Endoscopic ultrasound in gastric cancer staging before and after neoadjuvant chemotherapy. A comparison with PET-CT in a clinical series

Comprehensive evaluation of tumor response better evaluates the efficacy of neoadjuvant chemotherapy and predicts the prognosis in gastric cancer - a post hoc analysis of a single-center randomized controlled trial

BACKGROUND

Perioperative chemotherapy combined with D2 radical gastrectomy has been proven to be the standard treatment for local advanced gastric cancer. However, tumor regression grading (TRG) is the only neoadjuvant chemotherapy (NACT) response evaluation criterion recommended by the NCCN guideline for gastric cancer (GC). Given TRG's limitations, we aim to explore a better comprehensive response evaluation method in this study.

METHODS

Clinical information of 96 GC patients who received NACT was collected prospectively. Clinicopathological variables predictive of the response to NACT were identified by comparing the pre- and post-NACT examination results. The correlations between the response mode and long-term survival rate were assessed.

RESULTS

Univariate Cox regression analysis showed that CT-based evaluation of the primary lesion thickness (CT-thickness) and tumor markers (TMs) were significantly associated with prognosis. The comprehensive evaluation method, including CT-thickness, TRG, and TMs, was constructed and proved to have a higher Harrell's C index. Significant differences in overall survival (OS) and recurrence-free survival (RFS) were observed between responders and non-responders distinguished by the comprehensive evaluation method.

CONCLUSIONS

The combination of CT-thickness, TRG, and TMs could be used to construct a pragmatic NACT efficacy evaluation method with both high sensitivity and specificity, which could facilitate clinical decision-making, NACT-related clinical research conduction, and efficacy predictive biomarker exploration.

FAP-targeted PET/CT imaging in patients with breast cancer from a prospective bi-center study: insights into diagnosis and clinic management

PURPOSE

To evaluate the diagnostic accuracy and clinical impact of fibroblast activation protein (FAP)-targeted PET/CT imaging in primary and metastatic breast cancer and compare the results with those of standard-of-care imaging (SCI) and [18F]FDG PET/CT.

METHODS

We prospectively analyzed patients with diagnosed or suspected breast cancer who underwent concomitant FAP-targeted PET/CT (radiotracers including either [68Ga]Ga-FAPI-46 or [18F]FAPI-42) and [18F]FDG PET/CT scans from June 2020 to January 2024 at two medical centers. Breast ultrasound (US) imaging was performed in all treatment-naïve patients as SCI. The SUVmax, tumor-to-background ratio (TBR), lesion detection rate, and tumor-node-metastasis (TNM) classifications between FAP-targeted and [18F]FDG PET/CT were evaluated and compared.

RESULTS

Sixty-one female patients (median age, 52 y; range, 28-82 y) were included. Among them, 23 patients underwent evaluation for a definitive diagnosis of suspected breast lesions, 15 underwent initial staging, and 23 were evaluated for the detection of recurrence. The sensitivities of breast US, [18F]FDG, and FAP-targeted PET/CT for detecting primary breast tumors were 82%, 79%, and 100%, respectively. Regarding the diagnosis of recurrent/metastatic lesions, the lesion-based detection rate of FAP-targeted PET/CT was significantly higher than that of [18F]FDG, which included local and regional recurrence, neck lymph node (LN), abdomen LN, bone, and liver metastases. Compared with [18F]FDG PET/CT, FAP-targeted PET/CT altered thirteen patients' TNM staging/restaging (13/59, 22%) and nine patients' clinical management (9/59, 15%). Compared to SCI, FAPI changed fourteen patients' TNM staging/re-staging (14/59, 24%) and eleven patients' therapeutic regimens(11/59, 19%). There was no significant association between FAPI-derived SUVmax and receptor status/histologic type in both primary and metastatic lesions.

CONCLUSION

FAP-targeted PET/CT was superior to [18F]FDG in diagnosing primary and metastatic breast cancer, with higher radiotracer uptake and TBR, especially in the detection of primary/recurrent tumors, abdominal LN metastases, liver, and bone metastases. FAP-targeted PET/CT is superior to [18F]FDG and SCI in TNM staging and may improve tumor staging, recurrence detection, and implementation of necessary treatment modifications.

Advances in Diagnostic, Staging, and Restaging Evaluation of Esophageal and Gastric Cancer

The initial endoscopic and staging evaluation of esophagogastric cancers must be accurate and comprehensive in order to select the optimal therapeutic plan for the patient. Esophageal and gastric cancers (and treatment paradigms) are delineated by their proximity to the cardia (within 2 cm). The most frequent and important symptom that informs the initial staging evaluation is dysphagia, which is associated with at least cT3 or locally advanced disease. Endoscopic ultrasound is often needed if earlier stage disease is suspected, preferably in combination with endoscopic mucosal or submucosal resection or fine-needle aspiration of suspicious lymph nodes to enhance staging accuracy.

