Preoperative staging of superficial esophageal carcinoma: comparison of an ultrasound probe and standard endoscopic ultrasonography

Endoscopic mucosal resection

Endoscopic mucosal resection (EMR) is a promising therapeutic option for removal of superficial carcinomas or premalignant lesions throughout the gastrointestinal tract. This review discusses indications and the several techniques of EMR in early tumors of esophagus, stomach, duodenum, and colon. EMR is not yet widely utilized in the West. However, great benefits may be obtained from this non-invasive technique after an accurate evaluation of patients and a careful staging of lesions that may assess the depth of infiltration and exclude the presence of lymph node metastases. EMR permits a complete removal of the lesion with histologic assessment of the entire specimen and the change in the pathologic stage in a significant number of patients. To minimize the risk of serious complications (mostly bleeding and perforation), only experienced endoscopists should undertake EMR in an appropriate environment. Data from literature are encouraging on the use of EMR, but a long-term follow-up of a large number of patients is necessary to confirm the effectiveness of this therapy.

The endoscopic diagnosis and staging of oesophageal adenocarcinoma

The endoscopic evaluation of patients with oesophageal adenocarcinoma does not only serve the purpose of diagnosing the lesion and obtaining biopsies for histological evaluation: a systematic description of advanced lesions is also required to guide further therapeutic decisions. New endoscopic imaging modalities hold the promise of better endoscopic detection of early cancer and its precursor lesions in Barrett's oesophagus. Video-autofluorescence and narrow band imaging are the most promising techniques in this respect. The former may be used as a 'red flag' technique, identifying lesions that remain occult with white light endoscopy; the latter may be used as a targeted imaging technique, allowing for detailed inspection of the mucosal and vascular patterns that may help to distinguish early neoplasia from non-dysplastic tissue. Currently, prototypes are under investigation that combine high-resolution endoscopy, narrow band imaging and video-autofluorescence in one endoscopy system. Endoscopic ultrasonography (EUS) is superior to any other imaging modality in the assessment of local tumour infiltration of oesophageal adenocarcinoma and locoregional lymph nodes status. EUS allows for the identification of patients with advanced disease who are unlikely to benefit from attempts at curative surgery and in whom a conservative palliative treatment is indicated. EUS may also play a role in the selection of patients for local endoscopic treatment of early oesophageal cancer. EUS guided fine needle aspiration (EUS-FNA) of locoregional lymph nodes is safe with a high sensitivity and an impeccable specificity for assessment of malignant involvement. The indications for EUS-FNA of lymph nodes, however, depend on local treatment protocols: caeliac nodes (M1a) and lymph nodes located at or above the subcarinal area are the most widely used indications. In addition, it may be important if the choice for specific treatment protocols (e.g. neoadjuvant chemoradiotherapy) depends on lymph node status.

Clinical implications of the extent of invasion of T3 esophageal cancer by endoscopic ultrasound

BACKGROUND

Endoscopic ultrasound (EUS) is an accurate imaging modality for local staging of esophageal cancer. We aimed to determine if depth of tumor invasion beyond muscularis propria (MP), as determined by preoperative EUS, is predictive of tumor recurrence or survival (a positive change in mortality) in patients with T3 esophageal cancer.

METHODS

Records and images of all patients with T3 N1 M0 esophageal cancer staged with EUS at our institution between January 1999 and October 2003 were reviewed. EUS images were independently reviewed by five blinded endosonographers and tumors were classified as minimally invasive (invasion < 3 mm beyond MP) or advanced (invasion > or = 3 mm beyond MP) T3 disease.

RESULTS

One hundred and sixty-five patients with esophageal cancer underwent EUS for staging and 39 patients with T3 N1 esophageal cancer were identified; 17 patients had minimally invasive T3 disease and 22 had advanced disease. All patients underwent neoadjuvant chemoradiation therapy followed by esophagectomy. Median follow up was 13 months. Adjusting for age and sex, minimally invasive disease was not associated with a statistically significant improvement in recurrence-free survival (hazard ratio, 1.45; 95% CI, 0.88-2.41, P = 0.14) or mortality (hazard ratio, 0.96; 95% CI: 0.49-1.78, P = 0.91).

CONCLUSIONS

The extent of invasion of T3 esophageal cancer beyond MP, as determined by EUS, is not a significant predictor of tumor recurrence or mortality.

Diagnosis of the depth of invasion of esophageal carcinoma using digital radiography

OBJECTIVE

The purpose of our investigation was to determine the usefulness of digital radiography (DR) for diagnosing the depth of invasion of esophageal carcinoma.

METHODS

We evaluated 59 patients with esophageal carcinomas who underwent DR. During continuous DR in tangential views, the most distended image of the esophagus was chosen. Percent esophageal stenosis (PES) was based on the diameter across the lesion of maximal narrowing and the average of the normal oral and anal side diameters. The maximal thickness of the tumor was measured on sequentially prepared specimens. We evaluated whether the percent of esophageal stenosis correlated with the maximal thickness of the tumor on histologic findings. Receiver-operating characteristic (ROC) curves were constructed to establish the cut-off level for PES in diagnosing the depth of tumor invasion. Accuracies for the depth of the invasion were calculated based on PES using DR. For the accuracy rate, DR was compared with endoscopy and endoscopic ultrasonography (EUS).

RESULTS

There was a close correlation between PES and pathological thickness of the tumor. PES values (mean+/-S.D.) were 2.45+/-0.75% in Tis and T1a tumors, 13.3+/-10.9% in T1b tumors, 35.2+/-11.1% in T2 tumors, 55.2+/-18.1% in T3 tumors, and 86.1+/-7.5% in T4 tumors. Using the ROC analysis, 12.5, 37.5, and 44.4% were the highest cut-off values of PES for differentiating < or =T1a, < or =T1b, and < or =T2 tumors. Regarding T staging, 45 (76%) of 59 lesions were staged correctly with EUS, whereas 47 (80%) were staged correctly with DR.

