Optimizing locoregional staging in the preoperative setting
of resectable esophageal cancer
Charalambos Batsis
•
Ioannis Makris
Published online: 20 August 2010
Ó Springer Science+Business Media, LLC 2010
As preoperative, also called neoadjuvant, chemoradiother-
apy has increasingly been incorporated into clinical prac-
tice for the multimodal treatment of resectable esophageal
cancer, there is an increased interest in how accurately the
clinical stage (cTNM) needs to be predicted before the
initiation of neoadjuvant treatment, staging (yTNM), sub-
sequent surgery, and final histopathologic examination of
the surgical specimen (pTNM staging).
Imaging technology including endoscopic ultrasonog-
raphy (EUS), positron-emission tomography (PET), and
computed tomography (CT) currently is suggested for the
preoperative staging of esophageal cancer [1]. But some
controversy exists concerning the clinical utility of using of
all these imaging tools to improve staging considering
predictive accuracy and cost-effectiveness analysis.
To evaluate the utility and limitations of EUS, PET, and
CT in the pretreatment locoregional staging of resectable
esophageal cancer, Choi et al. [2] performed a comparative
study published in the June issue of Surgical Endoscopy.
For 109 patients, the sensitivity, specificity, and accuracy
of tumor depth (T) staging and regional lymph nodal (N)
staging for EUS, PET, and CT were compared with the
postoperative histopathologic stage (pTNM). Endoscopic
ultrasonography was the only method for delineating the
layers of the esophageal wall with an overall 72% accuracy
of T staging. The sensitivities for N staging ranged from
35% for CT to 49% for PET. Accuracy for N staging
showed no significant difference (66% for EUS, 68% for
PET, and 63% for CT). The authors concluded that espe-
cially for T staging, EUS may have an important integrated
role in the selection of surgery or neoadjuvant chemora-
diotherapy as primary treatment.
Although the report by Choi et al. [2] is limited by the
retrospective analysis of data for a small number of patients
without randomization, it is clinically very useful for
oncologists and surgeons in daily clinical practice. Despite
an initial overenthusiasm with PET and EUS, this study
provides realistic results for the accuracy of EUS, and CT in
the pretreatment T and N staging of resectable esophageal
cancer. The report by Choi et al. [2] provides realistic caution
for the current limitations of modern imaging technology.
The importance of primary treatment selection based on
pretreatment staging is shown by the following example. A
patient with cT1N0M0 or cT2N0M0 can benefit from
primary surgery rather than preoperative chemoradiother-
apy, which can be more suitable for more advanced stages
of disease. Given the potential impact of surgery or che-
moradiotherapy as the initial treatment on patients’ onco-
logic outcomes, clinicians should very carefully consider
the limitations of EUS, PET, and CT in deciding on a
treatment option.
Multimodal treatment of esophagogastric cancer has
been improved. Although the extent of surgery has been
standardized and although both chemoradiotherapy and the
timing of the application of these treatments have improved
the survival rates for resectable cancers, recurrence rates
still remain very high, particularly for more advanced stages
of solid tumors [3–5]. Promises to overcome the limitations
of current imaging technology for individualized treatment
provide the latest developments in cancer genetics and
personal genomics [6, 7].
C. Batsis (&)
Department of Surgery, School of Medicine,
University of Ioannina, 451 10 Ioannina, TK, Greece
e-mail: chbatsis@hotmail.com
I. Makris
Second Surgical Department, ‘‘G, Gennimatas’’
General Hospital, Aristotle University of Thessaloniki,
Thessaloniki, Greece
123
Surg Endosc (2011) 25:1344–1345
DOI 10.1007/s00464-010-1283-8