Limited additional value of positron emission tomography in staging oesophageal cancer

Role of Endoscopic Mucosal Resection and Endoscopic Submucosal Dissection in the Management of Barrett's Related Neoplasia

Endoscopic resection has been proven to be safe and highly effective for removing early neoplastic lesions in Barrett esophagus. It enables accurate histopathological assessment and is therefore considered as the cornerstone in the endoscopic work-up for patients with Barrett neoplasia. Various techniques are available to perform endoscopic resection. Multiband mucosectomy is the most commonly used resection technique. However, endoscopic submucosal dissection is gaining ground in the Western world. Endoscopic resection for low-risk submucosal lesions already is fully justified. Future studies have to point out whether endoscopic resection and subsequent follow-up are also justified in selected patients with high-risk submucosal tumors.

Optical coherence tomography to detect acute esophageal radiation-induced damage in mice: A validation study

Radiation therapy for patients with non-small-cell lung cancer is hampered by acute radiation-induced toxicity in the esophagus. This study aims to validate that optical coherence tomography (OCT), a minimally invasive imaging technique with high resolution (~10 μm), is able to visualize and monitor acute radiation-induced esophageal damage (ARIED) in mice. We compare our findings with histopathology as the gold standard. Irradiated mice receive a single dose of 40 Gy at proximal and distal spots of the esophagus of 10.0 mm in diameter. We scan mice using OCT at two, three, and seven days post-irradiation. In OCT analysis, we define ARIED as a presence of distorted esophageal layering, change in backscattering signal properties, or change in the esophageal wall thickness. The average esophageal wall thickness is 0.53 mm larger on OCT when ARIED is present based on histopathology. The overall sensitivity and specificity of OCT to detect ARIED compared to histopathology are 94% and 47%, respectively. However, the overall sensitivity of OCT to assess ARIED is 100% seven days post-irradiation. We validate the capability of OCT to detect ARIED induced by high doses in mice. Nevertheless, clinical studies are required to assess the potential role of OCT to visualize ARIED in humans.

FDG-PET might not contribute to improving survival in patients with locally advanced inoperable esophageal cancer

BACKGROUND

In Japan, positron emission tomography using ¹⁸F-fluorodeoxyglucose (FDG-PET) has been covered by the national health insurance for esophageal cancer since 2006. FDG-PET is commonly performed in advanced esophageal cancer. The aim of this study was to determine the effect of FDG-PET on survival in patients with locally advanced inoperable esophageal cancer.

METHODS

We retrospectively reviewed all patients with cT4 and without M1 esophageal cancer on CT in our institution between 2000 and 2014, and data for 78 patients who meet the eligibility criteria described below were used for analysis in this study. The eligibility criteria included (1) cT4 esophageal cancer without distant metastases or M1 lymph node metastasis (UICC 2002), (2) histologically proven squamous cell carcinoma, (3) 20-79 years of age, (4) having undergone at least 1 cycle of concomitant chemotherapy, (5) having been irradiated with 50 Gy or more, and (6) no other active malignant tumor during treatment.

RESULTS

Two patients were excluded because abdominal lymph node metastases or neck lymph node metastases were detected by FDG-PET. In 78 eligible patients, FDG-PET was not performed before treatment in 41 of the 78 patients and was performed in the other patients. The median observation period was 68 months. The 3-year and 5-year overall survival rates in 78 patients were 36.9% and 30.8%, respectively. There was no significant difference in overall survival or progression-free survival between patients in whom FDG-PET was performed and those in whom FDG-PET was not performed (12.0 months vs. 11.0 months, p = 0.920 and 6.0 months vs. 6.0 months, p = 0.844, respectively).

CONCLUSIONS

Compared with only CT, additional information from FDG-PET is not associated with improving survival in patients with locally advanced esophageal cancer. Our results suggest that FDG-PET might not have much meaning for survival in locally advanced esophageal cancer.

The role of surgery in advanced disease for esophageal and junctional cancer

The incidence of esophageal and junctional cancer has been increasing in western industrialized nations in the past 30 years. At the time of diagnosis, approximately 50% of patients with esophageal and junctional cancers have distant metastases and are considered incurable. In the recent ESMO guidelines and the German S3 guidelines, surgical therapy for metastatic disease is not recommended. In spite of these recommendations, the treatment of limited metastatic (oligo-metastastic) esophagogastric cancer is currently undergoing a shift towards a more aggressive therapy. Selected patients with oligo-metastatic disease may be considered for surgical resection of the primary tumor and the metastases after chemo(radio)therapy and careful evaluation in an interdisciplinary tumor board. We discuss in this review the literature and some guidelines for extended surgical approaches is laid out. In the future, randomized prospective studies like the German RENAISSANCE/FLOT5 trial and the French SURGIGAST trial will feed us with more evidence if multimodal therapy including surgery for limited metastatic disease is indicated.

Feasibility of using optical coherence tomography to detect radiation-induced fibrosis and residual cancer extent after neoadjuvant chemo-radiation therapy: an ex vivo study

Treatment of resectable esophageal cancer includes neoadjuvant chemo-radiation therapy (nCRT) followed by esophagectomy in operable patients. High-risk surgery may have been avoided in patients with a pathological complete response (pCR). We investigated the feasibility of optical coherence tomography (OCT) to detect residual cancer and radiation-induced fibrosis in 10 esophageal cancer patients that underwent nCRT followed by esophagectomy. We compared our OCT findings with histopathology. Overall, OCT was able to differentiate between healthy tissue, fibrotic tissue, and residual cancer with a sensitivity and specificity of 79% and 67%, respectively. Hence, OCT has the potential to add to the assessment of a pCR.

Mediastinal node staging by positron emission tomography-computed tomography and selective endoscopic ultrasound with fine needle aspiration for patients with upper gastrointestinal cancer: Results from a regional centre

AIM

To investigate the impact of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) and positron emission tomography-computed tomography (PET-CT) in the nodal staging of upper gastrointestinal (GI) cancer in a tertiary referral centre.

METHODS

We performed a retrospective review of prospectively recorded data held on all patients with a diagnosis of upper GI cancer made between January 2009 and December 2015. Only those patients who had both a PET-CT and EUS with FNA sampling of a mediastinal node distant from the primary tumour were included. Using a positive EUS-FNA result as the gold standard for lymph node involvement, the sensitivity, specificity, positive and negative predictive values (PPV and NPV) and accuracy of PET-CT in the staging of mediastinal lymph nodes were calculated. The impact on therapeutic strategy of adding EUS-FNA to PET-CT was assessed.

RESULTS

One hundred and twenty one patients were included. Sixty nine patients had a diagnosis of oesophageal adenocarcinoma (Thirty one of whom were junctional), forty eight had oesophageal squamous cell carcinoma and four had gastric adenocarcinoma. The FNA results were inadequate in eleven cases and the PET-CT findings were indeterminate in two cases, therefore thirteen patients (10.7%) were excluded from further analysis. There was concordance between PET-CT and EUS-FNA findings in seventy one of the remaining one hundred and eight patients (65.7%). The sensitivity, specificity, PPV and NPV values of PET-CT were 92.5%, 50%, 52.1% and 91.9% respectively. There was discordance between PET-CT and EUS-FNA findings in thirty seven out of one hundred and eight patients (34.3%). MDT discussion led to a radical treatment pathway in twenty seven of these cases, after the final tumour stage was altered as a direct consequence of the EUS-FNA findings. Of these patients, fourteen (51.9%) experienced clinical remission of a median of nine months (range three to forty two months).

CONCLUSION

EUS-FNA leads to altered staging of upper GI cancer, resulting in more patients receiving radical treatment that would have been the case using PET-CT staging alone.

18F-FDG PET-CT after Neoadjuvant Chemoradiotherapy in Esophageal Cancer Patients to Optimize Surgical Decision Making

BACKGROUND

Prognosis of esophageal cancer patients can be significantly improved by neoadjuvant chemoradiotherapy (nCRT). Given the aggressive nature of esophageal tumors, it is conceivable that in a significant portion of patients treated with nCRT, dissemination already becomes manifest during the period of nCRT. The aim of this retrospective study was to determine the value and diagnostic accuracy of PET-CT after neoadjuvant chemoradiotherapy to identify patients with metastases preoperatively in order to prevent non-curative surgery.

METHODS

From January 2011 until February 2013 esophageal cancer patients deemed eligible for a curative approach with nCRT and surgical resection underwent a PET-CT after completion of nCRT. If abnormalities on PET-CT were suspected metastases, histological proof was acquired. A clinical decision model was designed to assess the cost-effectiveness of this diagnostic strategy.

RESULTS

156 patients underwent a PET-CT after nCRT. In 31 patients (19.9%) PET-CT showed abnormalities suspicious for dissemination, resulting in 17 cases of proven metastases (10.9%). Of the patients without proven metastases 133 patients were operated. In 6 of these 133 cases distant metastases were detected intraoperatively, corresponding to 4.5% false-negative results. The standard introduction of a post-neoadjuvant therapy PET-CT led to a reduction of overall health care costs per patient compared to a scenario without restaging with PET-CT ($34,088 vs. $36,490).

CONCLUSION

In 10.9% of esophageal cancer patients distant metastases were detected by standard PET-CT after neoadjuvant chemoradiotherapy. To avoid non-curative resections we advocate post-neoadjuvant therapy PET-CT as a cost-effective step in the standard work-up of candidates for surgery.

Positron emission tomography-computed tomography in oesophageal cancer staging: a tailored approach

BACKGROUND

Positron emission tomography-computed tomography (PET-CT) scanning is used routinely in the staging of oesophageal cancer to identify occult metastases not apparent on CT and changes the management in typically 3-18% patients. The authors aim to re-evaluate its role in the management of oesophageal cancer, investigating whether it is possible to identify a group of patients that will not benefit and can safely be spared from this investigation.

METHODS

Consecutive patients with oesophageal cancer undergoing PET-CT staging between 2010 and 2013 were identified from a specialist modern multidisciplinary team database. Without knowledge of the PET-CT result, patients were stratified into low-risk or high-risk groups according to the likelihood of identifying metastatic disease on PET-CT based on specified criteria routinely available from endoscopy and CT reports. Clinical outcomes in the two groups were investigated.

RESULTS

In 383 undergoing PET-CT, metastatic disease was identified in 52 (13.6%) patients. Eighty-three patients were stratified as low risk and 300 as high risk. None of the low-risk patients went on to have metastatic disease identified on PET-CT. Of the high-risk patients, 17% had metastatic disease identified on PET-CT.

CONCLUSIONS

In one of the largest studies to date investigating the influence of staging PET-CT on management of patients with oesophageal cancer, the authors report a classification based on endoscopy/CT criteria is able to accurately stratify patients according to the risk of having metastatic disease. This could be used to avoid unnecessary PET-CT 22% of patients, saving cost, inconvenience and reducing potential delay to definitive treatment in this group.

Impact of Adjuvant Chemotherapy on Patients with Lymph Node-Positive Esophageal Cancer who are primarily Treated with Surgery

BACKGROUND

Whereas the optimal therapeutic strategy in node positive esophageal cancer primarily treated by surgery remains unknown, the study was designed to evaluate the impact of adjuvant chemotherapy on survival in such population.

METHODS

Among 2944 consecutive patients operated on for esophageal cancer between 2000 and 2010 in 30 European centers, patients with lymph node metastasis treated by adjuvant treatment (n = 178) were compared to patients who did not received adjuvant treatment (n = 378). Multivariable analyses and propensity score matching were used to compensate for differences in baseline characteristics.

RESULTS

After matching, patients were comparable between the two groups. When comparing adjuvant treatment and nonadjuvant treatment groups, there was no significant differences in 3-year overall (40.9 vs. 35.8 %, P = 0.560) and disease-free (33.9 vs. 28.5 %, P = 0.190) survivals. Locoregional recurrence was lower in the adjuvant treatment group (14.4 vs. 30.9 %, P = 0.012). In the adjuvant treatment group, 94 patients received chemotherapy and 84 chemoradiotherapy, without significant survival benefit over chemoradiotherapy compared with chemotherapy alone (P = 0.280). Predictive factors of overall survival were age ≥60 years, ASA III-IV score, and pN+ classification. No survival benefit was observed according to histological subtype or occurrence of postoperative complications.

CONCLUSIONS

Adjuvant chemo(radio)therapy did not offer survival benefit in lymph node-positive esophageal cancer patients primarily treated with surgery.

Clinical utility of 18F-fluorodeoxyglucose positron emission tomography/computed tomography in the staging of patients with potentially resectable esophageal cancer

INTRODUCTION

(18)F-fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) may play an important role in staging patients with potentially resectable esophageal cancer but its impact on clinical management remains unclear.

METHODS

In a multicenter prospective cohort study of patients with potentially resectable esophageal cancer, we compared stage of disease based on PET/CT with the stage based on conventional staging performed before PET/CT (American Joint Committee on Cancer, 6th edition). The primary outcome was the proportion of patients with a clinically important change in stage, based on PET/CT findings. We used health administrative databases to track health services use and mortality after the index PET/CT scan.

RESULTS

Four hundred ninety-one patients who received a PET/CT scan for staging of potentially resectable esophageal cancer were included in the study cohort. PET/CT led to clinically important changes in stage for a total of 188 patients (24.0%): 107 patients (21.8%) were upstaged and 11 patients (2.2%) were downstaged. Results of PET/CT were associated with differences in actual management. At the 6-month follow-up, use of surgery was greater in patients with M0 disease (54.4%) compared with those with M1a (25.0%; p < 0.001) or M1b (7.3%; p < 0.001) disease based on PET/CT. The overall cohort had a median survival of 603 days, and higher stage of disease on PET/CT (i.e., M stage) was associated with shorter survival (p < 0.001).

CONCLUSIONS

PET/CT identifies disease not otherwise detected on conventional staging and results in clinically important changes in stage for an appreciable number of patients with potentially resectable esophageal cancer and can make important contributions to the management of these patients.

Appraisal of staging endoscopic ultrasonography in a modern high-volume esophageal program

BACKGROUND

Accurate pretreatment staging is essential to decision making for patients with esophageal and junctional cancers, particularly when choosing endoscopic therapy or a multimodal approach. As the efficacy of endoscopic ultrasonography (EUS) has been reported as variable, we assessed it prospectively in a large cohort from a high-volume center.

METHODS

The EUS data from 2007 to 2011 were reviewed and analyzed. We conducted a comparative analysis with computed tomography-positron emission tomography (CT-PET) staging and pathology. Survival was analyzed by Kaplan-Meier testing on EUS-predicted T- and N-stage cohorts.

RESULTS

Altogether, 222 patients underwent EUS. Among patients undergoing primary surgical resection, preoperative EUS diagnosed the T stage correctly in 71 % (55/77) of cases. Sensitivity and specificity for T1, T2, and T3 tumors were 94 and 89 %, 55 and 80 %, and 66 and 93 %, respectively. Mean maximum standard uptake volume on CT-PET correlated moderately with the EUS T stage (r = 0.42, p < 0.0001). EUS accuracy for nodal disease was 65 %. Survival was statistically better for the EUS T1 group than for those with T3 tumors (p = 0.01). Nodal metastases diagnosed on EUS predicted a significantly worse prognosis than EUS-negative nodes on both univariate and multivariate analyses (p < 0.0001 and p = 0.005 respectively).

CONCLUSIONS

There was a significant relation between EUS T and N stages and overall survival. EUS demonstrated 71 % accuracy for the overall T stage. Staging accuracy of EUS for large lesions was less effective than for T1 tumors, underlining the need for a multimodal investigative approach to stage esophageal tumors accurately.

Oesophageal cancer--an overview

Oesophageal carcinoma is one of the most virulent malignant diseases and a major cause of cancer-related deaths worldwide. Diagnosis and accuracy of pretreatment staging have substantially improved throughout the past three decades. Therapy is challenging and the optimal approach is still debated. Oesophagectomy is considered to be the procedure of choice in patients with operable oesophageal cancer. Endoscopic measures and limited surgical procedures provide an alternative in patients with early carcinomas confined to the oesophageal mucosa. Chemotherapy and radiotherapy or concurrent chemoradiotherapy are also frequently applied, either as definitive treatment or as neoadjuvant therapy within multimodal approaches. The question of whether multimodal treatment offers improved results has been the focus of many studies since the 1990s. Although results are discordant and even some meta-analyses remain inconclusive, it is now widely accepted that multimodal therapy leads to a modest survival benefit. The role of minimally invasive oesophagectomy is not yet defined. Endoscopic stent insertion, radiotherapy and other palliative measures provide relief of tumour-related symptoms in advanced, unresectable tumour stages.

Multimodal treatment of esophageal cancer

BACKGROUND

The treatment of localized esophageal cancer has been debated controversially over the past decades. Neoadjuvant treatment was used empirically, but evidence was limited due to the lack of high-quality confirmatory studies. Meanwhile, data have become much clearer due to recently published well-conducted randomized controlled trials and meta-analyses.

METHODS

Neoadjuvant and perioperative platinum fluoropyrimidine-based combination chemotherapy has now an established role in the treatment of stage II and stage III esophageal adenocarcinoma and cancer of the esophago-gastric junction. Neoadjuvant chemoradiation is now the standard of care for treating stage II and stage III esophageal squamous cell cancer and can also be considered for treating esophageal adenocarcinoma.

RESULTS

Patients with esophageal squamous cell cancer treated with definitive chemoradiation achieve comparable long-term survival compared with surgery. Short-term mortality is less with chemoradiation alone, but local tumor control is significantly better with surgery.

CONCLUSION

This expert review article outlines current data and literature and delineates recommendable treatment guidelines for localized esophageal cancer.

Improving the quality of pretreatment staging in patients with esophageal carcinoma - a fast track study

BACKGROUND

Current guidelines for esophageal cancer recommend series of diagnostic investigations to determine pretreatment TNM stage. When investigations are done sequentially, diagnostic work-up time may be prolonged considerably. Aim of the study was to determine the feasibility and efficacy of a fast track staging strategy within five days after the first consultation.

MATERIAL AND METHODS

Between 2007 and 2010 all patients presenting with esophageal cancer at the Department of Gastroenterology in a tertiary referral center were prospectively analyzed. At Day 1 all patients underwent computed tomography (CT), endoscopic ultrasound (EUS) and ultrasonography of the neck (US). Results and treatment implications were discussed within a multidisciplinary meeting. This fast track strategy was considered completed successfully if pre-treatment TNM classification was achieved and therapy was proposed to the patient at the outpatient clinic at Day five. In those cases where staging period time was prolonged, the number and type of additional tests were documented including the ensuing time delay.

RESULTS

In 111 patients CT, EUS and US were performed in 100%, 88.3% and 97.3% respectively. A final TNM stage and treatment proposal was reached at Day 5 in 60% of the patients. Additional tests were diverse and mainly used to prove local irresectabilty or presence of distant metastasis. Multivariate analysis identified presence of lymphadenopathy (HR 0.25 p = 0.03) and metastasis (HR 0.27 p = 0.03) as significant predictors of not completing the staging period within five days. In 18% of patients overuse of at least one test occurred, most commonly because CT already revealed distant metastasis.

CONCLUSION

Employment of a fast track five day staging strategy in patients with esophageal carcinoma is feasible. Definite TNM stage and treatment proposal can be achieved in 60% of cases, but comes at the expense of test overuse in about one fifth of patients.

The role of integrated F-18-FDG-PET scanning in the detection of M1 disease in oesophageal adenocarcinoma and impact on clinical management

INTRODUCTION

The aim of this study was to evaluate the efficacy of F-18-fluorodeoxyglucose positron emission tomography (FDG-PET) scanning in the staging of oesophageal adenocarcinoma.

METHODS

One hundred four patients with biopsy-proven adenocarcinoma underwent (18)F-FDG-PET scan. FDG avid lesions were further investigated to their diagnostic conclusion.

RESULTS

Nineteen patients (18.26%) were found to have non-loco-regional FDG uptake. Of the patients, 3.84% were found to have M1 disease and 7.69% were found to have a second primary tumour. The sensitivity and specificity of FDG-PET scanning to detect metastatic disease in our series was 57.14% and 84.53%, respectively. The overall diagnostic accuracy was 82.69%.

CONCLUSIONS

PET scanning improves staging and prevents unnecessary surgery in patients with M1 disease. It represents a good adjunct to computed tomography scanning and endoscopic ultrasound in the staging of oesophageal adenocarcinoma. The detection of asymptomatic coexisting synchronous cancers is an added benefit provided by PET scanning over similar diagnostic modalities.

The value of [18F]fluorodeoxyglucose-PET/CT in oesophageal cancer

[¹⁸F]Fluorodeoxyglucose-positron emission tomography/computed tomography (CT) is recognized as a useful adjunct to conventional imaging with CT and endoscopic ultrasonography for the staging of oesophageal cancer, for response assessment and identification of recurrent disease and it may provide prognostic information.

Update: modern approaches to the treatment of localized esophageal cancer

The optimal treatment strategy for esophageal cancer continues to be a topic of debate. Improvements in chemotherapy drugs, surgical techniques, and radiotherapy planning and delivery have led to the design of treatment approaches that are specific to both the stage of the tumor and the overall performance status of the patient. Surgery continues to be the standard treatment option for localized disease, but multimodality treatments that include radiation and chemotherapy with surgery are increasingly used. The next few years will continue to see improvements in radiation techniques, especially proton beam treatment; the development of additional minimally invasive surgical approaches to minimize postoperative side effects; and the discovery of molecular biomarkers to help specifically target treatment of esophageal cancer in individual patients.

Management of esophageal adenocarcinoma

The incidence of esophageal adenocarcinoma is increasing in Western countries with a tendency to exceed that of squamous-cell carcinoma. Prognosis is unfavorable with 5-year survival less than 15%, irrespective of treatment and the stage. At the time of diagnosis, more than two thirds of patients have a non-operable cancer because of extension or associated co-morbidities. Most studies have included different tumoral locations (esophagus and stomach) and different histological types (adenocarcinoma and squamous-cell carcinoma), making it difficult to interpret results. Surgery is currently the standard treatment for small tumors. Surgery should be preceded by neo-adjuvant treatment for patients with locally advanced resectable tumors, either preoperative chemotherapy or preoperative chemoradiation therapy. The therapeutic choice should be decided during multidisciplinary meetings according to patient and tumor characteristics and the expertise of the center. For patients with contraindications to surgery, exclusive chemoradiation therapy is recommended. Herein we reviewed and synthesized the different therapeutic strategies for esophageal adenocarcinoma.

Value of EUS in Determining Curative Resectability in Reference to CT and FDG-PET: The Optimal Sequence in Preoperative Staging of Esophageal Cancer?

BACKGROUND

F-fluorodeoxyglucose positron emission tomography (FDG-PET) in the optimal sequence in staging esophageal cancer has not been investigated adequately.

METHODS

The staging records of 216 consecutive operable patients with esophageal cancer were reviewed blindly. Different staging strategies were analyzed, and the likelihood ratio (LR) of each module was calculated conditionally on individual patient characteristics. A logistic regression approach was used to determine the most favorable staging strategy.

RESULTS

Initial EUS results were not significantly related to the LRs of initial CT and FDG-PET results. The positive LR (LR+) of EUS-fine-needle aspiration (FNA) was 4, irrespective of CT and FDG-PET outcomes. The LR+ of FDG-PET varied from 13 (negative CT) to 6 (positive CT). The LR+ of CT ranged from 3-4 (negative FDG-PET) to 2-3 (positive FDG-PET). Age, histology, and tumor length had no significant impact on the LRs of the three diagnostic tests.

CONCLUSIONS

This study argues in favor of PET/CT rather than EUS as a predictor of curative resectability in esophageal cancer. EUS does not correspond with either CT or FDG-PET. LRs of FDG-PET were substantially different between subgroups of negative and positive CT results and vice versa.

FDG-PET parameters as prognostic factor in esophageal cancer patients: a review

BACKGROUND

(18)F-fluorodeoxyglucose positron emission tomography (FDG-PET) has been used extensively to explore whether FDG Uptake can be used to provide prognostic information for esophageal cancer patients. The aim of the present review is to evaluate the literature available to date concerning the potential prognostic value of FDG uptake in esophageal cancer patients, in terms of absolute pretreatment values and of decrease in FDG uptake during or after neoadjuvant therapy.

METHODS

A computer-aided search of the English language literature concerning esophageal cancer and standardized uptake values was performed. This search focused on clinical studies evaluating the prognostic value of FDG uptake as an absolute value or the decrease in FDG uptake and using overall mortality and/or disease-related mortality as an end point.

