title: Endoscopic ultrasound for early stage esophageal adenocarcinoma: implications for staging and survival.
abstract: BACKGROUND
  Patients often receive induction therapy based on endoscopic ultrasound (EUS)-identified nodal spread (N1) or deep tumor invasion (T3), although controversy exists regarding the role of induction therapy for early stage disease. We aim to evaluate the reliability of EUS in identifying early stage disease and the subsequent impact on treatment and outcomes.
  
  
  METHODS
  We retrospectively studied 149 patients who underwent EUS and esophagectomy for adenocarcinoma between January 2000 and December 2008. Computed tomography (CT) was performed in all patients, whereas positron emission tomography (PET) was performed in 91%. Clinical stage (c), pathologic stage (p), operative mortality, and survival were recorded.
  
  
  RESULTS
  Unanticipated pathologic nodal disease was similar in patients with cT1N0 and cT2N0 tumors (6/25 [24%] versus 7/18 [38.8%]; p=0.6). Among the 18 cases of cT2N0 disease, 9 (50%) were pathologically staged as T1N0, 8 (44%) were upstaged to pT3N0-1, and 1 (6%) was pT2N0. One case of cT1N0 tumor (4%) was upstaged to pT3N0. Among patients with cT1-2N0 tumors, 5-year disease-free survival for the group that was appropriately staged was 89.8% versus 39.9% for the group that had a higher pathologic stage than their clinical stage (ie, >T2N0) (p<0.001). Operative mortality for patients with cT1-2N0 tumors was 0/43 (0%), which was no different from that in the higher clinical stage groups with (1/37, 2.7%) or without (2/68, 2.9%) induction therapy (p=0.5). Multivariate analysis identified marked/intense uptake on staging PET (odds ratio, 5.76, 95%; confidence interval, 1.25 to 26.52; p=0.021) to be a factor predictive of upstaging of cT1-2N0 tumors.
  
  
  CONCLUSIONS
  Current staging techniques are inadequate for predicting T1-2N0 disease in esophageal adenocarcinoma. Survival is excellent with operation alone in patients with tumors appropriately staged as T1-2N0, although patients with tumors upstaged to greater than T2N0 have significantly worse survival. Other preoperative factors such as PET uptake may help select patients with cT1-2N0 tumors that will be upstaged at resection.
authors: Department of Surgery, Washington University School of Medicine, and Barnes-Jewish Hospital, St. Louis, Missouri 63110, USA. crabtreet@wudosis.wustl.edu
authors: Traves D
authors: TD
authors: Crabtree
authors: Wael N
authors: WN
authors: Yacoub
authors: Varun
authors: V
authors: Puri
authors: Riad
authors: R
authors: Azar
authors: Jennifer Bell
authors: JB
authors: Zoole
authors: G Alexander
authors: GA
authors: Patterson
authors: A Sasha
authors: AS
authors: Krupnick
authors: Daniel
authors: D
authors: Kreisel
authors: Bryan F
authors: BF
authors: Meyers
mesh_terms: D000230:Adenocarcinoma / Q000000981:diagnostic imaging* / Q000401:mortality* / Q000473:pathology / Q000601:surgery; D000368:Aged; D001707:Biopsy, Needle; D015331:Cohort Studies; D016001:Confidence Intervals; D003952:Diagnostic Imaging / Q000379:methods; D018572:Disease-Free Survival; D019160:Endosonography / Q000379:methods*; D004938:Esophageal Neoplasms / Q000000981:diagnostic imaging* / Q000401:mortality* / Q000473:pathology / Q000601:surgery; D016629:Esophagectomy / Q000379:methods / Q000401:mortality; D005260:Female; D005500:Follow-Up Studies; D017052:Hospital Mortality / Q000639:trends*; D006801:Humans; D007150:Immunohistochemistry; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009361:Neoplasm Invasiveness / Q000473:pathology; D009367:Neoplasm Staging; D016017:Odds Ratio; D049268:Positron-Emission Tomography; D011183:Postoperative Complications / Q000401:mortality; D012189:Retrospective Studies; D018570:Risk Assessment; D016019:Survival Analysis; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome