Appraisal of staging endoscopic ultrasonography in a modern high-volume esophageal program

Favorable effect of endoscopic reassessment of clinically staged T2 esophageal adenocarcinoma: a multicenter prospective cohort study

BACKGROUND : Clinical tumor stage of esophageal adenocarcinoma (EAC) is determined by endoscopic ultrasound and/or computed tomography scan, which have low accuracy for stages T1 and T2, potentially leading to overtreatment. We aimed to assess the proportion of cT2 EACs downstaged to cT1 after endoscopic reassessment (ERA) by an experienced interventional endoscopist. METHODS : We performed a prospective multicenter cohort study. Patients with cT2N0M0 EAC were included and underwent ERA. The primary outcome was proportion of cT2 EACs downstaged to cT1 after ERA. RESULTS : 15/25 included patients (60 %) were downstaged from cT2 to cT1 EAC after ERA and underwent attempted endoscopic resection. Endoscopic resection was aborted in 3/15 patients because of tumor invasion into the muscle layer; all three underwent successful surgical resection. Endoscopic resection was successful in 12/15 patients (80 %), all of whom had pT1 tumors. Overall, 10/25 (40 %) were treated with endoscopic resection alone. CONCLUSIONS : ERA downstaged about half of the cT2 tumors to cT1, rendering them suitable for endoscopic resection. ERA had substantial clinical impact on therapeutic management, preventing overtreatment in 40 % of patients.

Clinical TNM staging for esophageal, gastric, and colorectal cancers in the era of neoadjuvant therapy: A systematic review of the literature

AIM

Clinical staging is vital for selecting appropriate candidates and designing neoadjuvant treatment strategies for advanced tumors. The aim of this review was to evaluate diagnostic abilities of clinical TNM staging for gastrointestinal, gastrointestinal cancers.

METHODS

We conducted a systematic review of recent publications to evaluate the accuracy of diagnostic modalities on gastrointestinal cancers. A systematic literature search was performed in PubMed/MEDLINE using the keywords "TNM staging," "T4 staging," "distant metastases," "esophageal cancer," "gastric cancer," and "colorectal cancer," and the search terms used in Cochrane Reviews between January 2005 to July 2020. Articles focusing on preoperative diagnosis of: (a) depth of invasion; (b) lymph node metastases; and (c) distant metastases were selected.

RESULTS

After a full-text search, a final set of 55 studies (17 esophageal cancer studies, 26 gastric cancer studies, and 12 colorectal cancer studies) were used to evaluate the accuracy of clinical TNM staging. Positron emission tomography-computed tomography (PET-CT) and/or magnetic resonance imaging (MRI) were the best modalities to assess distant metastases. Fat and fiber mode of CT may be useful for T4 staging of esophageal cancer, CT was a partially reliable modality for lymph node staging in gastric cancer, and CT combined with MRI was the most reliable modality for liver metastases from colorectal cancer.

CONCLUSION

The most reliable diagnostic modality differed among gastrointestinal cancers depending on the type of cancer. Therefore, we propose diagnostic algorithms for clinical staging for each type of cancer.

Use of endoscopic ultrasound in pre-treatment staging of esophageal cancer did not alter management plan

Background

Initial staging of esophageal cancer relies on EUS in addition to FDG-PET/CT. It is our hypothesis that with the advancement of FDG-PET/CT staging, endoscopic ultrasound may not be required for initial staging in all cases. The purpose of this study is to analyze whether EUS affects initial treatment stratification in patients diagnosed with esophageal cancer.

