Utility of baseline positron emission tomography with computed tomography for predicting endoscopic resectability and survival outcomes in patients with early esophageal adenocarcinoma

The role of primary tumor SUVmax in the diagnosis of invasion depth: a step toward clinical T2N0 esophageal cancer

Background

The controversy regarding optimal clinical T2N0 esophageal cancer treatment ultimately stems from the clinical staging modalities’ inaccuracy. Because most inaccuracies lie in clinical T2 to pathological T1, it is vital to discriminate whether the muscularis propria is invaded.

Methods

We investigated the association between the primary tumor maximal standard uptake value (SUVmax), and the pathological features and overall survival. We attempted to construct a discriminative model through logistic regression analysis.

Results

A total of 140 cN0 esophageal squamous cell carcinoma (ESCC) patients were enrolled. Primary tumor SUVmax differed significantly in paired pathological T categories (P<0.05), but not pT2 vs. pT3 (P=0.648). Age (≤65 vs. >65), biopsy differentiation grades (well or moderately vs. poorly vs. unknown), and primary tumor SUVmax (continuous) were independent risk factors for invasion depth. Subsequently, the age categories, the biopsy differentiation grade categories, and the primary tumor SUVmax categories (≤7.4 vs. >7.4) were included in the logistic regression analysis to construct a discriminative model, showing a good performance in discriminating pT2–3 vs. pT1 in terms of accuracy 87.1%, sensitivity 93.6%, specificity 73.9%, and area under the curve (AUC) 0.887 [95% confidence interval (CI): 0.822 to 0.951]. Of these factors, biopsy differentiation grades and primary tumor SUVmax showed significant differences in overall survival (P<0.05), while the age categories did not.

Conclusions

The novel baseline model comprised of age, biopsy differentiation grades, and primary tumor SUVmax provide much discriminative performance in determining whether the muscularis propria is invaded. Further studies are necessary to validate the findings and guide clinical practice for cT2N0 esophageal cancer.

Metabolic parameters of sequential 18F-FDG PET/CT predict overall survival of esophageal cancer patients treated with (chemo-) radiation

BACKGROUND

To evaluate the prognostic value of metabolic parameters of pre-treatment and interim 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) for overall survival (OS) of esophageal cancer(EC) patients undergoing (chemo-) radiotherapy.

METHODS

A retrospective analysis of 134 patients with pathology confirmed squamous cell EC treated between July 2009 and October 2013 in our hospital was performed. Inclusion criteria for this study were curative intended radiotherapy and availability of pre-treatment and interim 18F-FDG PET. 18F-FDG PET/CT scans were acquired before treatment and after 40 Gray (Gy) of radiotherapy. Maximum standard uptake value (SUV_max), metabolic tumor volume(MTV), total lesion glycolysis (TLG), and the percentual changes during both PET scans were recorded. The parameters were named as SUVmax1,MTV1,TLG1,SUVmax2,MTV2,TLG2,△SUV_max,△MTV and △TLG. The receiver operating characteristic curve (ROC) was used to analyze the relationship between metabolic parameters and OS, survival analysis was carried out by Kaplan-Meier and Cox regression analysis.

RESULTS

Univariate survival analysis showed that SUVmax2、MTV1、△MTV、TLG1、TLG2 and △TLG were associated with OS. Based on the largest Youden index of ROC curves, patients with SUVmax2 < 7.8, MTV1 < 10.5, △MTV < 0.075, TLG1 < 59.8, TLG2 < 44.3 and △TLG < 0.27 tended to live longer. Stratified for these parameters, the estimated median survival time were 27.9 months (m) vs 9.8 m, 36.9 m vs 11.3 m, 41.6 m vs 12 m, 48.9 m vs 14.3 m, 32.6 m vs 13.2 m, and 41.6 m vs 14.5 m. Cox multi-factor regression analyses revealed SUV_max2 as an independent prognostic factor for OS complementary to TNM staging and the length of primary tumor.

CONCLUSIONS

Sequential 18F-FDG PET/CT metabolic parameters bear important prognostic value for OS of EC patients. 18F-FDG PET/CT scan before treatment and during chemoradiotherapy seems helpful to evaluate the effect of chemoradiotherapy, guide clinical decisions and provide patients with personalized treatment.

Prognostic value of pre-treatment F-18-FDG PET-CT in patients with hepatocellular carcinoma undergoing radioembolization

AIM

To evaluate the value of pre-treatment 18F-FDG PET/CT in patients with HCC following liver radioembolization.

METHODS

We identified 34 patients with HCC who underwent an FDG PET/CT scan prior to hepatic radioembolization at our institution between 2009 and 2013. Patients were seen in clinic one month after radioembolization and then at 2-3 mo intervals. We assessed the influence of FDG tumor uptake on outcomes including local liver control (LLC), distant liver control (DLC), time to distant metastases (DM), progression free survival (PFS) and overall survival (OS).

