Role of endoscopic ultrasonography in the staging and follow-up of esophageal cancer

Endoscopic ultrasound-based radiomics for predicting pathologic upgrade in esophageal low-grade intraepithelial neoplasia

BACKGROUND

There is no consensus on managing patients with endoscopic suspicion of early esophageal squamous cell carcinoma (ESCC) but biopsy-confirmed low-grade intraepithelial neoplasia (LGIN). The aim of this study is to evaluate the utility of an endoscopic ultrasound (EUS)-based radiomics nomogram for predicting esophageal LGIN pathological progression before diagnostic endoscopic submucosal dissection (ESD).

METHODS

In the development phase, EUS images of 535 patients who had biopsy-confirmed LGIN and were undergoing ESD were retrospectively included. Concurrently, 251 patients were prospectively included for independent model validation. A radiomics signature (RS) was constructed using Pearson test and the least absolute shrinkage and selection operator (LASSO) algorithm. A radiomics nomogram was then developed with multivariate logistic regression to predict pathologic upgrade before ESD. Model performance was assessed with receiver operating characteristic (ROC) analysis, calibration curves, and decision curve analysis (DCA).

RESULTS

Following stepwise multivariate logistic regression analysis, statistically significant clinical features were incorporated into the clinical predictive model. From EUS images, 105 radiomic features were extracted, with 11 key features selected for RS development. The RS showed strong predictive performance in identifying pathologic upgrade (AUC = 0.786). Moreover, when integrated with the clinical model (AUC = 0.648), the RS performance remarkably improved (AUC = 0.818). These results were subsequently validated in the prospective test cohort (RS: AUC = 0.792; Clinical model: AUC = 0.669; Combined model: AUC = 0.821). The combined model presented as a nomogram also excelled in calibration tests and DCA, underlining its potential for clinical application.

CONCLUSION

The EUS-based radiomics nomogram showed potential for predicting pathologic upgrade in esophageal LGIN, which helps to distinguish high-risk from low-risk cases and assists clinicians in assessing the necessity of diagnostic ESD.

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.

Endoscopic ultrasound for structured surveillance after curative treatment of esophageal cancer

BACKGROUND

Structured surveillance after treatment of esophageal cancer is not established. Due to a paucity of data, no agreement exists on how surveillance should be performed. The main argument against intensive follow-up in esophageal cancer is that it may not lead to true survival advantage.

METHODS

Structured surveillance was performed in 42 patients after multimodal therapy with peri-operative chemotherapy (29) or definitive chemoradiotherapy (13) of esophageal cancer. The surveillance protocol included gastroscopy, endoscopic ultrasound, chest X-ray, abdominal ultrasound, and CEA measurement at regular intervals of up to five years. We analyzed relapse rate, time to relapse, localization of recurrence, diagnosis within or without structured surveillance, diagnostic method providing the first evidence of a relapse, treatment of recurrence, and outcome.

RESULTS

Median follow-up was 48 months; 18/42 patients suffered from tumor relapse, with 16 asymptomatic patients diagnosed within structured surveillance. Median time to recurrence was 9 months. Isolated local or locoregional recurrence occurred in 6, and isolated distant relapse in 9 patients. All patients with isolated locoregional recurrence were exclusively diagnosed with endoscopic ultrasound. Six patients received curatively intended therapy with surgery or chemoradiation, leading to long-lasting survival.

CONCLUSION

Structured surveillance offers the chance to identify limited and asymptomatic tumor relapse. Especially in cases of locoregional recurrence, long-lasting survival or even a cure can be achieved. Endoscopic ultrasound is the best method for the detection of locoregional tumor recurrence and should be an integral part of structured surveillance after curative treatment of esophageal cancer.

The Usability of Intensive Imaging Surveillance After Esophagectomy in Patients with Esophageal Cancer

BACKGROUND

Although imaging surveillance after esophagectomy is required to achieve long-term survival for patients with esophageal cancer, the optimal surveillance timing and interval remain unclear. This study was designed to investigate the differences in oncological outcomes based on the detection method for recurrence and surveillance interval in patients with recurrence detected by routine imaging examination after esophagectomy.

METHODS

A total of 527 patients who underwent thoracic esophagectomy for esophageal cancer with R0 resection between 2003 and 2021 in our department were enrolled in this study. Postoperative, routine surveillance was conducted at an outpatient clinic every 3 months, thoracoabdominal computed tomography (CT) every 4-6 months, and esophagogastroduodenoscopy every 6 months. The detection method and optimal interval of imaging surveillance also were investigated.

RESULTS

Of all patients, 161 patients developed recurrence during surveillance; 110 (68.3 %) by routine surveillance and 37 (23.0%) not detected by routine surveillance. Among patients who were diagnosed with recurrence following routine surveillance, patients with pStage IV disease on imaging surveillance by thoracoabdominal CT at an interval of ≤ 5 months had a better survival rate than those with an interval of 6 months (P = 0.004), whereas no significant difference among different intervals was observed in patients with pStage I-III disease.

CONCLUSIONS

Recurrence may have been detectable by our routine surveillance in approximately 70% of patients who developed recurrence. These findings demonstrate the necessity of different imaging surveillance intervals for different pStages of esophageal cancer.

Clinical models to predict lymph nodes metastasis and distant metastasis in newly diagnosed early esophageal cancer patients: A population-based study

BACKGROUND

Patients with early esophageal cancer (EC) receive individualized therapy based on their lymph node metastasis (LNM) and distant metastasis (DM) status; however, deficiencies in current clinical staging techniques and the issue of cost-effectiveness mean LNM and DM often go undetected preoperatively. We aimed to develop three clinical models to predict the likelihood of LNM, DM, and prognosis in patients with early EC.

METHOD

The Surveillance, Epidemiology, and End Results database was queried for T1 EC patients from 2004 to 2015. Multivariable logistic regression and Cox proportional hazards models were used to recognize the risk factors of LNM and DM, predict overall survival (OS), and develop relevant nomograms. Receiver operating characteristic (ROC)/concordance index and calibration curves were used to evaluate the discrimination and accuracy of the three nomograms. Decision curve analyses (DCAs), clinical impact curves, and subgroups based on model scores were used to determine clinical practicability.

RESULTS

The area under the curve of the LNM and DM nomograms were 0.668 and 0.807, respectively. The corresponding C-index of OS nomogram was 0.752. Calibration curves and DCA showed an effective predictive accuracy and clinical applicability. In patients with T1N0M0 EC, surgery alone (p < 0.01) proved a survival advantage. Chemotherapy and radiotherapy indicated a better prognosis in the subgroup analysis for T1 EC patients with LNM or DM.

CONCLUSIONS

We created three nomograms to predict the likelihood of LNM, DM, and OS probability in patients with early EC using a generalizable dataset. These useful visual tools could help clinical physicians deliver appropriate perioperative care.

Risk factors of lymph node metastasis or lymphovascular invasion for superficial esophageal squamous cell carcinoma: A practical and effective predictive nomogram based on a cancer hospital data

Background

Lymphovascular invasion (LVI) is mostly used as a preoperative predictor to establish lymph node metastasis (LNM) prediction models for superficial esophageal squamous cell carcinoma (SESCC). However, LVI still needs to be confirmed by postoperative pathology. In this study, we combined LNM and LVI as a unified outcome and named it LNM/LVI, and aimed to develop an LNM/LVI prediction model in SESCC using preoperative factors.

Methods

A total of 512 patients who underwent radical resection of SESCC were retrospectively collected. Logistic regression and least absolute shrinkage and selection operator (LASSO) regression were adopted to identify the predictive factors of LNM/LVI. Integrated discrimination improvement (IDI) and net reclassification improvement (NRI) were calculated to select the potential predictive factors from the results of LASSO and logistic regression. A nomogram for predicting LNM/LVI was established by incorporating these factors. The efficacy, accuracy, and clinical utility of the nomogram were, respectively, assessed with the area under the curve (AUC), calibration curve, and decision curve analysis (DCA). Finally, the random forest (RF) algorithm was used to further evaluate the impact of these factors included in the nomogram on LNM/LVI.