CONCLUSION

DR is useful for diagnosing the depth of the invasion because esophageal stenosis calculated using DR is an objective index of tumor infiltration. The accuracy rate of the depth of invasion with DR was as good as that of EUS.

Role of endoscopic ultrasonography in the staging and follow-up of esophageal cancer

PURPOSE

To evaluate the role of endoscopic ultrasonography (EUS) in the initial staging and follow-up of esophageal cancer on the basis of a review of the published literature.

METHODS

Articles published from 1985 to 2005 were searched and reviewed using the following keywords: "esophageal cancer staging," "endoscopic ultrasound," and "endoscopic ultrasonography."

RESULTS

For initial anatomic staging, EUS results have consistently shown more than 80% accuracy compared with surgical pathology for depth of tumor invasion (T). Accuracy increased with higher stage, and was >90% for T3 cancer. EUS results have shown accuracy in the range of 75% for initial staging of regional lymph nodes (N). EUS has been invariably more accurate than computed tomography for T and N staging. EUS is limited for staging distant metastases (M), and therefore EUS is usually performed after a body imaging modality such as computed tomography or positron emission tomography. Pathologic staging can be achieved at EUS using fine-needle aspiration (FNA) to obtain cytology from suspect Ns. FNA has had greatest efficacy in confirming celiac axis lymph node metastases with more than 90% accuracy. EUS is inaccurate for staging after radiation and chemotherapy because of inability to distinguish inflammation and fibrosis from residual cancer, but a more than 50% decrease in tumor cross-sectional area or diameter has been found to correlate with treatment response.

CONCLUSION

EUS has a central role in the initial anatomic staging of esophageal cancer because of its high accuracy in determining the extent of locoregional disease. EUS is inaccurate for staging after radiation therapy and chemotherapy, but can be useful in assessing treatment response.

Superficial Esophageal Cancer: Esophagographic Findings Correlated with Histopathologic Findings

PURPOSE

To retrospectively determine and evaluate the findings of superficial esophageal cancer at esophagography and to correlate the esophagographic findings with the depth of tumor invasion.

MATERIALS AND METHODS

The institutional review boards required neither their approval nor informed patient consent for this retrospective study. One hundred thirteen patients with superficial esophageal cancer who underwent esophagectomy at three institutions were included in this study. Double-contrast esophagograms were reviewed independently by two reviewers. For assessment of histopathologic findings, pathology reports were reviewed. Findings at esophagography, including morphologic type of the lesion, lesion extent, presence or absence of elevated or depressed component, margin and extent of elevated or depressed component, presence or absence of nodularity, extent of nodularity, esophageal luminal narrowing, and esophageal wall rigidity, were compared between mucosal and submucosal cancers by using chi2, Fisher exact, and independent-sample t tests.

RESULTS

Of 122 histopathologically proved superficial esophageal cancers in 113 patients, 100 (82%) were detected at esophagography. The most common morphologic type was the plaquelike form; 50 (50%) such lesions were depicted at esophagography. Morphologic types were significantly different between the mucosal and submucosal cancers (P < .001). Protruded and plaquelike lesions were more frequent among submucosal cancers, whereas most flat lesions were mucosal cancers. An elevated component (P < .001), a rigid esophageal wall (P < .001), and a lobulated or irregular margin of the elevated component (P = .023) were significantly more frequent among submucosal cancers. Also, total extent of the lesion (P < .001), size of the largest nodule (P < .001), and extent of nodularity (P = .036) were significantly larger in the submucosal cancers.

CONCLUSION

In the evaluation of patients with superficial esophageal cancer, esophagography appears to be helpful for diagnosing the tumor and differentiating mucosal from submucosal cancers.

Endoscopic ultrasound for luminal malignancies

Luminal gastrointestinal (GI) tract cancers are responsible for substantial morbidity and mortality. Since the first pairing of ultrasonography with endoscopy in 1980, technologic advances and the increased availability of trained endosonographers have propelled endoscopic ultrasonography (EUS) to the forefront of luminal GI cancer staging. In this article we discuss the role of EUS for evaluating luminal GI cancers.

Endoscopic ultrasound errors in esophageal cancer

BACKGROUND

Previous assessments of endoscopic ultrasound (EUS) classification of esophageal cancer are dominated by symptomatic patients with advanced stage disease. Fewer data exist on EUS errors in a cohort balanced between early and advanced disease.

PURPOSE

Assess EUS errors in classification of esophageal cancer in a more balanced cohort, and identify clinical and tumor characteristics associated with EUS errors.

METHODS

A total of 266 patients underwent EUS and esophagectomy without preoperative chemoradiotherapy. Pathologic classification of disease extent: 108 (41%) tumors were confined to the esophageal wall (pTis-pT2, pN0, pM0); 158 (59%) were advanced beyond (pT3-pT4, pN1, or pM1). Logistic regression analysis was performed to identify correlates of error in T classification and disease extent using 10 clinical and tumor characteristics (gender, age, dysphagia, weight loss, tumor length, location, traversability, morphology, histopathologic type, and histologic grade).

RESULTS

EUS erroneously predicted pathologic T (pT) in 119 patients (45%). When T classification was dichotomized into tumors whose depth of invasion was not beyond the muscularis propria (pTis-pT2) and those beyond (pT3-pT4), errors occurred in 42 patients (16%). EUS erroneously predicted N classification in 67 patients (25%), and was insensitive to the presence of distant metastases. EUS misclassified disease extent in 40 patients (15%). Logistic regression analysis indicated that weight loss and tumor length were the only clinical and tumor characteristics correlated with EUS errors; more weight loss was associated with decreased odds of misclassification, while the odds of misclassification were four to six times greater for intermediate length tumors than for shorter tumors.

