Relationship Between the Size of Metastatic Lymph Nodes and Positron Emission Tomographic/Computer Tomographic Findings in Patients with Esophageal Squamous Cell Carcinoma

Value of Computed Tomography Scan for Detecting Lymph Node Metastasis in Early Esophageal Squamous Cell Carcinoma

BACKGROUND

The necessity of computed tomography (CT) scan for detecting potential lymph node metastasis (LNM) in early esophageal squamous cell carcinoma (ESCC) before endoscopic and surgical treatments is under debate.

METHODS

Patients with histologically proven ESCC limited to the mucosa or submucosa were examined retrospectively. Diagnostic performance of CT for detecting LNM was analyzed by comparing original CT reports with pathology reports. The sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) were calculated.

RESULTS

A total of 625 patients from three tertiary referral hospitals were included. The rate of pathologically confirmed LNM was 12.5%. Based on original CT reports, the sensitivity, specificity, accuracy, PPV, and NPV of CT to determine LNM in T1 ESCC were 41.0%, 83.2%, 77.9%, 25.8%, and 90.8% respectively. For mucosal cancers (T1a), these parameters were 50.0%, 81.7%, 80.9%, 6.8%, and 98.4%, respectively. For submucosal cancers (T1b), they were 40.0%, 85.0%, 75.0%, 43.0%, and 83.3%, respectively. Additionally, the diagnostic performance of CT for LNM was relatively better for ESCC in the lower esophagus. Pathologically, 69.2% of patients with LNM did not exhibit lymphovascular invasion (LVI), and the sensitivity of CT for recognizing LNM in these patients (33.3%) was lower than those with LVI (58.3%).

CONCLUSIONS

Computed tomography can detect nearly half of the LNM cases in early ESCC with high specificity. The performance of CT further improved in LNM cases with LVI. Therefore, we conclude that routine preoperative CT for the assessment of potential LNM risk in patients with early ESCC is necessary.

Completely Resectable (cT1-2) Esophageal Squamous Cell Carcinoma with Minimal Lymph Node Involvement (cN1): Is Neoadjuvant Chemoradiation Therapy the Only Viable Treatment Option?

BACKGROUND

Neoadjuvant chemoradiation therapy (nCRT) is recommended when lymph node metastasis is evident or strongly suspected on preoperative imaging studies, even for a completely resectable (cT1-2) tumor with minimal lymph node involvement (cN1). We evaluated the validity of upfront surgical approach in this patient group.

METHODS

We retrospectively reviewed data from 247 patients with cT1-2 esophageal squamous cell carcinoma (ESCC) who underwent upfront radical esophagectomy followed by the pathology-based adjuvant treatment. Oncologic outcomes of cN1 patients were compared with those of cN0 patients.

RESULTS

There were 203 cN0 and 44 cN1 patients. The lymph node yield was 62.0 (interquartile range [IQR], 51.0-76.0) in cN0 and 65.5 (IQR, 57.5-85.0) in cN1 patients (p = 0.033). The size of metastatic node was 0.6 cm (IQR, 0.4-0.9 cm) in cN0 and 0.8 cm (IQR, 0.5-1.3 cm) in cN1 patients (p = 0.001). Nodal upstaging was identified in 29.1% of cN0 and 40.9% of cN1 patients, whereas 18.2% of the cN1 had no actual lymph node metastasis (pN0). The 5-year disease-free survival rate was not significantly different between the groups (cN0, 74.4%; cN1, 71.8%; p = 0.529). Survival rates were closely correlated with pN stage, and a multivariate analysis revealed that pN2-3 stage was a risk factor for poor disease-free survival.

CONCLUSIONS

Upfront radical surgery provided accurate nodal staging information, potentially sparing some cN1 patients from unnecessary nCRT while demonstrating comparable survival rates. It might be a valid option for the treatment of cT1-2N1 ESCC.

