Endoscopic ultrasonography in the diagnosis and staging of neoplasms of the head and neck

BACKGROUND AND STUDY AIMS: Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is a minimally invasive and highly accurate method of detecting mediastinal lymph-node metastases in gastrointestinal and lung cancer. Little information is available regarding the use of EUS-FNA to stage tumors in the head and neck region. This study reports experience with EUS in the diagnosis and staging of these tumors and their mediastinal spread. PATIENTS AND METHODS: The records of patients who underwent EUS for diagnosis and/or staging of head and neck tumors were reviewed. Referral criteria were suspected invasion of the esophagus by a lower-neck mass on cervical computed tomography (CT) or magnetic resonance imaging (MRI), or mediastinal lymphadenopathy > 10 mm on a chest CT. RESULTS: Thirty-two patients (23 men, nine women; mean age 65 years, range 44 - 80) were referred and underwent 35 EUS examinations. In one patient, EUS was not possible due to a benign esophageal stricture. In 17 patients with suspected esophageal invasion on CT scans, EUS demonstrated invasion of the esophagus in four cases and of the pleura in one; 12 tumors showed no visible invasion of adjacent structures. The other 17 examinations were carried out for suspected mediastinal metastatic disease. In eight cases, EUS-FNA confirmed metastatic disease, whereas only benign changes were shown in the other nine cases. EUS-FNA also provided the first tissue diagnosis in two primary tumors and identified malignancy in one patient with no CT suspicion of positive mediastinal lymph nodes. EUS avoided the need for more invasive investigations in all patients with mediastinal lymphadenopathy, and it changed the management in 12 of the 17 patients (71 %) with suspected esophageal invasion and in eight of the 17 patients (47 %) with suspected mediastinal disease. CONCLUSIONS: EUS with FNA provides a viable approach to the diagnosis and staging of tumors in the head and neck region when there is a suggestion of esophageal invasion on CT or MRI, or enlarged mediastinal lymph nodes. EUS with FNA may avoid the need for mediastinoscopy or other more invasive techniques for staging of these neoplasms.     

内镜超声引导下经食管肺细针穿刺活检的诊断价值

目的 在内镜超声引导下经食管行肺部病变的细针穿刺活检来确定肺部病变的性质，并评价这种方法的对肺部病变的诊断价值。方法 选择经CT或内镜超声检查发现的肺部占位病变患者28例，所有肺部病变均邻近食管。对其进行内镜超声检查，以明确病变的大小、形态、位置，并观察有无淋巴结转移。在内镜超声导引下经食管对肺部病变行细针穿刺活检。结果 28例患者中，全部患者均得到了充足的组织碎片，25例最终确定为肿瘤的患者经组织细胞学检查23例为阳性结果(其中鳞状细胞癌，n=11；小细胞肺癌，n=6；大细胞癌，n=5；腺癌，n=1)，全部患者经手术治疗，得出经食管肺活检对肺癌诊断的敏感性为92％，特异性为100％。无1例患者出现不良反应。结论 内镜超声经食管肺活检是诊断肺部病变安全、有效的方法。     

Cost-efficacy of endoscopic ultrasonography with fine-needle aspiration vs. mediastinotomy in patients with lung cancer and suspected mediastinal adenopathy

BACKGROUND AND STUDY AIMS: The use of endoscopic ultrasonography (EUS) guidance for fine-needle aspiration (FNA) of mediastinal lymph nodes has become an important aid in the staging of bronchogenic carcinoma. In many cases, it may be an alternative to mediastinoscopy/mediastinotomy (MED), but the cost-effectiveness of the two techniques has not been compared. The aim of this study was to apply a decision-analysis model to compare the cost-effectiveness of EUS and MED in the preoperative staging of patients with non-small-cell lung cancer. PATIENTS AND METHODS: A decision-analysis model was designed, taking as entry criteria lung cancer and abnormal mediastinal lymph nodes verified by computerized tomography (CT). Performance characteristics of MED and EUS were retrieved from the published literature, as were life expectancy data. Direct actual costs of the relevant procedures were retrieved from the billing system of our hospital. RESULTS: The cost per year of expected survival is US$ 1.729 with the EUS strategy, and US$ 2.411 with the MED strategy. The advantage conferred by EUS remains even when the negative predictive value of EUS is as low as 0.22. CONCLUSION: Because of its low cost and high yield, EUS-guided FNA is a cost-effective aid assessing mediastinal lymphadenopathy.     

