A prospective,blinded assessment of the impact of preoperative staging on the management of rectal cancer

BACKGROUND & AIMS: The influence of preoperative staging of rectal carcinoma on therapeutic decisions is uncertain. The use of fine-needle aspiration (FNA) of perirectal nodes in this setting has not been evaluated. The aim of this prospective, blinded study of patients with rectal cancer was to assess the impact of preoperative staging on treatment decisions and compare the tumor (T), nodal (N) staging performance characteristics of pelvic computed tomography (CT), rectal endoscopic ultrasonography (EUS), and EUS FNA. METHODS: Eighty consecutive patients with newly diagnosed rectal cancer were prospectively evaluated. Therapy decisions were recorded after sequential disclosure of staging information to the patient's surgeon. RESULTS: In 31% of patients (95% confidence interval, 21%-42%), EUS staging information changed the surgeon's original treatment plan based on CT alone. The further addition of FNA changed therapy in one patient. T staging accuracy was 71% (CT) and 91% (EUS) (P = 0.02); N staging accuracy was 76% (CT), 82% (EUS), and 76% (EUS FNA) (P = NS). CONCLUSIONS: Preoperative staging with EUS results in more frequent use of preoperative neoadjuvant therapy than if staging was performed with CT alone. The addition of FNA only changed the management of one patient, whereas FNA did not significantly improve N staging accuracy over EUS alone. FNA seems to offer the most potential for impacting management in those patients with early T stage disease, and its use should be confined to this subgroup of patients. EUS is more accurate than CT for determining T stage of rectal carcinoma.     

Impact of EUS-guided fine-needle aspiration on lymph node staging in patients with esophageal carcinoma

BACKGROUND: Preoperative identification of lymph node metastases associated with esophageal carcinoma may influence treatment. EUS is the most accurate method for locoregional staging of these tumors. The impact of EUS-guided fine-needle aspiration (EUS-FNA) on lymph node staging in esophageal carcinoma is unclear. METHODS: From May 1996 to May 1999, 74 patients with esophageal carcinoma underwent preoperative EUS. After October 1998 EUS-guided FNA was performed on nonperitumoral lymph nodes greater than 5 mm in width. The results of EUS with and without FNA were retrospectively reviewed and compared. Final diagnosis was based on surgical results or EUS-guided FNA malignant cytology. Ten of the 74 patients had to be excluded for lack of lymph node stage confirmation. Final diagnosis was obtained in the remaining 64 patients (33 from the EUS only group and 31 from the EUS-FNA group). RESULTS: The results of EUS versus EUS-FNA for lymph node staging were sensitivity 63% versus 93% (p = 0.01), specificity 81% versus 100% (not significant), and accuracy 70% versus 93% (p = 0.02), respectively. Complications comprised 1 patient who developed self-limited bleeding after dilation that did not preclude completion of the EUS (1%, 95% CI [0%, 7%]). CONCLUSIONS: EUS-FNA is more sensitive and accurate than EUS alone for preoperative staging of locoregional and celiac lymph nodes associated with esophageal carcinoma. EUS-FNA of nonperitumoral lymph nodes in patients with esophageal carcinoma is safe and should be routinely performed when treatment decisions will be affected by nodal stage.     

