Comparison of CT and MRI for the diagnosis recurrent esophageal carcinoma after operation

Advancing Esophageal Cancer Staging and Restaging: The Role of MRI in Precision Diagnosis

This review provides an in-depth analysis and comprehensive overview of recent advancements in MRI techniques for evaluating esophageal cancer (EC). It discusses the specific MRI acquisition protocols and parameters that enhance image quality and diagnostic accuracy. The review highlights MRI's role and performance in the initial TNM staging and its potential to refine treatment strategies by improving tumor delineation and characterization. Additionally, the paper explores MRI utility in restaging after NAT, focusing on its accuracy in assessing treatment response and detecting residual or recurrent disease. Comparisons with other imaging modalities currently used-such as endoscopic ultrasound (EUS), contrast-enhanced computed tomography (CE-CT), and 18F-fluorodeoxyglucose (FDG) positron emission tomography/CT (PET/CT)-are included to highlight the strengths and limitations of each method. Illustrated with numerous Figures, this article proposes a novel MRI-based strategy for EC staging and restaging. It aims to integrate MRI into clinical practice by leveraging its superior soft-tissue contrast and functional imaging capabilities to enhance diagnostic precision and improve patient outcomes. Through this comprehensive evaluation, the review underscores the potential of MRI to become a cornerstone in the precision diagnosis and management of EC.

State-of-the-art imaging in oesophago-gastric cancer

Radiological investigations are essential in the management of oesophageal and gastro-oesophageal junction cancers. The current multimodal combination of CT, 18F-fluorodeoxyglucose positron emission tomography combined with CT (PET/CT) and endoscopic ultrasound (EUS) has limitations, which hinders the prognostic and predictive information that can be used to guide optimum treatment decisions. Therefore, the development of improved imaging techniques is vital to improve patient management. This review describes the current evidence for state-of-the-art imaging techniques in oesophago-gastric cancer including high resolution MRI, diffusion-weighted MRI, dynamic contrast-enhanced MRI, whole-body MRI, perfusion CT, novel PET tracers, and integrated PET/MRI. These novel imaging techniques may help clinicians improve the diagnosis, staging, treatment planning, and response assessment of oesophago-gastric cancer.

Endoscopic Evaluation of Radiologic Distal Esophageal Thickening

GOALS

We aim to determine the incidence of esophagogastroduodenoscopies (EGDs) primarily performed for imaging findings of distal esophageal thickening (DET). We also aim to determine if patients with imaging findings of DET have a higher incidence of cancer, and to evaluate the risk factors associated with findings of malignancy.

BACKGROUND

The growth of diagnostic imaging has led to an increase in incidental findings of DET. This nonspecific finding frequently prompts an EGD for evaluation-many of which demonstrate benign conditions. There may be a misuse of valuable resources.

STUDY

We performed a retrospective chart review of 1080 EGDs from January 2016 to July 2018 at the Veterans Affairs Medical Center, comparing EGDs for the indication of imaging report of DET with EGDs for other indications. Patient demographics, clinical history, imaging, procedure, and pathology reports were collected. Descriptive analysis and biostatistical analysis with χ2, Fisher exact, Wilcoxon rank sum, and Kruskal-Wallis tests were utilized in analyzing the data.

RESULTS

Of the 1080 total endoscopies, 8.2% (n=88) were done specifically because of the imaging findings of DET. Those who had EGDs performed because of DET had a higher percentage of abnormal esophageal findings and of cancer. A history of Barrett's esophagus, tobacco use, and having gastrointestinal symptoms were not significant predictors of abnormal findings or of cancer for EGDs done for DET.

CONCLUSIONS

There may be a role for EGDs performed for radiologic findings of DET. Even those without risk factors for malignancy should have EGDs performed for DET. Radiologists should consider reporting the DET size in order to determine if significant endoscopic findings correlate with wall thickness.

