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Foley KG, Franklin J, Jones CM, Coles B, Roberts SA, Underwood TJ, Crosby T. The impact of endoscopic ultrasound on the management and outcome of patients with oesophageal cancer: an update of a systematic review. Clin Radiol 2022; 77:e346-e355. [PMID: 35289292 DOI: 10.1016/j.crad.2022.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 02/01/2022] [Indexed: 11/30/2022]
Abstract
AIM To provide an updated systematic review concerning the impact of endoscopic ultrasound (EUS) in the modern era of oesophageal cancer staging. MATERIALS AND METHODS To update the previous systematic review, databases including MEDLINE and EMBASE were searched and studies published from 2005 onwards were selected. Studies reporting primary data in patients with oesophageal or gastro-oesophageal junction cancer who underwent radiological staging and treatment, regardless of intent, were included. The primary outcome was the reported change in management after EUS. Secondary outcomes were recurrence rate and overall survival. Two reviewers extracted data from included articles. This study was registered with PROSPERO (CRD42021231852). RESULTS Eighteen studies with 11,836 patients were included comprising 2,805 patients (23.7%) who underwent EUS compared to 9,031 (76.3%) without EUS examination. Reported change of management varied widely from 0% to 56%. When used, EUS fine-needle aspiration precluded curative treatment in 37.5%-71.4%. Overall survival improvements ranged between 121 and 639 days following EUS intervention compared to patients without EUS. Smaller effect sizes were observed in a randomised controlled trial, compared to larger differences reported in observational studies. CONCLUSION Current evidence for the effectiveness of EUS in oesophageal cancer pathways is conflicting and of limited quality. In particular, the extent to which EUS adds value to contemporary cross-sectional imaging techniques is unclear and requires formal re-evaluation.
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Affiliation(s)
- K G Foley
- Department of Clinical Radiology, Royal Glamorgan Hospital, Llantrisant, UK; Department of Clinical Radiology, Velindre Cancer Centre, Cardiff, UK.
| | - J Franklin
- Institute of Medical Imaging and Visualisation, Bournemouth University, UK
| | - C M Jones
- Department of Clinical Oncology, Leeds Cancer Centre, The Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - B Coles
- Velindre University NHS Trust Library & Knowledge Service, Cardiff University, UK
| | - S A Roberts
- Department of Clinical Radiology, University Hospital of Wales, Cardiff, UK
| | - T J Underwood
- School of Cancer Sciences, Faculty of Medicine, University of Southampton, UK
| | - T Crosby
- Department of Clinical Oncology, Velindre Cancer Centre, Cardiff, UK
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2
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Feng H, Zheng J, Zheng C, Deng Z, Liao Q, Wang J, Li Y. The probability of Lymph node metastasis with a tumor size larger than and smaller than 4 cm is different in stages T1-T3 of Siewert type II adenocarcinoma of esophagogastric junction: A Population-Based Study. J Cancer 2021; 12:6873-6882. [PMID: 34659575 PMCID: PMC8518009 DOI: 10.7150/jca.63392] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 09/12/2021] [Indexed: 11/23/2022] Open
Abstract
Background: In adenocarcinoma of esophagogastric junction (AEG), the relationship between tumor size (TS) and lymph node metastasis (LNM) is unclear. This study aimed to explore the relationship between TS and LNM, and to construct a prediction model for LNM. Materials and Methods: Data from 4649 Siewert type II AEG patients were retrospectively acquired from the Surveillance, Epidemiology, and End Result (SEER) database. TS data was analyzed as a continuous variable, but also divided into 1-cm-interval categorical groups for further analysis. The logistic regression model and restricted cubic spline (RCS) model was used to explore the relationship between TS and LNM, after adjusting for covariates. Internal validations as well as external validation (Single-Center data) were used to check our LNM prediction model. Results: TS and LNM showed a significant relationship in the logistic regression analysis, regardless of the TS data being entered as a continuous or a categorical variable, after adjusting for covariates. The logistic regression model and RCS consistently showed that larger TS resulted in larger Odds Ratio (OR) values. When tumors were larger than 4 cm, the OR value remained relatively constant. The receiver operator characteristic curve evaluated the nomogram by the area under the curve (AUC) (AUC=0.737, in internal validation; AUC=0.626, in external validation), and the calibration curve of the nomogram showed an improved prediction system. Conclusions: In Siewert type II T1-T3 stage AEG patients, we reported that LNM increased with TS up to 4-cm, and our nomogram provided a simple tool to predict LNM.
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Affiliation(s)
- Huolun Feng
- Department of gastrointestinal surgery, Guangdong Provincial People's Hospital; Guangdong Academy of Medical Sciences, Guangzhou 510080, Guangdong, P. R. China.,The Second School of Clinical Medicine, Southern Medical University, Guangzhou 510515, Guangdong, P. R. China
| | - Jiabin Zheng
- Department of gastrointestinal surgery, Guangdong Provincial People's Hospital; Guangdong Academy of Medical Sciences, Guangzhou 510080, Guangdong, P. R. China
| | - Chengbin Zheng
- Department of gastrointestinal surgery, Guangdong Provincial People's Hospital; Guangdong Academy of Medical Sciences, Guangzhou 510080, Guangdong, P. R. China
| | - Zhenru Deng
- Department of gastrointestinal surgery, Guangdong Provincial People's Hospital; Guangdong Academy of Medical Sciences, Guangzhou 510080, Guangdong, P. R. China
| | - Qianchao Liao
- Department of gastrointestinal surgery, Guangdong Provincial People's Hospital; Guangdong Academy of Medical Sciences, Guangzhou 510080, Guangdong, P. R. China
| | - Junjiang Wang
- Department of gastrointestinal surgery, Guangdong Provincial People's Hospital; Guangdong Academy of Medical Sciences, Guangzhou 510080, Guangdong, P. R. China.,The Second School of Clinical Medicine, Southern Medical University, Guangzhou 510515, Guangdong, P. R. China
| | - Yong Li
- Department of gastrointestinal surgery, Guangdong Provincial People's Hospital; Guangdong Academy of Medical Sciences, Guangzhou 510080, Guangdong, P. R. China.,The Second School of Clinical Medicine, Southern Medical University, Guangzhou 510515, Guangdong, P. R. China
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3
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Klamt AL, Neyeloff JL, Santos LM, Mazzini GDS, Campos VJ, Gurski RR. Echoendoscopy in Preoperative Evaluation of Esophageal Adenocarcinoma and Gastroesophageal Junction: Systematic Review and Meta-analysis. ULTRASOUND IN MEDICINE & BIOLOGY 2021; 47:1657-1669. [PMID: 33896677 DOI: 10.1016/j.ultrasmedbio.2021.03.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 02/23/2021] [Accepted: 03/13/2021] [Indexed: 06/12/2023]
Abstract
Esophageal adenocarcinomas of the esophagus and esophagogastric junction constitute a global health problem, the incidence of which has increased in recent decades. It has a poor prognosis and a low 5-year survival rate. Its treatment is based on preoperative clinical staging, in which echoendoscopy plays an essential role. The aim of this study was to evaluate the current accuracy of echoendoscopy in the staging of esophageal and esophogogastric junction adenocarcinomas. A systematic review was performed in PubMed, Embase and Portal BVS using the search terms Esophageal Neoplasm, Esophagus Neoplasms, Esophagus Cancers, Esophageal Cancers, EUS, EUS-FNA, Endoscopic Ultrasonography, Echo Endoscopy, Endosonographies and Endoscopic Ultrasound, with subsequent meta-analysis of the data found. The accuracy of tumor (T) staging was 65.55%. For T1, sensitivity was 64.7%, and specificity 89.1%, with an accuracy of 89.6%. For T2, sensitivity and specificity were 35.7% and 89.2%, respectively, with an accuracy of 87.1%. For T3, sensitivity and specificity were 82.5% and 83%, respectively, with an accuracy of 87%. For T4, sensitivity and specificity were 38.6% and 94%, respectively, with an accuracy of 66.4%. For node (N) staging, sensitivity was 77.3% and specificity 67.4%, with an accuracy of 77.9%. Echoendoscopy exhibits suboptimal accuracy in preoperative staging of esophageal adenocarcinoma and esophagogastric junction.
