Imaging for esophageal tumors

Prognostic significance of the size and number of lymph nodes on pre and post neoadjuvant chemotherapy CT in patients with pN0 esophageal squamous cell carcinoma: a 5-year follow-up study

The prognosis of patients with esophageal cancer improves by using neoadjuvant chemotherapy (NAC). More patients obtain pathological N0 staging (pN0) after surgery. The heterogeneity of prognosis of these patients poses a great challenge of customizing therapeutic strategies for individual patients. The signs of lymph nodes on both pre and post NAC computer tomography (CT) scan can provide more information for evaluation. Therefore, we investigated a new approach to lymph node (LN)-survival analysis by using pre-/post-NAC CT in pN0 esophageal cancer. 79 patients undergone curative resection after NAC obtained pN0 staging. The long and short axis diameter of maximal lymph node (MaxLN) and LN number on pre-/post-NAC CT scans were recorded and assessed for predicting survival by univariate and multivariate survival analysis. The prognosis of patients with esophageal cancer was correlated with the LN size and number on pre-/post-NAC CT. The LN number on pre-NAC CT and short-axis diameter of MaxLN on post-NAC CT remained the independent predictor of overall survival. By using these two factors as classification criterion, N0b group included patients with LN number>4 on pre-NAC CT or short-axis diameter of MaxLN >7 mm on post-NAC CT and the rest patients were included in N0a group. N0a group had a significantly better overall survival than N0b group (5-year survival rate: 75.2% vs. 32.6%). The size and number of lymph node on pre-/post-NAC CT were reliable and important prognostic factors in patients with pN0 esophageal cancer. This new criterion could distinguish these patients into N0a and N0b, according to different prognosis.

Esophageal Cancer: Role of Imaging in Primary Staging and Response Assessment Post Neoadjuvant Therapy

Advances in the early detection and treatment of esophageal cancer have meant improved survival rates for patients with esophageal cancer. Accurate pretreatment and post-neoadjuvant treatment staging of esophageal cancer is essential for assessing operability and determining the optimum treatment plan. This article reviews the multimodality imaging approach in the diagnosis, staging, and assessment of treatment response in esophageal cancer.

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.

Is Endoscopic Ultrasound (EUS) necessary in the pre-therapeutic assessment of Barrett's esophagus with early neoplasia?

Endoscopic ultrasound (EUS) is considered the most accurate tool for the TNM staging of esophageal cancer, but its role in early Barrett's neoplasia is still debatable. The aim was to evaluate the utility of EUS in Barrett's patients prior to therapy. Retrospective review of 109 patients enrolled in a treatment protocol for Barrett's neoplasia in our institution. EUS assessment was classified as suspicious for invasion in 19 patients; 84% of them had no evidence of invasion in final pathology. The assessment of depth of invasion of Barrett's neoplasia based solely on EUS findings leads to overstaging in most patients.

Confirmation of histology of PET positive lymph nodes recovered by hand-video-assisted thoracoscopy surgery

PET/CT (Positron Emission Tomography-Computed Tomography) is an advanced diagnostic imaging device that combines both PET and an X-ray CT. This study evaluates the effects of PET/CT on detecting primary tumors and metastases, and looks at the therapeutic effect of minimally invasive surgery on esophageal cancer patients. Eighty patients with esophageal cancer were enrolled in the study between January, 2004 and December, 2007, who were randomly divided into two groups of 40, one of which was treated with hand-video-assisted thoracoscopy surgery (HVATS) esophagectomy and one of which was treated with conventional surgery. All patients underwent a PET/CT scan 2-3 weeks before their operation, and their cervical, thoracic and upper abdominal lymph nodes were biopsied. All the primary esophageal lesions showed high FDG uptake. The maximum standardized uptake value (SUV) was 3.78-25.64 (11.73±5.32), while the mean SUV was 3.65=16.92 (9.12±4.37). Using 2.5 as the SUV standard, all esophageal lesions were detected by PET/CT image. Of the 80 patients, 53 had lymph nodal metastases, with a total of 142 metastatic lymph nodes, which showed high FDG uptake. The maximum SUV was 2.77-14.63 (7.98±3.25), and the mean SUV was 2.31-12.84 (5.34±3.19). The visual analysis from the PET/CT scan showed a sensitivity of 86.62%, a specificity of 95.85%, a positive predictive value of 93.89%, a negative predictive value of 90.69% and an accuracy of 91.94%. The PET/CT scan showed a high sensitivity and specificity in detecting primary esophageal cancer and lymph nodal metastases. The mean post-surgery life expectancies for patients undergoing HVATS and conventional surgery are 27.93 months and 28.05 months, respectively. The two groups showed no statistically significant difference. We thus conclude that PET/CT combined with HVATS is a new choice for esophageal carcinoma patients.

