Change in volume parameters induced by neoadjuvant chemotherapy provide accurate prediction of overall survival after resection in patients with oesophageal cancer

Prognostic value of [18F]FDG PET/CT on treatment response and progression-free survival of gastroesophageal cancer patients undergoing perioperative FLOT chemotherapy

PURPOSE

To evaluate the prognostic role of [¹⁸F]FDG PET/CT metabolic parameters in gastric cancer (GC) and gastroesophageal adenocarcinoma (GEJAC) patients receiving neoadjuvant chemotherapy.

METHOD

In this retrospective study, 31 patients with biopsy-proven GC or GEJAC were included between August 2016 and March 2020. [¹⁸F]FDG PET/CT was performed before the neoadjuvant chemotherapy. Primary tumours' semi-quantitative metabolic parameters were extracted. All patients received a perioperative FLOT regimen thereafter. Post-chemotherapy [¹⁸F]FDG PET/CT was performed in most patients (17/31). All patients underwent surgical resection. Histopathology response to treatment and progression-free survival (PFS) were evaluated. Two-sided p-values < 0.05 were considered statistically significant.

RESULTS

Thirty-one patients (mean age = 62 ± 8), including 21 GC and 10 GEJAC patients, were evaluated. 20/31(65%) patients were histopathology responders to neoadjuvant chemotherapy, including twelve complete and eight partial responders. During the median follow-up of 42.0 months, nine patients experienced recurrence. The median PFS was 60(95% CI:32.9-87.1) months. Pre-neoadjuvant chemotherapy SULpeak was significantly correlated with pathological response to treatment (p-value = 0.03;odds ratio = 16.75). In survival analysis, SUVmax (p-value = 0.01;hazard ratio[HR] = 1.55), SUVmean (p-value = 0.04;HR = 2.73), SULpeak (p-value < 0.001;HR = 1.91) and SULmean (p-value = 0.04;HR = 4.22) in the post-neoadjuvant chemotherapy pre-operative [¹⁸F]FDG PET/CT showed significant correlation with PFS. Additionally, aspects of staging were significantly correlated with PFS (p-value = 0.01;HR = 2.21).

CONCLUSIONS

Pre-neoadjuvant chemotherapy [¹⁸F]FDG PET/CT parameters, especially SULpeak, could predict the pathological response to treatment in GC and GEJAC patients. Additionally, in survival analysis, post-chemotherapy metabolic parameters significantly correlated with PFS. Thus, performing [¹⁸F]FDG PET/CT before chemotherapy may help to identify patients at risk for inadequate response to perioperative FLOT and, after chemotherapy, may predict clinical outcomes.

Risk stratification of oesophageal squamous cell carcinoma using change in total lesion glycolysis and number of PET-positive lymph nodes

BACKGROUND

The efficacy of neoadjuvant chemotherapy (NACT) correlates with patient survival in oesophageal squamous cell carcinoma (OSCC), but optimal evaluation of the treatment response based on PET-CT parameters has not been established.

METHODS

We analysed 226 OSCC patients who underwent PET-CT before and after NACT followed by surgery. We assessed SUVmax, metabolic tumour volume (MTV), and total lesion glycolysis (TLG) for the primary tumour and the number of PET-positive lymph nodes before and after NACT to predict patient survival.

RESULTS

In a stepwise analysis, we defined 60%, 80%, and 80% as the optimal cut-off values for SUVmax, MTV, and TLG reduction, respectively, to distinguish responders and non-responders to NACT. In the ROC analysis, the TLG reduction rate was the best predictor of recurrence among PET-CT parameters. The TLG responders achieved significantly more favourable prognoses than non-responders (2-year progression-free survival [PFS] rate: 64.1% vs. 38.5%; P = 0.0001). TLG reduction rate (HR 2.58; 95% CI 1.16-5.73) and the number of PET-positive lymph nodes after NACT (HR 1.79; 95% CI 1.04-3.08) were significant independent prognostic factors.

CONCLUSIONS

TLG reduction is the best predictor of prognosis. Preoperative PET-CT evaluation of both the primary tumour and lymph nodes could accurately stratify risk in OSCC patients.

Change in Density Not Size of Esophageal Adenocarcinoma During Neoadjuvant Chemotherapy Is Associated with Improved Survival Outcomes

BACKGROUND

Changes in the size and density of esophageal malignancy during neoadjuvant chemotherapy (NCT) may be useful in predicting overall survival (OS). The aim of this study was to explore this relationship in patients with adenocarcinoma.

METHODS

A retrospective single-centre cohort study was performed. Consecutive patients with esophageal adenocarcinoma who received NCT followed by en bloc resection with curative intent were identified. Pre- and post-NCT computed tomography scans were reviewed. The percentage difference between the greatest tumor diameter, esophageal wall thickness and tumor density was calculated. Multivariate Cox regression analysis identified variables independently associated with OS. A ROC analysis was performed on radiological markers to identify optimal cut-off points with Kaplan-Meier plots subsequently created.

RESULTS

Of the 167 identified, 88 (51.5%) had disease of the gastro-esophageal junction and 149 (89.2%) were clinical T3. In total, 122 (73.1%) had node-positive disease. Increased tumor density (HR 1.01 per % change, 95% CI 1.00-1.02, p = 0.007), lymphovascular invasion (HR 3.23, 95% CI 1.34-7.52, p = 0.006) and perineural invasion (HR 2.51, 95% CI 1.03-6.08, p = 0.048) were independently associated with a decrease in OS. Patients who had a decrease in their tumor density during the time they received NCT of ≥ 20% in Hounsfield units had significantly longer OS than those who did not (75.5 months versus 34.4 months, 95% CI 38.83-105.13/18.63-35.07, p = 0.025).

