World Journal of Surgery

, Volume 36, Issue 5, pp 1089–1095 | Cite as

Accuracy of PET-CT in Predicting Survival in Patients with Esophageal Cancer

  • Claire Brown
  • Ben Howes
  • Glyn G. Jamieson
  • Dylan Bartholomeusz
  • Urs Zingg
  • Thomas R. Sullivan
  • Sarah K. Thompson



Positron emission tomography (PET) is an integral part of tumor staging for patients with esophageal cancer. Recent studies suggest a role for PET scan in predicting survival in these patients, but this relationship is unclear in the setting of neoadjuvant therapy. We examined pretreatment maximum standard uptake value (SUVmax) of the primary tumor in patients treated with and without neoadjuvant therapy.


All patients undergoing esophagectomy with a preoperative PET scan over a nine-year period (2001–2010) were identified from a prospectively maintained database. Positron emission tomography data were obtained from computers housing the original PET scans. Overall survival was correlated with SUVmax of the primary tumor.


A total of 191 patients were identified, and 103 patients met inclusion criteria. Eighty-two had an adenocarcinoma (80%), and 21 (20%) had a squamous cell carcinoma. Fifty-seven (55%) patients received neoadjuvant therapy. In the surgery alone group, a SUVmax of > 5.0 in the primary tumor was associated with poor prognosis [Hazard Ratio (HR) 0.32; p = 0.007], but this factor did not retain its significance on multivariate analysis (HR 0.65; p = 0.43). Pretreatment SUVmax in patients who underwent neoadjuvant therapy was not significant in predicting overall survival (p = 0.10).


This study does not support the use of SUVmax on pretreatment PET scans as a prognostic tool for patients with esophageal cancer, especially in those who have received neoadjuvant therapy. Lymph node status is a more accurate predictor of outcome, and efforts to improve pretreatment staging should focus on this factor.


