Celiac Axis Lymph Nodes Research Articles

Postoperative recurrent patterns of gallbladder cancer: possible implications for adjuvant therapy

BackgroundGallbladder cancer (GBC) is an uncommon malignancy with high recurrent rate and poor prognosis. This study investigates the recurrent patterns of postoperative GBC, with the aim to guide the adjuvant treatments, including the radiotherapy.MethodsRetrospectively analyzed the 109 GBC patients who underwent surgery in our institution from January 2013 to 2018. Clinical follow-up revealed 54 recurrent cases, of which 40 had detailed locations of recurrence. The sites of recurrence were recorded and divided into the tumor bed, corresponding lymphatic drainage area, intrahepatic recurrence, and the other distant metastasis.ResultsThe median follow-up time is 34 months (IQR: 11–64). The median disease-free survival (DFS) and overall survival (OS) were 48.8 months and 53.7 months, respectively. Through univariate analysis, risk factors for DFS and OS include tumor markers (CA199 and CEA), hepatic invasion, perineural invasion, lymphovascular invasion, TNM staging and tumor differentiation. Through multivariate analysis, risk factors for DFS include hepatic invasion and TNM staging, and for OS is TNM staging only. Of the 40 cases with specific recurrent sites, 29 patients (29/40, 72.5%) had recurrence in the potential target volume of postoperative radiotherapy (PORT), which include tumor bed and corresponding lymphatic drainage area. The common recurrent lymph node groups included abdominal para-aortic lymph node (No.16, 15/29), hepatoduodenal ligament lymph node (No.12, 8/29), retro-pancreatic head lymph node (No.13, 7/29) and celiac axis lymph node (No.9, 4/29). Twenty cases with recurrences inside the potential PORT target volume were accompanied by distant metastasis. Another 11 cases had distant metastasis alone, so totally 31 cases developed distant metastasis (31/40, 77.5%), including 18 cases with hepatic metastasis.ConclusionThe recurrence and metastasis rates are high in GBC and adjuvant therapy is needed. Up to 75% of the recurrent cases occurred in the potential target volume of postoperative radiotherapy, suggesting that postoperative radiotherapy has the possible value of improving local-regional control. The potential target volume of radiotherapy should include the tumor bed, No.8, No.9, No.11, No.12, No.13, No.14, No. 16a2, No. 16b1 lymph node groups.

Role of endoscopic ultrasound-guided fine-needle aspiration in evaluating mediastinal and intra-abdominal lymphadenopathies of unknown origin

The aim of the present study was to evaluate the efficacy of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) in diagnosing mediastinal and intra-abdominal lymphadenopathies. A total of 154 patients with mediastinal and intra-abdominal lymphadenopathies were included in this retrospective study between February 2010 and March 2015. Malignancy was suspected in the patients as a result of imaging findings and EUS-FNAs were performed to confirm the diagnoses. EUS and EUS-FNA data, as well as hospital medical records, were reviewed. The accuracy of EUS-FNA was 90.8% for diagnosing malignancy and 85.6% for diagnosing benign lymphadenopathy. In combination with flow cytometry (FCM), the accuracy of EUS-FNA to determine lymphoma was 94.2%. Among the malignant lymphadenopathy cases, 80 were caused by metastasis, 19 by lymphoma and 1 by myeloid leukemia. In the 53 benign cases, EUS-FNA revealed a nonspecific inflammatory condition in 27 patients, tuberculosis in 21 patients and Castleman's disease in 5 patients. The factors revealed to be associated with malignant lymphadenopathy included the sex and age of patients, as well as the location and size of the enlarged lymph node. In particular, celiac axis lymphadenopathy was associated with malignancy (23.0% of cases of malignancy, vs. 3.8% of benign lymphadenopathy). EUS-FNA results additionally suggested that the malignant lymph nodes observed in celiac axis were more likely to result from lymphoma (42.1%; 8/19 cases) than metastasis (18.8%; 15/80 cases; P=0.039). By contrast, malignant lymph nodes observed in the mediastinum were more likely to be caused by metastasis (47.5%; 38/80 cases) than lymphoma (10.5%; 2/19 cases; P=0.004). The results of the present study suggested that EUS-FNA is accurate for differentiating between malignancy and benign lymphadenopathy. Therefore, EUS-FNA in combination with FCM analysis, as a minimally invasive and highly sensitive tool, should be routinely performed for the identification of lymphoma. Additionally, examining the enlarged celiac axis lymph nodes of elderly males, who exhibit an increased risk of malignancy, may be beneficial.

Laparoscopic gastric tube formation with pyloromyotomy for reconstruction in patients with esophageal cancer.

