Esophageal cancer. American College of Gastroenterology

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

BACKGROUND

It is well known that a learning curve exists for performing EUS.

OBJECTIVE

To determine whether the number of EUS investigations performed in a center affects the results of esophageal cancer staging.

DESIGN

We compared EUS in the evaluation of T stage and the presence of regional and celiac lymph nodes in a low-volume center where <50 EUS/endoscopist/y were performed with reported results from 7 high-volume EUS centers.

SETTING

A reference center for esophageal cancer (>90 cases/y) but a low-volume center for EUS when it comes to individual endoscopists.

PATIENTS

From 1994 to 2003, 244 patients underwent EUS, without specific measures to pass a stenotic tumor or FNA and with postoperative TNM stage as the criterion standard in the low-volume EUS center. In the high-volume centers, 670 EUS investigations for esophageal cancer were performed, if needed, with dilation, and with postoperative TNM stage and/or FNA as the criterion standard.

INTERVENTIONS

Retrospective analysis.

MAIN OUTCOME MEASUREMENTS

Sensitivity and specificity of EUS for esophageal cancer staging.

RESULTS

In the low-volume center, results of EUS for T3 staging in patients in whom passage of the EUS probe was possible were almost comparable for sensitivity (85% vs 88%-94%) but were lower for specificity (57% vs 75%-90%), whereas both sensitivity (58% vs 75%-90%) and specificity (87% vs 94%-97%) for T1 or T2 stages were lower than those reported in the high-volume centers. In the low-volume center, sensitivities of EUS for regional (45% vs 63%-89%) and celiac (19% vs 72%-83%) lymph nodes were lower, whereas specificities (75% vs 63%-82% and 99% vs 85%-100%, respectively) were comparable with those from high-volume centers. Results in the low-volume EUS center were worse if the EUS probe could not pass the stricture, which occurred in almost 30% of patients.

LIMITATIONS

Both FNA and dilation before EUS for stenotic tumors were not performed in the low-volume EUS center.

CONCLUSIONS

The results of EUS performed in a low-volume EUS center compared unfavorably with those reported from high-volume EUS centers. The results of this study suggest that preoperative staging by EUS should be performed by experienced and dedicated EUS endoscopists to optimize staging of esophageal cancer.

Endoscopic mucosal resection: an improved diagnostic procedure for early gastroesophageal epithelial neoplasms

Endoscopic mucosal resection (EMR), which is advocated for the treatment of early (superficial) gastroesophageal neoplasms, has also been alluded to represent a superior diagnostic and staging modality. We compared the diagnostic concordance of preceding biopsies with EMR specimens in 31 gastric and 10 esophageal EMRs consisting of 6 low-grade and 12 high-grade dysplasias, 21 intramucosal adenocarcinomas, and 2 submucosal invasive adenocarcinomas. Discrepancies were considered as either major or minor if the histologic grades differed by 2 or more, or by only 1, respectively. Discrepant and concordant cases were compared with regard to the size of lesion (maximum dimension and surface area), number of biopsy fragments, and extent of biopsy sampling (ratio between lesion size and number of biopsy fragments). These same variables were used to evaluate the differences seen between gastric and esophageal cases. Of the 41 cases, 16 (39%) had discrepant diagnoses, including 14 gastric and 2 esophageal neoplasms. A major discrepancy was seen in 2% of the cases (n = 1, gastric) and a minor discrepancy, in 15 cases. All but 2 of the discrepant cases were found to have a higher grade on EMR. The average number of biopsy fragments was 4.4 in both concordant and discrepant groups. The maximal dimension, surface area, and biopsy sampling ratios of the lesion were significantly greater in the discrepant cases than in the concordant cases. The esophageal cases trended toward having smaller size and a significantly extensive biopsy sampling. We conclude that EMR is superior to biopsy for diagnosing superficial gastroesophageal tumors. Discrepancies between the specimens occur in larger lesions (>10 mm) with less extensive biopsy sampling. EMR can substantially modify the diagnostic grade of a lesion and therefore facilitate optimal therapeutic decisions by avoiding undertreatment and overtreatment based on inaccurate grading and staging.