Vessel probe CT protocol in the study of esophageal carcinoma: can it improve preoperative T staging?

AIMS

This study aims to compare transverse images and vessel probe (VP) in MPR mode reconstructions obtained by 16-row MDCT with the histological findings in the preoperative T staging of esophageal cancer.

MATERIALS AND METHODS

Thirty-one patients (23 M, 8 F, mean age 63.2) with endoscopic and histological diagnosis of esophageal carcinoma underwent CT examination. Esophageal lumen was distended by CO2 and a biphasic technique with 35 s and 70 s delay was used after intravenous injection of contrast material. Transverse and VP in MPR mode images were evaluated and the following parameters were considered: presence and location of the tumor; esophageal wall thickness and enhancement; depth of visceral wall invasion; periesophageal fat morphology and infiltration of adjacent organs. Preoperative staging was performed and then it was compared with the histological findings considered as reference standard.

RESULTS

Sensibility, negative predictive and accuracy values were 67%, 64% and 79% by using axial images for preoperative T staging, while the use of VP increased the previous values up to 83%, 78% and 89%, respectively.

CONCLUSIONS

In the preoperative staging of esophageal cancer, VP in MPR mode reconstructions obtained by 16-row MDCT increase the sensibility and diagnostic accuracy values in the T parameter evaluation compared with axial images.

2-deoxy-2-[F-18]fluoro-D-glucose-positron emission tomography/computed tomography imaging evaluation of esophageal cancer

We evaluated the clinical utility of 2-deoxy-2-[F-18]fluoro-D-glucose (FDG)-positron emission tomography (PET)/computed tomography (CT) on the precise localization of pathologic foci and exclusion of normal variants in the imaging evaluation of patients with esophageal carcinoma. Combined PET/CT scans were performed in 60 patients (50 males, 10 females, age range 47-84 years) with history of esophageal carcinoma either at the time of initial diagnosis (group I, n=14) or for surveillance and/or detection of recurrent and metastatic disease (group II, n=46). Prior treatments included esophagectomy with gastric pull-up (n=23), surgery and chemotherapy (n=3), surgery and chemoradiation therapy (n=10), chemotherapy alone (n=5), radiation therapy alone (n=2), and chemoradiation without surgery (n=3). Diagnostic validation was by tissue sampling in three patients and clinical/radiological follow-up for up to 1.5 years in the remaining patients. In group I, discordant abnormalities were noted in seven patients. PET demonstrated hypermetabolism in normal-size lymph nodes on CT in three patients that were considered likely true positive in view of concurrent existence of other adjacent enlarged hypermetabolic lymph nodes in the same nodal basin. Hypometabolic incidental CT abnormalities of up to 1-cm lung nodules were noted in three patients and pleural effusion in one patient, which were considered true negative in view of no change on follow-up PET/CT studies. In group II, both PET and CT showed concordant abnormalities in 23 patients. The precise image fusion of hypermetabolism in a liver lesion allowed a diagnostic CT-guided biopsy in one patient. PET demonstrated true positive hypermetabolic abnormalities in four patients that localized to structures, which were normal by noncontrast CT criteria, and true negative in one patient with hepatic fatty deposits. PET showed decline in metabolic activity of the primary lesion in one patient after chemotherapy, while the corresponding CT abnormality remained unchanged. PET/CT image fusion provided relevant complementary diagnostic information in 14 patients with discordant findings (23% of total) that resulted in biopsy in three cases, institution of chemotherapy in four cases, and a wait-and-watch strategy in seven cases. In conclusion, our findings add to the current body of literature that suggests that FDG-PET/CT scanning may improve the imaging evaluation of patients with esophageal cancer by providing complementary structural-metabolic information. In particular, our findings support the notion that PET/CT may be the most appropriate imaging modality in the evaluation of patients of esophageal cancer that may impact patient management.

