A comparison of the accuracy of echo features during endoscopic ultrasound (EUS) and EUS-guided fine-needle aspiration for diagnosis of malignant lymph node invasion

The Role of Endoscopic Ultrasound and Ancillary Techniques in the Diagnosis of Autoimmune Pancreatitis: A Comprehensive Review

Autoimmune pancreatitis (AIP) is a unique form of chronic pancreatitis with a multifactorial pathogenesis. Historically, it has been classified as type 1 and type 2, according to its clinical and histological features. The diagnosis of AIP is challenging and relies on a combination of clinical, histopathologic, serologic, and imaging characteristics. In the available guidelines, the imaging hallmarks of AIP are based on cross-sectional imaging and cholangiopancreatography retrograde endoscopic findings. Endoscopic ultrasound (EUS) is generally used for pancreatic tissue acquisition to rule out pancreatic cancer and diagnose AIP with limited accuracy. Several papers reported the reliability of EUS for providing informative morphologic features of AIP. Nowadays, the improvement in the resolution of EUS conventional images and the development of new ancillary technologies have further increased the diagnostic yield of EUS: contrast-enhanced EUS and EUS elastography are non-invasive and real-time techniques that strongly support the diagnosis and management of pancreatic diseases. In this review article, we will present the role of conventional EUS and ancillary diagnostic techniques in the diagnosis of AIP to support clinicians and endosonographers in managing this condition.

Diagnostic Endoscopic Ultrasound (EUS) of the Luminal Gastrointestinal Tract

The purpose of this review is to focus on the diagnostic endoscopic ultrasound of the gastrointestinal tract. In the last decades, EUS has gained a central role in the staging of epithelial and sub-epithelial lesions of the gastrointestinal tract. With the evolution of imaging, the position of EUS in the diagnostic work-up and the staging flow-chart has continuously changed with two extreme positions: some gastroenterologists think that EUS is absolutely indispensable, and some think it is utterly useless. The truth is, as always, somewhere in between the two extremes. Analyzing the most up-to-date and strong evidence, we will try to give EUS the correct position in our daily practice.

Current perspectives on the diversification of endoscopic ultrasound-guided fine-needle aspiration and biopsy

Endoscopic ultrasound-guided tissue acquisition (EUS-TA) has undergone significant advancements since it was first reported in 1992. Initially focused on the pancreas, EUS-guided fine-needle aspiration (FNA) has now been extended to encompass all organs proximal to the gastrointestinal system. Recently, a novel fine-needle biopsy (FNB) needle with an end-cut tip was developed, allowing for the collection of specimens suitable for histological assessment, a feat hard to achieve with traditional needles. The FNB needle holds promise for applications in immunohistochemistry staining and genetics evaluation, and it has the potential to yield specimens of comparable quality to core needle biopsy during percutaneous puncture, especially for lesions beyond the pancreas, such as lymph nodes. This review focuses on the efficacy of EUS-FNA/FNB for extended target regions, specifically lymph nodes, spleen, adrenal gland, and ascites. The indications for EUS-FNA have greatly expanded beyond the pancreas over the years, and future improvements and innovations in puncture needles will allow for the collection of higher-quality specimens, which is expected to play a significant part in personalized cancer treatment.

Endoscopic ultrasound for the diagnosis and treatment of primary hepatocellular carcinoma

Chronic liver disease has emerged as a significant global concern, with primary hepatocellular carcinoma (HCC) representing a critical consequence of this disease. However, early detection of HCC remains challenging in clinical practice. Recently, there has been a growing interest in applying endoscopic ultrasound (EUS) as a diagnostic tool for gastrointestinal diseases. Nevertheless, using EUS to diagnose and treat HCC is uncommon. In this review we described the diagnostic and therapeutic applications of EUS in primary HCC and evaluated its clinical significance. The diagnostic procedures primarily involve EUS-guided fine-needle biopsy or aspiration, assessment of metastatic lymph nodes and portal vein thrombosis, portal pressure monitoring, and portal vein blood collection. Treatment mainly includes EUS-guided tumor ablation, brachytherapy, injectable chemotherapy, and managing variceal hemorrhage related to portal hypertension.

Endoscopic Management of Esophageal Cancer

Advances in technology and improved understanding of the pathobiology of esophageal cancer have allowed endoscopy to serve a growing role in the management of this disease. Precursor lesions can be detected using enhanced diagnostic modalities and eradicated with ablation therapy. Furthermore, evolution in endoscopic resection has provided larger specimens for improved diagnostic accuracy and offer potential for cure of early esophageal cancer. In patients with advanced esophageal cancer, endoluminal therapy can improve symptom burden and provide therapeutic options for complications such as leaks, perforations, and fistulas. The purpose of this review article is to highlight the role of endoscopy in the diagnosis, treatment, and palliation of esophageal cancer.

The expanding role of endoscopic ultrasound elastography

Endoscopic ultrasound (EUS) is an invaluable tool for assessing various GI diseases. However, using just the conventional B-mode EUS imaging may not be sufficient to accurately delineate the lesion's character. Using the principle of stress-induced tissue strain, EUS elastography (EUS-E) can help in the real-time sonographic assessment of the level of tissue stiffness or hardness of any organ of interest during a routine EUS procedure. Thus, EUS-E can better characterize the lesion's nature and highlight the more suspicious areas within an individual lesion. The most commonly studied lesions with EUS-E are the pancreatic lesions, namely, chronic pancreatitis, pancreatic cancer, and lymph nodes. However, EUS-E is gradually expanding its use for lesion characterization of the liver, bile duct, adrenals, gastrointestinal tract, and even therapy response. Moreover, the use of EUS-E along with other image enhancement techniques such as harmonic EUS and contrast-enhanced EUS can improve the accuracy of the diagnosis. However, several technical aspects need to be standardized before EUS-E can be truly used as a tool for "virtual biopsy". This review focuses on the various technical aspects of the use of EUS-E, it is established and expanding indications and an extensive outline of the various studies on EUS-E. We also discuss the current pitfalls and future trends in EUS-E.

High-Frequency Endoscopic Ultrasound Imaging With Phase-Corrected-and-Sum and Coherence Factor Weighting

High-frequency endoscopic ultrasound (HFEUS) imaging is an important tool commonly used in clinical practice for imaging hollow organs. The virtual source synthetic aperture (VSSA) method is effective in improving the imaging quality of HFEUS. However, interference from the motor control unit severely affects the accuracy of the conventional delay and sum (DAS) method, thus compromising the effectiveness of VSSA. In this article, a new computational method based on phase correction was proposed to overcome these shortcomings, which is named phase-corrected-and-sum (PCAS). Meanwhile, the parameters of coherence factor weighting (CFW) can be obtained from the correlation coefficient of the superimposed signals to further increase the imaging quality. Three kinds of imaging experiments were designed to evaluate the proposed method. Compared with the conventional method, the results show that the PCAS-CFW method improves the lateral resolution by about 10% and the contrast-to-noise ratio (CNR) by about 44%. Therefore, this proposed method is capable of significantly improving HFEUS image quality, and this method can be easily integrated into current HFEUS imaging systems, showing great potential for clinical applications.

Diagnostic accuracy and clinical impact of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) in Positron Emission Tomography - Computed Tomography (PET-CT)-positive mediastinal lymphadenopathies in patients with thoracic or extra-thoracic malignancies

BACKGROUND

The high sensitivity of PET-CT can identify hypermetabolic mediastinal adenopathies during cancer management, but specificity is low and a biopsy is sometimes required to eliminate benign adenopathies.

