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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?

Question

• Would you perform EUS for staging of this cancer

• Answer 1: yes

• Answer 2: no

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

Early Barrett’s cancer: role of EUS

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?

Question

• Would you perform EUS for staging of this cancer

• Answer 1: yes

• Answer 2: no

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

case

Histopathology: T1m3 G1-2 LVI-