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Affiliation(s)
- Alexandre Luis Klamt
- Gastroenterology Service of the Hospital de Clínicas de Porto Alegre (HCPA), Graduate Program in Medicine: Surgical Sciences, Faculty of Medicine, Federal University of Rio Grande do Sul (UFRGS), Port Alegre, Rio Grande do Sul, Brazil.
| | - Jeruza Lavanholi Neyeloff
- Graduate Program in Health Sciences: Cardiology and Cardiovascular Sciences, Federal University of Rio Grande do Sul (UFRGS), Port Alegre, Rio Grande do Sul, Brazil
| | - Letícia Maffazzioli Santos
- Radiology Service of the Hospital de Clínicas de Porto Alegre (HCPA), Graduate Program in Medicine: Surgical Sciences, Faculty of Medicine, Federal University of Rio Grande do Sul (UFRGS), Port Alegre, Rio Grande do Sul, Brazil
| | - Guilherme da Silva Mazzini
- Digestive Tract Surgery Service of the Hospital de Clínicas de Porto Alegre (HCPA), Faculty of Medicine, Federal University of Rio Grande do Sul (UFRGS), Port Alegre, Rio Grande do Sul, Brazil
| | - Vinicius Jardim Campos
- Faculty of Medicine, Federal University of Rio Grande do Sul (UFRGS), Port Alegre, Rio Grande do Sul, Brazil
| | - Richard Ricachenevsky Gurski
- Digestive Tract Surgery Service and Surgery Group of the Esophagus and Stomach of the Hospital de Clínicas de Porto Alegre (HCPA), Port Alegre, Rio Grande do Sul, Brazil; Department of Surgery, Faculty of Medicine, Federal University of Rio Grande do Sul (UFRGS), Port Alegre, Rio Grande do Sul, Brazil
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4
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Kang N, Fang Y, Zhu H, Shi Z, Chen L, Lu Y, Wang H, Lu J, Liu W, Hu K. Prognostic Value of CT Imaging-Based Tumor Volume in Patients With Non-Surgical Esophageal Squamous Cell Carcinoma. Front Oncol 2021; 10:602681. [PMID: 33575213 PMCID: PMC7871982 DOI: 10.3389/fonc.2020.602681] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 12/04/2020] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND The American Joint Committee on Cancer-Tumor (AJCC-T) staging system for esophageal carcinoma patients, which is based on the depth of tumor invasion, is not applicable in some cases. This study aims to assess the prognostic value of CT imaging-based tumor volume and its usefulness for T staging in patients with non-surgical esophageal squamous cell carcinoma (ESCC). METHODS We retrospectively reviewed the records of 158 ESCC patients undergoing definitive (chemo) radiotherapy from two hospitals. Tumor volume based on the CT imaging was calculated using the formula: V = πabc / 6. Three cutoff points for tumor volume were obtained with the X-tile software. Overall survival (OS) was analyzed using the Kaplan-Meier method. The -2 log-likelihood ratio and Akaike Information Criterion (AIC) value were evaluated to compare the AJCC-T staging system with the proposed T staging method. RESULTS The median tumor volume was 19.8 cm³ (range from 1.0 to 319.5 cm³). The three optimal cutoff points of tumor volume were 12.7, 22.8, and 51.9 cm³, and the patients were divided into four groups named as proposed T1-T4 stages. The 3-year OS rates in patients with proposed T1 to T4 stages were 67.9%, 30.6%, 21.3%, and 5.3%, respectively. The -2 log-likelihood ratios of the AJCC-T stage and proposed T stage were 1,068.060 and 1,047.418, respectively. The difference in the AIC value between the two T staging systems was 18.642. CONCLUSION CT imaging-based tumor volume was superior to the depth of tumor invasion for T staging in predicting the prognosis of non-surgical ESCC patient.
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Affiliation(s)
- Ning Kang
- Department of Radiation Oncology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
- Department of Radiation Oncology, The Second Affiliated Hospital of Guangxi Medical University, Nanning, China
- Department of Oncology, Yue Bei People’s Hospital, Shaoguan, China
| | - Yeying Fang
- Department of Radiation Oncology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Huijun Zhu
- Department of Radiation Oncology, The Second Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Zhiling Shi
- Graduate School of Guangxi Medical University, Nanning, China
| | - Liuyin Chen
- Graduate School of Guangxi Medical University, Nanning, China
| | - YuShuang Lu
- Graduate School of Guangxi Medical University, Nanning, China
| | - Housheng Wang
- Department of Radiation Oncology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Jiamei Lu
- Department of Radiation Oncology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Wenqi Liu
- Department of Radiation Oncology, The Second Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Kai Hu
- Department of Radiation Oncology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
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5
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Worrell SG, Bachman KC, Sarode AL, Perry Y, Linden PA, Towe CW. Minimally invasive esophagectomy is associated with superior survival, lymphadenectomy and surgical margins: propensity matched analysis of the National Cancer Database. Dis Esophagus 2020; 33:5811019. [PMID: 32206801 DOI: 10.1093/dote/doaa017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 02/11/2020] [Indexed: 12/11/2022]
Abstract
Despite excellent short-term outcomes of minimally invasive esophagectomy (MIE), there is minimal data on long-term outcomes compared to open esophagectomy. MIE's superior visualization may have improved lymphadenectomy and complete resection rate and therefore improved long-term outcomes. We hypothesized that MIE would have superior long-term survival. Patients undergoing an esophagectomy for cancer between 2010 and 2016 were identified in the National Cancer Database. MIE included laparoscopic/robotic approach, and conversions were categorized as open. A 1:1 propensity match was performed. Lymphadenectomy and margin status were compared between MIE and open using Stuart Maxwell marginal homogeneity and Wilcoxon matched-pair signed-rank test. Survival was compared using log-rank test. 13,083 patients were identified: 8,906 (68%) open and 4,177 (32%) MIE. Propensity matching identified 3,659 'pairs' of MIE and open esophagectomy patients. Among them, MIE was associated with higher number lymph nodes examined (16 vs. 14, P < 0.001) and similar number of positive lymph nodes (0 vs. 0, P = 0.33). MIE had higher rate of negative pathologic margin (95 vs. 93.5%, P < 0.001). MIE was also associated with shorter hospitalization (9 vs. 10 days, P < 0.001). Survival was improved among MIE patients (46.6 vs. 41.4 months for open, P = 0.003) and among pathologic node-negative patients (71.4 vs. 61.5 months, P = 0.005). These data suggest that MIE has improved short-term outcomes (improved lymphadenectomy, pathologic margins, and length of stay) and also associated improved overall survival. The etiology of superior overall survival is likely secondary to many factors related and unrelated to surgical approach.
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Affiliation(s)
- Stephanie G Worrell
- Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Katelynn C Bachman
- Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Anuja L Sarode
- Department of Surgery, University Hospitals Research in Surgical Outcomes & Effectiveness Center (UH-RISES), University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Yaron Perry
- Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Philip A Linden
- Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Christopher W Towe
- Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
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6
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Fountoulakis A, Souglakos J, Vini L, Douridas GN, Koumarianou A, Kountourakis P, Agalianos C, Alexandrou A, Dervenis C, Gourtsoyianni S, Gouvas N, Kalogeridi MA, Levidou G, Liakakos T, Sgouros J, Sgouros SN, Triantopoulou C, Xynos E. Consensus statement of the Hellenic and Cypriot Oesophageal Cancer Study Group on the diagnosis, staging and management of oesophageal cancer. Updates Surg 2019; 71:599-624. [DOI: 10.1007/s13304-019-00696-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 11/26/2019] [Indexed: 12/13/2022]
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7
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Chen J, Zhou C, He M, Zhen Z, Wang J, Hu X. A Meta-Analysis And Systematic Review Of Accuracy Of Endoscopic Ultrasound For N Staging Of Gastric Cancers. Cancer Manag Res 2019; 11:8755-8764. [PMID: 31632135 PMCID: PMC6774993 DOI: 10.2147/cmar.s200318] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 09/12/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Endoscopic ultrasonography (EUS) is widely used as a staging modality for gastric cancer. However, the results of studies on the use of EUS for N staging in gastric cancer vary. This study aimed at studying the overall diagnostic accuracy of EUS for N staging of gastric cancer. METHODS Published studies were identified through searching the MEDLINE, Web of Science, EMBASE, SpringerLink and ScienceDirect databases. A bivariate random effect model was used to estimate the sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), and diagnostic odds ratio (DOR). A hierarchical summary receiver operating characteristic curves (HSROC) based on the pooled data was also computed. RESULTS Fifty studies (5223 patients) were included in this analysis. The pooled sensitivity, specificity, PLR, NLR and DOR of EUS for N staging were 0.82 (95% CI 0.78 to 0.85), 0.68 (0.63 to 0.73), 2.6 (2.2 to 3.0), 0.27 (0.22 to 0.32), and 10 (8 to 12), respectively. The area under the HSROC was 0.83. CONCLUSION The EUS may provide a clinically useful tool to guide physicians in the N staging of gastric cancer. However, physicians must note that the EUS has a relatively low specificity.
