Staging accuracy of endoscopic ultrasound for esophageal cancer after neoadjuvant chemotherapy: a meta-analysis and systematic review

Advances in Diagnostic, Staging, and Restaging Evaluation of Esophageal and Gastric Cancer

The initial endoscopic and staging evaluation of esophagogastric cancers must be accurate and comprehensive in order to select the optimal therapeutic plan for the patient. Esophageal and gastric cancers (and treatment paradigms) are delineated by their proximity to the cardia (within 2 cm). The most frequent and important symptom that informs the initial staging evaluation is dysphagia, which is associated with at least cT3 or locally advanced disease. Endoscopic ultrasound is often needed if earlier stage disease is suspected, preferably in combination with endoscopic mucosal or submucosal resection or fine-needle aspiration of suspicious lymph nodes to enhance staging accuracy.

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.

Remarkable response as a new indicator for endoscopic evaluation of local efficacy of non-surgical treatments for esophageal cancer

In Japan, standard of care of the patients with resectable esophageal cancer is neoadjuvant chemotherapy (NAC) followed by esophagectomy. Patients unfitted for surgery or with unresectable locally advanced esophageal cancer are generally indicated with definitive chemoradiotherapy (CRT). Local disease control is undoubtful important for the management of patients with esophageal cancer, therefore endoscopic evaluation of local efficacy after non-surgical treatments must be essential. The significant shrink of primary site after NAC has been reported as a good indicator of pathological good response as well as favorable survival outcome after esophagectomy. And patients who could achieve remarkable shrink to T1 level after CRT had favorable outcomes with salvage surgery and could be good candidates for salvage endoscopic treatments. Based on these data, "Japanese Classification of Esophageal Cancer, 12th edition" defined the new endoscopic criteria "remarkable response (RR)", that means significant volume reduction after treatment, with the subjective endoscopic evaluation are proposed. In addition, the finding of local recurrence (LR) at primary site after achieving a CR was also proposed in the latest edition of Japanese Classification of Esophageal Cancer. The findings of LR are also important for detecting candidates for salvage endoscopic treatments at an early timing during surveillance after CRT. The endoscopic evaluation would encourage us to make concrete decisions for further treatment indications, therefore physicians treating patients with esophageal cancer should be well-acquainted with each finding.

Prospective evaluation of MR-TRG (Tumor Regression Grade) in esophageal cancer after neo-adjuvant therapy: Preliminary results

PURPOSE

To develop MRI-based criteria to assess tumor response to neoadjuvant therapies (NAT) of esophageal cancers (EC) and to evaluate its diagnostic performance in predicting the pathological Tumor Regression Grade (pTRG).

METHOD

From 2018 to 2022, patients with newly diagnosed locally advanced EC underwent MRI examinations for initial staging and restaging after NAT. Magnetic Resonance TRG (MR-TRG), equivalent to the Mandard and Becker classifications, were developed and independently assessed by two radiologists, blinded to pTRG, using T2W and DW-MR Images. All patients underwent surgery and benefited from a blinded pTRG evaluation by two pathologists. The agreement between readers and between MR-TRG and pTRG were assessed with Cohen's Kappa. The correlation of MR-TRG and pTRG was determined using Spearman's correlation.

RESULTS

28 patients were included. Interrater agreement was substantial between radiologists, improved when grouping grade 1 and 2 (κ = 0.78 rose to 0,84 for Mandard and 0.68 to 0,78 for Becker score). Agreement between pTRG and MR-TRG was moderate with a percentaged agreement (p) = 87.5 %, kappa (κ) = 0.54 and p = 83.3 %, κ = 0.49 for Mandard and Becker, respectively. Agreement was improved to substantial when grouping grades 1-2 for Mandard and 1a-1b for Becker with p = 89.3 %, κ = 0.65 and p = 85.2 %, κ = 0.65 respectively. Sensitivity and specificity of MR-TRG in predicting pTRG were 88.2 % and 72.7 % for Mandard system (scores 1-2 versus 3-5), and 83.3 % and 80 % for Becker system (scores 1a-1b versus 2-3).

CONCLUSION

A substantial agreement between MR-TRG and pTRG was achieved when grouping grade 1-2. Hence, MR-TRG could be used as a surrogate of complete and near-complete pTRG.

