Comparative study between endoscopic ultrasonography and positron emission tomography-computed tomography in staging patients with esophageal squamous cell carcinoma

Intravoxel incoherent motion diffusion-weighted imaging in evaluating preoperative staging of esophageal squamous cell carcinoma : Evaluation of preoperative stage of primary tumour and prediction of lymph node metastases from esophageal cancer using IVIM: a prospective study

BACKGROUND

The aim of this research is to prospectively investigate the diagnostic performance of intravoxel incoherent motion (IVIM) using the integrated slice-specific dynamic shimming (iShim) technique in staging primary esophageal squamous cell carcinoma (ESCC) and predicting presence of lymph node metastases from ESCC.

METHODS

Sixty-three patients with ESCC were prospectively enrolled from April 2016 to April 2019. MR and IVIM using iShim technique (b = 0, 25, 50, 75, 100, 200, 400, 600, 800 s/mm2) were performed on 3.0T MRI system before operation. Primary tumour apparent diffusion coefficient (ADC) and IVIM parameters, including true diffusion coefficient (D), pseudodiffusion coefficient (D*), pseudodiffusion fraction (f) were measured by two independent radiologists. The differences in D, D*, f and ADC values of different T and N stages were assessed. Intraclass correlation coefficients (ICCs) were calculated to evaluate the interobserver agreement between two readers. The diagnostic performances of D, D*, f and ADC values in primary tumour staging and prediction of lymph node metastasis of ESCC were determined using receiver operating characteristic (ROC) curve analysis.

RESULTS

The inter-observer consensus was excellent for IVIM parameters and ADC (D: ICC = 0.922; D*: ICC = 0.892; f: ICC = 0.948; ADC: ICC = 0.958). The ADC, D, D* and f values of group T1 + T2 were significantly higher than those of group T3 + T4a [ADC: (2.55 ± 0.43) ×10- 3 mm2/s vs. (2.27 ± 0.40) ×10- 3 mm2/s, t = 2.670, P = 0.010; D: (1.82 ± 0.39) ×10- 3 mm2/s vs. (1.53 ± 0.33) ×10- 3 mm2/s, t = 3.189, P = 0.002; D*: 46.45 (30.30,55.53) ×10- 3 mm2/s vs. 32.30 (18.60,40.95) ×10- 3 mm2/s, z=-2.408, P = 0.016; f: 0.45 ± 0.12 vs. 0.37 ± 0.12, t = 2.538, P = 0.014]. The ADC, D and f values of the lymph nodes-positive (N+) group were significantly lower than those of lymph nodes-negative (N0) group [ADC: (2.10 ± 0.33) ×10- 3 mm2/s vs. (2.55 ± 0.40) ×10- 3 mm2/s, t=-4.564, P < 0.001; D: (1.44 ± 0.30) ×10- 3 mm2/s vs. (1.78 ± 0.37) ×10- 3 mm2/s, t=-3.726, P < 0.001; f: 0.32 ± 0.10 vs. 0.45 ± 0.11, t=-4.524, P < 0.001]. The combination of D, D* and f yielded the highest area under the curve (AUC) (0.814) in distinguishing group T1 + T2 from group T3 + T4a. D combined with f provided the highest diagnostic performance (AUC = 0.849) in identifying group N + and group N0 of ESCC.

CONCLUSIONS

IVIM may be used as an effective functional imaging technique to evaluate preoperative stage of primary tumour and predict presence of lymph node metastases from ESCC.

Pathological response to neoadjuvant chemoradiotherapy for oesophageal squamous cell carcinoma in Eastern versus Western countries: meta-analysis

OBJECTIVE

Locally advanced oesophageal squamous cell carcinoma can be treated with neoadjuvant chemoradiotherapy or chemotherapy followed by oesophagectomy. Discrepancies in pathological response rates have been reported between studies from Eastern versus Western countries. The aim of this study was to compare the pathological response to neoadjuvant chemoradiotherapy in Eastern versus Western countries.

METHODS

Databases were searched until November 2022 for studies reporting pCR rates after neoadjuvant chemoradiotherapy for oesophageal squamous cell carcinoma. Multi-level meta-analyses were performed to pool pCR rates separately for cohorts from studies performed in centres in the Sinosphere (East) or in Europe and the Anglosphere (West).

RESULTS

For neoadjuvant chemoradiotherapy, 51 Eastern cohorts (5636 patients) and 20 Western cohorts (3039 patients) were included. Studies from Eastern countries included more men, younger patients, more proximal tumours, and more cT4 and cN+ disease. Patients in the West were more often treated with high-dose radiotherapy, whereas patients in the East were more often treated with a platinum + fluoropyrimidine regimen. The pooled pCR rate after neoadjuvant chemoradiotherapy was 31.7% (95% c.i. 29.5% to 34.1%) in Eastern cohorts versus 40.4% (95% c.i. 35.0% to 45.9%) in Western cohorts (fixed-effect P = 0.003). For cohorts with similar cTNM stages, pooled pCR rates for the East and the West were 32.5% and 41.9% respectively (fixed-effect P = 0.003).

CONCLUSION

The pathological response to neoadjuvant chemoradiotherapy is less favourable in patients treated in Eastern countries compared with Western countries. Despite efforts to investigate accounting factors, the discrepancy in pCR rate cannot be entirely explained by differences in patient, tumour, or treatment characteristics.

Diagnostic value of conventional endoscopic ultrasound for lymph node metastasis in upper gastrointestinal neoplasia: A meta-analysis

BACKGROUND

Upper gastrointestinal neoplasia mainly includes esophageal cancer and gastric cancer, both of which have high morbidity and mortality. Lymph node metastasis (LNM), as the most common metastasis mode of both diseases, is an important factor affecting tumor stage, treatment strategy and clinical prognosis. As a new fusion technology, endoscopic ultrasound (EUS) is becoming increasingly used in the diagnosis and treatment of digestive system diseases, but its use in detecting LNM in clinical practice remains limited.

AIM

To evaluate the diagnostic value of conventional EUS for LNM in upper gastrointestinal neoplasia.

METHODS

Using the search mode of "MeSH + Entry Terms" and according to the predetermined inclusion and exclusion criteria, we conducted a comprehensive search and screening of the PubMed, EMBASE and Cochrane Library databases from January 1, 2000 to October 1, 2022. Study data were extracted according to the predetermined data extraction form. The quality of the included studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies tool, and the results of the quality assessment were presented using Review Manager 5.3.5 software. Finally, Stata14.0 software was used for a series of statistical analyses.

RESULTS

A total of 22 studies were included in our study, including 2986 patients. The pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, diagnostic score and diagnostic odds ratio of conventional EUS in the diagnosis of upper gastrointestinal neoplasia LNM were 0.62 [95% confidence interval (CI): 0.50-0.73], 0.80 (95%CI: 0.73-0.86), 3.15 (95%CI: 2.46-4.03), 0.47 (95%CI: 0.36-0.61), 1.90 (95%CI: 1.51-2.29) and 6.67 (95%CI: 4.52-9.84), respectively. The area under the summary receiver operating characteristic curve was 0.80 (95%CI: 0.76-0.83). Sensitivity analysis indicated that the results of the meta-analysis were stable. There was considerable heterogeneity among the included studies, and the threshold effect was an important source of heterogeneity. Univariable meta-regression and subgroup analysis showed that tumor type, sample size and EUS diagnostic criteria were significant sources of heterogeneity in specificity (P < 0.05). No significant publication bias was found.

CONCLUSION

Conventional EUS has certain clinical value and can assist in the detection of LNM in upper gastrointestinal neoplasia, but it cannot be used as a confirmatory or exclusionary test.

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.

Difference in Computed Tomography Image Quality between Central Vein and Peripheral Vein Enhancement in Treatment Naive Esophageal Cancer Patients

Simple Summary

A chest CT via central vein enhancement not only eliminates peripheral vein regurgitation but also provides better image quality that facilitates precise clinical staging. A chest CT via central vein enhancement may be considered after tissue proof in order to better discriminate disease severity.

Abstract

The differences in chest computed tomography (CT) image quality may affect the tumor stage. The aim of this study was to compare the image quality and accuracy of chest CT via central vein and peripheral vein enhancement. Fifty consecutive patients were enrolled from a tertiary medical center in Taiwan from May 2016 to March 2019. All the patients received a chest CT via central vein enhancement prior to neoadjuvant concurrent chemoradiation in order to compare the chest CT that was obtained via the peripheral vein. In addition, blind independent central reviews of chest CT via central vein and peripheral vein enhancement were conducted. For T and N stage, chest CT via central vein enhancement had a greater consistency with endoscopic ultrasonography and positron-emission tomography-computed tomography findings (kappa coefficients 0.4471 and 0.5564, respectively). In addition, chest CT via central vein enhancement also showed excellent agreement in the blind independent central review (kappa coefficient 0.9157). The changes in the T and N stage resulted in stage migration in 16 patients. Chest CT via central vein enhancement eliminated peripheral vein regurgitation and also provided more precise clinical staging. This study is registered under the registered NCT number 02887261.

