Esophageal carcinoma: current staging strategies

A prospective analysis of the diagnostic accuracy of 3 T MRI, CT and endoscopic ultrasound for preoperative T staging of potentially resectable esophageal cancer

Background

Patients with esophageal cancer (EC) undergo endoscopic ultrasound and CT based cancer staging. Recent technical developments allow improved MRI quality with diminished motion artifact that may allow MRI to compare favorable to CT for noninvasive staging. Hence the purpose of the study was to assess image quality and diagnostic accuracy of 3 T MRI versus CT and EUS for preoperative T-staging of potentially resectable esophageal cancer.

Methods

Between October-2014 and December-2017, esophageal cancer patients with T-staging by EUS were enrolled in this prospective study. Post-operative histopathologic T-staging was the reference standard. All participants underwent MRI [T2- multi-shot turbo spin echo sequence (msTSE), diffusion-weighted imaging (DWI), and 3D gradient-echo based sequence (3D-GRE)] and CT [non-contrast and multiphase contrast-enhanced CT scanning] 5.6 + 3.6 days after endoscopy. Surgery was performed within 3.6 + 3.5 days after imaging. Two blinded endoscopists (reader 1 and 2) and radiologists (reader 3 and 4) independently evaluated EUS and CT/MRI, respectively. Considering the clinical relevance, patients were dichotomized into early (T1 and T2) vs late (T3 and T4) stage cancer before assessment. For statistical purpose, the binary decision was defined as the ability of the imaging technique to diagnose early stage/not early stage esophageal cancer. Diagnostic performance of EUS, MRI and CT was compared using McNemar’s test with Bonferroni correction; kappa values were assessed for reader performance.

Results

74 study participants (60 ± 8 yrs.; 56 men) with esophageal cancer were evaluated, of whom 85%(63/74) had squamous cell carcinoma, 61%(45/74) were at early stage and 39%(29/74) were at late stage cancer, as determined by histopathology. Intra- and Inter-reader agreement for pre-operative vs post-operative T-staging was excellent for all imaging modalities. Compared to CT, MRI showed significantly higher accuracy for both the readers (reader3: 96% vs 82%, p = 0.0038, reader4: 95% vs 80%, p = 0.0076, for MRI vs CT, respectively). Further, MRI outperformed EUS with higher specificity (reader 1 vs 3: 59% vs 93%, p = 0.0015, reader 2 vs 4: 66% vs 93%, p = 0.0081, for EUS vs MRI respectively), and accuracy (reader 1 vs 3: 81% vs 96%, p = 0.0022, reader 2 vs 4: 85% vs 95%, p = 0.057, for EUS vs MRI, respectively).

Conclusion

For resectable esophageal cancer, MRI had better diagnostic performance for tumor staging compared to CT and EUS.

Trial registration

ChiCTR, ChiCTR-DOD, Registered 2nd October 2014, http://www.chictr.org.cn/showproj.aspx?proj=9620

Comparison between free-breathing radial VIBE on 3-T MRI and endoscopic ultrasound for preoperative T staging of resectable oesophageal cancer, with histopathological correlation

OBJECTIVES

To compare the T staging of resectable oesophageal cancer (OC) using radial VIBE (r-VIBE) and endoscopic ultrasound (EUS) with pathological confirmation of the T stage.

METHODS

Forty-three patients with endoscopically proven OC and indeterminate T1/T2/T3/T4a stage by computed tomography (CT) and EUS were imaged on a 3-T magnetic resonance imaging (MRI) scanner. T stage was scored on MRI and EUS by two independent radiologists and one endoscopist, respectively, and compared with postoperative pathological findings. T staging agreement between r-VIBE and EUS with postoperative pathological T staging was analysed by a kappa test.

RESULTS

EUS and pathological T staging showed agreement of 69.8% (30/43). Radial VIBE and pathological T staging agreement was 86.0% (37/43) and 90.7% (39/43) for readers 1 and 2, respectively. High accuracy for T1/T2 stage was obtained for both r-VIBE readers (90.5% and 100% for reader 1 and reader 2, respectively) and EUS reader (100%). For T3/T4, r-VIBE showed accuracy of 81.8% and 90.9% for reader 1 and reader 2, respectively, while for EUS, accuracy was only 68.2% compared with pathological T staging.

