Prognostic significance of failure to cross esophageal tumors by endoluminal ultrasound

Abstract

Failure to intubate and cross esophageal tumors by endosonography is reported in as many as 30% of cases and is thought to be associated with an especially poor prognosis. The aim of this study was to audit the above in a large consecutive case series of Endoscopic Ultrasound (EUS) examinations for esophageal cancer performed in a regional specialist cancer network with particular reference to outcome. A consecutive series of 411 patients underwent EUS examination by a specialist radiologist over a period of 9 years. Forty (10%) of patients required dilation, and there was total failure to cross the tumor in 12 patients (2.9%). Failure to traverse the primary tumor was associated with a diagnosis of squamous cell cancer (8 of 12 patients, 66%, rho = -0.182, P = 0.011). Limited staging information was obtained in 7 of these patients, which altered the computed tomography stage in 5 patients (71%, 3 upstaged, 2 downstaged). Six patients received definitive chemoradiotherapy, two patients surgery and four patients palliative chemotherapy. The median and 5-year survival in patients whose tumors were not crossed was 10 months and 28%, respectively, compared with 24 months and 24%, respectively in patients whose tumors were fully assessed. Failure to cross esophageal tumors in practice was far less common than the literature suggests, and esophageal tumor luminal stenosis should no longer be considered a limitation of endosonography.

Prospective comparison of optic versus blind endoscopic ultrasound in staging esophageal cancer

“…This may be due to more accurate staging of disease, improved multidisciplinary treatment algorithms and improved outcome from neoadjuvant treatment [34][35][36]. The survival data adds to the argument that failure to cross esophageal tumours should no longer be seen as a significant barrier to treatment [8].…”

“…Treatment outcomes, especially after chemoradiotherapy, have improved [34][35][36], and the failure rate of full radiological staging has decreased [8]. In this study, the blind endoprobe provided additional staging data for 31% of patients who would previously have been unstaged with the EUS optic endoprobe.…”

“…High rates of failure to cross the primary tumour resulted in the introduction of a narrower, blind (MH-908, 9 mm diameter) ultrasound endoprobe, which has facilitated full EUS esophageal cancer staging in over 95% of cases [8]. Although the blind endoprobe has been in use for some 10 years there is currently little histologically verified data on its accuracy, and certainly data regarding accuracy derived using optimal statistical analyses is thin.…”

“…Although the blind endoprobe has been in use for some 10 years there is currently little histologically verified data on its accuracy, and certainly data regarding accuracy derived using optimal statistical analyses is thin. As rates of failure to cross tumours decrease, allied to specialist EUS, and multimodal treatments improve [8], data regarding the true accuracy of blind probe EUS is clearly important. The aim of this study was to determine the relative accuracy of both the optic and blind ultrasound endoprobe for assessing the T and N stages of esophageal tumours in a consecutive series of patients undergoing stage-directed radical therapy defined and agreed upon by a regional upper gastrointestinal multidisciplinary team network, by comparison with the final histopathological pTN stage.…”

EUS Staging of Luminal Cancers in the Upper GI Tract

“…This will allow the endosonographer to document the location of the tumor, measure the extent of stricture and assess whether the echoendoscope will easily pass the tumor if a stricture exists. Inability to pass the echoendoscope beyond a stricture is generally associated with a poorer prognosis as it may suggest advanced disease, but an effort should be made to traverse strictures as a more accurate T and N stage can be determined [9,10]. Dilation may be performed with either a Savary dilator over the wire, or with a through-the-scope (TTS) controlled radial expansion (CRE) dilation balloon.…”