Assessment of clinical impact of endoscopic ultrasound on esophageal cancer

BACKGROUND AND AIM: Endoscopic ultrasound (EUS) with fine needle aspiration (FNA) is the most accurate imaging modality for locoregional staging of esophageal cancer. It remains unclear whether this technology impacts on the outcome of patients with this malignancy. The aim of the present study was to assess the impact of EUS FNA by comparing the clinical outcomes of patients with esophageal cancer before and after the introduction of this staging modality in our institution. METHODS: Outcomes of patients with de novo non-metastatic esophageal cancer seen in 1998 without EUS FNA evaluation (non-EUS control group) were compared to patients evaluated in 2000 with EUS FNA (EUS group). RESULTS: Outcomes of 60 (non-EUS control group) and 107 (EUS group) patients with non-metastatic esophageal cancer were compared. Preoperative neoadjuvant therapy was administered to 35 patients in the EUS group, all of whom had advanced disease. Cox proportional hazards demonstrated EUS FNA to be associated with reduced recurrence risk (hazard ratio [HR]: 0.63; 95% confidence interval [CI]: 0.43-0.87), P = 0.004, and reduced mortality (HR: 0.66; 95% CI: 0.47-0.90), P = 0.008. CONCLUSIONS: The EUS staging of esophageal cancer leads to appropriate use of preoperative neoadjuvant therapy in patients with advanced disease. Use of EUS is associated with a recurrence-free survival advantage and overall survival advantage in patients, thus supporting its routine use in esophageal cancer staging.     

线阵式彩色内镜超声对食管癌的分级诊断

目的 探讨内镜超声（EUS）检查对判断肿瘤侵犯深度及淋巴结转移的效用，期望有助手术治疗。方法 选择20例胃镜诊断的食管癌患者，10例术前CT检查作T分级，20例行EUS检查并进行T分级，对其中3例淋巴结作EUS引导下细针穿刺细胞学检查。结果 10例中CT分级仅4例与手术结果吻合，EUS检查20例中17例与手术结果分期一致，分级误差主要发生在T4期上。3例淋巴结穿刺2例证实为恶性，无并发症发生。结论 EUS对食管癌T分级有较高的敏感性，EUS引导下穿刺可望进一步提高其准确性。     

Staging of esophageal carcinoma in a low-volume EUS center compared with reported results from high-volume centers

BACKGROUND: It is well known that a learning curve exists for performing EUS. OBJECTIVE: To determine whether the number of EUS investigations performed in a center affects the results of esophageal cancer staging. DESIGN: We compared EUS in the evaluation of T stage and the presence of regional and celiac lymph nodes in a low-volume center where <50 EUS/endoscopist/y were performed with reported results from 7 high-volume EUS centers. SETTING: A reference center for esophageal cancer (>90 cases/y) but a low-volume center for EUS when it comes to individual endoscopists. PATIENTS: From 1994 to 2003, 244 patients underwent EUS, without specific measures to pass a stenotic tumor or FNA and with postoperative TNM stage as the criterion standard in the low-volume EUS center. In the high-volume centers, 670 EUS investigations for esophageal cancer were performed, if needed, with dilation, and with postoperative TNM stage and/or FNA as the criterion standard. INTERVENTIONS: Retrospective analysis. MAIN OUTCOME MEASUREMENTS: Sensitivity and specificity of EUS for esophageal cancer staging. RESULTS: In the low-volume center, results of EUS for T3 staging in patients in whom passage of the EUS probe was possible were almost comparable for sensitivity (85% vs 88%-94%) but were lower for specificity (57% vs 75%-90%), whereas both sensitivity (58% vs 75%-90%) and specificity (87% vs 94%-97%) for T1 or T2 stages were lower than those reported in the high-volume centers. In the low-volume center, sensitivities of EUS for regional (45% vs 63%-89%) and celiac (19% vs 72%-83%) lymph nodes were lower, whereas specificities (75% vs 63%-82% and 99% vs 85%-100%, respectively) were comparable with those from high-volume centers. Results in the low-volume EUS center were worse if the EUS probe could not pass the stricture, which occurred in almost 30% of patients. LIMITATIONS: Both FNA and dilation before EUS for stenotic tumors were not performed in the low-volume EUS center. CONCLUSIONS: The results of EUS performed in a low-volume EUS center compared unfavorably with those reported from high-volume EUS centers. The results of this study suggest that preoperative staging by EUS should be performed by experienced and dedicated EUS endoscopists to optimize staging of esophageal cancer.     

