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The role of 11C-choline positron emission tomographycomputed tomography and videomediastinoscopy in the evaluation of diseases of middle mediastinum. Chin Med J (Engl) 2006. [DOI: 10.1097/00029330-200604020-00004] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Meyers BF, Haddad F, Siegel BA, Zoole JB, Battafarano RJ, Veeramachaneni N, Cooper JD, Patterson GA. Cost-effectiveness of routine mediastinoscopy in computed tomography– and positron emission tomography–screened patients with stage I lung cancer. J Thorac Cardiovasc Surg 2006; 131:822-9; discussion 822-9. [PMID: 16580440 DOI: 10.1016/j.jtcvs.2005.10.045] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2005] [Revised: 09/12/2005] [Accepted: 10/10/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Accurate preoperative staging is essential for the optimal management of patients with lung cancer. An important goal of preoperative staging is to identify mediastinal lymph node metastasis. Computed tomography and positron emission tomography may identify mediastinal lymph node metastasis with sufficient sensitivity to allow omission of mediastinoscopy. This study utilizes our experience with patients with clinical stage I lung cancer to perform a decision analysis addressing whether mediastinoscopy should be performed in clinical stage I lung cancer patients staged by computed tomography and positron emission tomography. METHODS We retrospectively reviewed our thoracic surgery database for cases between May 1999 and May 2004. Patients deemed clinical stage I by computed tomography and positron emission tomography were chosen for further study. Individual computed tomography, positron emission tomography, and operative and pathology reports were reviewed. The postresection pathologic staging and long-term survival were recorded. A decision model was created using TreeAgePro software and our observed data for the prevalence of mediastinal lymph node metastases and for the rate of benign nodules. Data reported in the literature were also utilized to complete the decision analysis model. A sensitivity analysis of key variables was performed. RESULTS A total of 248 patients with clinical stage I lung tumors were identified. One hundred seventy-eight patients (72%) underwent mediastinoscopy before resection, and 5/178 (3%) showed N2 disease. An additional 9 patients were found to have N2 metastasis in the final resected specimen, resulting in a total of 14/248 patients (5.6%) with occult mediastinal lymph node metastases. Benign nodules were found in 19/248 (8%) of patients. Decision analysis determined that mediastinoscopy added 0.008 years of life expectancy at a cost of 250,989 dollars per life-year gained. The outcome was sensitive to the prevalence of N2 disease in the population and the benefit of induction versus adjuvant therapy for N2 lung cancer. If the prevalence of N2 disease exceeds 10%, the sensitivity analysis predicts that mediastinoscopy would lengthen life at a cost of less than 100,000 dollars per life-year gained. CONCLUSION Patients with clinical stage I lung cancer staged by computed tomography and positron emission tomography benefit little from mediastinoscopy. The survival advantage it confers is very small and is dependent on the prevalence of N2 metastasis and the unproven superiority of induction therapy over adjuvant therapy.
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Affiliation(s)
- Bryan F Meyers
- Division of Cardiothoracic Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA.
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Senan S, De Ruysscher D. Critical review of PET-CT for radiotherapy planning in lung cancer. Crit Rev Oncol Hematol 2005; 56:345-51. [PMID: 15990331 DOI: 10.1016/j.critrevonc.2005.05.001] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2005] [Revised: 05/20/2005] [Accepted: 05/20/2005] [Indexed: 11/17/2022] Open
Abstract
In the last decade, FDG-PET scans have had a major impact on the treatment of patients with NSCLC. The benefits of staging PET scans are well established, with improved selection of patients for curative radiotherapy or aggressive chemo-radiotherapy. The large body of literature correlating FDG-PET with nodal pathology in NSCLC makes it rational to use PET for designing mediastinal radiation fields. However, suboptimal image-fusion and a low spatial resolution for PET scans, makes use of PET for defining target volumes for primary tumours questionable. Data on the role of PET scans for radiotherapy planning for limited stage small-cell lung cancer is limited, although the incorporation of FDG-PET positive regions would appear to be reasonable.
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Affiliation(s)
- Suresh Senan
- Department of Radiation Oncology, VU University Medical Center, De Boelelaan 1117, Post Box 7057, 1007 MB Amsterdam, The Netherlands.
