Appendix 4.1. Positron Emission Tomography (PET) Criteria for TNM Staging of Gastric Cancer*
T Stage
PET Criteria
T0
No increase in 18F-FDG uptake within the stomach
T+
Increased 18F-FDG uptake exceeding that of the adjacent normal gastric wall
N Stage
PET Criteria (described by the JGCA)
N0
No evidence of lymph node metastasis
N1
Increased 18F-FDG uptake in the perigastric node(s)
N2
Increased 18F-FDG uptake in the node(s) along the celiac artery and its branches
N3
Increased 18F-FDG uptake in the retropancreatic or para-aortic nodes
N stage
PET Criteria (described by AJCC/UICC)
N0
No regional lymph node metastases
N1
Increased 18F-FDG uptake in 1-6 regional lymph nodes
N2
Increased 18F-FDG uptake in 7-15 regional lymph nodes
N3
Increased 18F-FDG uptake in > 15 regional lymph nodes
M Stage
PET Criteria
M0
Distant metastases absent
M1
Increased 18F-FDG uptake in distant metastases
* Adapted from Yun M et al 2005 and Tian J et al 2004. All articles on preoperative PET staging adapted the above
definitions or slight variations of these definitions.
Appendix 4.2. Characteristics of the 9 Included Positron Emission Tomography (PET) studies on Preoperative Staging of Gastric Cancer
Study
Country
Study
Type
N
Patient
characteristics
Instrument
Field of
view
Spatial
Resolution
Chen J et
al. 2005
South
Korea
P
68
men: 49
women: 19
age: 55 (28-81) y
GE Advance
A
5 mm
Kim S et
al 2006
South
Korea
P
73
men: 61
women: 12
age: 55 ± 10.8 y
GE Advance
A and
TA
4.8 mm (TA)
4.0 mm (A)
Lim J et al
2006
South
Korea
R
112
men: 73
women: 39
age: 55 (16-80) y
GE Advance
or Philips
Allegro
centre
5 mm
Mochiki E
et al. 2004
Japan
P
85
men: 54
women: 31
age: 63a (36-85) y
Shimadzu
SET 2400W
A and
TA
5.0 mm (A)
4.2 mm (TA)
Mukai K
et al 2006
Japan
R
62
men: 42
women: 20
age: 67.6 y
Philips
Allegro
A and
TA
NR
Stahl A et
al 2003
Germany
R
40
men: 27
women: 13
age: 55 ± 10 y
Siemens/CTI
ECAT
EXACT HR+
A and
TA
8 mm (TA)
5 mm (A)
Tian J et
al. 2004
China
P
30
men: 26
women: 12
age: 53 (22-75) y
Siemens/CTI
ECAT
EXACT HR+
A, C, S
Yang Q et
al 2008c
Japan
R
78
men: 57
women: 21
age: 66 (38-84) y
GE
Discovery-ST
Yun M et
al. 2005
South
Korea
81
men: 53
women: 28
age: 57 (32-82) y
GE Advance
(2D mode) or
Philips
Allegro (3D
mode)
R
Reconstruction
Algorithm
No. BP and
Time/BP
Blood
Glucose
Test
IRA with 32I
BP: 6
Time: 5 min
immediately
prior to
scan
OSEM
BP: multiple
Time: 3-5 min
OSEM or
RAMLA
IV Contrast / Uptake
Period
NMP
18F-FDG: 370-555
MBq
UP: 60 min
NMP: 2
blind: yes
NR
18F-FDG: 555 MBq
UP: 60 min
NMP: 2
blind: yes
NR
NR
18F-FDG: 370-555
MBq
UP: 60 min
NMP: 2
blind: NR
OSEM
BP: multiple
Time: 8 min
yes, time
NR
18F-FDG: 275-370
MBq
UP: 40 min
NMP: 2
blind: yes
NR
BP: multiple
Time: 2.5 min
yes, time
NR
18F-FDG: 4.44
MBq/Kg
UP: 60
min
NMP: 2
blind: yes
filtered
backprojection
(Hanning filter)
BP: 1
Time: 20 min
NR
18F-FDG: 300 MBq
UP: 40 min
NMP: 2
blind: yes
NR
OSEM
BP: 4-6
Time: 3-4 min
NR
18F-FDGb: 148-185
MBq
UP: 50-60 min
NR
NR
NR
OSEM
BP: 6-7
Time: 1-3 min
1 hour prior
to exam
18F-FDG: 200 MBq
UP: NR
NR
centre
5 mm
(Advance)
5.3 mm
(Allegro)
OSEM or
RAMLA
BP: multiple
Time: 3-5 min
NR
18F-FDG: 370 MBq
(Advance) or 5.18
MBq (Allegro)
UP: 60 min
NMP: 2
blind: yes
N = number of patients; BP = bed position; No. BP = number of bed positions; Time/BP = time per bed position; IV = intravenous; UP = uptake period; NMP = nuclear medicine physician (number of
physicians who analyzed images); P = prospective; R = retrospective; EGC = early gastric cancer; AGC = advanced gastric cancer; y = years; NR = not recorded; A = axial; TA = transaxial; C = coronal;
S = sagittal; IRA = Iterative reconstruction algorithm; I = iterations; OSEM = order subset expectation maximization; RAMLA = low action maximal likelihood algorithm. Symbols: a = age reported as
median not mean; b = 2-3 g of vesicant powder producing 120 ml CO2 gas per gram with 40-60 ml of water was also given when imaging field moved upwards to the umbilical level; c = study refers to
PET-CT techniques combined.
