The role of PET scan in the preoperative management of oesophageal cancer

doi:10.1016/j.ejso.2004.07.020

European Journal of Surgical Oncology (EJSO)

Volume 30, Issue 9, November 2004, Pages 942-947

https://doi.org/10.1016/j.ejso.2004.07.020 Get rights and content

Abstract

Aim

The aim of this study was to evaluate the role of the ¹⁸F-FDG-PET in the preoperative evaluation of patients with oesophageal or gastro-oesophageal junction (GEJ) cancer and to define its impact on therapeutic management.

Patients and methods

This study included 58 patients with biopsy proven oesophageal or GEJ cancer who underwent PET in addition to the conventional diagnostic work-up. The sensitivity, specificity and accuracy of CT and PET were calculated for detection of tumour and distant metastases.

Results

The sensitivity, specificity and accuracy of tumour detection were, respectively, 84, 100 and 84% for CT and 87, 100 and 87% for PET (p=ns). PET permitted detection of distant metastases, which were not seen on CT in seven patients. In two patients, a second primary tumour was detected on PET.

Conclusions

The sensitivity of PET for loco regional lymph nodes detection is low. The major clinical impact is the detection of distant metastases.

Introduction

Most patients with oesophageal cancer in Western European countries present with advanced disease and consequently have a poor prognosis. After surgical resection, the overall 5-year survival is only 15–39%.1, 2 Nevertheless, surgery for oesophageal cancer offers the best chance of cure.³ The accurate determination of the extent of local tumour invasion (T), of lymph node involvement (N), and of metastases (M) at the time of diagnosis provides valuable prognostic information and help in selecting appropriate treatment. The poor long term survival in patients who have a complete tumour resection (R0) seems to be related to failure to detect distant metastases at the time of surgery.4, 5 The survival rates of non-curative surgery are similar to those achieved with non-surgical therapy using combined chemo-radiation.⁶ Surgery in patients with advanced disease can be avoided if accurate preoperative staging information is available. Computed tomography (CT) scan is the most common imaging technique for oesophageal cancer staging, but is fraught with low sensitivity yield.⁷ Endoscopic ultra sonography (EUS) is more accurate for local tumour invasion and regional lymph node metastasis, but passing the probe through a stenotic tumour may be impossible in 20–50% of cases in the literature.8, 9, 10 Laparoscopic surgery has been shown to be more accurate than CT in the preoperative staging of gastro-oesophageal junction tumours (GEJ), but it is more invasive.¹¹ Recent reports indicate a role for whole-body positron emission tomography (PET) using the radiolabeled glucose analogue ¹⁸F-FluoroDeoxyGlucose (FDG) for the preoperative staging of oesophageal and GEJ malignancies.12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25 Furthermore, PET seems more accurate for the extent of disease than other imaging methods, and may lead to a radical change in patient management.

The aim of this study was to report the role of FDG-PET in the preoperative evaluation of patients with oesophageal and/or GEJ cancer.

Section snippets

Patient selection

This study included 58 patients admitted at our institution between November 1998 and December 2002 with biopsy proven de novo oesophageal or GEJ cancer who underwent FDG-PET in addition to the conventional diagnostic work-up. This consisted of patient history, physical examination, laboratory tests, fiberoptic bronchoscopy and ENT examination, barium swallow, EUS and thoraco-abdominal CT scan. Forty-three underwent oesophagectomy; 13 patients were treated by palliative chemotherapy for distant

Results

58 patients were included in this study (47 men; 11 women) with a mean age of 60±10.3 years (range 37–80 years). The clinical and histological data are reported in Table 1. There were 31 squamous cell carcinoma, 26 adenocarcinoma and one adenosquamous tumours. There were, respectively, six, 22 and 30 tumours situated in the upper, middle and lower third and/or GEJ.

Staging

For preoperative staging and assessment of resectability, oesophageal contrast enhanced CT scan and EUS are both the most used imaging techniques. CT is poor at assessing lymph node involvement and EUS is limited in cases of obstruction or stenosis, which are reported in 20–50% of cases.8, 9, 10

The role of PET in various tumours has been widely investigated in recent years. PET has the advantage to offer an alternative method of evaluation providing a functional image of the tumour, opposite to

Conclusion

The sensitivity of PET in loco regional lymph nodes is low. Our experience is similar to previous reports, probably because of poor spatial resolution of PET. The major clinical impact was the detection of distant metastases and/or synchronous malignancies in a small number of patients. PET may have an important complementary role in the preoperative management of patients with oesophageal cancer, enhancing the selection for curative surgery.