Results

Tumor size, tumor location, tumor invasion depth, tumor differentiation, and macroscopic type were confirmed as independent risk factors for LNM/LVI according to the results of logistic regression, LASSO regression, IDI, and NRI analyses. A nomogram including these five variables showed a good performance in LNM/LVI prediction (AUC = 0.776). The calibration curve revealed that the predictive results of this nomogram were nearly consistent with actual observations. Significant clinical utility of our nomogram was demonstrated by DCA. The RF model with the same five variables also had similar predictive efficacy with the nomogram (AUC = 0.775).

Conclusion

The nomogram was adopted as a final tool for predicting LNM/LVI because its risk score system made it more user-friendly and clinically useful than the random forest model, which can help clinicians make optimal treatment decisions for patients with SESCC.

Monitoring for Recurrence After Esophagectomy

BACKGROUND

Current guidelines for follow-up after esophagectomy suggest only history and physical examination (HPE). With recent advances in chemotherapy and immunotherapy for patients with recurrent esophageal cancer, we hypothesized that surveillance imaging (SI) would identify patients with cancer recurrence earlier and improve long-term survival.

METHODS

A retrospective review of all patients undergoing esophagectomy for esophageal cancer at a single institution between 2007 and 2018 was conducted. Patients were categorized as recurrence detected through SI or recurrence detected through HPE alone. Patients were excluded if recurrence occurred within 3 months of esophagectomy.

RESULTS

During the study period, 225 esophageal cancer patients underwent an esophagectomy. Among these, 101 (44.9%) had SI and 124 (55.1%) had routine follow-up with HPE. There were 88 recurrences (39.1%) with median follow-up of 12 months. Rate of recurrence was similar based on screening method: 41 of 101 (40.6%) by SI and 47 of 124 (37.9%) by HPE (P = .68). Among patients with recurrence, recipients of additional treatment were also similar between groups, 36 of 41 (87.8%) by SI and 34 of 47 (72.3%) by HPE (P = .468). Among those who had a recurrence, the median overall survival was significantly longer in those undergoing SI at 23 months compared with those who received HPE at 16 months (P = .047).

CONCLUSIONS

SI after esophagectomy is not associated with improved detection of recurrence, but is associated with improved overall survival once recurrence is detected. These data suggest that earlier identification of esophageal cancer recurrence may have survival benefit. Standardizing SI may prove beneficial for patients after esophagectomy.

Esophagectomy versus definitive chemoradiotherapy as initial treatment for clinical stage I esophageal cancer: a systematic review and meta-analysis

BACKGROUND

Esophagectomy and definitive chemoradiotherapy are commonly used in the treatment of stage I esophageal cancer (EC). The present study aims to compare the efficacy and safety of esophagectomy and definitive chemoradiotherapy as the initial treatment for clinical stage I EC.

METHODS

This study was registered with the International Prospective Register of Systematic Reviews (CRD42020197203). Relevant studies were identified through PubMed, Web of Science, EMBASE, and Cochrane Library from database inception to June 30, 2020. Hazard ratio (HR) with 95% confidence intervals (CI) was employed to compare overall survival (OS) and progression-free survival (PFS). Odds ratio (OR) with 95% CI was employed to compare treatment-related death, complications, and tumor recurrence.

RESULTS

A total of 13 non-randomized controlled studies involving 3,346 patients were included. Compared with definitive chemoradiotherapy, esophagectomy showed an improved OS (HR 0.69, 95% CI 0.55-0.86; P < 0.001), PFS (HR 0.47, 95% CI 0.33-0.67; P < 0.001), and a lower risk of tumor recurrence (OR 0.43, 95% CI 0.30-0.61; P < 0.001). There was no significant difference in the incidence of complications (OR 1.11, 95% CI 0.75-1.65; P = 0.60) and treatment-related death (OR 1.15, 95% CI 0.31-4.30; P = 0.84) between the two treatments.

CONCLUSIONS

Current evidence shows esophagectomy has superior survival benefits as the initial treatment for clinical stage I EC. It is still the preferred choice for patients with clinical stage I EC. However, future high-quality randomized controlled trials are needed to validate this conclusion.

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.

EUS-guided fiducial marker insertion for radiotherapy in advanced esophageal carcinoma: submucosal insertion may lead to less migration when compared to intratumoral insertion

BACKGROUND

The use of radiotherapy is frequently required in the treatment of locally advanced esophageal squamous cell carcinoma. However, the margins of the tumor are often difficult to ascertain on computed tomography. Thus, EUS-guided fiducial marker insertion can aid the localization of the margins of the tumor. However, the optimal technique of the procedure is still uncertain.

METHODS

This was a retrospective study of all patients that received EUS-guided fiducial marker insertion between March 2015 and December 2018. All patients suffering from esophageal squamous cell carcinoma scheduled for radiotherapy underwent the procedure within one week of the scheduled appointment. Gold fiducial markers were inserted under EUS guidance either intratumorally or within the submucosa just proximal and distal to the tumor. Outcome parameters included tumor characteristics, early and late migration rates, and tumor response rates.

RESULTS

During the study period, 40 patients were recruited. 10 fiducial markers were placed intratumorally and 30 markers were placed submucosally. When comparing fiducials that were placed in the submucosa versus intratumorally, significantly more fiducials had early (40% vs 0%, RR = 0.6, 95% CI 0.36, 1.00) and late migration (60% vs 0%, RR = 0.33, 95% CI 0.13, 0.84) in the intratumoral group. The submucosal group had significantly more patients intended for curative intent (96.7% vs 70%, RR = 0.34, 95%CI 0.003, 0.361) and more patients with partial and complete response. There was no difference between the gross tumor volume, the clinical target volume, and the total radiation dose.

CONCLUSION

In esophageal carcinomas planned for radiotherapy, fiducial markers placed in the submucosa may lead to less migration.

Retrospective analysis of predictive factors for lymph node metastasis in superficial esophageal squamous cell carcinoma

This study aimed to identify the risk factors of lymph node metastasis (LNM) in superficial esophageal squamous cell carcinoma and use these factors to establish a prediction model. We retrospectively analyzed the data from training set (n = 280) and validation set (n = 240) underwent radical esophagectomy between March 2005 and April 2018. Our results of univariate and multivariate analyses showed that tumor size, tumor invasion depth, tumor differentiation and lymphovascular invasion were significantly correlated with LNM. Incorporating these 4 variables above, model A achieved AUC of 0.765 and 0.770 in predicting LNM in the training and validation sets, respectively. Adding macroscopic type to the model A did not appreciably change the AUC but led to statistically significant improvements in both the integrated discrimination improvement and net reclassification improvement. Finally, a nomogram was constructed by using these five variables and showed good concordance indexes of 0.765 and 0.770 in the training and validation sets, and the calibration curves had good fitting degree. Decision curve analysis demonstrated that the nomogram was clinically useful in both sets. It is possible to predict the status of LNM using this nomogram score system, which can aid the selection of an appropriate treatment plan.

Chemoradiation Therapy as Definitive Treatment of Esophageal Cancer

Definitive chemoradiation therapy avoids the perioperative and long-term morbidity of esophagectomy and is the standard of care for cervical esophageal cancer. There are significant differences in tumor response to chemoradiation and recurrence patterns between squamous cell cancer and adenocarcinoma of the esophagus. Multimodality therapy for esophageal cancer continues to progress, now with the widespread use of PET scanning and possible active surveillance in patients with complete clinical response to chemoradiation. As drug development and targeted therapy trials continue to expand, our understanding of tumor biology and precision medicine will continue to refine the treatment of esophageal cancer.

A Nomogram for Predicting Lymphovascular Invasion in Superficial Esophageal Squamous Cell Carcinoma

The lymphovascular invasion (LVI) status facilitates the determination of the optimal therapeutic strategy for superficial esophageal squamous cell carcinoma (SESCC), but in clinical practice, LVI must be confirmed by postoperative pathology. However, studies of the risk factors for LVI in SESCC are limited. Consequently, this study aimed to identify the risk factors for LVI and use these factors to establish a prediction model. The data of 516 patients who underwent radical esophagectomy between January 2007 and September 2019 were retrospectively collected (training set, n=361, January 2007 to May 2015; validation set, n=155, June 2015 to September 2019). In the training set, least absolute shrinkage and selection operator (LASSO) regression and multivariate analyses were utilized to identify predictive factors for LVI in patients with SESCC. A nomogram was then developed using these predictors. The area under the curve (AUC), calibration curve, and decision curve were used to evaluate the efficiency, accuracy, and clinical utility of the model. LASSO regression indicated that the tumor size, depth of invasion, tumor differentiation, lymph node metastasis (LNM), sex, circumferential extension, the presence of multiple lesions, and the resection margin were correlated with LVI. However, multivariate analysis revealed that only the tumor size, depth of invasion, tumor differentiation, and LNM were independent risk factors for LVI. Incorporating these four variables, model 1 achieved an AUC of 0.817 in predicting LVI. Adding circumferential extension to model 1 did not appreciably change the AUC and integrated discrimination improvement, but led to a significant increase in the net reclassification improvement (p=0.011). A final nomogram was constructed by incorporating tumor size, depth of invasion, tumor differentiation, LNM, and circumferential extension and showed good discrimination (training set, AUC=0.833; validation set, AUC=0.819) and good calibration in the training and validation sets. Decision curve analysis demonstrated that the nomogram was clinically useful in both sets. Thus, it is possible to predict the status of LVI using this nomogram scoring system, which can aid the selection of an appropriate treatment plan.

Predicting Lymph Node Metastasis Using Computed Tomography Radiomics Analysis in Patients With Resectable Esophageal Squamous Cell Carcinoma

OBJECTIVES

We investigated the value of radiomics data, extracted from pretreatment computed tomography images of the primary tumor (PT) and lymph node (LN) for predicting LN metastasis in esophageal squamous cell carcinoma (ESCC) patients.

MATERIALS AND METHODS

A total 338 ESCC patients were retrospectively assessed. Primary tumor, the largest short-axis diameter LN (LSLN), and PT and LSLN interaction term (IT) radiomic features were calculated. Subsequently, the radiomic signature was combined with clinical risk factors in multivariable logistic regression analysis to build various clinical-radiomic models. Model performance was evaluated with respect to the fit, overall performance, differentiation, and calibration.

RESULTS

A clinical-radiomic model, which combined clinical and PT-LSLN-IT radiomic signature, showed favorable discrimination and calibration. The area under curve value was 0.865 and 0.841 in training and test set.

CONCLUSIONS

A venous computed tomography radiomic model based on the PT, LSLN, and IT radiomic features represents a novel noninvasive tool for prediction LN metastasis in ESCC.

Prognostic Value of CT Imaging-Based Tumor Volume in Patients With Non-Surgical Esophageal Squamous Cell Carcinoma

BACKGROUND

The American Joint Committee on Cancer-Tumor (AJCC-T) staging system for esophageal carcinoma patients, which is based on the depth of tumor invasion, is not applicable in some cases. This study aims to assess the prognostic value of CT imaging-based tumor volume and its usefulness for T staging in patients with non-surgical esophageal squamous cell carcinoma (ESCC).

METHODS

We retrospectively reviewed the records of 158 ESCC patients undergoing definitive (chemo) radiotherapy from two hospitals. Tumor volume based on the CT imaging was calculated using the formula: V = πabc / 6. Three cutoff points for tumor volume were obtained with the X-tile software. Overall survival (OS) was analyzed using the Kaplan-Meier method. The -2 log-likelihood ratio and Akaike Information Criterion (AIC) value were evaluated to compare the AJCC-T staging system with the proposed T staging method.

RESULTS

The median tumor volume was 19.8 cm³ (range from 1.0 to 319.5 cm³). The three optimal cutoff points of tumor volume were 12.7, 22.8, and 51.9 cm³, and the patients were divided into four groups named as proposed T1-T4 stages. The 3-year OS rates in patients with proposed T1 to T4 stages were 67.9%, 30.6%, 21.3%, and 5.3%, respectively. The -2 log-likelihood ratios of the AJCC-T stage and proposed T stage were 1,068.060 and 1,047.418, respectively. The difference in the AIC value between the two T staging systems was 18.642.

CONCLUSION

CT imaging-based tumor volume was superior to the depth of tumor invasion for T staging in predicting the prognosis of non-surgical ESCC patient.

Narrative review of the role of gastroenterologist in the diagnosis, treatment and palliation in gastric and gastroesophageal cancer

Esophageal cancer (EC) and gastric cancer (GC) carry a high mortality rate. Unfortunately, a majority of patients are asymptomatic and at the time of diagnosis, the disease may invariably be in its advanced stages with limited curative options. Thus, it is imperative to recognize certain risk factors including gastroesophageal reflux disease (GERD), male gender, pre-existing Barrett’s esophagus, smoking history, obesity, Helicobacter pylori infection, atrophic gastritis among others for both EC and GC, intervene on time with screening and surveillance modalities if indicated and optimize treatment plans. With advances in endoscopic techniques, early neoplastic lesions are increasingly managed by gastroenterologists, offering an alternative to surgery. The gold standard for diagnosis of EC and GC is high definition endoscopy with adequate targeted biopsies. Endoscopic ultrasound (EUS) is a key in the staging of early cancers dictating the pathway for treatment options. We also play a key role in palliation cases with the aim to reduce the symptoms like nausea, vomiting and even when possible, restore oral intake and improve nutrition in both advanced GC and EC. This review article discusses the risk factors, diagnostic and endoscopic treatment modalities of early EC and GC and palliation of advanced cancer where gastroenterologists play a key role.

Novel Endoscopic Criteria for Predicting Tumor Invasion Depth in Superficial Esophageal Squamous Carcinoma

BACKGROUND

Accurate prediction of tumor invasion depth in superficial esophageal squamous carcinoma (SESC) is essential for deciding the appropriate treatment strategy. We proposed novel endoscopic criteria to differentiate between mucosal and submucosal esophageal cancers and to evaluate the diagnostic accuracy and usefulness of the criteria.

METHODS

A total of 352 patients who underwent endoscopic or surgical resection for SESC between 1991 and 2010 were included. First, the novel endoscopic criteria were created based on the endoscopic features of 60 randomly selected patients as follows: for T1m cancers, I. flat or slightly elevated or depressed lesion with smooth/even surface of any size, II. slightly elevated lesion of ≤ 1 cm with granular or uneven surface, III. hyperemic flat lesion of ≤ 3 cm with granular or uneven surface, IV. slightly depressed lesion of ≤ 2 cm with uneven surface and for T1sm cancers, I. irregularly (unevenly) nodular or protruded lesion of any size, II. slightly elevated lesion of > 1 cm with granular or uneven surface, III. hyperemic flat lesion of > 3 cm with granular or uneven surface, IV. irregularly (unevenly) depressed lesion of > 2 cm, and V. ulcerative lesion of any size. Next, the endoscopic findings of the remaining 292 patients were reviewed according to the criteria.

RESULTS

The accuracy of novel endoscopic criteria was 79.5% (232/292). The sensitivity and specificity of mucosal cancers were 78.4% and 81.0%, respectively, whereas those for submucosal cancers were 81.0% and 78.4%, respectively. The accuracy for mucosal cancers was high (97.3%, 72/74) when the lesions were flat or slightly elevated/depressed with smooth/even surface regardless of size, whereas that for submucosal cancers was high (85.7%, 18/21) when the lesions were irregular/nodular protrusions regardless of size. In multivariate analysis, macroscopic type IIb lesion was identified as an independent factor affecting accuracy (P < 0.05). The difference in recurrence-free survival rates between endoscopically mucosal and submucosal cancers was significant (P = 0.026).

CONCLUSION

The novel endoscopic criteria appear to be accurate and useful in predicting invasion depth in SESC. Our criteria might help not only to decide the treatment strategy between surgery and endoscopic resection but also to predict the outcomes of SESC.

Pretreatment Primary Tumor Stage is a Risk Factor for Recurrence in Patients with Esophageal Squamous Cell Carcinoma Who Achieve Pathological Complete Response After Neoadjuvant Chemoradiotherapy

Background

Although pathological complete response (pCR) after multimodal treatment for esophageal cancer is associated to the best prognosis, recurrence may occur in 20–40% of cases. The present study investigated the recurrence pattern and predictive factors of recurrence after pCR in patients with esophageal cancer.

Methods

In this study, 427 patients received preoperative treatment for either esophageal squamous cell carcinoma (SCC) or adenocarcinoma at Verona University Hospital between 2000 and 2018. Of these, 145 patients (34%) achieved a pCR. Long-term prognosis, recurrence pattern, and risk factors for relapse in pCR patients were analysed.

