Overexpression of Cap43 is associated with malignant status of esophageal cancer.

Cap43 protein has been proven to be upregulated by nickel compounds or hypoxic stress, often during cell differentiation or cell growth arrest. However, the function of this gene remains unknown. Although, several studies have been performed, none of these have evaluated the expression of Cap43 in esophageal cancer. To clarify its function and role in esophageal cancer, a clinical archive of cancer specimens was examined for the expression of Cap43 by immunohistochemistry. The expression level of Cap43 protein was also investigated by Western blotting and mRNA by realtime RT-PCR using esophageal cancer cell lines. Immunohistochemistry results showed that overexpression of Cap43 was correlated with malignant status of esophageal cancer and that was considered as an independent prognostic marker. Interestingly, adenocarcinoma of the esophagus did not express Cap43. In esophageal cancer cell lines, Western blotting and real-time RT-PCR, showed a variation in the expression level of Cap43 and there was no obvious correlation between protein and mRNA levels. The present report shows for the first time that the expression of the Cap43 gene has a function in tumor progression and that its expression correlates independently with patient survival. Cap43 gene could be considered as a new and important cancer marker.

Preoperative serum vascular endothelial growth factor-C (VEGF-C) levels predict recurrence in patients with esophageal cancer.

BACKGROUND: Circulating vascular endothelial growth factor-C (VEGF-C) levels were measured in patients with esophageal cancer to assess the value of VEGF-C as a biomarker for predicting tumor recurrence. PATIENTS AND METHODS: Preoperative serum samples were acquired from 80 patients and healthy volunteers who served as normal controls. VEGF-C levels were assessed using enzyme-linked immunosorbent assay (ELISA). RESULTS: The preoperative serum VEGF-C level in patients with esophageal cancer was significantly higher than in healthy volunteers. Furthermore, patients with recurrence had significantly higher preoperative serum VEGF-C levels than patients without recurrence, and a high preoperative serum VEGF-C level was found to be an independent risk factor for recurrence, in addition to lymph node metastasis. CONCLUSION: Preoperative VEGF-C levels may reflect malignancy, such as lymph node metastasis, and predict recurrence in patients with esophageal cancer. Therefore, the preoperative VEGF-C level may be a useful biomarker for choice of multimodality therapy.

Prediction of response to definitive chemoradiotherapy in esophageal cancer using positron emission tomography.

BACKGROUND: Positron emission tomography (PET) with 18-F-fluorodeoxyglucose (FDG) has already proven useful in assessing the extension of esophageal carcinomas, detecting tumor recurrence and monitoring responses to therapy. The current study aims to assess the potential role of FDG-PET in predicting the response of esophageal squamous cell carcinoma (SCC) to definitive chemoradiotherapy (CRT). PATIENTS AND METHODS: Twenty-seven patients with thoracic esophageal SCC who received definitive CRT between January 2001 and December 2005 underwent PET before and after CRT. The clinical evaluation of the primary tumor response to treatment was classified as either complete response (CR) or non-CR. RESULTS: All patients had intensive FDG uptake in the primary tumor prior to CRT. The standardized uptake value (SUV) averaged 8.2+/-4.7 before CRT and decreased significantly to 2.8+/-1.8 after CRT (p<0.0001). The SUV before CRT averaged 10.2 in the non-CR group (n=17) and 4.9 in the CR group (n= 10). The SUV after CRT averaged 3.7 in the non-CR group and 1.4 in the CR group. The change in SUV for the CR group was higher than that in the non-CR group (p<0.05). The relationship between clinical features and clinical CR was analyzed using logistic regression analysis which revealed significant correlations between clinical CR and the longitudinal dimension of the tumor (p <0.05), SUV before CRT (p<0.05), SUV after CRT (p<0.01) and tumor classification (p <0.05). If the clinical features before CRT were limited, multivariate analysis revealed that the SUV before CRT was an independent predictor for clinical CR (p<0.05). CONCLUSION: In predicting clinical evaluation of therapy prior to CRT, we suggest that SUV prior to definitive CRT is one of the most reliable predictors of response, along with tumor dimensions and classification.