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Affiliation(s)
- Jiafei Chen
- Department of Radiology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, People’s Republic of China
| | - Chaoyang Zhou
- Department of Radiology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, People’s Republic of China
| | - Min He
- Department of Radiology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, People’s Republic of China
| | - Zhiming Zhen
- Department of Radiology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, People’s Republic of China
| | - Jie Wang
- Department of Radiology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, People’s Republic of China
| | - Xiaofei Hu
- Department of Radiology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, People’s Republic of China
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8
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Cosgrove ND, Mullady DK. Endoscopic evaluation of the esophageal cancer patient after chemoradiotherapy for persistent/recurrent cancer. Dis Esophagus 2018; 31:5040371. [PMID: 29931309 DOI: 10.1093/dote/doy023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Endoscopy has an important role in the pre- and post-treatment staging of esophageal cancer. Complete pathologic response following neoadjuvant chemoradiation therapy occurs in approximately 25% of patients. However, the ability to accurately detect this preoperatively with currently available endoscopic modalities is limited such that the default pathway is for fit patients to proceed with surgical resection. This article discusses the available endoscopic modalities (primarily Esophagogastroduodenoscopy [EGD] with mucosal biopsies and endoscopic ultrasonography with or without fine needle aspiration) used for post-treatment staging of esophageal cancer. We present data regarding the benefits and limitations of endoscopic methods in assessing for residual disease. Unfortunately, endoscopic modalities are not accurate enough to identify complete pathological responsers who may avoid surgical resection.
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Affiliation(s)
- N D Cosgrove
- Division of Gastroenterology, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - D K Mullady
- Division of Gastroenterology, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
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9
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Yang J, Luo GY, Liang RB, Zeng TS, Long H, Fu JH, Xu GL, Yang MZ, Li S, Zhang LJ, Lin P, Wang X, Hou X, Yang HX. Efficacy of Endoscopic Ultrasonography for Determining Clinical T Category for Esophageal Squamous Cell Carcinoma: Data From 1434 Surgical Cases. Ann Surg Oncol 2018; 25:2075-2082. [PMID: 29667114 DOI: 10.1245/s10434-018-6406-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Indexed: 01/07/2023]
Abstract
BACKGROUND The efficacy of endoscopic ultrasonography (EUS) for determining T category is variable for esophageal squamous cell carcinoma (ESCC). We aimed to assess the efficacy of EUS in accurately identifying T category for ESCC based on the 8th AJCC Cancer Staging Manual. METHODS A retrospective analysis was conducted using a prospectively collected ESCC database from January 2003 to December 2015, in which all patients underwent EUS examination followed by esophagectomy. The efficacy of EUS was evaluated by sensitivity, specificity, and accuracy compared with pathological T category as gold standard. Overall survival of different EUS-T (uT) categories was assessed. RESULTS In total, 1434 patients were included, of whom 58.2% were correctly classified by EUS, with 17.9% being overstaged and 23.9% being understaged. The sensitivity and accuracy of EUS for Tis, T1a, T1b, T2, T3, and T4a categories were 15.8 and 98.8%, 16.3 and 95.7%, 33.1 and 89.3%, 56.8 and 65.0%, 65.8 and 70.0%, and 27.3 and 97.5%, respectively. The survival difference between uT1a and uT1b was not statistically significant (p = 0.90), nor was that between uT4a and uT4b (p = 0.34). However, when uT category was integrated as uTis, uT1, uT2, uT3, and uT4, overall survival was clearly distinguished between the categories (p < 0.01). CONCLUSIONS EUS is in general feasible for classifying clinical T category for ESCC. However, EUS should be used with caution for discriminating between Tis, T1a, and T1b disease, as well as T4 disease.
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Affiliation(s)
- Jie Yang
- Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China.,State Key Laboratory of Oncology in South China, Guangzhou, Guangdong, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
| | - Guang-Yu Luo
- State Key Laboratory of Oncology in South China, Guangzhou, Guangdong, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China.,Department of Endoscopy, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China
| | - Run-Bin Liang
- Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China.,State Key Laboratory of Oncology in South China, Guangzhou, Guangdong, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
| | - Tai-Shan Zeng
- School of Mathematical Sciences, South China Normal University, Guangzhou, Guangdong, China
| | - Hao Long
- Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China.,State Key Laboratory of Oncology in South China, Guangzhou, Guangdong, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
| | - Jian-Hua Fu
- Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China.,State Key Laboratory of Oncology in South China, Guangzhou, Guangdong, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
| | - Guo-Liang Xu
- State Key Laboratory of Oncology in South China, Guangzhou, Guangdong, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China.,Department of Endoscopy, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China
| | - Mu-Zi Yang
- Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China.,State Key Laboratory of Oncology in South China, Guangzhou, Guangdong, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
| | - Shuo Li
- Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China.,State Key Laboratory of Oncology in South China, Guangzhou, Guangdong, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
| | - Lan-Jun Zhang
- Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China.,State Key Laboratory of Oncology in South China, Guangzhou, Guangdong, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
| | - Peng Lin
- Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China.,State Key Laboratory of Oncology in South China, Guangzhou, Guangdong, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
| | - Xin Wang
- Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China.,State Key Laboratory of Oncology in South China, Guangzhou, Guangdong, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
| | - Xue Hou
- State Key Laboratory of Oncology in South China, Guangzhou, Guangdong, China. .,Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China. .,Department of Medical Oncology, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China.
| | - Hao-Xian Yang
- Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China. .,State Key Laboratory of Oncology in South China, Guangzhou, Guangdong, China. .,Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China.
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10
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Sohail A, Bég OA, Li Z, Celik S. Physics of fractional imaging in biomedicine. PROGRESS IN BIOPHYSICS AND MOLECULAR BIOLOGY 2018; 140:13-20. [PMID: 29544821 DOI: 10.1016/j.pbiomolbio.2018.03.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 03/06/2018] [Accepted: 03/08/2018] [Indexed: 12/24/2022]
Abstract
The mathematics of imaging is a growing field of research and is evolving rapidly parallel to evolution in the field of imaging. Imaging, which is a sub-field of biomedical engineering, considers novel approaches to visualize biological tissues with the general goal of improving health. "Medical imaging research provides improved diagnostic tools in clinical settings and supports the development of drugs and other therapies. The data acquisition and diagnostic interpretation with minimum error are the important technical aspects of medical imaging. The image quality and resolution are really important in portraying the internal aspects of patient's body. Although there are several user friendly resources for processing image features, such as enhancement, colour manipulation and compression, the development of new processing methods is still worthy of efforts. In this article we aim to present the role of fractional calculus in imaging with the aid of practical examples.
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Affiliation(s)
- Ayesha Sohail
- Department of Mathematics, Comsats Institute of Information Technology, Lahore, 54000, Pakistan.
| | - O A Bég
- Fluid Mechanics, Bio-Propulsion and Nanosystems, Aeronautical and Mechanical Engineering Department, University of Salford, Newton Building, UG17, Manchester, M54WT, UK.
| | - Zhiwu Li
- School of Electro-Mechanical Engineering, Xidian University, Xi'an, 710071, China; Institute of Systems Engineering, Macau University of Science and Technology, Taipa, Macau.
| | - Sebahattin Celik
- Department of General Surgery, Yuzuncu Yil University Faculty of Medicine, Van, 65080, Turkey
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11
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Bohle W, Zachmann R, Zoller WG. Sequential endoscopic ultrasound identifies predictive variables for relapse-free follow-up after neoadjuvant chemotherapy in gastric cancer. Scand J Gastroenterol 2017; 52:754-761. [PMID: 28355948 DOI: 10.1080/00365521.2017.1303845] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The accuracy of endosonographic tumor staging after neoadjuvant therapy is less reliable than in primary staging. Therefore, the value of sequential endosonographic examinations after neaodjuvant chemotherapy in gastro-esophageal cancer is discussed controversially. Previous data suggest, that endoscopic ultrasound (EUS) after neoadjuvant treatment using other variables than classic uTN-criteria may identify patients with a better prognosis. METHODS In 67 patients with locally advanced gastric cancer treated in curative intent, we performed EUS before and after neoadjuvant chemotherapy. Endosonographic yTN-stage was compared to pathohistological yTN-stage after curative resection. The uTN-stage, yuTN-stage, maximal tumor thickness and maximal lymph node diameter as well as the shift of these variables after neoadjuvant therapy were analyzed for their usefulness to predict recurrence-free follow-up. RESULTS Accuracy of EUS for yTN-staging after neoadjuvant therapy was poor, especially in lower tumor stages. However, three heavily correlated variables analyzed by sequential EUS could be used for the prediction of prognosis: low endosonographic tumor stage (yuT0-2) after neoadjuvant chemotherapy, a decrease of two or more steps in uT-stage and a maximal tumor thickness of <15 mm after chemotherapy were significantly associated with recurrence-free follow-up. Endosonographic T-stage before neoadjuvant therapy, as well as lymph node variables before or after chemotherapy, were of no predictive value. CONCLUSION In spite of poor concordance between endosonographic and pathohistological TN-stage after neoadjuvant treatment, sequential EUS, performed before and after neoadjuvant therapy, possibly identify patients at risk for tumor relapse after multimodal treatment in gastric cancer. This finding should be validated in a larger patient cohort.
