The utility of FDG-PET in the preoperative staging of esophageal cancer

Abstract

Accurate staging of esophageal cancer is important when determining which patients will potentially benefit from curative surgery. The aim of this study was to evaluate the incremental effect of 2-fluoro-2-deoxyglucose positron emission tomography (FDG-PET) when used in addition to standard staging modalities. Patients referred to two surgeons in an Australian metropolitan teaching hospital with esophageal or esophago-gastric junction malignancy between May 2002 and December 2006 were included. Patients who had undergone prereferral treatment with chemotherapy or radiotherapy were excluded. Patients undergoing resection for gastrointestinal stromal tumors or high-grade dysplasia within Barrett's esophagus were also excluded. Clinical and non-clinical data were recorded prospectively. Pretreatment staging included routine CT scan and selective endoscopic ultrasound (EUS). FDG-PET was performed in patients judged to have curable disease on CT scanning and EUS. From a total of 130 eligible patients, 76 were judged to have curable disease on the basis of CT and EUS findings. Of these 76 patients, 19 (25%) were excluded from surgery due to additional information obtained from FDG-PET. The addition of FDG-PET to routine preoperative staging resulted in the exclusion from surgery of 19 (25%) patients who prior to the introduction of FDG-PET would have undergone attempted resection. FDG-PET should be performed in all patients under consideration for esophagogastric resection in order to avoid resection in patients with disseminated disease.

Additional benefit of 18F-fluorodeoxyglucose integrated positron emission tomography/computed tomography in the staging of oesophageal cancer

“…PET/CT led to a change in the management plan of 17% of patients, with occult metastases being detected in 11%. This latter figure is similar to that reported by the three earlier smaller studies of PET/CT; it is considerably lower, however, than that reported by many earlier studies of PET where unexpected metastases, not demonstrated by CT or EUS, were detected in up to 25% of patients [2,3,11,12]. This is likely because all MDCT examinations were reviewed by a gastrointestinal specialist radiologist, with specific expertise in oesophageal MDCT, at a centralised multidisciplinary meeting before referral for PET/CT.…”

“…The use of FDG PET to improve the accuracy of staging oesophageal cancer has been well described [2,3,[9][10][11][12]. The largest study to date, involving 199 patients, reported upstaging by PET of just 4% of patients, leading the authors to conclude that it offered limited additional value over a comprehensive staging protocol, consisting of CT, EUS and neck US with selective FNA cytology, and that its widespread introduction into routine clinical practice was questionable [4].…”

“…Only one case in our series, a non-avid 13 mm liver metastasis, might be considered to be a true failure of PET/CT staging. The reported false negative rate for PET varies from 3% to 12% [2][3][4][10][11][12]. In a population-based cohort study the false negative rate for PET/CT was just 1%, although the proportion of patients who underwent laparoscopy was not stated and may have varied widely between the different centres involved [14].…”

“…The main strength of PET lies in its ability to detect unsuspected distant metastases in up to 20-25% of patients thought to have potentially resectable disease based on CT and EUS [2,3]. A large prospective study, however, reported that PET detected occult metastases in just 4% of patients after a comprehensive staging scheme, leading the authors to conclude that it offered only limited additional value [4].…”

Surgical Outcomes Associated with Oesophagectomy in New South Wales: An Investigation of Hospital Volume

“…Accurate and comprehensive preoperative staging with computed tomography, positron emission tomography (PET) scanning, endoscopic ultrasound (EUS) and laparoscopy improves patient selection for surgery by excluding those with metastases and may increase postoperative survival. [8][9][10] Determinants of outcomes from oesophageal cancer surgery include hospital volume (as a proxy measure for surgeon and/or facility experience), hospital peer group classification, tumour stage and location and patient comorbidity. [11][12][13][14][15] Outcomes which are frequently measured include in-hospital mortality, morbidity and survival.…”