Endoscopic clips prevent self-expandable metallic stent migration.

BACKGROUND/AIMS: Self-expandable metallic stents (SEMS) have been used for many years in the palliation of esophageal cancer symptoms. Stent migration is one of the most recognized complications of SEMS. To prevent SEMS migration, this study reported the use of endoscopic clips, and carefully analyzed the patients who underwent implantation. METHODOLOGY: From January 2000 to December 2002, nine patients consecutively underwent SEMS implantation. After successful placement of the SEMS and to maintain its position, endoscopic clips were used to fix the branch of the upper end of the stent to the esophageal mucosa. RESULTS: Stent implantation was technically successful in all patients, three of whom had strictures and six of whom had digestive-respiratory fistulas. No stent migration was observed in any of the patients, and dysphagia improved significantly after stent placement. Five patients did, however, experience delayed complications, two in the form of obstructions, two with recurrent fistulas, and one with a perforation. CONCLUSIONS: In conclusion, this new technique is recommended as endoscopic clipping can diminish the risks of stent migration, in particular those associated with esophago-respiratory fistulas without luminal obstruction.

Comprehensive investigations of quality of life after esophagectomy with special reference to the route of reconstruction.

BACKGROUND/AIMS: Esophagectomy is a very invasive operation, therefore, it is important to improve the postoperative quality of life (QOL) of the patients. The aim of this study was to evaluate the QOL of patients who had undergone esophagectomy for thoracic esophageal cancer. METHODOLOGY: We investigated 37 patients who had undergone esophagectomy. The anastomosis was made at the cervical location by the retrosternal route in 12 patients (RS group), at the high thoracic location by the posterior mediastinal route in 18 patients (HT group), and at the cervical location by the posterior mediastinal route in seven patients (PM group). QOL was evaluated by patient questionnaires concerning reflux esophagitis using QUEST and dumping syndrome, body weight, ambulatory pH monitoring, and immunostaining for iNOS and COX-2 as markers of inflammation. RESULTS: The QUEST score revealed that the findings suggesting reflux were few in the HT group. Patients suffered from dumping syndrome were significantly few in the HT group (p = 0.0399). The percentage time of pH < or =4.0 was shortest in the HT group at the position of the esophagogastric anastomosis (p < 0.0281). Body weight recovery was best in HT group (p < 0.0001). There was a tendency that iNOS and COX-2 immunoreactivity were weaker in HT group than other two groups. CONCLUSIONS: Our results suggest that QOL after esophageal reconstruction using a gastric tube is good in patients with the anastomosis at the high thoracic location by the posterior mediastinal route.

Surgical treatment for esophageal cancer. Current issues.

Esophageal cancer is one of the most difficult malignancies to cure. The prognosis remains unsatisfactory despite significant advances in surgical techniques and perioperative management. The optimal treatment strategy for localized esophageal cancer has not yet been established. Surgical resection remains the mainstay of treatment for esophageal cancer, and curative resection is the most important surgery. Extended esophagectomy with three-field lymphadenectomy provides the highest quality of tumor clearance and prolongation of patient survival. There has been intense effort in developing novel strategies to treat patients with resectable esophageal cancer. Various combined-modality approaches have been attempted to improve treatment outcomes. Definitive chemoradiotherapy has an impact on long-term survival in patients with resectable esophageal cancer. Accordingly, there are three main combined-modality approaches: esophagectomy with adjuvant chemotherapy or chemoradiotherapy; primary definitive chemoradiotherapy with or without salvage esophagectomy, and preoperative chemoradiotherapy followed by planned esophagectomy. Recently, owing to the remarkable advances in optical technology, minimally invasive esophagectomy using endoscopic instruments has been introduced into esophageal cancer surgery. This article reviews recent changes in the treatment of esophageal cancer surgery, and considers the role of esophagectomy.

