HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): James D. Luketich Rodney J. Landreneau Peter F. Ferson Robert J. Keenan Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Luketich, J. D. Articles by Belani, C. P. Search for Related Content PubMed PubMed Citation Articles by Luketich, J. D. Articles by Belani, C. P. Related Collections Related Article

Ann Thorac Surg 1997;64:765-769
© 1997 The Society of Thoracic Surgeons

---

Original Article: General Thoracic

Role of Positron Emission Tomography in Staging Esophageal Cancer

Section of Thoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania

	Abstract

Top Footnotes Abstract Introduction Material and Methods Staging PET Methods Results Distant Metastases Lymph Node Metastases Comment References

 
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.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Staging PET Methods Results Distant Metastases Lymph Node Metastases Comment References

 
See also page 769.

Recently, reports [1, 2] of minimally invasive surgical staging of esophageal cancer have shown that conventional radiologic imaging is inaccurate in detecting local-regional and distant metastases in up to 40% of patients. Endoscopic ultrasound has been validated for its accuracy in estimating depth of penetration of the primary tumor, but it has been shown to be inaccurate in the evaluation of nodal status [2]. Surgical staging remains the gold standard for staging esophageal cancer but is an invasive and expensive methodology.

Positron emission tomography (PET) is an imaging technology that can be used to identify focal areas of increased metabolism associated with some malignancies. In lung cancer, for example, the primary tumor and metastases can be visualized in some cases by their increased focal uptake of various positron-emitting tracers that can be detected by PET scanning [3]. Preliminary data from our group [4] demonstrated that PET scanning in patients with esophageal cancer identified suspicious areas of increased metabolism with ¹⁸F-fluorodeoxyglucose (FDG) that were confirmed as metastases by minimally invasive staging. The purpose of this study was to further investigate the role of PET in staging esophageal cancer.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Staging PET Methods Results Distant Metastases Lymph Node Metastases Comment References

 
This was a retrospective study of all consecutive patients with potentially resectable esophageal cancer referred to the Thoracic Surgery Service at the University of Pittsburgh Cancer Institute between July 1995 and October 1996. Resectability was determined by conventional staging, which included computed tomography (CT) of the chest and abdomen, bone scan, and endoscopic ultrasound. Patients with limited local-regional metastases considered to have resectable disease by the thoracic surgeon were referred for a PET scan and were included in this study. Patients with multiple enlarged lymph nodes with obliteration of normal tissue planes and hence with disease thought too extensive for curative resection were excluded from the study. Patients with distant metastatic disease identified by conventional scanning and confirmed by fine-needle aspiration were also excluded. Those with small (<1 cm), indeterminate pulmonary nodules were included.

	Staging

Top Footnotes Abstract Introduction Material and Methods Staging PET Methods Results Distant Metastases Lymph Node Metastases Comment References

 
Positron emission tomographic scans were performed, and areas of increased focal uptake of FDG were compared with CT scans for anatomic localization. In all cases, the CT scans showed no evidence of metastases, but aligning the PET scans with the CT scans allowed a better anatomic estimate of the location of the increased uptake of the FDG tracer. Video-assisted thoracoscopy (VATS) or laparoscopy was used to stage all patients. If no distant metastases at laparoscopy or VATS (eg, liver or lung) were detected, extensive lymph node biopsies were performed, and biopsies of areas of increased focal uptake detected by PET scanning were done. In this study, laparoscopic staging included intraoperative ultrasound of the liver. Videothoracoscopic lymph node sampling of the thoracic esophagus was also performed. In most cases, a right-sided VATS approach was used, but if an indeterminate pulmonary nodule was present on the left side, a left-sided approach was chosen.

	PET Methods

Top Footnotes Abstract Introduction Material and Methods Staging PET Methods Results Distant Metastases Lymph Node Metastases Comment References

 
Patients were instructed to fast after midnight the day of the PET study. No diabetic patients were studied. An intravenous injection of 6 to 8 mCi of FDG was administered, followed by a 45-minute delay prior to PET scanning to allow tracer uptake by the tumor. Whole-body imaging was performed and evaluated for focally increased uptake of FDG relative to adjacent tissues and compared with CT results for anatomic localization. Positive findings were reported through visual analysis by the clinical nuclear medicine physician.

