EUS Staging Research Articles

Feasibility and tolerability of multimodality treatment of locally advanced rectal cancer, particularly in elderly patients in a community cancer center.

e14090 Background: Preoperative chemoradiation followed by surgery is the current recommended treatment for locally advanced rectal cancer. We aim to review our community cancer center experience with this approach, with attention to feasibility, toxicity, EUS staging accuracy, and elderly patient tolerance. Methods: A chart review was performed on all consecutive patients treated in cancer center between 08/01/2005 and 12/31/2009, with T3 or Any T, N+ disease. Results: 47 patients were treated with multidisciplinary evaluation, and EUS staging. 6 patients had surgery first due to bleeding (2), obstruction (1) and patient preference (3), while 41 patients underwent neoadjuvant treatment. The median radiation dose was 50.4 Gy in 28 fractions of 1.8 Gy daily; 14 (34%) and 25 (60.9%) patients received continuous infusion (CIV) 5-FU and capecitabine chemotherapy respectively. There were 29 males, 12 females; with ages from 35 to 86, median = 63 years, 10 (24.3%) patients were more than 75 years old. All 41 pa...

W1154 EUS Accuracy in Restaging Rectal Cancer After Neoadjuvant Chemoradiotherapy: A Preliminary Report

Colorectal cancer (CRC) is the second most frequent cause of cancer-related death in Western countries: one third of CRC is represented by rectal cancer (RC). Accurate staging is recommended to provide an optimal treatment strategy. Neoadjuvant chemoradiotherapy (NCRT) is increasingly used in the treatment of advanced RCwith the intention of downsizing and downstaging the tumour and to reduce tumour recurrence. Accuracy of EUS staging is reported to be 75-94% for tumour penetration and 7283% for nodal metastases. However after NCRT the EUS accuracy for T staging may decrease (50%) because marked fibrosis, peritumoral infiltration of inflammatory cell necrosis. AIMS: the aims of this study was to verify the accuracy of EUS in restaging RC after neoadjuvant CRT and the efficacy of the therapy in the downstaging and downsizing the tumour. METHODS: we prospectively enrolled consecutive patients affected by RC in stage II-b and III who underwent EUS and MRI or CT or PET before and after neoadjuvant CRT. EUS scanning was performed by one endosonographer using an electronic radial ecoendoscope (Olympus GF UE 160-AL5) with imaging at 7,5-10 MHz. Patients underwent surgical resection after reassessment staging. The reduction of diameter of RC was evaluated using RECIST criteria. Pathological staging was undertaken according to the TNM classification. RESULTS: 14 patients with locally advanced RC were assessed: 10 male, median age 64 yrs (range 56-73). The median distance from the anus was 5 cm. Seven patients were in in stage II-b and 7 in stage III. All patients underwent radiotherapy with no complication associated with chemotherapy (10 pts with CDDP, 2 pts with FOLFOX and 2 pts with FUFA). The downstaging after neadjuvant therapy was observed in 7/14 patients, and significant reduction of tumor diameter in 13/14 patients. There were 13 anterior resections and 1 abdominoperineal resections. EUS post-NCRT T stage was correct in 11/14 pts (3 T0, 5 T3, 3 T2), while 3 pts were over staged (2 T2 and 1 T1). Overall accuracy of EUS post-RCT for pathologic T stage was 93% for T0-T1 stage and 86% for T3 stage. EUS accuracy for N-stage was 79%. CONCLUSION: in our preliminary study neoadjuvant CRT was useful to downstage and downsize locally advanced RC. EUS seems to be an accurate tool to restage RC after neoadjuvant CRT. However our results needed to be confirmed in a large cohort of patients with locally advanced RC.

