchial view is limited and shows only the mucosa adjacent to the ultrasound transducer. (D) Schematic drawing of the sheet and needle tip. Before puncturing the node, the tip of the sheet is locked a few millimeters outside the endoscope to protect the endoscope from the needle (C). When a needle is used with a beveled stylet, the stylet is retracted before the node is punctured. AV, azygos vein; N, needle; LN, lymph node; PIN, picture in picture.

Figure 14.4 Endoscopic view with side-viewing optique. The EBUS scope (Pentax EB 1970 UK) is located in the distal part of the trachea. At 5 o'clock, the ultrasound transducer is visible. US, ultrasound transducer; LMB, left main bronchus; RMB, right main bronchus.

Figure 14.5 EBUS image with Doppler flow for the detection of blood vessels (in this case, the aorta), showing an enlarged lymph node paratracheally to the left at station 4L, with a short axis of 13 mm. Ao, aorta; PA, pulmonary artery; LN, lymph node.

Figure 14.6 Six schematic drawings of the six key images visible with the EBUS scope. (A) All lymph node stations accessible with the EBUS scope. (B) Station 4L, paratracheally to the left, located between the aorta and left pulmonary artery. (C) Subcarinal node (station 7; here pictured with the scope in the right main bronchus). (D) Station 10L. (E) Station 10R. (F) Station 4R, located paratracheally to the right. The inferior border of the azygos vein marks the inferior border of station 4R.

Figure 14.7 Schematic drawing of the order in which samplings should be taken with EUS FNA and/or EBUS-TBNA to avoid upstaging in a patient with a right-sided lung tumor (from N3 to N2 to N1 to the tumor).

Figure 14.8 (A) Schematic drawing of station 4L, located between the aorta and the pulmonary artery, with the EBUS scope positioned paratracheally to the left. (B) Corresponding EBUS image of station 4L, located paratracheally to the left. Ao, aorta; PA, pulmonary artery; Tr, lumen of the trachea; LN, lymph node station 4L.

Figure 14.9 (A) Schematic drawings of the subcarinal node, station 7. This station is located below the main carina with the EBUS scope in the right or the left main bronchus facing medially. The main carina forms the upper border of this station. (B) Transesophageal overview of station 7 and its relations to the vascular structures. Endoscopy performed with the EBUS scope (EUS-B).

Figure 14.10 (A) Computed tomography (CT) of the chest, demonstrating a right-sided centrally located lung tumor. (B) Corresponding EBUS image (ultrasound transducer positioned in the right main bronchus) showing the large tumor mass. In the left upper corner, the endoscopic view can be seen. (C) Corresponding FNA demonstrating small cells with scant cytoplasm and nuclear molding compatible with small-cell anaplastic carcinoma. T, tumor; PA, pulmonary artery.

Figure 14.11 Esophageal imaging of the mediastinum. In order to systematically check all mediastinal nodes located adjacent to the esophagus, the scope should be retracted while rotating 360° every 4 cm. The left adrenal gland and celiac nodes can be visualized by a transgastric approach.

Figure 14.12 Schematic drawing of six key images visible by EUS. Mediastinal nodes are given their number based on their relation to vascular structures (left atrium, pulmonary artery, aorta, azygos vein). The dot shows where the proximal part of the endoscope is located. Note that station 4R is not always visible from the esophagus by EUS.

Figure 14.13 (A) CT scan of the chest, demonstrating a centrally located tumor in the left upper lobe, causing obstruction of the airways and a postobstruction atelectasis. (B) PET-CT showing an intense FDG-avid centrally located mass in the left upper lobe. On the ventral side of this mass is an FDG-negative atelectasis. At station 4L, an intense FDG-avid lymph node is visible. (C) Corresponding EBUS image showing the enlarged lymph node at station 4L and the pulmonary tumor. (D) Corresponding FNA demonstrating tumor cells that focally have keratinization compatible with squamous cell carcinoma. A, atelectasis; T, tumor; LN, lymph node; Ao, aorta; PA, pulmonary artery.

