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Assessment of malignant lymph nodes and tumour invasion by EUS

Assessment of malignant lymph nodes and tumour invasion by EUS. Dr Bernard Stacey SUHT. T1. T2. T3. T4. Malignant features of LNs. Size >1cm Hypoechoic Distinct margins Round shape All 4 present  accuracy = 80% - All 4 features present only in 25%.

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Assessment of malignant lymph nodes and tumour invasion by EUS

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  1. Assessment of malignant lymph nodes and tumour invasion by EUS Dr Bernard Stacey SUHT

  2. T1

  3. T2 T3

  4. T4

  5. Malignant features of LNs • Size >1cm • Hypoechoic • Distinct margins • Round shape • All 4 present  accuracy = 80% - All 4 features present only in 25% Bhutani MS and Hawes R, Gastrointestinal Endoscopy 1997

  6. Evidence for this? • Prospective study of 100 patients • All underwent resection • EUS LN features recorded wrt the 4 features • Correlation with histology • Sensitivity 89.1% • Specificity 91.7% • If LN imaged, likelihood of N1 disease = 86% • If no LN imaged  79% chance of N0 Catalano MF, Gastrointestinal Endoscopy 1994

  7. More evidence for this • Prospective study of 457 patients • EUS features of LNs, cysts, wall lesions and extra-luminal lesions recorded • Correlation with clinical / histopathological data • EUS FNA for LNs • Sensitivity 92% • Specificity 93% • Complication rate 0.5% (higher for cystic lesions) Wiersema MJ, Gastroenterology 1997

  8. Does this change outcome? • Retrospective study • 198 patients (SCC > adeno) • FNA in 20% • Sensitivity 97%, specificity 100% • This modified staging in 77.5% of cases • Surgery withheld from 60% of these Giovannini M, Endoscopy 1999

  9. Changing outcome - Mayo clinic data • 74 patients - FNA on non-peritumoural LNs >5mm • half EUS + FNA, half EUS alone EUS aloneEUS + FNA Sensitivity 63% 93% * Specificity 81% 100% Complications 0 1

  10. Is FNA the ideal test? • Availability • Complications • Interceding tumour • Sensitivity <100% (ie- false -ves) • Experience (US survey 2000  median number of EUS FNA performed / yr = 3) • LN characteristics may vary according to different primary tumour site

  11. Intra-observer variability:agreement & reproducibility • Variability of T stage reporting even amongst experienced endosonographers • Best at extremes of T stage • Inexperienced --> poor T stage reporting but good at N stage • T2 least well reported • Repeatable in many studies • Pallazzo L, Hawes R Catalano MF, Gastrointestinal Endoscopy 1995

  12. Computer assisted lymph node analysis • EUS images of LNs in oesophageal cancer correlated with histology after resection • EUS features of: • Echogenitcity • Whole-node heterogenicity • Regional variability • Assessed by computerized image analysis Loren DE et al, Gastrointestinal endoscopy 2002

  13. Computer assisted lymph node analysis Benign v malignant • Hypoechoic p<0.04 • Heterogeneity p<0.004 • Regional variability p0.09 • Long/short axis p=0.05

  14. Oesophageal cancer and PET • Metastases • Sensitivity 67% • Specificity 97% • Lymph nodes • Sensitivity 51% • Specificity 84% 16% false positives ie: benign - need FNA + ? Meta-analysis, Van Westreenen, J Clin Onc

  15. T N M EUS CT PET Oesophageal cancer staging

  16. The future • Prospective study into the Wessex experience: In what % of patients does EUS +/- FNA influence treatment in oesophageal cancer? Prospective / retrospective?

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