Endoscopy 2006; 38(9): 953
DOI: 10.1055/s-2006-925097
Unusual cases and technical notes
© Georg Thieme Verlag KG Stuttgart · New York

Fine-Needle Aspiration of Peritumoral Lymph Nodes in Esophageal Cancer with Endobronchial Ultrasound

K.  W.  Noh1 , M.  B.  Wallace1 , J.  M.  Pascual1 , H.  C.  Wolfsen1 , M.  Raimondo1 , T.  A.  Woodward1
  • 1Division of Gastroenterology and Hepatology and Division of Pulmonary Diseases, Mayo Clinic, Jacksonville, Florida, USA
Further Information

T. A. Woodward, M.D.

Division of Gastroenterology and Hepatology, Mayo Clinic

4500 San Pablo RoadJacksonvilleFL 32224, USA

Fax: 904-953-7260

Email: woodward.timothy@mayo.edu

Publication History

Publication Date:
03 March 2006 (online)

Table of Contents

A 70-year-old man underwent esophagogastroduodenoscopy for dysphagia and weight loss. Two islands of abnormal mucosa 22 cm from the incisors were biopsied and found to consist of squamous-cell carcinoma. Four-quadrant biopsies demonstrated severe dysplasia or carcinoma in situ throughout the esophagus. The endoscopic ultrasound (EUS) examination did not reveal a discrete mass. In the mediastinum, 22 cm from the incisors, a diffusely hypoechoic round periesophageal lymph node with sharp margins, 5.2 mm in size, was identified (Figure [1]). This was positioned in the area adjacent to the previously documented patch of carcinoma. EUS-guided fine-needle aspiration (FNA) was not carried out due to concern regarding contamination from the needle as it traversed the cancerous mucosa. Endobronchial ultrasonography (EBUS) was therefore used to sample the suspicious lymph node (Figure [2]). With ultrasound guidance using the EBUS scope, the periesophageal lymph node was identified and sampled, and the cytology findings showed that it was negative for malignancy. The patient underwent a transhiatal esophagectomy. The final pathological assessment revealed severe dysplasia or squamous-cell carcinoma in situ in the esophagus. The periesophageal and perigastric lymph nodes were free of tumor.

Zoom Image

Figure 1 The endoscopic ultrasound image shows a round, hypoechoic lymph node with sharp margins, 5.2 mm in size (arrow).

Zoom Image

Figure 2 The endobronchial ultrasound image shows a round, hypoechoic lymph node with sharp margins, 5.1 mm in size (arrow).

The presence of peritumoral lymphadenopathy detected on EUS examination poses a challenge in the staging of esophageal cancer. The endosonographic appearance of the lymph nodes alone cannot reliably predict the likelihood of malignant infiltration, and FNA is often necessary [1] [2] [3]. However, as the needle passes through the primary tumor during FNA, a positive result is difficult to interpret.

Since the introduction of EBUS in 1992, the technique has been limited to the staging of pulmonary malignancies [4]. The new indication for EBUS described here allows the detection of malignant cells in lymph nodes without the risk of contamination from the primary tumor and eliminating the risk of tumor seeding into a lymph node. This technique is particularly important during planning for nonsurgical treatments such as photodynamic therapy, as the presence of malignant nodes would preclude such interventions [5].

Competing interests: None

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References

  • 1 Bhutani M S, Hawes R H, Hoffman B J. A comparison of the accuracy of echo features during endoscopic ultrasound and EUS-guided fine-needle aspiration for the diagnosis of malignant lymph node invasion.  Gastrointest Endosc. 1997;  45 474-479
  • 2 Vazquez-Sequeiros E, Wiersema M J, Clain J E. et al . Impact of lymph node staging on therapy of esophageal carcinoma.  Gastroenterology. 2003;  125 1626-1635
  • 3 Eloubeidi M A, Chen V K. Endoscopic ultrasound-guided fine needle aspiration is superior to lymph node echofeatures: a prospective evaluation of mediastinal and peri-intestinal lymphadenopathy.  Am J Gastroenterol. 2004;  99 628-633
  • 4 Hurter T, Hanrath P. Endobronchial sonography: feasibility and preliminary results.  Thorax. 1992;  47 565-567
  • 5 Conio M, Cameron A J, Chak A. et al . Endoscopic treatment of high-grade dysplasia and early cancer in Barrett’s oesophagus.  Lancet Oncol. 2005;  6 311-321

T. A. Woodward, M.D.

Division of Gastroenterology and Hepatology, Mayo Clinic

4500 San Pablo RoadJacksonvilleFL 32224, USA

Fax: 904-953-7260

Email: woodward.timothy@mayo.edu

#

References

  • 1 Bhutani M S, Hawes R H, Hoffman B J. A comparison of the accuracy of echo features during endoscopic ultrasound and EUS-guided fine-needle aspiration for the diagnosis of malignant lymph node invasion.  Gastrointest Endosc. 1997;  45 474-479
  • 2 Vazquez-Sequeiros E, Wiersema M J, Clain J E. et al . Impact of lymph node staging on therapy of esophageal carcinoma.  Gastroenterology. 2003;  125 1626-1635
  • 3 Eloubeidi M A, Chen V K. Endoscopic ultrasound-guided fine needle aspiration is superior to lymph node echofeatures: a prospective evaluation of mediastinal and peri-intestinal lymphadenopathy.  Am J Gastroenterol. 2004;  99 628-633
  • 4 Hurter T, Hanrath P. Endobronchial sonography: feasibility and preliminary results.  Thorax. 1992;  47 565-567
  • 5 Conio M, Cameron A J, Chak A. et al . Endoscopic treatment of high-grade dysplasia and early cancer in Barrett’s oesophagus.  Lancet Oncol. 2005;  6 311-321

T. A. Woodward, M.D.

Division of Gastroenterology and Hepatology, Mayo Clinic

4500 San Pablo RoadJacksonvilleFL 32224, USA

Fax: 904-953-7260

Email: woodward.timothy@mayo.edu

Zoom Image

Figure 1 The endoscopic ultrasound image shows a round, hypoechoic lymph node with sharp margins, 5.2 mm in size (arrow).

Zoom Image

Figure 2 The endobronchial ultrasound image shows a round, hypoechoic lymph node with sharp margins, 5.1 mm in size (arrow).