Eur J Cardiothorac Surg 1999;16:S31-S33
© 1999 Elsevier Science NL
The role of thoracoscopic staging of esophageal cancer patients
Mark J Krasna*,
You Sheng Mao,
Joshua Sonett,
Ziv Gamliel
Division of Thoracic and Cardiovascular Surgery, University of Maryland Medical School Baltimore, Maryland, USA
* Corresponding author. University of Maryland, Division of Thoracic and Cardiovascular Surgery, 22 South Greene Street, Rm N4W94, Baltimore, Maryland 21201, USA Tel.: +1-410-328-6366; fax: +1-410-328-0693 (Email: mkrasna{at}surgery1ab.umd.edu).
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Abstract
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Introduction: This study was designed to compare thoracoscopy/1aparoscopy (TS/LS) staging with non-invasive clinical staging by CT and EUS for patients with esophageal carcinoma.Methods and results: CT and EUS followed by TS/LS were used to stage 88 patients with EGD proven esophageal carcinoma. Thoracoscopic staging was done in 82 patients and found N1 in 11 patients. Fifty-four patients had laparoscopy which detected N1 in 21 patients. Thirty-four cases had chemoradiation followed by surgery. Esophagectomy was performed in 47 patients after thoracoscopic staging and 33 with laparoscopic staging. Of these 47 resected patients, thoracoscopic staging showed N0 in 42 patients and N1 in five patients with an accuracy of 93.6%. Laparoscopic staging detected normal celiac lymph nodes in 20 patients and diseased LN in 11 patients with an accuracy of 93.9%. Comparing with final resection pathology, the sensitivity, specificity and positive predictive value of staging for N1 disease in the chest was 62.5, 100.0 and 100.0% by TS; 75.0, 75.6, and 23.1% by CT and 0.0, 51.4 and 5.5% by EUS, respectively. For N1 disease in the abdomen it was 84.6, 100.0 and 100.0% by Ls; 0.0, 97.1 and 0.0% by CT and 22.2, 81.5 and 28.6% by EUS, respectively.Conclusion: TS/LS staging of esophageal cancer patients with or without preoperative chemoradiation has a higher specificity and accuracy than CT and EUS, especially for N1 disease in the chest. It also allows individualization of preoperative radiotherapy fields.
Key Words: Thoracoscopy • Laparoscopy • TNM Staging • Esophageal cancer • CT • EUS
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1. Introduction
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Esophageal carcinoma treated by surgery alone has been reported with a dismal prognosis over the past several decades [1,2]. It has been suggested that preoperative chemotherapy/radiotherapy may improve survival of those patients with esophageal cancer who have complete pathological response [3–6]. in order to evaluate the results of preoperative neo-adjuvant chemotherapy/radiotherapy, accurate TNM staging and definition of standard staging methods for esophageal cancer are important. If accurate TNM staging could be achieved, it would be possible to identify a group of patients who might benefit from preoperative chemotherapylradiotherapy. Computed tomography (CT), magnetic resonance imaging (MRI) and esophageal ultrasonography (EUS) are non-invasive, preoperative staging methods generally used for staging esophageal cancer. CT is sensitive in detecting the presence of LN in the chest but is not sensitive in T staging. EUS has a higher sensitivity in detecting the depth of the lesion invading the esophageal wall (T staging) but is limited when the lesion is advanced and occludes the esophageal lumen or when LN are distant from the esophagus. The reported accuracy of these non-invasive methods have generally not included pathological comparison. Preoperative staging by thoracoscopy/1aparoscopy (TS/LS) has been shown to be effective, safe and accurate in patients with esophageal cancer [7–9]. We report herein a comparison of pretreatment staging by TS/LS staging and non-invasive clinical staging by CT or EUS for patients with esophageal carcinoma.
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2. Clinical data and results
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Non-invasive CT and EUS examination followed by TS/LS were used to stage 88 esophageal cancer patients proven by EGD between 1991 and 1997. The pathology of the patients included squamous cell carcinoma (49 cases), adenocarcinoma (35 cases), small cell carcinoma (two cases) and poorly differentiated carcinoma (two cases). There were 72 males and 16 females with a mean age of 60.7 years (range 38–78 years). Thoracoscopic staging were successfully done in 82 patients and was aborted in three patients because of adhesions. Fifty-five patients had laparoscopy staging. Forty-nine patients underwent both TS and LS staging. Thirty-nine cases did not undergo resection following staging because of an advanced lesion (T4 – 12 cases; Ml – three cases), patient refusal (four cases) poor health status (severe liver cirrhosis one case), and other reasons. TS/LS staging detected 13 patients with T4 lesions; three patients with M1 lesions (two pleural Ml and one liver Ml) were detected by TS/LS. Lymph node staging in the chest and abdomen was the emphasis of TSILS staging. Thoracic LN staging demonstrated N0 status in 71 patients and N1 in 11 patients. Celiac lymph nodes were normal in 34 patients and positive in 21.
Esophagectomy was performed in 47 patients after thoracoscopic staging, 33 of them also had laparoscopic staging. Of these 47 resected patients, thoracoscopic staging showed N0 lymph nodes status in 42 patients and N1 in five patients. Three of the 42 patients (6.3%) with N0 disease by thoracoscopy were found at resection to have thoracic lymph node involvement (N1). Thoracoscopic staging was therefore accurate in detecting the presence of diseased thoracic lymph nodes in 44 of 47 cases (93.6%). Laparoscopic staging correctly detected normal celiac lymph nodes in 20 patients and diseased lymph nodes in 11 patients. Two patients who were N0 by LS staging actually had positive celiac lymph nodes at esophagectomy. Laparoscopic staging was accurate therefore in detecting lymph node metastasis in 31 of 33 patients (93.9%). Thirty-four cases were treated by neoadjuvant chemoradiation followed by surgery. Of 17 cases found to have positive LN by TSILS, 12 (70.6%) were downstaged to N0 after chemoradiation. Two cases with N0 at TS/LS staging progressed to N1 despite preoperative chemoradiation. Twenty-five patients (71.4%) were downstaged by T and/or N stage and 15 patients (44.8%) had complete pathologic response (CR) after chemoradiation. Of LN positive patients, there were 20% CR whereas there were 76% CR among LN negative patients.
Compared with resection pathology (Table 1
), the sensitivity, specificity and positive predictive value of TS staging for N1 disease in chest was 62.5, 100.0 and 100.0% by TS; 75.0, 75.6, and 23.1% by CT and 0.0, 51.4 and 5.5% by EUS, respectively. The sensitivity, specificity and positive predictive value for N1 disease in the abdomen was 84.6, 100.0 and 100.0% by Ls; 0.0, 97.1 and 0.0% by CT and 22.2, 81.5 and 28.6% by EUS, respectively. When compared with TS/LS staging, the relative sensitivity, specificity, and positive predictive value for detecting thoracic N1 disease was 27.3, 74.2 and 15.0% by CT and 62.5, 60.8 and 20.0% by EUS; for detecting N1 disease in the abdomen it was 23.8, 94.3 and 71.4% by CT and 47.1, 95.2 and 88.8% by EUS, respectively.
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Table 1. The sensitivity, specificity and positive predictive value of TS/LS, CT and EUS (as compared to resection pathology)
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3. Discussion
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In recent years, preoperative neoadjuvant chemotherapy/radiotherapy has become more and more popular since promising results have shown a possible increased survival of patients with esophageal cancer who had complete pathological response [10]. The early results reported in a few centers show more promise with combined modality than with either chemotherapy or radiation alone followed by surgery. In order to evaluate the results of these preoperative induction regimens, accurate TNM staging before treatment is essential. With the development of newer technology non-invasive staging tools such as CT, MRI and EUS can provide clinical TNM staging results for esophageal cancer patients [11–16]. Comparison results of CT and EUS with resection specimen pathology showed a low positive predictive value of N1 disease by CT and EUS in the chest and the abdomen. The positive predictive value of TSILS staging for N1 in the chest and abdomen was 100.0% in this series because it allowed direct visualization, biopsy and pathology examination. Thoracoscopic staging of thoracic lymph nodes was accurate in 44 of 47 patients (93.6%); laparoscopic staging in abdominal LN was accurate in 31 of 33 patients (93.9%). Since some of these patients underwent preoperative chemoradiation, the surgical pathological response to therapy after resection could be assessed (upstaged or downstaged). Of the patients in the group with N1 disease who underwent preoperative chemoradiation 70% were downstaged to N0. For this reason, it is not adequate to compare pretreatment CT and EUS staging with resection staging as there may have been a change in LN status post-treatment. As the results shown in Table 2 demonstrate, both CT and EUS had very low sensitivity and positive prediction value in detecting the N1 LN in the chest and relative higher positive predictive value (but still lower sensitivity) in detecting positive LN in the abdomen when compared to pathological results of TS/LS staging.
The accuracy of TS/LS staging is essential for patients who will undergo preoperative chemoradiation. Combining non-invasive staging with CT and EUS with minimal invasive staging using TS and LS can provide accurate pretreatment TNM staging for esophageal cancer patients. TS/LS staging can also provide pretreatment specimens to investigate the presence of LN metastasis and the changes before and after chemoradiation [17,18]. Using biomarkers like Ber-P4 to stain the sampled LN by IHC in esophageal cancers [19], may improve the specificity and accuracy to detect the occult LN metastasis. Finally, esophageal cancer patients who undergo trimodality therapy need a clearly dedicated regimen of preoperative chemotherapy and radiotherapy so as to decrease the morbidity and mortality during the perioperative period. TS/LS can provide preoperative pathological results of LN metastasis in the chest and abdomen, which allows an individualized dedicated radiation field design for each patient to avoid unnecessary morbidity due to extended radiation fields [20].
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4. Conclusion
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TS/LS staging in esophageal cancer patients has a higher specificity and accuracy than CT and EUS in esophageal cancer patients, especially for N1 disease in the chest. TS/LS is a helpful tool in assessment of results of preoperative chemoradiation. It also has allowed individualized preoperative radiotherapy fields.
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Footnotes
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Presented at the 2nd MITSIG International Symposium: Controversies in Cardiothoracic Surgery, Hong Kong, November 20–21, 1998.
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Abstract
1. Introduction
