CLAUDIO DE ANGELIS - Paolo BOCUS

IEC

ATLAS OF
ENDOSCOPIC
ULTRASOUND

EDIZIONI MINERVA MEDICA

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ABBREVIATIONS
AA = Ascending Aorta
AoA = Aortic Arch
AoV = Aortic Valve
AV = Ampulla Vateri
AzA = Azygous Arch
AzV = Azygous Vein
CA = Celiac Artery
CBD = Common Bile Duct
CC = Common Carotid Artery
CD = Cystic Duct
Con = Splenoportal Confluence
DA = Descending Aorta
DC = Diaphragmatic Crus
DM = Deep Mucosa
ES = External Anal Sphincter
Eso = Esophagus
GB = Gallbladder
GDA = Gastroduodenal Artery
HA = Hepatic Artery
HV = Hepatic Veins
ICA = Internal Carotid Artery
IIV = Internal Iliac Vessels
IJV = Internal Jugular Vein
IS = Internal Anal Sphincter
IV = Innominate Vein
IVC = Inferior Vena Cava
L = Lung
LA = Levator Ani
LA = Left Atrium
LAG = Left Adrenal Gland
LI = Liver
LK = Left kidney
LN = Lymph Node(s)
LRA = Left Renal Artery
LRV = Left Renal Vein
LV = Left Ventricle
MP = Muscularis Propria
MSB = Mainstem Bronchus

MU = Membranous Urethra
MV = Mitral Valve
O = Ovary
P = Prostate
PA = Pulmonary Artery
PB = Pancreatic Body
PD = Pancreatic Duct
PH = Pancreas Head
Pl = Pleura
PN = Pancreas Neck
PT = Pancreas Tail
PV = Portal Vein
RA = Right Atrium
RAG = Right Adrenal Gland
RK = Right Kidney
RV = Right Ventricle
SA = Splenic Artery
Sac = Sacrum
SC = Subclavian Artery
SeV = Seminal Vesicles
SM = Submucosa
SMA = Sup. Mesenteric Artery
SMV = Sup. Mesenteric Vein
Sp = Spine
Spl = Spleen
SV = Splenic Vein
SVC = Superior Vena Cava
T = Trachea
TD = Thoracic Duct
TG = Thymus Gland
Th = Thyroid
UB = Urinary Bladder
UP = Uncinate Process
Ur = Urethra
Ut = Uterus
V = Vagina
VP = Ventral Pancreas

ISBN: 978-88-7711-761-8
2013 EDIZIONI MINERVA MEDICA S.p.A. Corso Bramante 83/85 10126 Turin (Italy)
www.minervamedica.it / e-mail: minervamedica@minervamedica.it

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any
means.

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Preface

After the first pioneering studies in the 80s brought about by Giancarlo Caletti in Bologna, and by very
few other researchers in the world, EUS has gradually become a mainstay technique. It is now essential to the
clinical practice and the diagnostic and therapeutic work-up of many digestive disorders.
In particular, the last decade has witnessed the definitive consecration of EUS in almost all the main Italian
hospitals, where it has entered busy routine clinical practice together with several educational events and symposia, dedicated to spread the knowledge of its indications also to non-EUS users.
The Italian Club of Endosonography (IEC - Italian Endosonography Club) was founded in 2002 with the
aim of bringing together the Italian doctors, involved in EUS or willing to approach this technique, in order
to exchange views on EUS-related clinical issues, technical aspects, administrative issues and research projects.
Teaching of EUS was also included among the main aims of the club.
Through our association we also aim to promote EUS among colleagues who do not practice it personally
but nevertheless have to deal with it almost on a daily basis (such as internists, surgeons, oncologists), so that
they can refer their patients according to the most appropriate indications. Moreover, the IEC is constantly
striving to promote the utilization of EUS within hospitals, universities and other scientific organizations. The
IEC also promoted relationships and initiated collaboration with international EUS experts, some of which
are also among the contributors of this volume and with Clubs or EUS Groups of interest of other European
countries, by founding in 2003, the European Group for Endoscopic UltraSound (EGEUS).
IEC remains strongly committed to advancing and promoting EUS through education and training. So
the present atlas appears as a natural consequence of these premises and a continuation of the clubs educational
activities. The format of the book encompasses essentially bare EUS images with explicative legends, preceded
by just a more or less brief introduction to each chapter. The ratio images/text is all in favor of the former, collecting the most significant cases seen at our centers. In fact, all the IEC members have had the opportunity to
submit their own cases to the editors.
The readers will find here a collection of relevant images for the most common but also the less known or
even anecdotal pathologies studied by EUS. The atlas aims at providing a referral manual, which hopefully
will assist all the endosonographers with reference images for almost each pathological condition amenable to
be investigated by our fascinating technique.
We sincerely hope that this textbook will help in their daily practice current and future endosonographers,
at last leading to improvement in the practice of EUS and the care of our patients. In order to better achieve
these goals a unique collection of online EUS videos will be made available to our readers and it will be continuously updated and enriched with new contents.
While we do hope that the commitment and sacrifices bestowed for the realization of this atlas will be
appreciated, we wish you a good reading but mainly a good watching.
Claudio De Angelis - Paolo Bocus

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EDITORS
Claudio De A ngelis, MD
Paolo Bocus, MD

ASSOCIATES EDITORS
Thomas Togliani, MD
M auro Bruno, MD

Acknowledgements
We would like to thank our families, especially our spouses and our children,
for the long time taken away from them in completing this project and mainly
for their continuous support and encouragement, particularly in the most difficult
moments when we felt that we would not be able to successfully complete the work.
C. De Angelis, P. Bocus
T. Togliani, M. Bruno

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Authors and Contributors

Authors
M arco Bianchi
Unit of Gastroenterology and Hepatology, San Filippo Neri
Hospital, Rome, Italy
Paolo Bocus
High Technology Endoscopy Unit, Veneto Institute of Oncology, IRCCS, Padua, Italy
Giacomo Bonanno
Gastroenterology and Digestive Endoscopy Unit, Vittorio
Emanuele Hospital, Catania, Italy
M auro Bruno
GastroHepatology Department, Endoscopy and Endosono
graphy Center, Azienda Ospedaliera Citt della Salute e
della Scienza, University of Turin, Italy
Elisabetta Buscarini
Gastroenterology and Digestive Endoscopy Unit, Maggiore
Hospital, Crema, Italy
Giancarlo C aletti
Department of Gastroenterology, University of Bologna,
Hospital of Imola, Italy
R enato C annizzaro
Department of Gastroenterology and Oncology, Centro di
Riferimento Oncologico IRCCS, Aviano, Italy
Patrizia C arucci
GastroHepatology Department, Endoscopy and Endosono
graphy Center, Azienda Ospedaliera Citt della Salute e
della Scienza, University of Turin, Italy
Claudio De A ngelis
GastroHepatology Department, Endoscopy and Endosono
graphy Center, Azienda Ospedaliera Citt della Salute e
della Scienza, University of Turin, Italy
Leonardo De Luca
Gastrointestinal Unit, Pellegrini Hospital, Naples, Italy
C arlo Fabbri
Department of Surgery, Unit of Gastroenterology and Digestive Endoscopy, Hospital Bellaria-Maggiore, AUSL of
Bologna, Italy

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Telemaco Federici
Senior GI Consultant. Gastroenterology Unit, San Camillo-Forlanini Hospital, Rome, Italy
Pietro Fusaroli
Department of Gastroenterology, University of Bologna,
Hospital of Imola, Italy
M argaret M. Johnson
Division of Pulmonary Medicine, Mayo Clinic Jacksonville,
FL, USA
Philip E. Lowman
Division of Pulmonary Medicine, Mayo Clinic Jacksonville,
FL, USA
C aterina M archi
Azienda Ospedaliera Citt della Salute e della Scienza,
Department of Medical Sciences, University of Turin, Italy
Pietro M arone
Department of Endoscopic Imaging, Istituto dei Tumori
Fondazione G. Pascale, Naples, Italy
Vincenzo Napolitano
Department of General and Specialistic Surgery, Unit of
Surgical Endoscopy, Second University of Naples, Italy
Donatella Pacchioni
Azienda Ospedaliera Citt della Salute e della Scienza,
Department of Medical Sciences, University of Turin, Italy
A ntonio Pisani
Department of Gastroenterology, Policlinico University of
Bari, Italy
A nna M aria Polifemo
O.U. of Gastroenterology and Digestive Endoscopy Hospital
Bellaria-Maggiore Bologna, Italy
M assimo R aimondo
Division of Gastroenterology and Hepatology, Mayo Clinic
Jacksonville, Florida, USA
A nna Sapino
Azienda Ospedaliera Citt della Salute e della Scienza,
Department of Medical Sciences, University of Turin, Italy

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VI

IEC - ATLAS OF ENDOSCOPIC ULTRASOUND

Ilaria Tarantino
Gastroenterology and Digestive Endoscopy Unit, Mediterranean Institute for Transplantation and High Specialized
Therapy (ISMETT)/ University of Pittsburgh Medical Center in Italy, Palermo, Italy

Giorgio De Stefano
Department of Infectious Diseases and Interventional Ultrasound, Endosonography Center, AORM-Ospedali Dei
Colli - P.O. D. Cotugno, Naples, Italy

Thomas Togliani
Endoscopy Unit, Carlo Poma Hospital, Mantua, Italy

M ara Fornasarig
Department of Gastroenterology and Oncology, Centro di
Riferimento Oncologico IRCCS, Aviano, Italy

Michael Wallace
Division of Gastroenterology and Hepatology, Mayo Clinic
Jacksonville, FL, USA

A ldo Garbarini
Emergency Surgery Department, Digestive Endoscopy Center, Azienda Ospedaliera Citt della Salute e della Scienza,
University of Turin, Italy

Contributors

Stefania M aiero
Department of Gastroenterology and Oncology, Centro di
Riferimento Oncologico IRCCS, Aviano, Italy

Daniela A ssisi
O.U. of Gastroenterology and Digestive Endoscopy. National Institute of Tumors, Regina Elena Institute, Rome, Italy

M arcello M artini
GastroHepatology Department, Endoscopy and Endosono
graphy Center, Azienda Ospedaliera Citt della Salute e
della Scienza, University of Turin, Italy

Giorgio Battaglia
High Technology Endoscopy Unit, Veneto Institute of Oncology, IRCCS, Padua, Italy

Emanuele Meroni
Endoscopic Unit, Fondazione IRCCS Istituto Nazionale
Tumori, Milan, Italy

Rosario Francesco Brizzi

GastroHepatology Department, Endoscopy and Endosono
graphy Center, Azienda Ospedaliera Citt della Salute e
della Scienza, University of Turin, Italy

Selene Francesca M anfr

GastroHepatology Department, Endoscopy and Endosono
graphy Center, Azienda Ospedaliera Citt della Salute e
della Scienza, University of Turin, Italy

Vincenzo C anzonieri
Department of Pathology, Centro di Riferimento Oncologico IRCCS, Aviano, Italy

R inaldo Pellicano
GastroHepatology Department, Azienda Ospedaliera Citt
della Salute e della Scienza, University of Turin, Italy

Emanuele Dabizzi
Gastroenterology and Digestive Endoscopy Unit, Sanremo
Hospital, ASL1 Imperiese, Italy

Dario R eggio
Liver Transplantation Center, Azienda Ospedaliera Citt
della Salute e della Scienza, University of Turin, Italy

M arco Daperno
Gastroenterology Unit, Mauriziano Hospital, Turin, Italy

Rodolfo Rocca
Gastroenterology Unit, Mauriziano Hospital, Turin, Italy

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Contents

Preface.......................................................................................................................................................................... III
Authors and Contributors......................................................................................................................................... V
1 EUS HISTORY............................................................................................................................................................1

C. De Angelis, G. Caletti

2 Instruments and Accessories.....................................................................................................................9

M. Bruno, A.M. Polifemo, C. De Angelis

3 EUS ROOM SETUP................................................................................................................................................ 21

P. Fusaroli

4 Normal GI wall and imaging artifacts.............................................................................................. 27

M. Bianchi, A. Pisani
With the collaboration of: C. De Angelis

5 Esophagus.......................................................................................................................................................... 33

P. Bocus, T. Togliani

6 MEDIASTINUM...................................................................................................................................................... 57

M. Wallace, V. Napolitano

Endobronchial ultrasound...................................................................................................................................... 69

P.E. Lowman, M.M. Johnson

7 STOMACH AND DUODENUM............................................................................................................................. 73

R. Cannizzaro, P. Marone
With the collaboration of: M. Fornasarig, S. Maiero, V. Canzonieri

8 Pancreas............................................................................................................................................................. 87

