Value of Dilation in the EUS Staging of Obstructing Esophageal Cancer

Abstract

Introduction: Endoscopic ultrasound (EUS) staging of esophageal cancer is often limited by a tumor stricture preventing passage of the endosonoscope, and thus evaluation of potential distal metastatic lesions. It remains controversial whether dilation should be performed to allow complete EUS examination in these cases. The objective of this study was to assess the benefit and safety this approach. Patients and Methods: 114 consecutive patients underwent EUS staging of esophageal cancer at our institution from 2004-2007. Data were retrospectively obtained regarding need for and success of dilation, cancer staging, sampling of lesions distal to the stricture, complications, type of endosonoscope used, and treatment recommendations. Results: 114 patients underwent EUS staging of esophageal cancer. 56 patients (49%) had strictures that prevented endosonoscope passage. Of those, 52 patients underwent dilation, which allowed successful passage of the echoendoscope in 41 (79% success rate). Dilation was performed to a median diameter of 15 mm (range 10-18 mm) with a balloon (n = 5), Savary dilators (n = 45) or both (n = 2). Cases with an obstructing stricture were more often staged T3 or greater than those without an obstructing stricture (93% vs. 59%, p < 0.001). Biopsy of additional structures distal to the stricture was performed in 14 of the 41 cases (34%) where distal endosonoscope passage was possible after dilation, and demonstrated M1a (n = 7) or M1b disease (n = 2) in 9 cases (22%). This altered the therapeutic recommendations in 8 patients (20%). Perforation occurred in 2 patients who underwent dilation and in one patient who did not undergo dilation. All perforations were managed conservatively. Conclusions: A tumor stricture requiring dilation for endosonoscope passage is a strong indicator of T3 disease or greater. Dilation provides the opportunity for identification of metastatic involvement which can justify the small risk of perforation. Detection of M1a and M1b status distal to the stricture altered management in most of our cases. However, this may be different at other institutions since treatment recommendations for patients with non-regional lymph node metastases are not uniform.