STAGING OF OESOPGAGO-GASTRIC CANCER USING EUS – …



Staging of oesophago-gastric carcinoma by endoscopic ultrasonography: guidance and minimum standardsProduced by the UK EUS Users Group in association with:British Society of Gastroenterology (BSG)Prepared by:Ian Penman, Consultant Gastroenterologist, Western General Hospital, EdinburghSally Norton, Consultant Upper GI Surgeon, Southmead Hospital, BristolKeith Harris, Consultant Radiologist, The General Infirmary at Leeds, LeedsDraft 1.0 - 21/09/04ContentsIntroductionBackgroundEUS staging - structureStaging sequenceStaging techniqueDocumentation & terminologyTumourNodesMetastasesReferencesAppendices1. TNM classification of OG carcinoma and stage grouping2. AJCC lymph node stations in OG carcinoma3. Example of minimum data collection proforma4. Classification of junctional tumours5. Definition of coeliac LN by EUSExamples of T,N,M stages by EUSContact authors’ details1. IntroductionThis document provides minimum standards and guidance for endosonographers involved in the staging of oesophago-gastric malignancy. It has been produced by the UK EUS Users Group in collaboration with the British Society of Gastroenterology, Association of Upper GI Surgeons and the Royal College of Radiologists.2. BackgroundEUS is a vital part of the pre-operative staging algorithm for oesophago-gastric cancer as it provides the most accurate assessment of resectability and of the need for neo-adjuvant treatment. With the decision to provide palliative or potentially curative treament dependant on EUS assessment, it is imperative that a standardised protocol is used. This will also help facilitate audit, governance and collaborative research needs.3. EUS staging – structureThe following are recommended for centres performing EUS staging of oesophagogastric cancer:EUS should be performed in fully equipped Endoscopy departments or in Radiology departments with full endoscopic facilities. Units should conform to JAG standards and have modern radial and/or linear echoendoscopes. The availability of the non-optical oesophagoprobe (e.g. Olympus MH-908) is recommended for patients with tight strictures. High frequency catheter probes should be available in centres assessing early lesions and regularly undertaking endoscopic mucosal resection (EMR).Centres should have modern image recording facilities for stills (paper and/or digital) and video.EUS staging should take place in centres performing at least 100 cases per year for OGC staging.Each centre should have at least one fully trained endosonographer.Centres undertaking FNA or biopsy should be familiar with the range of EUS-FNA / biopsy needles available and the preparation of samples for cytology.Endosonographers should be part of a local multidisciplinary team (MDT) for OG cancer, at which results of EUS should be discussed.Audit is essential and EUS performance and outcomes should be regularly audited.Accuracy for T & N staging should be similar to published data (approximately 80-85% for T and 60-70% for N stage). Major complication rate for staging EUS without FNA (mainly perforation) should be <1%.Major complication rate for EUS-FNA/biopsy (perforation, bleeding, infection) should be <1%.90% of FNA samples should have diagnostically adequate cellularity.4. Staging sequenceEUS should generally only be performed after staging CT, which may detect distant metastases or direct the EUS to specific abnormalities needing clarification. The CT report and, whenever possible the films, should be available and reviewed at the time of the EUS.For patients with junctional tumours, discussion at the relevant MDT should decide whether EUS or laparoscopy should be the next investigation after CT.Immediately prior to EUS, it is recommended that the endosonographer performs a thorough endoscopy to confirm previous findings and to enable selection of the most appropriate echoendoscope. Tight strictures are almost always traversable with the MH-908 oesophagoprobe (Olympus) and dilation of a tumour is not recommended except in exceptional circumstances (e.g. to enable coeliac lymph node FNA). Such cases should first be discussed with the surgeon who is likely to be undertaking surgery in case perforation occurs and emergency surgery is required.The accuracy of staging with radial and linear echoendoscopes is equivalent and either type of instrument is suitable for staging.5. Staging techniqueUsually outpatient, conscious sedationCareful OGD prior to EUSDilatation if indicated – see aboveExamination beginning in duodenal bulb – image right lobe liver if possibleLeft adrenalSplenic vessels, coeliac axis and hepatic arteryLeft gastric artery and lesser curveCrura of diaphragmMediastinal examination as proximally as tolerated (at least to top aortic arch)6. Documentation and terminologyStandardised nomenclature of anatomical sites and lesions is important. The minimum standard terminology (MST) set out by the European Society of Gastrointestinal Endoscopy (ESGE) is recommended (3).Staging should be performed and described as laid out in the latest editions of the UICC or AJCC staging manuals (1,2). In particular, lymph node stations should be identified as defined in the AJCC staging manual, 6th edition (1). These are detailed in appendix 2In order to inform treatment decisions, EUS staging of oesophago-gastric cancer (with upper endoscopy) should include, as a minimum, assessment and clear documentation of the following:-Tumour Upper margin of tumour (in cm from incisors and from top of aortic arch)1Lower margin of tumour (in cm from incisors and from top of aortic arch)1Relation of tumour to gastro-oesophageal junction (GOJ)not involving GOJ i.e purely oesophageal or purely gastricjunctional tumour type I, II or III (Siewert grading – see appendix Z; ref. 4)NoteThis extent may not correlate with the mucosal extent as seen at endoscopy due to submucosal extension – this should be documented.Presence and location of satellite lesions or synchronous tumoursPresence and extent of any co-existing Barrett’s oesophagusTumour stage 2,3T1m (mucosal)T1sm (submucosal)T24T3 (minimal – i.e. tumour just breaches m.propria, 4th layer)T3 (bulky – i.e. extensive invasion of m.propria but not T4)T4 Note1. May assist in radiotherapy planning2. It must be documented whether pleura, diaphragm, azygous vein, pulmonary vein, pericardium, aorta, bronchus, carina, trachea or other structures are involved in a T4 tumour as not all will preclude surgery).3. Presence of full thickness tumour below diaphragm should be recorded as this may influence decision to perform laparoscopy4. For type 3 junctional tumours, stage as gastric cancer i.e. T2a = breaches m. propria; T2b = breaches subserosa.NodesInvolved nodes may be recognised by established EUS criteria (size > 1cm, hypoechoic, well demarcated and round) – if all 4 criteria are present the probability of malignancy is around 80%.Nodal staging should document all apparently involved or suspicious nodes by station as set out in the attached diagram (appendix 2).The total number of involved or suspicious nodes correlates with prognosis and should be documented (0, 1-3, 4-7 or >7).If possible, especially if likely to directly alter management, fine-needle aspiration (FNA) or core biopsy should be performed to confirm or exclude malignancy as long as the target node can be sampled without traversing the primary tumour.Coeliac lymph nodes are defined as those below the coeliac trifurcation (not simply within 2 cm of coeliac axis as defined by the TNM classification). Those nodes above trifurcation should be classified according to the appropriate branch of the coeliac axis (e.g. splenic artery origin node or proximal left gastric artery node).MetastasesLiver metastasis or small volume ascites may be evident with EUS and FNA should be performed if possible. Occasionally adrenal metastasis may be present and should be looked for.Other featuresThe level of the aortic arch and the relationship of the tumour to the top of the arch may be helpful in planning radiotherapy and should be documented.7. ReferencesTNM classification and stage grouping of esophagal carcinoma. From: Greene FL, Page DL, Fleming ID et al (eds). American Joint Committee on Cancer. Cancer staging manual. 6th Edition, New York, Springer, 2002, pp 91-98.Sobin LH, Wittekind C (Eds). TNM Classification of Malignant Tumours, 6th Edition, Hoboken, USA. Wiley Press.Aabakken L. Standardized terminology in endoscopic ultrasound. Eur J Ultrasound. 1999 Nov;10:179-83.Siewert JR, Stein HJ. Carcinoma of the cardia: carcinoma of the gastroesophageal junction – classification, pathology and extent of resection. Dis Esoph 1996; 9: 173-1828. AppendicesAppendix 1.TNM classification and stage grouping of oesophageal carcinoma (1,2)Primary Tumor (T)TXPrimary tumor cannot be assessedT0No evidence of primary tumorTisCarcinoma in situT1Tumor invades lamina propria or submucosaT2Tumor invades muscularis propriaT3Tumor invades adventitiaT4Tumor invades adjacent structuresRegional Lymph Nodes (N)NXRegional lymph nodes cannot be assessedN0No regional lymph node metastasesN1Regional lymph node metastasesDistant metastases (M)MXDistant metastases cannot be assessedM0No distant metastasesM1Distant metastasesTumors of the lower thoracic esophagusM1ametastases in celiac lymph nodesM1bOther distant metastasesTumors of the midthoracic esophagusM1aNot applicableM1bnonregional lymph nodes and/or other distant