Esophageal Cancer

Staging

Accurate measurement of the depth of tumor and the extent of metastasis are critical factors that determine the therapeutic options and prognosis of patients with carcinoma of the esophagus, and may reduce the cost of care. EUS is currently the most accurate modality available to determine the depth of tumor and the status of regional lymph node involvement. Based on a review of 739 reported cases, EUS is accurate for evaluation of tumor depth in 85% of cases, and of nodal stage in 79% (Rosch and Classen, 1992). EUS staging is more accurate for T3/T4 tumors (> 90%) than for T1/T2 tumors (65%). However, the use of high-frequency (15 to 30 MHz) US catheter probes for staging small T1 and T2 tumors improves this accuracy to 83 to 92%. EUS-guided FNA has further improved the specificity of EUS in diagnosing lymph node metastasis and also provides pathological evidence of metastasis to peritoneal or pleural fluid, or liver.

In patients with malignant esophageal strictures (about 30% of cases), EUS assessment may require dilatation for complete assessment of the abdominal organs and lymph nodes, or remain incomplete. I usually employ dilatation only if absolutely necessary and then only up to three incremental dilator sizes. This helps to minimize perforations (forcing an operation in patients who most likely would benefit from neoadjuvant therapy), which in the literature may be as high as 24%. Adhering to this guideline may at times require a pre-EUS dilatation session. However, this strategy has resulted in successful complete staging in the vast majority of cases with a minimal risk of perforation. An alternative to dilatation may be the use of a 7.5 MHz nonoptical wire-guided tapered esophagoprobe that may traverse the stricture. FNA, however, is not possible with this instrument.

We studied the role of EUS in combination with FNA in guiding the choice of therapy made by patients who had esophageal cancer (EC) who otherwise were surgical candidates (Chang et al, 2003). Among 60 consecutive patients, the accuracy of EUS/FNA in tumor and lymph node staging was 83% and 89%, respectively. Twenty-five patients (42%) had EUS stages I and II and were candidates for curative surgery. Twenty-eight patients (47%) had stage III and 7 (12%) had stage IV. All patients with stage I had surgery, whereas all patients with stage IV had medical therapy. The majority (62%) of patients with stage II had surgery, whereas only the minority (25%) of patients with stage III had surgery. Altogether, 36 patients (60%) decided to have medical therapy. Patients' medical decisions toward surgical or medical therapy correlated strongly to results of their EUS staging (p = .005), but not to age, sex, or referring physicians (surgeons versus nonsurgeons). This suggests that EUS plays a significant role in patients' decision making. In addition, EUS-guided therapy had potentially decreased the cost of care by $870,564 ($14,509/patient) by reducing the number of thoracotomies.

The general clinical algorithm for staging EC once diagnosed by endoscopy with biopsy is shown in Figure 5-1. A helical computed tomography (CT) scan should be performed to rule out distant metastasis, such as to the liver, lung, and bone. In addition to distant metastatic disease (M1b), careful attention should be placed at looking for

T4 disease (direct extension into trachea or aorta) or distant lymph node involvement (M1a), such as celiac/hepatic (in patients with proximal or mid-esophageal tumors) or cervical nodal metastasis in patients with distal esophageal tumors. Surgical resection is indicated for all operable candidates who are considered curable (T1N0 or T2N0). Patients with locally advanced disease (T3 or N1) should be offered neoadjuvant chemoradiotherapy (CRT) followed by surgical resection. Although adenocarcinoma (AC) of the esophagus is generally less sensitive to CRT than squamous cell cancer, patients with AC experience a greater survival benefit with multimodal therapy before surgical intervention. The chapter on esophageal carcinoma provides details on therapeutic options.

Restaging

TNM restaging by EUS has been found to be inaccurate due to inflammation, fibrosis, and "ghost cells" after CRT. However, a a 50% reduction in the tumor's maximal transverse cross-sectional area has been shown to correlate with both a pathologic tumor regression and with improved clinical outcomes. In addition, finding new metastatic lesions with EUS/FNA would preclude further deliberations about surgery. Likewise, in patients who have apparent complete response on endoscopy with biopsy, an EUS/FNA showing definite residual cancer in the wall of the esophagus or in an adjacent lymph node would confirm the need for resection. Thus, in patients with locally

Distant mets

Palliation

T1/T2 or N0

Surgery

Esophageal cancer Dx by EGD/bx

Helical CT

Local tumor

EUS/FNA

T3 or N1

Chemo/XRT Re-evaluate for surgery

T4 or M1

Palliation

FIGURE 5-1. Algorithm for management of esophageal cancer. bx = <AU/ED: please provide definitions CT = computed tomography; EUS = endoscopic ultrasonography; FNA = fine needle aspiration.

advanced disease who have completed neoadjuvant chemoradiation, I will usually perform preoperative EUS, especially if the patient is uncertain about surgery.

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