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Endoscopic Ultrasound Is Insufficient for Recommending Endoscopic Management of Early Staged Esophageal Cancers

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Edward J. Bergeron, Jules Lin, Andrew C. Chang, Mark B. Orringer, Rishindra M. Reddy; Section of Thoracic Surgery, University of Michigan, Ann Arbor, MI

Objective(s): Esophageal endoscopic ultrasound (EUS) is an essential component of esophageal cancer staging. There is an increasing trend towards endoscopic-based alternative therapies (i.e., endoscopic mucosal resection, radiofrequency ablation) for early stage esophageal cancers (T0 - T1 tumors) due to concerns of perioperative esophagectomy outcomes. We evaluated our institutional experience with preoperative EUS staging of early esophageal cancers in patients having undergone esophagectomy for concerns of understaging by EUS and potential inadequate treatment recommendations.
Methods: A prospective esophagectomy database of all patients having an esophagectomy for esophageal cancer at a single, high volume institution was retrospectively reviewed for patients with early stage esophageal cancer. This study analyzes the substages of T0 and T1 disease as predicted by preoperative EUS and the correlation with pathologic T- and N- stages following esophagectomy and postoperative outcomes.
Results: From 2005 to 2011, 107 patients (93 males, 14 females) with a mean age of 65 years (range 39 - 91) were staged by preoperative EUS to have esophageal high grade dysplasia, carcinoma in situ, or T1 cancer and underwent an esophagectomy. EUS understaged 87% of clinical T0 tumors (20 of 23), 39.1% of clinical T1a tumors (18 of 46), and 2.6% of clinical T1b tumors (1 of 38). Of the EUS staged N0 lesions, there were positive lymph nodes in 15% of lesions in the T1a lamina propria (2 of 13) and 18% of lesions in the T1a muscularis mucosa (5 of 28). When the threshold for endoscopic treatment is set from T0 to T1a lamina propria lesions, EUS has a sensitivity of 36% and a specificity of 69%. Transhiatal esophagectomy was performed in 105 patients. The median hospital stay was 8 days (range 7 - 48). Postoperative complications included anastomotic leak (11.2%, 12 of 107 patients), atrial fibrillation (11.2%, 12 of 107), hoarseness (4.67%, 5 of 107), chylothorax (1.87%, 2 of 107), deep venous thrombosis ( < 1%, 1 of 107), and wound infection (1.87%, 2 of 107). The 30-day mortality rate was < 1% (1 of 107).
Conclusions: The sensitivity and specificity of EUS for determining endoscopic therapy versus esophagectomy is poor for early staged esophageal cancers. EUS routinely understaged lesions felt to be T0 - T1a. Tumors felt to be T1a were shown to have at least N1 disease in 15% of cases. Esophagectomy with lymph node dissection is still the gold standard operation for EUS-early staged esophageal cancers.

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