References (35)

Y. Refaely et al.
Multimodality therapy for esophageal cancer
Surg Clin North Am
(2002)
S.C. Chung et al.
Surgical therapy for squamous-cell carcinoma of the oesophagus
Lancet
(1994)
H.S. Saunders et al.
Esophageal cancer
Radiol Clin North Am
(1997)
J. Luketich et al.
The role of positron emission tomography in staging esophageal cancer
Ann Thorac Surg
(1997)
S. Rankin et al.
Computed tomography and positron emission tomography in the pre-operative staging of esophageal carcinoma
Clin Radiol
(1998)
H. Kato et al.
Usefulness of positron emission tomography for assessing the response of neoajuvant chemoradiotherapy in patients with esophageal cancer
Am J Surg
(2002)
P. Flamen et al.
The utility of positron emission tomography for the diagnosis and staging of recurrent esophageal cancer
J Thorac Cardiovasc Surg
(2000)
I. El Nakadi et al.
Does esophagectomy cure a resectable esophageal cancer?
World J Surg
(1993)
B.J. Roth
L.L. Anderson et al.
Autopsy findings in squamous-cell carcinoma of the esophagus
Cancer
(1982)

A. Herskovic et al.

Combined chemotherapy and radiotherapy compared with radiotherapy alone in patients with cancer of the esophagus

N Engl J Med

(1992)

P.A. Barbier et al.

Quality of life and patterns of recurrence following transhiatal esophagectomy for cancer: results of a prospective follow-up in 50 patients

World J Surg

(1988)

K. Ziegler et al.

Evaluation of endosonography in TN staging of esophageal cancer

Gut

(1991)

H.J. Dittler et al.

Role of endoscopic ultrasonography in esophageal carcinoma

Endoscopy

(1993)

M.G. O'Brien et al.

A prospective comparison of laparoscopy and imaging in the staging of esophagogastric cancer before surgery

Am J Gastroenterol

(1995)

S. Yasuda

Application of whole body positron emission tomography in the imaging of esophageal cancer: report of a case

Surg Today

(1995)

J. Luketich et al.

A comparaison of endoscopic ultrasound and minimally invasive surgical staging in esophageal cancer

Am J Gastroenterol

(1996)

