Surgically resected T1- and T2-stage esophageal squamous cell carcinoma: T and N staging performance of EUS and PET/CT

Preoperative prediction of clinical and pathological stages for patients with esophageal cancer using PET/CT radiomics

BACKGROUND

Preoperative stratification is critical for the management of patients with esophageal cancer (EC). To investigate the feasibility and accuracy of PET-CT-based radiomics in preoperative prediction of clinical and pathological stages for patients with EC.

METHODS

Histologically confirmed 100 EC patients with preoperative PET-CT images were enrolled retrospectively and randomly divided into training and validation cohorts at a ratio of 7:3. The maximum relevance minimum redundancy (mRMR) was applied to select optimal radiomics features from PET, CT, and fused PET-CT images, respectively. Logistic regression (LR) was applied to classify the T stage (T1,2 vs. T3,4), lymph node metastasis (LNM) (LNM(-) vs. LNM(+)), and pathological state (pstage) (I-II vs. III-IV) with features from CT (CT_LR_Score), PET (PET_LR_Score), fused PET/CT (Fused_LR_Score), and combined CT and PET features (CT + PET_LR_Score), respectively.

RESULTS

Seven, 10, and 7 CT features; 7, 8, and 7 PET features; and 3, 6, and 3 fused PET/CT features were selected using mRMR for the prediction of T stage, LNM, and pstage, respectively. The area under curves (AUCs) for T stage, LNM, and pstage prediction in the validation cohorts were 0.846, 0.756, 0.665, and 0.815; 0.769, 0.760, 0.665, and 0.824; and 0.727, 0.785, 0.689, and 0.837 for models of CT_LR_Score, PET_ LR_Score, Fused_ LR_Score, and CT + PET_ LR_Score, respectively.

CONCLUSIONS

Accurate prediction ability was observed with combined PET and CT radiomics in the prediction of T stage, LNM, and pstage for EC patients.

CRITICAL RELEVANCE STATEMENT

PET/CT radiomics is feasible and promising to stratify stages for esophageal cancer preoperatively.

KEY POINTS

• PET-CT radiomics achieved the best performance for Node and pathological stage prediction. • CT radiomics achieved the best AUC for T stage prediction. • PET-CT radiomics is feasible and promising to stratify stages for EC preoperatively.

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Exosomal miR-10527-5p Inhibits Migration, Invasion, Lymphangiogenesis and Lymphatic Metastasis by Affecting Wnt/β-Catenin Signaling via Rab10 in Esophageal Squamous Cell Carcinoma

Background

Cancer cell-derived exosomal microRNAs (miRNAs) play critical role in orchestrating intercellular communication between tumor cells and tumor microenvironmental factors, including lymphatic endothelial cells (LECs). Nevertheless, the functions and underlying mechanisms of exosomal miRNAs in lymphatic metastasis and lymphangiogenesis in esophageal squamous cell carcinoma (ESCC) remain unclear.

Methods

Small RNA sequencing, Gene Expression Omnibus (GEO) analysis and qRT‒PCR were performed to identify the candidate exosomal miRNAs involved in ESCC metastasis. Receiver operating characteristic curve analysis was conducted to evaluate the diagnostic potential of exosomal miR-10527-5p in predicting lymph node metastasis (LNM) status. An in vitro coculture system was used to investigate the effects of exosomal miR-10527-5p on ESCC cells and human LECs (HLECs), followed by a popliteal LNM assay in vivo. The relationship between miR-10527-5p and Rab10 was identified by dual-luciferase reporter, fluorescence in situ hybridization and qRT‒PCR assays. Then, a series of rescue assays were performed to further investigate whether Rab10 is involved in exosomal miR-10527-5p mediated ESCC metastasis.