Concordance of studies for nodal staging is prognostic for worse survival in esophageal cancer

Pretreatment clinical staging in esophageal cancer influences prognosis and treatment strategy. Current staging strategies utilize multiple imaging modalities, and often the results are contradictory. No studies have examined the implications of concordance of computed tomography (CT), positron emission tomography (PET), and endoscopic ultrasound (EUS) when used for the evaluation of nodal disease. The objective of this study was to determine if concordance of CT, PET, or EUS for nodal disease predicts worse overall survival. We reviewed 615 esophageal cancer patients with pretreatment CT, PET, and EUS that underwent esophagectomy for survival outcomes based on concordance of studies for nodal disease. Concordant N+ is defined as two or three studies positive for nodal disease; non‐concordant N+ is defined as only one positive study. Node‐positive disease by any study predicted shorter survival than node‐negative disease (42% vs. 73% 5‐year survival; P < 0.001). Additionally, non‐concordant N+ patients had shorter survival than N? patients (52% vs. 73% 5‐year survival; P < 0.001). Concordant N+ patients had shorter survival than non‐concordant N+ patients (38‐ vs. 61‐month median survival; P = 0.017). There were no statistically significant differences in survival based on specific combinations of studies. When PET was disregarded, patients with both CT+ and EUS+ had shorter survival than patients with either CT+ or EUS+ (39‐ vs. 58‐month median survival; P = 0.029). Pretreatment CT, PET, or EUS concordance for node‐positive disease predicts shorter overall survival in patients that undergo esophagectomy for esophageal cancer. Predicting survival in esophageal cancer should consider the synergistic capabilities of CT, PET, and EUS in evaluating nodal status.     

EUS GUIDED FNA FOR MEDIASTINAL TUMORS (LUNG CANCER AND LYMPH NODES)

Trans‐esophageal endoscopic ultrasound‐guided fine needle aspiration biopsy (EUS‐FNA) has proven to be a safe and minimally invasive tissue‐sampling method which can be used to obtain a cytological diagnosis from mediastinal lesions. The aims of EUS‐FNA in the mediastinum are either to diagnose a lesion of unknown origin, to stage mediastinal lymph nodes in lung cancer patients or to diagnose other diseases involving lymph nodes of the mediastinum. In patients with non‐small cell lung cancer (NSCLC), surgery may be regarded as futile in up to 45% of patients operated, apparently because the stage of the disease is more advanced than expected preoperatively. This, combined with a stage‐dependent multimodality treatment, underlines the importance of exact staging of the disease. Conventional imaging and tissue sampling methods all have variable sensitivities. Twenty‐two studies concerning EUS‐FNA and mediastinal staging of lung cancer have been published with a total number of 1245 patients. The reported sensitivity for mediastinal malignancy range from 0.61–1.00 (median 0.90), and with specificities of 0.71–1.00 (median 1.00). The majority of the studies are retrospective and present the results of EUS‐FNA performed in lung cancer patients selected by computer tomography (CT). Recent data suggests that EUS‐FNA in addition can diagnose advanced mediastinal disease in 22–42% of NSCLC patients with normal sized lymph nodes (< 1 cm) on chest CT. EUS‐FNA may also be used as a re‐staging procedure after induction chemotherapy and it seems that EUS‐FNA is more accurate for mediastinal staging of NSCLC compared to positron emission tomography (PET). However, further studies are necessary before final conclusions can be made. At present, mediastinoscopy is still considered complementary to EUS‐FNA because EUS‐FNA cannot visualize structures anterior to the air‐filled trachea and main bronchi. Endoscopic trans‐bronchial real‐time ultrasound guided biopsy (EBUS‐TBNA) performed via the trachea and main bronchi seems to be an obvious solution. Preliminary experience with a prototype EBUS‐TBNA bronchoscope (Olympus, XBF‐UC40P, Tokyo, Japan) in 214 patients has shown promising results. Hopefully the combination of EUS‐FNA and EBUS‐TBNA will be able to replace more invasive and risky staging methods and improve the N‐staging accuracy of the mediastinum and lung hilar regions in the near future.     