18F-FAPI PET/CT performs better in evaluating mediastinal and hilar lymph nodes in patients with lung cancer: comparison with 18F-FDG PET/CT

BACKGROUND

The aim of this study was to evaluate the efficacy of fluorine 18 (18F) labeled fibroblast activation protein inhibitor (FAPI) in identifying mediastinal and hilar lymph node metastases and to develop a model to quantitatively and repeatedly identify lymph node status.

METHODS

Twenty-seven patients with 137 lymph nodes were identified by two PET/CT images. The sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) of lymph node status were analyzed, and the optimal cut-off value was identified by ROC analysis.

RESULTS

The SUVmax of metastatic lymph nodes on 18F-FAPI was higher than that on 18F-FDG PET/CT (10.87 ± 7.29 vs 6.08 ± 5.37, p < 0.001). 18F-FAPI presented much greater lymph node detection sensitivity, specificity, accuracy, PPV and NPV than 18F-FDG PET/CT (84% vs. 71%; 92% vs. 67%; 90% vs. 69%, 84% vs. 52%, and 92% vs. 83%, respectively). Additionally, the diagnostic effectiveness of 18F-FAPI in small lymph nodes was greater than that of 18F-FDG PET/CT (specificity: 96% vs. 72%; accuracy: 93% vs. 73%; PPV: 77% vs. 33%, respectively). Notably, the optimal cut-off value for specificity and PPV of 18F-FAPI SUVmax was 5.3; the optimal cut-off value for sensitivity and NPV was 2.5.

CONCLUSION

18F-FAPI showed promising diagnostic efficacy in metastatic mediastinal and hilar lymph nodes from lung cancer patients, with a higher SUVmax, especially in small metastatic nodes, compared with 18F-FDG. In addition, this exploratory work recommended optimal SUVmax cutoff values to distinguish between nonmetastatic and metastatic lymph nodes, thereby advancing the development of image-guided radiation. Trial registration ClinicalTrials.gov identifier: ChiCTR2000036091.

Imaging advances in efficacy assessment of gastric cancer neoadjuvant chemotherapy

Effective neoadjuvant chemotherapy (NAC) can improve the survival of patients with locally progressive gastric cancer, but chemotherapeutics do not always exhibit good efficacy in all patients. Therefore, accurate preoperative evaluation of the effect of neoadjuvant therapy and the appropriate selection of surgery time to minimize toxicity and complications while prolonging patient survival are key issues that need to be addressed. This paper reviews the role of three imaging methods, morphological, functional, radiomics, and artificial intelligence (AI)-based imaging, in evaluating NAC pathological reactions for gastric cancer. In addition, the advantages and disadvantages of each method and the future application prospects are discussed.

Superiority of FAPI-PET/CT for examining multiple malignant tumors: a retrospective study

To compare the diagnostic value of [18F]-AlF-NOTA-FAPI-04 PET/CT and [18F]-FDG PET/CT for primary and metastatic lesions in different types of tumors. A retrospective analysis was conducted on 51 patients with 11 different types of tumors. Among them, 20 patients underwent PET/CT, and 31 patients underwent restaging. The patients were diagnosed using [18F]-AlF-NOTA-FAPI-04 PET/CT and [18F]-FDG PET/CT scan techniques, and adverse reactions were recorded. Thickness of primary lesions, metastasis, and lymph node involvement were analyzed and confirmed by histological analysis. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of [18F]-AlF-NOTA-FAPI-04 PET/CT and [18F]-FDG PET/CT were calculated. Neither [18F]-AlF-NOTA-FAPI-04 PET/CT nor [18F]-FDG PET/CT scan techniques caused adverse reactions in the patients. [18F]-AlF-NOTA-FAPI-04 PET/CT performed well in detecting recurrence, with a positive rate of 100%, higher than 71.0% of [18F]-FDG PET/CT. Compared with [18F]-FDG PET/CT, [18F]-AlF-NOTA-FAPI-04 PET/CT identified 6 types of malignant tumors more clearly, and could improve the detection rate of primary and metastatic tumors (97.0% vs. 84.8%, P<0.001). [18F]-AlF-NOTA-FAPI-04 PET/CT exhibited a higher sensitivity for detecting lymph node (81.8% vs. 50.0%, P<0.05) than [18F]-FDG PET/CT. Additionally, [18F]-AlF-NOTA-FAPI-04 PET/CT demonstrated higher diagnostic sensitivity (67.39% vs. 58.7%, P=0.387) and accuracy (82.14% vs. 60.71%, P=0.377) for detecting metastatic lesions compared to [18F]-FDG PET/CT. [18F]-AlF-NOTA-FAPI-04 PET/CT outperforms [18F]-FDG PET/CT in diagnosing primary and metastatic lesions across various types of tumors, especially in identifying lymph node, visceral, and peritoneal metastases. It can improve diagnostic efficiency and accuracy, thereby positively influencing clinical decision-making for optimal patient management.