CONCLUSIONS

Interval changes in the density, not size, of esophageal adenocarcinoma during the time that NCT are independently associated with OS.

Significance of mid-radiotherapy 18F-fluorodeoxyglucose positron emission tomography/computed tomography in esophageal cancer

BACKGROUND AND PURPOSE

Metabolic parameters evaluated by 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/computed tomography (CT) are known as prognostic markers in various cancers. We aimed to validate the predictive value of mid-radiotherapy (RT) FDG PET/CT parameters in esophageal cancer.

MATERIALS AND METHODS

Eighty-three patients treated with RT with or without chemotherapy between 2015 and 2020 were included. PET parameters including metabolic tumor volume (MTV), total lesion glycolysis, and mean (SUV_mean) and maximum standardized uptake value (SUV_max) were analyzed. Locoregional recurrence-free rate (LRFR) and distant metastasis-free rate (DMFR) were analyzed.

RESULTS

The median follow-up period was 10.5 months. Mid-RT SUV_max was significantly associated with LRFR (HR 1.07, p = 0.009) and DMFR (HR 1.13, p=0.047) while mid-RT MTV was associated with DMFR (HR 1.06, p=0.007). Treatment response after RT was associated with overall survival (HR, 1.52, p=0.025). Further, treatment response was significantly associated with mid-RT SUV_max. The optimal cutoff value for mid-RT SUV_max in predicting LRFR and DMFR was 11 while cutoff value for mid-RT MTV was 15. The patients with mid-RT SUV_max≤11 showed superior LRFR and DMFR compared to SUV_max>11 (1-year LRFR; 73.4% vs 48.4%, p=0.028, 1-year DMFR; 74.6% vs 40.7%, p=0.007). The 1-year DMFR was significantly different between patients with mid-RT MTV≤15 and >15 (1-year DMFR; 78.2% vs 31.9%, p=0.002).

CONCLUSION

Tumor metabolism changes during RT can be a useful predictive tool for treatment response and recurrence in patients with esophageal cancer. Clinicians may consider early response evaluation with PET during RT for information about prognosis.

PET Imaging and Rate of Pathologic Complete Response in Esophageal Squamous Cell Carcinoma

BACKGROUND

For locally advanced esophageal squamous cell carcinoma (ESCC), chemoradiation (ChemoRT) followed by surgery offers the best chance of cure, with a 35-50% pathologic complete response (pCR) rate. Given the morbidity of esophagectomy and the possibility of pCR with ChemoRT, a 'watch and wait' strategy has been proposed, particularly for squamous cell carcinoma. The ability to accurately predict which patients will have pCR from ChemoRT is critical in treatment decision making. This study assessed positron emission tomography (PET) in predicting pCR after neoadjuvant ChemoRT for ESCC.

METHODS

ESCC patients treated with ChemoRT followed by surgery were identified. Maximum standard uptake value (SUV), metabolic tumor volume, total lesion glycolysis, and first-order textual features of standard deviation, kurtosis and skewness were measured from PET. Univariable and multivariable generalized linear method analyses were performed. A metabolic complete response (mCR) was defined as a post-therapy PET scan with maximum SUV < 4.0.

RESULTS

Twenty-seven patients underwent ChemoRT followed by surgery, with overall pCR seen in 11 (41%) patients and radiographic mCR seen in 12 (44%) patients. Final pathology for these 12 patients revealed pCR (ypT0N0M0) in 5 (42%) patients and persistent disease in 7 (58%) patients. Univariate analysis did not reveal PET parameters predictive of pCR.

CONCLUSION

Treatment of ESCC with ChemoRT often results in a robust clinical response. Among patients with an mCR after ChemoRT, disease persistence was found in 58%. The inability of PET to predict pCR is important in the context of a 'watch and wait' strategy for ESCC treated with ChemoRT.

Evaluating the effect of Neoadjuvant chemotherapy for esophageal Cancer using the RECIST system with shorter-axis measurements: a retrospective multicenter study

Background

Evaluating the effect on primary lesions is important in determining treatment strategies for esophageal cancer. The Response Evaluation Criteria in Solid Tumors system, which employs the longest diameter for measuring tumors, is commonly used for evaluating treatment effects. However, the usefulness of these criteria in assessing primary esophageal tumors remains controversial. Thus, we evaluated this issue by measuring not only the longest diameter but also the shorter axis of the tumor.

Methods

We retrospectively reviewed data from 313 patients with esophageal cancer treated with neoadjuvant chemotherapy followed by esophagectomy at three major high-volume centers in Japan. All patients underwent contrast-enhanced computed tomography before and after chemotherapy. The longest and shortest tumor diameters were measured in each case. Treatment effects were adapted to the Response Evaluation Criteria in Solid Tumors system. Correlations between pathological and survival data were also analyzed.

Results

Inter-observer discrepancies were examined for changes in the longest diameter and shorter axis of the tumor (the intraclass correlation coefficients were 0.550 and 0.624, respectively). The shorter axis was correlated with the pathological response in the multivariate analysis (p < 0.001). The shorter axis was significantly associated with overall survival and disease-free survival (both p < 0.001), whereas this association was not observed for the longest tumor diameter.

Conclusions

This multicenter study demonstrated that the Response Evaluation Criteria in Solid Tumors system is useful for predicting pathological response and survival by incorporating the shorter axis of the primary esophageal tumor.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08747-y.

Does a high Mandard score really define a poor response to chemotherapy in oesophageal adenocarcinoma?

BACKGROUND

A high Mandard score implies a non-response to chemotherapy in oesophageal adenocarcinoma. However, some patients exhibit tumour volume reduction and a nodal response despite a high score. This study examines survival and recurrence patterns in these patients.

