No Additional Value of Bronchoscopy After Eus in the Preoperative Assessment of Patients with Esophageal Cancer At Or Above the Carina
Mark Van Heijl*1, Jikke M. Omloo1, Jacques J. Bergman2, Mia G. Koolen4, Mark I. Van Berge Henegouwen1, Jan J. Van Lanschot1,3
1Surgery, Academic Medical Centre, Amsterdam, Netherlands; 2Gastroenterology, Academic Medical Center, Amsterdam, Netherlands; 3Surgery, Erasmus Medical Center, Rotterdam, Netherlands; 4Pulmonary Diseases, Academic Medical Center, Amsterdam, Netherlands
Introduction: Esophageal cancer is an aggressive disease with a strong tendency to infiltrate into surrounding structures. Especially tumors at or above the carina are associated with early invasion of the tracheobronchial tree, precluding radical surgical resection. Endoscopic ultrasonography (EUS) is considered the most accurate diagnostic modality to determine the T-stage of the tumor. In the preoperative work-up for patients with tumors at or above the carina, it is recommended to perform a bronchoscopy (with biopsy on indication) to exclude airway invasion. Aim of the present study is to determine the additional value of bronchoscopy (with biopsy on indication) for detecting invasion of the tracheobronchial tree after having performed EUS in the preoperative assessment of patients with esophageal cancer at or above the carina.
Methods: Between January 2003 and December 2006, 45 patients were analyzed in our department for histologically proven esophageal cancer at or above the carina. All patients underwent both EUS and bronchoscopy (with biopsy on indication) in the preoperative assessment of local resectability.
Results: After extensive diagnostic work-up 19 of 45 patients (42%) were eligible for potentially curative oesophagectomy. Distant metastases were found in 13 of 26 patients (50%) not suitable for curative surgery. In the 13 other patients (50%) local irresectability (T-stage 4) due to invasion of vital structures was described on EUS: invasion of the aorta in three patients, invasion of the pleura in six patients and invasion of the lung in two patients; in two patients invasion of the tracheobronchial tree was described, which was confirmed by bronchoscopy with positive biopsy results. Therefore, no additional value of bronchoscopy after EUS was seen in this cohort of patients.
Conclusion: For patients with newly diagnosed esophageal tumors at or above the carina, no additional value of bronchoscopy (with biopsy on indication) to exclude invasion of the tracheobronchial tree is seen after performing EUS in a specialized centre. Even though based on small numbers, we conclude that bronchoscopy is not indicated if no invasion of the airways is identified on EUS.
