Introduction

Endoscopic ultrasound (EUS) and positron emission tomography (PET) have been widely recognized as valuable imaging modalities for tumor-node-metastasis (TNM) staging and treatment decision-making in patients with esophageal cancer. However, the accuracy of EUS and PET in esophageal cancer patients following neoadjuvant concurrent chemoradiotherapy (CCRT) remains inconsistent. Our objective was to conduct a comparative study between EUS and PET to evaluate their accuracy in staging post-CCRT patients who underwent resection surgery and were diagnosed with tumor complete remission.

Aims & Methods

The subjects of this study comprised patients diagnosed with esophageal squamous cell carcinoma and treated with CCRT before surgery at National Taiwan University Hospital (NTUH). Data were collected from May 1, 2007, to May 31, 2022, from a database of 828 esophageal cancer patients who underwent both EUS and PET before and after CCRT, and subsequently underwent resection surgery with pathologically complete response, resulting in a total of 231 patients. After excluding 14 patients who did not receive CCRT, 217 patients were enrolled for further study. The analysis focused on the T and N stages of esophageal cancer as reported by EUS and PET before and after CCRT, correlating clinical stages with pathologic stages. Using pathological diagnosis as the criterion standard, the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of EUS and PET were calculated. Patients who did not receive EUS or PET before CCRT and those who did not receive EUS or PET after CCRT (n=87) were excluded, resulting in a final inclusion of 128 cases for analysis.

Results

Among the 128 recruited patients, the overall accuracy of EUS for T-stage was 6.3%, while PET exhibited an accuracy of 13.3%. For N-stage, the accuracy of EUS was 20.3%, whereas PET demonstrated an accuracy of 33.6%.

Conclusion

In post-CCRT esophageal patients who achieved complete pathological remission, PET exhibited superior accuracy compared to EUS for both T and N staging; however, neither modality attained satisfactory levels of accuracy.

References

• 1. Yen, T. J., et al. (2012). "Comparative study between endoscopic ultrasonography and positron emission tomography-computed tomography in staging patients with esophageal squamous cell carcinoma." Dis Esophagus 25(1): 40-47
• 2. Ajani, J. A., et al. (2019). "Esophageal and Esophagogastric Junction Cancers, Version 2.2019, NCCN Clinical Practice Guidelines in Oncology." Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 17(7): 855-883.
• 3. Rice, T. W., et al. (2017). "8th edition AJCC/UICC staging of cancers of the esophagus and esophagogastric junction: application to clinical practice." Ann Cardiothorac Surg 6(2): 119-130.

Introduction

Quantitative fluorescence molecular endoscopy (qFME) enables real-time in vivo visualization and quantification of fluorescence and can thereby highlight tumor tissue. qFME has proven its potential in detection of lesions and residual disease but is limited to the mucosal side only^1,2. Ultrasound guided needle biopsy (USNB/SFF) single fiber fluorescence spectroscopy may enable assessment of lymph nodes and all tissue layers of the esophageal wall. This pilot study evaluated the clinical impact of USNB/SFF spectroscopy using the fluorescent tracer bevacizumab-800CW for the identification of residual tumor in patients with esophageal cancer.

Aims & Methods

Patients diagnosed with locally advanced esophageal adenocarcinoma scheduled for neoadjuvant chemoradiotherapy followed by surgery were included. Patients were intravenously injected with either 4.5, 10 or 25 mg bevacizumab-800CW 2-3 days prior to the qFME to establish the optimal dose. FME collected real-time white light and fluorescence images of the primary tumor site and normal esophageal tissue. Quantitative fluorescent measurements were acquired superficially using multi-diameter single fiber reflectance / single fiber fluorescence (MDSFR/SFF) and inside the esophageal wall and within lymph nodes using USNB-SFF spectroscopy. Additionally, the reduced scattering coefficient and absorption coefficient were determined from the MDSFR/SFF data.

Results

Fifteen patients were included in the dose-escalation, where 25 mg showed the best differentiation between primary tumor site and normal tissue and was extended with 3 additional patients (TBR: 2.63±0.60, p=0.0002). VEGF immunohistochemistry confirmed the higher uptake of VEGF at the primary tumor site. USNB was evaluated in 6/8 patients from the 25mg cohort. The primary tumor site (p=0.071) and lymph nodes (p=0.090) showed higher fluorescence intensity compared to normal tissue. Fluorescence measurements of normal tissue were comparable between the luminal MDSFR/SFF and USNB/SFF measurements. In 33% of all patients residual tumor was found only below a tumor-free mucosa signifying the need to analyze the deeper tissue layers. Last, the optical properties, the reduced scattering coefficient and absorption coefficient. The combination of the intrinsic fluorescence, absorption and scattering coefficient was converted into the new variable omega and improved the differentiation between tumor and normal tissue even further.

