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 Table of Contents  
Year : 2012  |  Volume : 8  |  Issue : 4  |  Page : 619-625

Positron emission tomography/computed tomography and esophageal cancer in the clinical practice: How does it affect the prognosis?

1 Radiotherapy and Nuclear Medicine Unit, Istituto Oncologico Veneto (IOV - IRCCS), Padova, Italy
2 Endoscopic Surgery Unit, Istituto Oncologico Veneto (IOV - IRCCS), Padova, Italy
3 Oncology Unit, Istituto Oncologico Veneto (IOV - IRCCS), Padova, Italy
4 Oncology Radiology Unit, Istituto Oncologico Veneto (IOV - IRCCS), Padova, Italy

Date of Web Publication29-Jan-2013

Correspondence Address:
Anna R Cervino
Radiotherapy and Nuclear Medicine Unit, Istituto Oncologico Veneto (IOV - IRCCS), Via Gattamelata, 64 35128, Padova
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0973-1482.106580

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 > Abstract 

Aims: The aim of this study was to assess the diagnostic value of positron emission tomography/computed tomography (PET/CT) in staging of esophageal cancer and to evaluate the prognostic role of metabolic parameters before and after neo-adjuvant treatment.
Settings and Design: Mono-institutional retrospective study.
Materials and Methods: We retrospectively evaluated 29 patients who underwent PET/CT at initial staging and after neo-adjuvant therapy. Metabolic parameters were calculated: mean, average, maximum standardized uptake value (SUVmax), and total lesion glycolysis (TLG). Diagnostic advantages of PET/CT over conventional imaging (CI) were determined. The relationships between baseline and after-therapy SUVmax and TLG, change in SUV and TLG (reported as ∆) for the primary tumor and prognosis were assessed.
Statistical Analysis Used: Non-parametric statistic (e.g. Wilcoxon test and chi-square test).
Results: Twenty-nine patients were eligible for the initial staging. Thirteen patients were incorrectly staged based on CI; PET/CT was able to identify distant lymph nodes in seven patients (59%) and distant metastases in four (31%). The median SUVmax before and after neoadjuvant therapy was 10.38 and 3.53 (P = 0.0005), respectively. Only few semi-quantitative parameters obtained by PET/CT after neoadjuvant therapy seemed to have a prognostic value. TLG and ∆TLG were significantly different between disease-free and died patients (0.49 versus 15.51 and 100% versus 94%, respectively; all P = <0.05).
Conclusions: PET/CT is confirmed as being able to detect distant metastases and to avoid unnecessary surgery. Although not routinely reported, post-neoadjuvant TLG and ∆TLG might be considered as useful prognostic parameters and should be further evaluated prospectively.

Keywords: Esophageal cancer, neoadjuvant therapy, positron emission tomography, staging

How to cite this article:
Cervino AR, Evangelista L, Alfieri R, Castoro C, Sileni VC, Pomerri F, Corti L, Muzzio PC. Positron emission tomography/computed tomography and esophageal cancer in the clinical practice: How does it affect the prognosis?. J Can Res Ther 2012;8:619-25

How to cite this URL:
Cervino AR, Evangelista L, Alfieri R, Castoro C, Sileni VC, Pomerri F, Corti L, Muzzio PC. Positron emission tomography/computed tomography and esophageal cancer in the clinical practice: How does it affect the prognosis?. J Can Res Ther [serial online] 2012 [cited 2022 Jun 29];8:619-25. Available from: https://www.cancerjournal.net/text.asp?2012/8/4/619/106580

 > Introduction Top

The esophageal cancer (EC) has spread throughout the world with high incidence in Asia and lowest in Europe, where it was recorded as an incidence of 11-12 cases per year in 100,000 people. It is often asymptomatic in early stages and when it becomes clinically manifest often has already locally advanced. The radical surgical resection (R0) still remains the best therapeutic approach. Neoadjuvant chemotherapy and external radiotherapy can increase the possibility to perform an R0 treatment to improve the survival rate. [1],[2] The correct staging is crucial for choosing the therapeutic strategy. The best investigation employed for loco-regional staging is the endoscopic ultrasound (EUS) that has been demonstrated to have the highest T and N staging accuracies (85% and 75%, respectively). [3] Moreover, at initial staging, radiography of the digestive tract, bronchoscopy, and computed tomography (CT) of the neck, chest, and abdomen are widely used. In recent years, the introduction of functional imaging, such as 18F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) has changed many protocols of tumor staging, including EC (NCCN guidelines 2010). Being FDG PET/CT able to detect a tumor with high glucose metabolism, some authors suggest the hypothesis using it as a tool for routine staging. [4]

