Martin
K. Baker,
MD
#{149} Kenyon
Endoscopic and Gastric E
SOPHAGEAL
and
K. Kopecky
US In the Cancer’ cancer,
gastric
the preoperative
rela-
tively uncommon malignancies in the United States, together were estimated to account for about 3% of new cancer
cases
and
5% of cancer
deaths
Staging
in
1990 (1). Because of this low overall mcidence, general screening for these diseases is impractical in the United States. At the time of clinical presentation, they
and
gastric
The
staging
cancer
most
of esophageal
significant
finding articles
described
is the
capac-
the extent of wall by gastrointestinal malignancy,
invasion
in this
regard,
EUS
proved
has occurred
authors’
in both esophageal in whites, overall
mately
8% and
The
for each
16%,
mainstay
disease
and survival (approxi-
respectively)
of treatment
(1). for
these
diseases remains surgery because resection alone has been shown to provide the best chance for cure. Traditionally, surgery has been offered to all patients whose tumors are potentially resectable, and
therefore,
the
main
goals
of preop-
erative evaluation have been to exclude patients who are unlikely to survive surgery and to identify widespread disease in patients who then could be spared a more aggressive operation if a less
invasive
palliative
treatment
could
be substituted. In this issue of Radio!ogy, Botet describe their use and comparison endoscopic
dynamic
ultrasonography
computed
et al of
(EUS)
tomography
with
(CT) in
data
invasion dicator, pathologic introduced
The
(4-6).
extent
capacity
lymph
nodes and
feature
ered Computed
tomography
(CT),
preoperative . Editorials #{149} Endoscopy, 71.12981 #{149} Esophagus, neoplasms, 71.321, 71.332 #{149} Lymphatic system, neoplasms, 996.8323, 999.8323 #{149} Stomach, CT, 72.1211 Stomach, neoplasms, 72.321 #{149} Stomach, US studies, 72.12989 #{149} Ultrasound (US), tissue
characterization, Radiology
71.321,
71.332, 72.321
1991; 181:342-343
I From the Department of Radiology/114, Veterans Administration Medical Center, 1481 W 10th St, Indianapolis, IN 46202 (M.K.B.); and the Department of Radiology, Indiana University Medical Center, Indianapolis (M.K.B., K.K.K.). Received August 15, 1991; accepted August 16. Address reprint requests to M.K.B. RSNA, 1991 See also the articles by Botet et al (pp 419-425 and 426-432) in this issue.
42
of echo
tex-
by the authors
of adenopathy
in the staging
of esophageal cancer, EUS proved more accurate in identification of adenopathy in the authors’ study of gastric cancer. Because diagnosis of adenopathy with
CT is based
terms:
identification
and illustrated by others (8,9). Previous efforts at tissue characterization with ultrasound (US) have had limited success, and further study is needed to clarify the role of EUS in the characterization of lymph nodes. Although no statistical difference existed in the capacity of EUS and dynamic CT to enable
detection
only
on size,
enlarged.
Although
CT therefore of malignot consid-
current
criteria
for identification of adenopathy with EUS vary, the evolving capacity of EUS to enable guided biopsy of lymph nodes
should only increase regard (5,8,10,11). It should be noted
accuracy that
The authors
in this
in the authors’
The
and study
make
others of gas-
tric cancer by Botet et al contains only nine patients (18%) with surgical stage IV disease-less than half the usual proportion of patients in whom the disease is initially diagnosed at this stage (1).
one
of
the inability with
staging
accu-
often
Why in the
is
staging
and gastric cancer? EUS must combine the
of an experienced
those
endoscopist
of an equally
ultrasonographer doscopist can
probe,
wonder:
more
with
experienced
(8,11). accurately
While place
the ultrasonographer
the enthe US
is needed
to adjust the US machine, guide the endoscopist on the basis of US landmarks, and interpret the images obtained. This situation is similar to intraoperative
sonography,
in which
the combined
skills of a surgeon and sonographer/ sonologist, a long combined learning curve, and a spirit of cooperation are necessary. Although the structure of some radiology practices may make co-
operation
in such
joint
ventures
an at-
tamable goal, mutual involvement may be impossible for others, and this likely accounts for slow acceptance in some centers.
