Primary Motility  Disorders of the  Esophagus
 The Esophageal
 Esophagogastric  Junction

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Volume: Barrett's Esophagus
Chapter: Adenocarcinomas

Can unnecessary surgery be avoided by endoscopic ultrasound guided fine needle aspiration?

M. Giovannini (Marseille)

Endoscopic ultrasound (EUS) is now widely used for the assessment of locoregional involvement of adenocarcinoma of the esophagus and the esophagogastric junction. It allows accurate assessment of wall involvement in 85% of cases and lymph node involvement in 75% of cases. But the EUS specificity to distinguish malignant from inflammatory lymph nodes is low, no more than 50%. A correct staging is mandatory before treatment. According to the UICC classification, distant lymph nodes are considered as metastasis and surgery is not recommended. The main problem is the EUS specificity to distinguish malignant and benign lymph nodes. EUS lymph node imaging has poor specificity, but as the therapeutic decision depends on the lymph node staging, it is essential to have an histologic characterisation of the lymph nodes. Recent series published about EUS guided biopsy show that, with this new technique, a specificity of 95% to differentiate malignant and inflammatory lymph nodes can be expected [1].

In our Institution, we have performed a prospective study on the impact of EUS guided lymph node biopsy in patients with esophageal adenocarcinoma [2].

From January 1994 to January 1998, 77 patients (52 men and 25 women) with a mean age of 66 years (range: 42-76 years) underwent EUS for the local staging of an adenocarcinoma of the esophagus before treatment. In all patients pretreatment work-up included gastrointestinal fiberoscopy, thoracic CT scan and abdominal ultrasonography. All patients were considered as operable and CT scan didn't show local contraindication to surgery.

EUS was performed using an echoendoscope with a curved array transducer (FG32UAFG 36-X, Pentax). Wall involvement was staged according to the EUS TN classification and lymph nodes were considered as metastases if 3 of the following 4 criteria were observed: round shape, hypoechogenic, well-defined borders, and diameter greater than 1 cm. However, when the lymph node was located in a distant area (aortico-cava, superior mediastinal and cervical) EUS guided biopsy was performed even if the EUS malignancy criteria were not observed.

The puncture is realized at the end of the examination, the patient being in left lateral decubitus. A neuroleptanalgesia is generally necessary. The technique of puncture is the following:
- positioning of the lesion on the way of exit of the needle;
- withdrawal of the stylet, then introduction of the needle in the tumor. The visualization of the echo-tip of the needle allows to verify its good positioning in the lesion;
- aspiration with a 20 ml syringe associated with back and forth movements of the needle in the tumor.

One to three passages are generally necessary to obtain a microbiopsy. It is currently possible to obtain microfragments of tissue in approximately 90% of cases with the needle of Vilmann-Hancke (22 gauges and 12 cm length. Microbiopsies are obtained as follows:
- the totality of the specimen contained inside the needle is collected with the reintroduction of the stylet;
- this microcore is then put in the formalin-adelhyde, then included in paraffin.

Contrarily to American teams, we do not administer systematically an injection of antibiotic following the biopsy. At the end of the examination, it is necessary to watch over the patient during at least three hours. The EUS guided biopsy can, in the majority of cases, be performed ambulatory. The main limits to the technique are size of the lesion lesser than 5 mm, the depth of the lesion, as compared to the probe, greater than 6-7 cm, and a trouble of blood coagulation (TP < 60%, platelets < 80,000/mm3).

Ten over 77 patients (13%) underwent EUS - lymph node a guided biopsy. Patient tolerance was excellent and the insertion of the needle into the lesion was always successful. The mean size of the lymph nodes was 8.6 mm (range: 6-11 mm). The mean number of needle passages was 1,3 (range: 1-2). The diagnosis of malignant lymph nodes was obtain on microhistology and cytology in 6 cases, on microhistology alone in 3 cases and on cytology alone in 1 case. These 10 patients were treated by concomitant chemoradiation therapy.

EUS guided biopsy of lymph nodes resulted in a change in the stage of the tumor in 10/77 cases, these tumors with distant lymph node involvement being considered as metastatic according the UICC classification.


1. Wieserma M, Vilmann P, Giovannini M, Chang KJ. Endosonography-guided fine needle aspiration biopsy: diagnostic accuracy and complication assessment. Gastroenterology 1997;112;1087-1095.

2. Giovannini M, Monges G, Seitz JF, Moutardier V, Bernardini D, Thomas P, Houvenaeghel G, Delpero JR, Giudicelli R, Fuentes P. Distant lymph node metastases in esophageal cancer: impact of endoscopic ultrasound guided biopsy. Endoscopy 1999;31:795-801.

Publication date: August 2003 OESO©2015