T1645 EUS Staging Accuracy in Oesophageal Cancer After CRT

T1645 EUS Staging Accuracy in Oesophageal Cancer After CRT

W1155 Burden of Undergoing EUS-MRI Based Pancreatic Cancer Screening in High-Risk Individuals; First Experiences

Colorectal cancer (CRC) is the second most frequent cause of cancer-related death in Western countries: one third of CRC is represented by rectal cancer (RC). Accurate staging is recommended to provide an optimal treatment strategy. Neoadjuvant chemoradiotherapy (NCRT) is increasingly used in the treatment of advanced RCwith the intention of downsizing and downstaging the tumour and to reduce tumour recurrence. Accuracy of EUS staging is reported to be 75-94% for tumour penetration and 7283% for nodal metastases. However after NCRT the EUS accuracy for T staging may decrease (50%) because marked fibrosis, peritumoral infiltration of inflammatory cell necrosis. AIMS: the aims of this study was to verify the accuracy of EUS in restaging RC after neoadjuvant CRT and the efficacy of the therapy in the downstaging and downsizing the tumour. METHODS: we prospectively enrolled consecutive patients affected by RC in stage II-b and III who underwent EUS and MRI or CT or PET before and after neoadjuvant CRT. EUS scanning was performed by one endosonographer using an electronic radial ecoendoscope (Olympus GF UE 160-AL5) with imaging at 7,5-10 MHz. Patients underwent surgical resection after reassessment staging. The reduction of diameter of RC was evaluated using RECIST criteria. Pathological staging was undertaken according to the TNM classification. RESULTS: 14 patients with locally advanced RC were assessed: 10 male, median age 64 yrs (range 56-73). The median distance from the anus was 5 cm. Seven patients were in in stage II-b and 7 in stage III. All patients underwent radiotherapy with no complication associated with chemotherapy (10 pts with CDDP, 2 pts with FOLFOX and 2 pts with FUFA). The downstaging after neadjuvant therapy was observed in 7/14 patients, and significant reduction of tumor diameter in 13/14 patients. There were 13 anterior resections and 1 abdominoperineal resections. EUS post-NCRT T stage was correct in 11/14 pts (3 T0, 5 T3, 3 T2), while 3 pts were over staged (2 T2 and 1 T1). Overall accuracy of EUS post-RCT for pathologic T stage was 93% for T0-T1 stage and 86% for T3 stage. EUS accuracy for N-stage was 79%. CONCLUSION: in our preliminary study neoadjuvant CRT was useful to downstage and downsize locally advanced RC. EUS seems to be an accurate tool to restage RC after neoadjuvant CRT. However our results needed to be confirmed in a large cohort of patients with locally advanced RC.

Placement of Polyflex stents in patients with locally advanced esophageal cancer is safe and improves dysphagia during neoadjuvant therapy

Patients with locally advanced esophageal cancer who require neoadjuvant therapy have significant dysphagia. To prospectively evaluate Polyflex stents to treat malignant dysphagia and to ameliorate weight loss in patients with locally advanced esophageal cancer who will undergo neoadjuvant therapy. A prospective nonrandomized study. Tertiary-referral cancer center. Thirteen patients with esophageal cancer (11 adenocarcinoma, 2 squamous-cell carcinoma). All patients were men, with a mean age of 63 years. EUS followed by stent placement. Dysphagia scores and patient weights. There were no perforations and no episodes of bleeding. Immediate complications included chest discomfort in 12 of 13 patients. The mean dysphagia score at the time of stent placement was 3. Mean dysphagia scores obtained at 1, 2, 3, and 4 weeks after stent placement were 1.1 (P = .005), 0.8 (P = .01), 0.9 (P = .02), and 1.0 (P = .008), respectively. Stent migration occurred at some point in 6 of 13 patients (46%). A single center and small size of study. Simultaneous EUS staging and Polyflex stent placement is safe and allows oral feeding during neoadjuvant therapy. Dysphagia scores improved in a statistically significant manner. Stent migration was a common event, although not all patients with a migrated stent will require stent replacement, because migration may be a sign of tumor response to neoadjuvant therapy.

