Introduction

The sensitivity of endoscopic ultrasound (EUS) in detecting pancreatic tumors exceeds 90% and can detect tumors with a diameter of less than 2 cm. EUS plays an important role in the management of patients with pancreatic cancer, providing precise diagnosis, determining local-regional extension and resectability assessment, conducting biopsies, and managing complications.
The objective of our study was to specify the impact of EUS on the diagnosis, staging, histological proof, and treatment of complications of solid pancreatic tumors.

Aims & Methods

A retrospective study was conducted over 5 years (2019-2024), including all patients admitted with clinical suspicion of solid pancreatic tumors and who experienced EUS.

Results

Out of the 115 patients admitted with clinical suspicion of pancreatic tumor, 86 (74.8%) had undergone EUS. The mean age was 68.2 years, ranging from 30 to 90 years, with a clear male predominance (sex ratio 1.1).
Biological assessment showed cholangitis grade I and grade II in 35.6% (n=31) of cases, and grade III in 4 patients (4.6%).
EUS revealed a pancreatic mass in 98.9% (n=85) of cases, with 75.5% (n=64) in the head, 14% (n=12) in the uncinate process, 7% (n=6) in the body, and 3.5% (n=3) in the neck. The size was over 3 cm in 59 cases (69.4%), between 2-3 cm in 23 cases (27.1%), and less than 2 cm in 3 cases (3.5%). double duct dilation was shown in 57 cases (66.3%), isolated bile duct dilation in 31 cases (36%), and isolated Wirsung duct dilation in 4 cases (4.6%). Pancreatic atrophy was observed in 31.4% (n=27) of cases.
EUS allowed the determination of vascular invasion in 78 cases (90.7%), invasion of the portal trunk (TP) and superior mesenteric vein (SMV) was present in 43 cases (55.1%), with invasion over >180 in 28 cases (35.9%) and <180 in 15 cases (19.2%), thrombosis in 3 cases (3.5%), and absence of invasion in 15 cases (19.2%). Invasion of the celiac trunk (CT) and superior mesenteric artery (SMA) was present in 31 cases (39.9%), with invasion over >180 in 22 cases (28.2%) and <180 in 9 cases (11.6%), thrombosis in 2 cases (2.3%), and absence of invasion in 24 cases (30.7%). Invasion of the common hepatic artery (CHA) was present in 6 cases (7.7%), with invasion over >180 in 5 cases (83.3%) and <180 in one case (16.7%), and absence of invasion in 6 cases (7.7%).
Locoregional lymph node extension was observed in 12 cases (15.4%), invasion of the common bile duct (CBD) in one case (1.3%), duodenal invasion in 3 cases (3.9%), secondary hepatic localization in 7 cases (9%), and peritoneal in 2 cases (2.6%).
Cytopuncture under EUS was performed in 70 cases (89.7%), the results of which were conclusive in 65.4% (n=51) of cases and inconclusive in 24.6% (n=19). The histological type was adenocarcinoma in 48 cases (94.1%), clear cell carcinoma, squamous cell carcinoma, and neuroendocrine tumor in one case (1.9%).
Therapeutically, EUS allowed the treatment of pancreatic abdominal pain resistant to medical treatment by celiac plexus block in 2 cases, neurolysis in one case, and also performing anterograde hepatic gastric biliary drainage after the failure of retrograde drainage due to duodenal strictures in 5 cases.

Conclusion

EUS reveals pancreatic tumors in 98.9% of cases, with its main importance lying in locoregional staging, where vascular invasion was correctly determined in 90.7% of cases, and lymph node extension in 15.4%. The value of EUS lies in determining histological type (65.4%), as well as therapeutic aspects such as pain management and biliary drainage.

Introduction

Endoscopic submucosal dissection (ESD) is the preferred treatment for superficial esophageal squamous cell carcinoma (ESCC). However, curative resection is not always achievable for all patients¹. Currently, the curability criteria was inconsistent among different societies^2-3 and may be overly stringent for suggesting additional treatments⁴, which causes dilemmas in clinical decision-making and potential overtreatments in some low-risk cases.

Aims & Methods

The research aim was to develop and validate a risk scoring system to assess curability after ESD for superficial ESCC. This study was based on a nationwide cohort, the China Early Esophageal Cancer Cohort, and all patients were follow-up at least for 3 years. Patients with superficial ESCC undergoing ESD were included, and those with positive horizontal margin, adjuvant chemoradiotherapy, and metachronous esophegeal cance after ESD were excluded. The primary outcome was noncurative resection, defined as either (1) pathological confirmation of residual tumor or lymph node metastasis (LNM) after additional surgery, or (2) identification of local recurrence, LNM, or distant metastasis during follow-up. Data from South and North China were used to develop and validate the scoring system, respectively. Logistic regression analysis was used for model construction, and Kaplan-Meier survival estimates, the C-statistic, and decision curve analysis were employed for performance evaluation.

Results

A total of 1,273 patients with superficial ESCC were included, with 995 for model development and 278 for validation. Multivariable analysis identified 6 independent risk factors for noncurative resection: tumor size ≥30 mm, submucosa invasion, positive vertical margin, lymphatic invasion, vascular invasion, and poor differentiation. For the risk scoring system (ESCC-eCura), lymphatic invasion was assigned as 2 points, and others were assigned as 1 point. In the development cohort, the non-curative resection rates of the low- (≤1 point), intermediate- (2 to 3 points), and high-risk (≥4 points) groups was 4.5%, 16.3%, and 75.0%, respectively. The ESCC-eCura demonstrated a C-statistic of 0.75 (95% condifence interval [CI], 0.69 - 0.81). In the validation cohort, the C-statistic was 0.84 (95% CI, 0.73-0.95), and intermediate- or high-risk groups were significant predictors for subsequent recurrence (hazard ratio [HR] for intermediate-risk group 14.35, 95% CI 4.01-51.35, P<0.001; HR for high-risk group 28.16, 95% CI 4.90-161.83, P<0.001; all compared with the low-risk group). Decision curve analysis also showed acceptable clinical benefits and utility.

Conclusion

This ESCC-eCura scoring system can predict non-curative resection after ESD for superficial ESCC, which offers a practical tool for individualized management. Additiomal treatments should be recommended for patients in ESCC-eCura intermediate- or high-risk groups, while follow-up may be acceptable for the low-risk group.

References

1.Jiang, H., et al., Risk and Pathological Factors of Recurrence after Endoscopic Resection for Superficial Esophageal Squamous Cell Carcinoma: A Systematic Review and Meta-analysis. Gastrointest Endosc, 2024.
2. Kitagawa, Y., et al., Esophageal cancer practice guidelines 2022 edited by the Japan esophageal society: part 1. Esophagus, 2023. 20(3): p. 343-372.
3. Pimentel-Nunes, P., et al., Endoscopic submucosal dissection for superficial gastrointestinal lesions: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2022. Endoscopy, 2022. 54(6): p. 591-622.
4.Liu, Z., et al., Additional Esophagectomy Following Noncurative Endoscopic Resection for Early Esophageal Squamous Cell Carcinoma: A Multicenter Retrospective Study. Ann Surg Oncol, 2021. 28(12): p. 7149-7159.

Disclosure

Nothing to disclose.