Routine vs. selective EUS-guided FNA approach for preoperative nodal staging of esophageal carcinoma

Accuracy of clinical staging for T2N0 oesophageal cancer: systematic review and meta-analysis

Oesophageal cancer is the sixth commonest cause of overall cancer mortality. Clinical staging utilizes multiple imaging modalities to guide treatment and prognostication. T2N0 oesophageal cancer is a treatment threshold for neoadjuvant therapy. Data on accuracy of current clinical staging tests for this disease subgroup are conflicting. We performed a meta-analysis of all primary studies comparing clinical staging accuracy using multiple imaging modalities (index test) to histopathological staging following oesophagectomy (reference standard) in T2N0 oesophageal cancer. Patients that underwent neoadjuvant therapy were excluded. Electronic databases (MEDLINE, Embase, Cochrane Library) were searched up to September 2019. The primary outcome was diagnostic accuracy of combined T&N clinical staging. Publication date, first recruitment date, number of centers, sample size and geographical location main histological subtype were evaluated as potential sources of heterogeneity. The search strategy identified 1,199 studies. Twenty studies containing 5,213 patients met the inclusion criteria. Combined T&N staging accuracy was 19% (95% CI, 15-24); T staging accuracy was 29% (95% CI, 24-35); percentage of patients with T downstaging was 41% (95% CI, 33-50); percentage of patients with T upstaging was 28% (95% CI, 24-32) and percentage of patients with N upstaging was 34% (95% CI, 30-39). Significant sources of heterogeneity included the number of centers, sample size and study region. T2N0 oesophageal cancer staging remains inaccurate. A significant proportion of patients were downstaged (could have received endotherapy) or upstaged (should have received neoadjuvant chemotherapy). These findings were largely unchanged over the past two decades highlighting an urgent need for more accurate staging tests for this subgroup of patients.

New endoscopic ultrasonography criteria for malignant lymphadenopathy based on inter-rater agreement

BACKGROUND AND AIMS

Various studies have been previously conducted on the diagnosis of lymphadenopathy as benign or malignant, but the results vary. These studies did not describe the inter-rater agreement on the EUS features of lymphadenopathy. In this study, we evaluate the inter-rater agreement on EUS features and propose EUS diagnostic norms for lymphadenopathy based on inter-rater agreement.

METHOD

A total of 68 lymph nodes subjected to EUS-fine needle aspiration (FNA) were reviewed by five endoscopic experts. The EUS features evaluated lymph node size, shape, border, margin, echogenicity, homogeneity, and the hilum of the lymph node. Inter-rater agreement (multi-rater kappa statics) was performed. We established new criteria using results with a high degree of inter-rater agreement from EUS features and compared them with the former criteria.

RESULT

There was a moderate agreement on shape, kappa (K) = 0.44 (95% confidence interval [CI]: 0.34-0.54), and fair agreement on echogenicity, homogeneity, border, and hilum of the lymph node, K (95% CI) = 0.33 (0.17-0.38), 0.34 (0.26-0.35), 0.22 (0.21-0.31), and 0.22 (0.11-0.26), respectively. This resulted in the establishment of new EUS diagnostic criteria using shape, long axis > 20 mm and short axis > 10 mm. New criteria were superior to old criteria (area under the curve 0.82 vs 0.52, P < 0.001).

CONCLUSION

EUS diagnostic criteria for lymphadenopathy based on inter-rater agreement were more accurate than old criteria. This result will be useful for the diagnosis of lymphadenopathy.

A prospective, controlled assessment of the technical characteristics of a novel forward-viewing echoendoscope

INTRODUCTION

endoscopic ultrasound (EUS) is a highly useful technique for the diagnosis and management of different gastrointestinal (GI) tract conditions.

OBJECTIVE

to prospectively assess the clinical usefulness of a novel forward-viewing echoendoscope (FV-CLA).

METHODS

this was a cross-sectional observational study. All patients that underwent EUS over a two-month period were considered for the study. All mediastinal, perigastric and periduodenal stations were consistently assessed with a rating from 0 to 10 points with regard to the ease to obtain ultrasonographic sections and the quality of ultrasound images. The identified lesions were punctured when clinically indicated.

RESULTS

a total of 45 patients were included. EUS was completed in 100% of patients, with two minor complications recorded. Echoendoscope maneuverability was graded as "A" (9-10 points), overall plane visibility was graded as "B" (7-8 points) and only stations 4L and 5 visualization were graded as "D" (< 7 points). Visualization of the pancreas and the rest of the EUS stations were rated as excellent or very good. The feasibility to perform EUS-FNA, even from the second portion of the duodenum, was graded excellent or very good.

CONCLUSION

the FV-CLA allows a complete, high-quality examination of the upper GI tract, including EUS-FNA punctures. Some mediastinal stations are hardly accessible with this new device. A formal validation of the FV-CLA for EUS-guided therapy would be of interest.

Is endoscopic ultrasound examination necessary in the management of esophageal cancer?

Despite substantial efforts at early diagnosis, accurate staging and advanced treatments, esophageal cancer (EC) continues to be an ominous disease worldwide. Risk factors for esophageal carcinomas include obesity, gastroesophageal reflux disease, hard-alcohol use and tobacco smoking. Five-year survival rates have improved from 5% to 20% since the 1970s, the result of advances in diagnostic staging and treatment. As the most sensitive test for locoregional staging of EC, endoscopic ultrasound (EUS) influences the development of an optimal oncologic treatment plan for a significant minority of patients with early cancers, which appropriately balances the risks and benefits of surgery, chemotherapy and radiation. EUS is costly, and may not be available at all centers. Thus, the yield of EUS needs to be thoughtfully considered for each patient. Localized intramucosal cancers occasionally require endoscopic resection (ER) for histologic staging or treatment; EUS evaluation may detect suspicious lymph nodes prior to exposing the patient to the risks of ER. Although positron emission tomography (PET) has been increasingly utilized in staging EC, it may be unnecessary for clinical staging of early, localized EC and carries the risk of false-positive metastasis (over staging). In EC patients with evidence of advanced disease, EUS or PET may be used to define the radiotherapy field. Multimodality staging with EUS, cross-sectional imaging and histopathologic analysis of ER, remains the standard-of-care in the evaluation of early esophageal cancers. Herein, published data regarding use of EUS for intramucosal, local, regional and metastatic esophageal cancers are reviewed. An algorithm to illustrate the current use of EUS at The University of Texas MD Anderson Cancer Center is presented.

