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de Moura DTH, McCarty TR, Jirapinyo P, Ribeiro IB, Farias GFA, Ryou M, Lee LS, Thompson CC. Endoscopic Ultrasound Fine-Needle Aspiration versus Fine-Needle Biopsy for Lymph Node Diagnosis: A Large Multicenter Comparative Analysis. Clin Endosc 2019; 53:600-610. [PMID: 31794654 PMCID: PMC7548151 DOI: 10.5946/ce.2019.170] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 09/26/2019] [Indexed: 02/06/2023] Open
Abstract
Background/Aims Endoscopic ultrasound fine-needle aspiration (EUS-FNA) is preferred for sampling of lymph nodes (LNs) adjacent to the gastrointestinal wall; however, fine-needle biopsy (FNB) may provide improved diagnostic outcomes. This study aimed to evaluate the comparative efficacy and safety of FNA versus FNB for LN sampling.
Methods This was a multicenter retrospective study of prospectively collected data to evaluate outcomes of EUS-FNA and EUS-FNB for LN sampling. Characteristics analyzed included sensitivity, specificity, accuracy, the number of needle passes, diagnostic adequacy of rapid on-site evaluation (ROSE), cell-block analysis, and adverse events.
Results A total of 209 patients underwent EUS-guided LN sampling. The mean lesion size was 16.22±8.03 mm, with similar sensitivity and accuracy between FNA and FNB ([67.21% vs. 75.00%, respectively, p=0.216] and [78.80% vs. 83.17%, respectively, p=0.423]). The specificity of FNB was better than that of FNA (100.00% vs. 93.62%, p=0.01). The number of passes required for diagnosis was not different. Abdominal and peri-hepatic LN location demonstrated FNB to have a higher sensitivity (81.08% vs. 64.71%, p=0.031 and 80.95% vs. 58.33%, p=0.023) and accuracy (88.14% vs. 75.29%, p=0.053 and 88.89% vs. 70.49%, p=0.038), respectively. ROSE was a significant predictor for accuracy (odds ratio, 5.16; 95% confidence interval, 1.15–23.08; p=0.032). No adverse events were reported in either cohort.
Conclusions Both EUS-FNA and EUS-FNB are safe for the diagnosis of LNs. EUS-FNB is preferred for abdominal LN sampling. EUS-FNA+ ROSE was similar to EUS-FNB alone, showing better diagnosis for EUS-FNB than traditional FNA. While ROSE remained a significant predictor for accuracy, due to its poor availability in most centers, its use may be limited to cases with previous inconclusive diagnoses.
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Affiliation(s)
- Diogo Turiani Hourneaux de Moura
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston MA, USA.,Harvard Medical School, Boston, MA, USA.,Department of Gastroenterology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Thomas R McCarty
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Pichamol Jirapinyo
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Igor Braga Ribeiro
- Department of Gastroenterology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Galileu Ferreira Ayala Farias
- Department of Gastroenterology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Marvin Ryou
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Linda S Lee
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Christopher C Thompson
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston MA, USA.,Harvard Medical School, Boston, MA, USA
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Rapid on-site evaluation during endoscopic ultrasound-guided fine-needle aspiration of lymph nodes does not increase diagnostic yield: A randomized, multicenter trial. Am J Gastroenterol 2018; 113:677-685. [PMID: 29681624 DOI: 10.1038/s41395-018-0025-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Accepted: 01/25/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Studies on the impact of rapid on-site evaluation (ROSE) during endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) of lymph nodes are retrospective and have shown conflicting results. We aimed to compare the diagnostic yield of EUS-FNA of lymph nodes with ROSE (ROSE+) and without ROSE (ROSE-). METHODS This was a multicenter, randomized controlled trial. Consecutive patients who were scheduled to undergo EUS-FNA of mediastinal or abdominal lymph nodes were randomized to ROSE+ or ROSE-. In the ROSE+ group, the number of passes was dictated by the on-site cytotechnician. In the ROSE- group, five passes were performed without interference from the cytotechnician. All samples were reviewed by a single-expert cytopathologist, blinded to group allocation. Primary endpoint was diagnostic yield with and without ROSE. RESULTS After inclusion of 90 patients, interim analysis showed futility of study continuation since diagnostic yield of ROSE+ and ROSE- were comparable. A total of 91 patients were randomized to ROSE+ (N = 45) or ROSE- (N = 46). Diagnostic yield of ROSE+ and ROSE- and diagnostic accuracy were comparable: 93.3% vs. 95.7% (P = 0.68) and 97.6% vs. 93.2% (P = 0.62), respectively. Two major complications (one per group) occurred (p = 0.99). ROSE- patients more often reported self-limiting post-procedural pain (p < 0.001). Median procedure time for ROSE+ (20 min) and ROSE- (23 min) was comparable (P = 0.06). Median time to review slides in the ROSE- group (12:47 min) was longer than with ROSE+ (7:52 min) (P < 0.001). Mean costs of ROSE- and ROSE+ were comparable: €938.29 (±172.70) vs. €945.98 (±223.38) (P = 0.91), respectively. CONCLUSIONS Diagnostic yield and accuracy of EUS-FNA of mediastinal and abdominal lymph nodes with and without ROSE are comparable. Time needed to review slides was shorter and post-procedural pain was less often reported in the ROSE+ group. Based on the primary outcome, the implementation of ROSE during EUS-FNA of mediastinal and abdominal lymph nodes cannot be advised. (Dutch Trial Register: NTR4876).
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Cai W, Lu JJ, Xu R, Xin P, Xin J, Chen Y, Gao B, Chen J, Yang X. Survival based radiographic-grouping for esophageal squamous cell carcinoma may impact clinical T stage. Oncotarget 2018; 9:9512-9530. [PMID: 29507707 PMCID: PMC5823661 DOI: 10.18632/oncotarget.24056] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2017] [Accepted: 01/02/2018] [Indexed: 12/26/2022] Open
Abstract
Most patients diagnosed with thoracic esophageal squamous cell carcinoma (ESCC) have progressed beyond surgical resection as a therapeutic option. Difficulties in the proper assessment of tumor invasion depth before treatment complicate determination of the type and extent of therapy. Therefore, accurate tumor clinical staging is a necessity for identifying treatment options and aiding in patient prognosis. We investigated radiographic factors as prognostic indicators for survival in ESCC. Between July 2006 - July 2010, 324 thoracic ESCC patients who underwent surgery were selected. All patients received contrast enhanced preoperative chest CT scans and esophageal barium swallow examinations. Measurement of maximal lesion cross-sectional area, the largest long diameter, largest short diameter, CT-indicated lesion length, barium-indicated lesion length and the length of pericardial fat reduction were performed. Relationships between these indicators and post-surgical survival time and the cutoff values of related factors were analyzed. Maximum long diameter, maximum lesion area and lesion length, as measured by CT imaging, were correlated with survival. Survival effects were clearly associated with group intervals, calculated by a genetic algorithm, and tumor stages. Risk-stratification intervals of esophageal lesions from radiographic imaging included: maximum long diameter < 28.7, 28.7-34.6mm, 34.6-41.4mm and >41.4mm; maximum lesion area < 355.8mm2, 355.8-568.0mm2, 568.0-907.3mm2 and >907.3mm2; and CT-indicated lesion length <30.9mm, 30.9-57.3mm, 57.3-70.6mm and > 70.6mm. The reasonable stratification of maximum esophageal lesion area, largest long diameter and lesion length measured in CT is valuable for clinical T staging of ESCC. Radiographic parameters may have prognostic clinical value in the staging of esophageal carcinoma.
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Affiliation(s)
- Wenjie Cai
- Department of Radiation Oncology, First Hospital of Quanzhou Affiliated to Fujian Medical University, Quanzhou 362000, P. R. China
| | - Jiade J. Lu
- Shanghai Proton and Heavy Ion Center, Shanghai 201315, P. R. China
| | - Rongyu Xu
- Department of Surgical Oncology, First Hospital of Quanzhou Affiliated to Fujian Medical University, Quanzhou 362000, P. R. China
| | - Peiling Xin
- Department of Radiation Oncology, First Hospital of Quanzhou Affiliated to Fujian Medical University, Quanzhou 362000, P. R. China
| | - Jun Xin
- Department of Surgery, First Hospital of Quanzhou Affiliated to Fujian Medical University, Quanzhou 362000, P. R. China
| | - Yayun Chen
- Department of Radiation Oncology, First Hospital of Quanzhou Affiliated to Fujian Medical University, Quanzhou 362000, P. R. China
| | - Bingzhong Gao
- Department of Radiation Oncology, First Hospital of Quanzhou Affiliated to Fujian Medical University, Quanzhou 362000, P. R. China
| | - Jieyun Chen
- Department of Radiology, First Hospital of Quanzhou Affiliated to Fujian Medical University, Quanzhou 362000, P. R. China
| | - Xiyang Yang
- Key Laboratory of Intelligent Computing and Information Processing, Quanzhou Normal University, Quanzhou 362000, P. R. China
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Shimodaira Y, Slack RS, Harada K, Bhutani MS, Elimova E, Staerkel GA, Sneige N, Erasmus J, Shiozaki H, Charalampakis N, Planjery V, Kaya DM, Amlashi FG, Blum MA, Skinner HD, Minsky BD, Maru DM, Hofstetter WL, Swisher SG, Mares JE, Rogers JE, Lin QD, Ross WA, Weston B, Lee JH, Ajani JA. Utility of endoscopic ultrasound-guided fine-needle aspiration of regional lymph nodes that are proximal to and far from the primary distal esophageal carcinoma. Oncotarget 2017; 8:79356-79365. [PMID: 29108314 PMCID: PMC5668047 DOI: 10.18632/oncotarget.18119] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 04/17/2017] [Indexed: 11/25/2022] Open
Abstract
Implications of assessing the proximal and far para-tracheal or sub-carinal nodes (para-tracheal [PTN] or sub-carinal [SCN]) associated with lower primary esophageal carcinomas (ECs) are unclear. To evaluate the value of endoscopic ultrasound guided fine-needle aspiration (EUS-FNA) for PTN and SCN, we analyzed results by positron emission tomography (PET) avidity, 4 EUS node malignancy features, and EUS-FNA results in all patients with Siewert’s I or II EC. Of 133 patients (PTN, n=102; SCN, n=31) with EUS-FNA, 47 (35%) patients had malignant node, leading to treatment modifications. EUS-FNA diagnosed significantly more patients with malignant nodes (p=0.02) even when PET and EUS features were combined. Among 94 PET-negative and EUS-negative patients, 9 (10%) had malignant EUS-FNA. At a minimum follow-up of 1 year, only 3 (5%) of 62 patients with benign EUS-FNA had evidence of malignancy in the nodal area of prior EUS-FNA. Patients with malignant EUS-FNA independently had a much shorter overall survival (OS) than those with benign EUS-FNA (p<0.001). Our data suggest that a benign EUS-FNA is highly accurate and need not be pursued further. However, malignant EUS-FNA of PTN/SCN was independently prognostic, conferred a shorter OS, and altered the management of 35% of patients.
