The Utility of Positron Emission Tomography in Staging of Patients with Potentially Operable Carcinoma of the Thoracic Esophagus
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Objectives: The American College of Surgeons Oncology Group trial Z0060 is a prospective multi-institutional trial with a primary objective to evaluate whether FDG positron emission tomography (PET) detects metastases that preclude esophagectomy in patients with esophageal cancer who are surgical candidates after routine staging procedures.
Methods: Patients with resectable and biopsy-proven carcinoma were enrolled after computed tomography of chest and upper abdomen demonstrated no evidence of metastatic disease. PET scan was performed according to specified quality standards. PET findings suggestive of metastases required confirmatory procedures and patients without evidence of metastases on PET were expected to proceed to surgery.
Results: 262 total patients were registered from 21 enrolling institutions, 194 (74%) met eligibility requirements. Of the 53 (20%) patients failing to meet all requirements, 31 had suspicious lesions on conventional imaging not investigated prior to PET, 11 had insufficient conventional staging which did not include the adrenals, 4 did not have invasive cancer and 7 were lacking for other reasons. Another 15/262 (5.7%) are felt to be ineligible but will require further investigation. 186/194 (95%) of eligible patients underwent FDG-PET scanning suitable for analysis and form the basis of this report. In these evaluable patients, 158/186 (85%) were resected. The reasons for no resection in evaluable patients included: M1 disease found by PET scan (4), M1 disease at exploration not found by PET scan (5), decline or death prior to surgery (7), patient refusal of surgery (6), unresectable local tumor at exploration (3), and extensive N1 disease precluding operation (3). Ten (6.3%) of the resected patients demonstrated recurrence in the first 6 months of follow-up.
Conclusions: Although 15% of eligible patients did not undergo esophagectomy, FDG PET following standard clinical staging for esophageal carcinoma identified 4.4 % of patients with "extensive N1" or M1 disease prior to resection.
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