Prospective study of bone scintigraphy as a staging investigation for oesophageal carcinoma

99m Tc bone scintigraphy does not affect preoperative workup for patients with potentially resectable esophageal squamous cell carcinoma

Background

^99mTc bone scintigraphy (BS) is the mainstay and most widely used technique in evaluation of bone metastasis (BM) in China. This study aimed to investigate the value of ^99mTc BS in preoperative workup for patients with potentially resectable (cT_1−4aN₀₋₃) esophageal squamous cell carcinoma (ESCC).

Methods

This prospective cross‐section clinical trial (ChiCTR1800020304) enrolled a total of 385 patients with ESCC diagnosed at thoracic surgery clinic from October 2018 to September 2020. All patients were diagnosed with stage cT_1−4aN₀₋₃ and were potential candidates for surgical resection. BS was performed preoperatively and the treatment strategy was changed after confirmation of BM. The primary endpoint was the rate of change of the treatment regimen because of BM, while the secondary endpoint was the rate of positive BS findings.

Results

Out of the 385 patients, only two (0.5%) changed their treatment regimen because of BM. The rate of positive BS findings was 1%, while two patients (0.5%) had false‐positive or false‐negative results. The BS diagnostic performance for BM was sensitivity 50%, specificity 99.5%, positive predictive value 50%, negative predictive value 99.5%, and accuracy 99.0%. There was no significant difference in BM in relation to age, sex, tumor location or clinical stage.

Conclusion

Our data demonstrated that ^99mTc bone scintigraphy does not significantly affect the preoperative workup in patients with potentially resectable ESCC, especially in early clinical stage patients.

[Costal metastasis revealing esophageal squamous cell carcinoma]

Esophageal cancer is associated with poor prognosis. Its severity is linked to delayed diagnosis which is most often made once a cancer has metastasized, in Africa. Costal metastases are rare. We report a case of a 38-year old Senegalese patient with squamous cell carcinoma of the lower esophagus with lytic metastases to the ribs. Mrs. TD, aged 38, was admitted with painful swelling in right hemithorax associated with weight loss. The patient also reported mechanical dysphagia evolving during 4 months which had not motivated consultation. Clinical examination showed a poor general condition, a hard, sensitive swelling measuring 3 cm along its longer axis, located on the anterolateral surface of the right hemithorax at the level of the 5^thrib. Biological examinations showed normocytic normochromic anemia with hemoglobin level of 9.4 g/dl, non-specific biological inflammatory syndrome, and hypercalcemia (corrected calcium = 107 mg/l. Oesogastroduodenal endoscopy showed a ulcerative, budding, stenotic lesion 32 cm from the dental arches. Anatomopathological examination of the biopsies revealed moderately differentiated squamous cell carcinoma. In addition to oesophageal tumor, thoracoabdominal-pelvic computed tomography showed bone lysis involving the anterior arch of the 5^th rib, carcinomatous pulmonary nodules and bilateral pleural effusion. Pleural fluid aspiration through an exploratory needle showed serohematic fluid and the cytological examination of this fluid objectified carcinomatous cells. The diagnosis of squamous cell carcinoma of the lower esophagus with rib, pleural and pulmonary metastases was retained and palliative treatment was initiated. The evolution was marked by the death of the patient 3 months after gastrostomy, within a context of respiratory distress. The originality of this observation is related to the atypical seat of metastases of this cancer of the esophagus as well as the risk factors of this tumor. Cancer of the esophagus in young adults is a major problem in Africa. The challenge is to determine its risk factors in order to prevent its occurrence.

Is there a role of whole-body bone scan in patients with esophageal squamous cell carcinoma

Background

Correct detection of bone metastases in patients with esophageal squamous cell carcinoma is pivotal for prognosis and selection of an appropriate treatment regimen. Whole-body bone scan for staging is not routinely recommended in patients with esophageal squamous cell carcinoma. The aim of this study was to investigate the role of bone scan in detecting bone metastases in patients with esophageal squamous cell carcinoma.

Methods

We retrospectively evaluated the radiographic and scintigraphic images of 360 esophageal squamous cell carcinoma patients between 1999 and 2008. Of these 360 patients, 288 patients received bone scan during pretreatment staging, and sensitivity, specificity, positive predictive value, and negative predictive value of bone scan were determined. Of these 360 patients, surgery was performed in 161 patients including 119 patients with preoperative bone scan and 42 patients without preoperative bone scan. Among these 161 patients receiving surgery, 133 patients had stages II + III disease, including 99 patients with preoperative bone scan and 34 patients without preoperative bone scan. Bone recurrence-free survival and overall survival were compared in all 161 patients and 133 stages II + III patients, respectively.

Results

The diagnostic performance for bone metastasis was as follows: sensitivity, 80%; specificity, 90.1%; positive predictive value, 43.5%; and negative predictive value, 97.9%. In all 161 patients receiving surgery, absence of preoperative bone scan was significantly associated with inferior bone recurrence-free survival (P = 0.009, univariately). In multivariate comparison, absence of preoperative bone scan (P = 0.012, odds ratio: 5.053) represented the independent adverse prognosticator for bone recurrence-free survival. In 133 stages II + III patients receiving surgery, absence of preoperative bone scan was significantly associated with inferior bone recurrence-free survival (P = 0.003, univariately) and overall survival (P = 0.037, univariately). In multivariate comparison, absence of preoperative bone scan was independently associated with inferior bone recurrence-free survival (P = 0.009, odds ratio: 5.832) and overall survival (P = 0.029, odds ratio: 1.603).

Conclusions

Absence of preoperative bone scan was significantly associated with inferior bone recurrence-free survival, suggesting that whole-body bone scan should be performed before esophagectomy in patients with esophageal squamous cell carcinoma, especially in patients with advanced stages.