Conclusion

We showed the potential of bevacizumab-800CW combined with qFME and USNB/SFF for response monitoring in esophageal cancer. This combination allows for both in vivo superficial and deeper tissue measurements to ensure that partial responders with a tumor-free mucosa are also adequately selected. A phase II study should establish its value for stratification of patients for active surveillance or surgery.

References

1. Tjalma JJJ, Koller M, Linssen MD, Hartmans E, de Jongh S, Jorritsma-Smit A, et al. Quantitative fluorescence endoscopy: an innovative endoscopy approach to evaluate neoadjuvant treatment response in locally advanced rectal cancer. Gut. 2020;69(3):406-10.
2. Nagengast WB, Hartmans E, Garcia-Allende PB, Peters FTM, Linssen MD, Koch M, et al. Near-infrared fluorescence molecular endoscopy detects dysplastic oesophageal lesions using topical and systemic tracer of vascular endothelial growth factor A. Gut. 2019;68(1):7-10.

Disclosure

Nothing to disclose

Introduction

Esophageal variceal (EV) bleeding is a severe complication of portal hypertension with significant morbidity and mortality. Guidelines for the American Association for the Study of Liver Diseases (AASLD) currently recommend endogastroduodenoscopy (EGD) at the time of diagnosis of cirrhosis. Traditionally, screening and grading of EV is performed by EGD. However, EGD is an invasive procedure and not risk-free; it is mostly performed using intravenous conscious sedation increasing its risks by adding the effects of sedative drugs in the cirrhotic population. Wired magnetic-assisted capsule endoscopy (MACE) uses a wire-connected capsule steerable by an external magnet and allows examination of the upper GI tract. However, its potential usefulness in diagnosing esophageal varices in patients with liver cirrhosis has not been assessed.

Aims & Methods

Method: We prospectively enrolled patients with cirrhosis and indications to receive EGD for screening or surveillance for esophageal varices. A wired MACE study was performed followed by an EGD which was performed by one experienced endoscopist within 6 hours. Capsule videos were assessed by two investigator who were blinded to the patients’ medical history and EGD findings. The diagnostic yield of wired MACE and EGD were compared. Patients’ tolerance and acceptance of wired MACE and EGD were also assessed.

Results

Thirty-two patients were included for analysis (mean age: 64 years, range: 41-83 years; 59.4% male); the clinical characteristics of enrolled patients were listed in Table1 and only 6 patients (18.8%) received sedated EGD. The mean examination time of wired MACE and EGD (including time of endoscopic variceal ligation) was 7.9 mins and 10.9 mins respectively. The combined sensitivity, specificity and accuracy of diagnosing EV by wire-MACE was 92.1% [95% confidence interval(CI): 78.6-98.3%], 88.5% (95% CI: 69.9-97.6%) and 90.6% (95% CI: 80.7-96.5%) respectively with good interobserver agreement (kappa=0.87). The combined sensitivity, specificity and accuracy of predicting the need for endoscopic variceal ligation (EVL) by wire-MACE was 70.0% (95% CI: 34.8-93.3%), 94.4% (95% CI: 84.6-98.8%) and 90.6% (95% CI: 80.7-96.5%) respectively with moderate interobserver agreement (kappa=0.54). Wired MACE has lower scores of discomfort (2.1 vs 4.4, p < 0.0001) and better scores of acceptance (4.2 vs 3.2, p <0.01) than that of EGD.

Conclusion

Wired MACE has good accuracy in diagnosing EV and predicting the need of prophylactic EVL; moreover, it has less discomfort and better acceptance than EGD.

