Clinical Impact - mafservizi.edinf.commafservizi.edinf.com/CMS/images/stories/EGEUS_2007_ppt/Sala500/... · Clinical Impact Giancarlo Caletti Gastroenterologia Universit à di Bologna

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Endoscopic Ultrasonography 2007Endoscopic Ultrasonography 2007Endoscopic Ultrasonography 2007

ClinicalClinical ImpactImpact

Giancarlo CalettiGiancarlo Caletti

Gastroenterologia UniversitGastroenterologia Universitàà di Bolognadi Bologna

AUSL di AUSL di ImolaImola, Castel S. Pietro , Castel S. Pietro TermeTerme(BO)(BO)

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Diagnosis of Diagnosis of SubmucosalSubmucosalTumors (SMT)Tumors (SMT)

Staging of Staging of NeoplasmsNeoplasms

Evaluation of Evaluation of PancreatoPancreato--BiliaryBiliary RegionRegion

Therapeutic applications ??Therapeutic applications ??

IndicationsIndications

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Staging of neoplasmsStaging of neoplasmsEsophageal cancerEsophageal cancerGastric lymphomaGastric lymphomaGastric cancerGastric cancerNon small cell lung cancerNon small cell lung cancerRectal cancerRectal cancer

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Staging of neoplasmsStaging of neoplasmsEsophageal cancerEsophageal cancerExtremely useful for stagingExtremely useful for stagingand triage the initial therapy and triage the initial therapy

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4/4 (100%)4/4 (100%)NumberNumber of EUS FNA of EUS FNA leadingleading toto management management changechange

ImagingImaging and/or and/or endoscopicendoscopic followfollow--upup toto clinicalclinical followfollow--upup (n=3)(n=3)

SurgerySurgery toto imagingimaging and/or and/or endoscopicendoscopic followfollow--upup (n=1)(n=1)

SurgerySurgery toto radiationradiation and/or and/or chemotherapychemotherapy (n=3)(n=3)

7/12 (58%)7/12 (58%)LessLess complexcomplex

ImagingImaging followfollow--upup toto chemotherapychemotherapy (n=1)(n=1)

DiagnosticDiagnostic endoscopy endoscopy toto endoscopicendoscopic mucosalmucosal resectionresection (n=1)(n=1)

ClinicalClinical followfollow--upup (palliative) (palliative) toto neodjuvantneodjuvant therapytherapy and and surgerysurgery (n=1)(n=1)

ChemotherapyChemotherapy toto surgerysurgery (n=1)(n=1)

SurgerySurgery toto neodjuvantneodjuvant therapytherapy and and surgerysurgery (n=1)(n=1)

5/12 (42%)5/12 (42%)More More complexcomplex12/22 (56%)12/22 (56%)Management plan Management plan changeschanges post EUS post EUS

ShahShah etet al. al. ClinClin GastroenterolGastroenterol HepatolHepatol 20042004

StagingStaging of of neoplasmsneoplasms::EsophagusEsophagus / / MediastinumMediastinum

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Staging of neoplasmsStaging of neoplasmsEsophageal cancerEsophageal cancerT1m, N0 T1m, N0 EndoscopyEndoscopy / Surgery/ SurgeryT1sm/T2, N0 T1sm/T2, N0 SurgerySurgeryT3, N1 T3, N1 NeoadjuvantNeoadjuvant Ch RXCh RX SurgerySurgeryT4, N1 T4, N1 PalliationPalliation

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0/1 (0%)0/1 (0%)NumberNumber of EUS FNA of EUS FNA leadingleading toto a management a management changechange

ImagingImaging and/or and/or endoscopicendoscopic followfollow--upup toto clinicalclinical followfollow--upup (n=5)(n=5)

SurgerySurgery toto clinicalclinical followfollow--upup (n=1)(n=1)

SurgerySurgery toto endoscopicendoscopic mucosalmucosal resectionresection (n=1)(n=1)


EndoscopicEndoscopic followfollow--upup toto endoscopicendoscopic mucosalmucosal resectionresection (n=1)(n=1)

ImagingImaging followfollow--upup toto surgerysurgery (n=1)(n=1)

2/9 (22%)2/9 (22%)More More complexcomplex

9/15 (60%)9/15 (60%)Management plan Management plan changeschanges postpost--EUSEUS