Preoperative prediction of clinical and pathological stages for patients with esophageal cancer using PET/CT radiomics

BACKGROUND

Preoperative stratification is critical for the management of patients with esophageal cancer (EC). To investigate the feasibility and accuracy of PET-CT-based radiomics in preoperative prediction of clinical and pathological stages for patients with EC.

METHODS

Histologically confirmed 100 EC patients with preoperative PET-CT images were enrolled retrospectively and randomly divided into training and validation cohorts at a ratio of 7:3. The maximum relevance minimum redundancy (mRMR) was applied to select optimal radiomics features from PET, CT, and fused PET-CT images, respectively. Logistic regression (LR) was applied to classify the T stage (T1,2 vs. T3,4), lymph node metastasis (LNM) (LNM(-) vs. LNM(+)), and pathological state (pstage) (I-II vs. III-IV) with features from CT (CT_LR_Score), PET (PET_LR_Score), fused PET/CT (Fused_LR_Score), and combined CT and PET features (CT + PET_LR_Score), respectively.

RESULTS

Seven, 10, and 7 CT features; 7, 8, and 7 PET features; and 3, 6, and 3 fused PET/CT features were selected using mRMR for the prediction of T stage, LNM, and pstage, respectively. The area under curves (AUCs) for T stage, LNM, and pstage prediction in the validation cohorts were 0.846, 0.756, 0.665, and 0.815; 0.769, 0.760, 0.665, and 0.824; and 0.727, 0.785, 0.689, and 0.837 for models of CT_LR_Score, PET_ LR_Score, Fused_ LR_Score, and CT + PET_ LR_Score, respectively.

CONCLUSIONS

Accurate prediction ability was observed with combined PET and CT radiomics in the prediction of T stage, LNM, and pstage for EC patients.

CRITICAL RELEVANCE STATEMENT

PET/CT radiomics is feasible and promising to stratify stages for esophageal cancer preoperatively.

KEY POINTS

• PET-CT radiomics achieved the best performance for Node and pathological stage prediction. • CT radiomics achieved the best AUC for T stage prediction. • PET-CT radiomics is feasible and promising to stratify stages for EC preoperatively.

Why is endosonography insufficient for residual diagnosis after neoadjuvant therapy for esophageal cancer? Solutions using muscle layer evaluation

BACKGROUND

The diagnosis of residual tumors using endoscopic ultrasound (EUS) after neoadjuvant therapy for esophageal cancer is considered challenging. However, the reasons for this difficulty are not well understood.

AIM

To investigate the ultrasound imaging features of residual tumors and identify the limitations and potential of EUS.

METHODS

This exploratory prospective observational study enrolled 23 esophageal squamous cell carcinoma patients receiving esophagectomy after neoadjuvant therapy [15 patients after neoadjuvant chemotherapy (NAC) and 8 patients after chemoradiotherapy (CRT)] at the Department of Surgery, Chiba University Hospital, between May 2020 and October 2021. We diagnosed the T stage for specimens using ultrasound just after surgery and compared ultrasound images with the cut surface of the fixed specimens of the same level of residual tumor. The ratio of esophageal muscle layer defect measured by ultrasound was compared with clinicopathological factors. Furthermore, the rate of reduction for the muscle layer defect was evaluated using EUS images obtained before and after neoadjuvant therapy.

RESULTS

The accuracy of T stage rate was 61% (n = 14/23), which worsened after CRT (38%, n = 3/8) than after NAC (73%, n = 11/15) because of overstaging. Moreover, pT0 could not be diagnosed in all cases. The detection rate of residual tumor for specimens using ultrasound retrospectively was 75% (n = 15/20). There was no correlation between after-NAC (79%, n = 11/14) and after-CRT (67%, n = 4/6) detection rate. The detection of superficial and submucosal types was poor. The pathologic tumor size and pathological response were correlated. Tumor borders were irregular and echogenicity was mixed type after CRT. There was a correlation between the pT stage (pT0/1 vs pT2/3) and the length of muscle layer circumference (P = 0.025), the length of muscle layer defect (P < 0.001), and the ratio of muscle layer defect (P < 0.001). There was also a correlation between the pT stage and the rate of muscle layer defect reduction measured by EUS (P = 0.001).

CONCLUSION

Compared to pathological images, some tumors are undetectable by ultrasound. Focusing on the esophageal muscle layer might help diagnose the depth of the residual tumor.

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.

