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

Abstract

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.

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

“…Since the presence of clinical abdominal LN metastases in the upper abdominal region was independently associated with DFS in the nCRT group, detection of these metastases is important. Although EUS is the preferred method to assess pathological abdominal LNs, PET-CT should be performed in case of stenosis, since the accuracy of PET-CT in detecting abdominal LNs is rather high [35]. Other possible explanations for difficult nodal staging are the complexity of longitudinal lymphatic drainage with skip metastases and large number (>50%) of small LN metastases (<5 mm) in EC [32,36].…”

The Prognostic Role of Pre-operative Positron Emission Tomography-Computed Tomography and Endoscopic Ultrasound Parameters in Oesophageal Adenocarcinoma

“…However, certain scenarios do require accurate lymph node prediction. The management of early tumours with endoscopic mucosal resection mandates an accurate assessment of local lymph nodes to avoid under-treating disease, particularly as the indications for endoscopic therapy expand to include tumours with early submucosal extension (T1b) (21). Likewise,…”

“…Increasing experience with EUS and PET/CT have improved the accuracy of both modalities. The addition of fine needle aspiration (FNA) has also been shown to improve the sampling accuracy of EUS although conceivably at the risk of seeding the primary tumour (21). Adding new parameters such as EUS elastography or PET/MRI (24,25), could potentially improve staging further.…”

Impact of postoperative TNM stages after neoadjuvant therapy on prognosis of adenocarcinoma of the gastro-oesophageal junction tumours

“…This observation is supported by the fact that N involvement is one of the most important and strongest prognostic factors of AEG tumours. Recent data, for example, show that lymph node involvement is more important than regional anatomic location for prognosis[ 23 , 24 ]. The 7 th edition AJCC TNM has already heralded the era of data-driven cancer staging and the incorporation of nonanatomic cancer characteristics[ 25 ].…”