PurposeTo analyze the benefit and feasibility of this procedure compared with those of open method.MethodsAbdominal procedure includes laparoscopic gastric mobilization, celiac axis lymph node dissection, formation of the gastric tube, and pyloromyotomy. The actual procedure performed during open surgery is the same as those of laparoscopic surgery except for the main incision. Minimally invasive esophagectomy (MIE) was performed on 54 patients with esophageal cancer. The short-term outcomes, including postoperative complications were analyzed and compared with 44 cases of open method.ResultsAlthough the total operative time was not different between 2 groups (349.8 minutes vs. 374.8 minutes, P = 0.153), the operation time of abdominal procedure was shorter in laparoscopic group (90.6 minutes vs. 162.1 minutes, P < 0.001). Operation related complications and hospital stay were not significantly different between the 2 groups. The number of transfused patients was significantly smaller in laparoscopic group (11.1% vs. 27.9%, P = 0.030).ConclusionLaparoscopic gastric tubing with pyloromyotomy is a feasible and safe treatment option for patients with esophageal cancer.

Quality indicators for EUS.

EUS has become integral to the diagnosis and staging of GI and mediastinal mass lesions and conditions. EUS-guided FNA (EUS-FNA) allows the endoscopist to obtain tissue or fluid for cytologic and chemical analysis, adding to the procedure's utility. Furthermore, the recent development of EUS-guided core biopsy techniques enables his-tologic sampling in selected cases and for obtaining tissue for molecular analysis in neoadjuvant and palliative settings. The clinical effectiveness of EUS and EUS-FNA depends on the judicious use of these techniques.

Novel Laparoscopic Gastric Tubing with Pyloromyotomy for Treatment of Esophageal Cancer

Purpose: We report on a novel method and outcomes of laparoscopic gastric tubing with pyloromyotomy. Methods: The abdominal procedure includes laparoscopic gastric mobilization, celiac axis lymph node dissection, formation of the gastric tube, and pyloromyotomy. Between January 2009 and April 2013, our minimally invasive esophagectomy (MIE) was performed on 54 patients with esophageal cancer. The short-term outcomes, including postoperative complications, were analyzed. Results: There were no cases of conversion to open surgery. Of 54 patients, 52 patients had squamous cell carcinoma (SCC) and two had adenocarcinoma. The total operative time was 349.8±77.4 minutes, of which 90.6±27.6 minutes was required for the abdominal procedure. The mean estimated operative blood loss during the abdominal procedure was 40.0 ±355.5 m l. The postoperative complication rate was 24.1%; three patients died of pneumonia. Conclusion: Laparoscopic gastric tubing with pyloromyotomy is a feasible and safe treatm ent option for patients with esophageal cancer.

Accurate Preoperative Staging of Gastric Cancer with Combined Endoscopic Ultrasonography and PET-CT

Accurate staging of gastric cancer is helpful to determine the most appropriate therapy, but no staging modality has been accepted as the standard. Objective is to evaluate the usefulness of endoscopic ultrasonograph (EUS) combined with position emission tomography and computed tomograph (PET-CT) in gastric cancer staging. A total of 124 patients confirmed with gastric cancer were subjected to staging with EUS and PET-CT scanning. The detection rate of primary tumor was 99.2% by combination use of two modalities and 97.6% by EUS alone (p = 0.6219), but the detection rate was 90.3% (112 of 124) by PET-CT alone (compared with the combination, p = 0.0027; compared with EUS alone, p = 0.0299). The locoregional lymph node invasion was identified in 84/124 (67.7%) by combined PET-CT and EUS, which was obviously higher than that with EUS (52.4%) or PET-CT (43.5%) alone (p = 0.0194 and p = 0.0002, respectively). There was no statistical difference in identification of celiac axis lymph node metastasis among three methods, but the combined examination or PET-CT alone was more effective than EUS alone in the detection of distant metastases (all p < 0.01). Furthermore, the combined EUS and PET-CT was more optimal than using EUS or PET-CT alone in the accurate T and N staging and the effect on change of treatment. The present study indicates that the combination of EUS and PET-CT is an ideal modality in the preoperative staging of gastric cancer and it provides beneficial guidance for the treatment of gastric cancer.