Is positron emission tomography useful in locoregional staging of esophageal cancer? Results of a multidisciplinary initiative comparing CT, positron emission tomography, and EUS

BACKGROUND: Various modalities including CT, positron emission tomography (PET), and EUS are being used for esophageal cancer staging. OBJECTIVE: We compared results of locoregional staging by CT, PET, and EUS with histologic staging. DESIGN: Retrospective chart review. SETTING: Tertiary referral center. PATIENTS AND INTERVENTIONS: Patients with esophageal cancer proven by endoscopy and biopsy underwent a CT scan of the chest and abdomen and a PET scan. Patients with no evidence of distant metastatic disease on CT and PET were referred for EUS for locoregional staging. MAIN OUTCOME MEASUREMENT: The tumor size (T) and lymph node (N) stage as determined by EUS were compared with surgical pathology or EUS-guided FNA cytology. The results of N staging with CT, PET, and EUS were compared with surgical pathology or EUS-FNA cytology. RESULTS: Between May 2005 and April 2006, 29 patients (24 men, mean age 68 years) underwent EUS. EUS was successful in 25 of 29 patients (86%). There were no EUS-related complications. Eleven of 16 patients with available lymph node histologic study had confirmed metastasis. Nodal metastasis was correctly identified by CT in 6 of 11 patients, by PET in 4 of 11 patients, and by EUS in 10 of 11 patients. Overall accuracy for N staging was 69% for CT, 56% for PET, and 81% for EUS. Fifteen patients had confirmed T staging by surgical pathologic examination. The percentage of agreement for T staging between EUS and surgical pathology was 80% (12/15 patients). LIMITATIONS: Single center, retrospective chart review. CONCLUSION: EUS is safe and accurate for tumor and node staging in esophageal cancer. The combination of CT plus EUS appears to be accurate for locoregional staging in esophageal cancer.     

Endoscopic US and Dynamic CT in Preoperative TN Staging of Esophageal Squamous Cell Carcinoma

Abstract: 〈Objective〉 The aim of this study was to assess the accuracy and limitations of endoscopic ultrasonography (US) and dynamic computed tomography (CT) in the preoperative evaluation of esophageal carcinoma. 〈Methods〉 Endoscopic US and dynamic CT were performed preoperatively in 96 patients with an esophageal squamous cell carcinoma. The results were correlated with the histology of specimens resected from patients who had undergone subtotal esophagectomy with lymph node dissection. 〈Results〉 According to the TN staging classification, endoscopic US was superior to dynamic CT for evaluating the depth of tumor infiltration (overall accuracy: EUS 75%, CT 35%) and in assessing regional lymph node metastases (overall accuracy: EUS 77%, CT 67%). However, the T4 stage was not accurately evaluated using endoscopic US in this study. Its specificity was high (97%) but its sensitivity was low (45%). 〈Conclusions〉 We believe endoscopic US is the most accurate method for local tumor staging in esophageal carcinoma. A limitation to endoscopic US staging performed with current instruments was severe stenosis, as it would not permit passage of the instrument (25% of all cases in this study).     

超声内镜及CT检查对食管癌术前TN分期的价值

目的 评价超声内镜、螺旋CT检查对食管癌术前TN分期的价值.方法 回顾性总结术前EUS、CT判断87例食管癌的分期资料,并与术后病理分期对照.患者均未行化、放疗.环扫超声内镜进行操作,5例轻度狭窄病例扩张后再予EUS分期.结果 EUS T分期总准确率为85.1%,CT无法区分T1、T2.对于N分期,EUS判断探及范围内淋巴结转移的灵敏度为85.0%,高于CT扫描的60.8%;CT探查纵隔淋巴结较EUS全面.EUS与cT联合判断T分期的准确率为85.1%,N分期的准确率为90.8%.结论 EUS判断肿瘤浸润深度准确性高,EUS联合CT可进行更为全面准确的TNM分期.     

