The impact of endoscopic ultrasound findings on clinical decision making in Barrett's esophagus with high-grade dysplasia or early esophageal adenocarcinoma

The clinical utility of endoscopic ultrasound (EUS) for staging patients with Barrett's esophagus and high-grade dysplasia(HGD) or intramucosal carcinoma (IMC) prior to endoscopic therapy is unclear. We performed a retrospective analysis of patients with HGD or IMC referred to an American medical center for endoscopic treatment between 2004 and 2010. All patients had pretreatment staging by EUS. We examined the frequency that EUS findings consistent with advanced disease (tumor invasion into the submucosa, lymph node involvement, or regional metastasis) led to a change in management. The analysis was stratified by nodularity and pre-EUS histology. We identified one hundred thirty-five patients with HGD (n = 106, 79%) or IMC (n = 29, 21%) had staging by EUS (79 non-nodular, 56 nodular). Pathologic lymph nodes or metastases were not found by EUS. There were no endosonographic abnormalities noted in any patient with non-nodular mucosa (0/79). Abnormal EUS findings were present in 8/56 patients (14%) with nodular neoplasia (five IMC, three HGD). Endoscopic mucosal resection was performed in 44 patients with a nodule, with 13% (6/44) having invasive cancer. In nodular neoplasia, the EUS and endoscopic mucosal resection were abnormal in 24% (5/21) and 40% (6/15) of those with IMC and 9% (3/35) and 0% (0/29) of those with HGD, respectively. In this study we found that EUS did not alter management in patients with non-nodular HGD or IMC. Because the diagnostic utility of EUS in subjects with non-nodular Barrett's esophagus is low, the value of performing endoscopic mucosal resection in this setting is questionable. For patients with nodular neoplasia, resection of the nodule with histological examination had greater utility than staging by EUS.