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Kahlon S, Aamar A, Butt Z, Urayama S. Role of endoscopic ultrasound for pre-intervention evaluation in early esophageal cancer. World J Gastrointest Endosc 2023; 15:447-457. [PMID: 37397975 PMCID: PMC10308272 DOI: 10.4253/wjge.v15.i6.447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 04/08/2023] [Accepted: 05/12/2023] [Indexed: 06/14/2023] Open
Abstract
BACKGROUND Endoscopic ultrasound (EUS) stands as an accurate imaging modality for esophageal cancer staging, however utilization of EUS in early-stage cancer management remains controversial. Identification of non-applicability of endoscopic interventions with deep muscular invasion with EUS in pre-intervention evaluation of early-stage esophageal cancer is compared to endoscopic and histologic indicators.
AIM To display the role of EUS in pre-intervention early esophageal cancer staging and how the index endoscopic features of invasive esophageal malignancy compare for prediction of depth of invasion and cancer management.
METHODS This was a retrospective study of patients who underwent pre-resection EUS after a diagnosis of esophageal cancer at a tertiary medical center from 2012 to 2022. Patient clinical data, initial esophagogastroduodenoscopy/biopsy, EUS, and final resection pathology reports were abstracted, and statistical analysis was conducted to assess the role of EUS in management decisions.
RESULTS Forty nine patients were identified for this study. EUS T stage was concordant with histological T stage in 75.5% of patients. In determining submucosal involvement (T1a vs T1b), EUS had a specificity of 85.0%, sensitivity of 53.9%, and accuracy of 72.7%. Endoscopic features of tumor size > 2 cm and the presence of esophageal ulceration were significantly associated with deep invasion of cancer on histology. EUS affected management from endoscopic mucosal resection/submucosal dissection to esophagectomy in 23.5% of patients without esophageal ulceration and 6.9% of patients with tumor size < 2 cm. In patients without both endoscopic findings, EUS identified deeper cancer and changed management in 4.8% (1/20) of cases.
CONCLUSION EUS was reasonably specific in ruling out submucosal invasion but had relatively poor sensitivity. Data validated endoscopic indicators suggested superficial cancers in the group with a tumor size < 2 cm and the lack of esophageal ulceration. In patients with these findings, EUS rarely identified a deep cancer that warranted a change in management.
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Affiliation(s)
- Sartajdeep Kahlon
- Department of Internal Medicine, University of California-Davis, Sacramento, CA 95817, United States
| | - Ali Aamar
- Department of Internal Medicine, University of California-Davis, Sacramento, CA 95817, United States
| | - Zeeshan Butt
- Department of Internal Medicine, Baystate Medical Center, Springfield, MA 01199, United States
| | - Shiro Urayama
- Department of Internal Medicine, University of California-Davis, Sacramento, CA 95817, United States
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Gomez Cifuentes JD, Haider M, Sanaka MR, Kumar P, Bena J, McMichael J, Sohal DP, Raja S, Murthy S, Thota PN. Clinical Predictors of Locally Advanced Pathology in Esophageal Adenocarcinoma. Cureus 2021; 13:e18991. [PMID: 34820244 PMCID: PMC8607361 DOI: 10.7759/cureus.18991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2021] [Indexed: 11/26/2022] Open
Abstract
Background In patients with resectable esophageal adenocarcinoma (EAC), the decision for neoadjuvant treatment depends on clinical staging with endoscopic ultrasound (EUS) and positron-emission tomography (PET) scan. Patients with locally advanced EAC pathology misclassified as early EAC by clinical staging are missing the opportunity to receive neoadjuvant therapy. We aim to identify predictors of locally advanced pathology in EAC to determine more accurately those who benefit from neoadjuvant therapy. Methods Retrospective study of patients who underwent upfront endoscopic or surgical resection for EAC without neoadjuvant therapy from January 2011 to December 2017 was performed. Clinical characteristics, EUS, PET scan and histologic findings were analyzed. Multivariable analysis of predictors of locally advanced stage was performed and a risk prediction score was developed. Results A total of 97 patients were included; 68 patients were staged as early EAC (pT1 or pT2 and pN0) and 29 patients were staged as locally advanced EAC (pT1 or pT2 with pN1 and pT3 or pT4 irrespective of N status). In a predictive model of EAC, patients presenting with dysphagia, tumor size >2 cm, exophytic mass appearance on endoscopy and absence of hiatal hernia were more likely to be have locally advanced pathology with a probability of 70% (C-statistic 0.766). Conclusions A risk prediction model based on the presence of dysphagia, tumor size >2 cm, exophytic mass appearance and absence of hiatal hernia can be used to identify locally advanced pathology in EAC patients.
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Affiliation(s)
| | - Mahnur Haider
- Section of General Internal Medicine, Tulane Medical Center, New Orleans, USA
| | - Madhusudhan R Sanaka
- Center of Excellence for Barrett's Esophagus, Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, USA
| | - Prabhat Kumar
- Center of Excellence for Barrett's Esophagus, Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, USA
| | - James Bena
- Department of Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, USA
| | - John McMichael
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, USA
| | - Davendra P Sohal
- Department of Hematology and Oncology, University of Cincinnati, Cincinnati, USA
| | - Siva Raja
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, USA
| | - Sudish Murthy
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, USA
| | - Prashanthi N Thota
- Center of Excellence for Barrett's Esophagus, Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, USA
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3
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Klamt AL, Neyeloff JL, Santos LM, Mazzini GDS, Campos VJ, Gurski RR. Echoendoscopy in Preoperative Evaluation of Esophageal Adenocarcinoma and Gastroesophageal Junction: Systematic Review and Meta-analysis. ULTRASOUND IN MEDICINE & BIOLOGY 2021; 47:1657-1669. [PMID: 33896677 DOI: 10.1016/j.ultrasmedbio.2021.03.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 02/23/2021] [Accepted: 03/13/2021] [Indexed: 06/12/2023]
Abstract
Esophageal adenocarcinomas of the esophagus and esophagogastric junction constitute a global health problem, the incidence of which has increased in recent decades. It has a poor prognosis and a low 5-year survival rate. Its treatment is based on preoperative clinical staging, in which echoendoscopy plays an essential role. The aim of this study was to evaluate the current accuracy of echoendoscopy in the staging of esophageal and esophogogastric junction adenocarcinomas. A systematic review was performed in PubMed, Embase and Portal BVS using the search terms Esophageal Neoplasm, Esophagus Neoplasms, Esophagus Cancers, Esophageal Cancers, EUS, EUS-FNA, Endoscopic Ultrasonography, Echo Endoscopy, Endosonographies and Endoscopic Ultrasound, with subsequent meta-analysis of the data found. The accuracy of tumor (T) staging was 65.55%. For T1, sensitivity was 64.7%, and specificity 89.1%, with an accuracy of 89.6%. For T2, sensitivity and specificity were 35.7% and 89.2%, respectively, with an accuracy of 87.1%. For T3, sensitivity and specificity were 82.5% and 83%, respectively, with an accuracy of 87%. For T4, sensitivity and specificity were 38.6% and 94%, respectively, with an accuracy of 66.4%. For node (N) staging, sensitivity was 77.3% and specificity 67.4%, with an accuracy of 77.9%. Echoendoscopy exhibits suboptimal accuracy in preoperative staging of esophageal adenocarcinoma and esophagogastric junction.