CONCLUSIONS

EUS errors, particularly in predicting pT, are more frequent than previously reported. Weight loss and tumor length are the only clinical and tumor characteristics correlated with EUS errors.

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

Initial treatment of locally advanced esophageal and gastroesophageal junction (GEJ) malignancies for selected patients at some institutions has recently changed from surgical resection to neoadjuvant therapy. The aim of this study is to evaluate the impact of this change in treatment strategy on both the overall disease profile and locoregional endoscopic ultrasound (EUS) staging accuracy for a cohort of patients managed with primary surgical resection over a 10-year period at our institution. All subjects at our institution who underwent primary esophagectomy from 1993 to 2002 following preoperative EUS for known or suspected esophageal and/or GEJ cancers were identified. Patients with dysplasia alone, prior upper gastrointestinal tract surgery, preoperative neoadjuvant therapy, cancer of the gastric cardia or recurrent malignancy were excluded. EUS findings and staging results were compared to surgical pathology following resection. The impact of the gradually increased use of primary chemoradiation during the second half of the study was assessed. Of the 286 operations performed, 184 subjects were excluded. The remaining 102 underwent primary surgical resection a median of 18 days following EUS staging for adenocarcinoma (88%) or squamous cell carcinoma (12%) of the esophagus (69%) or GEJ (31%). Overall EUS locoregional T and N staging accuracy was 72% and 75% respectively; accuracy for T1, T2, T3 and T4 cancer was 42%, 50%, 88% and 50% respectively. Despite an increased frequency of pathologically confirmed T1 and T2 cancers (P = 0.005) and an insignificant trend toward increased N0 malignancy (P = 0.05) during the second half of the study period, no statistically significant changes in T (P = 0.07) or N (P = 0.82) staging accuracies for EUS or disease characteristics were noted between the first and second half of the study period. Despite both inaccurate radial EUS staging and increased relative use of primary surgery for early cancers, recent increased use of primary neoadjuvant therapy did not change overall disease characteristics and accuracy of locoregional EUS staging of esophageal and GEJ cancers managed with primary surgical resection.

Endosonographic and histopathological staging of extrahepatic bile duct cancer: time to leave the present TNM-classification?

OBJECTIVES

The discrepancy between high rates of sensitivity, specificity, and accuracy for intraductal ultrasonography (IDUS) in extrahepatic bile duct carcinoma and the failure to depict different wall layers as defined by the TNM classification have not yet been elucidated sufficiently.

METHODS

In a prospective study, endosonographic images were correlated with histomorphology including immunohistochemistry. Using IDUS, we examined fresh resection specimens of patients who had undergone pancreato-duodenectomy. For histological analysis, the formalin-fixed and paraffin-embedded specimens were stained by hematoxylin-eosin, elastica-van-Gieson, and immunohistochemically by smooth muscle-actin. To confirm our hypothesis, further cases from the archives were analyzed histopathologically and immunohistochemically.

RESULTS

The various wall layers of the extrahepatic bile duct as described by the International Union Against Cancer are neither histomorphologically nor immunohistochemically consistently demonstrable. Especially, a clear differentiation between tumor invasion beyond the wall of the bile duct (T2) and invasion of the pancreas (T3) by histopathological means is often not possible. Endosonographic images using high-resolution miniprobes similarly confirm the difficulty in imaging various layers in the bile duct wall.

CONCLUSIONS

Most adaptations made by the sixth edition of the TNM classification accommodate to the endosonographic and most of the histopathological findings as demonstrated in our study. In contrast to the new edition, however, our findings suggest to combine T2- and T3-staged tumors into one single class leading to clarification, and improved reproducibility of histopathological staging.

Prospective evaluation of a jelly-like conducting medium for catheter US probe imaging of esophageal and duodenal lesions

BACKGROUND

The catheter probe EUS(C-EUS) relies on luminal water for acoustic coupling. However, in tubular structures, such as the esophagus and the duodenum, instilled water drains away rapidly. The use of water-filled balloons is limited by air artifact and other problems. This study evaluated the image quality, the penetration depth, the tumor staging accuracy, and the safety of C-EUS by using carboxymethylcellulose, an edible, nontoxic, transparent jelly-like substance (JC-EUS).

METHODS

Forty patients with an esophageal or a duodenal submucosal lesion or an esophageal carcinoma were evaluated prospectively in a crossover study with both C-EUS and JC-EUS when using a 12-MHz US catheter probe. Based on still images, depth of US penetration and image quality (by using a predefined 1 to 5 scale) were assessed by a blinded, independent endosonographer.

OBSERVATIONS

JC-EUS was superior in image quality compared with C-EUS overall (mean score: 4.9 vs. 2.6; p <0.001), as well as in each subgroup (esophageal carcinoma, esophageal submucosal lesion, duodenal submucosal lesion). Penetration depth was not significantly different (2.5 cm). Staging was 100% accurate in 14 patients with esophageal cancer who underwent surgery. There was no procedure-related complication.

CONCLUSIONS

JC-EUS is safe, provides superior image quality to C-EUS, and is accurate for local staging of esophageal cancer.

Endoscopic ultrasound in the diagnosis, staging, and management of gastrointestinal and adjacent malignancies

Endoscopic ultrasound (EUS) is a superior modality for local staging of gastrointestinal cancer. In interventional endosonography linear array echoendoscopes permit real-time EUS-guided puncture of target lesions for cytologic evaluation of such lesions. This article describes the basic principles of EUS, established indications pertaining to gastrointestinal cancer and other malignancies, and emerging indications for this minimally invasive technology.

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Relapse patterns after chemo-radiation for carcinoma of the oesophagus

AIM

The detailed review of patterns of failure in this report was undertaken to identify the continuing obstacles to the successful management of oesophageal cancer, and to establish whether there is a case to compare definitive chemo-radiation (Def-CR) and surgery for patients with squamous cancer in a randomized controlled trial.

