Endosonographic Staging of Obstructive Esophageal Cancer: How Far Should We Go?

Abstract

Objective: Endoscopic ultrasonography (EUS) is a valuable tool in staging esophageal cancer. TNM-staging accuracy decreases in stenotic esophageal cancer when visualization of the tumor is incomplete. Little is known about the best strategy in pre-treatment staging in stenotic esophageal cancer. In the USA patients are often carefully dilated to facilitate passage of a standard EUS instrument. In Europe patients are either staged using a slim ultrasonic probe, a miniprobe, or surgery is performed without complete endosonographic evaluation. To determine the optimal strategy we studied the outcome of patients with non-traversable esophageal cancer. Methods: Esophageal staging EUS examinations between 1999 and 2003 with a minimal follow-up of 6 months were analysed. Data were collected regarding location of stenosis, histology, operative results and outcome. The Olympus GF-UM20 radial echoendoscope (diameter 13.2 mm) was used. Results: 718 patients were analysed (70 % adeno; 30 % squamous). In 157 patients (22 %) the tumour could not be passed (65 % adeno; 35 % squamous; p=0.29). EUS staging in these patients was incomplete. Of these 157, 56 underwent primary surgery. Of these 56 patients, 23 (41 %) were irresectable due to local invasion (T4) or metastatic disease; 8 had liver or peritoneal metastases (M1b disease); 15 had T4 and/or M1a disease and could therefore have been detected by standard EUS with dilation or slim ultrasonic probe (65 %), or by miniprobe EUS (43 %). Of the remaining 33 patients, 24 underwent a microscopically radical resection (R0), 9 were microscopically irradical (R1). Disease-free survival after R0 resection was 46 % and after R1 resection 27 %. Overall 6 months disease-free survival was 27 % (15/56). Conclusions: The prognosis in severely stenotic esophageal cancer is poor. Maximal effort should be put in complete endosonographic staging since potentially 65% of primarily irresectable tumours could have been detected by EUS and surgery could have been avoided.