CONCLUSIONS

Contrast-enhanced r-VIBE is comparable to EUS in T staging of resectable OC with stage of T1/T2, and is superior to EUS in staging of T3/T4 lesions.

KEY POINTS

• Radial VIBE may be useful in preoperative T staging of OC • Accuracy of staging on r-VIBE is higher in T1/2 than in T3/4 • Accuracy of EUS was 100% and 68.2% for T1/T2 and T3/T4 stage • Inter-reader agreement of T staging for r-VIBE was good.

Study of metabonomic profiles of human esophageal carcinoma by use of high-resolution magic-angle spinning 1H NMR spectroscopy and multivariate data analysis

Esophageal carcinoma (EC) is one of the most common malignant tumors. EC survival has remained disappointingly low because of the high malignancy of esophageal cancer and the lack of obvious clinical symptoms at an early stage. Early diagnosis is often difficult because the small tumor nodules are frequently missed. Metabonomics based on high-resolution magic-angle spinning (HRMAS) NMR has been popular for tumor detection because it is highly sensitive, provides rich biochemical information and requires no sample pretreatment. (1)H HRMAS spectra of non-involved adjacent esophageal tissues and of well differentiated and moderately differentiated esophageal carcinoma tumors were recorded and analyzed by use of multivariate and statistical analysis techniques. Moderately differentiated EC tumors were found to have increased total choline, alanine, and glutamate and reduced creatine, myo-inositol, and taurine compared with non-involved adjacent tissues. Moreover, clear differences between the metabonomic profiles of EC tissues enabled tumor differentiation. Furthermore, the integral Gly/MI ratio for samples of different tissue types were statistically significantly different; this was sufficient both for distinguishing non-involved tissues from esophageal carcinoma and for classification of well differentiated and moderately differentiated EC tumors.

Neoadjuvant chemotherapy for resectable esophageal carcinoma: a meta-analysis of randomized clinical trials

Neoadjuvant chemotherapy for resectable esophageal carcinoma has been a focus of study, but no agreement has been reached on clinical randomized controlled trials and relevant systematic evaluation. The purpose of this study was to perform a meta-analysis on published randomized controlled trials (RCTs) that compared neoadjuvant chemotherapy and surgery with surgery alone for resectable esophageal carcinoma. Medline and manual searches was conducted in PubMed, ASCO (American Society of Clinical Oncology) meeting summary, Embase, the Cochrane Library (up to October 2010), Chinese Biomedical Literature Database, China National Knowledge Infrastructure, VIP Database, Wanfang Database. The selection contents were to identify all published and unpublished RCTs that compared neoadjuvant chemotherapy and surgery with surgery alone for resectable esophageal carcinoma. Sixteen RCTs which included 2,594 patients were selected. The risk ratio (RR) (95% confidence interval [CI]; P value), expressed as neoadjuvant chemotherapy and surgery versus surgery alone (treatment versus control), was 1.02 (0.95, 1.10; P=0.54) for 1-year survival, 1.29 (1.13, 1.47; P=0.0001) for 3-year survival, 1.31 (1.13, 1.51; P=0.0003) for 5-year survival, 1.00 (0.95, 1.04; P= 0.85) for rate of resection and 0.89 (0.64, 1.23; P=0.48) for operative mortality. The results showed that neoadjuvant chemotherapy for resectable esophageal carcinoma can raise the overall survival rate of patients with esophageal carcinoma, but it does not affect treatment-related mortality.

Efficacy of preoperative chemoradiotherapy plus surgery versus surgery alone for resectable esophageal carcinoma: a meta-analysis

AIM: To compare the efficacy of preoperative chemoradiotherapy plus surgery versus surgery alone for resectable esophageal carcinoma.

METHODS: We searched Pubmed and EMbase databases to identify eligible studies, and manual searches were done to ensure that no studies were missed.

