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。     

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.     

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.     

Impact of lymph node staging on therapy of esophageal carcinoma

BACKGROUND & AIMS: Therapy of esophageal carcinoma is stage dependent. The role of EUS-guided fine-needle aspiration (EUS FNA) in this setting is unclear. The aims of this study were to compare the performance characteristics of CT, EUS, and EUS FNA for preoperative nodal staging of esophageal carcinoma and to measure the impact of each staging test on treatment decisions. METHODS: From December 1999 to March 2001, all patients with esophageal carcinoma seen at the Mayo Clinic Rochester were prospectively evaluated with CT, EUS, and EUS FNA. The impact of tumor stage on final therapy was assessed. RESULTS: A total of 125 patients with esophageal carcinoma were enrolled. EUS FNA was more sensitive (83% vs. 29%; P < 0.001) than CT and more accurate than CT (87% vs. 51%; P < 0.001) or EUS (87% vs. 74%; P = 0.012) for nodal staging. Direct surgical resection was contraindicated in 77% of patients evaluated due to advanced locoregional/metastatic disease. Tumor location, patient age, comorbidities, and tumor stage determined by CT, EUS, and EUS FNA were associated with treatment decisions (P < 0.05). EUS FNA resulting in a higher/worse stage than CT (41 patients) was associated with a greater rate of treatments that were not direct surgeries compared with cases in which the stage was the same or better. CONCLUSIONS: EUS FNA is more accurate for nodal staging and impacts on therapy of patients with esophageal carcinoma. EUS FNA should be included in the preoperative staging algorithm of these patients.     

The utility of EUS and EUS-guided fine needle aspiration in detecting celiac lymph node metastasis in patients with esophageal cancer: a single-center experience.

BACKGROUND: The aims of this study were to determine the utility of EUS and EUS-guided fine needle aspiration (EUS-FNA) in the detection and confirmation of celiac lymph node metastasis in patients with esophageal cancer and to define EUS features predictive of celiac lymph node metastasis in these patients. METHODS: The records of 211 patients with esophageal cancer who underwent EUS staging were reviewed. The operating characteristics of EUS were determined in patients where either surgery, EUS-FNA of a celiac lymph node, or both were performed (n = 102). The association between selected variables and the presence of celiac lymph node metastasis was evaluated by univariate and multivariable analyses. RESULTS: EUS in 48 patients provided a true-positive diagnosis of celiac lymph node involvement, a false-positive and false-negative result, respectively, in 6 and 14 patients, and a true-negative diagnosis in 34 patients. The sensitivity of EUS in detecting celiac lymph node was 77% (95% CI [67, 88]), specificity 85% (95% CI [74, 96]), negative predictive value 71% (95% CI [58, 84]), and the positive predictive value 89% (95% CI [81, 97]). EUS-FNA was performed in 94% (51/54) of patients with celiac lymph nodes. The accuracy of EUS-FNA in detecting malignant celiac lymph nodes was 98% (95% CI [90, 100]). Advanced T-stage, the need for dilation, detection of peritumoral lymph nodes, and black race were associated with celiac lymph node involvement. In multivariable analysis, advanced T-stage was the strongest predictor of celiac lymph node involvement. CONCLUSION: EUS and EUS-FNA are highly accurate in detecting and confirming celiac lymph nodes metastasis. Depth of tumor invasion as assessed by EUS is a strong predictor of celiac lymph node metastasis in patients with esophageal cancer.     

Evaluation of metastatic celiac axis lymph nodes in patients with esophageal carcinoma: accuracy of EUS.

