CARCINOMA OF THE ESOPHAGUS
Esophageal carcinoma: Clinical TNM staging with
endosonography and computed tomography
TL TIO, MD, PHO, FCA OEN HARTOG JAGER, MD, PPLO COENE, MD
ABSTRACT: The prognosis of esophageal carcinoma has remained poor despite improvement of diagnostic modalities. Endosonography and computed tomography were performed for preoperative TNM staging (clinical TNM) of esophageal carcinoma. Endosonography was superior to computed tomography for diagnosing early stages and nonresectability of carcinoma. Endosonography was also superior to computed tomography in diagnosing regional lymph node metastases. For diagnosing nonmetastatic lymph nodes, however, computed tomography was superior. Endosonography was superior for diagnosing celiac lymph node metastases but less accurate in detecting liver involvement. Endosonography was accurate for clinical TNM staging of esophageal carcinoma. The possibility of performing cytology and biopsy will further enhance the diagnostic value of endosonography. Can J Gastroenterol 1990;4(9):603-607
Key Words: Clinical TNM staging, Computed wmography, Endosonography, Esophageal carcinoma
Le role de l'endosonographie dans le cancer de l'oesophage: La classification TNM clinique
RESUME: Le pronostic du cancer de l'oesophage reste mauvais malgre l'amelioration des modalites diagnostiques. L'endosonograph ie et la tomographie assistfr par ordinateur ont ete effectuees pour la classification pTNM (TNM clinique) des cancers de l'oesophage. L'endosonographie s'est averee superieure a la tomographic assistee par ordinateur clans le d iagnostic des cancers aux stades precoces el de la no n-resecabilite des tumeurs. L'endosonographie etaic egalement superieure a la tomographic assistee parordinateur pour diagnostiquer
Academic Medical Cemer. Department of Gastroenterology-He/mwlogy, Amsterdam. The Netherl.ands
Correspondence and reprints: Dr TL Tio, Academic Medical Center, Department of Gastroenterology-Hepawlogy , Meibergdreef9 , I 105 AZ Amsterdam, The Necherl.aruk Telephone 020 - 566 9 I 11 , Fax 020 - 566 4440
CAN J GASTROENTEROL VOL 4 No 9 DECEMHER 1990
ESOPI IACiEAL CARCINOMA IS USUal I y diagnosed in late stages. The
prognosis of advanced carcino ma is poor. Early stages of lhe disease are incidentally found in the evaluation of patients with dysphagia. Early esophageal carcinoma is defined as carcinoma localized in the mucosa or submucosa with no evidence of lymph node involvement. A large series nf patients with ea rl y esophageal cancer was reported in China and Japan ( 1-5 ). TNM classification ha~ been widely used for staging esophageal carcinoma (6-8). The depth of tumour infiltration is used as the crite rion for staging tumour categories. The defini tion of regional lymph nodes has been modified and lymph node classification simplified. Computed tomog raph y is widely used for staging esophageal carcinomas. The accuracy of computed tomography, however, is variable (9,10).
Endosonography - endoscopic and nonoptic sonography via the gastrointestinal lumen - has been reported to be accurate (or staging esophageal carcinoma because of its ability LO image the individual layers o( the gastrointestinal wall ~t ruct ure ( 11- 19). The
603
Tiner al
le~ mernsrnscs J es ganglions lymphatiques. P()ur le Jiagnost IC Jes gangliom lymphatiques non mcrnsrnsiqucs, toutefois, la tmnograph1c assistfr parorJinatL'Ur ctait supcricure. L'endosonographie etait supcrieure pour le diagnostic Je5 metastases Jes gangltom lymphauqucs celiaqucs mais moms cff1cacc Jam la Jctect1on Jc l'attc1nte hcpat1que. L'cndosonograph1c s'est avercc efficace dans la classification TNM cliniquc Jes cancers Jc l'ocsophagc. La possibilirc de proceder a unc cytnlogie et i'I une b1ops1e augmcntc encore la valcur Jiagnosuque de l'cnJosonngraphic.
Figure I) Ari Olym/>11 , echoendmcc>/l<! ( EU-M3) loaded u•rrli a small echoprobe (e) and a switch for changm,: the ulcra.1ow1d f reLjW!nn from 7.5 w 12 MH, A scl.:ro.1mi: needle ( n) passes through the ms1nm1ental chwmd }or as/nrauon cywlogv . h Clumnd for fillmg the halloon mth u·att·r
Figure 2) A flexible nm1opuc Aloka 11/crasomc instrument wich a small echoproll<! (c) at the ti/>
TABLE 1
authors have heen usmgOlympust'Cho, endoscopes EU-M2 and EU-M3 (Figure l ). Thc latteremitsa hiopsychannelfor cycolog1cally guided punc.ture nr b1opi1 For a nonopttc flexible mstrument, tht a uthors have heen usmg an Aloka protmyre (Figure 2). Relently, a ,mall rnthetc-r echoprohc bL·c.1mc available (Figure 3). Tahle L summarim tl-t spec 1fic.auons of these 11Ht nnnents.
TECHNIQUE OF INVESTIGATION
The mvesttgatton technique 1,com, parable to gastrmcopy a(ter local oro, pharyngeal anesthesia and 1mraveno1 sedation with m1dazolam. Sedat1on 1,
necessary hecattSl' of the discomfort of mtroduung thc ng1J lip of the 1t1'tru
mcnt mto the pharynx and 1tN1ffla11n~ the hallonn fixed at tlw ec.hoprobe wirh water. The pm 1cnt IS lymg 111 the lcn lateral dccuh1tw, position. The 1mtrument has w he imroduccd blinJly 1-,e.
causc side-viewing opt ics do not allll\\' enJosuipic \ 1sual1:a1 ion 11f the esophagus. The 1m1 ruml'nt should ~ introduced into the stomach whcnc1cr posS1hle rn v1sua l1ze the perigastrK lymph nodes, pam cu larly the ccl1ac lymph nodes (M=Discant metast,1,11) Images C1)mparable to cross ~cctional computed tomography cuts are used for standardizat ion of cndosonography In·
vestigarion. The 1mtrument is ,lowh withdrawn until thc mfiltrat 111g abnormality with adjacent lymph noJc, 1, imaged sonographically. In the c,1se ci severe stenos1s, which locs not allo" passage of the ec.hoendoswpc, ,l tl1:x1hle
Technical data of the Olympus echoendoscopes used for clinical TNM staging of esophageal carcinoma EU-M2 EU-M3 VU-M2 (video) Catheter echoprobe
Endoscope Side-viewing Side-viewing Side-viewing Forward-viewing (GIF
Echoprobe
Length (mm)
Diameter (mm) Frequency (MHz) Depth of
penetration (cm)
Mechanical sector or radial scanning ( 180° or 360°)
42
13 7.5 10
Axial resolution (mm) 0.2 EUS-guided No
puncture/biopsy ·sw,tchoble frequency EUS Endoullrosonogrophy
604
Mechanical sector or radial scanning ( 180° or 360°)
42
13 7.s112·
10/3
02/012 Yes
Mechanical sector or radial scanning (180° or 360°)
44
104 7.5 10
02 No
Ill 0/GIF-IT20) Catheter echo- probe
(360° rodiol scanning)
In total 140 cm with the catheter
3 7 3
? No
CAN J (,N,TRl1ENTl·Rl1L Vrn 4 Nl) 9 DH EMI\ER 199J
Figure 3) A minicatheter echoprobe ( e) passing chrough the mstmmenta1 channel of a large calibre gascroscope for endoscop,c-guided sonography
nonoptic instrument or an endoscopicguided catheter cchopmhe can be used.
INTERPRETATION OF ENDOSONOGRAPHIC IMAGES
Sonographic interpretation of gastrointestinal wall suuct ure and perigastrointestinal lymph no<les is based on results obtained through detailed examination of resected specimens and autqisy materials. In essence, endosonography visualizes a five layer structure, which shows close corrdation with wall histology. An esophageal carcinoma is imaged as a hypoechoic echo pattern with partial or total destruction of the normal architecture. Endosonography criteria for assessment of the depth of tumour infiltration are summarized in Table 2.
TABLE 2
Cnteria for assessing lymph node metastases are as follows: Lymph nodes with hypoechoic patterns and clearly delineated bnund,1ries are suspicious of malignancy. Direct extension of mural ahnormalities into adjacent lymph nodes is highly suspicious of malignancy (pathognomon1c). Lymph nodes with hyperechoic (echogenic) patterns and indistinctly demarcated boundaries are indicative of benignancy.
COMPUTED TOMOGRAPHY IMAGES
For computed tomography staging pTI and pT2 are grouped together because computed tomography is not able to image the muscularis propria (Tahle 3 ). Thus, distinct inn between these two groups is not possihle.
Endosonographlc criteria for assessment of depth of esophageal tumour Infiltration ES-Tl Hypoecholc tumour localized In mucosa or submucosa ES-T2 Hypoecholc tumour penetrating muscularis propria ES-T3 Hypoecholc tumour with penetration Into adventitla ES-T4 Hypoechoic tumour with penetration Into adjacent structures, eg, aorta.
pericardium. trachea. diaphragm. liver
TABLE 3 Computed tomography criteria for the assessment of depth of esophageal lumour infiltration CT-Tl (p T 1 + p T2) Wall thickness approximately 10 mm CT-T2 (pT3) Wall thickness greater than 10 mm with no evidence
of invasion Into adjacent structures (presence of fat plane) CH3 (p T 4) Woll thickness greater than 10 mm with evidence of
Invasion into adjacent structures (no fat plane) For computed tomography staging, pTl and pT2 are grouped together because computed tomography is not able to image the muscutarls proprta
CAN J GASTROENTEROL VOL 4 No 9 DECEMBER 1990
TNM staging of esophageal carcinoma
COMPARISON BETWEEN ENDOSONOGRAPHY,
COMPUTED TOMOGRAPHY AND HISTOLOGY
Recently, a prospective study was performed with en<losonography and computed tomography in 74 patients with esophageal carcinoma (20). The resul ts of this preoperative study were correlmed with the histology of rcsected specimens according to the new ( 1987) TNM classification.
In the assessment nf the depth of tumour infiltration, cndosonography b more accurate than computed tomography in diagnosing e.1rly stages (Tl + T2) and nonresecrahili1y (T4) of disease (Figures 4,5). The accuracy of endosonography 1n diagnosing Tl carcinoma was 88% and T2 carcinoma 78%. The overall accurac.y of endosonography and computed tomography for d iagnosing early stages (Tl and T2) were 82% and l Hh, respectively. The acc.uracy of endosonography anJ computed tomography in diagnosmg T4 carcmoma was 90% anJ 64%, rcspect1vdy. In diagnnsmg T3 carcinomas the accuracy of endosonography was 93% versus 88°4, for computed tomography. This difference was not significant (P=0.48).
En<losonography is more accurate than computed tomography in diagnosing metastatic involvement of regional lymph noJc~ vcrsu~ nonmetastatic lymph node~ (Figure 6). In contrast , computed tomography 1s more accurate in determining the prc~ence of bcnign
Figure 4) Endosonogram of a smnll intramural eso/Jhageal carcmmna ( r) penerratmg into the musculam pro/ma (mp) localized ventrally . wb Water-fill~d balloon; ao Aorca
605
T1ocral
Figure 5) Endosonogram of a transmural carcinoma ( t) wnh penerracum chrough che muscu luris propria (mf>) mw the 11djacen1 ad11en1itia, and a hypoechoic, clearly demarcated lymph node (In) (d1ame1er8 mm) sttS/)eC!
for mcrasiatic 111110!11emcn1 . la Lef1 arrium
lymph nodes. Clm1cally, the Jiagnrn,1s of lymph node metastasis is essential to
select ion of appropriate patients for surgery (Figure 6).
Endosonography 1s more nccuratc than computed tomography in dingnosmg celiac lymph node metastasis (distant meta.~tasis). Computed tomography,
however, is more accurate tha n cndosonography m diagnos ing live r metas
tasis b~ause of the l1m1ted penetration depth of ultrasound.
In another study with a more extensive series of patients (n=9 l) the ac
e u ra cy of encloso nogrnph y in diagnosing Tl carc inomas was 82%, T2
c;ucinomas 85%, T 3 carcinomas 94% and T4 carcinomas 92%. Overscaging
occurred 1n 6''.{, and understaging in 4%
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Figure 6) A Endmonogram of an ex1ensit•e esoplwgeal cc,rcmonl(I ( c) wuh pene1m1io11 imo rh~CIQl'lj] ( ao). la Lef1 amum. B Corresponding compuced tomography shows somr 1h1c~'11111g of the csoi. wall ( c) ad1acem w the aorta wllh a f eedmg wbe (f) m the esof1hagu..~
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CONCLUSIONS Endosonography is more acLuratc
than computed tomography in the preoperative TNM c lass ifica ttn n o t
esophageal c.arcinoma. l lowever, inadequate examinatio n of e nJosonn
graphy can occ.ur in the presence o f severe stenosis. Suc h obstructive tumours <lo not limit the role o f computed tomography scanning. The recently available catheter echoprohe is prom1smg for the staging of severe obstructed esophageal carc inoma. Moreover, endosonography stag mg can be
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Endosonography 1s accurate for~t.1g· ing esophagea l carcinomas inJcpcn, dent of their loca l 1zation Computed
tomography ts not as rcliahlc for staging Larcinoma at tht• esnphagocarJial 1110
uon as for staging esophage;i I ca rc1rurn The mutme U':,C tf cndosonography-gwJ. I cytok)!..ry for tissue Jiagi1os1s, part1cul 111
lymph node metastasis, will further en,
hance the J1agnos t1c va lue of cnclosonography. Moremcr, the cnm h I nauon of cndosonography and Doppler probe, which has alrcaJ} hten introduced m cardiology, will funh, · m crease l he va lue of endnsonograph1 in assessing va scular ahnmmalit1e, (22,23) .
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CAN J GA~'TROENTEROL VOL 4 NO 9 DECEMBER 1990
TNM staging of esophageal carcinoma
Preopcrm 1ve da,s1hcat11in comp,m::d w chi: ni:w ( 1987) TNM c.l.,~,1fo:ar1on. C.,ast rncnrcrolngy 1989;96: 14 78-tl6
21. T io TL, Coenc PPLO, Schouwmk M l I, T y1ga1 GNJ. EwphagogamiL c;1rcmllma: Prcopi:rativc TNM clas.,if1cation wi th cndn,onogrnphy. Rad1nl11gy 1989;173:411 -7.
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