Prospective evaluation of EUS versus CT scan for staging of ampullary cancer

Malignancies of the biliary and pancreatic systems are associated with a poor prognosis. However, ampullary cancer carries a better prognosis and is often diagnosed when curative treatment is still possible. Accurate staging is important for the determination of the most appropriate treatment option. (1) To determine the test performance characteristics of EUS and CT in loco-regional staging of ampullary neoplasms, and (2) to determine the impact of CT scan results on the test performance characteristics of EUS. Prospective single-arm intervention study performed in 2 academic hospitals. RESULTS AND MAIN OUTCOME MEASUREMENTS: Thirty-seven patients were screened and 33 staged with EUS and CT. A total of 27 patients (13 men; mean age, 69.5 years; mean serum bilirubin level, 12.6 mg/dL) with locally advanced disease completed the protocol with EUS and CT and underwent surgical resection. Tumor classifications were as follows: 2 patients (7.4%), T1 tumors; 13 patients (48.1%), T2 tumors; and 12 patients (44.4%), T3 tumors, as per surgical pathology. Seventeen tumors (62.9%) were classified as N0 and 10 (37.1%) as N1. The difference in proportion of correct tumor (74.1% vs 51.8%; P = .15, 95% CI, -0.06-0.50) and lymph node (81.4% vs 55.5%; P = .07, 95% CI, -0.01-0.53) staging by EUS and CT, respectively, was not statistically significantly different. However, the strength of tumor (kappa 0.51 vs 0.11) and nodal (kappa 0.59 vs 0.05) agreement with pathology was statistically significantly higher for EUS than for CT (P < .05). EUS was more sensitive and specific than CT for tumor and nodal staging, and the association of CT to EUS data did not improve the final test accuracy. Low number of T1 tumors. EUS is an accurate diagnostic test and exhibits a high level of agreement with surgical pathology. CT findings do not improve the test performance characteristics of EUS. Therefore, the evaluation for metastatic disease should not be compromised by CT protocols that aim to perform tumor and nodal staging. Further studies to determine the role of specialized CT protocols in patients with ampullary malignancies are needed.

Endoscopic Resection for Solitary Nodular Lesions After Ablation of Esophageal Dysplasia and Carcinoma

Purpose: Nodular lesions in Barrett's esophagus [BE] are suspicious for harboring invasive carcinoma. Endoscopic resection [ER] is of diagnostic and therapeutic importance for the removal and histologic staging of these lesions. There are few data available, however, regarding the safety and utility of ER for nodular lesions detected at surveillance endoscopy after ablation therapy. Methods: After IRB approval, patients with solitary nodular lesions detected after ablation therapy were identified. Medical records were abstracted for demographics, pre-ablation histology and endoscopic ultrasound [EUS] findings, ablation technique and ER procedure details including complications and disease recurrence. Results: Twelve patients with solitary nodular lesions were identified between 2001-08 after previous endoscopic ablation using porfimer sodium photodynamic therapy (PsPDT) or radiofrequency ablation (RFA) (10 were men; mean age 72 years [range: 43-82]). PsPDT was performed for Barrett's high grade dysplasia (7 pts); esophageal adenocarcinoma (1 pt) and squamous cell carcinoma (1 pt), both T1N0MX by EUS staging. RFA was performed for Barrett's high grade dysplasia in 3 pts. At follow up endoscopy, (median 335 days after endoscopic ablation; range: 105-1843 days) nodular mucosa suspicious for disease recurrence was detected. EUS findings were T1sm1 or less in each case and pts were referred for ER that was successful in 11/12 patients using either Wilson Cook Duette or Olympus cap technique with no complications. ER was unsuccessful in one patient (no lift sign). ER specimen histopathology found BE-HGD (3 pts), T1m adenocarcinoma (3 pt) and benign, hypertrophic glandular mucosa (5 pts). ER findings prompted further therapy (repeat endoscopic ablation in 3 pts, esophageal resection surgery in 1 pt, and failed esophageal resection in 1 pt due to adhesions from a previous surgery). Mean follow up after successful ER and negative adenocarcinoma in need of surgical resection was 303 days (27-676 days) with no further complications or disease recurrence. The patient who had an attempted but unsuccessful EMR due to lack of lift sign was later found to have adenocarcinoma and underwent esophagectomy as repeat PsPDT followed by liquid nitrogen cryotherapy treatment was unsuccessful. Conclusion: In our series of patients with nodular lesions detected at surveillance endoscopy after endoscopic therapy for esophageal dysplasia or carcinoma, ER was safely performed in most patients (11/12) and detected dysplasia or carcinoma in 6/11 patients leading to further ablation therapy and surgery.

Racial Disparity in Communication Between Physicians and Patients with Suspected Pancreatic Cancer Referred for EUS

Background: Patients with suspected pancreatic cancer are increasingly referred for EUS for staging and tissue diagnosis. Although most referring physicians are highly suspicious of an underlying diagnosis of pancreatic cancer, patients are often unaware of this likelihood. Due to poor communication in such cases, the endosonographer bears the unenviable burden of informing patients of their diagnosis. Aim: Evaluate the determinants of poor communication between referring physicians and patients with suspected pancreatic cancer.

Optimizing EUS Staging of Pancreatic Neuroendocrine Tumors (pNETs) Through FNA Confirmation of Nodal, Vascular, or Hepatic Metastasis and Determination of Adverse Prognostic Markers

Optimizing EUS Staging of Pancreatic Neuroendocrine Tumors (pNETs) Through FNA Confirmation of Nodal, Vascular, or Hepatic Metastasis and Determination of Adverse Prognostic Markers

Survival in Patients with Pancreatic Cancer Following the Diagnosis of Malignant Ascites or Liver Metastases By EUS-FNA

Background: The diagnosis of malignant ascites or liver metastases during EUS staging of pancreatic cancer signifies inoperable malignancy and implies a poor prognosis. However, there are limited data on expected survival following EUS in these patients. The purpose of this study is to report survival for a large cohort of patients with pancreatic cancer following the diagnosis of malignant ascites or liver metastases by EUS-FNA. Methods: A prospectively updated EUS database was searched from June 1998 and March 2008 for all patients in whom EUS-FNA of the liver or ascitic fluid was performed.

The value of EUS in neoadjuvant chemotherapy of gastric cancer

The aim of the present study was to evaluate the role of EUS in preoperative neoadjuvant chemotherapy of gastric cancer. The patient with T or 3 tumors and/or node-positive disease by EUS staging were eligible for entry. Neoadjuvant chemotherapy consisted of two cycles of 5-FU(2400mg/m2), Eloxatin (130mg/m2) and LV (400mg/m2)(Folfox7) one time every three weeks. Before operation, EUS examination was done again. Twenty-five patients were entered into the study (4 with T3N0 disease and 21 with T3N1 disease).

Impact of staging EUS–FNA on treatment choice in patients with pancreatic lesions

Impact of staging EUS–FNA on treatment choice in patients with pancreatic lesions

Routine positron emission tomography does not alter nodal staging in patients undergoing EUS-guided FNA for esophageal cancer

Although EUS-guided FNA (EUS-FNA) and 18F-fluorodeoxyglucose-positron emission tomography (FDG-PET) are both used in the staging of esophageal cancer, the utility of routinely performing both tests is unclear. The primary aim of the study was to determine the benefit of routine FDG-PET for esophageal cancer nodal staging in patients undergoing EUS-FNA. The secondary objective was to determine EUS criteria that selectively identify patients in whom PET yields additional information. Retrospective chart review. Tertiary-care academic medical center. All patients who underwent both EUS and PET for initial staging of esophageal cancer between April 2003 and August 2007. EUS and PET detection of malignant lymph nodes and distant metastases. Of 242 patients who underwent esophageal EUS for a malignant indication, 148 also underwent PET within 30 days. EUS detected locoregional-node disease by EUS criteria or cytology in 92 patients, and PET was positive in a minority of these patients (n = 41 [45%]). For celiac-node staging, PET was positive in 2 of 17 patients (12%) with celiac-node involvement detected by EUS. EUS was also significantly more sensitive than PET in the detection of nodal disease confirmed by cytology or histology (86% vs 44%). PET did not alter nodal staging in any patient with complete EUS-FNA. PET identified distant metastases only in those patients with incomplete EUS or nodal disease detected by EUS. Single institution, retrospective analysis. The addition of PET to a complete EUS examination did not alter regional-node or celiac-node staging. PET performance in overall staging is strongly associated with EUS assessment of lymph nodes.

