Routine positron emission tomography does not alter nodal staging in patients undergoing EUS-guided FNA for esophageal cancer

Background: Although EUS-guided FNA (EUS-FNA) and 18F-fluorodeoxyglucose-positron emission tomography (FDG-PET) are both used in the staging of esophageal cancer, the utility of routinely performing both tests is unclear. Objectives: The primary aim of the study was to determine the benefit of routine FDG-PET for esophageal cancer nodal staging in patients undergoing EUS-FNA. The secondary objective was to determine EUS criteria that selectively identify patients in whom PET yields additional information. Design: Retrospective chart review. Setting: Tertiary-care academic medical center. Patients and Interventions: All patients who underwent both EUS and PET for initial staging of esophageal cancer between April 2003 and August 2007. Main Outcome Measurements: EUS and PET detection of malignant lymph nodes and distant metastases. Results: Of 242 patients who underwent esophageal EUS for a malignant indication, 148 also underwent PET within 30 days. EUS detected locoregional-node disease by EUS criteria or cytology in 92 patients, and PET was positive in a minority of these patients (n = 41 [45%]). For celiac-node staging, PET was positive in 2 of 17 patients (12%) with celiac-node involvement detected by EUS. EUS was also significantly more sensitive than PET in the detection of nodal disease confirmed by cytology or histology (86% vs 44%). PET did not alter nodal staging in any patient with complete EUS-FNA. PET identified distant metastases only in those patients with incomplete EUS or nodal disease detected by EUS. Limitations: Single institution, retrospective analysis. Conclusions: The addition of PET to a complete EUS examination did not alter regional-node or celiac-node staging. PET performance in overall staging is strongly associated with EUS assessment of lymph nodes.