Results

During a median follow-up of 52 months, 37 relapses (25.5%) occurred, mostly at distant level (n = 28). Nearly all locoregional relapses (8/9) were detected in SCC cases. The 5-year overall survival and cancer-related survival were 71.7% (95% confidence interval [CI] 62.6–78.9%) and 77.5% (95% CI 68.5–84.2%) respectively. Male sex, higher body mass index, and cT4 were significant risk factors for recurrence at univariate analysis. The multivariate analysis confirmed the role of cT4 as predictor of recurrence only in SCCs.

Conclusions

Esophageal cancer recurs in about one-fourth of pCR cases. A fair number of local recurrences occurs in SCCs, but the main problem is the systemic disease control. According to our analysis, SCCs patients with cT4 stage have an increased risk to recur, so they should be managed differently by a personalized approach in terms of adjuvant treatment and follow-up.

Balloon Dilation for Endosonographic Staging in Esophageal Cancer: A Phase 1 Clinical Trial

BACKGROUND

Dilation in patients with malignant esophageal strictures precluding the passage of the endoscopic ultrasonography (EUS) scope allows complete evaluation; however, it may be associated with complications. This study evaluates the safety and clinical value of balloon dilation to complete EUS in patients with stenotic esophageal cancers.

METHODS

This study consists of a phase I clinical trial. One-hundred-and fifty patients were recruited. Endoscopic balloon dilation was performed before EUS in patients with high-grade stenosis. The analysis was focused on the ability to complete an endosonographic examination after dilation, 30-day morbidity, and change in the final stage or definitive management based on the completed endosonographic examination.

RESULTS

Dilation was required in 55 patients (36.7%), with a complication rate of 10.9% (n = 6). Dilation allowed completion of EUS in 53 patients (96.4%), leading to a modification of the clinical stage for 18 patients (34%) and a deviation in the treatment plan in 7 patients (13.2%). No differences were found in these variables when compared with the group that did not require dilation (26.3% and 14.7%, P = .33 and P = .79, respectively). Dilation was associated with more advanced disease on final pathology among patients who underwent surgical resection (P = .006).

CONCLUSIONS

High-grade malignant esophageal strictures that preclude the passage of the ultrasound probe are associated with advanced stage disease. Owing to the high risk of perforation and the limited benefit in staging, balloon dilation to complete the EUS staging should be avoided. (Clinicaltrials.gov identifier: NCT01950442.).

MRI features in differentiating mucosal high-grade neoplasia from early invasive squamous cell cancer of the esophagus

OBJECTIVES

To evaluate the diagnostic accuracy of unenhanced and contrast-enhanced MRI in the differentiation of mucosal high-grade neoplasia (MHN) from early invasive squamous cell cancer (EISCC) of the esophagus.

METHODS

Between March 2015 and January 2019, 72 study participants with MHN (n = 46) and EISCC (n = 26) of the esophagus were enrolled in this prospective study. Postoperative histopathologic analysis 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)). Two radiologists, blinded to participants' data, independently evaluated MRI and assigned MR features including shape (mucosal thickening or focal mass), signal on T2-msTSE and DWI, enhancement degree (intense or slight), and enhancement pattern (homogeneous, heterogeneous, or heart-shaped). Diagnostic performance of the 5 features was compared using the chi-square test; kappa values were assessed for reader performance.

RESULTS

Surgery was performed within 3.6 + 3.5 days after MR imaging. Inter-reader agreement on MR features was excellent (kappa value = 0.854, p < 0.001). All 8 mass-like MHN were "heart-shaped" in appearance. The degree of enhancement showed the best diagnosis performance in differentiating between MHN and EISCC of the esophagus. The combination of all 5 features had only borderline improved sensitivity, specificity, and AUC of 100%, 96.2%, and 0.999, respectively, which was not statistically significant compared with the degree of enhancement alone.

CONCLUSIONS

MRI can differentiate MHN from EISCC in esophagus; the presence of "heart-shaped" appearance favors the diagnosis of MHN.

KEY POINTS

• All 8 mass-like MHN showed a "heart-shaped" enhancement pattern which may help differentiating MHN from EISCC. • Degree of enhancement had the best diagnostic performance in differentiating between MHN and EISCC in esophagus. • The combined 5 features (shape, signal in T2-msTSE and DWI, enhancement degree, and enhancement pattern) provided sensitivity, specificity, and AUC of 100%, 96.2%, and 0.999, respectively, which was not statistically significant than tumor enhancement alone in distinguishing MHN from EISCC.

Submucosal Saline Injection Followed by Endoscopic Ultrasound versus Endoscopic Ultrasound Only for Distinguishing between T1a and T1b Esophageal Cancer

PURPOSE

To examine whether submucosal saline injection (SSI) can improve traditional endoscopic ultrasound (EUS) accuracy in distinguishing between T1a and T1b stage esophageal squamous cell carcinoma (ESCC).

EXPERIMENTAL DESIGN

Patients with T1N0M0 stage ESCC (n = 180) ages 18 to 85 years were enrolled between February 14, 2012 to June 4, 2018 at Sun Yat-sen University Cancer Center (Guangdong, China). They were randomly assigned (1:1) to receive either EUS examination after 3-5 mL SSI or EUS only examination. All the patients were referred to thoracic surgeons to receive endoscopic resection (ER) or esophagectomy 5 to 10 days after EUS examination. Standard EUS criteria were used to preoperatively stage the ESCC cases, and surgical pathology reports after referral were used to postoperatively stage the cases. The primary endpoint was the diagnostic accuracy of T1b staging [defined as the sum of the true positive (T1b) and true negative (T1a) cases divided by the total number of cases].

RESULTS

Among the per-protocol population, the SSI+EUS group (n = 81) was superior to the EUS-only group (n = 85) in terms of the diagnostic accuracy for T1b staging [93.8% (95% confidence interval (CI), 88.6-99.1) vs. 65.9% (95% CI, 55.8-76.0); P < 0.001]. The positive predictive value of SSI+EUS for diagnosing T1b ESCC reached 90.9% (95% CI, 81.1-100), which was significantly superior to that of EUS only [0.576 (0.450-0.702), P = 0.001].

CONCLUSIONS

SSI significantly improves the diagnostic accuracy of EUS in distinguishing between T1a and T1b ESCC, which might help avoid unnecessary esophagectomy and diagnostic ER.

A Novel Liquid Fiducial Marker in Esophageal Cancer Image Guided Radiation Therapy: Technical Feasibility and Visibility on Imaging

PURPOSE

To assess the technical feasibility of injection, visibility on imaging modalities, and positional stability of a novel liquid fiducial marker (ie, BioXmark) for radiation therapy in patients with esophageal cancer.

METHODS

First, the visibility on imaging of different volumes of the liquid marker was analyzed ex vivo in porcine tissue (ie, on computed tomography [CT], cone beam CT (CBCT), and magnetic resonance imaging [MRI]). Next, for the in vivo part, the liquid fiducial markers were injected under endoscopic (ultrasound) guidance in 10 patients with curable esophageal cancer. The technical feasibility of the injection procedure and the clinical performance (ie, visibility and positional stability on imaging) were evaluated. Planning CT, daily CBCT, and serial MRI images (before, during, and after chemoradiation therapy in a subset of 3 patients) were acquired.

RESULTS

Ex vivo, the optimal volume for good visibility without artifacts was 0.1 mL per injected marker. In vivo, a total of 28 markers were injected in 10 patients (range, 0.025-0.1 mL). No adverse effects were identified. The first 2 cases (4 markers) were considered as learning cases. A total of 19 of 24 of the liquid markers (79%) were visible on CT, 3 of 4 (75%) on MRI, and 19 of 24 (79%) on the first CBCT. All markers with an injected volume of >0.05 mL were visible on the different imaging modalities. Positional stability analysis on CBCT identified no time trend during the radiation therapy course. No artifacts could be detected for liquid marker volumes of 0.05 and 0.025 mL in CT or CBCT.

CONCLUSIONS

Injection of a liquid fiducial marker for esophageal cancer radiation therapy is technically feasible with no adverse events identified. Volumes of >0.05 mL have an appropriate visibility on CT, CBCT, and MRI, with an excellent positional stability. Liquid fiducial markers are therefore promising for use in image guided radiation therapy.

