Prediction of Metastatic Disease and Survival in Patients with Gastric and Gastroesophageal Junction Tumors: The Incremental Value of PET-CT over PET and the Clinical Role of Primary Tumor Volume Measurements

doi:10.1016/j.acra.2008.06.004

Academic Radiology

Volume 16, Issue 2, February 2009, Pages 218-226

https://doi.org/10.1016/j.acra.2008.06.004 Get rights and content

Rationale and Objectives

To investigate the accuracy of M staging (staging of metastatic disease) in esophageal carcinoma based on a visual interpretation and based on tumor volume measurements on positron emission tomography (PET) computed tomography (CT).

Materials and Methods

Fifty-nine untreated patients with gastroesophageal junction tumors were enrolled, including 36 subcardial gastric tumors (type III according to Siewert classification) and 23 adenocarcinomas of the cardia (AEG, type II Siewert). Patients were grouped in metastasis free (M0 stage, n = 34) and metastatic stages (M1 stage, n = 25). Tumor volume and mean and maximum standardized uptake value were measured on PET-CT. The accuracy of these quantitative tumor volume parameters in distinguishing metastasis-free tumors (M0 stage) from metastatic stages (M1 stage) was compared to the accuracy of a visual analysis with fused PET-CT. Furthermore, accuracy of PET-CT was compared to PET reviewed side by side with CT in a lesion-based analysis of 84 distant metastatic sites.

Results

In the visual interpretation, PET-CT (accuracy 88%, 74/84) was more accurate than PET (accuracy 78%, 66/84; P = .008) in characterizing the 84 potential metastatic sites in the 59 patients. Among the tumor parameters, the PET-CT tumor volume was the most accurate predictor of M1 stage and overall survival. With a threshold of 39 mL, PET-CT volume was able to predict M1 stage disease with a sensitivity of 96% and a specificity of 85%. The accuracy of M-staging was increased further when combining tumor volume measurements with the results from the visual analysis (combined results: sensitivity 96%, specificity 94%).

Conclusions

PET-CT was more accurate than PET (reviewed side by side with CT) in characterizing distant metastatic sites of gastroesophageal junction carcinomas. The highest accuracy for M-staging was obtained when combining the results of the visual analysis with the results from primary tumor volume measurements. Primary tumor volume was shown to be an independent prognostic factor.

Section snippets

Patients

Study subjects were 59 patients with adenocarcinomas of the GEJ, including 36 patients with subcardial gastric carcinomas (type III according to the Siewert classification) and 23 patients with tumors of the cardia (type II Siewert) (1). The study was compliant with the Health Insurance Portability and Accountability Act, and approval from the institutional review board was obtained.

Patients were primarily grouped into carcinomas with distant metastasis (M1) and those who were metastasis-free

Association between Tumor Volume Parameters and Risk of Metastatic Disease

Of the 59 patients, 25 had a metastatic tumor stage, whereas 34 were free of distant metastasis. Of the 25 patients with metastasis, 21 had M1b stage (metastasis to visceral organs), and 4 patients had M1a stage (metastasis to distant lymph nodes: celiac lymph nodes). Primary tumor volume and mean and maximum SUV of tumor volume were measured both on PET-CT and PET (Table 2). As shown in Table 2, tumor volume yielded higher sensitivity and specificity than SUVs both on PET-CT and PET

Discussion

The present study shows that fused PET-CT is more accurate than PET (reviewed side by side with CT) for assessing distant metastatic sites of GEJ tumors. On a patient-based analysis, the sensitivity of PET-CT and PET can be further increased by measuring primary tumor volume. The combination of a visual analysis and a quantitative analysis (tumor volume) resulted in a sensitivity of 96% and a specificity of 94% for defining M1 disease.

Detection of metastases in esophageal and gastric carcinomas

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Two studies were originally published in other languages (bilingual abstracts)23,24 but they had English equivalents so were included. Another 15 articles were excluded due to an overlap in study population,25–28 missing essential data,29–33 inappropriate reference standard34,35 and administration of chemotherapy before re-staging or RT planning.36–39 Finally, only 37 studies were included in this review.40–76
The aim of this study was to systematically review published data on the efficacy of positron emission tomography–computed tomography (PET–CT) in the radiotherapy planning process of patients with oesophageal carcinoma.
A systematic search of the PubMed, CINAHL, Cochrane Library and ScienceDirect databases was performed. The quality of the included studies was appraised using validated assessment tool. Data of the studies were synthesized, compared and evaluated by constructing evidentiary tables.
The 37 included studies, comprising a total sample size of 1921 patients, had moderate methodological quality. Overall primary tumour detection rate was 92.7%, and pooling estimate of specificity was 88% (95%CI: 83–91%) for local lymph node metastasis. The pooled studies presented heterogeneity for sensitivity (p < 0.01). The introduction of PET–CT to the radiotherapy planning process has facilitated target volume delineation. A standardized uptake value (SUV) of 2.5 could be used in supplementation to visual assessment by a qualified practitioner.
PET–CT has a high specificity but due to its variable sensitivity, information from other clinical investigations should still be sought. Discretion and sound clinical judgment must also be exercised before using the biologic information for radiotherapy planning.
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Original investigationPrediction of Metastatic Disease and Survival in Patients with Gastric and Gastroesophageal Junction Tumors: The Incremental Value of PET-CT over PET and the Clinical Role of Primary Tumor Volume Measurements

Rationale and Objectives

Materials and Methods

Results

Conclusions

Section snippets

Patients

Association between Tumor Volume Parameters and Risk of Metastatic Disease

Discussion

J Thorac Cardiovasc Surg

Int J Radiat Oncol Biol Phys

Radiother Oncol

Int J Radiat Oncol Biol Phys

J Thorac Cardiovasc Surg

Eur J Surg Oncol

Classification of adenocarcinoma of the oesophagogastric junction

Br J Surg

Trends in incidence of adenocarcinoma of the oesophagus and gastric cardia in ten European countries

Int J Epidemiol

Changing patterns in the incidence of esophageal and gastric carcinoma in the United States

Cancer

Esophagogastrectomy for carcinoma of the esophagus and cardia: a comparison of findings and results after standard resection in three consecutive eight-year intervals with improved staging criteria

J Thorac Cardiovasc Surg

Original investigation
Prediction of Metastatic Disease and Survival in Patients with Gastric and Gastroesophageal Junction Tumors: The Incremental Value of PET-CT over PET and the Clinical Role of Primary Tumor Volume Measurements