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

Accuracy of Detecting Residual Disease After Neoadjuvant Chemoradiotherapy for Esophageal Cancer: A Systematic Review and Meta-analysis

OBJECTIVE

The aim of this study was to perform a meta-analysis on the accuracy of endoscopic biopsies, EUS, and 18F-FDG PET(-CT) for detecting residual disease after neoadjuvant chemoradiotherapy (nCRT) for esophageal cancer.

SUMMARY OF BACKGROUND DATA

After nCRT, one-third of patients have a pathologically complete response in the resection specimen. Before an active surveillance strategy could be offered to these patients, clinically complete responders should be accurately identified.

METHODS

Embase, Medline, Cochrane, and Web-of-Science were searched until February 2018 for studies on accuracy of endoscopic biopsies, EUS, or PET(-CT) for detecting locoregional residual disease after nCRT for squamous cell- or adenocarcinoma. Pooled sensitivities and specificities were calculated using random-effect meta-analyses.

RESULTS

Forty-four studies were included for meta-analyses. For detecting residual disease at the primary tumor site, 12 studies evaluated endoscopic biopsies, 11 qualitative EUS, 14 qualitative PET, 8 quantitative PET using maximum standardized uptake value (SUVmax), and 7 quantitative PET using percentage reduction of SUVmax (%ΔSUVmax). Pooled sensitivities and specificities were 33% and 95% for endoscopic biopsies, 96% and 8% for qualitative EUS, 74% and 52% for qualitative PET, 69% and 72% for PET-SUVmax, and 73% and 63% for PET-%ΔSUVmax. For detecting residual nodal disease, 11 studies evaluated qualitative EUS with a pooled sensitivity and specificity of 68% and 57%, respectively. In subgroup analyses, sensitivity of PET-%ΔSUVmax and EUS for nodal disease was higher in squamous cell carcinoma than adenocarcinoma.

CONCLUSIONS

Current literature suggests insufficient accuracy of endoscopic biopsies, EUS, and 18F-FDG PET(-CT) as single modalities for detecting residual disease after nCRT for esophageal cancer.

Prognostic significance of middle paraesophageal lymph node metastasis in resectable esophageal squamous cell carcinoma: A STROBE-compliant retrospective study

Lymph node metastasis (LNM) of esophageal squamous cell carcinoma (ESCC) has important prognostic significance. In this study, we examined the correlations between lymph node metastatic sites and prognosis in patients with resectable ESCC.A total of 960 patients who received curative esophagectomy with systemic lymphadenectomy between 1996 and 2014 were included in the retrospective analysis. The Kaplan-Meier method and log-rank test were used to perform the survival analysis. The prognostic significance of LNM site was evaluated by Cox regression analysis.The LNM in middle paraesophageal (P < .001), subcarinal (P < .001), lower paraesophageal (P < .001), recurrent laryngeal nerve (P = .012), paratracheal (P = .014), and perigastric (P < .001) sites were associated with poor prognosis in univariate analysis. In multivariate analysis, only middle paraesophageal LNM (MPLNM, P = .017; HR, 1.33; 95%CI, 1.05-1.67) was the independent factor for worse prognosis. Additionally, patients with MPLNM had a lower 5-year survival rate (15.6%) than those with LNM at other sites. Furthermore, upper or middle tumor location and relatively late pN stage were associated with increased risk of MPLNM.Our findings suggested MPLNM could be a characteristic indicating the worst prognosis. Preoperative examinations should identify the existences of MPLNM, especially on patients with risk factors. And patients with MPLNM should be considered for more aggressive multidisciplinary therapies.

18F FDG-PET/CT evaluation of histological response after neoadjuvant treatment in patients with cancer of the esophagus or gastroesophageal junction

BACKGROUND

In most parts of the world, curatively intended treatment for esophageal cancer includes neoadjuvant therapy, either with chemoradiotherapy or chemotherapy alone, followed by esophagectomy. Currently 18F-FDG positron emission tomography/computed tomography (PET/CT) is used for preoperative disease staging, but is not well established in the evaluation of neoadjuvant treatment.

PURPOSE

To evaluate changes in PET parameters in relation to the histological primary tumor response in the surgical specimen in patients randomized to neoadjuvant chemoradiotherapy or chemotherapy.

MATERIAL AND METHODS

Patients were randomized between either neoadjuvant chemotherapy or chemoradiotherapy followed by esophagectomy.18F-FDG PET/CT exams were conducted at baseline and following neoadjuvant treatment. Standardized uptake ratio (SUR) values were measured in the primary tumor and compared as regards histological responders and non-responders as well as different treatment arms.