The cost of EUS consists bined costs of endoscopy
of the comand US. This
cost is not insignificant, especially if this procedure does not replace other preoperative staging procedures. The procedure is safe, and the risk associated with it is essentially the risk of endoscopy itself, although EUS will
usually
require
it is easy
as the authors
because
lesion
their
skills
carcinoma,
mentioned.
that
esophageal
EUS not used of esophageal
dure
have
EUS
racy, but other authors have considered this an important limitation and could not bypass lesions in 26%-50% of patients (8,10). These factors aside, the success of
overall comparisons of EUS and CT, some factors in the study favor EUS. A very large proportion of patients (76%) in their study of esophageal cancer had adenocarcinoma, which is more difficult to accurately stage with CT than the statistically more common epidermoid (12)
found
an
Successful
is an additional
of EUS described
cannot enable identification nant disease within nodes Index
in-
normal-sized
on the basis
morphology
favors
in the detection
metastases.
EUS may
of wall
classification
to enable within
bias
EUS did not affect
CT in recent asthe
prognostic in the new
TNM staging in 1987 (7).
of malignancy ture
The
is an important a fact reflected
distant to bypass
statisti-
are usually incurable. Although a statistically significant reduction in mortality cancer low
selection
EUS is insensitive
cally more accurate than dynamic the authors’ study groups. Other reports on the accuracy of EUS in sessment of wall invasion support
gastric remains
This
(2,3).
in these important ity of EUS to define and
of Esophageal
than
more
a typical
time
per proce-
endoscopic
exami-
nation. It is likely that the greatest limitation to use of this technique has been lack of demand for more detailed staging information from the surgeon. Except in some patients with distant metastases, to
forget
that
preoperative
staging often has little impact on the decision to perform or not to perform surgery. The type of operation an mdividual may undergo must often be determined at surgery on the basis of surgical findings, the patient’s condition,
and the training, skills, and operative philosophy of the cancer surgeon.
EUS is here
If the primary tumor in esophageal malignancy is found at surgery to be unresectable for cure, esophagectomy is commonly considered the best form of paffiation in patients with dysphagia (13,14). Other forms of paffiation exist
for esophageal malignancy, dilation, radiation therapy, prosthetic
intubation,
but for unresectable
and
gastric
including esophageal laser
surgery,
cancer,
gery is the only effective palliation can be offered to the patient with
tomatic disease. The impact of preoperative on surgery performed and and ject
mortality to evaluate
greatly value
from
though
staging on morbidity
is therefore a difficult and is likely to vary
surgeon
of CT in staging
has been radiology
to surgeon. these
with
CT has
sub-
The
diseases
a point of controversy and surgery literatures, staging
surthat symp-
in the al-
evaluated, However,
the cornerstone of evaluation of any comparison of different treatment modalities (16,i7).
Volume
181
#{149} Number
2
the technol-
pists are likely sary equipment
8.
to obtain both the necesand skill on their own.
The radiologist therefore should carefully consider his or her involvement in this new imaging technique. #{149}
classification
system.
3.
Radiology 1991; 181:419-425. Botet JF, Lightdale CJ, Zauber Preoperative staging of gastric comparison
of endoscopic
CT. Radiology
4.
5.
6.
7.
1991;
10.
11.
13.
CJ, Botet
JF.
carci-
BotetJF,
Lightdale
C.
Endoscopic
sonog-
raphy of the upper gastrointestinal tract. AJR 1991; 156:63-68. Vilgrain V. Mompoint D, Palazzo L, et al. Staging of esophageal carcinoma: companson of results with endoscopic sonography and CT. AJR 1990; 155:277-281. Orringer MB. Transhiatal esophagectomy without thoracotomy for carcinoma of the thoracic esophagus. Ann Surg 1984; 200: 1282-1288. DeMeester TR, Barlow AT. Surgery and current management for cancer of the esophagus and cardia. I. Curr Probl Surg 25:477-531.
15.
Halvorsen RA, Magruder-Habib WLJr, Roberts L Jr. Postlethwait
cancer:
Esophageal
Tio U, Tytgat CNJ. Endoscopic ultrasonography in analysing periintestinal lymph node abnormality. Scand J Castroenterology 1986; 21(suppl 123):158-163.
1988;
Tio TL, Coene PPLO, Luiken CJHM, Tytgat CNJ. Endosonography in the clinical staging of esophagogastric carcinoma. Gastrointest Endosc 1990; 36(suppl 2):S2-S10. Lightdale
En-
Skinner DB, Ferguson MK, Soriano A, Littie AC, Staszak VM. Selection of operation for esophageal cancer based on staging. Ann Surg 1986; 204:391-401.
