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7057 Esophageal dilation for stenotic esophageal cancer prior to eus. is it still contraindicated in 1999?
7056 ANALYSIS OF ENDOSCOPIC APPEARANCE AND A RE-STAGING ENDOSCOPIC ULTRASOUND (EUS) AFTER NEO-ADJUVANT THERAPY IN THE MANAGEMENT OF ESOPHAGEAL CANCER (EC). Girish Mishra, Stephen Vogel, Greg Lauwers, Robert Marsh, Robert Zlotecki, Manoop S. Bhutani, Univ of Florida, Gainesville, FL. Background: EUS has established itself as the most accurate pre-operative staging modality for EC. Its utility in assessing response after neo-adjuvant therapy has been less promising. Aims: To determine whether the initial EUS T-stage predicts response to neo-adjuvant therapy and if the endoscopic appearance at the time of a re-staging EUS correlated with pathology from the resected specimen (pTNM). Methods: 32 patients (27M, 5F, av age 63.9±10.3) with EC underwent an esophagectomy between 7/98 and 11/99 after neo-adjuvant therapy. A staging EUS was performed followed by a repeat EGD and EUS prior to surgery. Results: 19 patients (16 adeno, 3 SCCA) had an EUS prior to neo-adjuvant therapy for EC. 17 patients underwent an EGD with 15 undergoing concomitant EUS after receiving neo-adjuvant therapy. 14 patients underwent an esophagectomy. 50% (5/10) of T3 lesions and 57% (4/7) of T2 lesions had no mass by EGD after neo-adjuvant therapy (NS). The presence of a mass at EGD after neo-adjuvant therapy had the following sensitivity, specificity, positive predictive value, and negative predictive value for detecting tumor in resected specimens: 80%,100%,100%, and 90%. A re-staging EUS was unable to correctly downstage 54.5 % (6/11) when compared to pTNM. 86% (6/7) of patients downstaged to at least T2 by a re-staging EUS had no tumor in the resected specimen. Conclusions: Response rates to neo-adjuvant therapy appear to be equal in patients staged either T2 or T3 by EUS. The absence of a visible mass by EGD after neo-adjuvant therapy has a NPV of 90% for detecting tumor in the resected specimen. Although the ability of EUS to assess response to neo-adjuvant therapy remains poor, EUS may help in identifying a subset of patients who have a low likelihood of residual EC if downstaged to T2.
Performance Characteristics of EGD Post Chemotherapy + RT Sensitivity Specificity PPV NPV
80% 100% 100% 90%
7057 ESOPHAGEAL DILATION FOR STENOTIC ESOPHAGEAL CANCER PRIOR TO EUS. IS IT STILL CONTRAINDICATED IN 1999? Kiranpreet S. Parmar, Joseph B. Zwischenberger, Irving Waxman, The Univ of Texas Med Branch, Galveston, TX. Background/Aim: Endoscopic ultrasound (EUS) has become a valuable tool in the staging of esophageal carcinoma. However, a complete examination is precluded in 20-38% of cases due to a high grade stricture at time of initial presentation. Dilation and endosonographic staging in these patients has been associated with a 25% perforation rate. In patients in whom a complete evaluation is performed, a correlation has been shown between preoperative EUS findings and the survival and surgical outcomes. Due to advancements in echoendoscope design and improvement in dilation accessories, we reviewed the outcome of patients with malignant stenotic esophageal cancer who underwent endoscopic esophageal dilation prior to EUS staging. Methods: This was an analysis of 25 patients who presented to our institution (4/98 - 11/99) for evaluation of esophageal carcinoma. The patients with stenotic esophageal carcinoma were dilated using serially inflated TTS (through-the-scope) balloon dilators. Immediately after the dilatation, a radial and then curvi-linear array echoendoscope were passed and imaging performed. If suspicious lymph nodes were seen, they were biopsied and then examined by a cyto-pathologist present in the room during the procedure. Results: Of the 25 patients, 10 (40%) had strictures preventing passage of a diagnostic endoscope and required dilatation. Nine
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GASTROINTESTINAL ENDOSCOPY
out of the 10 (90%) dilations were successful. The dilatation range was 12mm to 16mm. All of the 10 cases were staged by EUS. Three (30%) were stage IV diagnosed by positive celiac lymph node fine needle aspiration (FNA), one (10%) was staged as IIB and six (60%) were staged as III. One tumor out of 10 was understaged. There were no complications due to dilatation. Thirteen patients (52%) underwent nodal FNA. Nine (69%)that were positive, 7 (78%) were celiac nodes and were diagnosed as stage IV disease. Two patients (22%) had positive para-esophageal nodes and were also found to have metastatic disease and, therefore, stage IV cancers. Four out of 13 (31%) FNA’s were negative and 3 (75%) out of 4 were truly negative when compared to resection specimens. Conclusion: EUS after dilatation changed management in 30% of the patients with high-grade esophageal stenosis by demonstrating celiac node metastasis. These patients underwent chemo-radiation instead of surgery. The accuracy rate of FNA was 92%. In summary, recent modifications in scope design and dilatation accessories have improved our ability to safely perform complete esophageal cancer staging.
