Download PDF
Endoscopy 2012; 44(06): 572-576
DOI: 10.1055/s-0032-1308950
Original article
© Georg Thieme Verlag KG Stuttgart · New York

Endoscopic ultrasound staging in gastric cancer: Does it help management decisions in the era of neoadjuvant treatment?[*]

A. Kutup
1   Department of General, Visceral, and Thoracic Surgery, University Medical Center of Hamburg-Eppendorf, Hamburg, Germany
,
Y. K. Vashist
1   Department of General, Visceral, and Thoracic Surgery, University Medical Center of Hamburg-Eppendorf, Hamburg, Germany
,
S. Groth
2   Department of Interdisciplinary Endoscopy, University Medical Center of Hamburg-Eppendorf, Hamburg, Germany
,
E. Vettorazzi
3   Department of Medical Biometry and Epidemiology, University Medical Center of Hamburg-Eppendorf, Hamburg, Germany
,
E. F. Yekebas
1   Department of General, Visceral, and Thoracic Surgery, University Medical Center of Hamburg-Eppendorf, Hamburg, Germany
,
N. Soehendra
2   Department of Interdisciplinary Endoscopy, University Medical Center of Hamburg-Eppendorf, Hamburg, Germany
,
J. R. Izbicki
1   Department of General, Visceral, and Thoracic Surgery, University Medical Center of Hamburg-Eppendorf, Hamburg, Germany
› Author Affiliations
Further Information

Publication History

submitted 10 February 2011

accepted after revision 10 January 2012

Publication Date:
23 April 2012 (online)

Also available at
    Permissions and Reprints

Background and study aims: Endoscopic ultrasonography (EUS) has been shown to be the most accurate test for locoregional staging of upper gastrointestinal tumors; however, recent studies have questioned its accuracy level in daily clinical application. The present retrospective study analyzes the accuracy of EUS in guiding interdisciplinary treatment decisions.

Patients and methods: 123 primarily operated patients (63 % men, mean age 61.4 years) were included; only cases with tumor-free resection margins and without evidence of distant metastases were selected. EUS and histopathological findings were compared. Main outcome parameter was the distinction between tumors to be primarily operated (T1 /2N0) and those to be treated by neoadjuvant or perioperative chemotherapy (T3/4, or any N + ), based on an assumed algorithm for treatment stratification.

Results: Overall staging accuracy of EUS was 44.7 % for T and 71.5 % for N status irrespective of tumor location. Overstaging was the main problem (44.9 % for T, 42.9 % for N staging). The overall EUS classification was correct in 79.7 % (accuracy), with a sensitivity 91.9 % and specificity 51.4 %; only 19 out of 37 cases with histopathological T1/2N0 were correctly classified by EUS. Positive and negative predictive values of EUS in diagnosing advanced tumor stage for assignment to neoadjuvant therapy were 81.4 % and 73.1 %, respectively.

Conclusions: Whereas EUS has a high sensitivity in the diagnosis of locally advanced gastric cancer, endosonographic overstaging of T2 cancers appears to be a frequent problem. EUS stratification between local (T1 /2N0) and advanced (T3/4 or any N + ) tumors would thus result in incorrect assignment to neoadjuvant treatment in half of cases.

* A. Kutup and Y. K. Vashist contributed equally.


 