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Affiliation(s)
- Wolfram Bohle
- a Department of Gastroenterology , Katharinenhospital , Klinikum Stuttgart , Germany
| | - Ruben Zachmann
- a Department of Gastroenterology , Katharinenhospital , Klinikum Stuttgart , Germany
| | - Wolfram G Zoller
- a Department of Gastroenterology , Katharinenhospital , Klinikum Stuttgart , Germany
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Rice TW, Patil DT, Blackstone EH. 8th edition AJCC/UICC staging of cancers of the esophagus and esophagogastric junction: application to clinical practice. Ann Cardiothorac Surg 2017; 6:119-130. [PMID: 28447000 DOI: 10.21037/acs.2017.03.14] [Citation(s) in RCA: 452] [Impact Index Per Article: 64.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The 8th edition of the American Joint Committee on Cancer (AJCC) staging of epithelial cancers of the esophagus and esophagogastric junction (EGJ) presents separate classifications for clinical (cTNM), pathologic (pTNM), and postneoadjuvant (ypTNM) stage groups. Histopathologic cell type markedly affects survival of clinically and pathologically staged patients, requiring separate groupings for each cell type, but ypTNM groupings are identical for both cell types. Clinical categories, typically obtained by imaging with minimal histologic information, are limited by resolution of each method. Strengths and shortcomings of clinical staging methods should be recognized. Complementary cytology or histopathology findings may augment imaging and aid initial treatment decision-making. However, prognostication using clinical stage groups remains coarse and inaccurate compared with pTNM. Pathologic staging is losing its relevance for advanced-stage cancer as neoadjuvant therapy replaces esophagectomy alone. However, it remains relevant for early-stage cancers and as a staging and survival reference point. Although pathologic stage could facilitate decision-making, its use to direct postoperative adjuvant therapy awaits more effective treatment. Prognostication using pathologic stage groups is the most refined of all classifications. Postneoadjuvant staging (ypTNM) is introduced by the AJCC but not adopted by the Union for International Cancer Control (UICC). Drivers of this addition include absence of equivalent pathologic (pTNM) categories for categories peculiar to the postneoadjuvant state (ypT0N0-3M0 and ypTisN0-3M0), dissimilar stage group compositions, and markedly different survival profiles. Thus, prognostication is specific for patients undergoing neoadjuvant therapy. The role of ypTNM classification in additional treatment decision-making is currently limited. Precision cancer care advances are necessary for this information to be clinically useful.
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Affiliation(s)
- Thomas W Rice
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Deepa T Patil
- Department of Pathology, Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Research Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
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13
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Real-time optical diagnosis of gastric cancer with serosal invasion using multiphoton imaging. Sci Rep 2016; 6:31004. [PMID: 27499365 PMCID: PMC4976383 DOI: 10.1038/srep31004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Accepted: 07/11/2016] [Indexed: 12/16/2022] Open
Abstract
A real-time optical biopsy, which could determine tissue histopathology, would be of extraordinary benefit to staging laparoscopy for gastric cancer with serosal invasion (T4) that requires downstage treatment. We investigated the feasibility of using multiphoton imaging to perform a real-time optical diagnosis of gastric cancer with or without serosal invasion. First, a pilot study was performed to establish the optical diagnostic features of gastric cancer with or without serosal invasion using multiphoton imaging compared with hematoxylin-eosin staining and Masson’s trichrome staining. Second, a blinded study was performed to compare the diagnostic sensitivity, specificity, and accuracy of multiphoton imaging and endoscopic ultrasonography (EUS) for T4 gastric cancer. In the pilot study, multiphoton imaging revealed collagen loss and degradation and cellular and nuclear pleomorphism in gastric cancer with serosal invasion. The collagen content in gastric cancer with or without serosal invasion was 0.36 ± 0.18 and 0.79 ± 0.16 (p < 0.001), respectively. In the blinded study, the sensitivity, specificity, and accuracy of EUS and multiphoton imaging for T4 gastric cancer were 70% and 90% (p = 0.029), 66.67% and 96.67% (p = 0.003), and 68.33% and 93.33% (p = 0.001), respectively. It is feasible to use multiphoton imaging to make a real-time optical diagnosis of gastric cancer with or without serosal invasion.
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Fang TC, Oh YS, Szabo A, Khan A, Dua KS. Utility of dysphagia grade in predicting endoscopic ultrasound T-stage of non-metastatic esophageal cancer. Dis Esophagus 2016; 29:642-8. [PMID: 26382588 DOI: 10.1111/dote.12394] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Patients with non-metastatic esophageal cancer routinely undergo endoscopic ultrasound (EUS) for loco-regional staging. Neoadjuvant therapy is recommended for ≥T3 tumors while upfront surgery can be considered for ≤T2 lesions. The aim of this study was to determine if the degree of dysphagia can predict the EUS T-stage of esophageal cancer. One hundred eleven consecutive patients with non-metastatic esophageal cancer were retrospectively reviewed from a database. Prior to EUS, patients' dysphagia grade was recorded. Correlation between dysphagia grade and EUS T-stage, especially in reference to predicting ≥T3 stage, was determined. The correlation of dysphagia grade with EUS T-stage (Kendall's tau coefficient) was 0.49 (P < 0.001) for the lower and 0.59 (P = 0.008) for the middle esophagus. The sensitivity and specificity of dysphagia grade ≥2 (can only swallow semi-solids/liquids) for T3 cancer were 56% (95% confidence interval [CI] 43-67%) and 93% (95% CI 79-98%), respectively. The sensitivity, specificity, and positive predictive value of dysphagia grade ≥3 (can only swallow liquids or total dysphagia) for T3 lesions were 36% (95% CI 25-48%), 100% (95% CI 89-100%), and 100% (95% CI 83-100%), respectively. Overall, there was a significant positive correlation between dysphagia grade and the EUS T-stage of esophageal cancer. All patients with dysphagia grade ≥3 had T3 lesions. This may have clinical implications for patients who can only swallow liquids or have complete dysphagia by allowing for prompt initiation of neoadjuvant therapy, especially in countries/centers where EUS service is difficult to access in a timely manner or not available.
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Affiliation(s)
- T C Fang
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Y S Oh
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - A Szabo
- Division of Biostatistics, Institute for Health and Society, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - A Khan
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - K S Dua
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.,Clement J. Zablocki VA Medical Center, Milwaukee, Wisconsin, USA
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Kneuertz PJ, Hofstetter WL, Chiang YJ, Das P, Blum M, Elimova E, Mansfield P, Ajani J, Badgwell B. Long-Term Survival in Patients with Gastroesophageal Junction Cancer Treated with Preoperative Therapy: Do Thoracic and Abdominal Approaches Differ? Ann Surg Oncol 2016; 23:626-632. [DOI: 10.1245/s10434-015-4898-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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16
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Ripley RT, Sarkaria IS, Grosser R, Sima CS, Bains MS, Jones DR, Adusumilli PS, Huang J, Finley DJ, Rusch VW, Rizk NP. Pretreatment Dysphagia in Esophageal Cancer Patients May Eliminate the Need for Staging by Endoscopic Ultrasonography. Ann Thorac Surg 2015; 101:226-230. [PMID: 26603024 DOI: 10.1016/j.athoracsur.2015.06.062] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2015] [Revised: 06/09/2015] [Accepted: 06/22/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND Neoadjuvant therapy is commonly administered to patients with localized disease who have T3-4 esophageal disease as staged by endoscopic ultrasound (EUS). Previously, we noted that patients who present with dysphagia have a higher EUS T stage. We hypothesized that the presence of dysphagia is predictive of EUS T3-4 disease and that staging EUS could be forgone for esophageal cancer patients with dysphagia. METHODS We performed a prospective, intent-to-treat, single-cohort study in which patients with potentially resectable esophageal cancer completed a standardized four-tier dysphagia score survey. EUS was performed as part of our standard evaluation. To determine whether the presence of dysphagia predicted EUS T3-4 disease, the dysphagia score was compared with EUS T stage. RESULTS The study enrolled 114 consecutive patients between August 2012 and February 2014: 77% (88 of 114) received neoadjuvant therapy, 18% (20 of 114) did not, and 5% (6 of 114) pursued treatment elsewhere. In total, 70% (80 of 114) underwent esophagectomy; of these, 54% (61 of 114) had dysphagia and 46% (53 of 114) did not. Dysphagia scores were 66% (40 of 61) grade 1, 25% (15 of 61) grade 2, and 10% (6 of 61) grade 3 to 4. Among patients with dysphagia, 89% (54 of 61) had T3-4 disease by EUS; among those without dysphagia, only 53% (28 of 53) had T3-4 disease by EUS (p < 0.001). CONCLUSIONS The presence of dysphagia in patients with esophageal cancer was highly predictive of T3-4 disease by EUS. On the basis of this finding, approximately 50% of patients currently undergoing staging EUS at our institution could potentially forgo EUS before neoadjuvant therapy. Patients without dysphagia, however, should still undergo EUS.
