An analysis of multiple staging management strategies for carcinoma of the esophagus: computed tomography, endoscopic ultrasound, positron emission tomography, and thoracoscopy/laparoscopy

Computed tomography radiomics identification of T1-2 and T3-4 stages of esophageal squamous cell carcinoma: two-dimensional or three-dimensional?

BACKGROUND

To evaluate two-dimensional (2D) and three-dimensional (3D) computed tomography (CT) radiomics analysis for the T stage of esophageal squamous cell carcinoma (ESCC).

METHODS

398 patients with pathologically confirmed ESCC were divided into training and testing sets. All patients underwent chest CT scans preoperatively. For each tumor, based on CT images, a 2D region of interest (ROI) was outlined on the largest cross-sectional area, and a 3D ROI was outlined layer by layer on each section of the tumor. The radiomics platform was used for feature extraction. For feature selection, stepwise logistic regression was used. The receiver operating characteristic (ROC) curve was used to assess the diagnostic performance of the 2D radiomics model versus the 3D radiomics model. The differences were compared using the DeLong test. The value of the clinical utility of the two radiomics models was evaluated.

RESULTS

1595 radiomics features were extracted. After screening, two radiomics models were constructed. In the training set, the difference between the area under the curve (AUC) of the 2D radiomics model (AUC = 0.831) and the 3D radiomics model (AUC = 0.830) was not statistically significant (p = 0.973). In the testing set, the difference between the AUC of the 2D radiomics model (AUC = 0.807) and the 3D radiomics model (AUC = 0.797) was also not statistically significant (p = 0.748). A 2D model was equally useful as a 3D model in clinical situations.

CONCLUSION

The performance of 2D radiomics model is comparable to that of 3D radiomics model in distinguishing between the T1-2 and T3-4 stages of ESCC. In addition, 2D radiomics model may be a more feasible option due to the shorter time required for segmenting the ROI.

Tumor Differentiation as a Prognostic Marker in Clinically Staged T1bN0 Esophageal Adenocarcinoma

Current guidelines recommend that clinically staged T1N0 esophageal cancers are to be referred to surgery or endoscopic resection. Using the National Cancer Database, we identified 733 individuals with clinically staged T1N0 esophageal carcinoma, who underwent upfront surgery and did not receive any prior treatment. We assessed upstaging, which was defined as ≥ T2 disease or positive lymph nodes. Poorly differentiated adenocarcinomas were associated with upstaging, whereas squamous cell carcinomas were not. Specifically, the percentage of upstaging among individuals with clinically staged T1b and poorly differentiated tumor was 33.8%. Therefore, clinically staged T1bN0 poorly differentiated esophageal adenocarcinomas are at high risk for upstaging following surgery.

Intratumoral Metabolic Heterogeneity and Other Quantitative 18F-FDG PET/CT Parameters for Prognosis Prediction in Esophageal Cancer

PURPOSE

To evaluate the impact of intratumoral metabolic heterogeneity (IMH) and other quantitative fluorine 18 (¹⁸F) fluorodeoxyglucose (FDG) PET/CT parameters for predicting progression-free survival (PFS) and overall survival (OS) in patients with esophageal cancer.

MATERIALS AND METHODS

In this retrospective study, an automated gradient-based segmentation method was used to assess the maximum standardized uptake value, mean standardized uptake value, metabolic tumor volume (MTV), and IMH index of the primary tumor in patients with biopsy-proven adenocarcinoma or squamous cell carcinoma of the esophagus with an initial staging ¹⁸F-FDG PET/CT. Data were collected between July 2006 and February 2016. OS and PFS were calculated using multivariable Cox proportional hazards regression with the adjustment (as covariates) of age, sex, weight, stage, tumor type, tumor grade, and treatment. All PET parameters were standardized before analysis. Log-rank tests were performed, and corresponding Kaplan-Meier survival plots were generated.

RESULTS

A total of 71 patients (mean age, 64 years ± 10 [standard deviation], 62:9 men:women) were included. Median follow-up time was 28.2 months (range, 4-38 months), and median survival was 16.1 months (range, 0.1-60.3 months). Higher MTV was associated with reduced PFS for every standard deviation increase (hazard ratio [HR], 0.193; 95% CI: 0.052, 0.711; P = .01). Higher IMH was associated with reduced PFS for every standard deviation decrease in the area under the curve (HR, 10.78; 95% CI: 1.31, 88.96; P = .03).

CONCLUSION

PFS for patients with esophageal cancer was associated with MTV and with IMH.Keywords: Esophagus, Neoplasms-Primary, PET/CT, Tumor Response © RSNA, 2020.

Contribution of FDG-PET/CT to the management of esophageal cancer patients at multidisciplinary tumor board conferences

Background

A multidisciplinary team approach to the management of esophageal cancer patients leads to better clinical decisions.

Purpose

The contribution of CT, endoscopic and laparoscopic ultrasound to clinical staging and treatment selection by multidisciplinary tumor boards (MTB) in patients with esophageal cancer is well documented. However, there is a paucity of data addressing the role that FDG-PET/CT (PET/CT) plays to inform the clinical decision-making process at MTB conferences. The aim of this study was to assess the impact and contribution of PET/CT to clinical management decisions and to the plan of care for esophageal cancer patients at the MTB conferences held at our institution.

Materials and methods

This IRB approved study included all the cases discussed in the esophageal MTB meetings over a year period. The information contributed by PET/CT to MTB decision making was grouped into four categories. Category I, no additional information provided for clinical management; category II, equivocal and misguiding information; category III, complementary information to other imaging modalities, and category IV, information that directly changed clinical management. The overall impact on management was assessed retrospectively from prospectively discussed clinical histories, imaging, histopathology, and the official minutes of the MTB conferences.

Results

79 patients (61 males and 18 females; median age, 61 years, range, 33–86) with esophageal cancer (53 adenocarcinomas and 26 squamous cell carcinomas) were included. The contribution of PET/CT-derived information was as follows: category I in 50 patients (63%); category II in 3 patients (4%); category III in 8 patients (10%), and category IV information in 18 patients (23%). Forty-five patients (57%) had systemic disease, and in 5 (11%) of these, metastatic disease was only detected by PET/CT. In addition, PET/CT detected previously unknown recurrence in 4 (9%) of 43 patients. In summary, PET/CT provided clinically useful information to guide management in 26 of 79 esophageal cancer patients (33%) discussed at the MTB.

Conclusion

The study showed that PET/CT provided additional information and changed clinical management in 1 out of 3 (33%) esophageal cancer cases discussed at MTB conferences. These results support the inclusion whenever available, of FDG-PET/CT imaging information to augment and improve the patient management decision process in MTB conferences.

Use of endoscopic ultrasound in pre-treatment staging of esophageal cancer did not alter management plan

Background

Initial staging of esophageal cancer relies on EUS in addition to FDG-PET/CT. It is our hypothesis that with the advancement of FDG-PET/CT staging, endoscopic ultrasound may not be required for initial staging in all cases. The purpose of this study is to analyze whether EUS affects initial treatment stratification in patients diagnosed with esophageal cancer.