Management of Locally Advanced Adenocarcinoma of the Esophagus and Gastroesophageal Junction: Finally a Consensus

Opinion statement: Adenocarcinoma of the esophagus is increasing in incidence in Western nations leading to increased interest in and opportunity to study optimal management. Randomized trials have now robustly demonstrated the preoperative therapy with chemoradiotherapy and chemotherapy alone improves survival outcome for the bulk of curable patients, those with locally advanced T1N1M0 and T2-3 N0-1 M0 disease. Evidence suggests but does not confirm that radiation-containing regimens are more beneficial. Clinical staging is designed to exclude patients with T1N0M0 disease who may be treated with surgery alone and those with metastatic disease who may not benefit from intensive local therapy. The approach to clinical staging includes endoscopy with ultrasound and fine needle aspirate to assess local and regional disease, supplemented by CT and PET scanning primarily to exclude metastatic disease. Minimally invasive approaches to esophagectomy may be used with the goal of reducing complications, but there is no evidence that mortality or ultimate outcome is improved.

Eastern Cooperative Oncology Group and American College of Radiology Imaging Network Randomized Phase 2 Trial of Neoadjuvant Preoperative Paclitaxel/Cisplatin/Radiation Therapy (RT) or Irinotecan/Cisplatin/RT in Esophageal Adenocarcinoma: Long-Term Outcome and Implications for Trial Design

PURPOSE

Toxicity, pathologic complete response, and long-term outcomes are reported for the neoadjuvant therapies assessed in a randomized phase 2 Eastern Cooperative Oncology Group and American College of Radiology Imaging Network trial for operable esophageal adenocarcinoma, staged as II-IVa by endoscopy/ultrasonography (EUS).

METHODS AND MATERIALS

A total of 86 eligible patients began treatment. For arm A, preoperative chemotherapy was cisplatin, 30 mg/m(2), and irinotecan, 50 mg/m(2), on day 1, 8, 22, 29 during 45 Gy radiation therapy (RT), 1.8 Gy per day over 5 weeks. Adjuvant therapy was cisplatin, 30 mg/m(2), and irinotecan, 65 mg/m(2) day 1, 8 every 21 days for 3 cycles. Arm B therapy was cisplatin, 30 mg/m(2), and paclitaxel, 50 mg/m(2), day 1, 8, 15, 22, 29 with RT, followed by adjuvant cisplatin, 75 mg/m(2), and paclitaxel, 175 mg/m(2), day 1 every 21 days for 3 cycles. Stratification included EUS stage and performance status.

RESULTS

In arm A, median overall survival was 35 months, and 5-, 6-, and 7-year survival rates were 46%, 39%, and 35%, respectively, whereas for arm B, they were 21 months and 27%, 27%, and 23%, respectively. Median progression- or recurrence-free survival (PFS) was 39.8 months with a 3-year PFS of 50% for arm A and 12.4 months (P=.046) with 3-year PFS of 28% for arm B. Eighty percent of the observed incidents of progression occurred within 19 months. Survival did not differ significantly by EUS and performance status strata.

CONCLUSIONS

Long-term survival was similar for both arms and did not appear superior to results achieved with other standard regimens.

The Role of Endosonography in the Staging of Gastrointestinal Cancers

Endosonography (EUS) enables the acquisition of clear images of the gastrointestinal tract wall and the surrounding structures. EUS enables much greater accuracy for staging decisions compared to computed tomography. Surgery for esophageal cancer has a high rate of morbidity and mortality, and it is important to decide on an appropriate treatment method through pre-surgical evaluation. Minimal invasive surgery is widely used for the treatment of gastrointestinal cancer, and endoscopic submucosal dissection is a safe treatment method for early cancer of the gastrointestinal tract that does not result in lymph node metastasis. EUS is essential for pre-surgical evaluation for all esophageal cancers. The use of EUS can effectively reduce unnecessary surgeries and thereby allow for appropriate treatment planning for patients. A number of different diagnostic modalities are available, but EUS is still the mainstay for pre-surgical evaluation of esophageal cancer. The role of EUS for early stomach cancer treatment as a tool for determining the need for endoscopic resection and for pre-surgical assessment is increasing.

Endoscopic ultrasound: Elastographic lymph node evaluation

Different imaging techniques can bring different information which will contribute to the final diagnosis and further management of the patients. Even from the time of Hippocrates, palpation has been used in order to detect and characterize a body mass. The so-called virtual palpation has now become a reality due to elastography, which is a recently developed technique. Elastography has already been proving its added value as a complementary imaging method, helpful to better characterize and differentiate between benign and malignant masses. The current applications of elastography in lymph nodes (LNs) assessment by endoscopic ultrasonography will be further discussed in this paper, with a review of the literature and future perspectives.

Distant lymph node metastases in gastroesophageal junction adenocarcinoma: impact of endoscopic ultrasound-guided fine-needle aspiration

OBJECTIVE

Endoscopic ultrasound (EUS) is established as the most accurate technique for pre-operative locoregional staging of gastroesophageal junction (GEJ) adenocarcinoma, the purpose of the present study was to evaluate the distant lymph nodes (LNs) EUS-fine-needle aspiration (FNA) impact in therapeutic decision for patients with GEJ adenocarcinoma.

MATERIALS AND METHODS

Retrospective study was made, with cross-sectional, non-probabilistic analysis from prospectively collected database for all GEJ adenocarcinoma staging patients referred between January 2009 and August 2012 in Paoli-Calmette Institute in Marseille-France.