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Affiliation(s)
- R Taylor Ripley
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Inderpal S Sarkaria
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Rachel Grosser
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Camelia S Sima
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Manjit S Bains
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - David R Jones
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Prasad S Adusumilli
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - James Huang
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - David J Finley
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Valerie W Rusch
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Nabil P Rizk
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
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Mocellin S, Pasquali S. Diagnostic accuracy of endoscopic ultrasonography (EUS) for the preoperative locoregional staging of primary gastric cancer. Cochrane Database Syst Rev 2015; 2015:CD009944. [PMID: 25914908 PMCID: PMC6465120 DOI: 10.1002/14651858.cd009944.pub2] [Citation(s) in RCA: 102] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Endoscopic ultrasound (EUS) is proposed as an accurate diagnostic device for the locoregional staging of gastric cancer, which is crucial to developing a correct therapeutic strategy and ultimately to providing patients with the best chance of cure. However, despite a number of studies addressing this issue, there is no consensus on the role of EUS in routine clinical practice. OBJECTIVES To provide both a comprehensive overview and a quantitative analysis of the published data regarding the ability of EUS to preoperatively define the locoregional disease spread (i.e., primary tumor depth (T-stage) and regional lymph node status (N-stage)) in people with primary gastric carcinoma. SEARCH METHODS We performed a systematic search to identify articles that examined the diagnostic accuracy of EUS (the index test) in the evaluation of primary gastric cancer depth of invasion (T-stage, according to the AJCC/UICC TNM staging system categories T1, T2, T3 and T4) and regional lymph node status (N-stage, disease-free (N0) versus metastatic (N+)) using histopathology as the reference standard. To this end, we searched the following databases: the Cochrane Library (the Cochrane Central Register of Controlled Trials (CENTRAL)), MEDLINE, EMBASE, NIHR Prospero Register, MEDION, Aggressive Research Intelligence Facility (ARIF), ClinicalTrials.gov, Current Controlled Trials MetaRegister, and World Health Organization International Clinical Trials Registry Platform (WHO ICTRP), from 1988 to January 2015. SELECTION CRITERIA We included studies that met the following main inclusion criteria: 1) a minimum sample size of 10 patients with histologically-proven primary carcinoma of the stomach (target condition); 2) comparison of EUS (index test) with pathology evaluation (reference standard) in terms of primary tumor (T-stage) and regional lymph nodes (N-stage). We excluded reports with possible overlap with the selected studies. DATA COLLECTION AND ANALYSIS For each study, two review authors extracted a standard set of data, using a dedicated data extraction form. We assessed data quality using a standard procedure according to the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) criteria. We performed diagnostic accuracy meta-analysis using the hierarchical bivariate method. MAIN RESULTS We identified 66 articles (published between 1988 and 2012) that were eligible according to the inclusion criteria. We collected the data on 7747 patients with gastric cancer who were staged with EUS. Overall the quality of the included studies was good: in particular, only five studies presented a high risk of index test interpretation bias and two studies presented a high risk of selection bias.For primary tumor (T) stage, results were stratified according to the depth of invasion of the gastric wall. The meta-analysis of 50 studies (n = 4397) showed that the summary sensitivity and specificity of EUS in discriminating T1 to T2 (superficial) versus T3 to T4 (advanced) gastric carcinomas were 0.86 (95% confidence interval (CI) 0.81 to 0.90) and 0.90 (95% CI 0.87 to 0.93) respectively. For the diagnostic capacity of EUS to distinguish T1 (early gastric cancer, EGC) versus T2 (muscle-infiltrating) tumors, the meta-analysis of 46 studies (n = 2742) showed that the summary sensitivity and specificity were 0.85 (95% CI 0.78 to 0.91) and 0.90 (95% CI 0.85 to 0.93) respectively. When we addressed the capacity of EUS to distinguish between T1a (mucosal) versus T1b (submucosal) cancers the meta-analysis of 20 studies (n = 3321) showed that the summary sensitivity and specificity were 0.87 (95% CI 0.81 to 0.92) and 0.75 (95% CI 0.62 to 0.84) respectively. Finally, for the metastatic involvement of lymph nodes (N-stage), the meta-analysis of 44 studies (n = 3573) showed that the summary sensitivity and specificity were 0.83 (95% CI 0.79 to 0.87) and 0.67 (95% CI 0.61 to 0.72), respectively.Overall, as demonstrated also by the Bayesian nomograms, which enable readers to calculate post-test probabilities for any target condition prevalence, the EUS accuracy can be considered clinically useful to guide physicians in the locoregional staging of people with gastric cancer. However, it should be noted that between-study heterogeneity was not negligible: unfortunately, we could not identify any consistent source of the observed heterogeneity. Therefore, all accuracy measures reported in the present work and summarizing the available evidence should be interpreted cautiously. Moreover, we must emphasize that the analysis of positive and negative likelihood values revealed that EUS diagnostic performance cannot be considered optimal either for disease confirmation or for exclusion, especially for the ability of EUS to distinguish T1a (mucosal) versus T1b (submucosal) cancers and positive versus negative lymph node status. AUTHORS' CONCLUSIONS By analyzing the data from the largest series ever considered, we found that the diagnostic accuracy of EUS might be considered clinically useful to guide physicians in the locoregional staging of people with gastric carcinoma. However, the heterogeneity of the results warrants special caution, as well as further investigation for the identification of factors influencing the outcome of this diagnostic tool. Moreover, physicians should be warned that EUS performance is lower in diagnosing superficial tumors (T1a versus T1b) and lymph node status (positive versus negative). Overall, we observed large heterogeneity and its source needs to be understood before any definitive conclusion can be drawn about the use of EUS can be proposed in routine clinical settings.
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Affiliation(s)
- Simone Mocellin
- Meta-Analysis Unit, Department of Surgery,Oncology and Gastroenterology, University of Padova, Via Giustiniani 2, Padova, Veneto, 35128, Italy. .
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Location of lymph node involvement in patients with esophageal adenocarcinoma predicts survival. World J Surg 2014; 38:106-13. [PMID: 24101018 DOI: 10.1007/s00268-013-2236-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND The location of positive lymph nodes has been abandoned in the seventh classification of the TNM staging system for esophageal adenocarcinoma. The present study evaluates whether distribution of involved nodes relative to the diaphragm in addition to TNM 7 further refines prediction. METHODS Pathology reports of patients who underwent esophagectomy between 2000 and 2008 for adenocarcinoma of the esophagus were reviewed and staging was performed according to the seventh UICC-AJCC staging system. In addition, lymph node involvement of nodal stations above and below the diaphragm was investigated by endoscopic ultrasonography (EUS) in a separate cohort of patients who were scheduled for esophagectomy between 2008 and 2009 at two institutions. Survival was calculated by the Kaplan-Meier method, and multivariate analysis was performed with a Cox regression model. RESULTS Some 327 patients who had undergone esophagectomy for cancer were included. Multivariate analysis revealed that patients with from three to six involved lymph nodes in the resection specimen on both sides of the diaphragm had a twofold higher chance of dying compared to patients with the same number of involved lymph nodes on one side of the diaphragm. EUS assessment of lymph node metastases relative to the diaphragm in 102 patients showed that nodal involvement on both sides of the diaphragm was associated with worse survival than when nodes on one side or no nodes are involved [HR (95 % CI) 2.38 (1.15-4.90)]. CONCLUSIONS A combined staging system that incorporates distribution of lymph nodes relative to the diaphragm refines prognostication after esophagectomy as assessed in the resected specimen and pretreatment as assessed by EUS. This improved staging has the potential to have a great impact on clinical decision making as to whether to embark upon potentially curative or palliative treatments.