Methods

A retrospective database at the University of Virginia was queried for patients diagnosed with esophageal squamous cell carcinoma and adenocarcinoma who underwent EGD with EUS and FDG-PET/CT at their initial evaluation from 10/2013 to 5/2017. Two thoracic surgeons were asked to determine appropriate management for each case. Options included surgical resection, neoadjuvant chemoradiotherapy followed by resection, definitive chemoradiotherapy, or chemotherapy with or without palliative radiation. Both surgeons received the FDG-PET/CT report along with the EGD report. For each case, one or both surgeons were randomly allocated to review EUS results in addition to the clinical information. The treatment decisions of each thoracic surgeon were compared to determine if EUS reports impacted clinical management. Simple and weighted correlation coefficients (kappa) were calculated to compare agreement of treatment choices between the two surgeons using McNemars test. Conditional logistic regression was used to assess the influence of EUS on the treatment recommendations.

Results

A total of 50 patients (44 male and 6 female) were enrolled and data was collected. The thoracic surgeons agreed on treatment decisions in 39 cases and disagreed on 11 cases. Agreement between surgeons was good despite lack of EUS information for one surgeon on each case (weighted Kappa =0.73, 95% CI: 0.57-0.89). Using conditional logistic regression, EUS did not have a statistically independent association with agreement on treatment plan (P for model =0.17).

Conclusions

EUS did not have a statistically independent association with agreement on treatment plan for newly diagnosed esophageal cancer (P for model =0.17). Our findings suggest that EUS may not be necessary in the algorithm for the initial staging of every case of esophageal cancer. Selective, rather than mandatory use of EUS seems warranted.

Upstream and downstream revenue of upper gastrointestinal endoscopic ultrasound determined with an episode-of-care approach

Background and study aims  Upper gastrointestinal endoscopic ultrasound (EUS) has clinical advantages that can lead to improved patient outcome. This study seeks to characterize and quantify the upstream and downstream healthcare utilizations and revenues. Patients and methods  A retrospective claims data analysis of upper gastrointestinal EUS procedures was conducted at a large health system. Types of care and total revenues associated with each episode of care were characterized by descriptive statistics. Comparisons were made between patients who had Medicare Advantage and commercial plans as well as those with and without cancer diagnoses during the downstream period. Results  A total of 436 cases were identified. The most frequent downstream healthcare utilizations consisted of radiology (31 %), pathology services (28 %), and high-revenue services including chemotherapy and inpatient admissions. The most common upstream utilizations included radiology (18 %) and lab services (22 %). Average total downstream revenue was $ 34 231 (95 %CI: $ 28 561 - $ 39 901) per case, and average total upstream revenue was $4373 (95 %CI: $3227 - $ 5519). Average total revenue per case did not differ significantly between Medicare Advantage and commercial plan members. However, patients who were diagnosed with cancer at or immediately following EUS (20 %) were associated with significantly higher total revenue compared to those without cancer diagnosis ( P  < 0.0001). Conclusions  This episode-of-care approach to quantifying the revenue impact of upper gastrointestinal EUS to the providers suggests there are substantial downstream as well as upstream revenues associated with upper gastrointestinal EUS procedures, driven by patients who are diagnosed with cancer by the EUS procedures and subsequently require oncologic care.

Endoscopic ultrasound staging in patients with gastro-oesophageal cancers: a systematic review of economic evidence

Background

The sensitivity of endoscopic ultrasound (EUS) in staging gastro-oesophageal cancers (GOCs) has been widely studied. However, the economic evidence of EUS staging in the management of patients with GOCs is scarce. This review aimed to examine all economic evidence (not limited to randomised controlled trials) of the use of EUS staging in the management of GOCs patients, and to offer a review of economic evidence on the costs, benefits (in terms of GOCs patients’ health-related quality of life), and economic implications of the use of EUS in staging GOCs patients.

Methods

The protocol was registered prospectively with PROSPERO (CRD42016043700; http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42016043700). MEDLINE (ovid), EMBASE (ovid), The Cochrane Collaboration Register and Library (including the British National Health Service Economic Evaluation Database), CINAHL (EBSCOhost) and Web of Science (Core Collection) as well as reference lists were systematically searched for studies conducted between 1996 and 2018 (search update 28/04/2018). Two authors independently screened the identified articles, assessed study quality, and extracted data. Study characteristics of the included articles, including incremental cost-effectiveness ratios, when available, were summarised narratively.

Results

Of the 197 articles retrieved, six studies met the inclusion criteria: three economic studies and three economic modelling studies. Of the three economic studies, one was a cost-effectiveness analysis and two were cost analyses. Of the three economic modelling studies, one was a cost-effectiveness analysis and two were cost-minimisation analyses. Both of the cost-effectiveness analyses reported that use of EUS as an additional staging technique provided, on average, more QALYs (0.0019–0.1969 more QALYs) and saved costs (by £1969–£3364 per patient, 2017 price year) compared to staging strategy without EUS. Of the six studies, only one included GOCs participants and the other five included oesophageal cancer participants.

Conclusions

The data available suggest use of EUS as a complementary staging technique to other staging techniques for GOCs appears to be cost saving and offers greater QALYs. Nevertheless, future studies are necessary because the economic evidence around this EUS staging intervention for GOCs is far from robust. More health economic research and good quality data are needed to judge the economic benefits of EUS staging for GOCs.

PROSPERO Registration Number

CRD42016043700.

Electronic supplementary material

The online version of this article (10.1186/s12885-019-6116-0) contains supplementary material, which is available to authorized users.

Prognostic values of mid-radiotherapy 18F-FDG PET/CT in patients with esophageal cancer

BACKGROUND

To identify whether early metabolic responses as determined using ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) during radiotherapy (RT) predict outcomes in patients with esophageal cancer.

METHODS

Twenty-one patients with esophageal cancer who received pre-treatment ¹⁸F-FDG PET/CT (PET1) and inter-fractional ¹⁸F-FDG PET/CT (PET2) after 11 fractions of RT (median 23.1 Gy, 2.1 Gy per fraction) were retrospectively reviewed. The region of interest for each calculation was delineated using "PET Edge". We calculated PET parameters including maximum and mean standardized uptake values (SUV_max and SUV_mean, respectively), metabolic tumor volume (MTV), and total lesion glycolysis (TLG). The relative changes (%) were calculated using the logarithmically transformed parameter values for the PET1 and PET2 scans. Multivariate analysis of locoregional recurrence and distant failures were performed using Cox regression analysis. After identifying statistically significant PET parameters for discriminating responders from non-responders, receiver operating characteristics curve analyses were used to assess the potentials of the studied PET parameters.

RESULTS

After a median follow-up of 13 months, the 1-year overall and progression-free survival rates were 79.0% and 34.4%, respectively. Four patients developed locoregional recurrences (LRRs) and 8 had distant metastases (DMs). The 1-year overall LRR-free rate was 76.9% while the DM-free rate was 60.6%. The relative changes in MTV (ΔMTV) were significantly associated with LRR (p = 0.03). Conversely, the relative changes in SUV_mean (ΔSUV_mean) were associated with the risk of DM (p = 0.02). An ΔMTV threshold of 1.14 yielded a sensitivity of 60%, specificity of 94%, and an accuracy of 86% for predicting an LRR. Additionally, a ΔSUV_mean threshold of a 35% decrease yielded a sensitivity of 67%, specificity of 83%, and accuracy of 76% for the prediction DM.

TRIAL REGISTRATION

Retrospectively registered.

CONCLUSIONS

Changes in tumor metabolism during RT could be used to predict treatment responses, recurrences, and prognoses in patients with esophageal cancer.