  • References

  • 1 Nakamura K, Ueyama T, Yao T et al. Pathology and prognosis of gastric carcinoma. Findings in 10,000 patients who underwent primary gastrectomy. Cancer 1992; 70: 1030-1037
    CrossrefPubMedSearch in Google Scholar
  • 2 Siewert JR, Böttcher K, Stein HJ et al. Relevant prognostic factors in gastric cancer: ten-year results of the German Gastric Cancer Study. Ann Surg 1998; 228: 449-461
    CrossrefPubMedSearch in Google Scholar
  • 3 Cunningham D, Allum WH, Stenning SP et al. Perioperative chemotherapy versus surgery alone for resectable gastroesophageal cancer. N Engl J Med 2006; 355: 11-20
    CrossrefPubMedSearch in Google Scholar
  • 4 Ychou M, Boige V, Pignon J et al. Perioperative chemotherapy compared with surgery alone for resectable gastroesophageal adenocarcinoma: An FNCLCC and FFCD multicenter phase III trial. J Clin Oncol 2011; 29: 1715-1721
    CrossrefPubMedSearch in Google Scholar
  • 5 Puli SR, Batapati Krishna Reddy J, Bechtold ML et al. How good is endoscopic ultrasound for TNM staging of gastric cancers? A meta-analysis and systematic review. World J Gastroenterol 2008; 14: 4011-4019
    CrossrefPubMedSearch in Google Scholar
  • 6 Kelly S, Harris KM, Berry E et al. A systematic review of the staging performance of endoscopic ultrasound in gastro-oesophageal carcinoma. Gut 2001; 49: 534-539
    CrossrefPubMedSearch in Google Scholar
  • 7 Bentrem D, Gerdes H, Tang L et al. Clinical correlation of endoscopic ultrasonography with pathologic stage and outcome in patients undergoing curative resection for gastric cancer. Ann Surg Oncol 2007; 14: 1853-1859
    CrossrefPubMedSearch in Google Scholar
  • 8 Willis S, Truong S, Gribnitz S et al. Endoscopic ultrasonography in the preoperative staging of gastric cancer: accuracy and impact on surgical therapy. Surg Endosc 2000; 14: 951-954
    CrossrefPubMedSearch in Google Scholar
  • 9 Mortensen MB, Edwin B, Hünerbein M et al. Impact of endoscopic ultrasonography (EUS) on surgical decision-making in upper gastrointestinal tract cancer: an international multicenter study. Surg Endosc 2007; 21: 431-438
    CrossrefPubMedSearch in Google Scholar
  • 10 Bösing N, Schumacher B, Frieling T et al. Endoscopic ultrasound in routine clinical practice for staging adenocarcinomas of the stomach and distal esophagus. Chirurg 2003; 74: 214-221
    CrossrefPubMedSearch in Google Scholar
  • 11 Bhandari S, Shim CS, Kim JH et al. Usefulness of three-dimensional, multidetector row CT (virtual gastroscopy and multiplanar reconstruction) in the evaluation of gastric cancer: a comparison with conventional endoscopy, EUS, and histopathology. Gastrointest Endosc 2004; 59: 619-626
    CrossrefPubMedSearch in Google Scholar
  • 12 Ahn HS, Lee HJ, Yoo MW et al. Diagnostic accuracy of T and N stages with endoscopy, stomach protocol CT, and endoscopic ultrasonography in early gastric cancer. J Surg Oncol 2009; 99: 20-27
    CrossrefPubMedSearch in Google Scholar
  • 13 Habermann CR, Weiss F, Riecken R et al. Preoperative staging of gastric adenocarcinoma: comparison of helical CT and endoscopic US. Radiology 2004; 230: 465-471
    CrossrefPubMedSearch in Google Scholar
  • 14 Kwee RM, Kwee TC. Imaging in local staging of gastric cancer: a systematic review. J Clin Oncol 2007; 25: 2107-2116
    CrossrefPubMedSearch in Google Scholar
  • 15 Polkowski M, Palucki J, Wronska E et al. Endosonography versus helical computed tomography for locoregional staging of gastric cancer. Endoscopy 2004; 36: 617-623
    Thieme ConnectPubMedSearch in Google Scholar
  • 16 Yoshikawa T, Sasako M, Yamamoto S et al. Phase II study of neoadjuvant chemotherapy and extended surgery for locally advanced gastric cancer. Br J Surg 2009; 96: 1015-1022
    CrossrefPubMedSearch in Google Scholar
  • 17 Solomon NL, Cheung MC, Byrne MM et al. Does chemoradiotherapy improve outcomes for surgically resected adenocarcinoma of the stomach or esophagus?. Ann Surg Oncol 2010; 17: 98-108
    CrossrefPubMedSearch in Google Scholar