Proteomic analysis of global alteration of protein expression in squamous cell carcinoma of the esophagus

Squamous cell carcinoma of the esophagus (ESCC), a major subtype of esophageal carcinoma, is one of the aggressive cancers with worst prognosis in the world. The dismal outcome of ESCC is attributed to multiple reasons including its aggressive nature, largely unknown molecular mechanism of its progression, and the lack of biomarkers for early detection and effective prediction of its clinical behavior. To identify proteins with prognostic and/or predictive value, we applied a proteomics strategy to quantify proteins differentially expressed in ESCC using matched samples of carcinoma and adjacent normal epithelial cells. The analysis led to identification of 28 proteins aberrantly expressed in cancer cells with changes of at least three-fold in ESCC relative to normal squamous epithelial cells. These changes represent functional alterations of essential proteins for normal cellular physiology, accounting for many cellular changes involved in development of ESCC, including cell transformation, loss of differentiation, tumor growth, apoptosis, tumor invasion, and cell metabolism. The differentially expressed proteins shed new insights on the mechanism of tumorigenesis and provide candidate biomarkers for early detection of ESCC.

Developing an appropriate staging system for esophageal carcinoma

BACKGROUND

Development of an optimal staging system for esophageal cancer is essential to estimate prognostic factors accurately and treat them appropriately. In this study, we evaluated the surgical outcomes of esophageal cancer according to five existing staging systems and assessed their prognostic significance.

STUDY DESIGN

For 113 patients with esophageal cancer who had undergone curative resection, lymph-node metastasis was classified using the 8th and 9th editions of the Japanese classification, the 6th edition of the Union Internationale Contre le Cancer (UICC) TNM classification, and systems based on the number (0, 1 to 3, or > or = 4) or ratio (0, < 0.15, or > or = 0.15) of metastatic lymph nodes. Survival and prognostic factors of the respective stages were evaluated.

RESULTS

Univariate analysis of disease-specific survival revealed that depth of invasion and lymph-node classification notably affected prognosis. Multivariate analysis confirmed that each classification independently influenced prognosis. According to the criteria of the two Japanese classifications, there was no clear correlation between lymph-node stage and survival. The Union Internationale Contre le Cancer/TNM classification, and those based on the number or ratio of metastatic lymph nodes showed a clear correlation between lymph-node metastasis and survival. These systems had better stratification than the Japanese classifications.

CONCLUSIONS

Staging systems for esophageal cancer based on the number or ratio of metastatic lymph nodes showed better prognostic significance than those based on the anatomic distribution of metastatic lymph nodes, because of their good stratification and clinical utility. Such classifications are suitable for use throughout the world.

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.

EUS followed by EMR for staging of high-grade dysplasia and early cancer in Barrett's esophagus

BACKGROUND

Accurate staging of high-grade dysplasia and of early cancer in Barrett's esophagus is important in the selection of patients for endoscopic therapy.

METHODS

Patients with Barrett's esophagus and biopsy specimen proven high-grade dysplasia and adenocarcinoma in focal nodular lesions or in endoscopically unapparent flat lesions in short-segment Barrett's esophagus were initially staged with EUS. In patients with disease limited to the mucosa on EUS, cap-assisted EMR was performed. The depth of tumor invasion on EMR specimens was classified in a similar manner to squamous-cell cancer of the esophagus: m1 (epithelial layer, dysplasia), m2 (lamina propria invasion), m3 (muscularis mucosae invasion), sm (submucosal invasion).

RESULTS

EUS was performed in 48 consecutive patients (27 with focal nodular lesions and 21 with microscopic lesions), and submucosal invasion was diagnosed in 8 (confirmed in 7/8 at surgery). EMR was carried out in the remaining 40 patients without significant complications. In the 25 patients with high-grade dysplasia on prior biopsy specimens, EMR confirmed m1 disease in 19; whereas in 6 (24%), invasive adenocarcinoma was detected (to m2 in 4; to m3 in 2). In the 15 patients with invasive cancer on prior biopsy specimens and staged as intramucosal cancer on EUS, intramucosal carcinoma was confirmed in 9 (m2 in 3; m3 in 6); whereas, in 6 patients (40%), submucosal invasion was found. Overall, EUS provided accurate staging in 41/48 patients (85%) with one patient overstaged and 6 patients understaged compared with pathologic staging obtained by surgery or EMR. Of the 34 patients with m1 to m3 staging after EMR, 29 were treated endoscopically and had no evidence of cancer after a mean follow-up of 22.9 months(standard deviation 9.2 months).

