| Summary: | This study aimed to compare the diagnostic performances of endoscopic ultrasound (EUS) and FDG PET/CT in the preoperative T-staging of esophageal squamous cell carcinoma (ESCC) and determine whether their innovative coordination achieves better prediction. In total, 100 patients diagnosed with ESCC, 57 without (CRT<sup>[−]sub</sup>) and 43 with (CRT<sup>[+]sub</sup>) neoadjuvant chemoradiotherapy, undergoing EUS and FDG PET/CT, followed by surgical resection of the tumor, were included in this analysis. EUS classified T-stages based on the depth of primary tumor invasion, and FDG PET/CT used thresholded maximal standardized uptake value (SUV<sub>max</sub>) classifications. By employing pathology results as the reference standard, we assessed the accuracy of EUS and FDG PET/CT, evaluated their concordance using the κ statistic, and conducted a comparative analysis between the two modalities through McNemar’s chi-square test. FDG PET/CT had higher overall accuracy than EUS (for CRT<sup>[−]sub</sup>: 71.9%, κ = 0.56 vs. 56.1%, κ = 0.31, <i>p</i> = 0.06; for CRT<sup>[+]sub</sup>: 65.1%, κ = 0.50 vs. 18.6%, κ = 0.05, <i>p</i> < 0.01) in predicting pT- and ypT-stage. Our proposed method of incorporating both FDG PET/CT and EUS information could achieve higher accuracies in differentiating between early and locally advanced disease in the CRT<sup>[−]sub</sup> group (82.5%) and determining residual viable tumor in the CRT<sup>[+]sub</sup> group (83.7%) than FDG PET/CT or EUS alone. FDG PET/CT had a better diagnostic ability than EUS to predict the (y)pT-stage of ESCC. Our complementary method, which combines the advantages of both imaging modalities, can deliver higher accuracy for clinical applications of ESCC.
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