Use of endoscopic ultrasound in pre-treatment staging of esophageal cancer did not alter management plan

Evaluation of optimal monoenergetic images acquired by dual-energy CT in the diagnosis of T staging of thoracic esophageal cancer

OBJECTIVES

The purpose of our study was to objectively and subjectively assess optimal monoenergetic image (MEI (+)) characteristics from dual-energy CT (DECT) and the diagnostic performance for the T staging in patients with thoracic esophageal cancer (EC).

METHODS

In this retrospective study, patients with histopathologically confirmed EC who underwent DECT from September 2019 to December 2020 were enrolled. One standard polyenergetic image (PEI) and five MEI (+) were reconstructed. Two readers independently assessed the lesion conspicuity subjectively and calculated the contrast-to-noise ratio (CNR) and the signal-to-noise ratio (SNR) of EC. Two readers independently assessed the T stage on the optimal MEI (+) and PEI subjectively. Multiple quantitative parameters were measured to assess the diagnostic performance to identify T1-2 from T3-4 in EC patients.

RESULTS

The study included 68 patients. Subjectively, primary tumor delineation received the highest ratings in MEI (+) _40 keV of the venous phase. Objectively, MEI (+) images showed significantly higher SNR compared with PEI (p < 0.05), peaking at MEI (+) _40 keV in the venous phase. CNR of tumor (MEI (+) _{40 keV -80 keV}) was all significantly higher than PEI in arterial and venous phases (p < 0.05), peaking at MEI (+) _40 keV in venous phases. The agreement between MEI (+) _40 keV and pathologic T categories was 81.63% (40/49). Rho values in venous phases had excellent diagnostic efficiency for identifying T1-2 from T3-4 (AUC = 0.84).

CONCLUSIONS

MEI (+) reconstructions at low keV in the venous phase improved the assessment of lesion conspicuity and also have great potential for preoperative assessment of T staging in patients with EC.

Outcomes of endoscopic submucosal dissection (ESD) plus radiofrequency ablation (RFA) for nodular Barrett's esophagus

BACKGROUND

Although Endoscopic Submucosal Dissection (ESD) was proven superior to Endoscopic Mucosal Resection (EMR) in achieving higher complete remission rates for neoplastic Barrett's Esophagus (BE), its safety with Radiofrequency Ablation (RFA) remains unstudied. We share our experience with ESD + RFA for nodular BE eradication.

METHODS

A retrospective study of all patients ≥18-years with nodular BE who underwent ESD + RFA between September 2015 and December 2020 at our tertiary center. Patients with advanced adenocarcinoma requiring esophagectomy were excluded. Primary outcomes included adverse events (AE) rates and complete eradication rates for adenocarcinoma (CE-EAC), dysplasia (CE-D), and intestinal metaplasia (CE-IM). Secondary outcomes included local recurrence rates following eradication.

RESULTS

Eighteen patients were included with a total of 22 ESDs performed and a median of 2 RFA sessions-per-patient [IQR: 1.25, 3]. Sixteen patients were males and/or white (88.9%) with a median BMI of 29.75 kg/m² [IQR: 26.9, 31.5]. Fourteen patients had long-segment BE (77.7%) while 16 had hiatal hernias (88.9%). Median resection size was 12.1 cm² [IQR: 5.6, 20.2]. AEs included one intraprocedural micro-perforation (4.5%) and 4 strictures (22.2%), only one of which developed post-RFA. All AEs were successfully treated endoscopically. Over a median of 42.5 months [IQR: 28, 59.25], CE-EAC was achieved in 13 patients (100%), CE-D in 15 patients (100%), and CE-IM in 14 patients (77.8%). Following eradication, 2 patients had recurrent dysplasia (2/15, 13.3%) and one had recurrent intestinal metaplasia (1/14, 7.1%).

CONCLUSION

In high-risk patients with long-segment neoplastic BE requiring extensive endoscopic resection, ESD + RFA offers excellent complete eradication rates with rare additional adverse events by RFA. Standard endoscopic surveillance following eradication remains important.

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.