Results

MiR-10527-5p was found to be notably reduced in both the plasma exosomes and tumor tissues of ESCC patients with LNM, and plasma exosomal miR-10527-5p had a high sensitivity and specificity for discrimination of LNM status. Moreover, exosome-shuttled miR-10527-5p suppressed the migration, invasion and epithelial-to-mesenchymal transition (EMT) of ESCC cells as well as the migration and tube formation of HLECs via Wnt/β-catenin signaling in vitro and in vivo. Further investigation revealed that Rab10 was a direct target of miR-10527-5p, and re-expression of Rab10 neutralized the inhibitory effects of exosomal miR-10527-5p.

Conclusion

Our study demonstrated that exosomal miR-10527-5p had a strong capability to predict preoperative LNM status and anti-lymphangiogenic effect. Exosomal miR-10527-5p inhibited lymphangiogenesis and lymphatic metastasis of ESCC in a vascular endothelial growth factor-C (VEGF-C)-independent manner, showing potential as a therapeutic target for ESCC patients.

Nomogram constructed by immunological and inflammatory indicators for predicting prognosis of patients with esophageal squamous cell carcinoma treated with neoadjuvant chemoradiotherapy plus surgery

OBJECTIVES

At present, esophageal squamous cell carcinoma (ESCC) patients accepting neoadjuvant chemoradiotherapy (nCRT) plus surgery lack corresponding prognostic indicators. This study aimed to construct a prognostic prediction model for ESCC patients undergoing nCRT and surgery based on immune and inflammation-related indicators.

METHODS

We retrospectively analyzed the levels of serum immune- and inflammation-related indicators of ESCC patients before receiving nCRT plus surgery in the training cohort (99 patients) and validation cohort (67 patients), which were collected from 2007 to 2020. Univariate and multivariate Cox survival analyses were conducted to evaluate the indicators to set up a nomogram associated with the patients' overall survival (OS). The prediction accuracy and discriminative ability of the nomogram were measured by the concordance index (C-index), decision curve, calibration curve, integrated discrimination improvement (IDI), and net reclassification improvement (NRI).

RESULTS

Univariate and multivariate Cox analyses demonstrated that immune globin A (IgA) and C-reactive protein (CRP) were independent risk factors. A nomogram based on IgA, CRP, and cTNM stage was established for predicted OS in the training cohort and validated in the validation cohort. The C-index of the nomogram was 0.820 (95% CI: 0.705-0.934), which was higher than that of the cTNM stage (0.655 (95% CI: 0.546-0.764), p < 0.05) in the training cohort, and similar results were observed in the validation cohort (0.832 (95% CI: 0.760-0.903 vs 0.635 (95% CI: 0.509-0.757), p < 0.001). Furthermore, the prediction accuracy and net benefit of the nomogram verified by the calibration curve, decision curve, NRI, and IDI were satisfactory in the training and validation cohorts.

CONCLUSION

The newly constructed nomogram concluding serum IgA, CRP, and cTNM stage might be helpful in the prognosis prediction for ESCC patients receiving nCRT plus surgery.

Value of 18F-FDG PET/MRI in the Preoperative Assessment of Resectable Esophageal Squamous Cell Carcinoma: A Comparison With 18F-FDG PET/CT, MRI, and Contrast-Enhanced CT

Objectives

To investigate the value of ¹⁸F-FDG PET/MRI in the preoperative assessment of esophageal squamous cell carcinoma (ESCC) and compare it with ¹⁸F-FDG PET/CT, MRI, and CECT.

Methods

Thirty-five patients with resectable ESCC were prospectively enrolled and underwent PET/MRI, PET/CT, and CECT before surgery. The primary tumor and regional lymph nodes were assessed by PET/MRI, PET/CT, MRI, and CECT, respectively, and the diagnostic efficiencies were determined with postoperative pathology as a reference standard. The predictive role of imaging and clinical parameters on pathological staging was analyzed.

