Pretherapeutic understaging in T2 N0 upper gastrointestinal cancers remains a clinical dilemma

Background: The optimal treatment strategy for cT2N0 carcinoma of the upper digestive tract remains a clinical challenge, primarily due to the lack of randomized clinical data and the limited reliability of pretherapeutic staging methods.

Aim of the project: This study aimed to assess the concordance between pretherapeutic endoscopic ultrasound (EUS) staging and final histopathology, and to identify potential clinicopathological risk factors associated with understaging.

Methods: Retrospectively all patients with cT2 cN0 carcinoma of the esophagus, gastroesophageal junction (GEJ), or stomach who underwent primary surgery between 2014 and 2024 at the University Medical Center in Göttingen were included. Besides comparing clinicopathological characteristics between understaged and correctly or overstaged patients, we analyzed the mean diameter of tumor-infiltrated lymph nodes and the size of corresponding lymph node metastases.

Results: A total of 52 patients met the inclusion criteria. 69.2% were male, and the majority of tumors were adenocarcinomas (90.4%). The most common tumor site was the GEJ (50%), followed by the stomach (40.4%), with a minority located in the distal esophagus (9.6%). In 25 cases (48.1%), final histopathology revealed understaging by EUS, while 27 cases (51.9%) were correctly staged or overstaged. Tumors of the GEJ and stomach were similarly understaged (11/25 vs. 13/25). Only one esophageal tumor was understaged. The mean age of understaged patients was 67.0 years compared to 66.2 years in the correctly or overstaged group (not significant). The mean BMI was 26.3 in understaged patients versus 26.6 in correctly or overstaged patients (not significant). The time interval between EUS and surgery was 14.8 days for understaged patients versus 10.6 days for the others. The N-category was more often understaged than the T-category (42.3% vs. 32.7%). Mostly both were understaged. Among the assessed clinical features, none were identified as significant risk factors for pretherapeutic understaging. However, preliminary results suggest that the majority of tumor-infiltrated lymph nodes in understaged patients measured less than 10 mm and that understaged tumors were primarily poorly differentiated.

Conclusions: Pretherapeutic EUS remains highly inaccurate for staging cT2N0 tumors of the upper digestive tract. In the absence of risk factors for understaging, neoadjuvant treatment strategies should be considered for this patient subgroup.

 

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Publication History

Article published online:
04 September 2025