Transgastric endoscopic ultrasound (EUS) guided fine needle aspiration (FNA) in patients with esophageal narrowing using the ultrasonic bronchovideoscope

Endobronchial ultrasound-guided fine needle aspiration (EBUS-FNA) is emerging as a critical technology in the evaluation of mediastinal lesions and is increasingly regarded as complementary to endoscopic ultrasound (EUS) in this arena. This complementary role may extend into the abdomen in cases where esophageal strictures prevent the passage of the echoendoscope. The objective of the study was to characterize the uses of EBUS-FNA in the evaluation of gastrointestinal lesions in patients with esophageal narrowing. The study design was a single-center case series. The setting was in a tertiary referral center. Four patients underwent EBUS-FNA to evaluate gastrointestinal lesions; esophageal strictures prevented EUS passage in three, the fourth patient did not tolerate transbronchial EBUS but had abdominal lesions within reach of the EBUS scope. EBUS was used to evaluate the liver, adrenal gland, a retroperitoneal mass, and a celiac axis lymph node. EBUS-FNA has greater potential to evaluate abdominal lesions than has been previously recognized. The EBUS scope represents a safe and readily available technology to evaluate patients with esophageal strictures. Interventional endoscopists should be exposed to this modality.

Accuracy of Endoscopic Ultrasound in the Diagnosis of Distal and Celiac Axis Lymph Node Metastasis in Esophageal Cancer: A Meta-Analysis and Systematic Review

Published data on the accuracy of endoscopic ultrasound (EUS) for staging distant and celiac axis lymph node (CLN) metastasis in patients with esophageal cancer (ECA) has varied. To evaluate the accuracy of EUS in diagnosing distal and CLN metastasis in ECA patients. EUS studies confirmed by surgery were selected. Pooling was conducted by both fixed and random-effects models. Data were extracted from 25 studies (N = 2029) which met the inclusion criteria. In ECA patients, pooled sensitivity of EUS was 67.2% (95% CI: 62.6-71.6) in diagnosis of distal metastasis and 66.6% (95% CI: 61.9-71.1) in diagnosis of CLN metastasis. EUS had a pooled specificity of 97.9% (95% CI: 97.1-98.6) for distal metastasis and 98.1% (95% CI: 97.3-98.7) for CLN metastasis. Although EUS has excellent specificity in accurately diagnosing distal and CLN metastasis in patients with ECA, the sensitivity is low.

Is There Improvement over Years in the Diagnostic Accuracy of Endoscopic Ultrasound in Evaluating Celiac Axis Lymph Nodes Metastasis in Esophageal Cancers? A Meta-Analysis & Systematic Review

Purpose: To evaluate if technology over years affected the diagnostic accuracy of Endoscopic Ultrasound (EUS) in evaluating celiac axis lymph node (CLN) metastasis in esophageal cancers. This analysis was done by grouping EUS studies into three time periods to standardize the change in EUS technology and also to standardize the change in EUS criteria for lymph node involvement. These time periods were 1989 to 1995, 1996 to 1999, and 2000 to 2006. Methods: Study Selection Criteria: Only EUS studies confirmed by surgery or appropriate prolonged follow-up were selected. Data collection & extraction: Articles were searched in Medline, Pubmed, Ovid journals, CINAH, Medline nonindexed citations, and Cochrane control trial registry. Statistical Method: Meta-analysis for the accuracy of EUS was found by calculating pooled estimates of sensitivity, specificity, likelihood ratios, and diagnostic odds ratio. Pooling of likelihood ratios and diagnostic odds ratios was conducted by the fixed and random effects models. The heterogeneity of was tested using Cochran's Q test based upon inverse variance weights. Results: Initial search identified 3980 reference articles, of these, 362 relevant articles were selected and reviewed. Data was extracted from 23 studies (N = 1966) which met the inclusion criteria. There were 8 studies for the time period 1989 to 1995. During the time period of 1996 to 1999, there were 10 studies that met the inclusion criteria. Five studies met the inclusion criteria for the time period between 2000 to 2006. All the pooled estimates during the three time periods are given in table 1. The P for chi-squared heterogeneity for all the pooled accuracy estimates was >0.05. Conclusion: EUS-FNA is highly specific in diagnosing celiac axis lymph nodes metastasis in esophageal cancers. Over years, the specificity remained very high, while the sensitivity did not improve.[figure1]Figure

Endoscopic Ultrasoundʼs Diagnostic Accuracy in Detecting Distal Metastasis of Gastric Cancers: A Meta-Analysis and Systematic Review

