eus staging abstract

8/6/2019 Eus Staging Abstract

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:

: Utility of positron emission tomography for the staging of patients with potentially operable

esophageal carcinoma.

: J Clin Oncol 2000

: 3202-10

: Flamen P;Lerut A;Van Cutsem E;De Wever W;Peeters M;Stroobants S;Dupont P;Bormans G;Hiele

M;De Leyn P;Van Raemdonck D;Coosemans W;Ectors N;Haustermans K;Mortelmans L

: Department of Nuclear Medicine, University Hospital Gasthuisberg, Katholieke Universiteit

Leuven, Leuven, Belgium. [email protected]

: PURPOSE: A prospective study of preoperative tumor-node-metastasis staging of patients with

esophageal cancer (EC) was designed to compare the accuracy of 18-F-fluoro-deoxy-D-glucose (FDG)

positron emission tomography (PET) with conventional noninvasive modalities. PATIENTS AND

METHODS: Seventy-four patients with carcinomas of the esophagus (n = 43) or gastroesophageal

junction (n = 31) were studied. All patients underwent attenuation-corrected FDG-PET imaging, a

spiral computed tomography (CT) scan, and an endoscopic ultrasound (EUS). RESULTS: FDG-PET

demonstrated increased activity in the primary tumor in 70 of 74 patients (sensitivity: 95%).

False-negative PET images were found in four patients with T1 lesions. Thirty-four patients (46%) had

stage IV disease. FDG-PET had a higher accuracy for diagnosing stage IV disease compared with the

combination of CT and EUS (82% v 64%, respectively; P: =.004). FDG-PET had additional diagnostic

value in 16 (22%) of 74 patients by upstaging 11 (15%) and downstaging five (7%) patients.

Thirty-nine (53%) of the 74 patients underwent a 2- or 3-field lymphadenectomy in conjunction with

primary curative esophagectomy. In these patients, tumoral involvement was found in 21 local and 35

regional or distant lymph nodes (LN). For local LN, the sensitivity of FDG-PET was lower than EUS (33%

v 81%, respectively; P: =.027), but the specificity may have been higher (89% v 67%, respectively; P:

= not significant [NS]). For the assessment of regional and distant LN involvement, compared with the

combined use of CT and EUS, FDG-PET had a higher specificity (90% v 98%, respectively; P: =. 025)

and a similar sensitivity (46% v 43%, respectively; P: = NS). CONCLUSION: PET significantly improves

the detection of stage IV disease in EC compared with the conventional staging modalities. PET

improves diagnostic specificity for LN staging.

:

: A comparison of computerised tomography, laparoscopic ultrasound and endoscopic ultrasound

in the preoperative staging of oesophago-gastric carcinoma.

: Eur J Radiol 2002

: 161-7

: Wakelin SJ;Deans C;Crofts TJ;Allan PL;Plevris JN;Paterson-Brown S

: Department of Surgery, The Royal Infirmary, Lauriston Place, Edinburgh EH3 9YW, UK.


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[email protected]

: Introduction and objective: Oesophago-gastric carcinoma is associated with a poor prognosis

despite advances in diagnosis and treatment. Accurate preoperative staging of gastro-oesophageal

carcinoma is, therefore, essential in order to determine patient selection for potentially curative

resection. The aim of this study was to evaluate and compare the role of computerised tomography

(CT), laparoscopic ultrasound (LapUS) and endoscopic ultrasound (EUS) in the staging of

oesophago-gastric carcinoma. Methods and patients: Thirty-six patients with histologically proven

carcinoma of the oesophagus or stomach who were considered fit for surgical resection were

identified from a prospectively collected database. All patients underwent spiral CT, LapUS and EUS as

part of their preoperative staging investigations. Results from the staging modalities were

compared retrospectively with final histopathology where available and to intraoperative findings

where the tumour was irresectable. Results: Locally advanced tumours (T3/T4) were accurately

identified by CT in 15/16 (94%) and by EUS in 14/16 (88%). LapUS was unable to detect 11 tumours

(of which five were T3/T4) because they were above the diaphragm, but in the locally advanced

cases where the tumour could be seen the accuracy was 10/12 (83%). EUS was the best modality for

assessing early tumours and locoregional nodal involvement with accuracies of 8/13 (62%) and 21/29

(72%), respectively. EUS accuracies rose to 64, 92 and 83% for T1/T2, T3/T4 and N staging with the

exclusion of those patients (n=6) in whom strictures prevented full assessment. LapUS had a

specificity of 100%, compared to 90% for CT and was more accurate than CT for assessing distant

metastases (accuracy of 26/32 (81%) compared to 23/32 (72%) for CT). Conclusions: Although this

study is small it has confirmed that CT, EUS and LapUS act in a complimentary manner to provide the

most complete preoperative staging for patients with oesophago-gastric cancer.