BACKGROUND: Endosonography (EUS) is the most accurate modality for assessing depth of tumor invasion and local lymph node metastasis. However, its accuracy in the identification of metastatic (celiac axis) lymph nodes is less well defined. Our objective in this study was to determine the accuracy of Eus in detecting celiac axis lymph node metastasis in patients with esophageal carcinoma. METHODS: Two hundred fourteen patients with esophageal carcinoma underwent preoperative EUS. Of these, 145 underwent attempted surgical resection and staging, and 4 underwent EUS-guided fine-needle aspiration of mediastinal and celiac lymph nodes. Local (mediastinal) and distant (celiac axis) lymph nodes were assessed for malignancy on the basis of four criteria (larger than 1 cm, round, homogeneous echo pattern, sharp borders). Accuracy of EUS was determined by means of correlating histopathologic findings for the resected lymph nodes or results of EUS-guided fine-needle aspiration cytologic examination. RESULTS: Surgical exploration (n = 145) and fine-needle aspiration cytologic examination (n = 4) revealed metastatic celiac axis lymph nodes in 23 and metastatic mediastinal (local) lymph nodes in 93 of 149 patients with esophageal carcinoma. According to defined criteria for malignant lymph nodes, there were 19 true-positive and 4 falsenegative results. Sensitivity for the diagnosis of celiac lymph node metastasis with EUS was 83% with a 98% specificity. For the diagnosis of mediastinal lymph node metastasis, sensitivity was 79% and specificity was 63%. All patients with malignant celiac axis lymph nodes had local T3 (tumor breaching adventitia) or T4 (tumor invading adjacent organs) disease. CONCLUSION: EUS is an excellent modality in the evaluation of metastatic celiac axis lymph nodes in patients with esophageal carcinoma. These findings should be used in selecting options for treatment. Sensitivity for detecting malignancy is consistent with that of prior studies, and local and regional lymph nodes and specificity is significantly higher.     

EUS-guided FNA of regional lymph nodes in patients with unresectable hilar cholangiocarcinoma

BACKGROUND: The clinical impact of EUS-guided FNA (EUS-FNA) in regional lymph-node staging in patients with unresectable hilar cholangiocarcinoma before liver transplantation has yet to be determined. OBJECTIVES: To determine the frequency of regional lymph-node detection, identify EUS features predictive of benign or malignant lymph nodes, compare EUS lymph-node detection rates to CT/magnetic resonance imaging and exploratory laparotomy, and evaluate the impact of EUS-FNA on patient selection for liver transplantation. DESIGN: Retrospective case series. SETTING: Tertiary referral EUS unit. PATIENTS: Clinical, radiographic, EUS, cytologic, and surgical data of 47 patients with unresectable hilar cholangiocarcinoma before liver transplantation were evaluated. INTERVENTIONS: EUS-FNA. MAIN OUTCOME MEASUREMENTS: Lymph-node morphology and echo features. RESULTS: EUS identified lymph nodes in all patients. FNA of 70 lymph nodes identified metastases in 9 nodes of 8 patients (17%), who were then precluded from transplantation before a staging laparotomy. Identified lymph nodes, irrespective of malignant involvement, were typically oval and geographic in shape, of mixed echogenicity, with a hypoechoic border. There were no morphologic criteria or echo features to correlate with nodal malignancy. The EUS finding of absent regional lymph-node metastases was confirmed in 20 of 22 by a subsequent exploratory staging laparotomy. LIMITATIONS: Single institution, retrospective analysis. CONCLUSIONS: EUS identified lymph nodes in all patients, and confirmation of malignant lymph nodes detected by FNA precluded 17% of patients from transplantation. EUS-FNA of visualized lymph nodes irrespective of appearance is advised because morphology and echo features do not predict malignant involvement.     

EUS-guided fine needle aspiration in mediastinal lymphadenopathy of unknown etiology

