Original article
General thoracic
Endobronchial Ultrasonography Added to Endoscopic Ultrasonography Improves Staging in Esophageal Cancer

Presented at the Forty-ninth Annual Meeting of The Society of Thoracic Surgeons, Los Angeles, CA, Jan 26–30, 2013.
https://doi.org/10.1016/j.athoracsur.2013.03.023Get rights and content

Background

The gold standard for staging the local extension (T stage) and lymph node (LN) status (N stage) of esophageal cancer is endoscopic ultrasonography (EUS). When biopsy of the peritumoral LNs is performed using EUS, there is a risk of specimen contamination secondary to piercing the primary tumor; this shortcoming can be circumvented with endobronchial ultrasonography (EBUS). Moreover, EBUS allows for biopsy of LN stations not accessible with EUS.

Methods

The study consisted of a prospective clinical trial. Fifty-two consecutive patients with potentially resectable esophageal cancer referred for endoscopic staging were prospectively enrolled. Radial and convex EUS followed by convex EBUS were performed during a single staging procedure. The LNs not accessible by EUS were biopsied using EBUS. Results of the EBUS procedure were compared to those of EUS in terms of the addition of staging information, upstaging, and confirmation of stage.

Results

The combined EBUS-EUS procedure was performed in 42 patients. Ten patients were excluded. In all, 54 LNs were biopsied under EUS guidance and 48 LNs were biopsied under EBUS guidance. The EUS results were positive for metastatic esophageal cancer in 29 LNs (54%), and EBUS was positive in 10 LNs (21%). The addition of EBUS to EUS in the staging of esophageal cancer led to nodal and patient upstaging in 5 patients (12%) and confirmed the EUS stage with additional negative or positive LN sampling in 29 patients (69%). Positive EBUS that led to upstaging (5 patients) changed the treatment plan from potentially resectable to palliative. There was no morbidity related to EBUS.

Conclusions

A combined EBUS-EUS staging procedure improves precision in staging, leads to upstaging, and can change the treatment plan in patients with esophageal cancer.

Section snippets

Patients and Methods

The study consisted of a prospective clinical trial (clinicaltrials.gov NCT01038544). Consecutive patients with potentially resectable esophageal cancer (based on CT and PET-CT), referred for echoendoscopic staging at the Centre Hospitalier de l’Université de Montréal (CHUM) Endoscopic Tracheobronchial and Oesophageal Center (C.E.T.O.C.), Division of Thoracic Surgery, University of Montreal, were prospectively enrolled. Potential resectability was determined by one of five general thoracic

Results

Between January 2010 and September 2011 (21 months), 52 patients were enrolled into the trial. Ten patients were excluded (1, no tumor; 1, gastric cancer; 8, no EBUS). The combined EBUS-EUS procedure was performed in 42 consecutive patients. There were 8 patients enrolled in the trial who had esophageal cancer but did not undergo EBUS, owing to the endoscopists’ judgment at the time of echoendoscopic staging that the addition of EBUS to EUS in the clinical setting was unnecessary or superfluous.

Comment

Progression of disease from primary site to lymph nodes follows lymphatic drainage. Any lymph node surrounding the esophagus can be affected; that is especially true in esophageal cancer because the lymphatic drainage of the esophagus is not necessarily segmental and predictable, but more longitudinal with skip metastasis [12]. More often than not lymph nodes surrounding the primary tumor are affected by metastatic spread and biopsy is necessary to obtain a tissue diagnosis. Even though several

References (20)

There are more references available in the full text version of this article.

Cited by (22)

  • Pitfalls and Pearls in Esophageal Carcinoma

    2021, Seminars in Ultrasound, CT and MRI
    Citation Excerpt :

    Accordingly, EUS and EUS-fine needle aspiration (EUS-FNA) are recommended by the AJCC for accurate N staging. However, a potential limitation of EUS-FNA in the evaluation of regional lymph node metastasis is contamination of the biopsy needle as a result of passage through the primary malignancy resulting in a false-positive result.12 The M category is determined by absence of metastasis (M0) or the presence of metastasis (M1).

  • Esophageal Cancer Diagnosis and Staging

    2019, Shackelford's Surgery of the Alimentary Tract: 2 Volume Set
  • Indications, Preparation, and Adverse Effects

    2018, Endosonography, Fourth Edition
  • Response

    2015, Chest
View all citing articles on Scopus
View full text