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A Systematic Review of the Validity of Endoscopic Ultrasound for Esophageal Carcinoma Staging 3 rd presentation. - PowerPoint PPT Presentation

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  • A Systematic Review of the Validity of Endoscopic Ultrasound for Esophageal Carcinoma Staging3rd presentationClass 3: Ana Maria Reis, Ana Margarida Rodrigues, Ana Raquel Mara, Ana Raquel Freitas, Ana Raquel Marques, Ana Raquel Barreira, Ana Coelho, Ana Rita Linhas, Ana Rita Maia, Ana Rita Dias, Lus Gomes, Miguel Castro.

    Project Manager: Mrio Dinis RibeiroFaculty of Medicine University of Porto Introduo Medicina

    Introduo MedicinaEUS for Esophageal Carcinoma Staging

    Sistematic Review to evaluate validity of a diagnosis test: EUS

    Sensitivity: probability of, being ill, have a positive testEspecificity: probability of, not being ill, have a negative test

    Introduo MedicinaEUS for Esophageal Carcinoma Staging

    INTRODUCTION (I)

    Esophageal cancer is the eighth most common cancer in the world [1].

    Patients with esophageal cancer have less than 10% 5-year survival despite advances in multimodality therapy [1].

    [1] Allan Pickens, MD, Mark B., Orringer, MD. Geographical distribution and racial disparity in esophageal cancer.2003, 76:S1367-S1369.

    Introduo MedicinaEUS for Esophageal Carcinoma Staging

    INTRODUCTION (II):

    Curative attempts:

    SurgeryChemotherapyRadiation [2].

    [2]Kiran S.Parmar,MD,Joseph B. Zwischenberger,MD,Angela L. Reeves,CGRN and Irving Wacman,MD.Clinical Impact of Endoscopic Ultrasound-Guided Fine Needle Aspiration of Celiac Axis Lymph Nodes (M1a Disease) in Esophageal Cancer.2002,73:916-21.

    Introduo MedicinaEUS for Esophageal Carcinoma Staging

    INTRODUCTION (III):

    The esophageal cancer is usually treated according to tumour stage as defined in the TNM system developed by the American Joint Commission on Cancer [3]. Fleming I, Cooper JS, Hensen DE, et al., editors. AJCC cancer staging manual (esophagus), 5th ed. Philadelphia: Lippincott-Raven, 1997:65-69.[3]J. Vickers and D. Alderson. Oesophageal cancer staging using endoscopic ultrasonography.1998,85,994-998.

    TNM classification

    Definition

    T0

    No evidence of primary tumor

    T1

    Tumor invades submucosa or lamina propria

    T2

    Tumor invades muscularis propria

    T3

    Tumor invades adventicia

    T4

    Tumor invades adjacent structures

    N0

    No regional lymph nodes involved

    N1

    Regional lymph nodes present

    a See Fleming et al

    Introduo MedicinaEUS for Esophageal Carcinoma Staging

    INTRODUCTION (IV):

    Staging:

    Computerized tomography scan (CT-scan) Magnetic resonance (MRI) Endoscopic ultrassound (EUS) [4]. [4]Kiran S. Parmar,MD,Joseph B.Zwischenberger,MD,Angela L. Reeves,CGRN and Irving Wacman,MD 2002,73:916-21.

    Introduo MedicinaEUS for Esophageal Carcinoma Staging

    INTRODUCTION (V):Endoscopic ultrasound (EUS) has a central role in the initial staging of esophageal cancer, most notably because of its accuracy in determining depth of tumour invasion and regional lymph node metastases [4].http://www.b5orland-groover.com/articles/eus.htm

    Introduo MedicinaEUS for Esophageal Carcinoma Staging

    The aim of this study is to evaluate the consistency and validity of EUS namely in determining T3 + T4 or N+ for esphageal cancer.AIM:

    Introduo MedicinaEUS for Esophageal Carcinoma Staging

    Metanalysis

    Data Source

    Quality Criteria

    Data to be extracted

    Statistical analysis

    METHODS:

    Introduo MedicinaEUS for Esophageal Carcinoma Staging

    Data Source: Articles were searched using MEDLINE data base using the following clinical QUERY:

