Lymph node staging in esophageal/junctional tumors after chemoradiotherapy: should we change strategy?

We read the paper by van der Bogt et al. [1] that prospectively evaluated the role of radial endoscopic ultrasound (EUS) for lymph node (LN) restaging in esophageal/junctional tumors after chemoradiotherapy. Among the 101 patients, suspicious LNs were detected by radial EUS in 28 (22 %), of whom 19 (68 %) underwent EUS-guided fine-needle aspiration (FNA). Surgical pathology demonstrated LN involvement in 22 % of patients, with only 50 % of these being discovered by radial EUS. EUS-FNA revealed malignancy in only three patients (16 %), was negative in eight, and inconclusive in eight further patients.

This represents the first prospective study that assessed the performance of radial EUS in this clinical setting. From the present experience and a recent meta-analysis [2], it is clear that EUS criteria defining malignant LNs cannot be applied after chemoradiotherapy. Other techniques, such as positron emission tomography – computed tomography (PET-CT), also failed to detect residual tumor in small LNs, raising the question of how to make this important step more efficient [2].

One lesson can be learnt from Vasquez-Sequeros and colleagues [3], who not only showed the superiority of EUS-FNA over radial EUS for LN staging of esophageal cancer, but also developed a staging algorithm including rapid on-site cytopathological evaluation (ROSE). In contrast to what was performed in the present study, where no algorithm or EUS-FNA procedure standardization existed, with consequent overall poor results, Vasquez-Sequeros et al. started their staging procedure with EUS-FNA and ROSE from the celiac and non-peritumoral perigastric LN stations, and the procedure was terminated after a positive result [3].

The observation that almost all malignant LNs after chemoradiotherapy were located distal to the carina should mean restaging of such tumors by EUS-FNA and ROSE starting at these LN stations would increase the procedure performance [4], and decrease the number of LNs sampled and overall procedural time in these usually debilitated patients. Protocols implementing this restaging strategy should provide us with answers in order to avoid unnecessary surgery.

Publication History

Article published online:
25 March 2020

• References

• 1 van der Bogt RD, van der Wilk BJ, Poley JW. et al. Endoscopic ultrasound and fine-needle aspiration for the detection of residual nodal disease after neoadjuvant chemoradiotherapy for esophageal cancer. Endoscopy 2019; DOI: 10.1055/a-1065-1759.
• 2 Eyck BM, Onstenk BD, Noordman BJ. et al. Accuracy of detecting residual disease after neoadjuvant chemoradiotherapy for esophageal cancer: A systematic review and meta-analysis. Ann Surg 2020; 271: 245-256
• 3 Vazquez-Sequeiros E, Wiersema MJ, Clain JE. et al. Impact of lymph node staging on therapy of esophageal carcinoma. Gastroenterology 2003; 125: 1626-1635
• 4 Bang JY, Navaneethan U, Hasan MK. et al. Endoscopic ultrasound-guided specimen collection and evaluation techniques affect diagnostic accuracy. Clin Gastroenterol Hepatol 2018; 16: 1820-1828