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

Curriculum for diagnostic endoscopic ultrasound training in Europe: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement

The European Society of Gastrointestinal Endoscopy (ESGE) has recognized the need to formalize and enhance training in diagnostic endoscopic ultrasound (EUS). This manuscript represents the outcome of a formal Delphi process resulting in an official Position Statement of the ESGE and provides a framework to develop and maintain skills in diagnostic EUS. This curriculum is set out in terms of the prerequisites prior to training; the recommended steps of training to a defined syllabus; the quality of training; and how competence should be defined and evidenced before independent practice. 1:  Trainees should have achieved competence in upper gastrointestinal endoscopy before training in diagnostic EUS. 2:  The development of diagnostic EUS skills by methods that do not involve patients is advisable, but not mandatory, prior to commencing formal training in diagnostic EUS. 3:  A trainee's principal trainer should be performing adequate volumes of diagnostic EUSs to demonstrate maintenance of their own competence. 4:  Training centers for diagnostic EUS should offer expertise, as well as a high volume of procedures per year, to ensure an optimal level of quality for training. Under these conditions, training centers should be able to provide trainees with a sufficient wealth of experience in diagnostic EUS for at least 12 months. 5:  Trainees should engage in formal training and supplement this with a range of learning resources for diagnostic EUS, including EUS-guided fine-needle aspiration and biopsy (FNA/FNB). 6:  EUS training should follow a structured syllabus to guide the learning program. 7:  A minimum procedure volume should be offered to trainees during diagnostic EUS training to ensure that they have the opportunity to achieve competence in the technique. To evaluate competence in diagnostic EUS, trainees should have completed a minimum of 250 supervised EUS procedures: 80 for luminal tumors, 20 for subepithelial lesions, and 150 for pancreaticobiliary lesions. At least 75 EUS-FNA/FNBs should be performed, including mostly pancreaticobiliary lesions. 8:  Competence assessment in diagnostic EUS should take into consideration not only technical skills, but also cognitive and integrative skills. A reliable valid assessment tool should be used regularly during diagnostic EUS training to track the acquisition of competence and to support trainee feedback. 9:  A period of supervised practice should follow the start of independent activity. Supervision can be delivered either on site if other colleagues are already practicing EUS or by maintaining contacts with the training center and/or other EUS experts. 10:  Key performance measures including the annual number of procedures, frequency of obtaining a diagnostic sample during EUS-FNA/FNB, and adverse events should be recorded within an electronic documentation system and evaluated.

FDG PET/CT and Endoscopic Ultrasound for Preoperative T-Staging of Esophageal Squamous Cell Carcinoma

This study aimed to compare the diagnostic performances of endoscopic ultrasound (EUS) and FDG PET/CT in the preoperative T-staging of esophageal squamous cell carcinoma (ESCC) and determine whether their innovative coordination achieves better prediction. In total, 100 patients diagnosed with ESCC, 57 without (CRT[-]sub) and 43 with (CRT[+]sub) neoadjuvant chemoradiotherapy, undergoing EUS and FDG PET/CT, followed by surgical resection of the tumor, were included in this analysis. EUS classified T-stages based on the depth of primary tumor invasion, and FDG PET/CT used thresholded maximal standardized uptake value (SUVmax) classifications. By employing pathology results as the reference standard, we assessed the accuracy of EUS and FDG PET/CT, evaluated their concordance using the κ statistic, and conducted a comparative analysis between the two modalities through McNemar's chi-square test. FDG PET/CT had higher overall accuracy than EUS (for CRT[-]sub: 71.9%, κ = 0.56 vs. 56.1%, κ = 0.31, p = 0.06; for CRT[+]sub: 65.1%, κ = 0.50 vs. 18.6%, κ = 0.05, p < 0.01) in predicting pT- and ypT-stage. Our proposed method of incorporating both FDG PET/CT and EUS information could achieve higher accuracies in differentiating between early and locally advanced disease in the CRT[-]sub group (82.5%) and determining residual viable tumor in the CRT[+]sub group (83.7%) than FDG PET/CT or EUS alone. FDG PET/CT had a better diagnostic ability than EUS to predict the (y)pT-stage of ESCC. Our complementary method, which combines the advantages of both imaging modalities, can deliver higher accuracy for clinical applications of ESCC.

The Role of Magnetic Resonance Imaging in the Management of Esophageal Cancer

Esophageal cancer (EC) is the eighth more frequent cancer worldwide, with a poor prognosis. Initial staging is critical to decide on the best individual treatment approach. Current modalities for the assessment of EC are irradiating techniques, such as computed tomography (CT) and positron emission tomography/CT, or invasive techniques, such as digestive endoscopy and endoscopic ultrasound. Magnetic resonance imaging (MRI) is a non-invasive and non-irradiating imaging technique that provides high degrees of soft tissue contrast, with good depiction of the esophageal wall and the esophagogastric junction. Various sequences of MRI have shown good performance in initial tumor and lymph node staging in EC. Diffusion-weighted MRI has also demonstrated capabilities in the evaluation of tumor response to chemoradiotherapy. To date, there is not enough data to consider whole body MRI as a routine investigation for the detection of initial metastases or for prediction of distant recurrence. This narrative review summarizes the current knowledge on MRI for the management of EC.