Comparison of spectral computed tomography imaging parameters between squamous cell carcinoma and adenocarcinoma at the gastroesophageal junction

OBJECTIVE

To compare the spectral computed tomography (CT) imaging parameters between squamous cell carcinoma (SCC) and adenocarcinoma (AC) at the gastroesophageal junction (GEJ).

METHODS

A total of 80 patients were enrolled in this retrospective study. Among them, 35 were diagnosed with SCC (SCC group) and 45 were diagnosed with AC (AC group). All patients underwent an enhanced scan with spectral CT. The following CT imaging parameters were evaluated: iodine concentration (IC), water content (WC), effective atomic number (Eff-Z) and slope of the spectral HU curve (λHU) of lesions. Receiver operating characteristic (ROC) curve was used to analyze the predictive value of spectral CT imaging parameters for diagnosis of SCC and AC.

RESULTS

Patients with SCC had lower IC, Eff-Z, and λHU in arterial phase and venous phase compared with AC (p< 0.05). There were no significant differences in WC between the two groups. ROC curve analyses revealed that IC, Eff-Z, and λHU in arterial phase and venous phase were predictors for diagnosis of SCC and AC (AUC > 0.5). Moreover, the IC, Eff-Z and λHU in venous phase had better differential diagnostic performances than that in arterial phase.

CONCLUSIONS

Spectral CT could be useful in the differential diagnosis of SCC and AC at the GEJ. Therefore, a routine spectral CT scan is recommended for patients with carcinoma of the GEJ.

Role of precision imaging in esophageal cancer

Esophageal cancer is a major cause of morbidity and mortality worldwide. Recent advancements in the management of esophageal cancer have allowed for earlier detection, improved ability to monitor progression, and superior treatment options. These innovations allow treatment teams to formulate more customized management plans and have led to an increase in patient survival rates. For example, in order for the most effective management plan to be constructed, accurate staging must be performed to determine tumor resectability. This article reviews the multimodality imaging approach involved in making a diagnosis, staging, evaluating treatment response and detecting recurrence in esophageal cancer.

Esophagus and Stomach: Is There a Role for MR Imaging?

MR imaging has been increasingly used in the diagnostic work-up of benign and malignant conditions of the gastroesophageal tract. The use of an adequate MR imaging protocol is crucial, although standardization of imaging studies is still far from being implemented. Research on MR imaging-based biomarkers show promising results in assessing tumor aggressiveness and prognosis, and in the evaluation of response to treatment, both in esophageal and gastric cancers.

Comparison of different images in gross target volume delineating on VX2 nasopharyngeal transplantation tumor models

Background: To determine the optimum conditions for diagnosis of nasopharyngeal carcinoma, we established VX2 rabbit model to delineate gross target volume (GTV) in different imaging methods. Methods: The orthotopic nasopharyngeal carcinoma (NPC) was established in sixteen New Zealand rabbits. After 7-days inoculation, the rabbits were examined by CT scanning and then sacrificed for pathological examination. To achieve the best delineation, different GTVs of CT, MRI, ¹⁸F-FDG PET/CT, and ¹⁸F-FLT PET/CT images were correlated with pathological GTV (GTVp). Results: We found 45% and 60% of the maximum standardized uptake value (SUV_max) as the optimal SUV threshold for the target volume of NPC in ¹⁸F-FDG PET/CT and ¹⁸F-FLT PET/CT images, respectively (GTV_FDG45% and GTV_FLT60%). Moreover, the GTV_MRI and GTV_CT were significantly higher than the GTVp (P ≤ 0.05), while the GTV_FDG45% and especially GTV_FLT60% were similar to the GTVp (R = 0.892 and R = 0.902, respectively; P ≤ 0.001). Conclusions: Notably, the results suggested that ¹⁸F-FLT PET/CT could reflect the tumor boundaries more accurately than ¹⁸F-FDG PET/CT, MRI and CT, which makes ¹⁸F-FLT PET-CT more advantageous for the clinical delineation of the target volume in NPC.

