Predicting Stage of Esophageal Adenocarcinoma Using a Dysphagia Symptom Questionnaire

Abstract

Introduction: Endoscopic ultrasonography (EUS) is a standard component of staging in patients with esophageal adenocarcinoma (EAC). The current treatment paradigm for EAC is upfront resection for patients with early stage disease (T1 or T2 tumor with no lymph node metastasis) vs. neoadjunctive chemo-radiation therapy for patients with more advanced disease. The aim of the present study was to determine if the presence and severity of dysphagia at time of EUS staging could predict T and N stage. Methods: Patients undergoing EUS for staging of esophageal adenocarcinoma were prospectively identified at our tertiary referral center. Prior to EUS, patients were given a questionnaire to assess dysphagia related symptoms. Demographic data, EUS findings, and TNM cancer stage were recorded and extracted from review of medical records. Tumor staging was based on the basis of EUS and imaging findings in patients who did not undergo primary resection. For the purpose of this study, the primary outcome was grouped into local disease (stage 0-1) vs. locally advanced/metastatic disease (stage II-IV). Results: 99 patients (age 64.72 ± 11.4 years, 83.8% male) were prospectively identified from 2012-2014 and underwent EUS for EAC staging. T1 disease was found in 7 (7.1%), T2 in 20 (20.2%), T3 in 69 (69.7%), and T4 in 3 (3%) patients. Malignant appearing lymph nodes were seen in 58 (58.6%) patients and distant metastasis were seen in 13 (13.1%). Overall, locally advanced or metastatic disease was present in 81 (81.8%) patients with 18 (18.2%) having local disease only. 32 (32.3%) patients reported no dysphagia symptoms, 9 (9.1%) mild, 27(27.3%) moderate, 25 (25.2%) severe and 6 (6.1%) with very severe symptoms. On univariate analysis the presence of dysphagia predicted locally advanced/metastatic disease (p = 0.004). The overall severity of dysphagia did not predict advanced disease (p=0.069). However, dysphagia with solid food (OR = 4.5), breads (OR=3.96), meats (OR=3.52), and apples (OR=3.96) predicted at least locally advanced disease (p < 0.05 for all). Seven (7.1%) patients required esophageal dilation in order to complete the EUS with a trend toward predicting advanced staged disease (p = 0.056). Conclusion: In patients undergoing EUS for pre-treatment staging of EAC, the presence of dysphagia to solid foods is strongly associated with locally advanced or metastatic disease. These findings question the utility of pre-treatment EUS in patients presenting with dysphagia due to esophageal adenocarcinoma.Table: Table. Predictors of Advanced Disease