BACKGROUND: EUS-guided fine needle aspiration (EUS-FNA) has significantly expanded the diagnostic capability of GI EUS. FNA technology can also be helpful in the diagnosis of non-GI disorders. The role of EUS-guided FNA in the diagnosis of mediastinal lymphadenopathy of unknown etiology has not been described. The aim of this study was to evaluate the diagnostic accuracy and impact on subsequent evaluation and therapy of EUS-FNA in mediastinal lymphadenopathy of unknown cause. METHODS: Sixty-two patients (40 men, 22 woman; mean age 56 years, range 16-91 years) with mediastinal lymphadenopathy of unknown etiology underwent EUS-FNA at 6 tertiary referral centers. Presenting symptoms included the following: dysphagia, 6 patients; night sweats, 14; cough, 8; chest pain, 10; odynophagia, 10; fever, 6; weight loss, 8; and asymptomatic/abnormal radiograph, 12. A final diagnosis by EUS-FNA, surgery, autopsy, or long-term follow-up was available for all patients. EUS-FNA results were classified under 3 disease categories: (1) benign/infectious; (2) malignant pulmonary; and (3) malignant mediastinal (e.g., lymphoma, metastatic malignancy). Four EUS features were used as criteria for lymph node metastases: size greater than 1 cm, round shape, sharp border, and homogeneous/hypoechoic echo pattern. RESULTS: Final diagnoses included benign/infectious lymph nodes, 26; malignant pulmonary, 24; and malignant mediastinal, 12. EUS-FNA established a tissue diagnosis in 56 of 62 patients (90%). EUS criteria for malignant lymph nodes were more frequently present in malignant pulmonary (mean 2.6 features) and malignant mediastinal (mean 2.8) than benign/infectious (mean 1.9) lymph nodes. EUS results influenced subsequent evaluation in 87% and therapy in 87% of patients. There was no complication of EUS-FNA. CONCLUSIONS: EUS-FNA in patients with mediastinal lymphadenopathy is safe and guides subsequent therapy in the great majority of cases. Transesophageal EUS-FNA of mediastinal lymph nodes provides minimally invasive tissue sampling, obviating the need for mediastinoscopy or bronchoscopy.     

The impact of endoscopic ultrasonography with fine needle aspiration (EUS‐FNA) on esophageal cancer staging: a survey of thoracic surgeons and gastroenterologists

SUMMARY. Accurate staging of esophageal cancer is critical to achieving optimal treatment outcomes. End‐oscopic ultrasound with fine needle aspiration (EUS‐FNA) has emerged as a valuable tool for locoregional staging. However, it is unclear how different physician specialties perceive the benefit of EUS‐FNA for esophageal cancer staging, and thus utilize this modality in clinical practice. A survey regarding utilization of EUS‐FNA in esophageal cancer was distributed to 211 thoracic surgeons and 251 EUS‐capable gastroenterologists. Seventy‐six thoracic surgeons (36%) and 78 gastroenterologists (31%) responded to the survey. Most surgeons (75%) use EUS to stage potentially resectable esophageal cancer 75% of the time. Surgeons using EUS less often are less likely to have access to high‐quality EUS services than their peers. Fewer surgeons believe EUS is the most accurate test for T and N‐staging (84% and 71%, respectively) as compared with gastroenterologists (97% and 96%, P < 0.01 for both). Most endosonographers (68%) decide whether to dilate a malignant esophageal stricture to complete the staging exam on a case‐by‐case basis. Surgeons disagree as to whether involvement of celiac lymph nodes should preclude esophagectomy in distal esophageal cancer. While most thoracic surgeons have embraced EUS‐FNA as the most accurate locoregional staging modality in esophageal cancer, this attitude is not fully reflected in utilization patterns due to a lack of quality EUS services in some centers. Controversial areas that warrant further study include dilation of malignant strictures to facilitate EUS staging, and the implication of involved celiac lymph nodes on management.     

Malignant mediastinal lymphadenopathy detected by staging EUS in patients with pancreaticobiliary cancer

BACKGROUND: In patients with pancreatic cancer, the presence of malignant mediastinal lymphadenopathy (MML) would preclude definitive resection. A recent study suggested routine evaluation for mediastinal lymph-node metastases in all patients being evaluated for pancreaticobiliary masses. In our practice, we routinely assess for mediastinal lymph-node metastases in all patients undergoing EUS for pancreaticobiliary cancer. METHODS: We retrospectively evaluated the presence of MML by EUS-guided FNA (EUS-FNA) in 160 consecutive patients with a definite diagnosis of pancreaticobiliary cancer (pancreatic and periampullary cancers) who underwent EUS-FNA by a single operator from 2000 to 2004. Lymph nodes that were round and hypoechoic with sharp margins were considered suspicious and were sampled by FNA. RESULTS: Of the 160 patients included in this study, 78 had peripancreatic lymph nodes (49%: 95% CI[41%, 58%]), 25 had celiac lymph nodes (16%: 95% CI[10%, 22%]), and 14 patients had mediastinal lymph nodes (9%: 95% CI[4%, 13%]) that were suspicious for malignancy by morphologic criteria. In 8 of 14 patients with suspicious mediastinal lymph nodes, FNA documented MML in 5%: 95% CI[2%, 8%]. Only one of these 8 patients with MML had other sites of documented distant metastases by CT and/or positron emission tomography scans. However, 7 of 8 patients had locally advanced cancers. CONCLUSIONS: MML is detected by staging EUS-FNA in 5% of patients with pancreaticobiliary cancer. Because of its important implications, endosonographers should routinely assess for MML in patients who undergo staging EUS for pancreaticobiliary malignancy.     

