| The3DCRT or IMRT treatment of esophageal carcinoma had been used inclinic generally recent years, and the long term local control rates and survivalrates had improved significantly as well, but there were still quite a fewuncertain questions exited in the study of esophageal cancer, such as thedetermination of accuracy GTV(Gross Tumor Volume), reasonable extra-boundary of CTV(Clinic Target Volume), the standard comprehensivetreatment model of chemoradiotherapy, the consummation of clinical stagingfor esophageal carcinoma treated with non-surgical methods and well-definedshort-term therapeutic effect evaluation criterion, et al. Till now, thedelineation of GTV for esophageal carcinoma still must be accomplished onCT images, but as reported of the related studies, the determination forinvasion depth of tumor was not accurate on CT images especially for lesionsof T1and T2stages, the real lesion length could not be measured on CTimages accurately too. What’s more, CT scan, convensional MRI scan andesophagogram were commonly used for the evaluation of therapeutic effect,there was importment significance to evaluate the short-term therapeuticeffect(TE) objective and accurate, further regimen of treatment could be madeaccording to TE. But definitely short-term TE evaluation criterion stillabsently in current study. The examination of DWI was a new functionaliconography technology, initial study indicated that DWI scanning could beused to diagnose tumor early, clinical stages dividing and TE detection.Because conventional MRI image could manifest the tumor modality clearly,DWI image could afford metabolic information of tumor, and DWI imagecould be tranferred to TPS in radiotherapy department and used for target delineation, DWMRI study had been a hot spot of oncologist. Perspective andretrospective study were performed based on the above background, thepurpose of the series studys was to investigate the concordance of lesionlength measured by DWI and surgical specimen, the application value of DWIin short-term TE and prognosis evaluation.Part1: The Application Value Study of Diffusion-weighted MagneticResonance Imaging(DWI) and CT Scan in the Determination ofLeision Length for Esophageal carcinoma.Objective: Esophageal cancer patients who would receive radicaloperation were perspectively enrolled in this study and the lesion lengthsmeasured by endoscopy, CT scan and DWI at different b values werecompared with pathological length, the objective was to investigate theaccuracy of DWI in determination the length of GTV and affording optimizediconography method which could be referenced in the delineation of GTV foresophageal cancer.Methods: From October2012to May2013,35patients with thoracicesophageal carcinoma received radical operation, all the patients made theexaminations of endoscopy, CT scan of thorax and abdomen, conventionalMRI scan(T1WI、T2WI) and DWI scan before the operation, CT images weretransferred to treatment planning systems(TPS) through local area networkand esophageal gross tumor volume(GTV) were delineated based on CTimages. The region with hyperintense expression on DWI image were definedto the tumor and lesion length were calculated according to the amout sliceswith tumor on axial images. The tumor border were immobilized alonglongitudinal axis after surgical specimen were immobilized by10%formalinand the maximum long diameter of tumor were measured by ruler. Value of(90±10)%was adopted as shrinkage ratio of tumor specimen afterimmobilization, and the real tumor length were calculated by the formula oftumor surgical specimen length/0.9. Mehtod of Intraclass Correlation Coefficient(ICC) and Bland-Altman were used to analyzed the consistency oflesion lengths measured by iconography methods and pathological length.Results:⑴All the patients accomplished the examination ofconventional MRI scan(T1WI、T2WI) and DWI scan, there were4patientshad no esophagus wall thickening on MRI image and had no hyperintenseexpression on DWI image, the false-negative rate of DWI scan was11.4%(4/35).⑵There were31patients who had lesion length measured fromDWI, the length of tumor specimen calculated by ruler was4.12±1.81cm, thecomputative real tumor length was4.58±2.01cm, the lesion length of31patients measured from endoscopy, CT scan, DWI of b=600,800,1000s/mm2were4.56±1.99cm,5.58±2.15cm,4.41±1.93cm,3.99±1.95cm and3.83±1.94cm, respectively, the difference value compared with real tumor lengthwere0.07±1.27cm,1.05±1.37cm,-0.27±0.64cm,-0.69±0.92cm and-0.85±0.95cm. According to Pearson correlatived test, r=0.802,0.786,0.946,0.890and0.833, respectively, P=0.000.⑶According to test of ICC method,the ICC values of lesion lengths measured from endoscopy, CT scan, DWI ofb=600,800,1000s/mm2comparing with real tumor length were0.703,0.764,0.946,0.890and0.882, respectively, P=0.000for all. The reliability of tumorlength measured by endoscopy was only moderately(0.4~.075), the reliabilityof CT was slightly better, and that of DWI at differrent b values wassatisfactory(much greater than0.75). The reliability of lesion length measuredby DWI of b=600s/mm2was maximum and nearly closed to absolutelybilievable(ICC=1). In the results of Bland-Altman test, the mean value ofdifference calculated from endoscopy and DWI of b=600s/mm2compared topathological length was most close to0, which indicated that the resultsmeasured by endoscopy and DWI of b=600s/mm2had a higher concordancewith pathological results. Basing on the comprehensive weight of ICC methodand Bland-Altman menthod, tumor length measured by DWI of b=600s/mm2may be more close to pathogogical result.⑷The results of sub-group analysisshowed that4of9patients of T1stage had no hyperintense expression onDWI image, the false-negative rate was44.4%. The real tumor length of T1 stage was3.05±2.12cm, the resut measured by endoscopy was3.67±1.41cm, the reliability was moderate according to test of ICC method,ICC=0.636, P=0.024. The lesion length of T1stage measured by CT scan was5.22±2.11cm, ICC=0.492, P=0.074, the reference value was not so high. Thereal tumor length of T3and T4stages was4.81±1.74cm, the lesion lengthsmeasure by iconography method were4.80±1.91cm,5.78±1.97cm,4.54±1.68cm,4.11±1.75cm and3.93±1.72cm, respectively, the correspondingICC values were0.734,0.744,0.916,0.829and0.810, respectively, P=0.000for all, the reliability of DWI method was better.⑸The ADC values of tumorat different b values (600,800,1000s/mm2) were (1.69±0.29)×10-3mm2/s,(1.54±0.30) mm2/s,(1.47±0.28)mm2/s, respectively, the correspondingnormal esophageal tissues were(3.12±0.31)×10-3mm2/s,(2.69±0.30) mm2/s,(2.34±0.20)mm2/s, respectively. The higher of b value, the lower of ADCvalue of tumor and normal esophageal tissues. The ADC values of tumor weresignificantly lower than that of normal esophageal tissues according topared-samples T test, t=-15.535,-10.249,-11.892, respectively, P=0.000,0.000,0.000, respectively. There was no significant differrence of ADC valueamong sub-groups of different genders, ages, T stages, pathological categoriesand GTV volumes, P＞0.05.Conclusions: The esophageal tumor lengths measured by DWI scan wasclosely to real tumor length based on surgical specimen and had a highconcordance with pathology. The results measured by DWI scan of b=600s/mm2had the highest reliability and was a optimized reference for tumordelineation. However, the technology of DWI scan did not fit for the diagnosisand lesion length measurement of pristine esophageal carcinoma. The ADCvalue of esophageal cancer was significantly lower than that of normalesophageal tissues, but no relevance was observed between clinical,pathological parameters and ADC values. Part2: The Investigation of Using Diffusion-weighted MagneticResonance Imaging(DWI) to Evaluate Therapeutic Effect ofEsophageal Carcinoma Treated with3DCRT or IMRT.Objective: To investigate the value of DWI in the evaluation oftherapeutic effect of esophageal carcinoma treatment with3DCRT or IMRT,and to direct the clinic treatment program or regimen selection.Methods: From March2010to December2011,77patients withesophageal carcinoma received3DCRT or IMRT treatment. The prescribeddoses were ranged from54Gy-61.2Gy with median dose of60Gy andconventional fraction，33of them received concurrent chemotherapy of FP orTP regimen. All the patients received examination of Diffusion-weightedMagnetic Resonance Imaging(DWI) before, at the end of and3months afterradiotherapy. Therapeutic effect was evaluated by esophagogram, the status ofhyperintense expression in DWI and the value of apparent diffusioncoefficient(ADC). Prognosis analysis was performed associated with theabove facors.Results:⑴There were3patients diagnosed by pathology had nohyperintense expression in the examination of DWI, the false negative ratewas3.90%. In the other74patients, when finished radiotherapy the DWIhyperintense disappeared immediately was23patients, disappeared in3months after radiation was40patients, did not disappeared all the time was11patitents, the1-,2-,3-year survival rates of the anterior two groups were82.6%,56.5%,56.5%and72.5%,48.5%,34.5%， respectively, the1-yearsurvival rate of the third group only was9.1%, all the11patients had died tillthe date of follow up, χ2=38.070，P=0.000。⑵The ADC values of esophagealcarcinoma before radiotherapy,at the end of radiotherapy and normalesophageal tissues were1.64±0.48×10-3mm2/s,2.65±0.58×10-3mm2/s and3.12±0.53×10-3mm2/s，respectively, the ADC value of post-radiotherapy washigher than that of pre-radiotherapy, but they were both lower than that ofnormal esophageal tissues, t=13.737,2.773, and P=0.000,0.009.⑶The CR rates of low value ADC group(≤1.5×10-3mm2/s) and high value ADCgroup(＞1.5×10-3mm2/s) before radiotherapy were55.9%(19/34)and70.0%(28/40), respectively, χ2=1.581, P=0.209. The1-,2-,3-year survivalrates of the two groups were67.6%,40.2%,34.5%and65.0%,46.8%,36.7%,and no existed the significant difference, χ2=0.039, P=0.843. Univariateanalysis of Cox regression indicated the ADC value of pre-radiotherapy wasnot a significant prognosis factor.⑷The CR rates of low value ADCgroup(≤2.6×10-3mm2/s) and high value ADC group(＞2.6×10-3mm2/s) afterradiotherapy were45.9%and81.1%, respectively, χ2=9.855，P=0.002。Therewas a correlathion relationships between the ADC value and therapeuticeffects according to Spearman Bivariate Correlations analysis, r=0.434,P=0.000. The1-,2-,3-year survival rates of the two groups were48.5%,22.7%,13.6%and84.8%,66.0%,5.4%, respectively, survived significantdifference between the two groups, χ2=14.101, P=0.000. Univariate analysisof Cox regression further indicated the ADC value of post-radiotherapy was asignificant prognosis factor.⑸Multivariate analysis of Cox regressionindicated that hyperintense expression of DWI after radiotherapy andnon-surgical T stages were independent prognosis factors with P values of0.000,0.041, OR values of2.911,0.621.Conclusions: The examination of DWI could accurately evaluatetherapeutic effect and prognosis of esophageal carcinoma treated with3DCRTor IMRT. Compared to ADC value of pre-radiotherapy, the ADC value afterradiotherapy had more closed relationships with therapeutic effect andsurvival rate. The DWI hyperintense expression of esophageal carcinoma afterradiotherapy was an independent prognosis factor, and the undisappear ofhyperintense on DWI sequence indicated a poor prognosis. Part3: The Investigation of Using Diffusion-weighted MagneticResonance Imaging(DWI), CT Scan and Esophagogram toEvaluate the Therapeutic Effect of Esophageal PrimaryCarcinoma Treatment with3DCRT or IMRT.Objective: To compare the therapeutic effect(TE) of esophageal primarycancer evaluated by the examination of DWI, CT scan and esophagram, findmor objective and accurate TE evaluation method and therefore direct theclinical further treatment.Methods: From September2012to June2013,36patients withesophageal squamous carcinoma received3DCRT or IMRT treatment. Theprescribed doses were ranged from54Gy-64Gy with median dose of60Gy andconventional fraction，11of them received concurrent chemotherapy of FP orTP. All the patients performed the examinations of DWI, CT scan andesophagogram at the end of treatment. TE was evaluated by short-termtherapeutic effect evaluation criterion of1989version and2013version andhyperintense expression on DWI sequence.Results:⑴According to the short-term therapeutic effect evaluationcreterion of1989version,23patients achieved complete remission(CR) aftertreatment(63.89%),13achieved partly remission(PR)(36.11%), the1-yearlocal control rates of the two groups were70.6%and46.7%, respectively,χ2=1.135, P=0.287, the1-year survival rates were66.9%and57.7%,respectively, χ2=0.498, P=0.480.