RESULTS

A total of 154 patients with GEJ adenocarcinoma were managed in our institution, of whom 113 (73.3%) had non-distant metastatic disease at computed tomography (CT) scan and underwent EUS for initial tumor staging prior to a treatment decision. On A total of 113 patients undergoing EUS, 8 (7%) patients underwent endoscopic resection and 6 (5.3%) underwent direct surgical resection. Of the remaining 99 patients (87.6%), 24 (21.2%) distant LN EUS-FNA were made. Seventeen LN had EUS malignant features, including 9 (52.9%) that were confirmed as malignant and underwent palliative treatment with chemotherapy. Ninety (79.6%) patients were treated with pre-operative neoadjuvant therapy and were revaluated after. 4 (4.4%) had metastatic disease at CT scan (underwent palliative treatment) and 65 (72.2%) underwent EUS restaging to treatment decision revaluation. Of these, twelve (18.4%) distant LN EUS-FNA were performed. Seven had LN EUS malignancy features, including 4 (57.1%) that were confirmed as malignant and underwent palliative treatment. The remaining 61 patients underwent surgery. As stated above, 21 patients (23.3%) did not undergo EUS restaging, including 10 (47.6%) that did not go to surgery because patient's age, poor general status and comorbidities, 6 (28.5%) had a loss of follow-up, 1 (4.7%) underwent to surgery due to chemotherapy collateral effects, 3 (14.2%) were still on pre-operative chemotherapy and 1 (4.7%) died for sepsis after mediastinal EUS-FNA, this was the only complication event evidenced. EUS-FNA changed clinical management in 54.2% of patients who met the criteria inclusion (distant LN with malignancies EUS features), which corresponds to 11.5% of patients with GEJ adenocarcinoma.

CONCLUSION

EUS-FNA was able to provide a different tumor staging and these differences were associated with treatment received. EUS-FNA had a significant impact on treatment decision.

Distant lymph node metastases in gastroesophageal junction adenocarcinoma: impact of endoscopic ultrasound-guided fine-needle aspiration

OBJECTIVE

Endoscopic ultrasound (EUS) is established as the most accurate technique for pre-operative locoregional staging of gastroesophageal junction (GEJ) adenocarcinoma, the purpose of the present study was to evaluate the distant lymph nodes (LNs) EUS-fine-needle aspiration (FNA) impact in therapeutic decision for patients with GEJ adenocarcinoma.

MATERIALS AND METHODS

Retrospective study was made, with cross-sectional, non-probabilistic analysis from prospectively collected database for all GEJ adenocarcinoma staging patients referred between January 2009 and August 2012 in Paoli-Calmette Institute in Marseille-France.

RESULTS

A total of 154 patients with GEJ adenocarcinoma were managed in our institution, of whom 113 (73.3%) had non-distant metastatic disease at computed tomography (CT) scan and underwent EUS for initial tumor staging prior to a treatment decision. On A total of 113 patients undergoing EUS, 8 (7%) patients underwent endoscopic resection and 6 (5.3%) underwent direct surgical resection. Of the remaining 99 patients (87.6%), 24 (21.2%) distant LN EUS-FNA were made. Seventeen LN had EUS malignant features, including 9 (52.9%) that were confirmed as malignant and underwent palliative treatment with chemotherapy. Ninety (79.6%) patients were treated with pre-operative neoadjuvant therapy and were revaluated after. 4 (4.4%) had metastatic disease at CT scan (underwent palliative treatment) and 65 (72.2%) underwent EUS restaging to treatment decision revaluation. Of these, twelve (18.4%) distant LN EUS-FNA were performed. Seven had LN EUS malignancy features, including 4 (57.1%) that were confirmed as malignant and underwent palliative treatment. The remaining 61 patients underwent surgery. As stated above, 21 patients (23.3%) did not undergo EUS restaging, including 10 (47.6%) that did not go to surgery because patient's age, poor general status and comorbidities, 6 (28.5%) had a loss of follow-up, 1 (4.7%) underwent to surgery due to chemotherapy collateral effects, 3 (14.2%) were still on pre-operative chemotherapy and 1 (4.7%) died for sepsis after mediastinal EUS-FNA, this was the only complication event evidenced. EUS-FNA changed clinical management in 54.2% of patients who met the criteria inclusion (distant LN with malignancies EUS features), which corresponds to 11.5% of patients with GEJ adenocarcinoma.

CONCLUSION

EUS-FNA was able to provide a different tumor staging and these differences were associated with treatment received. EUS-FNA had a significant impact on treatment decision.

Evaluation of the reliability of clinical staging of T2 N0 esophageal cancer: a review of the Society of Thoracic Surgeons database

BACKGROUND

Clinical staging of esophageal cancer has improved with positron-emission tomography/computed tomography and endoscopic ultrasound imaging. Despite such progress, small single-center studies have questioned the reliability of clinical staging of T2 N0 esophageal cancer. This study broadly examines the adequacy of clinical staging of T2 N0 disease using The Society of Thoracic Surgeons database.

METHODS

We retrospectively studied 810 clinical stage T2 N0 patients from 2002 to 2011, with 58 excluded because of incomplete pathologic staging data. Clinical stage, pathologic stage, and preoperative characteristics were recorded. Logistic regression analysis was used to identify factors associated with upstaging at the time of surgical intervention.

RESULTS

Among 752 clinical stage T2 N0 patients, 270 (35.9%) received induction therapy before the operation. Of 482 patients who went directly to surgical intervention, 132 (27.4%) were confirmed as pathologic T2 N0, 125 (25.9%) were downstaged (ie, T0-1 N0), and 225 (46.7%) were upstaged at the operation (T3-4 N0 or Tany N1-3). Exclusive tumor upstaging (ie, pathologic T3-4 N0) accounted for 41 patients (18.2%), whereas exclusive nodal upstaging (ie, pathological T1-2 N1-3) accounted for 100 (44.5%). Combined tumor and nodal upstaging (ie, pathological T3-4 N1-3) accounted for 84 patients (37.3%). Among patients who received induction therapy, 103 (38.1%) were upstaged vs 225 (46.7%) without induction therapy (p = 0.026). Comparing the induction therapy group and the primary surgical group, postoperative 30-day mortality (3.7% vs 3.7%, p > 0.99) and morbidity (46.3% vs 45%, p = 0.76) were similar.

CONCLUSIONS

Despite advances in staging techniques, clinical staging of T2 N0 esophageal cancer remains unreliable. Recognizing T2 N0 as a threshold for induction therapy in esophageal cancer, many surgeons have opted to treat T2 N0 disease with induction therapy, even though one-quarter of these patients will be pathologic T1 N0. Although this study demonstrated similar perioperative morbidity and mortality with and without induction therapy, further study is needed to examine the effect of upstaging on long-term survival.