RESULTS

The majority of patients were males (n = 25, 74%), and had Child Pugh Class A (n = 31, 91%), with a median age of 68 years (46-84 years). FDG-avid disease was found in 19 (56%) patients with SUVmax ranging from 3 to 20. Female patients were more likely to have an FDG-avid HCC (P = 0.02). Median follow up of patients following radioembolization was 12 months (1.2-62.8 mo). FDG-avid disease was associated with a decreased 1 year LLC, DLC, DM and PFS (P < 0.05). Using multivariate analysis, FDG avidity predicted for LLC, DLC, and PFS (all P < 0.05).

CONCLUSION

In this retrospective study, pre-treatment HCC FDG-avidity was found to be associated with worse LLC, DLC, and PFS following radioembolization. Larger studies are needed to validate our initial findings to assess the role of F-18-FDG PET/CT scans as biomarker for patients with HCC following radioembolization.

The HIF/PHF8/AR axis promotes prostate cancer progression

Recent studies provide strong evidence that the androgen receptor (AR) signaling pathway remains active in castration-resistant prostate cancer (CRPC). However, the underlying mechanisms are not well understood. In this study, we demonstrate that plant homeo domain finger protein 8 (PHF8 )interacts with and functions as an essential histone demethylase activity-dependent AR coactivator. Furthermore, we demonstrate that the expression of PHF8 is induced by hypoxia in various prostate cancer cell lines. Knockdown of either hypoxia-inducible factor HIF2α or HIF1α almost completely abolished hypoxia-induced PHF8 expression. Importantly, we observed that PHF8 is highly expressed in clinical androgen deprived prostate cancer samples and expression of PHF8 correlates with increased levels of HIF1α and HIF2α. Moreover, elevated PHF8 is associated with higher grade prostate cancers and unfavorable outcomes. Our findings support a working model in which hypoxia in castrated prostate cancer activates HIF transcription factors which then induces PHF8 expression. The elevated PHF8 in turn promotes the AR signaling pathway and prostate cancer progression. Therefore, the HIF/PHF8/AR axis could serve as a potential biomarker for CRPC and is also a promising therapeutic target in combating CRPC.

Oesophageal carcinoma: comparison of ex vivo high-resolution 3.0 T MR imaging with histopathological findings

High-resolution magnetic resonance (MR) images clearly depict the normal oesophageal wall as consisting of eight layers, which correlates well with histopathological findings. In 56 (91.8%) of 61 lesions, the depth of oesophageal wall invasion determined through MR imaging was consistent with histopathological staging (r = 0.975, P < 0.001). The sensitivity, specificity and accuracy for the mucosa were 71.4%, 98.1%, and 95.1%, respectively, and the corresponding values for the submucosa were 82.4%, 95.5%, and 91.8%; for the muscularis propria, the sensitivity, specificity and accuracy were 100%, 95.7%, and 96.7%, respectively, and for the adventitia, these values were 100%, 100%, and 100%. The Cohen k values for interobserver agreement were excellent: K = 0.839, P < 0.001 (observer 1 vs. observer 2); K = 0.908, P < 0.001 (observer 1 vs. observer 3); and K = 0.885, P < 0.01 (observer 2 vs. observer 3). High-resolution ex vivo MR images obtained with a 3.0 T scanner can be used to precisely evaluate oesophageal carcinoma invasion and provide good diagnostic sensitivity, specificity and accuracy.

Esophageal carcinoma: Ex vivo evaluation by high-spatial-resolution T2 -mapping MRI compared with histopathological findings at 3.0T

PURPOSE

To prospectively determine the feasibility of T₂ -mapping magnetic resonance imaging (MRI) to quantitatively describe the signal characteristics of the normal esophageal wall and assess the depth of esophageal wall invasion by carcinoma at 3.0T.

MATERIALS AND METHODS

Thirty-two patient specimens, each having foci of carcinoma, were studied using 3.0T MR. Freehand regions of interest were placed to measure the T₂ value of the normal esophageal layers and were compared with the regions of carcinoma. Three independent readers reviewed the MR images to evaluate the depth of carcinoma invasion; when the three radiologists could not fully agree with each other, the final stage was determined by consensus. The Games-Howell test was used to compare the difference between the normal esophageal layers and carcinoma. Spearman correlation coefficient analysis was used to compare the stage at MRI with that at histopathological analysis. The interobserver agreement was compared with Cohen's kappa. The sensitivity, specificity, and accuracy for detecting carcinoma invasion were calculated.