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Evaluation of the reliability of clinical staging of T2 N0 esophageal cancer: a review of the Society of Thoracic Surgeons database. Ann Thorac Surg 2013; 96:382-90. [PMID: 23731608 DOI: 10.1016/j.athoracsur.2013.03.093] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Revised: 03/21/2013] [Accepted: 03/22/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND Clinical staging of esophageal cancer has improved with positron-emission tomography/computed tomography and endoscopic ultrasound imaging. Despite such progress, small single-center studies have questioned the reliability of clinical staging of T2 N0 esophageal cancer. This study broadly examines the adequacy of clinical staging of T2 N0 disease using The Society of Thoracic Surgeons database. METHODS We retrospectively studied 810 clinical stage T2 N0 patients from 2002 to 2011, with 58 excluded because of incomplete pathologic staging data. Clinical stage, pathologic stage, and preoperative characteristics were recorded. Logistic regression analysis was used to identify factors associated with upstaging at the time of surgical intervention. RESULTS Among 752 clinical stage T2 N0 patients, 270 (35.9%) received induction therapy before the operation. Of 482 patients who went directly to surgical intervention, 132 (27.4%) were confirmed as pathologic T2 N0, 125 (25.9%) were downstaged (ie, T0-1 N0), and 225 (46.7%) were upstaged at the operation (T3-4 N0 or Tany N1-3). Exclusive tumor upstaging (ie, pathologic T3-4 N0) accounted for 41 patients (18.2%), whereas exclusive nodal upstaging (ie, pathological T1-2 N1-3) accounted for 100 (44.5%). Combined tumor and nodal upstaging (ie, pathological T3-4 N1-3) accounted for 84 patients (37.3%). Among patients who received induction therapy, 103 (38.1%) were upstaged vs 225 (46.7%) without induction therapy (p = 0.026). Comparing the induction therapy group and the primary surgical group, postoperative 30-day mortality (3.7% vs 3.7%, p > 0.99) and morbidity (46.3% vs 45%, p = 0.76) were similar. CONCLUSIONS Despite advances in staging techniques, clinical staging of T2 N0 esophageal cancer remains unreliable. Recognizing T2 N0 as a threshold for induction therapy in esophageal cancer, many surgeons have opted to treat T2 N0 disease with induction therapy, even though one-quarter of these patients will be pathologic T1 N0. Although this study demonstrated similar perioperative morbidity and mortality with and without induction therapy, further study is needed to examine the effect of upstaging on long-term survival.
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Abstract
Tumors of the gastroesophageal junction have historically been treated as either gastric or esophageal cancer depending on institutional preferences. The Siewert classification system was designed to provide a more precise means of characterizing these tumors. In general, surgical treatment of Siewert 1 tumors is via esophagectomy. Siewert 2 and 3 tumors may be treated with either esophagectomy with proximal gastrectomy or extended total gastrectomy provided negative margins are obtained. All but the earliest stage tumors should be considered for neoadjuvant chemoradiotherapy.
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Cardoso R, Coburn N, Seevaratnam R, Sutradhar R, Lourenco LG, Mahar A, Law C, Yong E, Tinmouth J. A systematic review and meta-analysis of the utility of EUS for preoperative staging for gastric cancer. Gastric Cancer 2012; 15 Suppl 1:S19-26. [PMID: 22237654 DOI: 10.1007/s10120-011-0115-4] [Citation(s) in RCA: 105] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2011] [Accepted: 10/31/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND Accurate preoperative staging is important in determining the appropriate treatment of gastric cancer. Recently, endoscopic ultrasound (EUS) has been introduced as a staging modality. However, reported test characteristics for EUS in gastric cancer vary. Our purpose in this study was to identify, synthesize, and evaluate findings from all articles on the performance of EUS in the preoperative staging of gastric cancer. METHODS Electronic literature searches were conducted using Medline, Embase, and the Cochrane Central Register of Controlled Trials from 1 January 1998 to 1 December 2009. All search titles and abstracts were independently rated for relevance by a minimum of two reviewers. Meta-analysis for the performance of EUS was analyzed by calculating agreement (Kappa statistic), and pooled estimates of accuracy, sensitivity, and specificity for all EUS examinations, using histopathology as the reference standard. Subgroup analyses were also performed. RESULTS Twenty-two articles met our inclusion criteria and were included in the review. EUS pooled accuracy for T staging was 75% with a moderate Kappa (0.52). EUS was most accurate for T3 disease, followed by T4, T1, and T2. EUS pooled accuracy for N staging was 64%, sensitivity was 74%, and specificity was 80%. There was significant heterogeneity between the included studies. Subgroup analyses found that annual EUS volume was not associated with EUS T and N staging accuracy (P = 0.836, 0.99, respectively). CONCLUSION EUS is a moderately accurate technique that seems to describe advanced T stage (T3 and T4) better than N or less advanced T stage. Stratifying by EUS annual volume did not affect EUS performance in staging gastric cancer.
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Affiliation(s)
- Roberta Cardoso
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Canada
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Mihaljevic AL, Friess H, Schuhmacher C. Clinical trials in gastric cancer and the future. J Surg Oncol 2012; 107:289-97. [PMID: 22514058 DOI: 10.1002/jso.23120] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2012] [Accepted: 03/23/2012] [Indexed: 02/06/2023]
Abstract
Following the first successful gastric resection for gastric cancer by Theodor Billroth in 1881 surgery has made tremendous progress leading to improved surgical mortality and morbidity. However, while treatment of early gastric cancer is frequently curative, 5-year survival rates for advanced gastric cancer remain dismal despite the application of perioperative multimodal treatment concepts. In this article we will outline key clinical trials that have lead to an improvement in treatment of gastric cancer patients with specific emphasis on the last 20 years. We will then outline recent concepts and key clinical trials that are currently being conducted in the field. Finally we will outline open questions that remain to be elucidated in the future.
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Affiliation(s)
- André L Mihaljevic
- Department of Surgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
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Mocellin S, Marchet A, Nitti D. EUS for the staging of gastric cancer: a meta-analysis. Gastrointest Endosc 2011; 73:1122-34. [PMID: 21444080 DOI: 10.1016/j.gie.2011.01.030] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2010] [Accepted: 01/13/2011] [Indexed: 12/14/2022]
Abstract
BACKGROUND The role of EUS in the locoregional staging of gastric carcinoma is undefined. OBJECTIVE We aimed to comprehensively review and quantitatively summarize the available evidence on the staging performance of EUS. DESIGN We systematically searched the MEDLINE, Cochrane, CANCERLIT, and EMBASE databases for relevant studies published until July 2010. SETTING Formal meta-analysis of diagnostic accuracy parameters was performed by using a bivariate random-effects model. PATIENTS Fifty-four studies enrolling 5601 patients with gastric cancer undergoing disease staging with EUS were eligible for the meta-analysis. MAIN OUTCOME MEASUREMENTS EUS staging accuracy across eligible studies was measured by computing overall sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), and diagnostic odds ratio (DOR). RESULTS EUS can differentiate T1-2 from T3-4 gastric cancer with high accuracy, with overall sensitivity, specificity, PLR, NLR, and DOR of 0.86 (95% CI, 0.81-0.90), 0.91 (95% CI, 0.89-0.93), 9.8 (95% CI, 7.5-12.8), 0.15 (95% CI, 0.11-0.21), and 65 (95% CI, 41-105), respectively. In contrast, the diagnostic performance of EUS for lymph node status is less reliable, with overall sensitivity, specificity, PLR, NLR, and DOR of 0.69 (95% CI, 0.63-0.74), 0.84 (95% CI, 0.81-0.88), 4.4 (95% CI, 3.6-5.4), 0.37 (95% CI, 0.32-0.44), and 12 (95% CI, 9-16), respectively. Results regarding single T categories (including T1 substages) and Bayesian nomograms to calculate posttest probabilities for any target condition prevalence are also provided. LIMITATIONS Statistical heterogeneity was generally high; unfortunately, subgroup analysis did not identify a consistent source of the heterogeneity. CONCLUSIONS Our results support the use of EUS for the locoregional staging of gastric cancer, which can affect the therapeutic management of these patients. However, clinicians must be aware of the performance limits of this staging tool.
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Affiliation(s)
- Simone Mocellin
- Meta-Analysis Unit, Department of Oncological and Surgical Sciences, University of Padova, Padova, Italy.
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Crabtree TD, Yacoub WN, Puri V, Azar R, Zoole JB, Patterson GA, Krupnick AS, Kreisel D, Meyers BF. Endoscopic Ultrasound for Early Stage Esophageal Adenocarcinoma: Implications for Staging and Survival. Ann Thorac Surg 2011; 91:1509-15; discussion 1515-6. [DOI: 10.1016/j.athoracsur.2011.01.063] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2010] [Revised: 01/11/2011] [Accepted: 01/13/2011] [Indexed: 12/31/2022]
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Gastric cancer: surgery in 2011. Langenbecks Arch Surg 2011; 396:743-58. [PMID: 21234760 DOI: 10.1007/s00423-010-0738-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2010] [Accepted: 12/20/2010] [Indexed: 12/13/2022]
Abstract
BACKGROUND Treatment of gastric cancer is more and more becoming an individualized decision. The choice of the optimal approach is based on prognostic factors, on the anatomic site of the tumor, and on expectations about the response to neoadjuvant treatment. Early gastric cancer that is limited to the mucosal layer is the domain of endoscopic resections. As soon as the submucosal layer is invaded, surgical strategies with adequate lymphadenectomy become necessary. DISCUSSION In many East Asian Centers and some other centers in the world, these tumors are resected by a laparoscopic approach. With a high experience, this can be done with excellent quality and outcome. In locally advanced gastric cancer, multimodal treatment can improve survival in comparison to surgery alone. However, the strategies differ significantly around the world. While adjuvant chemoradiotherapy is standard in the USA, in Europe, perioperative chemotherapy is the first choice, and in Japan, adjuvant chemotherapy is recommended. In Europe, three randomized phase III studies on the value of preoperative chemotherapy have been performed. Two of them have shown that perioperative chemotherapy does significantly improve the survival of patients with adenocarcinoma of the stomach and of the esophagogastric junction. The one including only preoperative chemotherapy failed to show a survival benefit for the combined treatment arm but showed excellent outcomes in both the surgery alone and the preoperative chemotherapy arms. Based on these studies, patients with stage II or stage III disease are now treated with perioperative chemotherapy. Additionally, it is generally accepted for more than 10 years now that responding patients have a significantly improved prognosis compared to nonresponding patients. The percentage of responding patients varies depending on the applied regimen between 20% and 45%. Therefore, early response evaluation or response prediction is an utmost important field of research. Proximal tumors are treated with a transhiatal extended gastrectomy, tumors in the middle third with a total gastrectomy, and distal tumors with a subtotal gastrectomy, if possible. Modified D2 lymphadenectomy avoiding splenectomy is now accepted as the standard procedure, providing improved prognosis for certain subgroups of patients. Individualized resection and lymphadenectomy techniques for early tumor stages and response-based neoadjuvant concepts for locally advanced tumors are the challenge for the future.
