Staging and diagnosis of non-small cell lung cancer: invasive modalities

During the staging process of lung cancer, accurate mediastinal lymph node staging is one of the more important factors that affects patient outcome. Several different invasive and non-invasive modalities exist for mediastinal staging. Invasive tests include mediastinoscopy, thoracoscopy, transbronchial needle aspiration, transthoracic needle aspiration, endoscopic ultrasound-guided fine-needle aspiration and endobronchial ultrasound-guided transbronchial needle aspiration. Each of the invasive tests has limitations for particular locations, has particular risks and requires specific skills. Invasive tests are often used to confirm the staging of lung cancer, but are also used to obtain a diagnosis. The best approach depends upon the clinician's assessment of the patient. This review discusses the invasive staging tests that are available, with particular emphasis on newer modalities, especially endobronchial ultrasound-guided transbronchial needle aspiration. In addition, the current advances in diagnostic bronchoscopy for lung cancer will be reviewed.     

Laparoscopic pancreatic surgery: What now and what next?

In recent years, improved laparoscopic skill sets have expanded surgical management of pancreatic disease to encompass pancreatic resection, tumor enucleation, débridement, and drainage. With the aid of radio-logically guided drainage catheters, necrosectomy for acute pancreatitis can be delayed and accomplished laparoscopically in a select patient population. Pancreatic pseudocysts from chronic pancreatitis can now be approached via minimally invasive strategies, including emerging combined laparoendoscopic procedures and natural orifice transluminal endoscopic surgery. It is clear that laparoscopic pancreaticoduodenectomy is possible in experienced hands; pancreatic neoplasms in the body and tail are more suitable for laparoscopic procedures because distal pancreatic resection requires no reconstruction of the biliary or enteric tract. Laparoscopic staging of pancreatic tumors has decreased as preoperative radiographic imaging becomes more sensitive. Similarly, laparoscopic palliative procedures have decreased because of the emergence of other minimally invasive options for relieving gastric outlet obstruction and biliary obstruction. Nonetheless, major advances in minimally invasive pancreatic surgery will continue as technology and skill sets advance.     

An evidence-based approach to the diagnosis and staging of pancreatic cancer.

Technology has revolutionized the diagnosis and staging of pancreatic malignancy. Previously, staging of disease was accomplished by exploratory laparotomy. Now, however, tumor size, lymph node and vascular involvement and the presence of metastases can be reliably assessed prior to operation using a widely available series of diagnostic tests, facilitating a preoperative assessment of tumor resectability. Appropriate use of these tests often spares patients with unresectable disease the need for operative intervention. As part of our staging algorithm we routinely employ a combination of clinical suspicion, a high-resolution helical CT scan and a serum CA 19-9 level. Endoscopic ultrasonography is useful in the patient in whom CT findings are equivocal, or in whom a tissue diagnosis is desired. Laparoscopy is reserved for patients with suspected advanced disease despite imaging findings to the contrary. Using this strategy, pancreatic malignancy may be diagnosed as expeditiously and as cost-effectively as is possible given current technology.     

Surgical indications and optimization of patients for resectable esophageal malignancies

Esophageal cancer is a devastating diagnosis with very dire long-term survival rates. This is largely due to its rather insidious progression, which leads to most patients being diagnosed with advanced disease. Recently, however, a greater understanding of the pathogenesis of esophageal malignancies has afforded surgeons and oncologists with new opportunities for intervention and management. Coupled with improvements in imaging, staging, and medical therapies, surgeons have continued to enhance their knowledge of the nuances of esophageal resection, which has resulted in the development of minimally invasive approaches with similar overall oncologic outcomes. This marriage of more efficacious induction therapy and diminished morbidity after esophagectomy offers new promise to patients diagnosed with this aggressive form of cancer. The following review will highlight these most recent advances and will offer insight into our own approach to patients with resectable esophageal malignancy.KEYWORDS : Esophageal cancer, indication for surgery, preoperative optimization, review     

Diagnostics and staging procedures in non‐small cell lung cancer – is less more?