Radiomics models based on CT at different phases predicting lymph node metastasis of esophageal squamous cell carcinoma (GASTO-1089)

PURPOSE

To investigate the value of radiomics models based on CT at different phases (non-contrast-enhanced and contrast-enhanced images) in predicting lymph node (LN) metastasis in esophageal squamous cell carcinoma (ESCC).

METHODS AND MATERIALS

Two hundred and seventy-four eligible patients with ESCC were divided into a training set (n =193) and a validation set (n =81). The least absolute shrinkage and selection operator algorithm (LASSO) was used to select radiomics features. The predictive models were constructed with radiomics features and clinical factors through multivariate logistic regression analysis. The predictive performance and clinical application value of the models were evaluated by area under receiver operating characteristic curve (AUC) and decision curve analysis (DCA). The Delong Test was used to evaluate the differences in AUC among models.

RESULTS

Sixteen and eighteen features were respectively selected from non-contrast-enhanced CT (NECT) and contrast-enhanced CT (CECT) images. The model established using only clinical factors (Model 1) has an AUC value of 0.655 (95%CI 0.552-0.759) with a sensitivity of 0.585, a specificity of 0.725 and an accuracy of 0.654. The models contained clinical factors with radiomics features of NECT or/and CECT (Model 2,3,4) have significantly improved prediction performance. The values of AUC of Model 2,3,4 were 0.766, 0.811 and 0.809, respectively. It also achieved a great AUC of 0.800 in the model built with only radiomics features derived from NECT and CECT (Model 5). DCA suggested the potential clinical benefit of model prediction of LN metastasis of ESCC. A comparison of the receiver operating characteristic (ROC) curves using the Delong test indicated that Models 2, 3, 4, and 5 were superior to Model 1(P< 0.05), and no difference was found among Model 2, 3, 4 and Model 5(P > 0.05).

CONCLUSION

Radiomics models based on CT at different phases could accurately predict the lymph node metastasis in patients with ESCC, and their predictive efficiency was better than the clinical model based on tumor size criteria. NECT-based radiomics model could be a reasonable option for ESCC patients due to its lower price and availability for renal failure or allergic patients.

Perineural Invasion Is a Significant Indicator of High Malignant Degree and Poor Prognosis in Esophageal Cancer: A Systematic Review and Meta-Analysis

Background

Perineural invasion (PNI) is a malignant metastatic mode of tumors and has been reported in many tumors including esophageal cancer (EC). However, the role of PNI in EC has been reported differently. This systematic review and meta-analysis aims to focus on the role of PNI in EC.

Methods

Eight databases of CNKI, VIP, Wanfang, Scopus, Wiley, ISI, PubMed, and EBSCO are used for literature search. The association of PNI with gender, pathological stages of T and N (pT and pN), lymphovascular invasion (LVI), lymph node metastasis, 5-year overall survival (OS), and 5-year disease-free survival (DFS) was examined in the meta-analysis by Revman5.0 Software. The pooled OR/HR and 95% CI were used to assess the risk and prognostic value.

Results

Sixty-nine published studies were screened for analysis of PNI in EC. The incidence of PNI in esophageal squamous carcinoma (ESCC) and esophageal adenocarcinoma (EAC) was different, but not statistically significant (p > 0.05). The PNI-positive patients had a significantly higher risk of pT stage (OR = 3.85, 95% CI = 2.45–6.05, p < 0.00001), pN stage (OR = 1.86, 95% CI = 1.52–2.28, p < 0.00001), LVI (OR = 2.44, 95% CI = 1.55–3.85, p = 0.0001), and lymph node metastasis (OR = 2.87, 95% CI = 1.56–5.29, p = 0.0007). Furthermore, the cumulative analysis revealed a significant correlation between PNI and poor OS (HR = 1.37, 95% CI = 1.24–1.51, p < 0.0001), as well as poor DFS (HR = 1.55, 95% CI = 1.38–1.74, p < 0.0001).

Conclusion

PNI occurrence is significantly related to tumor stage, LVI, lymph node metastasis, OS, and DFS. These results indicate that PNI can serve as an indicator of high malignant degree and poor prognosis in EC.