Videofluoroscopic evaluation in oropharyngeal swallowing after radical esophagectomy with lymphadenectomy for esophageal cancer.

BACKGROUND: After esophagectomy a swallowing abnormality is the predominant symptom for esophageal cancer. The aims of this study were to examine (i) oropharyngeal swallowing by comparing pre- and postoperative period, and (ii) the relationship between oropharyngeal swallowing and the alimentary reconstruction route after esophagectomy. PATIENTS AND METHODS: We studied 27 patients in the upright position using videofluoroscopy in the lateral projection. Each patient was studied during 10 mL barium swallows in the pre- and post-operative period. RESULTS: Of the 27 patients studied, alimentary reconstruction with the retrosternal route (RS group) was performed in 8 patients, that with posterior mediastinal route (PM group) in 8 patients, and the intrathoracic (IT group) esophagogastrostomy inside the posterior mediastinum in 11 patients. With regard to the maximal extent of structural movement, the superior and anterior excursion of the hyoid bone was significantly reduced postoperatively among all groups. The maximal extent of the cricopharyngeal opening was significantly reduced postoperatively in the RS group, but not in the IT group. The changes in the peri-operative structural movement were the lowest in the RS group. CONCLUSION: A new-onset oropharyngeal swallowing abnormality following retrosternal reconstruction after esophagectomy may have appeared because the change in the peri-operative movement was the lowest. The results of the swallowing evaluation using videofluoroscopy suggest that to avoid oropharyngeal swallowing abnormalities the intrathoracic or cervical anastomosis with posterior mediastinal route should be chosen as reconstruction after esophagectomy if possible.

Lack of activated Smad2 in transforming growth factor-beta signaling is an unfavorable prognostic factor in patients with esophageal squamous cell carcinoma.

BACKGROUND AND OBJECTIVES: Transforming growth factor-beta (TGF-beta) regulates cell growth in various cells, and inactivation of the TGF-beta-signaling pathway contributes to tumor progression. In this study, we investigated the expression of Smad2 and Smad3, which are specific intracellular mediators of TGF-beta signaling. We also examined the relationship between the expression levels of activated Smad2 by TGF-beta and clinicopathologic characteristics of patients with esophageal squamous cell carcinoma (SCC). METHODS: Immunohistochemical staining with anti-phosphorylated Smad2 (P-Smad2) polyclonal antibody, anti-Smad2 monoclonal antibody, and anti-Smad3 polyclonal antibody was performed on surgical specimens obtained from 80 patients with esophageal SCC. RESULTS: Our data indicated that a low level of P-Smad2, as detected immunohistologically, correlated with lymph node metastasis (P = 0.0002), distant metastasis (P = 0.0338), pathologic stage (P = 0.0093), and poor survival rate (P = 0.0246). All patients without positive Smad2 immunostaining were included among those without positive P-Smad2 immunostaining. There was no significant correlation between expression of Smad2 or Smad3 and clinicopathologic characteristics. CONCLUSIONS: We demonstrated that a lack of Smad2-P appears to be correlated with tumor development and poor prognosis in patients with esophageal SCC.

Clinicopathological characteristics and outcome indicators of stage II gastric cancer according to the Japanese classification of gastric cancer.

BACKGROUND: The characteristics of stage II gastric cancer according to the Japanese Classification of Gastric Cancer (JCGC) were examined and the high-risk factors predicting poor prognosis were detected. PATIENTS AND METHODS: In total, 107 patients, who underwent clinically curative gastrectomy with D2 lymphadenectomy for stage II gastric cancer, were included. Survival curves of the depth of invasion, lymph node metastasis, the ratio of involved: resected lymph nodes and chemotherapy treatment were compared. RESULTS: The survival curves were related to tumor invasion depth and lymph node metastasis. The ratio of involved resected lymph nodes was a good prognostic indicator compared to the classification of regional lymph node metastasis (N classification). Survival rates with adjuvant chemotherapy were slightly higher than without adjuvant chemotherapy, but the difference was not significant. CONCLUSION: pT2pN1 (stage II) gastric cancers according to the JCGC, especially pSSpN1 cases, included stage IIIB and IV gastric cancers according to the International Union Against Cancer / American Joint Committee on Cancer (UICC/AJCC); therefore, the prognosis of these might be poor. With pSSpN1 cases, according to the JCGC, anticancer chemotherapy equivalent to that required for stage III gastric cancer cases is necessary.

