Endoscopic ultrasonography: Staging and therapeutic interventions

Abstract

Pancreatic cancer (PC) continues to vex and frustrate clinicians largely due to their inability to impact this sinister disease, which is often metastatic upon presentation. Endoscopic ultrasound (EUS) has rapidly cemented its role in the armamentarium of diagnostic tools available for accurate staging of PC. Initial euphoria touting EUS’ superiority in staging accuracy for EUS was soon met by the stark reality that EUS was no better than the latest cross-sectional imaging available for assessing vascular invasion. Endosonographers recommend that EUS should be performed when no detectable mass lesion is identified on CT in the face of clinical suspicion of PC. Patients and clinicians should take solace when EUS fails to detect a pancreatic mass as the likelihood of a pancreatic cancer is near zero. Contrast enhancement, sonoelastography, and confocal laser endomicroscopy represent few extensions of EUS in the ongoing quest to differentiate benign from malignant masses. The unlimited therapeutic potential of EUS is just now being realized. EUS has been used to access the bile and/or pancreatic duct to help relieve malignant biliary obstruction when ERCP has been unsuccessful or in the setting of altered anatomy. Initial reports of EUS-directed fiducial placement and/or direct intratumoral injection offer hope as a combined partner to conventional treatment for attacking and dissolving tumors. Finally, EUS-guided celiac plexus neurolysis allows ablation of the ganglion to relieve the crippling pain encountered by our patients.