A comparison of computerised tomography, laparoscopic ultrasound and endoscopic ultrasound in the preoperative staging of oesophago-gastric carcinoma

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.

The Role of Magnetic Resonance Imaging in the Management of Esophageal Cancer

Esophageal cancer (EC) is the eighth more frequent cancer worldwide, with a poor prognosis. Initial staging is critical to decide on the best individual treatment approach. Current modalities for the assessment of EC are irradiating techniques, such as computed tomography (CT) and positron emission tomography/CT, or invasive techniques, such as digestive endoscopy and endoscopic ultrasound. Magnetic resonance imaging (MRI) is a non-invasive and non-irradiating imaging technique that provides high degrees of soft tissue contrast, with good depiction of the esophageal wall and the esophagogastric junction. Various sequences of MRI have shown good performance in initial tumor and lymph node staging in EC. Diffusion-weighted MRI has also demonstrated capabilities in the evaluation of tumor response to chemoradiotherapy. To date, there is not enough data to consider whole body MRI as a routine investigation for the detection of initial metastases or for prediction of distant recurrence. This narrative review summarizes the current knowledge on MRI for the management of EC.

Diagnostic Performance of Artificial Intelligence-Centred Systems in the Diagnosis and Postoperative Surveillance of Upper Gastrointestinal Malignancies Using Computed Tomography Imaging: A Systematic Review and Meta-Analysis of Diagnostic Accuracy

Background

Upper gastrointestinal cancers are aggressive malignancies with poor prognosis, even following multimodality therapy. As such, they require timely and accurate diagnostic and surveillance strategies; however, such radiological workflows necessitate considerable expertise and resource to maintain. In order to lessen the workload upon already stretched health systems, there has been increasing focus on the development and use of artificial intelligence (AI)-centred diagnostic systems. This systematic review summarizes the clinical applicability and diagnostic performance of AI-centred systems in the diagnosis and surveillance of esophagogastric cancers.

Methods

A systematic review was performed using the MEDLINE, EMBASE, Cochrane Review, and Scopus databases. Articles on the use of AI and radiomics for the diagnosis and surveillance of patients with esophageal cancer were evaluated, and quality assessment of studies was performed using the QUADAS-2 tool. A meta-analysis was performed to assess the diagnostic accuracy of sequencing methodologies.

Results

Thirty-six studies that described the use of AI were included in the qualitative synthesis and six studies involving 1352 patients were included in the quantitative analysis. Of these six studies, four studies assessed the utility of AI in gastric cancer diagnosis, one study assessed its utility for diagnosing esophageal cancer, and one study assessed its utility for surveillance. The pooled sensitivity and specificity were 73.4% (64.6–80.7) and 89.7% (82.7–94.1), respectively.

Conclusions

AI systems have shown promise in diagnosing and monitoring esophageal and gastric cancer, particularly when combined with existing diagnostic methods. Further work is needed to further develop systems of greater accuracy and greater consideration of the clinical workflows that they aim to integrate within.

A meta-analysis of the utility of transabdominal ultrasound for evaluation of gastric cancer

BACKGROUND

Clinical discovery/staging of gastric cancer (GC) is crucial in designing the treatment strategies and largely decides GC patients' survival. Endoscopic ultrasonography (EUS) and computed tomography (CT) are 2 useful GC diagnosis tools. High doses of radiation associated with CT make its use limited, while the process of EUS is stressful, time-consuming, and challenging. Transabdominal ultrasound (TAUS) is a promising candidate to address these shortcomings. This study aimed to meta-analyze the diagnostic accuracy and sensitivity of TAUS in discriminating between advanced and early GCs, as well as compare its utility with other imaging techniques.Methods: Literature searches were conducted using PubMed, Web of Science, Embase, and Cochrane Library databases up to 2019. Data were analyzed using RevMan software (Cochrane Collaboration, Oxford, UK), and pooled estimates of accuracy, sensitivity, and other features were acquired. Seven papers were eventually selected for meta-analysis.

RESULTS

TAUS had distinct diagnostic efficacies for early and advanced GC patients. The accuracy and sensitivity were significantly higher in the advanced group. A high color Doppler vascularity index and a lesion larger than 1 cm were 2 features of advanced GC. Moreover, TAUS had a comparable (but slightly higher) accuracy than CT and EUS.

CONCLUSIONS

TAUS is more accurate and sensitive in diagnosing advanced GC compared to early GC. More features of advanced GC are required to improve the recognition ability. At least, TAUS can be considered as a complementary imaging diagnostic tool to CT and EUS.

Current status and future perspectives on neoadjuvant therapy in gastric cancer

Gastric cancer, with high morbidity and mortality rates, is one of the most heterogeneous tumors. Radical gastrectomy and postoperative chemotherapy are the standard treatments. However, the safety and efficacy of neoadjuvant therapy (NAT) need to be confirmed by many trials before implementation, creating a bottleneck in development. Although clinical benefits of NAT have been observed, a series of problems remain to be solved. Before therapy, more contributing factors should be offered for choice in the intended population and ideal regimens. Enhanced computed tomography (CT) scanning is usually applied to evaluate effectiveness according to Response Evaluation Criteria in Solid Tumors (RECIST), yet CT scanning results sometimes differ from pathological responses. After NAT, the appropriate time for surgery is still empirically defined. Our review aims to discuss the abovementioned issues regarding NAT for GC, including indications, selection of regimens, lesion assessment and NAT-surgery interval time.