Impact of staging transesophageal EUS on treatment and survival in patients with non-small-cell lung cancer

BACKGROUND: Transesophageal EUS-guided FNA (EUS-FNA) is safe, accurate, and cost effective in staging patients with non-small-cell lung cancer (NSCLC). However, the impact of EUS-FNA on patient survival has not been demonstrated. OBJECTIVE: To determine the impact of metastatic disease in mediastinal lymph nodes as determined by EUS staging on treatment choice and survival in patients with NSCLC. DESIGN: Retrospective analysis of prospectively collected data. SETTING: Tertiary university-based referral center. PATIENTS: Patients with biopsy-proven NSCLC who underwent staging EUS-FNA. The relationship between the EUS nodal status and patient survival was evaluated. Cox proportional hazards models were used to determine the significance of EUS nodal status and patient characteristics on patient survival. MAIN OUTCOMES MEASUREMENTS: Impact of EUS-FNA on therapy and survival in patients with NSCLC. RESULTS: Of 125 patients with NSCLC, EUS-FNA confirmed metastatic disease in 46% of the patients. Patients who were node positive were more likely to receive chemotherapy and/or radiation therapy and were less likely to undergo surgery compared with patients who were node negative (P< .0001). Patients with N2 or N3 disease by EUS-FNA had a shorter survival time than patients who were node negative (P= .004). Adjusting for age, race, and sex, EUS-FNA was the most important predictor of survival of patients with NSCLC in this cohort of patients (hazard ratio 2.34, 95% CI 1.31-4.21). LIMITATIONS: Lack of surgical reference standard in all patients and referral to a tertiary center. CONCLUSIONS: Patients with node-positive NSCLC as detected by EUS-FNA have a shorter survival time compared with patients who were node negative. They are more likely to receive neoadjuvant therapy and less likely to receive surgery. Preoperative EUS-FNA is a minimally invasive technique that provides important prognostic information in patients with NSCLC.     

EUS-guided FNA in the diagnosis of pancreatic neuroendocrine tumors before surgery

BACKGROUND: The use of EUS for precise preoperative evaluation of pancreatic neuroendocrine tumors is well established; up to 80% of insulinomas can be localized. However, the EUS appearance of pancreatic neuroendocrine tumors can be similar to that of benign peripancreatic lymph nodes. The aim of this study was to evaluate the role of EUS-guided FNA in this setting. METHODS: Thirty patients (18 women, 12 men) with 33 pancreatic/peripancreatic lesions confirmed by surgery underwent EUS-guided FNA between February 1997 and September 2002. Transabdominal US and CT were obtained in all patients before EUS. The diagnosis of pancreatic neuroendocrine tumor was established based on morphologic appearance and immunohistochemical staining of cytologic and surgical specimens. RESULTS: EUS detected 32 of the 33 (96.9%) lesions (mean diameter 20 mm, range 5-97 mm). There was one complication (abdominal pain). For the 30 patients, the following diagnoses were made: functioning pancreatic neuroendocrine tumor (16 patients), non-functioning pancreatic neuroendocrine tumor (7), peripancreatic lymph node (5), inflammatory intrapancreatic nodule (1), and peripancreatic splenosis (1). Sensitivity, specificity, positive and negative predictive values, and accuracy of EUS-guided FNA were 82.6%, 85.7%, 95%, 60%, and 83.3%, respectively. There was one false-positive diagnosis by EUS-guided FNA and 4 false-negative diagnoses. In two of the latter cases, EUS-guided FNA was unsuccessful. CONCLUSIONS: EUS-guided FNA is accurate and safe for the diagnosis of pancreatic neuroendocrine tumor and may have a role in determining management strategy.     

