Significance of post-chemoradiation biopsy in predicting residual esophageal carcinoma in the surgical specimen

Abstract

Pathologic complete response in the resected esophagus can be achieved in approximately 30% of patients with locally advanced esophageal or gastroesophageal junction carcinoma after preoperative chemoradiation therapy. These patients tend to have a longer survival than those who have less than pathologic complete response. Post-chemoradiation esophageal biopsy (PCEB) is used to check for the presence of residual tumor before a definitive resection is performed, but the clinical significance of PCEB findings is not clear due to the possibility of sampling bias and the superficial nature of the specimen obtained. We evaluated the use of PCEB (defined as biopsy taken within 30 days before esophagectomy) in predicting residual cancer in post-treatment esophagectomy specimens. PCEB was performed in 65 of 183 (36%) patients with locally advanced esophageal or gastroesophageal junction carcinoma, who received preoperative chemoradiation therapy. The cancer status in PCEB was correlated with the residual cancer in the esophagectomy specimens. PCEB had no cancer in 80% (52 of 65) of patients (Bx-negative) and cancer in 20% (13 of 65) of patients (Bx-positive). There was no difference in the presence of residual cancer (either in esophagus or lymph node) in esophagectomy specimens between Bx-negative patients (77%, 40 of 52) or Bx-positive patients (92%, 12 of 13), P = 0.44. The positive predictive value of biopsy was 92% (12 of 13), negative predictive value 23% (12 of 52), sensitivity 23% (12 of 52) and specificity 92% (12 of 13). There was no difference in the residual cancer staging in the esophagectomy specimen between Bx-positive and Bx-negative patients. In contrast, residual metastatic carcinoma in lymph nodes was more frequent in Bx-positive patients (69.2%, 9 of 13) than in Bx-negative patients (28.8%, 15 of 52), P = 0.01. Our data suggest that PCEB is a specific but not a sensitive predictor of residual cancer following esophagectomy. Bx-positive patients tend to have more frequent residual tumor in lymph nodes. The utility of PCEB in predicting residual cancer in the lymph nodes needs to be explored further along with molecular predictors of response to preoperative therapy.

Clinical utility of postchemoradiation endoscopic brush cytology and biopsy in predicting residual esophageal adenocarcinoma

“…More biopsy-positive patients demonstrated persistent lymph node disease in their study (69.2% vs 28.8%; P ¼ .01). 23 Our study did not reveal the same pattern.…”

“…Previous studies that evaluated endoscopic biopsy for predicting residual cancer after CRT have reported results similar to ours, including high positive predictive value (range, 92-100%) and specificity (range, 85-100%), but low sensitivity (range, 22-54%) and negative predictive value (range, 11-58%). 8,14,23,30,31 Additional studies have reported false-negative preoperative biopsies in 40% to 66% of patients who previously had what was determined to be a complete response to CRT. 14,32,33 It also has been demonstrated that esophageal biopsies taken from patients who completed CRT underestimated the histologic response within diseased tissue in up to 29% of patients.…”

“…However, the clinical value of these 2 diagnostic methods in predicting the presence of residual carcinoma is not clear, and data on the accuracy of these techniques are lacking. 23 The objectives of this study were 1) to evaluate the usefulness of endoscopic brush cytology and biopsy in predicting residual carcinoma after CRT and 2) to determine diagnostic pitfalls and ways to improve diagnostic accuracy in evaluating these specimens.…”

Factors affecting the prognosis of patients with esophageal cancer undergoing salvage surgery after definitive chemoradiotherapy

“…The reason for non-curative surgery was underestimation of the T4 factor by conventional examinations using CT or MRI. Fibrosis is usually promoted in radiation fields, and cancer cells are likely to be left behind in the deep layer of the esophageal wall after radiotherapy [12,13]. Therefore, it may be difficult to accurately evaluate the T factor of irradiated patients by diagnostic criteria, which were originally prepared for preoperative estimation of non-irradiated patients.…”

The Evaluation of Esophageal Adenocarcinoma Using Dynamic Contrast-Enhanced Magnetic Resonance Imaging

“…42 Unfortunately, current diagnostic modalities, including EUS and combined CT-PET scanning, cannot reliably assess the degree of response to chemoradiation. [9][10][11][43][44][45] Endoscopic ultrasound lacks the specificity to differentiate post-therapy scarring from residual live tumor. 12,13 A number of studies have investigated the usefulness of CT-PET in assessing the response to chemoradiation in esophageal cancer, with varied results.…”