signature=fc084601c4adad36b9886d8f3e1b5bcb,Response:

摘要：

I would like to thank Dr Schwartz for his comments and criticisms of our article "EUS staging of upper GI malignancies: results of a prospective randomized trial." I will try to address the issues surrounding the EUS staging of esophageal cancer. Our prospective trial in 41 patients with malignancy arising from the esophagus or stomach (UGI) was designed to compare detection of abnormal lymph nodes (based on EUS appearance) by linear and transverse array EUS. We hypothesized that the size and the number of abnormal lymph nodes detected would be greater with a transverse-array echoendoscope compared with the linear array instrument. The purpose of the study was not to compare the tumor (T) staging accuracy, because only a small subgroup of patients had confirmation of T staging with surgical pathology. Dr Schwartz questioned whether our study would have been strengthened with the use of tandem EUS examinations. However, if both endosonographers were called upon to provide dual examinations, this would have resulted in 4 examinations for each patient (2 EUS exams/physician), significantly increasing the risk of perforation. Regarding the endpoint of our trial, we felt obligated to halt the trial when a statistically significant greater number of lymph nodes were detected with transverse array EUS compared to linear EUS. In addition to comparing the number of abnormal lymph nodes by linear and transverse array endosonography, the 2 endosonographers also compared the imaging quality, as well as ease-of-us e, by using a subjective rating scale (1-5). We thought it was important to compare these important parameters with a new instrument (transverse array) against an established instrument (linear array). Our results indicated that the transverse array instrument provided imaging quality that was at least as high as that provided by the linear EUS instrument. We think the detection of abnormal lymph nodes in patients with gastroesophageal malignancy is very important, as is determining the number and distribution of nodes. Of course, FNA provided by linear EUS will improve the specificity of the nodal staging. The importance of lymph node detection and staging has recently been recognized by the American Joint Committee on Cancer (AJCC). The AJCC has recommended that "…revisions of the current AJCC staging system for esophageal cancer should include N staging based on the number of involved lymph nodes…" (italics ours). Despite Dr Schwartz's assertion that linear EUS imaging provides higher quality imaging, our data clearly demonstrate that the rate of detection of abnormal lymph nodes is greater with transverse array EUS. Based on our findings, we have changed our practice in our unit to include transverse array EUS staging in all patients with gastroesophageal malignancy.

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