Clinical utility of postchemoradiation endoscopic brush cytology and biopsy in predicting residual esophageal adenocarcinoma

Abstract

BACKGROUND:Esophageal adenocarcinoma generally carries a poor prognosis. Treatment with combination chemoradiation (CRT) followed by esophagectomy is becoming common. A pathologic complete response is uncommon but predicts improved survival. Identifying the subset of patients with residual carcinoma has potential management implications. Post‐CRT endoscopic brush cytology and biopsy may detect residual tumor; however, the accuracy and clinical value of these methods remain unclear.METHODS:Sixty‐seven patients with esophageal adenocarcinoma who underwent preoperative CRT and post‐CRT endoscopic brush cytology and biopsy followed by esophagectomy were identified. By using esophagectomy histology as the gold standard, the performance of cytology and biopsy was evaluated in diagnosing residual carcinoma. Two pathologists independently reviewed all false‐negative and false‐positive cases and resolved disagreements by consensus.RESULTS:The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of cytology for diagnosing residual carcinoma were 26%, 95%, 92%, 35%, and 45%, respectively. For biopsy, these rates were 13%, 90%, 75%, 31%, and 36%, respectively. Sampling error accounted for false‐negative diagnoses in approximately 66% of cytology analyses and 98% of biopsy analyses. Approximately 33% of false‐negative cytology analyses and 1 false‐negative biopsy analysis were caused by the under–recognition of tumor cells. Major diagnostic pitfalls included obscuring acute inflammation, necrosis, tumor cells that mimicked benign cells with radiation/reactive atypia, and the under recognition of mucin‐containing adenocarcinoma cells.CONCLUSIONS:Brush cytology and biopsy were specific but not sensitive methods for predicting residual cancer after CRT. However, cytology was superior. The current results indicated that brush cytology can be used alone to diagnose residual esophageal carcinoma, and awareness of specific diagnostic pitfalls will help pathologists improve its accuracy. Cancer (Cancer Cytopathol) 2009. © 2009 American Cancer Society.

Post-Treatment/Pre-operative PET Response Is Not an Independent Predictor of Outcomes for Patients With Gastric and GEJ Adenocarcinoma

“…Assessing response to neoadjuvant therapy can be difficult with conventional CT imaging or endoscopy. [8, 9] Metabolic change as seen on PET scan may be the most sensitive and quantitative method to determine response to treatment. Numerous studies investigating the predictive value of FDG-PET scanning after completion of preoperative therapy in patients with gastroesophageal cancers have identified a positive correlation with histologic response.…”

Residual Esophageal Cancer after Neoadjuvant Chemoradiotherapy Frequently Involves the Mucosa and Submucosa

“…[8][9][10] Several published studies have tried to identify patients with esophageal cancer with pCR after nCRT using conventional endoscopy with histological biopsies, endoscopic ultrasonography (EUS), computed tomography (CT), and positron emission tomography (PET). [11][12][13][14][15][16][17] So far, results from these studies have been mostly disappointing. It has been proven difficult to locate and to take targeted biopsies of limited amounts of residual tumor in the esophagus, when restaging is performed only at an early single time point after completion of nCRT.…”

Comparative Evaluation of Endoscopic Brush Cytology and Biopsy in the Diagnosis of Upper Gastrointestinal Neoplasm

“…Similar opinion was suggested by Hong-Qi Peng et al (2008). (16) All those 3 suspicious cases came positive only on repeat biopsy were having severe gastric outlet obstruction in one case and 2 cases with gastric carcinoma in the region of cardia and fundus where the biopsy forceps could not be introduced through it but brush easily got access to some extent. Thus it is evident in our study that brush has advantage over biopsy in sampling stenotic lesions and lesions of cardia and fundus of stomach.…”