:

: Impact of lymph node staging on therapy of esophageal carcinoma.

: Gastroenterology 2003

: 1626-35

: Vazquez-Sequeiros E;Wiersema MJ;Clain JE;Norton ID;Levy MJ;Romero Y;Salomao D;Dierkhising

R;Zinsmeister AR

: Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA.

: 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


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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.

:

: Utility of PET, CT, and EUS to identify pathologic responders in esophageal cancer.

: Ann Thorac Surg 2004

: 1152-60; discussion 1152-60

: Swisher SG;Maish M;Erasmus JJ;Correa AM;Ajani JA;Bresalier R;Komaki R;Macapinlac

H;Munden RF;Putnam JB;Rice D;Smythe WR;Vaporciyan AA;Walsh GL;Wu TT;Roth JA

: Department of Thoracic Surgery, University of Texas M. D. Anderson Cancer Center,

Houston, TX 77030, USA. [email protected]

: BACKGROUND: This study evaluates the utility of positron emission tomography (PET),

endoscopic ultrasonography (EUS), and computed tomographic (CT) scans to predict pathologic

response and survival following preoperative chemoradiation (CRT) in esophageal cancer. METHODS:

One hundred three sequential patients with locoregionally advanced esophageal cancer, who were

treated with CRT and esophageal resection between May 2001 and November 2003 at the University

of Texas M.D. Anderson Cancer Center, were retrospectively reviewed. PET, EUS, and CT were

performed before (pre) or after (post) CRT and before surgical resection. PET standardized uptake

value (SUV) was defined as maximal uptake in primary tumor. RESULTS: Most patients were male (91

[88%]) with adenocarcinoma (90 [87%]). Pretreatment clinical stages were: IIA (42 [41%]), IIB (5

[5%]), III (50 [49%]), and IVA (6 [6%]). At the time of surgery, 58 patients (56%) had a pathologic

response to CRT (< or =10% viable cells). Post-CRT measurements that correlated with pathologic

response were: CT esophageal wall thickness (13.3 vs 15.3 mm, p = 0.04), EUS mass size (0.7 vs 1.7

cm, p = 0.01) and PET SUV (3.1 vs 5.8, p = 0.01). Post-CRT PET SUV equal to or greater than 4 had the

highest accuracy for pathologic response (76%). Univariate and multivariate Cox regression analysis

demonstrated that a post-CRT PET SUV equal to or greater than 4 was an independent predictor of

survival (HR, 3.5, p = 0.04). CONCLUSIONS: The FDG-PET SUV is the most accurate noninvasive test

to predict long-term survival after preoperative CRT and before surgical resection. Post-CRT FDG-PET

cannot, however, rule out residual microscopic disease so esophagectomy should remain a

therapeutic option even if the post-CRT imaging modalities are normal.


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:

: Endoscopic ultrasound for preoperative staging of esophageal carcinoma.

: Surg Endosc 2005

: 1618-21

: Zhang X;Watson DI;Lally C;Bessell JR

: Flinders University Department of Surgery, Flinders Medical Centre, Bedford Park, South

Australia, 5042, Australia.

: BACKGROUND: Endoscopic ultrasound (EUS) is potentially the best method for pretreatment

staging of esophageal carcinoma once distant metastases have been excluded by other methods.

However, its apparent accuracy might be influenced by the use of neoadjuvant therapy. To determine

the accuracy of EUS in patients undergoing esophageal resection, the authors reviewed their

experience with EUS. METHODS: A total of 73 patients with esophageal carcinoma who underwent an

esophagectomy between April 2000 and February 2005 were examined using preoperative EUS and

computed tomography (CT). Of these patients, 39 also underwent preoperative neoadjuvant

chemoradiotherapy. Both EUS and CT scan were used to determine the depth of tumor penetration

(T-stage) and the presence of lymph node metastases (N-stage). These results then were compared

with staging determined after pathologic examination of the resected surgical specimen. RESULTS:

For patients not undergoing neoadjuvant therapy, T-stage was accurately determined by EUS in 79%,