METHODS

This prospective diagnostic accuracy study included patients with hypermetabolic mediastinal lymphadenopathies revealed on PET-CT during either the initial management of a cancer, treatment evaluation, or monitoring. All patients underwent EUS-FNA. Diagnoses of malignancy based on cytological analysis following EUS-FNA were compared with clinical and radiological follow-up information. The treatment strategy decided before the results of the EUS-FNA pathology reports (Multidisciplinary Team Meeting [MTM-1]) was recorded and compared to the treatment strategy decided once pathological data from EUS-FNA were available (MTM-2).

MAIN FINDINGS

Between 2013 and 2018, 75 patients were included with 47 eligible and evaluable patients. Sensitivity, specificity, and positive and negative predictive values of EUS-FNA were 93%, 100%, 100% and 90%, respectively. The concordance value between the therapeutic strategies determined for MTM-1 and MTM-2 was 44.7%. There were no significant differences in the intensity of fixation on PET-CT between malignant and benign lesions.

CONCLUSION

The diagnostic accuracy of the minimally invasive EUS-FNA procedure is sufficiently robust to avoid the need for diagnostic surgery. The combination of PET-CT and EUS-FNA may alter the therapeutic strategy that would be considered after PET-CT alone.

REGISTRATION

NCT01892501.

Role of endoscopic ultrasound in esophageal cancer

Esophageal cancer (ECA) affects 1 in 125 men and 1 in 417 for women and accounts for 2.6% of all cancer related deaths in the United States. The associated survival rate depends on the stage of the cancer at the time of diagnosis, making adequate work up and staging imperative. The 5-year survival rate for localized disease is 46.4%, regional disease is 25.6%, and distant/metastatic disease is 5.2%. Additionally, treatment is stage-dependent, making staging all that much important. For nonmetastatic transmural tumors (T3) and/or those that have locoregional lymph node involvement (N), neoadjuvant therapy is recommended. Conversely, for those who have earlier tumors, upfront surgical resection is reasonable. While positron emission tomography/computed tomography and other cross sectional imaging modalities are exceptional for detecting distant disease, they are inaccurate in staging locoregional disease. Endoscopic ultrasound (EUS) has played a key role in the locoregional (T and N) staging of newly diagnosed ECA and has an evolving role in restaging after neoadjuvant therapy. There is even data to support that the use of EUS facilitates proper triaging of patients and may ultimately save money by avoiding unnecessary or futile treatment. This manuscript will review the current role of EUS on staging and restaging of ECA.

Tuberculosis is still the most Common Cause of Mediastinal and Intra-abdominal Lymphadenopathy by EUS-FNA in India

Background Lymph nodal tuberculosis is reported to occur in 4% to 7% of all tuberculosis, and mediastinal lymphadenopathy accounts for 10% of lymph nodal tuberculosis but the diagnosis still remains a challenge due to inaccessibility to these sites. There is a scarcity of recent data from India about the etiology of intra-abdominal and mediastinal lymphadenopathy despite being frequently detected in cross-sectional imaging.

Methods A retrospective study was conducted after reviewing hospital records over a period of 3 years from December 2017 to December 2020 who underwent endoscopic ultrasonography (EUS). A total of 126 patients with mediastinal and/or intra-abdominal lymphadenopathy detected by cross-sectional imaging were examined for clinical features, EUS, and histopathology records.

Results The mean age of patients was 53.12 ± 14.15 years. Seventy-one patients (56%) had intra-abdominal lymph nodes and 55 (44%) had mediastinal lymph nodes. The average number of needle passes was 2.35 ± 0.58 (range: 2–4). The majority of patients had tubercular etiology (53.2%) followed by metastatic (26.2%). Other etiologies were reactive (4.8%), lymphoma (4.8%), sarcoidosis (3.2%), and GIST (1.6%). No diagnosis could be ascertained in 6.3% of patients. The EUS features that favored tubercular etiology over metastatic were heterogeneous echotexture (72% vs. 30%), irregular shape (78% vs. 12%), indistinct borders (81% vs. 30%) and calcification (43% vs. 15%). Partial anechoic area and hyperechoic area were seen in 21% and 64% of tubercular patients, respectively. EUS only had sensitivity and specificity of 63% and 84%, respectively, and EUS FNA had a very high sensitivity and specificity of 93% and 100%, respectively.

Conclusion Tuberculosis is still the most common cause of lymph nodes. EUS FNA had a very high sensitivity and specificity of 93% and 100%, respectively, for the diagnosis of mediastinal and intra-abdominal lymphadenopathy.

Optimal Size Criterion for Malignant Lymph Nodes and a Novel Lymph Node Clinical Staging System for Unresectable Esophageal Squamous Cell Carcinoma: Evaluation by Multislice Spiral Computed Tomography

Objectives: The current Chinese draft nodal clinical staging system for unresectable esophageal cancer is controversial. Our study aimed to propose a new diagnostic criterion for lymph node metastasis (LNM) detected by multislice spiral computed tomography (MSCT) in nonsurgically treated esophageal squamous cell carcinoma (ESCC) patients and then develop a novel lymph node (LN) clinical staging system for better individual prognostic prediction. Methods: The short-axis diameters of regional LNs were measured in 393 nonsurgical patients. Regional nodes were considered positive for malignancy if the nodal size exceeded the optimal size, which was determined by Kaplan-Meier survival analysis. The novel LN clinical staging system was then constructed using the LASSO model based on the relative prognostic importance of different LN stations. Validation cohort was included to confirm the prognostic performance. Results: Regional nodes were considered positive for malignancy if they were larger than 10 mm in the low cervical and upper thoracic segments, 7 mm in the middle thoracic segment, and 8 mm in the lower thoracic and celiac segments. Using the LASSO model, stations 2R, 3A, 7 and 16 were qualified in the model. Further analysis showed that our LN clinical staging system had better homogeneity, discriminatory ability and clinical value than the draft nodal staging system. Conclusions: Our results show that the new diagnostic criterion may improve the diagnostic value of MSCT in metastatic LNs. The novel LN clinical staging system can stratify nonsurgically treated ESCC patients into different risk groups, providing valuable information for decision making and outcome prediction.

Comparison of Endoscopic Ultrasound-Guided Fine-Needle Aspiration and Biopsy Device for Lymphadenopathy

Background

Accurate diagnosis of benign and malignant lymphadenopathy is important for determining the appropriate treatment and prognosis. This study evaluated the diagnostic accuracy and usefulness of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) with a conventional needle compared to endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) with a Franseen needle for diagnosing lymphadenopathy.

Methods

Patients who underwent EUS-FNA or EUS-FNB for mediastinal or abdominal lymphadenopathy between July 2013 and August 2020 were enrolled in the study. The outcomes between EUS-FNA patients (July 2013 to January 2017; 22-gauge conventional needle; Group A) and EUS-FNB patients (February 2017 to August 2020; 22-gauge Franseen needle; Group B) were compared.

Results

A total of 154 patients (Group A: 83; Group B: 71) were analyzed. The diagnostic accuracy (differentiating between malignant and benign lesions) was 88.0% (95% confidence interval [CI], 79.2–93.3%) in Group A and 95.8% (95% CI, 88.3–98.8%) in Group B. Group B had high diagnostic accuracy, but there was no difference between the groups (p = 0.14). Group B had significantly fewer passes (median 2, interquartile range (IQR): 2-4) than Group A (median 3, IQR: 3-4) (p < 0.001). No procedural adverse events occurred in either group.

Conclusions

Although the diagnostic accuracy between the groups was not statistically significant, EUS-FNB with a Franseen needle provided high diagnostic accuracy and required fewer passes to establish a diagnosis. Thus, EUS-FNB is useful for diagnosing lymphadenopathy.

