Original Contributions
Endoscopic ultrasound cannot determine suitability for esophagectomy after aggressive chemoradiotherapy for esophageal cancer

https://doi.org/10.1016/S0002-9270(99)00040-4Get rights and content

Abstract

OBJECTIVE:

Endoscopic ultrasound (EUS) provides important information in the initial staging of patients with esophageal cancer. With recent modifications in chemoradiotherapy protocols, a significant number of patients have no residual tumor at esophagectomy. The high surgical morbidity and mortality might be avoided if complete response to chemoradiotherapy could be predicted. Previously published clinical trials, with relatively small patient numbers, have suggested that EUS may accurately stage esophageal cancer after chemoradiotherapy. The aim of this study was to verify the accuracy of EUS in staging esophageal cancer after effective chemoradiotherapy.

METHODS:

EUS staging was performed before and after concurrent cisplatin, 5-fluorouracil, and hyperfractionated radiotherapy in 59 patients with newly diagnosed esophageal cancer. All patients underwent subsequent esophagectomy and pathological staging. The accuracy of preoperative, postchemoradiotherapy EUS was evaluated in a retrospective fashion by comparison to pathological staging.

RESULTS:

After chemoradiotherapy, 18 patients (31%) had no residual disease at pathological staging (T0N0). However, EUS correctly predicted complete response to chemoradiotherapy (T0N0) in only three patients (17%). The accuracy of postchemoradiotherapy EUS for pathological T stage was only 37%, and its sensitivity for N1 disease was only 38%. EUS was unable to distinguish postradiation fibrosis and inflammation from residual tumor.

CONCLUSION:

When aggressive preoperative chemoradiotherapy is provided to patients with esophageal cancer, the predictive value of postchemoradiotherapy EUS is inadequate for use in clinical decision making.

Introduction

The role of endoscopic ultrasound (EUS) in the initial evaluation and staging of esophageal cancer is well established. Its unique visualization of the gastrointestinal wall and surrounding tissues allows assessment of depth of tumor penetration (T stage) and regional lymph node involvement (N stage). Data from several institutions indicate that EUS accuracy in determining T stage is approximately 75–90%; its N stage accuracy is approximately 80% 1, 2, 3. Its staging accuracy is superior to computed tomography (CT) scanning (4). Accurate pretreatment staging of esophageal cancer provides important prognostic information. We have recently shown that the presence of regional lymph node metastasis in esophageal cancer is the principal predictor of reduced survival, independent of T stage (5). Information provided by EUS will also guide therapy, as surgery can be avoided if inoperability is reliably determined during initial staging. In the current era of multimodal treatment approaches for locally advanced esophageal cancer, EUS has become the clinical gold standard in staging, a necessity in patient selection and response determination.

As in the pretreatment staging of esophageal cancer, CT scanning, esophagram, and esophagoscopy are poor at assessing T and N after chemoradiotherapy 6, 7, 8, 9. Yet the response to chemoradiotherapy may be crucial in determining the optimal therapy. For example, some patients undergoing chemoradiotherapy may have no demonstrable tumor at esophagectomy. The significant morbidity and mortality associated with esophagectomy might be avoided if EUS could accurately determine which patients were disease free after successful induction chemoradiotherapy. Several series have indicated that EUS can accurately determine T stage after induction chemoradiotherapy 10, 11, 12, 13, 14, 15. However, in the majority of these series, chemoradiotherapy was relatively ineffective, i.e., the vast majority of patients were not significantly downstaged, and few were complete responders (i.e., pathological T0N0 at esophagectomy). Therefore, there are no data in the literature that indicate the ability of EUS to detect a complete response after chemoradiotherapy. In our facility, we have completed a clinical trial utilizing an aggressive chemoradiotherapy protocol, where the rate of complete response (pathological T0N0) was higher than in other clinical series where postchemoradiotherapy EUS was performed. The aim of our study was to determine the accuracy of EUS after this chemoradiotherapy protocol, and specifically, whether EUS would be able to detect a complete response, thereby sparing patients a potentially unnecessary surgery.

Section snippets

Materials and methods

Patients with newly diagnosed squamous cell or adenocarcinoma of the esophagus or gastroesophageal junction presenting over a 4-yr period underwent clinical staging, including physical examination, laboratory studies, pulmonary function tests, barium esophagram, CT scanning of the chest and abdomen, upper endoscopy and endoscopic ultrasound, before entry into a Cleveland Clinic Foundation induction chemoradiotherapy protocol. At the time of initial staging, routine esophagoscopy was performed

Results

A total of 72 patients were initially enrolled. Thirteen patients could not be evaluated for the purposes of this study. Two patients experienced significant medical toxicity related to chemoradiotherapy. In five patients, there was inability to obtain complete endosonographic staging information after chemoradiotherapy for technical reasons (e.g., extreme proximal location of the tumor and patient’s inability to tolerate detailed examination of the area). In four patients, there was no surgery

Discussion

Endoscopic ultrasound is the most accurate technique currently available for pretreatment determination of the T and N stage of esophageal cancer. Accurate determination of response to chemoradiotherapy may be crucial in determining optimal further therapy. For example, the significant morbidity and mortality associated with esophagectomy might be avoided if EUS could accurately determine which patients were disease free after induction chemoradiotherapy. After the chemotherapeutic regimen

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