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473 Predicting the Invasion Depth of Differentiated Early Gastric Cancer: Comparison of Narrow-Band Imaging Magnification and Endoscopic Ultrasonography
Abstracts
was recommended iCRCs may have been detected on follow-up colonoscopy. Conclusions: Interval colon cancers are responsible for about 5% of colon cancer diagnoses. Most iCRCs occur in patients with good preps, complete examinations and with small adenomas on index colonoscopy. Adherence to the most recent colonoscopy surveillance guidelines may decrease iCRC cases.
472 Accuracy of Endoscopic Ultrasonography for Staging of T1a and T1b Esophageal Squamous Cell Carcinomas Jung-hwan Lee*, Jong Yeul Lee, Chan Gyoo Kim, Soo-Jeong Cho, Young-Il Kim, Il Ju Choi Center for Gastric Cancer, National Cancer Center, Korea, Goyang, Gyunggi, Korea (the Republic of) Background/Aim: Accurate prediction of invasion depth in esophageal squamous cell carcinoma (ESCC) is essential for the choice of treatment. Endoscopic ultrasonography (EUS) is an essential tool in the assessment of loco-regional staging. However, the role of EUS in distinguishing mucosal (T1a) from submucosal cancer (T1b) in ESCC has not been established. Thus, we conducted a study to investigate the accuracy of EUS in staging T1a and T1b ESCCs and to identify the factors influencing the accuracy of EUS. Methods: We retrospectively reviewed 218 pathologically confirmed T1a or T1b ESCC from 214 patients, who underwent EUS using radial echoendoscope and/or high-frequency catheter probe between August 2006 and August 2015 at the National Cancer Center, Goyang, Korea. Accuracy distinguishing T1a from T1b and sensitivity/specificity for T1a of EUS were examined. Univariate and multivariate analyses were used for determination of the factors related to inaccuracy, overestimation or underestimation of EUS. Result: The overall accuracy of EUS for distinguishing T1a and T1b ESCC was 67.0% (146/218). The sensitivity and specificity of EUS relative to the T1a lesions were 64.9% (63/97) and 68.6% (83/121). Overestimation and underestimation of the invasion depth occurred in 34 (15.6%) and 38 lesions (17.4%) respectively. Multivariate analysis determined that poorly differentiated ESCC [odd ratio (OR): 2.98, pZ0.023], was associated with inaccuracy of EUS. Depressive morphology (OR: 5.39; pZ0.026) and using radial echoendoscope only (OR: 3.12; pZ0.008) were associated with overestimation, whereas poorly differentiated ESCC (OR: 3.12; pZ0.003) was associated with underestimation. Conclusion: The accuracy of EUS in staging T1a and T1b ESCC showed unsatisfactory results. Therefore, many efforts are needed to improve diagnostic accuracy of EUS in staging T1a and T1b ESCCs, especially with poorly differentiated histology.
473 Predicting the Invasion Depth of Differentiated Early Gastric Cancer: Comparison of Narrow-Band Imaging Magnification and Endoscopic Ultrasonography Shuo Zhang*, Bin Lv, Ting-Yuan Li GI Department, The First Affiliated Hospital, Zhejiang Chinese Medical University, HANG ZHOU, ZHE JIANG, China Objective: Predicting the invasion depth of differentiated early gastric cancer(EGC) is important when selecting among therapeutic strategies. The aim of this study was to compare magnifying endoscopy with narrow-band imaging magnification (MENBI) with endoscopic ultrasonography (EUS) for predicting the depth of tumor invasion in patients with differentiated EGC. Methods: This study enrolled 41 patients with EGC (43 lesions) who underwent both ME-NBI and EUS at The First Affiliated Hospital, Zhejiang Chinese Medicine University during 2013–2015. We reviewed the medical records and compared ME-NBI and EUS findings with histopathological results according to clinicopathological factors. Results: A total of 83 lesions in 81 patients were included in the final analysis. ME-NBI and EUS had overall accuracies of 81.4% and 86.0%, respectively, in distinguishing SM1 (invasion depth ＜500 mm) from SM2 (invasion depth 500 mm) cancers. There were no differences between ME-NBI and EUS in terms of sensitivities and specificities in distinguishing SM1 from SM2 cancers (p Z1.000 and p Z1.000, respectively). When both ME-NBI and EUS suggested a SM2 depth of invasion, the frequency of SM1 cancer was only 4.7%. And when both ME-NBI and EUS suggested a SM1 depth of lesion invasion, the frequency of SM2 cancer in the final histopathology was 0%. Conclusion: ME-NBI and EUS are accurate predictors of EGC invasion depth. If both methods used, the accuracy of the prediction is increased. Therefore, when possible, it would be better to evaluate the invasion depth of EGC using both ME-NBI and EUS before deciding to perform endoscopic resection.