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Young PE, Gentry AB, Acosta RD, Greenwald BD, Riddle M. Endoscopic ultrasound does not accurately stage early adenocarcinoma or high-grade dysplasia of the esophagus. Clin Gastroenterol Hepatol 2010; 8:1037-41. [PMID: 20831900 DOI: 10.1016/j.cgh.2010.08.020] [Citation(s) in RCA: 110] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2010] [Revised: 08/19/2010] [Accepted: 08/23/2010] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS Patients with esophageal high-grade dysplasia or mucosal esophageal cancer can be successfully treated by endoscopy. We performed a systematic review of the literature to determine whether endoscopic ultrasound (EUS) correctly predicts the T-stage of early esophageal cancers, compared with pathology specimens obtained by using endoscopic mucosal resection (EMR) or surgery. METHODS Standard systematic review methods were used to perform reference searches, determine eligibility, abstract data, and analyze data. When possible, individual patient-level data were abstracted, in addition to publication-level aggregate data. RESULTS Twelve studies had sufficient information to abstract and review for quality; 8 had individual patient-level data (n = 132). Compared with surgical or EMR pathology staging, EUS had T-stage concordance of 65%, including all studies (n = 12), but only 56% concordance when limited to individual patient-level data. Factors such as initial biopsy pathology (high-grade dysplasia vs early-stage cancer) did not appear to affect the concordance of staging between EUS and EMR/surgical staging. CONCLUSIONS EUS is not sufficiently accurate in determining the T-stage of high-grade dysplasias or superficial adenocarcinomas; other means of staging, such as EMR, should be used.
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Affiliation(s)
- Patrick E Young
- National Naval Medical Center, Bethesda, Maryland 20889, USA.
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27
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Twine CP, Roberts SA, Rawlinson CE, Davies L, Escofet X, Dave BV, Crosby TD, Lewis WG. Prognostic significance of the endoscopic ultrasound defined lymph node metastasis count in esophageal cancer. Dis Esophagus 2010; 23:652-9. [PMID: 20545976 DOI: 10.1111/j.1442-2050.2010.01072.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The key prognostic factor which predicts outcome after esophagectomy for cancer is the number of malignant lymph node metastases, but data regarding the accuracy of endoscopic ultrasound (EUS) in determining and predicting the metastatic lymph node count preoperatively are limited. The aim of this study was to assess the prognostic significance of EUS defined lymph node metastasis count (eLNMC) in patients diagnosed with esophageal cancer. Two hundred and sixty-seven consecutive patients (median age 63 years, 187 months) underwent specialist EUS followed by stage directed multidisciplinary treatment (183 esophagectomy [64 neoadjuvant chemotherapy, 19 neoadjuvant chemoradiotherapy], 79 definitive chemoradiotherapy, and 5 palliative therapy). The eLNMC was subdivided into four groups (0, 1, 2 to 4, >4) and the primary measure of outcome was survival. Survival was related to EUS tumor (T) stage (P < 0.0001), EUS node (N) stage (P < 0.0001), EUS tumor length (p < 0.0001), and eLNMC (P < 0.0001). Multivariable analysis revealed EUS tumor length (hazard ratio [HR] 1.071, 95% CI 1.008-1.138, P= 0.027) and eLNMC (HR 1.302, 95% CI 1.133-1.496, P= 0.0001) to be significantly and independently associated with survival. Median and 2-year survival for patients with 0, 1, 2-4, and >4 lymph node metastases were: 44 months and 71%, 36 months and 59%, 24 months and 50%, and 17 months and 32%, respectively. The total number of EUS defined lymph node metastases was an important and significant prognostic indicator.
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Affiliation(s)
- C P Twine
- South East Wales Cancer Network, Department of General and Upper GI Surgery, University Hospital of Wales, Cardiff, UK
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Nothacker M, Langer T, Weinbrenner S. [Diagnostic imaging in oncology--evidence reviews for evidence based guidelines by the Agency of Quality for Medicine (ÄZQ)]. ZEITSCHRIFT FUR EVIDENZ, FORTBILDUNG UND QUALITAT IM GESUNDHEITSWESEN 2010; 104:554-562. [PMID: 21095608 DOI: 10.1016/j.zefq.2010.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2010] [Revised: 08/02/2010] [Accepted: 08/17/2010] [Indexed: 05/30/2023]
Abstract
Within the context of the development of evidence-based oncology guidelines, the Agency for Quality in Medicine undertook evidence reviews for diagnostic imaging procedures. Systematic searches retrieved no randomised controlled trials, but only cohort studies and case series of mostly moderate quality. The identified studies provided only a restricted basis for the guideline recommendations as their validity was limited and only outcomes of diagnostic accuracy were examined. However, decision criteria for recommending diagnostic strategies significantly comprise judgements about required resources and availability of diagnostic imaging procedures. These criteria as well as patient out-comes were mostly implicit and should be explicated in future. In order to increase the relevance of evidence reviews for oncological diagnosis, high quality studies which examine resources and patient-centred outcomes for diagnostic strategies are required.
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Mortensen MB, Fristrup C, Ainsworth A, Nielsen HO, Pless T, Hovendal C. Combined pretherapeutic endoscopic and laparoscopic ultrasonography may predict survival of patients with upper gastrointestinal tract cancer. Surg Endosc 2010; 25:804-12. [PMID: 20676688 DOI: 10.1007/s00464-010-1258-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2010] [Accepted: 07/13/2010] [Indexed: 01/07/2023]
Abstract
BACKGROUND The combination of endoscopic and laparoscopic ultrasonography (EUS-LUS) is accurate for resectability assessment of patients with upper gastrointestinal cancer (UGIC). But neither the ability of EUS/LUS to predict long-term prognosis nor the potential impact on patient survival using this selection strategy has been investigated. This prospective, single-center study evaluated whether pretherapeutic EUS-LUS stratification related to the prognosis in UGIC patients and whether patient selection by this strategy provided a prognostic outcome comparable with survival data from the literature. METHODS Each patient had a pretherapeutic tumor node metastasis (TNM) stage and a resectability assessment assigned based on EUS-LUS findings. Survival curves were constructed and compared for each of the EUS-LUS TNM stage and resectability groups at the end of the observation period. Finally, the R0 resection rate, median, and 5-year survival rates were compared with the literature. RESULTS This study enrolled 936 consecutive patients with esophageal (n = 256), gastric (n = 273), or pancreatic (n = 407) cancer. A statistically significant survival difference (p < 0.01) between the different TNM stages and resectability groups predicted by EUS-LUS was observed regardless of the cancer type. The poor prognosis for the patients with irresectable or disseminated UGIC was accurately predicted by EUS and LUS. The R0 resection rate as well as the median and 5-year survival rates were comparable with data from the literature. CONCLUSION The pretherapeutic EUS-LUS patient stratification related significantly to the final prognosis for UGIC patients. An EUS-LUS-based patient selection strategy seemed to provide a prognostic outcome similar to data from computed tomography (CT)-based populations.