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Affiliation(s)
- Alexandre Luis Klamt
- Gastroenterology Service of the Hospital de Clínicas de Porto Alegre (HCPA), Graduate Program in Medicine: Surgical Sciences, Faculty of Medicine, Federal University of Rio Grande do Sul (UFRGS), Port Alegre, Rio Grande do Sul, Brazil.
| | - Jeruza Lavanholi Neyeloff
- Graduate Program in Health Sciences: Cardiology and Cardiovascular Sciences, Federal University of Rio Grande do Sul (UFRGS), Port Alegre, Rio Grande do Sul, Brazil
| | - Letícia Maffazzioli Santos
- Radiology Service of the Hospital de Clínicas de Porto Alegre (HCPA), Graduate Program in Medicine: Surgical Sciences, Faculty of Medicine, Federal University of Rio Grande do Sul (UFRGS), Port Alegre, Rio Grande do Sul, Brazil
| | - Guilherme da Silva Mazzini
- Digestive Tract Surgery Service of the Hospital de Clínicas de Porto Alegre (HCPA), Faculty of Medicine, Federal University of Rio Grande do Sul (UFRGS), Port Alegre, Rio Grande do Sul, Brazil
| | - Vinicius Jardim Campos
- Faculty of Medicine, Federal University of Rio Grande do Sul (UFRGS), Port Alegre, Rio Grande do Sul, Brazil
| | - Richard Ricachenevsky Gurski
- Digestive Tract Surgery Service and Surgery Group of the Esophagus and Stomach of the Hospital de Clínicas de Porto Alegre (HCPA), Port Alegre, Rio Grande do Sul, Brazil; Department of Surgery, Faculty of Medicine, Federal University of Rio Grande do Sul (UFRGS), Port Alegre, Rio Grande do Sul, Brazil
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Zhao Z, Zhang Y, Wang P, Wang X, Li M. The impact of the nodal status on the overall survival of non-surgical patients with esophageal squamous cell carcinoma. Radiat Oncol 2019; 14:161. [PMID: 31481064 PMCID: PMC6724275 DOI: 10.1186/s13014-019-1365-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 08/21/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The prognosis of N categories for patients with non-surgical esophageal carcinoma based on the number of metastatic lymph nodes is controversial. The present study analyzes prognostic implications of the number, extent, and size of metastatic lymph nodes for patients with esophageal squamous cell carcinoma (ESCC) treated with definitive (chemo-)radiotherapy to provide more information on treatment strategy. METHODS We reviewed 357 ESCC patients treated with definitive radiotherapy between January 2013 and March 2016 retrospectively. We assessed potential associations between the involved extent (N0, 1 region, 2 regions, and 3 regions), number (N0, 1-2, 3-6, and ≥ 7), and size (N0, ≤2 cm, and > 2 cm) of metastatic lymph nodes and overall survival. Multivariate analyses of the clinicopathological factors were performed using the Cox proportional hazard model. RESULTS 5-year survival rates were 43.6% for patients in the N0 group and 29.3% in the N+ group (p = 0.001). Kaplan-Meier analyses for all cases revealed that there were significant differences in survival based on the extent (the OS rates at 3 years were 53.3% for patients in the N0 group, 45.7% in the 1 region-involved group, 28.0% in the 2 regions-involved group, and 13.3% in the 3 regions-involved group, P < 0.001), number (the OS rates at 3 years were 49.0% for patients in the 1-2 LNs group, 27.8% in the 3-6 LNs group, 0 in the ≥7LNs group, P < 0.001), and size (the OS rates at 3 years were 41.6% for patients in the LNs ≤2 cm group and 20.7% in the LNs > 2 cm group, P = 0.001) of metastatic LNs. One hundred seventy-two patients (48.2%) had experienced GTV failure, 157 (43.1%) had distant failure, 49 (13.7%) had out-of-GTV nodal failure, and 70 patients (19.6%) had no evidence of disease at the last follow-up. Nodal status correlated statistically with GTV failure. Patients with LN metastases in the abdominal region had worse survival rates than those with metastases in the other regions. The extent and number of metastatic LNs, T category, Primary tumor location, and chemotherapy were independent prognostic factors of OS in multivariate analyses. CONCLUSIONS For patients with ESCC who received definitive (chemo-)radiotherapy, the number, extent, and size of metastatic LNs were prognostic factors, particularly of the T2/3 disease. Patients with LN metastases in the abdominal region had worse survival.
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Affiliation(s)
- Zongxing Zhao
- School of Medicine, Shandong University, Jinan, Shandong, China.,Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Jinan, Shandong, China.,Department of Radiation Oncology, Liaocheng People's Hospital, Liaocheng, Shandong, China
| | - Yanan Zhang
- Department of Health Care, Liaocheng People's Hospital, Liaocheng, Shandong, China
| | - Peiliang Wang
- School of Medicine, Shandong University, Jinan, Shandong, China.,Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Jinan, Shandong, China
| | - Xin Wang
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Jinan, Shandong, China.,Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | - Minghuan Li
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Jinan, Shandong, China.
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Kahn A, Kamboj AK, Muppa P, Sawas T, Lutzke LS, Buras MR, Golafshar MA, Katzka DA, Iyer PG, Smyrk TC, Wang KK, Leggett CL. Staging of T1 esophageal adenocarcinoma with volumetric laser endomicroscopy: a feasibility study. Endosc Int Open 2019; 7:E462-E470. [PMID: 30931378 PMCID: PMC6428686 DOI: 10.1055/a-0838-5326] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 11/26/2018] [Indexed: 12/17/2022] Open
Abstract
Background and study aims Precise staging in T1 esophageal adenocarcinoma (EAC) is critical in determining candidacy for curative endoscopic resection. High-frequency endoscopic ultrasound (EUS) has demonstrated suboptimal accuracy in T1 EAC staging due to insufficient spatial resolution. Volumetric laser endomicroscopy (VLE) allows for high-resolution wide-field visualization of the esophageal microstructure. We aimed to investigate the role of VLE in staging T1 EAC. Patients and methods Patients undergoing endoscopic mucosal resection (EMR) were prospectively enrolled and only T1 EAC cases were included. EMR specimens were imaged using second-generation VLE immediately after resection. VLE images were analyzed for signal intensity by depth and signal attenuation (dB/mm) in both cross-sectional and en-face orientation. A decision tree model was constructed to combine measured VLE parameters and delineate diagnostic thresholds. Results Thirty EMR scans were obtained - 15 T1a specimens from 9 patients and 15 T1b specimens from 11 patients. T1b specimen VLE scans exhibited higher signal intensity ( P < 0.0001) and higher signal attenuation compared to T1a specimens ( P = 0.03). A combination of signal attenuation and signal intensity at 150 µm depth yielded optimal diagnostic thresholds and an area under the curve (AUC) of 0.77. VLE signal attenuation was significantly associated with grade of differentiation, irrespective of EAC stage. Conclusions VLE signal intensity and signal attenuation are quantitatively distinct in T1a and T1b EAC and associated with grade of differentiation. This is the first study examining the role of VLE for staging of T1 EAC and demonstrates promising diagnostic performance. With further in vivo validation, VLE may serve a role in staging superficial EAC.