Diagnosis of Pancreatic Solid Lesions, Subepithelial Lesions, and Lymph Nodes Using Endoscopic Ultrasound

Currently, endoscopic ultrasound (EUS) has become widely accepted and has considerable advantages over computed tomography (CT) and other imaging modalities, given that it enables echostructure assessment in lesions with <1 cm diameter and permits high resolution imaging. EUS-guided tissue acquisition (EUS-TA) provides consistent results under ultrasound guidance and has been considered more effective compared to CT- or ultrasound-guided lesion biopsy. Moreover, complication rates, including pancreatitis and bleeding, have been extremely low, with <1% morbidity and mortality rates, thereby suggesting the exceptional overall safety of EUS-TA. The aggressive use of EUS for various lesions has been key in facilitating early diagnosis and therapy. This review summarizes the diagnostic ability of EUS for pancreatic solid lesions, subepithelial lesions, and lymph nodes where it is mainly used. EUS has played an important role in diagnosing these lesions and planning treatment strategies. Future developments in EUS imaging technology, such as producing images close to histopathological findings, are expected to further improve its diagnostic ability. Moreover, tissue acquisition via EUS is expected to be used for precision medicine, which facilitates the selection of an appropriate therapeutic agent by increasing the amount of tissue collected and improving genetic analysis.

Endoscopic ultrasound-guided-fine-needle aspiration/fine-needle biopsy in diagnosis of mediastinal lymphadenopathy - A boon

Background/Objectives:

Evaluation of mediastinal lymphadenopathy (MLA) is a great diagnostic challenge considering the myriad of causes. In recent years, the role of endoscopic ultrasound (EUS) has been greatly extended in evaluation of MLA due to its safety, reliability, and accuracy. The present study details the role of EUS-guided-fine-needle aspiration/fine-needle biopsy (EUS-FNA/FNB) in MLA of unknown origin.

Methods:

Seventy-two patients (34 men) with MLA of unknown etiology were studied. Mediastinum was evaluated with linear echoendoscope and FNA/FNB was performed with 22-G needle and sent for cytology, histopathological, and mycobacterial growth indicator tube/GeneXpert evaluation. EUS-FNA/FNB diagnosis was based on cytology reporting by pathologists. Patients tolerated the procedure, and insertion of needle into the lesion was always successful without any complications.

Results:

EUS-FNA/FNB established a tissue diagnosis in 66/72 patients in first sitting, while six patients underwent repeat procedure. EUS-FNA diagnoses (after second sitting) were tuberculous lymphadenitis in 45/72 (62.5%), metastatic lymph nodes 12/72 (16.7%), reactive lymphadenopathy 6/72 (8.3%), sarcoidosis 4/72 (5.6%), and lymphoma 2/72 (2.8%), while it was nondiagnostic in 3/72 (4.1%) patients. Final diagnosis was based on combined clinical presentation, EUS-FNA/FNB result and clinicoradiological response to treatment on long-term follow-up of 6 months.

Conclusion:

EUS echo features along with EUS-FNA/FNB can diagnose MLA and surgical biopsy can be avoided.

Contribution of endobronchial ultrasound elastography to the characterization of mediastinal lymphadenopathy: A single-center, prospective, observational study

BACKGROUND

Endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) is a reliable technique providing high diagnostic yield in mediastinal lymphadenopathy. However, mediastinoscopy is sometimes necessary to eliminate false-negative results. Elastography is a recent technique that can be combined with EBUS to evaluate the elasticity and consequently the nature of a tissue. The primary objective was to evaluate the diagnostic performance of EBUS-TBNA combined with elastography for the assessment of mediastinal lymph nodes.

METHODS

Single-center, prospective study in patients with mediastinal lymphadenopathy. EBUS-TBNA combined with elastography was performed in each patient. Several elastographic parameters were studied: colorimetric score, average elasticity, elasticity ratio, percentage of hard areas. The final diagnosis was that obtained by TBNA cytology, histology of a surgical biopsy, when performed, or follow-up CT and PET-CT at 6 months.

RESULTS

Overall, 110 lymph nodes were examined in 87 patients: 44 were malignant according to TBNA. These nodes had significantly higher elasticity ratio, percentage of hard areas and colorimetric score and significantly lower average elasticity compared to benign nodes (P<0.001). With a negative predictive value of 100%, the cut-offs defined by receiver operating characteristic curves were 1.4 for elasticity ratio, 84.8 for average elasticity, 32.6 for percentage of hard areas and 3 for colorimetric score. No adverse events were observed.

CONCLUSION

Endobronchial ultrasound elastography is a non-invasive technique that can contribute to prediction of the nature of lymph nodes by distinguishing malignant from benign nodes. Although EBUS cannot replace histological examination, elastography can provide reliable complementary information when combined with EBUS.

Endoscopic ultrasonography for pancreatic solid lesions

The incidence and mortality rates of pancreatic cancer, which has a poor prognosis, are rising rapidly. Endoscopic ultrasonography (EUS) provides superior spatial resolution compared with other imaging modalities such as transabdominal ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI), and it is considered among the most reliable and efficient diagnostic modalities for pancreatic diseases. In this review, we show that EUS is useful for detection of pancreatic solid lesions and staging of pancreatic cancer. EUS also plays an important role in screening patients with high-risk factors for pancreatic cancer. Although EUS is useful for detection of small pancreatic lesions, pancreatic lesions are difficult to characterize using this modality, because most pancreatic solid lesions appear hypoechoic on EUS. From this point of view, contrast-enhanced harmonic EUS (CH-EUS) plays an important role in the differential diagnosis of pancreatic lesions. EUS and CH-EUS are also useful for staging pancreatic cancer. Moreover, EUS-guided fine-needle aspiration (EUS-FNA) is superior to other modalities in terms of cytopathological diagnosis. Although EUS-FNA has a high diagnostic ability for pancreatic cancer, the combination of EUS-FNA and CH-EUS improves the diagnostic ability by decreasing the number of false-negative cases. Thus, conventional EUS, EUS-FNA, and CH-EUS are essential in clinical practice for the diagnosis of pancreatic solid lesions.

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.

Ongoing Challenges with Clinical Assessment of Nodal Status in T1 Esophageal Adenocarcinoma

BACKGROUND

Endoscopic mucosal resection (EMR) has emerged as an esophageal-preserving treatment for T1 esophageal adenocarcinoma (EAC); however, only patients with negligible risk of lymph node metastasis (LNM) are eligible. Reliable clinical diagnostic tools for LNM are lacking, as such, several risk assessment scores have been developed. The purpose of this study was to externally validate 2 previously published risk scores (Lee and Weksler) for clinical prediction of LNM in T1 EAC patients.

METHODS

In adherence with the Lee and Weksler scores, esophagectomy patients with pathologic T1 EAC were identified. Sub-analysis was performed in patients with clinical T1 based on EMR. Predictive accuracy of the scores was evaluated by calculating the area under the curve of the receiver operating characteristic curve and calibration plots. The areas under the curves were compared using Venkatraman's test for paired receiver operating characteristic curves.

RESULTS

Of 233 patients identified who met study criteria for external validation, 3 T1a and 32 T1b patients had LNM. The receiver operating characteristic curves demonstrated comparable high predictive and discriminatory capabilities with areas under the curves of 0.832 and 0.824 for the Lee and Weksler scores, respectively (p = 0.750). Results were more variable for the EMR cohort. Based on the risk thresholds defined by each score, the false-positive rate compared against the pathologic LNM status were 73% and 56% for Lee and Weksler, with 3% false negatives in the latter. On EMR, the false-positive rates were 70% and 50% for Lee and Weksler, with no false negatives.