N-stage in 74%, and tumor node metastasis (TNM) classification in 65% of the cases. However, when

patients who had undergone neoadjuvant chemoradiotherapy were included, the overall accuracy

of EUS was 64% for T-stage, 63% for N-stage, and 53% for TNM classification. For the patients who

underwent neoadjuvant therapy, EUS indicated a more advanced T-stage in 49%, N-stage in 38%, and

TNM classification in 51% of the cases, as compared with pathology. The overall accuracy of EUS for

T- and N-stage carcinomas was superior to that of CT scanning. CONCLUSION: For patients who do

not undergo preoperative neoadjuvant chemotherapy and radiotherapy, EUS is a more accurate

method for determining T- and N-stage resected esophageal carcinomas. Neoadjuvant therapy,

however, results in apparent overstaging, predominantly because of tumor downstaging, and this

reduces the apparent accuracy of EUS (and CT scanning) in this patient group. Nevertheless, EUS

staging before neoadjuvant therapy could be more accurate than pathologic staging after treatment,

thereby providing better initial staging information, which can be used to facilitate treatment.

:

: The role and clinical value of EUS in a multimodality esophageal carcinoma staging program

with CT and positron emission tomography.

: Gastrointest Endosc 2007

: 377-84


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: Pfau PR;Perlman SB;Stanko P;Frick TJ;Gopal DV;Said A;Zhang Z;Weigel T

: Section of Gastroenterology and Hepatology, Department of Medicine, University of

Wisconsin Medical School, 600 Highland Avenue, Madison, WI 53792, USA.

: BACKGROUND: EUS, CT, and positron emission tomography (PET) have all been used in the

preoperative staging of esophageal cancer separately or in various combinations. OBJECTIVE: Our

purpose was to determine the value and role of EUS when used in conjunction with CT and PET

imaging in staging cancer of the esophagus and gastroesophageal junction. DESIGN: Retrospective

single-center clinical trial. SETTING: Academic tertiary care center. PATIENTS: Data were examined for

56 patients who concomitantly underwent examination with EUS, CT, and PET in a multimodality

staging program. MAIN OUTCOME MEASUREMENTS: EUS, CT, and PET were examined for their ability

to detect the primary tumor, local tumor stage, locoregional adenopathy, and distant metastases.

With use of surgical resection as baseline therapy, the frequency at which EUS, CT, and PET affected

and changed management was examined. RESULTS: EUS is the only imaging test that identified all

primary tumors and provided tumor staging. EUS identified a significantly greater number of patients

(58.9%) with locoregional nodes than did CT (26.8%), P = .0006, or PET (37.5%), P = .02. CT

identified 14.3% and PET identified 26.8% of patients with distant metastases. With CT alone, 15.2%

of patients were not taken to surgery, whereas PET affected management by preventing surgery

because of metastatic disease in 28.3% of patients. EUS changed management by guiding the need

for neoadjuvant therapy in 34.8% of patients. LIMITATIONS: Retrospective study, nonblinded study,

lack of pathologic reference standard. CONCLUSION: The primary strength of EUS in a multimodality

staging strategy is in identifying patients with locally advanced disease and guiding the need for

preoperative neoadjuvant therapy. EUS is not suited to determine resectability of esophageal cancer

alone and thus is most effective when used in conjunction with other imaging tests such as CT and

PET.

:

: Endoscopic ultrasound in esophageal carcinoma: comparison with multislice computed

tomography and importance in the clinical decision making process.

: Minerva Chir 2007

: 217-23

: Moorjani N;Junemann-Ramirez M;Judd O;Fox B;Rahamim JS

: Department of Thoracic Surgery, Derriford Hospital, Plymouth, UK.

[email protected]

: AIM: As resective surgery for oesophageal carcinoma is only appropriate for a selected cohort

of patients, preoperative staging plays an important role in the management of these patients. This

study assessed the accuracy of endoscopic ultrasound (EUS) staging in comparison with computerised

tomography (CT) staging and the impact of EUS in management of patients with oesophageal


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carcinoma undergoing gastro-esophagectomy. METHODS: Ninety-six consecutive patients with

oesophageal carcinoma underwent preoperative staging with multislice CT and EUS. Of these, 50

patients underwent gastro-esophagectomy, allowing preoperative staging data from these imaging

modalities to be compared to postoperative histopathological staging, classified according to the

TNM system. Management plans for these patients made without use of EUS were then compared to

those following EUS staging. RESULTS: The overall accuracy rate of EUS for T staging was 64%,

showing good agreement with postoperative histopathological staging of the resected specimen

