Oxford OesophagoGastric Centre, Oxford, UK.
National Institute for Health Research Oxford Biomedical Research Centre, Oxford, UK.
Br J Surg. 2015 Nov;102(12):1488-99. doi: 10.1002/bjs.9905. Epub 2015 Sep 7.
Following CT, guidelines for staging oesophageal and gastro-oesophageal junction (GOJ) cancer recommend endoscopic ultrasonography (EUS), PET-CT and laparoscopy for T3-T4 GOJ tumours. These recommendations are based on generic utilities, but it is unclear whether the test risk outweighs the potential benefit for some patients. This study sought to quantify investigation risks, benefits and utilities, in order to develop pragmatic, personalized staging recommendations.
All patients with a histological diagnosis of oesophageal or GOJ cancer staged between May 2006 and July 2013 comprised a development set; those staged from July 2013 to July 2014 formed the prospective validation set. Probability thresholds of altering management were calculated and predictive factors identified. Algorithms and models (decision tree analysis, logistic regression, artificial neural networks) were validated internally and independently.
Some 953 patients were staged following CT, by [(18) F]fluorodeoxyglucose PET-CT (918), EUS (798) and laparoscopy (458). Of these patients, 829 comprised the development set (800 PET-CT, 698 EUS, 397 laparoscopy) and 124 the validation set (118 PET-CT, 100 EUS, 61 laparoscopy). EUS utility in the 71.8 per cent of patients with T2-T4a disease on CT was minimal (0.4 per cent), its risk exceeding benefit. EUS was moderately accurate for pT1 N0 disease. A number of factors predicted metastases on PET-CT and laparoscopy, although none could inform an algorithm. PET-CT altered management in 23.0 per cent, and laparoscopy in 7.1 per cent, including those with T2 and distal oesophageal tumours.
Although EUS provided additional information on T and N category, its risk outweighed potential benefit in patients with T2-T4a disease on CT. Laparoscopy seemed justified for distal oesophageal tumours of T2 or greater.
在 CT 检查后，针对食管和食管胃交界部（GOJ）癌症的分期推荐使用内镜超声检查（EUS）、PET-CT 和腹腔镜检查用于 T3-T4 GOJ 肿瘤。这些建议基于一般效用，但尚不清楚对于某些患者而言，检查风险是否超过了潜在获益。本研究旨在量化检查风险、获益和效用，以便制定实用的个体化分期推荐。
所有经组织学诊断为食管或 GOJ 癌且在 2006 年 5 月至 2013 年 7 月期间进行分期的患者构成开发集；在 2013 年 7 月至 2014 年 7 月期间进行分期的患者构成前瞻性验证集。计算了改变管理策略的概率阈值，并确定了预测因素。对算法和模型（决策树分析、逻辑回归、人工神经网络）进行了内部和独立验证。
在 CT 检查后，对 953 例患者进行了[（18）F]氟脱氧葡萄糖 PET-CT（918 例）、EUS（798 例）和腹腔镜检查（458 例）分期。其中，829 例患者构成开发集（800 例 PET-CT、698 例 EUS、397 例腹腔镜检查），124 例患者构成验证集（118 例 PET-CT、100 例 EUS、61 例腹腔镜检查）。EUS 在 CT 上 T2-T4a 疾病患者中的效用极小（0.4%），风险超过获益。EUS 对 pT1N0 疾病的准确性中等。PET-CT 和腹腔镜检查有多项预测转移的因素，但没有任何因素可以提供算法信息。PET-CT 改变了 23.0%的患者的管理策略，腹腔镜检查改变了 7.1%的患者的管理策略，包括 T2 和远端食管肿瘤患者。
尽管 EUS 提供了关于 T 和 N 分期的额外信息，但在 CT 上 T2-T4a 疾病患者中，其风险超过了潜在获益。对于 T2 或更大的远端食管肿瘤，腹腔镜检查似乎是合理的。