CONCLUSIONS

EMR provides pathologic staging information that, in addition, may be helpful after EUS if a stage-determined approach is used in the management of high-grade dysplasia and of early cancer in Barrett's esophagus. EMR may be particularly useful for staging of focal nodules or in short-segment Barrett's esophagus with microscopic lesions when endoscopic therapy is an option.

Management of superficial Barrett's epithelium-related neoplasms by endoscopic mucosal resection: clinicopathologic analysis of 27 cases

Endoscopic mucosal resection (EMR), a relatively new endoluminal therapeutic technique with low morbidity and no mortality reported to date, is advocated for the treatment of Barrett's esophagus (BE)-related superficial neoplasms. However, recent studies revise its success downward, particularly regarding the ability to achieve complete excision. To evaluate what remains an evolving technique, we analyzed our experience with a series of 27 esophageal EMRs (20 lesions in 18 patients). Our goal was to evaluate the diagnostic, staging, and therapeutic advantages of EMR separately by correlating the initial biopsies and pre-EMR endoscopic ultrasound (EUS) staging with the final histologic diagnoses and stage. Persistence/recurrence of neoplastic tissue was also correlated with the margin status of the resections. The mean size of the neoplasms, which included low-grade dysplasias (n=2), high-grade dysplasias (n=8), intramucosal carcinomas (n=14), and submucosal invasive carcinomas (n=3), was 11 mm. EUS correctly reported an intramucosal or submucosal lesion in 70% of the cases while it overstaged 18% and understaged 12% of the cases. The biopsy diagnosis corresponded to the EMR diagnosis in 63% of the cases. The biopsy underestimated the grade of the lesion in 21% of the cases. EMR revealed a lower histologic grade compared with the biopsy in 16% of the cases. The resection was microscopically complete in only 4% of the cases. No residual/recurrent disease was observed in 10 lesions (9 patients) at 4 to 63 months (mean, 23 months) post-EMR. However, 9 lesions (8 patients) persisted/recurred 28 days to 25 months (mean, 6 months) after treatment; 56% of the cases with positive lateral margin(s) and negative deep margin persisted/recurred. However, 86% of the EMRs with positive deep margin showed residual tumor/recurrence on follow-up biopsies. In conclusion, we observed that EMR offers improved diagnosis and staging as compared with biopsy and EUS. This is a significant advantage since it can modify patients' management. However, frequent incompleteness of resection and high persistence/recurrence are significant pitfalls that dictate continued endoscopic surveillance.

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

BACKGROUND

Although EUS provides superior local staging of esophageal carcinoma when compared with other tests, EUS seems to be underused by physicians. We designed this prospective study to determine whether EUS is ordered in the evaluation of esophageal cancer and whether staging information obtained would change management.

METHODS

A total of 114 physicians were mailed a questionnaire that surveyed which tests are used in evaluating patients with esophageal cancer, the order in which they are requested, and their estimated cost. Physicians were asked to estimate prognosis and to indicate which therapy would be used for each specific TNM cancer stage.