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.

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.

Usefulness of Combined PET/CT to Assess Regional Lymph Node Involvement in Gastric Cancer

Aims and Background

The aim of this study was to evaluate the value of positron emission tomography/computed tomography (PET/CT) for preoperative staging of gastric cancer and to compare the diagnostic performance of PET/CT with that of contrast-enhanced computed tomography (CECT).

Methods

We retrospectively reviewed 74 gastric cancer patients who underwent preoperative PET/CT and CECT, and subsequent curative surgical resection between April 2007 and July 2011. Preoperative PET/CT and CECT images for primary tumors of the stomach and lymph node metastases were reviewed retrospectively. The final diagnoses of primary tumors and LN metastases were based on histopathological specimens in all patients.

Results

Advanced gastric cancer was present in 65% of patients (n = 48), and the remaining patients had early gastric cancer (n = 26). Sixteen patients (22%) showed signet-ring-cell histology. For the detection of the primary tumor, the sensitivity of PET/CT was significantly higher than that of CECT (67% vs 55%, respectively; P = 0.049). For the evaluation of regional lymph node metastasis, the sensitivity, specificity, and accuracy of PET/CT and CECT were 34% and 51% (P = 0.065), 88% and 79% (P = 0.687), and 58% and 64% (P = 0.332), respectively. Neither PET/CT nor CECT detected regional lymph node metastases in early gastric cancer patients. Signet-ringcell histology showed trends of non-FDG-avid lymph node metastases (odds ratio = 0.15, 95% confidence interval 0.17–1.37, P = 0.093)

Conclusions

The accuracy of PET/CT is low and it is not a useful tool in the staging of gastric cancer overall in early gastric cancer and in signet-ring-cell carcinoma. Furthermore, the sensitivity of PET/CT could be inferior to that of CECT in the diagnosis of regional lymph node metastasis.

Comparison between free-breathing radial VIBE on 3-T MRI and endoscopic ultrasound for preoperative T staging of resectable oesophageal cancer, with histopathological correlation

OBJECTIVES

To compare the T staging of resectable oesophageal cancer (OC) using radial VIBE (r-VIBE) and endoscopic ultrasound (EUS) with pathological confirmation of the T stage.

METHODS

Forty-three patients with endoscopically proven OC and indeterminate T1/T2/T3/T4a stage by computed tomography (CT) and EUS were imaged on a 3-T magnetic resonance imaging (MRI) scanner. T stage was scored on MRI and EUS by two independent radiologists and one endoscopist, respectively, and compared with postoperative pathological findings. T staging agreement between r-VIBE and EUS with postoperative pathological T staging was analysed by a kappa test.

RESULTS

EUS and pathological T staging showed agreement of 69.8% (30/43). Radial VIBE and pathological T staging agreement was 86.0% (37/43) and 90.7% (39/43) for readers 1 and 2, respectively. High accuracy for T1/T2 stage was obtained for both r-VIBE readers (90.5% and 100% for reader 1 and reader 2, respectively) and EUS reader (100%). For T3/T4, r-VIBE showed accuracy of 81.8% and 90.9% for reader 1 and reader 2, respectively, while for EUS, accuracy was only 68.2% compared with pathological T staging.

CONCLUSIONS

Contrast-enhanced r-VIBE is comparable to EUS in T staging of resectable OC with stage of T1/T2, and is superior to EUS in staging of T3/T4 lesions.

KEY POINTS

• Radial VIBE may be useful in preoperative T staging of OC • Accuracy of staging on r-VIBE is higher in T1/2 than in T3/4 • Accuracy of EUS was 100% and 68.2% for T1/T2 and T3/T4 stage • Inter-reader agreement of T staging for r-VIBE was good.

Multidetector Computed Tomography Versus Staging Laparoscopy for the Detection of Peritoneal Metastases in Esophagogastric Junctional and Gastric Cancer

OBJECTIVE

Staging laparoscopy (SL) is the gold standard investigation for detecting peritoneal metastases (PM) in patients with esophagogastric cancer but computed tomography (CT) has undergone significant improvements in recent years. The aim of this study was to investigate whether CT can replace SL in the detection of PM.

MATERIALS AND METHODS

Patients undergoing SL between January 2008 and December 2009 were identified from a prospectively collected database, operation notes were reviewed for the detection of PM. Corresponding CTs were reassessed by 2 experienced gastrointestinal radiologists, blinded to the SL results.

RESULTS

In total, 74 patients undergoing SL were included. Sensitivity and specificity of SL for PM were 94.1% (95% confidence interval, 69.2-99.7) and 100% (90.7-100). Sensitivity and specificity of CT were 58.8% (33.5-80.6) and 89.6% (76.6-96.1), respectively. Area under the curve of receiver operating characteristic curves for SL and CT were 0.971 (SE, 0.033) and 0.742 (SE, 0.78), respectively.