Preoperative Placement of Polyflex Esophageal Stents in Patients with Locally Advanced Esophageal Cancer Undergoing Neoadjuvant Therapy

Purpose: Most patients with esophageal cancer have dysphagia and/or weight loss. Polyflex stents may serve to relieve dysphagia and improve oral intake in patients undergoing neoadjuvant therapy. The aims of the study were 1) to determine if Polyflex esophageal stents improve dysphagia and weight loss in patients with locally advanced esophageal cancer undergoing neoadjuvant therapy 2) and to evaluate complications. Methods: Subjects with esophageal cancer with EUS staging from April 2006 to Nov 2007 were enrolled. Subjects were >18 y with dysphagia, locally advanced esophageal cancer, and had Polyflex stent placement. Subjects with distant metastatic disease or with a malignant stricture within 2 cm of the upper esophageal sphincter were excluded. Subjects were followed until removal of stent or death. All patients received neoadjuvant therapy following stent placement. Dysphagia was assessed by a 5-point scale prior to stent placement and at one week intervals. Weight change was assessed. The dysphagia score was analyzed using Wilcoxon signed rank. Results: 13 subjects met entry criteria and were enrolled. All subjects were male, the mean age was 63.3 ± 12.3 (45–82). One subject was not included in the analysis due to unrecognized metastatic disease. Stents remained in place for a mean of 65.9 ± 56.2 days (2–180). Dysphagia scores were significantly improved at weeks 1, 2, 3, and 4 when compared to the mean baseline score of 3.1 (1.1, 0.8 0.9, 1) (P= 0.005, P= 0.01, P= 0.02, P= 0.008). All subjects reported weight loss prior to stent placement (mean, 9.9 ± 5.6 kg). Weight loss slowed with a mean weight change of −2.6 ± 7.8 kg over a mean of 2.4 ± 1.6 weeks. There were no immediate complications. All but one patient experienced chest or abdominal pain following stent placement. Stents migrated in 6/13 (46%) patients in a mean of 42.7 days (2–90). 3/6 patients with migrated stents went on to esophagectomy at an average of 8.5 weeks later. 5/6 migrated stents were safely removed during endoscopy, 1 was removed at time of esophagectomy. One stent was removed due to severe pain 2 days after placement. 1 stent remained in place 180 days and showed tumor overgrowth. Conclusion: Polyflex stents provided safe and rapid relief from dysphagia in patients undergoing neoadjuvant therapy. Complications were mild. Weight loss largely stabilized. The stents served either as a bridge to surgery, migrated when they were no longer needed, or remained in place in patients not felt to be operative candidates. Chest pain is common following stent placement. Although stent migration is common following chemoradiation, the stents were easily removed endoscopically or at the time of surgery.

EUS Staging of Primary Ampullary Neoplasms in Patients with Versus without a Biliary Stent

EUS Staging of Primary Ampullary Neoplasms in Patients with Versus without a Biliary Stent

The impact of endoscopic ultrasonography with fine needle aspiration (EUS-FNA) on esophageal cancer staging: a survey of thoracic surgeons and gastroenterologists

Accurate staging of esophageal cancer is critical to achieving optimal treatment outcomes. End-oscopic ultrasound with fine needle aspiration (EUS-FNA) has emerged as a valuable tool for locoregional staging. However, it is unclear how different physician specialties perceive the benefit of EUS-FNA for esophageal cancer staging, and thus utilize this modality in clinical practice. A survey regarding utilization of EUS-FNA in esophageal cancer was distributed to 211 thoracic surgeons and 251 EUS-capable gastroenterologists. Seventy-six thoracic surgeons (36%) and 78 gastroenterologists (31%) responded to the survey. Most surgeons (75%) use EUS to stage potentially resectable esophageal cancer 75% of the time. Surgeons using EUS less often are less likely to have access to high-quality EUS services than their peers. Fewer surgeons believe EUS is the most accurate test for T and N-staging (84% and 71%, respectively) as compared with gastroenterologists (97% and 96%, P < 0.01 for both). Most endosonographers (68%) decide whether to dilate a malignant esophageal stricture to complete the staging exam on a case-by-case basis. Surgeons disagree as to whether involvement of celiac lymph nodes should preclude esophagectomy in distal esophageal cancer. While most thoracic surgeons have embraced EUS-FNA as the most accurate locoregional staging modality in esophageal cancer, this attitude is not fully reflected in utilization patterns due to a lack of quality EUS services in some centers. Controversial areas that warrant further study include dilation of malignant strictures to facilitate EUS staging, and the implication of involved celiac lymph nodes on management.