StagingStaging of of neoplasmsneoplasms: : stomachstomach

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•• Treatment decisions were changed in Treatment decisions were changed in 34% based on EUS results, and the 34% based on EUS results, and the majority of these changes were majority of these changes were toward toward nonsurgicalnonsurgical and palliative and palliative treatments (85%)treatments (85%)

Mortensen et al. Mortensen et al. SurgSurg EndoscEndosc 20072007

Impact of EUS on Impact of EUS on SurgerySurgery in UGI in UGI CancerCancer

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NeoadjuvantNeoadjuvant therapytherapy and and surgerysurgery toto surgerysurgery alone (n=1)alone (n=1)

SurgerySurgery toto chemotherapychemotherapy


SurgerySurgery alone alone toto neoadjuvantneoadjuvant therapytherapy and and surgerysurgery (n=2)(n=2)

2/4 (50%)2/4 (50%)More More complexcomplex

4/10 (40%)4/10 (40%)Management plan Management plan changeschanges postpost--EUSEUS


StagingStaging of of neoplasmsneoplasms: : rectalrectal

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EUS: T1mEUS: T1m

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IndicationsIndications forfor EUSEUS

Evaluation of Evaluation of pancreatopancreato --biliarybiliary regionregion

Pancreatic and periampullary cancerAcute PancreatitisCholedocholithiasisNeuroendocrineNeuroendocrine tumorstumorsPancreatic cystsPancreatic cystsChronic pancreatitisChronic pancreatitis

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Endoscopic Ultrasonography 2007Endoscopic Ultrasonography 2007Endoscopic Ultrasonography 2007EUS EUS vsvs MRCP in MRCP in pancreatobiliarypancreatobiliary diseasesdiseases: :

prospectiveprospective comparisoncomparison

91%91%92%92%MRCPMRCP

94%94%78%78%EUSEUSCholedocholithiasisCholedocholithiasis

97.4%97.4%96%96%MRCPMRCP

100%100%98%98%EUSEUSMalignancyMalignancy

NPVNPVPPVPPV

FernandezFernandez--EsparrachEsparrach et al. Am J et al. Am J GastroenterolGastroenterol 20072007

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PuliPuli etet al.al. GastrointestGastrointest EndoscEndosc 20072007

Pancreatic cancer metaPancreatic cancer meta--analysis: EUS analysis: EUS sensitivity for vascular invasionsensitivity for vascular invasion

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PuliPuli etet al.al. GastrointestGastrointest EndoscEndosc 20072007

Pancreatic cancer metaPancreatic cancer meta--analysis: EUS analysis: EUS specificity for vascular invasionspecificity for vascular invasion

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Negative Negative predictivepredictive valuevalue of EUS of EUS forforPancreaticPancreatic CancerCancer

NPV of EUS NPV of EUS waswas 100%100%•• RetrospectiveRetrospective reviewreview of of 693 693 ptspts.. ((JanJan 19991999--Mar Mar

2003) 2003) suspectedsuspected of of havinghaving PC PC •• 155 155 ptspts. . werewere foundfound toto havehave a a normalnormal pancreaspancreas•• No No ptspts. . developeddeveloped PC PC duringduring followfollow upup ((meanmean 25 25

monthsmonths))•• No No furtherfurther workwork--up up waswas requiredrequired in 88% of in 88% of ptspts..•• In In ptspts. . withwith a a clinicalclinical suspicionsuspicion of PC, EUS of PC, EUS shouldshould

bebe consideredconsidered asas the the initialinitial diagnosticdiagnostic modalitymodality

KlapmanKlapman etet al.al. AmAm J J GastroenterolGastroenterol 20052005

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Endoscopic Ultrasonography 2007Endoscopic Ultrasonography 2007Endoscopic Ultrasonography 2007ClinicalClinical impactimpact


ImagingImaging toto clinicalclinical followfollow--upup (n=1)(n=1)

RadiologyRadiology guidedguided biopsybiopsy examinationexamination toto imagingimaging followfollow--upup (n=2)(n=2)

ERCP ERCP toto imagingimaging followfollow--upup (n=3)(n=3)

ERCP ERCP toto clinicalclinical followfollow--upup (n=2)(n=2)

SurgerySurgery toto radiationradiation and or and or chemotherapychemotherapy (n=4)(n=4)

SurgerySurgery toto clinicalclinical followfollow--upup (n=3)(n=3)


ImagingImaging toto ERCP (n=2)ERCP (n=2)

ImagingImaging toto surgerysurgery (n=2)(n=2)