CONCLUSIONS

Both scoring systems demonstrated good discriminatory ability and predictive accuracy for LNM, but the defined thresholds resulted in a high false-positive rate. A better scoring system based on clinical characteristics is needed to better identify patients with local disease.

Miniaturized High-Resolution Integrated 360° Electronic Radial Ultrasound Endoscope for Digestive Tract Imaging

To improve the accuracy and operating flexibility of digestive diagnostic applications in situ, this paper demonstrates the design, fabrication, and evaluation of a miniaturized high-resolution integrated 360° electronic radial ultrasound endoscope. To improve the uniformity between elements of the radial array transducer, an optimal fabrication procedure based on a flexible matching layer was developed. The radial ultrasound endoscope has a 128.3° 5-million-pixel camera module integrated with an approximately 8-MHz 128-element radial ultrasonic array in a package with an outer diameter of 9.5 mm. The results showed that the array has a center frequency of 8.2 MHz, a -6-dB fractional bandwidth of 83.4%, and a two-way insertion loss of 39.62 dB at the center frequency. Annulus and wire phantoms can be distinctly imaged with the radial array. Printed eight-point font can be distinctly imaged with both a large view and a 3-18-mm depth of field in lumen short-range optical imaging. A porcine esophagus can be distinctly imaged in vitro with the integrated endoscope. The results indicate that the fabrication method based on a flexible matching layer can achieve high uniformity between elements of a radial array transducer. In addition, the proposed ultrasound endoscope demonstrates a good image resolution.

Contrast-enhanced endoscopic ultrasound for the differential diagnosis between benign and malignant lymph nodes: a meta-analysis

Background  The differential diagnosis between benign and malignant lymph nodes (LNs) is crucial for patient management and clinical outcome. The use of contrast-enhanced endoscopic ultrasound (EUS) has been evaluated in several studies with diverse results. The aim of this meta-analysis was to evaluate the pooled diagnostic accuracy of contrast-enhanced EUS (CE-EUS) and contrast-enhanced harmonic EUS (CH-EUS) in this setting. Methods  A systematic electronic search was performed, including all original papers dealing with assessment of the nature of the LNs using CE-EUS or CH-EUS. A meta-analysis was performed to obtain pooled sensitivity, specificity, positive and negative likelihood ratio, and diagnostic odds ratio. The Summary Receiver Operating Characteristic (ROC) Curve method was used to calculate the area under the curve. Statistical analysis was carried out using Meta-Disc V.1.4, Stata V.12.0 and Review Manager V.5.2. Results  Among 210 pertinent studies, four (336 patients) were included in the analysis. The pooled sensitivity was 82.1 % (75.1 - 87.7 %) and pooled specificity was 90.7 % (85.9 - 94.3 %) with significant heterogeneity found in sensitivity; the positive-likelihood ratio (LR) was 7.77 (5.09 - 11.85) and the negative-LR was 0.15 (0.05 - 0.46); the pooled diagnostic odds ratio (DOR) was 54 (15 - 190). Subgroup analysis including studies performed using CH-EUS (two studies, 177 LNs) showed a pooled sensitivity of 87.7 % (77.0 - 93.9 %) and a pooled specificity of 91.8 % (84.5 % - 96.4 %) with no significant heterogeneity; the pooled positive-LR was 9.51 (4.95 - 18.28) and the pooled negative-LR was 0.14 (0.06 - 0.35); pooled DOR was 68.42 (15.5 - 301.4). Conclusions  From these data, CE-EUS is not recommended due to inadequate sensitivity. On the other hand, CH-EUS studies showed optimal accuracy (pooled sensitivity 87.7 % and specificity 91.8 %), comparable to elastography and even EUS-guided fine needle aspiration (EUS-FNA), suggesting a role in the diagnostic algorithm.

Prognostic significance of preoperative lymph node assessment for patients with stage pN0 esophageal squamous cell carcinoma after esophagectomy

Background

Accurate preoperative lymph node (LN) staging is important for surgical treatments of esophageal squamous cell carcinoma (ESCC). The aim of the study was to investigate the role of preoperative lymph nodes assessment by computed tomography (CT) scans in prognostic estimates and lymph nodes dissection strategy.

Methods

A total of 233 stage pN0 ESCC patients who underwent radical esophagectomy from 2009 to 2016 were included, with the last follow-up time in 2018. Survival analysis was conducted to assess the relationship between preoperative clinical LN metastasis and the prognosis of patients with pN0 ESCC.

Results

Ninety-nine patients were classified as clinical positive LN metastasis by CT scans, but were confirmed as stage N0 by postoperative pathological examination, and survival analysis suggested that these patients had relatively poorer prognosis (P=0.027). Cox regression analysis indicated that the clinical LN metastasis on CT scans was an independent negative prognostic factor for patients with pN0 ESCC (P=0.031). The number of LNs dissected affected the prognosis of pN0 patients. Patients with positive LN metastasis on CT would have better prognosis when the number of dissected LNs was equal to or more than 15 LNs (P=0.036). Especially for patients with higher T stage, they were would obtain prognostic benefit with at least 17 LNs dissected (P=0.037). On the other hand, for those with negative LN metastasis on CT, at least 12 LNs dissected indicated better prognosis (P=0.019).

Conclusions

Preoperative LN assessment for ESCC patients is critically important, the optimal LN dissection number should refer to the preoperative CT performance.

New endoscopic ultrasonography criteria for malignant lymphadenopathy based on inter-rater agreement

Background and aims

Various studies have been previously conducted on the diagnosis of lymphadenopathy as benign or malignant, but the results vary. These studies did not describe the inter-rater agreement on the EUS features of lymphadenopathy. In this study, we evaluate the inter-rater agreement on EUS features and propose EUS diagnostic norms for lymphadenopathy based on inter-rater agreement.

Method

A total of 68 lymph nodes subjected to EUS-fine needle aspiration (FNA) were reviewed by five endoscopic experts. The EUS features evaluated lymph node size, shape, border, margin, echogenicity, homogeneity, and the hilum of the lymph node. Inter-rater agreement (multi-rater kappa statics) was performed. We established new criteria using results with a high degree of inter-rater agreement from EUS features and compared them with the former criteria.

Result

There was a moderate agreement on shape, kappa (K) = 0.44 (95% confidence interval [CI]: 0.34–0.54), and fair agreement on echogenicity, homogeneity, border, and hilum of the lymph node, K (95% CI) = 0.33 (0.17–0.38), 0.34 (0.26–0.35), 0.22 (0.21–0.31), and 0.22 (0.11–0.26), respectively. This resulted in the establishment of new EUS diagnostic criteria using shape, long axis > 20 mm and short axis > 10 mm. New criteria were superior to old criteria (area under the curve 0.82 vs 0.52, P < 0.001).

Conclusion

EUS diagnostic criteria for lymphadenopathy based on inter-rater agreement were more accurate than old criteria. This result will be useful for the diagnosis of lymphadenopathy.

Predictive Factors for Inaccurate Diagnosis of Swollen Lymph Nodes in Endoscopic Ultrasound-Guided Fine Needle Aspiration

Background/Aims

This study aimed to identify the predictive factors for inaccurate endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) diagnosis of swollen lymph nodes without rapid on-site cytopathological evaluation.

Methods

Eighty-three consecutive patients who underwent EUS-FNA for abdominal or mediastinal lymph nodes from January 2008 to June 2017 were included from a prospectively maintained EUS-FNA database and retrospectively reviewed. The sensitivity, specificity, and accuracy of EUS-FNA for the detection of neoplastic diseases were calculated. Candidate factors for inaccurate diagnosis (lymph node size and location, needle type, puncture route, number of passes, and causative disease) were evaluated by comparison between accurately diagnosed cases and others.

Results

The final diagnosis of the punctured lymph node was classified as neoplastic (65 cases: a metastatic lymph node, malignant lymphoma, or Crow-Fukase syndrome) or non-neoplastic (18 cases: a reactive node or amyloidosis). The sensitivity, specificity, and accuracy were 83%, 94%, and 86%, respectively. On multivariate analyses, small size of the lymph node was the sole predictive factor for inaccurate EUS-FNA diagnosis with a significant difference (odds ratios, 19.8; 95% confidence intervals, 3.15–124; p=0.0015).

Conclusions

The lymph node size of <16 mm was the only independent factor associated with inaccurate EUS-FNA diagnosis of swollen lymph nodes.

Esophageal cancer N staging study with endoscopic ultrasonography

Esophageal cancer staging is important for the treatment of esophageal cancer. Endoscopic ultrasonography (EUS) is a common diagnostic tool for esophageal cancer prior to surgery. However, EUS is unable to accurately discriminate the N-staging of lymph nodes. In order to distinguish an optimized standard for malignant lymph node diagnosis, the present study compared lymph nodes detected by EUS and surgery. A total of 112 patients were preoperatively examined with EUS and staged according to the 7th Edition of the American Joint Committee on Cancer Staging Manual. The results of EUS were compared with surgical findings. The critical values of long diameter, short diameter and lymph node number detected by EUS were >7.5, >5.5 mm and >2, respectively; indexes, including long diameter >7.5 mm, short diameter >5.5 mm, round, low echo, edge smooth, near lesion and detected lymph node number (>2) and T3/4 staging, met significance in the EUS group compared with the surgical group (P<0.05). Furthermore, the area under curve (AUC) value of the EUS (0.801) was superior to the conventional, surgical method (0.779). Although EUS improved the diagnostic accuracy of esophageal N staging, it was not able to satisfactorily distinguish between N2 and N3 staging. Advancements in EUS may enhance its detection ability, further improving the diagnostic accuracy of lymph node metastasis.

Endoscopic Ultrasound Elastography for Evaluation of Lymph Nodes: A Single Center Experience

Background and Aim

The differentiation between malignant and benign lymph nodes (LNs) is important for tumor staging, for detection of prognosis, and for selection of the best treatment strategy in many cancers. On B-mode EUS, there are some known criteria that suggest the malignant nature of LNs; these criteria may be found in benign LNs. The aim of the work is to evaluate the effectiveness of elasticity score and SR to differentiate between benign and malignant LNs.

Patients and Methods

The study was designed as a retrospective study that included 40 patients with abdominal or mediastinal LNs, either associated with primary masses or isolated, referred for EUS evaluation. Elasticity scores and SR were determined during the examination and finally, EUS-FNA was done at the end of the procedure.

Results

In this 2-years study, 40 patients were enrolled (24 malignant; 16 benign). There were 23 males and 17 females. Their mean age was 52.5 years (range: 28-77). ES alone had a specificity of 87.5%, sensitivity of 41.7%, PPV of 83.3%, NPV of 50%, and accuracy of 60%. Based on the ROC curve analysis results, the best cut-off level of SR to obtain the maximum area under the curve (AUC) was 6.7 with a specificity of 99.9%, sensitivity of 57.1%, PPV of 99.9%, NPV of 64%, and accuracy of 77.5%.

Conclusion

The use of elasticity score and SR increases the reliability of differentiation between benign and malignant LNs and can decrease the number of unnecessary biopsies.

Rapid on-site evaluation during endoscopic ultrasound-guided fine-needle aspiration of lymph nodes does not increase diagnostic yield: A randomized, multicenter trial

OBJECTIVES

Studies on the impact of rapid on-site evaluation (ROSE) during endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) of lymph nodes are retrospective and have shown conflicting results. We aimed to compare the diagnostic yield of EUS-FNA of lymph nodes with ROSE (ROSE+) and without ROSE (ROSE-).

METHODS

This was a multicenter, randomized controlled trial. Consecutive patients who were scheduled to undergo EUS-FNA of mediastinal or abdominal lymph nodes were randomized to ROSE+ or ROSE-. In the ROSE+ group, the number of passes was dictated by the on-site cytotechnician. In the ROSE- group, five passes were performed without interference from the cytotechnician. All samples were reviewed by a single-expert cytopathologist, blinded to group allocation. Primary endpoint was diagnostic yield with and without ROSE.

RESULTS

After inclusion of 90 patients, interim analysis showed futility of study continuation since diagnostic yield of ROSE+ and ROSE- were comparable. A total of 91 patients were randomized to ROSE+ (N = 45) or ROSE- (N = 46). Diagnostic yield of ROSE+ and ROSE- and diagnostic accuracy were comparable: 93.3% vs. 95.7% (P = 0.68) and 97.6% vs. 93.2% (P = 0.62), respectively. Two major complications (one per group) occurred (p = 0.99). ROSE- patients more often reported self-limiting post-procedural pain (p < 0.001). Median procedure time for ROSE+ (20 min) and ROSE- (23 min) was comparable (P = 0.06). Median time to review slides in the ROSE- group (12:47 min) was longer than with ROSE+ (7:52 min) (P < 0.001). Mean costs of ROSE- and ROSE+ were comparable: €938.29 (±172.70) vs. €945.98 (±223.38) (P = 0.91), respectively.

CONCLUSIONS

Diagnostic yield and accuracy of EUS-FNA of mediastinal and abdominal lymph nodes with and without ROSE are comparable. Time needed to review slides was shorter and post-procedural pain was less often reported in the ROSE+ group. Based on the primary outcome, the implementation of ROSE during EUS-FNA of mediastinal and abdominal lymph nodes cannot be advised. (Dutch Trial Register: NTR4876).

Comparative study of computed tomography (CT) and pathological diagnosis toward mediastinal lymph node metastasis in esophageal carcinoma

OBJECTIVE

To investigate the diagnostic criteria of mediastinal lymph node metastasis (MLNM) in esophageal carcinoma (EC) by comparing the lymph node sizes measured by computed tomography (CT) and obtained by postoperative pathological examination.

METHOD

A total of 305 EC patients were selected. MLNM location, shortest diameter and number were investigated one week before surgery, and then compared with their pathological findings.

RESULTS

The receiver operating characteristic (ROC) curve analysis revealed that the minimum diameters of MLNM in the thoracic cavity was 8 mm (area under curve [AUC] = 0.766, Youden index = 0.424), 5 mm in supraclavicular fossa (AUC = 0.785, Youden index = 0.494), 6 mm in tracheoesophageal groove (AUC = 0.755, Youden index = 0.405); the sensitivity was increased significantly, and the Youden index was increased significantly when compared with 10 mm.

CONCLUSION

The shortest diameter of diagnostic criteria of lymph nodes in EC could be less than 10 mm on CT.

Prevalence and echo features of mediastinal lymph nodes in EUS for non-malignant indications: a prospective study in a Southern European Population

BACKGROUND AND STUDY AIMS

 Significant heterogeneity in geographic distribution regarding the prevalence of mediastinal lymph nodes (MLN) has been documented in autopsy and computed tomography (CT) studies. Awareness of the local prevalence and characteristics of lymph nodes will be relevant when performing endoscopic ultrasonography (EUS) for staging of malignant neoplasias. The aims of this study were to document the prevalence and echo features of MLN in patients undergoing EUS for non-malignant extrathoracic disease and to identify predictive factors for the presence of MLN.