References

Garcia-Tsao, G., et al., Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Am J Gastroenterol, 2007. 102(9): p. 2086-102.
2.Stipho, S., et al., String capsule endoscopy for screening and surveillance of esophageal varices in patients with cirrhosis. J Interv Gastroenterol, 2012. 2(2): p. 54-60.
3.Sacher-Huvelin, S., et al., Screening of esophageal varices by esophageal capsule endoscopy: results of a French multicenter prospective study. Endoscopy, 2015. 47(6): p. 486-92.
4.Ishiguro, H., et al., Esophageal Capsule Endoscopy for Screening Esophageal Varices among Japanese Patients with Liver Cirrhosis. Gastroenterol Res Pract, 2012. 2012: p. 946169.
5.Chavalitdhamrong, D., et al., Capsule endoscopy is not as accurate as esophagogastroduodenoscopy in screening cirrhotic patients for varices. Clin Gastroenterol Hepatol, 2012. 10(3): p. 254-8.e1.
6.McCarty, T.R., Y. Afinogenova, and B. Njei, Use of Wireless Capsule Endoscopy for the Diagnosis and Grading of Esophageal Varices in Patients With Portal Hypertension: A Systematic Review and Meta-Analysis. J Clin Gastroenterol, 2017. 51(2): p. 174-182.

Introduction

Patients with esophageal cancer are prone to poor nutrition. Concurrent chemoradiation therapy (CCRT) further influence body compositions including skeletal muscle and adipose tissue which are key indicators of nutritional status.

Aims & Methods

This study aimed to evaluate whether body compositional change during CCRT could be a predictor of prognosis in esophageal cancer patients. From 2006 to 2018, esophageal cancer patients who received CCRT as initial treatment were consecutively enrolled. We assessed body compositions, including subcutaneous fat (SCF), intramuscular fat (IMF), and skeletal muscle (SM) mass by measuring the cross-sectional area (CSA) of the fourth thoracic vertebral body on computed tomography (CT) scan. The body compositional change was assessed by comparing baseline and post-CCRT CSA. The association of body compositions and their changes during CCRT with patient prognosis was analyzed.

Results

A total of 178 patients were enrolled with a mean baseline BMI of 22.0 (SD 3.4). Compared to baseline, a significant decrease in the mean bodyweight (BW), SCF, IMF, and SM after CCRT was noted (p<0.001). Baseline or post-CCRT BMI and body compositions were not significantly associated with patient prognosis. Patients with SCF loss during CCRT had poorer CCRT response (OR 3.7, p<0.001), shorter time to tumor progression (8.5 vs 23.7months, p=0.011), and overall survival (13.7 vs 25.9months, p<0.001) than patients with SCF gain/stable. IMF, SM, and BW change did not correlate with CCRT response or survival. In multivariate Cox regression analysis, SCF loss (HR 1.49, 95%CI: 1.03–2.14, p=0.033) during CCRT was an independent poor prognostic factor after adjusting baseline BMI, cancer stage, treatment modality, and CCRT response.

Conclusion

Body compositional change is more sensitive than weight in predicting CCRT response and survival of esophageal cancer patients. SCF loss during CCRT is associated with worse CCRT response and survival in esophageal cancer patients.

Introduction

When esophageal cancer is diagnosed at an advanced stage, it requires a highly invasive treatment, and its prognosis is poor. Although the number of endoscopic examinations has been increasing globally, esophageal cancer is still difficult to diagnose at an early stage. The rapidly increasing number of endoscopic examinations performed over a short period might influence diagnostic performance. Accessing the association between calendar month and esophageal cancer detection rates might improve policy and guide institutional support.

Aims & Methods

We aimed to evaluate the association between the increased number of examinations over a certain period and esophageal cancer detection rates (EDR) among a large population in the Korean National Cancer Screening Program (KNCSP). We performed a retrospective population-based study using the KNCSP database for gastric cancer between 2015 and 2019. We included 28,032,590 Koreans aged ≥40 years. We assessed monthly EDR and performed a negative binomial regression model and least square mean evaluation to evaluate the association between the screening month and EDR.

Results

In total, 28,032,590 subjects underwent upper endoscopy, according to KNCSP. The monthly number of subjects who underwent examinations was the highest in December (n=4,819,606, 17.2%). EDR tended to decrease towards the end of the year, and EDR was the lowest in December 2015 – 2019 (0.06 – 0.08). In the multivariable logistic model, the association of calendar month with detected cancer remained after adjusting for other confounding factors (December 2015: odds ratio, 0.58; 95% CI, 0.43 – 0.79; P < .001; 2016: odds ratio, 0.51; 95%CI, 0.38 – 0.67; P < .001). The age group adjusted the calendar month, and the predicted detection rate significantly decreased at the end of the year compared with the beginning of the year in 2015, 2016, and 2017 respectively.