The whole-body images were acquired on an ECAT ART scanner, a low-cost PET tomograph comprising two arrays of bismuth germanate detectors rotating at 30 rpm. The scanner has no septa, and acquisition and reconstruction are performed fully in three dimensions. The spatial resolution is about 6 mm in all three spatial directions, and the sensitivity is close to 300 kc • s^-1 • µCi^-1 • mL^-1 for a uniform cylinder 20 cm in diameter. Two rod sources attached to the rotating arrays are used to provide transmission measurements for attenuation correction.

Whole-body data are collected at six to eight bed positions for 6 minutes per position, resulting in a total scan time of less than 1 hour. To improve axial noise uniformity, adjacent bed positions are overlapped by 4 cm. Whole-body images are reconstructed in three dimensions at each bed position using the reprojection algorithm of Kinahan and Rogers [5], and smoothed with a Hanning window, cut off at 80% of Nyquist. After reconstruction, the six to eight bed positions are assembled into a complete whole-body image and displayed as transverse, sagittal, or coronal images. In this study, to limit noise amplification in such low statistics whole-body scans, attenuation and scatter correction were not applied. Although this results in reduced contrast and artifactually increased uptake in the lungs and the skin, the uncorrected whole-body images have lower noise, and interpretation is generally more straightforward.

	Results

Top Footnotes Abstract Introduction Material and Methods Staging PET Methods Results Distant Metastases Lymph Node Metastases Comment References

 
Among 50 patients screened, potentially resectable esophageal cancer was identified in 35 patients. Of these 35 patients, 25 had a diagnosis of adenocarcinoma; 9, squamous cell carcinoma; and 1, a neuroendocrine tumor of the esophagus. Positron emission tomographic imaging identified the primary esophageal cancer in 97% of patients (Fig 1). In 18 patients (51%), PET identified foci of increased FDG uptake outside the esophagus consistent with local-regional or distant metastatic disease. In 16 of the patients with positive PET scans, confirmation of local-regional (n = 9) or distant (n = 7) metastases was obtained by VATS or laparoscopic staging (n = 15) or magnetic resonance imaging (MRI) and clinical correlation confirmation of a bone metastasis (n = 1). In 2 patients, PET showed increased focal uptake in bone that was a false-positive finding.

View larger version (128K): [in this window] [in a new window]   Fig 1. . Positron emission tomographic scan showing primary tumor uptake only (arrow).

	Distant Metastases

Top Footnotes Abstract Introduction Material and Methods Staging PET Methods Results Distant Metastases Lymph Node Metastases Comment References

View larger version (119K): [in this window] [in a new window]   Fig 2. . Positron emission tomographic scan suggested bone metastases to (a) the third vertebral body and (c) the ischium not seen on the bone scan and (b) a liver metastasis not seen by computed tomography.

View larger version (122K): [in this window] [in a new window]   Fig 3. . False-positive positron emission tomographic scan. Follow-up radiography demonstrated no evidence of a metastatic lesion in the humerus (arrow).

In 7 patients, CT of the chest showed small (<1 cm), indeterminate pulmonary lung nodules. In 6 of these patients, PET was negative for lung lesions, and VATS staging confirmed the PET results as benign hamartomas in 2 patients and benign granulomas or fibrosis in 4. In the other patient, PET showed increased focal uptake in the area of the lung identified by CT, and a metastasis was confirmed.

The bone scan was read as abnormal in 5 patients and was followed by plane radiographs, MRI, and PET to further assess the areas in question. In 3 of the 5 patients, the bone scan was inconclusive, and additional studies were requested. In these 3 patients, the PET scan, plane radiographs, and MRI were negative for bone metastases. In the other 2 patients, the PET scan suggested bone metastases, but plane radiographs, MRI, and clinical follow-up confirmed a benign enchondroma in 1 and no lesion in the other. The PET scan was considered false-positive in these 2 patients. In 1 patient, the bone scan was read as negative for metastases, but PET showed increased focal uptake in the third vertebral body, and MRI was positive for metastases. A radiculopathy of this vertebral body ultimately developed, and the patient died of metastatic disease. This was the only patient in whom positive bone metastases were confirmed, which precluded a meaningful calculation of sensitivity and specificity of PET for bone metastases.