C. De Angelis, M. Raimondo
With the collaboration of: S.F. Manfr, R. Pellicano, E. Dabizzi

9 BILE DUCTS.......................................................................................................................................................... 131

E. Buscarini, I. Tarantino

10 IDUS and EDUS.................................................................................................................................................. 141

M. Bruno, C. De Angelis
With the collaboration of: D. Reggio, A. Garbarini

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11 ANORECTUM AND COLON............................................................................................................................... 141

T. Federici, G. Bonanno
With the collaboration of: D. Assisi

12 Other Organs................................................................................................................................................. 167

P. Carucci, L. De Luca

13 Therapeutic EUS and new applications............................................................................................. 181

C. De Angelis, C. Fabbri, P. Fusaroli

With the collaboration of: D. Reggio, S.F. Manfr. R.F. Brizzi, A. Garbarini, R. Rocca

14 THE ROLE OF CYTOPATHOLOGY.....................................................................................................................207

D. Pacchioni, C. Marchi, A. Sapino

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Esophagus
P. Bocus, T. Togliani

In the late 80s EUS has been proposed as a new

method to study the gastroesophageal wall and biliopancreatic district, and it soon demonstrated its potential in the evaluation of some esophageal diseases;
adenocarcinoma and squamous cell carcinoma are
the main indications for esophageal EUS, although
subepithelial lesions such as Abrikosoff tumors, leiomyomas, varices, cysts can be easily displayed.
Esophageal cancer is a common tumor and its
incidence is rising in western countries. As far as patients prognosis and cost-effectiveness of therapeutic
protocols are strongly related to tumor staging, many
efforts have been made in the last three decades to
improve the diagnostic techniques.
EUS showed the best accuracy for locoregional
staging of esophageal cancer, as it can precisely determine the degree of parietal infiltration (T parameter
of TNM classification); it also provides a good visualization of periesophageal and celiac lymph nodes,
that can be sampled by means of FNA (fine needle
aspiration) in the suspect of nodal metastasis (N parameter of TNM classification). Some recent software applications coupled to EUS miniprobes allow
the three dimensional reconstruction, that permits a
better spatial visualization of the lesions, the inner
superficial rendering and the volume measurements.
For a complete distant staging (M parameter of TNM
classification) a thoraco-abdominal CT/PET scan is
mandatory.
In the last years many different multimodal therapeutic approaches have been proposed, according to
the initial staging and the surgical risk of the patient:
endoscopic resection, surgery, chemo-radiation, adjuvant and neoadjuvant therapy, endoscopic stenting.
The introduction of new neoadjuvant protocols needs
tools able to confirm, before surgery, if a real downstaging has occurred, but traditional radiology seems
to have a limited accuracy in this field. Few data
in the literature are available on the role of EUS in
the staging of esophageal cancer after neoadjuvant

ATLANTE ENDOSCOPIA IMPAGINATO.indd 33

therapy; parietal fibrosis of the esophageal wall and

the inflammatory enlargement of periesophageal
lymph nodes make EUS (like all the other imaging
techniques) less accurate in this particular situation.
To improve EUS accuracy in the evaluation of
lymph nodes two promising innovations have been
introduced: contrast enhanced EUS and EUS-elastography. These new techniques could find interesting
applications in the study of esophageal cancer, by improving the detection of malignancy and targeting
FNA in lymph nodes with suspicion of metastasis.
The examination of the esophagus using a radial probe, which is the most frequently used for
esophageal tumor staging, is one of the easiest EUS
procedures to perform, since the esophagus is essentially a straight tube requiring little manipulation of the echoendoscope. However, examination
of the esophagus cannot be competently performed
without a strong knowledge of the spatial anatomy of
the mediastinum. EUS staging of esophageal cancer
is rarely performed with linear echoendoscopes,
which imposes a multi-step 360 degrees rotation to
obtain a complete circumferential image of the entire esophageal wall; on the contrary, these probes are
crucial for a correct lymph node assessment in the
suspect of node metastasis. Superficial small lesions
or tight neoplastic stenoses can be studied with echographic miniprobes through the operative channel of
a normal gastroscope.
In case of tumor staging the maximum depth
of wall infiltration, the presence of extraesophageal
infiltration, the upper and lower edges of the lesion,
and the presence of celiac or mediastinal lymph node
metastases should be described in the report.
The following is a brief description of the anatomical landmarks that must be recognized in a standard
radial examination of the esophagus.

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TNM classification of esophageal cancer (7th edition).

Ta

Infiltration of the lamina propria

T1b

Infiltration of the submucosa

T2

Infiltration of the muscularis propria

T3

Infiltration of the adventitia

T4a

Infiltration of pleura, pericardium, diaphragm

T4b

Infiltration of aorta, vertrebral body, trachea

N0

No regional lymph node metastasis

N1

1-2 regional lymph nodes

N2

3-6 regional lymph nodes

N3

7 or more regional lymph nodes

M1

Distant metastases

Once the radial scanning echoendoscope is

introduced into the esophagus, it should be advanced slowly into the stomach just below the gastroesophageal junction, which is usually approximately 40 cm from the incisors. At the beginning
of EUS scanning, the aorta should be positioned at
five oclock; the image can be adjusted by rotating
the aorta (either manually or electronically) to the
correct anatomical position. With this orientation,
like in CT scan images, the anterior region of the
patient is displayed in the upper part of the screen,
the posterior in the lower, the left is on the right,
the right is on the left.
With the scope in the stomach, just above the
neck of the pancreas, the celiac axis and its main
branches (the hepatic, the splenic and the left gastric
arteries) can be visualized coming out from the aorta
(which is located at 5 oclock position). Between 6
oclock and 12 oclock position the left lobe of the
liver, the inferior vena cava and hepatic veins can be
seen.
The five-layers wall pattern of the esophagus
comes into view as the echoendoscope is slowly withdrawn cephalad; the esophageal wall, whose normal
thickness is 3 to 4 mm, is gradually explored up to
the upper esophageal sphincter. During withdrawal
of the scope in the thorax the left atrium, the mitral
valve and the pulmonary veins will come into view
between 12 oclock and 3 oclock position. Upon further interrogation of this area, the left pulmonary artery can be seen. The left ventricle, right atrium, and
right ventricle are more difficult to image and may
not be seen distinctly in all cases.
As the echoendoscope is further withdrawn
the left lung will appear at the 2 oclock position

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while the right lung can be seen in the 9 oclock

location. The lungs have a unique EUS image of
hyperechoic rings that represents air within the
lung parenchyma. Further withdrawal of the instrument will image structures surrounding the
mid-esophagus.
Keeping the aorta in the 5 oclock position, the
spine is visualized at the 7 oclock position. The
azygos vein will be seen to the right of the aorta and
will move upwards along the right lung. The thoracic duct will appear as a small, round anechoic dot
between the azygos vein and the aorta. As the scope
is further withdrawn, the azygos vein will be seen
moving forward and merging into the superior vena
cava. The aortic arch will be noted on the left as it
arises from the aorta and can be seen curving towards the right. Also, the left and right bronchi can
be seen, as small hyperechoic rings that represent cartilage and air artifacts, at the 1 oclock and 11 oclock
positions, respectively.
As the echoendoscope is withdrawn, the left and
right bronchi can be observed forming the trachea
at the level of the carina, which is usually about 26
to 28 cm from the incisors. Just below this region
lies the subcarina region, where lymph nodes can frequently be seen. These lymph nodes characteristically
appear as small hyperechoic structures with indistinct
margins and ovalar or triangular shapes. In cases of
malignant nodes an hypoechoic pattern with more
distinct and sharper borders and a round shape are
typical.
The proximal or cervical esophagus is entered
upon further withdrawal of the instrument. In this
position, the blood vessels of the neck come into
view above the aortic arch. The left subclavian artery can be seen posteriorly while the left common
carotid artery and sometimes the brachiocephalic
trunk are seen anteriorly. The location of the trachea in the mid-plane causes air artifacts, which can
hamper imaging at this station. In the neck laterally to the esophagus the right and the left internal
carotid arteries and internal jugular vein are clearly
displayed. In some patients, the thyroid gland can
be seen mainly its left lobe, appearing as a hypoisoechoic structure laterally to the crycoid echos. A
further withdrawal makes the instrument pass the
upper esophageal sphincter (approximately 18 cm
from the incisors).
During the whole exam overinflation of the balloon, oblique scanning of the esophageal wall and
lack of complete air suction should be avoided since
they can cause imaging artifacts and misinterpretations of the images.

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5Esophagus

35

Figure 5.1Esophagus, normal wall, Olympus radial

electronic GF UE 160 (7.5 MHz): note the normal 5-layers
echostructure of the esophageal wall.

Figure 5.2Esophagus, normal wall, Olympus radial mechanical GF UM 160 (20 MHz): note the normal 7-layers
echostructure of the esophageal wall which is visible at high
frequencies.

Figure 5.3Esophagus, T1a N0 adenocarcinoma, Olympus

miniprobe (20 MHz): a small isoechoic thickening (3 mm) of
the mucosa, with preservation of the other layers is clearly visible.

Figure 5.4Esophagus, T1a N0 adenocarcinoma, Olympus

radial mechanical UMQ130 probe with the water filled balloon (20 MHz): note a small hypoechoic thickening (3 mm) of
the mucosa, with preservation of the other layers.

Figure 5.5Esophagus, T1a N0 adenocarcinoma, Olympus

radial mechanical UMQ130 probe (20 MHz): note a hypoechoic thickening (6 mm) of the mucosa, with preservation of
the other layers.

Figure 5.6Esophagus, small adenocarcinoma in a segment

of Barretts metaplasia, endoscopic view.

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IEC - ATLAS OF ENDOSCOPIC ULTRASOUND

Figure 5.7Esophagus, small adenocarcinoma in a segment

of Barretts metaplasia (same patient), NBI view.

Figure 5.8Esophagus, T1a N0 adenocarcinoma (same patient), Olympus radial mechanical UM160 probe (20 MHz):
note a small hypoechoic thickening (3 mm) of the mucosa,
with preservation of the other layers.

Figure 5.9Esophagus, specimen from endoscopic mucosectomy (same patient); pathology confirmed EUS staging.

Figure 5.10Esophagus, T1a N0 adenocarcinoma, Aloka

miniprobe (15 MHz): note a small hypoechoic thickening (3
mm) of the mucosa, with preservation of the other layers

Figure 5.11Esophagus, small adenocarcinoma above the

cardia, Olympus GF 140.

ATLANTE ENDOSCOPIA IMPAGINATO.indd 36

Figure 5.12Esophagus, T1b N0 adenocarcinoma (same

patient), Olympus radial electronic UE 160 probe (7.5 MHz):
note a hypoechoic thickening (12 x 8 mm) of the mucosa, with
initial infiltration of the submucosa; muscularis propria and
adventitia are preserved.

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5Esophagus

37

Figure 5.13Esophagus, T2 N0 adenocarcinoma, Olympus

radial mechanical UM 160 probe (20 MHz): note a hypoechoic
circumferential thickening (13 mm) of the esophageal wall, with
fusion of mucosa, submucosa and muscularis propria; the adventitia is preserved; no periesophageal lymph nodes are visible.

Figure 5.14Esophagus, T2 N0 adenocarcinoma, Olympus

radial mechanical UM 160 probe (7.5 MHz): note a hypo-isoechoic circumferential thickening of the esophageal wall, with
fusion of mucosa, submucosa and muscularis propria; the adventitia is preserved; no periesophageal lymph nodes are visible.

Figure 5.15Esophagus, T2 N0 adenocarcinoma, Olympus

radial electronic UE 160 probe (6 MHz): note a hypoechoic
circumferential thickening of the esophageal wall, with partial
fusion of mucosa, submucosa and muscularis propria; the adventitia is preserved; no periesophageal lymph nodes are visible;
the echographic layers, where no fusion occurs, are measured.

Figure 5.16Esophagus, T2 N1 adenocarcinoma, Olympus

radial mechanical UM 160 probe (7.5 MHz): note a hypo-isoechoic circumferential thickening of the esophageal wall, with
fusion of mucosa, submucosa and muscularis propria; the adventitia is preserved; two round isoechoic 15 mm (pathologic)
and 5 mm periesophageal lymph nodes are visible.

Figure 5.17Esophagus, T2 NX adenocarcinoma, Olympus

radial electronic UE 160 (10 MHz): note a hypo-isoechoic
semi-circumferential thickening of the esophageal wall, with
fusion of mucosa, submucosa and muscularis propria; the adventitia is preserved; a round hypoechoic 6 x 3 mm periesophageal lymph node is visible.

Figure 5.18Esophagus, T2 adenocarcinoma, 3D volume

reconstruction using Olympus dual planner mini-probe (UMDP12-25R) and 3D upgrade kit (MAJ-1330).