Purpose: Distal metastasis in patients with gastric cancer predicts prognosis and guides therapy. The published data on accuracy of endoscopic ultrasound (EUS) for diagnosing distal metastasis (M1) in patients with gastric cancers has been inconsistent. Aim: To evaluate the accuracy of EUS in diagnosing distal metastasis of gastric cancers. Methods: Study Selection Criteria: Distal metastasis was defined as metastasis to peritoneum, liver, cervical lymph nodes, celiac axis lymph nodes, or abdominal lymph nodes. Data collection & extraction: Articles were searched in Medline, Pubmed, Ovid journals, and Cochrane control trial registry. Two reviewers independently searched and extracted data. Statistical Method: Meta-analysis for the accuracy of EUS was analyzed by calculating pooled estimates of sensitivity, specificity, likelihood ratios, and diagnostic odds ratios. Pooling was conducted by both fixed and random effects models. The heterogeneity of studies was tested using Cochran's Q test based upon inverse variance weights. Results: Initial search identified 3630 reference articles, in which, 346 relevant articles were selected and reviewed. Four studies met the inclusion criteria and data for EUS accuracy to diagnose distant metastasis was extracted from those studies. The pooled sensitivity to diagnose distal metastasis was 73.2% (95% CI: 63.2–81.7). EUS specificity was 88.6% (84.8–91.7). The positive likelihood ratio to diagnose distal metastasis was 17.2 (2.8–106.3) and the negative likelihood ration was 0.4 (95% CI: 0.2–0.7). The diagnostic odds ratio of EUS to correctly diagnose distal metastasis was 60.9 (95% CI: 8.2–463.7). The SROC curve showed an AUC of 0.98 with a standard error (SE) of 0.005. This curve showed a Q value of 0.94 with a SE of 0.0. All the pooled estimates, calculated by fixed and random effect models, were similar. The P for chi-squared heterogeneity for all the pooled accuracy estimates was >0.10. Conclusion: For distant metastasis, though the number of studies with data was smaller, the pooled specificity is high but the sensitivity is not as high. Though EUS is not designed to detect all areas of distal metastasis, improvements in technology or diagnostic criteria are needed to enhance the sensitivity.

The Role of Combined Positron Emission Tomography/Computed Tomography (PET/CT) and Endoscopic Ultrasound (EUS) in the Staging of Esophageal Cancer

Background: Accurate staging of esophageal cancer (ECA) is critical in determining appropriate therapy. EUS, CT, and PET scanning are used in various combinations for this purpose. PET scanning combined with a simultaneous non-contrast CT scan can facilitate more accurate localization/detection of lesions (PET/CT scan). No data exists regarding the utility of PET/CT compared to EUS in the staging of ECA. Aim: To compare PET/CT and EUS in the staging of ECA. Methods: Patients with ECA diagnosed from 5/04-8/06 undergoing both PET/CT and EUS were reviewed. Data regarding TNM staging and presence of celiac axis (CAX) lymph nodes based on these exams and surgical pathology were collected. Data on age, gender, histology, and treatment rendered was examined. Results: 42 patients identified. Mean age 64 years. 33 (78.6%) male, 9 (22.4%) female. 30 (71.4%) adenocarcinoma, 12 (28.6%) squamous cell. PET/CT identified the primary tumor in 37/42 (88.1%) of cases, compared to 42/42 (100%) with EUS. PET/CT provided no T-staging. T-staging by EUS was T1 (5/42, 12%), T2 (4/42, 9.5%), and T3 (33/42, 78.6%). Malignant appearing locoregional adenopathy was seen by PET/CT in 15/42 (35.7%) of cases, compared to 25/42 (59.5%) by EUS (p = 0.0039). No locoregional nodes seen by PET/CT were missed by EUS. PET/CT identified CAX adenopathy in 6/42 (14.3%) of cases, compared to 5/42 (11.9%) with EUS. The one CAX node missed by EUS was due to inability to pass the scope past the tumor. 8/42 (19%) of cases had distant metastases identified by PET/CT (4 distant nodes, 3 liver, 1 lung). 27 patients underwent surgery, 13 with neo-adjuvant therapy; 11 received chemo ± XRT as primary therapy; 4 received palliation. EUS directly affected therapy in 13/42 (31%) of cases by directing the need for neo-adjuvant therapy based on T3 or N1 stage. 8/42 (19%) were not taken to surgery based on PET/CT findings of distant metastatic disease. 13 patients undergoing surgery as primary therapy without chemo/XRT were examined with regard to accuracy of T and N staging using surgical pathology as the gold standard. T-staging by EUS was accurate in 11/13 (84.6%) of cases (two T2 lesions by EUS proved to be T3 at surgery). There was a trend toward more accurate N-staging by EUS (10/13, 76.9% of cases) compared to PET/CT (8/13, 61.5%), though this was not statistically significant (p = 0.15). Conclusions: 1) EUS is superior to PET/CT for T-staging and in identifying locoregional malignant adenopathy in ECA while PET/CT provides M staging. 2) EUS and PET/CT appear to independently affect treatment decisions, indicating complimentary roles in the staging of esophageal cancer.