Modified method to improve the diagnostic efficiency of 18F-FDG PET/CT in regional lymph node metastasis of esophageal squamous cell carcinoma

Background

Regional lymph node (LN) metastasis is a significant factor influencing the treatment choice of esophageal squamous cell carcinoma (ESCC). The performance PET/CT as an imaging evaluation method for regional LNs in ESCC, is unsatisfactory due to the lack of logical criterion. We explored how a modified criterion improved the diagnostic value of ¹⁸F-FDG PET/CT in regional LN metastasis.

Methods

The data from 111 patients with ESCC were analyzed retrospectively. All patients underwent preoperative PET/CT examination, resection of the cancer, and regional LN dissection. The PET/CT images were interpreted by two experienced diagnosticians. LNs were allocated to five subregions. Each LN was diagnosed by two diagnostic criteria of PET/CT (traditional criterion and the modified criterion) one by one across the same field, and the accuracy of PET/CT was determined using the histopathologic results as the reference standard.

Results

A total of 4,847 LNs were dissected, of which 147 were confirmed as metastases by postoperative pathology. A total of 656 LNs were screened by ¹⁸F-FDG PET/CT imaging. The determination of all 656 LNs by PET/CT was compared with the pathological results. The diagnostic accuracy of the modified and traditional criteria for the five subregions (paraesophageal, neck, upper mediastinal, middle-lower mediastinal and ventral subregions) was: 74.60% vs. 61.90%, 86.44% vs. 81.36%, 90.26% vs. 70.78%, 96.19% vs. 75.09%, and 87.91% vs. 85.71%, respectively.

Conclusions

The modified diagnostic criterion had better diagnostic efficiency because it combined PET and CT imaging data.

Prediction of lymph node metastasis by PET/CT metabolic parameters in patients with esophageal squamous cell carcinoma

OBJECTIVE

The aim of this study was to investigate the capability of F-FDG PET/computed tomography (CT)-related metabolic parameters to predict lymph node metastasis (LNM) and occult lymph node metastasis (OLNM) in patients with esophageal squamous cell carcinoma (ESCC).

METHODS

Totally 84 patients undergoing curative esophagectomy with lymph node dissection were enrolled in this study. Metabolic tumor volume (MTV) was measured using threshold-based methods with a threshold of 40% maximum standardized uptake value (SUVmax). The derivative of the volume (V)-threshold (T) function (volume difference/threshold difference) was defined as the heterogeneity factor (HF). In addition, SUVmax, SUVmean, total lesion glycolysis (TLG), maximum tumor-to-blood SUV ratio (SURmax), SURmean and several clinicopathologic parameters were analyzed to identify risk factors of LNM and OLNM.

RESULTS

SUVmax, SUVmean, MTV, TLG, SURmax, SURmean and HF were significantly different between LNM (+) and LNM (-). The optimal cut-off values of those parameters were 12.5, 8.34, 15.01, 117.185, 7.885, 4.855 and 0.300, respectively. Logistic regression analysis showed that MTV (OR = 1.127, P = 0.04) and SURmax (OR = 1.446, P = 0.004) were independent predictors of LNM, with sensitivity and specificity were 51.2%, 83.7% vs. 53.7%, 79.1%. In univariate and multivariate analysis, MTV was the sole parameter associated with OLMN (P = 0.024).

CONCLUSION

MTV and SURmax were statistically significant predictors of LNM in patients with ESCC, while MTV was a predictor of OLNM. High SURmax and MTV may indicate that the treatment planning should be tailored, which may improve patient prognosis.

