Endobronchial Ultrasound Application for Diagnosis of Tracheobronchial Tree Invasion by Esophageal Cancer
Teresa GarridoFauze Maluf‐FilhoRubens Antônio Aissar SallumVivíane Rossi FigueiredoMárcia JacomelliMiguel Lia Tedde
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Abstract:
Esophageal cancer staging has been performed through bronchoscopy, computerized tomography (CT), positron emission tomography (PET), and endoscopic ultrasound (EUS). Whereas CT and PET scan provide assessments of distant metastasis, bronchoscopy importantly diagnoses tracheobronchial involvement, complementing chest CT findings. EUS is the most accurate examination for T and N staging but is technically limited when tumoral stenoses cannot be traversed. Endobronchial ultrasound (EBUS) appears to present greater accuracy than EUS, CT, and bronchoscopy for assessing tracheobronchial wall involvement. EBUS has been recently associated with EUS for esophageal cancer staging in our unit.To compare EBUS findings in esophageal cancer patients without evident signs of tracheobronchial invasion on conventional bronchoscopy with EUS and CT.Fourteen patients with esophageal cancer underwent CT, conventional bronchoscopy, EUS, and EBUS for preoperative staging. All patients underwent EBUS and EUS with an Olympus(R) MH-908 echoendoscope at 7.5 MHz. Seven patients were eligible for the study according to the inclusion criteria.The echoendoscope could not traverse tumoral esophageal stenosis to perform EUS in two patients, and invasion was effectively diagnosed by EBUS. In 4 (57%) of 7 patients EBUS revealed additional information to staging. In the remaining 3 cases the invasion findings were the same under both EUS and EBUS.EBUS showed signs of tracheobronchial invasion not observed by conventional bronchoscopy, adding information to staging in most of the cases when compared with CT and EUS.Keywords:
Endoscopic Ultrasound
Esophageal cancer staging has been performed through bronchoscopy, computerized tomography (CT), positron emission tomography (PET), and endoscopic ultrasound (EUS). Whereas CT and PET scan provide assessments of distant metastasis, bronchoscopy importantly diagnoses tracheobronchial involvement, complementing chest CT findings. EUS is the most accurate examination for T and N staging but is technically limited when tumoral stenoses cannot be traversed. Endobronchial ultrasound (EBUS) appears to present greater accuracy than EUS, CT, and bronchoscopy for assessing tracheobronchial wall involvement. EBUS has been recently associated with EUS for esophageal cancer staging in our unit.To compare EBUS findings in esophageal cancer patients without evident signs of tracheobronchial invasion on conventional bronchoscopy with EUS and CT.Fourteen patients with esophageal cancer underwent CT, conventional bronchoscopy, EUS, and EBUS for preoperative staging. All patients underwent EBUS and EUS with an Olympus(R) MH-908 echoendoscope at 7.5 MHz. Seven patients were eligible for the study according to the inclusion criteria.The echoendoscope could not traverse tumoral esophageal stenosis to perform EUS in two patients, and invasion was effectively diagnosed by EBUS. In 4 (57%) of 7 patients EBUS revealed additional information to staging. In the remaining 3 cases the invasion findings were the same under both EUS and EBUS.EBUS showed signs of tracheobronchial invasion not observed by conventional bronchoscopy, adding information to staging in most of the cases when compared with CT and EUS.
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Accurate staging of esophageal cancer has important prognostic and management implications. Before the development of endoscopic ultrasound (EUS), esophageal cancers were staged by computed tomography (CT) and laparoscopy. EUS has since become an important imaging modality in determining the extent of locoregional spread of esophageal cancer and, in certain situations, distant metastasis. The addition of EUS-guided fine-needle aspiration (FNA) has only improved the accuracy of the procedure. Compared with CT, EUS-guided FNA is more accurate for local staging and results in a change in patient management in many cases [1]. Thus EUS and EUS-guided FNA have become an integral part of the preoperative staging algorithm for these patients.
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An 80-year-old man underwent follow-up examinations after endoscopic submucosal dissection (ESD) for esophageal cancer. Computed tomography showed enlarged lymph nodes of the right recurrent nerve. The patient had esophageal stenosis due to repeated ESD for multiple esophageal tumors. The stenosis made the passage of an endoscopic ultrasound (EUS) scope through the esophagus difficult. Thus, an endobronchial ultrasound bronchoscope, which had a thinner diameter than that of the EUS scope, was used for transesophageal endoscopic ultrasound with bronchoscope-guided fine-needle aspiration. This technique led to the diagnosis of mediastinal lymph node metastasis of esophageal cancer.