Role of Endoscopic Ultrasonography in the Staging and Follow-Up of Esophageal Cancer

To evaluate the role of endoscopic ultrasonography (EUS) in the initial staging and follow-up of esophageal cancer on the basis of a review of the published literature. Articles published from 1985 to 2005 were searched and reviewed using the following keywords: "esophageal cancer staging," "endoscopic ultrasound," and "endoscopic ultrasonography." For initial anatomic staging, EUS results have consistently shown more than 80% accuracy compared with surgical pathology for depth of tumor invasion (T). Accuracy increased with higher stage, and was >90% for T3 cancer. EUS results have shown accuracy in the range of 75% for initial staging of regional lymph nodes (N). EUS has been invariably more accurate than computed tomography for T and N staging. EUS is limited for staging distant metastases (M), and therefore EUS is usually performed after a body imaging modality such as computed tomography or positron emission tomography. Pathologic staging can be achieved at EUS using fine-needle aspiration (FNA) to obtain cytology from suspect Ns. FNA has had greatest efficacy in confirming celiac axis lymph node metastases with more than 90% accuracy. EUS is inaccurate for staging after radiation and chemotherapy because of inability to distinguish inflammation and fibrosis from residual cancer, but a more than 50% decrease in tumor cross-sectional area or diameter has been found to correlate with treatment response. EUS has a central role in the initial anatomic staging of esophageal cancer because of its high accuracy in determining the extent of locoregional disease. EUS is inaccurate for staging after radiation therapy and chemotherapy, but can be useful in assessing treatment response.

Comparison of Accuracy of the Positron Emission Tomography, Computed Tomography, and Endoscopic Ultrasonography for Detection of the Metastases at Celiac Axis Lymph Nodes in Lung Carcinoma: A Prospective Study

Comparison of Accuracy of the Positron Emission Tomography, Computed Tomography, and Endoscopic Ultrasonography for Detection of the Metastases at Celiac Axis Lymph Nodes in Lung Carcinoma: A Prospective Study Pankaj Singh, Rahul Gupta, Yashodeep Jadhav, Rama M. Reddy, Phalguni Mukhopadhyay, Rajnikanth S. Shah, Chetan Jinadatha, John C. Lasiter, Ashish Sharma, Richard A. Erickson Background: Previous studies using CT scan for staging Non-small cell lung cancer (NSCLC) have not reported celiac axis (CA) as a site for distant metastases. Detection of metastases to CA is critical since these patients are considered nonresectable. EUS is considered superior to CT scan for detection of CA lymphadenopathy. Aim: To determine the incidence of metastases to lymph nodes at CA in patients with lung carcinoma using EUS-FNA. Methods: Consecutive subjects with CT findings of newly detected lung mass were prospectively enrolled for EUS-FNA. FNA was performed whenever lymph node could be identified irrespective of the endosonographic features. Primary outcome was to determine the sensitivity of the EUS-FNA, CTscan and PETscan for detection of the metastases to lymph nodes at celiac axis. Gold standard for the diagnosis of metastases was cytologically positive malignant cells. Results: 53 consecutive cases of lung carcinoma were identified that underwent EUS evaluation of the celiac axis. EUS identified lymph nodes at CA in 11 of the 53 cases. EUS-FNA was performed in all the 11 cases. EUS-FNA cytologically confirmed malignancy in 9 of the 11 cases. CT scan and PET scan missed celiac lymphadenopathy in 4 of 9 cases and 2 of 5 cases, respectively. EUS influenced the management in 4 of the 9 cases. In two patients EUS avoided surgery by detection of the metastases at CA that were missed by CT scan and PET scan. In one patient with lung carcinoma and past history of lymphoma, EUS-FNA confirmed the enlarged lymph node to be metastastic lung carcinoma and not the recurrence of lymphoma and in one case immunocytochemisty of the cytology showed that celiac metastases is from non-lung primary. Conclusion: CA is an important site for distant metastasis in NSCLC. EUS-FNA detects metastasis at CA that is missed by both CT and PET scan. Of all the diagnostic tests, EUS-FNA is the only test that cytologically confirms the metastases and influences the management.