MATERIALS AND METHODS

First and subsequent sites of failure were reviewed in 274 patients treated with Def-CR using two cycles of cisplatin, infusional fluorouracil and 60 Gy; and 92 patients with limited chemo-radiation (CR), using one cycle and 35 Gy, followed by surgery (CR-Surg). All were treated on prospective non-randomized trials run by the Trans-Tasman Radiation Oncology Group between 1985 and 1999. Failure patterns were analysed using competing risks methodology, and pre-treatment variables predicting survival were identified by proportional hazards modelling.

RESULTS

Site, stage, performance status and gender were independently predictive of survival following Def-CR. Local failure was evident in 42.3% of patients, but distant failure in isolation occurred in an additional 18.1%. Lowest rates of local and distant failure at 5 years (29.9% and 26%) occurred in patients with squamous cancer (SCC) located in the upper-third, whose 5-year survival was also the most favourable (49.2%). Survival was least favourable in patients with adenocarcinoma (AC) in the lower two-thirds (18.1%) due to higher rates of local (51.5%) and distant (36.1%) failure. Local failure occurred in 31.5% of patients undergoing CR-Surg but distant failure in isolation was observed in a further 34.7%. Outcomes were least favourable in patients with AC of the lower-third in whom 57.7% failed distantly and 5-year survival was 3.8%. Response to pre-operative chemo-radiation was also strongly predictive of outcome. Patients with no residual cancer in the resection specimen had the lowest rates of local (0%) and distant (16.7%) failure and the best survival (64.9%). Survival in patients with residual cancer in nodes, however, was extremely poor (3.5%) with distant failure occurring in 66.7%.

CONCLUSION

The concurrent administration of chemotherapy with radiotherapy seems to have improved loco-regional control and has exposed distant failure as an obstacle to further improvements in outcome. Site, histological subtype, gender and response to chemo-radiation may predict biological differences in oesophageal cancer (OC) that influence outcome. A good case for a randomized comparison between Def-CR and CR-Surg in patients with SCC in the lower two-thirds exists.

The role of endoscopic ultrasound in the diagnosis and management of Barrett's esophagus

Although initial studies suggest a limited role for EUS in the detection of BE and the diagnosis and staging of dysplasia, a defined role in several specific situations is emerging. EUS is useful in selecting appropriate candidates for nonoperative therapies by excluding patients with submucosal cancers and those with malignant lymph nodes. EUS may also help in the selection of patients for EMR, either alone or in combination with ablative therapies.

Preoperative TN staging of esophageal cancer: Comparison of miniprobe ultrasonography, spiral CT and MRI

AIM: To evaluate the value of miniprobe sonography (MPS), spiral CT and MR imaging (MRI) in the tumor and regional lymph node staging of esophageal cancer.

METHODS: Eight-six patients (56 men and 30 women; age range of 39-73 years, mean 62 years) with esophageal carcinoma were staged preoperatively with imaging modalities. Of them, 81 (94%) had squamous cell carcinoma, 4 (5%) adenocarcinoma, and 1 (1%) adenoacanthoma. Eleven patients (12%) had malignancy of the upper one third, 41 (48%) of the mid-esophagus and 34 (40%) of the distal one third. Forty-one were examined by spiral CT in whom 13 were co-examined by MPS, and forty-five by MRI in whom 18 were also co-examined by MPS. These imaging results were compared with the findings of the histopathologic examination for resected specimens.

RESULTS: In staging the depth of tumor growth, MPS was significantly more accurate (84%) than spiral CT and MRI (68% and 60%, respectively, P < 0.05). The specificity and sensitivity were 82% and 85% for MPS; 60% and 69% for spiral CT; and 40% and 63% for MRI, respectively. In staging regional lymph nodes, spiral CT was more accurate (78%) than MPS and MRI (71% and 64%, respectively), but the difference was not statistically significant. The specificity and sensitivity were 79% and 77% for spiral CT; 75% and 68% for MPS; and 68% and 62% for MRI, respectively.

CONCLUSION: MPS is superior to spiral CT or MRI for T staging, especially in early esophageal cancer. However, the three modalities have the similar accuracy in N staging. Spiral CT or MRI is helpful for the detection of far-distance metastasis in esophageal cancer.

High-resolution EUS in children with eosinophilic "allergic" esophagitis

BACKGROUND

The pathophysiology of dysphagia associated with eosinophilic esophagitis is unknown. This study investigated possible anatomic alterations in children with eosinophilic esophagitis in comparison with healthy children by using high-resolution EUS to precisely measure individual tissue layers of the esophagus.

METHODS

Children with eosinophilic esophagitis (n = 11) and control children (n = 8) without esophagitis were prospectively evaluated by high-resolution EUS with a 20-MHz catheter US probe during an endoscopic examination. Real-time measurements of the distal esophagus were obtained including the thickness of the total wall, combined mucosa and submucosa, muscularis propria, and circular muscle.

RESULTS

Statistically significant differences were found between patients with eosinophilic esophagitis and control patients for mean values for thickness of the total wall (respectively, 2.8 vs. 2.1 mm; p = 0.004), combined mucosa and submucosa (respectively, 1.6 vs. 1.1 mm; p = 0.001), and muscularis propria (respectively, 1.2 vs. 1.0 mm; p = 0.043). Mean values for circular muscle did not differ between patient groups.

CONCLUSION

High-resolution EUS reveals significant expansion of the esophageal wall and individual tissue layers including the combined mucosa and submucosa, and muscularis propria in children with eosinophilic esophagitis compared with healthy control patients.

