Role of F18-FDG PET/CT in the Staging and Restaging of Esophageal Cancer: A Comparison with CECT

Analyzing risk factors and constructing a predictive model for superficial esophageal carcinoma with submucosal infiltration exceeding 200 micrometers

OBJECTIVE

Submucosal infiltration of less than 200 μm is considered an indication for endoscopic surgery in cases of superficial esophageal cancer and precancerous lesions. This study aims to identify the risk factors associated with submucosal infiltration exceeding 200 micrometers in early esophageal cancer and precancerous lesions, as well as to establish and validate an accompanying predictive model.

METHODS

Risk factors were identified through least absolute shrinkage and selection operator (LASSO) and multivariate logistic regression. Various machine learning (ML) classification models were tested to develop and evaluate the most effective predictive model, with Shapley Additive Explanations (SHAP) employed for model visualization.

RESULTS

Predictive factors for early esophageal invasion into the submucosa included endoscopic ultrasonography or magnifying endoscopy> SM1(P<0.001,OR = 3.972,95%CI 2.161-7.478), esophageal wall thickening(P<0.001,OR = 12.924,95%CI,5.299-33.96), intake of pickled foods(P=0.04,OR = 1.837,95%CI,1.03-3.307), platelet-lymphocyte ratio(P<0.001,OR = 0.284,95%CI,0.137-0.556), tumor size(P<0.027,OR = 2.369,95%CI,1.128-5.267), the percentage of circumferential mucosal defect(P<0.001,OR = 5.286,95%CI,2.671-10.723), and preoperative pathological type(P<0.001,OR = 4.079,95%CI,2.254-7.476). The logistic regression model constructed from the identified risk factors was found to be the optimal model, demonstrating high efficacy with an area under the curve (AUC) of 0.922 in the training set, 0.899 in the validation set, and 0.850 in the test set.

CONCLUSION

A logistic regression model complemented by SHAP visualizations effectively identifies early esophageal cancer reaching 200 micrometers into the submucosa.

The Prognostic Value of Sequential 18 F-FDG PET/CT Metabolic Parameters in Outcomes of Upper-Third Esophageal Squamous Cell Carcinoma Patients Treated with Definitive Chemoradiotherapy

Objective  The aim of this study is to determine prognostic values of sequential 18 F-FDG PET/CT metabolic parameters in locally advanced esophageal squamous cell carcinoma (ESCC) patients treated with definitive chemoradiotherapy. Materials and Methods  Forty locally advanced ESCC patients treated with definitive chemoradiotherapy (dCRT) who received pre-treatment 18 F-FDG PET/CT (PET1) and 3-months post-treatment 18 F-FDG PET/CT (PET2) were enrolled in the prospective study. 18 F-FDG PET parameters of the primary tumor including maximum and mean standardized uptake values (SUVmax, SUVmean), metabolic tumor volume (MTV), and total lesion glycolysis (TLG) were calculated on PET delineated primary tumor. Using Kaplan-Meier curves to estimated overall survival (OS), progression-free survival (PFS), and local-regional control (LRC). Cox regression analysis was performed to find significant prognostic factors for survival. Results  With a median follow-up of 13.5 months, the 4-year OS, PFS, and LRC rates were 67.3%, 52.6%, and 53.4% respectively. Patients with MTV 2 > 5.7 had lower OS, PFS, and LRC rates than the lower MTV 2 group (p < 0.05). Univariate Cox regression analysis showed that MTV2 was a significant prognostic factor for OS, PFS, and LRC (p < 0.05). Conclusion  MTV parameter of sequential 18 F-FDG PET/CT could be used as a prognostic factor for OS, PFS, and LRC in locally advanced ESCC patients treated with dCRT.

