Endosonography Overestimates Preoperative Staging of Primarily Resectable Esophageal Cancer Compared to Pathological T and N Status

BACKGROUND: Accurate preoperative staging of esophageal carcinoma guides the choice between neoadjuvant therapy and primary surgery. Endoscopic ultrasound (EUS) remains the principal modality for locoregional staging, yet its accuracy varies. We evaluated EUS diagnostic performance against final pathology in a homogeneous cohort undergoing primary esophagectomy at a high-volume center and identified factors influencing its reliability. METHODS: This retrospective analysis included 295 patients with esophageal adenocarcinoma (78%) or squamous cell carcinoma (22%) who underwent oncological esophagectomy between 2006 and 2017, primarily without neoadjuvant therapy. Preoperative uTNM staging by EUS was compared with pathological pTNM. Predictors of staging concordance were assessed by multivariate logistic regression. RESULTS: Overall T-stage accuracy was 57.2%. EUS correctly identified 85.9% of pT1 tumors but only 17.0% of pT2 and 64.6% of pT3 lesions. Tumors were overstaged in 36.6% and understaged in 6.1% of cases. Nodal staging accuracy was 65.8% (sensitivity 65%, specificity 68%). Younger age, female sex, shorter height, and ASA II status were independent predictors of reduced T-stage accuracy; no significant predictors emerged for N-stage. CONCLUSION: EUS accurately detects early-stage esophageal cancer but shows limited reliability for intermediate stages, particularly pT2 tumors, in this single-center study. Given the risk of misclassification, EUS findings should be interpreted cautiously and complemented by additional diagnostic tools to improve preoperative assessment and enable individualized treatment decisions.