RESULTS

Seventy-nine patients were enrolled and 51 were available for analysis. A significant rate of SUR reduction was observed ( P = 0.02) in the primary tumor in histological responders compared to non-responders. Changes in SUR were significantly greater in responders following chemoradiotherapy ( P = 0.02), but not following chemotherapy alone ( P = 0.49). There was no statistically significant difference in SUR in patients with a complete histological response compared to those with a subtotal response.

CONCLUSION

Our results are similar to those of previous studies and show that changes in the rate of SUR can be used reliably to differentiate histological responders from non-responders after neoadjuvant treatment with either chemoradiotherapy or chemotherapy. Limitations of current PET technology are likely to restrict the possibility of accurately ruling out limited residual disease.

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.

Systematic review and meta-analysis of the accuracy of 18F-FDG PET/CT for detection of regional lymph node metastasis in esophageal squamous cell carcinoma

Background

We performed a systematic review and meta-analysis to assess the accuracy of 18F-fluorodeoxyglucose positron emission tomography with computer tomography (18F-FDG PET/CT) for detection of regional lymph node metastasis in esophageal squamous cell carcinoma in per-patient and per-nodal station basis.

Methods

Electronic databases were researched for studies assessing the sensitivity and specificity of PET/CT to detect the regional lymph node metastasis published between January 2006 and December 2017 on esophageal squamous cell carcinoma. STATA software was performed to assess the sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odd ratio (DOR) and summary receiver operating characteristic (SROC) curve. The Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) and Deeks' Funnel Plot Asymmetry Test were performed to evaluate the study quality and publication bias of included studies.

Results

Nineteen studies were eligible for meta-analysis, comprising 1,089 patients with esophageal cancer who underwent 18F-FDG PET/CT before surgery. According to the content of the article, we divided the selected studies into per-patient basis group and per-nodal basis group (one of the articles was involved in both groups). For the per-nodal station basis group (12 studies, 5,681 stations), the pooled sensitivity and specificity estimates of 18F-FDG PET/CT for detecting regional lymph node metastasis were 66% [95% confidence interval (CI): 51-78%] and 96% (95% CI: 92-98%), respectively. The corresponding values on a per-patient basis group (8 studies; 506 patients) were 65% (95% CI: 49-78%) and 81% (95% CI: 69-89%) in sensitivity and specificity, respectively.

Conclusions

Overall, 18F-FDG PET/CT have a moderate to low sensitivity and a high to moderate specificity for detection of regional nodal metastasis in esophageal cancer. Therefore, since the false rate is considerable, extending the extent of lymph node dissection or radiotherapy target volume is necessary after diagnosis of regional nodal metastasis by 18F-FDG PET/CT.

Low-dose spectral insufflation computed tomography protocol preoperatively optimized for T stage esophageal cancer - preliminary research experience

AIM

To evaluate the T stage of esophageal squamous cell carcinoma (ESCC) using preoperative low-dose esophageal insufflation computed tomography (EICT).

METHODS

One hundred and twenty ESCC patients confirmed by surgery or esophagoscopy were divided into three groups. Groups B and C were injected with 300 mgI/kg contrast medium for automatic spectral imaging assist (GSI assist), while group A underwent a conventional 120 kVp computed tomography (CT) scan with a 450 mgI/kg contrast medium injection. EICT was performed in group C. Group A was reconstructed with filtered back projection, and groups B and C were reconstructed with 50% adaptive statistical iterative reconstruction. The contrast-to-noise ratio of lesion-to-mediastinal adipose tissue and the radiation dose were measured. Specific imaging features were observed, and T stage ESCCs were evaluated.

RESULTS

The sensitivity and accuracy of the T1/2 stage were higher in group C than in groups A and B (sensitivity: 43.75% vs 31.82% and 33.33%; accuracy: 54.29% vs 46.67% and 52.50%, respectively). With regard to the T3 stage, the sensitivity and specificity in group C were higher than those in groups A and B (sensitivity: 56.25% vs 41.17% and 44.44%; specificity: 73.68% vs 67.86% and 63.64%, respectively). The diagnostic sensitivity, specificity and accuracy of the T4 stage were similar among all groups. There were no significant differences in volume CT dose index [(5.91 ± 2.57) mGy vs (3.24 ± 1.20) vs (3.65 ± 1.77) mGy], dose-length product [(167.10 ± 99.08) mGy•cm vs (113.24 ± 54.46) mGy•cm vs (117.98 ± 32.32) mGy•cm] and effective dose [(2.52 ± 1.39) vs (1.63 ± 0.76) vs (1.73 ± 0.44) mSv] among the groups (P > 0.05). However, groups B and C received similar effective doses but lower iodine loads than group A [(300 vs 450) mgI/kg].