Impact of endoscopic ultrasound combined with fine-needle aspiration biopsy in the management of esophageal cancer

BACKGROUND AND STUDY AIMS: Endoscopic ultrasound (EUS) in combination with fine-needle aspiration biopsy (FNA) is a highly accurate method for the preoperative staging of esophageal cancer. Its impact on medical decision-making and the cost of care is unknown. This prospective case series was undertaken in order to determine the impact of EUS in combination with FNA on patients' choice of therapy and on the cost of care. PATIENTS AND METHODS: Sixty consecutive patients with esophageal cancer, referred for preoperative EUS staging in a large tertiary-care academic medical center, were enrolled. The accuracy of EUS, the impact of EUS-based staging on the patients' choice of therapy, and costs were studied. RESULTS: The accuracy rates for EUS combined with FNA in tumor and lymph-node staging were 83 % and 89 %, respectively. Twenty-five patients (42 %) had EUS stage I and II and were candidates for curative surgery. Twenty-eight patients (47 %) had stage III, and seven (12 %) had stage IV. All patients with stage I had surgery, while all patients with stage IV had medical therapy. The majority (62 %) of patients with stage II had surgery, while only a minority (25 %) of patients with stage III had surgery. Thirty-six patients (60 %) underwent medical therapy. Patients' medical decisions in favor of surgical or medical therapy correlated strongly with the results of their EUS staging ( P = 0.005), but not with age, sex, or referring physicians (surgeons vs. nonsurgeons). EUS-guided therapy potentially decreased the cost of care by $ 740 424 ($ 12 340/patient) by reducing the number of thoracotomies. CONCLUSIONS: Patients' decisions regarding therapy correlated with their overall tumor staging, suggesting that the information provided by EUS played a significant role in patients' decision-making. The use of EUS in combination with FNA reduces the cost of managing patients with esophageal cancer.     

非小细胞肺癌淋巴结的无创分期评价

目的 本研究通过对经胸部CT解剖显像后的非小细胞肺癌(NSCLC)患者进行18F-FDG PET全身扫描及经食管超声解剖显像，着重评估无创检查对NSCLC术前分期准确性及价值。方法 56例经病理证实的NSCLC术前患者经CT扫描、全身^18F-FDG PET显像，并与手术病理结果进行回顾性的分析。结果 所有56例NSCLC患者肺部及相应转移部位^18F-FDG摄取增高，^18F-FDG PET对预测NSCLC纵隔淋巴结转移的灵敏度为83％，特异性为91％，CT扫描纵隔淋巴结转移的灵敏度为58％，特异性为78％，其中38例行经食管超声解剖显像纵隔淋巴结转移的灵敏度为77％，特异性为72％。^18F-FDG PET对NSCLC对纵隔淋巴结优于胸部CT解剖显像和经食管超声解剖显像。结论 ^18F-FDG PET在对NSCLC的术前分期均优于CT等常规检查，但PET在精确定位方面仍然需要结合解剖显像，图像融合技术等是发展的方向。     

Indications, results, and clinical impact of endoscopic ultrasound (EUS)-guided sampling in gastroenterology: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline

This article is part of a combined publication that expresses the current view of the European Society of Gastrointestinal Endoscopy (ESGE) about endoscopic ultrasound (EUS)-guided sampling in gastroenterology, including EUS-guided fine needle aspiration (EUS-FNA) and EUS-guided trucut biopsy (EUS-TCB), of submucosal tumors, diffuse esophageal/gastric wall thickening, pancreatic solid masses and cystic-appearing lesions, mediastinal lesions unrelated to lung or esophageal cancer, cancer of the esophagus, stomach, and rectum, lymph nodes of unknown origin, adrenal gland masses, and focal liver lesions. False-positive cytopathological results and needle tract seeding are also discussed. The present Clinical Guideline describes the results of EUS-guided sampling in the different clinical settings, considers the role of this technique in patient management, and makes recommendations on circumstances that warrant its use. A two-page executive summary of evidence statements and recommendations is provided. A separate Technical Guideline describes the general technique of EUS-guided sampling, particular techniques to maximize the diagnostic yield depending on the nature of the target lesion, and sample processing. The target readership for the Clinical Guideline mostly includes gastroenterologists, oncologists, internists, and surgeons while the Technical Guideline should be most useful to endoscopists who perform EUS-guided sampling.     

