Does external ultrasonography of the neck add diagnostic value to
integrated PET-CT scanning in the diagnosis of cervical metastases in
patients with esophageal carcinoma?
R.L.G.M. Blom1, W.M.J. Schreurs2, I. Stohr3, L.E. Oostenbrug3, R.F.A.
Vliegen4, M.N. Sosef1
1Department
2Department
of Surgery, Atrium Medical Centre, Heerlen, The Netherlands
of Nuclear medicine, Atrium Medical Centre, Heerlen, The
Netherlands
3Department of Internal Medicine and Gastroenterology, Atrium Medical
Centre, Heerlen, The Netherlands
4Department of Radiology, Atrium Medical Centre, Heerlen, The Netherlands
One of the objectives of preoperative imaging in esophageal cancer (EC) patients is the exclusion of distant
metastases, obviating unnecessary surgical treatment. Traditionally, external ultrasonography of the neck
(EU) has been combined with CT in order to improve the detection of cervical metastases. In general, integrated
PET-CT has been shown to be superior to CT or PET regarding staging and therefore may limit the role of EU.
Information on this subject is scarce. Therefore, the objective of this study was to determine the additional value
(AV) of EU to PET-CT.
This retrospective study includes all patients referred to our centre for treatment of EC. Diagnostic staging was
performed to determine eligibility for resection. Cervical metastases were excluded by EU and PET-CT. Suspect
lymph nodes (LN) on EU were defined as LN with a short axis diameter >5mm and/or LN with suspect
morphology (shape, border, irregularity and echogenity). In case of suspect LN on EU, fine needle aspiration
(FNA) was performed. On PET-CT, suspect LN were defined as LN >8-10 mm or with an increased standard
uptake value (SUV). Additional FNA was performed in case of clinical relevance.
From January '08 - March '10 137 EC patients were referred to our centre.122 patients underwent both EU and
PET-CT. 5/122 patients had suspect cervical LN on both PET-CT and EU. 3/5 patients had cytologically
confirmed malignant LN, 1/5 had benign LN, in 1 patient FNA was not performed, exclusion from
esophagectomy was based on intra-abdominal metastases. In 105/122 patients, the cervical region was not
suspect; no FNA was performed. In 0 patients PET-CT showed suspect LN combined with a negative EU.
12/122 patients had a negative PET-CT with suspect LN on EU. In 12/12 patients, cervical LN were
cytologically confirmed benign. Positive and negative predicting values of PET-CT in the diagnosis of
malignant cervical LN were 75% and 100% respectively. The AV of EU to PET-CT was 0%.
The AV of EU to a negative PET-CT is 0%. According to our results it can be omitted in the primary workup. However, suspect LN on PET-CT should be confirmed by FNA to exclude false positives in case it would
change treatment plan.