Tumor staging of EC is important, since stage-specific treatment protocols are now routinely used in general practice. The depth of tumor invasion is one of the most used criteria for selection of multimodality therapy (chemotherapy plus radiotherapy). EUS represents the best diagnostic technique on predicting cancer depth and regional lymph node involvement being able to distinguish small tumor lesions without lymph node involvement from larger tumors with involved peri-tumoural lymph node. [5] CT is widely performed for the evaluation of primary tumor and for excluding distant lesions; its main limitation is inability to determine the depth of tumor infiltration in the esophageal wall. [3] In clinical practice, the use of PET in EC staging is increasing because often the tumors express high-glucose metabolism, but small lesions cannot be detectable. Therefore, PET/CT is not indicated in early stages, while is more accurate and recommended in stages II and III (NCCN guidelines 2010).

The evaluation of response to neoadjuvant treatment requires the repetition of diagnostic imaging, but the treatments can alter their overall sensitivity and specificity. EUS in T restaging showed sensitivity 20%, specificity 94%, and accuracy 70%, [6] while CT demonstrated low sensitivity and specificity (33-55% and 50-71%, respectively). [7] Currently, FDG PET/CT seems to be the best available tool for assessing the response to neoadjuvant therapy in EC showing a sensitivity and specificity of 71% and 82%, respectively. [8] It is able to quantify tumor metabolic response using qualitative and/or quantitative analysis. The first one compares tumor FDG uptake with physiological background activity, while the second one commonly can be obtained by the standardized uptake value (SUV) or kinetic models. The maximum SUV (SUVmax), which is normalized for injection dose and body weight, is the most employed. Another semi-quantitative parameter is total lesion glycolysis (TLG) that represents the absolute glycolysis of tumor tissue and depends on both tumor volume and FDG uptake expressed as SUVaverage. [9] TLG is less influenced by the effect of partial volume and motion-induced blurring than SUV, responsible of an overestimation of volume and underestimation of tumor metabolism, respectively.

The purposes of the study were to assess in locally advanced EC (1) the role of FDG PET/CT for staging in comparison with conventional imaging (CI) and (2) the prognostic impact of metabolic parameters before and after neoadjuvant therapy.

 > Materials and Methods Top

From February 2008 to December 2010, we enrolled 29 EC patients who performed PET/CT scan before and after neoadjuvant therapy. As inclusion criteria, we considered only patients who had at disposal the findings from CI and clinical data both initial staging and after neoadjuvant treatment. Conventional TNM staging system of the American Joint Committee on Cancer Staging Criteria (AJCC 2010) was employed. FDG PET/CT was performed within few days (median: 8 days; range: 7-14 days) from CI. The final reports of EGDS, EUS, and CT were collected and interpreted in accordance with their results. EUS was used to evaluate both esophageal wall and loco-regional lymph nodes. Mediastinal and upper lymph nodes were systematically evaluated in each patients and regional lymph node disease was staged as N1. In distal EC, celiac lymph node disease was staged as M1a. Suspicious lymph nodes for malignant involvement (>10 mm) were noted. CT scan reports were interpreted for (a) the characteristics of primary tumor, (b) the presence of loco-regional and distant lymph node, (c) the local invasion of adjacent structures, and (d) the distant metastases.

Out of 29 patients, 25 were eligible for the prognostic evaluation being free from distant metastases. These latter patients underwent the following combined treatments:

  1. Three patients were treated with cisplatin plus fluorouracil and two of them also with radiotherapy (RT) 50-60 Gy/25-30 fractions (fr);
  2. Two patients were treated with epirubicin plus cisplatin plus fluorouracil and RT 50 Gy/25-30 fr;
  3. 17 patients were treated with taxanes plus cisplatin plus fluorouracil and 10 of them also with RT 50-60 Gy/ 25-30 fr;
  4. Three patients were treated with folic acid plus fluorouracil plus cisplatin as induction chemotherapy followed by cetuximab and RT 50 Gy/25-30 fr, as expected from B152 clinical trial.
Within a mean of 40 days (range 28-53 days) from the end of neoadjuvant therapy, PET/CT was performed for assessing the response to treatment. The response to neoadjuvant treatment was definitively obtained by surgical specimen in 14 patients and incisional biopsy in 11 patients. The scoring system applied to evaluate the evidence of histopathological response was the Mandard tumor regression grade (TRG). Patients with a TRG score of 1 or 2 were considered to have a significant response; all others TRGs (score 3-5) were considered no responders, including patients with disease progression and stable disease. [10]