Value of a 18F-FDG PET/CT Semi-quantitative Parameter (SUVmax) in Predicting the Survival of Patients with Esophageal Cancer Subtypes

Background: Flourine-18 fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) scan is employed for initial staging and restaging of esophageal cancer patients. Objectives: The present study aimed to assess the value of a semi-quantitative parameter of 18F-FDG PET/CT scan, that is, maximum standardized uptake value (SUVmax), to determine its correlation with patient survival in two subtypes of esophageal cancer, including squamous cell carcinoma (SCC) and adenocarcinoma. Patients and Methods: This cross-sectional study was performed on patients with esophageal SCC and adenocarcinoma, undergoing 18F-FDG PET/CT scan for initial staging before any treatment. The 18F-FDG PET/CT semi-quantitative parameter (SUVmax) was determined by reviewing the PET/CT images. The patients were reevaluated using 18F-FDG PET/CT scan for restaging within 12 - 24 months. Results: No significant difference was observed in the SUVmax values of the primary tumor, metastatic lymph nodes, or distant metastasis between the adenocarcinoma and SCC groups, regardless of response to treatment. Similarly, no significant association was found between the short-term survival of patients with adenocarcinoma and the SUVmax values of the primary tumor, metastatic lymph nodes, or distant metastasis. Based on the survival curve, one- and two-year survival rates were estimated at 75% and 63.9% in patients with SCC and at 80% and 60% in patients with adenocarcinoma, respectively. In the SCC group, a significantly higher SUVmax was detected in deceased patients with distant metastatic lesions compared to cancer survivors. According to the area under the ROC curve, the SUVmax of metastatic lesions showed high potential for predicting the mortality of SCC patients. Conclusion: The assessment of SUVmax in distant metastatic lesions by 18F-FDG-PET/CT may help predict the survival of patients with esophageal SCC. However, 18F-FDG-PET/CT findings were not associated with the survival of esophageal adenocarcinoma; therefore, further evaluations on a larger sample size and a longer follow-up are required.

State-of-the-art imaging in oesophago-gastric cancer

Radiological investigations are essential in the management of oesophageal and gastro-oesophageal junction cancers. The current multimodal combination of CT, 18F-fluorodeoxyglucose positron emission tomography combined with CT (PET/CT) and endoscopic ultrasound (EUS) has limitations, which hinders the prognostic and predictive information that can be used to guide optimum treatment decisions. Therefore, the development of improved imaging techniques is vital to improve patient management. This review describes the current evidence for state-of-the-art imaging techniques in oesophago-gastric cancer including high resolution MRI, diffusion-weighted MRI, dynamic contrast-enhanced MRI, whole-body MRI, perfusion CT, novel PET tracers, and integrated PET/MRI. These novel imaging techniques may help clinicians improve the diagnosis, staging, treatment planning, and response assessment of oesophago-gastric cancer.

Pitfalls and Pearls in Esophageal Carcinoma

The management of patients with esophageal carcinoma (EC) requires accurate clinical staging and post-therapeutic evaluation. Currently, esophagogastroduodenoscopy/endoscopic ultrasound (EGD/EUS), endoscopic ultrasound-fine needle aspiration (EUS-FNA), computed tomography (CT), 18F- fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography (FDG-PET/CT) and magnetic resonance (MR) imaging are used for the initial clinical staging, evaluation of therapeutic response and follow-up in patients with EC. However, there are limitations and pitfalls that are commonly encountered when imaging these patients that can limit accurate assessment. Knowledge of the limitations and pitfalls associated with the use of these different imaging modalities is essential in avoiding misinterpretation and guaranteeing the appropriate management for patient with EC.

Presentation of gastroesophageal junction adenocarcinoma with synchronous metastases at the small intestine. Could treatment with curative intent be considered? A case report

Introduction

Introduction of multimodality treatment as the standard of care for management of esophageal and gastroesophageal junction (GEJ) cancer over the last years has led to significant improvement in survival for patients with localized disease. Nevertheless, treatment with curative intent is not considered in the case of metastatic disease. We report a case of a locally advanced GEJ adenocarcinoma with solitary resectable synchronous metastases at the jejunum and a good response to neoadjuvant therapy followed by esophagectomy with curative intention.

Case presentation

This is the case of a patient with poorly differentiated adenocarcinoma of the GEJ with synchronous metastases at the jejunum. The patient underwent extensive work-up including PET-CT. The metastases at the jejunum were completely resected during an initial staging laparoscopy and there was no evidence of further metastatic disease. The patient received chemotherapy and re-staging showed remarkable tumor response. Esophagectomy with curative intent was performed. Histopathology showed complete pathologic response after chemotherapy. Although our patient had a stage IV disease at presentation, he remained metastasis-free for a significant period of time, with no evidence of any distant recurrence during a follow-up of 16 months after esophagectomy.