The Role of Endoscopic Ultrasound in the Evaluation of Barrett's Esophagus with High Grade Dysplasia or Intramucosal Carcinoma in the Surgical Patient

Background: The accuracy and clinical utility of endoscopic ultrasound (EUS) in staging esophageal cancer is well established. The accuracy of EUS and its effect on the clinical management of patients with Barrett's esophagus (BE) and high grade dysplasia (HGD) or intramucosal carcinoma is not well established. Methods: Retrospective review of all patients who underwent EUS with standard 7.5 and 12 mHz Olympus radial echoendoscope for the evaluation of BE with HGD or intramucosal carcinoma without an endoscopic mass lesion over a 38 month period. Patients were evaluated for EUS T and N stage. EUS T and N stage was compared with surgical and pathologic staging. Management of patients was recorded and if EUS findings affected patient management. Results: EUS was perfomed on 20 patients. EUS stage was as follows T0 (10); T1 (9); T2 (1). All patients were EUS stage N0 with no EUS evidence of malignant appearing lymphadenopathy. No celiac axis lymph nodes were visualized. Surgical pathology from 16 esophagectomy specimens showed 1 patient with Barrett's metaplasia, 4 patients with low grade dysplasia, 6 patients with HGD, and 5 patients with carcinoma. Surgical T stage was as follows: T0 (11); T1 (5); T2 (0). All patients were surgical N0 with no malignant lymph nodes found in any patient at time of surgery. EUS T stage accuracy was (81%), N stage accuracy (100%). 16 patients underwent esophagectomy; 1 patient underwent PDT due to co-morbidities; 1 was lost to follow-up; in 2 patients surgery is pending. EUS staging did not change planned surgery in any patient. Conclusion: 1) EUS is accurate in staging patients with HGD or intramucosal CA in the esophagus 2) In patients with HGD or intramucosal carcinoma, EUS did not detect any unsuspected lymph node involvement or extension of tumor through the esophageal wall. 3) The surgically fit patient with BE and HGD or intramucosal carcinoma may be able to proceed directly to esophagectomy without EUS staging. Background: The accuracy and clinical utility of endoscopic ultrasound (EUS) in staging esophageal cancer is well established. The accuracy of EUS and its effect on the clinical management of patients with Barrett's esophagus (BE) and high grade dysplasia (HGD) or intramucosal carcinoma is not well established. Methods: Retrospective review of all patients who underwent EUS with standard 7.5 and 12 mHz Olympus radial echoendoscope for the evaluation of BE with HGD or intramucosal carcinoma without an endoscopic mass lesion over a 38 month period. Patients were evaluated for EUS T and N stage. EUS T and N stage was compared with surgical and pathologic staging. Management of patients was recorded and if EUS findings affected patient management. Results: EUS was perfomed on 20 patients. EUS stage was as follows T0 (10); T1 (9); T2 (1). All patients were EUS stage N0 with no EUS evidence of malignant appearing lymphadenopathy. No celiac axis lymph nodes were visualized. Surgical pathology from 16 esophagectomy specimens showed 1 patient with Barrett's metaplasia, 4 patients with low grade dysplasia, 6 patients with HGD, and 5 patients with carcinoma. Surgical T stage was as follows: T0 (11); T1 (5); T2 (0). All patients were surgical N0 with no malignant lymph nodes found in any patient at time of surgery. EUS T stage accuracy was (81%), N stage accuracy (100%). 16 patients underwent esophagectomy; 1 patient underwent PDT due to co-morbidities; 1 was lost to follow-up; in 2 patients surgery is pending. EUS staging did not change planned surgery in any patient. Conclusion: 1) EUS is accurate in staging patients with HGD or intramucosal CA in the esophagus 2) In patients with HGD or intramucosal carcinoma, EUS did not detect any unsuspected lymph node involvement or extension of tumor through the esophageal wall. 3) The surgically fit patient with BE and HGD or intramucosal carcinoma may be able to proceed directly to esophagectomy without EUS staging.

Influence of celiac axis lymph nodes in the definitive treatment of esophageal cancer.

The management of patients with cancer of the distal thoracic esophagus is often made difficult by the presence of disease in the celiac axis lymph nodes. We investigated the outcome of such patients treated for cure in an attempt to better define the best treatment. The charts of all patients with esophageal cancer treated at the Department of Radiation Oncology at the Medical University of South Carolina between 1990 and 1998 were reviewed. Three groups of patients were analyzed: NoMo, N1Mo, and patients with positive celiac axis lymph nodes (M1a). Among 217 patients, 56 patients received radiotherapy with intent to cure, along with surgery, chemotherapy, or some combination of these modalities. Of these, 14 had disease of the distal esophagus with the celiac axis as their only site of distant disease. Comparison of survival curves in the three analyzed groups revealed no statistically significant differences in terms of overall survival (p = 0.3458 by the log-rank test) or disease-free survival (p = 0.5509 by the log-rank test). Patients with positive celiac axis lymph nodes as their only site of "M1" disease experienced a 2-year survival rate similar to "Mo" patients when treated with curative intent.

Section III: Endoscopic and other staging techniques

Accurate staging of esophageal cancer is important as disease survival closely correlates with TNM stage. The optimal management of patients with esophageal cancer utilizes stage-dependent algorithms. The primary diagnosis of esophageal cancer is established by upper endoscopy and biopsy. Computed tomography (CT) is typically the next test performed and is most valuable at detecting metastatic (M) distant disease, particularly in the liver, lungs, and bone. Positron emission tomography (PET) scanning with 18-fluorodeoxyglucose also is useful in detecting distant disease. Endoscopic ultrasound (EUS) combines endoscopy with high-frequency ultrasonography to obtain detailed images of the tumor and surrounding structures. EUS is the most accurate technique for the locoregional (T and N) staging of esophageal cancer. The recent availability of EUS-directed fine needle aspiration (FNA) has allowed a tissue diagnosis of lymph nodes both periesophageal and in the celiac axis. EUS-FNA can also sample liver metastases. Laparoscopic and thoracoscopic techniques can also be used to sample thoracic and celiac axis lymph nodes. Optimal staging strategies for esophageal cancer combine EUS FNA with either CT or PET scans. © 2003 Elsevier Inc. All rights reserved.

Clinical impact of endoscopic ultrasound-guided fine needle aspiration of celiac axis lymph nodes (M1a disease) in esophageal cancer

Background. The purpose of this study was to determine how endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) with a histology confirmed biopsy protocol impacted on staging and managing esophageal carcinoma in terms of resectability and neoadjuvant therapy (chemotherapy and radiation therapy). Methods. The records of 40 consecutive patients diagnosed with esophageal cancer referred for EUS staging were reviewed. Computed tomography (CT) scan then EUS imaging and EUS-guided FNA staging, including involvement of celiac node (M1a stage), surgical pathology, and subsequent treatment were correlated. Through-the-scope balloons were used for dilatation when needed to examine the celiac nodes. Results. All 40 patients followed the protocol and were successfully imaged by EUS. Sixteen of the 40 required esophageal dilatation using the through-the-scope balloon. No complications were observed from esophageal dilatation for EUS. Twenty-three (58%) met the criteria for EUS-guided FNA biopsy from a total of 40 EUS imaging procedures. Twenty (87%) of the 23 EUS-guided FNA were directed toward the celiac nodes; 18 (90%) of the 20 were positive for malignancy and were treated by chemoradiation therapy and 2 (10%) FNA were negative for malignancy and were treated by surgical resection. The CT scan was able to detect only 6 (30%) of 20 cases of suspicious celiac lymph nodes, of which 5 (83%) were positive for malignancy by FNA. Conclusions. EUS-guided FNA of celiac nodes (20 patients) directed management in all patients biopsied. EUS-guided FNA is superior to CT scan for diagnosing M1a disease. Protocol-directed EUS-guided FNA is a pivotal study when used in conjunction with stage-oriented treatment protocols for esophageal carcinoma.

Evaluation of metastatic celiac axis lymph nodes in patients with esophageal carcinoma: accuracy of EUS

Background: Endosonography (EUS) is the most accurate modality for assessing depth of tumor invasion and local lymph node metastasis. However, its accuracy in the identification of metastatic (celiac axis) lymph nodes is less well defined. Our Objective In This Study Was To Determine The Accuracy Of Eus In Detecting Celiac Axis Lymph Node Metastasis In Patients With Esophageal Carcinoma. Methods: Two hundred fourteen patients with esophageal carcinoma underwent preoperative EUS. Of these, 145 underwent attempted surgical resection and staging, and 4 underwent EUS-guided fine-needle aspiration of mediastinal and celiac lymph nodes. Local (mediastinal) and distant (celiac axis) lymph nodes were assessed for malignancy on the basis of four criteria (larger than 1 cm, round, homogeneous echo pattern, sharp borders). Accuracy of EUS was determined by means of correlating histopathologic findings for the resected lymph nodes or results of EUS-guided fine-needle aspiration cytologic examination. Results: Surgical exploration (n = 145) and fine-needle aspiration cytologic examination (n = 4) revealed metastatic celiac axis lymph nodes in 23 and metastatic mediastinal (local) lymph nodes in 93 of 149 patients with esophageal carcinoma. According to defined criteria for malignant lymph nodes, there were 19 true-positive and 4 falsenegative results. Sensitivity for the diagnosis of celiac lymph node metastasis with EUS was 83% with a 98% specificity. For the diagnosis of mediastinal lymph node metastasis, sensitivity was 79% and specificity was 63%. All patients with malignant celiac axis lymph nodes had local T3 (tumor breaching adventitia) or T4 (tumor invading adjacent organs) disease. Conclusion: EUS is an excellent modality in the evaluation of metastatic celiac axis lymph nodes in patients with esophageal carcinoma. These findings should be used in selecting options for treatment. Sensitivity for detecting malignancy is consistent with that of prior studies, and local and regional lymph nodes and specificity is significantly higher. (Gastrointest Endosc 1999;50:352-6.)