Figure 14.14 (A) CT scan of the chest of a patient 4 months after concurrent chemoradiation therapy for cT3N0M0 NSCLC, showing an enlarged lymph node in the lower mediastinum suspected for mediastinal recurrence. (B) Corresponding EUS images showing aspiration of a slightly enlarged lymph node at station 9. L, lumen of the esophagus; LN, lymph node; N, needle.

Figure 14.15 (A) Schematic drawing of an EUS image of the left adrenal gland (LAG). The LAG is located at the upper pole of the left kidney. The normal LAG resembles a seagull. (B) LAG transgastrally visualized with an EBUS scope, demonstrating a normal seagull-shaped LAG. In the left upper corner, the endoscopic view is visible (gastric wall). The dot represents the position of the distal tip of the endoscope.

Chapter 15: EUS for esophageal cancer

Figure 15.1 Radial EUS image showing a T1b esophageal squamous cell carcinoma of the distal esophagus. The corresponding endoscopic view is provided.

Figure 15.2 Radial EUS image depicting a T2 esophageal adenocarcinoma of the midthoracic esophagus. The corresponding endoscopic view is provided.

Figure 15.3 Radial EUS image of a T3 esophageal adenocarcinoma, clearly showing invasion of the tumor through the muscularis propria. The corresponding endoscopic image is shown.

Figure 15.4 Radial EUS image of esophageal adenocarcinoma seen invading through the periesophageal adventitia and involving the adjacent pleura (T4a). The corresponding endoscopic image is shown.

Figure 15.5 EUS-based algorithm for the management of esophageal cancer. PET-CT, positron emission tomography–computed tomography; EUS, endoscopic ultrasonography; FNA, fine-needle aspiration; HGD, high-grade dysplasia; EMR, endoscopic mucosal resection.

Chapter 16: EUS of the stomach and duodenum

Figure 16.1 Endoscopic appearance of the stomach in a patient with thickened gastric folds.

Figure 16.2 At EUS, the gastric wall thickness is markedly thickened to >1 cm, and the five-layer pattern is obliterated. This patient had linitis plastica (gastric adenocarcinoma, diffuse-type).

Figure 16.3 EUS imaging of T1 gastric cancer. A hypoechoic mass involves the mucosa and infiltrates slightly (left side of picture) into the submucosa.

Figure 16.4 EUS image of a T2 gastric cancer. The mass projects fairly deeply into the gastric lumen as a polypoid lesion, but the fourth layer (muscularis propria) is intact, as demonstrated by smooth dark band around the entire lumen.

Figure 16.5 EUS image of T3 gastric cancer. The muscularis propria (dark band) is clearly disrupted by the tumor projecting through it.

Figure 16.6 Malignant lymph node (LN) in a patient with ampullary carcinoma. CBD, common bile duct.

Figure 16.7 Endoscopic appearance of an early (T1) gastric cancer.

Figure 16.8 EUS image of an early gastric cancer. A subtle hypodensity of the superficial and deep mucosa being imaged with the EUS miniprobe can be seen.

Figure 16.9 Defect left after ESD of the T1 gastric cancer shown in Figure 16.7. Appearance is blue due to submucosal injection of methylene blue prior to resection.

Figure 16.10 Resected T1 gastric cancer. Pathologic analysis confirmed T1m3 (invasion of the muscularis mucosae) cancer.

Figure 16.11 EUS image of linitis plastic, showing marked thickening of all wall layers. A bright intact-appearing mucosa layer is present, with hypoechoic enlargement of the remaining layers measuring 17 mm in cross-section. This was imaged with the miniprobe, because the standard radial echoendoscope could not be passed into the rigid stomach.

Figure 16.12 Ascites, shown as an anechoic band of fluid surrounding the stomach. Doppler is being used here to confirm this is not a vascular structure; Doppler is negative.

Figure 16.13 EUS FNA of perigastric ascites.

Figure 16.14 Ampullary cancer, stage T3. This is during pullback maneuver from the second portion of the duodenum. The cancer is a hypoechoic enlargement of the ampulla; the anechoic crescent to the left of the mass is the common bile duct in cross-section. The tumor invades the pancreatic head.