CONCLUSIONS

CT cannot replace SL for the detection of PM in lower esophageal and gastric cancer.

Support Vector Machines Model of Computed Tomography for Assessing Lymph Node Metastasis in Esophageal Cancer with Neoadjuvant Chemotherapy

Objective

The aim of this study was to diagnose lymph node metastasis of esophageal cancer by support vector machines model based on computed tomography.

Materials and Methods

A total of 131 esophageal cancer patients with preoperative chemotherapy and radical surgery were included. Various indicators (tumor thickness, tumor length, tumor CT value, total number of lymph nodes, and long axis and short axis sizes of largest lymph node) on CT images before and after neoadjuvant chemotherapy were recorded. A support vector machines model based on these CT indicators was built to predict lymph node metastasis.

Results

Support vector machines model diagnosed lymph node metastasis better than preoperative short axis size of largest lymph node on CT. The area under the receiver operating characteristic curves were 0.887 and 0.705, respectively.

Conclusions

The support vector machine model of CT images can help diagnose lymph node metastasis in esophageal cancer with preoperative chemotherapy.

The value of staging laparoscopy in gastric cancer

Treatment options for patients with gastric cancer (GC) are based on tumor staging and resectability. Although only surgery provides improved survival, resection is contraindicated and should be avoided in the presence of intra-abdominal disease stage M1 (liver, peritoneal, or non-local lymph node metastases). Thus, a detailed and precise evaluation is imperative for optimal treatment. Staging laparoscopy (SL) constitutes a major tool in the accurate diagnosis of several types of cancers, including GC. SL presents several critical advantages: it can diagnose intra-abdominal disease; serve as a complement to other imaging studies; allow for biopsies; facilitate intraoperative ultrasound evaluations; allow for sampling of peritoneal fluid for cytological examination; and serve as an option for the administration of intraperitoneal chemotherapy. Although considered and advocated as a very useful asset in the pre-treatment cancer-staging arsenal, the wider application of SL has been long debated. The purpose of our study was to evaluate the contribution of laparoscopy to GC staging.

The emerging field of radiomics in esophageal cancer: current evidence and future potential

'Radiomics' is the name given to the emerging field of extracting additional information from standard medical images using advanced feature analysis. This innovative form of quantitative image analysis appears to have future potential for clinical practice in patients with esophageal cancer by providing an additional layer of information to the standard imaging assessment. There is a growing body of evidence suggesting that radiomics may provide incremental value for staging, predicting treatment response, and predicting survival in esophageal cancer, for which the current work-up has substantial limitations. This review outlines the available evidence and future potential for the application of radiomics in the management of patients with esophageal cancer. In addition, an overview of the current evidence on the importance of reproducibility of image features and the substantial influence of varying smoothing scales, quantization levels, and segmentation methods is provided.

Endoscopic Ultrasound for Preoperative Esophageal Squamous Cell Carcinoma: a Meta-Analysis

Background

Treatment options and prognosis of esophageal squamous cell carcinoma (ESCC) depend on the primary tumor depth (T-staging) and regional lymph node status (N-staging). Endoscopic ultrasound (EUS) has emerged as a useful staging tool, but studies regarding its benefits have been variable. The objective of this study was to evaluate the diagnostic accuracy of EUS for detecting preoperative ESCC.

Methods

We included in our meta-analysis studies involving EUS-based staging of preoperative ESCC compared with pathological staging. Using a random-effects model, we performed a meta-analysis of the accuracy of EUS by calculating pooled estimates of sensitivity, specificity and the diagnostic odds ratio. In addition, we created a summary receiver operating characteristic (SROC) curve.

Results

Forty-four studies (n = 2880) met the inclusion criteria. The pooled sensitivity and specificity of T1 were 77% (95%CI: 73 to 80) and 95% (95%CI: 94 to 96). Among the T1 patients, EUS had a pooled sensitivity in differentiating T1a and T1b of 84% (95%CI: 80 to 88) and 83% (95%CI: 80 to 86), and a specificity of 91% (95%CI: 88 to 94) and 89% (95%CI: 86 to 92). To stage T4, EUS had a pooled sensitivity of 84% (95%CI: 79 to 89) and a specificity of 96% (95%CI: 95 to 97). The overall accuracy of EUS for T-staging was 79% (95%CI: 77 to 80), and for N-staging, 71% (95%CI: 69 to 73).

Conclusions

EUS has good diagnostic accuracy for staging ESCC, which has better performance in T1 sub-staging (T1a and T1b) and advanced disease (T4).

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.

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.

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.

Diagnostic accuracy of endoscopic ultrasonography (EUS) for the preoperative locoregional staging of primary gastric cancer

BACKGROUND

Endoscopic ultrasound (EUS) is proposed as an accurate diagnostic device for the locoregional staging of gastric cancer, which is crucial to developing a correct therapeutic strategy and ultimately to providing patients with the best chance of cure. However, despite a number of studies addressing this issue, there is no consensus on the role of EUS in routine clinical practice.

