Transgastric endoscopic ultrasound (EUS) guided fine needle aspiration (FNA) in patients with esophageal narrowing using the ultrasonic bronchovideoscope (2024)

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Summary

Introduction

Endoscopic ultrasound (EUS) is a well-established technique to evaluate mediastinal disease. EBUS has a burgeoning role in the characterization of benign and malignant diseases of the thorax. In this study, we evaluate the use of the EBUS scope to characterize abdominal lesions in patients who are ineligible for EUS using the echoendoscope due to esophageal stricture. The EBUS scope was chosen given that the diameter of the echoendoscope is significantly smaller than that of the EUS scope, but it retains full optical and sonographic imaging potential as well as the ability to perform fine needle aspiration (FNA).

Case 1

A 67-year-old woman with severe chronic obstructive pulmonary disease (COPD) presented with dysphagia. Endoscopy with biopsies confirmed squamous cell carcinoma. Positron emission tomography (PET) revealed suspicious peri-pancreatic lymph nodes, thus she was referred for EUS. A high-grade stricture prevented passage of the linear echoendoscope (GF-UC 140P; Olympus America, Center Valley, PA, USA). The smaller diameter EBUS scope (BF-UC 160F-OL8; Olympus America) was passed beyond the narrowed region. Evaluation revealed a hypoechoic lymph node in the celiac axis region measuring 33 mm in diameter. EBUS-guided transgastric FNA with a 22-gauge needle (NA-201SX-4022; Olympus America) confirmed the presence of squamous cell cancer (Fig. 1). A fully covered ALIMAXX-E esophageal stent (Alveolus, Charlotte, NC, USA) was placed in the same session to ameliorate her dysphagia for palliative purposes.

Case 2

A 67-year-old woman with COPD and recently diagnosed colorectal cancer was found to have a lung mass. PET-computed tomography (CT) revealed hypermetabolic mediastinal and mesenteric lymph nodes. Combined EUS and EBUS staging was planned. The EBUS scope was introduced into the bronchial system. However, the patient did not tolerate the procedure because of hypoxia and refractory coughing. The EBUS scope was passed into the stomach to evaluate the mesenteric lymph nodes. These were not appreciated but several round ‘cannonball’ lesions were delineated in the liver (Fig. 2). Transgastric FNA of the liver lesion performed with the 22-gauge needle revealed adenocarcinoma, immunostains confirmed colonic origin. She is being treated with additional chemotherapy.

Case 3

A 74-year-old was found to have a small lung nodule that was confirmed to be cancer by CT-guided biopsy. Seven years prior, he had been successfully treated for stage IIIB non-small cell lung cancer with chemotherapy and radiation. EUS was performed to evaluate a suspicious left adrenal lesion. A high-grade radiation-induced stricture in the mid-esophagus could not be crossed using the echoendoscope. The EBUS scope was easily passed beyond the obstruction and the 9 mm left adrenal nodule was identified. Transgastric FNA yielded adequate benign adrenal tissue. Stereotactic radiosurgery of the lung nodule was performed, and no changes in the adrenal lesion have been appreciated at 6 months.

Case 4

An 80-year-old woman presented with abdominal pain and nausea. PET-CT scan revealed a hypermetabolic 3 cm retroperitoneal mass as well as a hypermetabolic subcarinal lymph node. There was difficulty passing the linear array echoendoscope because of a proximal esophageal stricture associated with a Zenker’s diverticulum. The EBUS scope was used to traverse the markedly narrowed region, and the heterogeneous lesion seen on CT scan was identified. However, intervening vasculature precluded FNA. A round, hypoechoic subcarinal lymph node corresponding to the hypermetabolic subcarinal lesion was recognized and a transesophageal FNA was performed yielding benign tissue. The lesion has been stable at 4 months follow-up.

Discussion

During the past 15 years, the use of EUS to evaluate mediastinal pathology has driven an overlap in the fields of gastroenterology and pulmonology. Recently, EBUS has been used to further optimize the evaluation of patients with thoracic disease. In this article, we report the use of EBUS scope to evaluate targets in cases where esophageal narrowing limited the reach of EUS. Our work emphasizes the need to embrace new technologies in order to optimize the minimally invasive care of patients.