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Affiliation(s)
- Allon Kahn
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, United States
| | - Amrit K. Kamboj
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, United States
| | - Prasuna Muppa
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, United States
| | - Tarek Sawas
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Lori S. Lutzke
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Matthew R. Buras
- Division of Health Sciences Research, Mayo Clinic, Scottsdale, Arizona, United States
| | - Michael A. Golafshar
- Division of Health Sciences Research, Mayo Clinic, Scottsdale, Arizona, United States
| | - David A. Katzka
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Prasad G. Iyer
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Thomas C. Smyrk
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Kenneth K. Wang
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Cadman L. Leggett
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States,Corresponding author Cadman L. Leggett, M.D. Division of Gastroenterology and HepatologyMayo Clinic
200 1
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Street SW, Rochester, MN 55905
+1-480-301-8673
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Zhang Y, He S, Dou L, Liu Y, Ke Y, Yu X, Wang Z, Wang G. Esophageal cancer N staging study with endoscopic ultrasonography. Oncol Lett 2018; 17:863-870. [PMID: 30655840 PMCID: PMC6312948 DOI: 10.3892/ol.2018.9716] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Accepted: 10/04/2018] [Indexed: 01/15/2023] Open
Abstract
Esophageal cancer staging is important for the treatment of esophageal cancer. Endoscopic ultrasonography (EUS) is a common diagnostic tool for esophageal cancer prior to surgery. However, EUS is unable to accurately discriminate the N-staging of lymph nodes. In order to distinguish an optimized standard for malignant lymph node diagnosis, the present study compared lymph nodes detected by EUS and surgery. A total of 112 patients were preoperatively examined with EUS and staged according to the 7th Edition of the American Joint Committee on Cancer Staging Manual. The results of EUS were compared with surgical findings. The critical values of long diameter, short diameter and lymph node number detected by EUS were >7.5, >5.5 mm and >2, respectively; indexes, including long diameter >7.5 mm, short diameter >5.5 mm, round, low echo, edge smooth, near lesion and detected lymph node number (>2) and T3/4 staging, met significance in the EUS group compared with the surgical group (P<0.05). Furthermore, the area under curve (AUC) value of the EUS (0.801) was superior to the conventional, surgical method (0.779). Although EUS improved the diagnostic accuracy of esophageal N staging, it was not able to satisfactorily distinguish between N2 and N3 staging. Advancements in EUS may enhance its detection ability, further improving the diagnostic accuracy of lymph node metastasis.
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Affiliation(s)
- Yueming Zhang
- Department of Endoscopy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, P.R. China
| | - Shun He
- Department of Endoscopy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, P.R. China
| | - Lizhou Dou
- Department of Endoscopy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, P.R. China
| | - Yong Liu
- Department of Endoscopy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, P.R. China
| | - Yan Ke
- Department of Endoscopy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, P.R. China
| | - Xinying Yu
- Department of Endoscopy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, P.R. China
| | - Zhu Wang
- Department of Medical Image, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, P.R. China
| | - Guiqi Wang
- Department of Endoscopy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, P.R. China
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D'Journo XB. Clinical implication of the innovations of the 8 th edition of the TNM classification for esophageal and esophago-gastric cancer. J Thorac Dis 2018; 10:S2671-S2681. [PMID: 30345104 DOI: 10.21037/jtd.2018.03.182] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Epidemiology of esophageal cancer and esophagogastric junction (EGJ) has deeply changed for the past two decades with a dramatically increase of adenocarcinoma whereas squamous cell carcinoma (SCC) has slowly decreased. Moreover, the two histological types differ in a number of features including risks factors, tumor location, tumor biology and outcomes. In acknowledgement of these differences, the newest 8th edition of the American Joint Committee on Cancer (AJCC) tumor, node and metastasis (TNM) staging classification of epithelial cancers of the esophagus and EGJ has refined this histology-specific disease stage with incorporation of new anatomic and non-anatomic categories. Based on data-driven of patients collected through the Worldwide Esophageal Cancer Collaboration (WECC) group, the 8th edition database encompasses a six-continent cohort of 22,654 patients among 33 institutions including patients treated with surgery alone and, for the first time, patients treated after neoadjuvant treatment. Anatomic categories include T descriptors (tumor invasion), N descriptors (regional lymph node invasion) and M descriptors (distant site). Non anatomic categories include grade differentiation (G descriptors) and tumor location (L descriptors). Category descriptors are currently assessed by endoscopy with biopsy, by endoscopy ultrasound fine-needle aspiration (EUS-FNA), by thoracic-abdominal-pelvic computed tomography (CT) and whole body flurodeoxyglucose positron emission tomography (FDG-PET) fused with CT. The new 8th edition considers separate and temporally related cancer classification based on the treatment strategy: clinical cTNM (before any treatment), pathologic pTNM (after surgery alone) and postneoadjuvant pathologic ypTNM (after neoadjuvant treatment followed by surgery). The 8th edition permits a more robust and reliable random forest-based machine learning analysis. Refinement of each T, N, M categories and subcategories makes the 8th edition more accurate and more adaptable to the current practice including neoadjuvant regimen. The main objective of this review is to examine the current staging of esophageal cancer and the new aspects of the 8th edition with its applications to clinical practice.
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Affiliation(s)
- Xavier Benoit D'Journo
- Department of Thoracic surgery, North Hospital, Aix-Marseille University, 13915 Marseille, France
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8
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Liu C, Gao X. Determination of radiotherapy target volume for esophageal cancer. PRECISION RADIATION ONCOLOGY 2018. [DOI: 10.1002/pro6.37] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Affiliation(s)
- Chaoxing Liu
- First Hospital of shijiazhuang; Oncology; Shijiazhuang
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9
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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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Abstract
Barrett esophagus surveillance programs and more liberal use of upper endoscopy are leading to the identification of more patients with high-grade dysplasia or early stage esophageal adenocarcinoma. These patients have several options for therapy, including endoscopic mucosal resection, vagal-sparing esophagectomy, and a combination of endoscopic resection and ablation. Factors that should be considered include the length of the Barrett segment, the presence of a nodule or ulcer within the Barrett segment, and the age and overall physical condition of the patient. Of particular importance will be the incidence of recurrent Barrett esophagus or cancer in the long-term in patients that were initially successfully treated endoscopically.
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Affiliation(s)
- Michael Hermansson
- Department of Surgery, Keck School of Medicine, The University of Southern California, Los Angeles, CA 90033, USA
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11
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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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12
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Abstract
Patients with clinically staged T2N0 esophageal cancer are a small subset of patients for whom therapy is not standardized. Current clinical staging modalities are lacking in providing accurate staging for the presumed T2N0 subset. Problems with overstaging and understaging can each have adverse consequences for the patient. Furthermore, the benefit of induction therapy versus esophagectomy followed by adjuvant therapy for upstaged patients is unproven. The management of this challenging group of patients is reviewed.
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13
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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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14
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Crabtree TD, Yacoub WN, Puri V, Azar R, Zoole JB, Patterson GA, Krupnick AS, Kreisel D, Meyers BF. Endoscopic Ultrasound for Early Stage Esophageal Adenocarcinoma: Implications for Staging and Survival. Ann Thorac Surg 2011; 91:1509-15; discussion 1515-6. [DOI: 10.1016/j.athoracsur.2011.01.063] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2010] [Revised: 01/11/2011] [Accepted: 01/13/2011] [Indexed: 12/31/2022]
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Rice TW, Rusch VW, Ishwaran H, Blackstone EH. Cancer of the esophagus and esophagogastric junction: data-driven staging for the seventh edition of the American Joint Committee on Cancer/International Union Against Cancer Cancer Staging Manuals. Cancer 2010; 116:3763-73. [PMID: 20564099 DOI: 10.1002/cncr.25146] [Citation(s) in RCA: 355] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Previous American Joint Committee on Cancer/International Union Against Cancer (AJCC/UICC) stage groupings for esophageal cancer have not been data driven or harmonized with stomach cancer. At the request of the AJCC, worldwide data from 3 continents were assembled to develop data-driven, harmonized esophageal staging for the seventh edition of the AJCC/UICC cancer staging manuals. METHODS All-cause mortality among 4627 patients with esophageal and esophagogastric junction cancer who underwent surgery alone (no preoperative or postoperative adjuvant therapy) was analyzed by using novel random forest methodology to produce stage groups for which survival was monotonically decreasing, distinctive, and homogeneous. RESULTS For lymph node-negative pN0M0 cancers, risk-adjusted 5-year survival was dominated by pathologic tumor classification (pT) but was modulated by histopathologic cell type, histologic grade, and location. For lymph node-positive, pN+M0 cancers, the number of cancer-positive lymph nodes (a new pN classification) dominated survival. Resulting stage groupings departed from a simple, logical arrangement of TNM. Stage groupings for stage I and II adenocarcinoma were based on pT, pN, and histologic grade; and groupings for squamous cell carcinoma were based on pT, pN, histologic grade, and location. Stage III was similar for histopathologic cell types and was based only on pT and pN. Stage 0 and stage IV, by definition, were categorized as tumor in situ (Tis) (high-grade dysplasia) and pM1, respectively. CONCLUSIONS The prognosis for patients with esophageal and esophagogastric junction cancer depends on the complex interplay of TNM classifications as well as nonanatomic factors, including histopathologic cell type, histologic grade, and cancer location. These features were incorporated into a data-driven staging of these cancers for the seventh edition of the AJCC/UICC cancer staging manuals.
