Dilating Obstructing Esophageal Cancers during EUS

Abstract

Purpose: Dilating obstructing esophageal cancers to complete EUS staging is controversial. The purpose of this study was to determine practice patterns with regards to managing this clinical scenario. Methods: We conducted a survey of physicians performing EUS in the U.S. and abroad. Invitations by email were sent to members of the ASGE EUS special interest group who could access the survey online. Also, 41 physicians were directly emailed the survey, which inquired about practice setting, overall EUS experience, frequency of esophageal cancer staging, dilation of malignant esophageal strictures at the time of EUS, staging methods for non-traversable strictures and encounters with perforation from dilation. Results: We received 34 responses from physicians practicing in the U.S. (n = 18) and abroad (n = 16) in either academic centers (n = 29) or private practice (n = 7) (2 responders practiced in both). Twenty five (74%) endosonographers had performed over 1000 total EUS exams and 22 (65%) performed at least 5 EUS exams/month for esophageal cancer staging. With regards to dilating esophageal cancers during EUS, 7 (21%) responders dilated all stenotic cancers and 4 (12%) never dilated. The latter group reported perforation risk as the reason for not dilating and that such risk was greater than the potential benefit of complete staging with conventional echoendoscopes. The remaining 23 (67%) practiced selective dilation when, based on interaction with oncologists/surgeons, additional staging information was expected to make a clinical impact. Methods of dilation included fixed diameter dilators over a guidewire (n = 20), balloons (n = 12) or both (n = 2) to a mean diameter of 14mm (±1.3 mm). For non-traversable strictures even after dilation, physicians staged tumors by using: a standard echoendoscope to image to the proximal margin of the tumor (n = 12); a catheter US probe (n = 9); an esophagoprobe (n = 3); both an echoendoscope and catheter probe (n = 7); or all three (n = 1) (2 did not respond). Ten (29%) responders had encountered a perforation from dilation of an esophageal cancer during EUS. There was no significant correlation between dilation and practice setting, experience, esophagoprobe use, or prior perforations. Conclusions: There is considerable variability in dilating and staging obstructing esophageal cancers during EUS. Most endosonographers (67%) selectively dilate when significant clinical impact is expected. Less common strategies are universally dilating (21%) and never dilating (12%) obstructing cancers.