Abstract  INTRODUCTION:
CT scan is an important tool in staging of esophageal cancer. Survival can be improved by providing neoadjuvant treatment which depends on stage of esophageal cancer. So it is very important to stage the disease accurately.  METHODS:
The objective of this study is to determine diagnostic accuracy of CT scan to stage esophageal cancer. Ct scans of 62 patients included in the study were reviewed by a Consultant radiologist who was blinded to the final stage of tumour. Diagnosticaccuracy measured by comparing with histopathological staging.  RESULTS:
Accuracy, sensitivity and specificity of CT for T2 and T3 are 66%, 61%, 68% and 63%, 67%, 56% respectively. Accuracy, sensitivity and specificity of CT for presence of nodal disease are 65%, 59% and 75%.  CONCLUSIONS:
Ct scan alone has low diagnostic accuracy for staging Esophageal Cancer

Chawla, Tabish

Haider, Zishan

Sultan, Rizwan

English

eCommons@AKU

eCommons@AKUDepartment of Surgery Department of SurgeryJanuary 2016Diagnostic accuracy of CT scan in stagingresectable esophageal cancerRizwan SultanAga Khan University, imrizwan12@yahoo.comZishan HaiderAga Khan UniversityTabish ChawlaAga Khan University, tabish.chawla@aku.eduFollow this and additional works at: http://ecommons.aku.edu/pakistan_fhs_mc_surg_surgPart of the Surgery CommonsRecommended CitationSultan, R., Haider, Z., Chawla, T. (2016). Diagnostic accuracy of CT scan in staging resectable esophageal cancer. JPMA: Journal ofPakistan Medical Association, 66(1), 90-92.Available at: http://ecommons.aku.edu/pakistan_fhs_mc_surg_surg/152IntroductionEsophageal cancer is the 6th most common cancer inthe world1 with worldwide incidence of 20/100,000individuals. It is more prevalent in some parts of worldlike South Africa and China with incidence reaching upto 160/100,000 individuals. Either squamous oradenocarcinoma, its typical presentation is progressivedysphagia which is initially for solids and later on forliquids. Endoscopy is used for diagnosis and biopsy ofthe lesion. Staging of disease can be done by CT scan,PET-CT, Endoluminal Ultrasound, bronchoscopy anddiagnostic laparoscopy with different diagnosticaccuracies for Tumour site, nodal status and distantmetastasis were used for each of these. For Cervicalesophageal tumours, chemo radiation is the definitivetreatment.2 For mid and lower esophageal cancers,whether it is squamous or Adenocarcinoma, treatment isstage dependent. For early tumours upfront resection isadvised as per NCCN guidelines.2 For resectable tumourswith nodal spread and involving Muscularis Propria,there is enough evidence3 to support Neoadjuvantchemo radiation either with or without adjuvanttreatment. Hence it is very important to determine theexact stage of disease to properly plan most effectivetreatment strategy. EUS which is most sensitive fortumour size and nodal evaluation needs expensiveinstruments, expertise and is not readily available atevery center. CT scan which has low sensitivity fortumour size and nodal status is widely available, easy toreport and high sensitivity for distant metastasis. ThisStudy was conducted to find out the sensitivity andspecificity of respectable mid and lower Esophagealcancers.Material and MethodsIt was a retrospective Audit conducted at Aga KhanUniversity Hospital Karachi . Exemption from an ethicalreview committee of the institute was obtained. Allpatients who underwent upfront surgery (Iwor Lewis' twostage esophagectomy with reconstruction with gastrictube) for resectable mid and lower esophageal cancersand CT scan done from Aga Khan University HospitalKarachi from January 2008 to July 2014 were included inthe study. CT scans were done at 64 slice spiral CT scannerwith IV contrast and slice thickness of 3mm. The patientswith neoadjuvant treatment or Preoperative CT scan fromoutside Aga Khan University Hospital Karachi wereexcluded.ICD