Results

For primary tumor staging, the accuracy of PET/MRI, MRI, and CECT was 85.7%, 77.1%, and 51.4%, respectively. For lymph node assessment, the accuracy of PET/MRI, PET/CT, MRI, and CECT was 96.2%, 92.0%, 86.8%, and 86.3%, respectively, and the AUCs were 0.883, 0.745, 0.697, and 0.580, respectively. PET/MRI diagnosed 13, 7, and 6 more stations of lymph node metastases than CECT, MRI, and PET/CT, respectively. There was a significant difference in SUV_max, TLG, and tumor wall thickness between T1-2 and T3 tumors (p = 0.004, 0.024, and < 0.001, respectively). Multivariate analysis showed that thicker tumor wall thickness was a predictor of a higher T stage (p = 0.040, OR = 1.6).

Conclusions

¹⁸F-FDG PET/MRI has advantages over ¹⁸F-FDG PET/CT, MRI, and CECT in the preoperative assessment of primary tumors and regional lymph nodes of ESCC. ¹⁸F-FDG PET/MRI may be a potential supplement or alternative imaging method for preoperative staging of ESCC.

Value of 18F-FDG PET/MRI in the Preoperative Assessment of Resectable Esophageal Squamous Cell Carcinoma: A Comparison With 18F-FDG PET/CT, MRI, and Contrast-Enhanced CT

Objectives

To investigate the value of ¹⁸F-FDG PET/MRI in the preoperative assessment of esophageal squamous cell carcinoma (ESCC) and compare it with ¹⁸F-FDG PET/CT, MRI, and CECT.

Methods

Thirty-five patients with resectable ESCC were prospectively enrolled and underwent PET/MRI, PET/CT, and CECT before surgery. The primary tumor and regional lymph nodes were assessed by PET/MRI, PET/CT, MRI, and CECT, respectively, and the diagnostic efficiencies were determined with postoperative pathology as a reference standard. The predictive role of imaging and clinical parameters on pathological staging was analyzed.

Results

For primary tumor staging, the accuracy of PET/MRI, MRI, and CECT was 85.7%, 77.1%, and 51.4%, respectively. For lymph node assessment, the accuracy of PET/MRI, PET/CT, MRI, and CECT was 96.2%, 92.0%, 86.8%, and 86.3%, respectively, and the AUCs were 0.883, 0.745, 0.697, and 0.580, respectively. PET/MRI diagnosed 13, 7, and 6 more stations of lymph node metastases than CECT, MRI, and PET/CT, respectively. There was a significant difference in SUV_max, TLG, and tumor wall thickness between T1-2 and T3 tumors (p = 0.004, 0.024, and < 0.001, respectively). Multivariate analysis showed that thicker tumor wall thickness was a predictor of a higher T stage (p = 0.040, OR = 1.6).

Conclusions

¹⁸F-FDG PET/MRI has advantages over ¹⁸F-FDG PET/CT, MRI, and CECT in the preoperative assessment of primary tumors and regional lymph nodes of ESCC. ¹⁸F-FDG PET/MRI may be a potential supplement or alternative imaging method for preoperative staging of ESCC.

Value of 18F-FDG PET/MRI in the Preoperative Assessment of Resectable Esophageal Squamous Cell Carcinoma: A Comparison With 18F-FDG PET/CT, MRI, and Contrast-Enhanced CT

Objectives

To investigate the value of ¹⁸F-FDG PET/MRI in the preoperative assessment of esophageal squamous cell carcinoma (ESCC) and compare it with ¹⁸F-FDG PET/CT, MRI, and CECT.

Methods

Thirty-five patients with resectable ESCC were prospectively enrolled and underwent PET/MRI, PET/CT, and CECT before surgery. The primary tumor and regional lymph nodes were assessed by PET/MRI, PET/CT, MRI, and CECT, respectively, and the diagnostic efficiencies were determined with postoperative pathology as a reference standard. The predictive role of imaging and clinical parameters on pathological staging was analyzed.