RESULTS

Of 114 physicians, 71 (62.3%) physicians from 4 disciplines responded. Only 47.3% of physicians would use EUS in the patient workup for esophageal cancer. Physicians would only order EUS after first obtaining an endoscopy, then a barium swallow, and then a CT scan ( p < 0.0001). A significantly greater number of internists (78.9%, p = 0.055) would not order EUS, and 31.6% of internists would not use any staging data before referral to another physician for definitive management. Physicians were accurate in their assessment of the prognosis for each cancer stage and the cost of each test. There was no difference in the use of surgery between disciplines for stages O, I, IIA, and IV. However, significantly more surgeons than nonsurgeons would use surgery for stage IIB (100.0% vs. 71.3%, p = 0.019), with a trend toward greater use by surgeons for stage III (64.3% vs. 34.1%, p = 0.11). Except for significantly greater use of chemotherapy by surgeons and oncologists for stage IIA than internists and gastroenterologists (36.6% vs. 3.1%, p = 0.0006), there were no differences between subspecialties with use of chemotherapy for all other stages or use of radiation therapy for any stage.

CONCLUSIONS

Clinicians have an adequate understanding of patient survival based on cancer stage and a reasonable appreciation of cost for diagnostic tests regarding esophageal carcinoma. Specific data on cancer staging does impact treatment choices and management decisions. EUS is grossly underused by clinicians for staging esophageal cancer. Although internists may serve as gatekeepers, they fail to order EUS, order EUS only after less accurate tests, or fail to use staging data in management (especially referral) decisions. The ultimate modality of treatment may be more related to the type of physician that the patient is referred to, instead of the specific cancer stage. Education of primary care clinicians may be needed before the full impact of EUS on patient care can be appreciated.

Expression level of valosin-containing protein (p97) is associated with prognosis of esophageal carcinoma

PURPOSE

Esophageal squamous cell carcinoma (ESCC) frequently shows a poor prognosis because of the occurrence of systemic metastasis, mainly via lymphatic vessels. Valosin-containing protein (VCP) has been shown to be associated with antiapoptotic function and metastasis via activation of the nuclear factor-kappaB signaling pathway. In the present study, we examined the association of VCP with the recurrence and prognosis of ESCC.

EXPERIMENTAL DESIGN

VCP expression in 156 ESCC patients [139 males and 17 females; age range, 38-82 (median, 60) years] was analyzed by immunohistochemistry. Staining intensity in tumor cells was categorized as weaker (level 1) or equal to or stronger (level 2) than that in endothelial cells. The correlation of VCP expression between the mRNA and protein levels was examined in 12 patients.

RESULTS

Fifty-seven (37.3%) cases showed level 1 and 96 (62.7%) level 2 VCP expression. Quantitative reverse transcription-PCR analysis revealed greater VCP mRNA expression in level 2 (n = 6) than level 1 cases (n = 6; P < 0.05). ESCC with level 2 expression showed higher rates of lymph node metastasis (P < 0.01) and deep tumor invasion (P < 0.01), and poorer disease-free and overall survival rates (P < 0.001 for both analyses) than ESCC with level 1 expression. Multivariate analysis revealed that VCP expression level is an independent prognosticator for disease-free and overall survival. Furthermore, VCP level was an indicator for disease-free survival in the early (pT1) and the advanced (pT2-pT4) stage groups.

CONCLUSION

This study demonstrated the prognostic significance of VCP expression in ESCC.

Esophageal Carcinoma: Current Controversial Topics

Worldwide, esophageal carcinoma is a common gastrointestinal cancer with a high mortality. The incidence of adenocarcinoma of the esophagus is increasing in the western world, but squamous cell carcinoma remains dominant in the underdeveloped parts of the world. Both types of esophageal carcinoma remain equally virulent. Currently, there are no optimal preventative screening programs available and most patients present with advanced or metastatic disease. Although many options are available for improving diagnostic accuracy, a single method has not displayed significant advantages over the others. In addition, selecting a superior treatment regimen has not surfaced. Preferred resection techniques exist, but one method has not illustrated improvements in survival over the others. A lack of improved survival rates with single modality therapies has led to a multi modality approach. However, developments in neoadjuvant and adjuvant therapies have led to mixed conclusions. Collectively, past studies have not shown an optimal neoadjuvant or adjuvant regimen in terms of survival benefit. This review highlights existing staging modalities and treatment regimens for esophageal carcinoma, in an effort to illustrate the controversial nature surrounding its management.