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56
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Perrotin C, Lemeunier P, Grahek D, Molina T, Petino A, Alifano M, Bellenot F, Magdeleinat P, Talbot JN, Regnard JF. Résultats de la TEP [18F]-FDG dans la stadification préopératoire des tumeurs pulmonaires. Rev Mal Respir 2005; 22:579-85. [PMID: 16294177 DOI: 10.1016/s0761-8425(05)85610-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Positron emission tomography (PET) with [18F]fluorodeoxyglucose (FDG) has recently established itself as an important imaging strategy in the management of respectable non-small cell bronchial carcinoma (NSCLC). In this study we report our experience of the impact of FDG-PET in the pre-operative assessment of NSCLC. METHODS In a single centre retrospective study between 01 January 2000 and 31 Dec 2002, 108 FDGPET scans were performed during the preoperative assessment of histologically proven or strongly suspected NSCLC. RESULTS The sensitivity, specificity and accuracy of FDG-PET for the characterization of a parenchymatous opacity were 96%, 71% and 92% respectively (4 false negatives, 5 false positives). The sensitivity, specificity and accuracy for mediastinal node involvement were 62%, 94% and 84% respectively (10 false negatives and 4 false positives). The sensitivity, specificity and accuracy for the characterization of adrenal nodules were 88%, 100% and 97% (1 false negative) and for satellite pulmonary nodules 50%, 75% and 64% (2 false negatives and 3 false positives). CONCLUSION FDG-PET is a useful imaging modality in the pre-operative management of NSCLC but is limited particularly in the characterization of lesions less than 10 mm in diameter and in the evaluation of mediastinal lymph nodes.
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Affiliation(s)
- C Perrotin
- Service de Chirurgie Thoracique, Hôtel Dieu, Paris, France.
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57
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Yap KK, Yap KSK, Byrne AJ, Berlangieri SU, Poon A, Mitchell P, Knight SR, Clarke PC, Harris A, Tauro A, Rowe CC, Scott AM. Positron emission tomography with selected mediastinoscopy compared to routine mediastinoscopy offers cost and clinical outcome benefits for pre-operative staging of non-small cell lung cancer. Eur J Nucl Med Mol Imaging 2005; 32:1033-40. [PMID: 15875178 DOI: 10.1007/s00259-005-1821-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2005] [Accepted: 03/21/2005] [Indexed: 10/25/2022]
Abstract
PURPOSE (18)F-fluorodeoxyglucose positron emission tomography (FDG-PET) imaging is an important staging procedure in patients with non-small cell lung cancer (NSCLC). We aimed to demonstrate, through a decision tree model and the incorporation of real costs of each component, that routine FDG-PET imaging as a prelude to curative surgery will reduce requirements for routine mediastinoscopy and overall hospital costs. METHODS A decision tree model comparing routine whole-body FDG-PET imaging to routine staging mediastinoscopy was used, with baseline variables of sensitivity, specificity and prevalence of non-operable and metastatic disease obtained from institutional data and a literature review. Costings for hospital admissions for mediastinoscopy and thoracotomy of actual patients with NSCLC were determined. The overall and average cost of managing patients was then calculated over a range of FDG-PET costs to derive projected cost savings to the community. RESULTS The prevalence of histologically proven mediastinal involvement in patients with NSCLC presenting for surgical assessment at our institution is 20%, and the prevalence of distant metastatic disease is 6%. Based on literature review, the pooled sensitivity and specificity of FDG-PET for detection of mediastinal spread are 84% and 89% respectively, and for mediastinoscopy, 81% and 100%. The average cost of mediastinoscopy for NSCLC in our institution is 4,160 AUD, while that of thoracotomy is 15,642 AUD. The cost of an FDG-PET scan is estimated to be 1,500 AUD. Using these figures and the decision tree model, the average cost saving is 2,128 AUDper patient. CONCLUSION Routine FDG-PET scanning with selective mediastinoscopy will save 2,128 AUD per patient and will potentially reduce inappropriate surgery. These cost savings remain robust over a wide range of disease prevalence and FDG-PET costs.
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Affiliation(s)
- Kelvin K Yap
- Centre for PET, University of Melbourne, Austin Hospital Heidelberg, Victoria, 3084, Australia
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Erasmus JJ, Truong MT, Munden RF. CT, MR, and PET imaging in staging of non-small-cell lung cancer. Semin Roentgenol 2005; 40:126-42. [PMID: 15898410 DOI: 10.1053/j.ro.2005.01.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Affiliation(s)
- Jeremy J Erasmus
- Department of Diagnostic Radiology, University of Texas, MD Anderson Cancer Center, Houston, TX 77030, USA.