CONCLUSION

EICT combined with GSI assist allows differential diagnosis between the T1/2 and T3 stages. The ability to differentially diagnose the T3 and T4 stages of medullary ESCC can be improved by quantitatively and qualitatively analyzing the adipose tissue in front of the vertebral body.

The in vivo tissue effect of endoscopic balloon-based radiofrequency ablation in treating esophageal squamous cell neoplasia

Background

Endoscopic radiofrequency ablation (RFA) is a rapidly evolving therapeutic modality for early flat esophageal squamous cell neoplasms (ESCNs). However, the in vivo tissue effects of RFA on the esophageal wall are uncertain.

Methods

We prospectively enrolled eight patients with flat-type early ESCNs who were treated with balloon-based RFA. We evaluated the in vivo tissue effect on the esophagus using endoscopic ultrasound (EUS) and the histology of retrieved coagulum.

Results

The mean tumor length was 6.1 cm, and six of the eight patients achieved a complete response after primary RFA. Real-time evaluation of the tissue effect showed that the mucosa and submucosal layer were more edematous and thicker after RFA than before the procedure (mean 4.89 vs. 2.04 mm, p<.001), suggesting that the thermal effect of RFA may injure the submucosa. Histological evaluation of retrieved coagulum showed a severe cauterization (burning) effect with extensive cell necrosis; however, four cases had some residual viable neoplastic cells. Even though there were viable cells in the sloughed coagulum, half of the patients still achieved complete remission after RFA.

Conclusions

Our findings suggest that the thermal effect of RFA may injure the submucosal layer and enable neoplastic epithelium to slough off without "burning."

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.

PET/Computed Tomography Scanning and Precision Medicine: Esophageal Cancer

Esophageal cancer commonly has a poor prognosis, which requires an accurate diagnosis and early treatment to improve outcome. Other modalities for staging, such as endoscopic ultrasound imaging and computed tomography (CT) scans, have a role in diagnosis and staging. However, PET with fluorine-18 fluoro-2-deoxy-d-glucose/CT (FDG PET/CT) scanning allows for improved detection of distant metastatic disease and can help to prevent unnecessary interventions that would increase morbidity. FDG PET/CT scanning is valuable in the neoadjuvant chemotherapy assessment and predicting survival outcomes subsequent to surgery. FDG PET/CT scanning detects recurrent disease and metastases in follow-up.

Characterization of residual tumours at the primary site in patients with a near pathological complete response after neoadjuvant chemoradiotherapy for oesophageal cancer

BACKGROUND

A 'surgery as needed' strategy has been proposed for patients with oesophageal cancer who truly achieve a pathological complete response (pCR) following neoadjuvant chemoradiotherapy (nCRT). However, the ability to detect residual disease remains problematic. This study investigated the anatomical locations and pathological characteristics of residual cancer in patients with oesophageal squamous cell carcinoma (SCC) who achieved a near pCR following nCRT.

METHODS

Patients with oesophageal SCC who achieved a near pCR after nCRT were eligible. Near pCR was defined as residual cancer in the resection specimen representing less than 10 per cent of the apparent original tumour area.

RESULTS

Detailed histopathological reassessment of 76 consecutive patients (mean age 54·4 years) with a near pCR was undertaken. Some 32 patients (42 per cent) with a near pCR had no detectable mucosal lesions. Residual tumour was identified most frequently in the submucosal layer (54, 71 per cent), followed by the mucosa (44, 58 per cent), muscle layer (36, 47 per cent) and adventitia (22, 29 per cent) (P < 0·001). Among patients without ypT1a disease, increasing depth of tumour invasion correlated negatively with the likelihood of mucosal involvement. Of patients with ypT3 disease, 16 of 22 had no detectable cancer located in the mucosa, compared with six of 29 with ypT1b disease (P < 0·001).

CONCLUSION

Better tools for predicting pCR are required before considering a 'surgery as needed' approach in the management of oesophageal cancer.

Endoscopic Ultrasound for Preoperative Esophageal Squamous Cell Carcinoma: a Meta-Analysis

Background

Treatment options and prognosis of esophageal squamous cell carcinoma (ESCC) depend on the primary tumor depth (T-staging) and regional lymph node status (N-staging). Endoscopic ultrasound (EUS) has emerged as a useful staging tool, but studies regarding its benefits have been variable. The objective of this study was to evaluate the diagnostic accuracy of EUS for detecting preoperative ESCC.