Esophagectomy versus definitive chemoradiotherapy as initial treatment for clinical stage I esophageal cancer: a systematic review and meta-analysis

BACKGROUND

Esophagectomy and definitive chemoradiotherapy are commonly used in the treatment of stage I esophageal cancer (EC). The present study aims to compare the efficacy and safety of esophagectomy and definitive chemoradiotherapy as the initial treatment for clinical stage I EC.

METHODS

This study was registered with the International Prospective Register of Systematic Reviews (CRD42020197203). Relevant studies were identified through PubMed, Web of Science, EMBASE, and Cochrane Library from database inception to June 30, 2020. Hazard ratio (HR) with 95% confidence intervals (CI) was employed to compare overall survival (OS) and progression-free survival (PFS). Odds ratio (OR) with 95% CI was employed to compare treatment-related death, complications, and tumor recurrence.

RESULTS

A total of 13 non-randomized controlled studies involving 3,346 patients were included. Compared with definitive chemoradiotherapy, esophagectomy showed an improved OS (HR 0.69, 95% CI 0.55-0.86; P < 0.001), PFS (HR 0.47, 95% CI 0.33-0.67; P < 0.001), and a lower risk of tumor recurrence (OR 0.43, 95% CI 0.30-0.61; P < 0.001). There was no significant difference in the incidence of complications (OR 1.11, 95% CI 0.75-1.65; P = 0.60) and treatment-related death (OR 1.15, 95% CI 0.31-4.30; P = 0.84) between the two treatments.

CONCLUSIONS

Current evidence shows esophagectomy has superior survival benefits as the initial treatment for clinical stage I EC. It is still the preferred choice for patients with clinical stage I EC. However, future high-quality randomized controlled trials are needed to validate this conclusion.

Diagnostic Value of Endoscopic Ultrasound after Neoadjuvant Chemotherapy for Gastric Cancer Restaging: A Meta-Analysis of Diagnostic Test

This study aimed to evaluate the diagnostic value of endoscopic ultrasound (EUS) after neoadjuvant therapy (NT) for gastric cancer restaging by meta-analysis. We conducted a systematic search of studies published on PubMed and Web of Science up to 30th August 2021. Assessing the risk of bias in the included studies was done with the QUADAS-2 tool. We used R and Review Manager 5.4.1 for calculations and statistical analysis. To evaluate the diagnostic value of EUS after NT for gastric cancer restaging, we performed a meta-analysis on six studies, with a total of 283 patients, including true-positive, true-negative, false-positive, and false-negative results for T1-T4, N0. EUS as a diagnostic test for GC patients after chemotherapy has a relatively low DOR for the T2 (3.96) and T4 stages (4.79) and a relatively high partial AUC for the T2 (0.85) and T4 (0.71) stages. Our results reveal that the pooled sensitivity for T stages after chemotherapy is rather low (29–56%), except for the T3 stage (71%). A potential limitation of our study was the small number of included studies, but no significant heterogeneity was found between them. Our meta-analysis concludes that EUS is not recommended or is still under debate for GC restaging after NT.

Modeling the impact of delaying surgery for early esophageal cancer in the era of COVID-19

BACKGROUND

Surgical society guidelines have recommended changing the treatment strategy for early esophageal cancer during the novel coronavirus (COVID-19) pandemic. Delaying resection can allow for interim disease progression, but the impact of this delay on mortality is unknown. The COVID-19 infection rate at which immediate operative risk exceeds benefit is unknown. We sought to model immediate versus delayed surgical resection in a T1b esophageal adenocarcinoma.

METHODS

A decision analysis model was developed, and sensitivity analyses performed. The base case was a 65-year-old male smoker presenting with cT1b esophageal adenocarcinoma scheduled for esophagectomy during the COVID-19 pandemic. We compared immediate surgical resection to delayed resection after 3 months. The likelihood of key outcomes was derived from the literature where available. The outcome was 5-year overall survival.

RESULTS

Proceeding with immediate esophagectomy for the base case scenario resulted in slightly improved 5-year overall survival when compared to delaying surgery by 3 months (5-year overall survival 0.74 for immediate and 0.73 for delayed resection). In sensitivity analyses, a delayed approach became preferred when the probability of perioperative COVID-19 infection increased above 7%.

CONCLUSIONS

Immediate resection of early esophageal cancer during the COVID-19 pandemic did not decrease 5-year survival when compared to resection after 3 months for the base case scenario. However, as the risk of perioperative COVID-19 infection increases above 7%, a delayed approach has improved 5-year survival. This balance should be frequently re-examined by surgeons as infection risk changes in each hospital and community throughout the COVID-19 pandemic.