ATLANTE ENDOSCOPIA IMPAGINATO.indd 37

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Figure 5.19Esophagus, T3 N0 adenocarcinoma, Olympus

radial mechanical UM 160 probe (20 MHz): note a hypoechoic semi-circumferential thickening (14 mm) of the esophageal wall, with fusion of mucosa, submucosa and muscularis
propria; the adventitia is irregular; no periesophageal lymph
nodes are visible.

Figure 5.20Esophagus, T3 N0 adenocarcinoma, Olympus

radial electronic UE 160 probe (5 MHz): note a severe hypoechoic thickening (27 mm) of the esophageal wall that involves
3/4 of the circumference of the esophagus, with fusion of mucosa, submucosa and muscularis propria; the adventitia is irregular; no periesophageal lymph nodes are visible.

Figure 5.21Esophagus, T3 N0 adenocarcinoma, Olympus

radial mechanical UM 160 probe (12 MHz): note a moderate hypoechoic semi-circumferential thickening (8 mm) of the esophageal wall, with fusion of mucosa, submucosa and muscularis propria; the adventitia is interrupted by a single thin pseudopodium
of tumoral tissue; no periesophageal lymph nodes are visible.

Figure 5.22Esophagus, T3 N1 adenocarcinoma, Olympus

radial mechanical MH 908 blind Probe (7.5 MHz): note a
hypoechoic circumferential thickening of the esophageal wall,
with fusion of mucosa, submucosa and muscularis propria; the
adventitia is interrupted; an ovalar hypoechoic 13 mm (pathologic) periesophageal lymph node is visible.

Ln

Ln

Ln

Figure 5.23Esophagus, T3 N1 adenocarcinoma, Olympus radial mechanical UM 160 probe (5 MHz): note a severe hypoechoic semi-circumferential thickening (25 mm) of
the esophageal wall, with fusion of mucosa, submucosa and
muscularis propria; the adventitia is interrupted by tumoral
pseudopodia; a ovalar hypoechoic 14 mm (pathologic) periesophageal lymph node is visible.

ATLANTE ENDOSCOPIA IMPAGINATO.indd 38

Figure 5.24Esophagus, T3 N1 adenocarcinoma, Aloka

radial mechanical miniprobe (15 MHz): note a stenotic hypoechoic circumferential thickening of the esophageal wall, with
fusion of mucosa, submucosa and muscularis propria; the adventitia is irregular; two ovalar hypoechoic 10 mm periesophageal lymph node are visible.

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5Esophagus

Figure 5.25Esophagus, T3 N1 adenocarcinoma (same patient): endoscopic view of the tumoral mass of the lower esophagus.

39

Figure 5.26Esophagus, T3 adenocarcinoma, Olympus radial

mechanical miniprobe (12 MHz); 3D reconstruction with area
and volume calculation: note a stenotic hypoechoic circumferential thickening of the esophageal wall, with fusion of mucosa,
submucosa and muscularis propria; the adventitia is irregular.

DA

Figure 5.27Esophagus, T4 N0 adenocarcinoma, Olympus

radial mechanical UM 160 probe (7.5 MHz): note a hypoechoic circumferential thickening (up to 17 mm) of the esophageal wall, with fusion of all the layers and infiltration of the
right pleura; no periesophageal lymph nodes are visible.

Figure 5.28Esophagus, T4 N0 adenocarcinoma, Olympus

radial mechanical UM 130 probe (7.5 MHz): note a hypoechoic circumferential thickening (up to 25 mm) of the esophageal wall, with fusion of all the layers and infiltration of the trachea and right lung; no periesophageal lymph nodes are visible.

Li

DA

Figure 5.29Esophagus, T4 N0 adenocarcinoma, Olympus

radial mechanical UM 130 probe (7.5 MHz): note an isoechoic
3 cm mass of the posterior esophageal wall with infiltration
of the descending aorta; no periesophageal lymph nodes are
visible.

ATLANTE ENDOSCOPIA IMPAGINATO.indd 39

Figure 5.30Cardia, T4 N0 adenocarcinoma, Olympus radial electronic UE 160 probe (7.5 MHz): note a hypoechoic
circumferential thickening of the GI wall with infiltration of
the left diaphragmatic pillar.

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