Surg Endose Pathologic stagc Sensitivity (% Specificity (% PPV(凭) NPV ( MO MI PET 0 CT MO 103 05 MI ned 2 PPV p dance with Shimpi et al.[6).who had similar study set old standard wa tings.Our results could be explained by patient selection we included only pa who were iCopieieydkteminedAmaoratataegeoforstd s that of patients with t for four cases which were more difficult to distinguish from another than of EUS.CT.and PET was concomitantly evaluated for T4 cases.In addition,the designation of T2 stage had oc staging of esophage microscopic tumor invasion or peritumoral inflammatory metastasis in esophageal cancer.Regardless of echo fea ures an sie,90%of ther factor that may ymph nod of celiac nodes larger than Icm were malignant.n sage of an echoendoscope.Up to one -third of patients metaanalysis of 25 studies,EUS for celiac node me astas nt with mar of98毫T19 staging by EUS. An EUS examination from a position proximal to the tumor has astasis. which was not identified by EUS due to vie In of PET's ahility to stag (16%)had malignant stricture.for which we did not pe form a dilation procedure before EUS. An shown a sensitivity of a specificity of and eporte acy o EUS I161 have recently reported that dilation was safe as oot any better than the ability of cr.This was mostly due rules sequentia hu EUS o the lack of sensitivity in detecting distant lymph node creases in】 the oustudy.the ability of PET to predict N stage dthe patientmus be individually remained unsatisfactory.For detecting N s age.PET had 10. of the risk-benefit relation tvity of 42 and a spec of.Recent dat Previous the ative accuracy of only 57.a specificity of only and y of only 71[21].Our result was comparable with the p oled sensitivity (51%)and specificity (84%)reported in a 第24页 Springe 第16页
In our study, the accuracy of EUS for T staging was shown to be no greater than 72%, which was in concordance with Shimpi et al. [6], who had similar study settings. Our results could be explained by patient selection bias because we included only patients who were potential candidates for curative surgery. All our cases were therefore pathologic T1 to T3 stages except for four cases, which were more difficult to distinguish from another than clear T4 cases. In addition, the designation of T2 stage had the least accuracy, and equal numbers of lesions were under- and overstaged, which may be associated with microscopic tumor invasion or peritumoral inflammatory change. Another factor that may affect accuracy in staging of esophageal cancer is the presence of strictures that limit passage of an echoendoscope. Up to one-third of patients with esophageal cancer present with marked luminal stenosis that does not permit passage of EUS [15] and therefore prohibits complete staging by EUS. An EUS examination from a position proximal to the tumor has been shown to result in inaccurate T staging and inadequate evaluation of the celiac axis. In our study, 18 patients (16%) had malignant stricture, for which we did not perform a dilation procedure before EUS. An earlier study reported an unacceptably high perforation rate when dilation was administered before EUS [16]. Several studies have recently reported that dilation was safe as long as the rules of sequential dilation were followed. Thus, EUS gained increases in its yield of detected celiac lymph nodes [15, 17]. However, perforations during the dilation can occur occasionally, and the patient must be individually determined for assessment of the risk-benefit relation before the dilation procedure. Previous studies evaluated the comparative accuracy of esophageal cancer staging by EUS, PET, and CT with pathologic staging [2, 4, 7, 8]. However, these studies were somewhat limited by their relatively small size. Furthermore, some of the patients did not undergo curative surgery, and thus pathologic staging as a gold standard was not completely determined. A major advantage of our study was that a large number of patients with