Esophageal Cancer Stage: Does Dysphagia Predict EUS Tumor Stage in Esophageal Cancer

Abstract

Purpose: Dysphagia is the most common presenting symptom of esophageal cancer (ECa). Patients with newly diagnosed ECa undergo endoscopic ultrasonography (EUS) for local tumor staging. We aimed to determine whether dysphagia predicts EUS tumor stage and identify tumor characteristics associated with dysphagia. Methods: A retrospective chart review of all patients referred to our institution (Feb. 2002 to Sep. 2009) for EUS staging of newly diagnosed ECa was performed. The following information was collected on a spreadsheet: age, sex, race, presence of dysphagia, EUS stage, tumor length and circumference, interventions and complications. Odds Ratio (OR) and Chi square test were used for statistical analysis. Results: A total 146 patients (120 men, 26 women) underwent EUS staging for ECa with a mean age of 62.5 years (range 29-89, median 63). There were 143 (98%) Caucasian patients, and 3 (2%) African-American patients. Dysphagia was reported in 105 patients. Histopathology revealed adenocarcinoma in 118 (80.8%), squamous cell cancer in 20 (13.6%), and poorly differentiated in 8 (5.6%) of tumors. EUS stage T1 was seen in 7.5 % (n=11), T2 in 37.6% (n=55), T3 in 52.7% (n=77), and T4 in 2% (n=3) of patients. Dysphagia was absent in all patients with stage T1 and present in all with stage T4. In stages T2 and T3, 52.7% and 95% of patients had dysphagia, respectively. Dysphagia was associated with a tumor stage of T3 or higher (OR 24.2, 95% CI: 7.9-74, p<0.0001). Dysphagia was associated with nodal stage N1 or higher (OR, 9.5, 95% CI: 4.1-22.2, p<0.0001). Dysphagia was present in 96.4% of patients with fully circumferential tumors (n=57) and in 58% with partially circumferential tumors (n=82). Dysphagia was associated with tumors 6 cm or longer (OR, 7.1 95% CI: 2.0- 24.6, p=0.0006). Of the patients presenting with dysphagia, 63.8% required dilation. The OR of requiring dilation in patients with dysphagia was 34.3 (95%CI 7.8-150, p<0.0001). The perforation rate in patients undergoing dilation (n=69) was 2.8% (n=2). Conclusion: The presence of dysphagia in Eca is strongly associated with a higher tumor and nodal stage, full circumferential and longer tumors, and the need for dilation. In centers where EUS staging is not available this finding may play an important role in planning management strategy such as neoadjuvant chemo-radiation therapy.