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Affiliation(s)
- Thomas W Rice
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA.
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16
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Endoscopic mucosal resection in the management of esophageal neoplasia: current status and future directions. Clin Gastroenterol Hepatol 2010; 8:743-54; quiz e96. [PMID: 20541628 PMCID: PMC2932788 DOI: 10.1016/j.cgh.2010.05.030] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2009] [Revised: 05/20/2010] [Accepted: 05/21/2010] [Indexed: 02/07/2023]
Abstract
Endoscopic mucosal resection has expanded the role of the gastroenterologist in the management of esophageal neoplasia from screening and diagnosis to staging and endoscopic treatment. Its rise to prominence is a reflection of the long-identified need to obtain histologic information regarding depth of invasion and neoplastic margins during therapy that previously could not be achieved with ablative techniques. The resultant improvement in diagnosis and staging has allowed for better selection of patients for endoscopic therapy who may be spared invasive surgery. The clinical indications, endoscopic techniques, outcomes, and complications in the management of esophageal neoplasia are reviewed. Training requirements to achieve proficiency in endoscopic mucosal resection as well as potential quality measures to assess competence also are proposed in this review.
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17
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Zhong L, Liao JZ, Wang Y, Cheng B. Diagnostic value of endoscopic ultrasonography in preoperative TN staging of esophageal carcinoma. Shijie Huaren Xiaohua Zazhi 2010; 18:2258-2261. [DOI: 10.11569/wcjd.v18.i21.2258] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the diagnostic value of endoscopic ultrasonography (EUS) in preoperative TN staging of esophageal carcinoma.
METHODS: Thirty patients with esophageal carcinoma were subjected to preoperative TN staging by EUS and postoperative pathological staging. The results for preoperative and postoperative TN staging were then compared.
RESULTS: The accuracy of T and N staging by EUS was 76.7% (23/30) and 83.3% (25/30), respectively. The coincidence rate between preoperative T staging by EUS and postoperative pathological staging of early esophageal carcinoma was up to
100%.
CONCLUSION: EUS has a high accuracy in preoperative TN staging of esophageal carcinoma, especially early esophageal carcinoma, and may therefore be used to guide clinical treatment of the disease.
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18
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Huang W, Li B, Gong H, Yu J, Sun H, Zhou T, Zhang Z, Liu X. Pattern of lymph node metastases and its implication in radiotherapeutic clinical target volume in patients with thoracic esophageal squamous cell carcinoma: A report of 1077 cases. Radiother Oncol 2010; 95:229-33. [PMID: 20189259 DOI: 10.1016/j.radonc.2010.01.006] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2009] [Revised: 10/05/2009] [Accepted: 01/23/2010] [Indexed: 01/23/2023]
Abstract
PURPOSE To study the pattern of lymph node metastases after esophagectomy and clarify the clinical target volume (CTV) delineation of thoracic esophageal squamous cell carcinoma (ESCC). METHODS AND MATERIALS Total 1077 thoracic ESCC patients who had undergone esophagectomy and lymphadenectomy were retrospectively examined. The clinicopathologic factors related to lymph node metastasis were analyzed using logistic regression analysis. RESULTS The rates of lymph node metastases in patients with upper thoracic tumors were 16.7% (9/54) cervical, 38.9% (18/54) upper mediastinal, 11.1% (6/54) middle mediastinal, 5.6% (3/54) lower mediastinal, and 5.6% (3/54) abdominal, respectively. The rates of lymph node metastases in patients with middle thoracic tumors were 4.0% (27/680), 3.8% (26/680), 32.9% (224/680), 7.1% (48/680), and 17.1% (116/680), respectively. The rates of lymph node metastases in patients with lower thoracic tumors were 1.0% (5/343), 3.0% (10/343), 22.7% (78/343), 37.0% (127/343), and 33.2% (114/343), respectively. T stage, the length of tumor and the histological differentiation emerged as statistically significant risk factors of lymph node metastases of thoracic ESCC (P < 0.001). CONCLUSIONS T stage, the length of tumor and the histologic differentiation influence the pattern of lymph node metastases in thoracic ESCC. These factors should be considered comprehensively to design the CTV for radiotherapy (RT) of thoracic ESCC. Selective regional irradiation including the correlated lymphatic drainage regions should be performed as well.
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Affiliation(s)
- Wei Huang
- Department of Radiation Oncology (Chest Section), Shandong Cancer Institute (Hospital), Jinan, Shandong Province, PR China
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19
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Zehetner J, DeMeester SR. Treatment of Barrett's esophagus with high-grade dysplasia and intramucosal adenocarcinoma. Expert Rev Gastroenterol Hepatol 2009; 3:493-8. [PMID: 19817671 DOI: 10.1586/egh.09.44] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
High-grade dysplasia and intramucosal adenocarcinoma are premalignant and malignant lesions of the esophagus. The incidence of lymphatic or systemic metastases is low and esophagectomy is curative in most patients. Until recently, complete removal of the neoplastic tissue was reliably accomplished with only esophagectomy. New technologies have been developed that allow endoscopic mucosal resection and ablation with preservation of the esophagus for these lesions. Optimal treatment of the patient requires consideration of not only the stage of the lesion but also the pathophysiology of the esophagus and the severity of the underlying reflux disease. Only with this approach can outcomes be optimized for both the dysplasia or cancer and the patient's reflux disease and long-term quality of life. In this article, we summarize the experience from a surgical center's perspective.
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Affiliation(s)
- Jörg Zehetner
- Department of Surgery, Keck School of Medicine, University of Southern California, 1510 San Pablo St, Suite 514, Los Angeles, CA 90033, USA.
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20
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Puli SR, Reddy JBK, Bechtold ML, Ibdah JA, Antillon D, Singh S, Olyaee M, Antillon MR. Endoscopic ultrasound: it's accuracy in evaluating mediastinal lymphadenopathy? A meta-analysis and systematic review. World J Gastroenterol 2008; 14:3028-37. [PMID: 18494054 PMCID: PMC2712170 DOI: 10.3748/wjg.14.3028] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2007] [Revised: 01/03/2008] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the accuracy of endoscopic ultrasound (EUS), EUS-fine needle aspiration (FNA) in evaluating mediastinal lymphadenopathy. METHODS Only EUS and EUS-FNA studies confirmed by surgery or with appropriate follow-up were selected. Articles were searched in Medline, Pubmed, and Cochrane control trial registry. Only studies from which a 2 multiply 2 table could be constructed for true positive, false negative, false positive and true negative values were included. Two reviewers independently searched and extracted data. The differences were resolved by mutual agreement. Meta-analysis for the accuracy of EUS was analyzed by calculating pooled estimates of sensitivity, specificity, likelihood ratios, and diagnostic odds ratios. Pooling was conducted by both Mantel-Haenszel method (fixed effects model) and DerSimonian Laird method (random effects model). The heterogeneity of studies was tested using Cochran's Q test based upon inverse variance weights. RESULTS Data was extracted from 76 studies (n = 9310) which met the inclusion criteria. Of these, 44 studies used EUS alone and 32 studies used EUS-FNA. FNA improved the sensitivity of EUS from 84.7% (95% CI: 82.9-86.4) to 88.0% (95% CI: 85.8-90.0). With FNA, the specificity of EUS improved from 84.6% (95% CI: 83.2-85.9) to 96.4% (95% CI: 95.3-97.4). The P for chi-squared heterogeneity for all the pooled accuracy estimates was > 0.10. CONCLUSION EUS is highly sensitive and specific for the evaluation of mediastinal lymphadenopathy and FNA substantially improves this. EUS with FNA should be the diagnostic test of choice for evaluating mediastinal lymphadenopathy.