    (((((((((((("sensitivity and specificity"[All Fields]) OR "sensitivity and specificity/standards"[All Fields]) OR "specificity"[All Fields]) OR "screening"[All Fields]) OR "false positive"[All Fields]) OR "false negative"[All Fields]) OR "accuracy"[All Fields]) OR (((("predictive value"[All Fields] OR "predictive value of tests"[All Fields]) OR "predictive value of tests/standards"[All Fields]) OR "predictive values"[All Fields]) OR "predictive values of tests"[All Fields])) OR (("reference value"[All Fields] OR reference values"[All Fields]) OR "reference values/standards"[All Fields])) OR ((((((((((("roc"[All Fields] OR "roc analyses"[All Fields]) OR "roc analysis"[All Fields]) OR "roc and"[All Fields]) OR "roc area"[All Fields]) OR "roc auc"[All Fields]) OR "roc characteristics"[All Fields]) OR "roc curve"[All Fields]) OR "roc curve method"[All Fields]) OR "roc curves"[All Fields]) OR "roc estimated"[All Fields]) OR "roc evaluation"[All Fields])) OR "likelihood ratio"[All Fields]) AND notpubref [sb])). AND(("Endosonography"[MeSH] AND "Esophageal Neoplasms"[MeSH] staging) NOT cardia) LIMITS: title/abstract.

    METHODS (I):

    Walter L. Devill at al.Conducting systematic reviews of diagnostic studies: didactic guidelines. BMC Medical Research Methodology 2002, 2:9

    Introduo MedicinaEUS for Esophageal Carcinoma Staging

    METHODS (II):

    Data Source: Articles were also searched using Scopus data baseusing the following clinical QUERY:

    Endoscopic ultrasound OR endosonographyANDEsophageal carcinoma OR esophageal neoplasmAND NOTCardia

    Introduo MedicinaEUS for Esophageal Carcinoma Staging

    METHODS (III):

    Data Source79 articles 75 articles27PUBMED: 106 articlesSCOPUS: 102 articles

    Introduo MedicinaEUS for Esophageal Carcinoma Staging

    Inclusion Criteria:Staging of esophageal carcinomaEndoscopic ultrasound or ecoendoscopySurgery (gold standard)

    Exclusion Criteria:CardiaArticles that are not in Portuguese, English, French and SpanishCase reportsOther classification of staging other than TNM classification of malignant tumoursExtracted data unable to fill a 2 by 2 table of results (*)(*) only aplied to entire article

    METHODS (IV):

    Introduo MedicinaEUS for Esophageal Carcinoma Staging

    FLOWCHART18110127 excluded articles:- cardia (n=13);- articles not English, Portuguese, French or Spanish (n=9);- case reports (n= 25);- Other classification of staging other than TNM classification of malignant tumours (n= 46)- extracted data unable to fill a 2 by 2 table of results (n=37)- Articles not found (n=10)

    Start

    Pubmed and Scopus Search

    Articles found : 181

    Revision of titles and abstracts

    Excluded by 2 reviewers

    127 excluded articles:- cardia (n=13);- articles not English, Portuguese, French or Spanish (n=9);- case reports (n= 25);- Other classification of staging other than TNM classification of malignant tumours (n= 46)- extracted data unable to fill a 2 by 2 table of results (n=37)- Articles not found (n=10)

    Included by 2 reviewers

    Yes

    No

    54 included article

    Quality

    NO

    Yes

    10 articles included

    Yes

    No

    Introduce dates in SPSS

    End

    Introduce dates in Metadisc

    Included by a 3rd reviewer

    Read complete article

    Introduo MedicinaEUS for Esophageal Carcinoma Staging

    Quality Criteria

    After being selected, the articles had to be evaluated relatively to their methodological quality.The assessment of the methodological quality of each study was performed using a scale ranged from 0 to 24 points according to the following points:

    METHODS (V):

    Introduo MedicinaEUS for Esophageal Carcinoma Staging

    METHODS (VI):

    Patrick M. Bossuyt et al. Towards Complete and Accurate Reporting of Studies of Diagnostic Accuracy: The STARD Initiative. Ann Intern Med. 2003; 138:40-44

    Section

    Introduction

    State the research questions or study aims

    Methods

    Participants

    Inclusion criteria for the study population

    Exclusion criteria for the study population

    Setting where the data were collected

    Location where the data were collected

    Data collection

    Participants where selected based on diagnosis and not over another staging procedure

    Clinical diagnosis and inclusion was made before knowledge of reference test

    Consecutive sample

    Before or after the index tests and reference test (prospective or retrospective studies)

    Test methods

    Reference standard (reference of TN of surgery) and its rationale

    Technical specifications of material (type of instrument and/or frequency of the endoscope)

    How measurement were taken

    When were measurement taken

    Definition of categories (T and N) cut-off points for reference standard or clinical outcome (death for instance)

    Readers of reference and index tests where or where not blind to the results of other tests

    Statistical methods

    Methods for calculating or comparing measurements of diagnostic accuracy, and the statistical methods used to quantify uncertainty

