The Role of 18F-FDG PET/CT in Predicting the Pathological Response to Neoadjuvant Immunochemotherapy and Prognosis for Resectable Esophageal Squamous Cell Carcinoma

Fei Wang; Rui Guo; Xiangxi Meng; Hua Su; Xin Zhou; Yang Liu; Zhongwu Li; Zhi Yang; Nan Li

doi:10.1016/j.acra.2026.01.056

The Role of 18F-FDG PET/CT in Predicting the Pathological Response to Neoadjuvant Immunochemotherapy and Prognosis for Resectable Esophageal Squamous Cell Carcinoma

Acad Radiol. 2026 Feb 17:S1076-6332(26)00085-1. doi: 10.1016/j.acra.2026.01.056. Online ahead of print.

Authors

Fei Wang¹, Rui Guo¹, Xiangxi Meng¹, Hua Su¹, Xin Zhou¹, Yang Liu¹, Zhongwu Li², Zhi Yang³, Nan Li⁴

Affiliations

¹ Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Beijing Key Laboratory of Research, Investigation and Evaluation of Radiopharmaceuticals, NMPA Key Laboratory for Research and Evaluation of Radiopharmaceuticals (National Medical Products Administration), Department of Nuclear Medicine, Peking University Cancer Hospital & Institute, No. 52, Fu-cheng Rd., Haidian District, Beijing 100142, China (F.W., R.G., X.M., H.S., X.Z., Y.L., N.L.).
² Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Pathology, Peking University Cancer Hospital & Institute, Beijing, China (Z.L.).
³ State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers, Beijing Key Laboratory of Research, Investigation and Evaluation of Radiopharmaceuticals, NMPA Key Laboratory for Research and Evaluation of Radiopharmaceuticals (National Medical Products Administration), Department of Nuclear Medicine, Peking University Cancer Hospital & Institute, Beijing, China (Z.Y.).
⁴ Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Beijing Key Laboratory of Research, Investigation and Evaluation of Radiopharmaceuticals, NMPA Key Laboratory for Research and Evaluation of Radiopharmaceuticals (National Medical Products Administration), Department of Nuclear Medicine, Peking University Cancer Hospital & Institute, No. 52, Fu-cheng Rd., Haidian District, Beijing 100142, China (F.W., R.G., X.M., H.S., X.Z., Y.L., N.L.). Electronic address: rainbow6283@sina.com.

PMID: 41708387
DOI: 10.1016/j.acra.2026.01.056

Abstract

Rationale and objectives: Accurately predicting tumor response to neoadjuvant immunochemotherapy (NICT) and patient prognosis remains challenging in esophageal cancer. This study aimed to explore the value of ¹⁸F-FDG PET/CT in predicting the pathological response and prognosis of patients with resectable esophageal squamous cell carcinoma (ESCC) undergoing NICT.

Materials and methods: Patients who underwent NICT between January 2020 and April 2024 were retrospectively analyzed. ¹⁸F-FDG PET/CT scans were performed before (scan-1) and after NICT (scan-2). Parameters derived from ¹⁸F-FDG PET/CT and enhanced CT were analyzed for response evaluation and survival prediction. The pathological tumor regression grade served as the gold standard for response evaluation.

Results: Among the 94 patients, 41 patients (43.6%) achieved a major pathological response (MPR). ¹⁸F-FDG PET/CT identified more responders than CT. Compared with non-MPR patients, those achieving MPR demonstrated significantly lower uptake on scan-2 and a greater relative reduction (Δ%) between scan-1 and scan-2. The SUV_max of scan-2 demonstrated the best predictive performance for MPR (AUC = 0.829). The SUL_peak of scan-2 showed the highest sensitivity for predicting MPR (90.2%). Multivariate analysis indicated that CPS, SUV_max-2, and ΔSUV_max% were independent predictors of MPR, while pathological stage, PERCIST, and TLG-2 were independent predictors of PFS; further, the pathological stage, PERCIST, and ΔMTV% were independent predictors of OS. Patients with TLG-2 < 8.1 or ΔMTV% > 75.5% indicated better treatment response and longer survival.

Conclusion: Parameters after NICT and their changes before and after treatment were valuable in identifying patients achieving MPR and predicting prognosis. ¹⁸F-FDG PET/CT is a potentially valuable method for predicting the pathological response to NICT and the prognosis of resectable ESCC.

Take-home message: Metabolic parameters after NICT and their changes from baseline were valuable for identifying MPR and predicting prognosis. Post-treatment SUV_max and SUL_peak may serve as effective predictors of MPR, while a favorable PERCIST or lower TLG-2 relates to improved PFS, and a favorable PERCIST or higher ΔMTV% correlates with prolonged OS.

Keywords: (18)F-FDG PET/CT; Esophageal squamous cell carcinoma; Neoadjuvant therapy; Pathological response; Prognosis.