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Staging and Current Imaging of Lung Cancer. J Vasc Interv Radiol 2005. [DOI: 10.1016/s1051-0443(05)70111-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Hellwig D, Graeter TP, Ukena D, Georg T, Kirsch CM, Schäfers HJ. Value of F-18-fluorodeoxyglucose positron emission tomography after induction therapy of locally advanced bronchogenic carcinoma. J Thorac Cardiovasc Surg 2005; 128:892-9. [PMID: 15573074 DOI: 10.1016/j.jtcvs.2004.07.031] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVES Induction therapy is an important treatment option in locally advanced non-small cell lung cancer. F-18-fluorodeoxyglucose positron emission tomography (FDG-PET) has an important role in initial staging. The aim of this study was to assess the value of FDG-PET in restaging after induction therapy and in analyzing tumor viability, nodal status, distant metastases, and prognosis. METHODS Forty-seven patients with locally advanced non-small cell lung cancer accepted for resection after induction therapy underwent FDG-PET. Images were interpreted visually for mediastinal nodal status and metastatic spread. The FDG accumulation in the tumor site was measured by using the maximum standardized uptake value. RESULTS Unexpected metastases were detected by means of FDG-PET in 9 patients. Surgical intervention was not performed in 8 patients with confirmed metastases. The rate of unexpected findings increased from complete radiologic remission (0%) over partial remission (9%) to no change (67%). The standardized uptake value was higher in tumors with (n = 26) than in those without (n = 11) histologic proof of viability (6.4 +/- 5.3 vs 2.9 +/- 1.6, P = .006). All patients with standardized uptake values of greater than 5.8 had viable tumors. Sensitivity, specificity, and negative predictive value were 81%, 64%, and 58% for tumor viability and 50%, 88%, and 85% for persistent mediastinal disease. Median survival after resection was greater than 56 months for patients with tumor standardized uptake values of less than 4 and 19 months for patients with standardized uptake values of 4 or greater ( P < .001). CONCLUSION FDG-PET helps in the selection of patients for resection after induction therapy. It can be used to detect unexpected distant metastases, especially after poor response to induction therapy. Its high negative predictive value in mediastinal restaging allows for omission of repeat mediastinoscopy. Tumor standardized uptake value after induction is a prognostic factor.
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Affiliation(s)
- Dirk Hellwig
- Department of Nuclear Medicine, University Hospital Homburg, D-66421 Homburg/Saar, Germany
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Abstract
Combining positron emission tomography (PET) and X-ray computed tomography (CT) with simultaneous acquisition may improve diagnostic accuracy in oncology. Moreover this combination holds considerable promise in radiotherapy. Metabolic information may be used in decision making in radiotherapy and in planning target volumes. Furthermore early evaluation of treatment efficacy becomes possible. New tracers for the assessment of tumour hypoxia or apoptosis in clinical routine are currently being developed. These tracers may yield high relevance in radiotherapy. Hybrid scanners facilitate patient handling and shorten the duration of acquisition. Furthermore fusion accuracy is optimal. Prospective studies have to be conducted to show that the new technology improves patient care in terms of efficiency and quality.
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Affiliation(s)
- M Weckesser
- Klinik und Poliklinik für Nuklearmedizin, Universitätsklinikum Münster
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62
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Schrevens L, Lorent N, Dooms C, Vansteenkiste J. The Role of PET Scan in Diagnosis, Staging, and Management of Non‐Small Cell Lung Cancer. Oncologist 2004; 9:633-43. [PMID: 15561807 DOI: 10.1634/theoncologist.9-6-633] [Citation(s) in RCA: 175] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Positron emission tomography (PET) is now an important cancer imaging tool, both for diagnosis and staging, as well as offering prognostic information based on response. This report attempts to comprehensively review the value of PET in the locoregional and distant staging of non-small cell lung cancer (NSCLC), illustrate the potential effects on patient management, and give a short overview of newer applications. PET sets the gold standard in the evaluation of an indeterminate solitary pulmonary nodule or mass, where PET has proven to be significantly more accurate than computed tomography (CT) in the distinction between benign and malignant lesions. In the evaluation of metastatic spread to locoregional lymph nodes, PET is significantly more accurate than CT, so that invasive surgical staging may be omitted in many patients with negative mediastinal PET images. In patients with positive mediastinal PET images, invasive surgical staging remains mandatory because of the possibility of false-positive findings due to inflammatory nodes or granulomatous disorders. In the search for metastatic spread, PET is a useful adjunct to conventional imaging. This may be due to the finding of unexpected metastatic lesions or due to exclusion of malignancy in lesions that are equivocal on standard imaging. However, at this time, PET does not replace conventional imaging. Large-scale randomized studies are currently examining whether PET staging will actually improve the appearance of lung cancer outcome.
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Affiliation(s)
- Liesbet Schrevens
- Respiratory Oncology Unit (Pulmonology), University Hospital Gasthuisberg, Herestraat 49, B-3000 Leuven, Belgium
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Okubo K, Kato T, Hara A, Yoshimi N, Takeda K, