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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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<ul><li><p>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. </p><p>Project Manager: Mrio Dinis RibeiroFaculty of Medicine University of Porto Introduo Medicina</p><p>Introduo MedicinaEUS for Esophageal Carcinoma Staging </p><p>Sistematic Review to evaluate validity of a diagnosis test: EUS</p><p>Sensitivity: probability of, being ill, have a positive testEspecificity: probability of, not being ill, have a negative test</p><p>Introduo MedicinaEUS for Esophageal Carcinoma Staging </p><p>INTRODUCTION (I)</p><p>Esophageal cancer is the eighth most common cancer in the world [1].</p><p>Patients with esophageal cancer have less than 10% 5-year survival despite advances in multimodality therapy [1]. </p><p>[1] Allan Pickens, MD, Mark B., Orringer, MD. Geographical distribution and racial disparity in esophageal cancer.2003, 76:S1367-S1369.</p><p>Introduo MedicinaEUS for Esophageal Carcinoma Staging </p><p>INTRODUCTION (II):</p><p> Curative attempts:</p><p>SurgeryChemotherapyRadiation [2]. </p><p>[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.</p><p>Introduo MedicinaEUS for Esophageal Carcinoma Staging </p><p>INTRODUCTION (III):</p><p>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.</p><p>TNM classification</p><p>Definition</p><p>T0</p><p>No evidence of primary tumor</p><p>T1</p><p>Tumor invades submucosa or lamina propria</p><p>T2</p><p>Tumor invades muscularis propria</p><p>T3</p><p>Tumor invades adventicia</p><p>T4</p><p>Tumor invades adjacent structures</p><p>N0</p><p>No regional lymph nodes involved</p><p>N1</p><p>Regional lymph nodes present</p><p>a See Fleming et al</p><p>Introduo MedicinaEUS for Esophageal Carcinoma Staging </p><p>INTRODUCTION (IV):</p><p>Staging:</p><p>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.</p><p>Introduo MedicinaEUS for Esophageal Carcinoma Staging </p><p>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</p><p>Introduo MedicinaEUS for Esophageal Carcinoma Staging </p><p>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:</p><p>Introduo MedicinaEUS for Esophageal Carcinoma Staging </p><p>Metanalysis</p><p>Data Source</p><p>Quality Criteria</p><p>Data to be extracted</p><p>Statistical analysis</p><p>METHODS:</p><p>Introduo MedicinaEUS for Esophageal Carcinoma Staging </p><p>Data Source: Articles were searched using MEDLINE data base using the following clinical QUERY:</p><p>(((((((((((("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.</p><p>METHODS (I):</p><p>Walter L. Devill at al.Conducting systematic reviews of diagnostic studies: didactic guidelines. BMC Medical Research Methodology 2002, 2:9</p><p>Introduo MedicinaEUS for Esophageal Carcinoma Staging </p><p>METHODS (II):</p><p>Data Source: Articles were also searched using Scopus data baseusing the following clinical QUERY:</p><p>Endoscopic ultrasound OR endosonographyANDEsophageal carcinoma OR esophageal neoplasmAND NOTCardia</p><p>Introduo MedicinaEUS for Esophageal Carcinoma Staging </p><p>METHODS (III):</p><p>Data Source79 articles 75 articles27PUBMED: 106 articlesSCOPUS: 102 articles</p><p>Introduo MedicinaEUS for Esophageal Carcinoma Staging </p><p>Inclusion Criteria:Staging of esophageal carcinomaEndoscopic ultrasound or ecoendoscopySurgery (gold standard)</p><p>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</p><p>METHODS (IV):</p><p>Introduo MedicinaEUS for Esophageal Carcinoma Staging </p><p>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)</p><p>Start</p><p>Pubmed and Scopus Search </p><p>Articles found : 181</p><p>Revision of titles and abstracts</p><p>Excluded by 2 reviewers</p><p>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)</p><p>Included by 2 reviewers</p><p>Yes</p><p>No</p><p>54 included article</p><p>Quality</p><p>NO</p><p>Yes</p><p>10 articles included</p><p>Yes</p><p>No</p><p>Introduce dates in SPSS</p><p>End</p><p>Introduce dates in Metadisc</p><p>Included by a 3rd reviewer</p><p>Read complete article</p><p>Introduo MedicinaEUS for Esophageal Carcinoma Staging </p><p>Quality Criteria</p><p>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:</p><p>METHODS (V):</p><p>Introduo MedicinaEUS for Esophageal Carcinoma Staging </p><p>METHODS (VI):</p><p>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</p><p>Section</p><p>Introduction</p><p>State the research questions or study aims</p><p>Methods</p><p>Participants</p><p>Inclusion criteria for the study population</p><p>Exclusion criteria for the study population</p><p>Setting where the data were collected</p><p>Location where the data were collected</p><p>Data collection</p><p>Participants where selected based on diagnosis and not over another staging procedure </p><p>Clinical diagnosis and inclusion was made