Methods

We included in our meta-analysis studies involving EUS-based staging of preoperative ESCC compared with pathological staging. Using a random-effects model, we performed a meta-analysis of the accuracy of EUS by calculating pooled estimates of sensitivity, specificity and the diagnostic odds ratio. In addition, we created a summary receiver operating characteristic (SROC) curve.

Results

Forty-four studies (n = 2880) met the inclusion criteria. The pooled sensitivity and specificity of T1 were 77% (95%CI: 73 to 80) and 95% (95%CI: 94 to 96). Among the T1 patients, EUS had a pooled sensitivity in differentiating T1a and T1b of 84% (95%CI: 80 to 88) and 83% (95%CI: 80 to 86), and a specificity of 91% (95%CI: 88 to 94) and 89% (95%CI: 86 to 92). To stage T4, EUS had a pooled sensitivity of 84% (95%CI: 79 to 89) and a specificity of 96% (95%CI: 95 to 97). The overall accuracy of EUS for T-staging was 79% (95%CI: 77 to 80), and for N-staging, 71% (95%CI: 69 to 73).

Conclusions

EUS has good diagnostic accuracy for staging ESCC, which has better performance in T1 sub-staging (T1a and T1b) and advanced disease (T4).

Endoscopic biopsy and EUS for the detection of pathologic complete response after neoadjuvant chemoradiotherapy in esophageal cancer: a systematic review and meta-analysis

BACKGROUND AND AIMS

Accurate determination of residual cancer status after neoadjuvant chemoradiotherapy (nCRT) for esophageal cancer could assist in selecting the optimal treatment strategy. The aim of this study was to review the evidence on the diagnostic accuracy of endoscopic biopsy and EUS after nCRT for detecting residual cancer at the primary tumor site (ypT+) and regional lymph nodes (ypN+) as opposed to a pathologic complete response (ypT0 and ypN0).

METHODS

PubMed/Medline, Embase, and the Cochrane library were systematically searched. The analysis included diagnostic studies reporting on the accuracy of endoscopic biopsy or EUS in detecting residual cancer versus complete response after nCRT for esophageal cancer with histopathology as the reference standard. Bivariate random-effects models were used to estimate pooled sensitivities and specificities and examine sources of heterogeneity.

RESULTS

Twenty-three studies comprising 12 endoscopic biopsy studies (1281 patients), 11 EUS studies reporting on ypT status (593 patients), and 10 EUS studies reporting on ypN status (602 patients), were included. Pooled estimates for sensitivity of endoscopic biopsy after nCRT for predicting ypT+ were 34.5% (95% confidence interval [CI], 26.0%-44.1%) and for specificity 91.0% (95% CI, 85.6%-94.5%). Pooled estimates for sensitivity of EUS after nCRT were 96.4% (95% CI, 91.7%-98.5%) and for specificity were 10.9% (95% CI, 3.5%-29.0%) for detecting ypT+, and 62.0% (95% CI, 46.0%-75.7%) and 56.7% (95% CI, 41.8%-70.5%) for detecting ypN+, respectively.

CONCLUSIONS

Endoscopic biopsy after nCRT is a specific but not sensitive method for detecting residual esophageal cancer. Although EUS after nCRT yields a high sensitivity, only a limited number of patients will have negative findings at EUS with still a substantial false-negative rate. Furthermore, EUS provides only moderate accuracy for detecting residual lymph node involvement. Based on these findings, these endoscopic modalities cannot be used to withhold surgical treatment in test-negative patients after nCRT. (

CLINICAL TRIAL REGISTRATION NUMBER

CRD42015016527.).

Esophageal Cancer: Role of Imaging in Primary Staging and Response Assessment Post Neoadjuvant Therapy

Advances in the early detection and treatment of esophageal cancer have meant improved survival rates for patients with esophageal cancer. Accurate pretreatment and post-neoadjuvant treatment staging of esophageal cancer is essential for assessing operability and determining the optimum treatment plan. This article reviews the multimodality imaging approach in the diagnosis, staging, and assessment of treatment response in esophageal cancer.

Combination of FDG PET/CT and contrast-enhanced MSCT in detecting lymph node metastasis of esophageal cancer

BACKGROUND

Lymph node metastasis is believed to be a dependent negative prognostic factor of esophageal cancer. To explore detection methods with high sensitivity and accuracy for metastases to regional and distant lymph nodes in the clinic is of great significance. This study focused on clinical application of FDG PET/CT and contrast-enhanced multiple-slice helical computed tomography (MSCT) in lymph node staging of esophageal cancer.