Risk prediction of occult lymph node metastasis in patients with clinical T1 through T2 N0 esophageal squamous cell carcinoma

OBJECTIVES

To investigate long-term survival outcomes and develop a risk model for occult lymph node metastasis (LNM) in patients with clinical T1 through T2 N0 esophageal squamous cell carcinoma.

METHODS

From 2006 to 2018, 675 patients with clinical T1 through T2 N0 esophageal cancer who underwent upfront surgery were analyzed. The survival of patients with occult LNM was compared with that of 116 patients with clinical T1 through T2N+ cancer who underwent neoadjuvant therapy plus surgery. After randomly dividing the patients with clinical T1 through T2 N0 tumors into the training and testing sets, a risk model for occult LNM was developed and validated.

RESULTS

Among patients with clinical T1 through T2 N0 esophageal cancer, occult LNM was found in 147 (21.8%) but not in 528 (78.2%). Patients with occult LNM had significantly worse prognosis than those without (P < .001), but showed similar outcomes to patients with clinical T1 through T2 N+ cancer (P = .981). According to the risk model, tumor maximum standardized uptake >3.8 (P = .002), histological differentiation grade (P = .015), tumor length >25 mm (P < .001), and advanced clinical T stage (P < .001) were independent risk factors for occult LNM in clinical T1 through T2 N0 cancer. A risk scoring system based on this model showed high accuracy (0.81) and good discriminant ability in both training sets (area under the receiver operating characteristic curve, 0.759 and testing area under the receiver operating characteristic curve, 0.743).

CONCLUSIONS

Our risk scoring system for predicting occult LNM in clinical T1 through T2 N0 esophageal cancer has high accuracy and good discriminant ability.

An updated review of the TNM classification system for cancer of the oesophagus and its complications

Cancer of the esophagus is an aggressive cancer with high mortality. Because of the esophagus's lack of serosa and its peculiar lymphatic drainage, esophageal cancer is diagnosed in advanced stages. The eighth edition of the TNM (2017) aims to standardize care for esophageal cancer throughout the world; it includes not only patients treated with esophagectomy alone, but also those receiving neoadjuvant chemotherapy and/or radiotherapy. One new development in the eighth edition is that it establishes separate classifications for different time periods, with pathologic stage groups for prior to treatment (cTNM), after esophagectomy (pTNM), and after neoadjuvant therapy (ypTNM). The combined use of endoscopic ultrasound, CT, PET-CT, and MRI provides the greatest accuracy in determining the clinical stage, and these techniques are essential for planning treatment and for evaluating the response to neoadjuvant treatment. Esophagectomy continues to be the main treatment; it is also the elective gastrointestinal surgery that has the highest mortality, and it carries the risk of multiple complications, including anastomotic leaks, pulmonary complications, technical complications, and functional complications.

Difference in Computed Tomography Image Quality between Central Vein and Peripheral Vein Enhancement in Treatment Naive Esophageal Cancer Patients

Simple Summary

A chest CT via central vein enhancement not only eliminates peripheral vein regurgitation but also provides better image quality that facilitates precise clinical staging. A chest CT via central vein enhancement may be considered after tissue proof in order to better discriminate disease severity.

Abstract

The differences in chest computed tomography (CT) image quality may affect the tumor stage. The aim of this study was to compare the image quality and accuracy of chest CT via central vein and peripheral vein enhancement. Fifty consecutive patients were enrolled from a tertiary medical center in Taiwan from May 2016 to March 2019. All the patients received a chest CT via central vein enhancement prior to neoadjuvant concurrent chemoradiation in order to compare the chest CT that was obtained via the peripheral vein. In addition, blind independent central reviews of chest CT via central vein and peripheral vein enhancement were conducted. For T and N stage, chest CT via central vein enhancement had a greater consistency with endoscopic ultrasonography and positron-emission tomography-computed tomography findings (kappa coefficients 0.4471 and 0.5564, respectively). In addition, chest CT via central vein enhancement also showed excellent agreement in the blind independent central review (kappa coefficient 0.9157). The changes in the T and N stage resulted in stage migration in 16 patients. Chest CT via central vein enhancement eliminated peripheral vein regurgitation and also provided more precise clinical staging. This study is registered under the registered NCT number 02887261.