OBJECTIVES

To provide both a comprehensive overview and a quantitative analysis of the published data regarding the ability of EUS to preoperatively define the locoregional disease spread (i.e., primary tumor depth (T-stage) and regional lymph node status (N-stage)) in people with primary gastric carcinoma.

SEARCH METHODS

We performed a systematic search to identify articles that examined the diagnostic accuracy of EUS (the index test) in the evaluation of primary gastric cancer depth of invasion (T-stage, according to the AJCC/UICC TNM staging system categories T1, T2, T3 and T4) and regional lymph node status (N-stage, disease-free (N0) versus metastatic (N+)) using histopathology as the reference standard. To this end, we searched the following databases: the Cochrane Library (the Cochrane Central Register of Controlled Trials (CENTRAL)), MEDLINE, EMBASE, NIHR Prospero Register, MEDION, Aggressive Research Intelligence Facility (ARIF), ClinicalTrials.gov, Current Controlled Trials MetaRegister, and World Health Organization International Clinical Trials Registry Platform (WHO ICTRP), from 1988 to January 2015.

SELECTION CRITERIA

We included studies that met the following main inclusion criteria: 1) a minimum sample size of 10 patients with histologically-proven primary carcinoma of the stomach (target condition); 2) comparison of EUS (index test) with pathology evaluation (reference standard) in terms of primary tumor (T-stage) and regional lymph nodes (N-stage). We excluded reports with possible overlap with the selected studies.

DATA COLLECTION AND ANALYSIS

For each study, two review authors extracted a standard set of data, using a dedicated data extraction form. We assessed data quality using a standard procedure according to the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) criteria. We performed diagnostic accuracy meta-analysis using the hierarchical bivariate method.

MAIN RESULTS

We identified 66 articles (published between 1988 and 2012) that were eligible according to the inclusion criteria. We collected the data on 7747 patients with gastric cancer who were staged with EUS. Overall the quality of the included studies was good: in particular, only five studies presented a high risk of index test interpretation bias and two studies presented a high risk of selection bias.For primary tumor (T) stage, results were stratified according to the depth of invasion of the gastric wall. The meta-analysis of 50 studies (n = 4397) showed that the summary sensitivity and specificity of EUS in discriminating T1 to T2 (superficial) versus T3 to T4 (advanced) gastric carcinomas were 0.86 (95% confidence interval (CI) 0.81 to 0.90) and 0.90 (95% CI 0.87 to 0.93) respectively. For the diagnostic capacity of EUS to distinguish T1 (early gastric cancer, EGC) versus T2 (muscle-infiltrating) tumors, the meta-analysis of 46 studies (n = 2742) showed that the summary sensitivity and specificity were 0.85 (95% CI 0.78 to 0.91) and 0.90 (95% CI 0.85 to 0.93) respectively. When we addressed the capacity of EUS to distinguish between T1a (mucosal) versus T1b (submucosal) cancers the meta-analysis of 20 studies (n = 3321) showed that the summary sensitivity and specificity were 0.87 (95% CI 0.81 to 0.92) and 0.75 (95% CI 0.62 to 0.84) respectively. Finally, for the metastatic involvement of lymph nodes (N-stage), the meta-analysis of 44 studies (n = 3573) showed that the summary sensitivity and specificity were 0.83 (95% CI 0.79 to 0.87) and 0.67 (95% CI 0.61 to 0.72), respectively.Overall, as demonstrated also by the Bayesian nomograms, which enable readers to calculate post-test probabilities for any target condition prevalence, the EUS accuracy can be considered clinically useful to guide physicians in the locoregional staging of people with gastric cancer. However, it should be noted that between-study heterogeneity was not negligible: unfortunately, we could not identify any consistent source of the observed heterogeneity. Therefore, all accuracy measures reported in the present work and summarizing the available evidence should be interpreted cautiously. Moreover, we must emphasize that the analysis of positive and negative likelihood values revealed that EUS diagnostic performance cannot be considered optimal either for disease confirmation or for exclusion, especially for the ability of EUS to distinguish T1a (mucosal) versus T1b (submucosal) cancers and positive versus negative lymph node status.

AUTHORS' CONCLUSIONS

By analyzing the data from the largest series ever considered, we found that the diagnostic accuracy of EUS might be considered clinically useful to guide physicians in the locoregional staging of people with gastric carcinoma. However, the heterogeneity of the results warrants special caution, as well as further investigation for the identification of factors influencing the outcome of this diagnostic tool. Moreover, physicians should be warned that EUS performance is lower in diagnosing superficial tumors (T1a versus T1b) and lymph node status (positive versus negative). Overall, we observed large heterogeneity and its source needs to be understood before any definitive conclusion can be drawn about the use of EUS can be proposed in routine clinical settings.

Gastric Carcinoma: Ex Vivo MR Imaging at 7.0 T-Correlation with Histopathologic Findings

PURPOSE

To determine the imaging detail and diagnostic information that can be obtained at 7.0-T magnetic resonance (MR) imaging with a voxel volume of 9.5-14.0 nL as a means of evaluating the depth of mural invasion by gastric carcinomas ex vivo.