Methods

A retrospective database at the University of Virginia was queried for patients diagnosed with esophageal squamous cell carcinoma and adenocarcinoma who underwent EGD with EUS and FDG-PET/CT at their initial evaluation from 10/2013 to 5/2017. Two thoracic surgeons were asked to determine appropriate management for each case. Options included surgical resection, neoadjuvant chemoradiotherapy followed by resection, definitive chemoradiotherapy, or chemotherapy with or without palliative radiation. Both surgeons received the FDG-PET/CT report along with the EGD report. For each case, one or both surgeons were randomly allocated to review EUS results in addition to the clinical information. The treatment decisions of each thoracic surgeon were compared to determine if EUS reports impacted clinical management. Simple and weighted correlation coefficients (kappa) were calculated to compare agreement of treatment choices between the two surgeons using McNemars test. Conditional logistic regression was used to assess the influence of EUS on the treatment recommendations.

Results

A total of 50 patients (44 male and 6 female) were enrolled and data was collected. The thoracic surgeons agreed on treatment decisions in 39 cases and disagreed on 11 cases. Agreement between surgeons was good despite lack of EUS information for one surgeon on each case (weighted Kappa =0.73, 95% CI: 0.57-0.89). Using conditional logistic regression, EUS did not have a statistically independent association with agreement on treatment plan (P for model =0.17).

Conclusions

EUS did not have a statistically independent association with agreement on treatment plan for newly diagnosed esophageal cancer (P for model =0.17). Our findings suggest that EUS may not be necessary in the algorithm for the initial staging of every case of esophageal cancer. Selective, rather than mandatory use of EUS seems warranted.

A Diagnostic Algorithm That Combines Quantitative 18F-FDG PET Parameters and Contrast-Enhanced CT Improves Posttherapeutic Locoregional Restaging and Prognostication of Survival in Patients With Esophageal Cancer

PURPOSE

The aim of this study was to determine whether the combination of contrast-enhanced CT (CE-CT) and quantitative F-FDG PET parameters improves locoregional restaging in esophageal cancer (EC) after neoadjuvant therapy.

METHODS

Eighty-eight consecutive patients with locally advanced esophageal cancer, who underwent restaging after neoadjuvant chemotherapy or chemoradiotherapy before esophagectomy, were included in this retrospective study. The diagnostic accuracy of CE-CT, visual F-FDG PET/CT (vPET/CT), and quantitative PET parameters was assessed for T and N staging. Histopathology was used as the reference standard. The prognostic value for recurrence-free survival, cancer-specific survival, and overall survival was assessed using Cox regression analysis.

RESULTS

Sensitivity, positive predictive value, and accuracy were 78.8%, 70.2%, and 59.0% (CE-CT), and 81.1%, 81.1%, and 68.2% (vPET/CT) for T staging as well as 59.5%, 75.9%, and 50.0% (CE-CT), and 70.2%, 93.7%, and 67.0% (vPET/CT) for N staging, respectively. Tumor length and metabolic tumor volume (MTV) exhibited an incremental increase with advancing T stages (P = 0.002 and 0.038). Contrast-enhanced CT had the highest sensitivity to differentiate advanced T stages (T3/4 vs 0-2; area under the receiver operating curve [AUC], 0.86; P < 0.001), whereas MTV at a threshold of 5.8 mL had the highest sensitivity to detect complete response (T0 vs 1-4; AUC, 0.77; P = 0.002). Contrast-enhanced CT and MTV combined had an even superior accuracy to predict complete response (AUC, 0.82; P < 0.001). The imaging American Joint Committee on Cancer stage provided a better prognostication of recurrence-free survival, cancer-specific survival, and overall survival than either T stage, N stage derived from CE-CT or vPET/CT, or quantitative PET parameters alone.

CONCLUSIONS

Combined CE-CT and MTV had the highest diagnostic accuracy to identify the posttherapeutic T stage, allowing for robust prediction of recurrence and survival.

Preoperative lymph node status on computed tomography influences the survival of pT1b, T2 and T3 esophageal squamous cell carcinoma

PURPOSE

The preoperative lymph node status is critical for tailoring optimal treatments for esophageal squamous cell carcinoma (ESCC). This study aimed to evaluate the prognostic impact of a diagnostic criterion based solely on the short-axis diameters of lymph nodes depicted on computed tomography (CT) in ESCC patients undergoing upfront esophagectomy.

