Abstract
BackgroundPrognosis of esophageal cancer patients can be significantly improved by neoadjuvant chemoradiotherapy (nCRT). Given the aggressive nature of esophageal tumors, it is conceivable that in a significant portion of patients treated with nCRT, dissemination already becomes manifest during the period of nCRT. The aim of this retrospective study was to determine the value and diagnostic accuracy of PET-CT after neoadjuvant chemoradiotherapy to identify patients with metastases preoperatively in order to prevent non-curative surgery.MethodsFrom January 2011 until February 2013 esophageal cancer patients deemed eligible for a curative approach with nCRT and surgical resection underwent a PET-CT after completion of nCRT. If abnormalities on PET-CT were suspected metastases, histological proof was acquired. A clinical decision model was designed to assess the cost-effectiveness of this diagnostic strategy.Results156 patients underwent a PET-CT after nCRT. In 31 patients (19.9%) PET-CT showed abnormalities suspicious for dissemination, resulting in 17 cases of proven metastases (10.9%). Of the patients without proven metastases 133 patients were operated. In 6 of these 133 cases distant metastases were detected intraoperatively, corresponding to 4.5% false-negative results. The standard introduction of a post-neoadjuvant therapy PET-CT led to a reduction of overall health care costs per patient compared to a scenario without restaging with PET-CT ($34,088 vs. $36,490).ConclusionIn 10.9% of esophageal cancer patients distant metastases were detected by standard PET-CT after neoadjuvant chemoradiotherapy. To avoid non-curative resections we advocate post-neoadjuvant therapy PET-CT as a cost-effective step in the standard work-up of candidates for surgery.
Highlights
Esophageal cancer is the eighth most common malignancy in the world, amounting to nearly half a million new cases annually [1]
From January 2011 until February 2013 esophageal cancer patients deemed eligible for a curative approach with neoadjuvant chemoradiotherapy (nCRT) and surgical resection underwent a positron emission tomography (PET)-Computed tomography (CT) after completion of nCRT
In 10.9% of esophageal cancer patients distant metastases were detected by standard PET-CT after neoadjuvant chemoradiotherapy
Summary
Esophageal cancer is the eighth most common malignancy in the world, amounting to nearly half a million new cases annually [1]. After conventional staging (endoscopic ultrasonography, external ultrasonography of the neck and thoracoabdominal CT) new metastases were detected by PET in only 8 of 199 included patients (4%; 95%-CI: 1.3–6.7). These results and the high costs associated with PET led to the discouragement of standardized use of PET/ PET-CT at initial presentation. Given the aggressive nature of esophageal tumors, it is conceivable that in a significant portion of patients treated with nCRT, dissemination already becomes manifest during the period of nCRT The aim of this retrospective study was to determine the value and diagnostic accuracy of PET-CT after neoadjuvant chemoradiotherapy to identify patients with metastases preoperatively in order to prevent non-curative surgery
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