Introduction: Non‐small cell lung cancer (NSCLC) is a common cancer with approximately 85% of patients dying of the disease. The only chance for cure is in the early stages, when surgery or definite chemoradiotherapy can be performed. Diagnosis and staging of lung cancer can sometimes be difficult, particularly because the intrathoracic structures are not easy to reach. Objective: This review discusses the diagnosis and staging of lung cancer. Results: When performing lung cancer diagnostics, both invasive and noninvasive procedures, such as computed tomogram of the chest, bronchoscopy and abdominal ultrasound, are mandatory. Suspected mediastinal involvement should be differentiated: bulky disease, contralateral or high mediastinal nodes need further clarification by endoscopic ultrasound, endobronchial ultrasound or mediastinoscopy. In opposition to current guidelines, in all other cases, surgery should be performed. Positron emission tomography will gain even more importance when becoming widely accessible and might replace other imaging techniques in the future. In case of advanced disease, staging should be limited to those examinations with impact on symptom control. Conclusion: The diagnosis and staging of lung cancer should involve both invasive and noninvasive diagnostic procedures. In the case of advanced disease, staging should be limited to those examinations with impact on symptom control, whereas early stages call for rapid and thorough diagnosis. Please cite this paper as: Heigener DF, Diemel K‐D, Reck M and Gatzemeier U. Diagnostics and staging procedures in non‐small cell lung cancer – is less more? The Clinical Respiratory Journal 2008; 2: 67–73.     

Current status of laparoscopic surgery of the pancreas

Laparoscopic surgery of the pancreas remains, other than for certain clear indications, primarily investigational. However, in the past few years, laparoscopic therapy for pancreatic diseases has made significant strides and will undoubtedly contribute increasingly to the care of the surgical patient with pancreatic disease. This review discusses the current status of minimally invasive surgical therapy of pancreatic diseases and reviews the current literature. There are four major areas of clinical and laboratory investigation, including diagnostic laparoscopy for staging of pancreatic cancer, laparoscopic palliation of unresectable pancreatic cancer, laparoscopic management of pancreatic pseudocyst, and laparoscopic partial pancreatectomy (pancreaticoduodenectomy, distal pancreatectomy, and enucleation for islet cell tumors). The increased sensitivity of staging laparoscopy with laparoscopic ultrasound as a staging modality in the diagnosis of previously unrecognized metastatic disease from pancreatic cancer is clearly the most utilitarian application of laparoscopic technology in this patient population. Additionally, a natural extension of staging laparoscopy with laparoscopic ultrasound is the ability to improve the quality of life for the patient with unresectable pancreatic cancer by palliating the biliary and gastrointestinal obstruction and the debilitating pain, without the need for and morbidity of open laparotomy. Laparoscopic internal drainage of pancreatic pseudocysts remains early in its development but appears to have potential benefit from application of minimal access techniques. And laparoscopic partial pancreatectomy, both pancreaticoduodenectomy, and, to a lesser degree, distal pancreatectomy, remain primarily investigational without clearly established benefits from the use of minimal access techniques.     

Lung cancer staging

Accurate staging of lung cancer is essential for proper treatment and management of the disease, and allows predictions for patient survival. Several different invasive and noninvasive modalities exist for staging, and the determination of the best approach of one or a combination of those methods depends on the clinical situation and the clinician's assessment of the most appropriate means of staging evaluation. This review discusses the elements and framework of lung cancer staging, with particular emphasis on those newer modalities, especially positron emission tomography and endoscopic ultrasound needle biopsy, which will be expected to be used increasingly more common in clinical practice.     

Tissue diagnosis of suspected lung cancer: selecting between bronchoscopy,transthoracic needle aspiration,and resectional biopsy