Reliability of clinical nodal status regarding response to neoadjuvant chemoradiotherapy compared with surgery alone and prognosis in esophageal cancer patients

Background: Clinical nodal (cN) staging is a key element in treatment decisions in patients with esophageal cancer (EC). The reliability of cN status regarding the effect on response and survival after neoadjuvant chemoradiotherapy (nCRT) with esophagectomy was evaluated in determining the up- and downstaged pathological nodal (pN) status after surgery alone. Material and methods: From a prospective database, we included all 395 EC patients who had surgery with curative intent with or without nCRT between 2000 and 2015. All patients were staged by a standard pretreatment protocol: 16-64 mdCT, 18 F-FDG-PET or 18 F-FDG-PET/CT and EUS ± FNA. After propensity score matching on baseline clinical tumor and nodal (cT/N) stage and histopathology, a surgery-alone and nCRT group (each N = 135) were formed. Clinical and pathological N stage was scored as equal (cN = pN), downstaged (cN > pN) or upstaged (cN < pN). Prognostic impact on disease free survival (DFS) was assessed with multivariable Cox regression analysis (factors with p value <.1 on univariable analysis). Results: The surgery-alone and nCRT group did not differ in cT/N status. Pathologic examination revealed equal staging (32 vs. 27%), nodal up (43 vs. 16%) and downstaging (25 vs. 56%), respectively (p < .001). Nodal up-staging was common in cT3-4a tumors and adenocarcinomas in the surgery-alone group, while nodal downstaging was found in half of cT1-2 and cT3-4 regardless of tumortype after nCRT. Prognostic factors for DFS were pN (p = .002) and lymph-angioinvasion (p = .016) in surgery-alone, and upper abdominal cN metastases (p = .012) and lymph node ratio (p = .034) in the nCRT group. Conclusions: Despite modern staging methods, correct cN staging remains difficult in EC. Nodal overstaging (cN > pN) occurred more often than understaging impeding an adequate assessment of pathologic complete response and prognosis after nCRT.

Clinical Significance of 18F-Fluorodeoxyglucose-Positron Emission Tomography-Positive Lymph Nodes to Outcomes of Trimodal Therapy for Esophageal Squamous Cell Carcinoma

BACKGROUND

The clinical significance of lymph node (LN) status determined by preoperative ¹⁸F-fluorodeoxyglucose-positron emission tomography (FDG-PET) has not been investigated in patients with locally advanced esophageal squamous cell carcinoma (ESCC) treated with neoadjuvant chemoradiotherapy (NCRT) followed by surgery (trimodal therapy).

METHODS

This study reviewed 132 consecutive patients with ESCC who had been preoperatively evaluated using FDG-PET before and after NCRT to analyze associations among LN status according to PET findings, pathologic LN metastasis, and prognosis of ESCC after trimodal therapy.

RESULTS

Lymph nodes that were PET-positive both before and after NCRT comprised significant predictive markers of pathologic LN metastasis in station-by-station analyses (sensitivity, specificity, and accuracy respectively 41.7%, 95.0%, and 92.7% before, and 12.0%, 99.4%, and 95.6% after NCRT; both p < 0.0001). The numbers of LNs evaluated using PET before and after NCRT were significantly associated with those of pathologic metastatic LNs. Uni- and multivariable analyses selected LN status determined by PET before NCRT as a significant independent predictor of both recurrence-free [LN-negative vs LN-positive: hazard ratio (HR) 1.90; 95% confidence interval (CI) 1.02-3.23; p = 0.045] and overall survival (HR 2.62; 95% CI 1.29-5.30; p = 0.01).

CONCLUSIONS

The status of LN determined by preoperative FDG-PET is significantly associated with pathologic LN status and the prognosis of ESCC with trimodal therapy. Thus, FDG-PET is a useful diagnostic tool for preoperative prediction of pathologic LN metastasis and survival among patients with ESCC.

A Diagnostic Algorithm That Combines Quantitative 18F-FDG PET Parameters and Contrast-Enhanced CT Improves Posttherapeutic Locoregional Restaging and Prognostication of Survival in Patients With Esophageal Cancer

PURPOSE

The aim of this study was to determine whether the combination of contrast-enhanced CT (CE-CT) and quantitative F-FDG PET parameters improves locoregional restaging in esophageal cancer (EC) after neoadjuvant therapy.