Proposed revision of the 8th edition AJCC clinical staging system for esophageal squamous cell cancer treated with definitive chemo-IMRT based on CT imaging

PURPOSE

To validate and propose revision of the 8th edition American Joint Committee on Cancer (AJCC) clinical staging system for esophageal squamous cell cancer (ESCC) patients treated with definitive intensity-modulated radiation therapy combined with concurrent chemotherapy (Chemo-IMRT) based on computed tomography (CT) imaging.

METHODS

The clinical data of patients with ESCC treated with Chemo-IMRT were collected and retrospectively reviewed. All CT images were independently reevaluated and restaged according to the 8th edition AJCC staging system. The overall survival (OS) rates were analyzed statistically. ROC curves of the various parameters of the primary tumor and metastatic lymph nodes were generated in order to identify the cutoff values correlated to patient survival using the area under curve.

RESULTS

The gross tumor volume of the primary tumor (GTV-prT) and the clinical N stage (cN) were independent factors that influenced OS. The 5-year OS rate of patients with GTV-prT ≤28 cm3, GTV-prT > 28 and ≤ 56 cm3, and GTV-prT > 56 cm3 were 54.6, 31.1 and 18.6%, respectively. The 5-year OS rate of patients with cN0, cN1 SLNM (-), cN2 SLNM (-), cN3 SLNM (-) and SLNM (+) were 62.8 (P < 0.001), 34.0 (P = 0.16), 20.0 (P = 0.785), 0 (P < 0.001) and 26.9%, respectively. After restaging the SLNM as regional MLNs, the 5-year OS rates of the patients with cN0, 1, 2 and 3 were 62.8, 36.3, 23.7 and 7.8%, respectively. Various GTV-prT were combined with the cN to establish a new clinical TNM staging system: I, GTV-prT1 and cN0; II, GTV-prT2 or 3 and cN0, GTV-prT1 and cN1; III, GTV-prT1 and cN2, GTV-prT2 and cN1,2; Iva, GTV-prT3 and cN1,2; IVb, GTV-prTany and cN3; IVc, TanyNanyM1. Subsequently, the OS differed significantly between the adjacent GTV-prT cN categories, except those of stage I vs. II.

CONCLUSION

The SLNM should be dealt with as a regional rather than a distant disease in patients with ESCC when treated with CRT. The proposed nonsurgical staging system based on the GTV-prT and N appears to be a simple and accurate prognosis predictor for patients with ESCC who have undergone definitive Chemo-IMRT.

[Chemoradiation for oesophageal cancer: A critical review of the literature]

Locally advanced oesophageal cancer treatment requires a multidisciplinary approach with the combination of chemotherapy and radiotherapy for preoperative and definitive strategy. Preoperative chemoradiation improves the locoregional control and overall survival after surgery for locally advanced oesophageal cancer. Definitive chemoradiation can also be proposed for non-resectable tumours or medically inoperable patients. Besides, definitive chemoradiation is considered as an alternative option to surgery for locally advanced squamous cell carcinomas. Chemotherapy regimen associated to radiotherapy consists of a combination of platinum derived drugs (cisplatinum or oxaliplatin) and 5-fluorouracil or a weekly scheme combination of carboplatin and paclitaxel according to CROSS protocol in a neoadjuvant strategy. Radiation doses vary from 41.4Gy to 45Gy for a preoperative strategy or 50 to 50.4Gy for a definitive treatment. The high risk of lymphatic spread due to anatomical features could justify the use of an elective nodal irradiation when the estimated risk of microscopic involvement is higher than 15% to 20%. An appropriate delineation of the gross tumour volume requires an exhaustive and up-to-date evaluation of the disease. Intensity-modulated radiation therapy represents a promising approach to spare organs-at-risk. This critical review of the literature underlines the roles of radiotherapy for locally advanced oesophageal cancers and describes doses, volumes of treatment, technical aspects and dose constraints to organs-at-risk.

Clinical implication of the innovations of the 8th edition of the TNM classification for esophageal and esophago-gastric cancer

Epidemiology of esophageal cancer and esophagogastric junction (EGJ) has deeply changed for the past two decades with a dramatically increase of adenocarcinoma whereas squamous cell carcinoma (SCC) has slowly decreased. Moreover, the two histological types differ in a number of features including risks factors, tumor location, tumor biology and outcomes. In acknowledgement of these differences, the newest 8^th edition of the American Joint Committee on Cancer (AJCC) tumor, node and metastasis (TNM) staging classification of epithelial cancers of the esophagus and EGJ has refined this histology-specific disease stage with incorporation of new anatomic and non-anatomic categories. Based on data-driven of patients collected through the Worldwide Esophageal Cancer Collaboration (WECC) group, the 8^th edition database encompasses a six-continent cohort of 22,654 patients among 33 institutions including patients treated with surgery alone and, for the first time, patients treated after neoadjuvant treatment. Anatomic categories include T descriptors (tumor invasion), N descriptors (regional lymph node invasion) and M descriptors (distant site). Non anatomic categories include grade differentiation (G descriptors) and tumor location (L descriptors). Category descriptors are currently assessed by endoscopy with biopsy, by endoscopy ultrasound fine-needle aspiration (EUS-FNA), by thoracic-abdominal-pelvic computed tomography (CT) and whole body flurodeoxyglucose positron emission tomography (FDG-PET) fused with CT. The new 8^th edition considers separate and temporally related cancer classification based on the treatment strategy: clinical cTNM (before any treatment), pathologic pTNM (after surgery alone) and postneoadjuvant pathologic ypTNM (after neoadjuvant treatment followed by surgery). The 8th edition permits a more robust and reliable random forest-based machine learning analysis. Refinement of each T, N, M categories and subcategories makes the 8^th edition more accurate and more adaptable to the current practice including neoadjuvant regimen. The main objective of this review is to examine the current staging of esophageal cancer and the new aspects of the 8^th edition with its applications to clinical practice.

Predicting lymph node metastasis for endoscopic resection of superficial esophageal squamous cell carcinoma

OBJECTIVE

The aims of this study were to identify risk factors for lymph node metastasis and develop a reliable risk stratification system.

METHODS

Between May 2001 and December 2015, 262 patients who underwent endoscopic resection or surgery for superficial esophageal squamous cell carcinoma were enrolled. We evaluated possible predictive factors for lymph node metastasis: age, gender, tumor length, tumor area, circumferential spread, tumor location, gross appearance, depth of invasion, tumor differentiation, and lymphovascular invasion.

RESULTS

The incidence of lymph node metastasis was 14.5% (38/262). In multivariate analysis, tumor size (>15 mm), depth of invasion (submucosal invasion), and lymphovascular invasion were significantly associated with lymph node metastasis. These factors were included in the risk stratification system and assigned scores; the total risk stratification system score was 0 to 6. The area under the receiver operating characteristic curve for predicting lymph node metastasis was 0.869 (95% confidence interval, 0.813-0.926). The high-risk group (risk stratification system score ≥3) exhibited a significantly higher risk of lymph node metastasis than the low-risk group (score <3) (26.5% vs 1.6%). There was no lymph node metastasis in patients with a risk stratification system of 0. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the risk stratification system were 94.7%, 55.4%, 26.5%, 98.4%, and 61.1%, respectively.

CONCLUSIONS

We developed a risk stratification system that should facilitate the identification of patients with a high or low risk of lymph node metastasis. This may aid the precise selection of patients who can undergo endoscopic resection.

Endoscopic evaluation of the esophageal cancer patient after chemoradiotherapy for persistent/recurrent cancer

Endoscopy has an important role in the pre- and post-treatment staging of esophageal cancer. Complete pathologic response following neoadjuvant chemoradiation therapy occurs in approximately 25% of patients. However, the ability to accurately detect this preoperatively with currently available endoscopic modalities is limited such that the default pathway is for fit patients to proceed with surgical resection. This article discusses the available endoscopic modalities (primarily Esophagogastroduodenoscopy [EGD] with mucosal biopsies and endoscopic ultrasonography with or without fine needle aspiration) used for post-treatment staging of esophageal cancer. We present data regarding the benefits and limitations of endoscopic methods in assessing for residual disease. Unfortunately, endoscopic modalities are not accurate enough to identify complete pathological responsers who may avoid surgical resection.

