Case of the Month—February 2004

PET for Esophageal Cancer

History
This is a case of a 57-year-old female with newly diagnosed esophageal cancer. Staging chest CT showed a very small nodule in the right upper lobe of the lung. There were also a few nonpathologic-sized lymph nodes in the mediastinum. A whole-body PET FDG scan was requested for staging.

Finding
A whole-body FDG PET was performed and showed a focus of intense uptake in the distal esophagus. There are two additional foci of hypermetabolism in the azygoesophageal recess and left perispinal region at the base of the heart (Figure 1). There is no significant uptake corresponding to the right upper lobe pulmonary nodule.

Figure 1.

Follow–up
The patient received chemotherapy and radiation therapy. A repeat FDG PET was performed three months later, demonstrating complete resolution of the azygoesophageal uptake and the left perispinal uptake. There was residual uptake in the distal esophagus which can be related to post-radiation change or residual tumor (Figure 2). Follow-up CT scan again noted the small right upper lobe pulmonary nodule without significant change.

Figure 2.

How Did PET Help?
The findings of the PET study upgraded the stage of this patient and thus changed the anagement plan. Moreover, PET proved useful for monitoring the therapy response.

Discussion
PET has been used to detect lymph nodes metastases that are undetectable by CT or endoscopic ultrasonography. Studies have shown that PET FDG detects metastastic esophageal cancer in 15% of patients who were thought to have only localized disease on conventional images. Also, PET can help to monitor therapy response and predict overall survival and freedom from disease after induction therapy and resection in patients with esophageal cancer (1). Although thoracoscopic or laparoscopic staging is highly accurate, these procedures are invasive and have been replaced by PET at many institutions (2).

1. Journal of Clinical Oncology, 2003, 21:428-432.
2. New England Journal of Medicine, 2003, 349:2241-2252.

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