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Affiliation(s)
- Yusuke Shimodaira
- Department of Gastrointestinal Medical Oncology, University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Rebecca S Slack
- Department of Biostatistics, University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Kazuto Harada
- Department of Gastrointestinal Medical Oncology, University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Manoop S Bhutani
- Department of Gastroenterology, University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Elena Elimova
- Department of Gastrointestinal Medical Oncology, University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Gregg A Staerkel
- Department of Anatomic Pathology, University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Nour Sneige
- Department of Pathology, University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Jeremy Erasmus
- Department of Diagnostic Radiology, University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Hironori Shiozaki
- Department of Gastrointestinal Medical Oncology, University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Nikolaos Charalampakis
- Department of Gastrointestinal Medical Oncology, University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Venkatram Planjery
- Department of Gastrointestinal Medical Oncology, University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Dilsa Mizrak Kaya
- Department of Gastrointestinal Medical Oncology, University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Fatemeh G Amlashi
- Department of Gastrointestinal Medical Oncology, University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Mariela A Blum
- Department of Gastrointestinal Medical Oncology, University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Heath D Skinner
- Department of Radiation Oncology, University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Bruce D Minsky
- Department of Radiation Oncology, University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Dipen M Maru
- Department of Pathology, University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Wayne L Hofstetter
- Department of Thoracic and Cardiovascular Surgery, University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Stephen G Swisher
- Department of Thoracic and Cardiovascular Surgery, University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Jeannette E Mares
- Department of Gastrointestinal Medical Oncology, University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Jane E Rogers
- Department of Pharmacy, University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Quan D Lin
- Department of Gastrointestinal Medical Oncology, University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - William A Ross
- Department of Gastroenterology, University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Brian Weston
- Department of Gastroenterology, University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Jeffrey H Lee
- Department of Gastroenterology, University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Jaffer A Ajani
- Department of Gastrointestinal Medical Oncology, University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
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The 100 most cited articles investigating the radiological staging of oesophageal and junctional cancer: a bibliometric analysis. Insights Imaging 2016; 7:619-28. [PMID: 27278388 PMCID: PMC4956630 DOI: 10.1007/s13244-016-0505-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 05/18/2016] [Accepted: 05/24/2016] [Indexed: 12/15/2022] Open
Abstract
Objectives Accurate staging of oesophageal cancer (OC) is vital. Bibliometric analysis highlights key topics and publications that have shaped understanding of a subject. The 100 most cited articles investigating radiological staging of OC are identified. Methods The Thomas Reuters Web of Science database with search terms including “CT, PET, EUS, oesophageal and gastro-oesophageal junction cancer” was used to identify all English language, full-script articles. The 100 most cited articles were further analysed by topic, journal, author, year and institution. Results A total of 5,500 eligible papers were returned. The most cited paper was Flamen et al. (n = 306), investigating the utility of positron emission tomography (PET) for the staging of patients with potentially operable OC. The most common research topic was accuracy of staging investigations (n = 63). The article with the highest citation rate (38.00), defined as the number of citations divided by the number of complete years published, was Tixier et al. investigating PET texture analysis to predict treatment response to neo-adjuvant chemo-radiotherapy, cited 114 times since publication in 2011. Conclusion This bibliometric analysis has identified key publications regarded as important in radiological OC staging. Articles with the highest citation rates all investigated PET imaging, suggesting this modality could be the focus of future research. Main Messages • This study identifies key articles that investigate radiological staging of oesophageal cancer. • The most common topic was accuracy of staging investigations. • The article with the highest citation rate investigated the use of texture analysis in PET images.
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Litle VR. Staging Techniques for Carcinoma of the Esophagus. SABISTON AND SPENCER SURGERY OF THE CHEST 2016:645-656. [DOI: 10.1016/b978-0-323-24126-7.00037-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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Cho JW. The Role of Endosonography in the Staging of Gastrointestinal Cancers. Clin Endosc 2015; 48:297-301. [PMID: 26240802 PMCID: PMC4522420 DOI: 10.5946/ce.2015.48.4.297] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2015] [Accepted: 06/23/2015] [Indexed: 12/22/2022] Open
Abstract
Endosonography (EUS) enables the acquisition of clear images of the gastrointestinal tract wall and the surrounding structures. EUS enables much greater accuracy for staging decisions compared to computed tomography. Surgery for esophageal cancer has a high rate of morbidity and mortality, and it is important to decide on an appropriate treatment method through pre-surgical evaluation. Minimal invasive surgery is widely used for the treatment of gastrointestinal cancer, and endoscopic submucosal dissection is a safe treatment method for early cancer of the gastrointestinal tract that does not result in lymph node metastasis. EUS is essential for pre-surgical evaluation for all esophageal cancers. The use of EUS can effectively reduce unnecessary surgeries and thereby allow for appropriate treatment planning for patients. A number of different diagnostic modalities are available, but EUS is still the mainstay for pre-surgical evaluation of esophageal cancer. The role of EUS for early stomach cancer treatment as a tool for determining the need for endoscopic resection and for pre-surgical assessment is increasing.
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Affiliation(s)
- Jin Woong Cho
- Department of Gastroenterology, Presbyterian Medical Center, Jeonju, Korea
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Khanna LG, Gress FG. Preoperative evaluation of oesophageal adenocarcinoma. Best Pract Res Clin Gastroenterol 2015; 29:179-91. [PMID: 25743465 DOI: 10.1016/j.bpg.2014.12.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 12/23/2014] [Indexed: 01/31/2023]
Abstract
The preoperative evaluation of oesophageal adenocarcinoma involves endoscopic ultrasound (EUS), computed tomography (CT), and positron emission tomography (PET). With routine Barrett's oesophagus surveillance, superficial cancers are often identified. EUS, CT and PET have a limited role in the staging of superficial tumours. Standard EUS has limited accuracy, but high frequency ultrasound miniprobes are valuable for assessing tumour stage in superficial tumours. However, the best method for determining depth of invasion, and thereby stage of disease, is endoscopic mucosal resection. In contrast, in advanced oesophageal cancers, a multi-modality approach is crucial. Accurate tumour staging is very important since the treatment of advanced cancers involves a combination of chemotherapy, radiation, and surgery. EUS is very useful for staging of the tumour and nodes. High frequency ultrasound miniprobes provide the ability to perform staging when the lesion is obstructing the oesophageal lumen. CT and PET provide valuable information regarding node and metastasis staging.
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Affiliation(s)
- Lauren G Khanna
- Division of Digestive & Liver Diseases, Columbia University Medical Center, 630 West 168th Street, New York, NY 10032, USA.
| | - Frank G Gress
- Division of Digestive & Liver Diseases, Columbia University Medical Center, 161 Fort Washington Avenue, Herbert Irving Pavilion 13, New York, NY 10032, USA.
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Kundu U, Weston B, Lee J, Hofstetter W, Krishnamurthy S. Evolving role of endoscopic ultrasonography-guided fine-needle aspiration in tumor staging and treatment of patients with carcinomas of the upper gastrointestinal tract. J Am Soc Cytopathol 2014; 3:29-36. [PMID: 31051727 DOI: 10.1016/j.jasc.2013.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2013] [Revised: 07/31/2013] [Accepted: 09/04/2013] [Indexed: 06/09/2023]
Abstract
INTRODUCTION Treatments such as neoadjuvant chemotherapy and endoscopic mucosal resection for upper gastrointestinal carcinomas (UGC) necessitates preoperative staging evaluation of lymph nodes. Endoscopic ultrasonography (EUS)-guided fine-needle aspiration (FNA) of lymph nodes provides more accurate staging than EUS alone. Our study investigates the role of EUS-FNA in the staging/treatment of patients with UGC. MATERIALS AND METHODS We searched our database for patients who had EUS-FNA staging of lymph nodes for UGC over 1 year. The cytologic diagnoses were compared with clinical, radiographic, EUS-determined staging, and patient follow-up data. All EUS/EUS-FNA procedures used a standard radial and/or linear echo endoscope. Direct smears from the aspirated material were stained by Papanicolaou and Diff-Quik methods. RESULTS We studied 84 patients with esophageal or gastroesophageal junction carcinomas and 15 patients with gastric carcinomas. EUS-FNA confirmed N0 status for 100% of patients with T1 and T2 tumors and for 93% of patients with T3 tumors. Patients with T1N0 carcinomas confirmed by EUS were selected for endoscopic mucosal resection. All patients with gastric carcinomas had EUS-determined stage T3 and above tumors. Based on primary tumor stage, all patients with gastric carcinomas received neoadjuvant chemotherapy. CONCLUSIONS Cytologic diagnosis by EUS-FNA agreed with EUS nodal staging in 77% of the patients with UGC. EUS-FNA was useful to select patients with T1N0 esophageal or gastroesophageal junction carcinomas for endoscopic mucosal resection. EUS-FNA did not contribute significantly in treatment of patients with higher stage tumors whose disease was down-staged to N0 by EUS-FNA. These patients received neoadjuvant chemotherapy based on the status of the primary tumor.
