Potential impact of (18)FDG-PET/CT on surgical approach for operable squamous cell cancer of middle-to-lower esophagus

Abstract

Background: Fluorodeoxyglucose-positron emission tomography (PET)/computed tomography (CT) is reported to have a significant advantage over CT for staging esophageal cancer (EC). However, whether PET/CT may play a useful role in guiding surgical approach remains undetermined.

Methods: Patients with potentially resectable squamous cell EC were randomized into either PET/CT group or CT group. The surgical data and survival outcomes were compared.

Results: Compared to the CT group, the right-sided approach was more frequently used (42.6% versus 25.5%, P=0.065) in the PET/CT group in order to allow surgical access to radiographically suspicious lymph nodes inaccessible from the left, thus enabling the removal of more involved lymph nodes (2.83 versus 1.76; P=0.039) as well as their stations (1.65 versus 1.08; P=0.042). Although the overall survival between the two groups was similar, the PET/CT group had a longer disease-free survival (DFS) than the CT group (27.1 months versus 18.9 months; P=0.019), especially in the subgroup of node-positive patients (22.5 months versus 13.5 months; P=0.02). Preoperative imaging arm was the only prognostic factor found to independently influence DFS.

Conclusion: For patients with middle-to-lower EC, surgical approaches directed by PET/CT may increase the likelihood of complete resection and affect DFS.

Keywords: PET/CT; esophageal cancer; esophagectomy; surgical approach; survival.

Figure 1

Whole-body fusion PET/CT imaging for a 58-year-old male with squamous carcinoma of the lower thoracic esophagus at biopsy. Notes: Increased FDG accumulation exhibited at the esophagus with a SUVmax of 11.9, a positive lymph node adjacent to trachea, measuring 0.6 cm in short-axis diameter (SUV =5.6), was confirmed as malignant on pathology. Since PET/CT showed the positive node at the right-upper mediastinum, a right thoracotomy, instead of left transthoracic approach which was routinely used for the lower EC, was performed. Abbreviations: SUV, standardized uptake value; PET, positron emission tomography; CT, computed tomography; FDG, fluorine-18 fluorodeoxyglucose.

Figure 2

Kaplan–Meier curves of DFS for the two groups (PET/CT and CT group). Abbreviations: CT, computed tomography; PET, positron emission tomography; DFS, disease-free survival.

Figure 3

Kaplan–Meier curves of DFS for the subgroup of positive lymph nodes patients (PET/CT and CT group). Abbreviations: CT, computed tomography; PET, positron emission tomography; DFS, disease-free survival.