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Systematic review of the staging performance of 18F-fluorodeoxyglucose positron emission tomography in esophageal cancer

PURPOSE

Despite the increasing number of publications concerning (18)F-fluorodeoxyglucose positron emission tomography (FDG-PET) for staging of esophageal cancer and the increasing availability of this novel diagnostic modality, its exact role in preoperative staging of these tumors is still unknown. The aim of this study was to systematically review the literature regarding the diagnostic performance of FDG-PET in preoperative staging of patients with esophageal cancer, and to calculate summary estimates of its sensitivity and specificity.

METHODS

The databases of PubMed, Embase, and Cochrane were searched for relevant studies. Two reviewers independently assessed the methodological quality of each study. A meta-analysis of the reported sensitivity and specificity of each study was performed.

RESULTS

Twelve studies met the inclusion criteria. The studies had several design deficiencies. Pooled sensitivity and specificity for the detection of locoregional metastases were 0.51 (95% CI, 0.34 to 0.69) and 0.84 (95% CI, 0.76 to 0.91), respectively. For distant metastases, pooled sensitivity and specificity were 0.67 (95% CI, 0.58 to 0.76) and 0.97 (95% CI, 0.90 to 1.0), respectively.

CONCLUSION

FDG-PET showed moderate sensitivity and specificity for the detection of locoregional metastases, and reasonable sensitivity and specificity in detection of distant lymphatic and hematogenous metastases.

Multiple management modalities in esophageal cancer: epidemiology, presentation and progression, work-up, and surgical approaches

Annually, approximately 13,200 people in the U.S. are diagnosed with esophageal cancer and 12,500 die of this malignancy. Of new cases, 9,900 occur in men and 3,300 occur in women. In part I of this two-part series, we explore the epidemiology, presentation and progression, work-up, and surgical approaches for esophageal cancer. In the 1960s, squamous cell cancers made up greater than 90% of all esophageal tumors. The incidence of esophageal adenocarcinomas has risen considerably over the past two decades, such that they are now more prevalent than squamous cell cancer in the western hemisphere. Despite advances in therapeutic modalities for this disease, half the patients are incurable at presentation, and overall survival after diagnosis is grim. Evolving knowledge regarding the etiology of esophageal carcinoma may lead to better preventive methods and treatment options for early stage superficial cancers of the esophagus. The use of endoscopic ultrasound and the developing role of positron emission tomography have led to better diagnostic accuracy in this disease. For years, the standard of care for esophageal cancer has been surgery; there are several variants of the surgical approach. We will discuss combined modality approaches in part II of this series.

Self-expandable metallic stents for palliation of malignant esophageal obstruction: special reference to quality of life and survival of patients

SUMMARY. Self-expandable metallic stents (EMS) provide a common option for malignant esophageal stenosis because of the low complication rate and high dysphagia improvement rate. However, there are few studies on the functional duration of EMS and the extent of improvement of the quality of life. We retrospectively analyzed 18 patients who received EMSs in our division from 1996 to 2002. The median duration of possible food intake and the median survival period were 94.5 and 108 days. The median duration of domiciliary treatment was 56 days. Six of the 18 patients were not discharged from hospital after EMS insertion. The Karnofsky index was found to be a significant determinant of the feasibility of domiciliary treatment. One-third of the patients are incapable of obtaining the benefits of the palliative therapy. EMS deployment should be prudently selected for patients exhibiting low performance status.

Patients vivants à 5 ans après œsophagectomie curative pour cancer

AIM OF THE STUDY

To analyse the clinical and pathological parameters of 5-year survival patients after curative oesophageal resection for cancer and to identify factors predictive of long-term survival.

METHODS

The data of 370 patients who underwent oesophagectomy with curative intent from January 1982 for oesophageal squamous cell carcinoma (n = 320) or adenocarcinoma (n = 50) were reviewed. After excluding postoperative deaths (n = 20), these patients were surviving (S group, n = 113) or dead (NS group, n = 237) with a 60-month follow-up. Uni- and multivariate analysis allowed comparison between the two groups.

