Clinical significance of ¹⁸F-fluorodeoxyglucose positron emission tomography in superficial esophageal squamous cell carcinoma

Clinical Utility and Limitation of Diagnostic Ability for Different Degrees of Dysplasia of Intraductal Papillary Mucinous Neoplasms of the Pancreas Using 18F-Fluorodeoxyglucose-Positron Emission Tomography/Computed Tomography

Simple Summary

Elucidating risk factors for different degrees of dysplasia of intraductal papillary mucinous neoplasms (IPMNs) of the pancreas is important in determining strategies for management. In this study, we searched for risk factors for different degrees of dysplasia of IPMNs. Our study indicated that there were no useful factors that significantly differentiated low-grade dysplasia and high-grade dysplasia; however, ¹⁸F-fluorodeoxyglucose–positron emission tomography/computed tomography is useful for differentiating between non-invasive and invasive IPMNs. Our results offer critical information that may determine surgical treatment strategies.

Abstract

The diagnostic value of ¹⁸F-fluorodeoxyglucose (FDG) uptake in the management of intraductal papillary mucinous neoplasms (IPMNs) of the pancreas remains unclear. This study aimed to assess the role of FDG uptake in the diagnosis of different degrees of dysplasia of IPMNs. We retrospectively analyzed the following three points in 84 patients with IPMNs: (1) risk factors to predict high-grade dysplasia (HGD) and invasive carcinoma (INV); (2) the relationship between FDG uptake and glucose transporter 1 (GLUT-1) expression; and (3) the relationship between FDG uptake and the presence of mural nodules. The histopathological diagnosis was low-grade dysplasia (LGD) in 43 patients, HGD in 16, and INV in 25. The maximum standardized uptake value (SUV-max) was significantly higher in INV than in LGD/HGD (p < 0.0001, p = 0.0136). The sensitivity and specificity to discriminate INV from LGD/HGD were 80.0% and 86.2%, respectively, using the receiver operator characteristic curve, when the optimal cutoff score of SUV-max was set at 4.03. Those values were not different between HGD and LGD. More than half of HGD patients had low GLUT-1 expression. Taken together, FDG-PET/CT is useful in distinguishing between non-invasive and invasive IPMN. Our results offer critical information that may determine surgical treatment strategies.

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.

Superiority of NBI endoscopy to PET/CT scan in detecting esophageal cancer among head and neck cancer patients: a retrospective cohort analysis

Background

Second primary cancer of the esophagus is frequent in head and neck patients, especially in high-risk populations, and has a great impact on the prognosis. Although Positron emission tomography (PET)/computed tomography (CT) scan is commonly conducted in head and neck patients, its ability to detect early esophageal cancer is limited. Narrow-band imaging endoscopy is an accurate and convenient technique for esophageal examination. We aimed to compare PET/CT scan and narrow-band imaging endoscopy for the detection of esophageal cancer in head and neck cancer patients.

Methods

From November 2015 to November 2018, all head and neck cancer patients who underwent both PET/CT scan and narrow-band imaging endoscopy at Changhua Christian Hospital were retrospectively enrolled. Descriptive statistics, receiver operating characteristic curve analysis, logistic regression analysis, independent Student’s t-test, and Kaplan–Meier survival analysis were conducted with MedCalc Statistical Software.

Results

A total of 147 subjects were included in the analysis; suspicious esophageal lesions were identified by PET/CT scan in 8 (5.44%) and by narrow-band imaging in 35 (23.81%). The final pathologic diagnoses were esophageal squamous cell carcinoma in 10 and high-grade dysplasia in 5. The respective sensitivity, specificity, and area under the curve for detecting suspicious esophageal lesions were 33.33, 97.73%, and 0.655 for PET/CT scan, and 100.0, 84.85%, and 0.924 for narrow-band imaging endoscopy. Hypopharyngeal or laryngeal location of the primary head and neck cancer was the only risk factor for developing second primary esophageal cancer.

Conclusions

PET/CT scan was inferior to narrow-band imaging endoscopy in detecting second primary esophageal cancer in head and neck cancer patients. In addition to PET/CT scan, narrow-band imaging endoscopy should be considered in head and neck patients at high risk for developing second primary esophageal cancer.

