Abstract
Background and ObjectiveThe aim of this study was to assess the ability of Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography (18F-FDG PET/CT) to provide functional information useful in predicting pathological response to an intensive neoadjuvant chemo-radiotherapy (nCRT) protocol for both esophageal squamous cell carcinoma (SCC) and adenocarcinoma (ADC) patients.Material and MethodsEsophageal carcinoma (EC) patients, treated in our Center between 2014 and 2018, were retrospectively reviewed. The nCRT protocol schedule consisted of an induction phase of weekly administered docetaxel, cisplatin, and 5-fluorouracil (TCF) for 3 weeks, followed by a concomitant phase of weekly TCF for 5 weeks with concurrent radiotherapy (50–50.4 Gy in 25–28 fractions). Three 18F-FDG PET/CT scans were performed: before (PET1) and after (PET2) induction chemotherapy (IC), and prior to surgery (PET3). Correlation between PET parameters [maximum and mean standardized uptake value (SUVmax and SUVmean), metabolic tumor volume (MTV), and total lesion glycolysis (TLG)], radiomic features and tumor regression grade (TGR) was investigated.ResultsFifty-four patients (35 ADC, 19 SCC; 48 cT3/4; 52 cN+) were eligible for the analysis. Pathological response to nCRT was classified as major (TRG1-2, 41/54, 75.9%) or non-response (TRG3-4, 13/54, 24.1%). A major response was statistically correlated with SCC subtype (p = 0.02) and smaller tumor length (p = 0.03). MTV and TLG measured prior to IC (PET1) were correlated to TRG1-2 response (p = 0.02 and p = 0.02, respectively). After IC (PET2), SUVmean and TLG correlated with major response (p = 0.03 and p = 0.04, respectively). No significance was detected when relative changes of metabolic parameters between PET1 and PET2 were evaluated. At textural quantitative analysis, three independent radiomic features extracted from PET1 images ([JointEnergy and InverseDifferenceNormalized of GLCM and LowGrayLevelZoneEmphasis of GLSZM) were statistically correlated with major response (p < 0.0002).Conclusions 18F-FDG PET/CT traditional metrics and textural features seem to predict pathologic response (TRG) in EC patients treated with induction chemotherapy followed by neoadjuvant chemo-radiotherapy. Further investigations are necessary in order to obtain a reliable predictive model to be used in the clinical practice.
Highlights
Esophageal Cancer (EC) is a major health problem worldwide, representing the 7th leading cause of cancer-related mortality [1]
After the completion of a phase II study, an intensive neoadjuvant chemo-radiotherapy (nCRT) protocol consisting of induction chemotherapy (IC), followed by concurrent chemo-radiotherapy (CRT), and thereafter by surgery, was considered the standard approach for both Squamous Cell Carcinoma (SCC) and Adenocarcinoma (ADC) of the esophagus and gastroesophageal junction (EGJ)
Forty-four patients were excluded from the study for the following reasons: preoperative approach other than nCRT protocol (n=31); no surgery (n=8); lack of at least one 18F-FDG PET/CT scan (n=5)
Summary
Esophageal Cancer (EC) is a major health problem worldwide, representing the 7th leading cause of cancer-related mortality [1]. It can be hypothesized that the use of induction chemotherapy may allow to screen patients with EC in “good responders”, in which CRT following IC may determine an effective survival advantage and should be used, and in “bad responders”, in which CRT could be unnecessary or even detrimental due to possible adverse events In this unfavorable group, surgery should not be further delayed or, alternatively, a change in systemic therapy should be adopted. The aim of this study was to assess the ability of Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography (18F-FDG PET/CT) to provide functional information useful in predicting pathological response to an intensive neoadjuvant chemo-radiotherapy (nCRT) protocol for both esophageal squamous cell carcinoma (SCC) and adenocarcinoma (ADC) patients
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