92 TREATMENT OF 216 PORT WINE STAINS WITH PULSED DYE LASER IN ALGERIA

The gold standard treatment of early oesophageal carcinoma is oesophagectomy but the elderly population affected are often medically unfit for this radical intervention and less invasive curative options are required. We describe our experience of porfimer sodium photodynamic therapy (PDT) as an alternative to surgery in such a patient group.From 1999 to 2005 28 oesophageal cancer patients were found to have early stage disease based initially on endoscopy/CT and latterly on CT/endoscopic ultrasound (EUS) criteria. Although potentially suitable for major surgical resection these patients were judged to be medically unfit and were selected to have PDT. Patients were followed up endoscopically at 6–12-week intervals indefinitely with biopsy of the treated area.18/28 patients had an initial complete response 8 weeks post procedure. One patient died before reassessment of unrelated disease. Nine patients were non-responders. 7/18 complete responders remained disease free for a mean follow up period of 1166 days (249–2019). 11/18 developed recurrent local disease treated with further PDT with a median survival of 770 days (254–2049). Fourteen patients had EUS staging which accurately predicted response: all T1N0 patients (9/14) had initial complete response to treatment although 5/9 have required further PDT. All remain disease free at a follow up of 1103 days (249–2019). No patients with T2/3N0 disease had complete response to treatment. The major complication of PDT encountered was stricture formation which occurred in 50% of cases and required a median of five dilations (range 1–31).Porfimer sodium PDT is a potentially curative treatment in patients with early oesophageal carcinoma who may be unfit or unwilling to undergo major surgery.

Phase II study of docetaxel, cisplatin, and 5-fluorouracil (TPF) as first-line chemotherapy in advanced gastric cancer

15640 Background: Cisplatin and 5-FU is the standard chemotherapy for advanced gastric cancer. Single agent docetaxel or combination with cisplatin & 5-FU shows better efficacy in advanced gastric cancer. This study was conducted in different hospitals & institute to determine toxicity and efficacy of a combination chemotherapy using docetaxel, cisplatin and 5-fluorouracil (TPF) in Bangladeshi patients with advanced gastric cancer. Methods: Patients with previously untreated measurable metastatic gastric cancer were included in this trial. Pts with unresectable (T2–3N0–1M0) gastric cancer were treated with this combination chemotherapy repeated every 21 days for six cycle. Patient received docetaxel 75 mg/m2 on day 1, intravenously cisplatin 80 mg/m2 on day 1 and continuous infusion 5-FU 800 mg/m2 on day 1–4. Results: Between 2003 and 2007, 30 pts were enrolled in this protocol, Male/Female 25/5, Median age 59 (40–75), Adeno/Undifferentiated carcinoma 22/8, EUS staging: T2N0 5 pts, T2N1 2 pts, T3N0 10 pts, T3N1 13 pts. The major toxicity were Neutropenia (Grade 3 and 4, 56%), Leukocytopenia (Grade 3, 44%), Anemia (Grade 3, 11%), Diarrhea (Grade 3, 33%) and stomatitis (Grade 3, 11%). The overall response rate was 50.0%. Conclusions: This combination chemotherapy of TPF appeared to be highly active with a good response rate along with acceptable toxicities. No significant financial relationships to disclose.