  1. 1.
    National Comprehensive Cancer network, Inc (2010) NCCN practice guidelines in oncology. Esophageal cancer. Version 1.2010. Available at [accessed November 8, 2010]
  2. 2.
    Skehan SJ, Brown AL, Thompson M et al (2003) Imaging features of primary and recurrent esophageal cancer at FDG PET. Radiographics 20:713–723Google Scholar
  3. 3.
    Pan LL, Gu P, Huang G et al (2009) Prognostic significance of SUV on PET/CT in patients with esophageal cancer: a systematic review and meta-analysis. Eur J Gastroenterol Hepatol 21:1008–1015PubMedCrossRefGoogle Scholar
  4. 4.
    Rizk N, Downey RJ, Akhurst T et al (2006) Preoperative 18[F]-fluorodeoxyglucose positron emission tomography standardized uptake values predict survival after esophageal adenocarcinoma resection. Ann Thorac Surg 81:1076–1081PubMedCrossRefGoogle Scholar
  5. 5.
    Westerterp M, Sloof GW, Hoekstra OS et al (2008) 18FDG uptake in esophageal adenocarcinoma: linking biology and outcome. J Cancer Res Clin Oncol 134:227–236PubMedCrossRefGoogle Scholar
  6. 6.
    Omloo JM, Sloof GW, Boellaard R et al (2008) Importance of fluorodeoxyglucose-positron emission tomography (FDG-PET) and endoscopic ultrasonography parameters in predicting survival following surgery for esophageal cancer. Endoscopy 40:464–471PubMedCrossRefGoogle Scholar
  7. 7.
    Rizk NP, Tang L, Adusumilli PS et al (2009) Predictive value of initial PET-SUVmax in patients with locally advanced esophageal and gastroesophageal junction adenocarcinoma. J Thorac Oncol 4:875–879PubMedCrossRefGoogle Scholar
  8. 8.
    Shenfine J, Barbour AP, Wong P et al (2009) Prognostic value of maximum standardized uptake values from preoperative positron emission tomography in resectable adenocarcinoma of the esophagus treated by surgery alone. Dis Esophagus 22:668–675PubMedCrossRefGoogle Scholar
  9. 9.
    Aly A, Jamieson GG, Pyragius M et al (2004) Antireflux anastomosis following esophagectomy. ANZ J Surg 74:434–438PubMedCrossRefGoogle Scholar
  10. 10.
    Zhang X, Watson DI, Jamieson GG et al (2005) Outcome of esophagectomy for adenocarcinoma of the esophagus and oesophagogastric junction. ANZ J Surg 75:513–519PubMedCrossRefGoogle Scholar
  11. 11.
    Medical Services Advisory Committee (2008) Positron emission tomography for oesophageal and gastric cancer. Assessment report. Available at$File/MSAC_35b_i__PET_gastroesophageal_toprint_FINAL%20to%20print_301008.pdf [accessed November 12, 2010]
  12. 12.
    Wong R, Walker-Dilks C, Raifu AO (2009) Recommendation report—PET #4. PET imaging in esophageal cancer. Available at: [accessed December 12, 2010]
  13. 13.
    Palser T, Cromwell D, van der Meulen et al. (2008) National oesophago-gastric cancer audit: an audit of the care received by people with oesophago-gastric cancer in England and Wales. First Annual Report 2008. Available at [accessed December 12, 2010]
  14. 14.
    Facey K, Bradbury I, Laking G et al. (2007) Overview of the clinical effectiveness of positron emission tomography imaging in selected cancers. Health Technol Assess 11:iii–iv, xi–267Google Scholar
  15. 15.
    Vliet EPM, Heijenbrok-Kal MH, Hunink MGM et al (2008) Staging investigations for esophageal cancer: a meta-analysis. Br J Cancer 98:547–557PubMedCrossRefGoogle Scholar
  16. 16.
    Cerfolio RJ, Bryant AS (2006) Maximum standardized uptake values on positron emission tomography of esophageal cancer predicts stage, tumor biology, and survival. Ann Thorac Surg 82:391–395PubMedCrossRefGoogle Scholar
  17. 17.
    Cheze-Le Rest C, Metges JP, Teyton P et al (2008) Prognostic value of initial fluorodeoxyglucose-PET in esophageal cancer: a prospective study. Nucl Med Commun 29:628–635PubMedCrossRefGoogle Scholar
  18. 18.
    Makino T, Doki Y, Miyata H et al (2008) Use of 18F-fluorodeoxyglucose-positron emission tomography to evaluate responses to neo-adjuvant chemotherapy for primary tumor and lymph node metastasis in esophageal squamous cell carcinoma. Surgery 144:793–802PubMedCrossRefGoogle Scholar
  19. 19.
    Sepesi B, Raymond DP, Polomsky M et al (2009) Does the value of PET-CT extend beyond pretreatment staging? An analysis of survival in surgical patients with esophageal cancer. J Gastrointest Surg 13:2121–2127PubMedCrossRefGoogle Scholar
  20. 20.
    Fukunaga T, Okazumi S, Koide Y et al (1998) Evaluation of esophageal cancers using fluorine-18-fluorodeoxyglucose PET. J Nucl Med 39:1002–1006PubMedGoogle Scholar
  21. 21.
    Kato H, Kuwano H, Nakajima M (2002) Comparison between positron emission tomography and computed tomography in the use of the assessment of esophageal carcinoma. Cancer 94:921–928PubMedCrossRefGoogle Scholar
  22. 22.
    Choi JY, Jang HJ, Young MS (2004) 18F-FDG PET in patients with esophageal squamous cell carcinoma undergoing curative surgery: prognostic implications. J Nucl Med 45:1843–1850PubMedGoogle Scholar
  23. 23.
    Westreenen HL, Plukker JTM, Cobben DCP (2005) Prognostic value of the standardized uptake value in esophageal cancer. AJR Am J Roentgenol Radium Ther Nucl Med 185:436–440Google Scholar
  24. 24.