474 Endoscopic Ultrasound Staging in Suspected Superficial Esophageal Adenocarcinoma and Its Impact on Endoscopic Resection Strategy Timothy M. Wallace, Michael J. Bartel*, Herbert C. Wolfsen, Massimo Raimondo, Timothy A. Woodward, Victoria Gomez, Michael B. Wallace Gastroenterology, Mayo Clinic, Jacksonville, FL Background: Invasion depth of esophageal adenocarcinoma (EAC) predicts the risk of lymphatic spread, which is likely present in case of T stage T1b sm2 or deeper.
www.giejournal.org
Surgical resection, as apposed to endoscopic resection, is warranted in such cases. Along these lines, conflicting data has been reported for the accuracy of endoscopic ultrasound (EUS) on superficial EAC staging and its role in selecting cases for endoscopic resection. The aim of this study was to investigate the outcome of esophageal EUS for staging of treatment naïve premalignant BE and suspected superficial EAC. Methods: 481 patients underwent esophageal EUS between 1/2006 and 6/2014 at a single tertiary center. Of these, 336 had esophageal EUS for staging of treatment naïve suspected premalignant BE and superficial EAC, including 215 patients with nodular (Paris 0-IIa) BE. All remaining patients with large esophageal masses, squamous cell cancers, patients undergoing neoadjuvant therapy and other unrelated pathologies were excluded (nZ145). The final diagnosis of all 336 patients was verified by pathology reports (endoscopic mucosal resection with or without fine needle aspiration (EMR +/- FNA) nZ201, esophagectomy nZ28, forceps biopsy nZ107). Sensitivity, specificity and the rate of correct EUS staging, under-staging and over-staging were calculated. Results: 336 patients (mean age 68 years, SD 10.3, 86% male) with BE, Prague C mean 2.7cm (SD 3.7, range 0-17), Prague M mean 4.5cm (SD 3.7, range 0-18) were staged by EUS eT0 86%, eT1 1.5%, eT1a 3%, eT1b 8%, eT2 1.5%, eN0 97% and eN1 3%. Corresponding pathology reports revealed premalignant BE in 78% cases (no dysplasia nZ19, LGD nZ81, HGD nZ141, otherZ20) whereas 22% of patients (nZ75) had invasive EAC (T1 1%, T1a 13%, T1b 7%, and T2 1%). (Table 1). Sensitivity, specificity, positive (PPV) and negative predictive values (NPV) for correct EUS T-staging and N-staging were 48%, 95%, 75% and 86% as well as 25%, 88%, 25%, and 88%, respectively; with correct staging in 79%, over-staging in 8% and under-staging in 13%. Limiting results to nodular BE yielded comparable values. The sensitivity, specificity, PPV and NPV of EUS for correct patient selection with tumor stages warranting surgical resection (T1b sm2 or deeper and/or N1) were 56%, 94%, 43% and 96%, respectively. Limitations: Single center, retrospective study, minority of patients (22%) had EAC Strength: Large database with treatment naïve patients, pathology reports available for all patients Conclusion: EUS has a very limited sensitivity for superficial EAC. This corresponds with a high rate (21%) of incorrectly staged patients. In agreement with the latest American College of Gastroenterology (ACG) Barrett esophagus guidelines (November 2015) the management of dysplastic BE and superficial EAC needs to be based on biopsy and/or mucosal resection specimens and not on EUS imaging. Table 1 TMN Stage T Stage, n (%) 0 1 1a 1b 2 N Stage, n (%) 0 1 M Stage, n (%) 0 1
EUS
Pathology
288 (86) 5 (1.5) 11 (3) 28 (8) 4 (1.5)
261 (78) 3 (1) 45 (13) 24 (7) 3 (1)
327 (97) 9 (3)
25 4
335 (99.7) 1
26
475 New Frontiers in Cancer Staging: Microscopic Celiac Ganglia Metastases Naveen Gara*1, Ferga Gleeson1, Mark Topazian1, Barham K. Abu Dayyeh1, Suresh Chari1, Michael B. Farnell2, Prasad Iyer1, Michael L. Kendrick2, Randall K. Pearson2, Bret T. Petersen1, Elizabeth Rajan1, Mark J. Truty2, Santhi Swaroop Vege1, Kenneth K. Wang1, Michael J. Levy1 1 Gastroenterology, Mayo Clinic, Rochester, MN; 2Surgery, Mayo Clinic, Rochester, MN Background: Preoperative tumor staging helps to determine prognosis and guides patient care. Limited surgical and autopsy data demonstrate that malignancy may metastasize to celiac ganglia (CG) thus, negatively impacting survival. Endoscopic ultrasound fine needle aspiration (EUS FNA) now allows visualization and biopsy. Aims: To demonstrate that EUS FNA of CG can detect microscopic tumor spread and to correlate disease staging with non-invasive CT/MRI findings. Methods: Patients with metastatic CG were identified from a prospectively maintained EUS database. Results: Among 191 patients who underwent EUS FNA of CG (10/2004-10/2015), 36 (19%) patients [(18 females), 70 years (41-87)] with microscopic CG metastasis were identified. The cohort was comprised of 27 and 9 patients with positive and suspicious cytology for malignancy, respectively with neural tissue in the absence of lymphocytes. Six (16.7%) patients had a concomitant FNA of celiac lymph nodes interpreted as positive (nZ3) or negative (nZ3) for malignancy with lymphocytes observed in the absence of neural tissue. Trans-tumoral biopsy was avoided and there was no direct primary tumor infiltration to the CG. The primary tumor sites and types included pancreatic adenocarcinoma (PC) (nZ24; 22 newly diagnosed, 2 recurrent), esophageal adenocarcinoma (nZ5), secondary pancreatic metastasis (nZ3; colon, gastric, unknown primary), and 1 each of pancreatic neuroendocrine,
Volume 83, No. 5S : 2016 GASTROINTESTINAL ENDOSCOPY AB149
was recommended iCRCs may have been detected on follow-up colonoscopy. Conclusions: Interval colon cancers are responsible for about 5% of colon cancer diagnoses. Most iCRCs occur in patients with good preps, complete examinations and with small adenomas on index colonoscopy. Adherence to the most recent colonoscopy surveillance guidelines may decrease iCRC cases.
472 Accuracy of Endoscopic Ultrasonography for Staging of T1a and T1b Esophageal Squamous Cell Carcinomas Jung-hwan Lee*, Jong Yeul Lee, Chan Gyoo Kim, Soo-Jeong Cho, Young-Il Kim, Il Ju Choi Center for Gastric Cancer, National Cancer Center, Korea, Goyang, Gyunggi, Korea (the Republic of) Background/Aim: Accurate prediction of invasion depth in esophageal squamous cell carcinoma (ESCC) is essential for the choice of treatment. Endoscopic ultrasonography (EUS) is an essential tool in the assessment of loco-regional staging. However, the role of EUS in distinguishing mucosal (T1a) from submucosal cancer (T1b) in ESCC has not been established. Thus, we conducted a study to investigate the accuracy of EUS in staging T1a and T1b ESCCs and to identify the factors influencing the accuracy of EUS. Methods: We retrospectively reviewed 218 pathologically confirmed T1a or T1b ESCC from 214 patients, who underwent EUS using radial echoendoscope and/or high-frequency catheter probe between August 2006 and August 2015 at the National Cancer Center, Goyang, Korea. Accuracy distinguishing T1a from T1b and sensitivity/specificity for T1a of EUS were examined. Univariate and multivariate analyses were used for determination of the factors related to inaccuracy, overestimation or underestimation of EUS. Result: The overall accuracy of EUS for distinguishing T1a and T1b ESCC was 67.0% (146/218). The sensitivity and specificity of EUS relative to the T1a lesions were 64.9% (63/97) and 68.6% (83/121). Overestimation and underestimation of the invasion depth occurred in 34 (15.6%) and 38 lesions (17.4%) respectively. Multivariate analysis determined that poorly differentiated ESCC [odd ratio (OR): 2.98, pZ0.023], was associated with inaccuracy of EUS. Depressive morphology (OR: 5.39; pZ0.026) and using radial echoendoscope only (OR: 3.12; pZ0.008) were associated with overestimation, whereas poorly differentiated ESCC (OR: 3.12; pZ0.003) was associated with underestimation. Conclusion: The accuracy of EUS in staging T1a and T1b ESCC showed unsatisfactory results. Therefore, many efforts are needed to improve diagnostic accuracy of EUS in staging T1a and T1b ESCCs, especially with poorly differentiated histology.