RESULTS

Postoperative mortality and morbidity rates were 4.0% and 37.6%, respectively. Parameters related to 5-year survival were: absence of preoperative malnutrition or dysphagia, transhiatal resection, no reoperation, limited tumour, histological response to neoadjuvant treatment, absence of lymph node capsular invasion, number of invaded lymph nodes < or = 4, invaded lymph node ratio < or = 0.1, absence of tumour recurrence or metachronous primary cancer. On multivariate analysis, factors predictive of 5-year survival were: absence of preoperative dysphagia (P < 0.001), stage 0-I-IIA tumour (P<0.001) and absence of metachronous cancer (P = 0.016).

CONCLUSION

Complete surgical resection allows 5-year survival. Factors predictive of long-term survival assessed in preoperative evaluation, dysphagia and tumour stage, should be useful to select patients for neoadjuvant treatment.

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Cure of Barrett's carcinoma by ifosfamide chemotherapy

The prognosis of patients with oesophageal cancer is poor, with an overall 5-year survival rate below 15%. The best chance for cure of patients with oesophageal cancer is surgical resection. However, more than 50% of patients have inoperable disease and can only be palliated for dysphagia. Some of these patients participate in studies investigating the activity of single-agent or combination chemotherapy. We report a patient who was cured of metastatic adenocarcinoma in Barrett's oesophagus by six courses of ifosfamide, a chemotherapeutic agent with little or no activity in other patients with adenocarcinoma of the oesophagus or gastro-oesophageal junction. After a follow-up of 13 years and 7 months, no evidence of tumour recurrence was found, while biopsies from the Barrett's oesophagus revealed only low-grade dysplasia. This case obviously raises the question as to how patients with inoperable oesophageal carcinoma can sometimes be cured by chemotherapy alone.

Prognostic factors for the survival of patients with esophageal carcinoma in the U.S.: the importance of tumor length and lymph node status

BACKGROUND

The current TNM classification system does not consider tumor length or the number of lymph nodes in the staging and classification scheme for patients with esophageal carcinoma. Using data from the National Cancer Institute SEER Program, the authors explored the effect of tumor length and number of positive lymph nodes on survival in patients with esophageal carcinoma.

METHODS

Patients with esophageal adenocarcinoma or squamous cell carcinoma were subgrouped according to historic stage with localized, regional, or distant disease. Demographic factors (age at diagnosis, race, and gender) and tumor characteristics (morphology, histologic grade, tumor length, primary site, depth of invasion, number of positive lymph nodes, proportion of positive lymph nodes dissected, and distant metastatic sites) were examined.

RESULTS

Overall factors that were associated with an increased mortality risk included increasing age at diagnosis, black race versus white race, histologic grade, primary tumor site in the lower esophagus and abdomen versus upper regions, and increasing depth of invasion. Among patients with regional disease, the number of positive lymph nodes (>/= 5 vs. < 5) was related to an increasing risk (hazard ratio [HR], 1.29; 95% confidence interval [95%CI], 1.06-1.56). The proportion of positive lymph nodes compared with the number of lymph nodes dissected conferred an increased risk (HR, 1.63; 95%CI, 1.26-2.11). Among patients with distant disease, sites other than distant lymph nodes implied an increased mortality risk (HR, 1.37; 95%CI, 1.37-1.65). Tumor length was an independent predictor of mortality when controlling for depth of invasion in patients with localized disease (HR, 1.15; 95%CI, 1.08-1.21).

CONCLUSIONS

Tumor length, the number of involved lymph nodes, and the ratio of positive lymph nodes are important prognostic factors for survival in patients with esophageal carcinoma. A revised TNM classification system for patients with esophageal carcinoma might consider adding tumor length and number of positive lymph nodes as two important prognostic factors.

Complications of upper GI endoscopy

This is one of a series of statements discussing the utilization of gastrointestinal endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy prepared this text. In preparing this guideline, a MEDLINE literature search was performed, and additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants. When little or no data exist from well-designed prospective trials, emphasis is given to results from large series and reports from recognized experts. Guidelines for appropriate utilization of endoscopy are based on a critical review of the available data and expert consensus. Further controlled clinical studies are needed to clarify aspects of this statement, and revision may be necessary as new data appear. Clinical consideration may justify a course of action at variance to these recommendations.