RadiologyRadiology guidedguided biopsybiopsy toto radiationradiation and/or and/or chemotherapychemotherapy (n=1)(n=1)

ERCP ERCP toto surgerysurgery (n=1)(n=1)

6/21 (29%)6/21 (29%)More More complexcomplex21/43 (49%)21/43 (49%)Management plan Management plan changeschanges postpost--EUSEUS

ShahShah etet al.al. ClinClin GastroenterolGastroenterol HepatolHepatol 20042004

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Endoscopic Ultrasonography 2007Endoscopic Ultrasonography 2007Endoscopic Ultrasonography 2007EUSEUS--SonovueSonovue forfor pancreaticpancreatic cancercancer

Caletti Caletti etet al.al. UnsubmittedUnsubmitted Data 2007Data 2007

Sonovue: early venous phaseCytology: adenocarcinoma

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PatientPatient withwith a a pancreaticpancreatic mass mass byby CT/US or CT/US or suspectedsuspectedpancreaticpancreatic cancercancer withwith negative negative imagingimaging studiesstudies

No No obviousobvious metastaticmetastatic diseasedisease ObviousObvious metastatic metastatic diseasedisease((confirmconfirm byby FNA)FNA)

EUS EUS stagingstaging and FNAand FNA

No EUS No EUS evidenceevidence of of advancedadvanceddiseasedisease

SurgicalSurgical resectionresection and and stagingstaging

EUS EUS evidenceevidence of of advancedadvanceddiseasedisease

Palliative Palliative therapytherapy ((considerconsiderEUS EUS guidedguided celiacceliac block)block)??NeoadjuvantNeoadjuvant RxRx and and

restagingrestaging

Pancreatic cancer: EUS algorithmPancreatic cancer: EUS algorithm

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Detection of Detection of choledocholithiasischoledocholithiasis byby EUS in APEUS in AP100 consecutive 100 consecutive ptspts. . withwith APAP

GallbladderGallbladder stonesstones:: EUS more sensitive EUS more sensitive thanthan USUS(100% vs. 84%, p<0.005)(100% vs. 84%, p<0.005)

CholedocholithiasisCholedocholithiasis:: EUSEUS ERCPERCP (US)(US)–– sensitivitysensitivity 97%97% 97%97% (26%)(26%)–– specificityspecificity 98%98% 95%95% (100%)(100%)

–– accuracyaccuracy 98%98% 96%96% (75%)(75%)

LiuLiu, , GastrointestGastrointest EndoscEndosc 20012001

Acute Acute PancreatitisPancreatitisDeterminationDetermination of of EtiologyEtiology

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JamalJamal etet al.al. AmAm J J GastroenterolGastroenterol 20072007

ChangingChanging trendstrends in ERCPin ERCP

ERCP diagnostic vs. therapeutic 1988-2002

Advent of EUS

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InfluenceInfluence of biliary of biliary stentsstents on EUSon EUS

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InfluenceInfluence of biliary of biliary stentsstents on EUSon EUSOverall concordance EUS/gold standard: Overall concordance EUS/gold standard: 11/22 (50%) 11/22 (50%)

50 (5/10)50 (5/10)T3 (n = 5)T3 (n = 5)T4 (n = 5)T4 (n = 5)

T4T4

67 (2/3)67 (2/3)T2 (n = 1)T2 (n = 1)T3 (n = 2)T3 (n = 2)

T3T3

25 (1/4)25 (1/4)T0 (n = 2)T0 (n = 2)T2 (n = 1)T2 (n = 1)T4 (n = 1)T4 (n = 1)

T2T2

0 (0/2)0 (0/2)T0 (n = 1)T0 (n = 1)T3 (n = 1)T3 (n = 1)

T1T1

100 (3/3)100 (3/3)T0 (n = 3)T0 (n = 3)T0T0

%%EUSEUSSurgicalSurgical T T stagestage

FusaroliFusaroli etet al.al. EndoscopyEndoscopy 20072007

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DoesDoes normalnormal EUS EUS obviateobviate the the needneed forfor ERCP?ERCP?PProspectiverospective 11--year followyear follow--up studyup study in 238 in 238 ptspts. . referred referred

for biliary for biliary studystudy withwith normalnormal EUS EUS [e[earlyarly (1(1--month) month) and late (1and late (1--year) followyear) follow--up details were obtainedup details were obtained]]

