Staging of esophageal cancer: computed tomography, magnetic resonance imaging, and endoscopic ultrasound

Endoscopic ultrasound in staging esophageal cancer after neoadjuvant chemotherapy--results of a multicenter cohort analysis

BACKGROUND

Endoscopic ultrasound (EUS) is considered a gold standard in the initial staging of esophageal cancer. There is an ongoing debate whether EUS is useful for tumor staging after neoadjuvant chemotherapy (NAC).

METHODS

Ninety-five patients with esophageal cancer were retrospectively analyzed. In 45 patients, EUS was performed prior to and after NAC, while 50 patients had no induction therapy. Histological correlation through surgery was available. uT/uN classifications were compared to pT/pN stages. Statistical analysis included calculation of sensitivity, specificity, and accuracy rates. Agreement between endosonography and T staging was assessed with Cohen's kappa statistics.

RESULTS

For those patients with prior NAC, overall accuracy of yuT and yuN classification was 29 and 62%, respectively. Sensitivity, specificity, and accuracy rates for local tumor extension after NAC were as follows (%): T1: -/97/84, T2: 13/76/53, T3:86/29/46, T4:20/100/91, T1/2: 27/83/56, T3/4: 89/31/56. Cohen's kappa indicated poor agreement (kappa = 0.129) between yuT classification and ypT stage. Relative to positive lymph node detection, sensitivity and specificity were 100 and 6%, respectively (kappa = 0.06). T stage was overstaged in 23 (51%) and understaged in seven (16%) patients.

CONCLUSION

EUS is an unreliable tool for staging esophageal cancer after NAC. Overstaging of the T stage is common after NAC.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

KEY POINTS

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

Utility of restaging endoscopic ultrasound after neoadjuvant therapy for esophageal cancer

BACKGROUND

Currently, the most accurate staging test for patients with esophageal cancer is endoscopic ultrasound (EUS). At many institutions, patients who have completed neoadjuvant chemotherapy and radiotherapy for esophageal cancer undergo restaging EUS before proceeding to surgical resection. The benefit of this restaging procedure remains controversial.

METHODS

We retrospectively studied consecutive patients who had pre-resection restaging EUS after receiving neoadjuvant treatment to assess accuracy of EUS restaging and determine whether it predicted survival.

RESULTS

Final pathologic data were available for 73 patients who underwent restaging EUS (3 patients had missing T or N stage at one time point). Median time from restaging EUS to resection was 20 days. Restaging EUS accurately predicted pathologic T status in 26 of 72 patients (36%), N status in 44 of 71 (62%), and detected a complete pathologic response in 2 of 19 (10.5%). EUS inappropriately classified 10 patients as T0 N0. Agreement between EUS and pathologic staging was poor for T (κ=0.14) and N status (κ=0.24). Median time from resection to death or last follow-up was 20 months. Pathologic T and N status were each significant predictors of survival (p=0.049 and p=0.0004, respectively). There were nonsignificant trends toward better survival for lower EUS T (p=0.32) and N status (p=0.0946).

CONCLUSIONS

Restaging by EUS before resection did not accurately predict pathologic stage in patients with esophageal cancer who received neoadjuvant treatment. As a result of this investigation, our institution no longer routinely performs restaging EUS.

Impact of endoscopic ultrasonography and physician specialty on the management of patients with esophagus cancer