Development of a Trimodal Contrast Agent for Acoustic and Magnetic Particle Imaging of Stem Cells

Stem cell therapy has the potential to improve tissue remodeling and repair. For cardiac stem cell therapy, methods to improve the injection and tracking of stem cells may help to increase patient outcomes. Here we describe a multimodal approach that combines ultrasound imaging, photoacoustic imaging, and magnetic particle imaging (MPI). Ultrasound imaging offers real-time guidance, photoacoustic imaging offers enhanced contrast, and MPI offers high-contrast, deep-tissue imaging. This work was facilitated by a poly(lactic-co-glycolic acid) (PLGA)-based iron oxide nanobubble labeled with 1,1'-dioctadecyl-3,3,3',3'-tetramethylindotricarbocyanine iodide (DiR) as a trimodal contrast agent. The PLGA coating facilitated the ultrasound signal, the DiR increased the photoacoustic signal, and the iron oxide facilitated the MPI signal. We confirmed that cell metabolism, proliferation, differentiation, and migration were not adversely affected by cell treatment with nanobubbles. The nanobubble-labeled cells were injected intramyocardially into live mice for real-time imaging. Ultrasound imaging showed a 3.8-fold increase in the imaging intensity of labeled cells postinjection compared to the baseline; photoacoustic imaging showed a 10.2-fold increase in the cardiac tissue signal postinjection. The MPI intensity of the nanobubble-treated human mesenchymal stem cells injected into the hearts of mice was approximately 20-fold greater than the negative control.

Impact of Endoscopic Ultrasonography on 18F-FDG-PET/CT Upfront Towards Patient Specific Esophageal Cancer Treatment

INTRODUCTION

In patients with potentially resectable esophageal cancer (EC), the value of endoscopic ultrasonography (EUS) after fluorine-18 labeled fluorodeoxyglucose positron emission tomography with computed tomography (¹⁸F-FDG-PET/CT) is questionable. Retrospectively, we assessed the impact of EUS after PET/CT on the given treatment in EC patients.

METHODS

During the period 2009-2015, 318 EC patients were staged as T1-4aN0-3M0 with hybrid ¹⁸F-FDG-PET/CT or ¹⁸F-FDG-PET with CT and EUS if applicable in a nonspecific order. We determined the impact of EUS on the given treatment in 279 patients who also were staged with EUS. EUS had clinical consequences if it changed curability, extent of radiation fields or lymph node resection (AJCC stations 2-5), and when the performed fine-needle aspiration (FNA) provided conclusive information of suspicious lymph node.

RESULTS

EUS had an impact in 80 (28.7%) patients; it changed the radiation field in 63 (22.6%), curability in 5 (1.8%), lymphadenectomy in 48 (17.2%), and FNA was additional in 21 (7.5%). In patients treated with nCRT (n = 194), EUS influenced treatment in 53 (27.3%) patients; in 38 (19.6%) the radiation field changed, in 3 (1.5%) the curability, in 35 (18.0%) the lymphadenectomy, and in 17 (8.8%) FNA was additional. EUS influenced both the extent of radiation field and nodal resection in 31 (16.0%) nCRT patients.

CONCLUSIONS

EUS had an impact on the given treatment in approximately 29%. In most patients, the magnitude of EUS found expression in the extent of radiotherapy target volume delineation to upper/high mediastinal lymph nodes.

Early clinical esophageal adenocarcinoma (cT1): Utility of CT in regional nodal metastasis detection and can the clinical accuracy be improved?

INTRODUCTION

Treatment of early esophageal cancer depends on the extent of the primary tumor and presence of regional lymph node metastasis.(RNM). Short axis diameter>10mm is typically used to detect RNM. However, clinical determination of RNM is inaccurate and can result in inappropriate treatment. Purpose of this study is to evaluate the accuracy of a single linear measurement (short axis>10mm) of regional nodes on CT in predicting nodal metastasis, in patients with early esophageal cancer and whether using a mean diameter value (short axis+long axis/2) as well as nodal shape improves cN designation.

METHODS

CTs of 49 patients with cT1 adenocarcinoma treated with surgical resection alone were reviewed retrospectively. Regional nodes were considered positive for malignancy when round or ovoid and mean size>5mm adjacent to the primary tumor and>7mm when not adjacent. Results were compared with pN status after esophagectomy.

RESULTS

18/49 patients had pN+ at resection. Using a single short axis diameter>10mm on CT, nodal metastasis (cN) was positive in 7/49. Only 1 of these patients was pN+ at resection (sensitivity 5%, specificity 80%, accuracy 53%). Using mean size and morphologic criteria, cN was positive in 28/49. 11 of these patients were pN+ at resection (sensitivity 61%, specificity 45%, accuracy 51%). EUS with limited FNA of regional nodes resulted in 16/49 patients with pN+ being inappropriately designated as cN0.

CONCLUSIONS

Evaluation of size, shape and location of regional lymph nodes on CT improves the sensitivity of cN determination compared with a short axis measurement alone in patients with cT1 esophageal cancer, although clinical utility is limited.

Routine staging with endoscopic ultrasound in patients with obstructing esophageal cancer and dysphagia rarely impacts treatment decisions

BACKGROUND

Endoscopic ultrasound (EUS) has been routinely utilized for the locoregional staging of esophageal cancer. One important aspect of clinical staging has been to stratify patients to treatment with neoadjuvant chemoradiation or primary surgical therapy. We hypothesized that EUS may have a limited impact on clinical decision making in patients with dysphagia and obstructing esophageal masses.

METHODS

This retrospective cohort study included all patients with esophageal adenocarcinoma undergoing esophageal EUS between July 2008 and September 2013. Dysplastic Barrett's esophagus without invasive adenocarcinoma or incomplete staging was excluded. Patient demographics, endoscopic tumor characteristics, the presence of dysphagia, sonographic staging, and post-EUS therapy were recorded. Pathologic staging for patients who underwent primary surgical therapy was also recorded. Locally advanced disease was defined as at least T3 or N1, as these patients are typically treated with neoadjuvant therapy.

RESULTS

Two hundred sixteen patients underwent EUS for esophageal adenocarcinoma, with 147 (68.1%) patients having symptoms of dysphagia on initial presentation. Patients with dysphagia were significantly more likely to have locally advanced disease on EUS than patients without dysphagia (p < 0.0001). Additionally, 145 (67.1%) patients had a partially or completely obstructing mass on initial endoscopy, of which 136 (93.8%) were locally advanced (p < 0.0001 vs. non-obstructing lesions).

CONCLUSIONS

An overwhelming majority of patients presenting with dysphagia and/or the presence of at least partially obstructing esophageal mass at the time of esophageal cancer diagnosis had an EUS that demonstrated at least locally advanced disease. The present study supports the hypothesis that EUS may be of limited benefit for management of esophageal cancer in patients with an obstructing mass and dysphagia.

Impact of PET/CT on radiation treatment in patients with esophageal cancer: A systematic review

PURPOSE

With the advances in radiotracers, positron emission tomography/computed tomography (PET/CT) is recognized as a useful adjunct to anatomic imaging with CT, MRI and endoscopic ultrasonography (EUS). The objective of this review was to comprehensively analyze the roles of PET/CT for the radiotherapy of esophageal cancer.

METHODS

In this review, we focused on issues concerning the application of PET/CT in TNM staging, target volume delineation and response to therapy, both for the primary tumor and regional lymph nodes. Furthermore, the following questions were addressed: how does PET/CT guide appropriate treatment protocols, how does it allow accurate tumor delineation and how does it guide prognosis and future treatment decisions.

