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18F-FDG PET-Detected Synchronous Primary Neoplasms in the Staging of Esophageal Cancer: Incidence, Cost, and Impact on Management

Malik, Vinod MBBCh*; Johnston, Ciaran MD; Donohoe, Claire MBBCh*; Claxton, Zieta BSc*; Lucey, Julie PhD; Ravi, Narayanasamy MD*; Reynolds, John V. MD*

doi: 10.1097/RLU.0b013e31827083ba
Original Articles

Purpose 18F-Fluorodeoxyglucose positron emission tomography (18F-FDG PET) imaging is increasingly the standard of care in the staging of esophageal cancer. Synchronous neoplasms may be identified, and this study evaluated the prevalence of such tumors and their impact on management.

Methods Five hundred ninety-one (73.6%) of 803 consecutive patients with biopsy-proven esophageal cancer underwent staging 18F-FDG PET or PET/CT scans. 18F–FDG-avid lesions were considered synchronous primary neoplasms if occurring at locations atypical for metastases from the known primary, a marked discordance in the 18F-FDG avidity from that of the primary tumor, and if there was no prior detection on conventional imaging. Additional investigations as appropriate were undertaken, and histopathological verification was obtained where possible to validate the suspected synchronous neoplasm.

Results A synchronous neoplasm was suspected in 55 (9.3%) of 591 patients, predominantly at sites in the colon (26) and head and neck (21). Additional investigations in 43 cases revealed malignant neoplasms in 8 (18.6%), premalignant in 9 (20.9%), and benign lesions in 26 (60.5%) cases. The management plan was altered in 8 patients, 1.4% overall. The total cost of added tests was $27,482.57 (€21,024) with the decision to treat the esophageal cancer deferred by a mean of 10.7 days.

Conclusion 18F-FDG uptake concerning for synchronous neoplasms is evident in approximately 1 in 10 cases, and of these a minority will represent a malignant neoplasm that significantly impacts on treatment. The overall added costs per patient are relatively modest and the treatment delay within acceptable limits of clinical practice.

From the *Department of Surgery, and †Department of Radiology, St James’s Hospital and Trinity College, Dublin; and ‡Department of Nuclear Medicine, Blackrock Clinic, Dublin, Ireland.

Received for publication March 27, 2012; and revision accepted August 22, 2012.

Conflicts of interest and sources of funding: The study was funded by internal funds of the Department of Clinical Surgery, St James’s Hospital.

Reprints: John V. Reynolds, MD, Department of Clinical Surgery, Trinity Health Sciences Centre, St. James’s Hospital, Dublin 8, Ireland. E-mail:

Copyright © 2012 Wolters Kluwer Health, Inc. All rights reserved.