Whole-body FDG positron emission tomographic imaging for staging esophageal cancer comparison with computed tomography.

PURPOSE: The aim of the authors in this study was to critically evaluate the role of whole-body positron emission tomographic (PET) imaging with fluorine-18 fluorodeoxyglucose (FDG) in staging esophageal cancer, and further to compare this method with conventional imaging with computed tomography (CT). MATERIALS AND METHODS: The authors performed independent, blinded retrospective evaluations of FDG PET images obtained in 47 patients referred for the initial staging of esophageal cancer before minimally invasive surgical staging. Twenty PET studies from patients with nonesophageal thoracic cancers were randomly selected for inclusion in the PET readings. In a subset of 37 of 47 cases, the PET findings were compared with independent readings of CT studies acquired within the same 6-week interval. The utility of the imaging findings was evaluated using a high-sensitivity interpretation (i.e., assigning equivocal findings as positive) and a low-sensitivity interpretation (i.e., assigning equivocal findings as negative). RESULTS: PET was less sensitive (41% in high-sensitivity mode, 35% in low-sensitivity mode) than CT (63% to 87%) for diagnosing tumor involvement in locoregional lymph nodes, which was identified by surgical assessment in 72% of patients. Notable, however, was the greater specificity of PET-determined nodal sites (to approximately 90%) compared with CT (14% to 43%). In detecting histologically proved distant metastases (n = 10), PET performed considerably better when applied in the high-sensitivity mode, with a sensitivity rate of approximately 70% and a specificity rate of more than 90% in the total group and in the subset of patients with correlative CT data. In the low-sensitivity mode, CT identified only two of seven metastatic sites, whereas the high-sensitivity mode resulted in an unacceptably high rate of false-positive readings (positive predictive value, 29%). PET correctly identified one additional site of metastasis that was not detected by CT. CONCLUSIONS: The relatively low sensitivity of PET for identifying locoregional lesions precludes its replacement of conventional CT staging. However, the primary advantage of PET imaging is its superior specificity for tumor detection and improved diagnostic value for distant metastatic sites, features that may substantially affect patient management decisions. In conclusion, PET imaging is useful in the initial staging of esophageal cancer and provides additional and complementary information to that obtained by CT imaging.

Chest tube insertion: a prospective evaluation of pain management.

OBJECTIVE: To evaluate pain associated with chest tube insertion in a group of patients with malignant pleural effusions. DESIGN: Prospective case series. SETTING: Acute care cancer center in an academic institution. PATIENTS: Fifty-two patients with symptomatic malignant pleural effusions. Twenty-six evaluated by conventional approach to chest tube insertion (group 1), 26 evaluated after institution of a new chest tube protocol (group 2). INTERVENTIONS: A new protocol was designed to improve pain control during chest tube insertion. The protocol included improved housestaff and nursing education, premedication, proper insertion techniques, and more liberal and precise delivery of local anesthetic. OUTCOME MEASURES: Both groups were evaluated by a verbal self-report scale (1-10) to assess pain and anxiety. RESULTS: The mean pain rating in group 1 was 6.2 (+/-0.76) compared with 3.7 (+/-5.6) in group 2 (p < 0.01). In group 1, pain or anxiety was 9 or 10 in 12 of 26 on a scale of 1 to 10, compared with 2 of 26 in group 2 (p < 0.001). Anxiety rating was 4.5 (+/-0.72) in group 1 compared with 1.5 (+/-0.54) in group 2 (p < 0.01). CONCLUSIONS: Chest tube insertion was associated with an unacceptably high level of pain and anxiety in our hospital. A new protocol, including housestaff education and changes in nursing policies, technical aspects, local anesthetic dose and delivery, and pre-medication, allowed us to approach the goal of a painless chest tube insertion.

Role of positron emission tomography in staging esophageal cancer.

BACKGROUND: Conventional noninvasive staging of esophageal cancer is inaccurate. This study investigated the role of positron emission tomography (PET) in staging esophageal cancer. METHODS: Patients with potentially resectable esophageal cancer were included. A whole-body PET scan was acquired after injection of 18F-fluorodeoxyglucose and was evaluated for areas of increased focal uptake. Accuracy was determined by comparing PET with surgical staging. RESULTS: Potentially resectable esophageal cancer was identified in 35 patients. Positron emission tomography detected nine sites of distant metastases missed by conventional scanning, but one false-negative PET scan occurred in a patient with a 2-mm liver lesion. There were 11 false-negative PET scans for small, intracapsular local-regional nodal metastases (mean diameter 5.2 mm; range 2 to 10 mm). For distant metastases, the sensitivity was 88%, the specificity was 93%, and the accuracy was 91%. For local-regional nodal metastases, the sensitivity was 45%, the specificity was 100%, and the accuracy was 48%. CONCLUSIONS: Positron emission tomography improved our ability to detect distant metastases missed by conventional noninvasive staging of esophageal cancer. Small local-regional nodal metastases are not identified by current PET technology. Early use of PET in the staging of patients with esophageal cancer could facilitate treatment planning and identifying unsuspected distant metastases in up to 20% of patients with a negative metastatic survey by conventional staging.