coding 142.41 was used to obtain medical recordnumbers of patients who underwent two stageesophagectomy during the above mentioned timeperiod. Files were reviewed by the Primary investigator forage, gender, days between preoperative CT scan andsurgery, histopathology and histopathological TN stage oftumour. CT scans of patients were separately reviewed bya Consultant Radiologist to record radiological T&N stageof tumour who was blinded for histopathological stage ofdisease. Data was entered on SPSS19. Continuousvariables were expressed in Means ± SD and categoricalvariables were expressed in proportions. Accuracy,specificity and sensitivity of tumour and nodal status weremeasured by comparing a radiological TN stage withJ Pak Med Assoc90AuditDiagnostic accuracy of CT scan in staging resectable esophageal cancerRizwan Sultan,1 Zishan Haider,2 Tabish Umer Chawla3AbstractIntroduction: CT scan is an important tool in staging of esophageal cancer. Survival can be improved by providingneoadjuvant treatment which depends on stage of esophageal cancer. So it is very important to stage the diseaseaccurately.Methods: The objective of this study is to determine diagnostic accuracy of CT scan to stage esophageal cancer. Ctscans of 62 patients included in the study were reviewed by a Consultant radiologist who was blinded to the finalstage of tumour. Diagnostic accuracy measured by comparing with histopathological staging.Results: Accuracy, sensitivity and specificity of CT for T2 and T3 are 66%, 61%, 68% and 63%, 67%, 56% respectively.Accuracy, sensitivity and specificity of CT for presence of nodal disease are 65%, 59% and 75%.Conclusion: Ct scan alone has low diagnostic accuracy for staging Esophageal Cancer.Keywords: Diagnostic Accuracy, CT scan, Esophageal Cancer, Staging, TNM. (JPMA 66: 90; 2016)1,3Department of Surgery, 2Department of Radiology, Aga Khan UniversityHospital, Karachi, Pakistan.Correspondence: Rizwan Sultan. Email: imrizwan12@yahoo.comhistopathological TN stage using 2X2 tables.ResultsTotal number of files obtained were 155, 93 patients wereexcluded on the basis of exclusion criteria. 62 patientswere included in the study. Mean age of patients was52.6±11.8 years and 39 (62.9%) patients were males. Timelag between Preoperative CT scan and surgery was 15.3 ±11.5 days. 44 (71%) patients had squamous cellcarcinoma, while 18 (29%) patients had adenocarcinoma.According to the histopathological stage of disease, 1patient had T1 disease, 21 (33.9%) patients had T2 disease,37 (59.7%) patients had T3 disease and 3 (4.8%) patientshad T4 disease. While 42 (67.7%) patients had nodalinvolvement.Accuracy, Sensitivity and Specificity of CT for correctlydiagnosing T2 tumours were 66% (13+28/62), 61%(13/13+8) and 68% (28/28+13) as shown in Table-1.Accuracy, Sensitivity and Specificity of CT for correctlydiagnosing T3 tumours were 63% (25+14/62), 67%(25/25+12) and 56% (14/14+11) as shown in Table-2.Accuracy, Sensitivity and Specificity of CT for correctlydetecting nodal disease were 65% (25+15/62), 59%(25/25+17) and 75% (15/15+5) as shown in Table-3.DiscussionAccording to our data Accuracy, sensitivity and specificityof CT for T2 are 66%, 61% and 68%. Accuracy, sensitivityand specificity of CT for T3 are 63%, 67% and 56%.Accuracy, sensitivity and specificity of CT for nodal diseaseare 65%, 59% and 75%.Similar studies were done recently by Jeongmin et al.4with sample size of 109 and he calculated Accuracy,sensitivity and specificity of CT scan for Nodal status ofdisease which was found to be 63%, 35%, and 93%.Moschetta et al.5 calculated Accuracy, sensitivity andspecificity of CT scan for tumour status of disease whichwas reported to be 79%, 67% and 64% in a sample of 31patients. Chengg et al.6 reported sensitivity of CT scan tobe 100% for tumour size and 80% for nodal status ofdisease in 50 patients. EPM van vliet7 reviewed 943patients