Forward-view Endoscopic Ultrasound: A Systematic Review of Diagnostic and Therapeutic Applications

Endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) and therapeutic procedures have been performed by a curved linear array (CLA) echoendoscope since the early 1990's. This particular echoendoscope, allowing real time visualization of aspiration needles and of other devices, has substantially remained unchanged since its introduction to the market. In a context of rapidly expanding indications for EUS-guided procedures, a dedicated forward view (FV) echoendoscope has been developed and tested under different clinical conditions. The FV echoendoscope is equipped with front endoscopic and EUS view, allowing deployment of needles and other devices through the working channel in straight direction. Several new diagnostic and therapeutic applications may thereby potentially be feasible with the FV echoendoscope and the established ones may prove easier to accomplish. The published literature with the FV echoendoscope has been systematically reviewed and the results are presented analytically and discussed in detail. EUS-FNA and therapeutic procedures, including pancreatic pseudocyst drainage, treatment of gastric fundal varices, celiac plexus neurolysis, and duct drainage were reported. The FV echoendoscope showed some unique advantages, opening new possibilities such as EUS-FNA in difficult gastrointestinal tracts and combined endoscopic/EUS treatment with frontal approach. However, no statistically significant evidence of superiority of the FV echoendoscope vs. the CLA echoendoscope was found in pancreatic pseudocyst drainage. No complications specifically attributable to the use of the FV echoendoscope were reported.

Endoscopic ultrasound fine needle aspiration: Technique and applications in clinical practice

Since its initial report in 1992, endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) has now been incorporated into the diagnostic and staging algorithm for the evaluation of benign and malignant diseases of the gastrointestinal tract and of adjacent organs. Its introduction constitutes a major breakthrough in the endoscopic field and has gradually transformed EUS from a pure imaging modality into a more interventional. In addition, the possibility of collecting samples, providing a definitive cytological and/or histological evidence of the presence of malignancy, has strongly contributed to changing EUS from a subjective, highly operator dependant procedure into a more objective one. This article will review the instrumentation, technique and the most important clinical applications of EUS-FNA.

Diagnosis and staging of cancer of the esophagus and esophagogastric junction

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).

Interobserver agreement in contrast harmonic endoscopic ultrasound

BACKGROUND AND AIM

Contrast harmonic endoscopic ultrasound (CH-EUS) was recently introduced to clinical practice; its reproducibility among endosonographers is unknown. Our aim was to assess the interobserver agreement (IA) in CH-EUS.

METHODS

Fifteen endosonographers (eight experienced and seven non-experienced) from 11 Italian EUS centers evaluated 80 video-cases (40 solid pancreatic lesions, 20 pancreatic cystic lesions and 20 submucosal lesions) of CH-EUS, according to the degree of enhancement, the pattern of distribution and the washout of the contrast agent. IA within each group and between the two groups of observers was assessed with the Fleiss kappa statistic.

RESULTS

Overall IA was moderate for the uptake and fair for the pattern of distribution and the washout. In solid pancreatic lesions, IA was moderate for the uptake and fair for the pattern and the washout. In cystic pancreatic lesions, IA was uniformly moderate for the assessment of uptake, slight for the pattern and fair for the washout. In submucosal tumors, IA was substantial for the uptake, slight for the pattern and fair for the washout. Non-experienced endosonographers demonstrated, in most cases, comparable IA with the experienced ones.

CONCLUSIONS

Interobserver agreement among endosonographers for CH EUS was satisfactory. In particular, overall IA varied from slight to substantial, being fair in the majority of cases. Inherent structural features of the lesions, as well as technical differences between the variables assessed, could have accounted for the fluctuation of the results. Outcomes of IA were reproducible between experienced and non-experienced endosonographers.

Comparison of methods to detect neoplasia in patients undergoing endoscopic ultrasound-guided fine-needle aspiration

BACKGROUND & AIMS

Digital image analysis (DIA) and fluorescence in situ hybridization (FISH) can be used to evaluate biliary strictures with greater accuracy than conventional cytology (CC). We performed a prospective evaluation of the accuracy of CC, compared with that of DIA and FISH, in detection of malignancy in patients undergoing endoscopic ultrasonography (EUS) fine-needle aspiration (FNA).

METHODS

We collected a minimum of 6 FNA samples from each of 250 patients during EUS. CC or DIA and FISH analyses were performed on every other specimen (from every other FNA pass); patients were randomly assigned to the first test performed. CC slides were reviewed by gastrointestinal cytopathologists who were blinded to all data. Findings from cytohistologic analysis, after a minimum 24-month follow-up period, were used as the standard (n = 202; median age, 65 years).

RESULTS

Aspirates were collected from lymph nodes (n = 111), pancreas (n = 61), gastrointestinal lumen wall (n = 9), periluminal mass (n = 4), liver (n = 8), and miscellaneous sites (n = 9). Matched samples provided a mean of 3.2 passes for CC and 1.6 passes for DIA and FISH. The data indicate a potential lack of utility for DIA. The combination of CC and FISH detected malignancy with 11% greater sensitivity than CC alone (P = .0002), but specificity was reduced from 100% to 96%.

CONCLUSIONS

FISH analysis identifies neoplastic lesions with significantly greater sensitivity than CC in patients with diverse pathologies who underwent EUS with FNA, despite limited tissue sampling for FISH analysis.

