title: Endoscopic Ultrasound Estimates for Tumor Depth at the Gastroesophageal Junction Are Inaccurate: Implications for the Liberal Use of Endoscopic Resection.
abstract: BACKGROUND
  Endoscopic resection is increasingly utilized for treating early stage esophageal cancer, and endoscopic ultrasound (EUS) frequently guides treatment selection. Studies report greater than 80% sensitivity and 90% specificity, but our experience suggests less accuracy at the gastroesophageal (GE) junction. The objective of this study is to determine the accuracy of EUS for depth of GE junction cancer and the potential treatment implications.
  
  
  METHODS
  A retrospective review of a prospective database was performed for patients from 1995 to 2014 with GE junction esophageal cancer that underwent EUS staging and resection (surgical or endoscopic) without neo-adjuvant therapy. Patient, tumor, EUS, and pathologic characteristics were examined.
  
  
  RESULTS
  For the 181 patients that met criteria, the median age was 66 years, 17% were female, 91% white, and 98% had adenocarcinoma. Concordance between EUS (u) T and pathologic (p) T was 48%, with 23% under-staged and 29% over-staged. The EUS was accurate in the following: uT0 6% (1 of 18); uT1a 56% (23 of 41); uT1b 58% (41 of 71); uT2 10% (2 of 21); and uT3 70% (21 of 30). Inaccurate EUS depth had potential to lead to over-treatment in 38% (27 of 71) of uT1b and 76% (16 of 21) of uT2. In 50% of pT1a tumors, EUS depth was T1b or greater. Logistic regression revealed tumor length (continuous variable) to be associated with inaccurate uT (p = 0.016). Accurately staged tumors were significantly longer than inaccurately staged tumors (2.7 vs 1.7 cm, p = 0.011).
  
  
  CONCLUSIONS
  Early to intermediate GE junction tumors are frequently over-staged. This highlights the importance of diagnostic endoscopic resection for determining accurate tumor depth and selecting correct therapy.
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas.
authors.forename: Rajeev
authors.initials: R
authors.lastname: Dhupar
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas.
authors.forename: Robert D
authors.initials: RD
authors.lastname: Rice
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas.
authors.forename: Arlene M
authors.initials: AM
authors.lastname: Correa
authors.affiliation: Department of Gastroenterology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
authors.forename: Brian R
authors.initials: BR
authors.lastname: Weston
authors.affiliation: Department of Gastroenterology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
authors.forename: Manoop S
authors.initials: MS
authors.lastname: Bhutani
authors.affiliation: Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
authors.forename: Dipen M
authors.initials: DM
authors.lastname: Maru
authors.affiliation: Department of Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
authors.forename: Sonia L
authors.initials: SL
authors.lastname: Betancourt
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas.
authors.forename: David C
authors.initials: DC
authors.lastname: Rice
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas.
authors.forename: Stephen G
authors.initials: SG
authors.lastname: Swisher
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas. Electronic address: whofstetter@mdanderson.org.
authors.forename: Wayne L
authors.initials: WL
authors.lastname: Hofstetter
mesh_terms: D000230:Adenocarcinoma / Q000000981:diagnostic imaging* / Q000473:pathology* / Q000601:surgery; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D061827:Dimensional Measurement Accuracy; D019160:Endosonography; D004938:Esophageal Neoplasms / Q000000981:diagnostic imaging* / Q000473:pathology* / Q000601:surgery; D004943:Esophagogastric Junction / Q000000981:diagnostic imaging* / Q000473:pathology*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies