Retrospective Study
Copyright ©The Author(s) 2018. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Endosc. Jan 16, 2018; 10(1): 37-44
Published online Jan 16, 2018. doi: 10.4253/wjge.v10.i1.37
Mediastinal node staging by positron emission tomography-computed tomography and selective endoscopic ultrasound with fine needle aspiration for patients with upper gastrointestinal cancer: Results from a regional centre
Chris Harrington, Lyn Smith, Jennifer Bisland, Elisabet López González, Neil Jamieson, Stuart Paterson, Adrian John Stanley
Chris Harrington, Lyn Smith, Jennifer Bisland, Elisabet López González, Neil Jamieson, Stuart Paterson, Adrian John Stanley, Glasgow Royal Infirmary, Glasgow G4 0ET, United Kingdom
Chris Harrington, Stuart Paterson, Forth Valley Royal Hospital, Larbert FK5 4WR, United Kingdom
Elisabet López González, Hospital Vega Baja, Orihuela 03314, Spain
Neil Jamieson, Raigmore Hospital, Inverness IV2 3UJ, United Kingdom
Author contributions: Paterson S and Stanley AJ conceived this manuscript; Smith L, Bisland J, López González E and Harrington C collected data; Harrington C wrote the paper, with input from all co-authors who approved the final submission.
Institutional review board statement: After discussion with the local Ethics Service, they considered this retrospective project to be an audit rather than a research project, therefore ethical approval was not required.
Informed consent statement: As this retrospective study was accepted to be an audit project, with anonymised data and no intervention for any patient, informed consent from patients was not required.
Conflict-of-interest statement: There are no conflicts of interest for any of the authors.
Data sharing statement: The raw data is available from Harrington C at chrisharrington@nhs.net. Consent has not been obtained for sharing of this data but all data have been anonymised and the risk of identification is therefore low.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Dr. Adrian John Stanley, BM BCh, FRCP (C), MD, Associate Professor, Consultant Gastroenterologist, Glasgow Royal Infirmary, Walton Building, Castle Street, Glasgow G4 0ET, United Kingdom. adrian.stanley@ggc.scot.nhs.uk
Telephone: +44-141-2114073
Received: July 26, 2017
Peer-review started: July 28, 2017
First decision: September 11, 2017
Revised: November 4, 2017
Accepted: November 19, 2017
Article in press: November 20, 2017
Published online: January 16, 2018
Abstract
AIM

To investigate the impact of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) and positron emission tomography-computed tomography (PET-CT) in the nodal staging of upper gastrointestinal (GI) cancer in a tertiary referral centre.

METHODS

We performed a retrospective review of prospectively recorded data held on all patients with a diagnosis of upper GI cancer made between January 2009 and December 2015. Only those patients who had both a PET-CT and EUS with FNA sampling of a mediastinal node distant from the primary tumour were included. Using a positive EUS-FNA result as the gold standard for lymph node involvement, the sensitivity, specificity, positive and negative predictive values (PPV and NPV) and accuracy of PET-CT in the staging of mediastinal lymph nodes were calculated. The impact on therapeutic strategy of adding EUS-FNA to PET-CT was assessed.

RESULTS

One hundred and twenty one patients were included. Sixty nine patients had a diagnosis of oesophageal adenocarcinoma (Thirty one of whom were junctional), forty eight had oesophageal squamous cell carcinoma and four had gastric adenocarcinoma. The FNA results were inadequate in eleven cases and the PET-CT findings were indeterminate in two cases, therefore thirteen patients (10.7%) were excluded from further analysis. There was concordance between PET-CT and EUS-FNA findings in seventy one of the remaining one hundred and eight patients (65.7%). The sensitivity, specificity, PPV and NPV values of PET-CT were 92.5%, 50%, 52.1% and 91.9% respectively. There was discordance between PET-CT and EUS-FNA findings in thirty seven out of one hundred and eight patients (34.3%). MDT discussion led to a radical treatment pathway in twenty seven of these cases, after the final tumour stage was altered as a direct consequence of the EUS-FNA findings. Of these patients, fourteen (51.9%) experienced clinical remission of a median of nine months (range three to forty two months).

CONCLUSION

EUS-FNA leads to altered staging of upper GI cancer, resulting in more patients receiving radical treatment that would have been the case using PET-CT staging alone.

Keywords: Endoscopic ultrasound, Oesophago-gastric cancer staging, Oesophageal cancer, Positron emission tomography-computed tomography, Mediastinal nodes

Core tip: We have found that positron emission tomography-computed tomography (PET-CT) in the setting of upper gastrointestinal cancer has a high sensitivity and negative predictive value, but has poor specificity and positive predictive value for the detection of malignant mediastinal lymph nodes. This could lead to many patients being over-staged by PET-CT alone. The use of endoscopic ultrasound-guided fine-needle aspiration of mediastinal nodes results in more patients being offered radical therapy.