An important limitation of EUS is esophageal obstruction, and EBUS represents an important tool to address this problem. Tumor staging and evaluation of the celiac axis is potentially limited in nearly one-third of patients with esophageal cancer because of strictures.1 Early studies reported high complication rates when aggressive dilatation was used to facilitate echoendoscope passage.2 More cautious dilatation approaches and more facile instruments has improved our capability, though this continues to be a challenging problem for the endosonographer with a low yet significant perforation rate.1

A novel approach is to use scopes with a smaller diameter, which can be easily passed beyond narrowed regions. One alternative is the 7.5 MHz Slim Probe (Olympus/KeyMed, Southend-on-Sea, UK), which has a diameter of 7.9 mm. Prospective studies demonstrate that the use of the miniprobe in combination with the conventional echoendoscope may increase the ability of complete staging from 78% using conventional endoscope alone to 95%.3 Nonetheless, the miniprobe does not have an optical component and is available in very few centers. In comparison endobronchial ultrasound scope which has a diameter of 6.9 mm provides both optical and ultrasound images and is now available in most tertiary care centers with interventional pulmonology and thoracic surgical teams.

Shortly after its introduction, EUS-FNA was found to be highly accurate in the evaluation of mediastinal lymph nodes.4 In a large prospective cohort of patients with suspected or confirmed lung cancer with mediastinal lymphadenopathy, EUS-FNA confirmed advanced disease in 70%, obviating the need for mediastinoscopy or exploratory thoracotomy.5 While EUS is effective in the evaluation of the posterior mediastinum, its performance is more limited in the anterior mediastinum. During the past decade, EBUS has proven to be effective in the assessment of this region as well as the hilum and peripheral lung.6,7

Previous reports on the role of EBUS in gastrointestinal (GI) disease are primarily concerned with diagnostic EBUS to study esophageal cancer invasion of the mediastinum.8 Gupta et al. have reported the only prior study in which the EBUS scope was introduced into the GI lumen to evaluate intra-abdominal lesions.9 In this study, we report an expansion of the anatomic range and indications for EBUS technology. We report the first use of the EBUS scope to biopsy a celiac axis lymph node in a patient with esophageal cancer, thus upstaging the tumor to M1a. Additionally, we report the initial use of the EBUS scope to evaluate for distant metastasis, the adrenal gland, in a patient with lung cancer. In these cases, high-grade strictures made the use of the GI-designated echoendoscope imprudent, if not impossible. In this series, there were variable causes for esophageal narrowing including squamous cell malignancy, Zenker’s associated narrowing, and radiation. One limitation of the EBUS scope is that it does not permit air insufflation, which could theoretically increase the risk of esophageal perforation. In order to minimize this possibility, we advanced the scope only when adequate residual lumen could be centered immediately ahead of the instrument, and when no resistance to scope passage was encountered.

In a study of combined endoscopic staging for lung cancer, EUS and EBUS compensated for deficits in the other modality, yielding an overall accuracy of 100%.10 Our work emphasizes that patients with esophageal strictures represent another arena where EUS and EBUS may be complementary. All procedures were performed by an interventionalist (ME) who is expert in both EUS and EBUS. As developments in the field of lung cancer staging and our current project demonstrate, it is imperative that interventional endoscopists have exposure to both EBUS and EUS in order to recognize their potential indications.

Conclusion

Esophageal strictures have been a major impediment to the use of EUS. We have demonstrated that the smaller diameter endobronchial ultrasound scope has the potential to evaluate a broad range of anatomic regions for diverse indications in patients who would otherwise be ineligible for requisite endosonographic evaluation due to esophageal narrowing. This work underscores the need for the interventional endoscopists to understand the uses of EBUS technology as a valuable addition to the currently available armamentarium for performing EUS-FNA.

References

© 2011 International Life Sciences Institute

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