Is 18F-FDG PET and PET/CT imaging used appropriately for staging of esophageal carcinoma?

Objectives The aim of the study was to determine whether 18F-FDG PET or PET/CT scans performed for patients with newly diagnosed esophageal carcinoma were “appropriate” based on nationally-accepted consensus guidelines. For patients who did not have PET or PET/CT performed, we sought to determine if a scan would have been appropriate but was not ordered.

Methods We retrospectively reviewed the medical records of 109 patients with a recent diagnosis of esophageal carcinoma between January 2008 and July 2013. A clinical stage was determined for each patient based on American Joint Committee on Cancer guidelines. For patients who had PET or PET/CT scans performed for initial staging, each scan was rated as appropriate or inappropriate based on National Cancer Center Network (NCCN) esophageal carcinoma guidelines. For patients who did not have a PET or PET/CT scan, we used NCCN guidelines to determine whether a scan would have been appropriate for initial staging.

Results Nine of the original 109 patients were excluded due to misclassification of gastric rather than esophageal carcinoma, other primary carcinomas of the esophagus (i.e., lymphoma), or a scan performed for tumor of unknown primary origin. Of the 100 remaining patients, 65 (65%) had a PET or PET/CT performed. The scan was classified as appropriate in 59/65 (91%) patients and inappropriate in 6/65 (9%) patients. The study changed stage in 13/59 (22%) of the appropriate scans and 0/6 (0%) of the inappropriate scans. Thirty-five of 100 (35%) patients did not have a PET or PET/CT scan ordered for initial staging. However, a scan would have been appropriate in 25/35 (71%) patients and would have been inappropriate in 10/35 (29%) patients.

Conclusions Based on NCCN guidelines, PET was underutilized for patients with newly diagnosed esophageal carcinoma. Few inappropriate PET scans were performed for this indication. Inappropriate scans had limited diagnostic yield.