	Lymph Node Metastases

Top Footnotes Abstract Introduction Material and Methods Staging PET Methods Results Distant Metastases Lymph Node Metastases Comment References

 
In 8 of the 35 patients, the presence of distant metastases precluded the need of an extensive nodal dissection, and in 6 patients, lymph node sampling was inadequate (n = 3) or not performed secondary to cirrhosis (n = 1), tracheal invasion (n = 1), or intraabdominal carcinomatosis. Adequate nodal sampling was available for 21 of the 35 patients. Positron emission tomography detected local-regional metastases in 9 of these 21 patients, and all were confirmed positive by biopsy. In 12 patients, the PET scan was negative for local-regional metastases, but only 1 of them was truly negative at surgical staging. In all instances, the lymph nodes missed by PET scan were less than 1 cm in diameter (mean diameter, 5.2 mm; range, 2 to 10 mm). There were no false-positive PET scans for local-regional nodal metastases.

Overall, PET was 45% sensitive, 100% specific, and 48% accurate in detecting local-regional nodal involvement. Larger lymph nodes, in particular at the celiac axis (Fig 4) or paraesophageal location (Fig 5), contributed important information in several instances.

View larger version (109K): [in this window] [in a new window]   Fig 4. . Celiac lymph node metastasis (arrow) identified by positron emission tomographic scan and later confirmed by laparoscopic staging.

View larger version (117K): [in this window] [in a new window]   Fig 5. . Paraesophageal lymph node metastases (arrows) detected by positron emission tomography.

	Comment

Top Footnotes Abstract Introduction Material and Methods Staging PET Methods Results Distant Metastases Lymph Node Metastases Comment References

 
The incidence of adenocarcinoma of the esophagus is increasing at an alarming rate that exceeds that of all other gastrointestinal malignancies [6]. The 5-year survival rate with surgical intervention alone is approximately 30%, and no preoperative or postoperative regimen of chemotherapy, radiation therapy, or combination has proved superior to operation alone [7, 8]. A criticism of previous trials including the randomized trials [9, 10] published to date is that the pretreatment staging regimens have included only radiologic imaging, which has been shown to be inaccurate in up to 40% of patients compared with minimally invasive surgical staging (VATS or laparoscopy) [1, 11]. To more closely evaluate treatment responses and possibly identify subsets of patients with esophageal cancer who could benefit from adjuvant therapies, accurate pretreatment staging is essential. Because surgical staging is costly and time-consuming, it is important that new imaging technologies be evaluated.

Positron emission tomography is a noninvasive imaging technology that is capable of identifying areas of increased glucose metabolism using the positron-emitting tracer FDG [12]. Preliminary work in lung cancer has shown that PET may have advantages over conventional staging in identifying local-regional and distant metastases [3]. In another recent series [13], PET was found to be more accurate than CT in staging esophageal cancer. Positron emission tomography has also been shown to provide useful information on clinical and subclinical responses to chemotherapy in patients with lymphoma as well as colon, breast, and thyroid cancer [14].

In our series of patients with esophageal cancer, PET was 91% accurate in detecting distant metastatic sites. This calculation of accuracy may be an overestimation, as biopsies of all distant areas were not done, and certainly occult microscopic disease may ultimately develop. Longer clinical follow-up will be helpful in determining the incidence of missed occult metastatic disease. Positron emission tomography was only 45% sensitive in detecting local-regional lymph node metastases, although a specificity of 100% was maintained. This poor sensitivity was due to the inability of PET to detect small local-regional lymph node metastases, which may be attributed to the limited spatial resolution of the PET tomograph in the chest where attenuation is problematic. The mean diameter of histologically positive but PET negative lymph nodes was 5.2 mm (range, 2 to 10 mm), which we were able to determine through extensive nodal sampling during the minimally invasive staging procedure. Knowledge of the PET results and limitations has been useful in our ongoing minimally invasive staging protocol to direct efforts during surgical staging.