Appendix 4.3. Preoperative Tumor Staging of Gastric Cancer by Positron Emission
Tomography (PET) - sorted by highest overall detection
Study
N
OA: 95.9%
EGC = 8
AGC = 60
UICC/AJCC
(1997)
OA = 7.0 (0.9-27.7)
EGC = 2.1
AGC = 7.5
TA = 7.7
MA/SRCC = 4.2
OA = 94.1%
EGC = 63%
AGC = 98%
EGC = 17
AGC = 64
JRSGC (1995)
EGC = 2.8 ± 1.6
AGC = 7.9 ± 8.0
PDA = 6.8 ± 5.5
SRCC = 4.1 ± 0.9
OA = 87.7%
EGC = 47%
AGC = 98%
JGCA (1998)
T1 = 2.8 ± 0.2
T2 = 4.3 ± 0.3
T3 = 4.5 ± 0.3
T4 = 5.4 ± 0.9
OA = 75.3%
T1 = 40.0%
T2 = 87.5%
T3 = 90.5%
T4 = 100%
IT = 72.1%
non-IT = 78.6%
PDA = 78.8%
SRCC = 77.8%
WHO (2000)
T3 = 3.0 ± 3.3
T4 = 2.5 ± 2.3
IT = 6.7 ± 3.4
non-IT = 4.8 ± 2.8
MA = 7.2 ± 3.2
non-MA = 3.9 ± 2.1
OA = 60.0%
IT = 83.3%
non-IT = 40.9%
NR
OA: 58.1%
T1: 25.9%
T2: 81.3%
T3: 87.5%
T4: 66.7%
EGC: 25.9%
AGC: 82.9%
IT: 65.5%
DT: 51.5%
PDA: 61.5%
SRCC: 0%
MA: 100%
Chen J et
al. 2005
Yun M et
al. 2005
Mukai K et
al 2006
Detection
JGCA (1998)
Kim S et al
2006
Stahl A et
al 2003
SUV (mean)
IT = 9.6 ± 5.8
DT = 7.3 ± 5.7
TA = 9.3 ± 5.0
PDA = 9.9 ± 7.2
MA = 5.3 ± 1.2
SRCC = 4.7 ± 1.7
T1: 2
T2: 22
T3: 33
T4: 10
M1: 6
Mochiki E
et al. 2004
Classification
T1 = 25
T2 = 32
T3 = 21
T4 = 7
T3: 34
T4: 6
T1: 27
T2: 16
T3: 16
T4: 16
JGCA (1998)
N = number of patients per T stage according to pathology; SUV = standardized uptake
value; EGC = early gastric cancer; AGC = advanced gastric cancer; AJCC = American
Joint Committee on Cancer; Japanese Gastric Cancer Association; Japanese
Classification of Gastric Carcinoma; IT = intestinal type; non-IT = non intestinal type; DT
= diffuse type; PDA = poorly differentiated adenocarcinoma; SRCC = signet ring cell
carcinoma; MA = mucinous adenocarcinoma; TA = tubular adenocarcinoma; WHO =
world health organization.
Appendix 4.4. Preoperative N Staging of Gastric Cancer by Positron Emission Tomography (PET) - sorted by highest overall accuracy
Study
N
Classification
SUV (mean)
Chen J et al.
2005
N0 = 13
N1 = 19
N2 = 14
N3 = 15
UICC/AJCC
(1997)
N0 = 3.6
N1 = 7.5
N2 = 7.4
N3 = 8.7
Yun M et al.