METHODS

Clinicopathological factors were analysed using multivariable Cox regression assessing time to death and recurrence. Computed tomography-estimated tumour volume change was examined in a subgroup of consecutive patients.

RESULTS

Five hundred and fifty-five patients were included. Median survival was 55 months (Mandard 1-3) and 21 months (Mandard 4 and 5). In the Mandard 4 and 5 group (332 patients), comparison between complete nodal responders and persistent nodal disease showed improved survival (90 vs 18 months), recurrence rates (locoregional 14.75 vs 28.74%, systemic 24.59 vs 48.42%) and circumferential resection margin positivity (22.95 vs 68.11%). Complete nodal response independently predicted improved survival (hazard ratio 0.34 (0.16-0.74). Post-chemotherapy tumour volume reduction was greater in patients with a complete nodal response (-16.3 vs -7.7 cm³, p = 0.033) with no significant difference between Mandard groups.

CONCLUSION

Patients with a complete nodal response to chemotherapy have significantly improved outcomes despite a poor Mandard score. High Mandard score does not correspond with a non-response to chemotherapy in all cases and patients with nodal downstaging may still benefit from adjuvant chemotherapy.

Predicting tumor response and prognosis to neoadjuvant chemotherapy in esophageal squamous cell carcinoma patients using PERCIST: a multicenter study in Japan

PURPOSE

To investigate the usefulness of the positron emission tomography response criteria in solid tumors 1.0 (PERCIST1.0) for predicting tumor response to neoadjuvant chemotherapy and prognosis and determine whether PERCIST improvements are necessary for esophageal squamous cell carcinoma (ESCC) patients.

PATIENTS AND METHODS

We analyzed the cases of 177 ESCC patients and examined the association between PERCIST and their pathological responses. Associations of whole-PERCIST with progression-free survival (PFS) and overall survival (OS) were evaluated by a Kaplan-Meier analysis and Cox proportional hazards model. To investigate potential PERCIST improvements, we used the survival tree technique to understand patients' prognoses.

RESULTS

There were significant correlations between the pathologic response and PERCIST of primary tumor (p < 0.001). The optimal cutoff value of the primary tumors' SULpeak response to classify pathologic responses was -50.0%. The diagnostic accuracy of SULpeak response was 87.3% sensitivity, 54.1% specificity, 68.9% accuracy, positive predictive value 60.5%, and negative predictive value 84.1%. Whole-PERCIST was significantly associated with PFS and OS. The survival tree results indicated that a high reduction of the whole SULpeak response was significantly correlated with the patients' prognoses. The cutoff values for the separation of prognoses were - 52.5 for PFS and - 47.1% for OS.

CONCLUSION

PERCIST1.0 can help predict tumor responses and prognoses. However, ¹⁸F-FDG-PET/CT tends to underestimate residual tumors in histopathological response evaluations. Modified PERCIST, in which the partial metabolic response is further classified by the SULpeak response (-50%), might be more appropriate than PERCIST1.0 for evaluating tumor responses and stratifying high-risk patients for recurrence and poor prognosis.

Role of Multimodality Imaging in Gastroesophageal Reflux Disease and Its Complications, with Clinical and Pathologic Correlation

Gastroesophageal reflux disease (GERD) is a common condition and impairs the quality of life for millions of patients, accounts for considerable health care spending, and is a primary risk factor for esophageal adenocarcinoma. There have been substantial advances in understanding the pathogenesis of GERD and its complications and much progress in diagnosis and management of GERD; however, these have not been comprehensively discussed in the recent radiology literature. Understanding the role of imaging in GERD and its complications is important to aid in multidisciplinary treatment of GERD. GERD results from prolonged or recurrent reflux of gastric contents into the esophagus. Common symptoms include heartburn or regurgitation. Prolonged reflux of gastric contents into the esophagus can cause erosive esophagitis. Over time, the inflammatory response related to esophagitis can lead to deposition of fibrous tissue and development of strictures. Alternatively, the esophageal mucosa can undergo metaplasia (Barrett esophagus), a precursor to dysplasia (which can lead to adenocarcinoma). Conventional barium esophagography has long been considered the primary imaging modality for the esophagus, and the fluoroscopic findings for diagnosis of GERD have been well established. Multimodality imaging has a clear role in detection and assessment of the complications of GERD, specifically reflux esophagitis and Barrett esophagus; differentiation of benign and malignant strictures; and detection, staging, and posttreatment surveillance of esophageal adenocarcinoma. Given the dramatic changes in utilization of abdominal imaging during the past 2 decades, with significantly declining volume of fluoroscopic procedures and concomitant increase in CT and MRI studies, it is crucial that modern radiologists appreciate the value of barium esophagography in the workup of GERD and recognize the key imaging features of GERD and its complications at CT and MRI.

Meta-analysis of prognostic factors of overall survival in patients undergoing oesophagectomy for oesophageal cancer

INTRODUCTION

Currently, the American Joint Commission on Cancer (AJCC) staging system is used for prognostication for oesophageal cancer. However, several prognostically important factors have been reported but not incorporated. This meta-analysis aimed to characterize the impact of preoperative, operative, and oncological factors on the prognosis of patients undergoing curative resection for oesophageal cancer.

METHODS

This systematic review was performed according to PRISMA guidelines and eligible studies were identified through a search of PubMed, Scopus, and Cochrane CENTRAL databases up to 31 December 2018. A meta-analysis was conducted with the use of random-effects modeling to determine pooled univariable hazard ratios (HRs). The study was prospectively registered with the PROSPERO database (Registration: CRD42018157966).

RESULTS

One-hundred and seventy-one articles including 73,629 patients were assessed quantitatively. Of the 122 factors associated with survival, 39 were significant on pooled analysis. Of these. the strongly associated prognostic factors were 'pathological' T stage (HR: 2.07, CI95%: 1.77-2.43, P < 0.001), 'pathological' N stage (HR: 2.24, CI95%: 1.95-2.59, P < 0.001), perineural invasion (HR: 1.54, CI95%: 1.36-1.74, P < 0.001), circumferential resection margin (HR: 2.17, CI95%: 1.82-2.59, P < 0.001), poor tumor grade (HR: 1.53, CI95%: 1.34-1.74, P < 0.001), and high neutrophil:lymphocyte ratio (HR: 1.47, CI95%: 1.30-1.66, P < 0.001).

CONCLUSION

Several tumor biological variables not included in the AJCC 8th edition classification can impact on overall survival. Incorporation and validation of these factors into prognostic models and next edition of the AJCC system will enable personalized approach to prognostication and treatment.

Total Lesion Glycolysis Ratio in Positron Emission Tomography/Computed Tomography Images During Neoadjuvant Chemotherapy Can Predict Pathological Tumor Regression Grade and Prognosis in Patients with Locally Advanced Squamous Cell Carcinoma of the Esophagus

BACKGROUND

The usefulness of quantitating tumor lesion glycolysis (TLG) from ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) findings as a tool for determining the effect of neoadjuvant chemotherapy (NAC) in esophageal squamous cell carcinoma (ESCC) has not yet been established.

METHODS

The cohort of this retrospective study comprised 46 patients who had undergone NAC and subsequent esophagectomy for locally advanced ESCC between January 2008 and December 2017. PET/CT was conducted before and after NAC to assess its therapeutic effect. Associations between changes in TLG values during NAC and clinicopathological findings, pathological tumor regression grade (TRG), and prognosis were assessed.

RESULTS

Most patients received two courses of DCF (Docetaxel, Cisplatin, and Fluorouracil) as NAC. The mean TLG value of the primary tumor decreased significantly after NAC. The median follow-up period was 41 months. The Kaplan-Meier method, analyzed by log-rank test, showed that low TLG ratio (≤ 0.4) and low SUV_max ratio (≤ 0.6) were associated with favorable survival outcomes (P = 0.0073 and P = 0.032, respectively). Univariate and multivariate analysis revealed that TLG ratio and achievement of pathological cure were independent prognostic factors for overall survival. TLG ratio was also associated with pathological TRG (TRG 0-1a vs 1b-3) (P = 0.0016).

CONCLUSIONS

TLG ratio before and after NAC is clinically useful in predicting both histological response and survival outcome after NAC and subsequent esophagectomy in patients with ESCC.

Usefulness of 18 F-fluorodeoxyglucose positron emission tomography/computed tomography for predicting the prognosis and treatment response of neoadjuvant therapy for pancreatic ductal adenocarcinoma

BACKGROUND

The Response Evaluation Criteria in Solid Tumors (RECIST) for computed tomography (CT) is preoperatively used to evaluate therapeutic effects. However, it does not reflect the pathological treatment response (PTR) of pancreatic ductal adenocarcinoma (PDAC). The Positron Emission Tomography Response Criteria in Solid Tumors (PERCIST) for positron emission tomography (PET)/CT is effective in other cancers. This study aimed to confirm the usefulness of PERCIST and the prognostic utility of PET/CT for PDAC.

METHODS

Forty-two consecutive patients with PDAC who underwent neoadjuvant therapy (NAT) and pancreatectomy at our institution between 2014 and 2018 were retrospectively analyzed. We evaluated the treatment response and prognostic significance of PET/CT parameters and other clinicopathological factors.

RESULTS

Twenty-two patients who underwent PET/CT both before and after NAT with the same protocol were included. RECIST revealed stable disease and partial response in 20 and 2 cases, respectively. PERCIST revealed stable metabolic disease, partial metabolic response, and complete metabolic response in 8, 9, and 5 cases, respectively. The PTR was G3, G2, and G1 in 8, 12, and 2 cases, respectively. For comparing the concordance rates between PTR and each parameter, PERCIST (72.7% [16/22]) was significantly superior to RECIST (36.4% [8/22]) (P = .017). The area under the curve survival values of PET/CT parameters were 0.777 for metabolic tumor volume (MTV), 0.500 for maximum standardized uptake value, 0.554 for peak standardized uptake value corrected for lean body mass, and 0.634 for total lesion glycolysis. A 50% cut-off value for the MTV reduction rate yielded the largest difference in survival between responders and nonresponders. On multivariate analysis, MTV reduction rates < 50% were independent predictors for relapse-free survival (hazard ratio [HR], 3.92; P = .044) and overall survival (HR, 14.08; P = .023).

CONCLUSIONS

PERCIST was more accurate in determining NAT's therapeutic effects for PDAC than RECIST. MTV reduction rates were independent prognostic factors for PDAC.

Metabolic Tumor Volume Change Predicts Long-term Survival and Histological Response to Preoperative Chemotherapy in Locally Advanced Esophageal Cancer

OBJECTIVE

Here, we assess the ability of metabolic tumor volume (MTV) as measured by F-fluorodeoxyglucose-positron emission tomography/computed tomography (F-FDG PET/CT) to evaluate neoadjuvant chemotherapy response for patients with locally advanced esophageal cancer (EC).

BACKGROUND

Optimal methods to evaluate treatment response for EC patients have not yet been established. Although previous studies have reported the value of standardized uptake value (SUV), the accuracy of predicting histological response or long-term survival in EC is limited.

METHODS

In all, 102 EC patients without distant metastasis who underwent F-FDG PET/CT both before and after the preoperative chemotherapy series were analyzed.

RESULTS

The median primary tumor MTV values before and after preoperative chemotherapy were 22.55 (range 0.4-183.1) and 2.75 (0-52.9), respectively, and the median MVT reduction rate was 86.5%. We found the most significant difference in survival between PET responders and nonresponders with a cut-off value of 60% MTV reduction, using a 10% stepwise cut-off analysis [2-year progression-free survival (PFS): 79.2 vs 44.4%; hazard ratio (HR) 3.397; P < 0.0001). With this cut-off value, histological response (P = 0.0091), tumor location (P = 0.0102), pT (P = 0.0011), and pN (P = 0.0110) were significantly associated with PET response. Univariate analysis of PFS indicated a correlation between PFS and tumor size, cT, decrease of primary lesion by CT, SUVmax reduction rate, MTV reduction rate, pT, pN, and pM. Multivariate analysis further identified pM (HR 3.063; P = 0.0279) and MTV reduction rate (HR 2.471; P = 0.0263) to be independent prognostic predictors, but not decrease of primary lesion by CT or SUVmax reduction rate.

CONCLUSION

MTV change is clinically useful in predicting both long-term survival and histological response to preoperative chemotherapy in EC patients, after determining the optimal cut-off value based on survival analysis.

The Correlation Between Computed Tomography Volumetry and Prognosis of Advanced Gastric Cancer Treated with Neoadjuvant Chemotherapy

Purpose

To investigate the feasibility and utility of computer tomography (CT) volumetry in evaluating the tumor response to neoadjuvant chemotherapy (NAC) in advanced gastric cancer (AGC) patients.

Patients and Methods

One hundred and seventeen Patients with AGC who received NAC followed by R0 resection between January 2006 and December 2012 were included. Tumor volumes were quantified using OsiriX software. The volume reduction rate (VRR) was calculated as follows: VRR = [(pre-chemotherapy total volume) − (post-chemotherapy total volume)]/(pre-chemotherapy total volume) × 100%. The optimal cut-off VRR for differentiating favorable from unfavorable prognosis was determined by receiver operating characteristic (ROC) analysis. Overall survival was calculated using Kaplan-Meier analysis and values were compared using the Log-rank test. Multivariate analysis was determined by the Cox proportional regression model.

Results

The optimal cut-off VRR was 31.95% according to ROC analysis, with a sensitivity of 70.4% and a specificity of 71.7%. Based on the cut-off VRR, patients were divided into the VRR-High (VRR ≥ 31.95%, n = 63) and VRR-Low (VRR < 31.95%, n = 54) groups. The VRR-Low group exhibited a worse prognosis than that of the VRR-High group (HR, 2.85; 95% CI, 1.69–4.82, P < 0.001), with 3-year survival rates of 40.7% and 79.4%, and 5-year survival rates of 31.5% and 63.5%, respectively.

Conclusion

CT volumetry is a feasible and reliable method for assessing the tumor response to NAC in patients with AGC.

Opportunistic body composition evaluation in patients with esophageal adenocarcinoma: association of survival with 18F-FDG PET/CT muscle metrics

OBJECTIVE

¹⁸F-FDG PET is widely used to accurately stage numerous types of cancers. Although ¹⁸F-FDG PET/CT features of tumors aid in predicting patient prognosis, there is increasing interest in mining additional quantitative body composition data that could improve the prognostic power of ¹⁸F-FDG PET/CT, without additional examination costs or radiation exposure. The aim of this study was to determine the association between overall survival and body composition metrics derived from routine clinical ¹⁸F-FDG PET/CT examinations.

METHODS

Patients who received baseline ¹⁸F-FDG PET/CT imaging during workup for newly diagnosed esophageal adenocarcinoma (EAC) were included. From these studies, psoas cross-sectional area (CSA), muscle attenuation (MA), SUV_mean, and SUV_max were obtained. Correlation with overall survival was assessed using a Cox Proportional Hazards model, controlling for age, body mass index, ¹⁸F-FDG dose, glucose level, diabetes status, in-hospital status, and tumor stage.

RESULTS

Among the 59 patients studied, psoas MA and SUV_max were found to be significant predictors of survival (HR 0.94, 95% CI 0.88-0.99, p = 0.04, and HR 0.37, 95% CI 0.14-0.97, p = 0.04, respectively) and remained independent predictors. Psoas CSA and SUV_mean did not significantly influence survival outcomes.

CONCLUSIONS

Characterization of psoas muscles as a surrogate marker for sarcopenia on baseline ¹⁸F-FDG PET/CT imaging is relatively easily obtained and may offer additional prognostic value in patients with EAC.

Computed tomography volumetry of esophageal cancer - the role of semiautomatic assessment

Background

The clinical and research value of Computed Tomography (CT) volumetry of esophageal cancer tumor size remains controversial. Development in CT technique and image analysis has made CT volumetry less cumbersome and it has gained renewed attention. The aim of this study was to assess esophageal tumor volume by semi-automatic measurements as compared to manual.

Methods

A total of 23 esophageal cancer patients (median age 65, range 51–71), undergoing CT in the portal-venous phase for tumor staging, were retrospectively included between 2007 and 2012. One radiology resident and one consultant radiologist measured the tumor volume by semiautomatic segmentation and manual segmentation. Reproducibility of the respective measurements was assessed by intraclass correlation coefficients (ICC) and by average deviation from mean.

Results

Mean tumor volume was 46 ml (range 5-137 ml) using manual segmentation and 42 ml (range 3-111 ml) using semiautomatic segmentation. Semiautomatic measurement provided better inter-observer agreement than traditional manual segmentation. The ICC was significantly higher for semiautomatic segmentation in comparison to manual segmentation (0.86, 0.56, p < 0.01). The average absolute percentage difference from mean was reduced from 24 to 14% (p < 0.001) when using semiautomatic segmentation.

Conclusions

Semiautomatic analysis outperforms manual analysis for assessment of esophageal tumor volume, improving reproducibility.

A Diagnostic Algorithm That Combines Quantitative 18F-FDG PET Parameters and Contrast-Enhanced CT Improves Posttherapeutic Locoregional Restaging and Prognostication of Survival in Patients With Esophageal Cancer

PURPOSE

The aim of this study was to determine whether the combination of contrast-enhanced CT (CE-CT) and quantitative F-FDG PET parameters improves locoregional restaging in esophageal cancer (EC) after neoadjuvant therapy.

METHODS

Eighty-eight consecutive patients with locally advanced esophageal cancer, who underwent restaging after neoadjuvant chemotherapy or chemoradiotherapy before esophagectomy, were included in this retrospective study. The diagnostic accuracy of CE-CT, visual F-FDG PET/CT (vPET/CT), and quantitative PET parameters was assessed for T and N staging. Histopathology was used as the reference standard. The prognostic value for recurrence-free survival, cancer-specific survival, and overall survival was assessed using Cox regression analysis.

RESULTS

Sensitivity, positive predictive value, and accuracy were 78.8%, 70.2%, and 59.0% (CE-CT), and 81.1%, 81.1%, and 68.2% (vPET/CT) for T staging as well as 59.5%, 75.9%, and 50.0% (CE-CT), and 70.2%, 93.7%, and 67.0% (vPET/CT) for N staging, respectively. Tumor length and metabolic tumor volume (MTV) exhibited an incremental increase with advancing T stages (P = 0.002 and 0.038). Contrast-enhanced CT had the highest sensitivity to differentiate advanced T stages (T3/4 vs 0-2; area under the receiver operating curve [AUC], 0.86; P < 0.001), whereas MTV at a threshold of 5.8 mL had the highest sensitivity to detect complete response (T0 vs 1-4; AUC, 0.77; P = 0.002). Contrast-enhanced CT and MTV combined had an even superior accuracy to predict complete response (AUC, 0.82; P < 0.001). The imaging American Joint Committee on Cancer stage provided a better prognostication of recurrence-free survival, cancer-specific survival, and overall survival than either T stage, N stage derived from CE-CT or vPET/CT, or quantitative PET parameters alone.

CONCLUSIONS

Combined CE-CT and MTV had the highest diagnostic accuracy to identify the posttherapeutic T stage, allowing for robust prediction of recurrence and survival.

Clinical significance of SUVmax on preoperative 18F-fluorodeoxyglucose positron emission tomography in patients who underwent R0-esophagectomy for esophageal cancer

The standardized uptake value (SUV) is a marker of tumor glucose metabolism, detected using 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) and may reflect tumor aggressiveness. The purpose of this study was to evaluate the clinical significance of maximum SUV (SUVmax) of primary esophageal cancer (EC) lesions. A total of 86 patients with EC who underwent pre-treatment FDG-PET and R0-resection were included in our study. The mean patient age was 65 years, and 87% were men. Histologically, cancers included squamous cell carcinomas, adenocarcinomas, and other tumors in 72, 3, and 11 patients, respectively. Preoperative chemotherapy with or without radiotherapy was performed in 4 and 37 patients, respectively. Measured patient outcomes included the correlation between the SUVmax of the primary EC lesion and clinicopathological factors in patients who did not undergo preoperative treatment (n = 45), and the investigation of relapse-free survival (RFS) according to SUVmax and the relationship between SUVmax and recurrence sites in all patients (n=86). The mean SUVmax was 8.9 ± 4.6, and SUVmax values significantly correlated with tumor invasion depth and stage. The 5-year RFS for the enrolled patients was 57%, and the RFS of patients with SUVmax < 7.0 was better than that of patients with SUVmax ≥ 7.0, with a marginal difference (p = 0.0892). Lymph node recurrences were significantly more common in patients with SUVmax ≥ 7.0, compared to patients with SUVmax < 7.0. Therefore, the SUVmax value of the primary EC lesion before preoperative treatment may be predictive of RFS and lymph node recurrence.

Prognostic value of SUR in patients with trimodality treatment of locally advanced esophageal carcinoma

The prognosis of patients with esophageal carcinoma remains dismal despite ongoing efforts to improve treatment options. For locally advanced tumors, several randomized trials have shown the benefit of neoadjuvant chemoradiation followed by surgery compared to surgery alone. The aim of this exploratory study was to evaluate the prognostic value of different baseline positron emission tomography (PET) parameters and their potentially additional prognostic impact at the end of neoadjuvant radiochemotherapy. Furthermore, the standard uptake ratio (SUR) as a new parameter for quantification of tumor metabolism was compared to the conventional PET parameters metabolic active volume (MTV), total lesion glycolysis (TLG), and standardized uptake value (SUV) taking into account known basic parameters. Methods:18F-FDG-PET/CT was performed in 76 consecutive patients ((60±10) years, 71 males) with newly diagnosed esophageal cancer before and during the last week of neoadjuvant radiochemotherapy. MTV of the primary tumor was delineated with an adaptive threshold method. The blood SUV was determined by manually delineating the aorta in the low dose CT. SUR values were computed as scan time corrected ratio of tumor SUVmax and mean blood SUV. Univariate Cox regression and Kaplan-Meier analysis with respect to locoregional control (LRC), freedom from distant metastases (FFDM), and overall survival (OS) was performed. Additionally, independence of PET parameters from standard clinical factors was analyzed with multivariate Cox regression. Results: In multivariate analysis two parameters showed a significant correlation with all endpoints: restaging MTV and restaging SUR. Furthermore, restaging TLG was prognostic for LCR and FFDM. For all endpoints the largest effect size was found for restaging SUR. The only basic factors remaining significant in multivariate analyses were histology for OS and FFDM and age for LRC. Conclusion: PET provides independent prognostic information for OS, LRC, and FFDM in addition to standard clinical parameters in this patient cohort. Our results suggest that the prognostic value of tracer uptake can be improved when characterized by SUR rather than by SUV. Overall, our investigation revealed a higher prognostic value of restaging parameters compared to baseline PET; therapy-adjustments would still be possible at this point of time. Further investigations are required to confirm these hypothesis-generating results.