RESULTS AND CONCLUSION

For the staging of esophageal cancer, PET/CT played a crucial role in exploring distant malignant lymph nodes and metastasis with high sensitivity, specificity and accuracy. PET/CT using different radiotracer provided a serial of thresholding methods based on standardized uptake value (SUV) to assist in auto-contouring the gross tumor volume (GTV). The change in SUV may offer a potential paradigm of personalized treatment to definitive chemoradiotherapy (CRT). In total, PET/CT has sought to further optimize radiotherapy treatment planning for patients with esophageal cancer.

Stage-directed individualized therapy in esophageal cancer

Esophageal cancer is the eighth most common cancer worldwide, and the incidence of esophageal carcinoma is rapidly increasing. With the advent of new staging and treatment techniques, esophageal cancer can now be managed through various strategies. A good understanding of the advances and limitations of new staging techniques and how these can guide in individualizing treatment is important to improve outcomes for esophageal cancer patients. This paper outlines the recent progress in staging and treatment of esophageal cancer, with particularly attention to endoscopic techniques for early-stage esophageal cancer, multimodality treatment for locally advanced esophageal cancer, assessment of response to neoadjuvant treatment, and the role of cervical lymph node dissection. Furthermore, advances in robot-assisted surgical techniques and postoperative recovery protocols that may further improve outcomes after esophagectomy are discussed.

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

Objectives

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

Methods

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

Results

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

Conclusion

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

Main Messages

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

• The most common topic was accuracy of staging investigations.

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

The Comparison of Computed Tomography Perfusion, Contrast-Enhanced Computed Tomography and Positron-Emission Tomography/Computed Tomography for the Detection of Primary Esophageal Carcinoma

OBJECTIVE

The purpose of this study was to investigate the efficiency of computed tomography perfusion (CTP), contrast-enhanced computed tomography (CECT) and 18F-fluoro-2-deoxy-D-glucose (18F-FDG) positron-emission tomography (PET/CT) in the diagnosis of esophageal cancer.

SUBJECTS AND METHODS

This prospective study consisted of 33 patients with pathologically confirmed esophageal cancer, 2 of whom had an esophageal abscess. All the patients underwent CTP, CECT and PET/CT imaging and the imaging findings were evaluated. Sensitivity, specificity and positive and negative predictive values were calculated for each of the 3 imaging modalities relative to the histological diagnosis.

RESULTS

Thirty-three tumors were visualized on CTP, 29 on CECT and 27 on PET/CT. Six tumors were stage 1, and 2 and 4 of these tumors were missed on CECT and PET/CT, respectively. Significant differences between CTP and CECT (p = 0.02), and between CTP and PET/CT (p = 0.04) were found for stage 1 tumors. Values for the sensitivity, specificity and positive and negative predictive values on CTP were 100, 100, 100 and 100%, respectively. Corresponding values on CECT were 93.94, 0, 93.94 and 0%, respectively, and those on PET/CT were 87.88, 0, 93.55 and 0%, respectively. Hence, the sensitivity, specificity and positive and negative predictive values of CTP were better than those of CECT and PET/CT.

CONCLUSION

CTP had an advantage over CECT and PET/CT in detecting small lesions. CTP was valuable, especially in detecting stage 1 tumors.

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

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

Clinical staging of patients with early esophageal adenocarcinoma: does FDG-PET/CT have a role?

BACKGROUND

Esophageal carcinoma is a significant worldwide health problem and the incidence is increasing faster than that of any other malignancy. 18F-2-deoxy-D-glucose (FDG)-positron emission tomography/computed tomography (PET/CT) is important in the management of patients with potentially resectable esophageal cancer and is useful in initial staging of locally advanced cancer and after neoadjuvant therapy. The purpose of this study is to determine the utility of FDG-PET/CT in the clinical staging of early-stage esophageal cancer.

METHODS

Subjects in this retrospective study were 79 consecutive patients with cTisN0 (high-grade dysplasia) and cT1N0 primary esophageal adenocarcinoma diagnosed by endoscopy and endoscopic ultrasound biopsy that were evaluated with preoperative FDG-PET/CT and had not received neoadjuvant therapy. Seventh edition American Joint Committee on Cancer cTNM and FDG-PET/CT were compared with postoperative pTNM staging. pT1 was subdivided into intramucosal cancers with lamina propria or muscularis mucosa invasion (pT1a) and submucosal cancers (pT1b).

RESULTS

In pT staging, the frequency of FDG uptake increased with increasing pT, from pT1a 21 of 39 (53.8%) to pT1b 19 of 22 (55.8%). pTis was three of five (60.0%). Similarly, the maximum standardized uptake value of FDG-avid lesions increased with increasing pT, with median values of 3.7 for pTis, 3.8 for pT1a and 4.2 for T1b. In cN staging, FDG-PET/CT was negative in 76 patients and positive in three patients. All three patients with FDG-avid nodes on FDG-PET/CT were negative for metastatic disease on biopsy. In 12 patients with pN1 and in one patient with N2, FDG-PET/CT was falsely negative. Sensitivity and positive predictive value for pN disease were 0% and accuracy was 82%. There were no distant metastases. In cM staging, FDG-PET/CT was falsely positive in five patients (FDG avid nodules n = 3, distant nodal metastasis n = 2) and resulted in unwarranted biopsy in four patients.

CONCLUSION

FDG-PET/CT is not useful in the TNM staging of primary adenocarcinoma of the esophagus when endoscopy and biopsy indicate cTis and cT1. In fact, FDGPET/CT can be detrimental to patient management. Because regional nodal metastases are uncommon and distant metastases rare, and as FDG-PET/CT can result in inappropriate clinical care, FDG-PET/CT should not be performed in the evaluation of early-stage esophageal cancer.

Novel imaging strategies for upper gastrointestinal tract cancers

Accurate pretherapeutic imaging is the cornerstone of all cancer treatment. Unfortunately, modern imaging modalities have several unsolved problems and limitations. The differentiation between inflammation and cancer infiltration, false positive and false negative findings as well as lack of confirming biopsies in suspected metastases may have serious negative consequences in cancer patients. This review describes some of these problems and challenges the use of conventional imaging by suggesting new combined strategies that include selective use of confirming biopsies and complementary methods to detect microscopic cancer dissemination.

Value of oral effervescent powder administration for multidetector CT evaluation of esophageal cancer

PURPOSE

To assess the value of oral effervescent powder (EP) for evaluation of esophageal distension, and for detection and staging of esophageal cancer with contrast-enhanced CT.

MATERIALS AND METHODS

84 patients without esophageal pathology and 52 patients with histological confirmed diagnosis of esophageal cancer were included in this prospective IRB-approved study. Half of the patients in both groups received EP prior to CT. Esophageal distension was assessed by planimetry of the inner (IA) and outer area (OA). Two blinded readers evaluated the datasets separately with regard to diagnosis of esophageal cancer (yes/no) and staging (T0-T4), if applicable. Distension results were compared (t-Test). In patients with cancer sensitivity, specificity, NPV and PPV were calculated. CT staging results were compared to histopathology (Cohen-k).

RESULTS

IA and IA/OA were significantly larger after EP as compared to the group without EP (p<0.05). Sensitivity, specificity, NPV and PPV for cancer detection cancer were as follows: 78%/78%, 98%/98%, 95%/95%, 87%/87% with EP; 60%/68%, 98%/98%, 94%/94%, 80%/83% without EP. Staging with EP was good (k=0.84/0.67) and moderate without EP (k=0.58/0.59).