Results

For primary tumor staging, the accuracy of PET/MRI, MRI, and CECT was 85.7%, 77.1%, and 51.4%, respectively. For lymph node assessment, the accuracy of PET/MRI, PET/CT, MRI, and CECT was 96.2%, 92.0%, 86.8%, and 86.3%, respectively, and the AUCs were 0.883, 0.745, 0.697, and 0.580, respectively. PET/MRI diagnosed 13, 7, and 6 more stations of lymph node metastases than CECT, MRI, and PET/CT, respectively. There was a significant difference in SUV_max, TLG, and tumor wall thickness between T1-2 and T3 tumors (p = 0.004, 0.024, and < 0.001, respectively). Multivariate analysis showed that thicker tumor wall thickness was a predictor of a higher T stage (p = 0.040, OR = 1.6).

Conclusions

¹⁸F-FDG PET/MRI has advantages over ¹⁸F-FDG PET/CT, MRI, and CECT in the preoperative assessment of primary tumors and regional lymph nodes of ESCC. ¹⁸F-FDG PET/MRI may be a potential supplement or alternative imaging method for preoperative staging of ESCC.

Value of 18F-FDG PET/MRI in the Preoperative Assessment of Resectable Esophageal Squamous Cell Carcinoma: A Comparison With 18F-FDG PET/CT, MRI, and Contrast-Enhanced CT

Objectives

To investigate the value of ¹⁸F-FDG PET/MRI in the preoperative assessment of esophageal squamous cell carcinoma (ESCC) and compare it with ¹⁸F-FDG PET/CT, MRI, and CECT.

Methods

Thirty-five patients with resectable ESCC were prospectively enrolled and underwent PET/MRI, PET/CT, and CECT before surgery. The primary tumor and regional lymph nodes were assessed by PET/MRI, PET/CT, MRI, and CECT, respectively, and the diagnostic efficiencies were determined with postoperative pathology as a reference standard. The predictive role of imaging and clinical parameters on pathological staging was analyzed.

Results

For primary tumor staging, the accuracy of PET/MRI, MRI, and CECT was 85.7%, 77.1%, and 51.4%, respectively. For lymph node assessment, the accuracy of PET/MRI, PET/CT, MRI, and CECT was 96.2%, 92.0%, 86.8%, and 86.3%, respectively, and the AUCs were 0.883, 0.745, 0.697, and 0.580, respectively. PET/MRI diagnosed 13, 7, and 6 more stations of lymph node metastases than CECT, MRI, and PET/CT, respectively. There was a significant difference in SUV_max, TLG, and tumor wall thickness between T1-2 and T3 tumors (p = 0.004, 0.024, and < 0.001, respectively). Multivariate analysis showed that thicker tumor wall thickness was a predictor of a higher T stage (p = 0.040, OR = 1.6).

Conclusions

¹⁸F-FDG PET/MRI has advantages over ¹⁸F-FDG PET/CT, MRI, and CECT in the preoperative assessment of primary tumors and regional lymph nodes of ESCC. ¹⁸F-FDG PET/MRI may be a potential supplement or alternative imaging method for preoperative staging of ESCC.

Value of 18F-FDG PET/MRI in the Preoperative Assessment of Resectable Esophageal Squamous Cell Carcinoma: A Comparison With 18F-FDG PET/CT, MRI, and Contrast-Enhanced CT

Objectives

To investigate the value of ¹⁸F-FDG PET/MRI in the preoperative assessment of esophageal squamous cell carcinoma (ESCC) and compare it with ¹⁸F-FDG PET/CT, MRI, and CECT.

Methods

Thirty-five patients with resectable ESCC were prospectively enrolled and underwent PET/MRI, PET/CT, and CECT before surgery. The primary tumor and regional lymph nodes were assessed by PET/MRI, PET/CT, MRI, and CECT, respectively, and the diagnostic efficiencies were determined with postoperative pathology as a reference standard. The predictive role of imaging and clinical parameters on pathological staging was analyzed.

