Is 18F-FDG PET/CT Useful for Selecting Right Candidates for Endoscopic Resection Among Patients With Superficial Esophageal Squamous Cell Carcinomas?

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Introduction: Preoperative evaluation of invasion depth and lymph node metastasis facilitate optimal treatment of superficial esophageal squamous cell carcinomas (SESCCs). Although 18F-fluoro-deoxyglucose (FDG) PET-CT has been widely applied in advanced esophageal carcinomas, few reports are available on PET/CT for SESCCs, clinical significance of which has been remained controversial. Therefore, we first report our Chinese experience, and aims of the largest study are to explore the characteristics of FDG intake and its clinical significance on decision-making of SESCCs, endoscopic resection or esophagectomy. Methods: A total of 2,461 consecutive patients with confirmed esophageal carcinoma, who underwent endoscopic resection or esophagectomy from January 2007 to March 2014 in our hospital were analyzed retrospectively. Sixty-one SESCC patients (64 lesions) with preoperative PET/CT were enrolled. According to pathological invasion depth, lesions were divided into ≥sm2 surgery group (n=17) and ≤sm1 endoscopy group (n=47). Characteristics of lesions (endoscopy, pathology, PET/CT) were reviewed and analyzed. Results: Of the 64 lesions, 24 lesions were visible and 40 were non-visible. Univariate analysis showed both qualitative and semi-quantitive FDG intake (visibility, SUVmax, SUVmax ratio A (lesion/liver), SUVmax ratio B (lesion/blood)) were related to age, longitudinal diameter, circumferential degree, non-flat or nodal type endoscopic appearance and invasion depth (P<0.05). But multivariate logistic regression analysis showed longitudinal diameter ≥40mm and invasion depth ≥sm2 were the only two influence factors (OR value=23.2,10.4; P<0.05). When visible lesions indicated esophagectomy and non-visible for endoscopic resection, sensitivity (Sen), specificity (Spe) and accuracy was 82.3% (14/17), 78.7% (37/47) and 79.7% (51/64). With a SUVmax cutoff of 2.30 for clinical decision-making of SESCCs, Sen, Spe and accuracy was 70.6% (12/17), 76.6% (36/47) and 75% (48/64), respectively. With Roedl PET/CT scoring system, SESCCs with invasion depth ≥sm2 score more in FDG uptake intensity, focality and eccentricity parameters than ≤sm1 (P<0.05). ROC curves indicated that eccentricity-focality score ≥2 contributed to a highest diagnostic efficiency, with Sen, Spe and accuracy of 70.6%,87.2% and 82.8%. Conclusion: FDG visibility and uptake are closely related to longitudinal diameter ≥40mm and invasion depth ≥sm2. Despite limited diagnostic value of primary SESCCs, 18F-FDG PET/CT is very useful for indicating esophagectomy or endoscopic resection for SESCCs. Roedl PET/CT scoring system could be applied in differentiating ≥sm2 SESCCs from ≤sm1. However, to reach a higher diagnostic efficiency, some modifications are still required.