    Methods for calculating test reproducibility, if done

    Results

    Participants

    Demographic information (age, sex)

    Clinical characteristics of the study population (spectrum of disease) and severity

    Number of participants satisfying the criteria for inclusion that did not undergo the index tests and/or the reference standard; describe why participants failed to receive either tests

    Test results

    A cross tabulation of the results of the index tests by the results of the reference standard

    Time between the index test and the reference test, and any treatment administrated between

    Estimates

    Estimates of diagnostic accuracy and measurements of statistical uncertainty

    Estimates of test reproducibility, if done

    Introduo MedicinaEUS for Esophageal Carcinoma Staging

    Extraction Data:

    Data were extracted according to TNM classification for EUS and surgery.

    Endoscope frequency, type of instrument, number and type of observers, number of patients

    METHODS (VII):

    Introduo MedicinaEUS for Esophageal Carcinoma Staging

    Data were introduced in SPSS data base.

    Data were introduced in Metadisc.

    Statistical analysis:Data analysed in Metadisc.Chi-square test was used to statistically test the presence of heterogeneity.Forrest Plots with results grouped by dates, frequency and number of patients.

    METHODS (VIII):

    Introduo MedicinaEUS for Esophageal Carcinoma Staging

    RESULTS (I):Extraction Data

    Articles

    Endoscope Frequency

    Type of instrument

    Number of observers

    Number of patients

    7.5 MHz

    12 MHz

    20 MHz

    T. Lok Tio et al. 1989

    Yes

    Yes

    _____

    Olympus

    3

    171

    M. J. Hodijek et al. 1993

    Yes

    _____

    _____

    Olympus

    _____

    32

    S. Natsugoe et al. 1996

    Yes

    _____

    _____

    Toshiba

    _____

    37

    Ernesto Laterza et al. 1999

    Yes

    _____

    _____

    EUS and EUS-FNA

    _____

    126

    Gregory Zuccaro et al. 1999

    Yes

    Yes

    _____

    Olympus

    1

    97

    Jan Heidemann et al. 2000

    Yes

    Yes

    _____

    GFUM20 radial SCANNING device

    4

    61

    L. B. Nesje et al. 2000

    Yes

    Yes

    Yes

    Toshiba

    1 or 2

    107

    Enrique Vazquez-Sequeiros et al. 2001

    Yes

    Yes

    _____

    _____

    _____

    37

    Snia J. Wakelin et al. 2001

    Yes

    Yes

    _____

    EUM 20 oblique echoendoscope

    2

    29

    Ishaan Kalha et al. 2004

    Yes

    Yes

    _____

    Olympus

    1

    135

    Introduo MedicinaEUS for Esophageal Carcinoma Staging

    RESULTS (II)Graphic 1: Methodological EvaluationMedian: 16,5Minimum: 11Maximum: 20

    Introduo MedicinaEUS for Esophageal Carcinoma Staging

    RESULTS (III):

    Staging T parameter Sensitivity and specificity

    Graphic 2: T sensitivityGraphic 3: T specificity

    Introduo MedicinaEUS for Esophageal Carcinoma Staging

    RESULTS (IV):

    Staging - N parameter Sensitivity and specificityGraphic 4: N sensitivityGraphic 5: N specificity

    Introduo MedicinaEUS for Esophageal Carcinoma Staging

    All grafics, except grafic 5 for N specificity, show heterogeneity (p < 0,05).

    Results were grouped by frequency, dates, number of patients.

    Subgroup analysis didnt explain heterogeneity.

    DISCUSSION:

    Introduo MedicinaEUS for Esophageal Carcinoma Staging

    In T specificity the article with a more discrepant result is L. B. Nesje et all. 2000. Its results can be explained because it is the only one that uses 20 MHz has frequency.

    The reason for the discrepancy visualized in the graphics related to N sensitivity may be related to the changes that chemotherapy and radiation (treatments used) have on the intrawall layers of the esophagus.

    DISCUSSION:

    Introduo MedicinaEUS for Esophageal Carcinoma Staging

    Although heterogeneous, EUS appears to be more specific than sensitive.

    DISCUSSION:

    Introduo MedicinaEUS for Esophageal Carcinoma Staging

    Not all the articles had classifications for both Ts and Ns. Secondary data.Articles included that are not in the Internet, FMUP Library or IPO Library.LIMITS:

    Introduo MedicinaEUS for Esophageal Carcinoma Staging

    CONCLUSION:

    As the results are heterogeneous, it hasnt been possible to do a metanalysis.

    EUS should continue to be used as a diagnostic test in staging esophageal carcinoma.

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