Multimodality treatment with curative intent for early rectal carcinoma—Long term Clatterbridge(UK) experience

15018 Background: Local treatment of early rectal cancer with curative intent is highly controversial.The standard treatment for low rectal cancer is low anterior resection or APR.We present an update of our long-term results in patients treated with low rectal cancer using combined modality at Clatterbridge. Methods: From Jan’92 to July’07,local treatment was offered to 220 patients with low rectal cancer.Mean age 76 years (range 33–100). There were 129 males and 91 females. After MRI& EUS staging, patients with tumours <3cm had TEM or Papillon. Responders and those with R0 resection were watched closely. Larger tumours had CRT(45Gy/25/35) +5FU 1G/m2 or capecitabine 825mg/m2x5 wks. Papillon boost (80Gy)was offered to responders (90% regression). TEM was used to remove residual tumour for histology. Non responders (<25%regression) had radical immediate surgery,if they are fit. Delayed salvage surgery was offered to local recurrence with no metastatic spread. Results: Of 220 patients treated, 24(11%) had persistent residual disease and had immediate surgery. Twenty one patients were cured (87.5%)and 2 developed distant relapse. Out of 196 patients who responded well initially, 20 (10.2%) recurred. Delayed salvage with repeat Papillon or surgery was carried out on 9/11 patients with local recurrence alone and 7 were cured. Overall cure rate was 202/220 (92%)after salvage. Conclusions: Local treatment of early rectal cancer is a controversial and complex. Patients diagnosed with early rectal cancer is increasing and the ageing population is expanding. The demand for local treatment will increase as some of these patients will not be fit for radical surgery. It is important to balance the benefits of radical surgery (lower LR but increase in morbidity and mortality) against slightly higher LR (∼10 %) but much lower mortality and morbidity from conservative local treatment such as TEM or contact radiotherapy. Our study has shown that salvage surgery can be effectively carried out for recurrences after local treatment This can be offered for elderly patients with medical co morbidity and also for small number of younger patients who wish to avoid major surgery initially. We recommend a close follow up so that local recurrences can be detected early for salvage surgery. No significant financial relationships to disclose.

High Frequency of Intrabdominal Lung Cancer Metastases Justifies EUS As Test of Choice in a Specific Patient Subset: An Evidence-Based Staging Algorithm

Background: Lung cancer (LC) staging is performed to determine whether aggressive local therapy should be undertaken. Institutional variability in lung cancer staging algorithms is often due to differences in local expertise and availability of advanced diagnostics such as EUS, endobronchial ultrasound (EBUS), mediastinoscopy, interventional radiology and PET imaging. In our regional referral center EUS is employed for patients with known or suspected LC with EUS-accessible mediastinal adenopathy (MA) or abdominal findings suspicious for metastases. When imaging demonstrates only MA, EUS of the abdomen is always performed to evaluate for unsuspected metastases. EUS-FNA is performed to confirm metastases suggested by CT or PET as well as those discovered unexpectedly by EUS. Patients not meeting these criteria are staged by other means as suggested in our algorithm. Design: Retrospective chart review was conducted of 137 consecutive patients who underwent EUS for evaluation or staging of known or suspected, and ultimately confirmed, LC with imaging suggesting MA or abdominal metastases. EUS-FNA was performed on all suspicious MA and abdominal findings. Results: Intrabdominal metastases were confirmed by FNA in 33/137 (24%), most commonly the left adrenal (10%) and liver (9%). Intrabdominal metastasis were unexpected based on pre-EUS CT or PET in 12/33 (36%). Small cell cancer (SCC) metastasized to the abdomen more commonly than non-small cell cancer (NSCC) (15/42 vs. 18/95, p = 0.08). Unsuspected abdominal metastasis were more commonly found in SSC (7/42) than NSCC (5/95), (p = 0.04). In four patients, EUS-FNA of an enlarged adrenal gland identified by CT(3) or PET (1) was benign resulting in subsequent curative-intent therapy. Conclusion: Based on our experience, patients with LC and MA have a high frequency of intrabdominal metastases. Many of these are not suggested by pre-EUS imaging. Such patients would be inaccurately staged by mediastinoscopy or EBUS alone. Although infrequent, false positive abdominal findings suspicious for metastases that are not histologiclly confirmed can deprive patients of potentially curative treatments. We therefore propose EUS as the test of choice in patients with CT or PET scan of the chest suggesting LC and demonstrating EUS-accessible MA or abdominal abnormalities. We previously reported the incidence of abdominal metastases in an earlier, similar cohort. This updated report includes an additional 36 patient accrued over the subsequent 10 months, demonstrates a consistent frequency of intrabdominal metastases, and emphasizes, in graphic depiction, our staging algorithm.