Impact of Endoscopic Ultrasonography on 18F-FDG-PET/CT Upfront Towards Patient Specific Esophageal Cancer Treatment

Contrast-enhanced endoscopic ultrasound for swollen lymph nodes

Endoscopic ultrasound (EUS) is an important tool for the evaluation of lymphadenopathy, especially in intra-thoracic or intra-abdominal regions. EUS also provides tissue diagnosis via EUS fine-needle aspiration or biopsy. To select the target for biopsy or aspiration, conventional B-mode images are used for the evaluation, but this approach still lacks diagnostic accuracy. Contrast-enhanced EUS has been used to evaluate the vascularity of lesions. Most malignant lymphadenopathy shows heterogenous enhancement or defect of enhancement, while quantitative studies using time-intensity curves in contrast-enhanced harmonic EUS show a rapid decline in enhancement pattern. These findings are useful as an auxiliary method for tissue diagnosis or in cases in which tissue diagnosis is contraindicated.

The impact of endoscopic ultrasound on the management and outcome of patients with oesophageal cancer: an update of a systematic review

AIM

To provide an updated systematic review concerning the impact of endoscopic ultrasound (EUS) in the modern era of oesophageal cancer staging.

MATERIALS AND METHODS

To update the previous systematic review, databases including MEDLINE and EMBASE were searched and studies published from 2005 onwards were selected. Studies reporting primary data in patients with oesophageal or gastro-oesophageal junction cancer who underwent radiological staging and treatment, regardless of intent, were included. The primary outcome was the reported change in management after EUS. Secondary outcomes were recurrence rate and overall survival. Two reviewers extracted data from included articles. This study was registered with PROSPERO (CRD42021231852).

RESULTS

Eighteen studies with 11,836 patients were included comprising 2,805 patients (23.7%) who underwent EUS compared to 9,031 (76.3%) without EUS examination. Reported change of management varied widely from 0% to 56%. When used, EUS fine-needle aspiration precluded curative treatment in 37.5%-71.4%. Overall survival improvements ranged between 121 and 639 days following EUS intervention compared to patients without EUS. Smaller effect sizes were observed in a randomised controlled trial, compared to larger differences reported in observational studies.

CONCLUSION

Current evidence for the effectiveness of EUS in oesophageal cancer pathways is conflicting and of limited quality. In particular, the extent to which EUS adds value to contemporary cross-sectional imaging techniques is unclear and requires formal re-evaluation.

A national cross-sectional survey investigating the use of endoscopic ultrasound in the diagnosis and treatment of oesophageal cancer in the UK

AIM

To evaluate variation in the pre-pandemic use of endoscopic ultrasound (EUS) for oesophageal cancer diagnosis and treatment planning up to 2019, and which factors contributed to this.

MATERIALS AND METHODS

A UK-wide online survey of oesophagogastric multidisciplinary team lead clinicians was undertaken to determine perceptions towards, and the use of, EUS to aid staging and treatment planning in oesophageal cancer.

RESULTS

Thirty-five responses were received, representing 97 UK National Health Service Trusts/Health Boards. A majority of centres (n=21, 60%) did not have formal written guidance for EUS use. Although all respondents had access to EUS, a perceived lack of utility (n=7) and concerns about delaying treatment start dates (n=8) each restricted EUS use for a fifth of respondents. For most centres (n=24, 68.6%), EUS use is case-specific, whereas for 10 (28.6%) EUS is used for all patients with potentially curable disease. A majority of centres use diagnostic positron-emission tomography for radiotherapy target volume delineation (TVD), whereas 22 (62.9%) use EUS. The factors contributing to decisions to use EUS for staging, TVD and surgical planning varied between centres. The proportion of centre respondents who would request EUS in each of six clinical scenarios varied considerably.

CONCLUSION

There were substantial differences in the patient and disease characteristics that are perceived to be indications for EUS use for both staging and treatment planning. Research to clarify in which patients with oesophageal cancer EUS affords benefit is required, as is urgent standardisation of its role in the diagnostic pathway.

Discordant nodal staging identifies intermediate-risk group for overall survival in patients with cT3 oesophageal adenocarcinoma

OBJECTIVES

Oesophageal adenocarcinoma has a poor prognosis and relies on multi-modality assessment for accurate nodal staging. The aim of the study was to determine the prognostic significance of nodal concordance between PET/CT and EUS in oesophageal adenocarcinoma.

METHODS

Consecutive patients with oesophageal adenocarcinoma staged between 2010 and 2016 were included. Groups comprising concordant node-negative (C-ve), discordant (DC), and concordant node-positive (C+ve) patients were analysed. Survival analysis using log-rank tests and Cox proportional hazards model was performed. The primary outcome was overall survival. A p value < 0.05 was considered statistically significant.