A cost analysis of endoscopic ultrasound in the evaluation of esophageal cancer

OBJECTIVE: The use of endoscopic ultrasound (EUS) with guided fine needle aspiration (FNA) of suspicious lymph nodes has become an important aid in the staging of esophageal carcinoma. The economic impact of this staging strategy has not yet been described. We applied a decision analysis model to compare the costs of EUS FNA, CT-guided FNA, and surgery in the management of esophageal tumors. A cost-minimization approach was employed, as viewed from the perspective of the payer. METHODS: A decision analysis model with three management arms was designed using DATA 3.5 software, taking the entry criteria as esophageal carcinoma without evidence of distant metastases as determined by CT. Detection of tumor on celiac lymph node (CLN) FNA signified unresectability and prompted palliative treatment: chemoradiotherapy with endoscopic esophageal stenting rather than surgery. Baseline probabilities were varied through plausible ranges using sensitivity analysis. Cost inputs were based on Medicare professional fees plus Medicare facility fees. The endpoint was the cost of management per patient. RESULTS: EUS FNA was the least costly strategy ($13,811), compared to CT FNA ($14,350) and surgery ($13,992). The model outcome was sensitive to changes in both EUS FNA sensitivity and prevalence of CLN metastases. EUS FNA remained the least costly option provided the prevalence of CLN involvement was >16%; below this value, surgery became the most economical strategy. CONCLUSION: By minimizing unnecessary surgery, primarily by detecting CLN involvement, EUS FNA is the least costly staging strategy in the workup of patients with nonmetastatic esophageal cancer. Under certain circumstances, surgery is the preferred strategy.     

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

BACKGROUND: EUS-guided FNA (EUS-FNA) is the most accurate method for lymph-node staging of esophageal carcinoma; however, it may not be necessary when EUS features are present that strongly suggest a benign or a malignant origin. AIMS: (1) To identify a combination of EUS criteria that have a sufficient sensitivity and specificity to preclude the need for EUS-FNA and (2) to assess the cost savings derived from a selective EUS-FNA approach. METHODS: A total of 144 patients with esophageal carcinoma were prospectively evaluated with EUS. Accuracy of standard (hypoechoic, smooth border, round, or width > 5 mm) and modified (4 standard plus EUS identified celiac lymph nodes, >5 lymph nodes, or EUS T3/4 tumor) criteria were compared (receiver operating characteristic curves). Resource utilization of two diagnostic strategies, routine (all patients with lymph nodes) and selective EUS-FNA (FNA only in those patients in whom the number of EUS malignant criteria provides a sensitivity and a specificity <100%), were compared. RESULTS: Modified EUS criteria for lymph-node staging were more accurate than standard criteria (area under the curve 0.88 vs. 0.78, respectively). No criterion alone was predictive of malignancy; sensitivity and specificity reached 100% when a cutoff value of >1 and >6 modified criteria were used, respectively. The EUS-FNA selective approach may avoid performing FNA in 61 patients (42%). CONCLUSIONS: Modified EUS lymph-node criteria are more accurate than standard criteria. A selective EUS-FNA approach reduced the cost by avoiding EUS-FNA in 42% of patients with esophageal carcinoma. These results require confirmation in future studies.     

超声内镜在胃癌食管癌术前诊断中的应用

为探讨超声内镜（ＥＵＳ）在胃癌、食管癌术前诊断中的应用价值，对３６例胃癌、１５例食管癌术前进行ＥＵＳ检查，将其结果与术后病理对照。根据肿瘤新ＴＮＭ分期，ＥＵＳ对胃癌、食管癌术前Ｔ分期判断的准确率分别为８１％，８７％；对Ｎ分期判断的准确率分别为７２％，８０％。对胃癌、食管癌术前可切除性分期（Ｒ０）判断的准确率分别为９５％，９３％。提示ＥＵＳ能较准确地判断胃癌、食管癌的分期；能准确地判断早期癌，为早癌的内镜切除提供可靠的依据；对ＢｏｒｒｍａｎｎⅣ型癌的诊断也有重要意义。     

The multidisciplinary team meeting improves staging accuracy and treatment selection for gastro-esophageal cancer

The object of this article is to assess current staging accuracies for individual modalities and to investigate the influence of the multidisciplinary team (MDT) on clinical staging accuracies and treatment selection for patients with gastro-esophageal cancer. Patients newly diagnosed with gastric or esophageal cancer and who were deemed suitable for surgical resection by the MDT were studied. Patients were staged with a combination of computerized tomography (CT), endoscopic ultrasound (EUS) and laparoscopic ultrasound (LUS). Additionally, the MDT determined an overall clinical stage for each patient after discussion at the MDT meeting. Treatments were selected according to this final clinical stage. Final histopathological staging (pTNM) was available for all patients and was used as the gold standard for determining staging accuracy. Suitability of treatment selection was assessed once final pTNM was available. One hundred and eighteen patients were studied. Endoscopic ultrasound was the most accurate individual staging modality for the loco-regional assessment of esophageal tumors (T stage accuracy 78%, N stage accuracy 70%). Laparoscopic ultrasound was the most accurate modality in T staging of gastric cancers (91%). The MDT stage was more accurate than each individual staging modality for T and N staging for both gastric and esophageal cancers (accuracy range: 88-89%) and was better for the assessment of nodal disease than each individual modality (CT P < 0.001, EUS P < 0.01, LUS P < 0.01). Overall staging accuracy as determined at the MDT meeting was increased and resulted in only 2/118 (2%) patients being under-treated. The MDT significantly improves staging accuracy for gastro-esophageal cancer and ensures that correct management decisions are made for the highest number of individual patients.     

Endoscopic ultrasound restaging after neoadjuvant chemotherapy in esophageal cancer

BACKGROUND: The role of endoscopic ultrasound (EUS) to evaluate treatment response postneoadjuvant therapy for restaging esophageal cancer prior to surgical resection is uncertain. Accuracy of EUS is lower but potential to predict response to chemoradiation indicates that EUS may be helpful prior to surgery. OBJECTIVE: To determine staging accuracy of EUS after neoadjuvant chemotherapy, predictors of tumor response, and survival in locally advanced esophageal cancer. METHODS: Single-center retrospective evaluation of patients with locally advanced esophageal cancer on a prospective chemotherapy study. Patients who underwent EUS without FNA pre- and postchemotherapy were included. RESULTS: A total of 49 patients (43 men and 6 women) were evaluated with EUS pre- and postneoadjuvant chemotherapy. Forty-seven patients had tumor localized at the GE junction and two had mid-esophageal lesions. The median survival time was 53 months. Tumor and nodal staging accuracy postchemotherapy were 60% (27 of 45). T-stage accuracy postchemotherapy was superior in patients without a response to chemotherapy (95.7%vs 26.1%, p<0.0001). More than 50% in reduction of tumor thickness postchemotherapy was associated with tumor downstage and better survival. N0 disease on final pathology was the best predictor of improved survival. CONCLUSION: Accuracy of EUS postchemotherapy is lower than initial staging accuracy; therefore the ability to predict downstaging based on EUS is marginal. Pathology N1 disease postchemotherapy is the best predictor of survival. EUS staging postneoadjuvant chemotherapy should focus on improving nodal staging accuracy with FNA.     

Do physician attitudes and practices limit use of EUS in the staging and the treatment of esophageal carcinoma?