Clinical Risk Prediction Model for Neoadjuvant Therapy in Resectable Esophageal Adenocarcinoma

GOALS AND BACKGROUND

Clinical staging with endoscopic ultrasound (EUS) and positron emission tomography (PET) is used to identify esophageal adenocarcinoma (EAC) patients with locally advanced disease and therefore, benefit from neoadjuvant therapy. However, EUS is operator dependent and subject to interobserver variability. Therefore, we aimed to identify clinical predictors of locally advanced EAC and build a predictive model that can be used as an adjunct to current staging methods.

STUDY

This was a cross-sectional study of patients with EAC who underwent preoperative staging with EUS and PET scan followed by definitive therapy at our institution from January 2011 to December 2017. Demographic data, symptoms, endoscopic findings, EUS, and PET scan findings were obtained.

RESULTS

Four hundred and twenty-six patients met the study criteria, of which 86 (20.2%) patients had limited stage EAC and 340 (79.8%) had locally advanced disease. The mean age was 65.4±10.3 years of which 356 (83.6%) were men and 393 (92.3%) were White. On multivariable analysis, age (above 75 or below 65 y), dysphagia [odds ratio (OR): 2.84], weight loss (OR: 2.06), protruding tumor (OR: 2.99), and tumor size >2 cm (OR: 3.3) were predictive of locally advanced disease, while gastrointestinal bleeding (OR: 0.36) and presence of visible Barrett's esophagus (OR: 0.4) were more likely to be associated with limited stage. A nomogram for predicting the risk of locally advanced EAC was constructed and internally validated.

CONCLUSIONS

We constructed a nomogram to facilitate an individualized prediction of the risk of locally advanced EAC. This model can aid in decision making for neoadjuvant therapy in EAC.

Role of Endoscopic Ultrasound in Selecting Superficial Esophageal Cancers for Endoscopic Resection

BACKGROUND

Endoscopic submucosal dissection (ESD) is a curative treatment option for superficial esophageal cancer with a minimal risk for lymph node metastasis. Before ESD, accurate clinical staging is important to select the appropriate candidate. We aimed to estimate the practicality of endoscopic ultrasound (EUS) to select pTis and pT1a.

METHODS

We included patients with squamous esophageal cancers who underwent surgical resection or ESD between 2005 and 2018. Pathologic reports were reviewed retrospectively, and pathologic T staging was compared with clinical stage evaluated by EUS.

RESULTS

Among 532 patients, 321 had superficial esophageal cancer (pTis: 42; pT1a: 115; and pT1b: 164). Accuracy rates, sensitivity, specificity, positive predicted value, and negative predicted value for selecting cT1a by EUS were 82.3%, 60.5%, 91.5%, 74.8%, and 84.7%, respectively. The rate of overstaged pTis-T1a was 39.5%. Upon multivariable analysis, tumor size (>2 cm), poor differentiation, protruding gross type, and use of conventional EUS (versus miniprobe) were associated factors for overstaging of pTis-T1a.

CONCLUSIONS

The accuracy of prediction of EUS for selecting mucosal esophageal cancer that can be treated with ESD was favorable. Target lesions with a large size (>2 cm), poor differentiation, and protruding morphology were related to T overstaging; precaution should be taken when evaluating the clinical stage for cancers with those conditions. Furthermore, miniprobe EUS provides higher accuracy for squamous esophageal cancers confined to mucosa.

Accuracy of endoscopic ultrasound in esophageal cancer staging

Since its advent in the 1980s endoscopic ultrasound (EUS) has played an important role in the diagnosis, staging, and therapeutic management of various gastrointestinal malignancies. EUS has emerged as a vital tool in the evaluation of esophageal cancer as it provides a detailed view of the layers of the esophageal wall and surrounding tissues. This permits determination of tumor invasion depth and local lymph node metastases. It is the most sensitive and specific method available for locoregional staging of esophageal cancer. The information obtained via EUS is vital in determining the appropriate diagnosis, prognosis, and treatment options. Thus, this article aims to present a review of the accuracy and utilization of EUS in the staging of esophageal cancer.

Spectral Computed Tomography for the Quantitative Assessment of Patients With Carcinoma of the Gastroesophageal Junction: Initial Differentiation Between a Diagnosis of Squamous Cell Carcinoma and Adenocarcinoma

OBJECTIVE

This study aimed to distinguish between esophageal squamous cell carcinoma (ESCC) and esophageal adenocarcinoma (EAC) using spectral computed tomography (CT) and to discuss the accuracy according to an optimal threshold of single and combined parameters.

METHODS

In this monoinstitution study, 61 patients, 35 of whom had ESCC and 26 had EAC confirmed by surgery or esophagoscopy, were recruited from August 2016 to March 2017. Enrolled patients underwent dual-phase chest CT enhancement. The spectral CT parameters (NIC, NICD, NICratio, Zeff, Zeff-C, K40-70 keV, K80-100 keV, and K110-140 keV) were measured during arterial phase (AP) and venous phase (VP). Binary logistic regression was used to calculate combined predictive probability. Thresholds of quantitative parameters and diagnostic accuracy were calculated using receiver operating characteristic curve.