Figure 16.15 Ampullary cancer extending up the bile duct over a distance of 2.4 cm from the ampulla. This will require a Whipple procedure for removal.

Chapter 17: Gastrointestinal subepithelial masses

Figure 17.1 Gastric lipoma. Note the characteristic hyperechoic mass in the submucosal layer. Musc pro, muscularis propria.

Figure 17.2 Duodenal carcinoid tumor. The subepithelial mass has mixed hypo- and hyperechoic areas and is clearly different from the typical hyperechoic lipoma or hypoechoic stromal cell tumor.

Figure 17.3 Granular cell tumor of the stomach. Note the slightly irregular hypoechoic mass in the submucosa with internal echoes. This is different from a typical lipoma or stromal cell tumor.

Figure 17.4 Duplication cyst in the gastric antrum. Note the round, anechoic structure in the third (submucosal) layer.

Figure 17.5 Gastric varices. The arrow points to hypoechoic, tubular structures in the submucosal layer, which correspond to intramural varices.

Figure 17.6 Stromal cell tumor of stomach. Note that this lesion is located within the muscularis propria (MP), which is typical for stromal cell tumors.

Figure 17.7 Stromal cell tumor of stomach. Note that this lesion is diffusely hypoechoic and located in the submucosa. This tumor probably developed as a bud from either the muscularis propria or the muscularis mucosa, and grew within the submucosa.

Figure 17.8 (A) Conventional EUS image of a 4 cm gastric stromal cell tumor with a radial echoendoscope. Note that more than half of the bulk of the lesion is actually outside the gastric wall. (B) Vessel image of CEH EUS of the same lesion in (A), showing the fine intratumoral vessels. (C) Perfusion image of CEH EUS of the same lesion in (A), showing a mostly homogeneous enhancement pattern. Histology subsequently confirmed a low-grade GIST with low mitotic Figure per high power field. GIST, gastrointestinal stromal tumor; MP, muscularis propria.

Figure 17.9 Posterior mediastinal lymph nodes (LN). These are suspected to be caused by histoplasmosis infection. AO, aorta; AZ, azygous vein.

Figure 17.10 Pancreatic pseudocyst pressing against the stomach.

Chapter 18: EUS for the diagnosis and staging of solid pancreatic neoplasms

Figure 18.1 Normal ventral pancreas, as imaged from the region of the major papilla using a linear array echoendoscope. A distinct border is seen between the hypoechoic ventral portion of the pancreas and the superior pancreatic head.

Figure 18.2 Normal confluence of the splenic vein with the superior vein to form the portal vein, as imaged from the gastric antrum or duodenal bulb with a linear instrument.

Figure 18.3 Aberrant right hepatic artery. A small-caliber vessel is seen arising from the superior mesenteric artery and heading superiorly toward the liver and portal vein.

Figure 18.4 Hypoechoic mass in pancreas. The mass is approximately 1 cm in diameter.

Figure 18.5 FNA of a small pancreatic mass lesion. The lesion measured 4 × 5 mm in diameter. Cytology confirmed the presence of a pancreatic endocrine neoplasm.

Figure 18.6 Cholangiocarcinoma. A nonshadowing, hypoechoic polypoid filling defect is seen within the lumen of the common bile duct.

Figure 18.7 Mass in the uncinate process. In this case, a mass is seen in the uncinate process on the opposite side of the superior mesenteric vein, as viewed from the gastric antrum.

Figure 18.8 Pancreatic endocrine neoplasm. (A) A well-circumscribed, 12 × 7 mm mass within the pancreatic body between the calipers. The mass is nearly identical in echogenicity to the surrounding pancreas. (B) Needle aspiration performed using a 25-gauge needle. Cytology returns relatively bland, uniform cells that show characteristic positive staining for chromogranin. All cytology images 400 × magnification.

Figure 18.9 Cystic pancreatic endocrine neoplasm. (A) A thick-walled, well-circumscribed isoechoic mass with an eccentric, irregularly shaped central cyst. (B) After needle aspiration of the fluid contents, the lesion appears to be a spherical, well-circumscribed solid lesion, similar to a standard endocrine neoplasm.