In pursuing a tissue diagnosis of a suspected lung cancer, there is a range of procedures to choose from. The principal goals are ideally to diagnose and pathologically stage the patient's lung cancer at the same time, preferably by using the safest, least invasive, and least costly tests. If there is clinical or radiographic evidence of extrapulmonary spread of disease, including supraclavicular N3 nodal involvement or a malignant pleural effusion, then radiology-guided or open biopsy will confirm tumor cell type and stage the patient as unresectable. For patients with symptoms, such as increasing cough or hemoptysis, that are suggestive of airways involvement. with or without radiographic finding of central lesions, sputum cytology is the least invasive study with a high specificity. A positive finding of cancer is especially helpful if the patient is not a surgical candidate because of anatomic location of the lesion or severe physiologic limitations. The limited sensitivity of sputum cytology and poor NPV may improve with improved sputum induction and collection and processing techniques. Bronchoscopy with direct examination of the visible airways is most often the preferred invasive diagnostic procedure. Although the procedure should be geared toward sampling the highest staged lesion to provide an accurate tissue staging at the time of diagnosis, additional procedures can be performed in sequence to sample different nodal stations, is well as the primary lung mass. The incidental finding of an unexpected central airways lesions or a synchronous second endobronchial lung primary will also affect plans for treatment. Autofluorescence bronchoscopy can improve the sensitivity for detecting early intraepithelial neoplasia. Bronchoscopy for central and peripheral lung masses that are suspected to be lung cancer should be performed with ROSE whenever available. For visible endobronchial lesions, given the similar yield of EBBX and EBNA, EBNA may provide an immediate diagnosis, thus obviating additional, possibly morbid, procedures such as BB or EBBX. For submucosal lesions, EBNA is superior. For central cancers that are peribronchial, TBNA performed as for regional nodal sampling should have a yield that is comparable to TBNA for staging. TBBX and TBNA of peripheral nodules that are smaller than 3 cm have a lower diagnostic yield. Coming generations of thin bronchoscopes and improved radiographic guidance systems may improve our ability to biopsy these lesions with greater accuracy and safety. Under all circumstances, immediate cytology feedback with ROSE will confirm the adequacy of the retrieved specimen for a definitive tissue diagnosis, thus avoiding the need for extra biopsies, or worse yet, the need for a second invasive procedure because of insufficient diagnostic material. ROSE is educational to the clinician and fellow-in-training in getting immediate feedback on the procedural techniques and in learning pulmonary pathology, as well. The diagnostic sensitivity of TTNA is high, especially for the larger peripheral-based lung lesion, and TTNA is a relatively rapid procedure. TTNA's sensitivity falls for smaller or more central lesions, where the false negative rate can approach 25% to 30%; the risk of pneumothoraces and bleeding increases with central biopsies. Furthermore, TTNA usually does not provide information about nodal staging, unless the TTNA is initially directed toward central lymph nodes. The central airways are not examined in the same appointment to address issues of resection margins when there may be central spread of disease. TTNA should, therefore, be held in reserve for cases in which the sputum cytology and subsequent bronchoscopy are negative, and the patient is not a surgical candidate or refuses surgery, even if the cancer is potentially resectable. TTNA may then provide the tissue diagnosis to permit initiation of cytotoxic chemotherapy and radiotherapy. TTNA may also be helpful in cases where the likelihood of cancer is only intermediate, such that a specific benign diagnosis or an adequate sample without cancer will greatly reduce the likelihood ratio of missing a cancer, and justify to the patient and physician an approach of careful observation. To maximize the yield of these diagnostic procedures, there must be continued improvement in the hands-on teaching of clinical fellows and pulmonary practitioners in the use of the various techniques of TBNA and TBBX, as well as the applications of new endoscopic technology, such as EBUS. Definitive curative surgery remains the goal for patients with lung cancer, with accurate pathological staging performed intraoperatively. Complete lobectomy or pneumonectomy remains the standard resectional approach. Therefore, for patients with sufficient cardiopulmonary reserve who can be clinically staged as IA or IB, either by good quality CT with contrast or increasingly with 18-FDG PET, the initial tissue diagnosis may be at the time of surgery, when a frozen section preceding a complete lobectomy with lymph node sampling will combine diagnosis and therapy.     

Ectopic pancreas at the ampulla of Vater diagnosed with endoscopic snare papillectomy: A case report and review of literature

BACKGROUND Ectopic pancreas is a rare developmental anomaly that results in a variety of clinical presentations. Patients with ectopic pancreas are mostly asymptomatic,and if symptomatic, symptoms are usually nonspecific and determined by the location of the lesion and the various complications arising from it. Ectopic pancreas at the ampulla of Vater(EPAV) is rare and typically diagnosed after highly morbid surgical procedures such as pancreaticoduodenectomy or ampullectomy. To our knowledge, we report the first case of confirmed EPAV with a minimally invasive intervention.CASE SUMMARY A 71-year-old male with coronary artery disease, presented to us with new-onset dyspepsia with imaging studies revealing a ‘double duct sign' secondary to a small subepithelial ampullary lesion. His hematological and biochemical investigations were normal. His age, comorbidity, poor diagnostic accuracy of endoscopy,biopsies and imaging techniques for subepithelial ampullary lesions, and suspicion of malignancy made us acquire histological diagnosis before morbid surgical intervention. We performed balloon-catheter-assisted endoscopic snare papillectomy which aided us to achieve en bloc resection of the ampulla for histopathological diagnosis and staging. The patient's post-procedure recovery was uneventful. The en bloc resected specimen revealed ectopic pancreatic tissue in the ampullary region. Thus, the benign histopathology avoided morbid surgical intervention in our patient. At 15 mo follow-up, the patient is asymptomatic.CONCLUSION EPAV is rare and remains challenging to diagnose. This rare entity should be included in the differential diagnosis of subepithelial ampullary lesions.Endoscopic en bloc resection of the papilla may play a vital role as a diagnostic and therapeutic option for preoperative histological diagnosis and staging to avoid morbid surgical procedures.     

