Preoperative Staging Of Esophageal Carcinoma Research Articles

Endoscopic ultrasonography for preoperative staging of esophageal carcinoma

Objective: To evaluate the diagnostic value of endoscopic ultrasonography (EUS) in preoperative staging of esophageal carcinoma (EC).Material and methods: A total of 86 surgical patients with EC who were confirmed by endoscopy and biopsy underwent preoperative TN staging with EUS examination. The EUS findings were compared with surgical pathologic results.Results: The accuracy of EUS in T and N staging of EC was 82.6% and 84.9%, respectively. While determining whether EC invades the muscularis propria or outer membrane, EUS had the favorable sensitivity, specificity, positive predictive value and negative predictive value. The short-axis diameter of lymph nodes of 5mm had high sensitivity and negative predictive value to determine malignance with low specificity and positive predictive value. The short-axis diameter of 10mm presented the satisfactory sensitivity, specificity, positive predictive value and negative predictive value.Conclusion: EUS can accurately determine the TN staging of EC and provide a reliable basis for the treatment of EC.

Progress in preoperative staging of esophageal carcinoma

Therapy methods of esophageal carcinoma have gradually becomecomprehensive treatment according to precise preoperative staging,Traditional preoperative examinations are difficult to meet the requirements of preoperative staging.The level of preoperative staging in esophageal carcinoma is improved by the progress of endoscopic esophageal ultrasound(EUS),EUS-FNA,three-dimensional re-construction,integrated PET-CT,endoscopic techniques and so on. Key words: Esophageal neoplasms; Neoplasm staging

Dedicated multi-detector CT of the esophagus: spectrum of diseases

Multi-detector computed tomography (CT) offers new opportunities in the imaging of the gastrointestinal tract. Its ability to cover a large volume in a very short scan time, and in a single breath hold with thin collimation and isotropic voxels, allows the imaging of the entire esophagus with high-quality multiplanar reformation and 3D reconstruction. Proper distention of the esophagus and stomach (by oral administration of effervescent granules and water) and optimally timed administration of intravenous contrast material are required to detect and characterize disease. In contrast to endoscopy and double-contrast studies of the upper GI tract, CT provides information about both the esophageal wall and the extramural extent of disease. Preoperative staging of esophageal carcinoma appears to be the main indication for MDCT. In addition, MDCT allows detection of other esophageal malignancies, such as lymphoma and benign esophageal tumors, such as leiomyma. A diagnosis of rupture or fistula of the esophagus can be firmly established using MDCT. Furthermore, miscellaneous esophageal conditions, such as achalasia, esophagitis, diverticula, and varices, are incidental findings and can also be visualized with hydro-multi-detector CT. Multi-detector CT is a valuable tool for the evaluation of esophageal wall disease and serves as an adjunct to endoscopy.

Prospective Evaluation of Positron Emission Tomography in the Preoperative Staging of Esophageal Carcinoma

Prospective Evaluation of Positron Emission Tomography in the Preoperative Staging of Esophageal Carcinoma

Endoscopic ultrasound for preoperative staging of esophageal carcinoma

Endoscopic ultrasound (EUS) is potentially the best method for pretreatment staging of esophageal carcinoma once distant metastases have been excluded by other methods. However, its apparent accuracy might be influenced by the use of neoadjuvant therapy. To determine the accuracy of EUS in patients undergoing esophageal resection, the authors reviewed their experience with EUS. A total of 73 patients with esophageal carcinoma who underwent an esophagectomy between April 2000 and February 2005 were examined using preoperative EUS and computed tomography (CT). Of these patients, 39 also underwent preoperative neoadjuvant chemoradiotherapy. Both EUS and CT scan were used to determine the depth of tumor penetration (T-stage) and the presence of lymph node metastases (N-stage). These results then were compared with staging determined after pathologic examination of the resected surgical specimen. For patients not undergoing neoadjuvant therapy, T-stage was accurately determined by EUS in 79%, N-stage in 74%, and tumor node metastasis (TNM) classification in 65% of the cases. However, when patients who had undergone neoadjuvant chemoradiotherapy were included, the overall accuracy of EUS was 64% for T-stage, 63% for N-stage, and 53% for TNM classification. For the patients who underwent neoadjuvant therapy, EUS indicated a more advanced T-stage in 49%, N-stage in 38%, and TNM classification in 51% of the cases, as compared with pathology. The overall accuracy of EUS for T- and N-stage carcinomas was superior to that of CT scanning. For patients who do not undergo preoperative neoadjuvant chemotherapy and radiotherapy, EUS is a more accurate method for determining T- and N-stage resected esophageal carcinomas. Neoadjuvant therapy, however, results in apparent overstaging, predominantly because of tumor downstaging, and this reduces the apparent accuracy of EUS (and CT scanning) in this patient group. Nevertheless, EUS staging before neoadjuvant therapy could be more accurate than pathologic staging after treatment, thereby providing better initial staging information, which can be used to facilitate treatment.

