ORIGINAL ARTICLES—ALIMENTARY TRACT Endoscopic Ultrasound Does Not Accurately Stage Early Adenocarcinoma or High-Grade Dysplasia of the Esophagus

CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2010;8:1037-1041 ORIGINAL ARTICLES-ALIMENTARY TRACT Endoscopic Ultrasound Does Not Accurately Stage Early Adenocarcinoma or High-Grade Dysplasia of the Esophagus PATRICK E. YOUNG,*·t ANDREW B. GENTRY,t.§ RUBEN D. ACOSTA;·t BRUCE D. GREENWALD,II and MARK RIDDLE, 1 "National Naval Mectical Center, Bet11esda, Maryland; 1 Uniformed Services Univt3rsity of Health Sciences, Betllescia, Maryland; §Naval Medical Center, Portsmouth, Virginia; iiUnivers11y of Maryland, Baltimore, Maryland; and 11Naval Medical ResearCh Center, Silver Spring, M;uyland This arricle has an accompanying continuing medical education activity on page e 125. Learning Objectives-At the end of this activity, the learner should be able ro recognize importance of staging for esophageal adenocarcinoma, appreciate the limitations of endoscopic ultrasound ro stage early cancer, and understand the potential role of endoscopic mucosal resection for staging. See related article, Peters CJ et al, on page 1995 In Gastroenterology. BACKGROUND & AIMS: Patients with esophageal high­grade dysplasia or mucosal esophageal cancer can he successfully treated hy endoscopy. We performed a systematic review of the literature to determine whether endoscopic ultrasound (EUS) cor­rectly predicts the T-stage of early esophageal cancers, compared with pathology specimens obtained by using endoscopic mucosal resection (EMR) or surgery. METHODS: Standard systematic review methods were used w perform reference searches, deter­mine eligibility, abstract data, and analyze data. \Vhen possible, individual patient-level data were abstracted, in addition to pub­lication-level aggregate data. RESULTS: Twelve studies had suf­ficient information to abstract and review for quality; 8 had indi­vidual patiem-level data (n = 132). Compared with surgical or EMR pathology staging, EUS had T-stage concordance of 65%, including all studies (n = 12), but only 56% concordance when limited to individual patient-level data. Factors such as initial biopsy pathology (high-grade dysplasia vs early-stage cancer) did not appear to affect the concordance of staging between EUS and EMR/surgical staging. CONCLUSIONS: BUS is not suffi­ciendy accurate in determining the T -stage of high-grade dys­plasias or superficial adenocarcinomas; other means of stag­ing, such as EMR, should be used. Keywords: Endosonography; Esophageal Cancer; Barrett's Esopha­gus; Staging. A denocarcinoma of the esophagus (ECA) hac; fa.c;test rising prevalence of any malignancy in the Western world. 1 The vast majority of ECA arise from specialized intestinal meta­plasia in the esophagus, so-called Barrett's esophagus. 2··' Be­cause surveillance of Barrett's esophagus is now recommended by specialty sociecies, endoscopists are discovering more high­grade dysplasia (HGD) and early malignancies that might be amenable to endoscopic therapy."-9 The risk of lymph node involvement in esophageal adeno­carcinoma correlates best with the depth of invasion.IO,tt Can­cers that are confined to the mucosa have a risk of nodal involvement of less than 2%, wherea.c; nodal is present in 19% of patients with cancer that invades submucosa (T1sm). 12 •13 Accurate pretreatment staging of cancer is neces­sary to determine the proper therapeutic modality for in­dividual patient. Tumor depth staging (ie, T-staging) is the primary determinant of whether a lesion might he completely resected endoscopically. Many studies of endoscopic resection therapy to date have used endoscopic ultrasound (EUS) to assess the depch of tumor invasion before resection. As such, an important clinical question is the accuracy of EUS in determin­ing which histologic layers are involved. The purpose of this systematic review is to determine, in adults undergoing EUS for pretreatment staging of ECA, the accuracy EUS in determin­ing the depth of invasion early esophageal cancers. Methods Literature Search and Eligibility Determination Two gastroenterologists (A.G., R.A) and a medical li­brarian performed independent searches of published liter­ature to include MEDLINE, EMBASE, and OVID. The search was limited w English-language publications and to clinical trials and humans and included the following MeSH search terms: "endoscopic ultrasound," "Barrett's esophagus," "adeno· carcinoma," "Barrett's esophagus and high grade dyspla.c;ia," "endoscopic ultrasound and high grade dysplasia or adenocar­cinoma." The search was performed from January I, 1980, to June 30,2008. The year 1980 was chosen as the origin because EUS was not performed before this date. From the resultant search, abstractS that contained "EUS" or "endoscopic ultrasound" were included for review. If no abstract was included, the article retrieved for review. The reference lists of each these publica­tions were reviewed for articles that might have heen missed on the initial search. Studies published only abstract form, conference abstracts or symposium proceedings, and case reports were not eligible for inclusion. The re[rieved articles were reviewed eli­gibility by 3 gastroenterologists (P.Y., A.G., R.A.), one whom a trained endosonographer (P.Y.). To be included in the systematic Abbreviations used In this paper: ECA, adenocarcinoma of the esophagus; EMR, endoscopic mucosal resection; EUS, ul­trasound; HGD, high-grade dysplasia.

Keywords:

• Radiology
• Endoscopy
• Endoscopic mucosal resection
• Esophagus
• Endoscopic ultrasound
• Dysplasia
• Surgery
• Esophageal cancer
• Medicine
• Adenocarcinoma
• Stage (cooking)

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