to find 50% sensitivity and 83% specificity of CTscan for nodal disease.NCCN guidelines now recommend using adjunct imagingmodalities along with CT scan to stage esophagealcancers accurately. These modalities include EndoscopicUS and PET-CT. But the issue with these modalities is costand availability. EUS costs about £1800 and PET-CT costsabout £1000 in the UK, and in countries where the patienthas to bear the cost of his/her treatment, finances are amajor concern. In order to solve the issue, there are someother techniques to increase the sensitivity and specificityof CT scan. One of these is a vessel probe CT scans inwhich after giving a small amount of oral contrast,effervescent granules are swallowed, which produce gasin the esophagus, causing distension of stricturedesophagus resulting in an increase in sensitivity andspecificity of CT scan from 68% to 89% when comparedwith final histology.8To make the study more significant separate calculation ofsensitivity and specificity for different stages of tumourwas done and the CT staging was performed by aconsultant radiologist who was blinded for thehistopathological stage of the disease. Weaknessincluded small sample size.ConclusionFrom this data, we can conclude that routine CT scansalone have a low diagnostic accuracy for staging ofesophageal cancer and we should include anotherstaging tool with CT scan to properly stage tumours anddirect further treatment towards the right direction.References1. Jemal A, Bray F, Center MM, Ferlay J, Ward E, Forman D. Globalcancer statistics. CA Cancer J Clin 2011; 61: 69-90.Vol. 66, No. 1, January 2016Diagnostic accuracy of CT scan in staging resectable esophageal cancer 91Table-1: Accuracy, Sensitivity and specificity of CT scan for T2.Histopathology Diagnosis on CT scan TotalT2 Yes T2 NoT2 13 8 21Others 13 28 4126 36 62Table-2: Accuracy, Sensitivity and specificity of CT scan for T3.Histopathology Diagnosis on CT scan TotalT3 Yes T3 NoT3 25 12 37Others 11 14 2536 26 62Table-3: Accuracy, Sensitivity and specificity of CT scan for the presence of Nodaldisease.Histopathology Diagnosis on CT scan TotalNodal disease absent Nodal disease presentNodal disease absent 15 5 20Nodal disease present 17 25 4232 30 622. NCCN Guidelines version 1.Esophageal and EsophagogastricJunction Cancer: National Comprehensive Cancer Network;2014.3. Ronellenfitsch U, Schwarzbach M, Hofheinz R, Kienle P, KieserM, Slanger T, et al; GE Adenocarcinoma Meta-analysis Group.Perioperative chemo (radio) therapy versus primary surgery forresectable adenocarcinoma of the stomach, gastroe-sophageal junction, and lower esophagus. Cochrane DatabaseSyst Rev 2013; 5: CD008107.4. Choi J, Kim SG. Optimizing locoregional staging in thepreoperative setting of resectable esophageal cancer. SurgEndosc 2011; 25: 1346.5. Moschetta M, Stabile Ianora A, Marzullo A, Scardapane A,Angelelli G. Vessel probe CT protocol in the study ofesophageal carcinoma: Can it improve preoperative T staging?Eur J Surg Oncol 2010; 36: 663-9.6. Cheng Z, Yang N, Xi X, Zhao K, Hu S, Xu G, et al. [Diagnostic andapplication value of 64-slice spiral CT scanning in preoperativestaging of esophageal cancer]. Zhonghua zhong liu za zhi[Chinese J Oncol] 2011; 33: 929-32.7. Van Vliet E, Heijenbrok-Kal M, Hunink M, Kuipers E, Siersema P.Staging investigations for oesophageal cancer: a meta-analysis. Br J Cancer 2008; 98: 547-57.8. Moschetta M, Ianora AA, Marzullo A, Scardapane A, Angelelli G.Vessel probe CT protocol in the study of esophagealcarcinoma: can it improve preoperative T staging?. Eur J SurgOncol 2010; 36: 663-9.J Pak Med Assoc92 R. Sultan, Z. Haider, T. U. Chawla

Diagnostic accuracy of CT scan in staging resectable esophageal cancer

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Diagnostic accuracy of CT scan in staging resectable esophageal cancer

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