Preoperative staging of esophageal carcinoma with multidetector CT and virtual endoscopy

Purpose The aim of this study was to assess the accuracy of multidetector computed tomography (MDCT), including virtual endoscopy (VE) for detection, precise localization, preoperative evaluation and staging of esophageal cancer (EC) by comparison with surgical and histopathological findings. Materials and methods Between September 2003 and April 2005, 44 patients with histologically proven EC underwent MDCT and VE. Among 44 patients, the findings were confirmed in 24 at surgery. The accuracy of three-dimensional MDCT for detection, localization, and staging of EC was determined, and compared with surgical finding and histopathology. Results The overall accuracy of three-dimensional multidetector row CT for detection of EC was 100% (24/24). MDCT staging was correct in 20 patients (83.3%). The T parameter was correctly assessed in 22 (91.7%) cases (understaged in 1 and overstaged in 1). The N parameter was correctly evaluated in 20 (83.4%) patients (understaged in 2 and overstaged in 2). The overall accuracy of VE for the morphologic classification of EC was 81.5%. Conclusions Three-dimensional MDCT, along with VE is a promising method for preoperative evaluation and staging of EC. Although accuracy in N staging remains low in comparison to PET, it provides a larger amount of diagnostic and staging information.

Prospective Evaluation of Positron Emission Tomography in the Preoperative Staging of Esophageal Carcinoma

Positron emission tomography (PET) is a useful tool in the selection of patients with esophageal cancer who may not benefit from esophageal resection. Case series. Tertiary care hospital. Eighty-one patients with newly diagnosed esophageal cancer who underwent PET and computer tomography (CT) of the chest and abdomen (and of the neck in 45 patients) within 45 days were included. We calculated the sensitivity and specificity in detecting metastatic sites on the basis of 31 histologically verified lesions. In addition to results obtained on CT, the information provided by PET was evaluated with a view to the choice of management strategies. The PET findings had a higher specificity (89% vs 11%) but a lower sensitivity (38% vs 63%) than CT findings in the detection of metastatic sites. The CT results showed greater agreement with histopathological findings than did PET results. In 8 patients (10%), PET detected distant metastases that were not identified with CT. In 4 patients (5%), PET detected bone metastases only, but in all of these patients metastases in other locations were detected by CT. Although PET led to upstaging (M1) in 2 patients (2%), it did not enable the exclusion of esophageal resection. Preoperative PET was not characterized by greater accuracy in the detection of metastatic sites previously identified by CT. Therefore, PET did not lead to a change in the indication for esophagectomy. An increase in the sensitivity and the combined use of CT and PET may lead to new indications for this staging procedure.

Miniprobe-sonography compared to conventional endoscopic ultrasound in preoperative staging of esophageal carcinoma

Miniprobe-sonography compared to conventional endoscopic ultrasound in preoperative staging of esophageal carcinoma

Postoperative screening for anastomotic recurrence of esophageal carcinoma by endoscopic ultrasonography

Background: The usefulness of endoscopic ultrasonography (EUS) in the preoperative staging of esophageal carcinoma is well established. Alternatively, the role of EUS in the early diagnosis of anastomotic recurrence is less well accepted. Methods: EUS was used to evaluate 30 asymptomatic and 10 symptomatic patients (i.e., with dysphagia) who had previously undergone resection of esophageal carcinoma. Results: There were 3 (10%) unsuspected anastomotic recurrences in the asymptomatic group. EUS correctly identified locally recurrent cancer in all cases, whereas endoscopy confirmed the presence of only one anastomotic recurrence. Computed tomography was not diagnostic in any of the three recurrences. Sensitivity of EUS for recurrence of esophageal carcinoma was 100% compared with 33% for endoscopic diagnosis while the specificity was 96% for EUS compared with 100% for endoscopic biopsy. There was one false positive diagnosis of recurrence by EUS because of postoperative fibrosis resulting in concentric hypertrophy of the esophageal wall near the surgical anastomosis. Of the 10 symptomatic patients, 4 were diagnosed with tumor recurrence. EUS correctly predicted recurrences in all symptomatic patients (100% sensitivity and specificity), as did upper endoscopy with biopsy. Conclusions: EUS is more sensitive than upper endoscopy and CT scan for the evaluation of anastomotic recurrence of esophageal carcinoma and should be considered as an adjunctive modality to conventional endoscopy for the postoperative surveillance of these patients. (Gastrointest Endosc 1995;42:540-4.)

Endosonography of stenotic esophageal carcinomas: Preliminary experience with an ultra-thin, balloon-fitted ultrasound probe in four patients

Endosonography (ES) is a generally accepted technique for the pre-operative staging of malignant tumors in the upper or lower gastrointestinal tract. One of the main indications for ES is the pre-operative staging of esophageal carcinoma, where T (depth of tumor invasion) and N (regional lymph node metastasis) stage are vital for determining prognosis.1,2 In series that have been published, an accuracy of 85% for T stage and approximately 80% for N stage have been reached.3-7 A major limiting factor for the use of ES is the fact that a considerable number of esophageal lesions cannot be traversed with standard echo-endoscopes (Olympus GF-UM3 or GF-UM20, Olympus America Inc., Lake Success, N.Y.).