RESULTS

Compared with ESCC, higher NICAP, NICVP, NICD, Zeff AP, Zeff VP, Zeff-C AP, and Zeff-C VP were observed for EAC, whereas NICratio was lower for EAC. Higher K40-70 keV, K80-100 keV, and K110-140 keV were exhibited in EAC than in ESCC. Area under the curve (AUC) of NICAP, K40-70 keV AP, and Zeff AP were 0.720, 0.730, and 0.706, respectively. The area under the curve of new combined predictive value of NICAP and λ40-0 keV AP was 0.804. The sensitivity and specificity were 77.80% and 80.60%, respectively, when the threshold of new predictive value was 0.60.

CONCLUSION

The diagnostic accuracy obtained by using NICAP and K40-70 keV AP combined is better than that obtained using a single parameter in differentiation between a diagnosis of squamous cell carcinoma and adenocarcinoma.

Feasibility of using optical coherence tomography to detect radiation-induced fibrosis and residual cancer extent after neoadjuvant chemo-radiation therapy: an ex vivo study

Treatment of resectable esophageal cancer includes neoadjuvant chemo-radiation therapy (nCRT) followed by esophagectomy in operable patients. High-risk surgery may have been avoided in patients with a pathological complete response (pCR). We investigated the feasibility of optical coherence tomography (OCT) to detect residual cancer and radiation-induced fibrosis in 10 esophageal cancer patients that underwent nCRT followed by esophagectomy. We compared our OCT findings with histopathology. Overall, OCT was able to differentiate between healthy tissue, fibrotic tissue, and residual cancer with a sensitivity and specificity of 79% and 67%, respectively. Hence, OCT has the potential to add to the assessment of a pCR.

The emerging field of radiomics in esophageal cancer: current evidence and future potential

'Radiomics' is the name given to the emerging field of extracting additional information from standard medical images using advanced feature analysis. This innovative form of quantitative image analysis appears to have future potential for clinical practice in patients with esophageal cancer by providing an additional layer of information to the standard imaging assessment. There is a growing body of evidence suggesting that radiomics may provide incremental value for staging, predicting treatment response, and predicting survival in esophageal cancer, for which the current work-up has substantial limitations. This review outlines the available evidence and future potential for the application of radiomics in the management of patients with esophageal cancer. In addition, an overview of the current evidence on the importance of reproducibility of image features and the substantial influence of varying smoothing scales, quantization levels, and segmentation methods is provided.

Endoscopic ultrasonography for staging depth of invasion in early gastric cancer: A meta-analysis

BACKGROUND AND AIM

Endoscopic ultrasonography (EUS) is a widely used imaging modality for detecting the depth of early gastric cancer (EGC) invasion. However, the studies pertaining to EUS for staging early gastric cancer have reported widely varied sensitivities and specificities. This study was conducted to estimate the overall diagnostic accuracy of EUS for staging the depth in EGCs.

METHODS

The literatures were identified by searching in PubMed, Embase, and Web of Knowledge databases. Two reviewers independently extracted the information from the literatures for constructing 2 × 2 table. A random-effect model or a fixed-effect model was used to estimate the sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio. A summary receiver operating characteristic curve also was constructed. Meta-regression and subgroup analysis were used to explore the sources of heterogeneity.

RESULTS

The pooled sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of EUS for M staging were 76% (95% confidence interval [CI], 74-78%), 72% (95% CI, 69-75%), 3.67 (95% CI, 2.48-5.44), and 0.31 (95% CI, 0.24-0.40), respectively. For SM staging, these results were 62% (95% CI, 59-66%), 78% (95% CI, 76-80%), 2.99 (95% CI, 2.26-3.96), and 0.43 (95% CI, 0.32-0.57), respectively. For M/SM1 staging, they were 90% (95% CI, 88-92%), 67% (95% CI, 61-72%), 3.14 (95% CI, 2.08-4.73), and 0.12 (95% CI, 0.07-0.22), respectively. The area under the curve for mucosal, submucosal, and mucosal/minimal submucosal invasion staging were 0.85, 0.82, and 0.81, respectively.

CONCLUSIONS

Endoscopic ultrasonography only has a relatively low accuracy for staging the depth of invasion in EGCs. Accordingly, EUS may be not indispensable in the staging of EGCs.

Staging accuracy of endoscopic ultrasound performed by nonexpert endosonographers in patients with resectable esophageal squamous cell carcinoma: is it possible?