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Ott K, Lordick F. [Neoadjuvant therapy in the upper gastro-intestinal tract. Gastric cancer from a surgical viewpoint]. Chirurg 2010; 80:1028-34. [PMID: 19756431 DOI: 10.1007/s00104-009-1736-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The prognosis of locally advanced gastric cancer remains poor. It has been shown that multimodal treatment can improve the outcome in comparison to surgery alone. Two randomized studies that have been performed in Europe have shown that peri-operative chemotherapy significantly improves the survival of patients with adenocarcinoma of the stomach and of the gastro-esophageal junction. These results have a profound effect on the treatment of patients presenting with stage II or stage III disease. For more than 10 years it has been accepted that responding patients have a significantly improved prognosis compared to non-responding patients. Therefore, (early) response evaluation or response prediction is of utmost importance. After neoadjuvant chemotherapy patients should undergo a D-2 lymphadenectomy due to the high probability of lymph node metastasis. Neither mortality nor complication rate are increased after neoadjuvant chemotherapy for gastric cancer. Patients with locally advanced gastric cancer should always be referred to experienced high volume centers, where the findings are discussed in a multidisciplinary tumor board.
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Affiliation(s)
- K Ott
- Chirurgische Klinik, Universität Heidelberg, Heidelberg.
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Walker AJ, Spier BJ, Perlman SB, Stangl JR, Frick TJ, Gopal DV, Lindstrom MJ, Weigel TL, Pfau PR. Integrated PET/CT Fusion Imaging and Endoscopic Ultrasound in the Pre-operative Staging and Evaluation of Esophageal Cancer. Mol Imaging Biol 2010; 13:166-71. [DOI: 10.1007/s11307-010-0306-0] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Shenfine J, Barbour AP, Wong D, Thomas J, Martin I, Gotley DC, Smithers BM. Prognostic value of maximum standardized uptake values from preoperative positron emission tomography in resectable adenocarcinoma of the esophagus treated by surgery alone. Dis Esophagus 2009; 22:668-75. [PMID: 19222534 DOI: 10.1111/j.1442-2050.2009.00941.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Preoperative staging for esophageal adenocarcinoma is suboptimal for predicting outcomes when compared with pathological data. The aim of this study was to assess if the quantitative values obtained by preoperative 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) are independent prognostic indicators for survival in patients with resectable adenocarcinoma of the esophagus undergoing surgical treatment without neoadjuvant therapy. Patients were identified from a prospective database, survival analyses were undertaken using log rank and Cox method. The median follow-up was 44 months (range 18-61 months). Between November 2002 and November 2005, 45 consecutive patients underwent FDG-PET followed by surgery. The median age was 72 years (range 38-82 years). On univariate analysis of overall survival and disease-free survival, preoperative FDG-PET maximum standardized uptake value (SUV(max); P= 0.008 and P= 0.015, respectively) and postoperative pathological stage (P= 0.001 and P= 0.001, respectively) as well as postoperative histological grade (P= 0.001 and P= 0.001, respectively) were significantly associated with outcome. Multivariate analysis demonstrated that only the postoperative pathological variables were independent predictors of outcome (Wald 11.81, P= 0.001). Preoperative FDG-PET SUV(max) is associated with outcome after esophageal adenocarcinoma resection but remains less accurate than postoperative variables. A high FDG-PET SUV(max) could be used to identify a high-risk population who would benefit most from neoadjuvant therapies.
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Affiliation(s)
- J Shenfine
- Northern Oesophago-Gastric Cancer Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK.
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Power DG, Schattner MA, Gerdes H, Brenner B, Markowitz AJ, Capanu M, Coit DG, Brennan M, Kelsen DP, Shah MA. Endoscopic ultrasound can improve the selection for laparoscopy in patients with localized gastric cancer. J Am Coll Surg 2008; 208:173-8. [PMID: 19228527 DOI: 10.1016/j.jamcollsurg.2008.10.022] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2008] [Revised: 10/20/2008] [Accepted: 10/27/2008] [Indexed: 12/11/2022]
Abstract
BACKGROUND The majority of newly diagnosed patients with gastric cancer have disease that is not resectable because of local extension or metastatic (M1) disease. Laparoscopy is a recommended staging evaluation to identify occult peritoneal metastatic disease. We determined if endoscopic ultrasound (EUS) could improve the selection of patients for laparoscopy. STUDY DESIGN Gastric cancer patients being screened for a preoperative chemotherapy clinical trial were prospectively examined. Patients underwent standard preoperative assessment. Those without obvious metastatic disease were referred for EUS and laparoscopy. EUS divided patients into risk categories for metastatic disease: low risk (T1-2, N0) and high risk (T3-4, N+, or both). Laparoscopy categories were M1 and M0. The ability of EUS to predict subradiographic peritoneal metastatic disease was evaluated. RESULTS Ninety-four patients were studied. The majority were EUS high risk (72%). Occult metastatic disease was identified in 19 patients, 18 of whom had high-risk EUS stage. The yields of identifying M1 disease by laparoscopy in EUS high- and low-risk patients were 25% (95% CI, 15% to 37%) and 4% (95% CI, 0.1% to 20%), respectively. The negative predictive value of low-risk EUS for laparoscopy and pathologic M0 was 96% (exact 95% CI, 80% to 100%). CONCLUSIONS This study suggested that laparoscopy can be avoided in patients with EUS early-stage gastric cancer. Patients with more advanced disease are at higher risk of occult peritoneal disease and require laparoscopy. Validation with greater numbers is warranted, but, based on these data, we propose a new staging algorithm allowing EUS low-risk patients to proceed directly to resection.
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Affiliation(s)
- Derek G Power
- Gastrointestinal Oncology Service, Memorial Sloan-Kettering Cancer Center, and the Department of Medicine, Weil Cornell Medical College of Cornell University, New York, NY, USA
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Carboni F, Lorusso R, Santoro R, Lepiane P, Mancini P, Sperduti I, Santoro E. Adenocarcinoma of the esophagogastric junction: the role of abdominal-transhiatal resection. Ann Surg Oncol 2008; 16:304-10. [PMID: 19050964 DOI: 10.1245/s10434-008-0247-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2008] [Revised: 10/01/2008] [Accepted: 10/28/2008] [Indexed: 12/23/2022]
Abstract
The surgical strategy for adenocarcinoma of the esophagogastric junction is still controversial. The aim of this study was to evaluate surgical results of the abdominal-transhiatal approach for 100 consecutively operated type II and III cardia adenocarcinoma, to clarify clinicopathological differences between these tumors, and to define prognostic factors. A prospectively maintained database identified 100 consecutively operated patients with Siewert type II and III cardia adenocarcinoma. Survival was analyzed by the Kaplan-Meier method. Differences between subgroups and prognostic factors were evaluated by the log rank test and Cox regression. Concerning clinicopathological characteristics, only the incidence of T1-2 stage was significantly higher in Siewert II type (P = .006). A complete (R0) resection was obtained in 74 patients (74%). Overall postoperative mortality and morbidity rates were 6% and 28%, respectively. Overall actuarial 5-year survival rate in resected patients was 27.4% (median 27 months), with 20.6% for type II and 34 for type III cancers (P = .07). Considering R0 resections, overall actuarial 5-year survival rate was 33.9% (median 33 months), with 26.7% for type II and 40.5 for type III cancer (P = .06). Pathologic T and N stage and R status were independent prognostic factors by multivariate analysis, and Siewert type showed a trend toward significance. The abdominal-transhiatal approach is a safe surgical approach, allowing complete tumor resection and adequate lymphadenectomy in these patients. True carcinoma of the cardia may be a distinct clinical entity with a more aggressive natural history than subcardial gastric carcinoma.
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Affiliation(s)
- Fabio Carboni
- Department of Digestive Surgery, Regina Elena Cancer Institute, Rome, Italy.
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Abstract
PURPOSE OF REVIEW Esophageal cancer staging continues to evolve, especially for advanced cases. Computer tomography (CT) scan of the thorax and abdomen to detect metastatic disease, and endoscopic ultrasound with fine needle aspiration (EUS-FNA) remain the preferred methods. Several recent studies have evaluated alternative methods for locoregional and distant disease detection and staging. RECENT FINDINGS There seems to be emerging roles for fluorine-18 fluorodeoxyglucose (FDG)-PET, laparoscopic staging, and high-resolution T2-weighted MRI in esophageal cancer staging. Perfusion CT and FDG-PET and FDG-PET/CT may have an emerging role in assessing response to neoadjuvant therapy. Restaging following neoadjuvant therapy remains suboptimal. A 50% or more reduction of tumor thickness by EUS postchemotherapy continues to be the best measure for tumor downstaging survival, while FDG-PET/CT may be more accurate than EUS-FNA and CT scan for predicting nodal status and complete responders after neoadjuvant therapy. Potential methylation analysis, digital image analysis, and fluorescence in-situ hybridization on EUS-FNA samples may increase the yield and prove to be better than routine cytology. SUMMARY For advanced esophageal cancer, locoregional staging is best performed with EUS-FNA, with CT scan of the thorax and abdomen and FDG-PET, to detect metastatic disease. The role of EUS in restaging following neoadjuvant therapy remains controversial, with recent studies showing that FDG-PET/CT may be more accurate than EUS-FNA and CT scan for predicting nodal status and complete responders after neoadjuvant therapy.
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