EUS-FNA of recurrent postoperative extraluminal and metastatic malignancy

BACKGROUND: EUS-guided FNA is safe and accurate for the diagnosis of benign or malignant neoplasia and lymphadenopathy; however, its role in the diagnosis of recurrent malignancy is not well described. METHODS: A prospectively updated EUS-guided FNA cytology database was used to identify patients in whom a diagnosis of postoperative, recurrent, extraluminal, or metastatic malignancy was made over a 5-year period. Only patients with a positive EUS-guided FNA were included in the analysis. All had undergone surgery for the primary malignancy and were in clinical and/or radiographic remission before the initial suspicion of tumor recurrence. RESULTS: Twenty-one patients underwent EUS-guided FNA of 21 lesions (19 masses, 2 lymph nodes) because of a suspicion of recurrent malignancy based on CT (n = 17) or EUS (n = 4) findings. Median time from the initial diagnosis to recurrence was 26 months (range 5-276 months). Lesions were located in the pancreas (9 patients), mediastinum (7), liver (3), perigastric region (1), and liver hilum (1). EUS-guided FNA (mean number of needle passes, 4.5; range 2-8) obtained diagnostic material for recurrent malignancy in all patients as follows: esophageal (6 patients), renal cell (6), pancreatic (2), breast (2), colon (2), bile duct (1), Ewing's sarcoma (1), and lung (1) cancer. No complication was encountered. Transgastric EUS-guided FNA (4 patients), distal, or transesophageal EUS-FNA (2) proximal to a surgical anastomosis was required to confirm recurrence in all 6 patients with esophageal cancer. The initial cytologic diagnosis of recurrent malignancy was made by EUS in 20 of 21 (95%) patients. One patient with recurrent breast cancer had CT-guided FNA of a right lung mass preceding EUS-guided FNA of an AP window lymph node. CONCLUSIONS: EUS-guided FNA can detect and safely diagnose recurrent malignancy in the mediastinum, retroperitoneum, and liver. When possible, correlation between EUS-guided FNA cytology and original tumor histopathology/cytology, or the use of immunostaining to confirm the diagnosis, is recommended.     

A cost analysis of endoscopic ultrasound in the evaluation of pancreatic head adenocarcinoma

OBJECTIVE: Endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) biopsy of nonperitumoral (NPT) lymph nodes (LN) can be helpful in preoperative staging of pancreatic head adenocarcinoma. The economic impact of this staging strategy has not yet been described. The aim of this study was to apply a decision analysis model to compare the costs of three approaches to the management of nonmetastatic pancreatic head adenocarcinoma: EUS FNA versus CT-guided FNA versus surgery. A cost minimization approach was employed, as viewed from the perspective of the payer. METHODS: A decision analysis model was designed using DATA Version 3.5, taking the entry criteria as "resectable" pancreatic head adenocarcinoma as determined by helical CT. Detection of metastatic NPT LN on FNA signified unresectability and obviated the need for surgery. Baseline probabilities were varied through plausible ranges using sensitivity analysis. Cost inputs were based on Medicare professional plus facility fees. The endpoint was cost of management per patient. RESULTS: EUS FNA was the least costly strategy ($15,938) compared with CT FNA ($16,378) and surgery ($18,723). Sensitivity analysis revealed that EUS FNA remained the least costly option provided the frequency of NPT LN involvement was >4%; below this value, surgery became the least costly. CONCLUSIONS: EUS FNA is the least costly staging strategy in the workup of patients with nonmetastatic pancreatic head adenocarcinoma primarily because of confirmation of NPT LN involvement avoiding unnecessary surgery. These results support performing EUS in patients whose tumors are thought to be resectable on helical CT to enhance NPT LN assessment.     