59 (25 %) pts59 (25 %) pts.. underwent underwent cholecystectomycholecystectomy, with (n=31) , with (n=31) or without (n=28) or without (n=28) IOCIOC, and 30 , and 30 (13%) (13%) ptspts.. underwent underwent ERCERCPP (13 %)(13 %)

CBD stone was found in 14 (6 %) patientsCBD stone was found in 14 (6 %) patientsNPV NPV of EUS for CBD stones was 95.4 %of EUS for CBD stones was 95.4 %

NapoleonNapoleon, Endoscopy 2003, Endoscopy 2003

Acute Acute PancreatitisPancreatitis: : DeterminationDetermination of of EtiologyEtiology

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IdiopathicIdiopathic APAP•• ExtensiveExtensive and invasive and invasive evaluationsevaluations ((suchsuch

asas ERCP) are ERCP) are notnot neededneeded after a single after a single episodeepisode of of IdiophaticIdiophatic AP.AP.

•• In In patientspatients in in whomwhom PCaPCa isis more more likelylikely(>40 (>40 yrsyrs, , smokerssmokers), ), anan evaluationevaluation usingusingMRCP, or EUS MRCP, or EUS isis preferablypreferably toto usingusing ERCP ERCP initiallyinitially..

Acute Acute PancreatitisPancreatitis: : DeterminationDetermination of of EtiologyEtiology

ForsmarkForsmark and and BaillieBaillie. . GastroenterologyGastroenterology 20072007

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•• EUS group: 49 successful and 1 failed initial EUS, EUS group: 49 successful and 1 failed initial EUS, 15 15 ERCsERCs for CBD stone for CBD stone txtx, and 6 procedures , and 6 procedures during fduring f--upup

•• ERC group: 36 successful and 12 failed initial ERC group: 36 successful and 12 failed initial ERCsERCs, 13 repeat procedures (EUS or ERC) and 2 , 13 repeat procedures (EUS or ERC) and 2 during fduring f--upup

•• In intermediate probability CBD stones, EUS (with In intermediate probability CBD stones, EUS (with selective ERC in pts. with stones) is safer and not selective ERC in pts. with stones) is safer and not associated with an excess of endoscopic associated with an excess of endoscopic procedures compared with ERC aloneprocedures compared with ERC alone

PolkowskiPolkowski et al. Endoscopy 2007et al. Endoscopy 2007

EUS first vs. ERCP first EUS first vs. ERCP first forfor CBD CBD StonesStones

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Endoscopic Ultrasonography 2007Endoscopic Ultrasonography 2007Endoscopic Ultrasonography 2007EUS first vs. ERCP firstEUS first vs. ERCP first

in in BiliaryBiliary Acute Acute PancreatitisPancreatitis•• OccultOccult cholelithiasischolelithiasis ((missedmissed byby US) US) isis best best

detecteddetected byby EUS or MRCP.EUS or MRCP.•• EUS EUS sensitivitysensitivity of 90%.of 90%.•• SludgeSludge in the in the gallbladdergallbladder maymay formform withwith

prolongedprolonged fastingfasting and and maymay representrepresent the the consequenceconsequence ratherrather thanthan the cause of the cause of pancreatitispancreatitis..

•• EUS EUS isis usedused toto identifyidentify patientspatients withwith biliarybiliary AP AP whowho havehave persistentpersistent CBD CBD stonesstones and and thusthus selectselectpatientspatients forfor ERCP.ERCP.


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EUS first vs. ERCP firstEUS first vs. ERCP firstin in BiliaryBiliary Acute Acute PancreatitisPancreatitis

•• In In patientspatients withwith mildmild or or resolvedresolved biliarybiliary AP AP whowho are are scheduledscheduled forfor cholecystectomycholecystectomy, , in in whomwhom a a preoperativepreoperative questionquestion existsexists asastoto the the presencepresence of of persistentpersistent CBD CBD stonesstones, , preoperativepreoperative EUS or MRCP EUS or MRCP isis appropriate appropriate ratherrather thanthan proceedingproceeding directlydirectly toto ERCP.ERCP.

LiuLiu etet al.al. ClinClin GastroenterolGastroenterol HepatolHepatol 20052005

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•• MalignancyMalignancy isis a a potentialpotential etiologyetiology ((ageage>40 >40 yrsyrs).).