Contrast-enhanced endoscopic ultrasound for swollen lymph nodes

Endoscopic ultrasound (EUS) is an important tool for the evaluation of lymphadenopathy, especially in intra-thoracic or intra-abdominal regions. EUS also provides tissue diagnosis via EUS fine-needle aspiration or biopsy. To select the target for biopsy or aspiration, conventional B-mode images are used for the evaluation, but this approach still lacks diagnostic accuracy. Contrast-enhanced EUS has been used to evaluate the vascularity of lesions. Most malignant lymphadenopathy shows heterogenous enhancement or defect of enhancement, while quantitative studies using time-intensity curves in contrast-enhanced harmonic EUS show a rapid decline in enhancement pattern. These findings are useful as an auxiliary method for tissue diagnosis or in cases in which tissue diagnosis is contraindicated.

What radiolabeled FAPI pet can add in breast cancer? A systematic review from literature

To provide an overview of the current available data about FAPI PET in breast cancer patients, with a perspective point of view. A literature search for studies about FAPI PET in the last 5 years (from 2017 to January 2023) was carried out on MEDLINE databases, such as PubMed, EMBASE, Web of Science and Google Scholar using the following keywords: "PET" AND "FAPI" AND "Breast Cancer" AND "Fibroblast imaging". The Critical Appraisal Skills Program (CASP) checklist for diagnostic test studies was used for testing the quality of selected papers. 13 articles were selected, including 172 patients affected by breast cancer who underwent FAPI-based PET images. CASP checklist was used in 5/13 papers, demonstrating a general low quality. Different types of FAPI-based tracers were used. No difference in terms of FAPI uptake was reported based on the histopathological characteristics, such as immunohistochemistry and grading of breast cancer. FAPI demonstrated more lesions and yielded much higher tumor-to-background ratios than 2-[18F]FDG. Preliminary experiences with FAPI PET in breast cancer showed some advantages than the current available 2-[18F]FDG, although prospective trials are needed to further evaluate its diagnostic utility in clinical practice.

Preoperative EUS vs. PET-CT Evaluation of Response to Neoadjuvant Therapy for Esophagogastric Cancer and Its Correlation with Survival

BACKGROUND

The objective of our study was to investigate whether Endoscopic Ultrasonography (EUS) and Positron Emission Tomography-Computed Tomography (PET-CT) restaging can predict survival in upper gastrointestinal tract adenocarcinomas and to assess their accuracy when compared to pathology.

METHODS

We conducted a retrospective study on all patients who underwent EUS for staging of gastric or esophago-gastric junction adenocarcinoma between 2010 and 2021. EUS and PET-CT were performed, and preoperative TNM restaging was conducted using both procedures within 21 days prior to surgery. Disease-free survival (DFS) and overall survival (OS) were evaluated.

RESULTS

A total of 185 patients (74.7% male) were included in the study. The accuracy of EUS for distinguishing between T1-T2 and T3-T4 tumors after neoadjuvant therapy was 66.7% (95% CI: 50.3-77.8%), and for N staging, the accuracy was 70.8% (95% CI: 51.8-81.8%). Regarding PET-CT, the accuracy for N positivity was 60.4% (95% CI: 46.3-73%). Kaplan-Meier analysis revealed a significant correlation between positive lymph nodes on restaging EUS and PET-CT with DFS. Multivariate COX regression analysis identified N restaging with EUS and PET-CT, as well as the Charlson comorbidity index, as correlated factors with DFS. Positive lymph nodes on EUS and PET-CT were predictors of OS. In multivariate Cox regression analysis, the independent risk factors for OS were found to be the Charlson comorbidity index, T response by EUS, and male sex.

CONCLUSION

Both EUS and PET-CT are valuable tools for determining the preoperative stage of esophago-gastric cancer. Both techniques can predict survival, with preoperative N staging and response to neoadjuvant therapy assessed by EUS being the main predictors.

Advances in Imaging of Inflammation, Fibrosis, and Cancer in the Gastrointestinal Tract

Gastrointestinal disease is prevalent and broad, manifesting itself in a variety of ways, including inflammation, fibrosis, infection, and cancer. However, historically, diagnostic technologies have exhibited limitations, especially with regard to diagnostic uncertainty. Despite development of newly emerging technologies such as optoacoustic imaging, many recent advancements have focused on improving upon pre-existing modalities such as ultrasound, computed tomography, magnetic resonance imaging, and endoscopy. These advancements include utilization of machine learning models, biomarkers, new technological applications such as diffusion weighted imaging, and new techniques such as transrectal ultrasound. This review discusses assessment of disease processes using imaging strategies for the detection and monitoring of inflammation, fibrosis, and cancer in the context of gastrointestinal disease. Specifically, we include ulcerative colitis, Crohn's disease, diverticulitis, celiac disease, graft vs. host disease, intestinal fibrosis, colorectal stricture, gastric cancer, and colorectal cancer. We address some of the most recent and promising advancements for improvement of gastrointestinal imaging, including unique discussions of such advancements with regard to imaging of fibrosis and differentiation between similar disease processes.

