7057 Esophageal dilation for stenotic esophageal cancer prior to eus. is it still contraindicated in 1999?

Abstract

Background/Aim: Endoscopic ultrasound (EUS) has become a valuable tool in the staging of esophageal carcinoma. However, a complete examination is precluded in 20-38% of cases due to a high grade stricture at time of initial presentation. Dilation and endosonographic staging in these patients has been associated with a 25% perforation rate. In patients in whom a complete evaluation is performed, a correlation has been shown between preoperative EUS findings and the survival and surgical outcomes. Due to advancements in echoendoscope design and improvement in dilation accessories, we reviewed the outcome of patients with malignant stenotic esophageal cancer who underwent endoscopic esophageal dilation prior to EUS staging. Methods: This was an analysis of 25 patients who presented to our institution (4/98 - 11/99) for evaluation of esophageal carcinoma. The patients with stenotic esophageal carcinoma were dilated using serially inflated TTS (through-the-scope) balloon dilators. Immediately after the dilatation, a radial and then curvi-linear array echoendoscope were passed and imaging performed. If suspicious lymph nodes were seen, they were biopsied and then examined by a cyto-pathologist present in the room during the procedure. Results: Of the 25 patients, 10 (40%) had strictures preventing passage of a diagnostic endoscope and required dilatation. Nine out of the 10 (90%) dilations were successful. The dilatation range was 12mm to 16mm. All of the 10 cases were staged by EUS. Three (30%) were stage IV diagnosed by positive celiac lymph node fine needle aspiration (FNA), one (10%) was staged as IIB and six (60%) were staged as III. One tumor out of 10 was understaged. There were no complications due to dilatation. Thirteen patients (52%) underwent nodal FNA. Nine (69%)that were positive, 7 (78%) were celiac nodes and were diagnosed as stage IV disease. Two patients (22%) had positive para-esophageal nodes and were also found to have metastatic disease and, therefore, stage IV cancers. Four out of 13 (31%) FNA's were negative and 3 (75%) out of 4 were truly negative when compared to resection specimens. Conclusion: EUS after dilatation changed management in 30% of the patients with high-grade esophageal stenosis by demonstrating celiac node metastasis. These patients underwent chemo-radiation instead of surgery. The accuracy rate of FNA was 92%. In summary, recent modifications in scope design and dilatation accessories have improved our ability to safely perform complete esophageal cancer staging.