Accuracy Of Endoscopic Ultrasound Staging Research Articles

Accuracy of endoscopic ultrasound staging for T2N0 esophageal cancer: a National Cancer Database analysis.

To determine accuracy of clinical staging of T2N0 esophageal cancer from the National Cancer Database (NCDB). The NCDB was accessed to identify patients with T2N0M0 esophageal cancer (adenocarcinoma or squamous cell carcinoma) treated between 2004-2013 that underwent esophagectomy. Pathologic staging was compared to clinical stage. Univariate (UVA) and multivariate analysis (MVA) was performed to identify factors related to pathologic upstaging using Cox proportional hazard ratio. We identified 1,840 patients with T2N0 esophageal cancer who underwent esophagectomy as first line therapy. The median age was 67 years. The vast majority of patients were male and had distal adenocarcinomas. Clinical staging in was accurate pathologically in 30.7% of patients. While there was a trend for worse accuracy with increasing year of diagnosis, there rate of pT0-2N0 was stable. Tumor length >3 cm was significantly associated with tumor upstaging, while poor differentiation was significantly associated with nodal upstaging. UVA and MVA identified younger age, tumor length >3 cm, and poor differentiation were significantly associated with overall upstaging. Gender, tumor location, and tumor histology were not prognostic. Clinical staging for T2N0M0 esophageal cancer continues to remain highly inaccurate, however, rates of pT0-2N0 have steadily remained over 50%. Tumor length >3 cm and poor differentiation are strongly associated with pathologic upstaging.

Comparative effectiveness of upfront esophagectomy versus induction chemoradiation in clinical stage T2N0 esophageal cancer: A decision analysis

ObjectivesWe compared the effectiveness of upfront esophagectomy versus induction chemoradiation followed by esophagectomy for overall survival in patients with clinical T2N0 (cT2N0) esophageal cancer. We also assessed the influence of the diagnostic uncertainty of endoscopic ultrasound on the expected benefit of chemoradiation. MethodsWe created a decision analysis model representing 2 treatment strategies for cT2N0 esophageal cancer: upfront esophagectomy that may be followed by adjuvant therapy for upstaged patients and induction chemoradiation for all patients with cT2N0 esophageal cancer followed by esophagectomy. Parameter values within the model were obtained from published data, and median survival for pathologic subgroups was derived from the National Cancer Database. In sensitivity analyses, staging uncertainty of endoscopic ultrasound was introduced by varying the probability of pathologic upstaging. ResultsThe baseline model showed comparable median survival for both strategies: 48.3 months for upfront esophagectomy versus 45.9 months for induction chemoradiation and surgery. The sensitivity analysis demonstrated induction chemoradiation was beneficial, with probability of upstaging > 48.1%, which is within the published range of 32% to 65% probability of pathologic upstaging after cT2N0 diagnosis. The presence of any of 3 key variables (size larger than 3 cm, high grade, or lymphovascular invasion) was associated with > 48.1% risk of upstaging, thus conferring a survival advantage to induction chemoradiation. ConclusionsThe optimal treatment strategy for cT2N0 esophageal cancer depends on the accuracy of endoscopic ultrasound staging. High-risk features that confer increased probability of upstaging can inform clinical decision making to recommend induction chemoradiation for select cT2N0 patients.

Mo1479 Staging of Esophageal and Junctional Cancer: Low Accuracy for EUS Tool in T2 N0 Patients