Predictive Value of Preoperative Endoscopic Ultrasound (EUS) After Neoadjuvant Chemotherapy in Locally Advanced Esophagogastric Cancer - Data From a Randomized German Phase II Trial

PURPOSE

The role of EUS before or after neoadjuvant chemotherapy (nCTX) in advanced esophagogastric cancer (EGC) is still unclear. The phase II NEOPECX trial evaluated perioperative chemotherapy with or without panitumumab in this setting. The aim of this sub-study was to investigate the prognostic value of EUS-guided preoperative staging before and after nCTX.

MATERIALS AND METHODS

Preoperative yuT/yuN stages by EUS were compared with histopathological ypT/ypN stages after curative resection. Reduction in T-stage from baseline to preoperative EUS was defined as downstaging (DS+) and compared to progression-free (PFS) and overall survival (OS) of patients without downstaging (DS-). In addition, preoperative EUS N-stages (positive N+ or negative N-) were correlated with clinical data.

RESULTS

The preoperative yuT-stage correlated with the ypT-stage in 48% of cases (sensitivity 48%, specificity 52%), while the preoperative yuN-stage correlated with the ypN-stage in 64% (sensitivity 76%, specificity 52%). Within DS+ patients who were downstaged by ≥ 2 T-categories, a trend towards improved OS was detected (median OS DS+: not reached (NR), median OS DS-: 38.5 months (M), p=0.21). Patients with yuN+ at preoperative EUS had a worse outcome than yuN- patients (median OS yuN-: NR, median OS yuN+: 38.5 M, p = 0.013).

CONCLUSION

The diagnostic accuracy of EUS to predict the response after nCTX in patients with advanced EGC is limited. In the current study the endosonographic detection of lymph node metastasis after nCTX indicates a poor prognosis. In the future, preoperative EUS with sectional imaging procedures may be used to tailor treatment for patients with advanced EGC.

Current and future imaging modalities in gastric cancer

Gastric adenocarcinoma treatment can include endoscopic mucosal resection, surgery, chemotherapy, radiation, and palliative measures depending on staging. Both invasive and noninvasive staging techniques have been used to dictate the best treatment pathway. Here, we review the current imaging modalities used in gastric cancer as well as novel techniques to accurately stage and screen these patients.

ENDOSCOPIC CHARACTERISTICS OF PATIENTS WITH COMPLETE PATHOLOGICAL RESPONSE AFTER NEOADJUVANT CHEMOTHERAPY FOR GASTRIC AND ESOPHAGOGASTRIC JUNCTION ADENOCARCINOMAS

Background:

Gastric and esophagogastric junction adenocarcinoma are responsible for approximately 13.5% of cancer-related deaths. Given the fact that these tumors are not typically detected until they are already in the advanced stages, neoadjuvancy plays a fundamental role in improving long-term survival. Identification of those with complete pathological response (pCR) after neoadjuvant chemotherapy (NAC) is a major challenge, with effects on organ preservation, extent of resection, and additional surgery. There is little or no information in the literature about which endoscopic signs should be evaluated after NAC, or even when such re-evaluation should occur.

Aim:

To describe the endoscopic aspects of patients with gastric and esophagogastric junction adenocarcinomas who underwent NAC and achieved pCR, and to determine the accuracy of esophagogastroduodenoscopy (EGD) in predicting the pCR.

Methods:

A survey was conducted of the medical records of patients with these tumors who were submitted to gastrectomy after NAC, with anatomopathological result of pCR.

Results:

Twenty-nine patients were identified who achieved pCR after NAC within the study period. Endoscopic responses were used to classify patients into two groups: G1-endoscopic findings consistent with pCR and G2-endoscopic findings not consistent with pCR. Endoscopic evaluation in G1 was present in an equal percentage (47.4%; p=0.28) in Borrmann classification II and III. In this group, the predominance was in the gastric body (57.9%; p=0.14), intestinal subtype with 42.1% (p=0.75), undifferentiated degree, 62.5% (p=0.78), Herb+ in 73.3% (p=0.68). The most significant finding, however, was that the time interval between NAC and EGD was longer for G1 than G2 (24.4 vs. 10.2 days, p=0.008).

Conclusion:

EGD after NAC seems to be a useful tool for predicting pCR, and it may be possible to use it to create a reliable response classification. In addition, the time interval between NAC and EGD appears to significantly influence the predictive power of endoscopy for pCR.

Diagnostic Value of Endoscopic Ultrasound after Neoadjuvant Chemotherapy for Gastric Cancer Restaging: A Meta-Analysis of Diagnostic Test

This study aimed to evaluate the diagnostic value of endoscopic ultrasound (EUS) after neoadjuvant therapy (NT) for gastric cancer restaging by meta-analysis. We conducted a systematic search of studies published on PubMed and Web of Science up to 30th August 2021. Assessing the risk of bias in the included studies was done with the QUADAS-2 tool. We used R and Review Manager 5.4.1 for calculations and statistical analysis. To evaluate the diagnostic value of EUS after NT for gastric cancer restaging, we performed a meta-analysis on six studies, with a total of 283 patients, including true-positive, true-negative, false-positive, and false-negative results for T1-T4, N0. EUS as a diagnostic test for GC patients after chemotherapy has a relatively low DOR for the T2 (3.96) and T4 stages (4.79) and a relatively high partial AUC for the T2 (0.85) and T4 (0.71) stages. Our results reveal that the pooled sensitivity for T stages after chemotherapy is rather low (29–56%), except for the T3 stage (71%). A potential limitation of our study was the small number of included studies, but no significant heterogeneity was found between them. Our meta-analysis concludes that EUS is not recommended or is still under debate for GC restaging after NT.