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Endoscopic ultrasonography (EUS) plays an important role in the diagnosis and staging of luminal gastrointestinal tumors. Esophageal and gastric cancer and other gastrointestinal tumors such as gastric lymphoma are staged using a combination of EUS and computed tomography (CT), with or without positron emission tomography (PET). EUS is the most accurate modality for local regional staging of esophageal and gastric cancer. EUS evaluates the individual esophageal and gastric wall layers and can sample lymph nodes distant to the primary tumor by fine-needle aspiration (FNA). This improves the tumor staging accuracy and thereby the best mode of therapy. In addition, EUS plays an important role in evaluating patients with large gastric folds of unclear origin, with the aim of diagnosing infiltrative diseases such as lymphoma, Ménétrier disease, or linitis plastica.
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Metastatic spread from oesophageal cancer can occur in unusual and unexpected locations and whole-body PET/CT allows for detection of those metastases that are not covered with conventional strategies, that are radiologically occult, or that are difficult to diagnose prospectively.64,65 By detecting unexpected distant metastases preoperatively, PET/CT decreases the number of inappropriate attempts of surgical exploration and should therefore be performed as a routine part of initial staging (Figs 4–5).3,57,66,67 Several studies have also reported usefulness of PET/CT for detection of new interval metastases after neoadjuvant therapy, which occur in 8–17% of patients.68–70
Integrated 2-[¹⁸F]-fluoro-2-deoxy-d-glucose (FDG) PET/CT and magnetic resonance imaging (MRI) with functional features of diffusion-weighted imaging (DWI) are advancing imaging technologies that have current and future potential to overcome important limitations of conventional staging methods in the management of patients with oesophageal cancer. PET/CT has emerged as an important part of the standard work-up of patients with oesophageal cancer. Besides its important ability to detect unsuspected metastatic disease, PET/CT may be useful in the assessment of treatment response, radiation treatment planning, and detection of recurrent disease. In addition, high-resolution T2-weighted MRI and DWI have potential complementary roles. Recent improvements in MRI protocols and techniques have resulted in better imaging quality with the potential to bring improvement in staging, radiation treatment planning, and the assessment of treatment response. Optimal use and understanding of PET/CT and MRI in oesophageal cancer will contribute to the impact of these advancing technologies in tailoring treatment to the individual patient and achieving best possible outcomes. In this article, we graphically outline the current and potential future roles of PET/CT and MRI in the multidisciplinary management of oesophageal cancer.
Clinical staging of patients with early esophageal adenocarcinoma: Does FDG-PET/CT have a role?
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Esophageal carcinoma is a significant worldwide health problem and the incidence is increasing faster than that of any other malignancy. 18F-2-deoxy-D-glucose (FDG)-positron emission tomography/computed tomography (PET/CT) is important in the management of patients with potentially resectable esophageal cancer and is useful in initial staging of locally advanced cancer and after neoadjuvant therapy. The purpose of this study is to determine the utility of FDG-PET/CT in the clinical staging of early-stage esophageal cancer.
Subjects in this retrospective study were 79 consecutive patients with cTisN0 (high-grade dysplasia) and cT1N0 primary esophageal adenocarcinoma diagnosed by endoscopy and endoscopic ultrasound biopsy that were evaluated with preoperative FDG-PET/CT and had not received neoadjuvant therapy. Seventh edition American Joint Committee on Cancer cTNM and FDG-PET/CT were compared with postoperative pTNM staging. pT1 was subdivided into intramucosal cancers with lamina propria or muscularis mucosa invasion (pT1a) and submucosal cancers (pT1b).
In pT staging, the frequency of FDG uptake increased with increasing pT, from pT1a 21 of 39 (53.8%) to pT1b 19 of 22 (55.8%). pTis was three of five (60.0%). Similarly, the maximum standardized uptake value of FDG-avid lesions increased with increasing pT, with median values of 3.7 for pTis, 3.8 for pT1a and 4.2 for T1b. In cN staging, FDG-PET/CT was negative in 76 patients and positive in three patients. All three patients with FDG-avid nodes on FDG-PET/CT were negative for metastatic disease on biopsy. In 12 patients with pN1 and in one patient with N2, FDG-PET/CT was falsely negative. Sensitivity and positive predictive value for pN disease were 0% and accuracy was 82%. There were no distant metastases. In cM staging, FDG-PET/CT was falsely positive in five patients (FDG avid nodules n = 3, distant nodal metastasis n = 2) and resulted in unwarranted biopsy in four patients.
FDG-PET/CT is not useful in the TNM staging of primary adenocarcinoma of the esophagus when endoscopy and biopsy indicate cTis and cT1. In fact, FDGPET/CT can be detrimental to patient management. Because regional nodal metastases are uncommon and distant metastases rare, and as FDG-PET/CT can result in inappropriate clinical care, FDG-PET/CT should not be performed in the evaluation of early-stage esophageal cancer.
Role of positron emission tomography-computed tomography in gastrointestinal malignancies
2013, Radiologic Clinics of North America
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The shortcomings of these modalities may be related to the high percentage of patients who historically experience recurrent disease soon after radical resection. Similar to its utility in other malignancies, FDG PET has shown usefulness in this aspect of staging.30–32 This fact is of particular importance given that 20% to 30% of patients with esophageal carcinoma present with metastatic disease, to either nonregional lymph nodes or other organs.16