US and dynamic
noma: pre-operative staging and evaluation of anastomotic recurrence. Gastrointest Endosc 1990; 36(suppl 2):S11-S16. Ziegler K, Sanft C, Zeitz M, et al. Evaluation of endosonography in TN staging of esophageal cancer. Gut 1991; 32:16-20. Sobin LH, Hermanek P, Hutter RVP. TNM classification of malignant tumors: a comparison between the new (1987) and old editions. Cancer 1988; 6:2310-2314.
PP. et al.
and computed tomography carcinoma: preoperative compared to new (1987) TNM Gastroenterology 1989; 96:1478-
14. AG, et al.
181:426-432.
P. Coene
1486.
9.
12. References Silverberg E, Boring CC, Squires TS. Cancer statistics, 1990. CA 1991; 40:9-26. 2. BotetJF, Lightdale CJ, Zauber AC, Cerdes H, Urmacher C, Brennan MF. Preoperative staging of esophageal cancer: companson of endoscopic US and dynamic CT.
Tio TL, Cohen
dosonography of esophageal
Color interven-
cutaneous abdominal imaging with these machines. If the aid of a skilled sonographer is not offered, endosco-
and few data are available. as the authors point out,
EUS may well influence selection and evaluation of patients within research protocols such as neoadjuvant chemotherapy for cancer of the esophagus because accurate pretreatment staging is
and
to improve. US-guided
tional procedures will be standard fare for the endoscopic sonographer. Handheld probes will be available for trans-
been
shown to significantly correlate with patient survival (15). The influence of EUS on patient care is only now being
to stay,
ogy will continue flow imaging and
Thompson ing
16.
17.
WM.
Esophageal
by CT: long-term
K, Foster
RW, cancer stag-
follow-up
study.
Ra-
diology 1986; 161:147-151. Kelsen DP, Bains M, Burt M. Neoadjuvant chemotherapy and surgery of cancer of the esophagus. Semin Surg Oncol 1990; 6:268-273. Leichman
L.
Cancer
of the esophagus:
the Wayne State University experience. Invest New Drugs 1989; 7:91-100.
Radiology
#{149} 343
K. Baker,
MD
#{149} Kenyon
Endoscopic and Gastric E
SOPHAGEAL
and
K. Kopecky
US In the Cancer’ cancer,
gastric
the preoperative
rela-
tively uncommon malignancies in the United States, together were estimated to account for about 3% of new cancer
cases
and
5% of cancer
deaths
Staging
in
1990 (1). Because of this low overall mcidence, general screening for these diseases is impractical in the United States. At the time of clinical presentation, they
and
gastric
The
staging
cancer
most
of esophageal
significant
finding articles
described
is the
capac-
the extent of wall by gastrointestinal malignancy,
invasion
in this
regard,
EUS
proved
has occurred
authors’
in both esophageal in whites, overall
mately
8% and
The
for each
16%,
mainstay
disease
and survival (approxi-
respectively)
of treatment
(1). for
these
diseases remains surgery because resection alone has been shown to provide the best chance for cure. Traditionally, surgery has been offered to all patients whose tumors are potentially resectable, and
therefore,
the
main
goals
of preop-
erative evaluation have been to exclude patients who are unlikely to survive surgery and to identify widespread disease in patients who then could be spared a more aggressive operation if a less
invasive
palliative
treatment
could
be substituted. In this issue of Radio!ogy, Botet describe their use and comparison endoscopic
dynamic
ultrasonography
computed
et al of
(EUS)
tomography
with
(CT) in
data
invasion dicator, pathologic introduced
The
(4-6).
extent
capacity
lymph
nodes and
feature
ered Computed
tomography
(CT),
preoperative . Editorials #{149} Endoscopy, 71.12981 #{149} Esophagus, neoplasms, 71.321, 71.332 #{149} Lymphatic system, neoplasms, 996.8323, 999.8323 #{149} Stomach, CT, 72.1211 Stomach, neoplasms, 72.321 #{149} Stomach, US studies, 72.12989 #{149} Ultrasound (US), tissue
characterization, Radiology
71.321,
71.332, 72.321
1991; 181:342-343
I From the Department of Radiology/114, Veterans Administration Medical Center, 1481 W 10th St, Indianapolis, IN 46202 (M.K.B.); and the Department of Radiology, Indiana University Medical Center, Indianapolis (M.K.B., K.K.K.). Received August 15, 1991; accepted August 16. Address reprint requests to M.K.B. RSNA, 1991 See also the articles by Botet et al (pp 419-425 and 426-432) in this issue.