(weighted k=0.42, 95%CI= 0.32-0.52). In terms of clinical decision making, the T stage accuracy rose

to 90% when differentiating T1 from T2/3 lesions. In terms of N staging, the overall accuracy was 72%

(weighted k=0.44, 95% CI=0.34-0.54). In comparison, N staging by CT was significantly less accurate

(62% vs 72%, P


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CT:PT=0.001(chi(2)=10.079) and PN


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with decreased odds of misclassification of the defined stage of oesophageal cancer by endoluminal

ultrasound (EUS). The aim of this study was to assess the strengths of agreement between the

perceived preoperative radiological T and N stage compared with the final histopathological stage

related to four categories of BMI (low 30 kg/m(2)). One

hundred sixty-six patients with oesophageal carcinoma were studied. Strength of agreement

between the CT and EUS stages and histopathological stage was determined by the weighted kappa

statistic (Kw). Kw for EUS T stage related to increasing BMI category was 0.840 (P = 0.0001) to 0.620 (P

= 0.001), compared with 0.415 (P = 0.018) to 0.260 (P = 0.011) for CT. Kw for EUS N stage related to

increasing BMI category was 0.438 (P = 0.067) to 0.513 (P = 0.010), compared with 0.143 (P = 0.584)

to 0.582 (P = 0.030) for CT. EUS was good at predicting tumour infiltration irrespective of BMI when

compared with CT, while CT N staging accuracy improved with higher BMIs. Multidisciplinary teams

should be aware of these limitations when planning treatment strategies.

:

: A study comparing endoscopic ultrasound (EUS) and computed tomography (CT) in staging

oesophageal cancer and their role in clinical decision making.

: J Gastrointest Cancer 2010

: 38-42

: Subasinghe D;Samarasekera DN

: University Surgical Unit, National Hospital of Sri Lanka, 28/1 Ishwari road, Colombo 06, Sri

Lanka.

: BACKGROUND AND AIM: Computed tomography (CT) and endoscopic ultrasound (EUS) are

part of the regular preoperative staging protocol in oesophageal cancer. At present, EUS is

increasingly being used for preoperative locoregional staging of oesophageal cancer. The aim of this

study is to compare EUS and CT findings and their role in clinical decision making. METHODS: The

CT staging of 30 patients with oesophageal carcinoma was compared with EUS. This is a single

centre-based study, and the EUS was carried out by a single operator. RESULTS: The mean age was

58.2 years. On EUS, one (3.3%), five (16.7%), 16(53.3%) and eight (26.7%) patients had T1, T2, T3

and T4 tumours, respectively, compared with CT which showed 12(40%), nine (30%) and seven

(23.3%) patients with T2, T3 and T4 tumours. On CT, two (6.7%) were shown as no tumour (T0). EUS

revealed lymph node involvement in 25 (83.3%) patients compared with CT which indicated lymph

node involvement in seven (23.3%) patients. On EUS, coeliac node involvement was shown in four

(13.3%) patients (M1). The TNM staging of CT and EUS were comparable in nine (30%) patients. EUS

staging revealed a more advanced stage of oesophageal cancer in 17 (56.7%) patients. Preoperative

EUS staging changed the decision of management in 15 (50%) patients (P < 0.005). CONCLUSIONS:

EUS staging revealed a more advanced stage of cancer in the majority of patients. It appears to be far

more superior in detecting lymph node involvement compared with CT. Therefore, EUS may have a


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significant impact on deciding the treatment modality of a patient with oesophageal carcinoma.

:

: Comparison of endoscopic ultrasonography (EUS), positron emission tomography (PET), and

computed tomography (CT) in the preoperative locoregional staging of resectable esophageal cancer.

: Surg Endosc 2010

: 1380-6

: Choi J;Kim SG;Kim JS;Jung HC;Song IS

: Department of Internal Medicine and Liver Research Institute, Seoul National University

College of Medicine, Yongun-dong 28, Chongno-gu, Seoul 110-744, South Korea.

