Esophageal carcinoma: Clinical TNM endosonography and...

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 echoprobe

(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%

REFERENCES I. Yang GR, Huang 1--1 , Q ui SL,

Chang YM. Endoswpic diagnosis of 115 ca,es of early esophageal carcmoma. Endoscopy 1982; 14: 157 · 61.

2. Yang GR, Qui SL. Endoscopic surveys 111 high-mk and low-risk populatiom for esophageal cancer in C hma with special references co precursors of esophage,11 cancer. Endoscopy 1987; 19:91-5.

J. Endo N, Takemoto T, Sh,rnkahe H. Minute lesions of esophageal cancer. Semin S urg Oncol 1986;2: 177-86.

4 Kahuto T, Taniguchi K, lw,mag,1 T, ct ;ii. Pnmary ,1Jcnn1d cystic carunom,1 nf the <'M>rhagus. Report llf a case. Cancer 1979;4 3:2452-6.

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606

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..~

(21). The results of staging regional

lymph nodes and distant metastas is were comparable to those of the previous study.

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

6.

7.

8.

9

f- Natural h1,rory of earl~ csophage,il ,quamllus Lare mnm,1 ,md early adenocarcinoma of the gastric cardia m the Pcopll'\ Rcpuhlll of China. Endoscopy I 988;20:95-8. I krmanck P, Sob in I 11 TNM Classtfication of Malignant Tum1>urs, 4th l'dn. He,dclhcrg: Spnnger-Yerlag, 1987. Sohm LI-I, I lcrmanek I\ Hutter RVP. TNM-class1f1Gtt11m of malign.mt tumours. A n>mpans,111 hctwel'n the nc\\. ( 1987) and tlw old l'dll111ns. C ancer 1988;6:21 I 0-4. J.,panl'sc Comm1ttl'e for Rcg1str,ir11111 of bophagcal Carcmoma A pmpos.il for a new TNM d,tsstfll,ll l1>n of l',1>rhag1:al L,m:inom,1. Jrn J Clin Onwl 1985; 14: 385 41 0. Picu, D, Halfr DM, K11d1lcr RE, Roper

performed dunng ., routine endoscorlC procedure.

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) .

Cl, (.)\,<'11 JW Compuu:d romo~r:1rhy m tlw st agmg of l''-Ophagt·al Cilrcinom.1 Radiology 198 3; 146:43 3-8.

I 0. Q uit I .M. G lazer GM, Omngcr MR, Gross Bl-I. bnph,iJ.?cal c.1rcmom,1: Comput<'d tomography fimlmgs. Radiology 1985; l 55: l 7 1-5.

11. Tio TL, Tytg,11 UNJ. Endoscopic ultrasonogr.1phy m the """"rncnt of 1111ra- and transmural mf1lira1mnof 1u1111nir, 111 thl· oc,ophagu, ,mJ pap,11.i of V,1rcr .md 111 r he detl't 110n of cxttl· oe,oph,tgl·al lesions. Endn,cnpy 1984; 16:203-10.

12. Tio T l , Tytgat GNJ. Lmlmrnp1c uh n,onognphy of norm.ii .111J pathologK uppt•r gastro1ntt·,11n,il w,111 st ruuure. Compam nn of st ud1es 111

\'l\'o .mJ 111 \'ltm with htstolng~ ~caml J Ga,tnl\'nrerol 1986;2 I

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(Suppl 123):27-H l 3. Tio TL, T yrg;1r GN J. EnJoscopic

ultrasonography in analysing pcri1ntcstinal lymph noJc abnormality. ScanJ J Gasrrocntcrol 1986;2 l (Suppl 123 ): l 58-6 3.

14. Tio TL, <len I hmog Jagcr FCA, Tytgat GNJ. EndnscopiL ultra,onogrnphy uf non-1 lo<lgkin lymphoma of the )tomach. Ga,trm:nrcrology 1986;9 l :401 -8.

15. Tio TL, den I la nog Jager FCA, Tyrgat GNJ. The role of cndoswpic ulrrasonography m asscssmg local rescccahd1ty of csophcigoga,rnc mal1gnanc1cs. Accuracy, pirfall, and pn:d1ct· ability. Scam! J Gastmcntcml 1986;21(Suppl 123):78-86.

16. Tio TL, Tytgar GNJ. Atla, ofTrnns-

111tcst111al Ultrasonogrnphy. Aabmcer: Mur-Krn,rverloren, 1986.

17. Takemoto T, Aibc T, Fu11 T, Okirn K. Endnscopic ulrrasonogr.iphy. C lin Gastrocntcml 1986; 15: 305-19.

18. Murarn Y. Munll M, Yoshida M, Ide 11, Hanyo F. Endoscopic ultra,onogrnphy in the diagno:,ii, of esophagc-al carcmoma. Surg Endosc. 1987; I: 11 -6.

19 Y,1suda K, Kiynta K, Nakay11na M, K,1wa1 K. F11ndamcnrals of cnd,,,cop1c. laser thl'rapy for (,l-rnmnurs. New ,,spcu with cnJoscopic ulrrasonogrnphy (EUS). Endoscopy 1987; 19:2-6.

20. Tiu TL, Cohen P. Cocne PP, Ud<ling J, den Hartog J,1gc.·r FCA, Tytgat GN J. EnJosonography and computc<l tollll>

grnphy of csoph,1gcal carcmoma:

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.

22. Parisi AF, Nieminen M, O'Boyle JE. Enhanced Jetl'CI 1011 of rhc cvaluaunn of ri,.,ui: changes after ac.ucc myoc.ardi;1l mfarcrnm 11sin1,: colnur encoded l wo J1mi:11S11H1al echornrdiogrnphy Ci,culauon 1982;66: 764-70.

21- Marrin RW, l]ilhi:rr DA, 'itlvn,trn, FF, Uchernc.• M, Ty1ga1 UNJ. An cnclosul('ll [)opplcr prnht tm assessing 111-tcsrinal vasculmuri:. UltrcismmJ Med Bwl l983;1 l:61 -9.

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