Esophageal cancer staging: improved accuracy by endoscopic ultrasound of celiac lymph nodes

Background. Clinical staging of esophageal cancer is required for optimal therapy but remains imprecise. Pathologic verification of involved lymph nodes could potentially direct treatment allocation. With the rising incidence of distal and gastroesophageal junction adenocarcinomas, assessment of the celiac axis lymph nodes (CLNs) becomes important because it is a common nodal drainage basin. Endoscopic ultrasound (EUS) permits evaluation of CLNs and biopsy by fine-needle aspiration. This study examined the usefulness of this staging tool. Methods. A consecutive series of 62 patients with esophageal cancer considered resectable by computed tomographic scan underwent EUS for T and N staging and were retrospectively studied. A CLN visualized by EUS as greater than 5 mm was considered positive. Fine-needle aspiration of the CLN was performed routinely. Endoscopic ultrasound and computed tomographic staging were compared on the basis of pathologic verification of CLNs. Results. It was possible to evaluate CLNs by EUS in 59 (95%) of 62 patients: positive in 19, negative in 40. In EUS-positive patients, fine-needle aspiration was positive in 15, falsely negative in 2, and not done in 2. By computed tomographic scan, CLNs were negative in 57 patients and positive in 2. The CLNs were positive in 23 of 54 patients eligible for CLN pathologic verification. All positive CLNs not identified by EUS (7 false-negative EUS) were microscopic foci in one or two nodes and were associated with T3 tumors. Sensitivity and specificity of EUS were 72% and 97%, respectively, compared with 8% and 100% for computed tomographic scan. When EUS identified CLNs, fine-needle aspiration confirmed positivity in 88% of cases. Conclusions. Endoscopic ultrasound with fine-needle aspiration is useful in the detection and confirmation of CLN metastasis. In T3 tumors of the distal esophagus, a negative EUS result does not substantiate absence of CLN disease. Endoscopic ultrasound with fine-needle aspiration may be important in guiding treatment for patients with distal adenocarcinoma and documenting disease before neoadjuvant therapy.

Advances in Staging of Esophageal Carcinoma

Staging criteria for thoracic malignancies are based on survival groupings that allow the stage groups to be used as prognosticators for cancer treatment. Definitive staging of esophageal cancer facilitates allocation of patients to appropriate treatment regimens according to each patient's stage. Existing noninvasive staging methods are imperfect in detecting abdominal and thoracic lymph node metastases in patients with esophageal cancer. Thoracoscopy is an excellent means for staging the chest and mediastinum. We have used thoracoscopic lymph node staging and laparoscopic lymph node staging for esophageal cancer since 1992. Thoracoscopy was performed in 45 patients with biopsy specimen-proved carcinoma of the esophagus. Laparoscopy was done in the last 20 patients. Laparoscopic-assisted feeding jejunostomies were performed in patients with obstructive symptoms. Directed liver biopsies were performed if lesions were present. Thoracoscopy was aborted in three patients because of adhesions. Thoracic lymph node stage was N0 in 40 patients and N1 in 3. Celiac lymph nodes were normal in 14 patients and abnormal in 6. Esophageal resection was performed in 30 patients after thoracoscopic lymph node staging; 18 of these underwent laparoscopic lymph node staging. Thoracoscopic staging showed N0 lymph node status in 28 patients and N1 in 2. Two of these N0 patients (7%) were found at resection to have paraesophageal lymph involvement (N1). Thoracoscopic lymph node staging was accurate in detecting the status of thoracic lymph nodes in 28 of 30 cases (93%). Laparoscopic staging found normal celiac nodes in 13 patients and abnormal lymph nodes in 5. After esophagectomy, final pathologic finding of the 13 N0 patients was N0 in 12 patients and N1 in 1 patient. Thus, laparoscopic lymph node staging was accurate in detecting lymph node status in 17 of 18 patients (94%). Six of 20 patients undergoing laparoscopy had unsuspected celiac axis lymph node involvement missed by standard noninvasive techniques. Three percent of thoracic lymph nodes and 17% of celiac lymph nodes were downstaged after preoperative chemoradiotherapy. Thoracoscopic and laparoscopic lymph node staging are more accurate than existing staging methods.