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Affiliation(s)
- Uma Kundu
- MD Anderson Cancer Center, Houston, Texas
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Li Z, Rice TW. Diagnosis and staging of cancer of the esophagus and esophagogastric junction. Surg Clin North Am 2012; 92:1105-26. [PMID: 23026272 DOI: 10.1016/j.suc.2012.07.010] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Esophageal/esophagogastric junction cancer staging in the 7th edition of the AJCC staging manual is data driven and harmonized with gastric staging. New definitions are Tis, T4, regional lymph node, N, and M. Nonanatomic characteristics (histopathologic cell type, histologic grade, cancer location) and TNM classifications determine stage groupings. Classifications before treatment define clinical stage (cTNM or ycTNM). Current best clinical staging modalities include endoscopic ultrasonography for T and N and CT/PET for M. Classifications at resection define pathologic stage (pTNM or ypTNM). Accurate pathologic stage requires communication/cooperation between surgeon and pathologist. Classifications are defined at retreatment (rTNM) and autopsy (aTNM).
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Affiliation(s)
- Zhigang Li
- Department of Thoracic and Cardiovascular Surgery, The Second Military Medical University, Changhai Hospital, Shanghai, People's Republic of China
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Celiac node failure patterns after definitive chemoradiation for esophageal cancer in the modern era. Int J Radiat Oncol Biol Phys 2012; 83:e231-9. [PMID: 22436793 DOI: 10.1016/j.ijrobp.2011.12.061] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2011] [Revised: 12/13/2011] [Accepted: 12/19/2011] [Indexed: 12/18/2022]
Abstract
PURPOSE The celiac lymph node axis acts as a gateway for metastatic systemic spread. The need for prophylactic celiac nodal coverage in chemoradiation therapy for esophageal cancer is controversial. Given the improved ability to evaluate lymph node status before treatment via positron emission tomography (PET) and endoscopic ultrasound, we hypothesized that prophylactic celiac node irradiation may not be needed for patients with localized esophageal carcinoma. METHODS AND MATERIALS We reviewed the radiation treatment volumes for 131 patients who underwent definitive chemoradiation for esophageal cancer. Patients with celiac lymph node involvement at baseline were excluded. Median radiation dose was 50.4 Gy. The location of all celiac node failures was compared with the radiation treatment plan to determine whether the failures occurred within or outside the radiation treatment field. RESULTS At a median follow-up time of 52.6 months (95% CI 46.1-56.7 months), 6 of 60 patients (10%) without celiac node coverage had celiac nodal failure; in 5 of these patients, the failures represented the first site of recurrence. Of the 71 patients who had celiac coverage, only 5 patients (7%) had celiac region relapse. In multivariate analyses, having a pretreatment-to-post-treatment change in standardized uptake value on PET >52% (odds ratio [OR] 0.198, p = 0.0327) and having failure in the clinical target volume (OR 10.72, p = 0.001) were associated with risk of celiac region relapse. Of those without celiac coverage, the 6 patients that later developed celiac failure had a worse median overall survival time compared with the other 54 patients who did not fail (median overall survival time: 16.5 months vs. 31.5 months, p = 0.041). Acute and late toxicities were similar in both groups. CONCLUSIONS Although celiac lymph node failures occur in approximately 1 of 10 patients, the lack of effective salvage treatments and subsequent low morbidity may justify prophylactic treatment in distal esophageal cancer patients.
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Didden P, Spaander MCW, Wijnhoven BPL, Kuipers EJ, Bruno MJ. Improving the quality of pretreatment staging in patients with esophageal carcinoma - a fast track study. Acta Oncol 2012; 51:362-7. [PMID: 22023087 DOI: 10.3109/0284186x.2011.626449] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Current guidelines for esophageal cancer recommend series of diagnostic investigations to determine pretreatment TNM stage. When investigations are done sequentially, diagnostic work-up time may be prolonged considerably. Aim of the study was to determine the feasibility and efficacy of a fast track staging strategy within five days after the first consultation. MATERIAL AND METHODS Between 2007 and 2010 all patients presenting with esophageal cancer at the Department of Gastroenterology in a tertiary referral center were prospectively analyzed. At Day 1 all patients underwent computed tomography (CT), endoscopic ultrasound (EUS) and ultrasonography of the neck (US). Results and treatment implications were discussed within a multidisciplinary meeting. This fast track strategy was considered completed successfully if pre-treatment TNM classification was achieved and therapy was proposed to the patient at the outpatient clinic at Day five. In those cases where staging period time was prolonged, the number and type of additional tests were documented including the ensuing time delay. RESULTS In 111 patients CT, EUS and US were performed in 100%, 88.3% and 97.3% respectively. A final TNM stage and treatment proposal was reached at Day 5 in 60% of the patients. Additional tests were diverse and mainly used to prove local irresectabilty or presence of distant metastasis. Multivariate analysis identified presence of lymphadenopathy (HR 0.25 p = 0.03) and metastasis (HR 0.27 p = 0.03) as significant predictors of not completing the staging period within five days. In 18% of patients overuse of at least one test occurred, most commonly because CT already revealed distant metastasis. CONCLUSION Employment of a fast track five day staging strategy in patients with esophageal carcinoma is feasible. Definite TNM stage and treatment proposal can be achieved in 60% of cases, but comes at the expense of test overuse in about one fifth of patients.
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Affiliation(s)
- Paul Didden
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
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Sgourakis G, Gockel I, Lyros O, Hansen T, Mildenberger P, Lang H. Detection of lymph node metastases in esophageal cancer. Expert Rev Anticancer Ther 2011; 11:601-612. [DOI: 10.1586/era.10.150] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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15
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Affiliation(s)
- Matthew J Schuchert
- Heart, Lung, and Esophageal Surgery Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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16
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Tong DKH, Law S. Management of oesophageal cancer. Indian J Surg 2009; 71:317-25. [PMID: 23133184 PMCID: PMC3452742 DOI: 10.1007/s12262-009-0087-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2009] [Accepted: 11/30/2009] [Indexed: 01/29/2023] Open
Abstract
Oesophageal cancer is a disease of dismal prognosis. There are variations of epidemiology among different ethnic groups and geographic regions. India is a country with high incidence. This can be attributed to the interplay between environmental, dietary factors and life-style of the population of the country. Optimal therapeutic strategy for patients with oesophageal cancer demands individual consideration.Majority of oesophageal cancer patients present at an advanced stage of disease. Screening programmes or strategies aiming at early diagnosis can improve the prognosis; unfortunately this is not cost-effective except in very high incidence areas. Accurate staging can help select the most appropriate treatments, such as excluding those patients with metastatic disease who are unlikely to benefit from surgery, and treating very early lesions with endoscopic means. When surgery is indicated, treating patient in a high-volume centre can improve the outcome and minimise complications. Although surgical resection remains the main treatment modality, long-term prognosis after surgical resection alone has been suboptimal except in those with early disease. Multidisciplinary approaches including chemotherapy and radiotherapy with or without surgery are increasingly employed for patients with advanced disease. Collaboration among surgeons, clinical oncologists, radiologists and physicians is of utmost importance to achieve the best results. Treatment for patients should be individualised to enhance outcome.
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Affiliation(s)
- Daniel K. H. Tong
- Department of Surgery, The University of Hong Kong, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong, China
| | - Simon Law
- Department of Surgery, The University of Hong Kong, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong, China
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17
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Polkowski M. Endosonographic staging of upper intestinal malignancy. Best Pract Res Clin Gastroenterol 2009; 23:649-61. [PMID: 19744630 DOI: 10.1016/j.bpg.2009.05.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2009] [Accepted: 05/26/2009] [Indexed: 02/07/2023]
Abstract
Numerous studies conducted over the last 25 years provide evidence on the high diagnostic accuracy and important role of endoscopic ultrasonography (EUS) in staging oesophageal and gastric carcinoma. This extensive research was recently subjected to metaanalyses, condensing our knowledge on EUS performance and facilitating its comparison with competing methods. It is, however, important to realise that the management of oesophageal and gastric carcinoma is evolving and so are staging algorithms, setting new challenges for EUS and re-defining its position. Restaging after neoadjuvant treatment and precise assessment of early carcinoma before endoscopic treatment are areas of growing interest, but the role of EUS in these settings is rather limited. Rapidly developing cross-sectional imaging has the potential to challenge the position of EUS as the most accurate method in loco-regional staging. On the other hand, EUS guided fine-needle aspiration offers the unique opportunity to obtain cytological confirmation of lymph node metastases, with future potential for molecular staging.
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Affiliation(s)
- M Polkowski
- Department of Gastroenterology and Hepatology, Medical Centre for Postgraduate Education, Warsaw, Poland.
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18
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Kim E, Telford JJ. Endoscopic ultrasound advances, part 1: diagnosis. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2009; 23:594-601. [PMID: 19816621 PMCID: PMC2776547 DOI: 10.1155/2009/876057] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2009] [Accepted: 07/27/2009] [Indexed: 12/17/2022]
Affiliation(s)
- Edward Kim
- Division of Internal Medicine, University of British Columbia
| | - Jennifer J Telford
- Division of Gastroenterology, St Paul’s Hospital, Vancouver, British Columbia
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19
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Kalaitzakis E, Meenan J. Controversies in the use of endoscopic ultrasound in esophageal cancer staging. Scand J Gastroenterol 2009; 44:133-44. [PMID: 18654933 DOI: 10.1080/00365520802273066] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Evangelos Kalaitzakis
- Department of Gastroenterology, St Thomas' Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK.
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20
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Abstract
Esophageal cancer is the third most common malignancy of the alimentary tract. The incidence of esophageal cancer has steadily increased over the past three decades. Almost all therapeutic modalities for esophageal cancer are associated with a considerable mortality and morbidity. Consequently, there has been growing concern regarding effective management of esophageal cancer. 18F-fluorodeoxyglucose positron emission tomography (18F-FDG PET) is playing an increasing role in the management of esophageal cancer, offering potential advantages in the accuracy of disease assessment at a number of decision points in the management pathway. This review evaluates the critical role of FDG-PET in (i) diagnosis, (ii) preoperative staging, (iii) monitoring of response to neoadjuvant therapy, (iv) assessment of recurrence and (v) prediction of prognosis of esophageal cancer. We have also compared diagnostic performance of FDG-PET and other current technologies such as computed tomography scan and endoscopic ultrasonography based on available evidence.