Surveillance and survival in Barrett's adenocarcinomas: a population-based study

BACKGROUND & AIMS

Guidelines recommend periodic endoscopic surveillance of Barrett's esophagus (BE) patients to detect and treat early esophageal adenocarcinomas; however, no trials or population-based studies exist. We evaluated the association between endoscopic surveillance of BE and survival among esophageal/gastric cardia adenocarcinoma patients.

METHODS

We studied a cohort of 23 BE patients, among 589 esophageal or gastric cardia adenocarcinoma patients diagnosed between 1990-1998 at Northern California Kaiser Permanente (a large health maintenance organization). We measured the presence of BE, detection of cancer by endoscopic surveillance, cancer stage, mortality, and potential confounders.

RESULTS

BE was diagnosed in 135 of 589 adenocarcinoma patients, with 23 BE patients diagnosed greater than 6 months before cancer was diagnosed. Among these 23 patients, 73% of the surveillance-detected cancer patients (n = 15) were alive at the end of follow-up, compared with none of the patients without surveillance-detected cancers (n = 8; P = 0.001). All surveillance-detected cancer patients had low-stage disease and none died directly from cancer. The surveillance/survival association was not substantially altered by stratification for age at BE diagnosis or other potential confounders.

CONCLUSIONS

Surveillance-detected BE-associated adenocarcinomas were associated with low-stage disease and improved survival. Additional studies are needed to evaluate potential biases and whether screening/surveillance programs decrease mortality among all patients in surveillance. Few patients (3.9%) had a BE diagnosed before their cancer. Thus, even if current surveillance techniques are effective, they are unlikely to substantially impact the population's mortality from esophageal cancer; better methods are needed to identify at risk 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.

Predictors of survival for esophageal cancer patients with and without celiac axis lymphadenopathy: impact of staging endosonography

BACKGROUND

Esophageal cancer patients with M1a disease are reported to have poor survival. We hypothesized that patients with celiac lymph node metastases (CLN) identified by endoscopic ultrasonography (EUS) would predict a cohort with significantly worse survival postoperatively. Accurate preoperative identification of this group will facilitate future adjuvant studies.

METHODS

During the study period, 211 patients with esophageal cancer underwent EUS staging. Patients with evaluable celiac axis (n = 182) were included in this study. Survival of patients with and without CLNs was compared and the factors affecting overall survival were assessed. A subgroup analysis based on CLN status was performed in the subgroup of patients who underwent surgical procedures.

RESULTS

Follow-up data was available in 91.2% (166 of 182) of the patients. As staged by EUS, T1, T2, T3, and T4 tumors accounted for 9.3%, 11.5%, 56%, and 21% of the cases, respectively. At least one CLN was imaged by EUS in 40% (72 of 182). The 5-year survival in patients with CLNs detected by EUS was 13% (95% confidence interval, 5% to 21%) compared with 30% (95% confidence interval, 21% to 40%) in patients with no CLNs detected by EUS (p = 0.007). In the subgroup of patients who underwent surgical procedures (n = 68), patients with CLN involvement had worse survival compared with those who did not have malignant involvement of CLNs at the time of their operation (median survival 39.8 versus 13.8 months, p = 0.0008). In a Cox proportional model, adjusting for race and the type of therapy, patients with CLN involvement or advanced EUS American Joint Committee on Cancer stage were more likely to have worse survival (p < 0.05)

CONCLUSIONS

EUS base line findings correlate with long term survival in patients with esophageal cancer. Patients with M1a disease as identified by EUS had a significantly worse postoperative survival when compared with non-M1a patients. This cohort of patients will be ideal for the study of induction therapy since the effect of down staging can be assessed before operation.

Delayed complications after esophageal stent placement for treatment of malignant esophageal obstructions and esophagorespiratory fistulas

PURPOSE

To evaluate delayed complications after esophageal expandable metallic stent placement.

