Endoscopic Ultrasound for Early Stage Esophageal Adenocarcinoma: Implications for Staging and Survival

Crabtree, Traves D.; Yacoub, Wael; Puri, Varun; Azar, Riad R.; Zoole, Jennifer Bell; Patterson, G. Alexander; Krupnick, Alexander S.; Kreisel, Daniel; Meyers, Bryan F.

doi:10.1016/j.athoracsur.2011.01.063

Cited by 53 publications

(43 citation statements)

References 21 publications

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“…9,10 Unfortunately, preoperative imaging to evaluate the extent of LN involvement with PET-CT has several limitations and EUS has been associated with high rates of inaccuracy. 11,12 Intraoperative identification of the anatomical lymphatic drainage of esophageal tumors may help surgeons to avoid unnecessarily …”

Section: Discussionmentioning

confidence: 99%

Identification of the Lymphatic Drainage Pattern of Esophageal Cancer with Near-Infrared Fluorescent Imaging

Schlottmann

Barbetta

Mungo

et al. 2017

Journal of Laparoendoscopic & Advanced Surgical Techniques

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Objective: Nodal status is one of the most important long-term prognostic factors for esophageal cancer. The aim of this study was to evaluate the ability of near-infrared (NIR) light fluorescent imaging to identify the lymphatic drainage pattern of esophageal cancer. Methods: Patients with distal esophageal cancer or esophagogastric junction cancer scheduled for esophagectomy were enrolled in this study. Before surgery, an endoscopy was performed with submucosal injection of 2 cc of indocyanine green (ICG) around the tumor. Real-time NIR images from the surgical field were obtained for each patient to visualize the lymphatic ICG drainage. Results: A total of nine patients were included in this study. Ivor Lewis esophagectomy was performed in all cases. ICG drainage was visualized to first drain along the left gastric nodes in eight patients (88.9%) and toward the diaphragmatic nodes in one patient (11.1%). The median number of resected nodes was 32. Three patients (33.3%) presented nodal involvement. All of them had positive nodes in the first nodal station identified with ICG. Conclusions: Evaluation of the lymphatic drainage pattern with real-time NIR light fluorescent technique is feasible. Distal and esophagogastric junction tumors showed to drain first in the left gastric nodes in most of the cases.

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Section: Discussionmentioning

confidence: 99%

Identification of the Lymphatic Drainage Pattern of Esophageal Cancer with Near-Infrared Fluorescent Imaging

Schlottmann

Barbetta

Mungo

et al. 2017

Journal of Laparoendoscopic & Advanced Surgical Techniques

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“…[9, 14-16] From these data, the reliability of the cT2N0 diagnosis was poor with only 27.4% confirmed pT2N0. While 46.7% were apparently understaged and ultimately upstaged at surgery, 25.9% were clinically overstaged and ultimately downstaged at surgery to pT0-1N0.…”

Section: Commentmentioning

confidence: 99%

“…[9, 13] This and other single center studies questioning the accuracy of clinical T2N0 esophageal cancer have been limited by small sample size. [9, 14-16]…”

Section: Introductionmentioning

confidence: 99%

Evaluation of the Reliability of Clinical Staging of T2 N0 Esophageal Cancer: A Review of The Society of Thoracic Surgeons Database

Crabtree

Kosinski

Puri

et al. 2013

The Annals of Thoracic Surgery

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Background Clinical staging of esophageal cancer has improved with PET/CT and endoscopic ultrasound. Despite such progress, small single center studies have questioned the reliability of clinical staging of T2N0 esophageal cancer. This study broadly examines the adequacy of clinical staging of T2N0 disease using the Society of Thoracic Surgeons database. Methods We retrospectively studied 810 clinical stage T2N0 patients from 2002-2011. There were 58 excluded because of incomplete pathologic staging data. Clinical stage, pathologic stage, and preoperative characteristics were recorded. Logistic regression analysis was utilized to identify factors associated with upstaging at the time of surgery. Results Among 752 clinical stage T2N0 patients, 35.9 %(270) received induction therapy prior to surgery. Of 482 patients that went directly to surgery, 27.4%(132) were confirmed as pathologic T2N0, 25.9%(125) were downstaged(i.e. T0-1N0), while 46.7%(225) were upstaged at surgery (T3-4N0 or TanyN1-3). Exclusive tumor upstaging(i.e. pathological T3-4N0) accounted for 18.2%(41), while exclusive nodal upstaging(i.e. pathological T1-2N1-3) accounted for 44.5%(100). Combined tumor and nodal upstaging(i.e. pathological T3-4N1-3) accounted for 37.3%(84). Among patients who received induction therapy, 38.1%(103) were upstaged vs. 46.7%(225) without induction therapy(p=0.026). Comparing the induction therapy group and the primary surgical group, postoperative 30-day mortality(3.7% vs. 3.7%, p=1.0) and morbidity(46.3% vs. 45%, p=0.76) were similar. Conclusion Despite advances in staging techniques clinical staging of T2N0 esophageal cancer remains unreliable. Recognizing T2N0 as a threshold for induction therapy in esophageal cancer, many surgeons have opted to treat T2N0 disease with induction therapy, despite the fact that one quarter of these patients will be pathological T1N0. While this study demonstrated similar perioperative morbidity and mortality with and without induction therapy, further study is needed to examine the impact of upstaging on long-term survival.

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“…Several studies have shown non-trivial rates of unanticipated nodal disease in initial staging of both early and locally advanced cancers that are treated surgically: 24% in cT1, 39-55% in cT2, and 78% in cT3 (19,20). Post-treatment effects, such as ongoing inflammation in the esophageal wall, enlarged reactive lymph nodes, and radiation-induced alterations in the echogenicity of lymph nodes seem to further limit reliable restaging with these techniques alone.…”

Section: Endoscopy and Eusmentioning

confidence: 99%

Surveillance versus esophagectomy in esophageal cancer patients with a clinical complete response after induction chemoradiation

Semenkovich¹,

Meyers²

2018

Ann. Transl. Med.

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There currently exists an area of controversy in treatment of esophageal cancer for patients who have an apparent clinical complete response (cCR) after induction chemoradiation. A standard treatment is to offer these patients an esophagectomy, but increasingly there is interest from both the patient and provider for active surveillance with so-called "salvage" esophagectomies for local recurrence as an alternative treatment paradigm. In this article, we review the existing evidence that stakeholders should consider for clinical decision-making in this specific patient population, including: the accuracy of post-induction clinical restaging, the reliability of operative risk assessment, the feasibility and adherence to surveillance strategies, and the observed outcomes in these patients after salvage esophagectomy or continued active surveillance.We also briefly discuss quality of life and future directions for this field.

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Endoscopic Ultrasound for Early Stage Esophageal Adenocarcinoma: Implications for Staging and Survival

Cited by 53 publications

References 21 publications

Identification of the Lymphatic Drainage Pattern of Esophageal Cancer with Near-Infrared Fluorescent Imaging

Identification of the Lymphatic Drainage Pattern of Esophageal Cancer with Near-Infrared Fluorescent Imaging

Evaluation of the Reliability of Clinical Staging of T2 N0 Esophageal Cancer: A Review of The Society of Thoracic Surgeons Database

Surveillance versus esophagectomy in esophageal cancer patients with a clinical complete response after induction chemoradiation

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