A novel technique to facilitate laparoscopic repair of large paraesophageal hernias.

BACKGROUND: Laparoscopic repair of large paraesophageal hernias (LPEH) is technically challenging, and requires advanced laparoscopic skills. We have developed a novel technique for facilitating laparoscopic repair of LPEHs safely and easily, using a Nelaton catheter. PATIENTS AND METHODS: Seven patients with LPEHs were operated on through a laparoscopic approach. During surgery, the left lobe of the liver and right diaphragmatic crus were elevated using a suspended thread covered by a Nelaton catheter. RESULTS: All patients were operated on laparoscopically using this technique. No patient required conversion to open method. The median operating time was 205 minutes and the range was from 155 to 295 minutes. No intraoperative or early complications occurred in any patient. Late complications occurred in 2 patients due to a small sliding hernia: a slipped fundoplication in 1 patient, and a gastric ulcer in the other. CONCLUSIONS: In conclusion, laparoscopic repair of LPEH is a challenging procedure that requires wide experience in laparoscopic gastroesophageal surgery. Further refinement for this operation may be necessary.

Factors predicting long-term responses to splenectomy in patients with idiopathic thrombocytopenic purpura.

BACKGROUND: Idiopathic thrombocytopenic purpura (ITP) is an autoimmune disorder for which appropriate diagnostic treatments are uncertain. The response to splenectomy varies from 60% to 90%, and the remaining patients relapse and require further treatment. Therefore, it is important to predict the outcome of splenectomy before and after surgery. The objective of this study was to evaluate the efficacy of splenectomy in patients diagnosed with ITP. MATERIALS AND METHODS: From 1988 to 2004, we splenectomized 32 patients with ITP; 17 underwent laparoscopic splenectomy (LS) and 15 underwent conventional open splenectomy (OS). For analysis, patients were separated retrospectively into two groups: the "responding group," those who showed good outcomes with splenectomy, and the "non-responding group," those who did not show good outcomes with splenectomy. Blood samples were examined before and immediately after surgery (day 0) and on postoperative days (POD) 1, 3, 5, and 7. RESULTS: The median follow-up was 8.3 years (range: 1-16 years). The overall 5- and 10-year survival rates after splenectomy were 96.9% (one death). The responding group included 24 patients (75%), and the non-responding group included 7 (21.9%). Platelet counts in the responding group increased gradually until POD 7, and although platelet counts in the non-responding group were almost constant until POD 5, they subsequently decreased until POD 7. Average platelet counts in the responding and non-responding groups were 269 and 124 x 10(9)/l on POD 7, respectively (P < 0.05). The pre- to post-surgery ratio of platelet counts were almost the same as the result of the actual data. Platelet counts during the long-term follow-up for the responding and non-responding groups were related to those noted on discharge. CONCLUSIONS: A high platelet count on POD 7 was associated with a good response to splenectomy, but age at surgery, the time interval between diagnosis and splenectomy, and prior responses to corticosteroid were not. We suggest that long-term outcomes of splenectomy can easily be predicted by platelet counts on POD 7.

Comparison between whole-body positron emission tomography and bone scintigraphy in evaluating bony metastases of esophageal carcinomas.