MATERIALS AND METHODS

One hundred and fifteen cases were examined with enhanced 64-slice-MSCT scan, and FDG PET/CT imaging was conducted for neck, chest and upper abdomen within one week. The primary lesion, location and numbers of metastatic lymph nodes were observed. Surgery was performed within one week after FDG PET/CT detection. All resected lesions were confirmed histopathologically as the gold standard. Comparative analysis of the sensitivity, specificity, and accuracy based on FDG PET/CT and MSCT was conducted.

RESULTS

There were 946 lymph node groups resected during surgery from 115 patients, and 221 were confirmed to have metastasis pathologically. The sensitivity, specificity, accuracy of FDG PET/CT in detecting lymph node metastasis were 74.7%, 97.2% and 92.0%, while with MSCT they were 64.7%, 96.4%, and 89.0%, respectively. A significance difference was observed in sensitivity (p=0.030), but not the others (p>0.05). The accuracy of FDG PET/CT in detecting regional lymph node with or without metastasis were 91.9%, as compared to 89.4% for MSCT, while FDG PET/CT and MSCT values for detecting distant lymph node with or without metastasis were 94.4% and 94.7%. No significant difference was observed for either regional or distant lymph node metastasis. Additionally, for detecting para-esophageal lymph nodes metastasis, the sensitivity of FDG PET/CT was 72%, compared with 54.7% for MSCT (p=0.029).

CONCLUSIONS

FDG PET/CT is more sensitive than MSCT in detecting lymph node metastasis, especially for para-esophageal lymph nodes in esophageal cancer cases, although no significant difference was observed between FDG PET/CT and MSCT in detecting both regional and distant lymph node metastasis. However, enhanced MSCT was found to be of great value in distinguishing false negative metastatic lymph nodes from FDG PET/CT. The combination of FDG PET/CT with MSCT should improve the accuracy in lymph node metastasis staging of esophageal cancer.

Diagnostic value of ¹⁸F-FDG PET/CT for lymph node metastasis of esophageal squamous cell carcinoma

PURPOSE

This study investigated the diagnostic accuracy of hybrid positron-emission tomography/computed tomography (PET/CT) for lymph node (LN) metastasis of esophageal cancer. We also investigated the correlation between the size of metastatic nests and the detection by PET/CT.

METHODS

Two hundred and fifty-eight patients with esophageal squamous cell carcinoma who underwent esophagectomy with two- or three-field radical lymphadenectomy were analyzed retrospectively. We compared the diagnosis of preoperative PET/CT to the postoperative histopathological examination by each anatomical field (n = 1,231) in all 258 patients. The metastatic LNs resected from PET/CT positive fields were classified as belonging to the PET/CT-N-positive group (n = 229) and those from negative fields as belonging to the PET/CT-N-negative group (n = 352). The cross-sectional areas of metastatic nests were measured in each metastatic LN.

RESULTS

Of the 1,231 fields, 275 (22 %) were positive for metastasis, including 581 LNs from 408 regional LN stations. The sensitivity and specificity of PET/CT examined by each anatomical field were 25.8 and 97.8 %, respectively. The median area of metastatic nests was 17.7 mm2 in the PET/CT-N-positive group, and 7.7 mm2 in the PET/CT-N-negative group (p < 0.001).

CONCLUSIONS

A significant correlation was suggested between the nest size and detection by PET/CT. Because of its low sensitivity, PET/CT alone is insufficient to determine the surgical procedures, especially when considering reduction surgery.

[Importance of PET in surgery of esophageal cancer]

Perioperative or preoperative radiochemotherapy (RCTx) is nowadays standard for locally advanced esophageal cancer in Europe, as randomized studies have shown a significant survival benefit for patients with multimodal treatment. As responders and nonresponders have a significantly different prognosis, a response-based tailored preoperative treatment would be of utmost interest. An established method is a metabolic response evaluation by 18F-fluorodeoxyglucose positron emission tomography (FDG-PET). The level of metabolic response is known to be dependent on the localization, tumor entity and type of preoperative treatment. Association of FDG-PET with later response and prognosis was shown for absolute standardized uptake values (SUV) or a decrease of SUV levels before and after therapy but there are also contradictory findings in the literature and no prospective validation. However, neither time points nor cut-off for metabolic response evaluation have been defined so far. The most interesting approach seems to be early response monitoring during preoperative chemotherapy, which has shown promising results in prospective single center trials (MUNICON I/II) during chemotherapy of adenocarcinoma of the esophagogastric junction (AEG), but needs to be validated in prospective multicenter trails.

Accuracy of multidetector-row CT for restaging after neoadjuvant treatment in patients with oesophageal cancer

OBJECTIVES

To assess the diagnostic accuracy of 64-multidetector CT (MDCT) for restaging of patients with oesophageal cancer undergoing neoadjuvant therapy.