Interventional endoscopy in the diagnosis and staging of upper gastrointestinal malignancy

Increased population longevity as well as an emphasis on earlier diagnosis and more effective treatment of cancer have created an environment for new technologies and techniques to flourish. Some of the endoscopic entities discussed in this article have not been fully validated in clinical practice. Innovative spectroscopic modalities hold a great deal of promise, but are years away from general applicability. In contrast, many interventional endoscopic techniques are currently available and confer heightened levels of diagnostic and staging accuracy for gastric and esophageal malignancies. Earlier diagnosis can identify patients who may be eligible for less-invasive treatment options such as EMR. Minimally invasive treatment options and maximum staging accuracy are more important for patients who are marginal surgical candidates and for accurate comparison of clinical trials studying treatment options. Our challenge for the future is to properly integrate these technologic advances with the science of good medical practice.

High-frequency US catheter-based staging of early esophageal tumors

BACKGROUND

High-frequency catheter US probes provide greater accuracy compared with dedicated echoendoscopes in the staging of superficial esophageal carcinoma. However, it may be difficult and time consuming to obtain acoustic coupling with these devices. The aim of this study was to test a novel catheter US technique for staging superficial esophageal carcinoma.

METHODS

Twelve patients underwent examination with a 2-channel endoscope. US images were obtained with a catheter US probe (20 MHz) fitted with a balloon sheath.

RESULTS

Adequate endoscopic and catheter US images were obtained in all patients. Depth of tumor invasion as determined with the catheter US probe was confirmed in all 5 patients who underwent surgery. No procedure-related complications occurred.

CONCLUSIONS

US with a catheter US probe and sheath allows complete endoscopic examination and preoperative determination of depth of invasion of superficial esophageal carcinoma in a single endoscopic procedure. Preliminary results suggest this technique is accurate and safe.

High-frequency probe EUS-assisted endoscopic mucosal resection: a therapeutic strategy for submucosal tumors of the GI tract

BACKGROUND

The aim of this study was to evaluate the efficacy and safety of high-frequency probe EUS (HFPE)-assisted endoscopic mucosal resection in the management of submucosal tumors of the GI tract.

METHODS

HFPE-assisted endoscopic mucosal resection was attempted in 28 patients with submucosal tumors less than 2 cm in diameter. HFPE was performed with a 20-MHz "through-the-scope" probe. Saline solution was injected into the submucosa. After confirming detachment of the lesion from the muscularis propria by repeat HFPE, endoscopic mucosal resection was performed with a lift-and-cut or endoscopic mucosal resection cap technique. Follow-up endoscopy was performed in all patients.

RESULTS

Submucosal tumors from the following areas were included: esophagus 3, stomach 4, duodenum 3, and colon 18. The submucosal tumors were located in the upper third (n = 3), middle third (n = 18), and lower third (n = 7) of the submucosa. Twenty-one submucosal tumors were removed by the lift-and-cut technique and 6 by the cap method. One patient required surgical resection after unsuccessful endoscopic mucosal resection. The origin and depth of penetration of all lesions was accurately depicted by HFPE. Median tumor diameter was 9 mm (range 3-20 mm). Resection was successful and complete in 93% of the cases. There were no immediate postprocedure complications (exact 95% CI [0%, 12.3%]). During a median follow-up of 21.5 months (range 2-74 months) no recurrence was found.

CONCLUSIONS

HFPE-assisted endoscopic mucosal resection is safe and effective for the management of selected submucosal tumors of the GI tract. A management algorithm based on endoscopic and HFPE findings is proposed.

High-resolution endoscopic imaging of the GI tract: a comparative study of optical coherence tomography versus high-frequency catheter probe EUS

BACKGROUND

Both optical coherence tomography (OCT) and catheter probe EUS (CPEUS) are candidates for high-resolution imaging of the GI wall, but their potential roles in this clinical context have not been investigated.

METHODS

OCT and CPEUS were used to image normal-appearing portions of the GI tract at the same sites. CPEUS was performed with a 20-MHz or a new 30-MHz catheter probe.

RESULTS

Forty-four histologically confirmed normal sites in 27 patients were evaluated. With OCT, mucosa and muscularis mucosa were clearly seen at all sites. Except for stomach, OCT demonstrated the submucosa in all sites. OCT penetration ranged from 0.7 to 0.9 mm. Microscopic structures such as esophageal glands, intestinal villi, colonic crypts, and blood vessels were easily identified. CPEUS penetration ranged from 10 mm to 20 mm, and 5 to 7 distinct layers were discernible. However, both mucosa and submucosa were seen as thin layers without microscopic detail.

CONCLUSION

OCT resolution is superior to high-frequency CPEUS, but depth of penetration is limited to mucosa and submucosa. OCT images the major structural components of the mucosa and submucosa whereas CPEUS does not. Potentially, OCT and high-frequency CPEUS may be complementary for clinical imaging.

Radiation therapy for superficial esophageal cancer: a comparison of radiotherapy methods

PURPOSE

A comparison of treatment outcomes in response to various methods of radiotherapy for superficial esophageal cancer (SEC) was carried out for a large series of patients.

METHODS AND MATERIALS

During the period from March 1987 to November 1998, 147 patients with superficial esophageal cancer received definitive radiation therapy at nine radiotherapy institutions in Japan. Fifty-five patients were treated with external radiation therapy alone, 69 with high-dose-rate intracavitary radiation therapy with or without external radiation therapy, and 23 with low-dose-rate intracavitary radiation therapy and external radiation therapy.

RESULTS

The 5-year survival rates for mucosal and submucosal cancer patients were 62% and 42%, respectively. The 5-year cause-specific survival rates for mucosal and submucosal cancer patients were 81% and 64%, respectively (p = 0.013). There was no statistically significant difference in the survival rates for either mucosal or submucosal cancer patients between treatment groups. Metastasis was observed only in submucosal cancer patients. Esophageal ulcers developed only in patients who received intracavitary radiation therapy, and were especially common in patients treated with a fraction size of 5 Gy or more.

CONCLUSIONS

The use of intracavitary radiation therapy does not influence the survival or local control rate of SEC. Optimal radiotherapy methods for SEC should be determined by a randomized clinical trial.