Discussion and conclusions

Synchronous metastasis to the small bowel from an esophageal carcinoma is a rare entity. Routine PET-CT in addition to conventional CT may assist in more precise staging of a patient with resectable disease. Stage IV esophageal cancer with limited and resectable metastatic disease and good tumor response to oncological therapy may be considered for treatment with potentially curative intent.

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Synchronous metastasis to the small bowel from an esophageal carcinoma is a rare entity.

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PET-CT in addition to conventional CT may assist in more precise staging of esophageal cancer.

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Esophageal cancer with resectable metastases may be considered for treatment with curative intent.

Improved detection of metastatic lymph nodes in oesophageal squamous cell carcinoma by combined interpretation of fluorine-18-fluorodeoxyglucose positron-emission tomography/computed tomography

Background

We sought to evaluate the diagnostic performance of fluorine-18-fluorodeoxyglucose positron-emission tomography/computed tomography (¹⁸F-FDG PET/CT) in the detection of metastatic lymph nodes by combined interpretation of PET/CT images in patients with oesophageal squamous cell carcinoma.

Methods

Two hundred three patients with oesophageal squamous cell carcinoma underwent ¹⁸F-FDG PET/CT before oesophagectomy and lymph node dissection. Maximum standardized uptake value (SUV_max), mean Hounsfield unit (HU), short axis diameter (size), and visual CT attenuation (high, iso-, low) were evaluated on noncontrast CT and PET images following PET/CT scan. In this combined interpretation protocol, the high attenuated lymph nodes were considered benign, even if the SUV_max value was high. The diagnostic accuracy of each method was compared using the postoperative histologic result as a reference standard.

Results

A total of 1099 nodal stations were dissected and 949 nodal stations were proven to demonstrate metastasis. SUV_max and size of the malignant lymph nodes were higher than those of the benign nodes, and visual CT attenuation was significantly different among the two groups (P < 0.001). Using cutoff values of 2.6 for SUV_max and 10.2 mm for size, the combined interpretation of an SUV_max of more than 2.6 with iso- or low CT attenuation [area under the curve (AUC): 0.846, 95% confidence interval (CI): 0.824–0.867] showed significantly better diagnostic performance for detecting malignant lymph nodes than SUV_max only (AUC: 0.791, 95% CI: 0.766–0.815) and size (AUC: 0.693, 95% CI: 0.665–0.720) methods (P < 0.001) in a receiver operating characteristic curve analysis.

Conclusions

The diagnostic accuracy of PET/CT for nodal metastasis in oesophageal squamous cell carcinoma was improved by the combined interpretation of ¹⁸F-FDG uptake and visual CT attenuation pattern.

18FDG-PET/CT is useful in the follow-up of surgically treated patients with oesophageal adenocarcinoma

OBJECTIVE

The purpose of this study was to evaluate fludeoxyglucose-positron emission ;tomography/CT's (FDG-PET/CT) performance in the follow ;up of patients with surgically treated oesophageal adenocarcinoma.

METHODS

The follow-up FDG-PET/CT scans of 162 consecutive patients with surgically treated oesophageal adenocarcinoma were retrospectively reviewed. Histopathological and/or imaging examinations confirmed recurrent disease. The accuracy, sensitivity, specificity and negative and positive predictive values were calculated.

RESULTS

Recurrence occurred in 71 (43%) patients, usually within the first year following surgery (60%) and in more than one site (76%). The sensitivity, specificity, positive-predictive value, negative-predictive value and accuracy of FDG-PET/CT for anastomotic recurrence were 77, 76, 16, 98 and 76%; for regional nodal recurrence were 88, 85, 43, 97 and 86%; and for distant metastatic recurrence were: 97, 96, 91, 99 and 96%. In 5 of the 42 patients (12%) with distant metastases, the metastatic sites were outside the area covered by a conventional follow-up chest-abdomen CT and in 4 patients (9%) metastases were barely perceptible on the CT component of the FDG-PET/CT and consequently were unlikely to be detected without the aid of the FDG uptake.