The Added Value of 68Ga-FAPI-04 PET/CT in Patients with Head and Neck Cancer of Unknown Primary with 18F-FDG Negative Findings

¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) positron emission tomography/computed tomography (PET/CT) plays an important role in locating of primary tumor for patients with head and neck cancer of unknown primary (HNCUP). Nevertheless, it can be challenging to locate the primary malignancy in ¹⁸F-FDG-PET/CT scan in some cases. As ⁶⁸Ga-radiolabeled fibroblast activation protein inhibitor (FAPI) PET/CT has promising results in detecting different tumor entities, our study aimed to evaluate the performance of ⁶⁸Ga-FAPI-PET/CT for detecting the primary tumor in HNCUP patients with negative ¹⁸F-FDG findings. Methods: A total of eighteen patients (16 males and 2 females; median age, 55 years; range, 24-72 years) with negative ¹⁸F-FDG findings were enrolled in this study. All patients underwent ¹⁸F-FDG and ⁶⁸Ga-FAPI-PET/CT within one week. Biopsy and histopathological examinations were done in the sites with positive ⁶⁸Ga-FAPI-PET/CT findings. Results: ⁶⁸Ga-FAPI-PET/CT detected the primary tumor in 7 out of 18 patients (38.89%). Among the 7 patients, in respect of the primary tumor sites, 1 was in nasopharynx, 2 were in palatine tonsil, 2 were in submandibular gland, and 2 were in hypopharynx. The primary tumors showed moderate to intensive uptake of FAPI (mean SUV_max, 8.79; range, 2.60-16.50) and excellent tumor-to-contralateral normal tissue ratio (mean SUV_max ratio, 4.50; range, 2.17-8.21). In lesion-based analysis, a total of 65 lymph nodes and 17 bone metastatic lesions were identified. The mean SUV_max of lymph node metastases were 9.05 ± 5.29 for FDG and 9.08 ± 4.69 for FAPI (P = 0.975); as for bone metastases, the mean SUV_max were 8.11 ± 3.00 for FDG and 6.96 ± 5.87 for FAPI, respectively (P = 0.478). The mean tumor-to-background ratio (TBR) values of lymph node and bone metastases were 10.65 ± 6.59 vs. 12.80 ± 8.11 (P = 0.100) and 9.08 ± 3.35 vs. 9.14 ± 8.40 (P = 0.976), respectively. Conclusion: We presented first evidence of diagnostic role of ⁶⁸Ga-FAPI-PET/CT in HNCUP, and our study demonstrated that ⁶⁸Ga-FAPI-PET/CT had the potential to improve the detection rate of primary tumor in HNCUP patients with negative FDG findings. Moreover, ⁶⁸Ga-FAPI had similar performance in assessing metastases with ¹⁸F-FDG.

18F-FDG-PET/CT Imaging for Gastrointestinal Malignancies

Gastrointestinal malignancies encompass a variety of primary tumor sites, each with different staging criteria and treatment approaches. In this review we discuss technical aspects of 18F-FDG-PET/CT scanning to optimize information from both the PET and computed tomography components. Specific applications for 18F-FDG-PET/CT are summarized for initial staging and follow-up of the major disease sites, including esophagus, stomach, hepatobiliary system, pancreas, colon, rectum, and anus.

Evaluation of dual time-point fluorodeoxyglucose PET/computed tomography imaging in gastric cancer

BACKGROUND

We aimed to evaluate the efficiency of dual time-point fluorodeoxyglucose (FDG) PET/computed tomography (CT) imaging in detecting primary and metastatic lesions in gastric cancer.

METHODS

Between May 2019 and January 2020, 52 patients with gastric carcinoma were prospectively involved in our study. And dual time-point FDG PET/CT imaging performed to the patients. Of detected primary and metastatic lesions, the ones that are better visualized or only appear in delayed imaging were visually identified. Also, maximum standardized uptake value (SUVmax) of the primary and metastatic lesions and the intact liver tissue were measured in early and delayed imaging. Acquired SUVmax values and SUVmax ratios were compared statistically.

RESULTS

In delayed images, lesions were better visualized in 32 patients (61.5%) and extra lesions were detected in 4 patients (7.7%). SUVmax of primary tumor, SUVmax of liver metastases, SUVmax of lymph node metastases, primary tumor SUVmax/liver SUVmax ratio and lymph node metastasis SUVmax/liver SUVmax ratio were significantly higher in delayed images (P < 0.001, P = 0.022, P < 0.001, P < 0.001, P < 0.001, respectively). However, SUVmax of liver parenchyma was significantly lower in delayed images (P < 0.001).

