Restaging oesophageal cancer after neoadjuvant therapy with (18)F-FDG PET-CT: identifying interval metastases and predicting incurable disease at surgery.

OBJECTIVES: It is unknown whether restaging oesophageal cancer after neoadjuvant therapy with positron emission tomography-computed tomography (PET-CT) is more sensitive than contrast-enhanced CT for disease progression. We aimed to determine this and stratify risk. METHODS: This was a retrospective study of patients staged before neoadjuvant chemotherapy (NAC) by (18)F-FDG PET-CT and restaged with CT or PET-CT in a single centre (2006-2014). RESULTS: Three hundred and eighty-three patients were restaged (103 CT, 280 PET-CT). Incurable disease was detected by CT in 3 (2.91 %) and PET-CT in 17 (6.07 %). Despite restaging unsuspected incurable disease was encountered at surgery in 34/336 patients (10.1 %). PET-CT was more sensitive than CT (p = 0.005, McNemar's test). A new classification of FDG-avid nodal stage (mN) before NAC (plus tumour FDG-avid length) predicted subsequent progression, independent of conventional nodal stage. The presence of FDG-avid nodes after NAC and an impassable tumour stratified risk of incurable disease at surgery into high (75.0 %; both risk factors), medium (22.4 %; either), and low risk (3.87 %; neither) groups (p < 0.001). Decision theory supported restaging PET-CT. CONCLUSIONS: PET-CT is more sensitive than CT for detecting interval progression; however, it is insufficient in at least higher risk patients. mN stage and response (mNR) plus primary tumour characteristics can stratify this risk simply. KEY POINTS: • Restaging (18) F-FDG-PET-CT after neoadjuvant chemotherapy identifies metastases in 6 % of patients • Restaging (18) F-FDG-PET-CT is more sensitive than CT for detecting interval progression • Despite this, at surgery 10 % of patients had unsuspected incurable disease • New concepts (FDG-avid nodal stage and response) plus tumour impassability stratify risk • Higher risk (if not all) patients may benefit from additional restaging modalities.

Perioperative outcomes after transition from conventional to minimally invasive Ivor-Lewis esophagectomy in a specialized center.

BACKGROUND: Minimally invasive techniques are now increasingly adopted for the treatment of esophageal cancers. Benefits such as earlier functional recovery and less need for transfusion and intensive care stay should be balanced by a determination to avoid compromise to the oncologic integrity of the procedure, especially in the early phase of transition from open to laparoscopic surgery. This study aimed to compare primary outcomes including oncologic clearance, complications, and functional recovery between open and laparoscopic esophagectomy in a single center. METHODS: This prospective study recruited 75 consecutive patients undergoing Ivor-Lewis esophagectomy, all treated by a single surgeon. These patients were divided into three groups. The 24 patients in group A underwent open Ivor-Lewis esophagectomy. The remaining patients underwent laparoscopic Ivor-Lewis esophagectomy in two groups: 25 patients in an early cohort (group B) and 26 patients in a later cohort (group C). All the patients were treated according to the same protocol. RESULTS: The three groups were adequately matched. The findings showed trends toward a reduction in median operative time, with group A requiring 260 min, group B requiring 249 min, and group C requiring 223 min (p = 0.06), and a significant reduction in the requirement for perioperative blood transfusion between groups A (65%) and C (27%) (p = 0.02). The median lymph node yield was significantly less in group B (n = 13) than in group A (n = 24) or group C (n = 22) (p = 0.003). There was no significant difference between the three groups in the length of hospital stay (median stay, 14-16 days) or the requirement for critical care beds (median stay, 3-4 days). The in-hospital mortality rate was zero, and the morbidity rate did not differ between the three groups. CONCLUSIONS: This study shows that laparoscopic Ivor-Lewis esophagectomy is associated with a reduced need for blood transfusion, a shorter operative time, and an adequate lymph node harvest. Oncologic principles are not compromised during the transition phase from open to laparoscopic esophagectomy.