Can EUS elastography improve lymph node staging in esophageal cancer?

BACKGROUND: Endoscopic ultrasound (EUS) elastography can assess the hardness of tissue by measuring its elasticity. Few data have been published on EUS elastography for lymph node (LN) staging in patients with esophageal cancer. This study analyzes the value of elastography as an additional diagnostic tool for LN staging. METHODS: Forty patients (mean age 68 years) with known esophageal cancer (34 Barrett's carcinoma, 6 squamous cell carcinoma) were included prospectively. On conventional EUS, suspicious LNs were assessed using sonomorphologic criteria, and EUS elastography was then used to assess their tissue hardness. The sonomorphologic criteria and elastographic images for the LN were later reviewed on recorded video clips by an endosonographer blinded to the histology results. The proportions of color pixels in LNs in selected patients were assessed using computer analysis of the elastography images. Fine-needle aspiration was performed in all of the LNs, and the histological/cytological results were used as the gold standard. RESULTS: Twenty-one of the 40 LNs examined (52.5 %) were positive for neoplasia, confirmed by histology/cytology. The first assessment by the examiner during the procedure, based on sonomorphologic criteria, showed sensitivity of 91.3 % and specificity of 64.7 %. EUS elastography alone had sensitivity of 100 % and specificity of 64.1 %. When computer analysis of the elastographic images was added, the specificity improved significantly to 86.7 %, with a slight decrease in sensitivity to 88.9 %. CONCLUSIONS: EUS elastography is easily included in clinical staging and, particularly with computer-aided pixel analysis, significantly improves the specificity of LN staging.

Endosonography of high-grade intra-epithelial neoplasia/early cancer.

Endosonography (EUS) is frequently used for staging of early malignant gastrointestinal lesions. High-grade intra-epithelial neoplasia (HGIN) and mucosal cancer have a very low risk for lymphatic metastasis and therefore are suitable for endoscopic therapy. In HGIN and early oesophageal and gastric cancer, high-frequency miniprobes can provide detailed imaging of the different layers. However, diagnostic accuracy differentiating between mucosal and submucosal disease is not sufficient, and therefore (diagnostic) endoscopic resection should be performed in all localisable lesions to detect submucosal cancer at risk for lymph node metastasis. EUS for lymph node staging is considered to be the method with the highest accuracy, especially compared with computed tomography.

Long-term results of endoscopic resection in early gastric cancer: the Western experience.

OBJECTIVES: In the West, neither acute nor long-term results of endoscopic resection (ER) for early gastric cancer (EGC) have been reported in large studies. The aim of this study was to prospectively evaluate the efficacy and safety of ER in patients with EGC in a long-term follow-up (FU). METHODS: From May 1995 to October 2004, 179 patients were referred to our department for endoscopic therapy (ET) of gastric cancer (GC). Of these, 43 patients had intramucosal GC with a diameter of up to 30 mm and underwent ER with curative intent. All patients underwent a strict FU protocol at regular intervals. RESULTS: Of the 43 patients, 42 fulfilled our low-risk criteria for ET of EGC: gross tumor type I/II, intramucosal GC, diameter up to 30 mm, tumor differentiation G1/G2, and no infiltration into lymph vessels/veins. Two patients were not available for FU (remission status not evaluated). In another patient, gastric mucosa-associated lymphoid tissue lymphoma was detected simultaneously, and he was referred for surgery. 38 (97%) of the remaining 39 patients who underwent definitive ET (23 males (59%); mean age 69+/-10 years) achieved complete remission (CR) after a mean of 1.3+/-0.6 ER sessions. Minor complications (not Hb-relevant bleeding) occurred in 7 of the 39 patients (18%) and major complications (5 Hb-relevant bleeds, 1 covered perforation; all managed conservatively) in 6 patients (15%). During FUs (mean 57 months; range 5-137), recurrent or metachronous lesions were observed in 11 patients (29%). All lesions were successfully treated by repeated ET. No tumor-related deaths occurred during FU. CONCLUSIONS: Although ER for EGC in Western countries is effective, it is associated with a relevant risk of complications. In view of the possibility of recurrent or metachronous neoplasia, a strict FU protocol is mandatory.

Early Barrett's carcinoma with "low-risk" submucosal invasion: long-term results of endoscopic resection with a curative intent.

BACKGROUND: Endoscopic therapy (ET) has become a less risky alternative to open surgery in mucosal Barrett's cancer (BC) because of the very low risk of lymph node (LN) metastasis. Recently published surgical series demonstrated that even in case of minimal submucosal invasion of BC, the risk for LN metastasis is very low. In consequence, also these patients might be eligible for curative ET. The aim of this study was to prospectively evaluate the efficacy and safety of endoscopic resection (ER) in these patients. METHODS: From September 1996 to September 2003, the suspicion or definite diagnosis of submucosal BC was made in 80 patients referred to our department. Of those, 21 patients (20 male [95.2%], mean age 62 +/- 9 yr, range 47-78) fulfilled the definition of "low-risk" submucosal cancer: invasion of the upper submucosal third (sm1), absence of infiltration into lymph vessels/veins, histological grade G1/2, and macroscopic type I/II. ET was carried out using ER with the suck-and-cut technique with or without an additive ablation of non-neoplastic remnants of Barrett's esophagus. RESULTS: One of the 21 patients was referred to surgery directly after the detection of sm1 invasion at the beginning of the study. One patient died (not tumor-related) before completion of ET. Using definitive ET, complete remission (CR) was achieved in 18 of 19 patients (95%) after a mean of 5.3 months (range 1-18) and a mean of 2.9 resections (range 1-9). Only one minor complication (bleeding without drop in hemoglobin level >2 g/dL) occurred (5% of patients). During a mean follow-up (FU) of 62 months (range 45-89), recurrent or metachronous carcinomas were found in 5 patients (28%). Repeat ET was carried out successfully using ER (4 patients) and argon plasma coagulation (1 patient). In one of the 19 patients (5%), tumor freedom had not been achieved after a total of 2 ER. This patient died of a heart attack before surgery could be performed. The calculated 5-yr survival rate of all 21 patients was 66%. No tumor-related death occurred. CONCLUSIONS: As in mucosal BC, ER is associated with favorable outcomes even in case of "low-risk" submucosal BC. Further and larger clinical trials are required before a general recommendation for ER as the treatment of choice in "low-risk" submucosal BC can be given.