Cancerous esophageal stenosis before treatment was significantly correlated to poor prognosis of patients with esophageal cancer: a meta-analysis

Background

Cancerous esophageal stenosis encountered during endoscopic ultrasonography before treatment was observed in about 30% of esophageal cancer patients. Since the pT stage in TNM classification measures only the depth of infiltration but not the growth to esophagus, it is interesting to know whether tumor growth into the esophagus (and eventual stenosis) is of added value in prognostic assessment. However, the impact of esophageal stenosis on survival of esophageal cancer patient remains unclear. Therefore, we conducted a meta-analysis focusing on current topic for the first time.

Methods

A systematic literature search in PubMed and EMBASE was conducted to identify relevant studies up to 14 March 2018. Data of 5-year overall survival (OS) was extracted and analysed.

Results

A total of five cohort studies consisting of 1,282 patients (278 patients with cancerous esophageal stenosis before treatment and 1,004 patients without) with esophageal cancer treated with surgery, chemoradiotherapy, or palliative therapy were included for analysis. Meta-analysis showed that patients with esophageal stenosis had significantly lower 5-year OS [22.3% and 33.0%, respectively; risk ratio (RR) =1.21; 95% CI, 1.11-1.32; P<0.001; I²=27.1%] than those without. No heterogeneity or publication bias was observed during analysis.

Conclusions

Patients with cancerous esophageal stenosis identified by endoscopy before treatment had significantly poorer survival than those without. High-quality studies with appropriate adjustments for confounding factor are needed to confirm the findings.

Does delayed esophagectomy after endoscopic resection affect outcomes in patients with stage T1 esophageal cancer? A propensity score-based analysis

BACKGROUND

Although endoscopic resection (ER) may be sufficient treatment for early-stage esophageal cancer, additional treatment is recommended when there is a high risk of cancer recurrence. It is unclear whether delaying esophagectomy by performing and assessing the success of ER affects outcomes as compared with immediate esophagectomy without ER. Additionally, long-term survival after sequential ER and esophagectomy required further investigation.

METHODS

Between 2011 and 2015, 48 patients with stage T1 esophageal cancer underwent esophagectomy after ER with curative intent at our institution. Two-to-one propensity score methods were used to identify 96 matched-control patients who were treated with esophagectomy only using baseline patient, tumor characteristics and surgical approach. Time from initial evaluation to esophagectomy, relapse-free survival, overall survival, and postoperative complications were compared between the propensity-matched groups.

RESULTS

In the ER + esophagectomy group, the time from initial evaluation to esophagectomy was significantly longer than in the esophagectomy only group (114 vs. 8 days, p < 0.001). The incidence of dense adhesion (p = 0.347), operative time (p = 0.867), postoperative surgical complications (p = 0.966), and postoperative length of hospital stay (p = 0.125) were not significantly different between the groups. Moreover, recurrence-free survival and overall survival were also similar between the two groups (p = 0.411 and p = 0.817, respectively).

CONCLUSIONS

Treatment of stage T1 esophageal cancer with ER prior to esophagectomy did not increase the difficulty of performing esophagectomy or the incidence of postoperative complications and did not affect survival after esophagectomy. These results suggest that ER can be recommended for patients with stage T1 cancer even if esophagectomy is warranted eventually.

Endoscopic traversability in patients with locally advanced esophageal squamous cell carcinoma: Is it a significant prognostic factor?

The purpose of this study was to evaluate the prognostic impact of endoscopic traversability in patients with locally advanced esophageal squamous cell carcinoma.This retrospective study was based on medical records from a single tertiary medical center. The records of 317 patients with esophageal squamous cell carcinoma treated with surgery or definitive chemoradiotherapy (CRT) between January 2009 and March 2016 were reviewed. Finally, we retrieved the data on 168 consecutive patients. These 168 patients were divided into 2 groups based on their endoscopic traversability findings: Group A (the endoscope traversable group), and Group B (the endoscope non-traversable group). We then retrospectively compared the clinical characteristics of these 2 groups.The endoscope non-traversable group (Group B) revealed an advanced clinical stage, a poor Eastern Cooperative Oncology Group (ECOG) score, a lower serum albumin level, a higher rate of requirement for esophageal stent insertion and definitive CRT as initial treatment than the endoscope traversable group (Group A). Patients with endoscope traversable cancer showed a significantly higher 3-year overall survival and 3-year relapse-free survival than patients who were endoscope non-traversable (53.8% vs 17.3%, P < .001 and 71.1% vs 45.3%, P = .003, respectively). Upon multivariate analysis of patients with locally advanced esophageal squamous cell carcinoma treated with definitive CRT, the serum albumin level <3.5 g/dL and endoscopic non-traversability were significant negative factors of survival.Endoscopic traversability in patients with locally advanced esophageal squamous cell carcinoma treated with definitive CRT is a significant prognostic factor.

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.

Utility of endoscopic ultrasound-guided fine-needle aspiration of regional lymph nodes that are proximal to and far from the primary distal esophageal carcinoma

Implications of assessing the proximal and far para-tracheal or sub-carinal nodes (para-tracheal [PTN] or sub-carinal [SCN]) associated with lower primary esophageal carcinomas (ECs) are unclear. To evaluate the value of endoscopic ultrasound guided fine-needle aspiration (EUS-FNA) for PTN and SCN, we analyzed results by positron emission tomography (PET) avidity, 4 EUS node malignancy features, and EUS-FNA results in all patients with Siewert’s I or II EC. Of 133 patients (PTN, n=102; SCN, n=31) with EUS-FNA, 47 (35%) patients had malignant node, leading to treatment modifications. EUS-FNA diagnosed significantly more patients with malignant nodes (p=0.02) even when PET and EUS features were combined. Among 94 PET-negative and EUS-negative patients, 9 (10%) had malignant EUS-FNA. At a minimum follow-up of 1 year, only 3 (5%) of 62 patients with benign EUS-FNA had evidence of malignancy in the nodal area of prior EUS-FNA. Patients with malignant EUS-FNA independently had a much shorter overall survival (OS) than those with benign EUS-FNA (p<0.001). Our data suggest that a benign EUS-FNA is highly accurate and need not be pursued further. However, malignant EUS-FNA of PTN/SCN was independently prognostic, conferred a shorter OS, and altered the management of 35% of patients.

Clinical implications of endoscopic ultrasonography non-traversability in patients with locoregional esophageal cancer receiving multimodality therapy

BACKGROUND/AIMS

Approximately 30% of esophageal cancer (EC) patients cannot complete endoscopic ultrasonography (EUS) due to malignant stricture (EUS non-traversability). This study examines clinical implications of EUS non-traversability in patients with advanced locoregional squamous EC receiving preoperative chemoradiotherapy (CRT) followed by esophagectomy.

METHODS

We retrieved data on 89 consecutive patients with advanced locoregional squamous EC (stage II or III). Relevant clinical and tumor-specific parameters were reviewed retrospectively. Significant factors affecting survival was determined by Cox regression analysis.

RESULTS

EUS non-traversable EC was observed in 26 of 89 patients (29.2%). Median serum albumin level (3.6 g/dL vs. 3.9 g/dL, p = 0.028), tumor length (6.0 cm vs. 4.0 cm, p = 0.002), and percentage of clinical stage III disease (65.4% vs. 38.1%, p = 0.019) were significantly different between the patients with EUS non-traversable and traversable EC, respectively. Patients with EUS non-traversable EC demonstrated a significantly lower 5-year overall survival than patients with EUS traversable EC (30.8% vs. 49.3%, p = 0.023). In multivariate analysis, weight loss ≥ 10% (p = 0.033), EUS non-traversability (p = 0.003), non-response to preoperative CRT (p = 0.002), and incompletion of esophagectomy (p = 0.002) were significant negative factors of survival.

CONCLUSIONS

EUS non-traversability has significant negative prognostic implications in patients with advanced locoregional squamous EC receiving preoperative CRT followed by esophagectomy.

Preoperative T Staging of Potentially Resectable Esophageal Cancer: A Comparison between Free-Breathing Radial VIBE and Breath-Hold Cartesian VIBE, with Histopathological Correlation

PURPOSE

To compare the T staging of potentially resectable esophageal cancer using free-breathing radial VIBE (r-VIBE) and breath-hold Cartesian VIBE (C-VIBE), with pathologic confirmation of the T stage.