Role of computed tomography in lung cancer staging

PURPOSE OF REVIEW: Computed tomography has always been an important imaging technique in lung cancer staging but, due to its well-known limitations, additional imaging and/or invasive tests are usually performed. Purpose of this review is to determine whether new developments in CT and in the other staging techniques have changed the role of CT. RECENT FINDINGS: Despite important technical improvements and the availability of new CT applications, the recent literature confirms the limitations of CT in staging patients with NSCLC. Most attention was given however to other invasive and noninvasive staging techniques and their accuracy in comparison with CT. It was shown that FDG-PET is very useful in the preoperative patient with NSCLC and that it is, especially in N-staging, more accurate than CT. Also combining CT or FDG-PET with EUS-FNA biopsy seems to be a good approach in some indications. Finally, the first reports on the use of integrated PET-CT scanners in lung cancer staging were published and very promising results were shown. SUMMARY: Computed tomography stays nevertheless the routine imaging procedure for staging patients with NSCLC although performing a PET scan in addition to this CT examination seems to be a good approach that can reduce but certainly not always avoid invasive staging procedures. Mediastinoscopy is still generally considered the standard of care when tissue needs to be obtained from suspicious nodes on FDG-PET and/or CT, although minimally invasive biopsy techniques could replace to a large extent this more invasive technique in the near future.     

The Road to Cystectomy: Who, When and Why?

Objectives:

Bladder cancer is the fifth most common solid malignancy amongst men in the western world. Around 30% of newly diagnosed patients will eventually die from the disease. Radical treatment with curative intent is the best option for patients with invasive bladder cancer. Cystectomy and urinary diversion represents a time-tested robust approach to treating this disease. Here we review the current indications for cystectomy and staging methods for transitional cell carcinoma (TCC).

Methods:

We conducted a search of the current literature to evaluate the evidence for the indications for cystectomy and the staging of TCC of the urinary bladder.

Results:

Radical cystectomy is usually performed for either invasive or high risk superficial bladder cancer. The outcome is dependent on the pathological stage of tumour at cystectomy. Whilst novel molecular staging methods are in development, current staging is by clinical, pathological and radiological methods. There is a recognised risk of either over- or under- staging the disease using current imaging techniques.

Conclusion:

The indications for radical cystectomy are changing with more emphasis on surgery for high-risk superficial disease. Better stratification of superficial disease has allowed the identification of such high risk cancers. It is likely that advances in molecular diagnosis and staging will come through to clinical practice in the near future.     

The future in diagnosis and staging of lung cancer: surgical techniques

Surgical techniques remain central to the diagnosis and staging of lung cancer. Clinical situations which invoke the role of surgery include the diagnosis of solitary pulmonary masses, staging of the mediastinum, restaging of the mediastinum and the assessment of resectability. The techniques available include cervical mediastinoscopy, anterior mediastinotomy, video-assisted thoracoscopy and different procedures for intra-operative mediastinal lymph node assessment including systematic nodal dissection, lobe-specific nodal dissection and sentinel node mapping. The staging of lung cancer is continuously evolving as technological advances combine with clinical advances to better stratify patients into treatment and prognostic categories and alter pre-operative investigation algorithms. Although most of the surgical techniques have been around for many years, it is their application in future which is likely to change. The increasing use of positron emission tomography/computed tomography fusion imaging is raising the proportion of patients being shown to have additional lesions that could contraindicate surgical treatment but which require tissue confirmation to exclude a false-positive examination. Many such lesions are amenable to the expanding techniques available to the interventional endoscopist. The relationship between the surgeon and the endoscopist must become closer to ensure that the appropriate technique is used at each point in the patient's pathway. The future of surgical techniques will be driven by: (1) developments in screening and imaging, with a likelihood that more early stage cancers will present and may be amenable to minimally invasive surgical approaches with the possibility of a role for robotics and nanotechnology; (2) improvements in neoadjuvant therapies which will demand flawless mediastinal staging and restaging; (3) advances in molecular biology which, whilst currently requiring that surgery provide samples of tumour and lymph node tissue to fully characterize the disease, do hold the promise that ever smaller amounts of tissue will be required and that eventually the genetic fingerprint will provide a biological ultrastaging to perhaps supersede anatomical staging.     