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21
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Abstract
Esophageal malignancy is a major source of morbidity and mortality, despite the recently increased attention to screening and early detection. Prognosis for esophageal cancer remains grim, with advanced tumor stage and lymph node metastases conferring even graver outcomes. Several studies have demonstrated that the addition of preoperative neoadjuvant chemoradiotherapy may improve survival in patients with locally advanced tumor (T3) disease or local lymph node metastases. It is here that endoscopic ultrasonography finds its niche in the precise staging of these tumors and the subsequent use of stage-dependent treatment protocols.
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Affiliation(s)
- Alan Brijbassie
- Carilion Clinic, 3113-G Honeywood Lane, Roanoke, VA 24018, USA
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22
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Accuracy of endoscopic ultrasound in the diagnosis of distal and celiac axis lymph node metastasis in esophageal cancer: a meta-analysis and systematic review. Dig Dis Sci 2008; 53:2405-14. [PMID: 18097752 DOI: 10.1007/s10620-007-0152-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2007] [Accepted: 11/26/2007] [Indexed: 12/15/2022]
Abstract
BACKGROUND Published data on the accuracy of endoscopic ultrasound (EUS) for staging distant and celiac axis lymph node (CLN) metastasis in patients with esophageal cancer (ECA) has varied. AIM To evaluate the accuracy of EUS in diagnosing distal and CLN metastasis in ECA patients. STUDY SELECTION EUS studies confirmed by surgery were selected. STATISTICAL METHOD Pooling was conducted by both fixed and random-effects models. RESULTS Data were extracted from 25 studies (N = 2029) which met the inclusion criteria. In ECA patients, pooled sensitivity of EUS was 67.2% (95% CI: 62.6-71.6) in diagnosis of distal metastasis and 66.6% (95% CI: 61.9-71.1) in diagnosis of CLN metastasis. EUS had a pooled specificity of 97.9% (95% CI: 97.1-98.6) for distal metastasis and 98.1% (95% CI: 97.3-98.7) for CLN metastasis. CONCLUSIONS Although EUS has excellent specificity in accurately diagnosing distal and CLN metastasis in patients with ECA, the sensitivity is low.
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23
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Naini BV, Apple SK, Presley M, Moatamed NA. A correlation study on diagnostic endoscopic ultrasound-guided fine-needle aspiration of lymph nodes with histological and clinical diagnoses, the UCLA Medical Center experience. Diagn Cytopathol 2008; 36:460-6. [PMID: 18528891 DOI: 10.1002/dc.20825] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Endoscopic ultrasound guided (EUS) FNA procedure has two aspects, the endoscopic sampling and the FNA interpretation. The two aspects of the procedure are performed in two different disciplines; gastroenterology (EUS) and pathology (FNA). The aim of this study was to evaluate the concordance, sensitivity, specificity, positive predictive (PPV), and negative predictive values (NPV).Sixty-one EUS-FNA procedures of the lymph nodes were analyzed by correlating the FNA results with histological or clinical diagnoses. The lymph nodes were divided in five groups; mediastinal, gastrohepatic, peripancreatic, portal, and perirectal.The study showed a concordance of 92% in mediastinal, 80% in gastrohepatic, 81% in peripancreatic, 95% in portal, and 100% in perirectal lymph nodes with an overall sensitivity of 84%, specificity of 92%, PPV of 88%, and NPV of 89%. In conclusion, EUS-FNA offers an invaluable approach for diagnostic examination of the internal lymph nodes where percutaneous FNA is either difficult or impossible. impossible.
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Affiliation(s)
- Bita V Naini
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
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24
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Siddiqui AA, Eloubeidi MA. Esophageal endoscopic ultrasound fine-needle aspiration as a diagnostic tool. EXPERT OPINION ON MEDICAL DIAGNOSTICS 2007; 1:423-431. [PMID: 23489360 DOI: 10.1517/17530059.1.3.423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNA) may be employed for procurement of a tissue diagnosis in a minimally invasive fashion. In many cases, EUS-FNA excludes the need for more invasive diagnostic procedures when a tissue diagnosis is required. In patients with esophageal neoplasms, EUS-FNA is a safe and accurate tool for the preoperative diagnosis of metastatic spread to the paraesophageal and celiac lymph nodes. EUS-FNA is also increasingly recognized as an accurate, cost-effective and safe means of evaluating and staging patients with lung cancer. EUS-FNA is useful in providing tissue confirmation of cancer in cases in which bronchoscopy or computed tomography-guided approaches has been non-diagnostic. EUS-guided therapies are paving the way for therapeutic/interventional EUS. The interventional endoscopist will now play a more central role in the diagnosis and treatment of various gastrointestinal malignancies by delivering antitumor agents.
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Affiliation(s)
- Ali A Siddiqui
- The University of Texas Southwestern Medical School, Dallas Veterans Affairs Medical Center, Department of Internal Medicine, Dallas, TX, USA
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25
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van Vliet EPM, Steyerberg EW, Eijkemans MJC, Kuipers EJ, Siersema PD. Detection of distant metastases in patients with oesophageal or gastric cardia cancer: a diagnostic decision analysis. Br J Cancer 2007; 97:868-76. [PMID: 17848957 PMCID: PMC2360396 DOI: 10.1038/sj.bjc.6603960] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Computed tomography (CT) is presently a standard procedure for the detection of distant metastases in patients with oesophageal or gastric cardia cancer. We aimed to determine the additional diagnostic value of alternative staging investigations. We included 569 oesophageal or gastric cardia cancer patients who had undergone CT neck/thorax/abdomen, ultrasound (US) abdomen, US neck, endoscopic ultrasonography (EUS), and/or chest X-ray for staging. Sensitivity and specificity were first determined at an organ level (results of investigations, i.e., CT, US abdomen, US neck, EUS, and chest X-ray, per organ), and then at a patient level (results for combinations of investigations), considering that the detection of distant metastases is a contraindication to surgery. For this, we compared three strategies for each organ: CT alone, CT plus another investigation if CT was negative for metastases (one-positive scenario), and CT plus another investigation if CT was positive, but requiring that both were positive for a final positive result (two-positive scenario). In addition, costs, life expectancy and quality adjusted life years (QALYs) were compared between different diagnostic strategies. CT showed sensitivities for detecting metastases in celiac lymph nodes, liver and lung of 69, 73, and 90%, respectively, which was higher than the sensitivities of US abdomen (44% for celiac lymph nodes and 65% for liver metastases), EUS (38% for celiac lymph nodes), and chest X-ray (68% for lung metastases). In contrast, US neck showed a higher sensitivity for the detection of malignant supraclavicular lymph nodes than CT (85 vs 28%). At a patient level, sensitivity for detecting distant metastases was 66% and specificity was 95% if only CT was performed. A higher sensitivity (86%) was achieved when US neck was added to CT (one-positive scenario), at the same specificity (95%). This strategy resulted in lower costs compared to CT only, at an almost similar (quality adjusted) life expectancy. Slightly higher specificities (97–99%) were achieved if liver and/or lung metastases found on CT, were confirmed by US abdomen or chest X-ray, respectively (two-positive scenario). These strategies had only slightly higher QALYs, but substantially higher costs. The combination of CT neck/thorax/abdomen and US neck was most cost-effective for the detection of metastases in patients with oesophageal or gastric cardia cancer, whereas the performance of CT only had a lower sensitivity for metastases detection and higher costs. The role of EUS seems limited, which may be due to the low number of M1b celiac lymph nodes detected in this series. It remains to be determined whether the application of positron emission tomography will further increase sensitivities and specificities of metastases detection without jeopardising costs and QALYs.
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Affiliation(s)
- E P M van Vliet
- Department of Gastroenterology and Hepatology, Erasmus MC - University Medical Center Rotterdam, Rotterdam, The Netherlands.
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26
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Levy MJ, Clain JE, Clayton A, Halling KC, Kipp BR, Rajan E, Roberts LR, Root RM, Sebo TJ, Topazian MD, Wang KK, Wiersema MJ, Gores GJ. Preliminary experience comparing routine cytology results with the composite results of digital image analysis and fluorescence in situ hybridization in patients undergoing EUS-guided FNA. Gastrointest Endosc 2007; 66:483-90. [PMID: 17725938 DOI: 10.1016/j.gie.2007.03.1053] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2007] [Accepted: 03/19/2007] [Indexed: 12/17/2022]
Abstract
BACKGROUND Studies indicate enhanced diagnostic accuracy for digital image analysis (DIA) and fluorescence in situ hybridization (FISH) versus routine cytology examination (RC) when biliary strictures are evaluated. These tumor markers have not been applied to EUS-guided FNA. OBJECTIVE Our purpose was to determine the accuracy of RC versus the composite results of DIA/FISH. DESIGN Patients enrolled with known or suspected malignancy. The final diagnosis was based on strict cytopathologic and imaging criteria and 12-month follow-up. SETTINGS Tertiary referral center. PATIENTS A total of 39 patients were enrolled in whom each diagnostic test was performed on samples from 42 sites to evaluate lymphadenopathy (n=19), pancreatic mass (n=19), esophageal or gastric wall mass (n=3), and thyroid mass (n=1). INTERVENTIONS EUS-guided FNA with RC, DIA, and FISH. MAIN OUTCOME MEASUREMENT Diagnostic accuracy of RC, DIA, and FISH. RESULTS Malignancy was diagnosed in 30 of 42 patients, including esophageal squamous cell carcinoma, esophageal adenocarcinoma, gastric adenocarcinoma, pancreatic adenocarcinoma, pancreatic mucinous cystic neoplasia, intraductal papillary mucinous neoplasia, metastatic forearm sarcoma, small cell and non-small cell lung cancer, thyroid carcinoma, malignant GI stromal tumor, melanoma, adenocarcinoma of unknown primary, and lymphoma. The sensitivity, specificity, and accuracy of DIA/FISH versus RC for detecting malignancy were 97%, 100%, and 98% versus 87%, 100%, and 90%, respectively. LIMITATIONS Single-center pilot study. CONCLUSIONS Our findings suggest that DIA and FISH processing of EUS-guided FNA specimens provides higher diagnostic accuracy than RC does. These data suggest that these tumor markers incorporate generic targets as suggested by the high diagnostic sensitivity in this patient cohort with diverse pathologic conditions.