RESULTS

In total, 310 patients (median age = 66.0; interquartile range 59.5-72.5, males = 264) were included. The median overall survival was 23.0 months (95% confidence intervals (CI) 18.73-27.29). There was a significant difference in overall survival between concordance groups (X² = 44.91, df = 2, p < 0.001). The hazard ratios for overall survival of DC and C+ve patients compared with those of C-ve patients with cT3 tumours were 1.21 (95% CI 0.81-1.79) and 1.79 (95% CI 1.23-2.61), respectively. On multivariable analysis, nodal concordance was significantly and independently associated with overall survival (HR 1.44, 95% CI 1.12-1.83, p = 0.004) and performed better than age at diagnosis (HR 1.02, 95% CI 1.003-1.034, p = 0.016) and current cN-staging methods (HR 1.20, 95% CI 0.978-1.48, p = 0.080).

CONCLUSIONS

Patients with discordant nodal staging on PET/CT and EUS represent an intermediate-risk group for overall survival. This finding was consistent in patients with cT3 tumours. These findings will assist optimum treatment decisions based upon perceived prognosis for each patient.

KEY POINTS

• Clinicians are commonly faced with results of discordant nodal staging in oesophageal adenocarcinoma. • There is a significant difference in overall survival between patients with negative, discordant, and positive lymph node staging. • Patients with discordant lymph node staging between imaging modalities represent an intermediate-risk group for overall survival.

Endoscopic Ultrasound Stagingof Esophageal Cancer

Esophageal cancer has increased in incidence over the last several decades and is now the sixth leading cause of all cancer deaths, with more than 500,000 deaths in 2018. The 2 most common types of esophageal cancer, squamous cell cancer and esophageal adenocarcinoma, make up nearly 95% of diagnoses. Based on the global distribution of these histologic types, esophageal adenocarcinoma is more common in the United States while squamous cell cancer is more common throughout the world. For both the squamous cell cancer and esophageal adenocarcinoma variants of esophageal cancer, the most important step in determining prognosis and survival is accurate staging. Endoscopy, computed tomography, whole-body positron emission tomography with 18-fluorodeoxyglucose, and endoscopic ultrasound (EUS) all have important roles in the diagnosis and staging of esophageal cancer. EUS is key for locoregional staging and guides treatment planning of esophageal cancer in the absence of distant metastases. EUS has been shown to improve survival across various stages of esophageal cancer and to have a positive financial impact in cost-effectiveness analyses. This article describes current EUS technology and the role of EUS in esophageal cancer staging, as well as the applications, challenges, and limitations of EUS in the management of this disease.

Reliability of clinical nodal status regarding response to neoadjuvant chemoradiotherapy compared with surgery alone and prognosis in esophageal cancer patients

Background: Clinical nodal (cN) staging is a key element in treatment decisions in patients with esophageal cancer (EC). The reliability of cN status regarding the effect on response and survival after neoadjuvant chemoradiotherapy (nCRT) with esophagectomy was evaluated in determining the up- and downstaged pathological nodal (pN) status after surgery alone. Material and methods: From a prospective database, we included all 395 EC patients who had surgery with curative intent with or without nCRT between 2000 and 2015. All patients were staged by a standard pretreatment protocol: 16-64 mdCT, 18 F-FDG-PET or 18 F-FDG-PET/CT and EUS ± FNA. After propensity score matching on baseline clinical tumor and nodal (cT/N) stage and histopathology, a surgery-alone and nCRT group (each N = 135) were formed. Clinical and pathological N stage was scored as equal (cN = pN), downstaged (cN > pN) or upstaged (cN < pN). Prognostic impact on disease free survival (DFS) was assessed with multivariable Cox regression analysis (factors with p value <.1 on univariable analysis). Results: The surgery-alone and nCRT group did not differ in cT/N status. Pathologic examination revealed equal staging (32 vs. 27%), nodal up (43 vs. 16%) and downstaging (25 vs. 56%), respectively (p < .001). Nodal up-staging was common in cT3-4a tumors and adenocarcinomas in the surgery-alone group, while nodal downstaging was found in half of cT1-2 and cT3-4 regardless of tumortype after nCRT. Prognostic factors for DFS were pN (p = .002) and lymph-angioinvasion (p = .016) in surgery-alone, and upper abdominal cN metastases (p = .012) and lymph node ratio (p = .034) in the nCRT group. Conclusions: Despite modern staging methods, correct cN staging remains difficult in EC. Nodal overstaging (cN > pN) occurred more often than understaging impeding an adequate assessment of pathologic complete response and prognosis after nCRT.

Novel imaging techniques in staging oesophageal cancer

The survival of oesophageal cancer is poor as most patients present with advanced disease. Radiological staging of oesophageal cancer is complex but is fundamental to clinical management. Accurate staging investigations are vitally important to guide treatment decisions and optimise patient outcomes. A combination of baseline computed tomography (CT), endoscopic ultrasound (EUS) and positron emission tomography (PET) are currently used for initial treatment decisions. The potential value of these imaging modalities to re-stage disease, monitor response and alter treatment is currently being investigated. This review presents an essential update on the accuracy of oesophageal cancer staging investigations, their use in re-staging after neo-adjuvant therapy and introduces evolving imaging techniques, including novel biomarkers that have clinical potential in oesophageal cancer.