In summary, PET scanning represents a dramatic improvement over conventional radiologic imaging in the staging of esophageal cancer. Further prospective studies will be required to define the ultimate role of PET scanning in the staging of esophageal cancer.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Staging PET Methods Results Distant Metastases Lymph Node Metastases Comment References

 
Presented at the Thirty-third Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Feb 3-5, 1997.

Address reprint requests to Dr Luketich, Section of Thoracic Surgery, University of Pittsburgh Medical Center, 300 Kaufmann Building, 3471 5th Ave, Pittsburgh, PA 15213 (e-mail: luketich{at}pittsurg.nb.upmc.edu).

	References

Top Footnotes Abstract Introduction Material and Methods Staging PET Methods Results Distant Metastases Lymph Node Metastases Comment References

 

1. Krasna MJ, Flowers JL, Attar S, et al. Combined thoracoscopic/laparoscopic staging of esophageal cancer. J Thorac Cardiovasc Surg 1996;111:800–7.[Abstract/Free Full Text]
2. Luketich JD, Kim R, Landreneau RJ, et al. A comparison of endoscopic ultrasound and minimally invasive surgical staging in esophageal cancer [Abstract]. Am J Gastroenterol 1996;91:1892.
3. Valk PE, Pounds TR, Hopkins DM, et al. Staging non–small cell lung cancer by whole-body positron emission tomographic imaging. Ann Thorac Surg 1995;60:1573–82.[Abstract/Free Full Text]
4. Luketich JD, Schauer PR, Kassis ES, et al. PET scan–directed minimally invasive surgical staging of esophageal cancer. Presented at the Minimally Invasive Thoracic Surgery Interest Group International Symposium, Boston, MA, Sep 13, 1996.
5. Kinahan, Rogers. IEEE Trans Nucl Sci 1989;35:964–8.
6. Blot WJ, Devesa SS, Kneller RW, Fraumeni JF. Rising incidence of adenocarcinoma of the esophagus and gastric cardia. JAMA 1991;265:1287–91.[Abstract]
7. Ajani JA. Contributions of chemotherapy in the treatment of carcinoma of the esophagus: results and commentary. Semin Oncol 1994;2:474–82.
8. Ilson DH, Kelson DP. Combined modality therapy in the treatment of esophageal cancer. Semin Oncol 1994;21:493–507.[Medline]
9. Roth JA, Pass HI, Flanagan MM, et al. Randomized clinical trial of preoperative and postoperative adjuvant chemotherapy with cisplatin, vindesine, and bleomycin for carcinoma of the esophagus. J Thorac Cardiovasc Surg 1988;96:242–8.[Abstract]
10. Forastiere AA, Orringer MB, Perez-Tamayo C, et al. Preoperative chemoradiation followed by transhiatal esophagectomy for carcinoma of the esophagus: final report. J Clin Oncol 1993;11:1118–23.[Abstract/Free Full Text]
11. Belani CP, White CS, Slowson R, et al. Value of minimally invasive thoracoscopy (TS) versus non-invasive surgery (NIS) techniques in esophageal cancer (EC) [Abstract]. Proc Am Soc Clin Oncol 1994;13:195.
12. Strauss LG, Conti PS. The applications of PET in clinical oncology. J Nucl Med 1991;32:623–48.[Abstract/Free Full Text]
13. Flanagan FL, Dehdashti F, Siegel BA, et al. Staging of esophageal cancer with ¹⁸fluorodeoxyglucose positron emission tomography.Am J Radiol1997;168:417–24.[Abstract/Free Full Text]
14. Price P, Jones T, on behalf of EC PET Oncology Concerted Action and the EORTC PET Study Group. Can positron emission tomography (PET) be used to detect subclinical response to cancer therapy? Eur J Cancer 1995;31A:1924–7.[Medline]

This article has been cited by other articles:

				A. Pennathur, J. D. Luketich, R. J. Landreneau, J. Ward, N. A. Christie, M. K. Gibson, M. Schuchert, K. Cooper, S. R. Land, and C. P. Belani Long-term results of a phase II trial of neoadjuvant chemotherapy followed by esophagectomy for locally advanced esophageal neoplasm. Ann. Thorac. Surg., June 1, 2008; 85(6): 1930 - 1936. [Abstract] [Full Text] [PDF]