Figure 18.10 Solid pseudopapillary tumor of the pancreas. The lesion is a complex collection of (A) irregularly shaped cystic components of variable size and (B) isoechoic/hypoechoic solid portions. It is encapsulated. Surgical pathology demonstrates an encapsulated lesion filled with papillary excrescences.

Figure 18.11 Metastatic squamous cell (lung primary) to the pancreas. A complex mass is seen in the pancreatic tail, with (A) cystic and (B) solid components, in a patient undergoing treatment for primary squamous cell carcinoma of the lung. Needle aspiration shows evidence of squamous cell carcinoma (400× magnification).

Figure 18.12 Metastatic RCC to the pancreas. (A) A large mass was identified in the pancreatic body on CT in this patient with abdominal pain. There was a remote history of RCC approximately 7 years earlier. EUS biopsy was requested to determine whether this was of primary pancreatic origin. (B) EUS demonstrated two additional focal masses in the pancreatic head that were not seen on CT. (C) Needle aspiration was performed, documenting metastatic RCC.

Figure 18.13 Calcific debris following AP. The patient had a well-circumscribed, hypodense pancreatic mass seen on CT, interpreted as concerning for malignancy. There was a very remote history of AP managed at another institution. EUS demonstrated a 4.5 cm hypoechoic region that produced acoustic shadowing. Diagnostic needle aspiration returned pasty material with cytology showing necrotic, acellular debris with crystalline structures. DiffQuik stain at 200× magnification.

Figure 18.14 Fatty infiltration of the pancreas. The patient underwent CT scanning of the abdomen for unrelated issues, with an incidental note of a focal hypodense mass in the pancreatic head. EUS demonstrates abnormally hyperechoic tissue in the expected region of the pancreatic head, which shadows and precludes visualization of deeper structures. Subsequent MRI confirmed increased fat density and the absence of a mass to correspond to the region of concern on CT.

Figure 18.15 AIP. A focal, well-circumscribed mass was seen in the pancreatic head on CT imaging of a young woman with abdominal pain and elevated lipase. EUS demonstrated (A) a 37 × 27 mm hypoechoic mass in the pancreatic head resulting in (B) upstream pancreatic duct dilation. The pancreatic body was relatively normal. (C) A second hypoechoic lesion was seen in the pancreatic tail. Needle aspiration of the pancreatic head was performed and was interpreted by cytopathology as showing adenocarcinoma. Outside cytology review confirmed the diagnosis, but surgical resection revealed AIP without malignancy. This is the only instance of false-positive cytology in our experience.

Figure 18.16 Disease-specific 5-year survival as per AJCC stage for pancreatic adenocarcinoma. Localized: stage I; regional: stages II and III; distant: stage IV.

Figure 18.17 Venous interface loss. A hyperechoic tissue plane is seen separating the mass and portal vein below the mass in this picture. This interface is lost in the region labeled “PV.”

Figure 18.18 Partial venous encasement. This mass encircles approximately 50% of the circumference of the portal vein.

Figure 18.19 Venous compression. In this case, a large mass was seen on CT and MRI, both of which demonstrated portal vein narrowing and suggested unresectability (without venous reconstruction). Although EUS confirmed a large mass, there was an intact hyperechoic tissue plane between the mass and portal vein in all views, suggesting a lack of venous adherence. The lesion was successfully resected without venous reconstruction.

Figure 18.20 Intravenous filling defects associated with tumor invasion. A small defect is seen in (A), which was not evident on CT. (B) shows a more obvious region of tumor ingrowth directly extending from a large mass, which is compressing the portal vein.

Figure 18.21 Cavernous transformation of the portal vein. Numerous anechoic structures are seen in the region of the porta hepatica. The bile duct passed through the region. Doppler examination showed flow with a venous waveform. The portal vein could not be identified in the region of a large mass.

Figure 18.22 EUS-guided needle aspiration of a lymph node metastasis.

Chapter 19: EUS for pancreatic cysts

Figure 19.1 A 3 cm septated mucinous cystadenoma in the body of the pancreas.

