The use of Neck ultrasound scan in the staging of oesophageal cancer

1
The use of Neck ultrasound scan in the staging of
oesophageal cancer

• A Krishnan, N Wong, B Kumar,
• J Shenfine, R Holmes, DL Richardson, SM Griffin
• Northern Oesophago-Gastric Cancer Unit
• Royal Victoria Infirmary

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Background

• Neck ultrasound has been shown to be a useful
  staging tool when used to assess supra-azygos
  lymphadenopathy
• It can be both highly sensitive (up to 86) and
  highly specific (up to 90)1
• Can be more cost effective when used with CT to
  stage metastatic oesophageal cancer1
• After normal CT and PET, ultrasound neck can have
  up to 5 additional value2
• Should be part of the routine staging work-up2
• EPM van Vliet et al. 2007. Detection of distant
  metastases in patients with oesophageal or
  gastric cardia cancer a diagnostic decision
  analysis. Br J Cancer. 2007 Oct 897(7)868-76.
• Omloo et al 2009. Additional Value of external
  ultrasonography of the neck after CT and PET
  scanning in the preoperative assessment of
  patients with esophageal cancer. Dig Surg.
  200926(1) 43-9.

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Aims

• To evaluate the use of USS neck in patients with
  supra-azygous lymph nodes
• To evaluate the eventual outcome of the patients
  who had USS neck

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Methods

• Retrospective study
• Neck USS in 2010
• Upper GI cancer proformas, clinic letters,
  diadem summaries, radiological reports
• Radiological staging, results of USS neck, FNA
  findings, further scans, and outcome

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Methods

• Indications for USS neck
• High Paratracheal nodes
• Upper paraoesophageal nodes
• Neck nodes
• Thyroid lesions

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Results

• Radiological Staging (6th edition TNM staging)
  was determined using CT and EUS
• Included both squamous cell cancer and
  adenocarcinoma of the oesophagus
• 34 patients with gtT3 N1 disease had CT evidence
  of supra-azygos lymphadenopathy
• 32 USS neck were performed after MDT discussion

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Results

• Radiological Stage
• Lymph node distribution on CT (USS neck
  Indication)

32 USS
29 T3N1
3 T4N1
Para-trachael Para-Oesophageal Neck Nodes
22/32 7/32 3/32
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Results

• 18 patients had suspicious neck lymph nodes
• 13 patients underwent FNA

13 FNA
6 Positive
7 Negative
3 CT PET
4 NO CT PET
6 Palliative
2 Curative
1 Palliative
2 Palliative
2 Curative
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Results

• 5 patients had suspicious nodes on USS but no FNA
• FNA was not technically achievable

18 USS Suspicious
13 FNA
5 NO FNA
3 NO CT PET
2 CT PET
1 Curative
2 Palliative
1 Curative
1 Palliative
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Results

• 14 USS were negative for suspicious nodes

32 USS
18 suspicious
14 non-suspicious
9 CT PET
5 NO CT PET
6 Curative
3 Palliative
2 palliative
3 Curative
After further MDTs
2 inoperable at time of surgery
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Summary of Results
Sensitivity 72 Specificity 65
32 USS
18 positive
14 Negative
11 Palliative
7 Curative
6 Palliative
8 Curative
USS under detected disease in 6 patients and over
detected disease in 7 patients
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Conclusions

• Neck US FNA is a useful staging modality when
  managing oesophageal carcinoma
• It has been shown to be cost-effective and has
  reasonable specificity and sensitivity (van
  Vliet, 2007)
• CT PET appears to be a useful adjunct to USS in
  particular USS negative patients
• A large prospective study with comparison to
  final pathological stage is required

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Acknowledgements

• Nick Hayes
• Daya Karat
• Kamil Wynne
• Claire Sedgewick
• Rachel Colver
• Miss Sarah Robinson
• Paula Brooks
• Helen Jaretzke
• Mark Irving
• Jane Osborne