METHODS

Eighty-eight consecutive patients with locally advanced esophageal cancer, who underwent restaging after neoadjuvant chemotherapy or chemoradiotherapy before esophagectomy, were included in this retrospective study. The diagnostic accuracy of CE-CT, visual F-FDG PET/CT (vPET/CT), and quantitative PET parameters was assessed for T and N staging. Histopathology was used as the reference standard. The prognostic value for recurrence-free survival, cancer-specific survival, and overall survival was assessed using Cox regression analysis.

RESULTS

Sensitivity, positive predictive value, and accuracy were 78.8%, 70.2%, and 59.0% (CE-CT), and 81.1%, 81.1%, and 68.2% (vPET/CT) for T staging as well as 59.5%, 75.9%, and 50.0% (CE-CT), and 70.2%, 93.7%, and 67.0% (vPET/CT) for N staging, respectively. Tumor length and metabolic tumor volume (MTV) exhibited an incremental increase with advancing T stages (P = 0.002 and 0.038). Contrast-enhanced CT had the highest sensitivity to differentiate advanced T stages (T3/4 vs 0-2; area under the receiver operating curve [AUC], 0.86; P < 0.001), whereas MTV at a threshold of 5.8 mL had the highest sensitivity to detect complete response (T0 vs 1-4; AUC, 0.77; P = 0.002). Contrast-enhanced CT and MTV combined had an even superior accuracy to predict complete response (AUC, 0.82; P < 0.001). The imaging American Joint Committee on Cancer stage provided a better prognostication of recurrence-free survival, cancer-specific survival, and overall survival than either T stage, N stage derived from CE-CT or vPET/CT, or quantitative PET parameters alone.

CONCLUSIONS

Combined CE-CT and MTV had the highest diagnostic accuracy to identify the posttherapeutic T stage, allowing for robust prediction of recurrence and survival.

Diagnostic value of 18F-fluorodeoxyglucose positron-emission tomography/computed tomography for preoperative lymph node metastasis of esophageal cancer: A meta-analysis

OBJECTIVE

We determined the value of F-fluorodeoxyglucose positron-emission tomography/computed tomography (FDG PET/CT) for the assessment of preoperative lymph node metastases in patients with esophageal cancer.

METHODS

We searched electronic database indexes for articles on PET/CT assessment of lymph node status. Information including true positives, false positives, false negatives, and true negatives was obtained. Based on these data, the pooled sensitivity, specificity, diagnostic odds ratio, and likelihood ratio were calculated using bivariate models and receiver operating characteristic curves (ROCs) were drawn.

RESULTS

Patients without neoadjuvant treatment had a pooled sensitivity and specificity (95% confidence interval [CI]) of 0.57 (0.45-0.69) and 0.91 (0.85-0.95), respectively. Patients who received neoadjuvant treatment had a pooled sensitivity and specificity of 0.53 (0.35-0.70) and 0.96 (0.86-0.99), respectively.

CONCLUSIONS

The PET/CT has a high diagnostic specificity but its diagnostic sensitivity is low; thus, its diagnosis findings cannot accurately reflect the lymph node status.

Preoperative lymph node status on computed tomography influences the survival of pT1b, T2 and T3 esophageal squamous cell carcinoma

PURPOSE

The preoperative lymph node status is critical for tailoring optimal treatments for esophageal squamous cell carcinoma (ESCC). This study aimed to evaluate the prognostic impact of a diagnostic criterion based solely on the short-axis diameters of lymph nodes depicted on computed tomography (CT) in ESCC patients undergoing upfront esophagectomy.

METHODS

We retrospectively reviewed 246 pT1b-T3 ESCC patients undergoing upfront esophagectomy. Clinically positive lymph node metastasis (cN+) was defined as nodes with a short-axis diameter of at least 8 mm on CT.

