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FEASIBILITY OF USING SELECTIVE ENDOSCOPIC ULTRASOUND FOR STAGING OF OESOPHAGEAL CANCER
Maged F. Farag*, Ning Lo, Tarig Abdelrahman, Mahmoud A. Abdeldayem, Rhiannon Bowen, Tim Havard, Xavier Escofet, Anita Willicombe
general surgery, cwm taf health board, Merthyr Tydfil, United Kingdom
Introduction:The usage of Endoscopic Ultrasound (EUS) as part of staging Oesophageal and Gastro-Oesophageal junctional (GOJ) cancer is well established.Service constraints of EUS provision by the centralized diagnostic units resulted in potential delays in the staging process and treatment pathways.Recently it has been suggested that the use of selective EUS in patients with T1 and T4b disease on other imaging modalities Computed Tomography (CT),Positron Emission Tomography (PETCT) as it provides consequential additional information for the treatment plan.
Aim: To assess the value of EUS before the start of treatment in Oesophageal cancer patients and analyze the impact of a selective usage of EUS.
Methods: Retrospective analysis of all patients diagnosed with Oesophageal and GOJ cancers from 2000-2016 was performed.As per protocol patients with T1/2N0 disease proceed to definitive treatment.Neoadjuvant therapy is considered in our unit for T1N1 disease and above.T4b disease is considered for palliative treatment.Data collected from prospective databases and statistical analysis performed using SPSS.
Results:645 patients were identified during the study period, of which 253 patients (39.3%) were potentially curable and fully staged with CT, EUS +/- PET-CT.The introduction of PET-CT in the later stage of the study period resulted in 100 patients having triple staging modality. On CT, 23 patients were confirmed T1N0 disease(14 confirmed by EUS), 33 patients were T4Nx disease (24 confirmed by EUS, 2 upstaged to T4b disease).The remaining 197 patients with T2/3Nx disease on CT +/- PET-CT, 5 patients (2.5%) were upstaged to T4b disease with EUS. 14 patients (7.1%) were upstaged by EUS for non regional lymph nodes (LN), however, only 2 of those had PET-CT assessment positive for non regional LNs.For early T1N0 disease, 9 of the 23 patients (39.1%) were upstaged by EUS with change in treatment plan requiring neoadjuvant therapy.33 patients with T4 disease, 7 of which (21%) were upstaged by EUS. 23 patients had T2N0 disease, 14 of those (60.9%) were upstaged with EUS and therefore needed neoadjuvant therapy.The 100 patients who had triple modality for staging, 8 patients (8%) were upstaged by EUS, of which 4 were in the T1N0 disease group, 3 in the T2/3Nx group and 1 patient in the T4Nx group.Significant statistical reduction of EUS related change in management since the introduction of PET (Fisher’s exact test, P= 0.039)
Conclusion:EUS remains an essential tool in staging Oesophageal cancer.Since the introduction of PET-CT in the staging process, EUS related change in management plan has decreased and the value of EUS remains predominately in the T1 and T4b disease.However our data supports the use of EUS in staging T2 disease prior to the start of treatment and therefore we cannot support the use of selective EUS in patients with Oesophageal cancer.
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