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Affiliation(s)
- Michael J Levy
- Division of Gastroenterology and Hepatology, Department of Pathology, Mayo Clinic College of Medicine, Rochester, Minnesota 55905, USA
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Deans DAC, Wigmore SJ, de Beaux AC, Paterson-Brown S, Garden OJ, Fearon KCH. Clinical prognostic scoring system to aid decision-making in gastro-oesophageal cancer. Br J Surg 2007; 94:1501-8. [PMID: 17703501 DOI: 10.1002/bjs.5849] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Abstract
Background
Accurate prediction of prognosis in gastro-oesophageal cancer remains challenging. The aim of this study was to develop a robust model for outcome prediction.
Methods
The study included 220 patients with gastric or oesophageal cancer newly diagnosed over a 2-year period. Patients were staged and underwent treatment following discussion at a multidisciplinary team (MDT) meeting. Clinical and investigative variables were collected, including performance and nutritional status, and serum C-reactive protein (CRP) level. Primary endpoints were death within 12 and 24 months.
Results
Overall median survival was 13 months. Advanced clinical stage (P < 0·001), reduced performance score (P < 0·001), weight loss exceeding 2·75 per cent per month (P = 0·026) and serum CRP concentration above 5 mg/l (P = 0·031) were identified as independent prognostic indicators in multivariable analysis. A prognostic score was constructed using these four variables to estimate a probability of death. Applying the model gave an area under the receiver–operator characteristic curve of 0·84 and 0·85 for prediction of death at 12 and 24 months respectively (both P < 0·001).
Conclusion
This model accurately estimated the probability of death within 12 and 24 months. This may aid the MDT decision-making process.
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Affiliation(s)
- D A C Deans
- University Department of Surgery, Royal Infirmary, 51 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SA, UK.
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28
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Magno P, Giday SA, Gabrielson KL, Shin EJ, Buscaglia JM, Clarke JO, Ko CW, Jagannath SB, Canto MI, Sedrakyan G, Kantsevoy SV. EUS-guided implantation of radiopaque marker into mediastinal and celiac lymph nodes is safe and effective. Gastrointest Endosc 2007; 66:387-92. [PMID: 17643719 DOI: 10.1016/j.gie.2006.12.063] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2006] [Accepted: 12/26/2006] [Indexed: 02/08/2023]
Abstract
BACKGROUND EUS is the preferred modality for local staging of esophageal cancer. The presence of a long-lasting fluoroscopically visible marker of malignant lymph nodes would facilitate subsequent radiation and surgical therapy. OBJECTIVE To assess the feasibility of EUS-guided implantation of a radiopaque marker (tantalum) into mediastinal and celiac lymph nodes in a porcine model. SETTING Survival experiments on six 50-kg pigs. DESIGN AND INTERVENTIONS A linear-array echoendoscope was advanced into the esophagus and the stomach. Mediastinal and celiac lymph nodes were identified and injected with 1 mL tantalum suspension by using 19- and 22-gauge FNA needles under fluoroscopy. The pigs were recovered. Fluoroscopy was repeated after 1, 2, and 4 weeks, then a postmortem examination was performed. MAIN OUTCOME MEASUREMENTS Long-term opacification of lymph nodes. RESULTS It was not possible to inject tantalum through the 22-gauge FNA needle because of its rapid precipitation inside the needle, which caused needle occlusion. Intranodal injection with the 19-gauge FNA needle was easily accomplished and resulted in excellent fluoroscopic opacification of injected lymph nodes. Repeat fluoroscopy at 1, 2, and 4 weeks demonstrated stable tantalum deposition at the injection site. There were no complications. Histologic examination of harvested lymph nodes revealed intranodal tantalum depositions without signs of infection, inflammation, tissue damage, or necrosis. CONCLUSIONS EUS-guided implantation of tantalum as a radiopaque marker into mediastinal and celiac lymph nodes in a porcine model is technically feasible, safe, and results in long-lasting intranodal depositions to facilitate subsequent surgical and radiotherapeutic interventions.
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Affiliation(s)
- Priscilla Magno
- Department of Medicine, Division of Gastroenterology, Johns Hopkins University, Baltimore, Maryland 21205, USA
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29
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Davies AR, Deans DAC, Penman I, Plevris JN, Fletcher J, Wall L, Phillips H, Gilmour H, Patel D, de Beaux A, Paterson-Brown S. The multidisciplinary team meeting improves staging accuracy and treatment selection for gastro-esophageal cancer. Dis Esophagus 2006; 19:496-503. [PMID: 17069595 DOI: 10.1111/j.1442-2050.2006.00629.x] [Citation(s) in RCA: 116] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The object of this article is to assess current staging accuracies for individual modalities and to investigate the influence of the multidisciplinary team (MDT) on clinical staging accuracies and treatment selection for patients with gastro-esophageal cancer. Patients newly diagnosed with gastric or esophageal cancer and who were deemed suitable for surgical resection by the MDT were studied. Patients were staged with a combination of computerized tomography (CT), endoscopic ultrasound (EUS) and laparoscopic ultrasound (LUS). Additionally, the MDT determined an overall clinical stage for each patient after discussion at the MDT meeting. Treatments were selected according to this final clinical stage. Final histopathological staging (pTNM) was available for all patients and was used as the gold standard for determining staging accuracy. Suitability of treatment selection was assessed once final pTNM was available. One hundred and eighteen patients were studied. Endoscopic ultrasound was the most accurate individual staging modality for the loco-regional assessment of esophageal tumors (T stage accuracy 78%, N stage accuracy 70%). Laparoscopic ultrasound was the most accurate modality in T staging of gastric cancers (91%). The MDT stage was more accurate than each individual staging modality for T and N staging for both gastric and esophageal cancers (accuracy range: 88-89%) and was better for the assessment of nodal disease than each individual modality (CT P < 0.001, EUS P < 0.01, LUS P < 0.01). Overall staging accuracy as determined at the MDT meeting was increased and resulted in only 2/118 (2%) patients being under-treated. The MDT significantly improves staging accuracy for gastro-esophageal cancer and ensures that correct management decisions are made for the highest number of individual patients.
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Affiliation(s)
- A R Davies
- Department of Surgery, Lothian Oesophago-Gastric Cancer Group, Royal Infirmary, Edinburgh, UK
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30
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Singh P, Camazine B, Jadhav Y, Gupta R, Mukhopadhyay P, Khan A, Reddy R, Zheng Q, Smith DD, Khode R, Bhatt B, Bhat S, Yaqub Y, Shah RS, Sharma A, Sikka P, Erickson RA. Endoscopic ultrasound as a first test for diagnosis and staging of lung cancer: a prospective study. Am J Respir Crit Care Med 2006; 175:345-54. [PMID: 17068326 DOI: 10.1164/rccm.200606-851oc] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
RATIONALE Multiple tests are required for the management of lung cancer. OBJECTIVES Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) was evaluated as a single test for the diagnosis and staging (thoracic and extrathoracic) of lung cancer. METHODS Consecutive subjects with computed tomography (CT) findings of a lung mass were enrolled for EUS and results were compared with those from CT and positron emission tomography scans. RESULTS Of 113 subjects with lung cancer, EUS was performed as a first test (after CT scan) for diagnosis in 93 (82%) of them. EUS-FNA established tissue diagnosis in 70% of cases. EUS-FNA, CT, and positron emission tomography detected metastases to the mediastinal lymph nodes with accuracies of 93, 81, and 83%, respectively. EUS-FNA was significantly better than CT at detecting distant metastases (accuracies of 97 and 89%, respectively; p = 0.02). Metastases to lymph nodes at the celiac axis (CLNs) were observed in 11% of cases. The diagnostic yields of EUS-FNA and CT for detection of metastases to the CLNs were 100 and 50%, respectively (p < 0.05). EUS was able to detect small metastases (less than 1 cm) often missed by CT. Metastasis to the CLNs was a predictor of poor survival of subjects with non-small cell lung cancer, irrespective of the size of the CLNs. Of 44 cases with resectable tumor on CT scan, EUS-FNA avoided thoracotomy in 14% of cases. CONCLUSIONS EUS-FNA as a first test (after CT) has high diagnostic yield and accuracy for detecting lung cancer metastases to the mediastinum and distant sites. Metastasis to the CLNs is associated with poor prognosis. EUS-FNA is able to detect occult metastasis to the CLNs and thus avoids thoracotomy.
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Affiliation(s)
- Pankaj Singh
- Division of Gastroenterology, Central Texas Veterans Health Care System, Temple, TX 76504, USA.
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31
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Matthes K, Bounds BC, Collier K, Gutierrez A, Brugge WR. EUS staging of upper GI malignancies: results of a prospective randomized trial. Gastrointest Endosc 2006; 64:496-502. [PMID: 16996338 DOI: 10.1016/j.gie.2006.01.023] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2005] [Accepted: 01/02/2006] [Indexed: 02/08/2023]
Abstract
BACKGROUND Electronic 270 degrees transverse-array EUS (TA-EUS) provides high-quality cross-sectional images but cannot guide FNA. Linear EUS (L-EUS) provides longitudinal images of malignancies and the ability to guide FNA. OBJECTIVE We conducted a prospective randomized comparison of TA-EUS and L-EUS for the staging of upper-GI (UGI) malignancies. DESIGN Forty-three patients underwent L-EUS immediately followed by TA-EUS (N = 27, 63%) or TA-EUS immediately followed by L-EUS (N = 16, 37%). PATIENTS Forty-three subjects (mean age, 64 years; 37 men) with an UGI malignancy (4 stomach and 38 esophageal) were evaluated with both TA-EUS and L-EUS. INTERVENTIONS Abnormal lymph nodes were sampled by FNA for cytology. RESULTS There was agreement on the T stage by linear and radial techniques in 38 of 43 subjects (88%). Twenty-seven of 43 patients (63%) had abnormal lymph nodes by linear or transverse-array imaging. L-EUS demonstrated 66 abnormal lymph nodes in 27 subjects (average of 2.4 nodes/subject). TA-EUS demonstrated 90 abnormal lymph nodes in 27 subjects (average of 3.3 nodes/subject, P = .009, compared with L-EUS). In 16 of the 27 subjects, an FNA was performed, which was positive in 13 cases (81%) and negative in 3 cases (10%) for malignancy. CONCLUSIONS TA-EUS and L-EUS provide similar results of T staging of UGI malignancies. However, the number of abnormal lymph nodes detected by TA-EUS was more than by L-EUS. These findings suggest that radial or transverse-array EUS imaging should be the primary method for staging of UGI malignancies.