The accuracy of endoscopic ultrasound (EUS) is operator-dependent. According to learning curve study, the accuracy of EUS T-staging for esophageal cancer has been reported to be greater in an investigator who had performed at least 100 EUS examinations. We determined comparative study regarding T-staging accuracy of EUS for esophageal squamous cell carcinoma between expert and nonexpert endoscopic ultrasonographers. We retrospectively identified 73 consecutive patients with esophageal squamous cell carcinoma who underwent EUS and endoscopic mucosal resection, endoscopic submucosal dissection, or surgery. EUS was performed by expert (Group 1) and nonexpert (Group 2) endoscopic ultrasonographers in multitertiary hospitals. Groups 1 and 2 were 37 and 36 patients during 2005-2011, respectively. Forty-two patients (57.5%) of the overall patients underwent surgical exploration. Correct endoscopic ultrasonographic T-staging of Group 1 was observed in 34 (91.9%) patients, while that of Group 2 was observed in 26 (72.2%) patients. And there was significant difference in correct endoscopic ultrasonographic T-staging between Group 1 and Group 2 (P = 0.035). The incorrect endoscopic ultrasonographic T-staging of Group 1 were three cases that were overstaging (8.1%), but in Group 2 there were seven overstaging (19.4%) and three understaging (8.3%). There was no significant difference in overstaging or understaging of incorrect endoscopic ultrasonographic T-staging between Group 1 and Group 2 (P = 0.528). This study first provides evidence that endoscopic ultrasonographic T-staging of nonexpert endoscopic ultrasonographers was inferior to be correct, compared with that of expert endoscopic ultrasonographers. EUS staging for esophageal cancer should be performed by expert endoscopic ultrasonographers to provide appropriate management strategy.

Hospital of diagnosis and probability to receive a curative treatment for oesophageal cancer

BACKGROUND

Surgical treatment of oesophageal cancer in the Netherland is performed in high volume centres. However, the decision to refer patients for curative surgery is made in the referring hospital of diagnosis. The objective of this study was to determine the influence of hospital of diagnosis on the probability of receiving a curative treatment and survival.

MATERIAL AND METHOD

All patients with resectable oesophageal cancer (cT1-3, cN0-3, cM0-1A) diagnosed between 2003 and 2010 (n = 849) were selected from the population-based Eindhoven Cancer Registry, an area with ten non-academic hospitals. Multivariate logistic regression analysis was conducted to examine the independent influence of hospital of diagnosis on the probability to receive curative treatment. Furthermore, the effect of hospital of diagnosis on overall survival was examined using multivariate Cox regression analysis.

RESULTS

849 patients were included in the study. A difference in proportion of patients referred for surgery was observed ranging from 33% to 67% (p = 0.002) between hospitals of diagnosis. Multivariate logistic regression analysis confirmed the effect of hospital of diagnosis on the chance of undergo curative treatment (OR 0.1, 95% CI 0.1-0.4). Multivariate Cox regression analysis showed that hospital of diagnosis also had an effect on overall survival, up to hazard ratio (HR) 2.2 (95% CI 1.3-3.7).

CONCLUSION

There is a strong relation between hospital of diagnosis and the chance of referring patients with oesophageal cancer for a curative treatment as well as overall survival. Patients diagnosed with oesophageal cancer should be discussed within a regional multidisciplinary expert panel.

Imaging strategies in the management of oesophageal cancer: what's the role of MRI?

OBJECTIVES

To outline the current role and future potential of magnetic resonance imaging (MRI) in the management of oesophageal cancer regarding T-staging, N-staging, tumour delineation for radiotherapy (RT) and treatment response assessment.

METHODS

PubMed, Embase and the Cochrane library were searched identifying all articles related to the use of MRI in oesophageal cancer. Data regarding the value of MRI in the areas of interest were extracted in order to calculate sensitivity, specificity, predictive values and accuracy for group-related outcome measures.

RESULTS

Although historically poor, recent improvements in MRI protocols and techniques have resulted in better imaging quality and the valuable addition of functional information. In recent studies, similar or even better results have been achieved using optimised MRI compared with other imaging strategies for T- and N-staging. No studies clearly report on the role of MRI in oesophageal tumour delineation and real-time guidance for RT so far. Recent pilot studies showed that functional MRI might be capable of predicting pathological response to treatment and patient prognosis.

CONCLUSIONS

In the near future MRI has the potential to bring improvement in staging, tumour delineation and real-time guidance for RT and assessment of treatment response, thereby complementing the limitations of currently used imaging strategies.

KEY POINTS

• MRI's role in oesophageal cancer has been somewhat limited to date. • However MRI's ability to depict oesophageal cancer is continuously improving. • Optimising TN-staging, radiotherapy planning and response assessment ultimately improves individualised cancer care. • MRI potentially complements the limitations of other imaging strategies regarding these points.

Advances in endoluminal therapy for esophageal cancer

Advances in endoscopic therapy have resulted in dramatic changes in the way early esophageal cancer is managed as well as in the palliation of dysphagia related to advanced esophageal cancer. Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are effective therapies for accurate histopathologic staging and provide a potential for complete cure. Mucosal ablative techniques (radiofrequency ablation and cryotherapy) are effective adjuncts to EMR and ESD and reduce the occurrence of synchronous and metachronous lesions within the Barrett esophagus. The successes of these techniques have made endoscopic therapy the primary means of management of early esophageal cancer.

