Utility of dysphagia grade in predicting endoscopic ultrasound T-stage of non-metastatic esophageal cancer

Abstract

Patients with non-metastatic esophageal cancer routinely undergo endoscopic ultrasound (EUS) for loco-regional staging. Neoadjuvant therapy is recommended for ≥T3 tumors while upfront surgery can be considered for ≤T2 lesions. The aim of this study was to determine if the degree of dysphagia can predict the EUS T-stage of esophageal cancer. One hundred eleven consecutive patients with non-metastatic esophageal cancer were retrospectively reviewed from a database. Prior to EUS, patients' dysphagia grade was recorded. Correlation between dysphagia grade and EUS T-stage, especially in reference to predicting ≥T3 stage, was determined. The correlation of dysphagia grade with EUS T-stage (Kendall's tau coefficient) was 0.49 (P < 0.001) for the lower and 0.59 (P = 0.008) for the middle esophagus. The sensitivity and specificity of dysphagia grade ≥2 (can only swallow semi-solids/liquids) for T3 cancer were 56% (95% confidence interval [CI] 43-67%) and 93% (95% CI 79-98%), respectively. The sensitivity, specificity, and positive predictive value of dysphagia grade ≥3 (can only swallow liquids or total dysphagia) for T3 lesions were 36% (95% CI 25-48%), 100% (95% CI 89-100%), and 100% (95% CI 83-100%), respectively. Overall, there was a significant positive correlation between dysphagia grade and the EUS T-stage of esophageal cancer. All patients with dysphagia grade ≥3 had T3 lesions. This may have clinical implications for patients who can only swallow liquids or have complete dysphagia by allowing for prompt initiation of neoadjuvant therapy, especially in countries/centers where EUS service is difficult to access in a timely manner or not available.

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

“…For confirmed T1a cancers, ER followed by ablation of high-risk residual tissue via radiofrequency ablation or photodynamic therapy, offers survival rates similar to surgery[ 55 - 63 ]. EUS prior to ER is especially important in patients with large intraluminal tumors[ 64 ]. When EUS is combined with cross-sectional imaging, patients are considered to have completed clinical staging, thereby identifying stage T2 or T3 patients who may benefit from radical esophagectomy with extended lymphadenectomy[ 58 , 61 , 65 , 66 ].…”

Clinical Predictors of Locally Advanced Pathology in Esophageal Adenocarcinoma

“…Dysphagia is a well-established predictor for T3 or T4 disease. In 111 patients with nonmetastatic EAC, the sensitivity, specificity, and positive predictive value of dysphagia grade ≥3 (can only swallow liquids or total dysphagia) for T3 lesions were 36% (95% CI 25-48%), 100% (95% CI 89-100%), and 100% (95% CI 83-100%), respectively [ 22 ]. Overall, there was a significant positive correlation between dysphagia grade and the EUS T-stage of esophageal cancer.…”

Comparative effectiveness of upfront esophagectomy versus induction chemoradiation in clinical stage T2N0 esophageal cancer: A decision analysis

“…While no studies have explicitly examined the probability of upstaging in cT2N0 patients with dysphagia, several series on resectable esophageal cancer have shown the presence of dysphagia to have a specificity for “at least T3 disease” of greater than 88%. 26–28 Similarly, studies examining PET SUV have not been done exclusively in cT2N0 patients, however a SUVmax greater than 2.5 in the primary tumor has been associated with presence of nodal disease. 29,30 Presence of these factors will likely place a cT2N0 patient above the 48.1% threshold for benefit of induction chemoradiation and should be considered during clinical decision-making about the best strategy.…”