Prospective comparison of catheter-based endoscopic sonography versus standard endoscopic sonography: evaluation of gastrointestinal-wall abnormalities and staging of gastrointestinal malignancies

PURPOSE

Endoscopic sonography (EUS) is an important imaging modality for evaluating benign and malignant luminal gastrointestinal-tract abnormalities. The objectives of this study were to evaluate the feasibility of catheter-based EUS (C-EUS) during standard upper and lower endoscopy in patients with malignancies and other abnormalities of the gastrointestinal-tract lumen, to assess the image quality obtained with the 12.5-MHz catheter-based ultrasound transducer, and to prospectively compare the interpretations of C-EUS images with those of the standard EUS (S-EUS) images.

METHODS

One hundred thirty-seven consecutive patients referred for EUS were evaluated with C-EUS followed by S-EUS. The patients were assigned to 1 of 2 groups: group A, patients with intramural masses or intestinal wall thickening, with biopsies negative for malignancy; and group B, patients with esophageal, gastric, duodenal, or rectal cancer referred for staging. The results of C-EUS and S-EUS were compared for each group.

RESULTS

C-EUS was completed in 134 patients: 81 patients with 83 lesions in group A and 53 patients in group B. For group A, C-EUS image interpretation concurred with that of S-EUS in 74 (89%) of 83 lesions. For group B, C-EUS concurred with S-EUS for tumor depth (T) and nodal (N) classifications in 19 cases (36%) and 26 cases (49%), respectively. The depth of invasion was underestimated by C-EUS in all 34 cases in which the T classifications by C-EUS and S-EUS were discordant. In 1 of 6 patients with stenotic cancer that was nontraversable by S-EUS, C-EUS identified lymphadenopathy (incorrectly classified as N0 by S-EUS).

CONCLUSIONS

C-EUS was easily performed, and the C-EUS images were comparable to the S-EUS images in assessing mucosal and intramural lesions. The limited depth of penetration of the catheter-based transducer resulted in understaging the extent of tumor invasion and underestimating the nodal spread.

Esophageal cancer: a systematic review

Carcinoma of the esophagus has one of the lowest possibilities of cure, with 5-year survival rates estimated to be approximately 10% overall; these rates are second only to hepatobiliary and pancreatic cancers. This fact and the rapid increase in the incidence of adenocarcinomas of the esophagus in recent years challenges us to identify areas of improvement for all aspects of this disease. We discuss potential reasons for the increase in the incidence of adenocarcinomas, evidence that defines the similarity between tumors of the gastroesophageal junction and the tubular esophagus, and other prognostic factors that may influence future modifications of our staging classification of this disease. Surgical advances have translated into improvements in surgical morbidity and mortality rates. Current therapeutic options and the relative merits of the options are discussed. Improvements in patient outcome most likely hinge on earlier diagnosis, more accurate staging, and the optimal use of combined modalities, coupled with technical advances in the modalities. A systematic review approach was undertaken to evaluate the performance characteristics of newer staging tools and the value of different combined modality approaches with particular focus on the use of those approaches for patients with potentially curable disease. A similar methodologic approach was used to address the utility of the many strategies currently used in practice for the palliation of esophageal tumors, with particular focus on the relief of malignant dysphagia. Finally, a summary of published guidelines and population-based patterns of care are presented. This serves as an overview of how all of this evidence actually translates into the care we are providing. A coordinated international effort in population-based research and randomized controlled trials would be the cornerstone to future advances in this relatively uncommon but devastating disease.

Comparison of a linear miniature ultrasound probe and a radial-scanning echoendoscope in TN staging of esophageal cancer

BACKGROUND

Endoscopic ultrasonography is a precise method for TN staging of esophageal cancer. We explored the staging properties of a linear miniprobe as compared with a radial-scanning echoendoscope.

METHODS

Sixty-eight patients with esophageal cancer underwent preoperative TN staging using a 20-MHz linear miniprobe and a 7.5/12-MHz radial-scanning echoendoscope. Tumor stage was verified by surgery and/or histology.

RESULTS

T and N stages were verified in 53 and 54 patients, respectively. T-staging accuracy using the echoendoscope was 70%. The high-frequency miniprobe could not differentiate between T3 and T4 tumors, but both systems had an accuracy of 87% in discriminating between T1, T2, and T3/4 stages. With traversable tumors, the accuracy of N staging was significantly better with the echoendoscope than with the miniprobe (90% vs. 48%, P = 0.008).

CONCLUSIONS

The two endosonographic systems had similar accuracy for assessing transmural tumor growth, but the echoendoscope was superior in staging advanced transmural tumors and in predicting lymph node metastasis with traversable tumors.

Clinical outcome of endoscopic mucosal resection for superficial GI lesions and the role of high-frequency US probe sonography in an American population

BACKGROUND

Endoscopic mucosal resection, a major advance in endoscopy, provides an endoscopic option for management of focal and superficial lesions of the gastrointestinal tract. Although popular in the Orient due to the high incidence of superficial neoplasia, there are scant data on its use in the United States. Our aim was to assess the efficacy and safety of endoscopic mucosal resection in our patient population and evaluate whether high-frequency ultrasound (US) probe sonography provides useful information relative to the procedure.

METHODS

Endoscopic mucosal resection was performed in 32 of 33 patients referred for endoscopic management of superficial neoplastic or submucosal lesions. High-frequency US probe sonography was performed with a 20 MHz US probe. Endoscopic mucosal resection was performed after submucosal saline solution injection with the strip biopsy technique.

RESULTS

Thirty-two superficial lesions were resected. Of 24 epithelial lesions resected, 22 were intramucosal and 2 had early submucosal invasion (SM1); the 2 patients with the latter 2 lesions were poor candidates for surgery. Depth of penetration of 25 of 26 lesions scanned was accurately predicted by high-frequency US probe sonography. Eight lesions raised from the submucosa. Minor complications were limited to the colon. Of the 7 patients with carcinomas, 6 had no evidence of recurrence at a mean follow-up of 12 months; 1 died of a second primary cancer.