Prospective study of a Trucut needle for performing EUS-guided biopsy with EUS-guided FNA rescue

BACKGROUND: EUS-guided FNA (EUS-FNA) is an accurate technique for sampling extraintestinal masses and lymph nodes. The use of a Trucut needle to perform EUS-guided biopsy (EUS-TCB) may improve the results or simplify the procedure. To date, few studies have prospectively assessed the performance and the safety of EUS-TCB. METHODS: Patients with a known or a suspected malignancy referred for a diagnostic and/or staging EUS examination were enrolled in a prospective study. EUS-guided biopsy was performed first with a 19-gauge Trucut needle. If the Trucut failed to obtain an adequate sample or when the "in room" touch preparation was benign, EUS-FNA was performed with a standard 22-gauge FNA needle. The objective of the study was to assess the yield of detection of malignancy and the safety of EUS-TCB in patients with known or suspected malignancies and to investigate if EUS-FNA has a role for rescue in cases of Trucut failure. OBSERVATIONS: Thirty-nine lesions underwent EUS-TCB in 30 patients. Sufficient follow-up was available for all patients. By using EUS-TCB, we were able to obtain a sample for diagnosis in all but 3 patients (one pancreatic mass and two lymph nodes) in which technical problems arose. In these patients, the diagnosis was obtained in two cases by EUS-FNA and in the other one by EUS-TCB from the primary pancreatic tumor. The yield of detection of malignancy for EUS-TCB was 84%. No complications were recorded in any patients at 1 and 7 days of follow-up. The sample size is limited to generalize conclusions. CONCLUSIONS: EUS-TCB is a safe and an accurate procedure to obtain a histologic diagnosis in patients with known or suspected malignancies. EUS-FNA can serve as a rescue technique in cases of Trucut failure.     

Accuracy of EUS criteria and primary tumor site for identification of mediastinal lymph node metastasis from non-small-cell lung cancer

BACKGROUND: EUS with FNA is useful for staging non-small-cell lung cancer. However, benign mediastinal adenopathy is common. The aims of this study were to identify clinical factors, especially primary tumor location, and EUS lymph nodal characteristics predictive of aortopulmonary window and subcarinal lymph node metastases of non-small-cell lung cancer. METHODS: Patients with known or suspected non-small-cell lung cancer underwent EUS staging at which EUS-FNA was performed for all identified mediastinal lymph nodes. Clinical characteristics, primary tumor data, EUS findings, and histopathology were reviewed. Exact tests were performed for both aortopulmonary window and subcarinal lymph nodes to identify factors predictive of malignant cytology. RESULTS: Ninety-two patients with non-small-cell lung cancer were included. Fifty-one had aortopulmonary window, and 73 had subcarinal lymph nodes on EUS. The EUS with FNA specimens were interpreted as suspicious or diagnostic for malignancy for 9 aortopulmonary window and 9 subcarinal lymph nodes. When comparing benign vs. malignant EUS with FNA findings for aortopulmonary window and subcarinal lymph nodes, only lymph node size of 1 cm or greater and sharp lymph nodal edges were associated with malignancy in lymph nodes at both sites, whereas primary tumor site, lymph node shape, and echogenicity were associated with malignant subcarinal nodes. When 4 classic lymph nodal features of malignancy were evaluated, the presence of 3 or more typical features had positive and negative predictive values of, respectively, 41% and 96%. CONCLUSIONS: Although tumor location and EUS lymph nodal characteristics are associated with malignant involvement of lymph nodes, the accuracy of these predictors does not obviate the need for cytologic evaluation. EUS with FNA should be performed for all lymph nodes when an abnormal finding will alter management.     

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.     

Impact of endoscopic ultrasonography and physician specialty on the management of patients with esophagus cancer

SUMMARY.  While endoscopic ultrasonography (EUS) and EUS-guided fine-needle aspiration (EUS-FNA) are the most accurate techniques for locoregional staging of esophageal cancer, little evidence exists that these innovations impact on clinical care. The objective on this study was to determine the frequency with which EUS and EUS-FNA alter the management of patients with localized esophageal cancer, and assess practice variation among specialists at a tertiary care center. Three gastroenterologists, three medical oncologists, three radiation oncologists and four thoracic surgeons were asked to independently report their management recommendations as the anonymized staging information of 50 prospectively enrolled patients from another study were sequentially disclosed on-line. Compared to initial management recommendations, that were based upon history, physical examination, upper endoscopy and CT scan results, EUS prompted a change in management 24% (95% CI: 12–36%) of the time; usually to a more resource-intensive approach (71%), for example from recommending palliation to recommending neoadjuvant chemoradiation therapy. EUS-FNA plus cytology results altered management an additional 8% (95% CI: 6–15%) of the time. Agreement between specialists ranged from fair (intraclass correlation [ICC=0.32) to substantial (ICC=0.65); improving with additional information. Among specialists, agreement was greatest for patients with stage I disease. EUS and EUS-FNA changed patient management the most for patients with stages IIA, IIB or III disease. EUS, with or without FNA, significantly impacts the management of patients with localized esophageal cancer. With respect to the optimal treatment for each patient, agreement among physicians incrementally increases with endoscopic ultrasound results. Specialty training appears to influence therapeutic decision-making behavior.     

Lymph node staging in esophageal squamous cell carcinoma: A comparative study of endoscopic ultrasonography versus computed tomography

Background and Aim:  Endoscopic ultrasonography (EUS) is established as a standard approach for locoregional staging of esophageal cancer. However, only a few published studies have attempted to correlate the station of the abnormal lymph nodes detected by EUS with the definitive histology. We compared EUS and computed tomography (CT) in the initial staging of esophageal squamous cell carcinoma.
Methods:  Consecutive patients with esophageal cancer undergoing EUS were evaluated. EUS findings and patient data including histopatology were collected prospectively and analyzed retrospectively. Lymph node locations were divided into three groups; abdominal (A), paraesophageal (B), and thoracic paratracheal (C).
Results:  A total of 365 consecutive patients underwent EUS and 159 patients underwent esophagectomy without neoadjuvant chemotherapy. Thirty-eight patients were excluded (insufficient EUS, etc.), and 121 patients were enrolled. The overall accuracy of EUS was 64% (sensitivity 68%, specificity 58%, positive predictive value [PPV] 68%), CT was 51% (sensitivity 33%, specificity 75%, PPV 64%), and CT + EUS was 64% (sensitivity 74%, specificity 50%, PPV 66%). The accuracy of EUS was higher than CT in Groups A and C. Sensitivity of CT was lower than that of EUS alone and CT + EUS.
Conclusions:  This study has demonstrated that EUS is a more accurate technique than contrast-enhanced CT for detecting abnormal lymph nodes. Sensitivity of CT was lower than that of EUS alone and CT + EUS. But some metastatic lymph nodes in neck and abdominal fields are only detectable by CT. Therefore, both EUS and CT should be undertaken for routine examination prior to treatment of esophageal cancer.     

Computer-assisted analysis of lymph nodes detected by EUS in patients with esophageal carcinoma

BACKGROUND: EUS determination of lymph nodal spread of intestinal cancer based on imaging alone is problematic. A noninvasive, reliable means of determining tumor spread to lymph nodes is desirable. This study investigated the feasibility of a computer-assisted evaluation of lymph nodes detected by EUS in patients with esophageal carcinoma. METHODS: Images were obtained during EUS of esophageal lesions and correlated with histopathologic findings after esophagectomy. Sonographic features of echogenicity, whole-node heterogeneity, and regional variability were assessed by computerized image analysis in patients with benign versus malignant lymphadenopathy. RESULTS: Malignant lymph nodes were hypoechoic compared with benign lymph nodes (p < 0.04). Whole lymph node heterogeneity was increased in malignant lymph nodes (p < 0.004). Regional variability was greater for benign lymph nodes. CONCLUSIONS: These data support the feasibility of a computer-assisted system for analysis of lymph node metastasis in patients with esophageal carcinoma. Further refinements of such a system could increase the accuracy of EUS staging of tumors.