BACKGROUND: Although EUS provides superior local staging of esophageal carcinoma when compared with other tests, EUS seems to be underused by physicians. We designed this prospective study to determine whether EUS is ordered in the evaluation of esophageal cancer and whether staging information obtained would change management. METHODS: A total of 114 physicians were mailed a questionnaire that surveyed which tests are used in evaluating patients with esophageal cancer, the order in which they are requested, and their estimated cost. Physicians were asked to estimate prognosis and to indicate which therapy would be used for each specific TNM cancer stage. RESULTS: Of 114 physicians, 71 (62.3%) physicians from 4 disciplines responded. Only 47.3% of physicians would use EUS in the patient workup for esophageal cancer. Physicians would only order EUS after first obtaining an endoscopy, then a barium swallow, and then a CT scan ( p < 0.0001). A significantly greater number of internists (78.9%, p = 0.055) would not order EUS, and 31.6% of internists would not use any staging data before referral to another physician for definitive management. Physicians were accurate in their assessment of the prognosis for each cancer stage and the cost of each test. There was no difference in the use of surgery between disciplines for stages O, I, IIA, and IV. However, significantly more surgeons than nonsurgeons would use surgery for stage IIB (100.0% vs. 71.3%, p = 0.019), with a trend toward greater use by surgeons for stage III (64.3% vs. 34.1%, p = 0.11). Except for significantly greater use of chemotherapy by surgeons and oncologists for stage IIA than internists and gastroenterologists (36.6% vs. 3.1%, p = 0.0006), there were no differences between subspecialties with use of chemotherapy for all other stages or use of radiation therapy for any stage. CONCLUSIONS: Clinicians have an adequate understanding of patient survival based on cancer stage and a reasonable appreciation of cost for diagnostic tests regarding esophageal carcinoma. Specific data on cancer staging does impact treatment choices and management decisions. EUS is grossly underused by clinicians for staging esophageal cancer. Although internists may serve as gatekeepers, they fail to order EUS, order EUS only after less accurate tests, or fail to use staging data in management (especially referral) decisions. The ultimate modality of treatment may be more related to the type of physician that the patient is referred to, instead of the specific cancer stage. Education of primary care clinicians may be needed before the full impact of EUS on patient care can be appreciated.     

Helical CT versus EUS with fine needle aspiration for celiac nodal assessment in patients with esophageal cancer

BACKGROUND: Conventional CT is insensitive for detection of metastatic involvement of celiac lymph nodes in esophageal cancer. Helical CT has theoretical advantages over "slice" CT in this regard, but its performance has not yet been prospectively studied. METHODS: Consecutive patients with untreated esophageal cancer were recruited after obtaining informed consent. Helical CT was performed on all patients and TNM staging was performed by a single radiologist. Subsequently, all patients underwent esophageal radial and, as needed, curvilinear array EUS with fine needle aspiration (FNA), for evaluation of celiac lymph nodes and TNM staging. Test performance characteristics with 95% confidence intervals were calculated, assuming EUS with FNA as the reference standard. RESULTS: Forty-eight patients were recruited, of whom 37 (77%) were men. The mean (SD) age was 63.6 (10) years. Excluding 5 patients in whom a confirmatory FNA was not available (n = 43), helical CT identified celiac lymph nodes in 12 (28%) patients. The reference standard of EUS with FNA identified 15 (35%) patients with metastatic celiac lymph nodes, giving a sensitivity, specificity, and positive and negative predictive values for helical CT of 53% (95% CI [28%, 79%]), 86% (95% CI [73%, 99%]), 67% (95% CI [40%, 93%]), and 77% (95% CI [63%, 92%]), respectively, for assessing celiac lymph nodal involvement. The sensitivity and specificity of helical CT in detecting T4 disease were 25% (95% CI [3.8%, 46%]) and 94% (95% CI [85%, 100%]), respectively. There were 12 patients (25%; 95% CI [13%, 37%]) who were felt to have resectable disease by helical CT but had either metastatic involvement of celiac lymph nodes or T4 disease by EUS/FNA. CONCLUSIONS: Despite technological advances, helical CT still appears unreliable, mainly because of insensitivity, for the identification of inoperable T4 or metastatic involvement of celiac lymph node disease in esophageal cancer.     