Comparative study between endoscopic ultrasonography and positron emission tomography-computed tomography in staging patients with esophageal squamous cell carcinoma

Treatment strategy of esophageal cancer mainly depends on accurate staging. At present, no single ideal staging modality is superior to another in preoperative tumor-node-metastasis (TNM) staging of patients with esophageal cancer. We aimed to investigate the efficacy of endoscopic ultrasonography (EUS) and positron emission tomography-computed tomography (PET-CT) for staging of esophageal cancer. We retrospectively studied 118 consecutive patients with esophageal squamous cell carcinoma who underwent esophagectomy with or without neoadjuvant chemoradiotherapy (CRT) over a near 3-year period between January 2005 and November 2008 at a tertiary hospital in Taiwan. Patients were separated into two groups: without neoadjuvant CRT (group 1, n= 28) and with CRT (group 2, n= 90). Medical records of demographic data and reports of EUS and PET-CT of patients before surgery were reviewed. A database of clinical staging by EUS and PET-CT was compared with one of pathological staging. The accuracies of T staging by EUS in groups 1 and 2 were 85.2% and 34.9%. The accuracies of N staging by EUS in groups 1 and 2 were 55.6% and 39.8%. The accuracies of T and N staging by means of PET-CT scan were 100% and 54.5% in group 1, and were 69.4% and 86.1% in group 2, respectively. In group 2, 38 of 90 patients (42.2%) achieved pathologic complete remission. Among them, two of 34 (5.9%) and 12 of 17 (70.6%) patients were identified as tumor-free by post-CRT EUS and PET-CT, respectively. EUS is useful for initial staging of esophageal cancer. PET-CT is a more reliable modality for monitoring treatment response and restaging. Furthermore, the accuracy of PET-CT with regard to N staging is higher in patients who have undergone CRT than those who have not.

Endosonography-guided fine needle aspiration cytology of intra-abdominal lymph nodes with unknown primary in a tuberculosis endemic region

BACKGROUND AND AIM

Intra-abdominal lymphadenopathy poses a diagnostic and management challenge in highly endemic regions for tuberculosis. Opting for empirical anti-tuberculosis treatment raises the risk of wrong or delayed treatment. Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is the procedure of choice for tissue acquisition from peri-luminal lymph nodes. We studied the utility of EUS-FNA in evaluating intra-abdominal lymph nodes of unknown etiology, in the setting of high endemicity of tuberculosis.

METHODS

Consecutive patients with intra-abdominal lymph nodes of unknown etiology underwent EUS-FNA using a 22-gauge needle. Final diagnosis was made on surgical histology or on 6-months follow-up. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and diagnostic yield were calculated.

RESULTS

Sixty-six patients were included. Final diagnoses were tuberculosis, 35 (53%); metastatic adenocarcinoma, 11 (16.7%); lymphoma, three (4.5%); carcinoid, one (1.5%) and reactive nodes, 16 (24.2%). EUS-FNA provided a diagnosis in 61 patients (92.4%). Sensitivity, specificity, PPV and NPV for diagnosing tuberculosis via EUS-FNA were 97.1%, 100%, 100% and 96.9%, respectively. In 10 (15.2%) patients receiving empirical anti-tuberculosis treatment, the final diagnoses were metastatic adenocarcinoma (5), lymphoma (2), carcinoid (1) and reactive adenopathy (2).

CONCLUSION

Despite being in a highly endemic area, almost half of the patients studied have a non-tuberculosis etiology. EUS-FNA is a safe and accurate procedure for establishing the diagnosis of unexplained intra-abdominal lymphadenopathy.

Endosonographic features predictive of malignancy in mediastinal lymph nodes in patients with lung cancer

BACKGROUND

EUS is useful in determining mediastinal lymph node (LN) metastases in patients undergoing staging for lung cancer. However, FNA of LNs is often performed only if suspicious features are present. The utility of individual LN features in predicting malignant cytology remains unclear.

OBJECTIVE

To evaluate the utility of EUS-determined LN features for predicting malignant cytology.

DESIGN

Prospective observational study.

SETTING

Two U.S. tertiary-care centers.

PATIENTS

This study involved 425 patients with primary lung cancer who underwent EUS.

INTERVENTION

All mediastinal LNs were described according to size, shape, echogenicity, and margin characteristics. FNA was performed on LNs with any features suggestive of malignancy. EUS-guided FNA cytology was classified as benign or abnormal (suspicious/malignant). The utility of LN features in predicting malignant cytology was determined and further analyzed by logistic regression, and a predictive model was established.

MAIN OUTCOME MEASUREMENTS

Accuracy of individual LN features for predicting malignancy.

RESULTS

EUS detected 836 LNs in 425 patients, and FNA was obtained in 698 patients. On multivariable analysis, only round shape, a short axis of >8.3 mm, and sharp margins were predictive of malignant cytology. According to the predictive model, the calculated probability of having malignancy is less than 4% (95% confidence interval [CI], 0.022-0.064) when none of the LN features are present and 63% (95% CI, 51%-72.2%) when all features were seen.

LIMITATIONS

No surgical histology as the criterion standard.

CONCLUSION

Among patients with lung cancer, EUS features of round shape, sharp margins, and short axis of >8.3 mm are significant predictors of malignancy. The probability of malignancy is low when none of the features are present.

Endosonographic staging of upper intestinal malignancy

Numerous studies conducted over the last 25 years provide evidence on the high diagnostic accuracy and important role of endoscopic ultrasonography (EUS) in staging oesophageal and gastric carcinoma. This extensive research was recently subjected to metaanalyses, condensing our knowledge on EUS performance and facilitating its comparison with competing methods. It is, however, important to realise that the management of oesophageal and gastric carcinoma is evolving and so are staging algorithms, setting new challenges for EUS and re-defining its position. Restaging after neoadjuvant treatment and precise assessment of early carcinoma before endoscopic treatment are areas of growing interest, but the role of EUS in these settings is rather limited. Rapidly developing cross-sectional imaging has the potential to challenge the position of EUS as the most accurate method in loco-regional staging. On the other hand, EUS guided fine-needle aspiration offers the unique opportunity to obtain cytological confirmation of lymph node metastases, with future potential for molecular staging.

Endoscopic versus surgical therapy for early cancer in Barrett's esophagus: a decision analysis

BACKGROUND

Esophagectomy for early esophageal adenocarcinoma is associated with increased operative mortality and morbidity, but possibly a decreased recurrence rate compared with endoscopic therapy when using EMR and radiofrequency ablation.

OBJECTIVE

To compare the cost-effectiveness of esophagectomy and endoscopic therapy in the treatment of early esophageal adenocarcinoma.

DESIGN

Decision analysis model.

MAIN OUTCOME MEASUREMENTS

Incremental cost-effectiveness ratio.

