Clinical Trends in the Utilization of Endoscopic Ultrasonography with Fine Needle Aspiration (EUS-FNA) in Esophageal Cancer: A Survey of Thoracic Surgeons

Background: To assess the utilization of EUS-FNA for staging esophageal cancer and its impact on surgical resection. Methods: A 15 question survey was distributed via email to thoracic surgeons. This survey included questions related to clinical practice patterns. Two case vignettes were used to assess if EUS-FNA of lymph nodes changed therapeutic decisions. Results: 61 thoracic surgeons responded to the survey (29% response rate). 85% practice in an academic institution exclusively. 90% personally perform more than 10 esophagectomies per year with 29% performing greater than 40 per year. Nearly half of the respondents practice in a high volume hospital (>50 esophagectomies per year). EUS-FNA is available at 96% of academic institutions as compared to 83% of other hospitals where esophagectomies are performed. Nearly every respondent surveyed prefers to have a CT scan (98%), PET scan (86%) and EUS (89%) performed before making a therapeutic decision. Over 85% of respondents find EUS-FNA to be the most accurate T-staging and over two-thirds thought it is the most accurate N-staging test. In cases where no obvious nodal or metastatic disease is known, over 98% of surveyed thoracic surgeons feel EUS-FNA would help in making therapeutic decisions. Over 75% of respondents surveyed found EUS-FNA changed their therapeutic plans in greater than 15% of cases. If EUS-FNA found either a positive celiac or gastrohepatic ligament lymph node in a patient with proximal esophageal cancer, the majority of respondents (84% and 67% respectively) felt this represents metastatic disease that precludes surgical resection. Among thoracic surgeons surveyed, there is disagreement whether positive lymph nodes in a patient with a distal esophageal cancer precludes esophagectomy. 61%, 74% and 57% of surveyed thoracic surgeons would still perform an esophagectomy in patients with positive proximal para-esophageal, gastrohepatic ligament and celiac lymph nodes respectively in patients with distal esophageal cancer. Conclusion: EUS-FNA has become widely utilized by thoracic surgeons for accurate staging and directing therapy for esophageal cancer. EUS-FNA of celiac and gastrohepatic ligament lymph nodes often changes the management of patients with proximal esophageal cancer. This survey demonstrates that significant controversy remains in regards to nodal positivity and its impact on treatment of distal esophageal cancer.