Preoperative evaluation of periampullary tumors by endoscopic sonography, transabdominal sonography, and computed tomography.

PURPOSE: The purpose of this retrospective study was to compare the sensitivity of endoscopic sonography (EUS), transabdominal sonography (US), and CT in the detection of, local staging of, and prediction of vascular involvement by or distant metastasis from periampullary tumors. METHODS: Seventy-four consecutive patients with presumed periampullary tumors were evaluated by EUS, US, and CT during a 3.25-year period. The local staging accuracy of the modalities was assessed in the 36 patients with solid tumors who underwent surgery. The sensitivity of the modalities in predicting vascular involvement and distant metastasis was assessed in the 56 patients with carcinomas. RESULTS: EUS was the most sensitive modality in the detection (EUS, 97%; US, 24%; and CT, 39%; p < 0.001 for EUS versus US or CT) and T classification (EUS, 72%; US, 11%; CT, 22%; p < 0.001 for EUS versus US or CT) of periampullary tumors. EUS also had better sensitivity than US in detecting lymph node metastasis from periampullary cancers (EUS, 47%; US, 7%; and CT, 33%; p = 0.02 for EUS versus US; p = 0.7 for EUS versus CT). The accuracy of EUS in determining the T classification (without stent, 81%; with stent, 65%) and N classification (without stent, 80%; with stent, 70%) tended to decrease in the presence of an endobiliary stent, but the differences were not significant. EUS was the most sensitive modality in demonstrating vascular involvement (EUS, 100%; US, 0%; and CT, 33%; p = 0.002 for EUS versus US; p = 0.03 for EUS versus CT) but was not significantly different in detecting distant metastasis (EUS, 11%; US, 44%; and CT, 44%). CONCLUSIONS: EUS is superior to US and CT in the local assessment of periampullary tumors. The staging accuracy of EUS is minimally but not significantly affected by the presence of an endobiliary stent.     

胸腔镜手术与开胸手术在胸段食管癌患者淋巴结清扫中的对比

目的探讨胸腔镜手术与开胸手术下胸段食管癌患者的淋巴结清扫状况。方法选取2012年8月-2015年6月在该院接受胸腔镜手术治疗的胸段食管癌患者16例(微创组),选取同期经传统开胸手术的相同病理分期的胸段食管癌患者17例(传统组),比较两组患者清扫淋巴结数、阳性率及淋巴结转移情况。结果微创组16例,清扫淋巴结总数228枚,均数(14.27±5.61)枚,阳性率为12.50%;传统组17例,清扫淋巴结总数241枚,均数(16.20±6.24)枚,阳性率为11.76%。两组不同病理分期患者淋巴结清扫数差异无统计学意义(P0.05)。微创组转移淋巴结例数7例,转移淋巴结45枚,转移率为43.75%,转移度为19.74%;传统组转移淋巴结例数8例,转移淋巴结55枚,转移率为47.06%,转移度为22.82%。结论微创手术能够取得与传统开胸手术一致的淋巴结清扫效果,在胸段食管癌的临床治疗方面具有较高可操作性。     

EUS-guided fine needle biopsy: minimally invasive access to metastatic or recurrent cancer.