Diagnostic accuracy of EUS in differentiating mucosal versus submucosal invasion of superficial esophageal cancers: a systematic review and meta-analysis

BACKGROUND

The prognosis of esophageal cancer (EC) depends on the depth of tumor invasion and lymph node metastasis. EC limited to the mucosa (T1a) can be treated effectively with minimally invasive endoscopic therapy, whereas submucosal (T1b) EC carries relatively high risk of lymph node metastasis and requires surgical resection.

OBJECTIVE

To determine the diagnostic accuracy of EUS in differentiating T1a EC from T1b EC.

DESIGN

We performed a comprehensive search of MEDLINE, SCOPUS, Cochrane, and CINAHL Plus databases to identify studies in which results of EUS-based staging of EC were compared with the results of histopathology of EMR or surgically resected esophageal lesions. DerSimonian-Laird random-effects model was used to estimate the pooled sensitivity, specificity, and likelihood ratio, and a summary receiver operating characteristic (SROC) curve was created.

SETTING

Meta-analysis of 19 international studies.

PATIENTS

Total of 1019 patients with superficial EC (SEC).

INTERVENTIONS

EUS and EMR or surgical resection of SEC.

MAIN OUTCOME MEASUREMENTS

Sensitivity and specificity of EUS in accurately staging SEC.

RESULTS

The pooled sensitivity, specificity, and positive and negative likelihood ratio of EUS for T1a staging were 0.85 (95% CI, 0.82-0.88), 0.87 (95% CI, 0.84-0.90), 6.62 (95% CI, 3.61-12.12), and 0.20 (95% CI, 0.14-0.30), respectively. For T1b staging, these results were 0.86 (95% CI, 0.82-0.89), 0.86 (95% CI, 0.83-0.89), 5.13 (95% CI, 3.36-7.82), and 0.17 (95% CI, 0.09-0.30), respectively. The area under the curve was at least 0.93 for both mucosal and submucosal lesions.

LIMITATIONS

Heterogeneity was present among the studies.

CONCLUSION

Overall EUS has good accuracy (area under the curve ≥0.93) in staging SECs. Heterogeneity among the included studies suggests that multiple factors including the location and type of lesion, method and frequency of EUS probe, and the experience of the endosonographer can affect the diagnostic accuracy of EUS.

Service provision and training for endoscopic ultrasound in the UK

Endoscopic ultrasound (EUS) is a standard procedure that plays an important role in the management of both malignant and benign disease. The development of EUS services in the UK has been haphazard and training inconsistent. The British Society of Gastroenterology has charged a working group with the task of laying down a national framework for how such services might be commissioned, structured and regulated; with particular attention to defining how endoscopist skills might be acquired, assessed and maintained. This report lays out a map for this process and its future revision.

Quality indicators of surgery for adenocarcinoma of the esophagus and gastroesophageal junction

Surgical treatment of adenocarcinoma of the esophagus and gastroesophageal junction is complex and challenging. Huge variation exist in the immediate and long term outcomes of such interventions and it is generally accepted that this is a direct consequence of the experience of the surgical team. However beside surgical quality many other indicators of quality management may influence outcome. Definition of the gastroesophageal junction remains controversial and the performance of staging procedures i.e. CT scan, endoscopy and fine needle aspiration, PET scan still suboptimal. As a result there is disagreement on the selection of patients for surgery, type of surgical approach in particular in relation to the extent of lymph node dissection as well as the extent of esophageal and/or gastric resection. In the design of randomized controlled trials comparing primary surgery versus multimodality treatment surgical quality criteria are notoriously lacking. It therefore remains a matter of debate which patients eventually will benefit from primary surgery versus those who will benefit from induction therapy. A lack of surgical quality indicators is also very prominent when assessing the value of new surgical technologies such as minimally invasive surgery or robotic surgery. Improvements in this wide spectrum of aspects is mandatory and will certainly be of great value to further improve both short and long term outcome after surgery for these complex cancers.

Performance of EUS-FNA for mediastinal lymphadenopathy: impact on patient management and costs in low-volume EUS centers

Background

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) of mediastinal lymphadenopathy has been shown to be a valuable diagnostic tool in high-volume EUS centers (≥50 mediastinal EUS-FNA/endoscopist/year). Our goal was to assess the diagnostic accuracy of EUS-FNA and its impact on clinical management and costs in low-volume EUS centers (<50 mediastinal EUS-FNA/endoscopist/year).

Methods

Consecutive patients referred to two Dutch endoscopy centers in the period 2002–2008 for EUS-FNA of mediastinal lymphadenopathy were reviewed. The gold standard for a cytological diagnosis was histological confirmation or clinical follow-up of more than 6 months with repeat imaging. The impact of EUS-FNA on clinical management was subdivided into a positive impact by providing (1) adequate cytology that influenced the decision to perform surgery or (2) a diagnosis of a benign inflammatory disorder, and a negative impact which was subdivided into (1) false-negative or inconclusive cytology or (2) an adequate cytological diagnosis that did not influence patient management. Costs of an alternative diagnostic work-up without EUS-FNA, as established by an expert panel, were compared to costs of the actual work-up.