High-grade malignant stricture is predictive of esophageal tumor stage. Risks of endosonographic evaluation.

Endosonography is very accurate for the preoperative staging of esophageal carcinoma. Approximately 20-38% of patients with esophageal carcinoma present with high-grade malignant strictures that preclude passage of the dedicated echoendoscope. In patients with such strictures, endosonographic staging of esophageal tumors may be performed after aggressive esophageal dilatation. However, aggressive dilatation and passage of the echoendoscope in patients with high-grade malignant strictures is not without risk. A detailed assessment of the tumor stage in patients presenting with high-grade malignant stenoses has not been previously reported to the authors' knowledge. Seventy-nine patients with esophageal carcinoma were staged preoperatively using endosonography. The results of preoperative staging were compared with the pathologic stage of the esophagectomy specimen when available or the surgical stage (detection of adjacent organ involvement [Stage T4] or metastatic disease [Stage M1] at the time of surgery). Twenty-one patients (26.6%) presented with high-grade malignant strictures precluding endosonographic examination without prior esophageal dilatation. Nineteen of the 21 patients (91%) with high-grade malignant stricture had Stage III or IV disease by histopathologic examination of the surgical specimen. Five of these 21 patients (24%) sustained an esophageal perforation as a result of either wire-guided dilatation, or as a direct consequence of the endosonographic staging procedure. The discovery of metastatic lymph nodes proximal to the stricture resulted in successful staging (assessment of depth of tumor penetration and lymph node involvement) in only 2 of these 21 patients before esophageal dilatation (incomplete staging). Staging of the proximal aspect of the tumor was obtained in the remaining 19 patients before dilatation; however, the accuracy for such incomplete staging was only 33%. The majority of patients with esophageal carcinoma presenting with high-grade malignant strictures precluding endoscope passage without prior dilatation have a relatively advanced stage of disease (Stage III or IV) compared with those patients presenting with less severe stenoses. There is a significant risk for esophageal perforation (24%) when patients with high-grade malignant esophageal strictures undergo preoperative staging using endosonography. Patients with high-grade malignant strictures, therefore, present a relative contraindication to endosonography using the dedicated echoendoscope.

Primary neoplasms of the hollow organs of the gastrointestinal tract. Staging and follow-up

The number of imaging modalities available to stage and follow-up patients with primary neoplasms of the gastrointestinal (GI) tract continues to increase. Magnetic resonance imaging (MRI), computed tomography (CT), and ultrasonography are useful techniques for both staging and follow-up. For staging, CT is most frequently used for the detection of liver metastases and is increasingly used as a substitute for the chest radiograph in the detection of lung metastases. CT is still the imaging test of choice for the preoperative staging of esophageal carcinoma. CT is less helpful in staging the patient with gastric carcinoma or colorectal carcinoma. The current usefulness of MRI in the staging of GI tract malignancies is limited by the lack of an adequate oral intraluminal contrast agent and degradation of images due to motion. Sonography, especially the new technique of endoscopic ultrasound, is promising for the detection of local invasion from GI tract malignancies. CT is used in the follow-up of patients with tumors of the GI tract to detect liver, adrenal, and nodal metastases as well as local recurrence because of the ability of CT to detect extraluminal masses. CT of the pelvis has been recommended as a routine follow-up procedure in patients who have undergone abdominal-peroneal resection. Both CT and MRI can be used to detect local recurrence, but suffer from the inability to differentiate scar from recurrent tumor. The initial hope that MRI would be capable of differentiating postoperative scar tissue from recurrent tumor has not been realized. Therefore, with positive CT or MRI findings, occasionally a percutaneous biopsy will be required to confirm local recurrence.

Computed tomographic staging of gastrointestinal tract malignancies. Part I. Esophagus and stomach.

The utility and limitations of CT staging of carcinomas of the esophagus, stomach, small bowel, and colon are reviewed. Routine preoperative staging of esophageal carcinoma is recommended because of CT's sensitivity of more than 90% in detecting mediastinal invasion and a specificity of more than 85% in collected series. We recommend the use of CT as a problem-solving technique rather than as a routine preoperative test in patients with gastroesophageal junction, and gastric and small bowel malignancies. Routine use of CT to stage colorectal carcinomas also does not seem justifiable, due to the inability of CT to determine the depth of bowel wall involvement and to detect tumor in normal size lymph nodes. CT can help differentiate tumors that invade the pelvic side walls from more limited cancers and, therefore, in certain cases can aid in therapy planning. CT is the best method for detecting local recurrence in patients with rectosigmoid carcinomas.