RESULTS

During the 5-year study period, endoscopic therapy cost $17,000.00 and yielded 4.88 quality-adjusted life years, compared with $28,000.00 and 4.59, respectively, for esophagectomy. Varying the recurrence rates of cancer or Barrett's esophagus metaplasia after endoscopic therapy did not change the overall outcome. The sensitivity analysis demonstrated, however, that the outcome depended on the rate of lymph node involvement and operative mortality. Under the best of circumstances in favor of esophagectomy, such as 2% operative mortality, no reduced quality of life after esophagectomy, and a low 5-year survival rate after recurrence of endoscopic ablation, the risk of positive lymph nodes still needed to exceed 25% before esophagectomy became the preferred treatment option. This threshold is twice as high as the values reported for early submucosal cancer invasion.

LIMITATIONS

Limited data are available about the long-term outcome of EMR and radiofrequency ablation.

CONCLUSIONS

Endoscopic therapy for early Barrett's esophagus adenocarcinoma is more effective and less expensive than esophagectomy. Even in early esophageal adenocarcinoma with submucosal invasion, endoscopic therapy is a cost-effective alternative to esophagectomy, especially in patients with a high operative risk.

Endoscopic ultrasound elastography for evaluation of lymph nodes and pancreatic masses: a multicenter study

AIM

To evaluate the ability of endoscopic ultrasound (EUS) elastography to distinguish benign from malignant pancreatic masses and lymph nodes.

METHODS

A multicenter study was conducted and included 222 patients who underwent EUS examination with assessment of a pancreatic mass (n = 121) or lymph node (n = 101). The classification as benign or malignant, based on the real time elastography pattern, was compared with the classification based on the B-mode EUS images and with the final diagnosis obtained by EUS-guided fine needle aspiration (EUS-FNA) and/or by surgical pathology. An interobserver study was performed.

RESULTS

The sensitivity and specificity of EUS elastography to differentiate benign from malignant pancreatic lesions are 92.3% and 80.0%, respectively, compared to 92.3% and 68.9%, respectively, for the conventional B-mode images. The sensitivity and specificity of EUS elastography to differentiate benign from malignant lymph nodes was 91.8% and 82.5%, respectively, compared to 78.6% and 50.0%, respectively, for the B-mode images. The kappa coefficient was 0.785 for the pancreatic masses and 0.657 for the lymph nodes.

CONCLUSION

EUS elastography is superior compared to conventional B-mode imaging and appears to be able to distinguish benign from malignant pancreatic masses and lymph nodes with a high sensitivity, specificity and accuracy. It might be reserved as a second line examination to help characterise pancreatic masses after negative EUS-FNA and might increase the yield of EUS-FNA for lymph nodes.

Endoscopic ultrasound elastography for evaluation of lymph nodes and pancreatic masses: a multicenter study

AIM

To evaluate the ability of endoscopic ultrasound (EUS) elastography to distinguish benign from malignant pancreatic masses and lymph nodes.

METHODS

A multicenter study was conducted and included 222 patients who underwent EUS examination with assessment of a pancreatic mass (n = 121) or lymph node (n = 101). The classification as benign or malignant, based on the real time elastography pattern, was compared with the classification based on the B-mode EUS images and with the final diagnosis obtained by EUS-guided fine needle aspiration (EUS-FNA) and/or by surgical pathology. An interobserver study was performed.

RESULTS

The sensitivity and specificity of EUS elastography to differentiate benign from malignant pancreatic lesions are 92.3% and 80.0%, respectively, compared to 92.3% and 68.9%, respectively, for the conventional B-mode images. The sensitivity and specificity of EUS elastography to differentiate benign from malignant lymph nodes was 91.8% and 82.5%, respectively, compared to 78.6% and 50.0%, respectively, for the B-mode images. The kappa coefficient was 0.785 for the pancreatic masses and 0.657 for the lymph nodes.

CONCLUSION

EUS elastography is superior compared to conventional B-mode imaging and appears to be able to distinguish benign from malignant pancreatic masses and lymph nodes with a high sensitivity, specificity and accuracy. It might be reserved as a second line examination to help characterise pancreatic masses after negative EUS-FNA and might increase the yield of EUS-FNA for lymph nodes.

Prospective assessment of EUS criteria for lymphadenopathy associated with rectal cancer

BACKGROUND

There are few data that assess the accuracy of echo characteristics for predicting lymph-node (LN) metastases in patients with rectal cancer.

OBJECTIVE

To identify nodal echo characteristics and size predictive of malignant infiltration and to determine if any combination of standard nodal criteria has sufficient predictive value to preclude FNA.

DESIGN

Prospective uncontrolled study.

SETTING

Tertiary-referral hospital.

PATIENTS

Seventy-six patients (68% men) with untreated rectal cancer; 52 had visualized LNs.

INTERVENTION

EUS-guided FNA.

MAIN OUTCOME MEASUREMENTS

Evaluation of perirectal nodal morphology accuracy that corresponds to malignant cytology and identification of echo criteria, including LN size, to have sufficient predictive value to predict malignancy.

RESULTS

Forty-three of 52 patients (83%) underwent FNA of a visualized LN. Nodal hypoechogenicity and short-axis length >or=5 mm were factors independently predictive of malignancy. The number of malignant nodal echo features per node did not distinguish benign from malignant pathology, except when all 4 features were present. Only 68% of malignant LN had >or=3 echo characteristics. An optimum LN short-axis or long-axis length cutoff value of 6 mm or 9 mm were 90% and 95% specific, respectively, for the presence of malignancy by receiver operating characteristic analysis.

LIMITATIONS

FNA was performed in a subset of identified LNs.

CONCLUSIONS

Nodal echo features alone are often inadequate to establish the presence of locoregional metastatic disease by EUS. These data support the value of FNA to confirm the presence of malignancy in place of relying on imaging criteria.

Defining the lymph node burden in a Northern European population without malignancy: the potential effect of geography in determining a need for FNA?