esophageal cancer were enrolled. All of these patients provided the complete information regarding pathologic staging, and the accuracy of EUS, CT, and PET was concomitantly evaluated for locoregional staging of esophageal cancer. Endoscopic ultrasonography plays a role in the evaluation of celiac nodal involvement, which indicates distant metastasis in esophageal cancer. Regardless of echo features and size, 90% of all detected celiac lymph nodes were proved to be malignant in one study [18]. Moreover, 100% of celiac nodes larger than 1 cm were malignant. In a metaanalysis of 25 studies, EUS for celiac node metastasis showed a sensitivity of 67% and a specificity of 98% [19]. We performed EUS for surgically resectable patients at preoperative staging, and only one patient had celiac node metastasis, which was not identified by EUS due to malignant stricture. Promising reports of PET’s ability to stage esophageal cancer have been published. For distant metastasis, PET has shown a sensitivity of 88%, a specificity of 93%, and an accuracy of 91% [20]. Our findings showed that the overall accuracy of PET in detecting distant metastasis was not any better than the ability of CT. This was mostly due to the lack of sensitivity in detecting distant lymph node metastases. In our study, the ability of PET to predict N stage remained unsatisfactory. For detecting N stage, PET had a sensitivity of 42% and a specificity of 91%. Recent data have shown that for N staging, PET has a sensitivity of only 57%, a specificity of only 83%, and an accuracy of only 71% [21]. Our result was comparable with the pooled sensitivity (51%) and specificity (84%) reported in a Table 4 Comparison of positron emission tomography (PET) and computed tomography (CT) for metastasis (M) staging Pathologic stage Sensitivity (%) Specificity (%) PPV (%) NPV (%) Accuracy (%) M0 M1 PET M0 103 3 40 99 66 97 96 M1 1 2 CT M0 103 4 20 99 50 96 95 M1 1 1 Combined 2 methods M0 102 3 40 98 50 97 95 M1 2 2 PPV positive predictive value, NPV negative predictive value Surg Endosc 义 123 第 16 页
Surg Endose metaanalysis [13].Not surprisingly. primary tumor with PET.In addition,PET may not detect SB. Frick TJ.Gopal DV.Said A metastasis of lymph nodes due to its limite In a metaanalysis of the EUS,PET,and CT results for slage were and 0.50 for Cl analyed concomitantly 22.However,the overall diag nostic accuracy for Nsaging did not differsigficntly and sen eaimcnNg these tests for N staging,EUS-guided fine-needle aspira staging me The ed41-30g-315 tumor to obtain a specimen.This carries the potential risk of cancer cells spreading into lymph nodes that may not be 46 malignan atient ewhat nar pectrum of diseas only surgically resectable patients were enrolled in this 12. disease stages were excl lymph nodes shows good diagnostic cy of at the 4 EUS is as good as that of PETorCT.Therefore,EUS cou 15. B Haw Sahai AV.Van Velse A.Hoffr 16 1993H Rice TW. References Lew RJ.Faigel DO.Smith DB.Ke ictures is safe and effective.Am 1.CMayer RJ()phageal er. 2.1 e VJ.Booya F.Fle Clain J店 RH,F n BJ (20 005) ided dle pa MR,Ibdah JA (2008 in the is of distal a teview.Dis Dis sei 53:2405-2414 Springer 第25页 第17页
metaanalysis [13]. Not surprisingly, lymph nodes adjacent to the primary tumor are difficult to differentiate from the primary tumor with PET. In addition, PET may not detect microscopic metastasis of lymph nodes due to its limited resolution effects. In a metaanalysis of the EUS, PET, and CT results for esophageal cancer staging, the pooled sensitivities for N stage were 0.80 for EUS, 0.57 for PET, and 0.50 for CT, although these three methods were not performed and analyzed concomitantly [22]. However, the overall diagnostic accuracy for N staging did not differ significantly and was in line with our results. Regarding the relatively low accuracy and sensitivity of these tests for N staging, EUS-guided fine-needle aspiration (EUS-FNA) may be considered for preoperative staging method. The