    Choi JY, Jang KT, Shim YM (2006) Prognostic significance of vascular endothelial growth factor expression and microvessel density in esophageal squamous cell carcinoma: comparison with positron emission tomography. Ann Surg Oncol 13:1054–1062PubMedCrossRefGoogle Scholar
  25. 25.
    Chung HW, Lee KH, Lee EJ et al (2008) Comparison of uptake characteristics and prognostic value of 201T1 and 18F-FDG in esophageal cancer. World J Surg 32:69–75PubMedCrossRefGoogle Scholar
  26. 26.
    Kato H, Nakajima M, Sohda M et al (2009) The clinical application of 18F-fluorodeoxygloucose positron emission tomography to predict survival in patients with operable esophageal cancer. Cancer 115:3196–3203PubMedCrossRefGoogle Scholar
  27. 27.
    Downey RJ, Akhurst T, Ilson D (2003) Whole body 18FDG-PET and the response of esophageal cancer to induction therapy: results of a prospective trial. J Clin Oncol 21:428–432PubMedCrossRefGoogle Scholar
  28. 28.
    Hong D, Lunagomez S, Kim EE et al (2005) Value of baseline positron emission tomography for predicting overall survival in patients with nonmetastatic esophageal or gastroesophageal junction carcinoma. Cancer 104:1620–1626PubMedCrossRefGoogle Scholar
  29. 29.
    Stahl A, Stollfuss J, Ott K et al (2005) FDG PET and CT in locally advanced adenocarcinomas of the distal oesophagus. Clinical relevance of a discordant PET finding. Nuklearmedizin 44:249–255PubMedGoogle Scholar
  30. 30.
    Ott K, Weber WA, Lordick F (2006) Metabolic imaging predicts response, survival, and recurrence in adenocarcinomas of the esophagogastric junction. J Clin Oncol 24:4692–4698PubMedCrossRefGoogle Scholar
  31. 31.
    Konski AA, Cheng JD, Goldberg M et al (2007) Correlation of molecular response as measured by 18-FDG PET with outcome after chemo-radiation in patients with esophageal carcinoma. Int J Radiat Oncol Biol Phys 69:358–363PubMedCrossRefGoogle Scholar
  32. 32.
    Weider HA, Ott K, Lordick F et al (2007) Prediction of tumor response by FDG-PET: comparison of the accuracy of single and sequential studies in patients with adenocarcinomas of the esophagogastric junction. Eur J Nucl Med Mol Imaging 34:1925–1932CrossRefGoogle Scholar
  33. 33.
    Chatterton BE, Shon IH, Baldey A (2009) Positron emission tomography changes management and prognostic stratification in patients with oesophageal cancer: results of a multicentre prospective study. Eur J Nucl Med Mol Imaging 36:354–361PubMedCrossRefGoogle Scholar
  34. 34.
    Javeri H, Xiao L, Rohren E et al (2009) Influence of the baseline 18F-fluoro-2-deoxy-D-glucose positron emission tomography results on survival and pathologic response in patients with gastroesophageal cancer undergoing chemoradiation. Cancer 115:624–630PubMedCrossRefGoogle Scholar
  35. 35.
    Kato H, Kuwano H, Nakajima M et al (2002) Usefulness of positron emission tomography for assessing the response of neoadjuvant chemoradiotherapy in patients with esophageal cancer. Am J Surg 184:279–283PubMedCrossRefGoogle Scholar
  36. 36.
    West CML, Charnley N (2005) The potential of PET to increase understanding of the biological basis of tumor and normal tissue response to radiotherapy. Br J Radiol Suppl 28:50–54Google Scholar
  37. 37.
    Vaupal P, Mayer A (2007) Hypoxia in cancer: significance and impact on clinical outcome. Cancer Metastasis Rev 26:225–239CrossRefGoogle Scholar
  38. 38.
    Soret M, Bacharach SL, Buvat I (2007) Partial-volume effect in PET tumor imaging. J Nucl Med 48:932–945PubMedCrossRefGoogle Scholar
  39. 39.
    Adams MC, Turkington TG, Wilson JM et al (2010) A systematic review of the factors affecting accuracy of SUV measurements. AJR Am J Roentgenol 195:310–320PubMedCrossRefGoogle Scholar
  40. 40.
    Scheuermann JS, Saffer JR, Karp JS (2009) Qualification of PET scanners for use in multicenter cancer clinical trials: the American College of Radiology Imaging Network experience. J Nucl Med 50:1187–1193PubMedCrossRefGoogle Scholar
  41. 41.
    Thompson SK, Ruszkiewicz AR, Jamieson GG et al (2008) Improving the accuracy of TNM staging in esophageal cancer: a pathological review of resected specimens. Ann Surg Oncol 15:3447–3458PubMedCrossRefGoogle Scholar
  42. 42.
    Edge SB, Byrd DR, Compton CC et al (eds) (2010) AJCC cancer staging manual, 7th edn. Springer, New YorkGoogle Scholar
  43. 43.
    Bruzzi JF, Munden RF, Truong MT et al (2007) PET/CT of esophageal cancer: its role in clinical management. Radiographics 27:1635–1652PubMedCrossRefGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2012

Authors and Affiliations

  • Claire Brown
    • 1
  • Ben Howes
    • 1
  • Glyn G. Jamieson
    • 1
  • Dylan Bartholomeusz
    • 2
  • Urs Zingg
    • 1
  • Thomas R. Sullivan
    • 3
  • Sarah K. Thompson
    • 1
    • 4
  1. 1.Discipline of SurgeryUniversity of AdelaideAdelaideAustralia
  2. 2.Department of Nuclear Medicine, PET and Bone Densitometry, and Department of Gastroenterology and HepatologyRoyal Adelaide HospitalAdelaideAustralia
  3. 3.Discipline of Public HealthUniversity of AdelaideAdelaideAustralia
  4. 4.Department of SurgeryRoyal Adelaide HospitalAdelaideAustralia

Personalised recommendations