METHODS

Results of pathological staging were correlated with those from 64-MDCT before and after neoadjuvant treatment in 35 patients using the American Joint Committee on Cancer/TNM classification (7th edition). CT response was determined using the Response Evaluation Criteria in Solid Tumours (RECIST) method, modified for one-dimensional tumour diameter measurement.

RESULTS

64-MDCT predicted T stage correctly in 34 % (12/35), overstaged in 49 % (17/35) and understaged in 17 % (6/35). Sensitivity/specificity values were as follows: T0, 20 %/92 %; T1-T2, 31 %/59 %; T3, 60 %/64 %; T4, 100 %/4 %. Negative predictive values for T3/T4 were 80 %/100 %. MDCT accurately predicted complete histopathological response in 20 % (accuracy 74 %) and overstaged in 80 %. Tumour regression grade was predicted correctly in only 8 % (2/25) and underestimated in 68 % (17/25). Accurate N stage was noted in 69 % (24/35).

CONCLUSION

Although MDCT tends to be able to exclude advanced tumour stages (T3, T4) with a higher likelihood, the diagnostic accuracy of high resolution MDCT for restaging oesophageal cancer and assessing the response to neoadjuvant therapy has not improved in comparison to older-generation CT. Therefore, the future assessment of oesophageal tumour response should focus on combined morphologic and metabolic imaging.

KEY POINTS

• Multidetector CT (MDCT) has been beneficial for the evaluation of many tumours. • However diagnostic accuracy for restaging oesophageal cancer has not improved with MDCT. • MDCT tends to be able to exclude advanced tumour stages (T3/T4). • MDCT has a low accuracy for determining lymph node metastasis. • Oesophageal tumour response should be assessed by combined morphological and metabolic imaging.

Outcomes associated with surgery for T4 esophageal cancer

BACKGROUND

T4 esophageal cancer often portends a dismal prognosis even after surgical resection. Historical incomplete resections and poor survival rates often make surgery palliative rather than curative.

METHODS

Using a comprehensive esophageal cancer database, we identified patients who underwent an esophagectomy for T4 tumors between 1994 and 2011. Neoadjuvant treatment (NT) and pathologic response variables were recorded, and response was denoted as complete response (pCR), partial response (pPR), and nonresponse (NR). Clinical and pathologic data were compared. Survival was calculated using Kaplan-Meier curves with log-rank tests for significance.

RESULTS

We identified 45 patients with T4 tumors all who underwent NT. The median age was 60 years (range, 31-79 years) with a median follow-up of 27 months (range, 0-122 months). There were 19 pCR (42 %), 22 pPR (49 %), and 4 NR (9 %). R0 resections were accomplished in 43 (96 %). There were 18 recurrences (40 %) with a median time to recurrence of 13.5 months (2.2-71 months). In this group pCR represented 7 (38.9 %), whereas pPR and NR represented 10 (55.5 %), and 1 (5.5 %) respectively. The overall and disease-free survival for all patients with T4 tumors were 35 and 36 %, respectively. Patients achieving a pCR had a 5 year overall and disease-free survival of 53 and 54 %, compared with pPR 23 and 28 %, while there were no 5 year survivors in the NR cohort.

CONCLUSION

We have demonstrated that neoadjuvant therapy and downstaging of T4 tumors leads to increased R0 resections and improvements in overall and disease-free survival.

Meta-analysis of 18FDG PET-CT for nodal staging in patients with esophageal cancer

BACKGROUND

We aimed to evaluate the value of (18)FDG PET-CT for detection of regional nodal metastasis in patients with esophageal cancer before surgery.

METHODS

A computer search about PET-CT original articles was conducted from January 2000 to December 2012. The reference standard was histopathologic analysis. Two reviewers independently searched articles and extracted data. Sensitivity, specificity, diagnostic odds ratio, and likelihood ratio were pooled for PET-CT using bivariate models. Summary receiver operating characteristic (SROC) curves were also used to summarize overall test performance.

RESULTS

Across all seven studies on a per-station analysis (2232 stations), the pooled sensitivity and specificity with 95% confidence interval for PET-CT were 0.62 (0.40-0.79) and 0.96 (0.93-0.98). Across all 6 studies on a per-patient analysis (245 patients), corresponding values for PET-CT were 0.55 (0.34-0.74) and 0.76 (0.66-0.83).

CONCLUSIONS

(18)FDG PET-CT had lower sensitivity and accuracy for detection of regional nodal metastasis in patients with esophageal cancer before surgery.

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.