Effectiveness of Repeat 18F-Fluorodeoxyglucose Positron Emission Tomography Computerized Tomography (PET-CT) Scan in Identifying Interval Metastases for Patients with Esophageal Cancer

Advances in Diagnostic, Staging, and Restaging Evaluation of Esophageal and Gastric Cancer

The initial endoscopic and staging evaluation of esophagogastric cancers must be accurate and comprehensive in order to select the optimal therapeutic plan for the patient. Esophageal and gastric cancers (and treatment paradigms) are delineated by their proximity to the cardia (within 2 cm). The most frequent and important symptom that informs the initial staging evaluation is dysphagia, which is associated with at least cT3 or locally advanced disease. Endoscopic ultrasound is often needed if earlier stage disease is suspected, preferably in combination with endoscopic mucosal or submucosal resection or fine-needle aspiration of suspicious lymph nodes to enhance staging accuracy.

False Liver Metastasis by Positron Emission Tomography/Computed Tomography Scan after Chemoradiotherapy for Esophageal Cancer-Potential Overstaged Pitfalls of Treatment

In patients with esophageal cancer undergoing neoadjuvant chemoradiotherapy (nCRT), subsequent restaging with F-18-fluorodeoxyglucose (18F-FDG) positron emission tomography-computed tomography (PET-CT) can reveal the presence of interval metastases, such as liver metastases, in approximately 10% of cases. Nevertheless, it is not uncommon in clinical practice to observe focal FDG uptake in the liver that is not associated with liver metastases but rather with radiation-induced liver injury (RILI), which can result in the overstaging of the disease. Liver radiation damage is also a concern during distal esophageal cancer radiotherapy due to its proximity to the left liver lobe, typically included in the radiation field. Post-CRT, if FDG activity appears in the left or caudate liver lobes, a thorough investigation is needed to confirm or rule out distant metastases. The increased FDG uptake in liver lobes post-CRT often presents a diagnostic dilemma. Distinguishing between radiation-induced liver disease and metastasis is vital for appropriate patient management, necessitating a combination of imaging techniques and an understanding of the factors influencing the radiation response. Diagnosis involves identifying new foci of hepatic FDG avidity on PET/CT scans. Geographic regions of hypoattenuation on CT and well-demarcated regions with specific enhancement patterns on contrast-enhanced CT scans and MRI are characteristic of radiation-induced liver disease (RILD). Lack of mass effect on all three modalities (CT, MRI, PET) indicates RILD. Resolution of abnormalities on subsequent examinations also helps in diagnosing RILD. Moreover, it can also help to rule out occult metastases, thereby excluding those patients from further surgery who will not benefit from esophagectomy with curative intent.

Meta-Analysis of Comparative Trials Evaluating a Single-Use Closed-Incision Negative-Pressure Therapy System

BACKGROUND

Surgical site infections (SSIs) pose a significant surgical complication. Application of closed-incision negative-pressure therapy (ciNPT) has been associated with reduced SSI rates in published literature. This meta-analysis examines the effect of ciNPT use over closed incisions in reducing SSIs versus traditional dressings.

METHODS

A systematic literature search using PubMed, The Cochrane Library, OVID, EMBASE, ScienceDirect, and QUOSA was performed focusing on publications between January 1, 2005, and April 30, 2018. Characteristics of study participants, surgical procedure, type of dressing used, duration of treatment, incidence of SSI, and length of follow-up were extracted. Weighted odds ratios and 95% CIs were calculated to pool study and control groups in each publication for analysis. Treatment effects were combined using Mantel-Haenszel odds ratios as the summary statistics, and a fixed-effects model was used for each analysis performed. The chi-square test was used to statistically assess heterogeneity. For each meta-analysis performed, the more conservative random-effects models were conducted as sensitivity analyses.

RESULTS

For all meta-analyses (randomized controlled trial only, observational studies only, colorectal/abdominal, obstetrics, lower extremity, groin/vascular, cardiac), heterogeneity tests were nonsignificant (P > 0.05). All fixed-effects meta-analyses were significant in favor of ciNPT use over traditional dressings (P < 0.05). When the random-effects analyses were performed, all analyses except obstetrics remained significant (P < 0.05).

CONCLUSION

For all meta-analyses performed using the fixed-effects approach, ciNPT usage demonstrated a statistically significant reduction in incidence of SSI relative to traditional dressings.

Prediction and diagnosis of interval metastasis after neoadjuvant chemoradiotherapy for oesophageal cancer using 18F-FDG PET/CT

OBJECTIVE

During neoadjuvant chemoradiotherapy for oesophageal cancer, or in the interval prior to surgery, some patients develop systemic metastasis. This study aimed to evaluate the diagnostic performance of ¹⁸F-FDG PET/CT for the detection of interval metastasis and to identify predictors of interval metastases in a large cohort of oesophageal cancer patients.

METHODS

In total, 783 consecutive patients with potentially resectable oesophageal cancer who underwent chemoradiotherapy and pre- and post-treatment ¹⁸F-FDG PET/CT between 2006 and 2015 were analyzed from a prospectively maintained database. Diagnostic accuracy measures were calculated on a per-patient basis using histological verification or clinical follow-up as a reference standard. Multivariable logistic regression analysis was performed to determine pre-treatment predictors of interval metastasis. A prediction score was developed to predict the probability of interval metastasis.

RESULTS

Of 783 patients that underwent ¹⁸F-FDG PET/CT restaging, 65 (8.3%) were found to have interval metastasis and 44 (5.6%) were deemed to have false positive lesions. The resulting sensitivity and specificity was 74.7% (95% CI: 64.3-83.4%) and 93.7% (95% CI: 91.6-95.4%), respectively. Multivariable analysis revealed that tumor length, cN status, squamous cell tumor histology, and baseline SUV_max were associated with interval metastasis. Based on these criteria, a prediction score was developed with an optimism adjusted C-index of 0.67 that demonstrated accurate calibration.

CONCLUSIONS

¹⁸F-FDG PET/CT restaging detects distant interval metastases in 8.3% of patients after chemoradiotherapy for oesophageal cancer. The provided prediction score may stratify risk of developing interval metastasis, and could be used to prioritize additional restaging modalities for patients most likely to benefit.

A rare case of esophageal metastasis from pancreatic ductal adenocarcinoma: a case report and literature review

Purpose

We report a very unique case of an esophageal metastasis from a pancreatic ductal adenocarcinoma (PDAC) primary.

Methods

After obtaining consent from the patient, all relevant records of the case were obtained and retrospectively reviewed.

Results

At presentation, the patient was diagnosed with synchronous pancreatic and esophageal cancer. He received six months of neoadjuvant therapy including FOLFIRINOX (5-fluorouracil, leucovorin, irinotecan, and oxaliplatin) and stereotactic body radiation therapy (SBRT) to the pancreatic tumor followed by a combined pancreaticoduodenectomy and Ivor Lewis esophagectomy. Review of the final esophageal specimen revealed normal overlying squamous mucosa with an underlying focus of metastatic PDAC. The patient remains alive with no evidence of disease 17 months from surgery and 25 months from diagnosis.

Conclusions

Differentiating an esophageal metastasis from a PDAC primary versus a synchronous esophageal carcinoma is very difficult despite state-of-the-art diagnostic techniques performed at a high-volume tertiary cancer center. Extensive evaluation and continued follow-up of PDAC patients presenting with a synchronous esophageal lesion in a multidisciplinary setting may help ensure efficient and accurate management. In our case, neoadjuvant FOLFIRINOX and SBRT to the primary PDAC tumor followed by surgery has been an effective approach for this patient.