CONCLUSION

FDG PET/CT is accurate in detecting oesophageal adenocarcinoma recurrence, especially within the first post-operative year when most recurrences occur, and is useful in identifying patients with a solitary metastasis. Advances in knowledge: FDG-PET/CT should be considered as a valuable tool in the routine follow ;up of surgically treated oesophageal cancer patients within the first 2 years after surgery.

Role of Pre-therapeutic (18)F-FDG PET/CT in Guiding the Treatment Strategy and Predicting Prognosis in Patients with Esophageal Carcinoma

OBJECTIVES

The present study aimed to evaluate the role of pre-therapeutic (18)fluorine-fluorodeoxyglucose positron emission tomography-computed tomography ((18)F-FDG PET-CT) and maximum standardized uptake value (SUVmax) in guiding the treatment strategy and predicting the prognosis of esophageal carcinoma, using the survival data of the patients.

METHODS

The present retrospective, cohort study was performed on 40 consecutive patients with esophageal carcinoma (confirmed by endoscopic biopsy), who underwent pre-operative (18)F-FDG PET-CT staging between January 2009 and June 2014. All the patients underwent contrast-enhanced CT and non-contrasted (18)F-FDG PET-CT evaluations. The patients were followed-up over 12 months to assess the changes in therapeutic strategies. Survival analysis was done considering the primary tumor SUVmax, using the Kaplan-Meier product-limit method.

RESULTS

In a total of 40 patients, (18)F-FDG PET-CT scan led to changes in disease stage in 26 (65.0%) cases, with upstaging and downstaging reported in 10 (25.0%) and 16 (40.0%) patients, respectively. The management strategy changed from palliative to curative in 10 out of 24 patients and from curative to palliative in 7 out of 16 cases. Based on the (18)F-FDG PET-CT scan alone, the median survival of patients in the palliative group was 4.0 (95% CI 3.0-5.0) months, whereas the median survival in the curative group has not been reached, based on the 12-month follow-up. Selection of treatment strategy on the basis of (18)F-FDG PET/CT alone was significantly associated with the survival outcomes at nine months (P=0.03) and marginally significant at 12 months (P=0.03). On the basis of SUVmax, the relation between survival and SUVmax was not statistically significant.

CONCLUSION

(18)F-FDG PET/CT scan had a significant impact on stage stratification and subsequently, selection of a stage-specific treatment approach and the overall survival outcome in patients with esophageal carcinoma. However, pre-treatment SUVmax failed to stablish its usefulness in the assessment of patient prognosis and survival outcome.

Usefulness of positron emission tomography-computed tomography in pre-operative evaluation of intra-thoracic esophageal cancer

Background

The purpose of the study was to clarify the usefulness of positron emission tomography-computed tomography (PET-CT) for pre-operative evaluation of intra-thoracic esophageal cancer, especially in terms of regional lymph node status.

Methods

Medical records of 93 consecutive cases from July 2007 to October 2012 were retrospectively reviewed. All patients underwent curative and complete esophagectomies for intra-thoracic esophageal cancer. We compared pre-operative maximum standard uptake values (SUVmax) of esophageal tumors and regional lymph nodes (LN) with other variables (chronic obstructive pulmonary disease, history of previous other primary cancer, gender, differentiation, and neoadjuvant therapy). In addition, the SUVmax of tumors and LNs were analyzed with pathologic findings.

Results

There was no significant difference of each tumor and LN SUVmax according to factors including chronic lung disease, age, history of previous other cancer, differentiation, and gender. Pre-operative evaluations by PET-CT were not accurate (tumor sensitivity 76.4%, specificity 25%; LN sensitivity 45.2%, specificity 54.8%). Receiver operating characteristic analysis showed that LN metastasis could not be appropriately diagnosed with SUVmax (P = 0.871). There was no difference in SUVmax between pathologically positive and negative LN subgroups. Tumor SUVmax correlated with the progression of esophageal cancer in patients without neoadjuvant therapy (P < 0.001). However, LN SUVmax had no correlation with overall pathologic stage. After neoadjuvant therapy, there were significant decreases in SUVmax in both pathologically positive and negative LN subgroups (P = 0.043, P = 0.008).

Conclusion

 Surgery should not be withheld in N-stage according to PET-CT findings and carefully considered in conjunction with other conditions.