Additional Value of External Ultrasonography of the Neck after CT and PET Scanning in the Preoperative Assessment of Patients with Esophageal Cancer

Abstract

Introduction: Lymphatic dissemination of a (non-cervical) esophageal tumor to the neck is generally considered as distant metastasis. The aim of this study was to determine the additional value of external ultrasonography (US) to detect lymphatic metastasis to the neck after normal CT scan (CT) with or without normal PET scan (PET). Methods: Between January 2003 and December 2005, 306 patients were analyzed for esophageal cancer in our department. A total of 233 patients underwent both CT and external US of the neck. PET was performed in 109 of these patients as part of a prospective cohort study. Fine needle aspiration (FNA) was only performed if external US reported suspected lymph nodes. FNA was defined as gold standard. Results: In 176 patients (76%), CT did not identify any suspected nodes, but external US disagreed in 36 of them. In 9 of these patients, FNA confirmed metastasis, resulting in an additional value of external US after normal CT scanning of 5% (9/176). In 74 patients (68%), CT and PET did not identify any suspected nodes, but external US disagreed in 11 of them. In 3 of these patients, FNA confirmed metastasis, resulting in an additional value of external US after normal CT and PET of 4% (3/74). Conclusion: Considering its minimal invasiveness and wide availability in combination with the importance of the potential therapeutic consequences, we conclude that external US of the neck should be part of the routine diagnostic work-up in patients with esophageal cancer, even after normal CT and PET scanning.

External ultrasonography of the neck does not add diagnostic value to integrated positron emission tomography-computed tomography (PET-CT) scanning in the diagnosis of cervical lymph node metastases in patients with esophageal carcinoma

“…Omloo et al . found an additional value of ultrasonography of the neck of 4% after normal CT and PET‐scanning; however, in that study, CT and PET were also performed subsequently instead of integrated PET‐CT scanning as in the present study 21 …”

S3-Leitlinie Magenkarzinom – Diagnostik und Therapie der Adenokarzinome des Magens und des ösophagogastralen Übergangs – Langversion 2.0 – August 2019. AWMF-Registernummer: 032/009OL

“…Die B-Bild-Sonografie ist der Computertomografie im Nachweis von Halslymphknotenmetastasen gleichwertig oder geringfügig überlegen [282][283][284][285] und daher ergänzend sinnvoll, wenn nicht bereits im Rahmen der CT-Untersuchung eine Beurteilung der zervikalen Lymphknotenstationen erfolgt ist. Die ultraschallgestützte Feinnadelaspirationsbiopsie ist geeignet, den metastatischen Lymphknotenbefall histologisch zu sichern [283,[286][287][288].…”

Stage‐directed individualized therapy in esophageal cancer

“…This is suggested by two large series that found no additional value of external ultrasonography over PET/CT with regard to the detection of cervical lymph node metastases . Only one study has shown an additional value of 4% (3/74) of external ultrasonography over CT and PET imaging . However, in the latter study, the CT and PET scans were performed separately, which may yield lower diagnostic accuracy compared with integrated PET/CT scanning .…”

“…31 However, in the latter study, the CT and PET scans were performed separately, which may yield lower diagnostic accuracy compared with integrated PET/CT scanning. 31 This implies that external ultrasonography may be omitted in the standard workup of patients with esophageal cancer. However, histopathologic confirmation in PET/CT-suspected lesions remains required because of potential false-positive lesions.…”

“…Only one study has shown an additional value of 4% (3/74) of external ultrasonography over CT and PET imaging . However, in the latter study, the CT and PET scans were performed separately, which may yield lower diagnostic accuracy compared with integrated PET/CT scanning . This implies that external ultrasonography may be omitted in the standard workup of patients with esophageal cancer.…”