While endoscopic ultrasonography (EUS) and EUS-guided fine-needle aspiration (EUS-FNA) are the most accurate techniques for locoregional staging of esophageal cancer, little evidence exists that these innovations impact on clinical care. The objective on this study was to determine the frequency with which EUS and EUS-FNA alter the management of patients with localized esophageal cancer, and assess practice variation among specialists at a tertiary care center. Three gastroenterologists, three medical oncologists, three radiation oncologists and four thoracic surgeons were asked to independently report their management recommendations as the anonymized staging information of 50 prospectively enrolled patients from another study were sequentially disclosed on-line. Compared to initial management recommendations, that were based upon history, physical examination, upper endoscopy and CT scan results, EUS prompted a change in management 24% (95% CI: 12-36%) of the time; usually to a more resource-intensive approach (71%), for example from recommending palliation to recommending neoadjuvant chemoradiation therapy. EUS-FNA plus cytology results altered management an additional 8% (95% CI: 6-15%) of the time. Agreement between specialists ranged from fair (intraclass correlation [ICC=0.32) to substantial (ICC=0.65); improving with additional information. Among specialists, agreement was greatest for patients with stage I disease. EUS and EUS-FNA changed patient management the most for patients with stages IIA, IIB or III disease. EUS, with or without FNA, significantly impacts the management of patients with localized esophageal cancer. With respect to the optimal treatment for each patient, agreement among physicians incrementally increases with endoscopic ultrasound results. Specialty training appears to influence therapeutic decision-making behavior.

Routine vs. selective EUS-guided FNA approach for preoperative nodal staging of esophageal carcinoma

BACKGROUND

EUS-guided FNA (EUS-FNA) is the most accurate method for lymph-node staging of esophageal carcinoma; however, it may not be necessary when EUS features are present that strongly suggest a benign or a malignant origin.

AIMS

(1) To identify a combination of EUS criteria that have a sufficient sensitivity and specificity to preclude the need for EUS-FNA and (2) to assess the cost savings derived from a selective EUS-FNA approach.

METHODS

A total of 144 patients with esophageal carcinoma were prospectively evaluated with EUS. Accuracy of standard (hypoechoic, smooth border, round, or width > 5 mm) and modified (4 standard plus EUS identified celiac lymph nodes, >5 lymph nodes, or EUS T3/4 tumor) criteria were compared (receiver operating characteristic curves). Resource utilization of two diagnostic strategies, routine (all patients with lymph nodes) and selective EUS-FNA (FNA only in those patients in whom the number of EUS malignant criteria provides a sensitivity and a specificity <100%), were compared.

RESULTS

Modified EUS criteria for lymph-node staging were more accurate than standard criteria (area under the curve 0.88 vs. 0.78, respectively). No criterion alone was predictive of malignancy; sensitivity and specificity reached 100% when a cutoff value of >1 and >6 modified criteria were used, respectively. The EUS-FNA selective approach may avoid performing FNA in 61 patients (42%).

CONCLUSIONS

Modified EUS lymph-node criteria are more accurate than standard criteria. A selective EUS-FNA approach reduced the cost by avoiding EUS-FNA in 42% of patients with esophageal carcinoma. These results require confirmation in future studies.

Plasma D-dimer levels show correlation with number of lymph node metastases in patients with esophageal cancer

BACKGROUND

Systemic activation of hemostasis and fibrolysis has been shown to be related to tumor progression in patients with malignancies such as lung cancer and colorectal cancer, but there has been no report of these clotting abnormalities in esophageal cancer. We investigated the clinical importance of measuring plasma levels of D-dimer (DD), which is a marker of the hypercoagulable stage, in preoperative patients with esophageal cancer.

STUDY DESIGN

Preoperative plasma DD levels were measured in 96 patients with primary esophageal cancer who were scheduled for esophagectomy with lymphadenectomy without preoperative treatment at our hospital. Results were correlated with the clinicopathological findings.

RESULTS

Significantly different plasma DD levels were found with respect to histologic T (p = 0.0015), histologic N (p < 0.0001), number of metastatic nodes (p < 0.0001), and histologic stages (p < 0.0001). The number of lymph node metastases (0/1 to 3/4 to 7/8-) was found to have the strongest association with DD level among the significant clinicopathologic factors (Spearman rank correlation 0.591, p < 0.0001). The most useful cut-off level of the plasma DD levels for diagnosis of lymph node metastasis was determined to be 0.4 microg/mL, with specificity and sensitivity for lymph node metastasis being 62.9% and 88.2%, respectively.

CONCLUSIONS

Plasma DD levels are useful for assessing lymph node metastasis in patients with esophageal cancer and should be measured preoperatively.

