Value of endoscopic ultrasonography for assessment of patients presenting elevated tumor marker levels after surgery for colorectal cancers.

BACKGROUND AND STUDY AIMS: This prospective study was undertaken to evaluate the role of endoscopic ultrasound (EUS) in patients presenting with elevated tumor marker levels (CEA, CA 19-9) after surgery for colorectal cancer. PATIENTS AND METHODS: During a 26-month period, colonic EUS was performed in 21 patients who had undergone surgical treatment for colorectal cancers. All patients presented with elevated tumor marker levels at the time of examination but all other diagnostic procedures (US, CT scan of the abdomen and thorax, bone scintigraphy and colonoscopy) did not demonstrate recurrence. Colonic EUS was performed using a linear convex probe (echoendoscopes Pentax: FG 32 UA, 36 U, 38 UX). In cases with normal findings on colonic EUS, upper gastrointestinal tract EUS was also performed. RESULTS: 21 colonic EUS and six upper gastrointestinal tract EUS examinations were performed. Of 21 colonic EUS examinations, 15 showed either local recurrence (n = 9) or peritoneal carcinomatosis (n = 6) and six EUS-guided biopsies were performed. Of these 15 patients, 13 were operated on and results were confirmed in 12 of 13 patients, namely in 8/9 cases with suspected anastomotic recurrence and in all four operated cases with presumed peritoneal carcinomatosis. EUS-guided biopsy had diagnosed three of the four cases before. Upper GI EUS was performed in the six cases with normal colonic EUS; two cases showed mediastinal lymph nodes and one showed celiac lymph nodes. EUS-guided biopsy confirmed the malignancy of these nodes. For the diagnosis of recurrence, sensitivity, specificity and accuracy of lower plus upper gastrointestinal EUS were 94.4%, 66.6% and 90.4% respectively. CONCLUSION: EUS of the colon and--in selected cases--also of the upper gastrointestinal tract is quite useful in this clinical setting. Further studies are needed to evaluate the impact of EUS on outcome in larger patient numbers.

Endoscopic ultrasonography for assessment of the response to combined radiation therapy and chemotherapy in patients with esophageal cancer.

BACKGROUND AND STUDY AIMS: Measuring the response of esophageal cancer to combined chemotherapy and radiotherapy is difficult. Initial results using ultrasonography have been contradictory. The purpose of this study was to correlate the endoscopic ultrasonography (EUS) findings after preoperative chemoradiotherapy with the histology of the resected specimens, and to assess the accuracy of EUS in predicting the response to treatment. PATIENTS AND METHODS: From October 1991 to February 1995, 32 patients with esophageal cancer staged as T3 or T4 on EUS were treated by chemoradiotherapy, followed by surgical resection. There were 28 men and four women, with a mean age of 54 years (range 38-70 years). In 25 cases, the diagnosis was squamous-cell carcinoma, and in seven cases it was adenocarcinoma. EUS was carried out using a curved-array ultrasonic transducer (Pentax FG-32 UA). After two courses of chemoradiotherapy, the wall involvement was classified using the following modified post-chemoradiotherapy classification: T0, complete restitution of wall layers; Tw, echo-poor nodules located in the submucosa or muscularis propria, but with wall layers discernible; T2, echo-poor wall thickening without distinguishable layers, but not infiltrating beyond the fifth hyperechoic layer; T3, thickened hypoechoic or heterogeneous wall, no distinguishable layers, infiltrating beyond the fifth hyperechoic layer; T4: a hypoechoic or heterogeneous mass in contact with a mediastinal structure. RESULTS: Using this post-chemoradiotherapy classification, the sensitivity, specificity, and accuracy of EUS in detecting residual tumor (T0 + Tw versus T2, T3, and T4) were 91.3%, 77.7%, and 77.7%, respectively. The accuracy of EUS, endoscopic, and CT criteria in assessing the parietal response was 81.2%, 56.2%, and 59.3%, respectively. CONCLUSION: Complete restoration of the esophageal wall (T0) and Tw stage corresponded to disease-free histology in 78% of cases, and corresponded in all cases either to disease-free esophageal wall or to microscopic tumor residues in the mucosa. No conclusions could be drawn in the other categories (T2-T4), but residual tumor was detected in 87% of cases.

Incidence and management of major urinary complications after pelvic exenteration for gynecological malignancies.

Urinary fistulae and obstruction following pelvic exenteration are frequent and life-threatening complications. They increase the mortality and morbidity rates of large exereses performed during pelvic exenteration for gynecological cancers. From a series of 97 patients who underwent pelvic exenteration for gynecological cancers we report the incidence, risk factors, and management of major urinary complications. Eighty patients had had previous surgery and/or pelvic radiation therapy at the time of pelvic exenteration. A urinary diversion was performed in 63 patients. Major early urinary complications were: urinary fistula in seven patients and ureteral obstruction in four patients (11.3% of the patients). Ten patients had a late urinary complication: stenosis of the cutaneous ureteral meatus (five), stenosis of the ureteroileal anastomosis following ileal loop (two), and urinary fistulae (three). Cancer recurrence was found in 4 of these 10 cases. Major early urinary complications were significantly increased in patients who had received previous pelvic radiation therapy (P < 0.05) and in patients who had had an intestinal conduit for urinary diversion (P < 0.05). Reoperation was done in six of seven cases of early urinary fistula (urinary undiversion four, nephrectomy one, ureteral reimplantation one). Three of four ureteral obstructions were managed with percutaneous nephrostomy and ureteral stent. We recommend the use of nonirradiated bowel segment for urinary diversion as transverse colon or jejunal conduit in patients who have received previous high doses of pelvic radiotherapy. For the management of urinary complications post pelvic exenteration, reoperation is required for most urinary fistula but ureteral obstructions can be managed with percutaneous nephrostomy and ureteral stent.