Clinical biomarkers of angiogenesis inhibition

INTRODUCTION

An expanding understanding of the importance of angiogenesis in oncology and the development of numerous angiogenesis inhibitors are driving the search for biomarkers of angiogenesis. We review currently available candidate biomarkers and surrogate markers of anti-angiogenic agent effect.

DISCUSSION

A number of invasive, minimally invasive, and non-invasive tools are described with their potential benefits and limitations. Diverse markers can evaluate tumor tissue or biological fluids, or specialized imaging modalities.

CONCLUSIONS

The inclusion of these markers into clinical trials may provide insight into appropriate dosing for desired biological effects, appropriate timing of additional therapy, prediction of individual response to an agent, insight into the interaction of chemotherapy and radiation following exposure to these agents, and perhaps most importantly, a better understanding of the complex nature of angiogenesis in human tumors. While many markers have potential for clinical use, it is not yet clear which marker or combination of markers will prove most useful.

[Oesophageal tumours--what does the surgeon need from the radiologist?]

Surgery is the most important therapeutic discipline for oesophageal cancers and the surgeon has specific questions for the radiologist which can require various imaging procedures. The radiological presentation is, for example, necessary for the topographic imaging of larger space occupying processes, the localization and axial spread of which are important for the surgical procedure chosen. Imaging diagnostics helps with the identification of R0 resectable patients. High resolution computed tomography (CT) of the mediastinum is used to clarify the spatial relationship between oesophageal cancer and the tracheobronchial system. This method also helps demonstrate the presence of fistulas in the tracheobronchial system or mediastinum. Using a neck or thorax CT, or a PET-CT distant metastases can be documented and a second tumour excluded. Imaging procedures gain additional significance for the evaluation of the T stage of the oesophageal tumour or the response to neoadjuvant therapy concepts, for which an earliest possible response evaluation is of great importance. Imaging procedures are also of importance in aftercare as it is sometimes possible and valuable to carry out surgery for local relapses.

High-frequency probe ultrasonography has limited accuracy for detecting invasive adenocarcinoma in patients with Barrett's esophagus and high-grade dysplasia or intramucosal carcinoma: a case series

AIM

To evaluate prospectively the accuracy of preoperative high-frequency (20 MHz) probe ultrasonography (HFPUS) for detecting invasive cancer in patients referred for esophagectomy because of an endoscopic biopsy diagnosis of high-grade dysplasia (HGD) or intramucosal carcinoma (ICA) in Barrett's esophagus (BE).

PATIENTS AND METHODS

Nine consecutive male patients (median age of 69 yr) who were referred for esophagectomy for HGD or ICA in BE agreed to participate. We performed conventional upper gastrointestinal endoscopy followed by HFPUS using a through-the-scope ultrasound probe (20 MHz), and we compared our preoperative findings with the pathologist's findings in the resected esophageal specimens.

RESULTS

There was complete agreement between the postoperative pathological findings and the preoperative HFPUS findings in only 4 of the 9 patients. HFPUS resulted in two false-negative diagnoses of esophageal cancer (both had T1 lesions in the resected specimens), one false-positive diagnosis of esophageal cancer, and two errors in tumor staging (1 understaged, 1 overstaged).

CONCLUSIONS

HFPUS has limited accuracy for identifying invasive cancer in patients found to have HGD or IMC in BE. Pending further refinements in technology, clinical management decisions in such patients should not be based solely on the results of HFPUS.