RESULTS

Ninety-three patients had a cN+ status according to this criterion. The overall and recurrence-free survival rates were significantly lower in the cN+ group than in the cN- group (P < 0.001). The overall survival rate was markedly lower in the "pN2/3 and cN+" group than in the other groups (vs. pN0: P < 0.001, vs. pN1: P = 0.002, vs. "pN2/3 and cN-": P < 0.001). However, the overall survival rate of the "pN2/3 and cN-" group was similar to that of the pN0-1 groups. A multivariate analysis showed that cN+ (P = 0.002), major complications (P = 0.001), and pT3 (P = 0.021) were independently associated with a poor prognosis.

CONCLUSION

A diagnostic criterion based solely on the short-axis diameters of lymph nodes depicted on CT was useful for stratifying the survival in ESCC patients.

A new clinical staging system for esophageal cancer to predict survival after definitive chemoradiation or radiotherapy

This study is to evaluate the prognostic value of a new clinical staging system for esophageal cancer to predict survival after (chemo)radiotherapy. This retrospective study enrolled 444 patients with esophageal squamous cell carcinoma who underwent definitive intensity-modulated radiotherapy with or without chemotherapy between January 2008 and May 2014. A clinical staging system based on the gross tumor volume and maximum diameter of metastatic lymph nodes was developed and the prognostic value of this staging system was compared with that of the 8th edition of American Joint Committee on Cancer TNM staging system. The 3-year survival rate in the whole group was 44.5%. Multivariate analysis showed that gross tumor volume and maximum diameter of metastatic lymph nodes were independent prognostic factors. According to the proposed clinical staging system, the 3-year survival curves of each T, N, and TNM stage were well segregated. On the other hand, 3-year survival rates based on the 8th edition of cTNM staging system were similar between cT3 and cT4, cN1 and cN2, cN2, and cN3, III and IVa stages.The proposed clinical staging system appears to be a simple and accurate predictor of outcome in patients with esophageal squamous cell carcinoma who underwent definitive (chemo) intensity-modulated radiotherapy.

Comparison of the 11th Japanese classification and the AJCC 7th and 8th staging systems in esophageal squamous cell carcinoma patients

Background

Although the American Joint Committee on Cancer (AJCC) staging system has been used worldwide for esophageal squamous cell carcinoma (ESCC), another staging system has been proposed by Japanese surgeons. The two systems have different lymph node maps, N staging, and stage grouping. This retrospective study compared the predictive ability of these two staging systems for survival.

Methods

We retrospectively reviewed records for 143 patients who underwent esophagectomy and mediastinal lymphadenectomy for ESCC from January 2006 to July 2015. Patients were staged by 7^th, 8^th AJCC stage and 11^th Japanese classification. The concordance indexes (C-indexes) of these staging systems were compared.

Results

Mean age was 63.14±8.10 years with 131 (91.6%) men. Median follow-up was 47.73 (6.27-134.40) months. All patients received R0 resection. Recurrences developed in 30 (20.9%) patients. Both AJCC N staging and Japanese N staging well predicted disease-free survival (DFS) (P<0.001). Stage groupings of AJCC 7^th and 8^th and Japanese 11^th classification also predicted DFS well (P<0.001). The c-index was 0.755 (95% CI, 0.650-0.860) for AJCC N staging and 0.734 (0.634-0.835) for Japanese N staging (P=0.11). The c-index was 0.813 (0.732-0.896) for AJCC 7^th stage grouping, 0.805 (0.726-0.885) for AJCC 8^th, and 0.837 (0.766-0.908) for Japanese stage grouping. The C-index for the Japanese stage grouping was slightly higher than for AJCC, but differences were not significant.

Conclusions

Both N staging and stage grouping for the 11^th Japanese classification and 7^th and 8^th AJCC staging for ESCC showed similar predictive power for DFS. Both systems could be applied in clinical situations.

Near-Infrared Lymphatic Mapping of the Recurrent Laryngeal Nerve Nodes in T1 Esophageal Cancer

BACKGROUND

It is still unclear that dissection of recurrent laryngeal nerve nodes is mandatory in patients with cT1 middle or lower thoracic esophageal squamous cell carcinoma when the nodes are negative in preoperative staging workup. We aimed to evaluate the feasibility of near-infrared image-guided lymphatic mapping of bilateral recurrent laryngeal nerve nodes.