CONCLUSIONS

There is a visually and statistically significant increase in the number and detectability of lesions seen in delayed images and dual time-point FDG PET/CT imaging seems useful in detecting primary and metastatic lesions in gastric cancer.

Potential survival benefits of open over laparoscopic radical gastrectomy for gastric cancer patients beyond three years after surgery: result from multicenter in-depth analysis based on propensity matching

BACKGROUND

The oncologic efficacy of laparoscopic versus open surgery for advanced distal gastric cancer (ADGC) beyond 3 years after surgery remain obscure.

METHODS

A total of 1256 patients with ADGC at two teaching institutions in China from April 2007 to December 2014 were enrolled. The general data of the two groups were identified to enable rigorous estimation of propensity scores. Restricted mean survival time (RMST) and Landmark analysis was used to compare survival.

RESULTS

After matching 461 patients each in the open distal gastrectomy (ODG) and laparoscopic distal gastrectomy (LDG) groups, they were included into analysis. The 3- and 5-year overall survival (OS) and disease-free survival were comparable in two groups. RMST-stratified analysis showed that the 3-year RMST of ODG group was similar to that of LDG group in patients with cT4a (- 1.38 years, p = 0.163) or with cT4a and tumor size > 5 cm, whereas the 5-year RMST had significant differences between groups in cT4a patients(- 8.36 years, P = 0.005) or cT4a and tumor size > 5 cm patients(4.67 years, P = 0.042). In patients with cT4a and tumors > 5 cm, the number of peritoneal recurrences was significantly fewer in the ODG group than in the LDG group (4 vs. 17, P = 0.033), and the peritoneal recurrence time and multiple-site recurrence time were both later in the ODG group.

CONCLUSION

By reducing recurrence, ODG achieves a better survival for GC patients with serous infiltration and tumors larger than 5 cm beyond 3 years after surgery. The present findings can serve as a reference for surgical options and the setting of follow-up time point for clinical studies.

68Ga-FAPI-04 PET/CT, a new step in breast cancer imaging: a comparative pilot study with the 18F-FDG PET/CT

AIM

We aimed to compare the roles of 68Ga-FAPI-04 PET/CT and 18F-FDG PET/CT in the evaluation of primary tumor and metastases in primary and recurrent breast cancer.

MATERIALS AND METHOD

Twenty female patients with histopathologically confirmed primary and recurrent breast cancer were included in the prospective study. All patients underwent FDG and FAPI PET/CT imaging in the same week. The number of primary and metastatic lesions, SUVmax values, and tumor-to-background ratios (TBR) were recorded from both scans. Data obtained were statistically compared.

RESULTS

FAPI PET/CT was superior to FDG in detecting breast lesions, as well as hepatic, bone, lymph node, and cerebral metastases in terms of patient- and lesion-based assessments. The sensitivity and specificity of FAPI in detecting primary breast lesions were 100% and 95.6%, respectively, while the sensitivity and specificity of FDG were 78.2% and 100%, respectively. The SUVmax values of primary breast tumors, lymph nodes, lung metastases, and bone metastases were significantly higher on FAPI imaging than FDG imaging (p < 0.05). However, SUVmax values of hepatic metastases did not exhibit a statistically significant difference between two imaging techniques (p > 0.05). Also, FAPI imaging yielded significantly higher TBR in breast lesions as well as hepatic, bone, brain and lung metastases compared to FDG (p < 0.05).

CONCLUSION

68 Ga-FAPI-04 PET/CT is superior to 18F-FDG PET/CT in detecting the primary tumor in patients with breast cancer with its high sensitivity, high SUVmax, and high TBR. 68 Ga-FAPI-04 PET/CT is also superior to 18F-FDG PET/CT in detecting lymph node, hepatic, bone, and cerebral metastases because it has lower background activity and higher uptake in subcentimetric lesions.

Epidemiology, Diagnosis, Staging and Multimodal Therapy of Esophageal and Gastric Tumors

Gastric and esophageal tumors are diverse neoplasms that involve mucosal and submucosal tissue layers and include squamous cell carcinomas, adenocarcinomas, spindle cell neoplasms, neuroendocrine tumors, marginal B cell lymphomas, along with less common tumors. The worldwide burden of esophageal and gastric malignancies is significant, with esophageal and gastric cancer representing the ninth and fifth most common cancers, respectively. The approach to diagnosis and staging of these lesions is multimodal and includes a combination of gastrointestinal endoscopy, endoscopic ultrasound, and cross-sectional imaging. Likewise, therapy is multidisciplinary and combines therapeutic endoscopy, surgery, radiotherapy, and systemic chemotherapeutic tools. Future directions for diagnosis of esophageal and gastric malignancies are evolving rapidly and will involve advances in endoscopic and endosonographic techniques including tethered capsules, optical coherence tomography, along with targeted cytologic and serological analyses.