Results

For primary tumor staging, the accuracy of PET/MRI, MRI, and CECT was 85.7%, 77.1%, and 51.4%, respectively. For lymph node assessment, the accuracy of PET/MRI, PET/CT, MRI, and CECT was 96.2%, 92.0%, 86.8%, and 86.3%, respectively, and the AUCs were 0.883, 0.745, 0.697, and 0.580, respectively. PET/MRI diagnosed 13, 7, and 6 more stations of lymph node metastases than CECT, MRI, and PET/CT, respectively. There was a significant difference in SUV_max, TLG, and tumor wall thickness between T1-2 and T3 tumors (p = 0.004, 0.024, and < 0.001, respectively). Multivariate analysis showed that thicker tumor wall thickness was a predictor of a higher T stage (p = 0.040, OR = 1.6).

Conclusions

¹⁸F-FDG PET/MRI has advantages over ¹⁸F-FDG PET/CT, MRI, and CECT in the preoperative assessment of primary tumors and regional lymph nodes of ESCC. ¹⁸F-FDG PET/MRI may be a potential supplement or alternative imaging method for preoperative staging of ESCC.

Value of 18F-FDG PET/MRI in the Preoperative Assessment of Resectable Esophageal Squamous Cell Carcinoma: A Comparison With 18F-FDG PET/CT, MRI, and Contrast-Enhanced CT

Objectives

To investigate the value of ¹⁸F-FDG PET/MRI in the preoperative assessment of esophageal squamous cell carcinoma (ESCC) and compare it with ¹⁸F-FDG PET/CT, MRI, and CECT.

Methods

Thirty-five patients with resectable ESCC were prospectively enrolled and underwent PET/MRI, PET/CT, and CECT before surgery. The primary tumor and regional lymph nodes were assessed by PET/MRI, PET/CT, MRI, and CECT, respectively, and the diagnostic efficiencies were determined with postoperative pathology as a reference standard. The predictive role of imaging and clinical parameters on pathological staging was analyzed.

Results

For primary tumor staging, the accuracy of PET/MRI, MRI, and CECT was 85.7%, 77.1%, and 51.4%, respectively. For lymph node assessment, the accuracy of PET/MRI, PET/CT, MRI, and CECT was 96.2%, 92.0%, 86.8%, and 86.3%, respectively, and the AUCs were 0.883, 0.745, 0.697, and 0.580, respectively. PET/MRI diagnosed 13, 7, and 6 more stations of lymph node metastases than CECT, MRI, and PET/CT, respectively. There was a significant difference in SUV_max, TLG, and tumor wall thickness between T1-2 and T3 tumors (p = 0.004, 0.024, and < 0.001, respectively). Multivariate analysis showed that thicker tumor wall thickness was a predictor of a higher T stage (p = 0.040, OR = 1.6).

Conclusions

¹⁸F-FDG PET/MRI has advantages over ¹⁸F-FDG PET/CT, MRI, and CECT in the preoperative assessment of primary tumors and regional lymph nodes of ESCC. ¹⁸F-FDG PET/MRI may be a potential supplement or alternative imaging method for preoperative staging of ESCC.

Value of 18F-FDG PET/MRI in the Preoperative Assessment of Resectable Esophageal Squamous Cell Carcinoma: A Comparison With 18F-FDG PET/CT, MRI, and Contrast-Enhanced CT

Objectives

To investigate the value of ¹⁸F-FDG PET/MRI in the preoperative assessment of esophageal squamous cell carcinoma (ESCC) and compare it with ¹⁸F-FDG PET/CT, MRI, and CECT.

Methods

Thirty-five patients with resectable ESCC were prospectively enrolled and underwent PET/MRI, PET/CT, and CECT before surgery. The primary tumor and regional lymph nodes were assessed by PET/MRI, PET/CT, MRI, and CECT, respectively, and the diagnostic efficiencies were determined with postoperative pathology as a reference standard. The predictive role of imaging and clinical parameters on pathological staging was analyzed.

Results

For primary tumor staging, the accuracy of PET/MRI, MRI, and CECT was 85.7%, 77.1%, and 51.4%, respectively. For lymph node assessment, the accuracy of PET/MRI, PET/CT, MRI, and CECT was 96.2%, 92.0%, 86.8%, and 86.3%, respectively, and the AUCs were 0.883, 0.745, 0.697, and 0.580, respectively. PET/MRI diagnosed 13, 7, and 6 more stations of lymph node metastases than CECT, MRI, and PET/CT, respectively. There was a significant difference in SUV_max, TLG, and tumor wall thickness between T1-2 and T3 tumors (p = 0.004, 0.024, and < 0.001, respectively). Multivariate analysis showed that thicker tumor wall thickness was a predictor of a higher T stage (p = 0.040, OR = 1.6).

Conclusions

¹⁸F-FDG PET/MRI has advantages over ¹⁸F-FDG PET/CT, MRI, and CECT in the preoperative assessment of primary tumors and regional lymph nodes of ESCC. ¹⁸F-FDG PET/MRI may be a potential supplement or alternative imaging method for preoperative staging of ESCC.

18F-FDG-PET/CT Imaging for Gastrointestinal Malignancies

Gastrointestinal malignancies encompass a variety of primary tumor sites, each with different staging criteria and treatment approaches. In this review we discuss technical aspects of 18F-FDG-PET/CT scanning to optimize information from both the PET and computed tomography components. Specific applications for 18F-FDG-PET/CT are summarized for initial staging and follow-up of the major disease sites, including esophagus, stomach, hepatobiliary system, pancreas, colon, rectum, and anus.

Trimodality therapy for locally advanced esophageal squamous cell carcinoma: the role of volume-based PET/CT in patient management and prognostication

PURPOSE

To evaluate the role of positron emission tomography/computed tomography (PET/CT) in predicting pathologic complete response (pCR) and identify relevant prognostic factors from clinico-imaging-pathologic features of locally advanced esophageal squamous cell carcinoma (eSCC) patients undergoing trimodality therapy.

METHODS

We evaluated 275 patients with eSCCs of T3-T4aN0M0 and T1-T4aN1-N3M0 who received trimodality therapy. We correlated volume-based PET/CT parameters before and after concurrent chemoradiation therapy with pCR after surgery, clinico-imaging-pathologic features, and patient survival.

RESULTS

pCR occurred in 75 (27.3%) of 275 patients, of whom 61 (80.9%) showed 5-year survival. Pre-total lesion glycolysis (pre-TLG, OR = 0.318, 95% CI 0.169 to 0.600), post-metabolic tumor volume (post-MTV, OR = 0.572, 95% CI 0.327 to 0.999), and % decrease of average standardized uptake value (% SUVavg decrease, OR = 2.976, 95% CI = 1.608 to 5.507) were significant predictors for pCR. Among them, best predictor for pCR was pre-TLG with best cutoff value of 205.67 and with AUC value of 0.591. Performance status (HR = 5.171, 95% CI 1.737 to 15.397), pathologic tumor size (HR = 1.645, 95% CI 1.351 to 2.002), pathologic N status (N1, HR = 1.572, 95% CI 1.010 to 2.446; N2, HR = 3.088, 95% CI 1.845 to 5.166), and post-metabolic tumor volume (HR = 1.506, 95% CI 1.033 to 2.195) were significant predictors of overall survival.

CONCLUSION

Pre-TLG, post-MTV, and % SUVavg decrease are predictive of pCR. Additionally, several clinico-imaging-pathologic factors are significant survival predictors in locally advanced eSCC patients undergoing trimodality therapy.

Clinical TNM staging for esophageal, gastric, and colorectal cancers in the era of neoadjuvant therapy: A systematic review of the literature

AIM

Clinical staging is vital for selecting appropriate candidates and designing neoadjuvant treatment strategies for advanced tumors. The aim of this review was to evaluate diagnostic abilities of clinical TNM staging for gastrointestinal, gastrointestinal cancers.

METHODS

We conducted a systematic review of recent publications to evaluate the accuracy of diagnostic modalities on gastrointestinal cancers. A systematic literature search was performed in PubMed/MEDLINE using the keywords "TNM staging," "T4 staging," "distant metastases," "esophageal cancer," "gastric cancer," and "colorectal cancer," and the search terms used in Cochrane Reviews between January 2005 to July 2020. Articles focusing on preoperative diagnosis of: (a) depth of invasion; (b) lymph node metastases; and (c) distant metastases were selected.

RESULTS

After a full-text search, a final set of 55 studies (17 esophageal cancer studies, 26 gastric cancer studies, and 12 colorectal cancer studies) were used to evaluate the accuracy of clinical TNM staging. Positron emission tomography-computed tomography (PET-CT) and/or magnetic resonance imaging (MRI) were the best modalities to assess distant metastases. Fat and fiber mode of CT may be useful for T4 staging of esophageal cancer, CT was a partially reliable modality for lymph node staging in gastric cancer, and CT combined with MRI was the most reliable modality for liver metastases from colorectal cancer.

CONCLUSION

The most reliable diagnostic modality differed among gastrointestinal cancers depending on the type of cancer. Therefore, we propose diagnostic algorithms for clinical staging for each type of cancer.

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.

Surgically Resected Esophageal Squamous Cell Carcinoma: Patient Survival and Clinicopathological Prognostic Factors

We aimed to report patients' survival after surgical resection of eSCC and to ascertain the clinical, imaging, and pathological factors related to patient prognosis. This retrospective study included 435 patients with eSCC of <stage T2 (median follow-up period, 49.3 months). A total of 103 (23.7%) patients died, and 89 (20.5%) experienced recurrence during follow-up. The maximum standardized uptake value (SUV_max) on positron emission tomography (PET)/computed tomography (CT) of the primary tumor was significantly correlated with tumor length, nodal metastasis, and pathologic T stage in a positive linear fashion. In the multivariate analysis, higher SUV_max on PET/CT was a negative prognostic factor for both disease-free survival (DFS) and overall survival (OS). Contrarily, the presence of nodal metastasis was a prognostic factor only for DFS, and pathologic T stage only for OS. By applying SUVmax cut-off, both DFS and OS were significantly different among three groups when divided by cut-off values (A: SUVmax ≤ 3.05, B: SUVmax 3.06 - 5.64, C: SUVmax ≥ 5.65). In patients with a surgically resectable eSCC, measuring the SUV_max of the primary tumor during PET/CT can help predict patient survival. Additionally, PET/CT renders triage criterion for endoscopic submucosal dissection (ESD; T1a cancer and SUVmax, ≤3.05).

Prognostic value of tumor length and diameter for esophageal squamous cell cancer patients treated with definitive (chemo)radiotherapy: Potential indicators for nonsurgical T staging

PURPOSE

The aim of this work was to evaluate the prognostic value of tumor length and diameter for patients with esophageal squamous cell cancer (ESCC) treated with definitive (chemo)radiotherapy to identify potential indicators for separate nonsurgical T staging, which are needed in clinical practice.

MATERIALS AND METHODS

A total of 682 patients with ESCC who underwent definitive (chemo)radiotherapy between 2009 and 2015 were reviewed. Esophageal tumor length and diameter were determined by barium esophagography and computed tomography before treatment. Univariate and multivariate analyses were used to assess the impact of tumor length and diameter on long-term overall survival (OS) and progression-free survival (PFS). Propensity score matching (PSM) analysis was also used to control intergroup heterogeneity.

RESULTS

The median OS and PFS were 22.2 months and 15.4 months, respectively, in the tumor length ≤ 6 cm group, which were significantly longer than those in the tumor length > 6 cm group (13.4 and 8.5 months, respectively). The median OS and PFS were 23.3 months and 15.9 months, respectively, in the tumor diameter ≤ 3.5 cm group, which were also significantly longer than those in the tumor diameter > 3.5 cm group (13.3 and 8.8 months, respectively). Similar results were found after PSM. Univariate and multivariate analyses showed that tumor length and diameter were both independent predictors of long-term survival.