Mo1479 Staging of Esophageal and Junctional Cancer: Low Accuracy for EUS Tool in T2 N0 Patients Germana De Nucci*, Emanuele Dabizzi, Maria C. Petrone, Sabrina G. Testoni, Davide Bona, Luigi Bonavina, Pier Alberto Testoni, Paolo G. Arcidiacono Gastroenterology and Gatrointestinal Endoscopy Unit, Division of Experimental Oncology, IRCCS San Raffaele Scientific Institute, VitaSalute San Raffaele University, Milan, Italy; Gastroenterology and Digestive Endoscopy, G. Salvini Hospital, Milan, Italy; Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, Milan, Italy Background & Aim: Despite the poor prognosis of esophageal carcinoma (EC), the stage of the disease correlates with the length of survival and recommended treatment. Accurate staging of EC is important since it directs further management. After distant metastases have been ruled out by CT scanning or PET-CT, Endoscopic Ultrasound (EUS) is the best available tool in the preoperative locoregional staging, being able to define the depth of tumor invasion and to visualize and even sample locoregional lymph nodes. Accurate staging is important to define T2N0 cancers, which can proceed directly to surgery. When compared to surgical pathology, EUS showed to have about 85 % of accuracy in staging tumor depth and about 75 % in detecting regional lymph node metastases. Aim of the present study was to report a single high volume center’s experience with EUS staging in a rare subset of patients with T2N0 esophageal cancers, evaluating the accuracy of EUS staging for T2N0 tumors. Materials & Methods: We conducted a retrospective study from our database of patients, enrolled prospectively, that underwent EUS for staging EC between January 2010 and August 2014. We identified patients with T2N0 tumors who underwent surgical resection. The preoperative EUS staging (cTNM) was then compared to surgical pathology (pTNM) results to evaluate accuracy. Results: 509 patients underwent EUS for staging of EC. Of these, 43 patients (33 men, mean age 67 years) received a diagnosis of cT2N0 disease by EUS. Surgical resection of EC was performed after a mean of 11 days post-EUS. When compared to final pathologic outcomes, 40 % of patients (17/43) were evaluated correctly and referred for appropriate therapy, 49 % of patients (21/ 43) were understaged by EUS and 12 % of patients (5/43) were overstaged. Among the 21 understaged patients, understaging occurred due to tumor depth in 6 patients (29 %), nodal involvement in 7 patients (33 %) and both in 8 patients (38 %). The 5 overstaged patients had a histological T1b stage, without nodal involment. EUS showed an accuracy of 65 % in staging for tumor depth and of 82 % in staging for nodal involvement. Positive predictive value of EUS diagnosis of cT2N0 EC was 40 % (17 pT2N0/43 cT2N0). Conclusions: In this challenging group of patients with T2N0 tumors, EUS understaged EC in 49 % of cases resulting in surgical resection when neoadjuvant chemoradiation may have been beneficial. This underline that T2N0 EC is a branching point in the clinical decision making for the management of EC and that accurate clinical staging in patients with T2N0 EC is of paramount importance. Further improvement in EUS imaging quality at various depth is needed.

Accuracy of endoscopic ultrasound in the diagnosis of T2N0 esophageal cancer.

Accurate staging of esophageal carcinoma (EC) is important since it directs further management. Endoscopic ultrasound (EUS) is the best tool available in the locoregional staging of EC; however, differentiating depth of tumor invasion (T) and nodal involvement (N) can be challenging. Accurate staging is particularly important to differentiate T1-2 N0 cancers, which can proceed directly to surgical resection versus TXN1 or T3N0/1 cancers, which benefit from induction chemoradiation prior to surgery. We report the accuracy of EUS staging for cT2N0 lesions. Six hundred six patients underwent EUS for staging of EC between October 2003 and February 2013 by a single interventional endoscopist specially trained in endoscopic ultrasound. Thirty-eight patients were diagnosed with T2N0 tumors and underwent surgical resection without preoperative chemoradiation. EUS staging was compared to surgical pathology to evaluate accuracy. Patient follow-up was obtained from a retrospective chart review. Thirty-eight patients (34 men, mean age 65.8 ± 10.5 years) with cT2N0 tumors by EUS underwent surgical resection of EC without chemoradiation after a mean of 22.4 ± 13.7 days post-EUS. When compared with final pathologic outcomes, 12 (32%) were understaged by EUS and 18 (47%) were overstaged. Understaging occurred due to tumor depth (T) in two patients (17%), nodal disease (N) in six (50%), and both in four (33%). Overstaging occurred due to pathology consistent with pT1b tumors instead of T2 tumors in all 17 cases. Based on EUS, 74% were referred for appropriate therapy. While EUS is highly accurate in staging EC, it is less accurate in staging tumors which are not on either ends of the spectrum (mucosally based or clearly transmural). In this challenging group of patients, EUS understaged EC in 32% of cases resulting in surgical resection when neoadjuvant chemoradiation may have been beneficial. We suspect that newer generation EUS systems, which provide better imaging, will result in improved accuracy in staging this group of patients.