Evaluation of acute esophageal radiation-induced damage using magnetic resonance imaging: a feasibility study in mice

BACKGROUND

Thoracic and head and neck cancer radiation therapy (RT) can cause damage to nearby healthy organs such as the esophagus, causing acute radiation-induced esophageal damage (ARIED). A non-invasive method to detect and monitor ARIED can facilitate optimizing RT to avoid ARIED while improving local tumor control. Current clinical guidelines are limited to scoring the esophageal damage based on the symptoms of patients. Magnetic resonance imaging (MRI) is a non-invasive imaging modality that may potentially visualize radiation-induced organ damage. We investigated the feasibility of using T2-weighted MRI to detect and monitor ARIED using a two-phased study in mice.

METHODS

The first phase aimed to establish the optimal dose level at which ARIED is inducible and to determine the time points where ARIED is detectable. Twenty four mice received a single dose delivery of 20 and 40 Gy at proximal and distal spots of 10.0 mm (in diameter) on the esophagus. Mice underwent MRI and histopathology analysis with esophageal resection at two, three, and 4 weeks post-irradiation, or earlier in case mice had to be euthanized due to humane endpoints. In the second phase, 32 mice received a 40 Gy single dose and were studied at two, three, and 7 days post-irradiation. We detected ARIED as a change in signal intensity of the MRI images. We measured the width of the hyperintense area around the esophagus in all mice that underwent MRI prior to and after irradiation. We conducted a blind qualitative comparison between MRI findings and histopathology as the gold standard.

RESULTS/CONCLUSIONS

A dose of 40 Gy was needed to induce substantial ARIED. MRI detected ARIED as high signal intensity, visible from 2 days post-irradiation. Quantitative MRI analysis showed that the hyperintense area around the esophagus with severe ARIED was 1.41 mm wider than with no damage and MRI-only mice. The overall sensitivity and specificity were 56 and 43% respectively to detect any form of ARIED. However, in this study MRI correctly detected 100% of severe ARIED cases. Our two-phased preclinical study showed that MRI has the potential to detect ARIED as a change in signal intensity and width of enhancement around the esophagus.

Spectral Computed Tomography for the Quantitative Assessment of Patients With Carcinoma of the Gastroesophageal Junction: Initial Differentiation Between a Diagnosis of Squamous Cell Carcinoma and Adenocarcinoma

OBJECTIVE

This study aimed to distinguish between esophageal squamous cell carcinoma (ESCC) and esophageal adenocarcinoma (EAC) using spectral computed tomography (CT) and to discuss the accuracy according to an optimal threshold of single and combined parameters.

METHODS

In this monoinstitution study, 61 patients, 35 of whom had ESCC and 26 had EAC confirmed by surgery or esophagoscopy, were recruited from August 2016 to March 2017. Enrolled patients underwent dual-phase chest CT enhancement. The spectral CT parameters (NIC, NICD, NICratio, Zeff, Zeff-C, K40-70 keV, K80-100 keV, and K110-140 keV) were measured during arterial phase (AP) and venous phase (VP). Binary logistic regression was used to calculate combined predictive probability. Thresholds of quantitative parameters and diagnostic accuracy were calculated using receiver operating characteristic curve.

RESULTS

Compared with ESCC, higher NICAP, NICVP, NICD, Zeff AP, Zeff VP, Zeff-C AP, and Zeff-C VP were observed for EAC, whereas NICratio was lower for EAC. Higher K40-70 keV, K80-100 keV, and K110-140 keV were exhibited in EAC than in ESCC. Area under the curve (AUC) of NICAP, K40-70 keV AP, and Zeff AP were 0.720, 0.730, and 0.706, respectively. The area under the curve of new combined predictive value of NICAP and λ40-0 keV AP was 0.804. The sensitivity and specificity were 77.80% and 80.60%, respectively, when the threshold of new predictive value was 0.60.

