Amy Schindler 10/18/10

 Endoscopic appearance: Early cancers: superficial plaque, nodule, or ulceration Advanced lesions: strictures, ulcerated masses, circumferential masses, or large ulcerations

 Preoperative staging is warranted in patients who are considered to be surgical candidates (“can help to take someone off the table”).  If distant metastases are not demonstrated by CT or PET, upper EUS allows a more detailed evaluation of locoregional disease extent (T and N stage).

Modified from AJCC Cancer Staging Manual. 7 th ed

 Distant metastases including extraregional lymph node spread (including paraaortic or mesenteric) Malignant celiac nodes*  Unresectable primary disease including invasion of the aorta, trachea, heart, great vessels, or presence of TE fistula  Cervical esophageal tumors with infiltration into prevertebral fascia or posterior larynx, invasion of the membranous trachea to the level of the carina, or significant bilateral encasement of major neurovascular structures

 In a meta-analysis of 2558 patients, pooled sensitivity and specificity of EUS to diagnose T4 were 92.4% and 97.4%. FNA increases sensitivity of EUS to diagnose N stage from 84.7% to 96.7%. (World J Gastroenterol 2008; 14(10): )

 Endosonographic criteria suggestive of malignant involvement of lymph nodes include: Width greater than 10 mm Round shape Smooth border Echo-poor pattern  When all four suspicious features are present in a lymph node, there is an % chance of metastatic involvement.  Only 25% of malignant nodes have all four features.  Lymph node involvement supports the selection of induction chemoradiotherapy over surgery alone, particularly in T2 disease.  EUS-FNA appears to improve accuracy of N staging as long as the primary tumor is not in the pathway of the aspiration needle.

 Instrument cannot traverse a tumor- induced stenosis (affects 30% of patients), leading to understaging because the entire lesion and the celiac axis are not seen  Lymph node assessment in the immediate vicinity of the tumor is restricted

 Among expert endosonographers (>75 esophageal cancer examinations): Overstaging occurs in 8-14% of patients, more often with T2 lesions (peritumoral inflammation leading to overestimation of mural penetration?) Understaging in 3-15% of cases, more often with T3 tumors with microscopic infiltration of the adventitia beyond resolution capability of the echoendoscope Gatrointest Endosc 1996; 7: 162. Surg Endosc 1999; 13: 894. Endoscopy 1992; 24 Suppl 1: 324.

 Accuracy of EUS for restaging after chemoradiation is poor Thought to be due to inability to differentiate between residual tumor and post-treatment inflammation and fibrosis  Detection of locoregional recurrence EUS has sensitivity and specificity >92% and >96% for detecting locoregional relapse in patients with worrisome signs or symptoms that have a negative endoscopic and radiographic evaluation EUS surveillance of resected patients every 6 months for 2 years has been shown to have a strong positive predictive value (92%) for tumor recurrence, and two-thirds with EUS-shown relapse were asymptomatic at the time. BUT, has not been shown that early detection of tumor recurrence improves survival.