Endoscopic ultrasound combined with submucosal saline injection for differentiation of T1a and T1b esophageal squamous cell carcinoma: a novel technique

Endoscopic ultrasound (EUS) is the optimum method for investigation of early esophageal squamous cell carcinoma (ESCC). However, it is difficult to substage early ESCC as T1a or T1b. The aim of this study was to improve the staging accuracy of early ESCC by using EUS combined with submucosal saline injection (SSI). The study enrolled 15 patients with suspected early ESCC who were examined by EUS and subsequently by SSI combined with EUS. The patients then underwent endoscopic or surgical resection within 10 days. The accuracy of EUS staging (alone or following SSI) was evaluated and compared with the pathological results postoperatively. No severe complications of the SSI arose. EUS plus SSI easily distinguished the mucosa from the lesion and the submucosa because of the low-echoic saline-filled cushion in the submucosa. The accuracy of SSI combined with EUS for staging T1a or T1b was 86.7 %, which was better than that using EUS alone (60.0 %).

Mo1561 Accuracy of Endoscopic Ultrasound (EUS) in T-Staging of Ampullary Tumors: A Meta Analysis and Systematic Review

EUS is routinely used for confirming the diagnosis and staging ampullary tumors. EUS staging helps to identify patients optimal candidates for endoscopic ampullectomy and avoid surgery in this group or those with unresectable disease. The reported accuracy of EUS staging of ampullary cancer has been variable.

Accuracy of endoscopic ultrasound staging of gastric cancer in routine clinical practice in Singapore

Endoscopic ultrasound has emerged as the leading modality to assess the T and N stage in gastric cancer. This study aimed to assess the accuracy of TN staging by endoscopic ultrasound in routine clinical practice in Singapore. Over a period of 7 years, 77 patients (male: 70%; median age 62.8 years) with gastric cancer underwent preoperative staging with endoscopic ultrasound. Fifty-seven patients eventually underwent surgery with tissues available for histopathological staging and comparison. The tumor locations were: cardia: 13; corpus: 20; incisura: 19; antrum: 25. The majority was poorly differentiated (57.1%); 26% were moderately differentiated and 16.9% were well differentiated adenocarcinoma. Compared to pathological staging, the overall accuracy of T staging by endoscopic ultrasound was 77.2% (17.5% under-staged: 5.3% over-staged). The staging accuracy of T1 (92.9%) and T3 (81.8%) was higher than T2 (57.1%) and T4. For N staging, the accuracy of endoscopic ultrasound was 59.6% (26.3% under-staged; 14% over-staged); this was significantly superior to computer tomography (43.9%). Endoscopic ultrasound is useful for the T staging of gastric cancer, with an overall accuracy rate of 77%, and up to 93% for T1 lesions. Under-staging may occur due to microscopic tumor infiltration, while over-staging may arise due to inflammatory reactions. The accuracy of N staging is lower at 60%, but could be further improved with the use of fine needle aspiration.

Does endoscopic ultrasound staging already allow individual treatment regimens in gastric cancer

The aim of our study was to evaluate the accuracy of preoperative TNM staging with endoscopic ultrasound (EUS) in gastric cancer patients in comparison with the pathohistological stage of the resected specimen, and to determine the possible implications of EUS for individualized treatment of gastric cancer patients at our institution. The study included 82 patients operated for resectable gastric cancer between January 1(st) 2001 and July 1(st) 2003 at the Maribor Teaching Hospital Department of Abdominal and General Surgery. The EUS stage was assessed preoperatively at the Endoscopical Unit, and the pathohistological stage in the resected specimen was determined postoperatively at the Department of Pathologic Morphology according to recommended standards. Comparison of EUS and pathohistological assessments revealed accuracy of EUS staging for locoregional tumor infiltration (category T) in 68% of patients. The accuracy of EUS staging was 68% for T1, 69% for T2, 69% for T3 and 60% for T4. Lymph nodes (category N) were correctly staged with EUS in 57% of cases. The EUS stage was correct for lymph nodes with no metastases (N-) in 40% of cases, and for lymph nodes with metastases (N+) in 90%. There was no significant difference in accuracy of EUS staging with regard to tumor site (P = 0.768) or tumor size (P = 0.766). According to our results the accuracy of EUS staging matched pathohistological staging with regard to tumor infiltration and lymph node stage in 68% and 57% of cases respectively. Underestimation of the final T2 and T3 stages as T1 stage by EUS presents a problem regarding the consistency of EUS examination at our institution, particularly with respect to individual treatment for early gastric cancer. The present uncertainty in EUS stage reliability makes it necessary to have a strategy of radical resection with D2 lymphadenectomy in patients within EUS stages T1-T3, with additional CT examinations in more advanced EUS stages in order to visualize the circumstances of tumor growth. Nevertheless, EUS provides an opportunity for the surgeon to gain more insight into the loco-regional circumstances of the gastric tumor process. For development of individual modes of treatment based on EUS staging, a more reliable assessment of EUS stage is mandatory.

