Esophageal cancer staging: Improved accuracy by endoscopic ultrasound of celiac lymph nodes

Background. Clinical staging of esophageal cancer is required for optimal t herapy but remains imprecise. Pathologic verification of involved lymph nod es could potentially direct treatment allocation. With the rising incidence of distal and gastroesophageal junction adenocarcinomas, assessment of the celiac axis lymph nodes (CLNs) becomes important because it is a common no dal drainage basin. Endoscopic ultrasound (EUS) permits evaluation of CLNs and biopsy by fine-needle aspiration. This study examined the usefulness of this staging tool. Methods. A consecutive series of 62 patients with esophageal cancer conside red resectable by computed tomographic scan underwent EUS for T and N stagi ng and were retrospectively studied. A CLN visualized by EUS as greater tha n 5 mm was considered positive. Fine-needle aspiration of the CLN was perfo rmed routinely. Endoscopic ultrasound and computed tomographic staging were compared on the basis of pathologic verification of CLNs. Results. It was possible to evaluate CLNs by EUS in 59 (95%) of 62 patients : positive in 19, negative in 40. In EUS-positive patients, fine-needle asp iration was positive in 15, falsely negative in 2, and not done in 2. By co mputed tomographic scan, CLNs were negative in 57 patients and positive in 2. The CLNs were positive in 23 of 54 patients eligible for CLN pathologic verification. All positive CLNs not identified by EUS (7 false-negative EUS ) were microscopic foci in one or two nodes and were associated with T3 tum ors. Sensitivity and specificity of EUS were 72% and 97%, respectively, com pared with 8% and 100% for computed tomographic scan. When EUS identified C LNs, fine-needle aspiration confirmed positivity in 88% of cases. Conclusions. Endoscopic ultrasound with fine-needle aspiration is useful in the detection and confirmation of CLN metastasis. In T3 tumors of the dist al esophagus, a negative EUS result does not substantiate absence of CLN di sease. Endoscopic ultrasound with fine-needle aspiration may be important i n guiding treatment for patients with distal adenocarcinoma and documenting disease before neoadjuvant therapy. (C) 1999 by The Society of Thoracic Su rgeons.