Cervical ultrasonography has no additional value over negative 18F-FDG PET/CT scans for diagnosing cervical lymph node metastases in patients with oesophageal cancer

Abstract

ObjectivesTo investigate the additional value of cervical ultrasonography over 18F-FDG PET/CT for diagnosing cervical lymph node metastases in patients with newly diagnosed oesophageal cancer.MethodsBetween January 2013 and January 2016, 163 patients with newly diagnosed oesophageal cancer underwent both cervical ultrasonography and 18F-FDG PET/CT at a tertiary referral centre in the Netherlands. Retrospective clinical data analysis was performed to assess the diagnostic value of cervical ultrasonography and 18F-FDG PET/CT for the detection of cervical lymph node metastases. Fine needle aspiration or clinical follow-up was used as reference standard.ResultsThe overall incidence of patients with cervical lymph node metastases was 14%. The sensitivity of 18F-FDG PET/CT to detect cervical lymph node metastases was 82% (95% CI 59–94%) and specificity was 91% (95% CI 85–95%). The sensitivity and specificity of cervical ultrasonography were 73% (95% CI 50–88%) and 84% (95% CI 77–90%), respectively. In patients with a negative 18F-FDG PET/CT, 12 of 133 (9%) patients had suspicious nodes on cervical ultrasonography. In all these 12 patients the nodes were confirmed benign.ConclusionsCervical ultrasonography has no additional diagnostic value to a negative integrated 18F-FDG PET/CT for the detection of cervical lymph node metastases in patients with newly diagnosed oesophageal cancer.Key Points• Cervical ultrasonography has no value over PET/CT in evaluating cervical node metastases. • PET/CT provides greater diagnostic confidence compared to cervical ultrasonography. • Cervical ultrasonography during standard diagnostic work-up may be considered unnecessary. • Cervical lesions on PET/CT require cytopathological confirmation by FNA.

Cervical Lymph Nodes Detected by F-18 FDG PET/CT in Oncology Patients: Added Value of Subsequent Ultrasonography for Determining Nodal Metastasis

“…A recent study argues that neck US has no additional value over negative PET/CT for diagnosing cervical LN metastases in esophageal cancer [26]. However, this study had a limitation on the generalizability of its results for the following reasons: (1) it was confined to esophageal cancer with various TNM staging; (2) it did not apply the clinically available cut-off value of SUVmax for determining metastasis; (3) the incidence of cervical LN metastasis in patients with esophageal cancer is not uncommon (up to 23%) owing to the dual embryologic origin of lymphatic pathways from branchiogenic and body mesenchyme, resulting in lymphatic interconnections among the three segmental drainage regions of the esophagus [27]; and (4) in general, only PET/CT positive LNs are of interest in oncology patients for the clinician to decide whether to perform additional examinations using other imaging modalities or tissue confirmation.…”

Commentary: Fluorodeoxyglucose–positron emission tomography/computed tomography for cervical adenopathy in esophageal carcinoma, an option for the selective surgeon

“…These findings are in contrast to other recent publications. In a recent paper by Goense and colleagues, 7 PET/CT was found to be both sensitive and specific for disease located in cervical nodes (82% and 91%, respectively). However, as opposed to the study by Li and colleagues, 6 an ultrasound-directed node biopsy revealing tumor in cervical nodes was preclusive of surgery in this group's study.…”

“…However, as opposed to the study by Li and colleagues, 6 an ultrasound-directed node biopsy revealing tumor in cervical nodes was preclusive of surgery in this group's study. 7 Ouside of their study, surgeons from the study by Li and colleagues 6 selectively use 3-field dissection based on findings from imaging and ultrasound. These conflicting findings between the 2 studies are not altogether exclusive nor unanticipated if we adjust for clinical stage and expected prevalence of disease.…”