CONCLUSIONS

Administration of EP prior to CT results in good distension of the esophagus, and improves detection and staging of esophageal cancer, as compared to control studies without EP.

Oesophageal cancer: assessment of tumour response to chemoradiotherapy with tridimensional CT

PURPOSE

To investigate whether changes in tumour volume were predictive of histopathological response to neoadjuvant therapy for oesophageal cancer.

MATERIALS AND METHODS

Thirty-five consecutive patients with locally advanced oesophageal cancer were treated with chemoradiotherapy and surgery in responders from July 2007 to July 2009. Tumour volume (TV) was calculated using innovative tumour volume estimation software which analysed computed tomography (CT) data. Tumour diameter and area were also evaluated. Variations in tumour measurements following neoadjuvant treatment were compared with the histopathological data.

RESULTS

Median baseline tumour diameter, area and volume were 3.51 cm (range 1.67-6.61), 7.51 cm(2) (range 1.79-21.0) and 33.80 cm(3) (range 3.36-101.6), respectively. Differences in TV between the pre- and post-treatment values were significantly correlated with the pathological stage (τ = 0.357, p = 0.004) and the tumour regression grade index (τ = 0.368, p = 0.005). According to the receiver operating characteristic analysis, TV measurements following treatment had moderate predictive values for the pathological T stage (area under the curve, AUC = 0.742, sensitivity = 55.56 %, specificity = 92.86 %, p = 0.005).Comparison of pathological and radiological volume showed a good precision (Pearson rho 0.77).

CONCLUSIONS

Changes in TV calculated on CT scans have a limited role in predicting pathological response to neoadjuvant treatment in oesophageal cancer patients. New imaging techniques based on metabolic imaging may provide better results.

Cost-effectiveness of PET and PET/computed tomography: a systematic review

The development of clinical diagnostic procedures comprises early-phase and late-phase studies to elucidate diagnostic accuracy and patient outcome. Economic assessments of new diagnostic procedures compared with established work-ups indicate additional cost for 1 additional unit of effectiveness measure by means of incremental cost-effectiveness ratios when considering the replacement of the standard regimen by a new diagnostic procedure. This article discusses economic assessments of PET and PET/computed tomography reported until mid-July 2014. Forty-seven studies on cancer and noncancer indications were identified but, because of the widely varying scope of the analyses, a substantial amount of work remains to be done.

Endoscopic ultrasonography in esophageal cancer leads to improved survival rates: results from a population-based study

BACKGROUND

The advantages of endoscopic ultrasound (EUS) and computed tomography (CT)-positron emission tomography (PET) with respect to survival for esophageal cancer patients are unclear. This study aimed to assess the effects of EUS, CT-PET, and their combination on overall survival with respect to cases not receiving these procedures.

METHODS

Patients who were ≥66 years old when diagnosed with esophageal cancer were identified in the Surveillance, Epidemiology, and End Results-Medicare linked database. Cases were split into 4 analytic groups: EUS only (n = 318), CT-PET only (n = 853), EUS+CT-PET (n = 189), and no EUS or CT-PET (n = 2439). Survival times were estimated with the Kaplan-Meier method and were compared with the log-rank test for each group versus the no EUS or CT-PET group. Multivariate Cox proportional hazards models were used to compare 1-, 3-, and 5-year survival rates.

RESULTS

Kaplan-Meier analyses showed that EUS, CT-PET, and EUS+CT-PET patients had improved survival for all stages (with the exception of stage 0 disease) in comparison with patients undergoing no EUS or CT-PET. Receipt of EUS increased the likelihood of receiving endoscopic therapies, esophagectomy, and chemoradiation. Multivariate Cox proportional hazards models showed that receipt of EUS was a significant predictor of improved 1- (hazard ratio [HR], 0.49; 95% confidence interval [CI], 0.39-0.59; P < .0001), 3- (HR, 0.57; 95% CI, 0.48-0.66; P < .0001), and 5-year survival (HR, 0.59; 95% CI, 0.50-0.68). Similar results were noted when the results were stratified on the basis of histology and for the CT-PET and EUS+CT-PET groups.

CONCLUSIONS

Receipt of either EUS or CT-PET alone in esophageal cancer patients was associated with improved 1-, 3-, and 5-year survival. Future studies should identify barriers to the dissemination of these staging modalities.

Clinical implication of PET/MR imaging in preoperative esophageal cancer staging: comparison with PET/CT, endoscopic ultrasonography, and CT

This was a study to compare the diagnostic efficacies of endoscopic ultrasonography (EUS), CT, PET/MR imaging, and PET/CT for the preoperative local and regional staging of esophageal cancer, with postoperative pathologic stage used as the reference standard.

METHODS

During 1 y, 19 patients with resectable esophageal cancer were enrolled and underwent preoperative EUS, CT, PET/CT, and PET/MR imaging. A chest radiologist and nuclear medicine physician retrospectively reviewed the images and assigned tumor and lymph node stages according to the seventh version of the TNM system and the American Joint Committee on Cancer staging system. Four patients who were treated nonsurgically were excluded from data analysis. The efficacies of EUS, CT, PET/CT, and PET/MR imaging were compared.

RESULTS

Primary tumors were correctly staged in 13 (86.7%), 10 (66.7%), and 5 (33.3%) patients at EUS, PET/MR imaging, and CT, respectively (P value ranging from 0.021 to 0.375). The accuracy of determining T1 lesions was 86.7%, 80.0%, and 46.7% for EUS, PET/MR imaging, and CT, respectively. For distinguishing T3 lesions, the accuracy was 93.3% for EUS and 86.7% for both PET/MR imaging and CT. For lymph node staging, the accuracy was 83.3%, 75.0%, 66.7%, and 50.0% for PET/MR imaging, EUS, PET/CT, and CT, respectively. In addition, area-under-the-curve values were 0.800, 0.700, 0.629, and 0.543 for PET/MR imaging, EUS, PET/CT, and CT, respectively.

CONCLUSION

PET/MR imaging demonstrated acceptable accuracy for T staging compared with EUS and, although not statistically significant, even higher accuracy than EUS and PET/CT for prediction of N staging. With adjustments in protocols, PET/MR imaging may provide an important role in preoperative esophageal cancer staging in the future.

Cost-effectiveness of Fluorine-18-Fluorodeoxyglucose positron emission tomography in tumours other than lung cancer: A systematic review

AIM: To systematically review published data on the cost-effectiveness of Fluorine-18-Fluorodeoxyglucose positron emission tomography (FDG-PET) or PET/computed tomography (PET/CT) in tumours other than lung cancer.

METHODS: A comprehensive literature search of studies published in PubMed/MEDLINE, Scopus and Embase databases through the 10^th of October in 2013 was carried out. A search algorithm based on a combination of the terms: (1) “PET” or “ PET/computed tomography (PET/CT)” or “positron emission tomography”; and (2) “cost-effectiveness” or “cost-utility” or “cost-efficacy” or “technology assessment” or “health technology assessment” was used. Only cost-effectiveness or cost-utility analyses in English language were included. Exclusion criteria were: (1) articles not within the field of interest of this review; (2) review articles, editorials or letters, conference proceedings; and (3) outcome evaluation studies, cost studies or health technology assessment reports. For each included study, information was collected concerning basic study, type of tumours evaluated, perspective/type of study, results, unit and comparison alternatives.

RESULTS: Sixteen studies were included. Head and neck tumours were evaluated in 4 articles, lymphoma in 4, colon-rectum tumours in 3 and breast tumours in 2. Only one article was retrieved for melanoma, oesophagus and ovary tumours. Cost-effectiveness results of FDG-PET or PET/CT ranged from dominated to dominant.

CONCLUSION: Literature evidence about the cost-effectiveness of FDG-PET or PET/CT in tumours other than lung cancer is still limited. Nevertheless, FDG-PET or PET/CT seems to be cost-effective in selective indications in oncology (staging and restaging of head and neck tumours, staging and treatment evaluation in lymphoma).

Evolving role of endoscopic ultrasonography-guided fine-needle aspiration in tumor staging and treatment of patients with carcinomas of the upper gastrointestinal tract

INTRODUCTION

Treatments such as neoadjuvant chemotherapy and endoscopic mucosal resection for upper gastrointestinal carcinomas (UGC) necessitates preoperative staging evaluation of lymph nodes. Endoscopic ultrasonography (EUS)-guided fine-needle aspiration (FNA) of lymph nodes provides more accurate staging than EUS alone. Our study investigates the role of EUS-FNA in the staging/treatment of patients with UGC.

MATERIALS AND METHODS

We searched our database for patients who had EUS-FNA staging of lymph nodes for UGC over 1 year. The cytologic diagnoses were compared with clinical, radiographic, EUS-determined staging, and patient follow-up data. All EUS/EUS-FNA procedures used a standard radial and/or linear echo endoscope. Direct smears from the aspirated material were stained by Papanicolaou and Diff-Quik methods.

RESULTS

We studied 84 patients with esophageal or gastroesophageal junction carcinomas and 15 patients with gastric carcinomas. EUS-FNA confirmed N0 status for 100% of patients with T1 and T2 tumors and for 93% of patients with T3 tumors. Patients with T1N0 carcinomas confirmed by EUS were selected for endoscopic mucosal resection. All patients with gastric carcinomas had EUS-determined stage T3 and above tumors. Based on primary tumor stage, all patients with gastric carcinomas received neoadjuvant chemotherapy.

CONCLUSIONS

Cytologic diagnosis by EUS-FNA agreed with EUS nodal staging in 77% of the patients with UGC. EUS-FNA was useful to select patients with T1N0 esophageal or gastroesophageal junction carcinomas for endoscopic mucosal resection. EUS-FNA did not contribute significantly in treatment of patients with higher stage tumors whose disease was down-staged to N0 by EUS-FNA. These patients received neoadjuvant chemotherapy based on the status of the primary tumor.

Minimally invasive surgery for esophageal cancer: review of the literature and institutional experience

BACKGROUND

Esophageal cancer represents a major public health problem in the world. Several minimally invasive esophagectomy (MIE) techniques have been described and represent a safe alternative for the surgical management of esophageal cancer in selected centers with high volume and surgeons experienced in minimally invasive procedures.

METHODS

The authors reviewed the most recent and largest studies published in the medical literature that reported the outcomes for MIE techniques.

RESULTS

In larger series, MIE has proven to be equivalent in postoperative morbidity and mortality to the open esophagectomy. However, MIE has been associated with less blood loss, reduced postoperative pain, decreased time in the intensive care unit, and shortened length of hospital stay compared with the conventional open approaches. Despite limited data, no significant difference in survival stage for stage has been observed between open esophagectomy and MIE.

CONCLUSIONS

The myriad of MIE techniques complicates the debate for defining the optimal surgical approach for the treatment of esophageal cancer. Randomized controlled trials comparing MIE with conventional open esophagectomy are needed to clarify the ideal procedure with the lowest postoperative morbidity, best quality of life after surgery, and long-term survival.

EUS versus CT for preoperative TN staging of adenocarcinoma of the esophagogastric junction

AIM: To compare the accuracy of endoscopic ultrasonography (EUS) versus computed tomography (CT) in TN staging of the adenocarcinoma of the esophagogastric Junction (AEG).

METHODS: Ninety-one patients with pathologically proven AEG who received preoperative EUS and helical CT and surgical resection from February 2007 to December 2012 and had complete clinical data were included in this study. The accuracy of EUS versus CT in TN staging of AEG was compared.

RESULTS: The overall accuracy rates of preoperative T staging and N staging by EUS were 81.3% and 86.8%, respectively, significantly higher than those by helical CT (58.2% and 58.3%, respectively).

CONCLUSION: Compared with helical CT, EUS is associated with a higher accuracy in preoperative TN staging of AEG.

Low impact of staging EUS for determining surgical resectability in esophageal cancer

BACKGROUND

Although studies have shown that EUS has a high sensitivity and specificity for T and N staging, the value of EUS for staging tumors as resectable or nonresectable after CT of the chest and abdomen and US neck assessment, is largely unknown. This study was designed to assess the diagnostic value of EUS for determining resectability of esophageal cancer.

METHODS

A retrospective analysis of all consecutive patients with esophageal carcinoma who underwent staging EUS, CT, and US. Tumors were considered resectable when there was no evidence of metastases or ingrowth in adjacent structures. Sensitivity, specificity, positive (PPV), and negative (NPV) predictive value of CT/US neck and CT/US neck + EUS for predicting surgical resectability were calculated. PPVs of CT/US alone and CT/US + EUS together were compared for assessing the diagnostic value of EUS.

RESULTS

In total, 211 patients (155 men; mean age of 64 ± 9.4 years) were included, of which 176 (83 %) underwent all three staging investigations. Based on preoperative staging, 173 (82 %) patients were considered resectable and 38 (18 %) nonresectable. Of all 173 initially resectable patients, 145 were operated on. Of these patients, five (3.4 %) tumors were found nonresectable during surgery. Postoperative sensitivity, specificity, PPV, and NPV of CT/US and CT/US + EUS for predicting surgical resectability were 88 versus 87 %, 20 versus 40 %, 97 versus 98 %, and 6 versus 10 %, respectively.

CONCLUSIONS

Although EUS adds to the specificity of preoperative esophageal cancer staging after CT chest and abdomen, and US of the neck have been performed, the overall added value of EUS is limited.

Treatment strategies for oesophageal cancer - time-trends and long term outcome data from a large tertiary referral centre

Background and objectives

Treatment options for oesophageal cancer have changed considerably over the last decades with the introduction of multimodal treatment concepts dominating the progress in the field. However, it remains unclear in how far the documented scientific progress influenced and changed the daily routine practice. Since most patients with oesophageal cancer generally suffer from reduced overall health conditions it is uncertain how high the proportion of aggressive treatments is and whether outcomes are improved substantially. In order to gain insight into this we performed a retrospective analysis of patients treated at a larger tertiary referral centre over time course of 25 years.

Patients and methods

Data of all patients diagnosed with squamous cell carcinoma (SCC) and adenocarcinoma (AC) of the oesophagus, treated between 1983 and 2007 in the department of radiation oncology of the LMU, were obtained. The primary endpoint of the data collection was overall survival (calculated from the date of diagnosis until death or last follow up). Changes in basic clinical characteristics, treatment approach and the effect on survival were analysed after dividing the cohort into five subsequent time periods (I-V) with 5 years each. In a second analysis any pattern of change regarding the use of radio(chemo)therapy (R(C)T) with and without surgery was determined.