OBJECTIVE: Endoscopic ultrasound (EUS) is a sensitive technique for preoperative staging of gastrointestinal tumors. However, the value of this technique in the diagnosis of metastatic or recurrent disease is limited by the inability to differentiate malignant and benign lesions. We have prospectively investigated the role of EUS-guided biopsy in the evaluation of peri-intestinal tumors. METHODS: EUS-guided biopsy was performed in 167 patients with thoracic, intra-abdominal or pelvic lesions. The upper gastrointestinal tract was examined with a flexible echoendoscope equipped with a 7.5 MHz curved array transducer. For transrectal EUS a rigid endoprobe with a bifocal multiplane transducer (10 MHz) was used. Both instruments allowed to observe the biopsy procedure exactly in the longitudinal scan plane. RESULTS: Real time ultrasonography guidance of the biopsy needle enabled precise tissue sampling even of small lesions with a diameter of 1 cm. Overall EUS-guided fine needle biopsy yielded tissue samples for histopathologic or cytologic analysis in of 151 of 167 patients. Histology demonstrated benign lesions in 71 of 74 patients and malignant tumors in 68 of 93 patients. EUS-guided fine needle biopsy failed to provide the correct diagnosis in 28 cases. The overall sensitivity and specificity of EUS-guided biopsy in the diagnosis of malignancy were 73 and 96%, respectively. The histopathological results changed the clinical and endosonographic diagnosis in 49 patients. No complications were observed related to the biopsy. CONCLUSIONS: EUS-guided needle biopsy is a safe and efficient method for tissue sampling of peri-intestinal lesions. This minimally invasive technique provides adequate biopsies and improves the diagnostic value of endoscopic ultrasonography considerably.     

内镜超声结合E-钙粘素和CD44v6检查在食管癌诊断中的价值

目的　探讨术前内镜超声检查 (EUS)及E -钙粘素 (E -CD)、CD4 4v6表达在食管癌术前分期诊断中的价值。方法　对 5 8例食管鳞癌患者术后标本应用SP法检测E -CD和CD4 4v6的表达 ,对其中 30例食管鳞癌患者术前进行了EUS。结果　EUS诊断食管鳞癌术前TNM分期与术后病理分期对照 ,其T期总的准确率为 83% ,N期总的准确率为 77%。E -CD、CD4 4v6阳性表达率与食管鳞癌患者肿瘤细胞浸润深度、淋巴结转移显著有关 (P <0 .0 1) ,与食管癌患者临床分期有关 (P <13.0 5 )。但在食管鳞癌原发灶中E -CD和CD4 4v6表达无相关性 (P >0 .0 5 )。食管癌患者中UESTN分期与E -CD、CD4 4v6阳性表达率显著相关 (P<0 .0 1)。结论　E -CD和CD4 4v6均可反映食管癌生物学行为的指标 ,将两种细胞粘附分子的检测与EUS结合起来 ,能更准确地对食管癌患者进行TNM分期。     

Endoscopic ultrasonography in patients with gastro-esophageal cancer.

For patients with gastro-esophageal cancer ultrasonography (EUS) is superior to any other imaging modality in the assessment of local tumor infiltration and local lymph nodes status. EUS is especially important in the preoperative staging of patients with esophageal cancer and patients with proximal gastric cancer. Here it allows for the identification of those patients with advanced disease who are unlikely to benefit from surgery and in whom a conservative palliative treatment is indicated. In advanced gastric cancer the clinical implications of EUS less clear. Still preoperative EUS is indicated in every patient with cancer of the proximal stomach to assess tumor infiltration in the esophagus. Relatively new is the use of EUS in staging early cancers in order to select patients for local endoscopic treatment. High-frequency miniprobes are the instruments of choice for imaging these lesions. Strict criteria should be applied in the selection of patients for local endoscopic treatment of early gastro-esophageal cancers. EUS guided fine needle aspiration (EUS-FNA) is currently only indicated in patients with esophageal cancer and suspicious celiac lymph nodes. It may become more important if new treatment protocols demand more objective and reliable assessment of lymph node status.     