use of EUS-FNA increases both sensitivity and accuracy for the detection of nonperitumoral lymph node metastases [23]. However, lymph nodes at the level of the primary tumor often are not accessible to EUS-FNA because the needle would have to traverse the tumor to obtain a specimen. This carries the potential risk of cancer cells spreading into lymph nodes that may not be malignant. Our data are limited by the inclusion of patients with a somewhat narrowed clinical spectrum of disease because only surgically resectable patients were enrolled in this study. Patients with advanced disease stages were excluded, which may be related to underestimation of both sensitivity and accuracy in the detection of metastasis to lymph nodes. In conclusion, our study shows good diagnostic accuracy for EUS T staging of esophageal cancer, and our findings show that the diagnostic accuracy of N staging by EUS is as good as that of PET or CT. Therefore, EUS could be useful for determining a therapeutic strategy for esophageal cancer, especially for resectable diseases. Disclosures Jeongmin Choi, Sang Gyun Kim, Joo Sung Kim, Hyun Chae Jung, and In Sung Song have no conflicts of interest or financial ties to diclose. References 1. Enzinger PC, Mayer RJ (2003) Esophageal cancer. N Engl J Med 349:2241–2252 2. Lowe VJ, Booya F, Fletcher JG, Nathan M, Jensen E, Mullan B, Rohren E, Wiersema MJ, Vazquez-Sequeiros E, Murray JA, Allen MS, Levy MJ, Clain JE (2005) Comparison of positron emission tomography, computed tomography, and endoscopic ultrasound in the initial staging of patients with esophageal cancer. Mol Imaging Biol 7:422–430 3. van Westreenen HL, Heeren PA, van Dullemen HM, van der Jagt EJ, Jager PL, Groen H, Plukker JT (2005) Positron emission tomography with F-18-fluorodeoxyglucose in a combined staging strategy of esophageal cancer prevents unnecessary surgical explorations. J Gastrointest Surg 9:54–61 4. Pfau PR, Perlman SB, Stanko P, Frick TJ, Gopal DV, Said A, Zhang Z, Weigel T (2007) The role and clinical value of EUS in a multimodality esophageal carcinoma staging program with CT and positron emission tomography. Gastrointest Endosc 65:377– 384 5. Liberale G, Van Laethem JL, Gay F, Goldman S, Nagy N, Coppens E, Gelin M, El Nakadi I (2004) The role of PET scan in the preoperative management of oesophageal cancer. Eur J Surg Oncol 30:942–947 6. Shimpi RA, George J, Jowell P, Gress FG (2007) Staging of esophageal cancer by EUS: staging accuracy revisited. Gastrointest Endosc 66:475–482 7. Rasanen JV, Sihvo EI, Knuuti MJ, Minn HR, Luostarinen ME, Laippala P, Viljanen T, Salo JA (2003) Prospective analysis of accuracy of positron emission tomography, computed tomography, and endoscopic ultrasonography in staging of adenocarcinoma of the esophagus and the esophagogastric junction. Ann Surg Oncol 10:954–960 8. Choi JY, Lee KH, Shim YM, Lee KS, Kim JJ, Kim SE, Kim BT (2000) Improved detection of individual nodal involvement in squamous cell carcinoma of the esophagus by FDG PET. J Nucl Med 41:808–815 9. Catalano MF, Sivak MV Jr, Rice T, Gragg LA, Van Dam J (1994) Endosonographic features predictive of lymph node metastasis. Gastrointest Endosc 40:442–446 10. Greene FL, American Joint Committee on Cancer (2002) AJCC cancer staging manual, 6th edn. Springer, New York 11. Dwyer AJ (1991) Matchmaking and McNemar in the comparison of diagnostic modalities. Radiology 178:328–330 12. Salminen JT, Farkkila MA, Ramo OJ, Toikkanen V, Simpanen J, Nuutinen H, Salo JA (1999) Endoscopic ultrasonography in the preoperative staging of adenocarcinoma of the distal oesophagus and oesophagogastric junction. Scand J Gastroenterol 34:1178– 1182 13. Puli SR, Reddy JB, Bechtold ML, Antillon D, Ibdah JA, Antillon MR (2008) Staging accuracy of esophageal cancer by endoscopic ultrasound: a meta-analysis and systematic review. World J Gastroenterol 14:1479–1490 14. Rosch T (1995) Endosonographic staging of esophageal cancer: a review of literature results. Gastrointest