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Introduction: Endoscopic ultrasound (EUS) is an essential component of pre-operative staging for esophageal cancer. EUS is used to determine which patients should have primary endoscopic or surgical therapy and which should have neoadjuvant therapy prior to resection. However, when the EUS endoscope cannot traverse a tumor, the role of pre-dilatation is controversial. Esophageal dilation of malignant strictures is associated with potential complications including perforation in 15% of cases. The aim of this study was to determine the pathologic stage of esophageal cancer treated by primary surgery without induction therapy when the EUS endoscope could not pass. We hypothesized that when the EUS endoscope cannot traverse the tumor, locally advanced disease (stage III) is present, and these patients should proceed to neoadjuvant therapy without the need for pre-dilatation and EUS staging.
Methods: A retrospective single-institution review was conducted of all patients with esophageal cancer undergoing esophagectomy from August 1988 to June 2012. Patients who received neoadjuvant therapy were excluded. The EUS reports were reviewed to determine which patients had a tumor that could not accommodate an EUS endoscope, and the patients who then proceeded directly to esophagectomy were included for analysis. The pathology results of these patients were classified based on the revised 7th edition AJCC staging system.
Results: A total of 27 patients (22 male: 5 female) had a tumor that would not accommodate the EUS endoscope and proceeded directly to esophagectomy without induction therapy. The histology was adenocarcinoma in all patients. The stages of the patients are shown [Table]. The majority of tumors were T3 (24/27, 89%) and the median number of metastatic nodes was 6. There were no stage I tumors, 15% (4/27) were stage II, 81% (22/27) were stage III, and 4% (1/27) were stage IV due to a resected solitary lung metastasis.
Conclusion: Tumors that cannot be assessed with an EUS endoscope due to tumor stenosis will have locally advanced disease that could benefit from neoadjuvant therapy in 85% of cases. In these situations, pre-dilatation of the tumor with EUS staging could be omitted when considering the risk of potential complications, such as esophageal perforation.