18F-FDG PET-Detected Synchronous Primary Neoplasms in the Staging of Esophageal Cancer Incidence, Cost, and Impact on Management

Purpose: F-18-Fluorodeoxyglucose positron emission tomography (F-18-FDG PET) imaging is increasingly the standard of care in the staging of esophageal cancer. Synchronous neoplasms may be identified, and this study evaluated the prevalence of such tumors and their impact on management. Methods: Five hundred ninety-one (73.6%) of 803 consecutive patients with biopsy-proven esophageal cancer underwent staging F-18-FDG PET or PET/CT scans. F-18-FDG-avid lesions were considered synchronous primary neoplasms if occurring at locations atypical for metastases from the known primary, a marked discordance in the F-18-FDG avidity from that of the primary tumor, and if there was no prior detection on conventional imaging. Additional investigations as appropriate were undertaken, and histopathological verification was obtained where possible to validate the suspected synchronous neoplasm. Results: A synchronous neoplasm was suspected in 55 (9.3%) of 591 patients, predominantly at sites in the colon (26) and head and neck (21). Additional investigations in 43 cases revealed malignant neoplasms in 8 (18.6%), premalignant in 9 (20.9%), and benign lesions in 26 (60.5%) cases. The management plan was altered in 8 patients, 1.4% overall. The total cost of added tests was $27,482.57 ((sic)21,024) with the decision to treat the esophageal cancer deferred by a mean of 10.7 days. Conclusion: F-18-FDG uptake concerning for synchronous neoplasms is evident in approximately 1 in 10 cases, and of these a minority will represent a malignant neoplasm that significantly impacts on treatment. The overall added costs per patient are relatively modest and the treatment delay within acceptable limits of clinical practice.