Surgical treatment and clinical course of patients with hypopharyngeal carcinoma

In the period between 1 January 1978 and 1 January 2004, 85 patients with hypopharyngeal squamocellular carcinoma were admitted at the Department of Esophagogastric Surgery in Belgrade. Among them, only 46 patients (54.1%) had radical surgical en-block resection and functional neck dissection, and they were included into an historical cohort study. In 40 patients a pharyngolaryngoesophagectomy was performed using for reconstruction, stomach tissue in 29 and colon tissue in 11 patients. Since 1996, in six patients with localized hypopharyngeal carcinoma pharyngolaryngectomy was performed with resection of cervical esophagus and free jejunal graft interposition. The overall incidence of morbidity was 50.0% and the overall mortality rate was 13.0% (6 patients). Mean hospital stay was 35 days (range, 18-78 days). The median survival of patients was 26 months, and overall 5-year survival rate was 26.5%. At present, surgery seems to be the appropriate therapeutic choice for patients with advanced hypopharyngeal carcinoma, providing a definitive palliation of dysphagia and relatively good long-term survival. At our Institution, after pharyngolaryngoesophagectomy, reconstructive method of choice is gastric 'pull-up', and the colon is used only when stomach tissue is not available, that is, previous gastric resections, inappropriate blood supply, synchronous gastric carcinoma and so on. Recently, pharyngolaryngectomy and free jejunal transfer has become the standard technique in patients with small carcinomas (up to 3 cm) confined to the hypopharynx in the absence of synchronous esophageal and/or gastric carcinoma.

Intraoperative endoscopy in obstructive hypopharyngeal carcinoma

AIM: To demonstrate the necessity of intraoperative endoscopy in the diagnosis of secondary primary tumors of the upper digestive tract in patients with obstructive hypopharyngeal carcinoma.

METHODS: Thirty-one patients with hypopharyngeal squamous cell carcinoma had been operated, with radical intent, at our Institution in the period between 1978 and 2004. Due to obstructive tumor mass, in 7 (22.6%) patients, preoperative endoscopic evaluation of the esophagus and stomach could not be performed. In those patients, intraoperative endoscopy, made through an incision in the cervical esophagus, was standard diagnostic method for examination of the esophagus and stomach.

RESULTS: We found synchronous foregut carcinomas in 3 patients (9.7%). In two patients, synchronous carcinomas had been detected during preoperative endoscopic evaluation, and in one (with obstructive carcinoma) using intraoperative endoscopy. In this case, preoperative barium swallow and CT scan did not reveal the existence of second primary tumor within esophagus, despite the fact that small, but T2 carcinoma, was present.

CONCLUSION: It is reasonable to use intraoperative endoscopy as a selective screening test in patients with obstructive hypopharyngeal carcinoma.

3D CT protocol in the assessment of the esophageal neoplastic lesions: can it improve TNM staging?

The purpose of this prospective observational study was the evaluation of the usefulness of MPR reconstructions and virtual endoscopy in the study of the esophageal carcinoma. Thirty-nine patients with esophageal cancer proved by means of endoscopy, underwent preoperative TNM staging with dynamic CT of the chest and abdomen with the aid of 3D rendering. Twenty-six patients underwent surgery, and the CT results were compared with histopathologic findings. In staging the T parameter, the CT with 3D reconstructions and virtual endoscopy, showed a sensitivity of 92% and an accuracy of 88%. In staging lymph nodes, the sensitivity in our study was 85%, the specificity 58%, and the accuracy 69%. Our protocol of the study of the esophageal cancer with 3D CT and virtual endoscopy, demonstrated a high concordance with the surgical and pathologic findings. The 3D reconstructed images were very helpful to the surgeons regarding preoperative planning. We performed an observational enquiry, and although this was a small study, it has, however, confirmed that the 3D imaging of the esophagus represents a valuable advantage to conventional imaging. Further studies with a larger number of patients are needed to prove its superiority to traditional CT imaging of the esophagus.