Routine staging with endoscopic ultrasound in patients with obstructing esophageal cancer and dysphagia rarely impacts treatment decisions
Endoscopic ultrasound (EUS) has been routinely utilized for the locoregional staging of esophageal cancer. One important aspect of clinical staging has been to stratify patients to treatment with neoadjuvant chemoradiation or primary surgical therapy. We hypothesized that EUS may have a limited impact on clinical decision making in patients with dysphagia and obstructing esophageal masses.
This retrospective cohort study included all patients with esophageal adenocarcinoma undergoing esophageal EUS between July 2008 and September 2013. Dysplastic Barrett’s esophagus without invasive adenocarcinoma or incomplete staging was excluded. Patient demographics, endoscopic tumor characteristics, the presence of dysphagia, sonographic staging, and post-EUS therapy were recorded. Pathologic staging for patients who underwent primary surgical therapy was also recorded. Locally advanced disease was defined as at least T3 or N1, as these patients are typically treated with neoadjuvant therapy.
Two hundred sixteen patients underwent EUS for esophageal adenocarcinoma, with 147 (68.1%) patients having symptoms of dysphagia on initial presentation. Patients with dysphagia were significantly more likely to have locally advanced disease on EUS than patients without dysphagia (p < 0.0001). Additionally, 145 (67.1%) patients had a partially or completely obstructing mass on initial endoscopy, of which 136 (93.8%) were locally advanced (p < 0.0001 vs. non-obstructing lesions).
An overwhelming majority of patients presenting with dysphagia and/or the presence of at least partially obstructing esophageal mass at the time of esophageal cancer diagnosis had an EUS that demonstrated at least locally advanced disease. The present study supports the hypothesis that EUS may be of limited benefit for management of esophageal cancer in patients with an obstructing mass and dysphagia.
KeywordsEndoscopic ultrasound Esophageal cancer Dysphagia Staging
Research reported in this publication was supported by the National Institutes of Health Awards T32-CA090223.
SAM, KAP, and JPW were involved in study conception and design. SAM, SE-D, SGK, KAP, and JPW acquired the data. SAM, SE-D, SGK, KAP, and JPW analyzed and interpreted the data. SAM, KAP, and JPW drafted the manuscript. SAM, SE-D, SGK, KAP, and JPW critically revised the manuscript for important intellectual content. SAM, and KAP performed all the statistical analyses.
Compliance with ethical standards
Sara A. Mansfield, Samer El-Dika, Somashekar G. Krishna, Kyle A. Perry, and Jon P. Walker have no conflicts of interest or financial ties to disclose.
- 2.Ajani JA, D’Amico TA, Almhanna K, Bentrem DJ, Besh S, Chao J, Das P, Denlinger C, Fanta P, Fuchs CS, Gerdes H, Glasgow RE, Hayman JA, Hochwald S, Hofstetter WL, Ilson DH, Jaroszewski D, Jasperson K, Keswani RN, Kleinberg LR, Korn WM, Leong S, Lockhart AC, Mulcahy MF, Orringer MB, Posey JA, Poultsides GA, Sasson AR, Scott WJ, Strong VE, Varghese TK Jr, Washington MK, Willett CG, Wright CD, Zelman D, McMillian N, Sundar H, National comprehensive cancer network (2015) Esophageal and esophagogastric junction cancers, version 1.2015. J Natl Compr Cancer Netw 13:194–227CrossRefGoogle Scholar
- 3.Wallace MB, Nietert PJ, Earle C, Krasna MJ, Hawes RH, Hoffman BJ, Reed CE (2002) An analysis of multiple staging management strategies for carcinoma of the esophagus: computed tomography, endoscopic ultrasound, positron emission tomography, and thoracoscopy/laparoscopy. Ann Thorac Surg 74:1026–1032CrossRefPubMedGoogle Scholar
- 9.Ripley RT, Sarkaria IS, Grosser R, Sima CS, Bains MS, Jones DR, Adusumilli PS, Huang J, Finley DJ, Rusch VW, Rizk NP (2016) Pretreatment dysphagia in esophageal cancer patients may eliminate the need for staging by endoscopic ultrasonography. Ann Thorac Surg 101(1):226–230CrossRefPubMedGoogle Scholar
- 20.Findlay JM, Bradley KM, Maile EJ, Braden B, Maw J, Phillips-Hughes J, Gillies RS, Maynard ND, Middleton MR (2015) Pragmatic staging of oesophageal cancer using decision theory involving selective endoscopic ultrasonography, PET and laparoscopy. Br J Surg 102(12):1488–1499CrossRefPubMedGoogle Scholar