•• EUS EUS couldcould bebe usedused toto screenscreen notnot onlyonly forformalignancymalignancy butbut alsoalso toto assessassess forforampullaryampullary massesmasses, , pancreaticpancreatic ductalductaldilatationdilatation, , signssigns of of chronicchronic pancreatitispancreatitis, , and and microlithiasismicrolithiasis..


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““ The The mostmost accurate accurate methodmethod toto identifyidentifycholelithiasischolelithiasis or or coledocholithiasiscoledocholithiasis in a in a patientpatient withwith acute acute pancreatitispancreatitis isisendoscopicendoscopic ultrasonographyultrasonography ..””


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•• Pancreatic Infection:Pancreatic Infection:MRI and EUS provide the most reliable MRI and EUS provide the most reliable information to define the internal character of information to define the internal character of the collection and gauging its consistency.the collection and gauging its consistency.

•• Pancreatic Fluid Collection and Pancreatic Fluid Collection and PseudocystPseudocyst::EndoscopicEndoscopic treatment, utilizing EUS treatment, utilizing EUS guidance is becoming much more common.guidance is becoming much more common.

Acute Acute PancreatitisPancreatitis:Management of :Management of ComplicationsComplications


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BaillieBaillie and Testoni. and Testoni. GutGut 20072007

ChangingChanging trendstrends in ERCPin ERCP

“…“… .Every ERCP should be performed for a .Every ERCP should be performed for a solid solid indicationindication : it is not a game!...: it is not a game!...……..With the ..With the avaliabilityavaliability of lessof less -- and nonand non --invasive invasive imaging techniques, such as EUS and MRCP, solely imaging techniques, such as EUS and MRCP, solely diagnostic ERCP is becoming a rarity.diagnostic ERCP is becoming a rarity.……..EUS is increasingly important in both the diagnos is ..EUS is increasingly important in both the diagnos is and staging of and staging of biliarybiliary and pancreatic cancer, and its and pancreatic cancer, and its therapeutic applications are increasing dailytherapeutic applications are increasing daily …….. .. ……..EUS and ERCP are complementary techniques..EUS and ERCP are complementary techniques ……..””

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PancreaticPancreatic CystsCysts

Sahani et al. Radiographics 2005

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Cooperative pancreatic cyst studyCooperative pancreatic cyst studyProspective study; 341 pts.Prospective study; 341 pts.CEA for all CEA for all mucinousmucinous CPTsCPTs was significantly was significantly

higher than CEA for all nonhigher than CEA for all non--mucinousmucinous CPTsCPTs(cutoff 192 (cutoff 192 ngng/ml)/ml)

CA 72CA 72--4 was the second best discriminating 4 was the second best discriminating markermarker

CONCLUSIONS: CONCLUSIONS: tthe determination of cyst fluid he determination of cyst fluid concentration of CEA alone is highly concentration of CEA alone is highly diagnostic and more accurate than any diagnostic and more accurate than any combination testing (p < 0.0001)combination testing (p < 0.0001)

BruggeBrugge et al. Gastroenterology 2004et al. Gastroenterology 2004

PancreaticPancreatic CystsCysts

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Endoscopic Ultrasonography 2007Endoscopic Ultrasonography 2007Endoscopic Ultrasonography 2007IntraIntra PapillaryPapillary MucinousMucinous NeoplasmsNeoplasms: :

IPMNIPMN

CalleryCallery, , GastroenterologyGastroenterology 20062006

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IPMNIPMN


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PC PC arisingarising in IPMNin IPMN

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IPMNIPMN

PathologicalPathological DiagnosisDiagnosis of of Invasive Invasive IPMNIPMN•• MalignantMalignant cellscells & & ductalductal structuresstructures infiltratinginfiltrating pancreaticpancreatic

parenchymaparenchyma are are requiredrequired..•• PerineuralPerineural, , lymphaticlymphatic, and , and vascularvascular invasioninvasion are are variablyvariably

seenseen withwith Invasive Invasive butbut nevernever withwith nonivasivenonivasive IPMN.IPMN.•• AcellularAcellular poolspools of of mucinmucin alone are alone are inadequateinadequate (non Invasive (non Invasive

IPMN).IPMN).•• MedianMedian overalloverall survivalsurvival isis onlyonly 23 23 monthsmonths forfor invasive invasive

IPMN, IPMN, comparedcompared toto 85 85 monthsmonths forfor noninvasivenoninvasive diseasedisease..

