title: Preoperative chemo-radiation-induced ulceration in patients with esophageal cancer: a confounding factor in tumor response assessment in integrated computed tomographic-positron emission tomographic imaging.
abstract: OBJECTIVE
  Positron emission tomography can be useful in predicting response of esophageal cancer after preoperative chemo-radiation therapy (CRT). We evaluated the use of integrated computed tomography (CT)-PET among patients with esophageal cancer being considered for resection after CRT.
  
  
  METHODS
  Three reviewers blinded to clinical and pathologic staging retrospectively reviewed the CT-PET scans of patients with esophageal cancer after preoperative CRT who underwent esophagectomy. [F]-fluoro-2-deoxy-D-glucose uptake for residual malignancy was determined by visual analysis and semi-quantitatively when standardized uptake value (SUV) was > or =4.
  
  
  RESULTS
  Forty-two patients underwent esophageal resection. Using visual analysis, CT-PET had a sensitivity of 47% and specificity of 58% in detecting residual malignancy. Using semi-quantitative analysis, 19 patients had a SUV > or =4 in the region of the primary esophageal tumor and were interpreted as having residual malignancy (sensitivity 43%, specificity 50%). Of these 19, six had complete pathologic response to CRT. These false-positive results, due to therapy-induced ulceration detected at endoscopy, limit the use of CT-PET alone in detecting residual malignancy. Similarly, sensitivity (25%) and specificity (73%) of endoscopy/biopsy in detecting residual malignancy were poor. However, the accuracy of CT-PET in detecting residual malignancy was improved when combined with endoscopic findings. In the absence of ulceration at endoscopy, 8 of 8 patients with SUV > or =4 after chemo-radiation had residual malignancy at surgery.
  
  
  CONCLUSIONS
  CRT-induced ulceration results in false-positive results on CT-PET and precludes accurate detection of residual esophageal tumor. However, CT-PET in combination with endoscopy is useful in identifying patients with a high risk of residual tumor post-CRT.
authors.affiliation: Department of Diagnostic Imaging, University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030, USA. jerasmus@di.mdacc.tmc.edu
authors.forename: Jeremy J
authors.initials: JJ
authors.lastname: Erasmus
authors.forename: Reginald F
authors.initials: RF
authors.lastname: Munden
authors.forename: Mylene T
authors.initials: MT
authors.lastname: Truong
authors.forename: Jeremy J
authors.initials: JJ
authors.lastname: Ho
authors.forename: Wayne L
authors.initials: WL
authors.lastname: Hofstetter
authors.forename: Homer A
authors.initials: HA
authors.lastname: Macapinlac
authors.forename: Arlene M
authors.initials: AM
authors.lastname: Correa
authors.forename: Tsung-Teh
authors.initials: TT
authors.lastname: Wu
authors.forename: John F
authors.initials: JF
authors.lastname: Bruzzi
authors.forename: Edith M
authors.initials: EM
authors.lastname: Marom
authors.forename: Bradley S
authors.initials: BS
authors.lastname: Sabloff
authors.forename: Jaffer A
authors.initials: JA
authors.lastname: Ajani
authors.forename: Ritsuko
authors.initials: R
authors.lastname: Komaki
authors.forename: Zhongxing
authors.initials: Z
authors.lastname: Liao
authors.forename: Jeffrey H
authors.initials: JH
authors.lastname: Lee
authors.forename: Norio
authors.initials: N
authors.lastname: Fukami
authors.forename: Robert
authors.initials: R
authors.lastname: Bresalier
authors.forename: Stephen G
authors.initials: SG
authors.lastname: Swisher
mesh_terms: D000328:Adult; D000368:Aged; D003131:Combined Modality Therapy / Q000009:adverse effects; D004935:Esophageal Diseases / Q000209:etiology*; D004938:Esophageal Neoplasms / Q000000981:diagnostic imaging / Q000473:pathology / Q000628:therapy*; D016629:Esophagectomy; D004945:Esophagoscopy; D005189:False Positive Reactions; D005260:Female; D019788:Fluorodeoxyglucose F18; D006801:Humans; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D018365:Neoplasm, Residual; D049268:Positron-Emission Tomography; D012189:Retrospective Studies; D014057:Tomography, X-Ray Computed; D014456:Ulcer / Q000209:etiology*
chemical_list: D019788:Fluorodeoxyglucose F18