: BACKGROUND: Endoscopic ultrasonography (EUS) has been a useful method for the accurate

staging of esophageal cancer. This study aimed to compare the diagnostic performance of EUS,

positron emission tomography (PET), and computed tomography (CT) in the locoregional staging of

resectable esophageal cancer. METHODS: A total of 109 patients with resectable esophageal cancer

were prospectively enrolled and retrospectively reviewed for evaluation of preoperative EUS, PET,

and CT. The sensitivity, specificity, and accuracy of tumor depth (T) staging and regional lymph

nodal (N) staging for each test were compared with the postoperative histopathologic stage as the

gold standard. RESULTS: The overall accuracy of EUS for T staging was 72%, and it was the only

method for delineating the layers of the esophageal wall. The sensitivities for N staging were 42%

for EUS, 49% for PET, and 35% for CT, and their specificities were, respectively, 91, 87, and 93%. The

accuracy for N staging was 66% for EUS, 68% for PET, and 63% for CT, and it did not differ significantly

across the three tests. CONCLUSIONS: Preoperative EUS for the locoregional staging of esophageal

cancer provides excellent T staging accuracy and similar accuracy for N staging compared with PET

and CT. Especially in T staging, EUS could play an important role in the choice of candidates for

esophageal cancer surgery.

:

: Clinical staging of adenocarcinoma of the esophagogastric junction.

: Recent Results Cancer Res 2010

: 73-83

: Cordin J;Lehmann K;Schneider PM

: Tumors of the esophagogastric junction are among the most frequent and cause lethal

cancers. Patients often do not present until late in the disease when the tumor is sufficiently large to

cause obstruction or invasion of the adjacent structures, and thus becomes symptomatic.

Preoperative staging is critical to select those patients whose disease is still locally confined for

curative surgery. Ideally, clinical staging should accurately predict tumor invasion, lymph node

involvement, and distant metastases. Upper endoscopy establishes the tumor diagnosis by multiple


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biopsies and defines the tumor type (Siewert I-III), based on tumor localization in relation to the

endoscopic cardia. Preoperative TNM staging has a strong impact on treatment strategy. Endoscopic

Ultrasound (EUS) determines the T category, and to a lesser extent, the presence of lymph node

metastases. Multislice Computed Tomography (CT) and 18Fluorode-ocx-glucose Positron Emission

Computed Tomography (18FDG-PET-CT) provide further information, especially about systemic

metastases. Diagnostic laparascopy is suggested in advanced (CT3/4) Siewert type II-III tumors to

exclude peritoneal carcinomatosis. This chapter summarizes current staging modalities and their

accuracy in clinical practice.

:

: Comparative study between endoscopic ultrasonography and positron emission

tomography-computed tomography in staging patients with esophageal squamous cell carcinoma. LID -

10.1111/j.1442-2050.2011.01204.x [doi]

: Dis Esophagus 2011

: Yen TJ;Chung CS;Wu YW;Yen RF;Cheng MF;Lee JM;Hsu CH;Chang YL;Wang HP

: Departments of Internal Medicine Nuclear Medicine Surgery Oncology Pathology, National

Taiwan University Hospital, College of Medicine, National Taiwan University Department of Internal

Medicine, Far Eastern Memorial Hospital, Taipei Department of Internal Medicine, Luodong Saint

Mary's Hospital, Yilan County, Taiwan.

: Treatment strategy of esophageal cancer mainly depends on accurate staging. At present, no

single ideal staging modality is superior to another in preoperative tumor-node-metastasis (TNM)

staging of patients with esophageal cancer. We aimed to investigate the efficacy of endoscopic

ultrasonography (EUS) and positron emission tomography-computed tomography (PET-CT) for staging

of esophageal cancer. We retrospectively studied 118 consecutive patients with esophageal

squamous cell carcinoma who underwent esophagectomy with or without neoadjuvant

chemoradiotherapy (CRT) over a near 3-year period between January 2005 and November 2008 at a

tertiary hospital in Taiwan. Patients were separated into two groups: without neoadjuvant CRT

(group 1, n= 28) and with CRT (group 2, n= 90). Medical records of demographic data and reports of

EUS and PET-CT of patients before surgery were reviewed. A database of clinical staging by EUS and

PET-CT was compared with one of pathological staging. The accuracies of T staging by EUS in groups 1

and 2 were 85.2% and 34.9%. The accuracies of N staging by EUS in groups 1 and 2 were 55.6% and

39.8%. The accuracies of T and N staging by means of PET-CT scan were 100% and 54.5% in group 1,

and were 69.4% and 86.1% in group 2, respectively. In group 2, 38 of 90 patients (42.2%) achieved

pathologic complete remission. Among them, two of 34 (5.9%) and 12 of 17 (70.6%) patients were

identified as tumor-free by post-CRT EUS and PET-CT, respectively. EUS is useful for initial staging of

esophageal cancer. PET-CT is a more reliable modality for monitoring treatment response and

restaging. Furthermore, the accuracy of PET-CT with regard to N staging is higher in patients who


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have undergone CRT than those who have not.

eus staging abstract

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