RautRaut etet al.al. AnnAnn SurgSurg OncolOncol 20062006

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IPMNIPMN

•• PreoperativePreoperative imagingimaging, , includigincludig EUSEUS•• CaCa 1919--9 9 levelslevels•• TargetedTargeted EUSEUS--FNAFNA•• CouldCould notnot reliablyreliably discriminate invasivediscriminate invasive and non and non

invasive IPMNinvasive IPMN•• OnlyOnly JaundiceJaundice isis predictivepredictive of Invasive IPMNof Invasive IPMN

RautRaut etet al.al. AnnAnn SurgSurg OncolOncol 20062006

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IPMNIPMN-- ConclusionsConclusions

•• A A defensivedefensive approachapproach isis toto removeremove themthem..•• ButBut decidingdeciding toto operate operate whenwhen observationobservation isis

appropriate appropriate isis wrongwrong..•• In the old In the old patientspatients withwith comorbiditycomorbidity, a , a misguidedmisguided

decisiondecision toto resectresect can do more can do more harmharm thanthan goodgood..•• WeWe stillstill needneed toto learnlearn more more aboutabout the the naturalnatural

historyhistory of IPMN of IPMN toto becomebecome confortableconfortable withwith suchsuchdecisionsdecisions..


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CysticCystic LesionLesion in the Pancreasin the Pancreas

FollowFollow upup

SurgerySurgery

EUSEUS

OtherOther featuresfeaturesMicrocysticMicrocystic (SCA)(SCA)

LowLow surgicalsurgical riskrisk

VegetationVegetation/Mass/MassWirsungWirsung dilateddilated

SymptomaticSymptomatic

UncertainUncertain EUSEUSAsymptomaticAsymptomatic

High High surgicalsurgical riskrisk

EUSEUS--FNAFNA

EUS in EUS in PancreaticPancreatic CystsCysts: : AlgorithmAlgorithm

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13 (8.1%)13 (8.1%)8 (11.6)8 (11.6)MinimallyMinimally/ / notnot usefuluseful

72 (44.4%)72 (44.4%)16 (23.2%)16 (23.2%)ModeratelyModerately p < 0.8p < 0.8

77 (47.5%)77 (47.5%)45 (65.2%)45 (65.2%)VeryVeryEUS EUS usefulnessusefulness

62 (38.3%)62 (38.3%)21 (30.4%)21 (30.4%)NoNo

33 (20.4%)33 (20.4%)5 (7.3%)5 (7.3%)PossiblePossible

p < 0.08p < 0.08

70 (43%)70 (43%)0/1 0/1 LungLung//mediastinalmediastinal

31/51 (61%) 31/51 (61%) PancreaticobiliaryPancreaticobiliary23/72 (32%) 23/72 (32%) esophagealesophageal16/34 (47%) 16/34 (47%) gastricgastric

45 (65 %)45 (65 %)33/44 (75%) 33/44 (75%) LungLung//mediastinalmediastinal10/21 (48%) 10/21 (48%) PancreaticobiliaryPancreaticobiliary2/3 (67%) 2/3 (67%) esophagealesophageal0/1 0/1 gastricgastric

YesYesAdditionalAdditionalinvestigationsinvestigationsavoidedavoided

162 (70%)162 (70%)69 (30%)69 (30%)PatientsPatientsp p ValueValueEUS EUS withoutwithout FNAFNAEUSEUS--FNAFNA

ChongChong etet al.al. GastrointestGastrointest EndoscEndosc 20052005

AvoidanceAvoidance of of additionaladditional investigationsinvestigations

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ConclusionsConclusions

•• EUS results in a change of management in EUS results in a change of management in approximately one half of the patients.approximately one half of the patients.

•• Staging with EUS is associated with a Staging with EUS is associated with a recurrence free survival advantage and an recurrence free survival advantage and an overall survival advantage.overall survival advantage.

•• EUS is deemed useful by referring EUS is deemed useful by referring physicians.physicians.

•• EUS is not only accurate but also costEUS is not only accurate but also cost--effective.effective.

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IVIV°° IEC / IEC / II°°EGEUSEGEUSEUS COURSEEUS COURSECastelCastel S. Pietro S. Pietro JuneJune 88--10 200810 2008

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Clinical Impact - mafservizi.edinf.commafservizi.edinf.com/CMS/images/stories/EGEUS_2007_ppt/Sala500/... · Clinical Impact Giancarlo Caletti Gastroenterologia Universit à di Bologna