Endoscopic ultrasound staging of rectal cancer: Diagnostic value before and following chemoradiation

Endoscopic ultrasound (EUS) has been shown to be a reliable tool for staging rectal cancer. Nevertheless, the accuracy of EUS after chemoradiation remains unclear; therefore the purpose of the present paper was to compare the accuracy of EUS staging for rectal cancer before and following chemoradiation. Patients with rectal cancer undergoing EUS staging were stratified into two groups. Group I consisted of 66 patients who underwent surgery following EUS staging without preoperative chemoradiation. Group II consisted of 25 patients who had EUS evaluation following chemoradiation. The EUS staging was compared to surgical/pathological staging. The accuracy of the T staging for group I was 86% (57/66). Inaccurate staging was mainly associated with overstaging EUS T2 tumors. The accuracy of the N staging for group I was 71% (47/66). The accuracy of EUS for a composite T and N staging relevant to treatment decisions in group I was 91%. In group II, the accuracy of T and N staging was 72% (18/25) and 80% (20/25), respectively. Overstaging EUS T3 tumors accounted for most inaccurate staging. The EUS staging predicted post-chemoradiation T0N0 stage correctly in only 50% of cases. Preoperative staging of rectal cancer by EUS is a useful modality in determining the need for preoperative chemoradiation. The EUS T staging following chemoradiation appears to be less accurate. Detection of complete response may be insufficient for selecting patients for limited surgical intervention.

Endoscopic Ultrasound (EUS) Staging of Rectal Cancer: Diagnostic Accuracy Before and Following Chemoradiation

Background: Staging of rectal cancer is required to determine the type of surgery and the need for preoperative chemoradiation. In a selected population, chemoradiation may induce complete pathological response that enables sphincter-preserving operations. Recently, large studies suggested that EUS might not be as accurate as initially reported. The accuracy of EUS for staging rectal cancer after radiation therapy has not been thoroughly evaluated. Aim: To determine accuracy of EUS staging for rectal cancer before and following chemoradiation. Methods: Patients with rectal cancer who underwent staging by EUS were stratified into two groups. Group I consisted of sixty-six patients who underwent only surgery following EUS staging. Group II consisted of twenty-five patients who had EUS evaluation following chemoradiation, and surgery was performed later. EUS staging was compared to the surgical/pathological staging. Results: In patients who were not treated by preoperative chemoradiation, the accuracy of T-staging was better that the accuracy for N-staging. EUS tended to overstage tumor invasion in both groups. The overall T-Staging of rectal tumors was less accurate following chemoirradiation therapy. In group I most cases of overstaging occurred in patients with pathological T1 stage, whereas in group II most cases of overstaging occurred in patients with pathological T2. Conclusions: Preoperative staging of rectal cancer by EUS is a useful modality to determine the need for chemoradiation. Accuracy is higher for T-stage than for N-stage. The effect of chemoradiation reduces the accuracy of EUS staging. This, however, does not compromise therapeutic decision, given the fact that most cases of overstaging occurred in T2.

Accuracy of endoscopic ultrasound staging of esophageal carcinoma in a newly established radial endoscopic ultrasound program

Accuracy of endoscopic ultrasound staging of esophageal carcinoma in a newly established radial endoscopic ultrasound program