Endoscopic ultrasound for luminal malignancies

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

[Esophageal disease: is cross sectional imaging contributive?]

For a long time, esophagography and endoscopy were the major diagnostic tests used for evaluation of the esophagus. Now, the development of computed tomography, endosonography and MR imaging has permitted more comprehensive evaluation of esophageal diseases. Cross sectional imaging is essential to evaluate the relationship between esophageal lesions and adjacent mediastinal structures and to evaluate the thickness of the esophageal wall.

EMR combined with chemoradiotherapy: a novel treatment for superficial esophageal squamous-cell carcinoma

BACKGROUND

Esophagectomy or chemoradiotherapy (CRT) are the procedures of choice for patients with superficial esophageal squamous-cell carcinoma. However, esophagectomy is highly invasive, and CRT is associated with the risk of local failure. A study was conducted of a novel treatment, EMR combined with CRT, for patients with superficial esophageal carcinoma. EMR was performed for the purpose of complete local tumor control and chemoradiotherapy was performed for regional and distant control.

METHODS

EMR combined with CRT was performed for patients with esophageal carcinoma invading the muscularis mucosae or upper submucosa who refused esophagectomy. The planned treatment after EMR was 40 to 46 Gy of external beam radiation to the mediastinum, including the supraclavicular fossa or cardia. Chemotherapy was given during weeks 1 and 5 (5-fluorouracil, 700 mg/m(2) per 24 hours in a 120-hour infusion, and cisplatin 15 mg/m(2) per day intravenously on days 1 to 5).

RESULTS

During the study period, 16 patients underwent EMR combined with CRT (EMR plus CRT group) and 39 patients with similar stage cancer underwent esophagectomy (surgical resection group). None of the patients in the EMR plus CRT group have had local recurrence or metastasis. Overall survival rates at 5 years in the EMR plus CRT and surgical resection groups were estimated to be, respectively, 100% and 87.5%.

CONCLUSIONS

Although this study was not randomized, the results suggest that EMR combined with CRT is a safe and effective method for treating patients with superficial esophageal carcinoma. The results were equivalent or, in view of the lower degree of invasiveness, superior to surgical resection.

Impact of lymph node staging on therapy of esophageal carcinoma

BACKGROUND & AIMS

Therapy of esophageal carcinoma is stage dependent. The role of EUS-guided fine-needle aspiration (EUS FNA) in this setting is unclear. The aims of this study were to compare the performance characteristics of CT, EUS, and EUS FNA for preoperative nodal staging of esophageal carcinoma and to measure the impact of each staging test on treatment decisions.

METHODS

From December 1999 to March 2001, all patients with esophageal carcinoma seen at the Mayo Clinic Rochester were prospectively evaluated with CT, EUS, and EUS FNA. The impact of tumor stage on final therapy was assessed.

RESULTS

A total of 125 patients with esophageal carcinoma were enrolled. EUS FNA was more sensitive (83% vs. 29%; P < 0.001) than CT and more accurate than CT (87% vs. 51%; P < 0.001) or EUS (87% vs. 74%; P = 0.012) for nodal staging. Direct surgical resection was contraindicated in 77% of patients evaluated due to advanced locoregional/metastatic disease. Tumor location, patient age, comorbidities, and tumor stage determined by CT, EUS, and EUS FNA were associated with treatment decisions (P < 0.05). EUS FNA resulting in a higher/worse stage than CT (41 patients) was associated with a greater rate of treatments that were not direct surgeries compared with cases in which the stage was the same or better.

CONCLUSIONS

EUS FNA is more accurate for nodal staging and impacts on therapy of patients with esophageal carcinoma. EUS FNA should be included in the preoperative staging algorithm of these patients.

Long-term outcome after endoscopic mucosal resection in patients with esophageal squamous cell carcinoma invading the muscularis mucosae or deeper

BACKGROUND

Endoscopic mucosal resection is recommended for squamous cell carcinoma of the esophagus confined to the lamina propria. However, endoscopic mucosal resection is often performed in patients with tumors that invade the muscularis mucosa or upper submucosa to minimize surgical invasiveness, despite the increased risk of lymph node metastasis. This study prospectively evaluated long-term outcome in such patients.