CONCLUSION

The diagnostic accuracy obtained by using NICAP and K40-70 keV AP combined is better than that obtained using a single parameter in differentiation between a diagnosis of squamous cell carcinoma and adenocarcinoma.

Is there association of gross tumor volume of adenocarcinoma of oesophagogastric junction measured on magnetic resonance imaging with N stage?

PURPOSE

To determine whether gross tumour volume (GTV) of adenocarcinoma of oesophagogastric junction (AOG) measured on fat-suppression T2-weighted imaging (FS-T2WI) and diffusion-weighted imaging (DWI) correlates with regional lymph node metastasis and N stage.

MATERIALS AND METHODS

The study was approved by the institutional ethics committee, and written informed consent was obtained. Forty-six patients with AOG underwent preoperative magnetic resonance scans including FS-T2WI and DWI with b-values of 500 and 800 s/mm2. GTV was measured on FS-T2WI and DWI. Statistical analyses were performed to determine association of GTV with N stage.

RESULTS

Univariate analysis showed GTV measured on FS-T2WI and DWI with b-values of 500 and 800 s/mm2 were correlated with lymph node metastasis (all Ps < 0.05). Spearman rank correlation tests demonstrated a trend toward an increase in GTV obtained on previous sequences with increasing N stage (r = 0.578 to 0.591, all Ps < 0.001). Mann-Whitney U tests showed GTV obtained on previous sequences could distinguish grouped N stages (all Ps < 0.05). Receiver operating curve analyses demonstrated that GTV obtained on FS-T2WI and DWI with b-value of 500 s/mm2 and DWI with b-value of 800 s/mm2 might differentiate stage N0 from stages N1-3 (cutoff, 19.70 cm3, 16.70 cm3 and 12.24 cm3, respectively), stages N0-1 from N2-3 (cutoff: 22.16 cm3, 17.54 cm3 and 14.17 cm3, respectively), stages N0-2 from N3 (cutoff: 25.57 cm3, 29.27 cm3 and 22.73 cm3, respectively).

CONCLUSION

There is a trend toward an increase in GTV obtained on FS-T2WI and DWI sequences with increasing N stage.

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).

Esophageal disease in Shantou area: an analysis of 1476 cases

AIM: To explore the incidence, prevention and treatment of esophageal diseases in Shantou residents.

METHODS: We retrospectively analyzed the data (e.g. gastroscopic findings, pathological results, imaging manifestations and surgical treatments) of 1476 patients endoscopically diagnosed with esophageal diseases.

RESULTS: Of the 1476 cases, 714 were diagnosed with esophageal cancer, 455 with esophagitis, 120 with esophageal varices, 85 with benign esophageal stenosis, 46 with esophageal mucosal laceration, 34 with esophageal foreign bodies, 23 with esophageal diverticulum, 6 with esophageal polyps, and 3 with esophageal achalasia. Conservative treatment was performed in 840 cases; endoscopic treatment was used in 124 cases; surgical treatment was achieved in 512 cases. Of the 714 patients with esophageal cancer, 218 cases (152 received operation and 66 with non-surgical treatment) were followed up, and the 1- and 3-year death rates of those with operation or non-operation were 40% and 90%, or 95% and 100%, respectively. Of the cases with esophagitis, 150 recovered while 10 died.

CONCLUSION: Esophagitis and esophageal cancer constitute the majority of esophageal diseases. The incidence of esophageal cancer is relatively high in this region, and residents should strengthen the sense of prevention.