CONCLUSIONS

Endoscopic mucosal resection provided definitive therapy for 24 early-stage neoplastic lesions and provided a diagnosis in the remaining 8. In our study, the technique proved to be safe with only three minor complications noted. High-frequency US probe sonography accurately delineated the depth of penetration of all lesions scanned, therefore making it an ideal imaging modality for selecting patients who may benefit from endoscopic mucosal resection.

Endoscopic mucosal resection

Endoscopic mucosal resection (EMR) is a major advance in endoscopy for treatment of patients with superficial esophageal, gastric, or colonic lesions, providing a nonsurgical treatment option for management of these lesions. With the assistance of endoscopic ultrasonography, it is now possible to obtain an accurate histologic diagnosis, confirm the depth of the lesion, and in many cases resect submucosal tumors. The main goal of EMR using the advances in endosonography is to detect early gastrointestinal cancers and successfully resect them, offering an outpatient, nonsurgical treatment option. Although popular in the Orient, where there is a high incidence of superficial neoplasia, limited data are available on the use of EMR in the United States. Gastrointestinal (GI) endoscopy nurses and assistants play important roles in successful EMR. This article informs GI staff on the indications for EMR, the procedure and accessories needed, the different resection methods, possible complications, and nursing care.

Gastrointestinal miniprobe sonography: the current status

Endoscopic ultrasonography (EUS) represents a major advance in endoscopic imaging. The usefulness and effectiveness of EUS have been established during the past few years. However, endosonography using dedicated echoendoscopes (7.5/12 MHz) has some serious drawbacks, as follows: 1) Combining endoscopy and ultrasonography in one instrument increases the diameter of such echoendoscopes (12-13 mm); 2) Because of the large diameter, complete passage of severe strictures is often not possible and, for examination of the pancreatobiliary duct system, is not feasible at all; 3) Image quality and resolution for small lesions is not always satisfactory; and 4) Conventional endosonography requires a second examination separate from the previous routine endoscopy. Recently developed ultrasonographic miniprobes (diameters about 2 mm; frequencies 12-20 MHz) can be passed through the working channel of standard endoscopes to provide high frequency ultrasound images. These miniprobes might overcome some of the above-mentioned drawbacks and contribute to patients' security and convenience. Moreover, in various diseases of the GI tract and the pancreatobiliary duct system, diagnostic accuracy of miniprobe ultrasonography has been shown to be even superior to that of EUS. In summary, miniprobe ultrasonography seems to be a promising tool in the armamentarium of gastroenterological diagnostics.

Dilation of malignant esophageal stenosis to allow EUS guided fine-needle aspiration: safety and effect on patient management

BACKGROUND

Endoscopic ultrasonography (EUS) with fine-needle aspiration identifies patients with esophageal cancer who are unlikely to be cured by surgery. In approximately 30% of patients the staging procedure cannot be completed without dilation of an obstructing tumor.

METHODS

All EUS examinations for esophageal cancer requiring dilation from July 1995 to December 1998 were included. Yield was defined as newly diagnosed metastatic (celiac lymph nodes) or locally invasive disease that could not have been detected without dilation.

RESULTS

EUS was performed in 132 patients. Forty-two (32%) required 44 dilations. No complications occurred. Of the 42 patients with obstruction, 18 (43%) had celiac adenopathy of which 7 had malignant cells confirmed histologically, 3 had benign adenopathy, and 8 did not undergo fine-needle aspiration due to T4 stage disease (5) or intervening vessels (3). Two patients were upstaged after successful dilation from T2 N1 Mx to T4 N1 Mx and from T3 Nx Mx to T3 N1 M1. Overall, dilation allowed detection of advanced disease in 8 of 42 (19%) patients. Dilation to 11 to 12.8 mm was insufficient (36% success rate) to complete EUS compared with dilation to 14 to 16 mm (87%, p < 0.01).

CONCLUSION

Dilation of obstructing esophageal tumors allows identification of a large number of patients with advanced stage malignancy. Dilation to 14 to 16 mm is sufficient for complete staging in almost all patients.

High dose rate brachytherapy for superficial cancer of the esophagus

PURPOSE

We analyzed our experience with external radiotherapy, combined modality treatment, or HDR brachytherapy alone to limited esophageal cancers.

METHODS AND MATERIALS

From 1991 to 1996, 25 patients with limited superficial esophagus carcinomas were treated by high dose rate brachytherapy. The mean age was 63 years (43-86 years). Five patients showed superficial local recurrence after external radiotherapy. Eleven patients without invasion of the basal membrane were staged as Tis. Fourteen patients with tumors involving the submucosa without spreading to the muscle were staged as T1. Treatment consisted of HDR brachytherapy alone in 13 patients, external radiotherapy and brachytherapy in 8 cases, and concomitant chemo- and radiotherapy in 4 cases. External beam radiation was administered to a total dose of 50 Gy using 2 Gy daily fractions in 5 weeks. In cases of HDR brachytherapy alone (13 patients), 6 applications were performed once a week.

RESULTS

The mean follow-up is 31 months (range 24-96 months). Twelve patients received 2 applications and 13 patients received 6 applications. Twelve patients experienced a failure (48%), 11/12 located in the esophagus, all of them in the treated volume. One patient presented an isolated distant metastasis. In the patients treated for superficial recurrence, 4/5 were locally controlled (80%) by brachytherapy alone. After brachytherapy alone, 8/13 patients were controlled (61%). The mean disease-free survival is 14 months (1-36 months). Overall survival is 76% at 1 year, 37% at 2 years, and 14% at 3 years. Overall survival for Tis patients is 24% vs. 20% for T1 (p = 0.83). Overall survival for patients treated by HDR brachytherapy alone is 43%. One patient presented with a fistula with local failure after external radiotherapy and brachytherapy. Four stenosis were registered, two were diagnosed on barium swallowing without symptoms, and two required dilatations.