METHODS

Twenty-six consecutive patients with squamous cell esophageal carcinoma invading the muscularis mucosa or submucosa who underwent endoscopic mucosal resection from June 1992 through March 2000 (extended endoscopic mucosal resection group) were studied. As control group, 44 consecutive patients with esophageal carcinoma invading the muscularis mucosae or upper third of the submucosa and no preoperative evidence of lymph node metastasis who underwent esophagectomy during the same period (surgical resection group) were studied.

RESULTS

Overall survival rates at 5 years in the extended endoscopic mucosal resection group and surgical resection group were, respectively, 77.4% and 84.5%. There was no significant difference between survival distributions. Cause-specific survival rates at 5 years in extended endoscopic mucosal resection and surgical resection groups were, respectively, 95.0% and 93.5%. Survival curves for the groups were similar.

CONCLUSION

Although patients were not randomized to extended endoscopic mucosal resection or surgical resection in this study, the results suggest that endoscopic mucosal resection may be safe and effective for management of squamous cell esophageal carcinoma invading the muscularis mucosae or upper submucosa.

The role of oesophageal stenting in the non-surgical management of oesophageal strictures

The role of oesophageal stenting continues to evolve, with several new stents currently on the market. These stents possess anti-reflux valves, internal plastic coatings and retrievable threads. In patients with malignant dysphagia, management should ideally take place within multi-disciplinary teams such that accurate tumour staging occurs prior to treatment. Multi-modality therapy can not only improve dysphagia and response rates but may also improve survival. Several non-surgical palliative techniques are available to recanalize malignant obstruction, including oesophageal stenting. Other therapeutic modalities include the use of endoluminal laser therapy, photodynamic therapy, argon beam and bipolar electrocoagulation, ethanol injection and intracavity brachytherapy. Their use often depends on local availability and expertise. Although the initial costs of metal stents are high, the overall costs compare favourably with other forms of palliative therapy that often require multiple procedures with repeated inpatient hospitalization. Treatment of refractory benign strictures with oesophageal stents remains uncommon and several recent reports using retrievable stents appear to improve outcome, although more work is required in this area.

Impact of EUS-guided fine-needle aspiration on lymph node staging in patients with esophageal carcinoma

BACKGROUND

Preoperative identification of lymph node metastases associated with esophageal carcinoma may influence treatment. EUS is the most accurate method for locoregional staging of these tumors. The impact of EUS-guided fine-needle aspiration (EUS-FNA) on lymph node staging in esophageal carcinoma is unclear.

METHODS

From May 1996 to May 1999, 74 patients with esophageal carcinoma underwent preoperative EUS. After October 1998 EUS-guided FNA was performed on nonperitumoral lymph nodes greater than 5 mm in width. The results of EUS with and without FNA were retrospectively reviewed and compared. Final diagnosis was based on surgical results or EUS-guided FNA malignant cytology. Ten of the 74 patients had to be excluded for lack of lymph node stage confirmation. Final diagnosis was obtained in the remaining 64 patients (33 from the EUS only group and 31 from the EUS-FNA group).

RESULTS

The results of EUS versus EUS-FNA for lymph node staging were sensitivity 63% versus 93% (p = 0.01), specificity 81% versus 100% (not significant), and accuracy 70% versus 93% (p = 0.02), respectively. Complications comprised 1 patient who developed self-limited bleeding after dilation that did not preclude completion of the EUS (1%, 95% CI [0%, 7%]).

CONCLUSIONS

EUS-FNA is more sensitive and accurate than EUS alone for preoperative staging of locoregional and celiac lymph nodes associated with esophageal carcinoma. EUS-FNA of nonperitumoral lymph nodes in patients with esophageal carcinoma is safe and should be routinely performed when treatment decisions will be affected by nodal stage.