A prediction model for degree of differentiation for resectable locally advanced esophageal squamous cell carcinoma based on CT images using radiomics and machine-learning

OBJECTIVE

To propose the prediction model for degree of differentiation for locally advanced esophageal cancer patients from the planning CT image by radiomics analysis with machine learning.

METHODS

Data of 104 patients with esophagus cancer, who underwent chemoradiotherapy followed by surgery at the Hiroshima University hospital from 2003 to 2016 were analyzed. The treatment outcomes of these tumors were known prior to the study. The data were split into 3 sets: 57/16 tumors for the training/validation and 31 tumors for model testing. The degree of differentiation of squamous cell carcinoma was classified into two groups. The first group (Group I) was a poorly differentiated (POR) patients. The second group (Group II) was well and moderately differentiated patients. The radiomics feature was extracted in the tumor and around the tumor regions. A total number of 3480 radiomics features per patient image were extracted from radiotherapy planning CT scan. Models were built with the least absolute shrinkage and selection operator (LASSO) logistic regression and applied to the set of candidate predictors. The radiomics features were used for the input data in the machine learning. To build predictive models with radiomics features, neural network classifiers was used. The precision, accuracy, sensitivity by generating confusion matrices, the area under the curve (AUC) of receiver operating characteristic curve were evaluated.

RESULTS

By the LASSO analysis of the training data, we found 13 radiomics features from CT images for the classification. The accuracy of the prediction model was highest for using only CT radiomics features. The accuracy, specificity, and sensitivity of the predictive model were 85.4%, 88.6%, 80.0%, and the AUC was 0.92.

CONCLUSION

The proposed predictive model showed high accuracy for the classification of the degree of the differentiation of esophagus cancer. Because of the good prediction ability of the method, the method may contribute to reducing the pathological examination by biopsy and predicting the local control.

ADVANCES IN KNOWLEDGE

For esophageal cancer, the differentiation of degree is the import indexes reflecting the aggressiveness. The current study proposed the prediction model for the differentiation of degree with radiomics analysis.

Esophageal Cancer: An Updated Review

The incidence of esophageal cancer (EC) is on the rise. With the distinct subtypes of adenocarcinoma and squamous cell carcinoma comes specific risk factors, and as a result, people of certain regions of the world can be more prone to a subtype. For example, squamous cell carcinoma of the esophagus has the highest incidence in eastern Africa and eastern Asia, with smoking being a major risk factor, whereas adenocarcinoma is more prevalent in North America and western Europe, with gastroesophageal reflux disease being a leading risk factor. With that being said, adenocarcinoma and squamous cell carcinoma have similar and unfortunately poor survival rates, partly because EC is prone to early metastasis given that the esophagus does not have a serosa, as well as the superficial nature of its lymphatics compared with the rest of the gastrointestinal tract. This makes early detection of the utmost importance, and certain patients have been shown to have the benefit of screening/surveillance endoscopies, including those with Barrett's esophagus, lye-induced/caustic strictures, tylosis, and Peutz-Jeghers syndrome. Until treatments significantly improve, identifying EC at the earliest stage will have the best success for patient outcomes, and further elucidation of its pathogenesis and risk factors may lead to identifying other high-risk groups that should be screened.

Brazilian Group of Gastrointestinal Tumours' consensus guidelines for the management of oesophageal cancer

Oesophageal cancer is among the ten most common types of cancer worldwide. More than 80% of the cases and deaths related to the disease occur in developing countries. Local socio-economic, epidemiologic and healthcare particularities led us to create a Brazilian guideline for the management of oesophageal and oesophagogastric junction (OGJ) carcinomas. The Brazilian Group of Gastrointestinal Tumours invited 50 physicians with different backgrounds, including radiology, pathology, endoscopy, nuclear medicine, genetics, oncological surgery, radiotherapy and clinical oncology, to collaborate. This document was prepared based on an extensive review of topics related to heredity, diagnosis, staging, pathology, endoscopy, surgery, radiation, systemic therapy (including checkpoint inhibitors) and follow-up, which was followed by presentation, discussion and voting by the panel members. It provides updated evidence-based recommendations to guide clinical management of oesophageal and OGJ carcinomas in several scenarios and clinical settings.

Preoperative EUS evaluation of the response to neoadjuvant therapy for gastric and esophagogastric junction cancer is correlated with survival: A single retrospective study of 97 patients

Background and Objectives:

The European Society for Medical Oncology suggests performing EUS staging for esophagogastric junction and gastric cancers to further assess the T and N stages. The use of EUS after neoadjuvant therapy (NT) is still under debate. We aimed to evaluate the contribution of EUS after NT to staging, therapeutic choices, and prognosis prediction.