PATIENTS AND METHODS

 A prospective single-center study was performed over 6 months. Mediastinal stations 9, 8, 7, 6, 5, 4 L and 2 were systematically evaluated using a linear echoendoscope in all patients undergoing EUS due to benign extrathoracic pathology and without history of oncologic disease. Demographic, clinical and EUS features of the lymph nodes were analysed.

RESULTS

 Seventy-five patients were included: male/female 32/43; mean age, 63 years. The majority of patients (72 %) had lymph nodes in at least one mediastinal station and 88 % of these were found in stations 7 or 4 L. Overall, 133 MLN were identified: 19 % were hypoechogenic, 6 % had a short-axis diameter > 10 mm, and 6 % were round. The prevalence of lymph nodes was higher in smokers (83 % vs 64 %, P  = 0.024), with a higher average number of lymph nodes per patient in this group (2.1 vs 1.6; P  = 0.017). By logistic regression analysis, none of the variables analyzed were independently associated with the presence of MLN.

CONCLUSION

 This prospective Portuguese study documented a higher prevalence of MLN than previously reported in Northern Europe, in patients with no evidence of oncologic disease. This higher prevalence may negatively influence the specificity and positive predictive value for malignancy of MLN (N) staging by EUS.

Diagnostic adequacy and safety of endoscopic ultrasound-guided fine-needle aspiration in patients with lymphadenopathy in a large cohort

BACKGROUND AND STUDY AIMS

The role of endoscopic-ultrasound (EUS) guided fine-needle aspiration (FNA) in patients with lymphadenopathy in terms of diagnostic adequacy and safety in large population is not well defined. The aim of this study was to evaluate diagnostic adequacy and safety of EUS-FNA in patients with lymphadenopathy.

PATIENTS AND METHODS

 Retrospective study from October 2010 to September 2015 at tertiary care center in Delhi-NCR. We analyzed data from 1005 EUS- FNAs of lymph nodes.

RESULTS

 The study cohort comprised 1005 lymph nodes in 865 patients; 68 % were males, mean age was 50 ± 14 years. Indications of FNA were to look for etiology of pyrexia of unknown origin or staging of malignancy mainly. FNA was taken from mediastinal nodes (n = 528, 52.5 %) and intra-abdominal nodes (n = 477, 47.5 %). Median size of nodes at long axis and short axis was 17 (12 - 25.7) and 10 (8 - 15) mm respectively. Adequate material by FNA was obtained in 92.8 % cases. The cytopathologic diagnosis were malignancy in 153 (15.2 %), granulomatous change in 452 (42 %), and reactive lymphadenopathy in 328 (35.6 %). There was statistically significant difference seen between groups with pathological and reactive lymph nodes regarding size at long and short axis, hypoechoic nature, well defined borders and presence of necrosis and calcification. Procedure-related adverse effects were encountered in 6 patients (0.8 %). Four patients had mild mucosal bleeding in chronic liver disease patients and two had mild hepatic encephalopathy related to sedation.

CONCLUSION

 EUS-FNA of lymph nodes has good diagnostic adequacy and safety.

Usefulness of endoscopic ultrasound-guided fine needle aspiration for lymphadenopathy

Lymphadenopathy may be difficult to diagnose using imaging results alone. Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) may help to diagnose and determine the appropriate management of lymphadenopathy. EUS-FNA has been used as a safe and less invasive method for obtaining pathologic specimens from extraluminal lesions using endoscopic ultrasound. The present study evaluated the usefulness of EUS-FNA for lymphadenopathy. Between July 2013 and December 2016, 72 patients undergoing EUS-FNA for lymphadenopathy that could not be diagnosed solely using imaging were included. The present study evaluated the sensitivity, specificity, positive and negative predictive value, overall accuracy, helpfulness in determining the management of lymphadenopathy and EUS-FNA-associated complications. Of the 72 included patients, 8 were diagnosed with benign (inflammatory or reactive) lymphadenopathy. The diagnostic sensitivity, specificity, positive and negative predictive value, and overall accuracy were 95.3, 100, 100, 72.7 and 95.8%, respectively. While EUS-FNA of metastatic nodes identified the origin in the majority of cases, the procedure resulted in a different histopathological diagnosis from the previous image-based diagnosis in 9 patients. Consequently, 2 patients with testicular cancer were administered bleomycin, etoposide, and cisplatin. An individual with GIST was administered imatinib, and a patient with prostate cancer was administered degarelix (antihormon drug). A total of 5 other patients received palliative medicine due to the change in diagnosis. EUS-FNA also helped determine the appropriate cancer management plan in other patients; specifically, based on the cytology of the metastatic lymph node, EUS-FNA helped determine the cancer stage, and to identify recurrence or the primary cancer from which tissue could not be collected. No EUS-FNA-associated symptoms were reported. To conclude, the present study suggested that EUS-FNA of suspected metastatic lymph nodes appears safe and useful for cancer staging and diagnosing recurrence. It may also useful for diagnosing patients whose collection of samples from the original cancer appeared impractical. EUS-FNA for lymphadenopathy that may not be diagnosed with imaging alone may assist in diagnosis and help to determine the appropriate management strategy.

New Imaging Techniques: Endoscopic Ultrasound-Guided Elastography

Endoscopic ultrasound (EUS) is a major imaging method in the management of several diseases of the gastrointestinal tract and surrounding structures. Elastography is a novel technique providing additional information to standard B-mode imaging on the tissue stiffness. Elastography can be performed under EUS guidance. This method has proven to be an accurate and additional tool in the evaluation of pancreatic diseases and lymph nodes analysis. Possible uses include the study of liver lesions, subepithelial masses, and many more. This article reviews current knowledge and future perspectives.

Endoscopic ultrasound in oncology: An update of clinical applications in the gastrointestinal tract

An accurate staging is necessary to select the best treatment and evaluate prognosis in oncology. Staging usually begins with noninvasive imaging such as computed tomography, magnetic resonance imaging or positron emission tomography. In the absence of distant metastases, endoscopic ultrasound plays an important role in the diagnosis and staging of gastrointestinal tumors, being the most accurate modality for local-regional staging. Its use for tumor and nodal involvement in pre-surgical evaluation has proven to reduce unnecessary surgeries. The aim of this article is to review the current role of endoscopic ultrasound in the diagnosis and staging of esophageal, gastric and colorectal cancer.

Utility of endoscopic ultrasound-guided fine-needle aspiration of regional lymph nodes that are proximal to and far from the primary distal esophageal carcinoma

Implications of assessing the proximal and far para-tracheal or sub-carinal nodes (para-tracheal [PTN] or sub-carinal [SCN]) associated with lower primary esophageal carcinomas (ECs) are unclear. To evaluate the value of endoscopic ultrasound guided fine-needle aspiration (EUS-FNA) for PTN and SCN, we analyzed results by positron emission tomography (PET) avidity, 4 EUS node malignancy features, and EUS-FNA results in all patients with Siewert’s I or II EC. Of 133 patients (PTN, n=102; SCN, n=31) with EUS-FNA, 47 (35%) patients had malignant node, leading to treatment modifications. EUS-FNA diagnosed significantly more patients with malignant nodes (p=0.02) even when PET and EUS features were combined. Among 94 PET-negative and EUS-negative patients, 9 (10%) had malignant EUS-FNA. At a minimum follow-up of 1 year, only 3 (5%) of 62 patients with benign EUS-FNA had evidence of malignancy in the nodal area of prior EUS-FNA. Patients with malignant EUS-FNA independently had a much shorter overall survival (OS) than those with benign EUS-FNA (p<0.001). Our data suggest that a benign EUS-FNA is highly accurate and need not be pursued further. However, malignant EUS-FNA of PTN/SCN was independently prognostic, conferred a shorter OS, and altered the management of 35% of patients.