METHODS

The day before operation, we injected indocyanine green (ICG) into the submucosal layer by endoscopy. At the time of upper mediastinal dissection, ICG-stained basins were identified along the bilateral recurrent laryngeal nerves and retrieved under guidance of the Firefly system. After the operation, remnant ICG-unstained basins were dissected from the specimen to assess the presence of metastasis.

RESULTS

Of 29 patients enrolled, ICG-stained basins could be identified in 25 patients (86.2%), and 6 of them (24.0%) had nodal metastasis; 4 in the right recurrent laryngeal nerve chain, 1 in the left recurrent laryngeal nerve chain, and 1 in both recurrent laryngeal nerve chains. On pathologic examination of 345 recurrent laryngeal nerve nodes, two metastatic nodes were identified in ICG-unstained basins along the left recurrent laryngeal nerve in a patient who had lymph node metastases in ICG-stained basins along both recurrent laryngeal nerves. Negative predictive value in detection of nodal metastasis was 100% for the right recurrent laryngeal nerve chain and 98.2% for the left recurrent laryngeal nerve chain.

CONCLUSIONS

Real-time assessment of recurrent laryngeal nerve nodes with near-infrared image was technically feasible, and we could detect lymphatic basins that most likely have nodal metastasis. Our technique might be useful in determining the optimal extent of lymphadenectomy.

Preoperative prediction of a pathologic complete response of esophageal squamous cell carcinoma to neoadjuvant chemoradiotherapy

BACKGROUND

The accurate prediction of a pathologic complete response (ypT0N0M [LYM] 0 ypStage 0) before operation is essential for selecting appropriate strategies for treating esophageal cancer after neoadjuvant chemoradiotherapy.

METHODS

We reviewed 130 consecutive patients with esophageal squamous cell carcinoma who were evaluated preoperatively using upper gastrointestinal endoscopy, computed tomography, and 18F-fluorodeoxyglucose-positron emission tomography after neoadjuvant chemoradiotherapy and subsequently underwent esophagectomy. Our aim was to determine the diagnostic abilities of computed tomography, 18F-fluorodeoxyglucose-positron emission tomography, and endoscopy to predict preoperatively a pathologic complete response of the primary site of the locally advanced esophageal squamous cell carcinoma and associated lymph nodes to trimodal neoadjuvant chemoradiotherapy. Associations between clinical complete response (ycT0N0M [LYM] 0 ycStage 0) and pathologic complete response were investigated preoperatively.

RESULTS

Twenty-nine (22.3%) and 43 (33.1%) patients, respectively, achieved clinical complete response and pathologic complete response, which were associated (P=.001). The sensitivity and specificity, as well as the positive and negative predictive values of clinical complete response to define pathologic complete response were 39.5%, 86.2%, 58.6%, and 74.3%, respectively. Univariate and multivariate analyses selected clinical complete response as the sole independent preoperative predictor of pathologic complete response (clinical complete responses versus non-clinical complete responses: odds ratio: 0.26, 95% confidence interval, 0.10-0.65, P=.004). Recurrence-free and overall survival (OS) rates were better in patients with than in those without clinical complete response (5-year recurrence-free and overall survival: 69.0% vs 41.4% and 75.9% vs 45.0%, respectively, both P=.02). Furthermore, clinical complete response was an independent preoperative predictor of recurrence-free survival (clinical complete response versus nonclinical complete response: hazard ratio: 2.20, 95% confidence interval, 1.08-4.45, P=.03).

CONCLUSION

Although pathologic complete response was predictable preoperatively to some extent, the accuracy was somewhat low. Considerable caution should be exercised when selecting the watch-and-wait approach with operation as needed and omitting planned operative intervention even for patients who achieve clinical complete response after neoadjuvant chemoradiotherapy.