Figure 19.2 (A) Main-duct IPMN with focal epithelial thickening due to papillary fronds. (B) Side-branch IPMN with a 4 mm mural nodule.

Figure 19.3 A 3 cm SCA in the body of the pancreas, showing the typical honeycomb appearance.

Figure 19.4 A 2 cm SPT in the pancreatic tail. It is a well-demarcated mass with microcystic spaces and shadowing calcifications.

Figure 19.5 A 6 cm heterogeneous but well-demarcated LEC arising from the pancreatic neck. The pancreatic duct can be seen below the lesion.

Figure 19.6 An 8 cm pseudocyst in the pancreatic tail with dependent, layering fine debris.

Figure 19.7 A 2 cm well-demarcated, round cystic islet cell tumor in the pancreatic body. This lesion has a “bullseye” appearance.

Figure 19.8 Adenocarcinoma with cystic degeneration. Note the poorly defined margins and irregular cystic space.

Figure 19.9 EUS FNA of a septated mucinous cystadenoma. While aspirating fluid, the needle is moved to and fro to contact the septation, in order to increase the cellular yield.

Chapter 20: The role of EUS in inflammatory diseases of the pancreas

Figure 20.1 Transduodenal imaging of the head of the pancreas, showing obstruction of the main pancreatic duct by an obstructing stone with upstream dilation.

Figure 20.2 EUS image of chronic calcific pancreatitis in the body of the pancreas using radial endosonography: hyperechoic foci, dilated pancreatic duct.

Figure 20.3 EUS image of CP in the body of the pancreas using radial endosonography: tortuous pancreatic duct, hyperechoic duct walls, hyperechoic stranding, hyperechoic foci.

Figure 20.5 Pancreaticolithiasis in the head of the pancreas as imaged with a linear echoendoscope.

Figure 20.6 EUS image of mild CP using radial endosonography in a patient with a normal pancreatogram on ERP: hyperechoic pancreatic duct walls, hyperechoic foci, and stranding.

Chapter 21: Autoimmune pancreatitis

Figure 21.1 The histologic triad of type 1 AIP: (A) periductal lymphoplasmacytic infiltration with epithelial damage, (B) storiform fibrosis, featuring collagen mixed with inflammation, and (C) infiltration of the vein wall with partial compression of the lumen.

Figure 21.2 Immunohistochemical stain for IgG

4

, demonstrating cytoplasmic staining in numerous plasma cells.

Figure 21.3 Needle biopsy from a patient with type 1 AIP. There is storiform fibrosis on the right. On the left, a muscular artery is accompanied by an obliterated vein.

Figure 21.4 Like type 1 AIP, type 2 also has (A) periductal lymphocytic inflammation, but with the added feature of (B) neutrophils in the epithelium.

Figure 21.5 Needle biopsy may not contain ducts, but neutrophils are increased in tubules and acini.

Figure 21.6 (A) Diffuse pancreatic parenchymal enlargement seen on the venous phase of biphasic CT. (B) Associated compression of the intrapancreatic biliary tree seen on MRCP.

Figure 21.7 (A) Intrapancreatic and (B) extrapancreatic multifocal strictures in IgG

4

-SC.

Figure 21.8 Extrapancreatic biliary stricture in IgG

4

-SC seen during ERC (A) before and (B) after treatment with steroids.

Figure 21.9 Classic AIP features on EUS with diffuse pancreatic enlargement featuring hypoechoic, heterogeneous parenchyma.

Figure 21.10 AIP presenting as a focal hypoechoic mass on EUS.

Figure 21.11 Focal mass with suggestion of peripancreatic vessel involvement, confirmed by EUS TCB as AIP.

Figure 21.12 Normal-appearing pancreas on EUS in a patient with type 1 AIP.

Figure 21.13 Classic appearance on EUS of IgG

4

-SC.

Chapter 22: EUS for biliary diseases

Figure 22.1 Linear EUS view of axx mm smallstone in the distal common bile duct stone, with acoustic shadows.

Figure 22.2 Linear EUS view of a mass that completely occupies the lumen of the distal common bile duct, which is highly suggestive of cholangiocarcinoma.