RESULTS

In total, 31 studies met the predefined criteria. Two main groups were identified based on the tested prognostic parameter: (1) FDG uptake and (2) decrease in FDG uptake. Most studies showed that pretreatment FDG uptake and postneoadjuvant treatment FDG uptake, as absolute values, are predictors for survival in univariate analysis. Moreover, early decrease in FDG uptake during neoadjuvant therapy is predictive for response and survival in most studies described. However, late decrease in FDG uptake after completion of neoadjuvant therapy was predictive for pathological response and survival in only 2 of 6 studies.

CONCLUSIONS

Measuring decrease in FDG uptake early during neoadjuvant therapy is most appealing, moreover because the observed range of values expressed as relative decrease to discriminate responding from nonresponding patients is very small. At present inter-institutional comparison of results is difficult because several different normalization factors for FDG uptake are in use. Therefore, more research focusing on standardization of protocols and inter-institutional differences should be performed, before a PET-guided algorithm can be universally advocated.

Positron emission tomography imaging approaches for external beam radiation therapies: current status and future developments

In an era in which it is possible to deliver radiation with high precision, there is a heightened need for enhanced imaging capabilities to improve tumour localisation for diagnostic, planning and delivery purposes. This is necessary to increase the accuracy and overall efficacy of all types of external beam radiotherapy (RT), including particle therapies. Positron emission tomography (PET) has the potential to fulfil this need by imaging fundamental aspects of tumour biology. The key areas in which PET may support the RT process include improving disease diagnosis and staging; assisting tumour volume delineation; defining tumour phenotype or biological tumour volume; assessment of treatment response; and in-beam monitoring of radiation dosimetry. The role of PET and its current developmental status in these key areas are overviewed in this review, highlighting the advantages and drawbacks.

Early recurrence and death after esophagectomy in patients with esophageal squamous cell carcinoma

BACKGROUND

The aim of this retrospective study is to analyze recurrence and death within 1 year after esophagectomy in patients with esophageal carcinoma.

METHODS

The records of 533 consecutive patients with esophageal squamous cell carcinoma who underwent surgery from January 2002 to January 2005 were reviewed. Patients who died of recurrence within 1 year after operation (group A) were compared with patients who survived more than 5 years without any recurrence (group B). Their clinicopathologic characteristics were evaluated by univariate and multivariate analyses.

RESULTS

The overall 1-year and 5-year survival rates for the entire cohort were 76.1% and 32.3%, respectively, with the follow-up rate of 93.4%. Of the 119 patients who died within 1 year after the esophagectomy, local recurrence or distant metastasis or both were documented in 62 patients (52.1%). The radicality of resection, size of tumor, radicality of resection, grade of differentiation, depth of invasion, status of lymph node metastasis, number of lymph node metastases, and marginal status were shown by univariate analysis to be the significant prognostic factors. By multivariate analysis, they were also the independent prognostic factors, except for the size of tumor and the radicality of resection.

CONCLUSIONS

More than half of early death in esophageal squamous cell carcinoma patients after esophagectomy were still tumor recurrence related, especially hematogeneous spreading. The grade of differentiation, depth of invasion, lymph node metastasis, number of lymph node metastases, and marginal status are valuable prognostic factors in predicting early death.

Staging of early adenocarcinoma in Barrett's esophagus

The main goal in the staging of patients with early neoplasia arising in the context of Barrett's esophagus (BE) is to identify individuals who are eligible for endoscopic therapy and differentiate them from those who require surgical management. To make the proper patient selection a combined staging strategy consisting of endoscopy evaluation, endoscopic ultrasonography, and endoscopic mucosal resection is necessary. In this article, the authors summarize the evidence behind each different staging modality in the setting of early BE adenocarcinoma and propose a staging approach that helps to select patients who are suitable for endoscopic therapy.

The use of FDG-PET to target tumors by radiotherapy

Fluorodeoxyglucose positron emission tomography (FDG-PET) plays an increasingly important role in radiotherapy, beyond staging and selection of patients. Especially for non-small cell lung cancer, FDG-PET has, in the majority of the patients, led to the safe decrease of radiotherapy volumes, enabling radiation dose escalation and, experimentally, redistribution of radiation doses within the tumor. In limited-disease small cell lung cancer, the role of FDG-PET is emerging. For primary brain tumors, PET based on amino acid tracers is currently the best choice, including high-grade glioma. This is especially true for low-grade gliomas, where most data are available for the use of (11)C-MET (methionine) in radiation treatment planning. For esophageal cancer, the main advantage of FDG-PET is the detection of otherwise unrecognized lymph node metastases. In Hodgkin's disease, FDG-PET is essential for involved-node irradiation and leads to decreased irradiation volumes while also decreasing geographic miss. FDG-PET's major role in the treatment of cervical cancer with radiation lies in the detection of para-aortic nodes that can be encompassed in radiation fields. Besides for staging purposes, FDG-PET is not recommended for routine radiotherapy delineation purposes. It should be emphasized that using PET is only safe when adhering to strictly standardized protocols.

[Clinicopathological characteristics and survival outcome of esophageal cancer. Results from a series of 200 patients]

BACKGROUND AND OBJECTIVE

The esophageal cancer (EC) is a slightly frequent but serious disease. Our aim is to describe the characteristics of the patients with EC in our Hospital.

PATIENTS AND METHOD

We included 200 patients consecutively diagnosed and/or treated for CE between between January, 2003 and December, 2007. The location of the tumor was analyzed, the histological type, the proofs realized for to establish the classification, the treatments, the survival and the morbi-mortality of the surgery.

RESULTS

The endoscopic ultrasonography (EUS) modified the therapeutic strategy in 12% of the patients. The survival to the year, 3 years and 5 years was 48%, 25% and 21%, respectively. 74 (32%) patients were operated, 48 (65%) of them was treated with neoadjuvant chemoradiotherapy. The postsurgical mortality was 8% (6 patients) and the morbidity was 57% (114 patients). In multivariate analysis, after adjustment for traditional risk factors, were the location in the average third ( [HR, hazard ratio]=2.3; confidence interval [IC] of 95%, 1.3-4.1) and not accomplishment of surgery after the chemotherapy and radiotherapy (HR=1.9; IC to 95%, 1.15-3).

CONCLUSIONS

The diagnosis is realized very later. The EUS has contributed a better therapeutic strategy to our patients. The mortality continues being high.

Positron emission tomography-computed tomography in predicting locoregional invasion in esophageal squamous cell carcinoma

BACKGROUND

In order to clarify the role of positron emission tomography-computed tomography (PET/CT) in thoracic esophageal squamous cell carcinoma we investigated its value in predicting locoregional invasion.

METHODS

Forty-five patients receiving curative esophagectomy and lymph node dissection were included. The relationship between PET/CT findings and pathology results were studied. Correlation between nodal uptake and the modified lymph node staging, which is based on number of involved nodes (N0 = no nodes; N1 = 1 to 3 nodes; N2 = more than 3 nodes), was evaluated.

RESULTS

The mean maximal standardized uptake value (SUV(max)) was 5.09 +/- 4.00 in T1, 14.17 +/- 2.46 in T2, 13.32 +/- 3.96 in T3, and 10.37 +/- 1.94 in T4 primary tumor. The SUV(max) was significantly lower in stage T1 tumors than in stage T2 and T3 tumors. For regional nodal involvement, PET/CT findings significantly correlated with pathology results. However, the sensitivity, specificity, and accuracy of PET/CT were only 57.1%, 83.3%, and 71.1%, respectively, and even lower for detecting nonregional lymph node metastasis. When stratified by the modified staging system, the mean SUV(max) was 0.64 +/- 1.60 in N0, 1.43 +/- 2.08 in N1, and 4.67 +/- 4.32 in N2 regional lymph node metastases, and was significantly higher in patients with N2 metastasis than in patients with N0 and N1 metastases.

CONCLUSIONS

Locoregional invasion in esophageal cancer can be predicted by PET/CT. The SUV(max) of the primary tumor helped identify T1 tumor, and the SUV(max) of the regional lymph nodes correlated with the severity of nodal involvement.

The early use of PET-CT alters the management of patients with esophageal cancer

INTRODUCTION

The routine use of positron emission tomography-computed tomography (PET-CT) in the staging of patients with esophageal carcinoma remains contentious, with conflicting reports of its benefit. In our unit, PET-CT has been used routinely in the staging of all patients considered for radical therapy (surgery or chemoradiotherapy). Our aim was to determine the frequency with which PET-CT influenced decision making in the management of patients with carcinoma of the esophagus or gastroesophageal junction.

METHODS

CT, PET-CT, and outcome information were collected on 38 patients considered for radical therapy. Patient proformas, with and without PET-CT findings, were constructed and each independently reviewed in a randomized and blinded fashion by five multidisciplinary team members (three surgeons, two oncologists) and a treatment strategy determined.

RESULTS

PET-CT changed the staging for ten patients (26%). This translated into a change in management decision for seven patients (18%). The concordance between individual management plans and treatment intent was 79% for CT (150 of 190 decisions) and it was 92% for PET-CT (175 of 190 decisions). Full concordance between multidisciplinary team members was 66% with CT staging and 74% with the addition of PET-CT.

CONCLUSION

The use of PET-CT early in the staging algorithm for esophageal carcinoma altered the staging for a quarter of patients and the management for a fifth of patients, supporting its inclusion early in the staging algorithm.

Impact of fluorodeoxyglucose PET on the management of esophageal cancer

Esophageal cancer is the third most common malignancy of the alimentary tract. The incidence of esophageal cancer has steadily increased over the past three decades. Almost all therapeutic modalities for esophageal cancer are associated with a considerable mortality and morbidity. Consequently, there has been growing concern regarding effective management of esophageal cancer. 18F-fluorodeoxyglucose positron emission tomography (18F-FDG PET) is playing an increasing role in the management of esophageal cancer, offering potential advantages in the accuracy of disease assessment at a number of decision points in the management pathway. This review evaluates the critical role of FDG-PET in (i) diagnosis, (ii) preoperative staging, (iii) monitoring of response to neoadjuvant therapy, (iv) assessment of recurrence and (v) prediction of prognosis of esophageal cancer. We have also compared diagnostic performance of FDG-PET and other current technologies such as computed tomography scan and endoscopic ultrasonography based on available evidence.

International survey on esophageal cancer: part II staging and neoadjuvant therapy

The outcome of esophagectomy could be improved by optimal diagnostic strategies leading to adequate preoperative patient selection. Neoadjuvant therapy could improve outcome by increasing the number of radical resections and by controlling metastatic disease. The purposes of this study were to gain insight into the current worldwide practice of staging modalities and neoadjuvant therapy in esophageal cancer, and to detect intercontinental differences. Surgeons with particular interest in esophageal surgery, including members of the International Society for Diseases of the Esophagus, the European Society of Esophagology - Group d'Etude Européen des Maladies de l'Oesophage, and the OESO, were invited to participate in an online questionnaire. Questions were asked regarding staging modalities, neoadjuvant therapy, and response evaluation applied in esophageal cancer patients. Of 567 invited surgeons, 269 participated resulting in a response rate of 47%. The responders currently performing esophagectomies (n= 250; 44%) represented 41 countries across the six continents. Esophagogastroscopy with biopsy and computed tomography (CT) scanning were routinely performed by 98% of responders for diagnosing and staging esophageal cancer, while endoscopic ultrasound (EUS) and barium esophagography were routinely applied by 58% and 51%, respectively. Neoadjuvant therapy is routinely administered by 33% and occasionally by 63% of responders. Of the responders that administer identical neoadjuvant regimens to esophageal adenocarcinoma (AC) and squamous cell carcinoma, 54% favor chemoradiotherapy. For AC, chemotherapy is preferred by 31% of the responders that administer neoadjuvant therapy, whereas for squamous cell carcinoma, the majority of responders (38%) prefer chemoradiotherapy. Response to neoadjuvant therapy is predominantly assessed by CT scanning of the chest and abdomen (86%). Barium esophagography, EUS, and combined CT/PET scan are requested for response monitoring in equal frequency (25%). Substantial differences in applied staging modalities and neoadjuvant regimens were detected between surgeons from different continents. In conclusion, currently the most commonly applied diagnostic modalities for staging and restaging esophageal cancer are CT scanning of the chest and abdomen, gastroscopy, barium esophagography and EUS. Neoadjuvant therapy is routinely applied by one third of the responders. Intercontinental differences have been detected in the diagnostic modalities applied in esophageal cancer staging and in the administration of neoadjuvant therapy. The results of this survey provide baseline data for future research and for the development of international guidelines.

Esophageal cancer

The incidence of esophageal cancer, in particular esophageal adenocarcinoma, is increasing, largely due to an increase in risk factors for adenocarcinoma. When esophageal cancer is confirmed by upper endoscopy, staging is required for the optimal selection of patients who should undergo esophageal resection. Neoadjuvant chemoradiation may be able to improve survival after esophageal cancer surgery. Endoscopic therapy for early esophageal neoplasia is effective and safe, with the best results being obtained by an individualized approach using endoscopic mucosal resection, ablative therapy, or both. Finally, dysphagia from esophageal cancer can be successfully treated with stent placement or single-dose brachytherapy. Future research should establish whether combinations of chemotherapy with or without radiation therapy play a role in survival.

Staging and restaging of advanced esophageal cancer

PURPOSE OF REVIEW

Esophageal cancer staging continues to evolve, especially for advanced cases. Computer tomography (CT) scan of the thorax and abdomen to detect metastatic disease, and endoscopic ultrasound with fine needle aspiration (EUS-FNA) remain the preferred methods. Several recent studies have evaluated alternative methods for locoregional and distant disease detection and staging.

RECENT FINDINGS

There seems to be emerging roles for fluorine-18 fluorodeoxyglucose (FDG)-PET, laparoscopic staging, and high-resolution T2-weighted MRI in esophageal cancer staging. Perfusion CT and FDG-PET and FDG-PET/CT may have an emerging role in assessing response to neoadjuvant therapy. Restaging following neoadjuvant therapy remains suboptimal. A 50% or more reduction of tumor thickness by EUS postchemotherapy continues to be the best measure for tumor downstaging survival, while FDG-PET/CT may be more accurate than EUS-FNA and CT scan for predicting nodal status and complete responders after neoadjuvant therapy. Potential methylation analysis, digital image analysis, and fluorescence in-situ hybridization on EUS-FNA samples may increase the yield and prove to be better than routine cytology.

SUMMARY

For advanced esophageal cancer, locoregional staging is best performed with EUS-FNA, with CT scan of the thorax and abdomen and FDG-PET, to detect metastatic disease. The role of EUS in restaging following neoadjuvant therapy remains controversial, with recent studies showing that FDG-PET/CT may be more accurate than EUS-FNA and CT scan for predicting nodal status and complete responders after neoadjuvant therapy.