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21
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Puli SR, Reddy JBK, Bechtold ML, Antillon D, Ibdah JA, Antillon MR. Staging accuracy of esophageal cancer by endoscopic ultrasound: A meta-analysis and systematic review. World J Gastroenterol 2008; 14:1479-90. [PMID: 18330935 PMCID: PMC2693739 DOI: 10.3748/wjg.14.1479] [Citation(s) in RCA: 245] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the accuracy of endoscopic ultrasound (EUS) in the staging of esophageal cancer.
METHODS: Only EUS studies confirmed by surgery were selected. Articles were searched in Medline and Pubmed. Two reviewers independently searched and extracted data. Meta-analysis of the accuracy of EUS was analyzed by calculating pooled estimates of sensitivity, specificity, likelihood ratios, and diagnostic odds ratio. Pooling was conducted by both the Mantel-Haenszel method (fixed effects model) and DerSimonian Laird method (random effects model). The heterogeneity of studies was tested using Cochran’s Q test based upon inverse variance weights.
RESULTS: Forty-nine studies (n = 2558) which met the inclusion criteria were included in this analysis. Pooled sensitivity and specificity of EUS to diagnose T1 was 81.6% (95% CI: 77.8-84.9) and 99.4% (95% CI: 99.0-99.7), respectively. To diagnose T4, EUS had a pooled sensitivity of 92.4% (95% CI: 89.2-95.0) and specificity of 97.4% (95% CI: 96.6-98.0). With Fine Needle Aspiration (FNA), sensitivity of EUS to diagnose N stage improved from 84.7% (95% CI: 82.9-86.4) to 96.7% (95% CI: 92.4-98.9). The P value for the χ2 test of heterogeneity for all pooled estimates was > 0.10.
CONCLUSION: EUS has excellent sensitivity and specificity in accurately diagnosing the TN stage of esophageal cancer. EUS performs better with advanced (T4) than early (T1) disease. FNA substantially improves the sensitivity and specificity of EUS in evaluating N stage disease. EUS should be strongly considered for staging esophageal cancer.
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22
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Mennigen R, Tuebergen D, Koehler G, Sauerland C, Senninger N, Bruewer M. Endoscopic ultrasound with conventional probe and miniprobe in preoperative staging of esophageal cancer. J Gastrointest Surg 2008; 12:256-62. [PMID: 17823841 DOI: 10.1007/s11605-007-0300-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2007] [Accepted: 08/09/2007] [Indexed: 01/31/2023]
Abstract
BACKGROUND Using an endoscopic ultrasound (EUS) miniprobe, even highly stenotic esophageal cancers precluding the passage of a conventional probe can be examined without prior dilatation. OBJECTIVE To assess: (1) staging accuracy of conventional EUS probe and miniprobe, (2) variables influencing staging accuracy, (3) endoscopic features predicting tumor stage. METHODS Ninety-seven consecutive patients with esophageal cancer undergoing complete surgical resection were included. Preoperative EUS was performed using a conventional probe in nonstenotic tumors and a miniprobe in stenotic tumors. Accuracy of EUS for T and N stages was compared to pathohistological staging. RESULTS Overall EUS staging accuracy was 73.2% for T stage and 74.2% for N stage. It was similar for the miniprobe used in stenotic tumors vs the conventional probe used in nonstenotic tumors. Based on EUS, 84.5% of the patients would have been assigned to the appropriate therapy protocol (primary surgery vs neoadjuvant therapy). Endoscopic tumor features had no influence on staging accuracy. Tumor length >5 cm predicted advanced T and nodal positive stages. CONCLUSIONS The miniprobe allows adequate EUS staging of stenotic esophageal tumors precluding the passage of a conventional probe. Therefore, dilatation therapy of stenotic cancers to conduct conventional EUS should be avoided.
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Affiliation(s)
- Rudolf Mennigen
- Department of General Surgery, University of Münster, Münster, Germany.
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23
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Gines A, Cassivi SD, Martenson JA, Schleck C, Deschamps C, Sinicrope FA, Alberts SR, Murray JA, Zinsmeister AR, Vazquez-Sequeiros E, Nichols FC, Miller RC, Quevedo JF, Allen MS, Alexander JA, Zais T, Haddock MG, Romero Y. Impact of endoscopic ultrasonography and physician specialty on the management of patients with esophagus cancer. Dis Esophagus 2008; 21:241-50. [PMID: 18430106 PMCID: PMC2577373 DOI: 10.1111/j.1442-2050.2007.00766.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
While endoscopic ultrasonography (EUS) and EUS-guided fine-needle aspiration (EUS-FNA) are the most accurate techniques for locoregional staging of esophageal cancer, little evidence exists that these innovations impact on clinical care. The objective on this study was to determine the frequency with which EUS and EUS-FNA alter the management of patients with localized esophageal cancer, and assess practice variation among specialists at a tertiary care center. Three gastroenterologists, three medical oncologists, three radiation oncologists and four thoracic surgeons were asked to independently report their management recommendations as the anonymized staging information of 50 prospectively enrolled patients from another study were sequentially disclosed on-line. Compared to initial management recommendations, that were based upon history, physical examination, upper endoscopy and CT scan results, EUS prompted a change in management 24% (95% CI: 12-36%) of the time; usually to a more resource-intensive approach (71%), for example from recommending palliation to recommending neoadjuvant chemoradiation therapy. EUS-FNA plus cytology results altered management an additional 8% (95% CI: 6-15%) of the time. Agreement between specialists ranged from fair (intraclass correlation [ICC=0.32) to substantial (ICC=0.65); improving with additional information. Among specialists, agreement was greatest for patients with stage I disease. EUS and EUS-FNA changed patient management the most for patients with stages IIA, IIB or III disease. EUS, with or without FNA, significantly impacts the management of patients with localized esophageal cancer. With respect to the optimal treatment for each patient, agreement among physicians incrementally increases with endoscopic ultrasound results. Specialty training appears to influence therapeutic decision-making behavior.