All enrolled patients observed a fast of at least 6 h before performing PET/CT examination. After evaluation of glucose blood levels, measured by a dedicated stick (acceptable value ≥ 130 mg/dL), 3 MegaBequerel (MBq) 18F-FDG for kilogram of body weight was injected. Patients rested in a comfortable room and 60 min after administration of tracer, the images were acquired. Whole-body 18F-FDG PET/CT was performed using a dedicated PET/CT scanner (Biograph 16, by Siemens Medical Solutions, IL, USA). The PET component is a high-resolution scanner with a spatial resolution of 4.7 mm and has no septa, thus allowing only three-dimensional acquisitions. The CT portion of the scanner is the Somatom Sensation 16 slices. Together with the PET system, the CT scanner is used both for attenuation correction of PET data and for anatomical localization of 18F-FDG uptake in PET images. Transmission images were performed using the followed parameters: 100 kV, 80 mA, 1.35:1 pitch, 0.5-s rotation, and a detector configuration of 8 mm × 1.25 mm. Emission images ranging from the proximal femur and the base of the skull were acquired for 2-3 min (based on the body weight) per acquisition field of view (AFOV). Acquired images were reconstructed using the attenuation weighted-ordered subset expectation maximization (OSEM) iterative reconstruction, with two iterations and eight subsets. The Gaussian filter was applied to the images after reconstruction along the axial and transaxial directions. The data were reconstructed over a 128 × 128 matrix with 5.25 mm pixel size and 2 mm slice thickness. The images were displayed on three planes (coronal, transverse, and sagittal).

At visual analysis, the images were considered as pathologic (positive results) if abnormal tracer accumulation was recognized outside of physiological uptake. For each identified lesion, we calculated the maximum/mean/average SUV and tumor volume (Vol) and its spatial coordinates (X, Y, Z) drawing a region of interest (ROI) on attenuation-corrected images. An adaptive threshold (SUV ≥ 2) using a standard ROI manually chosen by two experienced nuclear medicine specialists was used. [11] The calculation of SUV was computed from the following formula:

K (SUV) = K (Bq/cc)×[Weight (kg)/dose (Bq)]×1000cc/kg,


K (Bq/cc) = volume pixels calibrated and scaled

Dose (Bq) = injected dose in Bq and corrected for the decay time.

Semiquantitative analysis. The percentage change (Δ) in Vol and SUVmax were computed as followes:
ΔVol (%) = {[(Vol)1 - (Vol)2]/ (Vol)1}×100
ΔSUVmax (%) = {[(SUVmax)1 - (SUVmax)2]/(SUVmax)1}×100

The ΔTLG was obtained from the following formula:
ΔTLG (%) = {[(SUVaverage)1×(Vol)1]-[(SUVaverage)2×(Vol)2]/ [(SUVaverage)1×(Vol)1]}×100.

All previously described parameters were defined as 1 and 2 when calculated before and after neoadjuvant treatment, respectively.

Clinical and pathological stagings were compared to EGDS plus EUS, CT, and PET/CT imaging. The end-points of this study were to (1) understand whether the inclusion of PET/CT in EC staging can be useful to better define the therapeutic approach and (2) define the correlation of metabolic data with prognosis. The diagnostic accuracy of each technique was calculated using standard methods. The Wilcoxon test was used for the comparison of baseline and post-neo-adjuvant metabolic measures at PET/CT and Mann-Whitney U test for the comparison of the volumetric and metabolic parameters between the responder and no responder group. A receiver-operator characteristic (ROC) analysis was performed for identification of optimal ∆TLG and ∆SUV cut-off to better correlate with the response to neoadjuvant treatment; moreover, the areas under the ROC curve were computed. Statistical analysis was performed with SPSS software (Chicago, IL).