				D. K. Dhar, S. Hattori, Y. Tonomoto, T. Shimoda, H. Kato, M. Tachibana, K. Matsuura, Y. Mitsumoto, A. G. Little, and N. Nagasue Appraisal of a Revised Lymph Node Classification System for Esophageal Squamous Cell Cancer Ann. Thorac. Surg., April 1, 2007; 83(4): 1265 - 1272. [Abstract] [Full Text] [PDF]

				B. F. Meyers, R. J. Downey, P. A. Decker, R. J. Keenan, B. A. Siegel, R. J. Cerfolio, R. J. Landreneau, C. E. Reed, D. M. Balfe, F. Dehdashti, et al. The utility of positron emission tomography in staging of potentially operable carcinoma of the thoracic esophagus: Results of the American College of Surgeons Oncology Group Z0060 trial J. Thorac. Cardiovasc. Surg., March 1, 2007; 133(3): 738 - 745. [Abstract] [Full Text] [PDF]

				P. Singh, B. Camazine, Y. Jadhav, R. Gupta, P. Mukhopadhyay, A. Khan, R. Reddy, Q. Zheng, D. D. Smith, R. Khode, et al. Endoscopic Ultrasound As a First Test for Diagnosis and Staging of Lung Cancer: A Prospective Study Am. J. Respir. Crit. Care Med., February 15, 2007; 175(4): 345 - 354. [Abstract] [Full Text] [PDF]

				T. M. Blodgett, C. C. Meltzer, and D. W. Townsend PET/CT: Form and Function Radiology, February 1, 2007; 242(2): 360 - 385. [Abstract] [Full Text] [PDF]

				M. Armanios, R. Xu, A. A. Forastiere, D. G. Haller, J. W. Kugler, and A. B. Benson III Adjuvant Chemotherapy for Resected Adenocarcinoma of the Esophagus, Gastro-Esophageal Junction, and Cardia: Phase II Trial (E8296) of the Eastern Cooperative Oncology Group J. Clin. Oncol., November 15, 2004; 22(22): 4495 - 4499. [Abstract] [Full Text] [PDF]

				H.L. van Westreenen, M. Westerterp, P.M.M. Bossuyt, J. Pruim, G.W. Sloof, J.J.B. van Lanschot, H. Groen, and J.Th.M. Plukker Systematic Review of the Staging Performance of 18F-Fluorodeoxyglucose Positron Emission Tomography in Esophageal Cancer J. Clin. Oncol., September 15, 2004; 22(18): 3805 - 3812. [Abstract] [Full Text] [PDF]

				S. C. Malaisrie, B. Untch, G. V. Aranha, N. Mohideen, A. Hantel, and J. Pickleman Neoadjuvant Chemoradiotherapy for Locally Advanced Esophageal Cancer: Experience at a Single Institution Arch Surg, May 1, 2004; 139(5): 532 - 539. [Abstract] [Full Text] [PDF]

				L. Kostakoglu and S. J. Goldsmith PET in the Assessment of Therapy Response in Patients with Carcinoma of the Head and Neck and of the Esophagus J. Nucl. Med., January 1, 2004; 45(1): 56 - 68. [Abstract] [Full Text] [PDF]

				H. L. van Westreenen, P. A.M. Heeren, P. L. Jager, H. M. van Dullemen, H. Groen, and J. Th.M. Plukker Pitfalls of Positive Findings in Staging Esophageal Cancer With F-18-Fluorodeoxyglucose Positron Emission Tomography Ann. Surg. Oncol., November 1, 2003; 10(9): 1100 - 1105. [Abstract] [Full Text] [PDF]

				S. W. Fosko, W. Hu, T. F. Cook, and V. J. Lowe Positron Emission Tomography for Basal Cell Carcinoma of the Head and Neck Arch Dermatol, September 1, 2003; 139(9): 1141 - 1146. [Abstract] [Full Text] [PDF]