超声内镜在食管结核诊断中的9例应用并文献复习

目的总结食管结核超声内镜(EUS)声像图特征及其他临床资料结果,提高该病的诊断率。方法回顾性分析该院2011年6月-2016年5月经EUS检查或内镜超声引导下细针穿刺活检(EUS-FNA)而确诊为食管结核的9例患者的临床资料,并复习国内外文献。结果 9例患者中,表现为吞咽梗阻6例,胸骨后疼痛3例,伴有盗汗、低热症状2例,伴咳嗽、咯血1例,伴咽痛1例;病变位于食管中段7例(77.78%),上段1例,食管下段合并咽部病变1例;8例为隆起型病变,其中4例表面破溃,1例呈息肉样隆起,另1例为溃疡并憩室型病变;内镜下活检6例中5例确诊,其中3例活检2次;EUS表现为食管壁内不均质低回声占位,边界模糊,内见高回声光斑,侵及黏膜下层或全层,部分病灶突破外膜层与壁外肿大淋巴结融合贯通;2例行EUS-FNA穿刺,病理发现炎性肉芽肿,考虑结核;均予以抗结核治疗后症状缓解。结论食管结核临床表现主要为吞咽困难,好发于食管中段,内镜下表现主要为隆起型和溃疡型病变,通过多次内镜下活检,结合EUS特征或EUS-FNA穿刺病理学检查能明显提高该病的诊断率,减少误诊率。     

Influence of tumor characteristics on the accuracy of endoscopic ultrasonography in staging cancer of the esophagus and esophagogastric junction

BACKGROUND AND STUDY AIMS: Endoscopic ultrasonography (EUS) is the most accurate method of assessing the locoregional extent of cancer of the esophagus and esophagogastric junction. The aim of this study was to evaluate the influence of tumor-related factors such as length and location on the accuracy of EUS in staging these tumors. PATIENTS AND METHODS: Between January 1997 and September 2002, 280 consecutive patients underwent preoperative EUS for staging cancer of the esophagus and esophagogastric junction. The influence of histopathology, the presence of Barrett's dysplasia or stenosis, and the location and length of the primary tumor on the accuracy of EUS for T, N, and M staging were studied. RESULTS: The overall accuracy rates of EUS for assessing the T, N, and M stages were 73 %, 80 %, and 78 %, respectively. The influence of the tumor's histopathology and the presence of Barrett's dysplasia or stenosis was minimal. The accuracy of EUS was greater in tumors 5 cm or less in size than in tumors larger than 5 cm (82 % vs. 52 % for the T stage, P < 0.05; 88 % vs. 59 % for the N stage, P < 0.05; and 92 % vs. 56 % for the M stage, P < 0.001). The low accuracy of T staging in larger tumors may be due to the exclusion of patients with local unresectability or distant metastases. EUS was also significantly better in esophageal tumors, particularly for identifying celiac trunk metastases (93 % vs. 63 %; P < 0.001). CONCLUSIONS: The accuracy of EUS for staging esophageal cancer is lower in tumors larger than 5 cm and in esophagogastric junction tumors than in tumors 5 cm in size or less and in esophageal tumors. These findings should be considered when treatment decisions are being taken.     

MSCT引导TBNA联合LCT技术在诊断纵隔淋巴结肿大中的应用研究

目的探讨胸部CT影像学(MSCT)引导经支气管针吸活检术(TBNA)联合液基细胞学(LCT)技术在诊断纵隔淋巴结肿大中的应用价值。方法回顾性分析2011年8月～2015年4月间在宝鸡市中心医院224例行胸部CT检查发现纵隔淋巴结肿大病例,均行TBNA检查,总结穿刺结果,评价该技术的诊断价值和安全性。结果①224例患者经TBNA检查7个部位共394组淋巴结,TBNA穿刺成功788针(96.10%)。②190例恶性肿瘤患者中,TBNA结果阳性180例(94.74%),其中64例患者TBNA结果是惟一病理学依据。③44例TBNA阴性患者中,除12例经过TBNA确诊为结节病外,其余经开胸手术确诊,2例为淋巴瘤,8例为纵隔淋巴结转移癌,22例阴性。在纵隔淋巴结肿大诊断中敏感度、特异度和准确度分别为94.76%,100%和95.54%。④64例患者行肺癌根治术,以术后淋巴结病理结果为参考,TBNA判断肺癌纵隔淋巴结分期诊断的敏感度、特异度、准确度、阳性预测值和阴性预测值分别是96.05%,100%,96.51%,100%,76.92%。⑤小细胞肺癌TBNA的阳性率高于非小细胞肺癌,差异有统计学意义(χ2值为10.24,P＜0.01)。直径≥3　cm淋巴结TBNA的阳性率稍高于＜3 cm淋巴结,差异无统计学意义(χ2值为1.72,P＞0.05)。结论MSCT引导TBNA联合LCT技术在诊断纵隔淋巴结肿大中敏感度、准确度等均大大提高,且安全易行,值得基层医院临床推广应用。     

食管鳞癌新辅助化疗前后淋巴结CT表现及其预测术后pN分期的价值

目的 观察新辅助化疗（NACT）前后食管鳞癌淋巴结CT表现，并分析其预测术后pN分期的效能。方法 回顾性分析124例经胃镜活检病理确诊食管鳞癌并接受NACT患者化疗前后CT资料。比较NACT前后淋巴结总数、最大长/短径、长/短径均值、长/短径变异系数（CV），绘制NACT前后不同大小淋巴结所占比例分布图。应用受试者工作特征（ROC）曲线方法分析不同淋巴结径线标准下阳性淋巴结数目预测食管鳞癌术后pN分期的效能。结果 食管鳞癌NACT前后淋巴结总数、最大长/短径、长/短径均值差异均有统计学意义（P均<0.01），而淋巴结长/短径CV差异均无统计学意义（P均>0.05）。NACT前后不同大小淋巴结分布比例无明显变化。ROC曲线结果显示，以NACT前后不同径线为标准判断阳性淋巴结数目预测术后pN分期的曲线下面积（AUC）为0.65~0.71。结论 NACT前后食管鳞癌患者淋巴结CT表现存在一定差异；针对不同径线淋巴结采用相应标准判断的阳性淋巴结数目有助于预测术后pN分期。     

Early morbidity of endoscopic ultrasound: 13 years' experience at a referral center

BACKGROUND AND STUDY AIM: Endoscopic ultrasonography (EUS) now has an important place in the diagnosis of gastroenteropancreatic diseases. However, prospective data on the morbidity and mortality related to its use are sparse and often retrospective. We attempted to assess the acute and immediate complications of both diagnostic and interventional EUS. PATIENTS AND METHODS: At our university-affiliated tertiary care referral center, immediate (occurring during the procedure) and acute (occurring within 24 hours) complications of EUS were prospectively investigated. Over a first period, spanning 10 years, complications of diagnostic EUS involving 3207 consecutive patients were assessed. During the second period of 3 years, complications observed after EUS-guided fine-needle aspiration (FNA) biopsy were evaluated from 224 procedures. EUS was mostly done with the patient under sedation with intravenous propofol and spontaneous ventilation, and complications were evaluated by both the operator and the anesthesiologist. RESULTS: There were no deaths, and no surgery was required over the two periods of assessment. Three mild complications occurred among patients who underwent standard diagnostic EUS: two immediate complications were related to anesthesia and one to the procedure. There were five complications associated with interventional EUS; all were related to the procedure (acute pancreatitis, duodenal perforation, upper digestive bleeding, cyst, and mediastinal infection), with a mean delay of occurrence of 30 hours, and mean duration of hospitalization of 7 days. CONCLUSION: In our experience, which is the longest reported in Europe, the morbidity rates of diagnostic EUS and EUS-guided FNA biopsy were 0.093% and 2.2%, respectively, with no mortality.     

Endoscopic ultrasonography.

Over the past two decades, endoscopic ultrasonography (EUS) has undergone a transition from being a novel imaging technique to a clinical diagnostic test that is necessary for the optimal management of gastrointestinal diseases. EUS has established itself as an important diagnostic modality, mainly for the detection and staging of gastrointestinal cancers. As EUS has become more widespread, research has gradually shifted towards studies that explore the effect of EUS on patient management and outcome. These outcome studies have examined the primary clinical applications of EUS, such as esophageal, gastric, pancreatic, and colorectal cancer staging, as well as the role of EUS in the diagnosis of inflammatory pancreatic diseases. Widespread use of EUS has recently led to studies that examine complications associated with the performance of the procedure. Endosonographers have continued efforts to define a clinical role for EUS in other gastrointestinal diseases, such as portal hypertension. EUS-guided fine-needle aspiration (FNA) is continuing to develop into a powerful diagnostic tool for the management of lung cancer and other mediastinal diseases. New applications for EUS-FNA are also emerging. Finally, investigators are continuing to explore the remaining frontier of EUS-guided therapy.     