42
of echo
tex-
by the authors
of adenopathy
in the staging
of esophageal cancer, EUS proved more accurate in identification of adenopathy in the authors’ study of gastric cancer. Because diagnosis of adenopathy with
CT is based
terms:
identification
and illustrated by others (8,9). Previous efforts at tissue characterization with ultrasound (US) have had limited success, and further study is needed to clarify the role of EUS in the characterization of lymph nodes. Although no statistical difference existed in the capacity of EUS and dynamic CT to enable
detection
only
on size,
enlarged.
Although
CT therefore of malignot consid-
current
criteria
for identification of adenopathy with EUS vary, the evolving capacity of EUS to enable guided biopsy of lymph nodes
should only increase regard (5,8,10,11). It should be noted
accuracy that
The authors
in this
in the authors’
The
and study
make
others of gas-
tric cancer by Botet et al contains only nine patients (18%) with surgical stage IV disease-less than half the usual proportion of patients in whom the disease is initially diagnosed at this stage (1).
one
of
the inability with
staging
accu-
often
Why in the
is
staging
and gastric cancer? EUS must combine the
of an experienced
those
endoscopist
of an equally
ultrasonographer doscopist can
probe,
wonder:
more
with
experienced
(8,11). accurately
While place
the ultrasonographer
the enthe US
is needed
to adjust the US machine, guide the endoscopist on the basis of US landmarks, and interpret the images obtained. This situation is similar to intraoperative
sonography,
in which
the combined
skills of a surgeon and sonographer/ sonologist, a long combined learning curve, and a spirit of cooperation are necessary. Although the structure of some radiology practices may make co-
operation
in such
joint
ventures
an at-
tamable goal, mutual involvement may be impossible for others, and this likely accounts for slow acceptance in some centers.
The cost of EUS consists bined costs of endoscopy
of the comand US. This
cost is not insignificant, especially if this procedure does not replace other preoperative staging procedures. The procedure is safe, and the risk associated with it is essentially the risk of endoscopy itself, although EUS will
usually
require
it is easy
as the authors
because
lesion
their
skills
carcinoma,
mentioned.
that
esophageal
EUS not used of esophageal
dure
have
EUS
racy, but other authors have considered this an important limitation and could not bypass lesions in 26%-50% of patients (8,10). These factors aside, the success of
overall comparisons of EUS and CT, some factors in the study favor EUS. A very large proportion of patients (76%) in their study of esophageal cancer had adenocarcinoma, which is more difficult to accurately stage with CT than the statistically more common epidermoid (12)
found
an
Successful
is an additional
of EUS described
cannot enable identification nant disease within nodes Index
in-
normal-sized
on the basis
morphology
favors
in the detection
metastases.
EUS may
of wall
classification
to enable within
bias
EUS did not affect
CT in recent asthe
prognostic in the new
TNM staging in 1987 (7).
of malignancy ture
The
is an important a fact reflected
distant to bypass
statisti-
are usually incurable. Although a statistically significant reduction in mortality cancer low
selection
EUS is insensitive
cally more accurate than dynamic the authors’ study groups. Other reports on the accuracy of EUS in sessment of wall invasion support
gastric remains
This
(2,3).
in these important ity of EUS to define and
of Esophageal
than
more
a typical
time
per proce-
endoscopic
exami-
nation. It is likely that the greatest limitation to use of this technique has been lack of demand for more detailed staging information from the surgeon. Except in some patients with distant metastases, to
forget
that
preoperative
staging often has little impact on the decision to perform or not to perform surgery. The type of operation an mdividual may undergo must often be determined at surgery on the basis of surgical findings, the patient’s condition,
and the training, skills, and operative philosophy of the cancer surgeon.
EUS is here
If the primary tumor in esophageal malignancy is found at surgery to be unresectable for cure, esophagectomy is commonly considered the best form of paffiation in patients with dysphagia (13,14). Other forms of paffiation exist
for esophageal malignancy, dilation, radiation therapy, prosthetic
intubation,
but for unresectable
and
gastric
including esophageal laser
surgery,
cancer,
gery is the only effective palliation can be offered to the patient with
tomatic disease. The impact of preoperative on surgery performed and and ject
mortality to evaluate
greatly value
from
though
staging on morbidity
is therefore a difficult and is likely to vary
surgeon
of CT in staging
has been radiology
to surgeon. these
with
CT has
sub-
The
diseases
a point of controversy and surgery literatures, staging
surthat symp-
in the al-
evaluated, However,
the cornerstone of evaluation of any comparison of different treatment modalities (16,i7).