metastasesTumors of the upper thoracic esophagusM1ametastases in cervical lymph nodesM1bother distant metastasesAppendix 1 (contd). Stage grouping of oesophageal carcinoma (1,2).TNMStage 0TisN0M0Stage IT1N0M0Stage IIAT2N0M0T3N0M0Stage IIBT1N1M0T2N1M0Stage IIIT3N1M0T4Any NM0Stage IVAny TAny NM1Stage IVAAny TAny NM1aStage IVBAny TAny NM1bAppendix 2. Lymph node stations in oesophago-gastric carcinoma (1,2)Appendix 3. Example staging proformaoesophageal & oesophagogastric junctional cancersStaging Endoscopy & EUS data form5143549530Patient sticker or details:Name:Hospital No:D.O.B.00Patient sticker or details:Name:Hospital No:D.O.B.Referring Hospital:………………Referring Cons:………………Date:………………Endoscopist:………………Supervisor:………………Scope(s) used………………1. Endoscopic details (cm from incisors):Distance (cm) from incisor teeth to:Distance from top aortic arch (cm) to:Proximal margin tumour.……………cmProximal tumour margin……cmDistal margin tumour…………….cmDistal tumour margin……cmTumour length (cm)…………….cmLocation OG junction…………….cmHiatal hernia?Y / Nfrom ……. to ………….cmBarrett’s?Y / Nproximal extent ……….cmStricture:none/minimalmoderate/passabletight/impassableDilatationY / N2. Tumour classification (as per AJCC):Cervical OC (lower border cricoid to thoracic inlet)IntrathoracicUpper (inlet to tracheal bifurcation)Mid(bifurcation to just above OGJ)Lower thoracic/abdominal (inc. OGJ / intra-abdominal oesophagus)Type 1Type 2Type 33. other relevant data:prior antireflux surgery?Y / Nprior gastric surgeryY / Noesophageal & oesophagogastric junctional cancersStaging Endoscopy & EUS data form4. T staging:longitudinal submucosal spread not visible at OGD? Y / Nfrom ……..to ……..cmT1aT1bT2T3T4Details of advanced T stage:‘minimal’ T3 (just breaches m. propria, 4th layer) ‘bulky’ T3 (extensive invasion beyond m.propria) T4: aortapericardiumpleuracruraairwaysother………Full thickness disease below diaphragm?Y / N5. LN staging:Total number LN identified: ……………..FNA performed? Y / NNo. & short axis size(mm) for each siteFNA – documentsite)oesophageal & oesophagogastric junctional cancersStaging Endoscopy & EUS data form6. Details of metastasesLiver – left lobe / right lobeCoeliac LN (see below)Left adrenalCervical LN (see below)Other ………………………………FNA / Bx performed Y / N7. Staging summaryT……N……M……Group stageTNMStage 0TisN0M0Stage IT1N0M0Stage IIAT2N0M0T3N0M0Stage IIBT1N1M0T2N1M0Stage IIIT3N1M0T4Any NM0Stage IVAny TAny NM1Stage IVAAny TAny NM1aStage IVBAny TAny NM1bSigned ……………………………………………………………..Date ………………………..Status …………………………………………………………….Appendix 4. Classification of junctional tumours (see ref. 4)Type 1. Oesophageal – just involves OG junctionType 2. Tumour straddles junctionType 3. Cardia tumour involving OG junctionAppendix 5. Definition of coeliac lymph nodes (CLN) by EUSRadial – coeliac LN arise below the trifurcation of the main coeliac trunk, not just anywhere within 2cm of the coeliac axis.Linear – 9. Oesophageal cancer. Examples of T,N,M staging by EUST1 tumoursT1m. Tumour does not invade the submucosa (3rd layer) T1sm. The echorich 3rd layer (submucosa) is attenuated T1sm. Bulky lesion but only just invades submucosa T1sm N1. Invasion of submucosa but not m. propria. Note LN.T2 tumours T2. Tumour invades into but not through m.propria (top). T2. Tumour invades into but not through 4th layer (m. propria)T3 tumours ‘Minmal’ T3, N1. Tumour just breaches m. propria. Note LN. ‘Minimal T3. Tumour only minimally breaches m. propria. ‘Bulky’ T3. Extensive invasion into adventitia. ‘Bulky’ T3. Extensive tumour invasion beyond m. propria.T4 tumours T4. Loss of echorich interface between tumour (T) & aorta (Ao). T4. Extensive tumour (T) invading mediastinal pleura. T4. Tumour abuts and invades mediastinal pleura (Pl). T4. Tumour (T) invades the azygous vein (Az).Nodal disease Coeliac LN (M1a). LN below trifurcation of coeliac axis (CA). Size <10mm but round shape, distinct border and hypoechoic features suggest malignancy. Large suspicious LN adjacent to azygous vein (Az). Flat shape, indistinct border and echo-rich centre are features suggesting a benign/reactive LN.10. Authors’ contact detailsDr Ian PenmanConsultant GastroenterologistG.I. UnitWestern General HospitalEdinburghEH4 2XUTel:0131-537-1758Fax:0131-537-1007Email:ian.penman@luht.scot.nhs.ukMiss Sally NortonConsultant Upper GI SurgeonDept. of Upper GI SurgerySouthmead HospitalWestbury on TrymBristolBS10 5NBTel:0117 -9595163Fax:0117 -9595168Email:Sally.Norton@north-bristol.swest.nhs.ukDr Keith HarrisConsultant RadiologistDept. of Clinical RadiologyThe General Infirmary at LeedsGreat George StreetLeedsLS1 3EXTel:0113) 3923504Fax:0113) 392 5217Email:keith.harris@leedsth.nhs.uk ................
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