The impact of endoscopic ultrasound and computed tomography on TNM staging of early Barrett's cancer

Introduction: Computed tomography (CT) and endoscopic ultrasound (EUS) are part of the regular staging protocol in esophageal cancer. The value of the two methods was assessed in patients (pts) with early cancer in Barrett's esophagus (BC).

Methods: 100 consecutive pts (median age 64 years) with suspected early BC referred to our unit for endoscopic therapy (ET) were prospectively included. EGD, EUS, CT of the chest and upper abdomen, and abdominal ultrasonography were performed. On the basis of the lymph-node (LN) findings on CT and/or EUS, the pts were assigned to 3 categories: C1, no suspicious LN; C2, paraesophageal LN<1cm in size at tumor level, LN≥1cm in size not at tumor level in the mediastinum or celiac trunk); and C3, paraesophageal LN>1cm in size at tumor level or round and hypoechoic). Surgery was scheduled in operable pts if staging showed a T category higher than T1 and/or the LN staging was assessed as C3. Pts with suspected submucosal infiltration underwent diagnostic endoscopic resection, and if submucosal tumor was confirmed were referred for surgery.

Results: The median follow-up period was 25 months (IQR 19.5–30.0). The T category diagnosed with CT was ≤T1 in all pts. On EUS, the T category was classified as T1 in 92% of cases (n=92) and as >T1 in 8% (n=8; P<0.05). Enlarged LN (C2 and C3) were detected in 45% of the pts. Significantly more C2 LN were diagnosed with EUS than CT (28 vs. 19; P<0.05). LN at the level with the highest suspicion, C3, were detected using CT in only 3/9 cases. Sensitivity of CT for N-staging was not acceptable compared to EUS (38% vs. 75%). No extranodal metastases were found on CT.

	EUS	CT
Sensitivity	75%	38%
Specificity	97%	100%
Positive Predictive Value	75%	100%
Negative Predictive Value	98%	95%

	pT1m (n=44)	pT1sm (n=11)	pT2 (n=4)	pT3 (n=3)
EUS-T1m	39 (89%)	8	-	-
EUS-T1sm	5	3 (33%)	-	-
EUS-T2	-	-	2 (50%)	-
EUS-T3	-	-	2	3 (100%)

Conclusions: In suspected early BC, EUS is superior to CT for T and N staging. As CT had no influence on the TNM classification in any of these pts, it may be possible to dispense with this method as a staging procedure in pts with BC. By contrast, EUS is required in order to differentiate between pts with BC in whom ET is suitable and those in whom surgery is required.