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

Endoscopic Ultrasound in Cancer Staging

The authors review the role of endoscopic ultrasound (EUS) in the staging of cancers throughout the gastrointestinal tract. EUS offers an advantage over cross-sectional imaging in locoregional tumor staging but is less sensitive in identifying distant metastasis. The addition of FNA increases diagnostic accuracy and provides a tissue diagnosis. EUS combined with cross-sectional imaging is important in accurately staging GI tumors and thereby reducing unnecessary procedures and health care costs.

Impact of Slim Linear Echoendoscope on the Practice of EUS

BACKGROUND

Standard linear echoendoscopes have a large distal tip and bending radius, which can preclude adequate examination in some patients.

OBJECTIVE

We examined the impact of having available slim linear echoendoscopes (SLE) on our endoscopic ultrasound (EUS) practice.

MATERIALS AND METHODS

As a quality improvement measure, data on the need for the use of SLE were documented in 2000 consecutive procedures performed over a 10-month period from February to November 2022. When examination using a standard size echoendoscope failed due to technical limitations, the procedure was reattempted in the same session using a SLE. The main outcome was the impact of SLE, which was defined as the establishment of a new diagnosis or if findings altered treatment plan.

RESULTS

A complete EUS examination failed in 23 of 2000 procedures (1.15%, 95% CI, 0.73-1.72%) performed using standard size echoendoscope (14 male, median age 73 y [IQR 66 to 79]). The examination was technically successful when using SLE in 22 of 23 (95.6%) patients. SLE impacted clinical management in all 22 patients (100%) by establishing tissue diagnosis in 19 and/or altering subsequent treatment plan in 5. Adverse event of transient hypoxia was observed in one patient (4.3%).

CONCLUSIONS

A very experienced EUS team required SLE in 1.1% of consecutive examinations. Our findings suggest that when used, 95% of patients benefitted as it had a significant impact on their clinical management.

Imaging Recommendations for Diagnosis, Staging, and Management of Esophageal Cancer

Early staging and treatment initiation affect prognosis of patients with esophageal and esophagogastric junction cancer; hence, it is imperative to have knowledge of proper choice of imaging modality for staging of these patients, to effectively convey relevant imaging findings to the treating physician/surgeon. It is also essential to be aware of pertinent imaging findings that need to be conveyed to the treating physician/surgeon at staging, and after treatment, including post-therapy complications (if any), so as to provide timely management to such patients. In this article, we have provided imaging guidelines for diagnosis, staging, post-therapy response evaluation, follow-up, and assessment of post-therapy complications of esophageal and esophagogastric junction cancer in a systematic manner. Besides, risk factors and clinical workup have also been elucidated. We have also attached comprehensive staging and post-therapy contrast-enhanced computed tomography and fluorodeoxyglucose-positron emission tomography/computed tomography-based synoptic reporting formats “ECI-RADS” and “pECI-RADS,” respectively, for esophageal and esophagogastric junction cancer in the supplement, for effective communication of imaging findings between a radiologist and the treating physician/surgeon.

Balloon Dilation for Endosonographic Staging in Esophageal Cancer: A Phase 1 Clinical Trial

BACKGROUND

Dilation in patients with malignant esophageal strictures precluding the passage of the endoscopic ultrasonography (EUS) scope allows complete evaluation; however, it may be associated with complications. This study evaluates the safety and clinical value of balloon dilation to complete EUS in patients with stenotic esophageal cancers.

METHODS

This study consists of a phase I clinical trial. One-hundred-and fifty patients were recruited. Endoscopic balloon dilation was performed before EUS in patients with high-grade stenosis. The analysis was focused on the ability to complete an endosonographic examination after dilation, 30-day morbidity, and change in the final stage or definitive management based on the completed endosonographic examination.

RESULTS

Dilation was required in 55 patients (36.7%), with a complication rate of 10.9% (n = 6). Dilation allowed completion of EUS in 53 patients (96.4%), leading to a modification of the clinical stage for 18 patients (34%) and a deviation in the treatment plan in 7 patients (13.2%). No differences were found in these variables when compared with the group that did not require dilation (26.3% and 14.7%, P = .33 and P = .79, respectively). Dilation was associated with more advanced disease on final pathology among patients who underwent surgical resection (P = .006).

CONCLUSIONS

High-grade malignant esophageal strictures that preclude the passage of the ultrasound probe are associated with advanced stage disease. Owing to the high risk of perforation and the limited benefit in staging, balloon dilation to complete the EUS staging should be avoided. (Clinicaltrials.gov identifier: NCT01950442.).

What should be known prior to performing EUS?

Direct referral of patients for EUS – instead of preprocedural consultation with the endosonographer – has become standard practice (like for other endoscopic procedures) as it is time- and cost-effective. To ensure appropriate indications and safe examinations, the endosonographer should carefully consider what information is needed before accepting the referral. This includes important clinical data regarding relevant comorbidities, the fitness of the patient to consent and undergo the procedure, and the anticoagulation status. In addition, relevant findings from other imaging methods to clarify the clinical question may be necessary. Appropriate knowledge and management of the patients’ anticoagulation and antiplatelet therapy, antibiotic prophylaxis, and sedation issues can avoid unnecessary delays and unsafe procedures. Insisting on optimal preparation, appropriate indications, and clear clinical referral questions will increase the quality of the outcomes of EUS. In this paper, important practical issues regarding EUS preparations are raised and discussed from different points of view.

A new clinical staging system for esophageal cancer to predict survival after definitive chemoradiation or radiotherapy

This study is to evaluate the prognostic value of a new clinical staging system for esophageal cancer to predict survival after (chemo)radiotherapy. This retrospective study enrolled 444 patients with esophageal squamous cell carcinoma who underwent definitive intensity-modulated radiotherapy with or without chemotherapy between January 2008 and May 2014. A clinical staging system based on the gross tumor volume and maximum diameter of metastatic lymph nodes was developed and the prognostic value of this staging system was compared with that of the 8th edition of American Joint Committee on Cancer TNM staging system. The 3-year survival rate in the whole group was 44.5%. Multivariate analysis showed that gross tumor volume and maximum diameter of metastatic lymph nodes were independent prognostic factors. According to the proposed clinical staging system, the 3-year survival curves of each T, N, and TNM stage were well segregated. On the other hand, 3-year survival rates based on the 8th edition of cTNM staging system were similar between cT3 and cT4, cN1 and cN2, cN2, and cN3, III and IVa stages.The proposed clinical staging system appears to be a simple and accurate predictor of outcome in patients with esophageal squamous cell carcinoma who underwent definitive (chemo) intensity-modulated radiotherapy.

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.