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Affiliation(s)
- A. Gines
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, Minnesota
| | - S. D. Cassivi
- Division of General Thoracic Surgery, Mayo Clinic, Rochester, Minnesota
| | - J. A. Martenson
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - C. Schleck
- Division of Biostatistics, Mayo Clinic, Rochester, Minnesota
| | - C. Deschamps
- Division of General Thoracic Surgery, Mayo Clinic, Rochester, Minnesota
| | - F. A. Sinicrope
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, Minnesota,Division of Medical Oncology, Mayo Clinic, Rochester, Minnesota
| | - S. R. Alberts
- Division of Medical Oncology, Mayo Clinic, Rochester, Minnesota
| | - J. A. Murray
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, Minnesota
| | | | | | - F. C. Nichols
- Division of General Thoracic Surgery, Mayo Clinic, Rochester, Minnesota
| | - R. C. Miller
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - J. F. Quevedo
- Division of Medical Oncology, Mayo Clinic, Rochester, Minnesota
| | - M. S. Allen
- Division of General Thoracic Surgery, Mayo Clinic, Rochester, Minnesota
| | - J. A. Alexander
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, Minnesota
| | - T. Zais
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, Minnesota
| | - M. G. Haddock
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Y. Romero
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, Minnesota,Department of Otorhinolaryngology, Mayo Clinic, Rochester, Minnesota
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24
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Barbour AP, Rizk NP, Gerdes H, Bains MS, Rusch VW, Brennan MF, Coit DG. Endoscopic ultrasound predicts outcomes for patients with adenocarcinoma of the gastroesophageal junction. J Am Coll Surg 2007; 205:593-601. [PMID: 17903735 DOI: 10.1016/j.jamcollsurg.2007.05.010] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2007] [Revised: 03/05/2007] [Accepted: 05/09/2007] [Indexed: 11/19/2022]
Abstract
BACKGROUND Endoscopic ultrasound (EUS) is the most accurate locoregional staging tool for gastroesophageal junction (GEJ) adenocarcinoma, and it may allow pretreatment risk stratification. The purpose of this study was to compare preoperative EUS staging with postoperative pathologic staging and to assess the ability of EUS to predict survival after resection for GEJ adenocarcinoma. STUDY DESIGN Patients with GEJ adenocarcinoma, who had preoperative staging with EUS followed by resection, were identified from a prospectively maintained database. Patients receiving neoadjuvant therapy were excluded. EUS stage was compared with pathologic stage. Survival analyses were performed in patients who underwent complete gross resection. RESULTS From 1985 through 2003, 209 patients underwent preoperative EUS followed by surgery without neoadjuvant therapy for GEJ adenocarcinoma. EUS correlated with pathologic T stage in 128 of 209 (61%) patients and with pathologic nodal stage in 154 of 206 (75%) patients. EUS accurately stratified patients into "early" (T0-2 N0) or "advanced" (T3-4 or N1) disease categories in 173 (83%) patients. Curative (R0) resection was performed in 184 patients: EUS "early" (n=84) and "advanced" (n=122) stages were associated with R0 rates of 100% and 82%, respectively (p=0.001). EUS "early" versus "advanced" stage was highly predictive of outcomes (p < 0.0001). The 5-year disease-specific survival for EUS "early" patients was 65% compared with 34% for EUS "advanced" stage. CONCLUSIONS EUS accurately predicts pathologic stage. In addition, EUS is predictive of outcomes after complete gross resection without neoadjuvant treatment for GEJ adenocarcinoma and identifies a high-risk population that might benefit from preoperative therapy.
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Affiliation(s)
- Andrew P Barbour
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA
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25
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van Vliet EPM, Eijkemans MJC, Kuipers EJ, Hermans JJ, Steyerberg EW, Tilanus HW, van der Gaast A, Siersema PD. A comparison between low-volume referring regional centers and a high-volume referral center in quality of preoperative metastasis detection in esophageal carcinoma. Am J Gastroenterol 2006; 101:234-42. [PMID: 16454824 DOI: 10.1111/j.1572-0241.2006.00413.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM An inverse correlation between hospital volume and esophageal resection mortality has been reported. In this study, we compared the quality of preoperative metastasis detection between a high-volume referral center with that of low-volume referring regional centers. METHODS In 573 patients diagnosed with esophageal cancer (1994-2003), the results of preoperative staging investigations (CT-scan, ultrasound of abdomen and neck, and chest x-ray) performed in 61 regional centers were re-evaluated and/or repeated in one referral center. The gold standards were a radiological result with > or =6 months follow-up, fine-needle aspiration, or the postoperative TNM-stage. RESULTS In the same group of patients, the preoperative investigations performed in regional centers detected true-positive malignant lymph nodes in 8% of patients and true-positive distant metastases in 7% of patients, whereas these percentages were 16% and 20%, respectively, in the referral center. In 72/573 (13%) patients, one or more metastases detected in the referral center had been missed in the regional centers. After allowing resectability in the presence of M1a lymph nodes, this would still have resulted in futile esophageal resections in 6% of patients. In contrast to the higher diagnostic sensitivity in the referral center, specificity was comparable between referral and regional centers. CONCLUSIONS This study found that, in assessing the operability of esophageal cancer, the diagnostic sensitivity of metastasis detection in a high-volume referral center was higher than that in referring regional centers. This resulted from both better CT-scanning equipment and more experienced radiologists in the referral center. Should the decision to perform esophagectomy have only been based on metastasis detection in these regional centers, over 1 in 20 patients would have undergone resection in the presence of metastases.
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Affiliation(s)
- Evelyn P M van Vliet
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center Rotterdam, The Netherlands
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DeMeester SR. Adenocarcinoma of the esophagus and cardia: a review of the disease and its treatment. Ann Surg Oncol 2006; 13:12-30. [PMID: 16378161 DOI: 10.1245/aso.2005.12.025] [Citation(s) in RCA: 167] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2004] [Accepted: 07/20/2005] [Indexed: 02/06/2023]
Abstract
BACKGROUND Over the past 50 years there has been a remarkable change in the epidemiology of esophageal cancer. Previously rare, adenocarcinoma of the esophagus and gastroesophageal junction is now the most common esophageal cancer, and in the United States the incidence is increasing faster than that of any other malignancy. Surveillance in patients with Barrett's esophagus is identifying adenocarcinoma at an earlier, more curable stage in many patients, and at the same time new endoscopic and surgical options are available for the therapy of these localized tumors. METHODS This article is a review of the epidemiology, diagnosis, staging, and treatment options for esophageal and gastroesophageal junction adenocarcinoma. RESULTS The epidemiology, prognosis, patterns of lymphatic metastasis, and survival for esophageal and gastroesophageal junction adenocarcinoma suggest that these tumors are similar. New options for therapy, as well as the results of surgical resection with and without chemoradiotherapy, are reviewed. CONCLUSIONS Surveillance programs for Barrett's are identifying patients with early, curable adenocarcinoma of the esophagus or gastroesophageal junction. Therapy for more advanced tumors hinges on local control of the disease and the eradication of systemic metastases.
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Affiliation(s)
- Steven R DeMeester
- Department of Cardiothoracic Surgery, The University of Southern California, Keck School of Medicine, 1510 San Pablo Street, Suite 514, Los Angeles, California, 90033, USA.
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27
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DeMeester SR. Endoscopic Mucosal Resection and Vagal-Sparing Esophagectomy for High-Grade Dysplasia and Adenocarcinoma of the Esophagus. Semin Thorac Cardiovasc Surg 2005; 17:320-5. [PMID: 16428038 DOI: 10.1053/j.semtcvs.2005.09.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2005] [Indexed: 12/20/2022]
Abstract
Once a rare tumor, adenocarcinoma of the esophagus is currently the cancer with the fastest rising incidence in America. In addition to the increasing prevalence of the disease, surveillance programs for patients with Barrett's have led to the identification of increasing numbers of patients with high-grade dysplasia or early-stage esophageal adenocarcinomas. Although traditional esophagectomy is curative in the majority of these patients, associated morbidity and mortality remains a hurdle for patient acceptance of the procedure. New endoscopic and surgical therapies offer the potential of decreased morbidity, but do not include a lymphadenectomy, and consequently, are not appropriate in patients that have a significant risk of lymph node metastases. Endoscopic mucosal resection allows precise determination of the depth of tumor invasion and facilitates accurate local staging of early esophageal cancers. A vagal-sparing esophagectomy accomplishes the goal of removing the diseased esophagus while minimizing the physiologic impact of an esophagectomy in patients with early-stage esophageal cancer.
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Affiliation(s)
- Steven R DeMeester
- Department of Cardiothoracic Surgery, The University of Southern California, Keck School of Medicine, Los Angeles, California 90033, USA.