 > Results Top

The first end-point was to assess the diagnostic accuracy of PET/CT in comparison with CI in a population of 29 patients (16 men; mean age: 58±9; range: 38-74). The characteristics of study population are depicted in [Table 1].
Table 1: Characteristics of study population (n = 29 patients)

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According to clinical-instrumental staging, 5 patients were at stage II, 20 at stage III, and 4 at stages IV. CI findings showed a correct staging in 16 (55%), upstaging in 1 (3%), and under-staging in 12 (42%) patients. Among incorrectly staged patients (n = 13), CT imaging provided the correct staging in 8, whereas PET/CT in 9 (62% versus 69%). The main contribution of CT was for loco-regional lymph nodes, while PET/CT identified distant metastases (i.e. liver and bone). Furthermore, PET/CT correctly discriminate patients with false-positive CT-findings, one patient with liver involvement, and one with distant lymph node. In [Table 2], we report the diagnostic accuracy according to each CI, CT, and PET/CT staging.
Table 2: Diagnostic accuracy for CI, CT, and PET/CT (number of patients = 29)

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Twenty-five patients (86%) with initial staging II-III underwent neoadjuvant therapy. At the end of neoadjuvant treatment, there were 15 (60%) complete response, 3 (12%) partial response, and 7 (28%) no response (stable or progression of disease). Therefore, 15 patients were considered responders and 10 no responders (60 versus 40%). Fourteen (56%) patients were sent to surgery, and 8 (57%) of them had had complete response. The remnant 11 (44%) patients underwent biopsy evaluation, and 7 (64%) had shown complete response thus were not further treated. At baseline PET/CT scan, all 25 patients presented abnormal FDG avidity in the site of primary tumor. The median SUVmax1 was 10.38 (range 0-27.37), while the median values of SUVmin1 and SUVaverage1 were 2.68 (range: 0-3.9) and 4.61 (range: 0-12.58), respectively. After neoadjuvant treatment, the median SUVmax2, SUVmin2, and SUVaverage2 were 3.53 (range 0-7), 2.48 (range: 0-11), and 1.90 (range: 0-4), respectively. As illustrated in [Table 3], the SUVmax1 tended to be higher in patients who obtained an optimal response (14.36 versus 8.47). Furthermore, the median of other metabolic parameters, such as SUVmax2, SUVaverage2, and TLG2, was significantly different in responder than in no responder groups (all P < 0.01). ΔSUV and ΔTLG were significantly higher in responder than in no responder groups (100% versus 54.16% and 100% versus 90.05%, respectively; all P < 0.01). A ROC analysis was performed in order to determine a cut-off value for discriminating ΔSUV and ΔTLG values to predict response to treatment by PET/CT. For ΔSUV, the value of 64.2% was identified as predictive of response to treatment with a sensitivity of 100% and specificity of 82% (AUC: 0.909; P = 0.0001) whereas for ΔTLG the value of 94% had been identified with a sensitivity of 94% and specificity of 82% in the same category of patients (AUC: 0.921; P = 0.0001).

PET/CT contributed in patient management: (1) modifying the radiotherapy planning in one patient; (2) avoiding the surgery in two patients, who were not correctly staged by EUS alone but with evidence of distance metastases after neoadjuvant chemotherapy at nuclear scan; (3) demonstrating the presence of synchronous tumor (thyroid carcinoma) in one patient; (4) confirming complete response to neoadjuvant treatment in eight patients and thus delaying surgical treatment; and finally (5) recognizing one patient with high operatory risk who demonstrated incomplete response to treatment. Totally, PET/CT changed the therapeutic management in 13/29 (44%) patients.
Table 3: Median value of metabolic measures from PET/CT in no-responder and responder groups

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Metabolic data and prognosis

After the follow-up period of 16±9 months (range: 7-37 months), 14 (56%) patients were considered disease-free, 7 (28%) had disease relapse, and 4 (16%) died. At baseline PET/CT, as reported in [Table 4], no metabolic parameters were significantly different between patients without and with disease relapse (SUVmax1: 11.12 versus 10.38; SUVaverage1: 4.62 versus 4.72, and TLG1: 259.88 versus 249.71; all P = NS). Similarly on the second scan, none of the semi-quantitative measures were significantly different between patients without and with recurrence (SUVmax2: 3.52 versuss. 3.53; SUVaverage2: 3.15 versus 2.34 and TLG2: 0.49 versus 8.84; all P = NS).
Table 4: Semi-quantitative parameters from PET/CT and prognosis