EUS predictors of long-term survival in esophageal carcinoma

BACKGROUND

EUS is the most accurate nonsurgical modality for the staging of esophageal cancer, but the ability of EUS to predict outcomes or prognosis is unclear. Patients were examined who had EUS performed for esophageal cancer staging to determine which endosonographic features predict survival.

METHOD

Data on 203 patients undergoing EUS for esophageal cancer staging were studied retrospectively. Median survival was calculated for each T-stage and N-stage and according to the presence or absence of celiac axis (CAx) lymphadenopathy as determined by EUS. Kaplan-Meier survival curves were generated for each stage and the log-rank test was used to test for significant differences in survival. Multivariate analysis was performed to test for the relative importance in predicting survival of the EUS stages, also considering age, gender, histology, and type of treatment.

RESULTS

Significant differences were found in the ability of EUS-determined T-stage (p = 0.0005), N-stage (p < 0.0001), and presence of CAx nodes (p = 0.0049) to predict survival. Multivariate analysis showed N-stage to predict survival.

CONCLUSIONS

Pretreatment EUS can predict survival in esophageal cancer based on initial T-stage, N-stage, and the presence of CAx nodes. The presence of lymphadenopathy at EUS is an important predictor of survival. EUS should be performed in all patients with esophageal cancer, not only for staging patients before therapy, but also as a valuable method of determining prognosis.

Randomized trial of preoperative chemoradiation versus surgery alone in patients with locoregional esophageal carcinoma

PURPOSE

A pilot study of 43 patients with potentially resectable esophageal carcinoma treated with an intensive regimen of preoperative chemoradiation with cisplatin, fluorouracil, and vinblastine before surgery showed a median survival of 29 months in comparison with the 12-month median survival of 100 historical controls treated with surgery alone at the same institution. We designed a randomized trial to compare survival for patients treated with this preoperative chemoradiation regimen versus surgery alone.

MATERIALS AND METHODS

One hundred patients with esophageal carcinoma were randomized to receive either surgery alone (arm I) or preoperative chemoradiation (arm II) with cisplatin 20 mg/m2/d on days 1 through 5 and 17 through 21, fluorouracil 300 mg/m2/d on days 1 through 21, and vinblastine 1 mg/m2/d on days 1 through 4 and 17 through 20. Radiotherapy consisted of 1.5-Gy fractions twice daily, Monday through Friday over 21 days, to a total dose of 45 Gy. Transhiatal esophagectomy with a cervical esophagogastric anastomosis was performed on approximately day 42.

RESULTS

At median follow-up of 8.2 years, there is no significant difference in survival between the treatment arms. Median survival is 17.6 months in arm I and 16.9 months in arm II. Survival at 3 years was 16% in arm I and 30% in arm II (P = .15). This study was statistically powered to detect a relatively large increase in median survival from 1 year to 2.2 years, with at least 80% power.

CONCLUSION

This randomized trial of preoperative chemoradiation versus surgery alone for patients with potentially resectable esophageal carcinoma did not demonstrate a statistically significant survival difference.

CT or EUS for the initial staging of esophageal cancer? A cost minimization analysis

BACKGROUND

Patients with advanced (T4 and/or M1) esophageal cancer are offered palliative therapy. Computed tomography (CT) is sensitive for distant metastases but is less sensitive than endosonography for T4 disease and celiac lymphadenopathy. The aim of this study was to determine whether initial CT or endosonography costs less to diagnose advanced esophageal cancer.

METHODS

A decision model compared the costs of the 2 strategies. Sensitivity analysis and threshold analysis were used to identify the most important determinants of the overall cost of identifying advanced disease.

RESULTS

Initial CT is the least costly strategy if the probability of finding advanced disease by initial CT is greater than 20%, if the probability of finding advanced disease by initial endoscopic ultrasound (EUS) is less than 30%, or if the cost of EUS is greater than 3.5 times the cost of CT. However, in our referral center population, endosonography found advanced disease more frequently than CT (44% vs. 13%; p < 0.0001) and the least costly strategy was initial endosonography (expected cost $804 vs. $844).

