title: The decision to operate: role of integrated computed tomography positron emission tomography in staging oesophageal and oesophagogastric junction cancer by the multidisciplinary team.
abstract: OBJECTIVE
  Our objective was to assess the role of fusion positron emission tomography-computed tomography (PET-CT) in staging patients for minimally invasive oesophagectomy (MIO) with potentially resectable disease from the perspective of a multidisciplinary team (MDT) deciding on operability with conventional staging investigations.
  
  
  METHODS
  Fifty consecutive patients presenting with potentially operable oesophageal or oesophagogastric junctional tumours were staged with computed tomography (CT) and endoluminal ultrasound (EUS). The MDT categorised patients as group A (n=33; CT N0M0) or group B (n=17; CT N1/possible M1). All patients underwent FDG PET-CT. Patients with localised disease (at T3), including single level N1 disease on PET-CT, were deemed suitable for induction chemotherapy followed by surgery.
  
  
  RESULTS
  PET-CT re-categorised 12% of patients as inoperable on grounds of distant metastases (four in group A, two in group B). Five patients did not proceed to resection for other reasons. Two had metastatic disease at thoracoscopy. Resection specimens (n=37) contained 24 nodes (median). Compared with pN status, positive predictive value of PET-CT was 40% and negative predictive value was 43%. The expected PET-CT N1 group had the highest mean number of involved nodes. Median survival for all patients (n=50) was 31.9 months for group A compared with 17.3 months for group B (not statistically significant). There was no significant difference between patients who were PET-CT N0 or N1 in survival or disease-free survival in patients undergoing surgery (n=37).
  
  
  CONCLUSIONS
  PET-CT informs the MDT decision to operate in avoiding futile surgery in stage IV disease or widespread nodal disease. In this study, overall PET-CT N1 status has low positive and negative predictive value for overall pN status.
authors.affiliation: Royal Devon & Exeter NHS Foundation Trust, Barrack Road, Exeter EX2 5DW, United Kingdom. richard.berrisford@rdeft.nhs.uk
authors.forename: Richard G
authors.initials: RG
authors.lastname: Berrisford
authors.forename: Wei-Lup
authors.initials: WL
authors.lastname: Wong
authors.forename: David
authors.initials: D
authors.lastname: Day
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Toy
authors.forename: Mark
authors.initials: M
authors.lastname: Napier
authors.forename: Keith
authors.initials: K
authors.lastname: Mitchell
authors.forename: Saj
authors.initials: S
authors.lastname: Wajed
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003657:Decision Making; D004812:Epidemiologic Methods; D004938:Esophageal Neoplasms / Q000000981:diagnostic imaging* / Q000473:pathology / Q000601:surgery; D016629:Esophagectomy; D004943:Esophagogastric Junction / Q000000981:diagnostic imaging* / Q000601:surgery; D005260:Female; D006801:Humans; D008207:Lymphatic Metastasis; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures; D009367:Neoplasm Staging / Q000379:methods; D010348:Patient Care Team; D018579:Patient Selection; D049268:Positron-Emission Tomography