7058 EFFICACY AND SAFETY OF ESOPHAGEAL DILATION FOR ENDOSONOGRAPHIC EVALUATION OF MALIGNANT ESOPHAGEAL STRICTURES Patrick R. Pfau, Gregory G. Ginsberg, Ronald Lew, Michael Kochman, Division of Gastroenterology, Hosp of the Univ PA, Philadelphia, PA; Div of Gastroenterology, Hosp of the Univ PA, Philadelphia, PA. Endoscopic ultrasound (EUS) is accepted as the most accurate modality for T- and N-staging of esophageal cancer, but some malignant strictures prevent echoendoscope passage beyond the level of the tumor, and this may decrease staging accuracy. Previous studies have yielded conflicting results regarding the safety of esophageal dilation for endoscopic ultrasound. We prospectively evaluated patients undergoing EUS for the staging of esophageal cancer to determine the incidence of patients with strictures requiring dilation, the safety and efficacy of dilation, and the utility of performing EUS staging after dilation. Methods: 267 consecutive patients undergoing EUS for esophageal carcinoma staging at our institution over a 66 month time period were evaluated. If a stricture was present at the time of endoscopy that precluded passage of the echoendoscope, stricture diameter was measured, and the stricture was dilated in step wise fashion until a diameter of 14-16 mm was reached or unacceptable force to bypass the stricture was encountered. EUS staging was performed after dilation. Staging accuracy was determined in the subset of patients who underwent surgical exploration. Results: Among 267 endosonographic exams of the esophagus, 81 (30.3%) required dilation to advance the echoendoscope beyond the level of a stricture. Mean pre-dilation diameter was 8.5mm, mean post-dilation diameter was 14.0 mm. After dilation was performed, the echoendoscope could be passed through the stricture in 69 patients (85.2%), and in 63 of 67 patients dilated to at least 14 mm (94.0%). Of the fourteen patients dilated to less than 14 mm the echoendoscope could not be advanced beyond the stricture in eight (57. 1%). No complications have occurred secondary to the dilations performed in order to permit completion of the endosonographic exam. Tumor staging by EUS after dilation was T2 (14.8%), T3 (56.8%), T4 (21.0%); nodal staging N0 (14.6%), N1 (75.3%); and M1/ distant nodes (9.9%). T-stage accuracy was 61 %, N-stage accuracy was 74%. Conclusions: 1)Dilation of malignant strictures to 14 mm is safe and effective in permitting echoendoscope passage beyond the stenosis. 2) EUS T-staging accuracy for esophageal cancer is slightly lowered if a stricture is present but N stage accuracy is unchanged compared to established norms. 3) A small but significant % of patients have treatable, resectable disease (T2, N0) identified only after dilation and EUS exam. 4) Dilation and EUS staging is also needed to identify the 10% of patients with celiac axis or distant nodes prohibiting resection.