MATERIALS AND METHODS

This study was approved by the institutional review board, and written informed consent was obtained from each patient. Twenty gastric specimens containing 20 carcinomas were studied with a 7.0-T MR imaging system equipped with a four-channel surface coil. MR images were obtained with a 50-60 × 25-30 mm field of view, a 512 × 256 matrix, and a 1.0-mm section thickness, resulting in a voxel volume of 0.0095-0.0140 mm(3) (9.5-14.0 nL). The signal intensity of the gastric wall layers, tumor tissue, and fibrosis was described as low, intermediate, or high by comparing it with the signal intensity of the muscularis propria. Depth of invasion initially was assessed by two reviewers independently and then by the two reviewers in consensus. MR images were compared with histopathologic findings.

RESULTS

The 7.0-T T2-weighted MR images clearly depicted the normal gastric wall in all 20 specimens (100%) as consisting of seven layers, which clearly corresponded to the tissue layers of the gastric wall. These MR images enabled clear differentiation between tumor tissue and fibrosis. Reviewers disagreed on the depth of invasion at the initial reading in three (15%) of 20 specimens (between mucosa and submucosa in two specimens and between muscularis propria and subserosa and serosa in one specimen); however, in all 20 gastric carcinomas, the depth of invasion could be accurately determined on T2-weighted images after consensus interpretation.

CONCLUSION

Ex vivo 7.0-T MR imaging enables clear delineation of the gastric wall layers and clear differentiation of tumor tissue from fibrosis and allows one to assess the depth of mural invasion by gastric carcinomas.

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.

CT volumetry for gastric carcinoma: association with TNM stage

OBJECTIVES

We evaluated the feasibility of performing CT volumetry of gastric carcinoma (GC) and its correlation with TNM stage.

METHODS

This institutional review board-approved retrospective study was performed on 153 patients who underwent a staging CT study for histologically confirmed GC. CT volumetry was performed by drawing regions of interest including abnormal thickening of the stomach wall. Reproducibility of tumour volume (Tvol) between two readers was assessed. Correlation between Tvol and TNM/peritoneal staging derived from histology/surgical findings was evaluated using ROC analysis and compared with CT evaluation of TNM/peritoneal staging.

RESULTS

Tvol was successfully performed in all patients. Reproducibility among readers was excellent (r = 0.97; P = 0.0001). The median Tvol of GC showed an incremental trend with T-stage (T1 = 27 ml; T2 = 32 ml; T3 = 53 ml and T4 = 121 ml, P < 0.01). Tvol predicted with good accuracy T-stage (≥T2:0.95; ≥T3:0.89 and T4:0.83, P = 0.0001), M-stage (0.87, P = 0.0001), peritoneal metastases (0.87, P = 0.0001) and final stage (≥stage 2:0.89; ≥stage 3:0.86 and stage 4:0.87, P = 0.0001), with moderate accuracy for N-stage (≥N1:0.75; ≥N2:0.74 and N3:0.75, P = 0.0001). Tvol was significantly (P < 0.05) more accurate than standard CT staging for prediction of T-stage, N3-stage, M-stage and peritoneal metastases.

CONCLUSION

CT volumetry may provide useful adjunct information for preoperative staging of GC.

KEY POINTS

CT volumetry of gastric carcinoma is feasible and reproducible. Tumour volume <19.4 ml predicts T1-stage gastric cancer with 91% sensitivity and 100% specificity (P = 0.0001). Tumour volume >95.7 ml predicts metastatic gastric cancer with 87% sensitivity and 78.5% specificity (P = 0.0001). CT volumetry may be a useful adjunct for staging gastric carcinoma.

Esophageal cancer: A Review of epidemiology, pathogenesis, staging workup and treatment modalities

Esophageal cancer is a serious malignancy with regards to mortality and prognosis. It is a growing health concern that is expected to increase in incidence over the next 10 years. Squamous cell carcinoma is the most common histological type of esophageal cancer worldwide, with a higher incidence in developing nations. With the increased prevalence of gastroesophageal reflux disease and obesity in developed nations, the incidence of esophageal adenocarcinoma has dramatically increased in the past 40 years. Esophageal cancer is staged according to the widely accepted TNM system. Staging plays an integral part in guiding stage specific treatment protocols and has a great impact on overall survival. Common imaging modalities used in staging include computed tomography, endoscopic ultrasound and positron emission tomography scans. Current treatment options include multimodality therapy mainstays of current treatment include surgery, radiation and chemotherapy. Tumor markers of esophageal cancer are an advancing area of research that could potentially lead to earlier diagnosis as well as playing a part in assessing tumor response to therapy.

Esophageal carcinoma: ex vivo evaluation with diffusion-tensor MR imaging and tractography at 7 T

PURPOSE

To determine the feasibility of diffusion-tensor magnetic resonance (MR) imaging and tractography as a means of evaluating the depth of mural invasion by esophageal carcinomas.