Association of the primary tumor's SUVmax with survival after surgery for clinical stage IA esophageal cancer: a single-center retrospective study

BACKGROUND

Compared to other esophageal cancers, clinical stage IA esophageal cancer generally has a good prognosis, although a subgroup of patients has a poor prognosis. Unfortunately, clinical diagnoses of invasion depth or lymph node metastasis are not always accurate, which make it difficult to identify patients with a high risk of postoperative recurrence using the tumor-node-metastasis staging system. Fluorodeoxyglucose-positron emission tomography may help guide the identification of malignant tumors and the evaluation of their malignant grade based on glucose metabolism. We aimed to evaluate the association between pre-operative fluorodeoxyglucose-positron emission tomography findings and the postoperative prognosis of patients with clinical stage IA esophageal cancer.

METHODS

This single-center retrospective study evaluated pre-esophagectomy fluorodeoxyglucose-positron emission tomography findings from 38 patients with clinical stage IA esophageal cancer. Receiver operating characteristic curve analysis was performed to evaluate the prognostic significance of the primary tumor having low and high SUVmax values (cut-off: 3.56).

RESULTS

Overall survival (log-rank p = 0.034) and progression-free survival (log-rank p = 0.008) were significantly different between the groups with low SUVmax values (n = 18) and high SUVmax values (n = 20). Furthermore, the primary tumor's SUVmax value was related to pathological vascular invasion (p = 0.045) and distant metastasis (p = 0.042).

CONCLUSION

The SUVmax of the primary tumor is a predictor of postoperative survival for clinical stage IA esophageal cancer. Thus, using fluorodeoxyglucose-positron emission tomography to evaluate the primary tumor's glucose metabolism may reflect the tumor's grade and potentially compensate for inaccuracies in tumor-node-metastasis staging.

Clinical relevance of fluorodeoxyglucose positron emission tomography/computed tomography and magnifying endoscopy with narrow band imaging in decision-making regarding the treatment strategy for esophageal squamous cell carcinoma

BACKGROUND

Recent advances in endoscopic technology, especially magnifying endoscopy with narrow band imaging (ME-NBI) enable us to detect superficial esophageal squamous cell carcinoma (ESCC), but determining the appropriate method of resection, endoscopic resection (ER) vs surgical resection, is often challenging. Recently, several studies have reported that ¹⁸F-fluorodeoxyglucose positron emission tomography (FDG-PET) is a useful indicator for decision-making regarding treatment for superficial ESCC. Although, there are not enough reports on association between FDG-PET uptake and clinicopathological characteristics of superficial ESCC. And, there are not enough reports on evaluating the usefulness of combination of FDG-PET and ME-NBI for determining the treatment strategy for superficial ESCC. This study evaluated clinical relevance of FDG-PET and ME-NBI in decision-making regarding the treatment strategy for ESCC.

AIM

To investigate the association between FDG uptake and the clinicopathological characteristics of superficial ESCC and its usefulness of combination of FDG-PET and ME-NBI for determining the treatment strategy for superficial ESCC.

METHODS

A database of all patients with superficial ESCC who had undergone both ME-NBI and FDG-PET for pre-treatment staging at Aichi Cancer Center Hospital between January 2008 and November 2018 was retrospectively analyzed. FDG uptake was defined positive or negative whether the primary lesion was visualized or could be distinguished from the background, or not. The invasion depth of ESCC was classified according to the Japan Esophageal Society. Primary endpoint is to evaluate the association between FDG uptake and clinicopathological characteristics of superficial ESCC. Secondary endpoint is to investigate the efficacy of combination of FDG-PET and ME-NBI for determining the treatment strategy for superficial ESCC.

RESULTS

A total of 82 lesions in 82 patients were included. FDG-PET showed positive uptake in 29 (35.4%) lesions. Univariate analysis showed that uptake of FDG-PET had significant correlations with circumferential extension (P = 0.014), pathological depth of tumor invasion (P < 0.001), infiltrative growth pattern (P < 0.001), histological grade (P = 0.002), vascular invasion (P = 0.001), and lymphatic invasion (P < 0.001). On multivariate analysis, only depth of tumor invasion was independently correlated with FDG-PET/computed tomography visibility (P = 0.018). The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of Type B2 in ME-NBI for the invasion depth of T1a muscularis mucosae and T1b upper submucosal layer were 68.4%/79.4%/50.0%/89.3%/76.8%, respectively, and those of Type B3 for the depth of T1b middle and deeper submucosal layers (SM2 and SM3) were 46.7%/100%/100%/89.3%/90.2%, respectively. On the other hand, those of FDG-PET for SM2 and SM3 were 93.3%/77.6%/48.2%/98.1%/80.5%, respectively, whereas, if the combination of positive FDG uptake and type B2 and B3 was defined as an indicator for radical esophagectomy or definitive chemoradiotherapy, the sensitivity, specificity, PPV, NPV, and accuracy were 78.3%/91.5%/78.3%/91.5%/87.8%, respectively.