VOLUME 51, NO. 4, PART 2, 2000
Performance Characteristics of EGD Post Chemotherapy + RT Sensitivity Specificity PPV NPV
80% 100% 100% 90%
7057 ESOPHAGEAL DILATION FOR STENOTIC ESOPHAGEAL CANCER PRIOR TO EUS. IS IT STILL CONTRAINDICATED IN 1999? Kiranpreet S. Parmar, Joseph B. Zwischenberger, Irving Waxman, The Univ of Texas Med Branch, Galveston, TX. Background/Aim: Endoscopic ultrasound (EUS) has become a valuable tool in the staging of esophageal carcinoma. However, a complete examination is precluded in 20-38% of cases due to a high grade stricture at time of initial presentation. Dilation and endosonographic staging in these patients has been associated with a 25% perforation rate. In patients in whom a complete evaluation is performed, a correlation has been shown between preoperative EUS findings and the survival and surgical outcomes. Due to advancements in echoendoscope design and improvement in dilation accessories, we reviewed the outcome of patients with malignant stenotic esophageal cancer who underwent endoscopic esophageal dilation prior to EUS staging. Methods: This was an analysis of 25 patients who presented to our institution (4/98 - 11/99) for evaluation of esophageal carcinoma. The patients with stenotic esophageal carcinoma were dilated using serially inflated TTS (through-the-scope) balloon dilators. Immediately after the dilatation, a radial and then curvi-linear array echoendoscope were passed and imaging performed. If suspicious lymph nodes were seen, they were biopsied and then examined by a cyto-pathologist present in the room during the procedure. Results: Of the 25 patients, 10 (40%) had strictures preventing passage of a diagnostic endoscope and required dilatation. Nine
AB256
GASTROINTESTINAL ENDOSCOPY
out of the 10 (90%) dilations were successful. The dilatation range was 12mm to 16mm. All of the 10 cases were staged by EUS. Three (30%) were stage IV diagnosed by positive celiac lymph node fine needle aspiration (FNA), one (10%) was staged as IIB and six (60%) were staged as III. One tumor out of 10 was understaged. There were no complications due to dilatation. Thirteen patients (52%) underwent nodal FNA. Nine (69%)that were positive, 7 (78%) were celiac nodes and were diagnosed as stage IV disease. Two patients (22%) had positive para-esophageal nodes and were also found to have metastatic disease and, therefore, stage IV cancers. Four out of 13 (31%) FNA’s were negative and 3 (75%) out of 4 were truly negative when compared to resection specimens. Conclusion: EUS after dilatation changed management in 30% of the patients with high-grade esophageal stenosis by demonstrating celiac node metastasis. These patients underwent chemo-radiation instead of surgery. The accuracy rate of FNA was 92%. In summary, recent modifications in scope design and dilatation accessories have improved our ability to safely perform complete esophageal cancer staging.
7058 EFFICACY AND SAFETY OF ESOPHAGEAL DILATION FOR ENDOSONOGRAPHIC EVALUATION OF MALIGNANT ESOPHAGEAL STRICTURES Patrick R. Pfau, Gregory G. Ginsberg, Ronald Lew, Michael Kochman, Division of Gastroenterology, Hosp of the Univ PA, Philadelphia, PA; Div of Gastroenterology, Hosp of the Univ PA, Philadelphia, PA. Endoscopic ultrasound (EUS) is accepted as the most accurate modality for T- and N-staging of esophageal cancer, but some malignant strictures prevent echoendoscope passage beyond the level of the tumor, and this may decrease staging accuracy. Previous studies have yielded conflicting results regarding the safety of esophageal dilation for endoscopic ultrasound. We prospectively evaluated patients undergoing EUS for the staging of esophageal cancer to determine the incidence of patients with strictures requiring dilation, the safety and efficacy of dilation, and the utility of performing EUS staging after dilation. Methods: 267 consecutive patients undergoing EUS for esophageal carcinoma staging at our institution over a 66 month time period were evaluated. If a stricture was present at the time of endoscopy that precluded passage of the echoendoscope, stricture diameter was measured, and the stricture was dilated in step wise fashion until a diameter of 14-16 mm was reached or unacceptable force to bypass the stricture was encountered. EUS staging was performed after dilation. Staging accuracy was determined in the subset of patients who underwent surgical exploration. Results: Among 267 endosonographic exams of the esophagus, 81 (30.3%) required dilation to advance the echoendoscope beyond the level of a stricture. Mean pre-dilation diameter was 8.5mm, mean post-dilation diameter was 14.0 mm. After dilation was performed, the echoendoscope could be passed through the stricture in 69 patients (85.2%), and in 63 of 67 patients dilated to at least 14 mm (94.0%). Of the fourteen patients dilated to less than 14 mm the echoendoscope could not be advanced beyond the stricture in eight (57. 1%). No complications have occurred secondary to the dilations performed in order to permit completion of the endosonographic exam. Tumor staging by EUS after dilation was T2 (14.8%), T3 (56.8%), T4 (21.0%); nodal staging N0 (14.6%), N1 (75.3%); and M1/ distant nodes (9.9%). T-stage accuracy was 61 %, N-stage accuracy was 74%. Conclusions: 1)Dilation of malignant strictures to 14 mm is safe and effective in permitting echoendoscope passage beyond the stenosis. 2) EUS T-staging accuracy for esophageal cancer is slightly lowered if a stricture is present but N stage accuracy is unchanged compared to established norms. 3) A small but significant % of patients have treatable, resectable disease (T2, N0) identified only after dilation and EUS exam. 4) Dilation and EUS staging is also needed to identify the 10% of patients with celiac axis or distant nodes prohibiting resection.
VOLUME 51, NO. 4, PART 2, 2000