BACKGROUND: Positron emission tomography (PET) with 18-F-fluorodeoxyglucose (FDG) has already proved useful in assessing the extension of esophageal carcinomas, detecting tumor recurrence and monitoring responses to therapy. This study aimed to elucidate the potential role of FDG-PET compared with technetium-99m methylene diphosphonate (Tc-99m MDP) bone scintigraphy in the evaluation of bony metastasis in esophageal carcinoma patients. PATIENTS AND METHODS: Forty-four patients with thoracic esophageal carcinomas, who underwent FDG-PET together with bone scintigraphy within 1 month between January 2000 and September 2003, were included in this study. RESULTS: Of the 44 patients, 13 had 31 bone metastases and, of these, 6 were diagnosed pretreatment and 7 had recurrence after esophagectomy surgery. Of the 31 metastases, 9 were in the vertebral column, 11 in the thoracic cage (including the ribs, clavicle, sternum and scapula), 9 in the pelvic bones and 2 in the long bones of the extremities. In evaluating the detection of bony metastasis, FDG-PET showed 92% sensitivity, 94% specificity and 93% accuracy, compared with 77%, 84% and 82%o, respectively, for bone scintigraphy. Although the sensitivity, specificity and accuracy of PET were slightly higher than those of bone scintigraphy, these differences were not statistically significant according to the McNemar's test. Three patients with false-negative findings on their bone scans had positive findings with PET; all of these lesions were osteolytic metastases. CONCLUSION: FDG-PET scans were superior to bone scintigraphy in detecting bony metastases of esophageal carcinomas. Therefore, FDG-PET can be used for the detection and follow-up of bone tumors when Tc-99m MDP bone scintigraphy gives negative findings.

Evaluation of tumor malignancy in esophageal squamous cell carcinoma using different characteristic factors.

BACKGROUND: We have been investigating various molecules correlated with the malignancy of esophageal squamous cell carcinoma and, in the present study, we examined the correlation of four of them (KAI1, FAK, EphA2, Ki-67 labeling index) with the prognosis of affected patients. Furthermore, the use of biopsy samples was studied to evaluate whether the grade of tumor malignancy can be determined before treatment in a clinical setting. MATERIALS AND METHODS: Tissue specimens that had been surgically removed from 91 patients with thoracic esophageal cancer and 247 biopsy samples were examined. The malignancy index (MI) was defined in terms of the KAI1, FAK and EphA2 scores and the Ki-67 labeling index, and the reliability and utility of the correlation between MI and prognosis was evaluated. RESULTS: The mean 5-year survival rate of patients with MI=0 was 100%, while that of patients with MI=1, 2 and 3 was 70%, 48% and 10%, respectively. Patients with MI=4 all died, with the exception of one who has been observed for 3 years. The rate of concordance between the biopsy samples and surgical specimens was 79.4% for KAI1, 88.2% for FAK and 73.5% for EphA2, and the rates of concordance for 1, 2, 3, 4, 5, 6, 7 and 8 biopsy samples were 66.7%, 64.1%, 74.5%, 90.7%, 91.7%, 83.3%, 100% and 100%, respectively. CONCLUSION: It may be feasible to evaluate the malignancy of tumor cells and to predict patient outcome by using multiple marker molecules. It is anticipated that such data will accelerate the development of "tailor-made" therapy.

Serum p53 antibodies in drainage blood from the azygos vein in patients with esophageal carcinoma.

BACKGROUND: Serum p53 antibodies (p53-Ab) have been detected in some cancers. The possible correlation between serum p53-Ab levels in drainage blood from the azygos vein in patients with esophageal carcinoma and prognosis was investigated. MATERIALS AND METHODS: Serum p53-Ab levels were examined in both the peripheral and azygos veins of 57 patients, and in the peripheral vein of 17 healthy volunteers. Serum p53-Ab levels were measured using an enzyme-linked immunosorbent assay. RESULTS: The positive rate of serum p53-Ab in the peripheral vein of the patients was 31.6%, significantly higher than that of the normal volunteers. There were no significant correlations between the clinicopathological features and the serum p53-Ab in either the peripheral or azygos veins. Serum p53-Ab levels in either vein did not correlate with prognosis in the univariate survival analysis, although the levels in the two veins were significantly correlated. CONCLUSION: Serum p53-Ab levels in the azygos vein did not reflect the tumor status or prognosis more directly or accurately than those in the peripheral vein, since levels in the two veins were similar. Therefore, measurement of serum p53-Ab in the azygos vein does not appear to be necessary.