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28
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DeWitt J, Kesler K, Brooks JA, LeBlanc J, McHenry L, McGreevy K, Sherman S. Endoscopic ultrasound for esophageal and gastroesophageal junction cancer: Impact of increased use of primary neoadjuvant therapy on preoperative locoregional staging accuracy. Dis Esophagus 2005; 18:21-7. [PMID: 15773837 DOI: 10.1111/j.1442-2050.2005.00444.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Initial treatment of locally advanced esophageal and gastroesophageal junction (GEJ) malignancies for selected patients at some institutions has recently changed from surgical resection to neoadjuvant therapy. The aim of this study is to evaluate the impact of this change in treatment strategy on both the overall disease profile and locoregional endoscopic ultrasound (EUS) staging accuracy for a cohort of patients managed with primary surgical resection over a 10-year period at our institution. All subjects at our institution who underwent primary esophagectomy from 1993 to 2002 following preoperative EUS for known or suspected esophageal and/or GEJ cancers were identified. Patients with dysplasia alone, prior upper gastrointestinal tract surgery, preoperative neoadjuvant therapy, cancer of the gastric cardia or recurrent malignancy were excluded. EUS findings and staging results were compared to surgical pathology following resection. The impact of the gradually increased use of primary chemoradiation during the second half of the study was assessed. Of the 286 operations performed, 184 subjects were excluded. The remaining 102 underwent primary surgical resection a median of 18 days following EUS staging for adenocarcinoma (88%) or squamous cell carcinoma (12%) of the esophagus (69%) or GEJ (31%). Overall EUS locoregional T and N staging accuracy was 72% and 75% respectively; accuracy for T1, T2, T3 and T4 cancer was 42%, 50%, 88% and 50% respectively. Despite an increased frequency of pathologically confirmed T1 and T2 cancers (P = 0.005) and an insignificant trend toward increased N0 malignancy (P = 0.05) during the second half of the study period, no statistically significant changes in T (P = 0.07) or N (P = 0.82) staging accuracies for EUS or disease characteristics were noted between the first and second half of the study period. Despite both inaccurate radial EUS staging and increased relative use of primary surgery for early cancers, recent increased use of primary neoadjuvant therapy did not change overall disease characteristics and accuracy of locoregional EUS staging of esophageal and GEJ cancers managed with primary surgical resection.
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Affiliation(s)
- J DeWitt
- Department of Gastroenterology & Hepatology, Indiana University Medical Center, IN 46202, USA.
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29
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Maish MS, DeMeester SR. Endoscopic mucosal resection as a staging technique to determine the depth of invasion of esophageal adenocarcinoma. Ann Thorac Surg 2005; 78:1777-82. [PMID: 15511474 DOI: 10.1016/j.athoracsur.2004.04.064] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/20/2004] [Indexed: 01/03/2023]
Abstract
BACKGROUND Endoscopic ablation and vagal-sparing esophagectomy offer the potential for reduced morbidity in patients with high-grade dysplasia or early esophageal adenocarcinoma, but neither includes a lymphadenectomy. Although adequate for intramucosal tumors, both are potentially inadequate for patients with submucosal tumor invasion given the high prevalence of nodal metastases with these lesions. Currently there is no test including endoscopic ultrasound that can accurately determine whether a small tumor is confined to the mucosa or has penetrated into the submucosa. The aim of this study was to compare the pathologic depth of invasion by endoscopic mucosal resection with findings and outcome after surgical resection to assess the accuracy and reliability of endoscopic mucosal resection for staging early esophageal adenocarcinoma. METHODS From 2001 to 2003, 7 patients presented with small, endoscopically visible adenocarcinomas. All underwent endoscopic mucosal resection followed by surgical resection. RESULTS Analysis of the resected specimens confirmed that the endoscopic mucosal resection had accurately determined the depth of tumor invasion in all patients, and had completely excised the lesion in all but 1 patient (86%). Lymph node dissection was included as part of the resection in 2 patients with submucosal invasion by endoscopic mucosal resection, and a vagal-sparing esophagectomy was used in the 5 patients with only intramucosal tumors. All patients are alive and disease-free at a median follow-up of 7 months. CONCLUSIONS Endoscopic mucosal resection accurately determines the depth of tumor invasion, and should be used as a staging procedure in patients with early esophageal cancer when therapies that do not include a lymphadenectomy are considered.
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Affiliation(s)
- Mary S Maish
- Department of Surgery, The University of Southern California, Keck School of Medicine, Los Angeles, California, USA
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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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Abstract
Tide and ebb of interest in gastrointestinal tract cytology has followed technical advances in this field over the last 60 years. Cytologic samples can be obtained using gastric lavage, abrasive balloons, mucosal brushing, and fine needle aspiration (under percutaneous image guidance, endoscope and endoscopic ultrasound guidance). These advances now allow simultaneous performance of brushing the abnormal mucosa, obtaining fine needle aspirates and excising mucosal biopsy samples for evaluation. Use of endoscopic ultrasound guided fine needle aspirates now help to obtain diagnosis of submucosal lesions, preoperative staging of gastrointestinal tract malignancies and help determine further management of patients. Such advances have brought pathologists to the forefront of the patient management team for the treatment of gastrointestinal tract lesions. This manuscript reviews the advantages and limitations of each cytology associated technique as well as reviews the salient diagnostic features, differential diagnosis and diagnostic pitfalls of gastrointestinal tract lesions. Finally, it suggests the modalities best suited to obtain diagnosis for various gastrointestinal tract lesions.
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Affiliation(s)
- Nirag Jhala
- Department of Pathology, University of Alabama at Birmingham, Birmingham, AL 35233, USA.
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Shamoun DK, Chak A, Levy MJ, Pfau P, Jondal ML, Wiersema MJ. Evaluation of a new curved linear array echoendoscopy system for EUS. Gastrointest Endosc 2003; 57:937-42. [PMID: 12776050 DOI: 10.1016/s0016-5107(03)70038-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND EUS-FNA can be used to accurately diagnose and stage GI and pulmonary neoplasms. This study evaluated the performance characteristics of a new compact linear EUS system during EUS-FNA. METHODS A total of 37 patients enrolled in this prospective pilot study underwent clinically indicated EUS-FNA and/or celiac plexus neurolysis with the compact EUS system. RESULTS The mean time to perform a radial and linear array EUS with FNA and/or celiac plexus neurolysis was 24 minutes shorter with the compact EUS system compared with that for an historical control procedure in which a conventional linear EUS unit was used (p = 0.0007). The EUS images and visualization of the needle during EUS-FNA were rated good to excellent in greater than 95% of the patients. With respect to ease of esophageal intubation, duodenal intubation, and general maneuverability, the performance of the new linear echoendoscope, compared with a radial scanning videoechoendoscope, was the same or better in, respectively, 85%, 87%, and 100% of procedures. The video image quality of the new linear array echoendoscope was superior to that of the radial scanning videoechoendoscope in all patients. No complications were encountered. CONCLUSIONS EUS-FNA and celiac plexus neurolysis can be performed safely with the new compact EUS system. The efficiency of this procedure is enhanced compared with historical experience with other instruments. Although image quality is sufficient for EUS-FNA and celiac plexus neurolysis, the compact unit cannot be used as a "stand-alone" system for routine diagnostic EUS, and its use must be complemented by standard radial imaging.