before knowledge of reference test</p><p>Consecutive sample</p><p>Before or after the index tests and reference test (prospective or retrospective studies)</p><p>Test methods</p><p>Reference standard (reference of TN of surgery) and its rationale</p><p>Technical specifications of material (type of instrument and/or frequency of the endoscope)</p><p>How measurement were taken</p><p>When were measurement taken</p><p>Definition of categories (T and N) cut-off points for reference standard or clinical outcome (death for instance)</p><p>Readers of reference and index tests where or where not blind to the results of other tests</p><p>Statistical methods</p><p>Methods for calculating or comparing measurements of diagnostic accuracy, and the statistical methods used to quantify uncertainty</p><p>Methods for calculating test reproducibility, if done</p><p>Results </p><p>Participants</p><p>Demographic information (age, sex)</p><p>Clinical characteristics of the study population (spectrum of disease) and severity</p><p>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</p><p>Test results</p><p>A cross tabulation of the results of the index tests by the results of the reference standard</p><p>Time between the index test and the reference test, and any treatment administrated between</p><p>Estimates</p><p>Estimates of diagnostic accuracy and measurements of statistical uncertainty</p><p>Estimates of test reproducibility, if done</p><p>Introduo MedicinaEUS for Esophageal Carcinoma Staging </p><p>Extraction Data: </p><p>Data were extracted according to TNM classification for EUS and surgery.</p><p>Endoscope frequency, type of instrument, number and type of observers, number of patients</p><p>METHODS (VII):</p><p>Introduo MedicinaEUS for Esophageal Carcinoma Staging </p><p>Data were introduced in SPSS data base.</p><p>Data were introduced in Metadisc.</p><p>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.</p><p>METHODS (VIII):</p><p>Introduo MedicinaEUS for Esophageal Carcinoma Staging </p><p>RESULTS (I):Extraction Data</p><p>Articles</p><p>Endoscope Frequency</p><p>Type of instrument</p><p>Number of observers</p><p>Number of patients</p><p>7.5 MHz</p><p>12 MHz</p><p>20 MHz</p><p>T. Lok Tio et al. 1989</p><p>Yes</p><p>Yes</p><p>_____</p><p>Olympus </p><p>3</p><p>171</p><p>M. J. Hodijek et al. 1993</p><p>Yes</p><p>_____</p><p>_____</p><p>Olympus </p><p>_____</p><p>32</p><p>S. Natsugoe et al. 1996</p><p>Yes</p><p>_____</p><p>_____</p><p>Toshiba </p><p>_____</p><p>37</p><p>Ernesto Laterza et al. 1999</p><p>Yes</p><p>_____</p><p>_____</p><p>EUS and EUS-FNA</p><p>_____</p><p>126</p><p>Gregory Zuccaro et al. 1999</p><p>Yes</p><p>Yes</p><p>_____</p><p>Olympus </p><p>1</p><p>97</p><p>Jan Heidemann et al. 2000</p><p>Yes</p><p>Yes</p><p>_____</p><p>GFUM20 radial SCANNING device</p><p>4</p><p>61</p><p>L. B. Nesje et al. 2000</p><p>Yes</p><p>Yes</p><p>Yes</p><p>Toshiba </p><p>1 or 2</p><p>107</p><p>Enrique Vazquez-Sequeiros et al. 2001</p><p>Yes</p><p>Yes</p><p>_____</p><p>_____</p><p>_____</p><p>37</p><p>Snia J. Wakelin et al. 2001</p><p>Yes</p><p>Yes</p><p>_____</p><p>EUM 20 oblique echoendoscope</p><p>2</p><p>29</p><p>Ishaan Kalha et al. 2004</p><p>Yes</p><p>Yes</p><p>_____</p><p>Olympus </p><p>1</p><p>135</p><p>Introduo MedicinaEUS for Esophageal Carcinoma Staging </p><p>RESULTS (II)Graphic 1: Methodological EvaluationMedian: 16,5Minimum: 11Maximum: 20</p><p>Introduo MedicinaEUS for Esophageal Carcinoma Staging </p><p>RESULTS (III):</p><p>Staging T parameter Sensitivity and specificity</p><p>Graphic 2: T sensitivityGraphic 3: T specificity</p><p>Introduo MedicinaEUS for Esophageal Carcinoma Staging </p><p>RESULTS (IV):</p><p>Staging - N parameter Sensitivity and specificityGraphic 4: N sensitivityGraphic 5: N specificity</p><p>Introduo MedicinaEUS for Esophageal Carcinoma Staging </p><p>All grafics, except grafic 5 for N specificity, show heterogeneity (p &lt; 0,05).</p><p>Results were grouped by frequency, dates, number of patients.</p><p>Subgroup analysis didnt explain heterogeneity.</p><p>DISCUSSION:</p><p>Introduo MedicinaEUS for Esophageal Carcinoma Staging </p><p>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. </p><p>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.</p><p>DISCUSSION:</p><p>Introduo MedicinaEUS for Esophageal Carcinoma Staging </p><p>Although heterogeneous, EUS appears to be more specific than sensitive.</p><p>DISCUSSION:</p><p>Introduo MedicinaEUS for Esophageal Carcinoma Staging </p><p>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:</p><p>Introduo MedicinaEUS for Esophageal Carcinoma Staging </p><p>CONCLUSION:</p><p>As the results are heterogeneous, it hasnt been possible to do a metanalysis.</p><p>EUS should continue to be used as a diagnostic test in staging esophageal carcinoma. </p></li></ul>

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