The role and clinical value of EUS in a multimodality esophageal carcinoma staging program with CT and positron emission tomography

BACKGROUND: EUS, CT, and positron emission tomography (PET) have all been used in the preoperative staging of esophageal cancer separately or in various combinations. OBJECTIVE: Our purpose was to determine the value and role of EUS when used in conjunction with CT and PET imaging in staging cancer of the esophagus and gastroesophageal junction. DESIGN: Retrospective single-center clinical trial. SETTING: Academic tertiary care center. PATIENTS: Data were examined for 56 patients who concomitantly underwent examination with EUS, CT, and PET in a multimodality staging program. MAIN OUTCOME MEASUREMENTS: EUS, CT, and PET were examined for their ability to detect the primary tumor, local tumor stage, locoregional adenopathy, and distant metastases. With use of surgical resection as baseline therapy, the frequency at which EUS, CT, and PET affected and changed management was examined. RESULTS: EUS is the only imaging test that identified all primary tumors and provided tumor staging. EUS identified a significantly greater number of patients (58.9%) with locoregional nodes than did CT (26.8%), P = .0006, or PET (37.5%), P = .02. CT identified 14.3% and PET identified 26.8% of patients with distant metastases. With CT alone, 15.2% of patients were not taken to surgery, whereas PET affected management by preventing surgery because of metastatic disease in 28.3% of patients. EUS changed management by guiding the need for neoadjuvant therapy in 34.8% of patients. LIMITATIONS: Retrospective study, nonblinded study, lack of pathologic reference standard. CONCLUSION: The primary strength of EUS in a multimodality staging strategy is in identifying patients with locally advanced disease and guiding the need for preoperative neoadjuvant therapy. EUS is not suited to determine resectability of esophageal cancer alone and thus is most effective when used in conjunction with other imaging tests such as CT and PET.     

Endoscopic ultrasound for esophageal and gastroesophageal junction cancer: Impact of increased use of primary neoadjuvant therapy on preoperative locoregional staging accuracy

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.     

Diagnosis of solid pancreatic masses by endoscopic ultrasound-guided fine-needle aspiration

Background:  Endoscopic ultrasound (EUS) with fine-needle aspiration (FNA) is increasingly being used in the staging algorithm for pancreatic carcinoma. This allows for a tissue diagnosis, which was previously difficult to obtain. The aim of this study is to assess the utility of EUS–FNA in establishing the diagnosis of solid pancreatic mass lesions in an Australian population.
Methods:  A retrospective review of the EUS databases of St Vincent's Hospital Melbourne and Western Hospital, Melbourne from November 2002 to May 2006 was undertaken. The focus was on patients with a solid pancreatic mass who underwent EUS–FNA. Surgical pathology or long-term follow up was used to identify false-positive or false-negative results.
Results:  EUS was undertaken to investigate a solid pancreatic or distal common bile duct mass lesion in 155 patients. Seventy-two of these underwent EUS-guided FNA. Mean age was 68 years. A positive tissue diagnosis of malignancy could be made in 55 (76%). Nine (13%) had benign histology, with 8 (11%) having inadequate tissue obtained from FNA. A later tissue diagnosis of carcinoma was made in eight of those with either benign or inadequate histology, although in all cases there were EUS features diagnostic of malignancy, with FNA limited by technical difficulties. The overall utility of EUS–FNA showed a sensitivity of 87%, specificity 100%, positive predictive value 100%, negative predictive value 52% and overall accuracy 89%.
Conclusion:  EUS–FNA gives a high return for histological diagnosis of solid pancreatic mass lesions and should be part of the standard management algorithm for pancreatic carcinoma.