Predictors of Understaging with EUS and PET-CECT in Early Esophageal Carcinoma

The clinicoradiological staging for esophageal cancer is fraught with variable accuracy, potentially depriving patients who have been understaged of the benefit of neoadjuvant therapy, which has been shown to improve long-term survival in locally advanced malignancies. It is imperative to identify these high-risk tumors for tailored treatment.

Retrospective analysis of a prospective database of patients undergoing esophagectomy for carcinoma esophagus between 2011 and 2019. Patients with clinicoradiological early-stage esophageal carcinoma (T1/2 and N0), staged with EUS and fluoro-deoxy-glucose positron emission tomography with contrast-enhanced computed tomography (FDG PET-CECT), and undergoing upfront surgery were included. Demographic profile, staging, perioperative outcomes, and follow-up data were extracted from electronic records and analyzed using SPSS 26.0.

During this period, we performed 1496 esophagectomies, of which 68 patients (4.5%) underwent upfront surgery for early-stage tumors. The overall concordance between clinical and surgical staging was 55.8%. The positive predictive value (PPV) of EUS for T1, T2, and N0 was 81.6%, 46.7%, and 82.4%, respectively, with 10.2% and 17% upstaging to T3 and N + , respectively. On multivariate analysis, T2 on EUS and tumors longer than 3.5 cm and having standardized uptake value (SUVmax) > 3.05 on FDG PET were strong predictors of stage migration. The 3-year overall survival (OS) of the entire cohort was 74.2%, while those who were understaged had a worse outcome, with a 3-year survival of 48.2%.

Endoscopic T2 stage, length more than 3.5 cm, and SUVmax more than 3.05 are associated with significant understaging and hence should be considered for neoadjuvant therapy.