Results

In total, 213 patients (71% male, median age = 61 years, range = 23–88 years) underwent EUS-FNA. Sensitivity, specificity, and negative and positive predictive values were 89%, 100%, 80%, and 100%, respectively. EUS-FNA had a positive impact on clinical management in 84% of cases by either influencing the decision to perform surgery (49%) or excluding malignant lymphadenopathy (35%), and a negative impact in 7% of cases because of inadequate (3%) or false-negative (4%) cytology. In 9% of cases, EUS-FNA was performed without an established indication. Two nonfatal perforations occurred (0.9%). Total cost reduction was €100,593, with a mean cost reduction of €472 (SD = €607) per patient.

Conclusions

Mediastinal EUS-FNA can be performed in low-volume EUS centers without compromising diagnostic accuracy. Moreover, EUS-FNA plays an important role in the management of patients with mediastinal lymphadenopathy and reduces total diagnostic costs.

In vivo characterization of pancreatic and lymph node tissue by using EUS spectrum analysis: a validation study

BACKGROUND

Quantitative spectral analysis of the radiofrequency (RF) signals that underlie grayscale EUS images can be used to provide additional, objective information about tissue state.

OBJECTIVE

Our purpose was to validate RF spectral analysis as a method to distinguish between (1) benign and malignant lymph nodes and (2) normal pancreas, chronic pancreatitis, and pancreatic cancer.

DESIGN AND SETTING

A prospective validation study of eligible patients was conducted to compare with pilot study RF data.

PATIENTS

Forty-three patients underwent EUS of the esophagus, stomach, pancreas, and surrounding intra-abdominal and mediastinal lymph nodes (19 from a previous pilot study and 24 additional patients).

MAIN OUTCOME MEASUREMENTS

Midband fit, slope, intercept, and correlation coefficient from a linear regression of the calibrated RF power spectra were determined.

RESULTS

Discriminant analysis of mean pilot-study parameters was then performed to classify validation-study parameters. For benign versus malignant lymph nodes, midband fit and intercept (both with t test P < .058) provided classification with 67% accuracy and area under the receiver operating curve (AUC) of 0.86. For diseased versus normal pancreas, midband fit and correlation coefficient (both with analysis of variance P < .001) provided 93% accuracy and an AUC of 0.98. For pancreatic cancer versus chronic pancreatitis, the same parameters provided 77% accuracy and an AUC of 0.89. Results improved further when classification was performed with all data.

LIMITATIONS

Moderate sample size and spatial averaging inherent to the technique.

CONCLUSIONS

This study confirms that mean spectral parameters provide a noninvasive method to quantitatively discriminate benign and malignant lymph nodes as well as normal and diseased pancreas.

Endosonographic staging of upper intestinal malignancy

Numerous studies conducted over the last 25 years provide evidence on the high diagnostic accuracy and important role of endoscopic ultrasonography (EUS) in staging oesophageal and gastric carcinoma. This extensive research was recently subjected to metaanalyses, condensing our knowledge on EUS performance and facilitating its comparison with competing methods. It is, however, important to realise that the management of oesophageal and gastric carcinoma is evolving and so are staging algorithms, setting new challenges for EUS and re-defining its position. Restaging after neoadjuvant treatment and precise assessment of early carcinoma before endoscopic treatment are areas of growing interest, but the role of EUS in these settings is rather limited. Rapidly developing cross-sectional imaging has the potential to challenge the position of EUS as the most accurate method in loco-regional staging. On the other hand, EUS guided fine-needle aspiration offers the unique opportunity to obtain cytological confirmation of lymph node metastases, with future potential for molecular staging.

Esophageal cancer

The incidence of esophageal cancer, in particular esophageal adenocarcinoma, is increasing, largely due to an increase in risk factors for adenocarcinoma. When esophageal cancer is confirmed by upper endoscopy, staging is required for the optimal selection of patients who should undergo esophageal resection. Neoadjuvant chemoradiation may be able to improve survival after esophageal cancer surgery. Endoscopic therapy for early esophageal neoplasia is effective and safe, with the best results being obtained by an individualized approach using endoscopic mucosal resection, ablative therapy, or both. Finally, dysphagia from esophageal cancer can be successfully treated with stent placement or single-dose brachytherapy. Future research should establish whether combinations of chemotherapy with or without radiation therapy play a role in survival.

Analysis of gene expression identifies differentially expressed genes and pathways associated with lymphatic dissemination in patients with adenocarcinoma of the esophagus

INTRODUCTION

The presence of lymphatic dissemination is an important predictor of survival in esophageal adenocarcinoma (EA). The aim of this study was to discover a prognostic gene expression profile for lymphatic dissemination in EA and to identify genes and pathways that provide oncological insight in lymphatic dissemination.

METHODS

Patients who had lymphatic dissemination (N = 55) were compared with patients without lymphatic dissemination (N = 22). Whole-genome oligonucleotide microarrays were used to evaluate the genetic signature of 77 esophageal cancers. Multiple random validation was used to analyze the stability of the molecular signature and predictive power. Gene set enrichment analysis (GSEA) was applied to elucidate oncogenetic pathways.