Classification of recurrent esophageal cancer after radical esophagectomy with two- or three-field lymphadenectomy.

BACKGROUND: Although patients with recurrent diseases have a very poor prognosis, appropriate pretreatment classification for management of recurrent esophageal cancers has yet to be identified. The patterns of recurrence following radial esophagectomy were retrospectively assessed, and evaluated for possible adaptation as a novel classification of recurrent esophageal cancer. PATIENTS AND METHODS: One hundred and sixty thoracic esophageal cancer patients (142 men; 18 women), who underwent radical esophagectomy without preoperative treatment, were studied. RESULTS: Recurrence occurred in 59 (36.8%) patients. The relationship between recurrence and clinicopathological features revealed significant associations between recurrence and age at surgery (p<0.05), tumor (p<0.0001), lymph node (p<0.0001) and metastatic status (p<0.01), pathological stage (p<0.0001) and lymph node dissection (p<0.0001). Locoregional recurrence occurred in 13 (22%) patients, distant in 30 (51%) and mixed in 16 (27%). Mixed recurrence occurred the fastest and showed the poorest prognosis. A novel classification for recurrent esophageal cancer was proposed based on the clinical findings. Univariate analysis of the prognostic factors for post-recurrent survival revealed a significant association with distant organ recurrence (p<0.05). CONCLUSION: Mixed recurrence had a poorer outcome than other recurrences. The proposed classification of clinical findings for recurrent esophageal cancer was shown to be useful; however, further studies with a larger number of recurrent esophageal cancers are required for stage grouping of the proposed classification.

Predictors of response to chemo-radiotherapy and radiotherapy for esophageal squamous cell carcinoma.

BACKGROUND: The sensitivity of tumors to chemotherapy and radiotherapy differs from one case to another and may be influenced by the expression of biological molecules. The presence of six potential predictive markers in esophageal squamous cell carcinoma (ESCC) was investigated and the data obtained were related to the response of the tumors to chemo-radiotherapy and radiotherapy. MATERIALS AND METHODS: Biopsy specimens were obtained from 61 patients with ESCC before treatment with chemo-radiotherapy (31 patients) or radiotherapy (30 patients). External radiotherapy was delivered by a two-field technique to a total of 60-70 Gray. Concurrent chemotherapy consisted of cisplatin or nedaplatin and 5-fluorouracil administered intravenously. The patients were examined before and after treatment by endoscopy, esophagography and computed tomography. The clinical response was classified as effective (> 50% decrease in primary lesion), or ineffective. Immunohistochemical staining for p53, p21, bax, bcl2, heat-shock protein (Hsp) 27 and Hsp70 was performed on the biopsy specimens before therapy. RESULTS: The primary tumor response was effective in 73.8% (45/61) and ineffective in 26.2% (16/61) of patients. Tumors with p53-positive expression were less sensitive than p53-negative tumors (p = 0.033). p21-positive patients (p = 0.027), and Hsp27-negative (p = 0.0057) and Hsp70-negative patients (p = 0.010) were all good responders. Neither bcl2 nor bax expression was related to the efficacy of therapy. Multivariate analysis revealed that Hsp27 was the most reliable predictor of the effect of chemo-radiotherapy and radiotherapy among the four potential markers. p53-negative and Hsp70-negative patients had a more favorable prognosis than p53- and Hsp70-positive patients (p = 0.039, p = 0.038, respectively). CONCLUSION: Expression of Hsp27 was a good predictor of the response of ESCC to chemo-radiotherapy and radiotherapy.