METHODS

We retrospectively reviewed 246 pT1b-T3 ESCC patients undergoing upfront esophagectomy. Clinically positive lymph node metastasis (cN+) was defined as nodes with a short-axis diameter of at least 8 mm on CT.

RESULTS

Ninety-three patients had a cN+ status according to this criterion. The overall and recurrence-free survival rates were significantly lower in the cN+ group than in the cN- group (P < 0.001). The overall survival rate was markedly lower in the "pN2/3 and cN+" group than in the other groups (vs. pN0: P < 0.001, vs. pN1: P = 0.002, vs. "pN2/3 and cN-": P < 0.001). However, the overall survival rate of the "pN2/3 and cN-" group was similar to that of the pN0-1 groups. A multivariate analysis showed that cN+ (P = 0.002), major complications (P = 0.001), and pT3 (P = 0.021) were independently associated with a poor prognosis.

CONCLUSION

A diagnostic criterion based solely on the short-axis diameters of lymph nodes depicted on CT was useful for stratifying the survival in ESCC patients.

Specific Tumor Characteristics Predict Upstaging in Early-Stage Esophageal Cancer

BACKGROUND

Early-stage esophageal cancer (stages 0-1) has been shown to have relatively good outcomes after local endoscopic or surgical resection. For this reason, neoadjuvant chemoradiation usually is reserved for higher-stage disease. Some early tumors, however, are found after resection to be more advanced than predicted based on initial clinical staging, termed pathologic upstaging. Such tumors may have benefited from alternate treatment models had their true stage been known preoperatively. This study aimed to identify high-risk features in early esophageal cancers that might predict tumor upstaging and guide more individualized treatment algorithms.

METHODS

Through retrospective review of a single-institution foregut disease registry, we evaluated patients who underwent esophagectomy for high-grade dysplasia (Tis) or stage 1 esophageal cancer, searching for factors associated with pathologic upstaging.

RESULTS

The review included 110 patients (88% male, median age at diagnosis, 64.5 years) treated between January 2000 and June 2016. Upstaging occurred for 20.9% of the patients, and was more common for patients with angiolymphatic invasion (odds ratio [OR], 11.07; 95% confidence interval [CI], 2.96-41.44; P < 0.001) or signet-ring features (OR, 23.9; 95% CI, 2.6-216.8; P = 0.005). In the absence of other predictors, upstaging was associated with decreased overall survival (P = 0.006).

CONCLUSIONS

Approximately 20% of patients with early-stage esophageal cancer may be upstaged at resection. Angiolymphatic invasion and signet-ring features may predict tumors likely to be upstaged, resulting in decreased overall survival.

Efficacy of Endoscopic Ultrasonography for Determining Clinical T Category for Esophageal Squamous Cell Carcinoma: Data From 1434 Surgical Cases

BACKGROUND

The efficacy of endoscopic ultrasonography (EUS) for determining T category is variable for esophageal squamous cell carcinoma (ESCC). We aimed to assess the efficacy of EUS in accurately identifying T category for ESCC based on the 8th AJCC Cancer Staging Manual.

METHODS

A retrospective analysis was conducted using a prospectively collected ESCC database from January 2003 to December 2015, in which all patients underwent EUS examination followed by esophagectomy. The efficacy of EUS was evaluated by sensitivity, specificity, and accuracy compared with pathological T category as gold standard. Overall survival of different EUS-T (uT) categories was assessed.

RESULTS

In total, 1434 patients were included, of whom 58.2% were correctly classified by EUS, with 17.9% being overstaged and 23.9% being understaged. The sensitivity and accuracy of EUS for Tis, T1a, T1b, T2, T3, and T4a categories were 15.8 and 98.8%, 16.3 and 95.7%, 33.1 and 89.3%, 56.8 and 65.0%, 65.8 and 70.0%, and 27.3 and 97.5%, respectively. The survival difference between uT1a and uT1b was not statistically significant (p = 0.90), nor was that between uT4a and uT4b (p = 0.34). However, when uT category was integrated as uTis, uT1, uT2, uT3, and uT4, overall survival was clearly distinguished between the categories (p < 0.01).