Results

In total, 503 patients with SCC (78.5%) and AC (18.9%) of the oesophagus were identified. The average age was 60 years (range 35-91 years). 56.5% of the patients were diagnose with advanced UICC stages III-IV. R(C)T was applied to 353 (70.2%) patients; R(C)T+ surgery was performed in 134 (26.6%) patients, 63.8% of all received chemotherapy (platinum-based 5.8%, 5-fluorouracil (5-FU)12.1%, 42.3% 5-FU and mitomycin C (MMC)). The median follow-up period was 4.3 years. The median overall survival was 21.4 months. Over the time, patients were older, the formal tumour stage was more advanced, the incidence of AC was higher and the intensified treatment had a higher prevalence. However there was only a trend for an improved OS over the years with no difference between RCT with or without surgery (p = 0.09). The use of radiation doses over 54 Gy and the addition of chemotherapy (p = 0.002) were associated with improved OS.

Conclusion

Although more complex treatment protocols were introduced into clinical routine, only a minor progress in OS rates was detectable. Main predictors of outcome in this cohort was the addition of chemotherapy. The addition of surgery to radio-chemotherapy may only be of value for very limited patient groups.

The role of integrated F-18-FDG-PET scanning in the detection of M1 disease in oesophageal adenocarcinoma and impact on clinical management

INTRODUCTION

The aim of this study was to evaluate the efficacy of F-18-fluorodeoxyglucose positron emission tomography (FDG-PET) scanning in the staging of oesophageal adenocarcinoma.

METHODS

One hundred four patients with biopsy-proven adenocarcinoma underwent (18)F-FDG-PET scan. FDG avid lesions were further investigated to their diagnostic conclusion.

RESULTS

Nineteen patients (18.26%) were found to have non-loco-regional FDG uptake. Of the patients, 3.84% were found to have M1 disease and 7.69% were found to have a second primary tumour. The sensitivity and specificity of FDG-PET scanning to detect metastatic disease in our series was 57.14% and 84.53%, respectively. The overall diagnostic accuracy was 82.69%.

CONCLUSIONS

PET scanning improves staging and prevents unnecessary surgery in patients with M1 disease. It represents a good adjunct to computed tomography scanning and endoscopic ultrasound in the staging of oesophageal adenocarcinoma. The detection of asymptomatic coexisting synchronous cancers is an added benefit provided by PET scanning over similar diagnostic modalities.

The value of [18F]fluorodeoxyglucose-PET/CT in oesophageal cancer

[¹⁸F]Fluorodeoxyglucose-positron emission tomography/computed tomography (CT) is recognized as a useful adjunct to conventional imaging with CT and endoscopic ultrasonography for the staging of oesophageal cancer, for response assessment and identification of recurrent disease and it may provide prognostic information.

How radical should surgery be for early esophageal cancer?

BACKGROUND

We have compared the oncologic effectiveness of limited resection (LR) techniques such as transhiatal (TH) or limited resection of the esophagogastric junction with intestinal interposition (LREGJ) in the treatment of early esophageal carcinoma with that of the extended resection such as the classical thoracoabdominal (TA) en bloc esophagectomy.

METHODS

We performed a retrospective analysis of prospectively collected data of 113 patients with T1 esophageal cancer (57 adeno- and 56 squamous cell carcinomas) who had surgical resection with systematic lymphadenectomy. Forty-one underwent extensive (TA) and 72 limited resection (51 TH and 21 LREGJ).

RESULTS

Complete resection (R0) was achieved in all cases. Lymphatic metastases were seen in none of the mucosal but in 26.8% of the submucosal T1 cancers. The median lymph node yield was significantly higher in patients with extensive resection (24 vs. 15 lymph nodes; p=0.036), but this did not affect the overall survival (median=88 vs. 102 months, 5-year survival probability=57.8 vs. 67.7%; log rank=0.578). The median hospital stay and ICU stay were significantly shorter in the LR group (p=0.039 and p = 0.044, respectively).

CONCLUSION

Limited resection leads to lower lymph node yield but similar oncologic effectiveness as the extensive surgery. It may represent a valuable alternative in the treatment of patients with early (submucosal) esophageal carcinoma.

Prognostic factors for esophageal squamous cell carcinoma--a population-based study in Golestan Province, Iran, a high incidence area

Golestan Province in northern Iran is an area with a high incidence of esophageal squamous cell carcinoma (ESCC). We aimed to investigate prognostic factors for ESCC and survival of cases in Golestan, on which little data were available. We followed-up 426 ESCC cases participating in a population-based case-control study. Data were analyzed using the Kaplan–Meier method and the Cox proportional hazard models. Median survival was 7 months. Age at diagnosis was inversely associated with survival, but the association was disappeared with adjustment for treatment. Residing in urban areas (hazard ratio, HR = 0.70; 95% CI 0.54–0.90) and being of non-Turkmen ethnic groups (HR = 0.76; 95% CI 0.61–0.96) were associated with better prognosis. In contrast to other types of tobacco use, nass (a smokeless tobacco product) chewing was associated with a slightly poorer prognosis even in models adjusted for other factors including stage of disease and treatment (HR = 1.38; 95% CI 0.99–1.92). Opium use was associated with poorer prognosis in crude analyses but not in adjusted models. Almost all of potentially curative treatments were associated with longer survival. Prognosis of ESCC in Golestan is very poor. Easier access to treatment facilities may improve the prognosis of ESCC in Golestan. The observed association between nass chewing and poorer prognosis needs further investigations; this association may suggest a possible role for ingestion of nass constituents in prognosis of ESCC.

Accuracy of hydro-multidetector row CT in the local T staging of oesophageal cancer compared to postoperative histopathological results

OBJECTIVE

To evaluate the accuracy of multidetector computed tomography with water filling (Hydro-MDCT) in the T-staging of patients with oesophageal cancer.

MATERIALS AND METHODS

There were 131 consecutive patients who were preoperatively and prospectively examined in the prone position on arterial phase contrast-enhanced MDCT, after ingestion of 1,000-1,500 ml tap water and effervescent granules. Two readers staged the local tumour growth (T-staging) independently. They assessed tumour location, size, presence of stenosis, and morphology of the outer border of the oesophageal wall and perioesophageal fat planes on CT. CT findings were compared with histopathological results from resected specimens. Data were analyzed using the SPSS statistical package.

RESULTS

Both readers obtained a high sensitivity of 95% and a high positive predictive value of 96%. Accurate local staging was achieved in 76.3% and 68.7% for readers 1 and 2, respectively. Inter-reader agreement was excellent (weighted κ value of 0.93 and un-weighted κ of 0.89).

CONCLUSION

Using the hydro-technique and applying specific assessment criteria, MDCT appears to be an accurate, non-invasive diagnostic tool for local tumour staging of oesophageal cancer.

Impact of concentration of oesophageal and gastric cardia cancer surgery on long-term population-based survival

BACKGROUND

The objective was to evaluate the impact of concentration of surgery for oesophageal and gastric cardia cancer on long-term survival in the population-based Eindhoven Cancer Registry area. In contrast to most previous studies, this study aimed to evaluate both surgically and non-surgically treated patients, to avoid the confounding effect of selective referral.

METHODS

This retrospective cohort study included all patients diagnosed with oesophageal or gastric cardia cancer between 1995 and 2006. Results for the period 1995-1998 were compared with those for 1999-2006, after concentration of surgery.

