MRI outperforms CT for tracheal and vascular invasion staging in esophageal cancer

To validate a standardized MRI scoring system, tracheal invasion score (T-score) and vascular invasion score (V-score) against CT for detecting tracheal and major-vessel invasion in esophageal cancer, based on imaging obtained after neoadjuvant therapy.

Twenty-six patients (mean age 65 years) who underwent both MRI and CT after preoperative therapy and prior to esophagectomy were retrospectively reviewed. Two radiologists independently assigned T- and V-scores on MRI and CT-based T-stage (12th Japanese Classification). Diagnostic performance was measured by the area under the ROC curve (AUC) and κ for inter-reader agreement. Patient-level bootstrap resampling (2000 iterations) compared the combined MRI score-defined as max (T, V)-with CT.

MRI yielded higher AUCs than CT for tracheal invasion (0.943-0.990 vs. 0.529-0.706) and vascular invasion (0.878 for both readers). MRI achieved substantial-to-almost-perfect agreement (κ = 0.771-1.000), whereas CT was only moderate (κ = 0.369-0.487). Bootstrap analysis confirmed superior discrimination of the combined MRI score: ΔAUC + 0.19 (-0.05-0.43, p = 0.11) for Reader A and +0.38 (0.07-0.66, p = 0.02) for Reader B.

A combined MRI T/V-score provides better accuracy and inter-reader reliability than CT for evaluating critical local invasion, even after preoperative therapy, supporting routine integration of MRI when CT findings are equivocal.

Question Determine whether a standardized MRI scoring system for tracheal and vascular invasion improves diagnostic accuracy compared with contrast‑enhanced CT in esophageal cancer. Findings MRI outperforms CT in detecting tracheal and vascular invasion, with higher specificity and superior inter-reader agreement using standardized scoring criteria. Clinical relevance Standardized MRI scoring improves staging accuracy in suspected T4 esophageal cancer, aiding surgical decision-making and helping to avoid unnecessary surgery in inoperable patients as well as incomplete (R1/R2) resections.