Prognostic value of abdominal aortic calcification in patients with esophageal cancer undergoing neoadjuvant therapy and esophagectomy

BACKGROUND: Computed tomography (CT) is a first line imaging tool for staging of esophageal cancer (EC). Previous studies have shown promising results of the prognostic relevance of vessel calcifications quantified by CT, especially coronary and aortic calcifications, in oncological patients. The aim of this study was to analyze the prognostic relevance of aortic calcification assessed in staging CT in patients with EC undergoing curative treatment. METHODS: All patients with EC treated with neoadjuvant therapy followed by curative resection at the University of Leipzig Medical Center, a tertiary care hospital, were retrospectively evaluated between 2016 and 2023. A total of 89 patients were included in the analysis. Abdominal aorta and iliac artery calcification volume was measured in a semi-automated fashion at baseline before neoadjuvant therapy using staging CT images. The primary endpoint was overall survival and disease-free survival was assessed as a secondary endpoint. For statistical analysis group differences were calculated using the Mann-Whitney-U test. Kaplan-Meier curves and multivariable Cox regression analysis were used to test the effect of aortic calcification volume and clinical variables on mortality. RESULTS: In univariable Cox regression, higher abdominal aortic calcification volume was significantly associated with shorter overall survival (Hazard ratio (HR) 1.259 per 1 cm³, 95% CI: 1.100-1.411, p < 0.001) and disease-free survival (HR 1.279 per 1 cm³, 95% CI: 1.135-1.411, p < 0.001). The abdominal aortic calcification volume remained an independent predictor of overall survival in multivariable analysis (HR 1.248, 95% CI 1.069-1.458, p = 0.005). Kaplan-Meier analyses demonstrated progressively reduced overall survival and disease-free survival with increasing abdominal aortic calcification volume. CONCLUSIONS: CT-quantified abdominal aortic calcification provides independent prognostic information for both overall and disease-free survival in patients with EC undergoing neoadjuvant therapy followed by curative resection. Prospective evaluations of CT-defined vessel calcification and potential translation in clinical routine seem promising.