CONCLUSION

CT remains as the initial staging test of choice in most clinical settings. However, in referral centers, initial EUS may be reasonable, but individualized model inputs must be obtained before reliable conclusions can be drawn.

Endosonographic staging of 100 consecutive patients with esophageal carcinoma: introduction of the 8-mm esophagoprobe

Endoscopic ultrasound of esophageal carcinoma is conventionally performed using the 13-mm fiberoptic/ultrasound echoendoscope. However, the large diameter results in an inability to negotiate the primary tumor in 25% of patients. The aim of this study was first to determine whether use of the 8-mm esophagoprobe would overcome this problem and second to evaluate the accuracy of the smaller diameter instrument. One hundred consecutive patients with esophageal cancer underwent initial gastroscopy. Based upon the degree of luminal stenosis, patients were staged with either the conventional echoendoscope (luminal diameter > or = 15 mm) or the esophagoprobe (luminal diameter < 15 mm). The primary tumor was successfully negotiated in all subjects (echoendoscope 30, esophagoprobe 70) so that T- and N-staging was accomplished in every patient. Esophageal dilatation was performed in 12 patients (12%). The procedure was well tolerated and there were no complications, in particular no patient suffered esophageal perforation. The accuracy of the esophagoprobe for T-staging was 90% (19 out of 20) and that for N-staging was 75% (15 out of 20). This was similar to the accuracy of staging with the conventional echoendoscope, 90% (9 out of 10) for T-stage and 90% (9 out of 10) for N-stage. The esophagoprobe can safely and accurately stage patients with esophageal carcinoma, including those with high-grade stenoses.

Esophageal carcinoma: current staging strategies

A patient with suspected esophageal carcinoma represents a challenge to the treating physicians. Most patients present with an advanced stage of disease, and in the majority of cases only palliative treatment can be offered. Various treatment modalities are available, which are applied according to the TNM stage of the disease and the performance status of the patient. A precise histological diagnosis and highly accurate tumor staging of a patient with esophageal carcinoma is a prerequisite for the selection of the most suitable treatment option. Endoscopic ultrasound (EUS) has emerged as the most accurate diagnostic modality for locoregional staging. Problems in identifying early tumor stages or tumor strictures can be generally overcome by using miniprobe sonography (MPS). EUS/fine-needle aspiration biopsy (FNA) technology provides a valuable means of identifying suspicious locoregional lymph nodes. Patients with a proximal tumor (trachea bifurcation) should undergo bronchoscopy to rule out infiltration of the tracheobronchial system. Ultrasound (US), computed tomography (CT), and possibly magnetic resonance imaging (MRI) are the diagnostic tools of choice for extended tumor staging. After excluding extended tumor stage and severe concomitant diseases, diagnostic laparoscopy with intra-abdominal ultrasound should be performed in patients with adenocarcinoma of the esophagus prior to esophagectomy. Intra-abdominal metastases which can be missed preoperatively in some cases have to be ruled out in order to avoid unnecessary surgery.

Assessing chemotherapy response of squamous cell oesophageal carcinoma with spiral CT

45 patients with squamous cell carcinoma of the oesophagus were examined prior to, and following, pre-operative chemotherapy by spiral CT. Oesophageal CT was performed following gaseous distention of the oesophagus. TNM stage and perceived resectability on CT before and after chemotherapy were compared and related to surgical resectability and pathological staging. T-stage changed in 26% and N-stage changed in 9% of tumours after chemotherapy. Post-chemotherapy CT predicted pathological T-stage with an accuracy of 88% and N-stage with an accuracy of 84%. Six of 14 tumours considered irresectable on CT pre-chemotherapy were considered resectable on post-chemotherapy CT. Five of these six tumours were resectable at surgery. Post-chemotherapy CT predicted surgical resectability with an accuracy of 88%, the main pitfall being underestimation and overestimation of tracheobronchial invasion. CT prediction of chemotherapy response as judged by change in tumour volume was compared with a quantitative pathological assessment of chemotherapy response. 93% of oesophageal tumours changed volume after chemotherapy with 51% having a volume reduction of > or = 50%. However, no correlation was found between tumour volume reduction on serial CT examinations and either a quantitative pathological assessment of tumour response or patient survival.