  • 18 Sarela AI, Turnbull AD, Coit DG et al. Accurate lymph node staging is of greater prognostic importance than subclassification of the T2 category for gastric adenocarcinoma. Ann Surg Oncol 2003; 10: 783-791
    CrossrefPubMedSearch in Google Scholar
  • 19 Park SR, Kim MJ, Ryu KW et al. Prognostic value of preoperative clinical staging assessed by computed tomography in resectable gastric cancer patients: a viewpoint in the era of preoperative treatment. Ann Surg 2010; 251: 428-435
    CrossrefPubMedSearch in Google Scholar
  • 20 Siewert JR, Böttcher K, Stein HJ et al. Relevant prognostic factors in gastric cancer: ten-year results of the German Gastric Cancer Study. Ann Surg 1998; 228: 449-461
    CrossrefPubMedSearch in Google Scholar
  • 21 Botet JF, Lightdale CJ, Zauber AG et al. Preoperative staging of gastric cancer: comparison of endoscopic US and dynamic CT. Radiology 1991; 181: 426-432
    PubMedSearch in Google Scholar
  • 22 Wang JY, Hsieh JS, Huang YS et al. Endoscopic ultrasonography for preoperative locoregional staging and assessment of resectability in gastric cancer. Clinical Imaging 1998; 22: 355-359
    CrossrefPubMedSearch in Google Scholar
  • 23 Dittler HJ, Siewert JR. Role of endoscopic ultrasonography in gastric carcinoma. Endoscopy 1993; 25: 162-166
    Thieme ConnectPubMedSearch in Google Scholar
  • 24 Faigel DO. EUS in patients with benign and malignant lymphadenopathy. Gastrointest Endosc 2001; 53: 593-598
    CrossrefPubMedSearch in Google Scholar
  • 25 Sobin LH, Wittekind C. UICC TNM classification of malignant tumors. 6th edn. New York: Wiley-Liss; 2002
    Search in Google Scholar
  • 26 Martin RC 2nd, Jaques DP, Brennan MF et al. Extended local resection for advanced gastric cancer: increased survival versus increased morbidity. Ann Surg 2002; 236: 159-265
    CrossrefPubMedSearch in Google Scholar
  • 27 Lowy AM, Feig BW, Janjan N et al. A pilot study of preoperative chemoradiotherapy for resectable gastric cancer. Ann Surg Oncol 2001; 8: 519-524
    CrossrefPubMedSearch in Google Scholar
  • 28 Lowy AM, Mansfield PF, Leach SD et al. Response to neoadjuvant chemotherapy best predicts survival after curative resection of gastric cancer. Ann Surg 1999; 229: 303-308
    CrossrefPubMedSearch in Google Scholar
  • 29 Ajani JA, Mansfield PF, Janjan N et al. Multi-institutional trial of preoperative chemoradiotherapy in patients with potentially resectable gastric carcinoma. J Clin Oncol 2004; 22: 2774-2780
    CrossrefPubMedSearch in Google Scholar
  • 30 Schuhmacher C, Gretschel S, Lordick F et al. Neoadjuvant chemotherapy compared with surgery alone for locally advanced cancer of the stomach and cardia: European Organisation for Research and Treatment of Cancer randomized trial 40954. J Clin Oncol 2010; 28: 5210-5218 . Epub 2010 Nov 8
    CrossrefPubMedSearch in Google Scholar
  • 31 Cunningham D, Oliveira J. ESMO Guidelines Working Group. Gastric cancer: ESMO clinical recommendations for diagnosis, treatment and follow-up. Ann Oncol 2008; 19: ii23-ii24
    CrossrefPubMedSearch in Google Scholar
  • 32 May A, Günter E, Roth F et al. Accuracy of staging in early oesophageal cancer using high resolution endoscopy and high resolution endosonography: a comparative, prospective, and blinded trial. Gut 2004; 53: 634-640
    CrossrefPubMedSearch in Google Scholar
  • 33 Rösch T, Lorenz R, Zenker K et al. Local staging and assessment of resectability in carcinoma of the esophagus, stomach, and duodenum by endoscopic ultrasonography. Gastrointest Endosc 1992; 38: 460-467
    CrossrefPubMedSearch in Google Scholar
  • 34 Rösch T. Endosonographic staging of gastric cancer: a review of literature results. Gastrointest Endosc Clin N Am 1995; 5: 549-557
    PubMedSearch in Google Scholar
  • 35 Meining A, Dittler HJ, Wolf A et al. You get what you expect? A critical appraisal of imaging methodology in endosonographic cancer staging. Gut 2002; 50: 599-603
    CrossrefPubMedSearch in Google Scholar