2005
N1 = 53
N2 = 32
N3 = 6
JRSGC (1995)
Accuracy
Overstaging
Understaging
Sensitivity
Specificity
OA = 79.2%
L-LNa= 63.2%
D-LNa = 95.1%
NR
NR
L-LN = 56.4%**
D-LN = 87.5%**
L-LN = 92.3%**
D-LN = 96.2%**
NR
OA = 74.1%
N1 = 55.6%
N2 = 71.6%
N3 = 95.1%
NR
NR
N1 = 34.0%**
N2 = 34.4%**
N3 = 50.0%**
N1 = 96.4%**
N2 = 95.9%**
N3 = 98.7%**
OA = 73.3%
N0 = 100%
N1 = 36.4%
N2 = 83.3%
OA = 0%
N0 = 0%
N1 = 0%
N2 = ---
OA = 26.7%
N0 = --N1 = 63.6%
N2 = 16.7%
OA = 52.9%
OA = 100%
Tian J et al.
2004
N0 = 4
N1 = 11
N2 = 6
UICC (NR)
N0 = 6.0
N1 = 2.7
N2 = 9.0
PDA = 4.5 ± 2.7
MA = 5.1 ± 1.7
SRCC = 2.4 ±
0.7
Yang Q et al.
2008b
N0 = 36
N1 = 19
N2 = 23
JGCA (1999)
NR
OA = 55.1%
N0 = 97.2%
N1 = 26.3%
N2 = 13.0%
OA = 1.3%
N0 = 2.8%
N1 = 0%
N2 = ---
OA = 43.6%
N0 = --N1 = 73.7%
N2 = 87.0%
OA = 30.9%
OA = 97.2%
Mukai K et al
2006
N0 = 33
N1 = 14
N2 = 13
N3 = 2
JGCA (1998)
NR
OA = 17.7%
N0 = 3.0%
N1 = 21.4%
N2 = 46.2%
N3 = 50.0%
NR
NR
OA = 34.5%**
OA = 97.0%**
Kim S et al
2006
N0 = 8
N1 = 23
N2 = 21
N3 = 15
JGCA (1998)
IT = 5.3 ± 4.1
DT = 4.6 ± 2.7
TA = 4.5 ± 2.9
PDA = 6.0 ± 4.1
MA = 4.4 ± 0
SRCC = 2.3 ±
0.4
NR
NR
NR
OA = 40.0%**
N1 = 46.4%**
N2 = 35.5%**
N3 = 33.3%**
OA = 95.2%**
N1 = 90.9%**
N2 = 90.6%**
N3 = 100%**
Mochiki E et
al. 2004
N1 = 17
N2 = 19
N3 = 4
JGCA (1998)
N0 = 3.5 ± 0.3
N1 = 4.5 ± 0.3
N2 = 4.5 ± 0.2
N3 = 6.2 ± 0.7
NR
NR
NR
OA = 23.3%**
N1 = 17.6%**
N2 = 42.1%**
N3 = 75.0%**
OA = 100%**
N = number of patients per N stage according to pathology; SUV = standardized uptake value; NR = not reported/necessary information not provided; AJCC =
American Joint Committee on Cancer; Japanese Gastric Cancer Association; Japanese Classification of Gastric Carcinoma; UICC = Union International Contre
le Cancer; L-LN = local lymph node; D-LN = distant lymph node; OA = overall. Symbols: ** = calculated by study authors (see publication); a = local lymph node
group refers to compartment I or II whereas distant lymph node group refers to compartment III or IV as per publication; b = values reported for PET-CT
techniques combined (not PET alone); c = reported as SUV max (not mean)
Appendix 4.5. Preoperative M Staging of Gastric Cancer by Positron Emission Tomography (PET) - sorted by order of
highest overall accuracy
N
SUV (mean)
Tian J et al.
2004
Study
M0 = 21
M1 = 9
M1 = 6.5 (3.211.7)
OA = 100%
M1 = 100%
Accuracy
Sensitivity
Specificity
M1 = 100%
M1 = 100%
Lim J et al
2006
M0 = 95
M1 = 16
NR
OA = 89.3%**
Peritoneum = 89.3%**
Peritoneum = 35.3%**
Peritoneum = 98.9%**
Chen J et al.
2005
M0 = 66
M1 = 2
Peritoneum:
Positive = 6.8
Negative = 7.0
OA = 75.0%
Liver = 0%
Spleen = 100%
Peritoneum = 88.2%
Liver = 0%
Spleen = 100%
Peritoneum = 30%
Liver = 95.7%
Spleen = 100%
Peritoneum = 98.3%
Kim S et al
2006
M0 = 67
M1 = 6
NR
NR
M1 = 16.7%**
M1 = 92.3%**
N = number of patients per M stage according to pathology; SUV = standardized uptake value; NR = not reported/necessary
information not provided; OA = overall. Symbols: ** = calculated by study authors (see publication)