Primary squamous cell carcinoma of the stomach: a case report with immunohistochemical and molecular biologic studies.

Primary squamous cell carcinoma (SCC) of the stomach is an extremely rare tumor and its pathogenesis is still unknown. We report a case of SCC of the stomach in a 69-year-old man. The patient's stomach contained an area of SCC surrounded by squamous metaplasia. To our knowledge, this is the first reported study to have investigated the pathogenesis of this tumor type by immunohistochemistry, liquid hybridization assay for human papilloma virus (HPV) infection, and polymerase chain reaction for Epstein-Barr virus (EBV) infection. These tests yielded proof of EBV infection in surgical specimens of the tumor. Therefore, we suggest that EBV infection may be involved in the pathogenesis of SCC arising in the stomach.

Relationship between secretory leukocyte protease inhibitor levels in bronchoalveolar lavage fluid and postoperative pulmonary complications in patients with esophageal cancer.

BACKGROUND: We investigated whether secretory leukocyte protease inhibitor (SLPI) is associated with pulmonary complications after esophagectomy. METHODS: We measured serial changes in the SLPI concentration in the bronchoalveolar lavage fluid (BALF) of 34 patients who underwent and examined the relationship between SLPI and postoperative morbidity. RESULTS: Fifteen (44%) of 34 patients (high group) had a BALF SLPI concentration >90,000 pg/mL at the end of the surgery (postoperative day [POD] 0). There was no significant difference between the high group and other 19 patients (low group) with respect to age, sex, preoperative comorbid conditions, tumor stage, surgical technique, operating time, or blood loss volume. Days of intubation and pulmonary complication rate were significantly increased in the high group compared with the low group. Logistic regression analysis revealed that the BALF SLPI level on POD 0 was significant for pulmonary complications. CONCLUSIONS: Our results indicate that assaying SLPI levels in BALF can be useful for the prediction of pulmonary complications after esophagectomy.

The incremental effect of positron emission tomography on diagnostic accuracy in the initial staging of esophageal carcinoma.

BACKGROUND: The purpose of the current study was to assess whether [18F]fluorodeoxyglucose positron emission tomography (FDG-PET) provides incremental value (e.g., additional information on lymph node involvement or the presence of distant metastases) compared with computed tomography (CT) in patients with esophageal carcinoma. METHODS: The authors examined 149 consecutive patients with thoracic esophageal carcinoma. Eighty-one patients underwent radical esophagectomy without pretreatment, 17 received chemoradiotherapy followed by surgery, 3 underwent endoscopic mucosal resection, and the remaining 48 patients received definitive radiotherapy and chemotherapy. The diagnostic accuracy of FDG-PET and CT was evaluated at the time of diagnosis. RESULTS: The primary tumor was visualized using FDG-PET in 119 (80%) of 149 patients. Regarding lymph node metastases, FDG-PET had 32% sensitivity, 99% specificity, and 93% accuracy for individual lymph node group evaluation and 55% sensitivity, 90% specificity, and 72% accuracy for lymph node staging evaluation. PET exhibited incremental value over CT with regard to lymph node status in 14 of 98 patients who received surgery: 6 patients with negative CT findings were eventually shown to have lymph node metastases (i.e., they had positive PET findings and a positive reference standard [RS]); 6 patients with positive CT findings were shown not to have lymph node metastases (i.e., they had negative PET findings and a negative RS); and 2 patients were shown to have cervical lymph node metastases in addition to mediastinal or abdominal lymph node metastases. Among the remaining patients, PET showed incremental value over CT with regard to distant organ metastases in six patients. The overall incremental value of PET compared with CT with regard to staging accuracy was 14% (20 of 149 patients). CONCLUSIONS: FDG-PET provided incremental value over CT in the initial staging of esophageal carcinoma. At present, combined PET-CT may be the most effective method available for the preoperative staging of esophageal tumors.