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Standard staging of esophageal and gastroesophageal junction (GEJ) tumors substantially lacks accuracy. The aim of this study was to investigate whether the addition of PET with F-18-FDG is a valuable gain in the initial staging. Methods: Between January 1996 and January 2002, F-18-FDG PET was performed in 74 patients. Conventional staging included CT in all patients and well-performed endoscopic ultrasonography (EUS) in 52 patients. They were compared with F-18-FDG PET with pathology and follow-up of suspicious lesions as the gold standard. Results: PET identified 70 primary tumors (sensitivity, 95%). Sensitivity to identify locoregional metastases was highest for EUS (69%) but was not different for CT and PET (44% and 55%, respectively). PET was able to identify distant nodal disease in 71% (17/24 patients) compared with 29% (7/24 patients) after combined CT/EUS alone (P = 0.021). Sensitivity to detect distant nodal and systemic (M1) disease increased with PET (78% vs. 37%; P = 0.012). PET upstaged 15 patients (15/74; 20%) correctly as M1 disease, missed by CT/EUS, and correctly downstaged 4 patients (5%) from M1 to MO disease. However, false upstaging and downstaging was encountered in 5 (7%) and 3 (4%) patients, respectively. Conclusion: PET improves the currently applied staging of esophageal and GEJ tumors, particularly by ameliorating the detection of M1 disease.