MATERIALS AND METHODS

This study was approved by the institutional review board, and written informed consent was obtained from each patient. Twenty esophageal specimens, each containing a carcinoma, were studied with a 7.0-T MR imaging system equipped with a four-channel phased-array surface coil. Diffusion-tensor MR images were obtained with a field of view of 50-60 mm × 25-30 mm, matrix of 256 × 128, section thickness of 1 mm, b value of 1000 sec/mm(2), and motion-probing gradient in seven noncollinear directions. The MR images were compared with the histopathologic findings as the reference standard. The differences in diffusion-tensor MR imaging parameters between the carcinoma and the layers of the esophageal wall were statistically analyzed by using the Dunnett test.

RESULTS

In all 20 carcinomas (100%), the diffusion-weighted images, apparent diffusion coefficient (ADC) maps, fractional anisotropy (FA) maps, λ1 maps, and direction-encoded color FA maps made it possible to determine the depth of tumor invasion of the esophageal wall that was observed during histopathologic examination. The λ1 maps showed the best contrast between the carcinomas and the layers of the esophageal wall. The carcinomas had both lower ADC values and lower FA values than the normal esophageal wall; thus, the carcinomas were clearly demarcated from the normal esophageal wall. Diffusion-tensor tractography images were also useful for determining the depth of tumor invasion of the esophageal wall.

CONCLUSION

Diffusion-tensor MR imaging and tractography are feasible in esophageal specimens and provide excellent morphologic data for the evaluation of mural invasion by esophageal carcinomas.

Endoscopically assisted laparoscopic local resection of gastric tumor

Background

Minimally invasive procedures have been applied in treatment of gastric submucosal tumors. Currently, combined laparoscopic - endoscopic rendezvous resection (CLERR) emerges as a new technique which further reduces operative invasiveness.

Case presentation

A-57-year-old female patient presented with epigastric pain. She was submitted to gastroscopy, which revealed a tumor located at the angle of His. Biopsy specimens demonstrated a leiomyoma. The patient underwent endoscopically assisted laparoscopic resection of the tumor. The operative time was 45 minutes. Diagnosis of leiomyoma was confirmed by the final histopathological examination. The patient had an uneventful postoperative recovery and was discharged on the 2^nd postoperative day.

Conclusion

Combined laparoscopic and endoscopic rendezvous resection appears as a promising alternative minimally invasive technique. It offers easy recognition of the tumor, regardless of location, safe dissection, and full thickness resection with adequate margins as well as less operative time.

Gastric carcinoma: imaging diagnosis, staging and assessment of treatment response

Gastric carcinoma (GC) is one of the most common causes of cancer-related death worldwide. Surgical resection is the only cure available and is dependent on the GC stage at presentation, which incorporates depth of tumor invasion, extent of lymph node and distant metastases. Accurate preoperative staging is therefore essential for optimal surgical management with consideration of preoperative and/or postoperative chemotherapy. Multidetector computed tomography (MDCT) with its ability to assess tumor depth, nodal disease and metastases is the preferred technique for staging GC. Endoscopic ultrasonography is more accurate for assessing the depth of wall invasion in early cancer, but is limited in the assessment of advanced local or stenotic cancer and detection of distant metastases. Magnetic resonance imaging (MRI), although useful for staging, is not proven to be effective. Positron emission tomography (PET) is most useful for detecting and characterizing distant metastases. Both MDCT and PET are useful for assessment of treatment response following preoperative chemotherapy and for detection of recurrence after surgical resection. This review article discusses the usefulness of imaging modalities for detecting, staging and assessing treatment response for GC and the potential role of newer applications including CT volumetry, virtual gastroscopy and perfusion CT in the management of GC.

Imaging strategies in the management of oesophageal cancer: what's the role of MRI?

OBJECTIVES

To outline the current role and future potential of magnetic resonance imaging (MRI) in the management of oesophageal cancer regarding T-staging, N-staging, tumour delineation for radiotherapy (RT) and treatment response assessment.

METHODS

PubMed, Embase and the Cochrane library were searched identifying all articles related to the use of MRI in oesophageal cancer. Data regarding the value of MRI in the areas of interest were extracted in order to calculate sensitivity, specificity, predictive values and accuracy for group-related outcome measures.

RESULTS

Although historically poor, recent improvements in MRI protocols and techniques have resulted in better imaging quality and the valuable addition of functional information. In recent studies, similar or even better results have been achieved using optimised MRI compared with other imaging strategies for T- and N-staging. No studies clearly report on the role of MRI in oesophageal tumour delineation and real-time guidance for RT so far. Recent pilot studies showed that functional MRI might be capable of predicting pathological response to treatment and patient prognosis.

CONCLUSIONS

In the near future MRI has the potential to bring improvement in staging, tumour delineation and real-time guidance for RT and assessment of treatment response, thereby complementing the limitations of currently used imaging strategies.

KEY POINTS

• MRI's role in oesophageal cancer has been somewhat limited to date. • However MRI's ability to depict oesophageal cancer is continuously improving. • Optimising TN-staging, radiotherapy planning and response assessment ultimately improves individualised cancer care. • MRI potentially complements the limitations of other imaging strategies regarding these points.