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Only few semi-quantitative parameters seemed to have a prognostic value, in particular, Vol2, TLG2, and ΔTLG were significantly different between disease-free and died patients (0.12 versus 6.46; 0.49 versus 15.51, and 100% versus 94%, respectively; all P < 0.05). In [Figure 1] and [Figure 2], we depict PET/CT comparison of disease-free and died patients at follow-up.
Figure 1: A 55-year-old man who underwent baseline and postneoadjuvant PET/CT for a pathologically proven esophageal adenocarcinoma cancer with T3N1M0 (stage III) disease. At baseline PET/CT, an intense FDG-uptake was showed at distal thoracic esophagus with a SUVmax of 7.35 and a TLG of 559.82. The patient underwent combined neoadjuvant therapy (taxotere + cisplatin + fl uorouracil and radiotherapy). PET/CT after treatment showed a less intense uptake of FDG in the same site with a SUVmax of 2 and a TLG of 56. Therefore, the change in SUVmax was 52% and in TLG was 90%. After 2 weeks from the second PET/CT, the patient was treated with a defi nitive surgery demonstrating a fi nal stage I (partial response to combined neo-adjuvant therapy). After 17 months from the second PET/CT, the patient was alive without evidence of disease

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Figure 2: A 57-year-old woman who underwent baseline and post-neoadjuvant PET/CT for a pathologically proven esophageal squamous cellular cancer with T3N0M0 (stage II) disease. At baseline PET/CT, an intense FDG-uptake was showed at the cervical esophagus with a SUVmax of 25.76 and a TLG of 249.71. The patient underwent combined neoadjuvant therapy (cisfolates and radiotherapy). PET/CT after treatment showed a less intense uptake of FDG in the same site with a SUVmax of 7 and a TLG of 18. Therefore, the change in SUVmax was 73% and in TLG was 93%. After 3 weeks from the second PET/CT, the patient was sent to a defi nitive surgery demonstrating a fi nal stage II (no response to combined neoadjuvant chemotherapy). The patient passed away after 15 months from the second PET/CT scan for a disseminate disease

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 > Discussion Top

From our study, it emerged that metabolic and volumetric changes obtained by PET/CT before and after neoadjuvant therapy seemed to be correlated with patient survival; in particular, Vol2, TLG2, and ΔTLG were significantly different between disease-free and died patients (all P < 0.05). SUVmax were not related to prognosis (P = NS) as otherwise reported by Fukunaga et al. [11] In our results, ΔSUV showed a lower value in died patients than the disease-free group (58 versus 90%, respectively). This latter result was comparable with the report by Downey et al. [12] who demonstrated a significant correlation between the change in SUV greater than 60% and a better 2-year-disease-free survival. According to Eloubeidi et al., [13] in EC a recognized and well-documented risk factor is the tumour size, in particular the length: the patient's survival was worst when the tumor became longer. Moreover, Hatt et al. [14] reported that the functional tumor volume followed by length had additional value compared to commonly used SUV measurements for prognosis in patients with locally advanced EC treated with exclusive concomitant radio-chemotherapy. Our data did not confirm these concepts: the functional tumor volume at initial staging was not related to the prognosis, resulting similarly in disease-free and died groups (50.02 mm versus 57.92 mm, respectively). Our small population cannot surely define the prognostic data, but it can confirm the ability of PET/CT to assess the effectiveness of therapy. According to the literature, neoadjuvant treatment has to (a) achieve a complete response, prerequisite for ensuring a high rate of disease control and survival over time, (b) prevent distant metastases, and (c) increase the complete R0 rate.