Fabrication and Performance of a Miniaturized and Integrated Endoscope Ultrasound Convex Array for Digestive Tract Imaging

OBJECTIVE

this work presents the design, fabrication, and testing of a miniaturized and integrated ultrasound endoscope for use as an in situ digestive diagnostic device to facilitate real-time ultrasound guidance of intervention treatments.

METHODS

we designed an optimal structure to integrate an auto-focus 5-megapixel camera module with an 8-MHz, 64-element curvilinear ultrasonic array in one miniaturized package. A novel three-axis auto-focusing voice coil motor (VCM) was designed and manufactured for the camera module to move the lens position for auto-focusing and to adjust the lens tilt.

RESULTS

the results showed that the array had a center frequency of 8.09 MHz and a -6-dB fractional bandwidth of 83%. At the center frequency, the two-way insertion loss was 40.6 dB. Endoscopic ultrasound imaging demonstrated satisfactory performance for imaging an anthropomorphic phantom of the esophagus. By slightly adjusting the tilt angle of the optical axis of the lens, the optical image captured by the auto-focusing lens obtained improved definition regardless of changes in the view angle of the camera with respect to the objects being captured.

CONCLUSION

the integrated convex ultrasound endoscope, possessing minimal size, improved optical imaging definition, and good ultrasound imaging performance, can become a useful tool in digestive tract imaging.

SIGNIFICANCE

the miniaturized and integrated convex ultrasound endoscope can facilitate real-time ultrasound intervention guidance, reducing risks associated with the operation.

Endoscopic submucosal dissection and endoscopic mucosal resection for early stage esophageal cancer

Mortality from esophageal cancer remains high despite advances in medical therapy. Although the incidence of squamous cell carcinoma of the esophagus remains unchanged, the incidence of the esophageal adenocarcinoma has increased over time. Gastroesophageal reflux disease (GERD and obesity are contributing factors to the development of Barrett's esophagus and subsequent development of adenocarcinoma. Early recognition of the disease can lead to resection of esophageal cancer prior to the development of lymphovascular invasion. Various modalities have been implemented to aid identification of precancerous lesions and early esophageal cancer. Chromoendoscopy, narrowband imaging and endoscopic ultrasound examination are typically used for evaluating early esophageal lesions. Recently, confocal laser endomicroscopy (CLE) and volumetric laser scanning were implemented with promising results. Endoscopic management of early esophageal cancer may be done using endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD). Both techniques allow resection of the mucosa (and possibly a portion of the submucosa) containing the early tumor without interruption of deeper layers. A submucosal injection creating a cushion coupled with snare resection or cap assisted mucosal suction followed by ligation and snare resection are the most common techniques of EMR. EMR can remove lesions less than 2 cm in size en bloc. Larger lesions may require resection in piecemeal fashion. This may limit assessment of the margins of the lesion and orienting the lesion's border. ESD offers en bloc dissection of the lesion regardless of its size. ESD is performed with specialized needle knives, which allow incision followed by careful dissection of the lesion within the submucosal layer. Tumor recurrence after ESD is rare but the technique is labor intensive and has an increased risk of perforation. Esophageal stenosis remains a concern after extensive EMR or ESD. Dilation with balloon or stent placement is usually sufficient to treat post-resection stenosis.

Staging Early Esophageal Cancer

Staging esophageal cancer provides a standardized measure of the extent of disease that can be used to inform decisions about therapy and guide prognosis. For esophageal cancer, the treatment pathways vary greatly depending on stage of disease, and accurate staging is therefore crucial in ensuring the optimal therapy for each patient. For early esophageal cancer (T1 lesions), endoscopic resection can be curative and simultaneously gives accurate staging of depth of invasion. For tumors invading the submucosa or more advanced disease, comprehensive investigation is required to accurately stage the tumor and assess suitability for curative resection. A combined imaging approach of computed tomography (CT), positron emission tomography (PET), and endoscopic ultrasound (EUS) offers complementary diagnostic information and gives the greatest chance of accurate staging. Staging laparoscopy can identify peritoneal disease and small superficial liver lesions that could be missed on CT or PET, and alters management in up to 20 % of patients. Optical diagnostic techniques offer the prospect of further extending the possibilities of endoscopic staging in real time. Optical coherence tomography can image superficial lesions and could provide information on depth of invasion for these lesions. Real-time lymph node analysis using optical diagnostics such as Raman spectroscopy could be used to support immediate endoscopic therapy without waiting for results of cytology or further investigations.

Endoscopic ultrasonography is not required for staging malignant esophageal strictures that preclude the passage of a diagnostic gastroscope

BACKGROUND AND AIM

Endoscopic ultrasound (EUS) is considered the most sensitive modality for local staging of esophageal cancer (ECA) and current guidelines recommend EUS in all patients with non-metastatic disease. Our aim was to identify a subset of patients with stenotic, non-metastatic ECA who will not benefit from staging EUS.

METHODS

This multicenter study evaluated consecutive patients with newly diagnosed non-metastatic ECA referred for local staging by EUS. All patients had endoscopic evaluation of malignant strictures with 9.8/9.9-mm diagnostic gastroscope prior to EUS. Main outcome measure was to evaluate the relationship between degree of malignant stenosis and tumor staging by EUS.

RESULTS

Of 100 patients (median age, 65 years; male 81%), gastroscope could not be advanced past the stricture in 46, all of whom (100%) had locally advanced disease at EUS: T3N0/N+ in 39 and T4N0/N+ in seven. Echoendoscope could not traverse the stricture in any of these patients. Gastroscope could be advanced through the stricture in 54 patients in whom EUS staging was T1N0 in five, T2N0/N+ in eight and T3N0/N+ in 41; echoendoscope could not pass through the stricture in 24 of these 54 (44.4%) patients, all of whom had T3N0/N+ disease. On logistic regression analysis, inability to pass a gastroscope through the stricture was significantly associated with advanced (T3/4) tumor stage (OR = 28.7, 95% CI = 1.64-501.2; P = 0.021).

CONCLUSION

Routine EUS examination may not be required in all patients with ECA as the inability to advance a diagnostic gastroscope past a malignant stricture correlates 100% with locally advanced disease on EUS.

The Expanding Role of Contrast-Enhanced Endoscopic Ultrasound in Pancreatobiliary Disease

Since its introduction into clinical practice in the 1980s, endoscopic ultrasound (EUS) has been described as a good imaging modality for the diagnosis of pancreatobiliary diseases. However, differential diagnosis of certain lesions based only on B-mode ultrasound images can be challenging. Clinical use of ultrasound contrast agents has expanded the utility of EUS from that of detection to characterization of pancreatobiliary lesions based on the enhancement features of contrast-enhanced EUS (CE-EUS). Current low mechanical index techniques for CE-EUS using second-generation contrast agents have a number of distinct advantages over conventional diagnostic modalities in evaluating pancreatobiliary lesions, including real-time assessment of perfusion pattern, availability, and the absence of exposure to radiation. This article describes the technical aspects of CE-EUS and reviews the expanding indications in pancreatobiliary diseases and further development of this technique.