473 Predicting the Invasion Depth of Differentiated Early Gastric Cancer: Comparison of Narrow-Band Imaging Magnification and Endoscopic Ultrasonography Shuo Zhang*, Bin Lv, Ting-Yuan Li GI Department, The First Affiliated Hospital, Zhejiang Chinese Medical University, HANG ZHOU, ZHE JIANG, China Objective: Predicting the invasion depth of differentiated early gastric cancer(EGC) is important when selecting among therapeutic strategies. The aim of this study was to compare magnifying endoscopy with narrow-band imaging magnification (MENBI) with endoscopic ultrasonography (EUS) for predicting the depth of tumor invasion in patients with differentiated EGC. Methods: This study enrolled 41 patients with EGC (43 lesions) who underwent both ME-NBI and EUS at The First Affiliated Hospital, Zhejiang Chinese Medicine University during 2013–2015. We reviewed the medical records and compared ME-NBI and EUS findings with histopathological results according to clinicopathological factors. Results: A total of 83 lesions in 81 patients were included in the final analysis. ME-NBI and EUS had overall accuracies of 81.4% and 86.0%, respectively, in distinguishing SM1 (invasion depth ＜500 mm) from SM2 (invasion depth 500 mm) cancers. There were no differences between ME-NBI and EUS in terms of sensitivities and specificities in distinguishing SM1 from SM2 cancers (p Z1.000 and p Z1.000, respectively). When both ME-NBI and EUS suggested a SM2 depth of invasion, the frequency of SM1 cancer was only 4.7%. And when both ME-NBI and EUS suggested a SM1 depth of lesion invasion, the frequency of SM2 cancer in the final histopathology was 0%. Conclusion: ME-NBI and EUS are accurate predictors of EGC invasion depth. If both methods used, the accuracy of the prediction is increased. Therefore, when possible, it would be better to evaluate the invasion depth of EGC using both ME-NBI and EUS before deciding to perform endoscopic resection.
474 Endoscopic Ultrasound Staging in Suspected Superficial Esophageal Adenocarcinoma and Its Impact on Endoscopic Resection Strategy Timothy M. Wallace, Michael J. Bartel*, Herbert C. Wolfsen, Massimo Raimondo, Timothy A. Woodward, Victoria Gomez, Michael B. Wallace Gastroenterology, Mayo Clinic, Jacksonville, FL Background: Invasion depth of esophageal adenocarcinoma (EAC) predicts the risk of lymphatic spread, which is likely present in case of T stage T1b sm2 or deeper.