Volume
181
#{149} Number
2
the technol-
pists are likely sary equipment
8.
to obtain both the necesand skill on their own.
The radiologist therefore should carefully consider his or her involvement in this new imaging technique. #{149}
classification
system.
3.
Radiology 1991; 181:419-425. Botet JF, Lightdale CJ, Zauber Preoperative staging of gastric comparison
of endoscopic
CT. Radiology
4.
5.
6.
7.
1991;
10.
11.
13.
CJ, Botet
JF.
carci-
BotetJF,
Lightdale
C.
Endoscopic
sonog-
raphy of the upper gastrointestinal tract. AJR 1991; 156:63-68. Vilgrain V. Mompoint D, Palazzo L, et al. Staging of esophageal carcinoma: companson of results with endoscopic sonography and CT. AJR 1990; 155:277-281. Orringer MB. Transhiatal esophagectomy without thoracotomy for carcinoma of the thoracic esophagus. Ann Surg 1984; 200: 1282-1288. DeMeester TR, Barlow AT. Surgery and current management for cancer of the esophagus and cardia. I. Curr Probl Surg 25:477-531.
15.
Halvorsen RA, Magruder-Habib WLJr, Roberts L Jr. Postlethwait
cancer:
Esophageal
Tio U, Tytgat CNJ. Endoscopic ultrasonography in analysing periintestinal lymph node abnormality. Scand J Castroenterology 1986; 21(suppl 123):158-163.
1988;
Tio TL, Coene PPLO, Luiken CJHM, Tytgat CNJ. Endosonography in the clinical staging of esophagogastric carcinoma. Gastrointest Endosc 1990; 36(suppl 2):S2-S10. Lightdale
En-
Skinner DB, Ferguson MK, Soriano A, Littie AC, Staszak VM. Selection of operation for esophageal cancer based on staging. Ann Surg 1986; 204:391-401.
US and dynamic
noma: pre-operative staging and evaluation of anastomotic recurrence. Gastrointest Endosc 1990; 36(suppl 2):S11-S16. Ziegler K, Sanft C, Zeitz M, et al. Evaluation of endosonography in TN staging of esophageal cancer. Gut 1991; 32:16-20. Sobin LH, Hermanek P, Hutter RVP. TNM classification of malignant tumors: a comparison between the new (1987) and old editions. Cancer 1988; 6:2310-2314.
PP. et al.
and computed tomography carcinoma: preoperative compared to new (1987) TNM Gastroenterology 1989; 96:1478-
14. AG, et al.
181:426-432.
P. Coene
1486.
9.
12. References Silverberg E, Boring CC, Squires TS. Cancer statistics, 1990. CA 1991; 40:9-26. 2. BotetJF, Lightdale CJ, Zauber AC, Cerdes H, Urmacher C, Brennan MF. Preoperative staging of esophageal cancer: companson of endoscopic US and dynamic CT.
Tio TL, Cohen
dosonography of esophageal
Color interven-
cutaneous abdominal imaging with these machines. If the aid of a skilled sonographer is not offered, endosco-
and few data are available. as the authors point out,
EUS may well influence selection and evaluation of patients within research protocols such as neoadjuvant chemotherapy for cancer of the esophagus because accurate pretreatment staging is
and
to improve. US-guided
tional procedures will be standard fare for the endoscopic sonographer. Handheld probes will be available for trans-
been
shown to significantly correlate with patient survival (15). The influence of EUS on patient care is only now being
to stay,
ogy will continue flow imaging and
Thompson ing
16.
17.
WM.
Esophageal
by CT: long-term
K, Foster
RW, cancer stag-
follow-up
study.
Ra-
diology 1986; 161:147-151. Kelsen DP, Bains M, Burt M. Neoadjuvant chemotherapy and surgery of cancer of the esophagus. Semin Surg Oncol 1990; 6:268-273. Leichman
L.
Cancer
of the esophagus:
the Wayne State University experience. Invest New Drugs 1989; 7:91-100.
Radiology
#{149} 343