MATERIALS AND METHODS

Fifty patients with endoscopically proven esophageal cancer and indeterminate T1/T2/T3 stage by CT scan were examined on a 3-T scanner. The MRI protocol included C-VIBE at 150 seconds post-IV contrast, immediately followed by a work-in-progress r-VIBE with identical spatial resolution (1.1 mm × 1.1 mm × 3.0 mm). Two independent readers assigned a T stage on MRI according to the 7th edition of UICC-AJCC TNM Classification, and postoperative pathologic confirmation was considered the gold standard. Interreader agreement was also calculated.

RESULTS

The T staging agreement between both VIBE techniques and postoperative pathologic T staging was 52% (26/50) for C-VIBE, 80% (40/50) for r-VIBE for reader 1, and 50% (25/50), 82% (41/50) for reader 2, respectively. For the esophageal cancer with invading lamina propria, muscularis mucosae, or submucosa (T1 stage), r-VIBE achieved 86% (12/14) agreement for both readers 1 and 2. For invasion of muscularis propria (T2 stage), r-VIBE achieved 83% (25/30) for both readers 1 and 2, whereas for the invasion of adventitia (T3 stage), r-VIBE could only achieve agreement in 50% (3/6) and 67% (4/6) for readers 1 and 2, respectively.

CONCLUSION

Contrast-enhanced free-breathing r-VIBE is superior to breath-hold CVIBE in T staging of potentially resectable esophageal cancer, especially for T1 and T2.

Radiation Therapy for Locally Advanced Esophageal Cancer

The treatment of locally advanced esophageal cancer is controversial. For patients who are candidates for surgical resection, multiple prospective clinical trials have demonstrated the advantages of neoadjuvant chemoradiation. For patients who are medically inoperable, definitive chemoradiation is an alternative approach with survival rates comparable to trimodality therapy. Although trials of dose escalation are ongoing, the standard radiation dose remains 50.4 Gy. Modern radiotherapy techniques such as image-guided radiation therapy with motion management and intensity-modulated radiation therapy are strongly encouraged with a planning objective to maximize conformity to the intended target volume while reducing dose delivered to uninvolved normal tissues.

Is endoscopic ultrasound examination necessary in the management of esophageal cancer?

Despite substantial efforts at early diagnosis, accurate staging and advanced treatments, esophageal cancer (EC) continues to be an ominous disease worldwide. Risk factors for esophageal carcinomas include obesity, gastroesophageal reflux disease, hard-alcohol use and tobacco smoking. Five-year survival rates have improved from 5% to 20% since the 1970s, the result of advances in diagnostic staging and treatment. As the most sensitive test for locoregional staging of EC, endoscopic ultrasound (EUS) influences the development of an optimal oncologic treatment plan for a significant minority of patients with early cancers, which appropriately balances the risks and benefits of surgery, chemotherapy and radiation. EUS is costly, and may not be available at all centers. Thus, the yield of EUS needs to be thoughtfully considered for each patient. Localized intramucosal cancers occasionally require endoscopic resection (ER) for histologic staging or treatment; EUS evaluation may detect suspicious lymph nodes prior to exposing the patient to the risks of ER. Although positron emission tomography (PET) has been increasingly utilized in staging EC, it may be unnecessary for clinical staging of early, localized EC and carries the risk of false-positive metastasis (over staging). In EC patients with evidence of advanced disease, EUS or PET may be used to define the radiotherapy field. Multimodality staging with EUS, cross-sectional imaging and histopathologic analysis of ER, remains the standard-of-care in the evaluation of early esophageal cancers. Herein, published data regarding use of EUS for intramucosal, local, regional and metastatic esophageal cancers are reviewed. An algorithm to illustrate the current use of EUS at The University of Texas MD Anderson Cancer Center is presented.

Prospective comparison of MR with diffusion-weighted imaging, endoscopic ultrasound, MDCT and positron emission tomography-CT in the pre-operative staging of oesophageal cancer: results from a pilot study

OBJECTIVE

To compare the diagnostic performance of MR and diffusion-weighted imaging (DWI), multidetector CT, endoscopic ultrasonography (EUS) and 18F-FDG (fluorine-18 fludeoxyglucose) positron emission tomography CT (PET-CT) in the pre-operative locoregional staging of oesophageal cancer.

METHODS

18 patients with oesophageal or Siewert I tumour (9 directly treated with surgery and 9 addressed to chemo-/radiotherapy before) underwent 1.5-T MR and DWI, 64-channel multidetector CT, EUS and PET-CT before (n = 18) and also after neoadjuvant treatment (n = 9). All images were analysed and staged blindly by dedicated operators (seventh TNM edition). Two radiologists calculated independently the apparent diffusion coefficient from the first scan. Results were compared with histopathological findings. After the population had been divided according to local invasion (T1-T2 vs T3-T4) and nodal involvement (N0 vs N+), sensitivity, specificity, accuracy, positive- and negative-predictive values were calculated and compared. Quantitative measurements from DWI and PET-CT were also analysed.

RESULTS

For T staging, EUS showed the best sensitivity (100%), whereas MR showed the highest specificity (92%) and accuracy (83%). For N staging, MR and EUS showed the highest sensitivity (100%), but none of the techniques showed adequate results for specificity. Overall, MR showed the highest accuracy (66%) for N stage, although this was not significantly different to the other modalities. The apparent diffusion coefficient was different between surgery-only and chemo-/radiotherapy groups (1.90 vs 1.30 × 10-3 mm2 s-1, respectively; p = 0.005)-optimal cut off for local invasion: 1.33 × 10-3 mm2 s-1 (p = 0.05). Difference in standardized uptake value was also very close to conventional levels of statistical significance (8.81 vs 13.97 g cm-3, respectively; p = 0.05)-optimal cut off: 7.97 g cm-3 (p = 0.44).

CONCLUSION

In this pilot study, we have shown that MR with DWI could enrich the current pre-operative work-up for oesophageal cancer and could be used for T and N staging. However, larger studies will need to be carried out before introducing this technique in the standard diagnostic pathway, in order to understand if MR with DWI could change its management and replace more costly or invasive tests such as PET-CT or EUS. Advances in knowledge: This pilot study represents the first effort where the four techniques have been prospectively compared together for oesophageal cancer staging. The combination of MR and DWI could provide important, additional information for staging and initial treatment decision-making.

Persistent Dysphagia After Induction Chemotherapy in Patients with Esophageal Adenocarcinoma Predicts Poor Post-Operative Outcomes

PURPOSE

Preoperative therapy is frequently employed in the management of esophageal adenocarcinoma. However, many patients are found to have advanced pathologic stage and have poor outcomes. A prognostic factor which identifies this patient population before surgery would be desirable, as alternative treatment strategies may be warranted.

METHODS

Between 2/08 and 1/12, 60 evaluable patients with locally advanced esophageal adenocarcinoma enrolled in single-arm phase II trial of induction chemotherapy, surgery, and post-operative adjuvant chemo-radiotherapy (CRT). A clinical stage of T3, N1, or M1a (AJCC 6th) was required for eligibility. Induction chemotherapy with epirubicin 50 mg/m² d1, oxaliplatin 130 mg/m² d1, and fluorouracil 200 mg/m²/day continuous infusion for 3 weeks, was given every 21 days for 3 cycles and was followed by surgical resection. Adjuvant CRT consisted of 50-55 Gy @ 1.8-2.0 Gy/day and 2 cycles of cisplatin (20 mg/m²/day) and fluorouracil (1000 mg/m²/day) given as 96-h infusions during weeks 1 and 4 of radiotherapy. Dysphagia was assessed at baseline and after induction chemotherapy.

RESULTS

Persistent dysphagia was associated with worse distant metastatic control [HR 3.48 (1.43-8.43), p = 0.006], recurrence free survival [HR 3.04 (1.34-6.92), p = 0.008], and overall survival [HR 3.31 (1.43-7.66), p = 0.005]. Persistent dysphagia was associated with more advanced pathologic T descriptor (pT) (p = 0.048) and N descriptor (pN) (p = 0.002), a greater median number of involved lymph nodes (3 v 1, p = 0.003), and greater residual tumor viability (p = 0.05). No patients with persistent dysphagia had pT0-T2 or pN0 disease.

CONCLUSIONS

Persistent dysphagia after induction chemotherapy is associated with more advanced pathologic stage and inferior outcomes.