RESULTS

Lymphatic dissemination was correctly predicted in 75 +/- 14% of lymph node positive patients. The absence of lymphatic dissemination was correctly predicted in 41 +/- 23% of lymph-node-negative patients. Argininosuccinate synthetase (ASS) was selected for validation on the protein level because it was present in most prognostic signatures as well as the list of differentially expressed genes. ASS expression was lower (P = 0.048) in patients with lymphatic dissemination than in patients without. GSEA identified that arginine metabolism pathways and lipid metabolism pathways are related to less chance of developing lymphatic dissemination.

DISCUSSION

The predictive profile does not outperform current clinical practice to predict the presence of lymphatic dissemination in patients with EA. Several genes, including ASS, and genetic pathways which are important in the development of lymphatic dissemination in EA, were identified.

Prognostic significance of failure to cross esophageal tumors by endoluminal ultrasound

Failure to intubate and cross esophageal tumors by endosonography is reported in as many as 30% of cases and is thought to be associated with an especially poor prognosis. The aim of this study was to audit the above in a large consecutive case series of Endoscopic Ultrasound (EUS) examinations for esophageal cancer performed in a regional specialist cancer network with particular reference to outcome. A consecutive series of 411 patients underwent EUS examination by a specialist radiologist over a period of 9 years. Forty (10%) of patients required dilation, and there was total failure to cross the tumor in 12 patients (2.9%). Failure to traverse the primary tumor was associated with a diagnosis of squamous cell cancer (8 of 12 patients, 66%, rho = -0.182, P = 0.011). Limited staging information was obtained in 7 of these patients, which altered the computed tomography stage in 5 patients (71%, 3 upstaged, 2 downstaged). Six patients received definitive chemoradiotherapy, two patients surgery and four patients palliative chemotherapy. The median and 5-year survival in patients whose tumors were not crossed was 10 months and 28%, respectively, compared with 24 months and 24%, respectively in patients whose tumors were fully assessed. Failure to cross esophageal tumors in practice was far less common than the literature suggests, and esophageal tumor luminal stenosis should no longer be considered a limitation of endosonography.

Endoscopic ultrasound with conventional probe and miniprobe in preoperative staging of esophageal cancer

BACKGROUND

Using an endoscopic ultrasound (EUS) miniprobe, even highly stenotic esophageal cancers precluding the passage of a conventional probe can be examined without prior dilatation.

OBJECTIVE

To assess: (1) staging accuracy of conventional EUS probe and miniprobe, (2) variables influencing staging accuracy, (3) endoscopic features predicting tumor stage.

METHODS

Ninety-seven consecutive patients with esophageal cancer undergoing complete surgical resection were included. Preoperative EUS was performed using a conventional probe in nonstenotic tumors and a miniprobe in stenotic tumors. Accuracy of EUS for T and N stages was compared to pathohistological staging.

RESULTS

Overall EUS staging accuracy was 73.2% for T stage and 74.2% for N stage. It was similar for the miniprobe used in stenotic tumors vs the conventional probe used in nonstenotic tumors. Based on EUS, 84.5% of the patients would have been assigned to the appropriate therapy protocol (primary surgery vs neoadjuvant therapy). Endoscopic tumor features had no influence on staging accuracy. Tumor length >5 cm predicted advanced T and nodal positive stages.

CONCLUSIONS

The miniprobe allows adequate EUS staging of stenotic esophageal tumors precluding the passage of a conventional probe. Therefore, dilatation therapy of stenotic cancers to conduct conventional EUS should be avoided.

Staging investigations for oesophageal cancer: a meta-analysis

The aim of the study was to compare the diagnostic performance of endoscopic ultrasonography (EUS), computed tomography (CT), and ¹⁸F-fluoro-2-deoxy-D-glucose positron emission tomography (FDG-PET) in staging of oesophageal cancer. PubMed was searched to identify English-language articles published before January 2006 and reporting on diagnostic performance of EUS, CT, and/or FDG-PET in oesophageal cancer patients. Articles were included if absolute numbers of true-positive, false-negative, false-positive, and true-negative test results were available or derivable for regional, celiac, and abdominal lymph node metastases and/or distant metastases. Sensitivities and specificities were pooled using a random effects model. Summary receiver operating characteristic analysis was performed to study potential effects of study and patient characteristics. Random effects pooled sensitivities of EUS, CT, and FDG-PET for regional lymph node metastases were 0.80 (95% confidence interval 0.75–0.84), 0.50 (0.41–0.60), and 0.57 (0.43–0.70), respectively, and specificities were 0.70 (0.65–0.75), 0.83 (0.77–0.89), and 0.85 (0.76–0.95), respectively. Diagnostic performance did not differ significantly across these tests. For detection of celiac lymph node metastases by EUS, sensitivity and specificity were 0.85 (0.72–0.99) and 0.96 (0.92–1.00), respectively. For abdominal lymph node metastases by CT, these values were 0.42 (0.29–0.54) and 0.93 (0.86–1.00), respectively. For distant metastases, sensitivity and specificity were 0.71 (0.62–0.79) and 0.93 (0.89–0.97) for FDG-PET and 0.52 (0.33–0.71) and 0.91 (0.86–0.96) for CT, respectively. Diagnostic performance of FDG-PET for distant metastases was significantly higher than that of CT, which was not significantly affected by study and patient characteristics. The results suggest that EUS, CT, and FDG-PET each play a distinctive role in the detection of metastases in oesophageal cancer patients. For the detection of regional lymph node metastases, EUS is most sensitive, whereas CT and FDG-PET are more specific tests. For the evaluation of distant metastases, FDG-PET has probably a higher sensitivity than CT. Its combined use could however be of clinical value, with FDG-PET detecting possible metastases and CT confirming or excluding their presence and precisely determining the location(s).