Local Endoscopic Resection is Inferior to Gastrectomy for Early Clinical Stage T1a and T1b Gastric Adenocarcinoma: A Propensity-Matched Study

BACKGROUND

The role of endoscopic resection (ER) in the management of subsets of clinical T1N0 gastric adenocarcinoma remains controversial. The aim of this study was to evaluate the outcome of ER versus gastrectomy in node-negative cT1a and cT1b gastric adenocarcinoma.

METHODS

Data from the National Cancer Database (2010-2015) were used to identify patients with clinical T1aN0 (n = 2927; ER: n = 1157, gastrectomy: n = 1770) and T1bN0 (n = 2915; ER: n = 474, gastrectomy: n = 2441) gastric adenocarcinoma. Propensity score matching and Cox multivariable analyses were used to account for treatment selection bias.

RESULTS

ER for cT1a and cT1b cancers was performed more frequently over time. The rates of node-positive disease in patients with cT1a and cT1b gastric adenocarcinoma were 5% and 18%, respectively. In the matched cohort, gastrectomy was associated with increased survival compared with ER for cT1a cancers (hazard ratio [HR] 0.79, 95% confidence interval [CI] 0.66-0.95; p = 0.013), and corresponding 5-year survival for gastrectomy and ER was 72% and 66%, respectively (p = 0.013). For cT1b cancers, gastrectomy had a significantly longer survival compared with ER (HR 0.77, 95% CI 0.63-0.93; p = 0.008), and the corresponding 5-year survival for gastrectomy and ER was 60% and 50%, respectively (p = 0.013).

CONCLUSION

This study demonstrates ER is inferior in terms of long-term survival for clinical T1aN0 and T1bN0 gastric adenocarcinoma, despite current recommendations for ER in cT1 gastric cancers. Future research should seek to identify the subset of T1a and T1b cancers at low risk of nodal metastasis, and would thus maximally benefit from ER.

Preoperative EUS evaluation of the response to neoadjuvant therapy for gastric and esophagogastric junction cancer is correlated with survival: A single retrospective study of 97 patients

Background and Objectives:

The European Society for Medical Oncology suggests performing EUS staging for esophagogastric junction and gastric cancers to further assess the T and N stages. The use of EUS after neoadjuvant therapy (NT) is still under debate. We aimed to evaluate the contribution of EUS after NT to staging, therapeutic choices, and prognosis prediction.

Subjects and Methods:

In 97 patients with esophagogastric junction and gastric cancers who received NT (chemotherapy or radiochemotherapy) followed by carcinologic surgery, EUS was performed before (uT, uN) and after (yuT, yuN) NT. We compared the results of EUS staging after NT (yuT and yuN) and final histology (ypT and ypN). We analyzed the correlation between overall survival (OS), disease-free survival (DFS), and the objective and subjective responses to NT evaluated by EUS (comparison of uT and yuT and uN and yuN with OS and DFS).

Results:

EUS staging detected metastasis that went undetected by computed tomography in 16% of metastatic patients. The accuracy between EUS after NT and postoperative pathological findings was 44.4% (34.2%; 54.7%) for T stage and 49.3% (37.5%; 61.1%) for N stage. On multivariate analysis, OS had significantly correlated with the objective response to NT. In the case of a response to NT, the median OS was 64.77 months, and in the case of stable disease, the median OS was 22.9 months (P = 0.01).

Conclusion:

EUS after NT can be used for staging. Despite its moderate accuracy, the evaluation of the response to NT by EUS seems to be correlated with patient prognosis.

Endoscopic ultrasound as a diagnostic and predictive tool in idiopathic acute pancreatitis

Background

Endoscopic ultrasound (EUS) is useful in the diagnostic workup of idiopathic acute pancreatitis but its role as a predictor of recurrence has not been thoroughly assessed. Our aim was to study the performance of EUS in idiopathic acute pancreatitis, its impact on the natural history of the disease, and the factors related to recurrence.

Methods

Patients with idiopathic acute pancreatitis referred to our endoscopy unit were enrolled and followed, with assessment of the performance of endoscopic retrograde cholangiopancreatography (ERCP), cholecystectomy, and the incidence of recurrence. EUS findings and recurrence rates were compared between patients with a first episode or recurrent attacks and in patients with previous cholecystectomy versus those with gallbladder in situ.

Results

One hundred six patients were included (mean follow up: 53.59±27.79 months). Biliary disease related to stones was the most common finding on EUS (49.1%), and patients referred for recurrent attacks showed the highest recurrence rate during follow up (57.1%). ERCP or cholecystectomy reduced recurrences to 14.3% in patients with biliary disease. Age under 65 (odds ratio [OR] 3.56, 95% confidence interval [CI] 1.21-10.44; P=0.02), previous cholecystectomy (OR 3.19, 95%CI 1.11-9.17; P=0.03), and no lithiasis on EUS (OR 2.87, 95%CI 1.04-7.87; P=0.04) were independent risks factors for recurrence.

