how to stage early be cancer - eus or endoscopic...
TRANSCRIPT
Presented by
Institution
How to stage early BE cancer - EUS or endoscopic removal?
St. Antonius Hospital, Nieuwegein Academic Medical Center, Amsterdam
Bas Weusten
case
• 56 y old female patient
• Lung transplant in 2013
• Upper GI endoscopy for dyspepsia
• Bx: carcinoma
• EUS for staging?
Staging of early BE cancer – Why?
Questions to be answered in early BE cancer
• Is endoscopic therapy possible?
• Will endoscopic therapy be curative?
Will endoscopic therapy be curative?
Endoscopic Tx is
only justified if
probability of
LNM ≤
perioperative
surgical mortality
Early BE cancer – determinants of risk of LNMs
• Depth of invasion
• Tumor differentiation
• Invasion into (lymph)vessels
Most determinants can only be assessed on histopathology of the
resection specimen
Potential role of EUS: - Depth of invasion
- Lymph nodes?
Depth of tumor invasion
1000 μm 500 μm
mm
sm
lp ep
m1 m2 m3 sm1 sm2 sm3
T1A T1B
Endoscopic therapy for mucosal (sm1?) tumors only* Can EUS reliably predict depth of tumor invasion?
Early BE cancer – determinants of risk of LNMs
*Pech et al. Gastroenterology 2014;146:652-60 Manner et al. Surg Endosc 2015;29:1888-96
EUS for (early) BE cancer – literature
year journal 1st author EUS beneficial?
2004 GUT May + 2005 GIE Larghi +/- 2008 Endoscopy Chemaly - 2010 Endoscopy Pech - 2010 Surg Endoscopy Thomas - 2011 GIE Pouw - 2011 Ann Thorac Surg Crabtree - 2012 J Gastrointest Oncol Fernandez-Sordo - 2014 Dis Esophagus Bulsiewicz - 2014 J Thorac Cardiovasc Surg Bergeron -
EUS for T staging in esophageal cancer
Esophageal Cancer N=179
Barrett’s cancer n=134 (75%)
Surgical Esophageal Resection
Squamous cell cancer n=45 (25%)
Endoscopic Ultrasonography
Pech et al. Endoscopy 2010;42:456-61
EUS for T staging in esophageal cancer
Pech et al. Endoscopy 2010;42:456-61
Histopathological staging
pT1 pT2 pT3 pT4 Total (n)
EUS
stag
ing
EUS T1 88
EUS T2 35
EUS T3 56
EUS T4
Total (n) 99 30 46 4 179
EUS for T staging in esophageal cancer
Pech et al. Endoscopy 2010;42:456-61
Histopathological staging
pT1 pT2 pT3 pT4 Total (n)
EUS
stag
ing
EUS T1 81 3 4 - 88
EUS T2 17 13 4 1 35
EUS T3 1 14 38 3 56
EUS T4 - - - -
Total (n) 99 30 46 4 179
EUS for T staging in esophageal cancer
Pech et al. Endoscopy 2010;42:456-61
Histopathological staging
pT1 pT2 pT3 pT4 Total (n)
EUS
stag
ing
EUS T1 81 3 4 - 88
EUS T2 17 13 4 1 35
EUS T3 1 14 38 3 56
EUS T4 - - - -
Total (n) 99 30 46 4 179
overstaged 18% 46,7% - -
understaged 10,0% 17,4% 100%
EUS for T staging in esophageal cancer
Pech et al. Endoscopy 2010;42:456-61
Histopathological staging
pT1 pT2 pT3 pT4 Total (n) % correct
EUS
stag
ing
EUS T1 81 3 4 - 88 92%
EUS T2 17 13 4 1 35 37%
EUS T3 1 14 38 3 56 68%
EUS T4 - - - -
Total (n) 99 30 46 4 179 74%
overstaged 18% 46,7% - -
understaged 10,0% 17,4% 100%
Early Barrett’s cancer: role of EUS
Early Barrett’s cancer n=131
EUS unremarkable n=105 (80%)
Endoscopic Resection
Indication for surgery 24% (n=25)
No indication for surgery 76% (n=80)
Pouw et al. GIE 2011;73:662-8
Early Barrett’s cancer: role of EUS
Early Barrett’s cancer n=131
EUS suspicious n=26 (20%)
ER
Endoscopy suspicious 46% (n=12)
Endoscopy unremarkable
54% (n=14)
ER
Indication for surgery 50% (n=7)
No indication for surgery 50% (n=7)
Indication for surgery 75% (n=9)
No indication for surgery 25% (n=3)
Pouw et al. GIE 2011;73:662-8
How to stage early BE cancer - EUS or endoscopic removal?
CONCLUSION I:
• EUS is unreliable in the assessment of depth of tumor invasion in early BE cancer.
EUS for N staging in esophageal cancer
Esophageal Cancer N=179
Barrett’s cancer n=134 (75%)
Surgical Esophageal Resection
Squamous cell cancer n=45 (25%)
Endoscopic Ultrasonography
Pech et al. Endoscopy 2010;42:456-61
EUS for N staging in esophageal cancer
Pech et al. Endoscopy 2010;42:456-61
Histopathological staging
pN0 pN1 Total (n)
EUS
stag
ing
EUS N0 102
EUS N1 77
Total (n) 111 68 179
EUS for N staging in esophageal cancer
Pech et al. Endoscopy 2010;42:456-61
Histopathological staging
pN0 pN1 Total (n)
EUS
stag
ing
EUS N0 82 20 102
EUS N1 29 48 77
Total (n) 111 68 179
EUS for N staging in esophageal cancer
Pech et al. Endoscopy 2010;42:456-61
Histopathological staging
pN0 pN1 Total (n)
EUS
stag
ing
EUS N0 82 20 102
EUS N1 29 48 77
Total (n) 111 68 179
overstaged 26% -
understaged 29%
EUS for N staging in esophageal cancer
Pech et al. Endoscopy 2010;42:456-61
Histopathological staging
pN0 pN1 Total (n) % correct
EUS
stag
ing
EUS N0 82 20 102 80%
EUS N1 29 48 77 62%
Total (n) 111 68 179 73%
overstaged 26% -
understaged 29%
How to stage early BE cancer - EUS or endoscopic removal?
CONCLUSION I:
• EUS is unreliable in the assessment of depth of tumor invasion in early BE cancer.
CONCLUSION II:
• EUS is not reliably enough in the assessment of LNM in early BE cancer
Early BE cancer should be staged by means of histopathological analysis of the endoscopic resection specimen
case
• 56 y old female patient
• Lung transplant in 2013
• Upper GI endoscopy for dyspepsia
• Bx: carcinoma
• EUS for staging?
How to stage early BE cancer - EUS or endoscopic removal?
• If a lesion appears to be resectable by ER, just do it
• If a lesion invades into the muscularis propria
– MBM the band will simpy fall off
– EMR-cap non-lifting sign
• Histopathology of the resection specimen will guide you on further management
– Low-risk and R0-resection endoscopic management
– High-risk and/or R1-resection consider surgery
Practical guidence