Comparison of Positron Emission Tomography, Computed Tomography, and Endoscopic Ultrasound in the Initial Staging of Patients with Esophageal Cancer

Introduction Improvement in esophageal cancer staging is needed. Positron emission tomography (PET), computed tomography (CT), and endoscopic ultrasound (EUS) in the staging of esophageal carcinoma were compared. Methods PET, CT, and EUS were performed and interpreted prospectively in 75 patients with newly diagnosed esophageal cancer. Either tissue confirmation or fine needle aspiration (FNA) was used as the gold standard of disease. Sensitivity and specificity for tumor, nodal, and metastatic (TNM) disease for each test were determined. TNM categorizations from each test were used to assign patients to subgroups corresponding to the three treatment plans that patients could theoretically receive, and these were then compared. Results Local tumor staging (T) was done correctly by CT and PET in 42% and by EUS in 71% of patients (P value > 0.14). The sensitivity and specificity for nodal involvement (N) by modality were 84% and 67% for CT, 86% and 67% for EUS, and 82% and 60% for PET (P value > 0.38). The sensitivity and specificity for distant metastasis were 81% and 82% for CT, 73% and 86% for EUS, and 81% and 91% for PET (P value > 0.25). Treatment assignment was done correctly by CT in 65%, by EUS in 75%, and by PET in 70% of patients (P value > 0.34). Conclusions EUS had superior T staging ability over PET and CT in our study group. The tests showed similar performance in nodal staging and there was a trend toward improved distant disease staging with CT or PET over EUS. Assignment to treatment groups in relation to TNM staging tended to be better by EUS. Each test contributed unique patient staging information on an individual basis. This work was presented in part at The Society of Nuclear Medicine Annual Meeting, Los Angeles, CA June 15–19, 2002.     

High rate of lymph-node metastasis in submucosal esophageal squamous-cell carcinomas and adenocarcinomas

BACKGROUND AND STUDY AIMS: The application of endoscopic mucosectomy in early esophageal cancer is limited by the presence of lymph-node metastasis. The aim of this prospective study was to analyze the rate of lymph-node involvement relative to the depth of mucosal or submucosal tumor penetration, comparing squamous-cell carcinomas and adenocarcinomas. PATIENTS AND METHODS: A total of 60 patients with pT1 esophageal cancer--24 with squamous-cell carcinomas (SCCs) and 36 with adenocarcinomas--were treated with transthoracic en-bloc esophagectomy with two-field lymphadenectomy (n = 50) or transhiatal esophageal resection (n = 10). An average of 30 lymph nodes were examined, and the following characteristics were evaluated: histology, mucosal infiltration, depth of submucosal wall infiltration in three thirds (sm1, sm2, sm3), grading, resection category, ratio of metastatic to resected lymph nodes, and locations of metastatic nodes. RESULTS: The rates of lymph-node metastasis were 0% for the 16 mucosal carcinomas and 45% for the 44 submucosal carcinomas (P < 0.01). There were no significant differences in the extent of lymph-node involvement between submucosal adenocarcinomas (41%) and submucosal SCCs (50%). Sm1 carcinomas were associated with a lower rate of lymph-node metastasis (SCCs 33%, adenocarcinomas 22%) than sm3 carcinomas (SCCs 69%, adenocarcinomas 78%). Two patients (9%) with submucosal SCCs and five patients (23%) with submucosal adenocarcinomas were classified as having stage pM1 lymph. The average lymph-node ratio in patients with pN1 was 0.13 for adenocarcinomas and 0.1 for SCCs (difference not significant). In the multivariate analysis, the parameters mucosal vs. submucosal (P < 0.01) and G1/G2 vs. G3 (P < 0.05) showed a significant impact in relation to metastatic lymph nodes. CONCLUSIONS: The most important factor for predicting lymph-node metastasis in early esophageal cancer is the presence of submucosal infiltration. Early adenocarcinomas and SCCs do not differ with regard to their rate of lymphatic involvement. The rate of lymph-node metastasis increases with the depth of submucosal infiltration, but metastases can already occur in sm1 lesions. Submucosal infiltration is a contraindication for endoscopic mucosectomy. Limited surgical procedures without adequate lymphadenectomy do not appear to be appropriate in the treatment of patients with submucosal esophageal carcinomas.