Conclusions

EUS-directed ERCP/cholecystectomy was associated with lower relapse rates in idiopathic acute pancreatitis. Along with age and gallbladder status, it provides predictive information about recurrence likelihood.

Neoadjuvant therapy strategies for advanced gastric cancer: Current innovations and future challenges

Gastric cancer, which has a high incidence and poor prognosis, remains a therapeutic challenge. Recently, neoadjuvant therapy has attracted increasing attention due to high recurrence rate and low survival rate after resection in most patients with advanced stage. Clinical trials show that neoadjuvant approaches confer a significant survival advantage for resectable locally advanced gastric cancer. The specific advantages of chemoradiotherapy compared with chemotherapy have not been clarified; optimal regimens and cycles, particularly in the preoperative setting, should be studied further; and trials aimed at determining the role of targeted and immunological therapies should be conducted.

Comparison of [68Ga]Ga-DOTA-FAPI-04 and [18F] FDG PET/CT for the diagnosis of primary and metastatic lesions in patients with various types of cancer

PURPOSE

We evaluated the potential usefulness of [⁶⁸Ga]Ga-DOTA-FAPI-04 positron emission tomography/computed tomography (PET/CT) for the diagnosis of primary and metastatic lesions in various types of cancer, compared with [¹⁸F] FDG PET/CT.

METHODS

A total of 75 patients with various types of cancer underwent contemporaneous [⁶⁸Ga]Ga-DOTA-FAPI-04 and [¹⁸F] FDG PET/CT either for an initial assessment or for recurrence detection. Tumour uptake was quantified by the maximum standard uptake value (SUV_max). The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy of [¹⁸F] FDG and [⁶⁸Ga]Ga-DOTA-FAPI-04 PET/CT were calculated and compared to evaluate the diagnostic efficacy.

RESULTS

The study cohort consisted of 75 patients (47 males and 28 females; median age, 61.5 years; age range, 32-85 years). Fifty-four patients with 12 different tumour entities underwent paired [⁶⁸Ga]Ga-DOTA-FAPI-04 and [¹⁸F] FDG PET/CT for initial assessment, while the other 21 patients underwent paired scans for recurrence detection. [⁶⁸Ga]Ga-DOTA-FAPI-04 PET/CT was able to clearly identify 12 types of malignant tumours with favourable tumour-to-background contrast, which resulted in a higher detection rate of primary tumours than did [¹⁸F] FDG PET/CT (98.2% vs. 82.1%, P = 0.021). Meanwhile, [⁶⁸Ga]Ga-DOTA-FAPI-04 PET/CT showed a better sensitivity than [¹⁸F] FDG PET/CT in the detection of lymph nodes (86.4% vs. 45.5%, P = 0.004) and bone and visceral metastases (83.8% vs. 59.5%, P = 0.004).

CONCLUSION

[⁶⁸Ga]Ga-DOTA-FAPI-04 PET/CT showed a superior diagnostic efficacy than [¹⁸F] FDG PET/CT for the diagnosis of primary and metastatic lesions in patients with various types of cancer, especially in identifying liver metastases, peritoneal carcinomatosis, and brain tumours.

Accuracy of endoscopic ultrasound in gastric adenocarcinoma patient selection for neoadjuvant therapy

Background

Recent studies demonstrated the positive impact of neoadjuvant treatment in locally advanced gastric cancer.

Objective

To assess the accuracy of endoscopic ultrasound (EUS) in the selection of patients with gastric adenocarcinoma for neoadjuvant therapy (T ≥ 2 and/or N+).

Methods

Retrospective analysis of patients with an anatomopathological diagnosis of gastric adenocarcinoma between January 2011 and June 2017, who had EUS for staging and underwent surgery as a first therapeutic attempt. The concordance (k) and accuracy (area under the curve (AUC)) of EUS for T ≥ 2 and/or N+ were assessed using the anatomopathological staging of the resected surgical specimen as the gold standard.

Results

The final sample included 152 patients (66.4% male, 67.1 ± 12.2 years). The concordance, accuracy, sensitivity and specificity of the EUS for T ≥ 2 and/or N+ were 0.72, 0.86 ± 0.03, 88.5% and 83.1%, respectively. The results were higher in proximal (k = 0.93, AUC = 0.96 ± 0.05, sensitivity (S) = 99.0% and specificity (E) = 90.9%) compared with distal lesions (k = 0.67, AUC = 0.84 ± 0.04, S = 85.7% and E = 81.5%), and in intestinal subtype (k = 0.77, AUC = 0.88 ± 0.04, S = 92.6% and E = 84.1%) compared with diffuse (k = 0.58, AUC = 0.79 ± 0.10, S = 85.0% and E = 72.7%) or mixed-subtype tumours (k = 0.65, AUC = 0.84 ± 0.10, S = 76.9% and E = 90.0%).

Conclusion

In one of the largest series of patients, we showed that EUS has overall high agreement and accuracy in the selection of patients with gastric adenocarcinoma for neoadjuvant therapy, although the agreement and accuracy are greater for proximal and intestinal lesions.