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??Abstract??Interventional pulmonology is a newly developed medical discipline devoted to the performance of diagnosis and invasive therapy of respiratory diseases.The professional field of this discipline refers to diagnosis and staging of respiratory diseases??and focuses on treatment of pulmonary tumors??benign or malignant airway stenosis??pleural disease and pulmonary vascular diseases.So far??huge strides have been made in interventional pulmonology??and therefore some distinct features have been developed in China.Prevalent and common diseases??such as lung cancer??chronic obstructive pulmonary disease(COPD)and asthma??will hereafter be the focus of interventional pulmonary in China.     

Nonsurgical staging of the mediastinum: EBUS and EUS

A tissue diagnosis is frequently needed for accurate lung cancer staging of mediastinal nodes as well as the assessment of mediastinal masses. Noninvasive imaging techniques such as computed tomography (CT), magnetic resonance imaging (MRI), positron-emission tomography (PET), and PET-CT provide some answers but no tissue diagnosis. Transbronchial needle aspiration (TBNA), a safe procedure that is performed during routine bronchoscopy, has a high impact on patient management. Unfortunately, TBNA remains underused in current daily practice, mainly due to the lack of real-time needle visualization. The introduction of echo-endoscopes has overcome this problem. Endobronchial ultrasound-guided TBNA (EBUS-TBNA) allows real-time controlled tissue sampling of paratracheal, subcarinal, and hilar lymph nodes. Mediastinal lymph nodes located adjacent to the esophagus can be assessed by esophageal ultrasound-guided fine needle aspiration (EUS-FNA). Owing to the complementary reach of EBUS-TBNA and EUS-FNA in assessing different regions of the mediastinum, recent studies suggest that complete and accurate mediastinal staging can be achieved by the combination of both procedures. It is expected that implementation of minimally invasive endoscopic methods of EBUS-TBNA and EUS-FNA will reduce the need for surgical staging of lung cancer significantly.     

Clinical implications of quantification of mesorectal tumor invasion by endoscopic ultrasound: All T3 rectal cancers are not equal

BACKGROUND: Depth of invasion beyond the muscularis propria (MP) by T3 rectal cancer can vary. The purpose of the present paper was to determine if depth of invasion beyond MP, as assessed by preoperative endoscopic ultrasound (EUS), can predict tumor recurrence in patients with T3 rectal tumors. METHODS: Patients with T3NxM0 rectal cancer, as determined by EUS, who underwent surgical resection (without preoperative neoadjuvant therapy) were reviewed by two blinded endosonographers. Tumors were classified as minimally invasive T3 (invasion 2 mm). RESULTS: Forty-two patients with T3 rectal tumors underwent surgical resection without receiving preoperative neoadjuvant therapy, of whom 14 had minimally invasive T3 and 28 had advanced T3 disease, as determined by preoperative EUS. Median follow up was 19 months. Tumor recurrence rates in minimally invasive and advanced T3 tumors were 14.3% and 39.3%, respectively, P = 0.02 (log-rank test). Adjusting for nodal status and postoperative adjuvant therapy administration, Cox proportional hazards model demonstrated advanced T3 disease (by EUS) to predict tumor recurrence, hazard ratio, 2.28 (95% confidence interval: 1.17-5.81), P = 0.01. CONCLUSIONS: All T3 rectal tumors are not equal, with minimally invasive disease carrying a more favorable prognosis. By discriminating minimally invasive from advanced T3 disease, preoperative EUS provides important prognostic information. Further subclassification of T3 tumors, based on preoperative EUS staging, should be considered to enhance selection of patients for neoadjuvant therapy.     

Transbronchial and transoesophageal (ultrasound-guided) needle aspirations for the analysis of mediastinal lesions.