Biopsy-negative malignant esophageal stricture: diagnosis by endoscopic ultrasound

Endoscopic ultrasound (EUS) of the esophagus has been used primarily in staging biopsy-proven cancers. Its use as a primary diagnostic modality for esophageal malignancy has not been previously described. We report our recent experience in four patients with dysphagia and endoscopic biopsies negative for malignancy, including one patient with clinical and manometric features suggestive of achalasia. In all cases, EUS revealed a large infiltrating tumor invading through the esophageal wall into the surrounding tissues, and in one case into the aorta. Computed tomography suggested the possibility of a tumor in only one of the cases. Two patients underwent esophagectomy and were found to have adenocarcinoma. Two patients underwent repeat biopsy with alternative aggressive biopsy techniques and were found to have squamous cell carcinoma. We conclude that EUS is useful in the diagnosis of esophageal cancer and should be performed in selected patients with esophageal strictures whose biopsies are negative for malignancy; i.e., those with suspicious endoscopic or radiographic appearance, atypical presentation (e.g., profound weight loss, short duration of symptoms, or advanced age), and failure to respond to treatment.

Clinical value of diagnostic laparoscopy with laparoscopic ultrasound in patients with cancer of the esophagus or cardia

Accurate pretherapeutic tumor staging becomes increasingly important for the selection of therapy in patients with cancer of the upper gastrointestinal tract. We prospectively assessed the clinical value of diagnostic laparoscopy with laparoscopic ultrasound and peritoneal lavage in 127 consecutive patients with cancer of the esophagus or cardia but no evidence of hepatic metastases, peritoneal tumor dissemination, or other systemic tumor manifestations on standard staging techniques. There was no mortality or morbidity associated with diagnostic laparoscopy. Diagnostic laparoscopy with laparoscopic ultrasound showed relevant previously unknown findings, particularly in patients with locally advanced adenocarcinoma of the distal esophagus or cardia (hepatic metastases in 22% and peritoneal tumor spread or free tumor cells in the abdominal cavity in 25%), whereas the diagnostic gain was low in those with squamous cell esophageal cancer. The sensitivity and specificity of laparoscopic ultrasound in predicting positive celiac axis lymph nodes were 67% and 92%, respectively. These data indicate that diagnostic laparoscopy with laparoscopic ultrasound and peritoneal lavage is safe and frequently provides therapeutically relevant new information in patients with locally advanced adenocarcinoma of the distal esophagus or cardia, whereas the clinical value in patients with squamous cell esophageal cancer is limited.

Pre-operative staging of gastro-oesophageal junction carcinoma: comparison of endoscopic ultrasound and computed tomography

Fifteen patients with carcinoma of the gastro-oesophageal junction were pre-operatively staged with endoscopic ultrasound (EUS) and computed tomography (CT). The accuracy of tumour and nodal staging using both modalities was compared to the final histological staging of the resected specimens. In staging depth of tumour growth, EUS was significantly more accurate (87% of lesions correctly staged) than CT (40% correctly staged). In staging nodal involvement, EUS was again significantly more accurate (73% correctly staged) than CT (33%). Two-thirds of the lesions were traversable with the endoscopic probe, but most of the nontraversed lesions were correctly staged on EUS. In this study, CT has performed poorly as a staging modality for carcinoma at the gastro-oesophageal junction. Other studies have shown CT to be less accurate at this location than at other oesophageal sites. The orientation of the gastro-oesophageal junction, lack of surrounding fat planes, proximity of adjacent organs and patient motion contribute to the poor staging performance of CT at this location. In contrast, EUS has been an accurate staging modality at the gastro-oesophageal junction in this study and compares well with other studies evaluating EUS in the more proximal oesophagus. Endoscopic ultrasound is therefore a necessary modality if accurate pre-operative staging of gastro-oesophageal junction carcinoma is to be achieved.