Data from the USA suggest that morphological specificity is insufficient to permit an assumption of malignancy in nodal staging with endoscopic ultrasound (EUS). This may not hold true elsewhere as the background lymph node burden may vary in different geographic regions. We aimed to assess the prevalence and features of mediastinal and abdominal lymph nodes at EUS in a Northern European population without malignant disease. A total of 129 consecutive patients without malignant disease referred for radial EUS were prospectively evaluated for the prevalence and echo features of lymph nodes in the mediastinum and upper abdomen. Sixty-two percent of patients had mediastinal lymph nodes and 17% had abdominal nodes at EUS. A mean of 1.4 (standard deviation 1.3, range 0-8) nodes were found per patient. No celiac nodes were seen. The majority of detected nodes were 0.5 cm or less in short axis, had oval shape, centrally echogenic pattern, and indistinct borders. The most common node locations were the subcarinal and paraesophageal areas, and the hepatoduodenal ligament. In multivariate analysis mediastinal lymphadenopathy was related to body mass index and abdominal lymphadenopathy to acute pancreatitis. The occurence of mediastinal lymphadenopathy is markedly lower in Northern Europeans than reported for US patients. Celiac nodes are extremely rare in patients without malignancy. The majority of nodes have a width of 0.5 cm or less, have oval shape, centrally echogenic pattern, and indistinct borders. The characterization of the background lymph node burden may improve the selection of lymph nodes for fine needle aspiration.

Modern surgery for esophageal cancer

Primary treatment of carcinoma of the esophagus and cardia rests on surgical resection. Although recent advances have shown the suitability of endoscopic treatment in selected patients with very early cancers, and preliminary studies have suggested that responders to primary chemoradiation may be equivalent to resection in selected patients with squamous cell carcinoma, surgical resection remains the mainstay of therapy, as it has for the past 50 years. Various changes support highly individualized treatment decisions, in which each patient receives the treatment with the best chance of eliminating all disease.

Staging and restaging of advanced esophageal cancer

PURPOSE OF REVIEW

Esophageal cancer staging continues to evolve, especially for advanced cases. Computer tomography (CT) scan of the thorax and abdomen to detect metastatic disease, and endoscopic ultrasound with fine needle aspiration (EUS-FNA) remain the preferred methods. Several recent studies have evaluated alternative methods for locoregional and distant disease detection and staging.

RECENT FINDINGS

There seems to be emerging roles for fluorine-18 fluorodeoxyglucose (FDG)-PET, laparoscopic staging, and high-resolution T2-weighted MRI in esophageal cancer staging. Perfusion CT and FDG-PET and FDG-PET/CT may have an emerging role in assessing response to neoadjuvant therapy. Restaging following neoadjuvant therapy remains suboptimal. A 50% or more reduction of tumor thickness by EUS postchemotherapy continues to be the best measure for tumor downstaging survival, while FDG-PET/CT may be more accurate than EUS-FNA and CT scan for predicting nodal status and complete responders after neoadjuvant therapy. Potential methylation analysis, digital image analysis, and fluorescence in-situ hybridization on EUS-FNA samples may increase the yield and prove to be better than routine cytology.

SUMMARY

For advanced esophageal cancer, locoregional staging is best performed with EUS-FNA, with CT scan of the thorax and abdomen and FDG-PET, to detect metastatic disease. The role of EUS in restaging following neoadjuvant therapy remains controversial, with recent studies showing that FDG-PET/CT may be more accurate than EUS-FNA and CT scan for predicting nodal status and complete responders after neoadjuvant therapy.

Lymphovascular invasion as a tool to further subclassify T1b esophageal adenocarcinoma

BACKGROUND

Lymphovascular invasion (LVI) and/or lymph node metastases (LNM) adversely influence the overall survival (OS) of patients with T1 esophageal adenocarcinoma. Although endoscopic therapy may be adequate for patients with T1a cancer, patients with T1b cancer require esophagectomy/lymphadenectomy. The authors hypothesized that LVI status would subclassify T1b cancers and facilitate new therapeutic strategies.

METHODS

Ninety-nine consecutive patients with T1 adenocarcinoma were analyzed after they underwent esophagectomy/lymphadenectomy. LNM was assessed in all patients, and LVI was assessed in 89 patients. OS was correlated with pathologic cancer stage in association with LVI and LNM.

RESULTS

The 5-year OS rate for patients with T1a tumors (88%) was superior to that for patients with T1b tumors (62%; P = .001). The 5-year OS rate for patients who had cancers without LVI (85%) was superior to the rate for patients who had cancers with LVI (36%; P = .0001). It is noteworthy that, for cancers without LVI, the 5-year OS rate for patients with T1b tumors (77%) was similar to the rate for patients with T1a tumors (90%; P = .08), but it was superior to the rate for patients with T1b tumors that had LVI (27%; P = .006). The presence of LVI and/or LNM resulted in worse 5-year OS (< or =37%) compared with the lack of LVI and/or LNM (88%; P < .001). The rate of LNM for patients who had T1b tumors without LVI still was 19%, and the relapse rate was 16%.

CONCLUSIONS

The current results demonstrated that LVI distinguishes the biologic behavior of early esophageal cancer, and patients who have T1b cancer without LVI have a clinical biology similar to that of patients with T1a cancer. If LNM before surgery can be diagnosed with high sensitivity by better endoscopic techniques and/or molecular biomarkers, then a new therapeutic paradigm for T1b cancers could emerge. Further research is needed on patients with T1b esophageal adenocarcinoma.

Does FDG-PET add information to EUS and CT in the initial management of esophageal cancer? A prospective single center study

PURPOSE

There is no algorithm for the initial staging of esophageal cancer that is considered standard of care. This prospective blinded study analyzes the utility of FDG-PET as an adjunct to EUS and CT for the management of patients with esophageal cancer.

METHODS

Between December 2003 and October 2006, patients diagnosed with esophageal carcinoma underwent EUS, CT, and FDG-PET at their initial evaluation. Two thoracic surgeons were given staging EUS results and CT scan reports. They were asked if the patient needed surgical resection, neoadjuvant chemotherapy followed by resection, or palliation. With each case, one surgeon was unblinded to the FDG-PET results. The treatment decisions of each surgeon were compared to determine if PET altered clinical management.

RESULTS

A total of 50 patients (45 male, 5 female) were enrolled and data were prospectively collected. Forty-three (86%) had adenocarcinoma and 7 (14%) had squamous cell carcinoma. EUS was completed in 88% (44) of cases while 6 (12%) were incomplete secondary to tight stenosis. Nineteen were treated with surgery, 25 with neoadjuvant chemotherapy and surgery, and 6 with palliative chemoradiation. In 49 of 50 patients, the surgeons came to identical management decisions independent of PET results. In the one case that the treatment decision differed, the EUS was incomplete. The agreement on treatment strategy was 98% (kappa= 0.97, 95% CI 0.93-0.99).