www.giejournal.org
Surgical resection, as apposed to endoscopic resection, is warranted in such cases. Along these lines, conflicting data has been reported for the accuracy of endoscopic ultrasound (EUS) on superficial EAC staging and its role in selecting cases for endoscopic resection. The aim of this study was to investigate the outcome of esophageal EUS for staging of treatment naïve premalignant BE and suspected superficial EAC. Methods: 481 patients underwent esophageal EUS between 1/2006 and 6/2014 at a single tertiary center. Of these, 336 had esophageal EUS for staging of treatment naïve suspected premalignant BE and superficial EAC, including 215 patients with nodular (Paris 0-IIa) BE. All remaining patients with large esophageal masses, squamous cell cancers, patients undergoing neoadjuvant therapy and other unrelated pathologies were excluded (nZ145). The final diagnosis of all 336 patients was verified by pathology reports (endoscopic mucosal resection with or without fine needle aspiration (EMR +/- FNA) nZ201, esophagectomy nZ28, forceps biopsy nZ107). Sensitivity, specificity and the rate of correct EUS staging, under-staging and over-staging were calculated. Results: 336 patients (mean age 68 years, SD 10.3, 86% male) with BE, Prague C mean 2.7cm (SD 3.7, range 0-17), Prague M mean 4.5cm (SD 3.7, range 0-18) were staged by EUS eT0 86%, eT1 1.5%, eT1a 3%, eT1b 8%, eT2 1.5%, eN0 97% and eN1 3%. Corresponding pathology reports revealed premalignant BE in 78% cases (no dysplasia nZ19, LGD nZ81, HGD nZ141, otherZ20) whereas 22% of patients (nZ75) had invasive EAC (T1 1%, T1a 13%, T1b 7%, and T2 1%). (Table 1). Sensitivity, specificity, positive (PPV) and negative predictive values (NPV) for correct EUS T-staging and N-staging were 48%, 95%, 75% and 86% as well as 25%, 88%, 25%, and 88%, respectively; with correct staging in 79%, over-staging in 8% and under-staging in 13%. Limiting results to nodular BE yielded comparable values. The sensitivity, specificity, PPV and NPV of EUS for correct patient selection with tumor stages warranting surgical resection (T1b sm2 or deeper and/or N1) were 56%, 94%, 43% and 96%, respectively. Limitations: Single center, retrospective study, minority of patients (22%) had EAC Strength: Large database with treatment naïve patients, pathology reports available for all patients Conclusion: EUS has a very limited sensitivity for superficial EAC. This corresponds with a high rate (21%) of incorrectly staged patients. In agreement with the latest American College of Gastroenterology (ACG) Barrett esophagus guidelines (November 2015) the management of dysplastic BE and superficial EAC needs to be based on biopsy and/or mucosal resection specimens and not on EUS imaging. Table 1 TMN Stage T Stage, n (%) 0 1 1a 1b 2 N Stage, n (%) 0 1 M Stage, n (%) 0 1
EUS
Pathology
288 (86) 5 (1.5) 11 (3) 28 (8) 4 (1.5)
261 (78) 3 (1) 45 (13) 24 (7) 3 (1)
327 (97) 9 (3)
25 4
335 (99.7) 1
26
475 New Frontiers in Cancer Staging: Microscopic Celiac Ganglia Metastases Naveen Gara*1, Ferga Gleeson1, Mark Topazian1, Barham K. Abu Dayyeh1, Suresh Chari1, Michael B. Farnell2, Prasad Iyer1, Michael L. Kendrick2, Randall K. Pearson2, Bret T. Petersen1, Elizabeth Rajan1, Mark J. Truty2, Santhi Swaroop Vege1, Kenneth K. Wang1, Michael J. Levy1 1 Gastroenterology, Mayo Clinic, Rochester, MN; 2Surgery, Mayo Clinic, Rochester, MN Background: Preoperative tumor staging helps to determine prognosis and guides patient care. Limited surgical and autopsy data demonstrate that malignancy may metastasize to celiac ganglia (CG) thus, negatively impacting survival. Endoscopic ultrasound fine needle aspiration (EUS FNA) now allows visualization and biopsy. Aims: To demonstrate that EUS FNA of CG can detect microscopic tumor spread and to correlate disease staging with non-invasive CT/MRI findings. Methods: Patients with metastatic CG were identified from a prospectively maintained EUS database. Results: Among 191 patients who underwent EUS FNA of CG (10/2004-10/2015), 36 (19%) patients [(18 females), 70 years (41-87)] with microscopic CG metastasis were identified. The cohort was comprised of 27 and 9 patients with positive and suspicious cytology for malignancy, respectively with neural tissue in the absence of lymphocytes. Six (16.7%) patients had a concomitant FNA of celiac lymph nodes interpreted as positive (nZ3) or negative (nZ3) for malignancy with lymphocytes observed in the absence of neural tissue. Trans-tumoral biopsy was avoided and there was no direct primary tumor infiltration to the CG. The primary tumor sites and types included pancreatic adenocarcinoma (PC) (nZ24; 22 newly diagnosed, 2 recurrent), esophageal adenocarcinoma (nZ5), secondary pancreatic metastasis (nZ3; colon, gastric, unknown primary), and 1 each of pancreatic neuroendocrine,
Volume 83, No. 5S : 2016 GASTROINTESTINAL ENDOSCOPY AB149