A tissue diagnosis of mediastinal nodes is frequently needed for accurate lung cancer staging as well as the assessment of mediastinal masses. Transbronchial needle aspiration (TBNA) is a safe procedure that is performed during routine bronchoscopy. Provided mediastinal metastases are confirmed, TBNA has a high impact on patient management. Unfortunately, TBNA remains underused in current daily practice, mainly due to the lack of real-time needle visualisation. The introduction of echo-endoscopes has overcome this problem. Endobronchial ultrasound-guided TBNA (EBUS-TBNA) allows real-time controlled tissue sampling of paratracheal, subcarinal and hilar lymph nodes. Mediastinal lymph nodes located adjacent to the oesophagus can be assessed by transoesophageal ultrasound-guided fine needle aspiration (EUS-FNA). Owing to the complementary reach of EBUS-TBNA and EUS-FNA in assessing different regions of the mediastinum, recent studies suggest that complete and accurate mediastinal staging can be achieved by the combination of both procedures. It is expected that implementation of minimally invasive endoscopic methods of endobronchial ultrasound-guided transbronchial needle aspiration and transoesophageal ultrasound-guided fine needle aspiration will reduce the need for surgical staging of lung cancer significantly.     

Mediastinal staging of nonsmall cell lung carcinoma by endoscopic and endobronchial ultrasound-guided fine needle aspiration

Mediastinal staging is of vital importance in the treatment planning of patients with nonsmall cell lung cancer who do not have distant metastases. Nodal assessment is often a challenge, however, and the limitations of staging methods are well recognized. Noninvasive studies can yield a presumptive clinical stage, but invasive tests are often necessary to determine the status of nodes in the absence of extensive mediastinal infiltration. Endoscopic ultrasound-guided fine needle aspiration and endobronchial ultrasound-guided fine needle aspiration are minimally invasive additions to the staging armamentarium that facilitate nodal biopsy under direct visualization without full anesthesia. In some cases, these procedures offer the opportunity for a patient to receive both a tissue diagnosis and staging in one sitting. While their roles are debated and evolving, their availability is increasing and they are reducing the need for surgical staging. Radiologists contribute to the evaluation of patients who may benefit from these up-and-coming procedures and should become familiar with endoscopic ultrasound-guided fine needle aspiration and endobronchial ultrasound-guided fine needle aspiration.     

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.     

Staging esophageal adenocarcinoma

The incidence of esophageal adenocarcinoma has increased dramatically in Western societies over the last 20 years. Most patients present with advanced disease. Stage-dependent treatment protocols require the most complete and accurate staging possible. With all esophageal cancers (ie, adenocarcinomas and squamous carcinomas), it is perhaps most important to identify patients who are unlikely to benefit from aggressive treatment. The performance characteristics and clinical utility of CT scanning, endoscopic ultrasound, FDG-PET, and minimally invasive surgery in staging esophageal cancer are reviewed, including issues relating specifically to staging of adenocarcinomas. These investigations are not mutually exclusive and each has its own strengths and shortcomings. Accurate staging often requires the use of multiple modalities. The optimal staging algorithm for a given practice setting (if it exists) will be determined largely by local variables that include patient population, available technology, and local expertise in applying such technology. A lack of consensus on the effectiveness of therapeutic alternatives (particularly surgical v nonsurgical methods) may also affect the perceived value of the various staging modalities and how they are used.     

Endoscopic transesophageal and endoscopic transbronchial real-time ultrasound-guided biopsy

The goal of preoperative staging of non-small-cell lung cancer is to identify patients who will benefit from surgical resection. Various imaging and less invasive modalities are now available to improve therapy decision-making, and with the introduction of multimodality treatment of lung cancer, proper staging of this disease is becoming more and more important. This staging process is therefore not only a question of determining the prognosis, but it is also necessary information for institution of the right treatment. Proper staging and restaging of lung cancer should also be a must in the evaluation of the different treatments of lung cancer in controlled clinical trials. In lung cancer, endoscopic ultrasound scanning (EUS) is emerging as an accurate, nonsurgical alternative to staging the mediastinum through EUS-fine-needle aspiration (EUS-FNA). The author presents publications on evaluating EUS in diagnosing lymph node involvement in lung cancer and tumor ingrowths in the mediastinum. With EUS it is possible to guide FNA with direct visualization of the needle path into the lymph nodes in real time. Although this method is only able to visualize the posterior path and the inferior parts of the mediastinum, it makes it possible to visualize the aortopulmonary window. The limitation of EUS is a sensitivity of about 90%; nonetheless, this method is more precise than other staging procedures except for mediastinoscopy, which is limited to only the anterior parts of the mediastinum.