CONCLUSION

This study shows that the addition of FDG-PET to EUS and CT offers little information to the initial treatment stratification of patients with esophageal cancer. However, in patients with incomplete EUS, FDG-PET may have some clinical utility.

Esophageal endoscopic ultrasound fine-needle aspiration as a diagnostic tool

Endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNA) may be employed for procurement of a tissue diagnosis in a minimally invasive fashion. In many cases, EUS-FNA excludes the need for more invasive diagnostic procedures when a tissue diagnosis is required. In patients with esophageal neoplasms, EUS-FNA is a safe and accurate tool for the preoperative diagnosis of metastatic spread to the paraesophageal and celiac lymph nodes. EUS-FNA is also increasingly recognized as an accurate, cost-effective and safe means of evaluating and staging patients with lung cancer. EUS-FNA is useful in providing tissue confirmation of cancer in cases in which bronchoscopy or computed tomography-guided approaches has been non-diagnostic. EUS-guided therapies are paving the way for therapeutic/interventional EUS. The interventional endoscopist will now play a more central role in the diagnosis and treatment of various gastrointestinal malignancies by delivering antitumor agents.

Dynamic analysis of EUS used for the differentiation of benign and malignant lymph nodes

BACKGROUND

EUS elastography was reported to offer supplemental information that allows a better characterization of tissue, and that might enhance conventional EUS imaging.

OBJECTIVE

Our purpose was to apply real-time elastography during EUS examinations and to assess the accuracy of the differentiation of benign versus malignant lymph nodes.

DESIGN

Prospective cross-sectional feasibility study.

SETTING

Department of Surgical Gastroenterology, Gentofte University Hospital, Hellerup, Denmark.

PATIENTS

Patients diagnosed by EUS with cervical, mediastinal, or abdominal lymph nodes were included, with a total number of 78 lymph nodes examined. The final diagnosis of the type of lymph node was obtained by EUS-FNA cytologic analysis or by surgical pathologic examination and by a minimum 6 months of follow-up.

INTERVENTIONS

Hue histogram analysis of the average images computed from EUS elastography movies was used to assess the color information inside the region of interest and to consequently differentiate benign and malignant lymph nodes.

MAIN OUTCOME MEASUREMENTS

Differentiate between malignant and benign lymph nodes.

RESULTS

By using mean hue histogram values, the sensitivity, specificity, and accuracy for the differential diagnosis were 85.4%, 91.9%, and 88.5%, respectively, on the basis of a cutoff level of 166 (middle of green-blue rainbow scale). The proposed method might be useful to avoid color perception errors, moving artifacts, or possible selection bias induced by analysis of still images.

LIMITATIONS

Lack of the surgical standard in all cases.

CONCLUSIONS

Computer-enhanced dynamic analysis based on hue histograms of the EUS elastography movies represents a promising method that allows the differential diagnosis of benign and malignant lymph nodes, offering complementary information added to conventional EUS imaging.

Pathogenesis, diagnosis and therapeutic possibilities of esophageal cancer

PURPOSE OF REVIEW

This article reviews developments in pathogenesis, diagnosis and therapy of esophageal cancer published in 2006.

RECENT FINDINGS

Gene expression profiles in esophageal adenocarcinoma reveal information on its pathogenesis. One study disputed the UK guideline to perform upper endoscopy only in the presence of alarm symptoms. Evidence was presented that staging investigations for esophageal cancer should preferentially be performed in expert centers. Early [F]fluorodeoxyglucose PET was shown to predict response to neoadjuvant chemotherapy. A large randomized study demonstrated that peroperative chemotherapy improved survival in esophagogastric adenocarcinoma. The current American Joint Committee on Cancer staging system probably needs revision in that the number of involved lymph nodes and extent of lymphadenectomy should be included. Socioeconomic factors are involved in treatment decisions and outcome of esophageal cancer. Chemotherapy and chemoradiotherapy are increasingly being used in the palliation of esophageal cancer. Palliation of dysphagia with stents was disputed as these devices may be associated with a high complication risk and may not improve nutritional status.

SUMMARY

In 2006, microarray technology was introduced to elucidate the pathogenesis of esophageal cancer. In addition, refinements in staging of esophageal cancer were proposed. Finally, (chemo-)radiotherapy is increasingly being used in the neoadjuvant setting and for palliation of esophageal cancer.

Endoscopic Ultrasound-Guided Fine-Needle Aspiration for Non-small Cell Lung Cancer Staging

BACKGROUND

Endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) is a minimally invasive alternative technique for mediastinal staging of non-small cell lung cancer. A metaanalysis was performed to estimate the diagnostic accuracy of EUS-FNA for staging mediastinal lymph nodes (N2/N3 disease) in patients with lung cancer.

METHODS

Relevant studies were identified using Medline (1966 to November 2005), CINAHL, and citation indexing. Included studies used histology or adequate clinical follow-up (> 6 months) as the "gold standard," and provided sufficient data for calculating sensitivity and specificity. Summary receiver operating characteristic curves metaanalysis was performed to estimate the pooled sensitivity and specificity.

RESULTS

In 18 eligible studies, EUS-FNA identified 83% of patients (95% confidence interval [CI], 78 to 87%) with positive mediastinal lymph nodes (pooled sensitivity) and 97% of patients (95% CI, 96 to 98%) with negative mediastinal lymph nodes (pooled specificity). In eight studies that were limited to patients who had abnormal mediastinal lymph nodes seen on CT scans, the sensitivity was 90% (95% CI, 84 to 94%) and the specificity was 97% (95% CI, 95 to 98%). In patients without abnormal mediastinal lymph nodes seen on CT scans (four studies), the pooled sensitivity was 58% (95% CI, 39 to 75%). Minor complications were reported in 10 cases (0.8%). There were no major complications.

CONCLUSIONS

EUS-FNA is a safe modality for the invasive staging of lung cancer that is highly sensitive when used to confirm metastasis to mediastinal lymph nodes seen on CT scans. In addition, among lung cancer patients with normal mediastinal adenopathy seen on CT scans, despite lower sensitivity, it has the potential to prevent unnecessary surgery in a large proportion of cases missed by CT scanning.