Endosc Clin North Am 5:537–547 15. Wallace MB, Hawes RH, Sahai AV, Van Velse A, Hoffman BJ (2000) Dilation of malignant esophageal stenosis to allow EUSguided fine-needle aspiration: safety and effect on patient management. Gastrointest Endosc 51:309–313 16. Van Dam J, Rice TW, Catalano MF, Kirby T, Sivak MV Jr (1993) High-grade malignant stricture is predictive of esophageal tumor stage: risks of endosonographic evaluation. Cancer 71:2910–2917 17. Pfau PR, Ginsberg GG, Lew RJ, Faigel DO, Smith DB, Kochman ML (2000) Esophageal dilation for endosonographic evaluation of malignant esophageal strictures is safe and effective. Am J Gastroenterol 95:2813–2815 18. Eloubeidi MA, Wallace MB, Reed CE, Hadzijahic N, Lewin DN, Van Velse A, Leveen MB, Etemad B, Matsuda K, Patel RS, Hawes RH, Hoffman BJ (2001) The utility of EUS and EUSguided fine-needle aspiration in detecting celiac lymph node metastasis in patients with esophageal cancer: a single-center experience. Gastrointest Endosc 54:714–719 19. Puli SR, Reddy JB, Bechtold ML, Antillon MR, Ibdah JA (2008) Accuracy of endoscopic ultrasound in the diagnosis of distal and celiac axis lymph node metastasis in esophageal cancer: a metaanalysis and systematic review. Dig Dis Sci 53:2405–2414 Surg Endosc 123 义 第 17 页
Surg Endose Fer hageal cancer.Ann ncer a m Br JCar Surg ing KK.A面A 21 .W ng S).Lin KH.Huang CS.Hsich CC.Wu D. YC(2009)Posi (2001 of EUS- ded f edle Endosc53:751-757 第26页 Springe 第18页
20. Luketich JD, Schauer PR, Meltzer CC, Landreneau RJ, Urso GK, Townsend DW, Ferson PF, Keenan RJ, Belani CP (1997) Role of positron emission tomography in staging esophageal cancer. Ann Thorac Surg 64:765–769 21. Hsu WH, Hsu PK, Wang SJ, Lin KH, Huang CS, Hsieh CC, Wu YC (2009) Positron emission tomography-computed tomography in predicting locoregional invasion in esophageal squamous cell carcinoma. Ann Thorac Surg 87:1564–1568 22. van Vliet EP, Heijenbrok-Kal MH, Hunink MG, Kuipers EJ, Siersema PD (2008) Staging investigations for oesophageal cancer: a meta-analysis. Br J Cancer 98:547–557 23. Vazquez-Sequeiros E, Norton ID, Clain JE, Wang KK, Affi A, Allen M, Deschamps C, Miller D, Salomao D, Wiersema MJ (2001) Impact of EUS-guided fine-needle aspiration on lymph node staging in patients with esophageal carcinoma. Gastrointest Endosc 53:751–757 Surg Endosc 义 123 第 18 页
中国临依医学2o9年6月第16卷第3期Chne JoumClincMedicine,2M.Vol16.o.3 387 .论著 色素放大内镜与普通电子内镜诊断结肠黏膜 病变的价值比较 （上涛交通大学医学院附属璃全医院清化内科，上海200025) A 9 FCE系纯检 久然盆o2。 oscopy in De Digestion Medicine,Ruijin Hos ital. ity School of Medicine The se .3%,917% is v Key Words Neoplas ccoloniclesiou em: 结肠镜检查是目前诊断结肠疾病的主要方法，但 的敏感性和准确性， 资研对患者人选标准为：(1)年龄为18 为不会发生裔变，如何鉴别诊断结肠肿墙样息肉和非 75岁：性别 限：(2)2008年3 2008年9月我 能色素增石 intelligent color enhance FICE) 包括：(1)确诊的恶 性种患者：(2)合并肝肾功能不 统，是胃肠疾病诊斯领城中的一项新技术它。 女或有可能怀坐的妇女(4 认浅到定组织反射程度，并根据想要的波 有肠镜检者禁忌证者 内镜检查方法所有人选患者术前给予患者 长进行图像重建，从而发玩肉眼难以发现的病变。 高消化道病 良反应、药物口味评价比较另文报道)做肠道准备 缺乏，本研究以病理组织学检查结果为“金标准” 比较常规内镜检查与FICE系统诊断结肠粘膜病变 采用高能 (FCE)后 素做大内镜，进镜至回自部，然后边退镜边进行全 征」 时不使用色定 第27页 万方数据 第19页
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388 Chinese Journal of Clinical Medicine.2009.Vol.16.No.3 中回临东医学209年6月第16巷第3期 判断结果等同于普通大肠内镜，退镜时按F10的功 表】传统结肠镜对结肠粘膜疾变的检出创) 能键，数字盘1~9可变化9种颜色，用不同的色谱 货理组织学检查 结斯镜检查 肿瘦的变拿的座废变 g许 种空病变 3 7 采用盲法判断结果，内镜检查结果和FICE系统检 喜锁是分新由2位医师独立完，参照K 车韩缩病变 21 23 叶 0 13组织学检查在内镜观察区各取活检1一2块组 织%的尔马林固定石蜡包埋切片后，行HE 越计分折 计量料用均数标准若表 比较比较结墨2病理诊素的异增生和（或 计数资料用频数和百分率表示，组间比较采用卡力 豫与K:分类中的型和Y型之间存在显相 2结 系统选择24,6色谱时、能更好地观察血管形态，进 ，女床共人进30例患者，其中男性 中性划分，F1CE系统诊断非 肿瘤样病变的灵敏度为83.3%，特异度为91.7% 岁) 就论原因包括便立、腹痛腹润便秘和杏体 升数投出8处病杜其中息肉样特变 性预渊值为了 其灵度 ”30侧者中，24例为非 特异度和正确率均有显著提高(P<0.05), 病变(24例为增生性息肉)，6例为肿瘤病变(2 表2故大色素内镜对结膜病变的检出（例】 树魔)例为战毛状腹痘1为重度异型增 FCE成像 病理组的学按合 种病变非种病变 23骨通结肠镜与组叔病理学结果相关性 对 普调结肠镜检查诊断非 总计 24 结果进行比较 的灵敏度为6.7%，特异度为87.5%，阳性预测值 2.5善通结肠镜成像与FICE成像比较F1CE系 3%灵装性离值为913%，正确为 统显示的图像比常规内窥镜更加清陈（图1一8）， 透肠镜（病理结果：增生性泉肉国2对比国1的FCE像：图3对比图1的CE常：图4对比图1的CE成 管状糠：图6对比图5的FCE成：图7对比图5的C成像：图8对比图5的FCE成像 第28页 万方数据 第20页
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