Surg Endosc (1997) 11: 1213–1215 Surgical Endoscopy © Springer-Verlag New York Inc. 1997 Minimally invasive surgical biopsy confirms PET findings in esophageal cancer J. D. Luketich, P. Schauer, K. Urso, D. W. Townsend, C. P. Belani, C. Cidis Meltzer, P. F. Ferson, R. J. Keenan University of Pittsburgh Medical Center, 300 Kaufmann Building, 3471 Fifth Avenue, Pittsburgh, PA 15213, USA Received: 6 December 1997/Accepted: 14 January 1997 Abstract. This report describes our initial experience using the T3 vertebral body and the sacroiliac region of the pelvis and an un- positron emission tomography (PET) scanning in esopha- suspected liver metastasis. The presence of metastases was confirmed through laparoscopic biopsy. Surgical resection of the esophagus was not geal cancer patients. In two patients PET identified distant undertaken. Subsequently the patient developed a T3 radiculopathy and metastatic disease missed by conventional staging. Laparo- died of extensive metastatic disease 3 months later. scopic biopsy provided histological confirmation of metas- tases. In the third patient, locoregional lymph nodes were Case 2 identified by PET and confirmed by surgical staging. In this A 64-year-old male was diagnosed with adenocarcinoma of the distal preliminary report, PET appears to be a promising new esophagus. CT scans of the chest and abdomen and a bone scan were noninvasive modality for staging patients with esophageal negative for metastases. Endoscopic ultrasound revealed enlarged peri- cancer. esophageal and gastrohepatic lymph nodes. A PET scan was ordered to evaluate the extent of disease. The PET scan (Fig. 2) revealed foci of increased FDG uptake in the Key words: Esophageal Cancer — Positron emission to- distal esophagus, periesophageal, and gastrohepatic lymph regions, con- mography (PET) — Thoracoscopy — Laparoscopy sistent with a primary tumor and lymph node metastases. Biopsies taken at video-assisted thoracoscopic and laparoscopic staging procedures con- firmed metastases to these lymph nodes. The patient was entered into a taxol-platinum neoadjuvant protocol. Positron emission tomography (PET) is an imaging tech- Case 3 nology that can be used to assess tissue metabolism. The A 66-year-old male diagnosed with esophageal cancer underwent a trans- increased metabolic demands of tumors can be visualized hiatal esophagectomy, gastric pull-up, and a neck anastamosis 6 months through increased focal uptake of the positron-emitting before presenting to our clinic with complaints of dysphagia and a single tracer 18F-fluorodeoxyglucose (FDG). The distribution of palpable left cervical lymph node. Metastatic esophageal cancer was con- FDG has been used to distinguish benign from malignant firmed by a fine-needle aspirate of the lymph node, and CT scans of the neck and chest showed no other disease. A PET scan was performed to tissue in various types of cancers [4, 16]. This report de- assess the extent of metastatic recurrence. scribes the results of PET scanning in three patients with The PET image (Fig. 3) showed multiple foci of increased uptake of esophageal cancer. FDG in the cervical and supraclavicular nodes which were confirmed by fine-needle aspirate as sites of metastasis. Palliative radiotherapy was suc- cessful in relieving dysphagia. Case reports PET methods Each patient was requested to fast after midnight the evening prior to the PET study. PET imaging was performed on the ECAT ART tomograph Case 1 (CTI/Siemens PET Systems; Knoxville, TN), located in the UPMC PET Facility. An intravenous injection of 6–8 mCi of FDG was administered A 59-year-old male was diagnosed with localized adenocarcinoma of the followed by a 45-min delay for tracer uptake, prior to whole-body imaging distal esophagus and received neoadjuvant chemotherapy. Prior to esoph- at six bed positions. Images were evaluated for regions of focally increased agectomy, restaging including chest and abdominal CT and a bone scan uptake relative to adjacent tissues and compared with CT scans for ana- which were negative for distant metastatic disease. A PET scan was per- tomic correlation. formed to evaluate possible distant metastatic disease prior to surgery. The PET scan (Fig. 1) demonstrated unsuspected bone metastases to Discussion Patients with esophageal cancer are frequently diagnosed Correspondence to: J. D. Luketich late in the course of their disease, and up to 50% already 1214 Fig. 1. A PET scan (A) showing three sites of metastatic disease: (a) a thoracic vertebral metastasis, (b) a liver metastasis that was not seen on the abdominal CT scan, and (c) a sacroiliac bone metastasis. The bone scan (B) did not detect either of the two bone metastases. Fig. 2. A PET scan demonstrating periesophageal and gastrohepatic lymph node metastases in addition to the primary esophageal cancer. Fig. 3. A PET scan demonstrating multiple bilateral cervical lymph node metastases from esophageal cancer. have metastatic disease at presentation. For those with meta- there