Clinical usefulness of dual-time FDG PET-CT in assessment of esophageal squamous cell carcinoma
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We conducted this study to investigate the value of the dual-time 2-[¹⁸F]fluoro-2-deoxy-d-glucose (FDG) positron emission tomography–computed tomography (PET–CT) in assessment of the primary tumor, loco-regional lymph node and distant metastasis in patients with esophageal squamous cell carcinoma.
Twenty-six patients with histologically proved esophageal squamous cell carcinoma underwent dual-time FDG PET–CT before radical surgery. The standardized uptake values (SUV_max) were obtained including early SUV_max and delayed SUV_max, respectively. The retention index (RI) was also calculated. The results were evaluated retrospectively according to the final pathologic findings. Four diagnostic criteria including (1) early SUV_max ≧ 2.5 alone, (2) RI ≧ 10% alone, (3) a combination of early SUV_max ≧ 2.5 and RI ≧ 10%, and (4) a combination of early SUV_max ≧ 2.5 or RI ≧ 10% were used for differentiating malignancy from a benign lesion, respectively.
The sensitivity of FDG PET–CT in detecting the primary tumor with combination of early SUV_max ≧ 2.5 or RI ≧ 10% was 96.2%. It was statistically significantly higher than the results using the other three criteria (p < 0.0001). For loco-regional lymph node detection, there was no significant difference among the 4 criteria. For distal metastases, the significantly higher specificity (100%) was found when using combination of early SUV_max ≧ 2.5 and RI ≧ 10% or using early SUV_max ≧ 2.5 alone than using the other two criteria (p = 0.0058). With regard to accuracy, no significant correlations were observed among primary tumor, loco-regional lymph nodes and distant metastasis (p > 0.05).
The preliminary result of this study demonstrated that dual-time point FDG PET–CT had limited value in detection of primary tumor and loco-regional lymph nodes metastasis. For the distant metastasis, the sensitivity and specificity would be improved if RI ≧ 10% is used as a supplemental criterion. Efforts should be made to improve the ability of the dual-time FDG PET–CT technique to assess primary tumor and loco-regional lymph nodes metastasis.
Prediction of Metastatic Disease and Survival in Patients with Gastric and Gastroesophageal Junction Tumors. The Incremental Value of PET-CT over PET and the Clinical Role of Primary Tumor Volume Measurements
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To investigate the accuracy of M staging (staging of metastatic disease) in esophageal carcinoma based on a visual interpretation and based on tumor volume measurements on positron emission tomography (PET) computed tomography (CT).
Fifty-nine untreated patients with gastroesophageal junction tumors were enrolled, including 36 subcardial gastric tumors (type III according to Siewert classification) and 23 adenocarcinomas of the cardia (AEG, type II Siewert). Patients were grouped in metastasis free (M0 stage, n = 34) and metastatic stages (M1 stage, n = 25). Tumor volume and mean and maximum standardized uptake value were measured on PET-CT. The accuracy of these quantitative tumor volume parameters in distinguishing metastasis-free tumors (M0 stage) from metastatic stages (M1 stage) was compared to the accuracy of a visual analysis with fused PET-CT. Furthermore, accuracy of PET-CT was compared to PET reviewed side by side with CT in a lesion-based analysis of 84 distant metastatic sites.
In the visual interpretation, PET-CT (accuracy 88%, 74/84) was more accurate than PET (accuracy 78%, 66/84; P = .008) in characterizing the 84 potential metastatic sites in the 59 patients. Among the tumor parameters, the PET-CT tumor volume was the most accurate predictor of M1 stage and overall survival. With a threshold of 39 mL, PET-CT volume was able to predict M1 stage disease with a sensitivity of 96% and a specificity of 85%. The accuracy of M-staging was increased further when combining tumor volume measurements with the results from the visual analysis (combined results: sensitivity 96%, specificity 94%).
PET-CT was more accurate than PET (reviewed side by side with CT) in characterizing distant metastatic sites of gastroesophageal junction carcinomas. The highest accuracy for M-staging was obtained when combining the results of the visual analysis with the results from primary tumor volume measurements. Primary tumor volume was shown to be an independent prognostic factor.

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The role of PET scan in the preoperative management of oesophageal cancer

Abstract

Aim

Patients and methods

Results

Conclusions

Introduction

Section snippets

Patient selection

Results

Staging

Conclusion

Surg Clin North Am

Lancet

Radiol Clin North Am

Ann Thorac Surg

Clin Radiol

Am J Surg

J Thorac Cardiovasc Surg

Does esophagectomy cure a resectable esophageal cancer?

World J Surg

Autopsy findings in squamous-cell carcinoma of the esophagus

Cancer

Combined chemotherapy and radiotherapy compared with radiotherapy alone in patients with cancer of the esophagus

N Engl J Med

Quality of life and patterns of recurrence following transhiatal esophagectomy for cancer: results of a prospective follow-up in 50 patients

World J Surg

Evaluation of endosonography in TN staging of esophageal cancer

Gut

Role of endoscopic ultrasonography in esophageal carcinoma

Endoscopy

A prospective comparison of laparoscopy and imaging in the staging of esophagogastric cancer before surgery

Am J Gastroenterol

Application of whole body positron emission tomography in the imaging of esophageal cancer: report of a case

Surg Today

A comparaison of endoscopic ultrasound and minimally invasive surgical staging in esophageal cancer

Am J Gastroenterol