				Y. C. Yoon, K. S. Lee, Y. M. Shim, B.-T. Kim, K. Kim, and T. S. Kim Metastasis to Regional Lymph Nodes in Patients with Esophageal Squamous Cell Carcinoma: CT versus FDG PET for Presurgical Detection— Prospective Study Radiology, June 1, 2003; 227(3): 764 - 770. [Abstract] [Full Text] [PDF]

				S. Himeno, S. Yasuda, H. Shimada, T. Tajima, and H. Makuuchi Evaluation of Esophageal Cancer by Positron Emission Tomography Jpn. J. Clin. Oncol., September 1, 2002; 32(9): 340 - 346. [Abstract] [Full Text] [PDF]

				S. M. Wren, P. Stijns, and S. Srinivas Positron Emission Tomography in the Initial Staging of Esophageal Cancer Arch Surg, September 1, 2002; 137(9): 1001 - 1006. [Abstract] [Full Text] [PDF]

				K. S. Parmar, J. B. Zwischenberger, A. L. Reeves, and I. Waxman Clinical impact of endoscopic ultrasound-guided fine needle aspiration of celiac axis lymph nodes (M1a disease) in esophageal cancer Ann. Thorac. Surg., March 1, 2002; 73(3): 916 - 920. [Abstract] [Full Text] [PDF]

				J. W.C. Entwistle III and M. Goldberg Multimodality therapy for resectable cancer of the thoracic esophagus Ann. Thorac. Surg., March 1, 2002; 73(3): 1009 - 1015. [Abstract] [Full Text] [PDF]

				S. S. Gambhir, J. Czernin, J. Schwimmer, D. H. S. Silverman, R. E. Coleman, and M. E. Phelps A Tabulated Summary of the FDG PET Literature J. Nucl. Med., May 1, 2001; 42(90050): 1S - 93. [Full Text] [PDF]

				K. Kim, S. J. Park, B.-T. Kim, K. S. Lee, and Y. M. Shim Evaluation of lymph node metastases in squamous cell carcinoma of the esophagus with positron emission tomography Ann. Thorac. Surg., January 1, 2001; 71(1): 290 - 294. [Abstract] [Full Text] [PDF]

				S. J. Skehan, A. L. Brown, M. Thompson, J. E. M. Young, G. Coates, and C. Nahmias Imaging Features of Primary and Recurrent Esophageal Cancer at FDG PET RadioGraphics, May 1, 2000; 20(3): 713 - 723. [Abstract] [Full Text] [PDF]

				J. D. Luketich, D. M. Friedman, T. L. Weigel, M. A. Meehan, R. J. Keenan, D. W. Townsend, and C. C. Meltzer Evaluation of distant metastases in esophageal cancer: 100 consecutive positron emission tomography scans Ann. Thorac. Surg., October 1, 1999; 68(4): 1133 - 1136. [Abstract] [Full Text] [PDF]

				C. E. Reed Surgical Management of Esophageal Carcinoma Oncologist, April 1, 1999; 4(2): 95 - 105. [Abstract] [Full Text]

				C. E. Reed, G. Mishra, A. V. Sahai, B. J. Hoffman, and R. H. Hawes Esophageal cancer staging: improved accuracy by endoscopic ultrasound of celiac lymph nodes Ann. Thorac. Surg., February 1, 1999; 67(2): 319 - 321. [Abstract] [Full Text] [PDF]

				J. D. Luketich, E. S. Kassis, S. P. Shriver, N. T. Nguyen, P. R. Schauer, T. L. Weigel, S. A. Yousem, and J. M. Siegfried Detection of micrometastases in histologically negative lymph nodes in esophageal cancer Ann. Thorac. Surg., November 1, 1998; 66(5): 1715 - 1718. [Abstract] [Full Text] [PDF]

				V. J Lowe and K. S Naunheim Current role of positron emission tomography in thoracic oncology Thorax, August 1, 1998; 53(8): 703 - 712. [Full Text]

This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): James D. Luketich Rodney J. Landreneau Peter F. Ferson Robert J. Keenan Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Luketich, J. D. Articles by Belani, C. P. Search for Related Content PubMed PubMed Citation Articles by Luketich, J. D. Articles by Belani, C. P. Related Collections Related Article