title: Restaging oesophageal cancer after neoadjuvant therapy with (18)F-FDG PET-CT: identifying interval metastases and predicting incurable disease at surgery.
abstract: OBJECTIVE
  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.
  
  
  CONCLUSIONS
  • 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.
authors.affiliation: Oxford OesophagoGastric Centre, Churchill Hospital, Old Road, Headington, Oxford, OX3 7LJ, UK. john.findlay@oncology.ox.ac.uk.|NIHR Oxford Biomedical Research Centre, Churchill Hospital, Old Road, Headington, Oxford, OX3 7LE, UK. john.findlay@oncology.ox.ac.uk.
authors.forename: John M
authors.initials: JM
authors.lastname: Findlay
authors.affiliation: Oxford OesophagoGastric Centre, Churchill Hospital, Old Road, Headington, Oxford, OX3 7LJ, UK.
authors.forename: Richard S
authors.initials: RS
authors.lastname: Gillies
authors.affiliation: Department of Nuclear Medicine, Churchill Hospital, Old Road, Headington, Oxford, OX3 7LE, UK.
authors.forename: James M
authors.initials: JM
authors.lastname: Franklin
authors.affiliation: Department of Nuclear Medicine, Churchill Hospital, Old Road, Headington, Oxford, OX3 7LE, UK.
authors.forename: Eugene J
authors.initials: EJ
authors.lastname: Teoh
authors.affiliation: Oxford OesophagoGastric Centre, Churchill Hospital, Old Road, Headington, Oxford, OX3 7LJ, UK.|Royal Berkshire Hospital, Craven Road, Reading, RG1 5AN, UK.
authors.forename: Greg E
authors.initials: GE
authors.lastname: Jones
authors.affiliation: Oxford OesophagoGastric Centre, Churchill Hospital, Old Road, Headington, Oxford, OX3 7LJ, UK.|Queen's Medical Centre, Derby Road, Nottingham, NG7 2UH, UK.
authors.forename: Sara
authors.initials: S
authors.lastname: di Carlo
authors.affiliation: Department of Nuclear Medicine, Churchill Hospital, Old Road, Headington, Oxford, OX3 7LE, UK.
authors.forename: Fergus V
authors.initials: FV
authors.lastname: Gleeson
authors.affiliation: Oxford OesophagoGastric Centre, Churchill Hospital, Old Road, Headington, Oxford, OX3 7LJ, UK.
authors.forename: Nicholas D
authors.initials: ND
authors.lastname: Maynard
authors.affiliation: Department of Nuclear Medicine, Churchill Hospital, Old Road, Headington, Oxford, OX3 7LE, UK.
authors.forename: Kevin M
authors.initials: KM
authors.lastname: Bradley
authors.affiliation: NIHR Oxford Biomedical Research Centre, Churchill Hospital, Old Road, Headington, Oxford, OX3 7LE, UK.
authors.forename: Mark R
authors.initials: MR
authors.lastname: Middleton
mesh_terms: D000328:Adult; D000368:Aged; D017024:Chemotherapy, Adjuvant; D003662:Decision Theory; D018450:Disease Progression; D004938:Esophageal Neoplasms / Q000000981:diagnostic imaging* / Q000473:pathology* / Q000628:therapy; D016629:Esophagectomy / Q000379:methods; D005260:Female; D019788:Fluorodeoxyglucose F18; D006801:Humans; D008297:Male; D008875:Middle Aged; D020360:Neoadjuvant Therapy; D009362:Neoplasm Metastasis; D009367:Neoplasm Staging; D000072078:Positron Emission Tomography Computed Tomography / Q000379:methods; D011379:Prognosis; D019275:Radiopharmaceuticals; D012189:Retrospective Studies; D018570:Risk Assessment / Q000379:methods; D012680:Sensitivity and Specificity; D014057:Tomography, X-Ray Computed / Q000379:methods
chemical_list: D019275:Radiopharmaceuticals; D019788:Fluorodeoxyglucose F18
keywords: Cancer staging; Computed tomography; Esophageal cancer; Esophagectomy; Positron-emission tomography