Outcomes of Patients With Esophageal Cancer Staged With [¹⁸F]Fluorodeoxyglucose Positron Emission Tomography (FDG-PET): Can Postchemoradiotherapy FDG-PET Predict the Utility of Resection?

Abstract

Purpose To determine whether [18F]fluorodeoxyglucose positron emission tomography (FDG-PET) can delineate patients with esophageal cancer who may not benefit from esophagectomy after chemoradiotherapy. Patients and Methods We reviewed records of 163 patients with histologically confirmed stage I to IVA esophageal cancer receiving chemoradiotherapy with or without resection with curative intent. All patients received surgical evaluation. Initial and postchemoradiotherapy FDG-PET scans and prognostic/treatment variables were analyzed. FDG-PET complete response (PET-CR) after chemoradiotherapy was defined as standardized uptake value ≤ 3. Results Eighty-eight patients received trimodality therapy and 75 received chemoradiotherapy. Surgery was deferred primarily due to medical inoperability or unresectable/metastatic disease after chemoradiotherapy. A total of 105 patients were evaluable for postchemoradiotherapy FDG-PET response. Thirty-one percent achieved a PET-CR. PET-CR predicted for improved outcomes for chemoradiotherapy (2-year overall survival, 71% v 11%, P < .01; 2-year freedom from local failure [LFF], 75% v 28%, P < .01), but not trimodality therapy. On multivariate analysis of patients treated with chemoradiotherapy, PET-CR is the strongest independent prognostic variable (survival hazard ratio [HR], 9.82, P < .01; LFF HR, 14.13, P < .01). PET-CR predicted for improved outcomes regardless of histology, although patients with adenocarcinoma achieved a PET-CR less often. Conclusion Patients treated with trimodality therapy found no benefit with PET-CR, likely because FDG-PET residual disease was resected. Definitive chemoradiotherapy patients achieving PET-CR had excellent outcomes equivalent to trimodality therapy despite poorer baseline characteristics. Patients who achieve a PET-CR may not benefit from added resection given their excellent outcomes without resection. These results should be validated in a prospective trial of FDG-PET–directed therapy for esophageal cancer.

18F-fluorodeoxyglucose positron emission computed tomography for monitoring tumor response in esophageal carcinoma treated with concurrent chemoradiotherapy

“…18 F-FDG PET scans were performed and analyzed pre-and post-CRT. In a study undertaken by Monjazeb et al (16), for patients treated with definitive CRT, the median survival time and the 2-year overall survival (OS) rate for the patients achieving complete response was 38 months, and 71% vs. 11 months and 11% for those patients who had not achieved a complete response. Multivariate analysis indicated that PET complete response is the strongest independent prognostic factor for esophageal cancer [survival hazard ratio (HR), 9.82; P<0.01; local failure HR, 14.13; P<0.01].…”

“…Previous studies have suggested that 18 F-FDG PET is a non-invasive method for monitoring pathological response and prognosis for carcinomas of the esophagus during or following neoadjuvant CRT (4-8). Monjazeb et al (16) reviewed 163 patients with esophageal cancer receiving neoadjuvant CRT with or without resection. 18 F-FDG PET scans were performed and analyzed pre-and post-CRT.…”

Esophageal and Esophagogastric Junction Cancers

“…251,252 PET scan has also been shown to predict histopathologic complete response and outcome after definitive chemoradiation or preoperative chemoradiation in patients with locally advanced esophageal cancer. [253][254][255][256][257][258] However, other studies have shown conflicting results. [259][260][261][262][263][264] Swisher et al 254 also showed that a postchemoradiation 18-fluorodeoxyglucose (FDG) uptake value of 4 or less was found to be the only preoperative factor to correlate with decreased survival.…”

Advances in the management of esophageal cancer

“…The first 6 trials (Urba [55], Walsh [56], EORTC [57], Australasian [58], Korea [32], and CALGB 9781 [59]) had limited patient numbers, heterogeneous treatment regimens, and in some the dose of radiation was insufficient based. With the publication of the CROSS trial the standard of care for patients with locally advanced but medically resectable adenocarcinoma of the esophagus is now preoperative chemoradiation.…”

“…There are seven randomized trials comparing preoperative combined modality therapy with surgery alone in patients with clinically resectable disease, the most recent being the CROSS trial [32, [55][56][57][58][59][60].…”