Subjects and Methods:

In 97 patients with esophagogastric junction and gastric cancers who received NT (chemotherapy or radiochemotherapy) followed by carcinologic surgery, EUS was performed before (uT, uN) and after (yuT, yuN) NT. We compared the results of EUS staging after NT (yuT and yuN) and final histology (ypT and ypN). We analyzed the correlation between overall survival (OS), disease-free survival (DFS), and the objective and subjective responses to NT evaluated by EUS (comparison of uT and yuT and uN and yuN with OS and DFS).

Results:

EUS staging detected metastasis that went undetected by computed tomography in 16% of metastatic patients. The accuracy between EUS after NT and postoperative pathological findings was 44.4% (34.2%; 54.7%) for T stage and 49.3% (37.5%; 61.1%) for N stage. On multivariate analysis, OS had significantly correlated with the objective response to NT. In the case of a response to NT, the median OS was 64.77 months, and in the case of stable disease, the median OS was 22.9 months (P = 0.01).

Conclusion:

EUS after NT can be used for staging. Despite its moderate accuracy, the evaluation of the response to NT by EUS seems to be correlated with patient prognosis.

Narrative review of the role of gastroenterologist in the diagnosis, treatment and palliation in gastric and gastroesophageal cancer

Esophageal cancer (EC) and gastric cancer (GC) carry a high mortality rate. Unfortunately, a majority of patients are asymptomatic and at the time of diagnosis, the disease may invariably be in its advanced stages with limited curative options. Thus, it is imperative to recognize certain risk factors including gastroesophageal reflux disease (GERD), male gender, pre-existing Barrett’s esophagus, smoking history, obesity, Helicobacter pylori infection, atrophic gastritis among others for both EC and GC, intervene on time with screening and surveillance modalities if indicated and optimize treatment plans. With advances in endoscopic techniques, early neoplastic lesions are increasingly managed by gastroenterologists, offering an alternative to surgery. The gold standard for diagnosis of EC and GC is high definition endoscopy with adequate targeted biopsies. Endoscopic ultrasound (EUS) is a key in the staging of early cancers dictating the pathway for treatment options. We also play a key role in palliation cases with the aim to reduce the symptoms like nausea, vomiting and even when possible, restore oral intake and improve nutrition in both advanced GC and EC. This review article discusses the risk factors, diagnostic and endoscopic treatment modalities of early EC and GC and palliation of advanced cancer where gastroenterologists play a key role.

An updated review of the TNM classification system for cancer of the esophagus and its complications

Cancer of the esophagus is an aggressive cancer with high mortality. Because of the esophagus's lack of serosa and its peculiar lymphatic drainage, esophageal cancer is diagnosed in advanced stages. The eighth edition of the TNM (2017) aims to standardize care for esophageal cancer throughout the world; it includes not only patients treated with esophagectomy alone, but also those receiving neoadjuvant chemotherapy and/or radiotherapy. One new development in the eighth edition is that it establishes separate classifications for different time periods, with pathologic stage groups for prior to treatment (cTNM), after esophagectomy (pTNM), and after neoadjuvant therapy (ypTNM). The combined use of endoscopic ultrasound, CT, PET-CT, and MRI provides the greatest accuracy in determining the clinical stage, and these techniques are essential for planning treatment and for evaluating the response to neoadjuvant treatment. Esophagectomy continues to be the main treatment; it is also the elective gastrointestinal surgery that has the highest mortality, and it carries the risk of multiple complications, including anastomotic leaks, pulmonary complications, technical complications, and functional complications.

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.

Diagnostic Endoscopic Ultrasound: Technique, Current Status and Future Directions

Endoscopic ultrasound (EUS) is now well established as an important tool in clinical practice. From purely diagnostic imaging, it has progressed to include tissue acquisition, which provided the basis for therapeutic procedures. Even as interventional EUS developed, there has been ongoing progress in EUS diagnostic capabilities due to improved imaging systems, better needles for tissue acquisition and development of enhanced imaging functions such as contrast harmonic EUS (CHEUS) and EUS elastography. EUS is well established for differentiation of subepithelial lesions, for T-staging of luminal gastrointestinal and pancreaticobiliary malignancies, for differentiation of benign pancreaticobiliary disorders and for diagnostic tissue acquisition, which can be achieved by EUS-guided fine needle aspiration or by EUS-guided fine needle biopsy using dedicated biopsy needles. This review briefly describes the technique of performing EUS and then discusses its clinical utility in terms of gastrointestinal cancer staging, the evaluation of pancreaticobiliary disorders and tissue acquisition. Enhanced imaging techniques such as CHEUS and EUS elastography are briefly reviewed.

