Integrated FDG-PET/CT compared with intravenous contrast-enhanced CT for evaluation of metastatic regional lymph nodes in patients with resectable early stage esophageal cancer

Ann Nucl Med. 2009 Jan;23(1):73-80. doi: 10.1007/s12149-008-0209-1. Epub 2009 Feb 11.


Objective: To assess whether integrated fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) can improve the diagnostic accuracy of metastatic regional lymph nodes (LNs) in esophageal cancer compared with contrast enhanced CT (CECT).

Methods: We examined 180 consecutive patients with esophageal cancer by integrated PET/CT between April 2006 and March 2007. Eighteen patients (M:F 14:4) underwent radical esophagectomy after evaluations by PET/CT and CECT of 5-7-mm-thick slices 70-80 s after injection. Regional LNs of esophageal cancer were retrospectively reviewed on CECT images by two blinded evaluators on the basis of the following cutoff sizes: 7 mm for all regional LNs (Protocol A), 10 mm for paratracheal LNs (Protocol B), and 7 mm for others. In addition, the maximum standardized uptake value (SUVmax) on PET/CT was evaluated for positive uptake by LNs.

Results: Of 210 LNs excised at surgery, 25 were positive and 185 were negative for metastasis at pathology. The PET/CT images identified 15 true-positive and 184 true-negative LNs, whereas CECT identified 15 true positives and 176 true negatives in Protocol A, and 14 true positives and 180 true negative in Protocol B. The sensitivity, specificity, accuracy, positive, and negative predictive values of PET/CT were respectively 60.0%, 99.5%, 94.8%, 93.8%, and 94.8%, whereas those of CECT were 60.0%, 95.1%, 91.0%, 62.5%, and 94.6% (Protocol A) and 56.0%, 97.3%, 92.4%, 73.7%, and 94.2% (Protocol B). A comparison of the two CECT protocols revealed fewer false-positive LNs in Protocol B, but slightly lower sensitivity in Protocol B than in Protocol A. Substantial numbers of false-positive LNs were determined by CECT in the paratracheal regions (6 of 9, 66.7%) and CECT revealed central necrosis in 4 of 15 (26.7%) true-positive LNs > 1.8 cm. The mean SUVmax on PET/CT was 2.9 (range 1.7-5.5) in true-positive LNs. The smallest LN metastasis detectable by PET/CT was 6 mm.

Conclusions: Integrated PET/CT improves the PPV of regional LNs when compared with CECT.

Publication types

  • Comparative Study

MeSH terms

  • Aged
  • Contrast Media / administration & dosage
  • Esophageal Neoplasms / diagnosis*
  • Esophageal Neoplasms / surgery
  • Female
  • Fluorodeoxyglucose F18*
  • Humans
  • Injections, Intravenous
  • Iopamidol* / administration & dosage
  • Lymph Nodes / diagnostic imaging*
  • Lymphatic Metastasis
  • Male
  • Middle Aged
  • Neoplasm Staging
  • Positron-Emission Tomography / methods*
  • Radiopharmaceuticals
  • Reproducibility of Results
  • Sensitivity and Specificity
  • Subtraction Technique
  • Systems Integration
  • Tomography, X-Ray Computed / methods*


  • Contrast Media
  • Radiopharmaceuticals
  • Fluorodeoxyglucose F18
  • Iopamidol