The impact of endoscopic ultrasound and computed tomography on the TNM staging of early cancer in Barrett's esophagus.

INTRODUCTION: Computed tomography (CT) and endoscopic ultrasound (EUS) are part of the regular staging protocol in esophageal cancer. The value of the two methods was assessed in patients with early cancer in Barrett's esophagus. METHODS: One hundred consecutive patients (median age 64 yr, interquartile range [IQR] 58-72) with suspected early cancer in Barrett's esophagus who were referred to our hospital for endoscopic therapy were prospectively included in a standardized staging program with upper gastrointestinal endoscopy, EUS (7.5 MHz in all cases plus 12.5 or 20 MHz for elevated and/or depressed lesions), CT of the chest and upper abdomen, and abdominal ultrasonography. The results were summarized in accordance with the TNM classification. On the basis of the lymph node findings on CT and/or EUS, the patients were assigned to three categories: C1, no suspicious lymph nodes; C2, paraesophageal lymph nodes < or =1 cm in size at the tumor level, lymph nodes > or =1 cm in size not at the tumor level in the mediastinum or celiac trunk; and C3, paraesophageal lymph nodes > 1 cm in size at the tumor level. The EUS and CT findings were checked every 6 months in patients who underwent endoscopic treatment. Surgical resection was scheduled in operable patients if staging showed a T category higher than T1 and/or the lymph node staging was assessed as C3. Patients with suspected submucosal infiltration underwent diagnostic endoscopic resection, and if submucosal involvement was confirmed were referred for surgery. RESULTS: The median follow-up period was 25 months (IQR 19.5-30.0). The T category diagnosed with CT was < or = T1 in all patients. On EUS, the T category was classified as T1 in 92% of cases (N = 92) and as > T1 in 8% (N = 8, p < 0.05). Enlarged lymph nodes (C2 and C3) were detected in 45% of the patients. Significantly more C2 lymph nodes were diagnosed with EUS than CT (28 vs 19, p < 0.05). Lymph nodes at the level with the highest suspicion, C3, were detected using CT in only three of nine cases. Sensitivity of CT for N staging was not acceptable compared with EUS (38%vs 75%). No extranodal metastases were found on CT. CONCLUSIONS: In suspected early cancer in Barrett's esophagus, EUS is superior to CT for T staging and N staging. As CT had no influence on the TNM classification in any of these patients, it may be possible to dispense with this method as a staging procedure in patients with cancer in Barrett's esophagus. By contrast, EUS is required in order to differentiate between patients with cancer in Barrett's esophagus in whom endoscopic therapy is suitable and those in whom surgical treatment is required.

Local endoscopic therapy for intraepithelial high-grade neoplasia and early adenocarcinoma in Barrett's oesophagus: acute-phase and intermediate results of a new treatment approach.

BACKGROUND: Radical oesophageal resection has until now been regarded as the gold standard for treatment in intraepithelial high-grade neoplasia or early adenocarcinoma of the oesophagus. However, the mortality and morbidity rates are substantial. DESIGN: A new therapeutic approach involving low-risk endoscopic therapy modalities was examined in the framework of a prospective study. PATIENTS: A total of 115 patients with intraepithelial high-grade neoplasia (19) and early adenocarcinoma (96) in Barrett's oesophagus. METHODS: Endoscopic mucosal resection (EMR) was used in 70 patients, and photodynamic therapy (PDT) was used in 32 patients. The two procedures were combined in ten patients. Three patients underwent primary treatment with argon plasma coagulation (APC). The average follow-up was 34 +/- 10 months (range 24-60 months). RESULTS: Complete local remission was achieved in 98%. The overall complication rate was 9.5%. Major complications, such as perforation and severe bleeding, did not occur. Minor complications included not haemoglobin relevant bleeding (drop of haemoglobin less than 2 g/dl) (5) and stenosis (3) after EMR, and long-lasting odynophagia (1) and sunburn (2) after PDT. In all, 13 patients have died so far, but in only one case due to the underlying disease. The calculated overall 3-year survival rate is 88%. During the follow-up period, a 30% rate of metachronous lesions was observed; endoscopic therapy was performed successfully in all but one of these patients. CONCLUSIONS: These good acute-phase and intermediate results, along with low morbidity rates and no mortality, suggest that the organ-preserving local endoscopic procedure including EMR and PDT is an attractive alternative to oesophageal resection. Therefore, endoscopic therapy might replace radical oesophageal resection in future in cases of intraepithelial high-grade neoplasia and early mucosal adenocarcinoma in Barrett's oesophagus.