Reply to Bohle and Zoller

We appreciate Bohle and Zoller’s well-advised comments on our paper “Endoscopic ultrasound in gastric cancer: does it help management decisions in the era of neoadjuvant treatment?” [1]. Bohle and Zoller express concerns regarding the poor results of N staging. The use of endoscopic ultrasonography (EUS) findings to distinguish between benign and malignant lymph nodes is still controversial, and the accuracy of EUS in staging gastric cancers varies in reports alongside concerns that EUS over-stages nodal invasion because of inflammation around the tumor or in the lymph nodes [2] [3].

With regard to findings indicative of malignant lymph nodes, malignancy should be suspected when lymph nodes larger than 1 cm are found [4]. However, some lymph nodes that are larger than 1 cm are benign histologically, making it difficult to ascertain the nature of these nodes. Also, enlarged lymph nodes are increasingly detected with age, even in the absence of cancer [5] [6] [7] [8] [9]. EUS criteria for depth of tumor invasion and nodal metastasis have changed in the past two decades and technological changes in EUS have also occurred during this period. But it is not clear if these changes have impacted gastric cancer staging [10]. In our study, lymph node size > 5 mm was one of three parameters used to distinguish between benign and malignant lymph nodes. We agree with Bohle and Zoller that it may be helpful to carry out diagnostic histological examinations in parallel with EUS; although EUS remains the most reliable tool for cancer staging, N staging results especially are still disappointing. Therefore, more reliable results are expected with EUS-guided fine needle aspiration.

• References

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• 10 Puli SR, Reddy JBK, 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