RESULTS: Twelve randomized controlled trials that included 1 544 patients were included. Preoperative chemoradiotherapy plus surgery significantly improved 1-, 3- and 5-year survival rates [odds ratio (OR) = 1.28, 95% confidence interval (CI), 1.01-1.64, P = 0.05; OR = 1.84, 95% CI, 1.29-2.63, P = 0.00; OR = 1.53, 95% CI, 1.17-2.00, P = 0.00] compared to surgery alone. Postoperative mortality increased in patients treated by preoperative chemoradiotherapy (OR = 1.68, 95% CI, 1.03-2.73, P = 0.04), but the incidence of postoperative complications was similar between the two groups (OR = 1.15, 95% CI, 0.89-1.49, P = 0.28). Preoperative chemoradiotherapy reduced incidence of local -regional cancer recurrence (OR = 0.64, 95% CI, 0.41-0.99, P = 0.04), but incidence of distant cancer recurrence was similar between the two groups (OR = 0.94, 95% CI, 0.68-1.31, P = 0.73).

CONCLUSION: Preoperative chemoradiotherapy can remarkably improve the survival of patients with resectable esophageal carcinoma.

Neoadjuvant chemoradiotherapy for resectable esophageal carcinoma: A meta-analysis

AIM: To compare neoadjuvant chemoradiotherapy and surgery with surgery alone for resectable esophageal carcinoma.

METHODS: We used MEDLINE and EMBASE databases to identify eligible studies and manual searches were done to ensure no studies were missed. Trial validity assessment was performed and a trial quality score was assigned.

RESULTS: Eleven randomized controlled trials (RCTs) including 1308 patients were selected. Neoadjuvant chemoradiotherapy significantly improved the overall survival compared with surgery alone. Odds ratio (OR) [95% confidence interval (CI), P value], expressed as neoadjuvant chemoradiotherapy and surgery vs surgery alone, was 1.28 (1.01-1.64, P = 0.05) for 1-year survival, 1.78 (1.20-2.66, P = 0.004) for 3-year survival, and 1.46 (1.07-1.99, P = 0.02) for 5-year survival. Postoperative mortality increased in patients treated by neoadjuvant chemoradiotherapy (OR: 1.68, 95% CI: 1.03-2.73, P = 0.04), but incidence of postoperative complications was similar in two groups (OR: 1.14, 95% CI: 0.88-1.49, P = 0.32). Neoadjuvant chemoradiotherapy lowered the local-regional cancer recurrence (OR: 0.64, 95% CI: 0.41-0.99, P = 0.04), but incidence of distant cancer recurrence was similar (OR: 0.94, 95% CI: 0.68-1.31, P = 0.73). Histological subgroup analysis indicated that esophageal squamous cell carcinoma did not benefit from neoadjuvant chemoradiotherapy, OR (95% CI, P value) was 1.16 (0.85-1.57, P = 0.34) for 1-year survival, 1.34 (0.98-1.82, P = 0.07) for 3-year survival and 1.41 (0.98-2.02, P = 0.06) for 5-year survival.

CONCLUSION: Neoadjuvant chemoradiotherapy can raise the survival rate of patients with esophageal adenocarcinoma.

Lymph node staging in esophageal squamous cell carcinoma: a comparative study of endoscopic ultrasonography versus computed tomography

BACKGROUND AND AIM

Endoscopic ultrasonography (EUS) is established as a standard approach for locoregional staging of esophageal cancer. However, only a few published studies have attempted to correlate the station of the abnormal lymph nodes detected by EUS with the definitive histology. We compared EUS and computed tomography (CT) in the initial staging of esophageal squamous cell carcinoma.

METHODS

Consecutive patients with esophageal cancer undergoing EUS were evaluated. EUS findings and patient data including histopatology were collected prospectively and analyzed retrospectively. Lymph node locations were divided into three groups; abdominal (A), paraesophageal (B), and thoracic paratracheal (C).

RESULTS

A total of 365 consecutive patients underwent EUS and 159 patients underwent esophagectomy without neoadjuvant chemotherapy. Thirty-eight patients were excluded (insufficient EUS, etc.), and 121 patients were enrolled. The overall accuracy of EUS was 64% (sensitivity 68%, specificity 58%, positive predictive value [PPV] 68%), CT was 51% (sensitivity 33%, specificity 75%, PPV 64%), and CT + EUS was 64% (sensitivity 74%, specificity 50%, PPV 66%). The accuracy of EUS was higher than CT in Groups A and C. Sensitivity of CT was lower than that of EUS alone and CT + EUS.

