Original Articles
Helical CT versus EUS with fine needle aspiration for celiac nodal assessment in patients with esophageal cancer,☆☆

https://doi.org/10.1067/mge.2002.122650Get rights and content

Abstract

Background: Conventional CT is insensitive for detection of metastatic involvement of celiac lymph nodes in esophageal cancer. Helical CT has theoretical advantages over “slice” CT in this regard, but its performance has not yet been prospectively studied. Methods: Consecutive patients with untreated esophageal cancer were recruited after obtaining informed consent. Helical CT was performed on all patients and TNM staging was performed by a single radiologist. Subsequently, all patients underwent esophageal radial and, as needed, curvilinear array EUS with fine needle aspiration (FNA), for evaluation of celiac lymph nodes and TNM staging. Test performance characteristics with 95% confidence intervals were calculated, assuming EUS with FNA as the reference standard. Results: Forty-eight patients were recruited, of whom 37 (77%) were men. The mean (SD) age was 63.6 (10) years. Excluding 5 patients in whom a confirmatory FNA was not available (n = 43), helical CT identified celiac lymph nodes in 12 (28%) patients. The reference standard of EUS with FNA identified 15 (35%) patients with metastatic celiac lymph nodes, giving a sensitivity, specificity, and positive and negative predictive values for helical CT of 53% (95% CI [28%, 79%]), 86% (95% CI [73%, 99%]), 67% (95% CI [40%, 93%]), and 77% (95% CI [63%, 92%]), respectively, for assessing celiac lymph nodal involvement. The sensitivity and specificity of helical CT in detecting T4 disease were 25% (95% CI [3.8%, 46%]) and 94% (95% CI [85%, 100%]), respectively. There were 12 patients (25%; 95% CI [13%, 37%]) who were felt to have resectable disease by helical CT but had either metastatic involvement of celiac lymph nodes or T4 disease by EUS/FNA. Conclusions: Despite technological advances, helical CT still appears unreliable, mainly because of insensitivity, for the identification of inoperable T4 or metastatic involvement of celiac lymph node disease in esophageal cancer. (Gastrointest Endosc 2002;55:648-54.)

Section snippets

Patients and methods

Local institutional review board ethical approval and informed consent was obtained before commencement of this study. Consecutive patients referred with untreated esophageal cancer were recruited. Demographics, dysphagia scores, symptom durations, and tumor characteristics (pathology, location, size) were noted.

The hCT was performed in all patients and TNM staging, including the identification of distant metastases, was prospectively reported by a single GI CT radiologist, including those hCT

Demographics and spectrum of disease

Forty-eight patients (37 men [77%]; mean age 63.6 [10], range 47-91 years) with esophageal cancer were recruited into the study and underwent both an EUS and a hCT without prior adjuvant chemotherapy or radiotherapy. There were 37 men (77%) and the mean age was 63.6 (± 10) years (range 47-91). Twenty patients were African American (42%); one patient was Asian American; the remainder were white. The biopsy results indicated a diagnosis of adenocarcinoma in 17 (35%), with the remainder being

Discussion

The management of esophageal cancer is evolving, and the question of whether all patients with curable disease should undergo aggressive surgical therapy is being asked. In addition, advances in nonsurgical options for palliative therapy of esophageal cancer, including Nd-YAG laser photoablation, argon plasma coagulation, photodynamic therapy, and insertion of metal stents, have made accurate nonoperative staging increasingly important to avoid unnecessary surgical morbidity in patients with

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    Dr. Wallace is funded by the American Digestive Health Foundation: Wilson Cook Endoscopic Research Award and TAP Pharmaceutical Outcomes Research Award. Dr. Romagnuolo is funded by the Alberta Heritage Foundation for Medical Research.

    ☆☆

    Reprint requests: Michael B. Wallace, MD, MUSC Digestive Disease Center, 96 Jonathon Lucas St., Suite 922 CSB, Charleston, SC 29425.

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