Diagnosis and staging of cancer of the esophagus and esophagogastric junction

Esophageal/esophagogastric junction cancer staging in the 7th edition of the AJCC staging manual is data driven and harmonized with gastric staging. New definitions are Tis, T4, regional lymph node, N, and M. Nonanatomic characteristics (histopathologic cell type, histologic grade, cancer location) and TNM classifications determine stage groupings. Classifications before treatment define clinical stage (cTNM or ycTNM). Current best clinical staging modalities include endoscopic ultrasonography for T and N and CT/PET for M. Classifications at resection define pathologic stage (pTNM or ypTNM). Accurate pathologic stage requires communication/cooperation between surgeon and pathologist. Classifications are defined at retreatment (rTNM) and autopsy (aTNM).

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.

Advances in endoscopic diagnosis of early esophageal cancer

Esophageal cancer is one of the most common malignancies in China. The prognosis of esophageal carcinoma is closely related to the stage of the disease at the time of detection. Patients with early lesions have an excellent prognosis, whereas those with more advanced stages of the disease usually have a poor prognosis. Therefore, the early detection of these lesions is of the greatest importance for treatment. Recently, many endoscopic methods have been developed, such as fluorescence endoscopy, confocal endoscopy, optical coherence tomography (OCT), and electronic staining imaging technology which includes narrow band imaging (NBI), Fujinon intelligent chromoendoscopy (FICE) and I-Scan. However, the clinical value of these techniques needs to be ascertained in the coming years. This paper reviews the progress of endoscopic diagnosis of early esophageal cancer.

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.

The peak-standardized uptake value (P-SUV) by preoperative positron emission tomography-computed tomography (PET-CT) is a useful indicator of lymph node metastasis in gastric cancer

BACKGROUND AND OBJECTIVES

Little data is currently available on the usefulness of peak-standardized uptake value (P-SUV) by positron emission tomography-computed tomography (PET-CT) in gastric cancer. The purpose of the present study was to evaluate the value of PET-CT for the preoperative evaluation of patients with gastric cancer. The aim of this study was to assess the relation of between primary tumor P-SUV, as determined by preoperative PET-CT, and lymph node metastasis in gastric cancer.

METHODS

From December 2007 to March 2010, we analyzed the PET-CT of 147 patients that underwent gastrectomy for gastric cancer. P-SUV in PET-CT were measured by single nuclear medicine physician. Statistical analysis was performed to determine relations between clinicopathologic parameters including P-SUV and lymph node metastasis using the chi-square test, the independent t-test, and using logistic regression analysis.

RESULTS

Age, tumor depth, tumor size, and lymph node metastasis were found to be associated with primary tumor P-SUV by PET-CT (P=0.009, <0.001, <0.001, and <0.001, respectively). No association was found between P-SUV and tumor histology or tumor location (P=0.099). Advanced gastric cancer was found to have a higher P-SUV than early gastric cancer, and a higher P-SUV was found to be associated with lymph node metastases by both univariate and multivariate analysis.

CONCLUSIONS

P-SUV of primary tumor could be an independent indicator of lymph node metastasis in gastric cancer. Gastric surgeons should pay more attention to the dissection of lymph nodes when primary tumors have higher P-SUV values by PET-CT.

Lymph node metastasis of gastric cancer

Despite a decrease in incidence in recent decades, gastric cancer is still one of the most common causes of cancer death worldwide [1]. In areas without screening for gastric cancer, it is diagnosed late and has a high frequency of nodal involvement [1]. Even in early gastric cancer (EGC), the incidence of lymph node (LN) metastasis exceeds 10%; it was reported to be 14.1% overall and was 4.8 to 23.6% depending on cancer depth [2]. It is important to evaluate LN status preoperatively for proper treatment strategy; however, sufficient results are not being obtained using various modalities. Surgery is the only effective intervention for cure or long-term survival. It is possible to cure local disease without distant metastasis by gastrectomy and LN dissection. However, there is no survival benefit from surgery for systemic disease with distant metastasis such as para-aortic lymph node metastasis [3]. Therefore, whether the disease is local or systemic is an important prognostic indicator for gastric cancer, and the debate continues over the importance of extended lymphadenectomy for gastric cancer. The concept of micro-metastasis has been described as a prognostic factor [4-9], and the biological mechanisms of LN metastasis are currently under study [10-12]. In this article, we review the status of LN metastasis including its molecular mechanisms and evaluate LN dissection for the treatment of gastric cancer.

Efficacy of hydrogastric sonography and spiral Computed Tomography in staging of gastric carcinoma--a comparative study

OBJECTIVE

Accurate preoperative diagnosis and staging of patients with gastric cancer is essential for optimal treatment. The standard of care for staging gastric carcinoma is helical CT. This study was conducted to compare the efficacy of hydrogastric sonography (HGS) with that of helical CT in the staging of patients with gastric carcinoma.

METHODS

A total of 42 consecutive patients (29 men and 13 women) diagnosed with gastric carcinoma after endoscopy and biopsy were staged on the basis of TNM classification, preoperatively with HGS and helical CT and postoperatively with histopathologic examination (HPE). The findings of HGS and helical CT were compared with those on HPE with respect to TNM stage.

RESULTS

Regarding T stage, the accuracy of HGS was 78.6% (kappa = 0.68) and that of helical CT was 66.7% (kappa = 0.48). In evaluating the nodal status, the accuracy of HGS was 66.7% (kappa = 0.52) and that of helical CT was 54.6% (kappa = 0.39). Regarding distant metastases, accuracy was the same with HGS and helical CT (accuracy 95.2%, kappa = 0.89).

CONCLUSIONS

When compared with HPE, HGS was found to be more accurate than helical CT for assessment of T and N staging. Sonographic and helical CT were equally accurate for the assessment of M stage.

Gastric Adenocarcinoma: Is Computed Tomography (CT) Useful in Preoperative Staging?

BACKGROUND AND PURPOSE

Although multiple studies testing the accuracy of CT in the preoperative staging of gastric adenocarcinoma have been carried out, their results are controversial. Whilst some authors claim that CT is an accurate method for preoperatively staging gastric cancer, others have advocated the contrary. Because of this discrepancy we have retrospectively reviewed preoperative CT findings compared with histopathological results in patients with gastric adenocarcinoma.

PATIENTS AND METHODS

Seventy-two patients diagnosed with gastric cancer who underwent potentially curative surgery and preoperative staging CT of quality were included in the study. The size, gastric wall thickening, presence of lymphadenopathy, adjacent organ invasion and location of the gastric mass was recorded. Early tumors (T1 and T2) and more advanced tumors (T3 and T4) were grouped together. CT staging was correlated with the final histopathological stage (TNM). The global results were expressed as sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV).

RESULTS

Seventy-two cases were included with fifty-five being male and a median age of 67 years (range 33-91). CT correctly identified the location of the tumor in 56 (53% antropyloric, 18% subcardial). Median time from CT scan to surgery was fourteen days (range 2-49). In T detection: T1/T2 and T3/T4 with sensitivity of 70% and 61%. Lymph node involvement: Sensitivity 49%. Overstaged in 47% Understaged in 75%. Specificity of 53%. Nine patients with colon-mesocolon (5 patients) and pancreas (4 patients) invasion. Sensitivity 44% and specificity 96%.

CONCLUSION

Spiral CT is not an accurate method in predicting preoperative stages in gastric cancer.

Multimodality assessment of esophageal cancer: preoperative staging and monitoring of response to therapy

Esophageal cancer is a leading cause of cancer mortality worldwide. Complete resection of esophageal cancer and adjacent malignant lymph nodes is the only potentially curative treatment. Accurate preoperative staging and assessment of therapeutic response after neoadjuvant therapy are crucial in determining the most suitable therapy and avoiding inappropriate attempts at curative surgery. Computed tomography (CT) is recommended for initial imaging following confirmation of malignancy at pathologic analysis, primarily to rule out unresectable or distant metastatic disease. With the advent of multidetector CT, use of thin sections and multiplanar reformation allows more accurate staging of esophageal cancer. Endoscopic ultrasonography (US) is the best modality for determining the depth of tumor invasion and presence of regional lymph node involvement. Combined use of fine-needle aspiration and endoscopic US can improve assessment of lymph node involvement. Positron emission tomography (PET) is useful for assessment of distant metastases but is not appropriate for detecting and staging primary tumors. PET may also be helpful in restaging after neoadjuvant therapy, since it allows identification of early response to treatment and detection of interval distant metastases. Each imaging modality has its advantages and disadvantages; therefore, CT, endoscopic US, and PET should be considered complementary modalities for preoperative staging and therapeutic monitoring of patients with esophageal cancer.

Outcome of unresected gastric cancer after laparoscopic diagnosis of peritoneal carcinomatosis

BACKGROUND

Most gastric adenocarcinomas in western countries are locally advanced, and these tumours are often associated with metastatic spread at the time of diagnosis. It is controversial whether palliative surgery can improve symptom control in gastric cancer patients with peritoneal carcinomatosis.

OBJECTIVE

To determine the need of palliative procedures and survival in patients affected by gastric cancer with peritoneal carcinomatosis managed without resection. Methods and materials After standard preoperative staging, 160 patients were diagnosed with resectable gastric adenocarcinoma. Laparoscopy was performed in 107 patients (66.9%), finding peritoneal spread in 22 of them (21%). Seventeen of these patients were not submitted to any additional surgical procedure. Data regarding postoperative morbidity and mortality, need of endoscopic, percutaneous or surgical procedures to palliate symptoms, hospital stay and survival were collected. The same data were collected for the 6 non-resected patients who were diagnosed with carcinomatosis by laparotomy.

RESULTS

In the "laparoscopy alone" group, there were 2 minor complications and no postoperative mortality. Mean postoperative stay was 6 days. Eight patients had to be readmitted to hospital for symptoms derived from tumour progression, and 10 palliative endoscopic procedures were performed. Surgical interventions were not needed in any case. Mean survival was 11.5 months. Patients submitted only to laparotomy presented higher morbidity and mortality rates, with a longer postoperative stay and survival of less than 5 months.

CONCLUSIONS

Laparoscopic staging of gastric cancer can help to avoid unnecessary laparotomies. In patients with peritoneal carcinomatosis diagnosed by laparoscopy, nonsurgical treatment has low morbidity and mortality and permits good symptom relief with no shortening of survival.