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Original Investigation
October 27, 2021

18F-Fludeoxyglucose–Positron Emission Tomography/Computed Tomography and Laparoscopy for Staging of Locally Advanced Gastric Cancer: A Multicenter Prospective Dutch Cohort Study (PLASTIC)

Author Affiliations
  • 1Department of Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
  • 2Department of Surgery, the Netherlands Cancer Institute–Antoni van Leeuwenhoek, Amsterdam, the Netherlands
  • 3Department of Surgery, Amsterdam University Medical Center, location AMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
  • 4Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
  • 5Department of Surgery, Erasmus MC University Medical Center Rotterdam, the Netherlands
  • 6Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
  • 7Department of Surgery, Zuyderland MC, Sittard-Geleen, the Netherlands
  • 8Department of Surgery, Rijnstate Hospital, Arnhem, the Netherlands
  • 9Department of Surgery, ZGT hospital, Almelo, the Netherlands
  • 10Department of Surgery, Amsterdam University Medical Center, location VUmc, Cancer Center Amsterdam, Amsterdam, the Netherlands
  • 11Department of Pathology, Amsterdam University Medical Center, location VUmc, Cancer Center Amsterdam, Amsterdam, the Netherlands
  • 12Department of Surgery, Elisabeth Twee-Steden Hospital, Tilburg, the Netherlands
  • 13Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
  • 14Department of Surgery, Medical Center Leeuwarden, Leeuwarden, the Netherlands
  • 15Department of Gastroenterology, Albert Schweitzer Hospital, Dordrecht, the Netherlands
  • 16Department of Surgery, Albert Schweitzer Hospital, Dordrecht, the Netherlands
  • 17Department of Surgery, Gelre Ziekenhuizen, Apeldoorn, the Netherlands
  • 18Prospective Observational Cohort Study of Oesophageal-Gastric Cancer Patients (POCOP) of the Dutch Upper GI Cancer Group, Amsterdam, the Netherlands
  • 19Department of Medical Oncology, Amsterdam University Medical Center, location AMC, Cancer Center Amsterdam, Amsterdam, the Netherlands
  • 20Department of Surgery, Isala Ziekenhuis, Zwolle, the Netherlands
  • 21Department of Gastroenterology, Maasstad Ziekenhuis, Rotterdam, the Netherlands
  • 22Department of Radiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
  • 23Department of Medical Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
  • 24Julius Center for Health Sciences and Primary Care, Utrecht University, Utrecht, the Netherlands
  • 25Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
  • 26Department of Gastroenterology, Radboud University Medical Center, Nijmegen, the Netherlands
JAMA Surg. Published online October 27, 2021. doi:10.1001/jamasurg.2021.5340
Key Points

Question  Do 18F-fludeoxyglucose–positron emission tomography with computed tomography (FDG-PET/CT) and staging laparoscopy provide benefit in patients with locally advanced gastric cancer?

Findings  In this multicenter cohort study comprising 394 patients, FDG-PET/CT detected metastatic disease in 3% of patients and staging laparoscopy detected metastatic or noncurable disease in 19% of patients with locally advanced gastric cancer. Treatment intent changed from curative to palliative in 16% of the patients.

Meaning  These findings suggest that FDG-PET/CT has limited additive value, but staging laparoscopy adds considerably to the staging process in patients with locally advanced gastric cancer.

Abstract

Importance  The optimal staging for gastric cancer remains a matter of debate.

Objective  To evaluate the value of 18F-fludeoxyglucose–positron emission tomography with computed tomography (FDG-PET/CT) and staging laparoscopy (SL) in addition to initial staging by means of gastroscopy and CT in patients with locally advanced gastric cancer.

Design, Setting, and Participants  This multicenter prospective, observational cohort study included 394 patients with locally advanced, clinically curable gastric adenocarcinoma (≥cT3 and/or N+, M0 category based on CT) between August 1, 2017, and February 1, 2020.

Exposures  All patients underwent an FDG-PET/CT and/or SL in addition to initial staging.

Main Outcomes and Measures  The primary outcome was the number of patients in whom the intent of treatment changed based on the results of these 2 investigations. Secondary outcomes included diagnostic performance, number of incidental findings on FDG-PET/CT, morbidity and mortality after SL, and diagnostic delay.

Results  Of the 394 patients included, 256 (65%) were men and mean (SD) age was 67.6 (10.7) years. A total of 382 patients underwent FDG-PET/CT and 357 underwent SL. Treatment intent changed from curative to palliative in 65 patients (16%) based on the additional FDG-PET/CT and SL findings. FDG-PET/CT detected distant metastases in 12 patients (3%), and SL detected peritoneal or locally nonresectable disease in 73 patients (19%), with an overlap of 7 patients (2%). FDG-PET/CT had a sensitivity of 33% (95% CI, 17%-53%) and specificity of 97% (95% CI, 94%-99%) in detecting distant metastases. Secondary findings on FDG/PET were found in 83 of 382 patients (22%), which led to additional examinations in 65 of 394 patients (16%). Staging laparoscopy resulted in a complication requiring reintervention in 3 patients (0.8%) without postoperative mortality. The mean (SD) diagnostic delay was 19 (14) days.

Conclusions and Relevance  This study’s findings suggest an apparently limited additional value of FDG-PET/CT; however, SL added considerably to the staging process of locally advanced gastric cancer by detection of peritoneal and nonresectable disease. Therefore, it may be useful to include SL in guidelines for staging advanced gastric cancer, but not FDG-PET/CT.

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