[Radiological imaging of the upper gastrointestinal tract. Part 1. The esophagus]

In the diagnosis of diseases of the esophagus, conventional x-ray evaluation still plays a more important role than endoscopy in the visualization of stenoses. CT plays a major role in the staging of malignancies of the esophagus, while MRI plays does not play a major part in the diagnostic evaluation of the upper GI-tract but is equal to CT for the staging and evaluation of the extent of local infiltration. The main indication for the radiological examination of the esophagus by barium studies is dysphagia. The use of barium allows a functional examination of esophageal motility. Swallow motility disorders can be diagnosed by videofluorography using high frame rate imaging. Zenker's diverticulum and other pulsion diverticula should also be investigated by functional esophageal imaging. Candida esophagitis can be identified by its characteristic ulcerations using barium swallow. The extension of gastroesophageal hernias are more accurately evaluated with barium studies than with endoscopy. The diagnosis of gastroesophageal reflux disease should be made by barium studies, but discrete inflammation as well as epithelial dysplasia are best investigated by classic endoscopy and modern endoscopic techniques. In cases of esophageal carcinoma, radiology adds to the findings of endoscopy and endosonography.

h-Prune is an independent prognostic marker for survival in esophageal squamous cell carcinoma

BACKGROUND

The human homologue of Drosophila prune (PRUNE, which encodes h-prune) protein interacts with glycogen synthase kinase 3 and promotes cell motility. The aim of our study was to investigate the impact of immunohistochemically detected h-prune expression on the survival of patients with esophageal squamous cell carcinoma (ESCC).

METHODS

Immunohistochemical staining of h-prune was performed for 205 surgically resected specimens of ESCC.

RESULTS

In total, 43 (21%) of 205 ESCC cases were positive for h-prune. h-prune-positive ESCC cases showed a more-advanced T stage (P < 0.0001), N stage (P < 0.0001), and tumor stage (P < 0.0001) than h-prune-negative ESCC cases. In the group of 116 stage II and III ESCC cases, recurrence of ESCC was frequently found in h-prune-positive cases. In patients with lung recurrence, the tumors were more likely to be h-prune positive than h-prune negative. Univariate analysis revealed that T stage (P < 0.0001), N stage (P < 0.0001), tumor stage (P < 0.0001), and h-prune staining (P < 0.0001) were significant prognostic factors for survival. Multivariate analysis indicated that N stage (P = 0.0182) and h-prune staining (P < 0.0001) were independent predictors for survival.

CONCLUSIONS

These results indicate that immunostaining of h-prune is useful to identify patients at high risk for recurrence or poor prognosis associated with ESCC.

[MRI of esophagus. N staging and more...]

Esophageal disease is common. Fluoroscopy with or without fast cine-sequences is able to depict swallowing dynamics precisely and therefore is used in cases with swallowing disturbance, achalasia or diverticula etc. It is performed in addition to primary endoscopy. There is no evidence based indication for MRI in these settings as it is not to rule out post-surgical fistula and incompetence. Endoscopy and endosonography are gold standard for the depiction as well as staging of esophageal tumors hence differentiation of the esophageal wall layers and detection of suspicious lymph nodes is possible. And from both, biopsies may be taken. New techniques as OCT (optical coherence tomography) can demonstrate in situ carcinoma and therefore helps to decide for limited treatments as mucosectomy. For today multimodular treatment strategies in esophageal carcinoma the T-stage will lead to the treatment decision whereas the nodal-stage will give information about the prognosis. As a matter of fact endoscopy is unable to pass a stenosis esophageal tumor in up to 50% of the cases and will therefore not be able to give precise information on both T- and N-stage resulting in a good indication for MRI. Fetal MRI of the chest is a new topic in which MRI seems to be superior to ultrasonography.

Preoperative staging of esophageal carcinoma with multidetector CT and virtual endoscopy

PURPOSE

The aim of this study was to assess the accuracy of multidetector computed tomography (MDCT), including virtual endoscopy (VE) for detection, precise localization, preoperative evaluation and staging of esophageal cancer (EC) by comparison with surgical and histopathological findings.