is a potential for complete resection [2, 7, 8]. Unfor- static disease, the outcome is extremely poor: Most patients tunately, surgery alone results in 5-year survival rates of die within 6 months. For apparently localized disease, sur- only 20–30% in most series, and many patients develop gical resection alone has been the traditional approach when distant metastases within 6 months to 1 year. This suggests 1215 that clinically occult metastases were present at initial pre- References sentation. Recently, minimally invasive surgical staging has been employed to more accurately evaluate the extent of 1. Chin R, Ward R, Keyes JW, Choplin RH, Reed JC, Wallenhaupt S, locoregional disease and to rule out clinically occult sites of Hudspeth AS, Haponik EF (1995) Mediastinal staging of non-small cell metastases. Positron emission tomography (PET) scanning lung cancer with positron emission tomography. Am J Respir Crit Care may facilitate the staging of esophageal cancer. Med 152: 2090–2096 Preliminary reports on the use of PET scanning in pa- 2. Lerut T, DeLeyn P, Coosemans W, Van Raemdonck D (1992) Surgical tients with non–small cell lung cancer (NSCLC) are encour- strategies in esophageal carcinoma with emphasis on radical lymphad- aging [5]. Up to 90% sensitivity and specificity have been enectomy. Ann Surg 216(5): 583–590 reported in the detection of mediastinal lymph nodes in 3. Patz EF, Lowe VJ, Goodman PC, Herndon J (1995) Thoracic nodal NSCLC using PET. However, a false-positive rate of be- staging with PET imaging with FDG in patients with bronchogenic tween 13 and 20% has been noted in some series, and the carcinoma. Chest 108(6): 1617–1621 ultimate role of PET in staging NSCLC continues to be 4. Scott WJ, Schwabe JL, Gupta NC, Dewan NA, Reeb SD, Sugimoto JT evaluated [1, 3]. (1994) Positron emission tomography of lung tumors and mediastinal lymph nodes using F-18-fluorodeoxyglucose. Ann Thorac Surg 58: Our results suggest PET scanning could play an impor- 698–703 tant role as a noninvasive staging modality in patients with 5. Valk PE, Pounds TR, Hopkins DM, Haseman MK, Hofer GA, Greiss esophageal cancer. In this report, PET accurately detected HB, Meyers RW, Lutrin CL (1995) Staging non-small cell lung cancer local or distant unsuspected metastatic disease in all three by whole body PET imaging. Ann Thorac Surg 60: 1573–1582 patients. CT scans, bone scans, and endoscopic ultrasound 6. Wahl RL, Hutchins G, Buchsbaum D, Liebert M, Grossman HB, Fisher failed to detect lymph node involvement in two patients and S (1991) F-18-2-deoxy-fluoro-D-glucose (FDG) uptake in human tu- liver and bone metastases in one patient. The accurate de- mor xenografts: feasibility studies for cancer imaging with PET. Cancer tection of locoregional or distant metastases contributed sig- 67: 1544–1550 nificantly to the management of their disease. These pre- 7. Watson A (1994) Operable esophageal cancer: current results from the West. World J Surg 18: 361–366 liminary results suggest that PET scanning may play a role 8. Zhang DW, Cheng GU, Huang GJ, Zhang RG, Liu XY, Mao YS, Wang in the noninvasive staging of patients with esophageal can- YG, Chen SJ, Zhang LZ, Wang LJ, Zhang DC, Yang L, Meng PJ, Sun cer and may provide targets for minimally invasive surgical KL (1994) Operable squamous esophageal cancer: current results from biopsy. the East. World J Surg 18: 347–354 Surg Endosc (1997) 11: 1189–1193 Surgical Endoscopy © Springer-Verlag New York Inc. 1997 Video-assisted thoracoscopic treatment of spinal lesions in the thoracolumbar junction T. J. Huang,1 R. W. W. Hsu,1 H. P. Liu,2 K. Y. Hsu,1 Y. S. Liao,1 H. N. Shih,1 Y. J. Chen1 Department of Orthopedic Surgery1 and Thoracic and Cardiovascular Surgery,2 Chang Gung Memorial Hospital, Chang Gung Medical College, Taipei, Taiwan, R.O.C. Received: 6 February 1997/Accepted: 8 April 1997 Abstract port simplifies thoracoscopic spinal surgery in the thoraco- Background: The endoscopic treatment of spinal lesions in lumbar junction and makes it easier. It avoids division of the the thoracolumbar junction (T11–L2) poses a great chal- diaphragm, removal of the rib, and wide spread of the in- lenge to the surgeon. From November 1, 1995 to December tercostal space, and it allows greater control of intraopera- 31, 1996, we successfully used a combination of video- tive vessel bleeding. Using this technique, the number of assisted thoracoscopy and conventional spinal instruments portals required during the procedure can be reduced. In to treat 38 patients with anterior spinal lesions. Twelve of addition, the technique reduces the endoscopic materials them had lesions in the thoracolumbar junction. required, thus lowering overall cost. It is an effective and Methods: The so-called extended manipulating channel promising approach. method was used to perform vertebral biopsy, discectomy, decompressive corpectomy, interbody fusions, and/or inter- Key words: Video-assisted thoracoscopic surgery — Tho- nal fixations in these patients.