RESULTS

The T₂ values between the carcinoma and normal esophageal layers were different (all P < 0.01), except for the inner circular muscle (P = 0.511). The T₂ value of each layer of the normal esophageal wall was also different from that of the adjacent layer (all P < 0.01). In 29 of 32 lesions, the depth of the esophageal wall invasion determined by MR was consistent with the histopathological stage (r = 0.969, P < 0.001). The sensitivity, specificity, and accuracy were 80%, 96.3%, and 93.8%, respectively, for invasion into the mucosa; 77.8%, 95.7%, and 90.6%, respectively, for invasion into submucosa; 100%, 95.8%, and 96.9%, respectively, for invasion into muscularis propria; and 100%, 100%, and 100%, respectively, for invasion into the adventitia.

CONCLUSION

T₂ -mapping MR images obtained using a 3.0T MR scanner can be used to depict the precise histopathological layers of the esophageal wall clearly and provide excellent diagnostic accuracy for assessing esophageal carcinoma invasion.

LEVEL OF EVIDENCE

1 Technical Efficacy: Stage 2 J. MAGN. RESON. IMAGING 2017;45:1609-1616.

Epidemiology, Diagnosis, and Management of Esophageal Adenocarcinoma

Esophageal adenocarcinoma (EAC) is rapidly increasing in incidence in Western cultures. Barrett's esophagus is the presumed precursor lesion for this cancer. Several other risk factors for this cancer have been described, including chronic heartburn, tobacco use, white race, and obesity. Despite these known associations, most patients with EAC present with symptoms of dysphagia from late-stage tumors; only a small number of patients are identified by screening and surveillance programs. Diagnostic analysis of EAC usually commences with upper endoscopy followed by cross-sectional imaging. Endoscopic ultrasonography is useful to assess the local extent of disease as well as the involvement of regional lymph nodes. T1a EAC may be treated endoscopically, and some patients with T1b disease may also benefit from endoscopic therapy. Locally advanced disease is generally managed with esophagectomy, often accompanied by neoadjuvant chemoradiotherapy or chemotherapy. The prognosis is based on tumor stage; patients with T1a tumors have an excellent prognosis, whereas few patients with advanced disease have long-term survival.

Positron Emission Tomography (PET) in Oncology

Since its introduction in the early nineties as a promising functional imaging technique in the management of neoplastic disorders, FDG-PET, and subsequently FDG-PET/CT, has become a cornerstone in several oncologic procedures such as tumor staging and restaging, treatment efficacy assessment during or after treatment end and radiotherapy planning. Moreover, the continuous technological progress of image generation and the introduction of sophisticated software to use PET scan as a biomarker paved the way to calculate new prognostic markers such as the metabolic tumor volume (MTV) and the total amount of tumor glycolysis (TLG). FDG-PET/CT proved more sensitive than contrast-enhanced CT scan in staging of several type of lymphoma or in detecting widespread tumor dissemination in several solid cancers, such as breast, lung, colon, ovary and head and neck carcinoma. As a consequence the stage of patients was upgraded, with a change of treatment in 10%-15% of them. One of the most evident advantages of FDG-PET was its ability to detect, very early during treatment, significant changes in glucose metabolism or even complete shutoff of the neoplastic cell metabolism as a surrogate of tumor chemosensitivity assessment. This could enable clinicians to detect much earlier the effectiveness of a given antineoplastic treatment, as compared to the traditional radiological detection of tumor shrinkage, which usually takes time and occurs much later.

Endoscopic assessment and management of early esophageal adenocarcinoma

Esophageal carcinoma affects more than 450000 people worldwide and the incidence is rapidly increasing. In the United States and Europe, esophageal adenocarcinoma has superseded esophageal squamous cell carcinoma in its incidence. Esophageal cancer has a high mortality rates secondary to the late presentation of most patients at advanced stages. Endoscopic screening is recommended for patients with multiple risk factors for cancer in Barrett’s esophagus. These risk factors include chronic gastroesophageal reflux disease, hiatal hernia, advanced age, male sex, white race, cigarette smoking, and obesity. The annual risk of esophageal cancer is approximately 0.25% for patients without dysplasia and 6% for patients with high-grade dysplasia. Twenty percent of all esophageal adenocarcinoma in the United States is early stage with disease confined to the mucosa or submucosa. The significant morbidity and mortality of esophagectomy make endoscopic treatment an attractive option. The American Gastroenterological Association recommends endoscopic eradication therapy for patients with high-grade dysplasia. Endoscopic modalities for treatment of early esophageal adenocarcinoma include endoscopic resection techniques and endoscopic ablative techniques such as radiofrequency ablation, photodynamic therapy and cryoablation. Endoscopic therapy should be precluded to patients with no evidence of lymphovascular invasion. Local tumor recurrence is low after endoscopic therapy and is predicted by poor differentiation of tumor, positive lymph node and submucosal invasion. Surgical resection should be offered to patients with deep submucosal invasion.