MATERIALS AND METHODS

Between September 2003 and April 2005, 44 patients with histologically proven EC underwent MDCT and VE. Among 44 patients, the findings were confirmed in 24 at surgery. The accuracy of three-dimensional MDCT for detection, localization, and staging of EC was determined, and compared with surgical finding and histopathology.

RESULTS

The overall accuracy of three-dimensional multidetector row CT for detection of EC was 100% (24/24). MDCT staging was correct in 20 patients (83.3%). The T parameter was correctly assessed in 22 (91.7%) cases (understaged in 1 and overstaged in 1). The N parameter was correctly evaluated in 20 (83.4%) patients (understaged in 2 and overstaged in 2). The overall accuracy of VE for the morphologic classification of EC was 81.5%.

CONCLUSIONS

Three-dimensional MDCT, along with VE is a promising method for preoperative evaluation and staging of EC. Although accuracy in N staging remains low in comparison to PET, it provides a larger amount of diagnostic and staging information.

Whole-body MR imaging of bone marrow

In clinical routine, multimodality algorithms, including X-ray, computed tomography, scintigraphy and MRI, are used in case of suspected bone marrow malignancy. Skeletal scintigraphy is widely used to asses metastatic disease to the bone, CT is the technique of choice to assess criteria of osseous destruction and bone stability. MRI is the only imaging technique that allows direct visualization of bone marrow and its components with high spatial resolution. The combination of unenhanced T1-weighted-spin echo- and turbo-STIR-sequences have shown to be most useful for the detection of bone marrow abnormalities and are able to discriminate benign from malignant bone marrow changes. Originally, whole-body MRI bone marrow screening was performed in sequential scanning techniques of five body levels with time consuming coil rearrangement and repositioning of the patient. The introduction of a rolling platform mounted on top of a conventional MRI examination table facilitated whole-body MR imaging and, with the use of fast gradient echo, T1-weighted and STIR-imaging techniques, for the first time allowed whole-body imaging within less than one hour. With the development of parallel imaging techniques (PAT) in combination with global matrix coil concepts, acquisition time could be reduced substantially without compromises in spatial resolution, enabling the implementation of more complex and flexible examination protocols. Whole-body MRI represents a new alternative to the stepwise multimodality concept for the detection of metastatic disease, multiple myeloma and lymphoma of the bone with high diagnostic accuracy.

Unbiased estimation of tumor regression rates during chemoradiotherapy for esophageal carcinoma using CT and stereology

SUMMARY. The purpose of the present study is to estimate tumor volumes of 10 patients with esophageal carcinoma on serial CT images that are obtained before and after chemoradiotherapy using a stereological method. In this study, tumor volume was measured using the Cavalieri method of modern design stereology with a combination of three separate stages. Firstly, detailed systematic series of axial CT images of 1-cm thickness were obtained throughout the whole tumor area of each subject and to magnify them all CT images were projected on a screen by overhead projector and then were marked by manually tracing the outline of areas with tumor on serial CT images that are projected onto the screen. Secondly these images were drawn on paper. Finally the images on paper were evaluated with a point-counting method. It was shown in a pilot study analyzed that 100 test points counted on about 6--8 serial slices through for esophagus wall, lumen and wall + lumen are sufficient to secure coefficient of error (CE) on the estimates of volumes as in this study. It was found that tumor volumes before and after radiotherapy for esophagus wall, lumen and wall + lumen was 10.34 cm(3), 1.15 cm(3) and 11.75 cm(3) before and 5.93 cm(3), 1.43 cm(3) and 7.65 cm(3) after radiotherapy, respectively. When only esophagus wall and lumen volumes or wall + lumen volumes before and after radiotherapy were statistically compared, the difference between either esophagus wall (P<0.01) and lumen (P<0.01) volumes or total volumes (P<.1) were significant. It is concluded that CT estimated tumor volumes may be helpful in both evaluating the clinical situation of patients and providing a simple index to assess the efficiency of therapy, prediction of tumor regression rate and minimizing the risk of chemoradiotherapy damage.