We chose a timing of at least 4 weeks to evaluate the effectiveness of therapy. As reported by Cerfolio et al., the best time to repeat the PET/CT after chemo-radiotherapy is unknown in EC patients. The authors reported a median of 24 days (range 2-88 days), demonstrating that the optimal time to perform the FDG-PET/CT scan after neoadjuvant chemotherapy and high-dose radiotherapy to maximize its accuracy for restaging patient is about 1 month. [15] The combined neoadjuvant treatment should provide advantages in terms of survival both in complete response and in "down-staging" patients. [2],[16],[17] Our study demonstrated that ΔSUV and ΔTLG were significantly higher in the responder than in the no responder group (P < 0.05); also anatomical measures, Vol2 and Z2 axis, were different (both P < 0.05), while the SUVmax1 tended to be higher in patients who obtained an optimal response (14.36 versus 8.47), although not statistically significant. Further, our findings confirmed that patients with complete and partial response to neoadjuvant treatment had a better prognosis than patients without any response to therapy (P = 0.024). Cerfolio et al. [18] showed that PET/CT predicted a complete response with a sensitivity of 87%, specificity of 88%, and accuracy of 88%. The authors compared PET/CT, EUS, and CT demonstrating that metabolic imaging was more accurate than EUS (sensitivity 20%, specificity 94%, and accuracy 70%) and CT (sensitivity 27%, specificity 91%, and accuracy 71%). The low accuracy of CT was due to absent match between tumor length determined by morphological imaging and pathological findings. Nevertheless, currently CT is considered the state of the art for monitoring non-surgical therapy in solid tumors. [19] The ability of PET/CT to show the possible metabolic changes makes the method very promising for the evaluation of the treatment effectiveness and as Larson et al. [20] suggested FDG appears to be one of the most powerful biomarkers introduced to date for the assessment of clinical response. In our study, in patients who did not receive a surgical treatment, PET/CT for restaging showed higher NPV value (75%; 9/11 patients resulted correctly in clinical stage 0) than CT (40%). The remnant two patients resulted positive to metabolic imaging: one falsely positive for lymph nodes (inflammation post neoadjuvant treatment), while the other was falsely negative to CI (residual tumor resulted negative for both EUS and CT).

The metabolic behavior of the tumor tends to change from diagnosis to follow-up. Therefore, its evaluation by PET can add important diagnostic and prognostic information to CI. For staging, EUS and CT have several limitations both for instrumental and operator-dependent variables.

Yang et al. [21] reported that FDG-PET may have a potential use in primary tumor recognition, but it has low ability to identify peritumoral lymph nodes. Therefore, EUS remains the most effective method for the early detection of esophageal tumors and local evaluation.

The number, location, and size of involved lymph nodes are strong predictors of survival, but non-invasive modalities for lymph node detection are rather limited. Our results showed that falsely negative finding for lymph node determined by EUS was evident in 35% of patients, but both PET/CT and CT were unable to define correctly the nodal involvement. Some possible explanations are as follows: PET/CT had limitations for spatial resolution, while CT had criteria limitation for lymph node size. Many reports have demonstrated the superiority of PET/CT than CT showing metastasis both in normal-size and enlarged lymph nodes and in adding the metabolic data to anatomical findings. [22],[23],[24] On the other hand, PET/CT improves the evaluation of distant lymph node involvement and metastases. In fact, 4/29 patients with liver and bone metastases were correctly identified by PET/CT with a gain of 50% from CT studies.

The use of PET/CT in initial staging seems to be crucial for improving the stratification of patients. Several studies about FDG PET/CT have showed that management of patients with EC and esophageal-gastric junction changes in 20-38% of cases after nuclear scan, due to the identification of occult metastases and/or synchronous cancer unrecognized with CI. The findings of metastases allowed modifying the treatment plan and to avoid unnecessary surgery. Our results confirmed these data: the therapeutic management was modified in 44% of patients.

From our small population, we can conclude that 17% of patients were incorrectly staged by standard methods. A suitable staging would avoid unnecessary surgery and let the most appropriate treatment planning. PET/CT was able to identify 100% of distant metastases with a gain of 50% from CT studies. TLG2, Vol2, and ΔTLG seem to be the most predictive parameters, independently from the baseline Vol and SUVmax of primary tumor. Despite the rapid integration of PET and PET/CT in clinical practice, there has been relatively little systematic integration of metabolic imaging into clinical trial of new cancer treatment. Therefore, further investigations are required to optimize the timing and the use of functional parameters (SUV) in the assessment of therapy response. [25]

The findings reported should be interpreted carefully. The present study showed the following limitations: small number of patients, different histological subtypes of tumors, and heterogeneous schemes of neoadjuvant treatment. As reported by Smithers et al., [10] PET/CT is not able to differentiate between histological responders/no responder in patients with adenocarcinoma; on the contrary, Wieder et al. [26] found a robust correlation between histopatological response and the reduction in FDG-PET response in patients with squamous cellular carcinoma (SCC). In the present report, we found any correlation between histological response and PET/CT findings both in adenocarcinoma and SCC (63% versus 57%, respectively; P = NS). Finally, the assessment of each treatment scheme is beyond the purpose of the present report.

 > Acknowledgements Top

The authors are thankful to their collegues (Dr. Giorgio Saladini, Dr. Michele Gregianin, Dr. Matteo Cagol) and technical equipment for the general support and for technical help.

 > References Top

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