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Affiliation(s)
- Kai Matthes
- Gastrointestinal Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Gerke H, Silva RG, Shamoun D, Johnson CJ, Jensen CS. EUS characteristics of celiac ganglia with cytologic and histologic confirmation. Gastrointest Endosc 2006; 64:35-9. [PMID: 16813800 DOI: 10.1016/j.gie.2006.01.071] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2005] [Accepted: 01/23/2006] [Indexed: 02/08/2023]
Abstract
BACKGROUND Celiac ganglia have not been previously identified by EUS. OBJECTIVE To assess whether celiac ganglia can be detected by EUS and to define their characteristics. DESIGN Retrospective review followed by prospective study. METHODS Retrospective characterization was performed of all celiac ganglia that were incidentally identified by EUS-guided FNA or tru-cut needle biopsy from January 2004 to October 2005. We also prospectively assessed if these structures could be visualized in consecutive patients undergoing curved linear-array EUS. PATIENTS Seven patients with celiac ganglia diagnosed by EUS-guided FNA (n = 7) and/or tru-cut needle biopsy (n = 1) were reviewed. Twenty-two patients were prospectively evaluated by curved-linear-array EUS. SETTINGS Division of Gastroenterology and Hepatology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA. MAIN OUTCOME MEASUREMENTS EUS features and detection rate of celiac ganglia. RESULTS All retrospectively evaluated celiac ganglia were identified anterior to the aorta, slightly to the left, and cephalad to the celiac artery take-off, and medial to the left adrenal gland. The mean distance from the celiac artery take-off was 10 mm (+/-3 mm); mean size was 13 mm (+/-3 mm) by 6 mm (+/-2 mm). They appeared as hypoechoic and multilobulated structures with hyperechoic strands. Celiac ganglia with sonographic features as described above were identified in 16 of 22 prospectively evaluated patients (73%). LIMITATIONS Small number of patients; no tissue confirmation of prospectively evaluated patients. CONCLUSIONS Celiac ganglia can be identified with curved linear-array EUS in the majority of patients. Their typical EUS appearance allows distinction from celiac lymph nodes.
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Affiliation(s)
- Henning Gerke
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Iowa Hospitals and Clinics, 200 Hawkins Drive-4568 JCP, Iowa City, IA 52242, USA
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van Vliet EPM, Eijkemans MJC, Poley JW, Steyerberg EW, Kuipers EJ, Siersema PD. Staging of esophageal carcinoma in a low-volume EUS center compared with reported results from high-volume centers. Gastrointest Endosc 2006; 63:938-47. [PMID: 16733107 DOI: 10.1016/j.gie.2006.01.053] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2005] [Accepted: 01/09/2006] [Indexed: 02/08/2023]
Abstract
BACKGROUND It is well known that a learning curve exists for performing EUS. OBJECTIVE To determine whether the number of EUS investigations performed in a center affects the results of esophageal cancer staging. DESIGN We compared EUS in the evaluation of T stage and the presence of regional and celiac lymph nodes in a low-volume center where <50 EUS/endoscopist/y were performed with reported results from 7 high-volume EUS centers. SETTING A reference center for esophageal cancer (>90 cases/y) but a low-volume center for EUS when it comes to individual endoscopists. PATIENTS From 1994 to 2003, 244 patients underwent EUS, without specific measures to pass a stenotic tumor or FNA and with postoperative TNM stage as the criterion standard in the low-volume EUS center. In the high-volume centers, 670 EUS investigations for esophageal cancer were performed, if needed, with dilation, and with postoperative TNM stage and/or FNA as the criterion standard. INTERVENTIONS Retrospective analysis. MAIN OUTCOME MEASUREMENTS Sensitivity and specificity of EUS for esophageal cancer staging. RESULTS In the low-volume center, results of EUS for T3 staging in patients in whom passage of the EUS probe was possible were almost comparable for sensitivity (85% vs 88%-94%) but were lower for specificity (57% vs 75%-90%), whereas both sensitivity (58% vs 75%-90%) and specificity (87% vs 94%-97%) for T1 or T2 stages were lower than those reported in the high-volume centers. In the low-volume center, sensitivities of EUS for regional (45% vs 63%-89%) and celiac (19% vs 72%-83%) lymph nodes were lower, whereas specificities (75% vs 63%-82% and 99% vs 85%-100%, respectively) were comparable with those from high-volume centers. Results in the low-volume EUS center were worse if the EUS probe could not pass the stricture, which occurred in almost 30% of patients. LIMITATIONS Both FNA and dilation before EUS for stenotic tumors were not performed in the low-volume EUS center. CONCLUSIONS The results of EUS performed in a low-volume EUS center compared unfavorably with those reported from high-volume EUS centers. The results of this study suggest that preoperative staging by EUS should be performed by experienced and dedicated EUS endoscopists to optimize staging of esophageal cancer.
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Affiliation(s)
- Evelyn P M van Vliet
- Department of Gastroenterology and Hepatology, Erasmus MC-University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands
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Griffiths EA, Brummell Z, Gorthi G, Pritchard SA, Welch IM. Tumor length as a prognostic factor in esophageal malignancy: univariate and multivariate survival analyses. J Surg Oncol 2006; 93:258-67. [PMID: 16496364 DOI: 10.1002/jso.20449] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND OBJECTIVES Gastrointestinal specialists generally feel that long esophageal tumors carry a worse prognosis and are likely to be more advanced than shorter lesions. Our aim was to investigate the relationship between histologically determined tumor length and aspects of tumor pathology and survival for patients with resected esophageal malignancy. METHODS Three hundred and nine patients who underwent esophageal resection with curative intent in our unit between 1994 and 2003 were retrospectively analyzed. Pathological details such as TNM stage, differentiation, completeness of surgical resection, and overall stage were collected. Survival data were obtained for each patient and univariate and multivariate analyses were performed. Overall survival was used as the primary endpoint. RESULTS There were 225 adenocarcinomas, 72 squamous cell carcinomas, and 12 other tumor types with a median tumor length of 3.5 cm (range 0.5-14 cm). Tumor length greater than 3.5 cm was associated with increasing T stage (P = 0.0001), N stage (P = 0.032), overall stage (P = 0.003), and involvement of the longitudinal resection margins (P = 0.02). Univariate analysis found tumor length greater than 3.5 cm was associated with worse overall survival compared with shorter tumors (P = 0.0002). Tumor length remained a significant prognostic factor on multivariate analysis (P = 0.04). Other prognostic factors on multivariate analysis were age, tumor differentiation, nodal involvement, and resection margin status. CONCLUSION Tumor length greater than 3.5 cm (as determined histologically) is associated with worse disease stage and poor overall patient survival. If preoperative endoscopic tumor length bears a similar relationship, this could assist in patient selection for appropriate treatments.
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Affiliation(s)
- Ewen A Griffiths
- Department of Gastrointestinal Surgery, South Manchester University Hospitals NHS Trust, Wythenshawe, Manchester, United Kingdom
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Wittmann J, Kocjan G, Sgouros SN, Deheragoda M, Pereira SP. Endoscopic ultrasound-guided tissue sampling by combined fine needle aspiration and trucut needle biopsy: a prospective study. Cytopathology 2006; 17:27-33. [PMID: 16417562 DOI: 10.1111/j.1365-2303.2006.00313.x] [Citation(s) in RCA: 120] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) has a diagnostic accuracy of 70-90%, depending on the site under evaluation. In order to improve EUS-guided tissue sampling a novel 19-gauge trucut-type needle has been designed to obtain core biopsies during EUS. We prospectively evaluated the safety and accuracy of EUS-FNA alone versus combined EUS-FNA and trucut needle biopsy (TNB) in patients referred to our Unit over a 3-year period. PATIENTS AND METHODS A total of 159 patients underwent EUS-FNA alone (lesions<2 cm) or the combination of both sampling modalities (lesions>or=2 cm). The adequacy of sampling, sensitivity, specificity and overall accuracies of EUS-FNA or EUS-TNB alone and combined EUS-FNA/TNB were determined. RESULTS Adequate samples were obtained by EUS-FNA, EUS-TNB and EUS-FNA/TNB in 91%, 88% and 97% of patients, respectively. From the pancreas (n=83), adequate samples were obtained by FNA in 94% and by TNB in 81%, compared with 87% and 92% from non-pancreatic sites (n=76), respectively. The combination of both techniques resulted in more adequate samples from non-pancreatic cases than EUS-FNA alone (P=0.044). The specificity was 100%. Overall accuracy for EUS-FNA alone was 77%, for EUS-TNB alone 73% and for EUS-FNA/TNB 91% (P=0.008). For pancreatic sampling, the accuracy of EUS-FNA alone was 77%, for EUS-TNB alone 56% and for EUS-FNA/TNB 83%. For non-pancreatic sampling, the accuracy for EUS-FNA alone was 78%, for EUS-TNB alone 83% and for EUS-FNA/TNB 95% (P=0.006). The complication rate was 0.6%. CONCLUSIONS Combined EUS-FNA/TNB for lesions>or=2 cm improves adequacy of sampling and diagnostic accuracy compared with either technique alone and is safe.