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Affiliation(s)
- Dany K Shamoun
- Division of Gastroenterology and Hepatology, University of Iowa Hospitals and Clinics, Iowa City 52242, USA
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Rice TW, Blackstone EH, Adelstein DJ, Zuccaro G, Vargo JJ, Goldblum JR, Murthy SC, DeCamp MM, Rybicki LA. Role of clinically determined depth of tumor invasion in the treatment of esophageal carcinoma. J Thorac Cardiovasc Surg 2003; 125:1091-102. [PMID: 12771883 DOI: 10.1067/mtc.2003.404] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE We sought to evaluate the effectiveness of clinical staging of depth of tumor invasion (cT), the relationship of cT to survival, the benefits of downstaging cT, and the role of cT in treatment decisions. METHODS The accuracy of determining T by means of endoscopic ultrasonography and the relationship of cT to survival were assessed in 209 patients undergoing esophagectomy alone for esophageal carcinoma. The benefit of downstaging cT was assessed in 128 patients undergoing induction therapy and esophagectomy. The role of cT in treatment decisions was determined by integrating these results with the results of previous work. RESULTS Compared with pathologic T (pT), cT was 87% accurate, 82% sensitive, 91% specific, 89% positively predictive, and 86% negatively predictive of tumors confined to (< or =T2) or invading beyond (>T2) the esophageal wall. In cN0, increasing cT was predictive of progressively poorer survival. For each category of pT N0, cT accurately predicted survival, except for pT3, which was underestimated (P <.0001). In cN0, downstaging by induction therapy was beneficial only if tumors invaded beyond the wall (> or =cT3, P =.0003). In cN1, it was beneficial only when downstaging was synchronous in cT3/T4 (P <.001). CONCLUSIONS cT should be the principal determinant of treatment in cN0. In cN0, if endoscopic ultrasonography identifies tumors of greater than cT2, multimodality therapy should be considered. However, only when cT3/T4 tumors are downstaged to pT2 or less will patients benefit, but their survival will not equal that of patients with tumors of cT2 or less having esophagectomy alone. If endoscopic ultrasonography identifies tumors of cT2 or less, esophagectomy alone should be used because induction therapy might adversely affect survival.
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Affiliation(s)
- Thomas W Rice
- Center for Swallowing and Esophageal Disorders, Departments of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.
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Wu LF, Wang BZ, Feng JL, Cheng WR, Liu GR, Xu XH, Zheng ZC. Preoperative TN staging of esophageal cancer: Comparison of miniprobe ultrasonography, spiral CT and MRI. World J Gastroenterol 2003; 9:219-24. [PMID: 12532435 PMCID: PMC4611315 DOI: 10.3748/wjg.v9.i2.219] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
AIM: To evaluate the value of miniprobe sonography (MPS), spiral CT and MR imaging (MRI) in the tumor and regional lymph node staging of esophageal cancer.
METHODS: Eight-six patients (56 men and 30 women; age range of 39-73 years, mean 62 years) with esophageal carcinoma were staged preoperatively with imaging modalities. Of them, 81 (94%) had squamous cell carcinoma, 4 (5%) adenocarcinoma, and 1 (1%) adenoacanthoma. Eleven patients (12%) had malignancy of the upper one third, 41 (48%) of the mid-esophagus and 34 (40%) of the distal one third. Forty-one were examined by spiral CT in whom 13 were co-examined by MPS, and forty-five by MRI in whom 18 were also co-examined by MPS. These imaging results were compared with the findings of the histopathologic examination for resected specimens.
RESULTS: In staging the depth of tumor growth, MPS was significantly more accurate (84%) than spiral CT and MRI (68% and 60%, respectively, P < 0.05). The specificity and sensitivity were 82% and 85% for MPS; 60% and 69% for spiral CT; and 40% and 63% for MRI, respectively. In staging regional lymph nodes, spiral CT was more accurate (78%) than MPS and MRI (71% and 64%, respectively), but the difference was not statistically significant. The specificity and sensitivity were 79% and 77% for spiral CT; 75% and 68% for MPS; and 68% and 62% for MRI, respectively.
CONCLUSION: MPS is superior to spiral CT or MRI for T staging, especially in early esophageal cancer. However, the three modalities have the similar accuracy in N staging. Spiral CT or MRI is helpful for the detection of far-distance metastasis in esophageal cancer.
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Affiliation(s)
- Ling-Fei Wu
- Department of Gastroenterology, Second Affiliated Hospital, Shantou University Medical College, Shantou 515041, Guangdong Province China.
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Parmar KS, Zwischenberger JB, Reeves AL, Waxman I. Clinical impact of endoscopic ultrasound-guided fine needle aspiration of celiac axis lymph nodes (M1a disease) in esophageal cancer. Ann Thorac Surg 2002; 73:916-20; discussion 920-1. [PMID: 11899201 DOI: 10.1016/s0003-4975(01)03560-3] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND The purpose of this study was to determine how endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) with a histology confirmed biopsy protocol impacted on staging and managing esophageal carcinoma in terms of resectability and neoadjuvant therapy (chemotherapy and radiation therapy). METHODS The records of 40 consecutive patients diagnosed with esophageal cancer referred for EUS staging were reviewed. Computed tomography (CT) scan then EUS imaging and EUS-guided FNA staging, including involvement of celiac node (M1a stage), surgical pathology, and subsequent treatment were correlated. Through-the-scope balloons were used for dilatation when needed to examine the celiac nodes. RESULTS All 40 patients followed the protocol and were successfully imaged by EUS. Sixteen of the 40 required esophageal dilatation using the through-the-scope balloon. No complications were observed from esophageal dilatation for EUS. Twenty-three (58%) met the criteria for EUS-guided FNA biopsy from a total of 40 EUS imaging procedures. Twenty (87%) of the 23 EUS-guided FNA were directed toward the celiac nodes; 18 (90%) of the 20 were positive for malignancy and were treated by chemoradiation therapy and 2 (10%) FNA were negative for malignancy and were treated by surgical resection. The CT scan was able to detect only 6 (30%) of 20 cases of suspicious celiac lymph nodes, of which 5 (83%) were positive for malignancy by FNA. CONCLUSIONS EUS-guided FNA of celiac nodes (20 patients) directed management in all patients biopsied. EUS-guided FNA is superior to CT scan for diagnosing M1a disease. Protocol-directed EUS-guided FNA is a pivotal study when used in conjunction with stage-oriented treatment protocols for esophageal carcinoma.
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Affiliation(s)
- Kiran S Parmar
- Department of Surgery, University of Texas Medical Branch at Galveston, USA
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Hulscher JB, Buskens CJ, Bergman JJ, Fockens P, Van Lanschot JJ, Obertop H. Positive peritruncal nodes for esophageal carcinoma. not always a dismal prognosis. Dig Surg 2001; 18:98-101. [PMID: 11351153 DOI: 10.1159/000050108] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND/AIMS For esophageal carcinoma, positive truncal nodes are considered distant metastases, and might be a contraindication for potentially curative surgery. With the development of new diagnostic tools more/smaller peritruncal nodes may be found positive preoperatively. We evaluate whether it is justified to exclude all patients with positive peri-truncal nodes from curative surgery. METHODS Retrospective study of all patients undergoing transhiatal resection for a mid-/distal esophageal carcinoma between 1993 and 1997. RESULTS 110 patients underwent transhiatal resection for esophageal carcinoma. Sixteen patients had tumor-positive, resectable peritruncal lymph nodes not identified preoperatively, changing preoperative stage III into postoperative stage IV (M1a). After follow-up of 2.9 years (0.07-7.6), 49 patients (45%) were alive. On multivariate analysis radicality and lymph node status were independent prognostic factors. There was no significant difference in survival between stage III and stage IV (M1a) tumors: 1.7 and 1.5 years, respectively (p = 0.87). At the end of follow-up, 4/16 patients (25%) with stage IV (M1a) disease were alive without evidence of disease. CONCLUSION The presence of malignant cells in small, resectable peritruncal nodes does not preclude long-term survival. The results of new diagnostic modalities should be interpreted cautiously, until firm criteria for irresectability/incurability of positive truncal nodes are established.
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Affiliation(s)
- J B Hulscher
- Department of Surgery, Academic Medical Center/University of Amsterdam, The Netherlands.
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