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 evaluation of the esophageal cancer patient after chemoradiotherapy for persistent/recurrent cancer

Endoscopy has an important role in the pre- and post-treatment staging of esophageal cancer. Complete pathologic response following neoadjuvant chemoradiation therapy occurs in approximately 25% of patients. However, the ability to accurately detect this preoperatively with currently available endoscopic modalities is limited such that the default pathway is for fit patients to proceed with surgical resection. This article discusses the available endoscopic modalities (primarily Esophagogastroduodenoscopy [EGD] with mucosal biopsies and endoscopic ultrasonography with or without fine needle aspiration) used for post-treatment staging of esophageal cancer. We present data regarding the benefits and limitations of endoscopic methods in assessing for residual disease. Unfortunately, endoscopic modalities are not accurate enough to identify complete pathological responsers who may avoid surgical resection.

Texture analysis of CT imaging for assessment of esophageal squamous cancer aggressiveness

Background

To explore the role of texture analysis of computed tomography (CT) images in preoperative assessment of esophageal squamous cell carcinoma (ESCC) aggressiveness.

Methods

Seventy-three patients with pathologically confirmed ESCC underwent unenhanced and contrast enhanced CT imaging preoperatively. Texture analysis was performed on unenhanced and contrast enhanced CT images, respectively. Six CT texture parameters were obtained. One-way analysis of variance or independent-samples t-test (normality), independent-samples Kruskal-Wallis test or Mann-Whitney U test (non-normality), binary Logistic regression analysis (multivariable), Spearman correlation test, receiver operating characteristic (ROC) curve analysis and intraclass correlation coefficient (ICC) were used for statistical analyses.

Results

Kurtosis was an independent predictor for T stages (T1-2 vs. T3-4) as well as overall stages (I-II vs. III-IV) based on unenhanced CT images, while entropy was an independent predictor for T stages (T1-2 vs. T3-4), lymph node metastasis (N- vs. N+) and overall stages (I/II vs. III/IV). Skew and kurtosis based on unenhanced CT images showed significant differences among N stages (N0, N1, N2 and N3) as well as 90th percentile based on contrast enhanced CT images. In correlation with T stage of ESCC, kurtosis and entropy significantly correlated with T stage both on unenhanced and contrast enhanced CT images. Reversely, entropy and 90th percentile based on contrast enhanced CT images showed significant correlations with N stage (r: 0.526, 0.265; both P<0.05), as well as overall stage (r: 0.562, 0.315; both P<0.05). For identifying ESCC with different T stages (T1-2 vs. T3-4), lymph node metastasis (N- vs. N+) and overall stages (I/II vs. III/IV), entropy based on contrast enhanced CT images, showed good performance with area under ROC curve area under curve (AUC) of 0.637, 0.815 and 0.778, respectively.

Conclusions

Texture analysis of CT images held great potential in differentiating different T, N and overall stages of ESCC preoperatively, while failed to assess the differentiation degrees.

Predictors of pathologic upstaging in early esophageal adenocarcinoma: Results from the national cancer database

BACKGROUND

Upstaging in early esophageal adenocarcinoma (EAC) patients happens at a high rate and has implications for treatment. We sought to identify risk factors predicting upstaging.

STUDY DESIGN

The National Cancer Database (2010-2013) was queried for all patients with clinical T1/T2 and N0 EAC who underwent esophagectomy without neoadjuvant therapy. Logistic regression models were developed to investigate risk factors for upstaging.

RESULTS

A total of 1120 patients were included. Pathologic upstaging occurred in 21.3% (n = 239). After adjustment, risk of upstaging increased with tumor size (tumor size 1-3 cm, OR 4.57,95% CI 2.58-8.10, tumor size >3 cm, OR 10.57, 95% CI 5.77-19.35, as compared to tumors <1 cm) as well as with positive margins (OR 4.13, 95% CI 2.17-7.87) and > than 10 lymph nodes examined (OR 1.85, 95% CI 1.29-2.63), while facility volume was not significant. Odds of upstaging increased linearly with number of lymph nodes examined (OR 1.02 per node).