EUS spectrum analysis for in vivo characterization of pancreatic and lymph node tissue: a pilot study

BACKGROUND

EUS is limited by variability in the examiner's subjective interpretation of B-scan images to differentiate among normal, inflammatory, and malignant tissue. By using information otherwise discarded by conventional EUS systems, quantitative spectral analysis of the raw radiofrequency (RF) signals underlying EUS images enables tissue to be characterized more objectively.

OBJECTIVE

Our purpose was to determine the feasibility of using spectral analysis of EUS data for characterization of pancreatic tissue and lymph nodes.

DESIGN AND SETTING

A pilot study of eligible patients was conducted to analyze the RF data obtained during EUS by using spectral parameters.

PATIENTS

Twenty-one subjects who underwent EUS of the esophagus, stomach, pancreas, and surrounding intra-abdominal and mediastinal lymph nodes.

MAIN OUTCOME MEASUREMENTS

Linear regression parameters of calibrated power spectra of the RF signals were tested to differentiate normal pancreas from chronic pancreatitis and from pancreatic cancer as well as benign from malignant-appearing lymph nodes.

RESULTS

The mean intercept, slope, and midband fit of the spectra differed significantly among normal pancreas, adenocarcinoma, and chronic pancreatitis when all were compared with each other (P < .01). On direct comparison, mean midband fit for adenocarcinoma differed significantly from that for chronic pancreatitis (P < .05). For lymph nodes, mean midband fit and intercept differed significantly between benign- and malignant-appearing lymph nodes (P < .01 and P < .05, respectively).

LIMITATIONS

Small sample population and spatial averaging inherent to this technique.

CONCLUSIONS

Mean spectral parameters in EUS imaging can provide a noninvasive method to discriminate normal from diseased pancreas and lymph nodes.

Detection of distant metastases in patients with oesophageal or gastric cardia cancer: a diagnostic decision analysis

Computed tomography (CT) is presently a standard procedure for the detection of distant metastases in patients with oesophageal or gastric cardia cancer. We aimed to determine the additional diagnostic value of alternative staging investigations. We included 569 oesophageal or gastric cardia cancer patients who had undergone CT neck/thorax/abdomen, ultrasound (US) abdomen, US neck, endoscopic ultrasonography (EUS), and/or chest X-ray for staging. Sensitivity and specificity were first determined at an organ level (results of investigations, i.e., CT, US abdomen, US neck, EUS, and chest X-ray, per organ), and then at a patient level (results for combinations of investigations), considering that the detection of distant metastases is a contraindication to surgery. For this, we compared three strategies for each organ: CT alone, CT plus another investigation if CT was negative for metastases (one-positive scenario), and CT plus another investigation if CT was positive, but requiring that both were positive for a final positive result (two-positive scenario). In addition, costs, life expectancy and quality adjusted life years (QALYs) were compared between different diagnostic strategies. CT showed sensitivities for detecting metastases in celiac lymph nodes, liver and lung of 69, 73, and 90%, respectively, which was higher than the sensitivities of US abdomen (44% for celiac lymph nodes and 65% for liver metastases), EUS (38% for celiac lymph nodes), and chest X-ray (68% for lung metastases). In contrast, US neck showed a higher sensitivity for the detection of malignant supraclavicular lymph nodes than CT (85 vs 28%). At a patient level, sensitivity for detecting distant metastases was 66% and specificity was 95% if only CT was performed. A higher sensitivity (86%) was achieved when US neck was added to CT (one-positive scenario), at the same specificity (95%). This strategy resulted in lower costs compared to CT only, at an almost similar (quality adjusted) life expectancy. Slightly higher specificities (97–99%) were achieved if liver and/or lung metastases found on CT, were confirmed by US abdomen or chest X-ray, respectively (two-positive scenario). These strategies had only slightly higher QALYs, but substantially higher costs. The combination of CT neck/thorax/abdomen and US neck was most cost-effective for the detection of metastases in patients with oesophageal or gastric cardia cancer, whereas the performance of CT only had a lower sensitivity for metastases detection and higher costs. The role of EUS seems limited, which may be due to the low number of M1b celiac lymph nodes detected in this series. It remains to be determined whether the application of positron emission tomography will further increase sensitivities and specificities of metastases detection without jeopardising costs and QALYs.