Original article
General thoracic
Ability of Fluorine-18 Fluorodeoxyglucose Positron Emission Tomography to Predict Outcomes of Neoadjuvant Chemoradiotherapy Followed by Surgical Treatment for Esophageal Squamous Cell Carcinoma

https://doi.org/10.1016/j.athoracsur.2016.04.011Get rights and content

Background

Responses of esophageal cancer to neoadjuvant therapy and patient prognosis are difficult to predict preoperatively. This study aimed to determine the ability of fluorine-18 fluorodeoxyglucose (18FDG) positron emission tomography (FDG-PET) to predict outcomes of trimodal therapy on esophageal squamous cell carcinoma (ESCC).

Methods

The responses of 111 patients with ESCC were monitored using FDG-PET before and after neoadjuvant chemoradiotherapy (nCRT) followed by surgical treatment. Associations between the maximum standardized uptake value (SUVmax) and pathologic responses (PRs) and prognosis were analyzed.

Results

Responses were significantly associated with SUVmax after nCRT (post-SUVmax) and with the rate of decreases in the SUVmax (%ΔSUVmax) of the primary tumor. The optimal cutoffs for post-SUVmax and %ΔSUVmax determined from receiver operating characteristic (ROC) curves were 2.7 (area under the curve [AUC], 0.68; 95% confidence interval [CI], 0.58–0.78; p = 0.001) and 75 (AUC, 0.64; 95% CI, 0.54–0.75; p = 0.01) for predicting a pathologic complete response (pCR) and 3.7 (AUC, 0.76; 95% CI, 0.63–0.89; p < 0.001) and 70 (AUC, 0.65; 95% CI, 0.52–0.78; p = 0.02) for predicting a good response according to Japan Esophageal Society response criteria. These values reliably separated patients into groups with and without pCR and with and without a good response. Multivariate analysis showed that %ΔSUVmax (≤70 and >70) was an independent prognostic factor for disease-specific survival (hazard ratio [HR], 0.45; 95% CI, 0.21–0.98; p = 0.04).

Conclusions

SUVmax is a valuable preoperative predictor of tumor response and survival among patients who undergo trimodal therapy for ESCC.

Section snippets

Patients

We started preoperative evaluations of patients with esophageal cancer using FDG-PET/ computed tomography (CT) during October 2006. For this study, we reviewed 111 consecutive patients with ESCC who were evaluated preoperatively before and after nCRT induction using FDG-PET/CT and who were treated by esophagectomy with R0 resection between October 2006 and April 2015. These data were extracted from our surgical database. The Institutional Review Board at Hiroshima University approved this study.

Effects of nCRT

The clinical evaluation of the effect of nCRT showed a complete response (CR) in 31 (27.9%) patients, a partial response (PR) in 75 (67.6%) patients, and stable disease in 5 patients (4.5%). None of the patients had progressive disease, because those with unresectable progressive disease during nCRT were excluded. The mean number (±SD) of dissected lymph nodes was 48 ± 21 in all patients, and this was not significantly different between patients with cT2 and cT3/4 (47 ± 25 versus 48 ± 20; p =

Comment

Studies of the ability of FDG-PET to predict responses to nCRT in patients with esophageal cancer are contradictory 8, 9, 10, 11, 12. Moreover, some studies that have focused exclusively on ESCC have been limited by relatively small samples 19, 20, 21, 22. To our knowledge, the present assessment of only patients with locally advanced ESCC who underwent nCRT with 40-Gy radiotherapy and subsequent uniform surgical treatment (transthoracic esophagectomy with lymph node dissection in at least the

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