Published online Jun 16, 2023. doi: 10.4253/wjge.v15.i6.447
Peer-review started: February 24, 2023
First decision: March 24, 2023
Revised: April 8, 2023
Accepted: May 12, 2023
Article in press: May 12, 2023
Published online: June 16, 2023
Endoscopic ultrasound (EUS) has been utilized as the most accurate imaging modality for primary tumor staging in esophageal cancer. Primary tumor staging is key in management as cancers with submucosal invasion warrant esophagectomy while more superficial cancers are managed with endoscopic interventions like endoscopic muscoal resection (EMR) and endoscopic submucosal dissection (ESD). Studies exist that correlate endoscopic parameters with biopsy assessments to identify esophageal cancers with deep invasion in lieu of EUS.
EUS has proven to be useful in identifying advances stage tumors. Its usefulness in early-stage cancers has been more controversial. We wanted to assess how EUS influences management in early-stage esophageal cancers as the presence of submucosal invasion warrants surgery instead of endoscopic intervention.
The objectives of this study included evaluating the diagnostic capabilities of EUS in primary staging of esophageal cancers. We also sought to identify if EUS could reliably discriminate between early-stage cancers with and without submucosal invasion. The study aimed to substantiate endoscopic parameters associated with deep esophageal cancer vs superficial esophageal cancer. Finally, our objective was to determine how often EUS changed management by identifying submucosal invasion in cancers with endoscopic parameters associated with superficial esophageal cancers.
A retrospective cohort study was utilized to assess patients who had undergone primary staging of esophageal cancer via EUS at a tertiary medical center. Case data was gathered via chart review and statistical analysis was conducted to assess the accuracy of EUS, endoscopic parameters associated with deep invasion, and the frequency EUS findings changed management when endoscopic parameters suggested a superficial cancer.
In staging T1b lesions, EUS was specific in ruling in submucosal invasion but had relatively poor sensitivity in ruling out T1b lesions. Endoscopic parameters of tumor size > 2 cm and ulceration were associated with deep invasion (T2 and beyond). The EUS parameter of notable para-esophageal lymph was associated with deep invasion, while on pathology, moderate to poorly differentiated cancers were associated with deep invasion. When known endoscopic signs of deep invasion were not present, EUS altered management from EMR/ESD to esophagectomy in < 5% of cases.
EUS is accurate in staging deep invasive cancers (T2 or beyond) and reliably excludes deep invasive cancers from T1 Lesions. EUS is limited in distinguishing between T1a and T1b lesions. We reinforced that tumor size > 2 cm, lymph node involvement and poor differentiation are endoscopic parameters associated with deep invasion (T2 or beyond). EUS infrequently changes the outcome in the patients based on prior endoscopic features. While EUS may improve accuracy, our data indicates that it rarely finds deep submucosal invasion to warrant esophagectomy over EMR/ESD when endoscopic features suggest a superficial cancer (T1a or more superficial).
Future directions should focus on expanding the external validity of this study through either a larger sample size or prospective cohort analysis. This study also warrants further investigation on modalities for detecting the subtlety of submucosal invasion, including applications of technologies such as photoacoustic or scanning laser acoustic microscopy or optical coherence tomography.