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The decision to operate: role of integrated computed tomography positron emission tomography in staging oesophageal and oesophagogastric junction cancer by the multidisciplinary team

^a Royal Devon & Exeter NHS Foundation Trust, Barrack Road, Exeter EX2 5DW, United Kingdom
^b Paul Strickland Scanner Centre, Northwood, United Kingdom

Received 26 June 2007; received in revised form 20 December 2007; accepted 16 January 2008.

^_* Corresponding author. Tel.: +44 1392 402689; fax: +44 1302 402175. (Email: richard.berrisford{at}rdeft.nhs.uk).

Objective: Our objective was to assess the role of fusion positron emission tomography-computed tomography (PET-CT) in staging patients for minimally invasive oesophagectomy (MIO) with potentially resectable disease from the perspective of a multidisciplinary team (MDT) deciding on operability with conventional staging investigations. Methods: Fifty consecutive patients presenting with potentially operable oesophageal or oesophagogastric junctional tumours were staged with computed tomography (CT) and endoluminal ultrasound (EUS). The MDT categorised patients as group A (n = 33; CT N0M0) or group B (n = 17; CT N1/possible M1). All patients underwent FDG PET-CT. Patients with localised disease (at T3), including single level N1 disease on PET-CT, were deemed suitable for induction chemotherapy followed by surgery. Results: PET-CT re-categorised 12% of patients as inoperable on grounds of distant metastases (four in group A, two in group B). Five patients did not proceed to resection for other reasons. Two had metastatic disease at thoracoscopy. Resection specimens (n = 37) contained 24 nodes (median). Compared with pN status, positive predictive value of PET-CT was 40% and negative predictive value was 43%. The expected PET-CT N1 group had the highest mean number of involved nodes. Median survival for all patients (n = 50) was 31.9 months for group A compared with 17.3 months for group B (not statistically significant). There was no significant difference between patients who were PET-CT N0 or N1 in survival or disease-free survival in patients undergoing surgery (n = 37). Conclusions: PET-CT informs the MDT decision to operate in avoiding futile surgery in stage IV disease or widespread nodal disease. In this study, overall PET-CT N1 status has low positive and negative predictive value for overall pN status.

Key Words: Lymph nodes • Oesophageal neoplasm • Oesophagogastric junction neoplasm • Neoplasm staging • Prospective studies • Positron emission tomography