CONCLUSION

Tumor length and diameter are both independent prognostic factors for ESCC patients treated with definitive (chemo)radiotherapy. These two imaging parameters have the potential for development and use in nonsurgical T staging.

Improved detection of metastatic lymph nodes in oesophageal squamous cell carcinoma by combined interpretation of fluorine-18-fluorodeoxyglucose positron-emission tomography/computed tomography

Background

We sought to evaluate the diagnostic performance of fluorine-18-fluorodeoxyglucose positron-emission tomography/computed tomography (¹⁸F-FDG PET/CT) in the detection of metastatic lymph nodes by combined interpretation of PET/CT images in patients with oesophageal squamous cell carcinoma.

Methods

Two hundred three patients with oesophageal squamous cell carcinoma underwent ¹⁸F-FDG PET/CT before oesophagectomy and lymph node dissection. Maximum standardized uptake value (SUV_max), mean Hounsfield unit (HU), short axis diameter (size), and visual CT attenuation (high, iso-, low) were evaluated on noncontrast CT and PET images following PET/CT scan. In this combined interpretation protocol, the high attenuated lymph nodes were considered benign, even if the SUV_max value was high. The diagnostic accuracy of each method was compared using the postoperative histologic result as a reference standard.

Results

A total of 1099 nodal stations were dissected and 949 nodal stations were proven to demonstrate metastasis. SUV_max and size of the malignant lymph nodes were higher than those of the benign nodes, and visual CT attenuation was significantly different among the two groups (P < 0.001). Using cutoff values of 2.6 for SUV_max and 10.2 mm for size, the combined interpretation of an SUV_max of more than 2.6 with iso- or low CT attenuation [area under the curve (AUC): 0.846, 95% confidence interval (CI): 0.824–0.867] showed significantly better diagnostic performance for detecting malignant lymph nodes than SUV_max only (AUC: 0.791, 95% CI: 0.766–0.815) and size (AUC: 0.693, 95% CI: 0.665–0.720) methods (P < 0.001) in a receiver operating characteristic curve analysis.

Conclusions

The diagnostic accuracy of PET/CT for nodal metastasis in oesophageal squamous cell carcinoma was improved by the combined interpretation of ¹⁸F-FDG uptake and visual CT attenuation pattern.

Surgically resected T1- and T2-stage esophageal squamous cell carcinoma: T and N staging performance of EUS and PET/CT

This study aimed to evaluate the frequency of nodal metastases and to disclose the diagnostic performance of endoscopic ultrasonography (EUS) and PET/CT in T and N staging in surgically resected early-stage esophageal squamous cell carcinomas (eSCCs). Institutional review board approved this retrospective study with waiver of informed consent for reviewing medical record. We included 435 patients with an early T-stage (Tis or T1a [≤T1a], T1b and T2) eSCC. The rates of metastatic lymphadenopathy were calculated. Then, the performance of EUS and PET/CT in subdividing T and N stages was assessed. 131 ≤ T1a, 234 T1b, and 70 T2 eSCCs were identified. In discriminating ≤T1a from other cancers, the sensitivity, specificity, and accuracy of EUS were 60.3% (79/131), 80.3% (244/304), and 74.3% (323/435) respectively. With ROC curve analysis, cut-off value of SUVmax 3.05 at PET provided sensitivity 74.8% (98/131), specificity 70.1% (213/304), and accuracy 71.5% (311/435) for differentiating ≤T1a eSCCs from others. Ten (7.6%) of 131 ≤ T1a cancers had nodal metastasis. In discriminating N0 from node-positive disease, sensitivity, specificity, and accuracy of EUS were 89.6% (267/298), 41.6% (57/137), and 74.5% (324/435), respectively, whereas those of PET/CT were 88.9% (265/298), 38.7% (53/137), and 73.1% (318/435) respectively. In >70% of patients with ≤T1a eSCCs, the tumor stage can be discriminated from higher stage cancers by using EUS or PET/CT. Substantial percentage (7.6%) of ≤T1a eSCC patients have nodal metastases, which are missed in more than half of the patients in clinical staging.