MATERIALS AND METHODS

From April 1993 to December 1997, 90 expandable metallic stents were placed in 82 consecutive patients with inoperable malignant esophageal obstruction (n = 49) or malignant esophagorespiratory fistula (n = 33). Stents used included covered Gianturco-Rosch Z stents (n = 20), Wallstents (covered, n = 31; uncovered, n = 13), and Ultraflex stents (covered, n = 8; uncovered, n = 10). Patients were followed prospectively and monitored for delayed complications, defined as major (hemorrhage, tracheal compression, stent migration, perforation or fistula formation, granulomatous obstruction, tumor ingrowth and overgrowth, funnel phenomenon, and stent covering disruption) or minor (reflux, chest pain, and food impaction).

RESULTS

Mean survival was 4.5 months after stent placement (range, 3 weeks to 26 months). The overall incidence of delayed complications was 64.6%, with 17 patients (20.7%) experiencing more than one complication. The rates of delayed complications in patients with Z stents, Wallstents, and Ultraflex stents were 75.0%, 68.1%, and 44.4%, respectively (P <.05). Most complications were life-threatening and occurred more frequently when stents were placed in the proximal third of the esophagus, compared with more distally (P <.05). Thirteen patients (15.9%) died from complications directly related to stent placement.

CONCLUSION

Esophageal stent placement for malignant obstruction or fistula is associated with a substantial incidence of delayed complications.

Role of endoscopy in staging colorectal cancer

The treatment of colorectal cancer depends in large measure on the depth of tumor invasion and the extent of lymph node involvement. Endoscopic ultrasonography (EUS) has added a new dimension to the evaluation of tumor invasion and lymph node involvement in gastrointestinal cancer. The overall EUS accuracy for colorectal cancer T-staging is 78%, specificity is 73%, and sensitivity is 94%. In determining the nodal involvement by tumor, EUS has an accuracy of 75%, specificity of 73%, and sensitivity of 74%. Comparison with computerized tomography (CT), magnetic resonance imaging (MRI), and MRI with endorectal coil (MRIEC) shows that EUS is an effective single modality for assessing tumor penetration of the rectal wall. It does not, however, allow the assessment of distant metastatic disease. For assessing lymph node involvement, MRIEC offers the most comprehensive information.

Utility of positron emission tomography for the staging of patients with potentially operable esophageal carcinoma

PURPOSE

A prospective study of preoperative tumor-node-metastasis staging of patients with esophageal cancer (EC) was designed to compare the accuracy of 18-F-fluoro-deoxy-D-glucose (FDG) positron emission tomography (PET) with conventional noninvasive modalities.

PATIENTS AND METHODS

Seventy-four patients with carcinomas of the esophagus (n = 43) or gastroesophageal junction (n = 31) were studied. All patients underwent attenuation-corrected FDG-PET imaging, a spiral computed tomography (CT) scan, and an endoscopic ultrasound (EUS).

RESULTS

FDG-PET demonstrated increased activity in the primary tumor in 70 of 74 patients (sensitivity: 95%). False-negative PET images were found in four patients with T1 lesions. Thirty-four patients (46%) had stage IV disease. FDG-PET had a higher accuracy for diagnosing stage IV disease compared with the combination of CT and EUS (82% v 64%, respectively; P: =.004). FDG-PET had additional diagnostic value in 16 (22%) of 74 patients by upstaging 11 (15%) and downstaging five (7%) patients. Thirty-nine (53%) of the 74 patients underwent a 2- or 3-field lymphadenectomy in conjunction with primary curative esophagectomy. In these patients, tumoral involvement was found in 21 local and 35 regional or distant lymph nodes (LN). For local LN, the sensitivity of FDG-PET was lower than EUS (33% v 81%, respectively; P: =.027), but the specificity may have been higher (89% v 67%, respectively; P: = not significant [NS]). For the assessment of regional and distant LN involvement, compared with the combined use of CT and EUS, FDG-PET had a higher specificity (90% v 98%, respectively; P: =. 025) and a similar sensitivity (46% v 43%, respectively; P: = NS).

CONCLUSION

PET significantly improves the detection of stage IV disease in EC compared with the conventional staging modalities. PET improves diagnostic specificity for LN staging.