⑵The maximum tumor wall thicknessesof pre-radiotherapy(RT) and post-RT were2.24±0.89cm and1.03±0.29cm,the contraction rate of tumor wall thickness was (52.3±0.21)%. According tothe TE eavluation criterion of2013version which based the examination ofesophagogram and CT scan,18patients achieved CR(50.0%) and18achievedPR(50.0%), the1-year local control rates were82.4%and40.8%, respectively,χ2=4.219, P=0.040, the1-yeat survival rates were80.0%and49.5%,respectively, χ2=2.514, P=0.113.⑶According to the examination of DWI,14patients’ hyperintense disappeared completely at the end of radiotherapy,15 patients’ had a slightly hyperintense expression and7still had hyperintenseexpression on DWI sequence, the1-year local control rates were83.3%,60.6%and14.3%, respectively, χ2=23.448, P=0.000. In the group of still havinghyperintense expression(7pts), tumor control failure happened in6patients.The1-year survival rates of the three groups were69.6%,71.1%and0,respectively, χ2=6.235, P=0.044. The group whose hyperintense disappearedcompleted of DWI was defined to CR, and the others were defined to PR, theTE results evaluated by DWI and TE evaluation criterion of2013version werecompared according to Kappa test, as a result, the Kappa corfficient was0.444,P=0.006.⑷According to the examination of esophagogram, CT scan andDWI,11patients acieved CR in all exams, the local control rate was100%forthis group. The more obvious of tumor contraction according to esophagogramand CT scann, the more patients’ hyperintense disappeared completely aftertreatment, but the tumor change of morphology could not react thehyperintense expression on DWI sequence.⑸The ADC value of pre-RT,post-RT and normal esophageal tissues were1.67±0.44×10-3mm2/s,2.39±0.49×10-3mm2/s and3.04±0.30×10-3mm2/s, respectively, the ADC valueof post-RT was higher than that of pre-RT, t=-7.844, P=0.000, but the twoformers were both lower than that of normal esophageal tissues, t=-20.339,-10.286, P=0.000,0.000. The1-year local control rates of high ADC group(＞2.60×10-3mm2/s) and low ADC group(≤2.60×10-3mm2/s) were84.7%,37.5%, respectively, χ2=10.020, P=0.002, the1-year survival rates of thetwo groups were80.0%,44.9%, respectively, χ2=3.838, P=0.050. Univariatanalysis of Cox regression model indicated that ADC value of post-RT was ainfluence factor of local control, Wald=7.099, P=0.008, OR=0.114, and withthe95%CI of0.023to0.563.⑹The status of CR evaluated by esophagogram,CT scan and DWI was made a observe event in ROC(Receiver Operatingcharacteristic Curve) analysis, as a result, the area under the cure was0.737,the finded cut-off point was2.55×10-3mm2/s, with the correspondingsensitivity of81.8%, specificity of58.3%. For the group of ADC value≤2.55×10-3mm2/s after treatment, the CR rate of primary was only11.8%(2/17), for the group of ADC value＞2.55×10-3mm2/s, the CR rate was47.4%(9/19),χ2=4.900, P=0.027.Conclusions: The esophagogram and CT based TE evaluation criterioncould indicate local control status of esophageal cancer well, the examinationof DWI could afford visualized and quantifying reference information aboutthe TE of esophageal cancer, the expression of hyperintense at the end of RTindicated a high risk of recurrence, the post-RT ADC value of less than2.55×10-3mm2/s suggested a worse prognosis. The therapeutic effect evaluated byesophagogram, CT scan and DWI maybe more objective and more accurate,the therapeutic effect of CR evaluated congenerously by esophagogram, CTscan and DWI indicated a high local control probability. |
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