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Affiliation(s)
- J Wittmann
- Department of Gastroenterology, University College London Hospitals NHS Foundation Trust, London, UK
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Vazquez-Sequeiros E, Levy MJ, Clain JE, Schwartz DA, Harewood GC, Salomao D, Wiersema MJ. Routine vs. selective EUS-guided FNA approach for preoperative nodal staging of esophageal carcinoma. Gastrointest Endosc 2006; 63:204-11. [PMID: 16427921 DOI: 10.1016/j.gie.2005.08.053] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2005] [Accepted: 08/31/2005] [Indexed: 12/21/2022]
Abstract
BACKGROUND EUS-guided FNA (EUS-FNA) is the most accurate method for lymph-node staging of esophageal carcinoma; however, it may not be necessary when EUS features are present that strongly suggest a benign or a malignant origin. AIMS (1) To identify a combination of EUS criteria that have a sufficient sensitivity and specificity to preclude the need for EUS-FNA and (2) to assess the cost savings derived from a selective EUS-FNA approach. METHODS A total of 144 patients with esophageal carcinoma were prospectively evaluated with EUS. Accuracy of standard (hypoechoic, smooth border, round, or width > 5 mm) and modified (4 standard plus EUS identified celiac lymph nodes, >5 lymph nodes, or EUS T3/4 tumor) criteria were compared (receiver operating characteristic curves). Resource utilization of two diagnostic strategies, routine (all patients with lymph nodes) and selective EUS-FNA (FNA only in those patients in whom the number of EUS malignant criteria provides a sensitivity and a specificity <100%), were compared. RESULTS Modified EUS criteria for lymph-node staging were more accurate than standard criteria (area under the curve 0.88 vs. 0.78, respectively). No criterion alone was predictive of malignancy; sensitivity and specificity reached 100% when a cutoff value of >1 and >6 modified criteria were used, respectively. The EUS-FNA selective approach may avoid performing FNA in 61 patients (42%). CONCLUSIONS Modified EUS lymph-node criteria are more accurate than standard criteria. A selective EUS-FNA approach reduced the cost by avoiding EUS-FNA in 42% of patients with esophageal carcinoma. These results require confirmation in future studies.
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Affiliation(s)
- Enrique Vazquez-Sequeiros
- ivision of Gastroenterology and Hepatology, Pathology Department, Mayo Clinic Rochester, Rochester, Minnesota, USA
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Abstract
Endoscopic ultrasound, which was developed more than 20 years ago, is currently a valuable investigative tool for endoscopists. It began as a diagnostic instrument and in the short span of a decade made a clinical impact as a therapeutic tool with a promising potential for various interventional applications. The introduction of the curved linear array echoendoscope in the 1990s enabled a whole range of interventional applications of endoscopic ultrasound ranging from fine needle aspiration of lesions surrounding the gastrointestinal tract to celiac plexus block and drainage of pancreatic pseudocyst. This review article outlines the current interventional applications of endoscopic ultrasound and discusses potential future procedures. These procedures include endoscopic ultrasound guided creation of communication between the gastrointestinal tract and adjacent organs, such as hepaticogastrostomy and choledochoduodenostomy.
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Affiliation(s)
- Melvin Raj
- Department of Gastroenterology, Western Hospital, Melbourne, Victoria, Australia
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Abstract
Accurate staging defines groups for stage-specific treatment, minimising inappropriate treatment. Application of dedicated staging methods - including 16-64 multidetector computed tomography (CT), endoscopic ultrasonography with fine-needle aspiration (EUS-FNA) and positron emission tomography (PET) - results in better staging of oesophageal cancer. PET as a metabolic imaging technique that is usually applied after (or recently in combination with) CT (PET/CT) improves the accuracy of non-invasive staging, especially in locally advanced oesophageal cancer patients. Whether EUS-FNA or PET/CT should be performed as a first diagnostic step is still a matter of debate. Fluoro-2-deoxyglucose (FDG) PET is also promising tool in assessing neoadjuvant treatment response. Application of these dedicated staging methods has a learning curve, suggesting a prominent role for centralisation.
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Affiliation(s)
- J Th M Plukker
- Department of Surgical Oncology and Abdominal Surgery, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB Groningen, The Netherlands.
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Yau KK, Siu WT, Cheung HYS, Li ACN, Yang GPC, Li MKW. Immediate preoperative laparoscopic staging for squamous cell carcinoma of the esophagus. Surg Endosc 2005; 20:307-10. [PMID: 16362473 DOI: 10.1007/s00464-005-0336-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2005] [Accepted: 10/02/2005] [Indexed: 12/24/2022]
Abstract
BACKGROUND Conventional preoperative staging for esophageal carcinoma could be inaccurate. Laparoscopy has been applied for the staging of various upper gastrointestinal malignancies. It can identify peritoneal and liver deposits not shown by imaging, and could reduce the number of nontherapeutic laparotomies. This study aimed to evaluate the efficacy of laparoscopic staging for the management of squamous cell carcinoma involving the mid and distal esophagus. METHODS A retrospective review was performed for all patients with esophageal cancer evaluated for surgical resection from January 1998 to January 2004. Laparoscopy was performed for all the patients with mid and distal esophageal cancer immediately before open gastric mobilization. The efficacy of laparoscopy for the management of squamous cell carcinoma of the esophagus was evaluated. RESULTS Among the 63 patients with potentially resectable disease shown on conventional imaging, 54 (84%) underwent esophagectomy with curative intent after laparoscopic staging. Seven patients (11%) underwent laparoscopy alone because of abdominal metastases (n = 5) or other medical conditions (n = 2) that precluded esophagectomy. Two patients (3%) had exploratory right thoracotomy without esophagectomy despite normal laparoscopic findings. The sensitivity and specificity of laparoscopic staging were 100% in this series of patients (100% sensitivity and specificity means no false-positives or -negatives). CONCLUSION Laparoscopic staging is valuable for the management of patients with mid and distal squamous cell carcinoma of the esophagus. Patients with metastatic disease and those with prohibitive surgical risk can thus avoid unnecessary laparotomy and be offered other treatment methods.
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Affiliation(s)
- K K Yau
- Department of Surgery, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong
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40
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Milinić N. [Aspiration biopsy, puncture and neurolysis of coeliac plexus with guided linear endoscopic ultrasonography--personal experience]. ACTA ACUST UNITED AC 2005; 52:109-13. [PMID: 16119323 DOI: 10.2298/aci0501109m] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Endoscopic ultrasonography, as relatively new diagnostic procedure, has made a significant progress in detection and presentation of small lesions of digestive tract, as well as in other organs. By introducing linear ultrasonography in clinical practice, the possibilities of this procedure became even more apparent, anabling even more precise diagnosis and various therapeutic procedures. With endoscopic ultrasound (EUS) guided aspiration biopsy it is possible to obtain samples in specific, well defined layer of gastrointestinal tract wall, and also from different parts of other organs and formations, which finaly enables establishing definite patohystologic diagnosis. First linear EUS procedure in this part of south-east Europe, was performed in University Clinical Center "Bezanijska Kosa" (N. Milinic, M. Petrovic) in 1999, and first EUS guided aspiration biopsy was performed on July 4th 2000 (N. Milinic--biopsy of pancreas). Using "Pentax" FG-36UX linear echo-endoscope, until now, 40 pancreas biopsies, 34 stomach biopsies, 9 biopsies of mediastinal lymph nodes, cysts and tumors, 22 biopsies of masses in retroperitoneal region, 7 biopsies of papilla Vateri, 4 biopsies of left suprarenal gland, 2 punctures of renal cysts, 14 biopsies of focal liver lesions, 2 punctures of liver cysts, and 5 neurolyses of coeliac plexus was performed. From 134 EUS guided biopsy samples, 114 was, according to pathologist, adequate for patohystologic evaluation, and in 96 cases obtained samples was essential for obtaining definite diagnosis. The major problem in this issue was a lack of well trained and expirienced cytologist, as also is the current problem in Western countires with more expirience and practice in this field. EUS guided aspiration biopsy, as the procedure itself, was successful in all cases. There were no major complications during the procedures, mainly because of using Colour-Doppler technique in defferentiating vascular from other structures. Results so far are showing that linear endoscopic ultrasonography is extremely precise diagnostic method, and should be used in establishing definite diagnosis in many well defined indications, and also is showing the consecutive need for specialy trained and expirienced citologists.
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Lightdale CJ, Kulkarni KG. Role of endoscopic ultrasonography in the staging and follow-up of esophageal cancer. J Clin Oncol 2005; 23:4483-9. [PMID: 16002838 DOI: 10.1200/jco.2005.20.644] [Citation(s) in RCA: 124] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
PURPOSE To evaluate the role of endoscopic ultrasonography (EUS) in the initial staging and follow-up of esophageal cancer on the basis of a review of the published literature. METHODS Articles published from 1985 to 2005 were searched and reviewed using the following keywords: "esophageal cancer staging," "endoscopic ultrasound," and "endoscopic ultrasonography." RESULTS For initial anatomic staging, EUS results have consistently shown more than 80% accuracy compared with surgical pathology for depth of tumor invasion (T). Accuracy increased with higher stage, and was >90% for T3 cancer. EUS results have shown accuracy in the range of 75% for initial staging of regional lymph nodes (N). EUS has been invariably more accurate than computed tomography for T and N staging. EUS is limited for staging distant metastases (M), and therefore EUS is usually performed after a body imaging modality such as computed tomography or positron emission tomography. Pathologic staging can be achieved at EUS using fine-needle aspiration (FNA) to obtain cytology from suspect Ns. FNA has had greatest efficacy in confirming celiac axis lymph node metastases with more than 90% accuracy. EUS is inaccurate for staging after radiation and chemotherapy because of inability to distinguish inflammation and fibrosis from residual cancer, but a more than 50% decrease in tumor cross-sectional area or diameter has been found to correlate with treatment response. CONCLUSION EUS has a central role in the initial anatomic staging of esophageal cancer because of its high accuracy in determining the extent of locoregional disease. EUS is inaccurate for staging after radiation therapy and chemotherapy, but can be useful in assessing treatment response.
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Affiliation(s)
- Charles J Lightdale
- Columbia University Medical Center, 161 Fort Washington Ave, New York, NY 10032, USA.