CONCLUSION

FDG uptake was correlated with the invasion depth of superficial ESCC. Combined use of FDG-PET and ME-NBI, especially with the microvascular findings of Type B2 and B3, is useful to determine whether ER is indicated for the lesion.

18 F-Fluorodeoxyglucose positron emission tomography can be used to determine the indication for endoscopic resection of superficial esophageal cancer

¹⁸F‐Fluorodeoxyglucose positron emission tomography (FDG‐PET) is a useful imaging modality that reflects the tumor activity. However, FDG‐PET is mainly used for advanced cancer, not superficial cancer. In this study, we investigated the relationship between the superficial tumor depth of esophageal cancer and the FDG uptake to determine the indications for endoscopic resection (ER). From 2009 to 2017, 444 patients with esophageal cancer underwent esophagectomy or endoscopic submucosal dissection (ESD), and 195 patients were pathologically diagnosed with superficial cancer. Among them, 146 patients were examined by FDG‐PET before esophagectomy or ESD. In these 146 patients, the relationship between the pathological tumor depth and FDG uptake was analyzed. The mean maximum standardized uptake value in pT1a‐EP/LPM tumors was 1.362 ± 0.890, that in pT1a‐MM/pT1b‐SM1 tumors was 2.453 ± 1.872, and that in pT1b‐SM2/SM3 tumors was 4.265 ± 3.233 (P < .0001). Among 51 pT1a‐EP/LPM tumors, 10 (19.6%) showed positive detection of FDG. For pT1a‐MM/pT1b‐SM1 and pT1b‐SM2/SM3 tumors, the detection rate was 52.9% (18/34) and 82.0% (50/61), respectively. The detection rate of pT1a‐EP/LPM was significantly lower than in the other two groups (P < .0001). Among 10 FDG‐PET‐positive lesions, only 1 had no apparent reason for PET positivity; however, 9 of 10 had a suitable reason for detectability by PET and inadequacy for ER. Negative detection of superficial esophageal squamous cell carcinoma by FDG‐PET is useful to determine the indication for ER when the tumor depth cannot be diagnosed even after performing magnifying endoscopy with narrow band imaging and endoscopic ultrasonography. When FDG uptake is recognized, a therapeutic modality other than ER should be considered.

A Comparison Study of Esophageal Findings on (18)F-FDG PET/CT and Esophagogastroduodenoscopy

PURPOSE

The aim of this study was to compare the esophageal findings of 2-deoxy-2-[(18)F]fluoro-d-glucose positron emission tomography-computed tomography ((18)F-FDG PET/CT) and esophagogastroduodenoscopy (EGD).

METHODS

We retrospectively reviewed (18)F-FDG PET/CT and EGD findings of 369 subjects who underwent medical examination between January 2014 and December 2014. The range and intensity of esophageal (18)F-FDG uptake were visually analyzed. The maximum standardized uptake value (SUVmax) of the esophagus and around the esophagogastric (EG) junction was measured. EGD results were provided by the gastroenterologist. We compared the esophageal findings obtained using (18)F-FDG PET/CT and EGD.

RESULTS

There were typical linear FDG uptakes in (18)F-FDG PET/CT patients who underwent EGD the same day. In visual analysis of the range and intensity of the (18)F-FDG uptake, the patients who underwent (18)F-FDG PET/CT and EGD on the same day showed relatively diffuse and discernible (18)F-FDG uptake in the esophagus. Reflux esophagitis was diagnosed in 59 subjects, and 27 of these were classified as higher than Los Angeles classification A. With an increasing degree of reflux esophagitis observed on EGD, the SUVmax in the esophagus and around the EG junction was also increased.

CONCLUSION

Our study showed that FDG uptake at the esophagus or the EG junction might be clinically significantly related to esophagitis. However, EGD performed before (18)F-FDG PET/CT on the same day may affect the esophageal (18)F-FDG uptake.