Ann Thorac Surg 2001;72:219-220
© 2001 The Society of Thoracic Surgeons
Invited commentary
Mark K. Ferguson, MDa
a Department of Surgery, The University of Chicago, Medical Center, 5841 S Maryland Ave, MC 5035, Chicago, IL 60637, USA
e-mail: mferguso{at}surgery.bsd.uchicago.edu
Diagnosis precedes therapy, and, for most carcinomas, staging should also precede therapy. Until recently, the latter aphorism has not been applicable to esophageal cancer because of the inaccuracy of available staging studies. A recent expedited review of information regarding the utility of positron emission tomography (PET) in staging esophageal cancer led to its approval for this purpose at the end of 2000 by the Health Care Financing Administration. In contrast, endoscopic ultrasonography (EUS) has been available for a decade for staging esophageal cancer. However, its role has been uncertain due to the cost of and expertise needed to use the equipment, variations in the accuracy of readings, and the perceived inability of EUS to provide information that would influence clinical management decisions. Recent publications, including that of Eloubeidi and colleagues, now demonstrate the practical utility of this staging modality.
Surgeons historically have given patients with M1a disease (identified on the basis of metastases to celiac lymph nodes) the "benefit of the doubt" and have proceeded with resection. Surgeons at the Cleveland Clinic and from Leuven, Belgium, have reported that survival of patients with M1a disease is poor and is not dissimilar from that of patients with distant organ metastases. Using newer EUS-guided cytologic techniques, the group from the Medical University of South Carolina has shown that mere identification of celiac lymph nodes in patients with esophageal cancer is synonymous with stage M1a disease. They now demonstrate that the finding of M1a disease based on EUS staging is associated with poor long-term survival, corroborating reports from the surgical series mentioned above. These facts suggest that a new algorithm is necessary for selecting appropriate therapy for esophageal cancer patients, in which EUS evidence of M1a disease is a contraindication to routine resection.
This suggestion may cause distress and controversy among surgical and non-surgical oncologists alike. How will celiac nodes be more accurately defined so they can be reliably distinguished from left gastric artery lymph nodes, a task that is even difficult intraoperatively? Will cytologic proof of celiac nodal disease be necessary before concluding that patients are M1a? Might PET have a role in this regard, and can it adequately distinguish celiac nodes from left gastric artery lymph nodes? How do we manage a patient treated with neoadjuvant therapy who is downstaged from M1a to become a possible candidate for resection? These valuable techniques finally offer the ability to accurately and noninvasively define cancer stage, which provides physicians with the opportunity to select stage-specific therapy. It is incumbent upon surgeons to refine their staging algorithms utilizing these techniques to optimize the care of their patients.
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Predictors of survival for esophageal cancer patients with and without celiac axis lymphadenopathy: impact of staging endosonography
- Mohamad A. Eloubeidi, Michael B. Wallace, Brenda J. Hoffman, Margaret B. Leveen, Annette Van Velse, Robert H. Hawes, and Carolyn E. Reed
Ann. Thorac. Surg. 2001 72: 212-219.
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