Figure 22.3 EUS FNA of a distal common bile duct mass highly suggestive of cholangiocarcinoma.

Figure 22.4 EUS using the forward-viewing linear echoendoscope in a patient with hilar biliary stricture. (A) EUS image showing the hilar hypoechoic mass occluding the bile duct without invasion of the portal vein (PV) or the hepatic artery (HA). (B) EUS FNA of the lesion.

Figure 22.5 Linear EUS view of a 3 mm polyp in the gallbladder.

Figure 22.6 EUS FNA of a mass completely occupying the entire gallbladder bed.

Figure 22.7 EUS-guided biliary drainage using the forward-viewing echoendoscope and the Axios fully covered metal stent in a patient with inaccessible papilla due to malignant duodenal obstruction. (A) EUS view from the duodenal bulb of a dilated common bile duct (17 mm). (B) Puncture of the dilated common bile duct using a 19-gauge needle, which provides evidence of the presence of ascites. (C) Contrast injection showing a dilated common bile duct with a distal stricture. (D) Fluoroscopic view of 0.035 guidewire inside the common bile duct. (E) EUS view of the distal falange of the 6–8 mm AXIOS stent opened inside the dilated common bile duct. (F) Endoscopic view of the proximal falange of the AXIOS stent placed in the duodenal bulb.

Figure 22.8 EUS-guided gallbladder drainage using the AXIOS fully covered metal stent in a patient with acute cholecystitis of high surgical risk. (A) EUS view of the gallbladder, with wall thickening and presence of a big stone. (B) EUS view of the distal falange of the 15 mm AXIOS stent after opening inside the gallbladder. (C) Endoscopic view of the proximal falange of the stent in the duodenum, with pus coming out. (D) Endoscopic view of the gallbladder through the previously positioned stent, 2 days after placement. (E) Endoscopic view of big stones inside the gallbladder.

Chapter 23: EUS in liver disease

Figure 23.1 Homogenous normal liver parenchyma.

Figure 23.2 Cirrhotic liver parenchyma with diffuse, coarse, heterogenous echotexture.

Figure 23.3 Irregular nodular borders seen in a cirrhotic liver (arrows).

Figure 23.4 EUS-guided liver TCB in cirrhosis, with characteristic bridging fibrosis and regenerative nodules.

Figure 23.5 Ascites in the perihepatic region (stars).

Figure 23.6 (a) Varices in the gastric fundus in a patient with cirrhosis. (b) EUS showed anechoic tubular structures with flow on color Doppler.

Figure 23.7 Hyperechoic liver parenchyma in hepatic steatosis.

Figure 23.8 Metastatic liver mass with necrosis, seen as intratumoral mixed echogenicity.

Figure 23.9 (A) Hypoechoic metastatic liver lesion in a patient with a pancreatic mass. (B) FNA cytology showing metastatic pancreatic adenocarcinoma. Cytologic findings include irregular size, marked nuclear pleomorphism, and irregular mucin production (). Courtesy of Dr. Michael R. Henry.

Figure 23.10 Small hyperechoic liver hemangioma.

Figure 23.11 Anechoic, Doppler-negative liver cyst.

Chapter 24: Colorectal EUS

Figure 24.1 A T1 rectal adenocarcinoma (by radial EUS) arising in a villous adenoma with an intact submucosa and muscularis propria (arrow) beneath it.

Figure 24.2 Radial EUS image of a rectal adenocarcinoma that appears to be T2 (penetration into muscularis propria) in one portion and T3 (penetration through muscularis propria into perirectal fat – arrow) in another.

Figure 24.3 (A) Radial EUS of a T3N1 lesion, showing the primary rectal tumor penetration through the muscularis propria (MP) into perirectal fat (arrows). (B) Radial EUS of the patient in A, showing a 7 mm round, perirectal, hypoechoic lymph node with no flow on color Doppler, with an adjoining vessel nearby with color flow. CT, MRI, or PET may be used to evaluate for distant metastasis.

Figure 24.4 EUS-guided FNA of a perirectal lymph node. The tip of the needle is within the lymph node (arrow).

Figure 24.5 (A) Subepithelial bulge in the rectum from a large intramural, subepithelial mass. (B) EUS of the mass in A, showing it to be a hypoechoic mass contigous with the muscularis propria (MP). EUS FNA revealed it to be a GIST.

Chapter 25: Therapeutic EUS for cancer treatment

Figure 25.1 Fiducial marker placement. (A) A 19-gauge needle is preloaded with a fiducial marker to be deployed along the inferior border of a mediastinal mass. (B) The fiducial marker has been successfully deployed through the needle into the lesion. (C) Fluoroscopic image demonstrating fiducial marker deployment.

Figure 25.2 Celiac ganglion neurolysis. (A) A 22-gauge needle is advanced into the celiac ganglion (white arrows), which is subsequently injected with a mixture of alcohol and bupivacaine. (B) The depot injection produces an anechoic region with focal hyperechoic foci – c/w fluid containing small air bubbles – within the celiac ganglion (white arrows).

Chapter 26: EUS-guided biliary access

Figure 26.1 Measurement of the distance between stomach and intrahepatic bile duct using a linear-array echoendoscope.

Figure 26.3 Transgastric needle puncture into the hepatic bile duct.

Figure 26.4 Transgastric puncture of the left hepatic system, with contrast injection and cholangiogram.

Figure 26.5 Guidewire advancement through the transgastric puncture until it crosses the papilla.

Figure 26.6 Transduodenal puncture with antegrade wire advancement until it crosses the papilla.

Figure 26.7 Rendezvous technique. The wire is retrieved from the duodenum and a stent is inserted in a retrograde manner.

Figure 26.8 Guidewire advancement until multiple loops are seen in the intestinal tract, followed by balloon dilation.

Figure 26.9 Balloon dilation at the level of the gastrohepatic fistula.

Figure 26.10 Bruching of the common bile duct stricture.

Figure 26.12 Antegrade, transpapillary common bile duct deployment of a fully covered metal stent.

Chapter 27: Pancreatic fluid collection drainage

Figure 27.1 Pseudocyst accessed with a 19-gauge FNA needle.

Figure 27.2 Passage of a 0.035 inch guidewire into the pseudocyst under fluoroscopy.

Figure 27.3 Balloon dilatation of the puncture site.

Figure 27.4 Placement of a double-pigtail transmural stent.

Figure 27.5 Endoscopic view after insertion of NAGI SEMS.

Figure 27.6 X-ray view after insertion of NAGI SEMS.

Figure 27.7 View within the cavity of infected walled-off necrosis.

Figure 27.8 Appearance of the cavity of the walled-off necrosis after endoscopic necrosectomy.

Chapter 28: EUS-guided drainage of pelvic fluid collections

Figure 28.1 (A) Fluoroscopic image of the echoendoscope with coiled guidewire in a complex collection. Note the disorganized configuration of the guidewire. (B) Fluoroscopic image of the echoendoscope with a well-coiled guidewire in an uncomplicated pelvic fluid collection. (C) Fluoroscopic image at transluminal balloon dilation with demonstration of the “waist.” (D) Fluoroscopic image with balloon dilation revealing obliteration of the “waist.”

Figure 28.2 (a) Endoscopic view of a 0.035-inch guidewire entering through the mucosa into the collection, with discharge of purulent material into the colonic lumen. (b) Endoscopic image of balloon dilation revealing copious discharge of pus. (c) Endoscopic view of the fistula created by balloon dilation. (d) Endoscopic image of transcolonic stents with the pigtail in the colonic lumen.

Figure 28.3 CT images of a pelvic fluid collection (A) before and (B) after placement of transluminal stents.

Chapter 29: EUS hemostasis

Figure 29.1 EUS hemostasis of gastric varices with coils. (A) Endoscopic aspect before treatment. (B) Endoscopic aspect 1 month after treatment, visualizing coil extrusion. (C) EUS analysis before treatment. (D) EUS analysis 1 month after treatment, visualizing the trombo inside a varix (coils + cianoacrilate). (E) EUS Doppler analysis 1 month after treatment, confirming the absence of flux.