The 100 most cited articles investigating the radiological staging of oesophageal and junctional cancer: a bibliometric analysis

Objectives

Accurate staging of oesophageal cancer (OC) is vital. Bibliometric analysis highlights key topics and publications that have shaped understanding of a subject. The 100 most cited articles investigating radiological staging of OC are identified.

Methods

The Thomas Reuters Web of Science database with search terms including “CT, PET, EUS, oesophageal and gastro-oesophageal junction cancer” was used to identify all English language, full-script articles. The 100 most cited articles were further analysed by topic, journal, author, year and institution.

Results

A total of 5,500 eligible papers were returned. The most cited paper was Flamen et al. (n = 306), investigating the utility of positron emission tomography (PET) for the staging of patients with potentially operable OC. The most common research topic was accuracy of staging investigations (n = 63). The article with the highest citation rate (38.00), defined as the number of citations divided by the number of complete years published, was Tixier et al. investigating PET texture analysis to predict treatment response to neo-adjuvant chemo-radiotherapy, cited 114 times since publication in 2011.

Conclusion

This bibliometric analysis has identified key publications regarded as important in radiological OC staging. Articles with the highest citation rates all investigated PET imaging, suggesting this modality could be the focus of future research.

Main Messages

• This study identifies key articles that investigate radiological staging of oesophageal cancer.

• The most common topic was accuracy of staging investigations.

• The article with the highest citation rate investigated the use of texture analysis in PET images.

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.

Endoscopy/EUS-guided fiducial marker placement in patients with esophageal cancer: a comparative analysis of 3 types of markers

BACKGROUND

Markers placed at the borders of esophageal tumors are potentially useful to facilitate radiotherapy (RT) target delineation, which offers the possibility of image-guided RT.

OBJECTIVE

To evaluate and compare the feasibility and technical benefit of endoscopy/EUS-guided marker placement of 3 different types of markers in patients with esophageal cancer referred for RT.

DESIGN

Prospective, single-center, feasibility and comparative study.

SETTING

Tertiary-care medical center.

PATIENTS

Thirty patients with esophageal cancer who were referred for RT.

INTERVENTIONS

Patients underwent endoscopy/EUS-guided implantation of 1 type of marker. A solid gold marker (SM) with fixed dimensions, a flexible coil-shaped gold marker (FM) with hand-cut length (2-10 mm), and a radiopaque hydrogel marker (HG) were used. Technical feasibility and adverse events were registered. CT scans and cone-beam CT scans (CBCT) acquired during RT were analyzed to determine and compare the visibility and continuous clear visibility of the implanted markers.

MAIN OUTCOME MEASUREMENTS

Technical feasibility, technical benefit, and adverse events of 3 types of markers.

RESULTS

A total of 101 markers were placed in 30 patients. Implantation was technically feasible in all patients without grade 3 to 4 adverse events. Two patients with asymptomatic mediastinitis and one with asymptomatic pneumothorax were seen. Visibility on CT scan of all 3 types of implanted markers was adequate for target delineation. Eighty percent of FMs remained continuously visible over the treatment period on CBCT, significantly better than SMs (63%) and HGs (11%) (P = .015). When we selected FMs ≥5 mm, 90.5% remained visible on CBCT between implantation and the end of RT.

LIMITATIONS

Single-center, nonrandomized design.

CONCLUSION

Endoscopy/EUS-guided fiducial marker placement for esophageal cancer is both safe and feasible and can be used for target volume delineation purposes on CT. Our results imply a significant advantage of FMs over SMs and HGs, regarding visibility and continuous clear visibility over the treatment period. (

CLINICAL TRIAL REGISTRATION NUMBER

NTR4724.).

Improvement over time in outcomes for patients undergoing endoscopic therapy for Barrett's oesophagus-related neoplasia: 6-year experience from the first 500 patients treated in the UK patient registry

BACKGROUND

Barrett's oesophagus (BE) is a pre-malignant condition leading to oesophageal adenocarcinoma (OAC). Treatment of neoplasia at an early stage is desirable. Combined endoscopic mucosal resection (EMR) followed by radiofrequency ablation (RFA) is an alternative to surgery for patients with BE-related neoplasia.

METHODS

We examined prospective data from the UK registry of patients undergoing RFA/EMR for BE-related neoplasia from 2008 to 2013. Before RFA, visible lesions were removed by EMR. Thereafter, patients had RFA 3-monthly until all BE was ablated or cancer developed (endpoints). End of treatment biopsies were recommended at around 12 months from first RFA treatment or when endpoints were reached. Outcomes for clearance of dysplasia (CR-D) and BE (CR-IM) at end of treatment were assessed over two time periods (2008-2010 and 2011-2013). Durability of successful treatment and progression to OAC were also evaluated.

RESULTS

508 patients have completed treatment. CR-D and CR-IM improved significantly between the former and later time periods, from 77% and 56% to 92% and 83%, respectively (p<0.0001). EMR for visible lesions prior to RFA increased from 48% to 60% (p=0.013). Rescue EMR after RFA decreased from 13% to 2% (p<0.0001). Progression to OAC at 12 months is not significantly different (3.6% vs 2.1%, p=0.51).

CONCLUSIONS

Clinical outcomes for BE neoplasia have improved significantly over the past 6 years with improved lesion recognition and aggressive resection of visible lesions before RFA. Despite advances in technique, the rate of cancer progression remains 2-4% at 1 year in these high-risk patients.

TRIAL REGISTRATION NUMBER

ISRCTN93069556.

New TNM staging system for esophageal cancer: what chest radiologists need to know

Esophageal cancer is a leading cause of cancer-related deaths worldwide, and the 5-year relative survival rate remains less than 20% in the United States. The treatment of esophageal cancer should be stage specific for better clinical outcomes. Recent treatment paradigms tend to involve a multimodality approach to management, which includes surgical resection and preoperative or definitive chemoradiation therapy. Accurate pretreatment staging of esophageal cancer is integral for assessing operability and determining a suitable treatment plan. The American Joint Committee on Cancer (AJCC) and the Union for International Cancer Control (UICC) have published the seventh edition of the staging manual for cancer in the esophagus and esophagogastric junction. Unlike the sixth edition, the revised staging manual is data driven and harmonized with the staging of stomach cancer. Improvements include new definitions for the anatomic classifications Tis, T4, regional lymph node, N, and M and the addition of nonanatomic cancer characteristics (histopathologic cell type, histologic grade, and cancer location). Given the recent increase in the incidence of adenocarcinoma of the distal esophagus, esophagogastric junction, and gastric cardia, the staging of tumors in the esophagogastric junction has been addressed. Radiologists must understand the details of the seventh edition of the AJCC-UICC staging system for esophageal cancer and use appropriate imaging modalities, such as computed tomography (CT), endoscopic ultrasonography, and positron emission tomography/CT, for initial staging.

Esophageal cancer recurrence patterns and implications for surveillance

INTRODUCTION

After definitive treatment of esophageal cancer, patients are at high risk for recurrence. Consistent follow-up is important for detection and treatment of recurrence. The optimal surveillance regimen remains undefined. We investigated posttreatment recurrence patterns and methods of detection in survivors of esophageal cancer.

METHODS

We retrospectively studied a cohort of patients who had undergone surgical resection for esophageal cancer at our institution between 1996 and 2010. Routine computed tomography scan and upper endoscopy were performed for surveillance.

RESULTS

In total, 1147 patients with resected esophageal adenocarcinoma or squamous cell carcinoma were included (median follow-up, 46 months). Of these, 723 patients (63%) had received neoadjuvant therapy before surgery. During follow-up, there were 595 deaths (52%) and 435 recurrences (38%) (distant [55%], locoregional [28%], or both [17%]). Half of recurrences were detected as a result of symptoms (n = 217), 45% by routine chest and abdominal computed tomography scan (n = 194), and 1% by surveillance upper endoscopy (n = 6). The recurrence rate decreased from 27 per 100 person-years in posttreatment year 1 to 4 per 100 person-years in year 6. In the first 2 years, the rate of recurrence was higher among patients who had received neoadjuvant therapy (35 per 100 person-years) than among those who had not (14 per 100 person-years) (p < 0.001).

CONCLUSIONS

The incidence of recurrence is high after esophagectomy for cancer. Surveillance endoscopy has limited value for detection of asymptomatic local recurrence. The yield from follow-up scans diminishes significantly after the sixth year; surveillance scans after that point are likely unnecessary.