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Diagnostic accuracy of EUS in differentiating mucosal versus submucosal invasion of superficial esophageal cancers: a systematic review and meta-analysis.
Historically, EUS has had poor and varying accuracy in distinguishing between tumors confined to the mucosa (T1a) and those that invade the submucosa (T1b).
Improvements in EUS methods are therefore necessary for more definitive T1 staging of EEC.
Submucosal saline solution injection (SSI) is routinely used before EMR and endoscopic submucosal dissection (ESD) to minimize damage to the surrounding tissue of the esophageal wall. When SSI is performed, a water cushion forms in the loose connective tissue of the submucosa, which may serve as a good medium for US. Therefore, we proposed that SSI could improve the diagnostic accuracy in the preoperative EUS staging of EEC.
In March 2012, 10 patients with suspected EEC were recruited for evaluation of preoperative staging accuracy of SSI plus EUS (ClinicalTrial.gov Identifier: NCT01555801). The findings on US included the following: (1) After SSI, EUS showed low echo in the submucosa. However, regular EUS showed high echo in this tissue layer (Fig. 1). (2) After SSI, EUS showed the mucosa separate from the submucosa, with clear demarcations between each layer of the esophageal wall (Fig. 2). (3) SSI + EUS staging classified 7 cases as stage T1a. Postoperative pathological staging confirmed that 5 cases were stage T1a, and 2 cases were high-grade dysplasia (Tis). (4) Preoperative SSI + EUS classified 3 cases as stage T1b, which were all confirmed by postoperative pathology.
Figure 1Stage T1b of early esophageal cancer visualized by regular EUS (the schematic diagram on the right). The lesion and infiltration depth in the submucosa were difficult to distinguish from the mucosa.
Figure 2Submucosal saline solution injection (SSI) enhanced EUS of stage T1b of early esophageal cancer (EEC). Stage T1b EEC of visualized in the SSI + EUS mode (the schematic diagram on the right). After SSI, the boundary between the mucosa and submucosa became clear. The lesion and infiltration depth in the mucosa and submucosa were easily distinguished.
In our opinion, SSI helps to increase the thinness of the esophagus, augment the echoic contrast between the mucosa and submucosa, and precisely observe the infiltration depth of EEC on sonography. Therefore, the T1 stage of EEC can be staged more accurately by SSI + EUS.
References
TNM Classification of malignant tumors. 7th edition. Union for International Cancer Control (UICC),
2010
Diagnostic accuracy of EUS in differentiating mucosal versus submucosal invasion of superficial esophageal cancers: a systematic review and meta-analysis.
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