The value of routine endoscopic ultrasound in patients with esophageal cancer after neoadjuvant chemoradiotherapy undergoing active surveillance

Background Active surveillance for esophageal cancer after neoadjuvant chemoradiotherapy (nCRT) involves repeated diagnostic tests to detect cancer regrowth. In the SANO-trial, this included esophagogastroduodenoscopy (EGD) with biopsies, endoscopic ultrasound (EUS) with fine-needle aspiration (FNA) of suspected lymph nodes and FDG-PET-CT. The value of routine EUS in this setting remains largely unknown. This study assessed the diagnostic yield of EUS over FDG-PET-CT. Methods A retrospective analysis of patients with esophageal cancer who underwent nCRT followed by clinical response evaluations with EGD, EUS and PET-CT was performed. Initial response assessment was performed within 3 months post-nCRT. Patients without tumor regrowth underwent active surveillance with repeated diagnosic tests. The primary outcome was the rate of EUS-detected lymph node metastases missed by PET-CT,after excluding cases with positive EGD findings or distant metastases. Results In total, 327 patients underwent both PET-CT and EUS post-nCRT, accounting for 1006 combined procedures: 327 at initial response assessment and 679 during active surveillance (6-60 months post-nCRT) in 121 patients. Positive lymph nodes were detected by EUS in 3.7% (12/327) of initial response assessments, 2.1% (7/327) were unidentified by PET-CT. During surveillance, this dropped to 0.9% (6/679) with 0.1% (1/679) missed by PET-CT. Conclusions EUS with FNA adds most value at 3 months post-nCRT, when the likelihood of detecting recurrence is highest. Beyond 3 months, its added value is limited (0.1% with negative PET-CT). Restricting the use of EUS to PET-suspicious nodes could omit 97.8% of EUS procedures.

Publikationsverlauf

Eingereicht: 13. August 2025

Angenommen nach Revision: 18. Dezember 2025

Accepted Manuscript online:
21. Dezember 2025