Extent of Mediastinal Lymphadenectomy and Survival in Superficial Esophageal Squamous Cell Carcinoma

BACKGROUND

The aim of this study is to investigate the utility of total mediastinal lymphadenectomy (ML) in superficial esophageal squamous cell carcinoma (ESCC).

METHODS

The medical records of 129 patients who underwent esophagectomy and lymph node dissection for pathologically confirmed pT1 ESCC between July 2006 and December 2014 were retrospectively reviewed. Limited ML, such as traditional 2-field or transhiatal esophagectomy, was performed in 42 patients (group 1), and total ML, including the bilateral recurrent laryngeal nerve nodes, was performed in 87 patients (group 2).

RESULTS

R0 resection was achieved in all patients, and the number of dissected nodes was 28.0 ± 11.4 and 44.8 ± 16.1 in groups 1 and 2 (p < 0.001), respectively. The complication profile was similar in the two groups, but there were two operative mortalities in group 2. During a median follow-up of 32.4 months, loco-regional failure was found in 14.3% of group 1 and 3.5% of group 2 (p = 0.001). There was a significant difference in the 3-year overall survival (95.1% in group 2 vs. 83.3% in group 1, p = 0.043), and the 3-year disease-free survival rates (92.3% in group 2 vs. 73.7% in group 1, p = 0.001). On multivariate analysis, the extent of ML (HR, 5.200; 95% CI, 1.532 ~ 17.645; p = 0.008) and pT1b lesion classification (HR, 4.747; 95% CI, 1.024 ~ 21.997; p = 0.047) was a factor predictive of disease-free survival.

CONCLUSIONS

Total ML might be beneficial, especially in cases of pT1b ESCC, because it could lead to a lower incidence of recurrence and longer survival times.

Inclusion of PET-CT into planning of primary or neoadjuvant chemoradiotherapy of esophageal cancer improves prognosis

BACKGROUND

PET-CT is widely used for both the staging and planning of primary or neoadjuvant chemoradiotherapy for esophageal cancer. Inclusion of PET-CT information into radiotherapy planning often leads to substantial modifications of the target volume. In the case of detection of distant metastases, it may also result in a switch to a palliative treatment approach. This spares patients from therapy-related toxicities that provide no clinical benefit. However, due to a lack of studies, it is currently unclear whether the advantages of PET-CT also translate into a measurable improvement in patient survival.

PATIENTS AND METHODS

A retrospective analysis assessed the survival data of 145 patients with esophageal carcinoma stages I (eight patients; 5%), II (45; 31%), III (79; 55%), IV (8; 5%) and unknown (5; 4%). Patients were treated between 1999 and 2014 either with primary chemoradiation (n = 101) or neoadjuvant chemoradiation at the Department of Radiation Oncology, University Medical Center Mainz, followed by transabdominal or transthoracic tumor resection (n = 44). Of the 145 patients, 64 (44%) had undergone PET-CT.

RESULTS

Univariate analysis showed the use of PET-CT to be associated with significantly longer local recurrence-free survival (p = 0.006) and tended to translate into a measurable improvement of overall survival (p = 0.071). Since more patients underwent surgery in the group planned using PET-CT (20% vs. 44%; p = 0.002), we carried out a multivariate Cox regression analysis to adjust for this possible confounding factor. Surgery (p = 0.042; HR 0.55; 95% confidence interval: 0.31-0.98) as well as the use of PET-CT (p = 0.048; HR 0.60; 95% confidence interval: 0.36-0.99) nearly halved the risk of local recurrence. It was only in the group of patients with PET-CT that a trend towards a shorter overall survival was evident in lymph node-positive patients (p = 0.16), whereas nodal stage did not impact on survival in patients staged without PET-CT (p = 0.97).

CONCLUSION

To the best of our knowledge these data suggest for the first time that the use of PET-CT in the framework of staging and planning of primary or neoadjuvant chemoradiotherapy for esophageal cancer has a favorable impact on patient survival.