4507 Endoscopic ultrasound accurately stages and directs the surgical management of rectal carcinoma.

Background: Endoscopic Ultrasound (EUS) has become one of the best methods for staging gastrointestinal cancers. The preoperative local staging of rectal cancer is important since new transanal surgical techniques can preserve rectal and anal function. The purpose of this study is to assess the accuracy of EUS staging and evaluate the impact of EUS on the surgical management of rectal cancer. Method:A retrospective chart and database review of 23 patients with rectal cancer who underwent rectal EUS at Cornell Weill Medical College from 1997 to 1999 was performed. The medical history, EUS staging, surgical pathology, radiographic studies, and treatment were reviewed. Result: 17 patients had surgical pathology available from 23 patients. Using surgical pathology as the benchmark, accuracy of EUS staging was assessed. T stage accuracy was 94 % (16/17), and N stage accuracy was 100 % (17/17). Fine Needle Aspiration (FNA) was performed on 4 patients and yielded the correct diagnosis with 100% accuracy (4/4). In 6 patients with EUS stage T3N0 or greater (4 patients with EUS stage T3N0 and 2 patients with EUS stage T3N1), 2 patients underwent low anterior resection (LAR) and 3 patients underwent abdominal peritoneal resection (APR). 1 patient underwent transanal resection (TAR) because he was poor surgical candidate. In 11 patients with EUS stage T2 N0 or less (7 patients with EUS stage T2N0 and 4 patients with EUS stage T1N0), 2 patients had endoscopic removal, 5 patients underwent TAR and 4 patients had LAR. 10 of the 11 patients were accurately staged and 1 patient was overstaged as T2 by EUS. No patients were understaged. EUS directed surgical management in 85 % (12/14) of patients with rectal cancer. For these patients, T3 or N1 EUS staging resulted in LAR and EUS T2, T1, and N0 determinations resulted in TAR. Conclusion: EUS can accurately stage rectal cancer and direct the choice of surgical approach. Further study is needed to draw more definitive conclusions.

Role of EUS in the preoperative staging of pancreatic cancer: a large single-center experience

Background: Current methods for staging pancreatic cancer can be inaccurate, invasive, and expensive. Endoscopic ultrasound (EUS) is reported to be highly accurate for local staging of gastrointestinal tumors including pancreatic cancer. The aim of this study was to assess the utility of EUS and CT for staging pancreatic cancer by comparing staging accuracies in surgical patients and evaluating the potential impact of EUS staging and training. Methods: This was a preoperative comparison of the diagnostic operating characteristics of these procedures in a referral-based academic medical center. Data were collected on 151 consecutive patients referred with confirmed pancreatic cancer between April 1990 and November 1996. All patients had preoperative CT and EUS performed for staging. In patients undergoing surgery, the surgical staging and/or findings were used to confirm EUS and CT staging. Results: Eighty-one (60%) of 151 patients underwent surgery and made up the study subset. In these 81 patients, surgical exploration provided a final T staging in 93% (75 of 81), N staging in 88% (71 of 81) and data on vascular invasion in 93% (75 of 81). In the surgical patient group, with surgical correlation, EUS accuracy for T staging was as follows: T1 92%, T2 85%, T3 93%, and for N staging was: N0 72%, and N1 72%. CT accuracy for T staging was as follows: T1 65%, T2 67%, T3 38%, and for N staging was as follows: N0 52% and N1 100%. CT failed to detect a mass in 26% of patients with a confirmed tumor at surgery. Overall accuracy for T and N staging was 85% and 72% for EUS and 30% and 55% for CT, respectively. The ability to accurately predict vascular invasion was 93% for EUS and 62% for CT ( p < 0.001). EUS was 93% accurate for predicting local resectability versus 60% for CT ( p < 0.001). Last, the data were divided into two groups for the senior endosonographer’s experience: procedures performed between 1990 and 1992 (98 cases) and 1993 and 1994 (53 cases). This analysis revealed that 7 of 9 instances of misstaging (78%) occurred in the earlier group, during the learning phase for EUS. Conclusions: EUS is more accurate than CT for staging pancreatic malignancies, including predicting vascular invasion and local resectability. EUS staging was significantly better than CT for T1, T2, and T3 tumors. EUS staging accuracy improved after 100 cases, thus suggesting a correlation between the accuracy of EUS staging and the number of procedures performed. (Gastrointest Endosc 1999;50:786-91.)

Accuracy of endoscopic ultrasound staging in patients with Barrett's esophagus and intramucosal carcinoma

Accuracy of endoscopic ultrasound staging in patients with Barrett's esophagus and intramucosal carcinoma

Accuracy of endoscopic ultrasound staging of esophageal carcinoma after successful induction chemoradiotherapy

Accuracy of endoscopic ultrasound staging of esophageal carcinoma after successful induction chemoradiotherapy