CONCLUSIONS

This study has demonstrated that EUS is a more accurate technique than contrast-enhanced CT for detecting abnormal lymph nodes. Sensitivity of CT was lower than that of EUS alone and CT + EUS. But some metastatic lymph nodes in neck and abdominal fields are only detectable by CT. Therefore, both EUS and CT should be undertaken for routine examination prior to treatment of esophageal cancer.

[MRI of esophagus. N staging and more...]

Esophageal disease is common. Fluoroscopy with or without fast cine-sequences is able to depict swallowing dynamics precisely and therefore is used in cases with swallowing disturbance, achalasia or diverticula etc. It is performed in addition to primary endoscopy. There is no evidence based indication for MRI in these settings as it is not to rule out post-surgical fistula and incompetence. Endoscopy and endosonography are gold standard for the depiction as well as staging of esophageal tumors hence differentiation of the esophageal wall layers and detection of suspicious lymph nodes is possible. And from both, biopsies may be taken. New techniques as OCT (optical coherence tomography) can demonstrate in situ carcinoma and therefore helps to decide for limited treatments as mucosectomy. For today multimodular treatment strategies in esophageal carcinoma the T-stage will lead to the treatment decision whereas the nodal-stage will give information about the prognosis. As a matter of fact endoscopy is unable to pass a stenosis esophageal tumor in up to 50% of the cases and will therefore not be able to give precise information on both T- and N-stage resulting in a good indication for MRI. Fetal MRI of the chest is a new topic in which MRI seems to be superior to ultrasonography.

A comparison between low-volume referring regional centers and a high-volume referral center in quality of preoperative metastasis detection in esophageal carcinoma

BACKGROUND AND AIM

An inverse correlation between hospital volume and esophageal resection mortality has been reported. In this study, we compared the quality of preoperative metastasis detection between a high-volume referral center with that of low-volume referring regional centers.

METHODS

In 573 patients diagnosed with esophageal cancer (1994-2003), the results of preoperative staging investigations (CT-scan, ultrasound of abdomen and neck, and chest x-ray) performed in 61 regional centers were re-evaluated and/or repeated in one referral center. The gold standards were a radiological result with > or =6 months follow-up, fine-needle aspiration, or the postoperative TNM-stage.

RESULTS

In the same group of patients, the preoperative investigations performed in regional centers detected true-positive malignant lymph nodes in 8% of patients and true-positive distant metastases in 7% of patients, whereas these percentages were 16% and 20%, respectively, in the referral center. In 72/573 (13%) patients, one or more metastases detected in the referral center had been missed in the regional centers. After allowing resectability in the presence of M1a lymph nodes, this would still have resulted in futile esophageal resections in 6% of patients. In contrast to the higher diagnostic sensitivity in the referral center, specificity was comparable between referral and regional centers.

CONCLUSIONS

This study found that, in assessing the operability of esophageal cancer, the diagnostic sensitivity of metastasis detection in a high-volume referral center was higher than that in referring regional centers. This resulted from both better CT-scanning equipment and more experienced radiologists in the referral center. Should the decision to perform esophagectomy have only been based on metastasis detection in these regional centers, over 1 in 20 patients would have undergone resection in the presence of metastases.

Endoscopic ultrasound for preoperative staging of esophageal carcinoma

BACKGROUND

Endoscopic ultrasound (EUS) is potentially the best method for pretreatment staging of esophageal carcinoma once distant metastases have been excluded by other methods. However, its apparent accuracy might be influenced by the use of neoadjuvant therapy. To determine the accuracy of EUS in patients undergoing esophageal resection, the authors reviewed their experience with EUS.

METHODS

A total of 73 patients with esophageal carcinoma who underwent an esophagectomy between April 2000 and February 2005 were examined using preoperative EUS and computed tomography (CT). Of these patients, 39 also underwent preoperative neoadjuvant chemoradiotherapy. Both EUS and CT scan were used to determine the depth of tumor penetration (T-stage) and the presence of lymph node metastases (N-stage). These results then were compared with staging determined after pathologic examination of the resected surgical specimen.

