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J Thorac Cardiovasc Surg 2007;133:738-745
© 2007 The American Association for Thoracic Surgery

General Thoracic Surgery

The utility of positron emission tomography in staging of potentially operable carcinoma of the thoracic esophagus: Results of the American College of Surgeons Oncology Group Z0060 trial

^a Department of Surgery, Washington University School of Medicine, St. Louis, Mo
^b Department of Radiology, Washington University School of Medicine, St. Louis, Mo
^c Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
^d Department of Health Sciences Research, Mayo Clinic College of Medicine, Rochester, Minn
^e Department of Surgery, Allegheny General Hospital, Pittsburgh, Pa
^f Department of Cardiothoracic Surgery, University of Alabama at Birmingham, Ala
^g Department of Surgery, University of Pittsburgh, Pa
^h Department of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC
ⁱ Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tenn.

Read at the Eighty-sixth Annual Meeting of The American Association for Thoracic Surgery, Philadelphia, Pa, April 29-May 3, 2006.

Received for publication April 28, 2006; revisions received August 9, 2006; accepted for publication September 26, 2006.

^_* Address for reprints: Bryan F. Meyers, MD, MPH, Division of Cardiothoracic Surgery, Washington University School of Medicine, Suite 3108 Queeny Tower, 1 Barnes-Jewish Hospital Plaza, St Louis, MO 63110. (Email: meyersb{at}wustl.edu).

Objectives: The American College of Surgeons Oncology Group trial Z0060 is a prospective multi-institutional trial with a primary objective to evaluate whether positron emission tomography (PET) with F-18 fluorodeoxyglucose (FDG) detects evidence of metastastic disease that precludes esophagectomy in patients with esophageal cancer who are surgical candidates after routine staging.

Methods: Patients with resectable, biopsy-proven carcinoma were enrolled after computed tomography of chest and abdomen demonstrated no evidence of metastasis. FDG-PET was performed according to specified standards. FDG-PET findings suggesting metastases required confirmation and patients without metastases on PET were expected to proceed to surgery.

Results: A total of 262 patients were registered. Of these, 199 were deemed eligible and of these, 189 patients were evaluable. Seventy-three patients were ineligible or unevaluable. Reasons for ineligibility included nonresectable disease by routine staging (39), missing or outdated staging procedures (12), PET technical protocol violations (10), no cancer (4), pre-PET induction therapy (3), claustrophobia (1), and other causes (4). There were 145 (78%) patients who went on to have surgery, 42 (22%) who did not, and 2 patients for whom the surgical status was not determined. The reasons for no resection included the following: M1 disease found by PET and confirmed (9), M1 disease found by PET and not confirmed (2), M1 disease at exploration not found by PET (7), decline or death before surgery (10), patient refusal of surgery (7), unresectable local tumor at exploration (5), and extensive N1 disease precluding operation (2). Eight (4.2%) patients undergoing resection had a recurrence in the first 6 months.

Conclusions: Although 22% of eligible patients did not undergo esophagectomy, FDG-PET after standard clinical staging for esophageal carcinoma identified confirmed M1b disease in at least 4.8% (95% confidence interval: 2.2%-8.9%) of patients before resection. Unconfirmed PET evidence of M1 disease and regional adenopathy (N1 disease) led to definitive nonsurgical or induction therapy in additional patients.

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