CONCLUSION

Our data underscore the importance of tumor size as a predictor for upstaging and of completing a thorough lymph node dissection for staging purposes.

Is endoscopic ultrasound examination necessary in the management of esophageal cancer?

Despite substantial efforts at early diagnosis, accurate staging and advanced treatments, esophageal cancer (EC) continues to be an ominous disease worldwide. Risk factors for esophageal carcinomas include obesity, gastroesophageal reflux disease, hard-alcohol use and tobacco smoking. Five-year survival rates have improved from 5% to 20% since the 1970s, the result of advances in diagnostic staging and treatment. As the most sensitive test for locoregional staging of EC, endoscopic ultrasound (EUS) influences the development of an optimal oncologic treatment plan for a significant minority of patients with early cancers, which appropriately balances the risks and benefits of surgery, chemotherapy and radiation. EUS is costly, and may not be available at all centers. Thus, the yield of EUS needs to be thoughtfully considered for each patient. Localized intramucosal cancers occasionally require endoscopic resection (ER) for histologic staging or treatment; EUS evaluation may detect suspicious lymph nodes prior to exposing the patient to the risks of ER. Although positron emission tomography (PET) has been increasingly utilized in staging EC, it may be unnecessary for clinical staging of early, localized EC and carries the risk of false-positive metastasis (over staging). In EC patients with evidence of advanced disease, EUS or PET may be used to define the radiotherapy field. Multimodality staging with EUS, cross-sectional imaging and histopathologic analysis of ER, remains the standard-of-care in the evaluation of early esophageal cancers. Herein, published data regarding use of EUS for intramucosal, local, regional and metastatic esophageal cancers are reviewed. An algorithm to illustrate the current use of EUS at The University of Texas MD Anderson Cancer Center is presented.

Accuracy of ultrasound for the diagnosis of cervical lymph node metastasis in esophageal cancer: a systematic review and meta-analysis

BACKGROUND

Esophageal cancer is considered a serious malignancy with respect to its prognosis and mortality rate. Cervical lymph node status is one of the keys to determining prognosis and treatment methods. However, published data vary regarding the accuracy of ultrasound in the diagnosis of cervical lymph node metastasis. We performed a meta-analysis to assess the efficacy of ultrasound for detecting cervical lymph node metastasis in patients with esophageal cancer.

METHODS

The PubMed/MEDLINE, EMBASE, Web of Science, and Cochrane Library databases were searched to identify studies related to cervical lymph node metastasis, and 22 studies comprising 3,513 patients met our inclusion criteria. We used a bivariate meta-analysis following a random effects model to summarize the data. We also explored reasons for statistical heterogeneity using meta-regression, subgroup, and sensitivity analyses. Publication bias was assessed with a Deeks funnel plot.

RESULTS

The area under the receiver operating characteristic curve was 0.97 [95% confidence interval (CI): 0.95-0.98], and the pooled diagnostic odds ratio was 121.00 (95% CI: 47.57-307.79). With cut-off values of 5 mm and >5 mm for cervical lymph node size, the sensitivities and specificities (95% confidence interval) for ultrasound detection of cervical lymph node metastasis were 84% (67-93%) and 93% (90-95%); and 94% (76-98%) and 98% (89-100%), respectively.

CONCLUSIONS

We show for the first time the diagnostic accuracy of ultrasound for predicting cervical lymph node-positive metastasis in esophageal cancer. Our analysis shows that ultrasonography may be an effective and reliable approach to detect cervical lymph node metastasis in esophageal cancer. However, to accommodate heterogeneity, high-quality studies are needed to further verify the efficacy of ultrasound detection.

Stage-directed individualized therapy in esophageal cancer

Esophageal cancer is the eighth most common cancer worldwide, and the incidence of esophageal carcinoma is rapidly increasing. With the advent of new staging and treatment techniques, esophageal cancer can now be managed through various strategies. A good understanding of the advances and limitations of new staging techniques and how these can guide in individualizing treatment is important to improve outcomes for esophageal cancer patients. This paper outlines the recent progress in staging and treatment of esophageal cancer, with particularly attention to endoscopic techniques for early-stage esophageal cancer, multimodality treatment for locally advanced esophageal cancer, assessment of response to neoadjuvant treatment, and the role of cervical lymph node dissection. Furthermore, advances in robot-assisted surgical techniques and postoperative recovery protocols that may further improve outcomes after esophagectomy are discussed.