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The objective of the current study was to assess the yield of endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) for the diagnosis of sarcoidosis in a large patient group. Bronchoscopy with transbronchial lung biopsy (TBLB) is nondiagnostic in 30% of patients with suspected sarcoidosis and has a risk of pneumothorax and haemoptysis. In order to obtain a diagnosis, mediastinoscopy is often performed as the next diagnostic procedure. EUS-FNA provides a nonsurgical alternative for the demonstration of noncaseating granulomas by aspirating mediastinal lymph nodes from the oesophagus. In total, 51 patients with suspected sarcoidosis stage I and II underwent EUS-FNA. Thirty-six patients (71%) previously underwent a nondiagnostic bronchoscopy. All patients were clinically followed (median 18 months) and surgical-pathological verification occurred in those patients with EUS aspirates that contained unrepresentative material. EUS-FNA demonstrated noncaseating granulomas without necrosis in 41 of 50 patients (82%) with the final diagnosis of sarcoidosis. Specific ultrasound features of clustered, well-demarcated iso-echoic lymph nodes were observed in 64% of patients with sarcoidosis. No complications occurred. Endoscopic ultrasound-guided fine-needle aspiration has a high yield in diagnosing sarcoidosis and qualifies as the next diagnostic step after a nondiagnostic bronchoscopy. The current authors expect that endoscopic ultrasound-guided fine-needle aspiration will reduce the number of mediastinoscopies for the diagnosis of sarcoidosis dramatically.
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Results are presented of combined examinations of esophageal cancer patients. Current status and potentialities in preoperative diagnosis of local and metastatic cancer of the esophagus are specified for the following techniques: (1) roentgenological: roentgenoscopy and roentgenography of the esophagus, survey chest X-ray; (2) endoscopic: esophagoscopy and tracheobronchoscopy; (3) X-ray computed tomography (CT): esophageal, chest, hepatic paracardial and retroperitoneal lymph node CT; (4) radionuclide: 67Ca-citrate chest scanning and 99Tc-glucoheptonate scanning of the liver; (5) ultrasound tomography: identification of metastases to paracardial and retroperitoneal lymph nodes and to the liver. The validity of the combined use of the above techniques in preoperative diagnosis of local and metastatic cancer of the esophagus is substantiated, as well as surgical policy based on the information obtained with the above diagnostic examinations.
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Esophageal cancer has a poor prognosis since it is often diagnosed in the symptomatic and incurable state. Accurate staging at initial diagnosis is imperative as it determines prognosis and influences treatment. Computed tomography (CT) scan is sensitive for identifying metastatic disease but is insensitive for detecting the extent of wall involvement or nodal disease. Endoscopic ultrasound (EUS) has emerged as a powerful tool in staging esophageal cancer with an impressive accuracy. Use of endoscopic ultrasound-guided fine needle aspiration as an adjunct further improves accuracy in nodal staging and allows for histologic confirmation. The impact of this invaluable staging modality in the management of esophageal cancer continues to grow.
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Background : Bronchoscopy fails to establish a diagnosis in up to 30% of patients with centrally located lung cancer. EUS-guided FNA has been used for the diagnosis of suspected lung cancer near or adjacent to the esophagus in patients who had undergone a non-diagnostic bronchoscopy. Aim: To prospectively assess the feasibility and yield of EUS-FNA as first diagnostic step in the diagnosis of intrapulmonary tumours located near or adjacent to the esophagus. Study design: Patients with a CT-scan of the chest revealing an intrapulmonary tumour located near or adjacent to the esophagus were enrolled. They underwent EUS-FNA (Olympus, GF UCT 160) under deep sedation. Results: Fourteen patients were included, and EUS-FNA diagnosed lung cancer in all cases (12 NSCLC, 2 SCLC) (yield=100%). No complications occurred. The subtyping of (N)SCLC was allowed by cytological specimens in 9 cases (65%), by cell blocks in 3 cases (21%), whereas NSCLC could not be subtyped in 2 cases (14%). Conclusions: EUS-guided FNA might represent the first diagnostic step in patients with intrapulmonary tumours located near or adjacent to the esophagus.
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Mucosal and submucosal esophageal cancer has been defined as superficial cancer of the esophagus. And superficial cancer without metastasis was defined as early cancer of the esophagus. Of 104 cases of superficial esophageal cancer resected in the past twenty years, 62 were early cancer. The operative mortality rate of supeficial cancer was 1.9%. The 5-year survival rate of early cancer was 62%. Only 14 of 104 cases were mucosal cancer cases. 12 of 14 mucosal cancers belonged to early cancer and no vascular invasion was also recognized in 11 cases. There has been no case died of cancer in the early mucosal cancer. So the detection and surgical treatment of mucosal cancer are mandatory to obtain the excellent results. The endoscopic examination has come to a large role for this purpose.
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The first prototype of an endoscopic ultrasound (EUS) was constructed in Japan in 1980. The evolution continued quickly and within the past ten years this method became available in routine practice. One of the most significant indications of EUS in esophagus are locoregional staging and posttherapeutic monitoring of the esophageal cancer. (Ref. 4.).
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