EUS rectal CA staging

Jonathan Myers, DO Eugene Gastroenterology

Consultants

Objectives

• Recognize indications for rectal endoscopic ultrasound (EUS)

• Familiarize common structures and anatomy for rectal EUS

• Understanding rectal cancer staging via rectal EUS

• 63 yo Caucasian male presents with hematochezia. Pt denies f/c/n/v/d/constipation/melena. Pt reports 30lb wt loss, decreased energy, fatigue.

• PMHX: HTN, dyslipidemia, GERD • PSHX: none • MEDS: HCTZ, zocor, OTC omeprazole • SHX: 1 ppd/35 years, occasional ETOH • FHX: no malignancies

LABS

TP-

ALB-

TB-

DB-

AP-

AST-

ALT-

136

3.8

101

29

9

1

86

22.5

7.3

6.5

220

8 4.3 1.2 0.3 77 23 24

MCV – 61.2

RDW – 20.8

Fe – 11

TIBC – 405

Fe Sat – 3 %

Ferritin - 4

• Colonoscopy- large friable mass at in rectum – Biopsies -

adenocarcinoma

• NOW WHAT???

Staging

1. CT scan chest/abdomen/pelvis – Do this first…if lung mass(higher likelihood as

rectal CA goes to lung due to rectal blood supply), liver mass, pelvic mass…then you are staged already

2. Then….if CT scan negative - EUS

But first.... a little more about colorectal cancer

Colorectal Cancer

• 5-6% lifetime risk of colorectal cancer • 3rd most commonly diagnosed cancer • 3rd leading cause of cancer deaths male

and female • 72% colon cancer with 28% rectal cancer

split • 90% of CRC diagnosed age > 50 • 94% of deaths due to CRC age > 50

Colorectal Cancer Oregon

American Cancer Society. Colorectal Cancer Facts & Figures 2011-2013. Atlanta: American Cancer Society, 2011.

• Incidence – Non-Hispanic

• Men 51.5/100,000 • Women 39.2/100,000

– African American • Men 51/100,000 • Women 43/100,000

• Mortality – Non-Hispanic

• Men 19/100,000 • Women 15/100,000

– Data not available for African-American mortality due to < 25 cases or deaths

Awareness • The level of awareness among non-

gastroenterologists of the indications for EUS is unknown. This study assessed knowledge of the indications and the utility of EUS among gastroenterologists and non-gastroenterologists in a large multispecialty academic practice.

• Knowledge of appropriate indications was highest among gastroenterologists (84.3%) compared with internists (68.9%), non-gastroenterologist specialists (65.4%), and surgeons (65.3%) (p < 0.0001)

Yosuf T, Harewood GC, et al. Knowledge of indications for EUS among gastroenterologists and non-gastroenterologists. Gastrointestinal Endoscopy. 60(4):575-9, 2004 Oct

EUS-Indications 1. Staging of esophageal, gastric and rectal cancer 2. Evaluation of abnormalities of the gastrointestinal

wall or adjacent structures (submucosal masses, extrinsic compression)

3. Evaluation of thickened gastric folds 4. Diagnosis (FNA) and staging of pancreatic

cancer 5. Evaluation of pancreatic abnormalities

(suspected masses, cystic lesions including pseudocysts, suspected chronic pancreatitis)

EUS-Indications 6. Staging of ampullary neoplasms 7. Diagnosis and staging of cholangiocarcinoma 8. Evaluation of suspected choledocholithiasis 9. Celiac plexus neurolysis for chronic pain due to

intra-abdominal malignancy or chronic pancreatitis

10. Evaluation of fecal incontinence with endo-anal ultrasound

11. Therapeutic intervention for pancreatic pseudocyst drainage

Type of EUS Radial Echoendoscope Curvilinear (linear)

Echoendoscope

Electronic Radial Array Imaging

Radial Image in rectum Radial Image in stomach

Radial Array Imaging

Advantages: • 360 view • Mucosal cross-

sectional view for easier T-staging

Disadvantages: • No FNA/therapeutic

capabilities • Difficult to learn

Linear Imaging: Pancreatic Mass Example

Curvilinear echoendoscope

Curvilinear echoendoscope

Linear Array Imaging

Advantages: • Better resolution • Fine needle aspiration

(FNA)

Disadvantages: • Difficult to learn • Indirect anatomical

correlation

Mucosal layers

Mucosa

Muscularis mucosa

Submucosa

Muscularis propria

Serosa

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&docid=Q0V3S_s5OKj2nM&tbnid=lnXJNWXvu9OAfM:&ved=0CAUQjRw&url=http://www.coloncarcinoma.org/causes/&ei=1PV7UYueMarjiwKbqYEg&bvm=bv.45645796,d.cGE&psig=AFQjCNH5ja2epfy7UMNIOpb03RWxcpRt5A&ust=1367164616591919

• Why does it matter? – Current National Comprehensive Cancer

Network (NCCN) guidelines for Preoperative chemotherapy/radiation therapy

• T3-T4 mucosal staging • N1-N2 disease

EUS in rectal cancer

WHAT STAGE?

T2 – invades into muscularis propria

WHAT STAGE?

T3 – invades through muscularis propria

WHAT STAGE?

T1 – contained within submucosal and muscularis mucosa

WHAT STAGE?

T4 – invades into another organ - prostate

Summary

• Safe – same risk as flexible sigmoidoscopy

• Accurate

• Critical in determining effective treatment plan due to T and N staging