The 100 most cited articles investigating the radiological staging of oesophageal and junctional cancer: a bibliometric analysis

Objectives

Accurate staging of oesophageal cancer (OC) is vital. Bibliometric analysis highlights key topics and publications that have shaped understanding of a subject. The 100 most cited articles investigating radiological staging of OC are identified.

Methods

The Thomas Reuters Web of Science database with search terms including “CT, PET, EUS, oesophageal and gastro-oesophageal junction cancer” was used to identify all English language, full-script articles. The 100 most cited articles were further analysed by topic, journal, author, year and institution.

Results

A total of 5,500 eligible papers were returned. The most cited paper was Flamen et al. (n = 306), investigating the utility of positron emission tomography (PET) for the staging of patients with potentially operable OC. The most common research topic was accuracy of staging investigations (n = 63). The article with the highest citation rate (38.00), defined as the number of citations divided by the number of complete years published, was Tixier et al. investigating PET texture analysis to predict treatment response to neo-adjuvant chemo-radiotherapy, cited 114 times since publication in 2011.

Conclusion

This bibliometric analysis has identified key publications regarded as important in radiological OC staging. Articles with the highest citation rates all investigated PET imaging, suggesting this modality could be the focus of future research.

Main Messages

• This study identifies key articles that investigate radiological staging of oesophageal cancer.

• The most common topic was accuracy of staging investigations.

• The article with the highest citation rate investigated the use of texture analysis in PET images.

Diagnostics and Early Diagnosis of Esophageal Cancer

In the esophagus two different kinds of primary neoplasias may arise: squamocellular carcinomas (SCC) and esophageal adenocarcinomas (EAC). Although both types of carcinoma are rare diseases, especially the incidence of EAC rose in the last years. The management of esophageal cancer is challenging. There are no specific symptoms of early esophageal cancers. Due to this fact, most of the esophageal cancers are found incidentally, and only 12.5% of esophageal tumors are endoscopically resectable. Gastroscopy is the gold standard for the diagnosis of esophageal cancer. The sensitivity of detecting early-stage carcinoma may be improved by adjunct techniques such as chromoendoscopy, virtual chromoendoscopy, magnification endoscopy, and other advanced endoscopic imaging techniques. The diagnosis of esophageal cancer can be verified with targeted biopsies. Accurate staging information is crucial for establishing appropriate treatment choices for esophageal cancer, while the depth of the tumor determines the feasibility of therapy. In terms of staging, endosonography, abdominal ultrasound, and computed tomography scan of the thorax and abdomen should thus be performed before initiation of therapy.

Use of Endoscopic Ultrasound to Evaluate Large Gastric Folds: Features Predictive of Malignancy

The aim of this study was to investigate with endoscopic ultrasound (EUS) the features of the gastric wall that can be used to predict malignant disease in patients with large gastric folds. We retrospectively reviewed the EUS findings of 65 patients (26 with benign and 39 with malignant disease) with large gastric folds on endoscopy and EUS and analyzed the predictors of malignant disease (e.g., gastric wall thickness, preservation of five-layered structure, thickened layers). Gastric wall thickness (≥9.8 mm), thickened deep layer, thickened muscularis propria and non-preserved wall layer structures were significantly more prevalent in patients with malignant disease on EUS. Among them, gastric wall thickness (≥9.8 mm) (odds ratio = 6.72, 95% confidence interval = 1.23-36.73, p = 0.028) and thickened muscularis propria (odds ratio = 37.14, 95% confidence interval = 7.02-196.49, p < 0.001) were significantly associated with malignant disease. Our data indicate that EUS is a useful tool for assessing large gastric folds and that gastric wall thickness (≥9.8 mm) and thickened muscularis propria are significant features predictive of malignant disease on EUS.

Endoscopic ultrasound: Elastographic lymph node evaluation

Different imaging techniques can bring different information which will contribute to the final diagnosis and further management of the patients. Even from the time of Hippocrates, palpation has been used in order to detect and characterize a body mass. The so-called virtual palpation has now become a reality due to elastography, which is a recently developed technique. Elastography has already been proving its added value as a complementary imaging method, helpful to better characterize and differentiate between benign and malignant masses. The current applications of elastography in lymph nodes (LNs) assessment by endoscopic ultrasonography will be further discussed in this paper, with a review of the literature and future perspectives.

Role of endoscopic ultrasonography in the loco-regional staging of patients with rectal cancer

The prognosis of rectal cancer (RC) is strictly related to both T and N stage of the disease at the time of diagnosis. RC staging is crucial for choosing the best multimodal therapy: patients with high risk locally advanced RC (LARC) undergo surgery after neoadjuvant chemotherapy and radiotherapy (NAT); those with low risk LARC are operated on after a preoperative short-course radiation therapy; finally, surgery alone is recommended only for early RC. Several imaging methods are used for staging patients with RC: computerized tomography, magnetic resonance imaging, positron emission tomography, and endoscopic ultrasound (EUS). EUS is highly accurate for the loco-regional staging of RC, since it is capable to evaluate precisely the mural infiltration of the tumor (T), especially in early RC. On the other hand, EUS is less accurate in restaging RC after NAT and before surgery. Finally, EUS is indicated for follow-up of patients operated on for RC, where there is a need for the surveillance of the anastomosis. The aim of this review is to highlight the impact of EUS on the management of patients with RC, evaluating its role in both preoperative staging and follow-up of patients after surgery.

New TNM staging system for esophageal cancer: what chest radiologists need to know

Esophageal cancer is a leading cause of cancer-related deaths worldwide, and the 5-year relative survival rate remains less than 20% in the United States. The treatment of esophageal cancer should be stage specific for better clinical outcomes. Recent treatment paradigms tend to involve a multimodality approach to management, which includes surgical resection and preoperative or definitive chemoradiation therapy. Accurate pretreatment staging of esophageal cancer is integral for assessing operability and determining a suitable treatment plan. The American Joint Committee on Cancer (AJCC) and the Union for International Cancer Control (UICC) have published the seventh edition of the staging manual for cancer in the esophagus and esophagogastric junction. Unlike the sixth edition, the revised staging manual is data driven and harmonized with the staging of stomach cancer. Improvements include new definitions for the anatomic classifications Tis, T4, regional lymph node, N, and M and the addition of nonanatomic cancer characteristics (histopathologic cell type, histologic grade, and cancer location). Given the recent increase in the incidence of adenocarcinoma of the distal esophagus, esophagogastric junction, and gastric cardia, the staging of tumors in the esophagogastric junction has been addressed. Radiologists must understand the details of the seventh edition of the AJCC-UICC staging system for esophageal cancer and use appropriate imaging modalities, such as computed tomography (CT), endoscopic ultrasonography, and positron emission tomography/CT, for initial staging.

Preoperative evaluation of oesophageal adenocarcinoma

The preoperative evaluation of oesophageal adenocarcinoma involves endoscopic ultrasound (EUS), computed tomography (CT), and positron emission tomography (PET). With routine Barrett's oesophagus surveillance, superficial cancers are often identified. EUS, CT and PET have a limited role in the staging of superficial tumours. Standard EUS has limited accuracy, but high frequency ultrasound miniprobes are valuable for assessing tumour stage in superficial tumours. However, the best method for determining depth of invasion, and thereby stage of disease, is endoscopic mucosal resection. In contrast, in advanced oesophageal cancers, a multi-modality approach is crucial. Accurate tumour staging is very important since the treatment of advanced cancers involves a combination of chemotherapy, radiation, and surgery. EUS is very useful for staging of the tumour and nodes. High frequency ultrasound miniprobes provide the ability to perform staging when the lesion is obstructing the oesophageal lumen. CT and PET provide valuable information regarding node and metastasis staging.