Tumor response to neoadjuvant chemotherapy in patients with esophageal cancer assessed with CT and FDG-PET/CT - RECIST 1.1 vs. PERCIST 1.0

PURPOSE

We compared the response classification systems Response Evaluation Criteria in Solid Tumors (RECIST) 1.1 and Positron Emission Tomography Response Criteria in Solid Tumors (PERCIST) 1.0 for assessment of response to neoadjuvant chemotherapy in patients with esophageal cancer.

MATERIALS AND METHODS

Prior to planned surgical resection, 62 patients with esophageal cancer underwent fluorodeoxyglucose (FDG)-PET/CT and contrast-enhanced CT examinations before and after receiving neoadjuvant chemotherapy. Primary tumor largest diameter, maximum standardized uptake value (SUVmax), peak lean body mass SUV (SULpeak), metabolic tumor volume (MTV), and total lesion glycolysis (TLG) were determined. Patients were divided into responders (grade 1b-3) and non-responders (grade 0-1a) according to pathological response.

RESULTS

Concordance between RECIST 1.1 and PERCIST 1.0 for response classification was seen in 28 (45.2%) patients. For 18 defined as responders, the number of metabolic responders (partial metabolic response + complete metabolic response) shown by PERCIST 1.0 was 17 and the number of anatomic responders (partial response + complete response) shown by RECIST 1.1 was 13. To distinguish responders from non-responders, the area under the receiver operating characteristics curve values for reduced primary tumor largest diameter, SUVmax, SULpeak, MTV, and TLG were 0.724, 0.775, 0.781, 0.756, and 0.759, respectively. An optimal percent decrease in largest diameter cut-off value of 39.2% was found to have 66.7% sensitivity and 70.5% specificity, while that for SULpeak of 55.8% was 77.8% and 75.0%, respectively.

CONCLUSIONS

As compared to RECIST 1.1, PERSIST 1.0 may be more suitable for evaluation of neoadjuvant therapeutic response to esophageal cancer.

[18F]Fluorodeoxyglucose PET/CT and prediction of histopathological response to neoadjuvant chemotherapy for adenocarcinoma of the oesophagus and oesophagogastric junction

Background

The aim of this prospective study was to assess whether [18F]fluorodeoxyglucose PET can be used to predict histopathological response early in the course of neoadjuvant chemotherapy in patients with adenocarcinoma of the oesophagus and oesophagogastric junction.

Methods

Following the PET response criteria in solid tumours (PERCIST 1.0) as a standardized method for semiquantitative assessment of metabolic response, FDG-PET/CT was performed before (PET1) and after (PET2) initiation of the first cycle of chemotherapy. The relative changes in the peak standardized uptake value (ΔSUL) and total lesion glycolysis (ΔTLG) between PET1 and PET2 were correlated with histopathological response, defined as less than 50 per cent viable tumour cells in the resection specimen. A receiver operating characteristic (ROC) curve analysis was used to identify the optimal cut-off value with the highest accuracy of histopathological response prediction.

Results

PET2 was performed a median of 16 (range 12–22) days after the start of chemotherapy. Some 27 of 90 patients who underwent surgery had a histopathological response. There was no association between the median ΔSUL or median ΔTLG and the histopathological response. A post hoc analysis in 47 patients with PET2 performed 16 days or less after the start of chemotherapy showed that ΔTLG, but not ΔSUL, was associated with the histopathological response (P = 0·009). The optimal cut-off value of ΔTLG was 66 per cent or more.

Conclusion

FDG-PET/CT after the first cycle of chemotherapy does not predict histopathological response in patients with adenocarcinoma of the oesophagus and oesophagogastric junction.

Personalized therapy based on image for esophageal or gastroesophageal junction adenocarcinoma

Preoperative therapy is the gold standard for esophageal or gastroesophageal junction adenocarcinoma. Positron emission tomography (PET) is not only essential for tumor staging, but changes in glucose consumption correspond with response to therapy and correlated with prognosis. Therefore, with further refinement, PET parameter can serve as a tool for personalized therapy. For instance, the Municon trials suggested the possibility of PET-response guided therapy for esophageal adenocarcinoma (EAC) patients, however there are limitations. New PET parameters such as total lesion glycolysis (TLG) or magnetic resonance imaging (MRI) may provide better response prediction. Furthermore, PET parameters combined with genomic profiling might enhance better treatment selection, prediction, and prognostication. Here, we summarized the current state of understanding and future possibilities.

ECCO essential requirements for quality cancer care: Oesophageal and gastric cancer

BACKGROUND

ECCO essential requirements for quality cancer care (ERQCC) are checklists and explanations of organisation and actions that are necessary to give high-quality care to patients who have a specific type of cancer. They are written by European experts representing all disciplines involved in cancer care. ERQCC papers give oncology teams, patients, policymakers and managers an overview of the elements needed in any healthcare system to provide high quality of care throughout the patient journey. References are made to clinical guidelines and other resources where appropriate, and the focus is on care in Europe.

OESOPHAGEAL AND GASTRIC

ESSENTIAL REQUIREMENTS FOR QUALITY CARE: CONCLUSION: Taken together, the information presented in this paper provides a comprehensive description of the essential requirements for establishing a high-quality OG cancer service. The ERQCC expert group is aware that it is not possible to propose a 'one size fits all' system for all countries, but urges that access to multidisciplinary units or centres must be guaranteed for all those with OG cancer.

The impact of intratumoral metabolic heterogeneity on postoperative recurrence and survival in resectable esophageal squamous cell carcinoma

OBJECTIVE

To evaluate the impact of intratumoral metabolic heterogeneity measured by 18F-FDG PET imaging on postoperative recurrence and survival for patients with esophageal squamous cell carcinoma (ESCC).

RESULTS

AUC-CSH, metabolic tumor volume and pN-stage were significant prognostic factors for RFS. Additionally, tumor recurrence of the low AUC-CSH group (≤ 0.478) was 3 times higher than high group (P = 0.015). The median OS of patients with advanced AJCC stage or low AUC-CSH was also significantly shorter than that of patients with stage I & II or high AUC-CSH (P = 0.021, 0.009). Multivariate analysis identified the AUC-CSH to be the only significant risk factor for postoperative recurrence and overall survival in whole-group and stage III patients.

MATERIALS AND METHODS

116 ESCC patients who underwent staging 18F-FDG PET-CT scan and surgical resection were reviewed. The metabolic parameters were assessed as follows: maximum standardized uptake value (SUVmax), metabolic tumor volume, and the area under the curve of the cumulative SUV-volume histogram (AUC-CSH), which is known to reflect the intratumoral metabolic heterogeneity. Regression analyses were used to identify clinicopathological and imaging variables associated with relapse-free survival (RFS) and overall survival (OS).

CONCLUSIONS

Intratumoral metabolic heterogeneity characterized by AUC-CSH can predict postoperative recurrence and survival in patients with resectable ESCC.

Restaging oesophageal cancer after neoadjuvant therapy with (18)F-FDG PET-CT: identifying interval metastases and predicting incurable disease at surgery

OBJECTIVES

It is unknown whether restaging oesophageal cancer after neoadjuvant therapy with positron emission tomography-computed tomography (PET-CT) is more sensitive than contrast-enhanced CT for disease progression. We aimed to determine this and stratify risk.

METHODS

This was a retrospective study of patients staged before neoadjuvant chemotherapy (NAC) by (18)F-FDG PET-CT and restaged with CT or PET-CT in a single centre (2006-2014).

RESULTS

Three hundred and eighty-three patients were restaged (103 CT, 280 PET-CT). Incurable disease was detected by CT in 3 (2.91 %) and PET-CT in 17 (6.07 %). Despite restaging unsuspected incurable disease was encountered at surgery in 34/336 patients (10.1 %). PET-CT was more sensitive than CT (p = 0.005, McNemar's test). A new classification of FDG-avid nodal stage (mN) before NAC (plus tumour FDG-avid length) predicted subsequent progression, independent of conventional nodal stage. The presence of FDG-avid nodes after NAC and an impassable tumour stratified risk of incurable disease at surgery into high (75.0 %; both risk factors), medium (22.4 %; either), and low risk (3.87 %; neither) groups (p < 0.001). Decision theory supported restaging PET-CT.

CONCLUSIONS

PET-CT is more sensitive than CT for detecting interval progression; however, it is insufficient in at least higher risk patients. mN stage and response (mNR) plus primary tumour characteristics can stratify this risk simply.

KEY POINTS

• Restaging (18) F-FDG-PET-CT after neoadjuvant chemotherapy identifies metastases in 6 % of patients • Restaging (18) F-FDG-PET-CT is more sensitive than CT for detecting interval progression • Despite this, at surgery 10 % of patients had unsuspected incurable disease • New concepts (FDG-avid nodal stage and response) plus tumour impassability stratify risk • Higher risk (if not all) patients may benefit from additional restaging modalities.

Phase II Study of Irinotecan and Cisplatin Combination Chemotherapy in Metastatic, Unresectable Esophageal Cancer

Purpose

The objective of this multicenter phase II study was to evaluate the efficacy and safety of irinotecan and cisplatin combination chemotherapy in metastatic, unresectable esophageal cancer.

Materials and Methods

Patients were treated with irinotecan 65 mg/m² and cisplatin 30 mg/m² on days 1 and 8 of each 21-day treatment cycle. The primary endpoint was response rate, and secondary endpoints were survival, duration of response, initial metabolic response rate, and toxicity.

Results

A total of 27 patients with squamous cell histology were enrolled in the study. The median age of the patients was 61 years. The objective response rate of the 20 patients in the perprotocol group was 30.0% (90% confidence interval [CI], 13.2 to 46.9). The median follow-up duration was 10.0 months, and the median progression-free survival and overall survival were 4.5 months (95% CI, 1.6 to 6.2) and 8.8 months (95% CI, 4.7 to 10.5), respectively. Four of 13 patients (30.8%) evaluated showed initial metabolic response. The median duration of response for partial responders was 5.0 months (range, 3.4 to 8.0 months). The following grade 3/4 treatment-related hematologic toxicities were reported: neutropenia (40.7%), anaemia (22.2%), and thrombocytopenia (7.4%). Two patients experienced febrile neutropenia. The most common grade 3/4 non-hematologic toxicities were asthenia (14.8%) and diarrhoea (11.1%).

Conclusion

Irinotecan and cisplatin combination chemotherapy showed modest anti-tumour activity and manageable toxicity for patients with metastatic, unresectable esophageal cancer.