HIGH-GRADE MALIGNANT STRICTURE IS PREDICTIVE OF ESOPHAGEAL TUMOR STAGE - RISKS OF ENDOSONOGRAPHIC EVALUATION

Background. Endosonography is very accurate for the preoperative stagi ng of esophageal carcinoma. Approximately 20-38% of patients with esop hageal carcinoma present with high-grade malignant strictures that pre clude passage of the dedicated echoendoscope. In patients with such st rictures, endosonographic staging of esophageal tumors may he performe d after aggressive esophageal dilatation. However, aggressive dilatati on and passage of the echoendoscope in patients with high-grade malign ant strictures is not without risk. A detailed assessment of the tumor stage in patients presenting with high-grade malignant stenoses has n ot been previously reported to the authors' knowledge. Methods. Sevent y-nine patients with esophageal carcinoma were staged preoperatively u sing endosonography. The results of preoperative staging were compared with the pathologic stage of the esophagectomy specimen when availabl e or the surgical stage (detection of adjacent organ involvement [Stag e T4] or metastatic disease [Stage Mil at the time of surgery). Result s. Twenty-one patients (26.6%) presented with high-grade malignant str ictures precluding endosonographic examination without prior esophagea l dilatation. Nineteen of the 21 patients (91%) with high-grade malign ant stricture had Stage III or IV disease by histopathologic examinati on of the surgical specimen. Five of these 21 patients (24%) sustained an esophageal perforation as a result of either wire-guided dilatatio n, or as a direct consequence of the endosonographic staging procedure . The discovery of metastatic lymph nodes proximal to the stricture re sulted in successful staging (assessment of depth of tumor penetration and lymph node involvement) in only 2 of these 21 patients before eso phageal dilatation (incomplete staging). Staging of the proximal aspec t of the tumor was obtained in the remaining 19 patients before dilata tion; however, the accuracy for such incomplete staging was only 33%. Conclusions. The majority of patients with esophageal carcinoma presen ting with high-grade malignant strictures precluding endoscope passage without prior dilatation have a relatively advanced stage of disease (Stage III or IV) compared with those patients presenting with less se vere stenoses. There is a significant risk for esophageal perforation (24%) when patients with high-grade malignant esophageal strictures un dergo preoperative staging using endosonography. Patients with high-gr ade malignant strictures, therefore, present a relative contraindicati on to endosonography using the dedicated echoendoscope.