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EUS Provides New View of Pancreas

For patients with pancreatic tumors, clinical management has become increasingly complex, with the advances in surgical, oncologic, and endoscopic techniques. At NewYork-Presbyterian Hospital, endoscopic ultrasound (EUS) is not only vital to providing surgeons with crucial information regarding treatment options for patients with pancreatic diseases, but it is also expanding therapeutic options.

Endoscopic ultrasound of the pancreas: In patients with pancreatic cysts, EUS is used both to image the cyst for morphology and to aspirate fluid for analysis by cytology and chemistries.

Pancreatic cysts are increasingly identified and referred for evaluation. EUS is used both to image the cyst for morphology and to aspirate fluid for analysis by cytology and chemistries. In addition to routine studies, in borderline cases fluid can be sent for DNA analysis to determine a variety of features, including the DNA content and quality, the presence of K-ras mutations and the loss of heterozygosity, according to Peter D. Stevens, MD. The Hospital has established a database of all pancreatic cysts for ongoing study. "It's very important that we study these cysts over time so we can recognize their natural history," added Mark Pochapin, MD.

For inflammatory fluid collections such as pseudocysts and organized pancreatic necrosis, the use of EUS to guide endoscopic drainage makes it possible to drain most cysts directly into the GI tract without the need for surgery or external drainage catheters. Using similar techniques, EUS is being used to place stents directly from the stomach into the pancreatic duct or from the duodenum into the bile duct to provide drainage, according to Dr. Stevens. This procedure is being performed in patients whose anatomy is difficult because of the presence of a tumor and in those who have already undergone a resection such as a Whipple procedure.

EUS-guided therapeutic injection is finding increasing applications in the pancreas. The pain of some patients with advanced, unresectable pancreatic cancer can be managed with EUS-guided neurolysis of the celiac plexus. EUS is used to locate the celiac plexus and insert sclerosing agents, which ablate the nerve fibers and relieve pain, according to Dr. Schnoll-Sussman. Injection of other agents under EUS guidance is a possibility.

"It is my hope for the future that we move forward to inject new chemotherapeutic agents," added Dr. Pochapin.

EUS continues to play an essential role in diagnostic analysis. It is used to detect cancer in small pancreatic masses that are not revealed by CT. When other imaging modalities suggest the presence of a pancreatic mass, EUS has good negative predictive value, and if a mass is confirmed by EUS, a biopsy specimen can be simultaneously obtained.

In patients at high risk for pancreatic cancer because of familial clustering, EUS is used to detect the earliest indications of cancer. At NewYork-Presbyterian/Columbia University Medical Center, Harold Frucht, MD, serves as the principal investigator of a study examining a registry of high-risk patients. Dr. Schnoll-Sussman, meanwhile, uses EUS and other diagnostic/screening modalities as principal investigator of the NewYork-Presbyterian/Weill Cornell Medical Center registry on familial pancreatic cancer. EUS also assists in the diagnosis of chronic pancreatitis. In patients with gallstone pancreatitis, EUS can be used to confirm the presence of stones in the common bile duct or gallbladder.

"In many patients who have had pancreatitis of unknown etiology, a large proportion of them actually have stone disease," said Dr. Schnoll-Sussman. "With EUS, we have a much more sensitive modality to be able to look at the common bile duct or gallbladder and clarify the diagnosis."

John A. Chabot, MD, Director, Pancreas Center

In addition to its diagnostic and therapeutic roles, EUS provides surgeons with crucial information regarding pancreatic surgery and treatment. "It helps surgeons make decisions as to who should have surgery, and it helps us make decisions, for example, about whether we should be considering preoperative chemotherapy," said John Chabot, MD. "Years ago, often we didn't have a definitive diagnosis when performing pancreatic surgery."

Whereas other modalities such as CT and magnetic resonance imaging are used to stage disease in the vascular system, EUS has proved effective in clearly indicating vascular invasion. Many patients are found to have unresectable disease at EUS. With accurate staging, unnecessary exploratory surgery is prevented.

"The technique of EUS has been perfected to the point that we can localize tumors and determine whether there is vascular invasion with a high degree of accuracy. We can help the surgeons determine what type of surgery needs to be done," said Dr. Pochapin. Patients also benefit from the procedure. "The biggest value for patients is avoiding unnecessary surgery," said Dr. Stevens. "It's a devastating setback for the family and the patients when they wake up to find out they are unresectable. We try to avoid that at all costs."

In addition to preventing unnecessary surgery and the associated risks, EUS keeps patients with unresectable disease from being sidetracked from their definitive treatments of chemotherapy and radiation. Patients whose disease is found to be unresectable at EUS "are able to avoid the potential morbidity and risk of mortality associated with surgery," said Dr. Schnoll-Sussman.