RESULTS

For patients not undergoing neoadjuvant therapy, T-stage was accurately determined by EUS in 79%, N-stage in 74%, and tumor node metastasis (TNM) classification in 65% of the cases. However, when patients who had undergone neoadjuvant chemoradiotherapy were included, the overall accuracy of EUS was 64% for T-stage, 63% for N-stage, and 53% for TNM classification. For the patients who underwent neoadjuvant therapy, EUS indicated a more advanced T-stage in 49%, N-stage in 38%, and TNM classification in 51% of the cases, as compared with pathology. The overall accuracy of EUS for T- and N-stage carcinomas was superior to that of CT scanning.

CONCLUSION

For patients who do not undergo preoperative neoadjuvant chemotherapy and radiotherapy, EUS is a more accurate method for determining T- and N-stage resected esophageal carcinomas. Neoadjuvant therapy, however, results in apparent overstaging, predominantly because of tumor downstaging, and this reduces the apparent accuracy of EUS (and CT scanning) in this patient group. Nevertheless, EUS staging before neoadjuvant therapy could be more accurate than pathologic staging after treatment, thereby providing better initial staging information, which can be used to facilitate treatment.

CT and MR imaging for detecting neoplastic invasion of esophageal inlet

AIM: Direct neoplastic invasion of esophageal inlet is an uncommon but significant sequela of advanced head and neck carcinomas. The aim of this study was to seek an optimal CT or MRI criterion for determining the neoplastic esophageal inlet involvement in order to help tumor staging and surgical planning.

METHODS: CT and MRI of 78 head and neck tumor cases were investigated retrospectively. At the level of the esophageal inlet on axial CT and MRI scans, the distance between the posterior aspect of cricoid cartilage and the anterior aspect of vertebra (d-CV) was measured by two senior radiologists who were unaware of clinical findings. Then, according to pathologic evidence and follow-up findings, these patients were divided into patient group, including 32 cases with neoplastic invasion of esophageal inlet and control group, including 46 cases without neoplastic esophageal inlet involvement. The statistical difference based on d-CV between the two groups was determined. The optimal criterion of d-CV on CT or MRI was assessed and its accuracy, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were evaluated respectively.

RESULTS: In control group, d-CV at the esophageal inlet level was 0.94±0.15 cm on axial CT and 0.91±0.18 cm on axial MRI, whereas in patient group, d-CV was 1.24±0.32 cm on CT and 1.31±0.36 cm on MRI. There was a statistical significance in d-CV between the two groups on CT and MRI modalities (P<0.01). d-CV greater than 1.0 cm was the typical feature of neoplastic invasion of the esophageal inlet with 73% sensitivity, 83% specificity, 79% accuracy, 76% PPV, 80% NPV on CT and 84% sensitivity, 77% specificity, 80% accuracy, 70% PPV, 88% NPV on MRI respectively.

CONCLUSION: Except for other CT and MR imaging features of neoplastic invasion of esophageal inlet, d-CV greater than 1.0 cm is an optimal adjunct criterion for esophageal inlet invasion by advanced head and neck carcinomas.

Diagnostic radiology and nuclear medicine

The diagnosis and accurate staging of esophageal adenocarcinoma remains one of the greatest challenges for non-invasive imaging techniques. All modalities have limitations and require a rational application of combined tools in order to assess the extent of loco-regional tumor and distant metastatic disease. The fundamental role remains defining organ-confined disease and mapping non-organ confined disease. Endoscopic ultrasound combined with multislice computed tomography (CT) is the mainstay of morphologic loco-regional staging. In recent years, functional metabolic 2-[fluorine-18]fluoro-2-deoxy-D-glucose (FDG)-positron emission tomography (PET) has emerged as a particularly useful adjunct to detect occult metastatic disease, to predict response to neoadjuvant therapy and to document recurrent disease. The current imaging algorithm and new developments in imaging assessment will be reviewed.

[Esophageal disease: is cross sectional imaging contributive?]

For a long time, esophagography and endoscopy were the major diagnostic tests used for evaluation of the esophagus. Now, the development of computed tomography, endosonography and MR imaging has permitted more comprehensive evaluation of esophageal diseases. Cross sectional imaging is essential to evaluate the relationship between esophageal lesions and adjacent mediastinal structures and to evaluate the thickness of the esophageal wall.

Metastasis to regional lymph nodes in patients with esophageal squamous cell carcinoma: CT versus FDG PET for presurgical detection prospective study

PURPOSE

To prospectively compare the accuracy of fluorine 18 fluorodeoxyglucose (FDG) positron emission tomography (PET) and computed tomography (CT) for detection of primary tumor and metastasis to individual lymph node groups and for nodal staging.