CONCLUSIONS

EUS is in general feasible for classifying clinical T category for ESCC. However, EUS should be used with caution for discriminating between Tis, T1a, and T1b disease, as well as T4 disease.

Endoscopic ultrasound staging for early esophageal cancer: Are we denying patients neoadjuvant chemo-radiation?

AIM

To evaluate the accuracy of endoscopic ultrasound (EUS) in early esophageal cancer (EC) performed in a high-volume tertiary cancer center.

METHODS

A retrospective review of patients undergoing esophagectomy was performed and patients with cT1N0 and cT2N0 esophageal cancer by EUS were evaluated. Patient demographics, tumor characteristics, and treatment were reviewed. EUS staging was compared to surgical pathology to determine accuracy of EUS. Descriptive statistics was used to describe the cohort. Student’s t test and Fisher’s exact test or χ² test was used to compare variables. Logistic regression analysis was used to determine if clinical variables such as tumor location and tumor histology were associated with EUS accuracy.

RESULTS

Between 2000 and 2015, 139 patients with clinical stageIorIIA esophageal cancer undergoing esophagectomy were identified. There were 25 (18%) female and 114 (82%) male patients. The tumor location included the middle third of the esophagus in 11 (8%) and lower third and gastroesophageal junction in 128 (92%) patients. Ninety-three percent of patients had adenocarcinoma. Preoperative EUS matched the final surgical pathology in 73/139 patients for a concordance rate of 53%. Twenty-nine patients (21%) were under-staged by EUS; of those, 19 (14%) had unrecognized nodal disease. Positron emission tomography (PET) was used in addition to EUS for clinical staging in 62/139 patients. Occult nodal disease was only found in 4 of 62 patients (6%) in whom both EUS and PET were negative for nodal involvement.

CONCLUSION

EUS is less accurate in early EC and endoscopic mucosal resection might be useful in certain settings. The addition of PET to EUS improves staging accuracy.

Predictors of pathologic upstaging in early esophageal adenocarcinoma: Results from the national cancer database

BACKGROUND

Upstaging in early esophageal adenocarcinoma (EAC) patients happens at a high rate and has implications for treatment. We sought to identify risk factors predicting upstaging.

STUDY DESIGN

The National Cancer Database (2010-2013) was queried for all patients with clinical T1/T2 and N0 EAC who underwent esophagectomy without neoadjuvant therapy. Logistic regression models were developed to investigate risk factors for upstaging.

RESULTS

A total of 1120 patients were included. Pathologic upstaging occurred in 21.3% (n = 239). After adjustment, risk of upstaging increased with tumor size (tumor size 1-3 cm, OR 4.57,95% CI 2.58-8.10, tumor size >3 cm, OR 10.57, 95% CI 5.77-19.35, as compared to tumors <1 cm) as well as with positive margins (OR 4.13, 95% CI 2.17-7.87) and > than 10 lymph nodes examined (OR 1.85, 95% CI 1.29-2.63), while facility volume was not significant. Odds of upstaging increased linearly with number of lymph nodes examined (OR 1.02 per node).

CONCLUSION

Our data underscore the importance of tumor size as a predictor for upstaging and of completing a thorough lymph node dissection for staging purposes.

Endoscopic ultrasound for preoperative staging of esophageal cancer: Application value and problems encountered

AIM

To assess the value of endoscopic ultrasound (EUS) in preoperative staging of esophageal cancer and discuss the problems encountered.

METHODS

A retrospective review was conducted on 388 patients with esophageal cancer who underwent EUS examination and esophagectomy from April 2014 to September 2016 at our hospital. We calculated the sensitivity, specificity and accuracy of EUS in preoperative staging of esophageal cancer and compared the characteristics of the patients with and without stenosis.

