How to stage early BE cancer - EUS or endoscopic removal?

How to stage early BE cancer - EUS or endoscopic removal? Presented by Bas Weusten Institution St. Antonius Hospital, Nieuwegein Academic Medical Center, Amsterdam

case 56 y old female patient Lung transplant in 2013 Upper GI endoscopy for dyspepsia Bx: carcinoma EUS for staging?

Question Would you perform EUS for staging of this cancer Answer 1: yes Answer 2: no

Staging of early BE cancer Why? Questions to be answered in early BE cancer Is endoscopic therapy possible? Will endoscopic therapy be curative?

Will endoscopic therapy be curative? Endoscopic Tx is only justified if probability of LNM perioperative surgical mortality

Early BE cancer determinants of risk of LNMs Depth of invasion Tumor differentiation Invasion into (lymph)vessels Most determinants can only be assessed on histopathology of the resection specimen Potential role of EUS: - Depth of invasion - Lymph nodes?

Early BE cancer determinants of risk of LNMs Depth of tumor invasion T1A T1B m1 m2 m3 sm1 sm2 sm3 500 μm 1000 μm ep lp mm sm Endoscopic Can EUS reliably therapy predict for mucosal depth (sm1?) of tumor tumors invasion? only* *Pech et al. Gastroenterology 2014;146:652-60 Manner et al. Surg Endosc 2015;29:1888-96

EUS for (early) BE cancer literature year journal 1st author EUS beneficial? 2004 GUT May + 2005 GIE Larghi +/- 2008 Endoscopy Chemaly - 2010 Endoscopy Pech - 2010 Surg Endoscopy Thomas - 2011 GIE Pouw - 2011 Ann Thorac Surg Crabtree - 2012 J Gastrointest Oncol Fernandez-Sordo - 2014 Dis Esophagus Bulsiewicz - 2014 J Thorac Cardiovasc Surg Bergeron -

EUS for T staging in esophageal cancer Esophageal Cancer N=179 Barrett s cancer n=134 (75%) Squamous cell cancer n=45 (25%) Endoscopic Ultrasonography Surgical Esophageal Resection Pech et al. Endoscopy 2010;42:456-61

EUS staging EUS for T staging in esophageal cancer Histopathological staging pt1 pt2 pt3 pt4 Total (n) EUS T1 88 EUS T2 35 EUS T3 56 EUS T4 Total (n) 99 30 46 4 179 Pech et al. Endoscopy 2010;42:456-61

EUS staging EUS for T staging in esophageal cancer Histopathological staging pt1 pt2 pt3 pt4 Total (n) EUS T1 81 3 4-88 EUS T2 17 13 4 1 35 EUS T3 1 14 38 3 56 EUS T4 - - - - Total (n) 99 30 46 4 179 Pech et al. Endoscopy 2010;42:456-61

EUS staging EUS for T staging in esophageal cancer Histopathological staging pt1 pt2 pt3 pt4 Total (n) EUS T1 81 3 4-88 EUS T2 17 13 4 1 35 EUS T3 1 14 38 3 56 EUS T4 - - - - Total (n) 99 30 46 4 179 overstaged 18% 46,7% - - understaged 10,0% 17,4% 100% Pech et al. Endoscopy 2010;42:456-61

EUS staging EUS for T staging in esophageal cancer Histopathological staging pt1 pt2 pt3 pt4 Total (n) % correct EUS T1 81 3 4-88 92% EUS T2 17 13 4 1 35 37% EUS T3 1 14 38 3 56 68% EUS T4 - - - - Total (n) 99 30 46 4 179 74% overstaged 18% 46,7% - - understaged 10,0% 17,4% 100% Pech et al. Endoscopy 2010;42:456-61

Early Barrett s cancer: role of EUS Early Barrett s cancer n=131 EUS unremarkable n=105 (80%) Endoscopic Resection No indication for surgery 76% (n=80) Indication for surgery 24% (n=25) Pouw et al. GIE 2011;73:662-8

Early Barrett s cancer: role of EUS Early Barrett s cancer n=131 EUS suspicious n=26 (20%) Endoscopy unremarkable 54% (n=14) ER No indication for surgery 50% (n=7) Indication for surgery 50% (n=7) Pouw et al. GIE 2011;73:662-8 Endoscopy suspicious 46% (n=12) ER No indication for surgery 25% (n=3) Indication for surgery 75% (n=9)

Early Barrett s cancer: role of EUS Pouw et al. GIE 2011;73:662-8

How to stage early BE cancer - EUS or endoscopic removal? CONCLUSION I: EUS is unreliable in the assessment of depth of tumor invasion in early BE cancer.

EUS for N staging in esophageal cancer Esophageal Cancer N=179 Barrett s cancer n=134 (75%) Squamous cell cancer n=45 (25%) Endoscopic Ultrasonography Surgical Esophageal Resection Pech et al. Endoscopy 2010;42:456-61

EUS staging EUS for N staging in esophageal cancer Histopathological staging pn0 pn1 Total (n) EUS N0 102 EUS N1 77 Total (n) 111 68 179 Pech et al. Endoscopy 2010;42:456-61

EUS staging EUS for N staging in esophageal cancer Histopathological staging pn0 pn1 Total (n) EUS N0 82 20 102 EUS N1 29 48 77 Total (n) 111 68 179 Pech et al. Endoscopy 2010;42:456-61

EUS staging EUS for N staging in esophageal cancer Histopathological staging pn0 pn1 Total (n) EUS N0 82 20 102 EUS N1 29 48 77 Total (n) 111 68 179 overstaged 26% - understaged 29% Pech et al. Endoscopy 2010;42:456-61

EUS staging EUS for N staging in esophageal cancer Histopathological staging pn0 pn1 Total (n) % correct EUS N0 82 20 102 80% EUS N1 29 48 77 62% Total (n) 111 68 179 73% overstaged 26% - understaged 29% Pech et al. Endoscopy 2010;42:456-61

How to stage early BE cancer - EUS or endoscopic removal? CONCLUSION I: EUS is unreliable in the assessment of depth of tumor invasion in early BE cancer. CONCLUSION II: EUS is not reliably enough in the assessment of LNM in early BE cancer Early BE cancer should be staged by means of histopathological analysis of the endoscopic resection specimen

case 56 y old female patient Lung transplant in 2013 Upper GI endoscopy for dyspepsia Bx: carcinoma EUS for staging?

Question Would you perform EUS for staging of this cancer Answer 1: yes Answer 2: no

How to stage early BE cancer - EUS or endoscopic removal? Practical guidence If a lesion appears to be resectable by ER, just do it If a lesion invades into the muscularis propria MBM the band will simpy fall off EMR-cap non-lifting sign Histopathology of the resection specimen will guide you on further management Low-risk and R0-resection endoscopic management High-risk and/or R1-resection consider surgery

case Histopathology: T1m3 G1-2 LVI-