21 Diseases of the Esophagus (2005) 18, 21 –27 © 2005 ISDE Blackwell Publishing, Ltd. Original article Endoscopic ultrasound for esophageal and gastroesophageal junction cancer: Impact of increased use of primary neoadjuvant therapy on preoperative locoregional staging accuracy J. DeWitt, 1 K. Kesler, 2 J. A. Brooks, 2 J. LeBlanc, 1 L. McHenry, 1 K. McGreevy, 1 S. Sherman 1 Departments of 1 Gastroenterology & Hepatology and 2 Thoracic Surgery, Indiana University Medical Center Indianapolis, USA SUMMARY. Initial treatment of locally advanced esophageal and gastroesophageal junction (GEJ) malig- nancies for selected patients at some institutions has recently changed from surgical resection to neoadjuvant therapy. The aim of this study is to evaluate the impact of this change in treatment strategy on both the overall disease profile and locoregional endoscopic ultrasound (EUS) staging accuracy for a cohort of patients man- aged with primary surgical resection over a 10-year period at our institution. All subjects at our institution who underwent primary esophagectomy from 1993 to 2002 following preoperative EUS for known or suspected esophageal and/or GEJ cancers were identified. Patients with dysplasia alone, prior upper gastrointestinal tract surgery, preoperative neoadjuvant therapy, cancer of the gastric cardia or recurrent malignancy were excluded. EUS findings and staging results were compared to surgical pathology following resection. The impact of the gradually increased use of primary chemoradiation during the second half of the study was assessed. Of the 286 operations performed, 184 subjects were excluded. The remaining 102 underwent primary surgical resection a median of 18 days following EUS staging for adenocarcinoma (88%) or squamous cell carcinoma (12%) of the esophagus (69%) or GEJ (31%). Overall EUS locoregional T and N staging accuracy was 72% and 75% respectively; accuracy for T1, T2, T3 and T4 cancer was 42%, 50%, 88% and 50% respec- tively. Despite an increased frequency of pathologically confirmed T1 and T2 cancers (P = 0.005) and an insig- nificant trend toward increased N0 malignancy (P = 0.05) during the second half of the study period, no statistically significant changes in T (P = 0.07) or N (P = 0.82) staging accuracies for EUS or disease charac- teristics were noted between the first and second half of the study period. Despite both inaccurate radial EUS staging and increased relative use of primary surgery for early cancers, recent increased use of primary neo- adjuvant therapy did not change overall disease characteristics and accuracy of locoregional EUS staging of esophageal and GEJ cancers managed with primary surgical resection. KEY WORDS: endoscopic ultrasound, esophageal cancer, staging. INTRODUCTION The optimal management of locally advanced eso- phageal and gastroesophageal junction (GEJ) cancer is controversial. A single-center, randomized trial has demonstrated a statistically significant survival benefit in patients with esophageal cancer treated preoperatively with chemoradiotherapy compared with surgical management alone. 1 Five other rando- mized trials to date, 2–6 however, have failed to show any improved survival for subjects treated with preoperative chemotherapy and radiation compared with surgery alone. Despite these results, most patients with locally advanced esophageal and GEJ cancer currently receive preoperative chemoradio- therapy and this strategy has been generally employed at our institution since 1997. Following initial diagnosis, accurate stratification of subjects with early or locally advanced esopha- geal and GEJ malignancy requires precise staging. Initial staging usually includes a chest and upper abdominal computed tomography (CT) scan. While CT is useful for detection of distant metastases, multiple early studies demonstrated that endo- scopic ultrasound (EUS) is superior to CT scan for Address correspondence to: John DeWitt, MD, Department of Medicine, Division of Gastroenterology, Indiana University Medical Center, 550 N. University Blvd, UH 4100, Indianapolis, IN 46202-5121, USA. Email: jodewitt@iupui.edu Downloaded from https://academic.oup.com/dote/article/18/1/21/2419594 by guest on 04 August 2022