RESULTS

The diagnostic accuracy of EUS for T1, T2, T3 and T4 stages was 92.8%, 82.9%, 84.5%, and 95.4%, respectively. The sensitivity, specificity and accuracy of EUS for the diagnosis of N1+ were 59.6%, 81.8% and 69.2%, respectively. In patients with stenosis, 79.5% had T3+ and 64.4% had N1+, both of which were significantly higher than those in patients without stenosis (P < 0.05).

CONCLUSION

The accuracy of EUS in T staging in patients with esophageal cancer is high, and it is a reliable diagnostic tool. For patients with stenosis, pre-dilatation should be omitted and the patients should be referred for neoadjuvant therapy.

Does the modified Glasgow Prognostic Score (mGPS) have a prognostic role in esophageal cancer?

BACKGROUND

The modified Glasgow Prognostic Score (mGPS), which combines indices of decreased plasma albumin and elevated CRP, has reported independent prognostic significance in colorectal cancer, but its value in upper gastrointestinal cancer is unclear. The aim of this study was to assess the prognostic significance of mGPS in patients with operable esophageal malignancy.

METHODS

Patients undergoing resection with curative intent between January 2008 and June 2013 were included. The mGPS was scored as 0, 1, or 2 based on CRP(>10 mg/L) and albumin(<35g/L). The mGPS score (0 vs. 1/2 combined) was correlated with patient and tumor characteristics, and operative and oncologic outcomes.

RESULTS

Two hundred and twenty-three patients were included. Median (range) follow-up was 21(12-70) months. The mGPS was 0 in 174 patients(78%). mGPS was significantly associated with positive nodal status(P = 0.008) and stage ≥III (P = 0.017). There was a significant improvement in overall survival in patients with mGPS = 0 (47.8 vs. 37.5 months, P = 0.014) but in multivariate analysis, only TNM-stage and nodal status were found to be independent prognostic indicators.

CONCLUSIONS

mGPS is associated with advanced stage but has no independent prognostic significance and does not impact on operative outcomes. Consequently, this data does not support its routine application in patient selection or prognostication. J. Surg. Oncol. 2016;113:732-737. © 2016 Wiley Periodicals, Inc.

Pretreatment Dysphagia in Esophageal Cancer Patients May Eliminate the Need for Staging by Endoscopic Ultrasonography

BACKGROUND

Neoadjuvant therapy is commonly administered to patients with localized disease who have T3-4 esophageal disease as staged by endoscopic ultrasound (EUS). Previously, we noted that patients who present with dysphagia have a higher EUS T stage. We hypothesized that the presence of dysphagia is predictive of EUS T3-4 disease and that staging EUS could be forgone for esophageal cancer patients with dysphagia.

METHODS

We performed a prospective, intent-to-treat, single-cohort study in which patients with potentially resectable esophageal cancer completed a standardized four-tier dysphagia score survey. EUS was performed as part of our standard evaluation. To determine whether the presence of dysphagia predicted EUS T3-4 disease, the dysphagia score was compared with EUS T stage.

RESULTS

The study enrolled 114 consecutive patients between August 2012 and February 2014: 77% (88 of 114) received neoadjuvant therapy, 18% (20 of 114) did not, and 5% (6 of 114) pursued treatment elsewhere. In total, 70% (80 of 114) underwent esophagectomy; of these, 54% (61 of 114) had dysphagia and 46% (53 of 114) did not. Dysphagia scores were 66% (40 of 61) grade 1, 25% (15 of 61) grade 2, and 10% (6 of 61) grade 3 to 4. Among patients with dysphagia, 89% (54 of 61) had T3-4 disease by EUS; among those without dysphagia, only 53% (28 of 53) had T3-4 disease by EUS (p < 0.001).

CONCLUSIONS

The presence of dysphagia in patients with esophageal cancer was highly predictive of T3-4 disease by EUS. On the basis of this finding, approximately 50% of patients currently undergoing staging EUS at our institution could potentially forgo EUS before neoadjuvant therapy. Patients without dysphagia, however, should still undergo EUS.