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Reddy RP, Levy MJ, Wiersema MJ. Endoscopic ultrasound for luminal malignancies. Gastrointest Endosc Clin N Am 2005; 15:399-429, vii. [PMID: 15990049 DOI: 10.1016/j.giec.2005.03.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Luminal gastrointestinal (GI) tract cancers are responsible for substantial morbidity and mortality. Since the first pairing of ultrasonography with endoscopy in 1980, technologic advances and the increased availability of trained endosonographers have propelled endoscopic ultrasonography (EUS) to the forefront of luminal GI cancer staging. In this article we discuss the role of EUS for evaluating luminal GI cancers.
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Affiliation(s)
- Raghuram P Reddy
- Developmental Endoscopy Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, USA
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43
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Abstract
The management of solid organ cancers relies on accurate staging. Once distal metastasis has been excluded by conventional radiographic methods, local staging of the tumor and its nodal involvement is essential to determine the most optimal therapeutic approach. Many radiographic imaging modalities are unable to determine subtle tumor involvement. However, the emergence of endoscopic ultrasonography (EUS) has given promise to improved staging with its unique ability to examine tumors from within the gastrointestinal lumen with extremely close proximity. An additional advantage is the ability to perform fine-needle aspiration (FNA) biopsy to confirm or exclude tumor involvement. Many studies have shown superior accuracy in staging with EUS and EUS-FNA for tumors of the esophagus, stomach, pancreas, rectum, and mediastinum, including lung cancer. This review illustrates the principles of EUS and its role in staging of a variety of cancers and particularly its role alongside other imaging modalities.
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Affiliation(s)
- Jayaprakash Sreenarasimhaiah
- Department of Medicine, Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas 75390, USA.
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Wang KK, Wongkeesong M, Buttar NS. American Gastroenterological Association technical review on the role of the gastroenterologist in the management of esophageal carcinoma. Gastroenterology 2005; 128:1471-505. [PMID: 15887129 DOI: 10.1053/j.gastro.2005.03.077] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Kenneth K Wang
- Barrett's Esophagus Unit, St. Mary's Hospital, Mayo Clinic, Rochester, Minnesota, USA
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45
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Dhar DK, Yoshimura H, Kinukawa N, Maruyama R, Tachibana M, Kohno H, Kubota H, Nagasue N. Metastatic lymph node size and colorectal cancer prognosis. J Am Coll Surg 2005; 200:20-8. [PMID: 15631916 DOI: 10.1016/j.jamcollsurg.2004.09.037] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2004] [Revised: 09/14/2004] [Accepted: 09/21/2004] [Indexed: 12/17/2022]
Abstract
BACKGROUND Colorectal cancer patients with lymph node metastasis constitute a heterogeneous population with variable prognoses. In this study, my colleagues and I propose a simpler lymph node (LN) staging system for colorectal cancer. STUDY DESIGN Four-hundred and twenty-three consecutive colorectal cancer patients were studied. Of these, 36 were excluded because another carcinoma was present. The remaining 387 patients entered the TNM staging analysis. In the survival analysis, 76 patients with distant metastasis were excluded and the remaining 311 patients (LN(-) = 204 and LN(+) = 107) were studied. The diameter of the largest metastatic LN (MLN) was measured on histopathological slides. After examination of various cutpoints and survival outcomes, patients with MLNs were classified into n1 (< or = 9 mm) and n2 (> or = 10 mm) groups, according to size of MLNs (n-stage). RESULTS Using disease-free survival (DFS) and overall survival (OS) as outcomes, patients were separated into significant prognostic groups by MLN size (univariate, p < 0.0001) (5-year survival, DFS: n0 = 91.5%, n1 = 62.2%, and n2 = 34.4%; OS: n0 = 85.1%, n1 = 63.5%, and n2 = 42.5%) and International Union Against Cancer/American Joint Committee on Cancer (UICC/AJCC) (N-stage) (univariate, p < 0.0001) (5-year survival, DFS: N0 = 91.5%, N1 = 60.5%, and N2 = 36.8%; OS: N0 = 85.1%, N1 = 65.3%, and N2 = 38.0%). But in patients with fewer than 15 LNs examined (n = 31), only the new nodal stage stratified patients into significant groups (OS: p = 0.003 and DFS: p = 0.001). Only the UICC/AJCC N-stage subcategories were further split into significant prognostic groups by MLN size (UICC/AJCC N1: DFS, p = 0.048 and OS, p = 0.11; N2: DFS, p = 0.04 and OS, p = 0.04). n-stage was an independent important factor both in the DFS and OS in multivariable analysis. CONCLUSIONS MLN size is a strong prognostic variable in colorectal carcinoma. This new metric may help clinicians treating colorectal cancer patients, but additional studies are required before clinical application.
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Affiliation(s)
- Dipok Kumar Dhar
- Department of Digestive and General Surgery, Shimane University, Izumo 693-8501, Japan
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Abstract
Although the prognosis for patients with early cancer is good, throughout the world the majority of patients present with advanced disease, and in them, survival is poor. Accurate staging is essential to inform prognosis; to select candidates who may be cured by surgery alone; to select patients requiring neoadjuvant therapy, especially when new protocols are being studied; and to detect patients with advanced disease who would be best served by palliative therapy.
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Affiliation(s)
- Ian D Penman
- Gastrointestinal Unit, Western General Hospital, NHS Trust, Crewe Road, Edinburgh EH4 2XU, UK.
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47
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Abstract
The diagnosis and accurate staging of esophageal adenocarcinoma remains one of the greatest challenges for non-invasive imaging techniques. All modalities have limitations and require a rational application of combined tools in order to assess the extent of loco-regional tumor and distant metastatic disease. The fundamental role remains defining organ-confined disease and mapping non-organ confined disease. Endoscopic ultrasound combined with multislice computed tomography (CT) is the mainstay of morphologic loco-regional staging. In recent years, functional metabolic 2-[fluorine-18]fluoro-2-deoxy-D-glucose (FDG)-positron emission tomography (PET) has emerged as a particularly useful adjunct to detect occult metastatic disease, to predict response to neoadjuvant therapy and to document recurrent disease. The current imaging algorithm and new developments in imaging assessment will be reviewed.
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Affiliation(s)
- Ernesto Castillo
- Instituto Radiológico Castillo, Fernández de la Hoz 51, 28003 Madrid, Spain
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48
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Abstract
Since first introduced over 20 years ago, endoscopic ultrasonography (EUS) has become established as an important tool in the staging of gastrointestinal malignancies and potentially resectable non-small cell lung cancer. This review describes the current roles of EUS in staging these tumours, highlighting interventional roles, current problem areas and future developments.
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Affiliation(s)
- E Henry
- Gastrointestinal Unit, Western General Hospital, Edinburgh EH4 2XU, UK
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van Westreenen HL, Westerterp M, Bossuyt PMM, Pruim J, Sloof GW, van Lanschot JJB, Groen H, Plukker JTM. Systematic review of the staging performance of 18F-fluorodeoxyglucose positron emission tomography in esophageal cancer. J Clin Oncol 2004; 22:3805-12. [PMID: 15365078 DOI: 10.1200/jco.2004.01.083] [Citation(s) in RCA: 246] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
PURPOSE Despite the increasing number of publications concerning (18)F-fluorodeoxyglucose positron emission tomography (FDG-PET) for staging of esophageal cancer and the increasing availability of this novel diagnostic modality, its exact role in preoperative staging of these tumors is still unknown. The aim of this study was to systematically review the literature regarding the diagnostic performance of FDG-PET in preoperative staging of patients with esophageal cancer, and to calculate summary estimates of its sensitivity and specificity. METHODS The databases of PubMed, Embase, and Cochrane were searched for relevant studies. Two reviewers independently assessed the methodological quality of each study. A meta-analysis of the reported sensitivity and specificity of each study was performed. RESULTS Twelve studies met the inclusion criteria. The studies had several design deficiencies. Pooled sensitivity and specificity for the detection of locoregional metastases were 0.51 (95% CI, 0.34 to 0.69) and 0.84 (95% CI, 0.76 to 0.91), respectively. For distant metastases, pooled sensitivity and specificity were 0.67 (95% CI, 0.58 to 0.76) and 0.97 (95% CI, 0.90 to 1.0), respectively. CONCLUSION FDG-PET showed moderate sensitivity and specificity for the detection of locoregional metastases, and reasonable sensitivity and specificity in detection of distant lymphatic and hematogenous metastases.
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Affiliation(s)
- H L van Westreenen
- Department of Surgery, University Hospital Groningen, Groningen, The Netherlands
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Koshy M, Esiashvilli N, Landry JC, Thomas CR, Matthews RH. Multiple management modalities in esophageal cancer: epidemiology, presentation and progression, work-up, and surgical approaches. Oncologist 2004; 9:137-46. [PMID: 15047918 DOI: 10.1634/theoncologist.9-2-137] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Annually, approximately 13,200 people in the U.S. are diagnosed with esophageal cancer and 12,500 die of this malignancy. Of new cases, 9,900 occur in men and 3,300 occur in women. In part I of this two-part series, we explore the epidemiology, presentation and progression, work-up, and surgical approaches for esophageal cancer. In the 1960s, squamous cell cancers made up greater than 90% of all esophageal tumors. The incidence of esophageal adenocarcinomas has risen considerably over the past two decades, such that they are now more prevalent than squamous cell cancer in the western hemisphere. Despite advances in therapeutic modalities for this disease, half the patients are incurable at presentation, and overall survival after diagnosis is grim. Evolving knowledge regarding the etiology of esophageal carcinoma may lead to better preventive methods and treatment options for early stage superficial cancers of the esophagus. The use of endoscopic ultrasound and the developing role of positron emission tomography have led to better diagnostic accuracy in this disease. For years, the standard of care for esophageal cancer has been surgery; there are several variants of the surgical approach. We will discuss combined modality approaches in part II of this series.
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Affiliation(s)
- Mary Koshy
- Emory University School of Medicine, Department of Radiation Oncology, Atlanta, Georgia, USA
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