MATERIALS AND METHODS

From February 2000 to July 2001, 81 patients with squamous cell carcinoma of the esophagus (78 men and three women; age range, 31-90 years; mean age, 63 years) underwent CT and FDG PET before esophagectomy and lymph node dissection. During surgery, all visible and palpable lymph nodes in the surgical fields were removed. The accuracies of CT and FDG PET for depiction of metastasis to lymph nodes were compared.

RESULTS

For depiction of malignant nodal groups in each lymph node group, the sensitivity, specificity, and accuracy, respectively, of CT were 11% (11 of 96 nodal groups), 95% (553 of 581), and 83% (564 of 677), whereas those of FDG PET were 30% (29 of 96), 90% (525 of 581), and 82% (554 of 677) (P values: < .001, .009, and .382, respectively). Twenty-eight false-positive interpretations were rendered at CT in evaluations of 11 mediastinal, four hilar, and 13 abdominal nodal groups, and 56 false-positive interpretations were rendered at FDG PET in evaluations of 23 mediastinal, 32 hilar, and one abdominal nodal group.

CONCLUSION

FDG PET is more sensitive than CT for depicting nodal metastases in patients with squamous cell carcinoma of the esophagus. FDG PET is slightly less specific than CT for depicting metastases, but the difference in specificity between the two modalities is statistically significant. Both FDG PET and CT have low sensitivity for depicting nodal metastasis. The relatively low specificity of FDG PET for depiction of nodal metastasis compared with that of CT is caused mainly by a high rate of false-positive hilar node interpretations.

Photodynamic therapy for dysplastic Barrett esophagus and early esophageal adenocarcinoma

OBJECTIVE

To evaluate our results using photodynamic therapy (PDT) for the treatment of dysplasia or superficial cancer (T1 N0 M0) in patients with Barrett esophagus.

PATIENTS AND METHODS

We retrospectively reviewed our clinical experience with 48 patients (34 patients with high-grade dysplasia and 14 patients with superficial cancer in Barrett esophagus) who had been referred for PDT. Initial evaluation included computed tomography and standard and high-frequency catheter endosonography. Follow-up endoscopy was performed 4 to 6 weeks after PDT with ablation of any residual glandular mucosa, using the argon plasma coagulator. Patients were then followed up indefinitely every 3 to 6 months with computed tomography, endosonography, and endoscopic surveillance.

RESULTS

The median series follow-up was 18.5 months (range, 1-56 months). Apparent complete photoablation of Barrett mucosa and/or superficial neoplasm was documented in 47 of 48 cases. Complications included symptomatic strictures (11 patients), photosensitivity (7 patients), atrial fibrillation (1 patient) or recurrent congestive heart failure (1 patient), and self-limited esophageal perforation (1 patient). Failure to ablate T1 N0 M0 adenocarcinoma occurred in 1 patient.

CONCLUSIONS

Porfimer sodium PDT appears to eradicate dysplastic Barrett mucosa and neoplasia. These results are promising; however, long-term studies are needed to document the efficacy of PDT in reducing the morbidity and mortality in such patients.

Superficial esophageal carcinoma: an in vitro study of high-resolution MR imaging at 1.5T

The purpose of this study was to determine the diagnostic accuracy of high-resolution MR imaging at 1.5T for evaluating the mural invasion of superficial esophageal carcinoma. Forty-one esophageal specimens taken from patients suspected of having superficial carcinoma were studied using a 1.5T MR system with a surface coil. Spin-echo MR images were obtained with a field of view of 50mm, matrix of 256 x 256, and section thickness of 2mm (voxel size = 0.08 mm3). MR findings were compared with histopathologic findings. T2-weighted images clearly depicted the normal esophageal wall as consisting of 8 layers. In 39 (95%) of 41 carcinomas, the depth of mural invasion determined by MR imaging correlated well with that determined with histopathologic examination. The MR-based stage was higher in 2 (5%) cases than the histopathologic stage. High-resolution MR imaging at 1.5T shows a high diagnostic accuracy for evaluating the mural invasion of superficial esophageal carcinoma, thus potentially enabling preoperative histopathologic staging.