RESULTS

Between 1995 and 2006, 2212 patients were registered with the diagnosis, of whom 638 underwent resection. Before 1999, 73·4 per cent of surgically treated patients underwent a resection in a low-volume hospital (fewer than 4 resections per year) and 23·2 per cent were referred to an academic hospital. After concentration, 63·2 per cent of surgically treated patients underwent resection in one of two regional high-volume centres (15-20 resections per year) and 13·8 per cent were referred to an academic hospital. Three-year survival rates increased from 32·0 to 45·1 per cent for patients who had surgery (P = 0·004), and from 13·1 to 17·9 per cent for all included patients (P = 0·026). These improvements remained after adjustment for case mix or (neo)adjuvant treatments, and were similar for patients with squamous cell carcinoma or adenocarcinoma. However, adjustment for annual hospital volume attenuated this association for patients who had surgery.

CONCLUSION

Concentration of oesophageal and gastric cardia cancer surgery was associated with improvements in long-term, population-based overall survival for surgically as well as non-surgically treated patients, apparently mediated by an increase in volume.

Endoscopic ultrasound may be unnecessary in the preoperative evaluation of intraductal papillary mucinous neoplasm

OBJECTIVES

Several imaging modalities are commonly performed during work-up of intraductal papillary mucinous neoplasm (IPMN), but guidelines do not suggest any one technique. The aim of this study was to evaluate tumour and duct measurements by computed tomography (CT) and endoscopic ultrasound (EUS) and their ability to predict high-grade dysplasia (HGD) and cancer within pancreatic IPMN.

METHODS

Patients with IPMN who underwent preoperative CT and EUS between 2001 and 2009 were selected. Data were gathered retrospectively from medical records.

RESULTS

The study group was comprised of 52 patients, 33% (17/52) of whom had HGD or cancer. On fine needle aspirate (FNA), neither carcinoembryonic antigen (CEA) >200 nor cytological analysis correlated with malignancy. In multivariate analysis, duct size ≥ 1.0 cm (P= 0.034) was a significant predictor of HGD or cancer, and diameter on CT scan (P= 0.056) approached significance. Lesion diameter of ≥ 2.5 cm on CT scan identified malignancy in 71% (12/17) of patients (P= 0.037). When analysed, all patients with HGD or cancer had a lesion diameter ≥ 2.5 cm and/or a duct diameter ≥ 1.0 cm by CT scan.

CONCLUSIONS

The use of radiographic criteria on CT including lesion size ≥ 2.5 cm and/or pancreatic duct diameter ≥ 1.0 cm appears to reliably identify patients with either HGD or invasive cancer. High-resolution CT scanning may obviate the need for EUS and FNA in patients with suspected IPMN.

Preoperative staging of lung cancer with PET/CT: cost-effectiveness evaluation alongside a randomized controlled trial

PURPOSE

Positron emission tomography (PET)/CT has become a widely used technology for preoperative staging of non-small cell lung cancer (NSCLC). Two recent randomized controlled trials (RCT) have established its efficacy over conventional staging, but no studies have assessed its cost-effectiveness. The objective of this study was to assess the cost-effectiveness of PET/CT as an adjunct to conventional workup for preoperative staging of NSCLC.

METHODS

The study was conducted alongside an RCT in which 189 patients were allocated to conventional staging (n = 91) or conventional staging + PET/CT (n = 98) and followed for 1 year after which the numbers of futile thoracotomies in each group were monitored. A full health care sector perspective was adapted for costing resource use. The outcome parameter was defined as the number needed to treat (NNT)-here number of PET/CT scans needed-to avoid one futile thoracotomy. All monetary estimates were inflated to 2010 <euro>.

RESULTS

The incremental cost of the PET/CT-based regimen was estimated at 3,927 <euro> [95% confidence interval (CI) -3,331; 10,586] and the NNT at 4.92 (95% CI 3.00; 13.62). These resulted in an average incremental cost-effectiveness ratio of 19,314 <euro>, which would be cost-effective at a probability of 0.90 given a willingness to pay of 50,000 <euro> per avoided futile thoracotomy. When costs of comorbidity-related hospital services were excluded, the PET/CT regimen appeared dominant.

CONCLUSION

Applying a full health care sector perspective, the cost-effectiveness of PET/CT for staging NSCLC seems to depend on the willingness to pay in order to avoid a futile thoracotomy. However, given that four outliers in terms of extreme comorbidity were all randomized to the PET/CT arm, there is uncertainty about the conclusion. When hospital costs of comorbidity were excluded, the PET/CT regimen was found to be both more accurate and cost saving.

Staging Accuracy of Endoscopic Ultrasound Based on Pathologic Analysis after Minimally Invasive Esophagectomy

Endoscopic ultrasonography (EUS) is a common staging modality used in patients with esophageal cancer. The objective of this analysis was to evaluate the accuracy and sensitivity of EUS in determining the depth of penetration (T stage) and nodal status (N stage) in patients with esophageal cancer who underwent minimally invasive esophagectomy (MIE). A retrospective analysis of all patients at a university hospital who underwent preoperative EUS followed by MIE for cancer was performed. We compared the results of preoperative EUS to final pathologic analyses of the esophageal specimen, examining the accuracy of EUS staging. Ninety-five patients with esophageal cancer who underwent MIE had preoperative EUS. Twenty-four of the 95 patients were excluded for lack of a repeat EUS after neoadjuvant therapy before resection. Hence, 71 patients were evaluated for the accuracy of EUS staging. The accuracy of EUS for TO disease was 80 per cent; T1 disease was 75 per cent; T2 disease was 39 per cent; and T3 disease was 88 per cent. The overall EUS accuracy for T stage was 72 per cent with overstaging occurring mostly for pathologic T1 tumors in 18 per cent and understaging occurring mostly for pathologic T3 tumors in 11 per cent. The sensitivity and specificity for detection of nodal involvement were 79 per cent and 74 per cent, respectively. However the accuracy for T and N staging by EUS after neoadjuvant therapy decreased to 63 per cent and 38 per cent, respectively. Endoscopic ultrasound in the absence of neoadjuvant therapy is a relatively accurate and sensitive modality for determining the depth of tumor penetration and the presence of nodal disease in patients with esophageal carcinoma. The accuracy for T and N staging is less reliable after neoadjuvant therapy.

Does Medicare Have an Implicit Cost-Effectiveness Threshold?

Background. Despite the huge cost of the program, the Centers for Medicare and Medicaid Services (CMS) has maintained a policy that cost-effectiveness is not considered in national coverage determinations (NCDs). Objective. To assess whether an implicit cost-effectiveness threshold exists and to determine if economic evidence has been considered in previous NCDs. Methods. A literature search was conducted to identify estimates of cost-effectiveness relevant to each NCD from 1999—2007 (n = 103). The economic evaluation that best represented each coverage decision was included in a review of the cost-effectiveness of medical interventions considered in NCDs. Results. Of the 64 coverage decisions determined to have a corresponding cost-effectiveness estimate, 49 were associated with a positive coverage decision and 15 with a noncoverage decision. Of the positive decisions, 20 were associated with an economic evaluation that estimated the intervention to be dominant (costs less and was more effective than the alternative), 12 with an incremental cost-effectiveness ratio (ICER) of less than $50,000, 8 with an ICER greater than $50,000 but less than $100,000, and 9 with an ICER greater than $100,000. Fourteen of the sample of 64 decision memos cited or discussed cost-effectiveness information. Conclusions. CMS is covering a number of interventions that do not appear to be cost-effective, suggesting that resources could be allocated more efficiently. Although the authors identified several instances where cost-effectiveness evidence was cited in NCDs, they found no clear evidence of an implicit threshold.