Maximum Standardized Uptake Values on Positron Emission Tomography of Esophageal Cancer Predicts Stage, Tumor Biology, and Survival

doi:10.1016/j.athoracsur.2006.03.045

The Annals of Thoracic Surgery

Volume 82, Issue 2, August 2006, Pages 391-395

Presented at the Forty-second Annual Meeting of The Society of Thoracic Surgeons, Chicago, IL, Jan 30–Feb 1, 2006.

https://doi.org/10.1016/j.athoracsur.2006.03.045 Get rights and content

Background

The stage of esophageal cancer is currently determined by the anatomic TNM classification system as opposed to information about tumor biology.

Methods

A retrospective review was made of a prospective electronic database. Patients had esophageal cancer, dedicated positron emission tomography (PET) using F-18-fluorodeoxyglucose (FDG-PET) and maximum standardized uptake value (maxSUV) measured. Biopsies were obtained from suspicious nodal and systemic locations, and when indicated, resection with complete lymphadenectomy was performed.

Results

There were 89 patients (53 men). The median maxSUV for patients with high grade dysplasia, stage I, IIa, IIb, III, and IVa esophageal cancer was 1.7, 2.9, 8.9, 7.7, 9.5, and 12, respectively. Multivariate analysis showed patients with a high maxSUV were more likely to have poorly differentiated tumors (risk ratio 1.89, p = 0.032) and advanced stage (risk ratio 2.6, p < 0.001). The maxSUV correlated better (r² = 0.85) than the current TNM staging system for survival (r² = 0.68). Receiving operator characteristics curve demonstrated a maxSUV of 6.6 to be the optimal cut-off point. The 4-year survival of patients with a maxSUV of 6.6 or less was 89%, whereas it was only 31% for those patients with values greater than 6.6 (p < 0.001).

Conclusions

The maxSUV of an esophageal cancer on dedicated FDG-PET scan is an independent predictor of stage, tumor characteristics, and survival. It predicts survival better than the current TNM staging system. This information may help guide treatment strategies.

Section snippets

Patients

This is a retrospective analysis of an electronic prospective database. Patients who presented to one surgeon between May 2000 and June 2005 with biopsy-proven, apparently resectable (no evidence of T4 or M1 disease) esophageal cancer were eligible. Patients with high-grade dysplasia were also candidates for this study. All patients underwent clinical staging with a CT scan, endoscopic ultrasound fine-needle aspiration (EUS-FNA), and FDG-PET scanning. Patients were excluded if they were less

Patient Characteristics

Of the total of 92 patients, 3 operative deaths were excluded from further analysis, thus leaving 89 patients (53 men) with a median age of 64 years (range, 29 to 81). Patient characteristics, pathology, the median maxSUV, and outcomes are summarized in Table 1. Complications included atrial fibrillation in 8 patients, pneumonia in 7 (caused by aspiration in 4), chylothorax in 2, and liver failure, an ischemic cecum, acute renal failure, superior mesenteric embolus, and deep venous thrombosis

Comment

The treatment of esophageal cancer, like most solid organ tumors, is dependent on the stage. The current TNM staging system for esophageal cancer is based only on anatomic as opposed to biological factors. However, there is increasing evidence that biological factors influence prognosis just as much, if not more than, anatomical factors [10, 11, 12]; FDG-PET may be a noninvasive modality that aids in the detection of some of these genetic, oncologic, and biological factors. Most importantly, it

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Several authors have investigated the relationship between the SUVmax and patient prognosis. Cerfolio and colleagues14 reported that patients with an SUVmax ≥6.6 had significantly worse survival compared with those with an SUVmax <6.6. They concluded that FDG-PET provides better prognostic information than that obtained from the anatomical TNM staging system, which is in accordance with the results of the current study.
The purpose of this study was to analyze the risk factors of recurrence in patients with early stage esophageal squamous cell carcinoma (ESCC).
We retrospectively analyzed the medical records of 190 patients with confirmed T1N0M0 ESCC after curative esophagectomy. The following potential prognostic factors for recurrence were investigated: age, sex, pathologic T category, tumor location, differentiation grade, tumor size, venous invasion, angiolymphatic invasion, perineural invasion and the maximum standardized uptake value (SUVmax) of the primary tumor.
There were 174 male and 16 female patients with a median age of 66.0 years (range, 42.0–79.0 years). The pathologic status of the surgically resected ESCCs was T1a in 93 patients (48.9%) and T1b in 97 patients (51.1%). The median number of dissected lymph nodes was 35 (range, 10 to 86), and all lymph nodes were negative for tumors. The multivariate analysis showed presence of venous invasion [HR (hazard ratio), 11.433; P < 0.001) and SUVmax ≥ 3.2 (HR, 2.830; P = 0.011) as independent risk factors for recurrence. The 5-year recurrence-free survival (RFS) was 25.0% for patients with venous invasion and 78.9% for those without (P < 0.001). The 5-year RFS was 67.1% for patients with an SUVmax ≥3.2 and 81.5% for those with an SUVmax <3.2 (P = 0.003).
Venous invasion and high SUVmax could be important prognostic factors coupled with the TNM staging system, in patients with early stage ESCC.
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Original articleGeneral thoracicMaximum Standardized Uptake Values on Positron Emission Tomography of Esophageal Cancer Predicts Stage, Tumor Biology, and Survival

Background

Methods

Results

Conclusions

Section snippets

Patients

Patient Characteristics

Comment

Chest

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

physicians inquiry

A threshold method to improve standardized uptake value reproducibility

Nucl Med Comm

Improving the inaccuracies of clinical staging of patients with NSCLCa prospective trial

Ann Thorac Surg

Original article
General thoracic
Maximum Standardized Uptake Values on Positron Emission Tomography of Esophageal Cancer Predicts Stage, Tumor Biology, and Survival