Isenberg G, Chak A, Canto M I, Levitan N, Clayman J, Pollack B J, Sivak M V
University Hospitals of Cleveland, Case Western Reserve University, Department of Medicine, Ohio 44106-5066, USA.
Gastrointest Endosc. 1998 Aug;48(2):158-63. doi: 10.1016/s0016-5107(98)70157-9.
Endoscopic ultrasound (EUS) is established as the most accurate method currently available for determining the depth of primary cancer invasion (T stage). Standard EUS criteria may not be accurate in assessing depth of cancer invasion and nodal status after patients have received chemotherapy or radiotherapy.
We conducted a prospective study to determine whether EUS estimation of tumor size could be used to assess response to preoperative chemoradiation. Using EUS, TNM stage was assessed in 31 patients (22 men, 9 women; mean age 62 years) with cancer of esophagus or cardia (19 adenocarcinoma, 12 squamous cell cancer) before initiation of combined radiation and 5-fluorouracil/cisplatin (and/or carboplatinum) chemotherapy. The cross-sectional area of the tumor in the transverse plane at the location where the tumor had maximal thickness was calculated to estimate tumor size. EUS staging and measurement of maximal cross-sectional area were repeated at completion of chemoradiation just before surgery. Response to preoperative chemoradiation was defined as 50% reduction in maximal cross-sectional area. Surgical staging was compared between responders and nonresponders.
Eight patients who did not undergo surgery were excluded from analysis. EUST stage in the remaining 23 patients before therapy was as follows: 3 T2, 16 T3, and 4 T4. After chemoradiation, EUS T staging was changed in 6 patients (3 T4 downstaged to T3, 2 T3 downstaged to T2, and 1 T3 downstaged to T1). At surgical pathological examination, 3 patients had no residual tumor in the esophagus (T0), 5 had T1, 3 had T2, 10 had T3, and 2 had T4 tumors. EUS T staging accuracy after adjuvant therapy was only 43%. Maximal cross-sectional area decreased from a mean of 5.5 +/- 2.4 to 1.6 +/- 0.9 cm2 in responders, whereas maximal cross-sectional area went from 7.0 +/- 3.0 to 5.4 +/- 2.2 cm2 in nonresponders (p = 0.009). Ten of thirteen patients with at least a 50% reduction in maximal cross-sectional area (responders) had T0, T1, or T2 tumors at surgery, whereas 9 of 10 nonresponders had T3 or T4 tumors at surgery (p = 0.001).
(1) Standard EUS staging criteria are not accurate after neoadjuvant chemoradiation, (2) reduction in maximal cross-sectional area of tumor appears to be a more useful measure for assessing response of esophageal cancer to preoperative chemoradiation, and (3) responders have an increased likelihood of downstaging at surgery than nonresponders.
内镜超声检查（EUS）是目前确定原发性癌浸润深度（T分期）最准确的方法。在患者接受化疗或放疗后，标准EUS标准在评估癌浸润深度和淋巴结状态方面可能不准确。
我们进行了一项前瞻性研究，以确定EUS对肿瘤大小的估计是否可用于评估术前放化疗的疗效。使用EUS对31例（22例男性，9例女性；平均年龄62岁）食管或贲门癌（19例腺癌，12例鳞状细胞癌）患者在开始联合放疗及5-氟尿嘧啶/顺铂（和/或卡铂）化疗前进行TNM分期。计算肿瘤最大厚度处横断面上肿瘤的横截面积以估计肿瘤大小。在放化疗结束且术前再次进行EUS分期及最大横截面积测量。术前放化疗的疗效定义为最大横截面积缩小50%。比较反应者和无反应者的手术分期。
8例未接受手术的患者被排除在分析之外。其余23例患者治疗前的EUS T分期如下：3例T2，16例T3，4例T4。放化疗后，6例患者的EUS T分期发生改变（3例T4降为T3，2例T3降为T2，1例T3降为T1）。手术病理检查时，3例患者食管无残留肿瘤（T0），5例为T1，3例为T2，10例为T3，2例为T4肿瘤。辅助治疗后EUS T分期的准确率仅为43%。反应者的最大横截面积从平均5.5±2.4降至1.6±0.9 cm²，而无反应者的最大横截面积从7.0±3.0降至5.4±2.2 cm²（p = 0.009）。最大横截面积至少缩小50%的13例患者（反应者）中有10例在手术时为T0、T1或T2肿瘤，而10例无反应者中有9例在手术时为T3或T4肿瘤（p = 0.001）。
（1）新辅助放化疗后标准EUS分期标准不准确；（2）肿瘤最大横截面积的缩小似乎是评估食管癌术前放化疗疗效更有用的指标；（3）反应者手术时分期降低的可能性比无反应者大。