CONCLUSION

High dose rate brachytherapy permits the treating of patients with superficial esophageal cancer with good tolerance. Early tumors, located in the mucosa, might be treated by HDR brachytherapy alone or by a combined modality treatment in which HDR brachytherapy can take place like a boost. This approach may cure localized recurrences.

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.

Usefulness of contrast-enhanced EUS in the diagnosis of upper GI tract diseases

BACKGROUND

We evaluated the usefulness of contrast-enhanced endoscopic ultrasonography (EUS) in the diagnosis of upper gastrointestinal (GI) tract diseases.

METHODS

The subjects were 42 patients with upper GI tract diseases: 4 esophageal carcinomas, 30 gastric carcinomas, 5 gastric myogenic tumors, and 3 gastric ulcers. After the lesion was observed by EUS, air-filled albumin (0.22 mL/kg) was intravenously injected at a rate of 1 mL/sec into the right cubital median vein, and observation was continued for 10 minutes.

RESULTS

Enhancement of the third and fifth layers was observed in all normal esophageal and gastric walls. No esophageal carcinomas were enhanced. Enhancement was observed in 5 gastric carcinomas that had abundant, enlarged, and winding vascular beds. In all esophageal and the other 25 gastric carcinomas, although the tumors per se were not enhanced, enhancement of the third and fifth layers around the lesions clearly demarcated the tumor boundaries. As a result, accuracy for detection of the depth of gastric carcinoma improved from 76.7% for EUS to 90% for contrast-enhanced EUS. All gastric myogenic tumors were enhanced, and irregularly shaped sonolucent areas within these tumors became clear, but we could not distinguish between leiomyoma and leiomyosarcoma.

CONCLUSIONS

Contrast-enhanced EUS is a noninvasive, useful diagnostic method for assessment of the depth of invasion of esophageal and gastric carcinomas.

Clinical implications of endoluminal ultrasonography using through-the-scope catheter probes

BACKGROUND

Ultrasound catheter probe-assisted endosonography is a relatively new technique. The aim of this prospective multicenter study was to determine its potential clinical impact by assessing changes in diagnostic and therapeutic management affected by catheter probes compared with ultrasound endoscopes.

METHODS

Endosonographers at three centers selected theoretic diagnostic and therapeutic plans that would be followed if neither catheter probes nor ultrasound endoscopes were available. Patients with suitable lesions underwent endosonography with catheter probes followed by an ultrasound endoscope. Diagnostic and therapeutic plans were noted after each examination.

RESULTS

Sixty-six patients, of whom 15 had a stenotic esophageal cancer, 39 had a mucosal or submucosal lesion, and 12 had a stricture of the pancreaticobiliary system or the gastrointestinal tract, were enrolled. If neither form of endosonography were available, invasive or surgical diagnostic procedures would have been performed on 23 (35%) patients and surgical therapy would have been planned in 31 (47%) patients. Catheter probe-assisted ultrasonography and endoscopic ultrasonography led to a less invasive diagnostic plan in 11 (16%) and 12 (18%) patients and a less invasive therapeutic plan in 10 (15%) and 14 (21%) patients, respectively (p > 0.1 for differences).

CONCLUSIONS

Catheter probe-assisted endosonography has a modest effect on diagnostic and therapeutic management, comparable with endoscopic ultrasonography in the same patients. The vast majority of effected changes are toward less invasive management.

Squamous cell carcinoma of the esophagus: a review and update

Squamous cell carcinoma (SCC) of the esophagus is an often-lethal disease that most commonly presents in an advanced stage with dysphagia in elderly patients. Known risk factors include alcohol and tobacco abuse, lye stricture, and achalasia. Screening protocols for high-risk patients are practiced in Japan but not in the United States. The diagnosis usually is made based on the results of esophagogastroduodenoscopy and contrast upper gastrointestinal radiographs. Staging is determined using computed tomography scanning and esophageal ultrasound, the latter rapidly being accepted as a superior method. Treatment is based on the stage of disease at presentation. Lesions without metastatic spread or mediastinal invasion generally should be treated with esophagectomy. Dysphagia associated with advanced lesions is difficult to treat, but may be palliated by surgery, radiation therapy, chemotherapy, laser ablation, peroral dilation, or esophageal stenting. Despite numerous medical advances, little headway has been made in managing and treating SCC, and a multidisciplinary approach is recommended.

Intraductal ultrasonography in diagnosing tumor extension of cancer of the papilla of Vater

BACKGROUND

Intraductal ultrasonography is clinically useful in assessing various pancreatobiliary diseases. This study was carried out to evaluate the usefulness of intraductal ultrasonography in diagnosing tumor extension of cancer of the papilla of Vater.

METHODS

Thirty-two patients with cancer underwent intraductal ultrasonography. According to the spatial relationship between the tumor echo and the hypoechoic layers representing Oddi's muscle layer or the duodenal muscularis propria layer, the images were classified into four grades. We attempted to diagnose tumor extension using this grading system. Lymph nodes measuring over 10 mm were evaluated as involved. Findings were compared with postoperative histopathologic findings classified as follows: d0, tumor limited to Oddi's muscle layer; d1, tumor invading the duodenal submucosal layer; d2, tumor invading the duodenal muscularis propria layer; and panc(+), tumor invading the pancreas.

RESULTS

Diagnostic accuracy rate was 100% (6 of 6) in d0 cases, 92.3% (12 of 13) in d1 cases, 100% (1 of 1) in a d2 case, and 75% (9 of 12) in panc(+) cases. Overall accuracy rate was 87.5% (28 of 32). In assessing lymph node metastases, sensitivity was 66.7% (6 of 9) and specificity was 91.3% (21 of 23).

CONCLUSION

Intraductal ultrasonography examination is useful in diagnosing tumor extension of cancer of the papilla of Vater.