Conclusion

In the KNCSP, the workload of endoscopists increased excessively, with an increasing number of examinations towards the end of the year, as demonstrated by decreased EDR during this period.

Introduction

There has been a rise in the uptake of endoscopic submucosal dissection (ESD) for superficial pharyngeal cancers, including in patients with previous history of radiotherapy, whether as salvage treatment of residual lesions or for metachronous lesions inside the irradiated field. Previous studies have demonstrated the safety and effectiveness of ESD for pharyngeal cancers¹. However, the safety and the effectiveness of pharyngeal ESD in cases with previous history of radiotherapy is not clear^2,3.

Aims & Methods

Our aim was to investigate whether radiotherapy affects outcomes after pharyngeal ESD. We conducted a retrospective cohort study of consecutive patients who underwent pharyngeal ESD between December 2016 and February 2025 at our institution. All the cases were managed together with otolaryngologists, including the daily assessment of the wound and swallowing function with the transnasal flexible laryngoscope in order to decide the timing of the re-initiation of food after ESD. The ESD itself, as well as the short and long-term outcomes were compared between the patients with or without history of radiotherapy.

Results

There were 22 cases (25 lesions) of ESD performed with previous history of radiotherapy and 32 cases (33 lesions) without prior radiotherapy. The median age was 71 (range 55-85) and 98.3% were men. Radiotherapy dose ranged from 54 to 70 Gy. There were no significant differences in the baseline characteristics between the groups of patients with or without prior radiotherapy including the age, sex, or the proportion of patients with previous history of pharyngeal ESD. En-bloc resection was achieved in all cases. ESD in the pharynx post-radiotherapy was associated with an increased percentage of cases with severe fibrosis (41% vs. 14% p<0.05), and the speed of dissection was slower (33.4mm²/min vs. 45.8mm²/min p=0.03), but there were no significant differences in the short-term outcomes between the groups of patients with or without prior radiotherapy in terms of of bleeding (0% vs. 3%), aspiration pneumonia (8% vs. 9%), the duration to the resumption of food (median 4 vs. 5 days) or hospital stay (median 9 vs. 9 days). During a median follow-up period of 906.5 days (range 22-3021 days), the 3-year overall survival rate was lower in patients with previous history of radiotherapy compared to patients without prior radiotherapy (55.1% vs. 100%, p=0.000177). Of the patients with previous history of radiotherapy, one patient died from metastatic recurrence of pharyngeal cancer, but the other five deaths were not directly associated with pharyngeal cancer (1=acute cardiac death, 1=unknown cause but unrelated to pharyngeal cancer, 1=lung cancer, 1=mantle cell lymphoma, 1=sinonasal neuroendocrine cancer) . There were no significant differences in the 3-year recurrence-free survival and the 3-year disease-related survival rates between the patients with and without prior history of radiotherapy (92.9% vs. 91.7% and 92.3% vs. 100%, respectively).

Conclusion

Previous history of radiotherapy increases the risk of severe fibrosis during ESD and is associated with slower speed of dissection, but does not compromise the safety or the swallowing function. In the long-term, ESD is an effective method for the treatment of superficial pharyngeal cancers, including in patients with previous history of radiotherapy. Furthermore, ESD is a minimally-invasive and surgery-sparing treatment option, which may be all the more important in patients with prior history of radiotherapy, given the worse prognosis from illnesses other than pharyngeal cancers in this group of patients.

References

1. Watanabe A, Taniguchi M, Kimura Y, Hosokawa M, Ito S, Tsukamoto S, Sasaki S. Synopsis of transoral endoscopic laryngopharyngeal surgery for superficial pharyngeal cancers. Head Neck. 2017 Sep;39(9):1779-1787.
2. Yoshida T, Shimizu Y, Ono S, Oridate N, Kato M, Asaka M. Successful salvage endoscopic mucosal resection for residual superficial hypopharyngeal carcinoma after chemoradiotherapy, with long-term survival. Endoscopy. 2009 Jun;41(6):568-9.
3. Satake H, Yano T, Yoda Y, Fujii S, Zenda S, Tomioka T, Shinozaki T, Miyazaki M, Kaneko K, Hayashi R. Feasibility of salvage endoscopic resection for patients with locoregional failure after definitive radiotherapy for pharyngeal cancer. Endosc Int Open. 2015 Aug;3(4):E274-80.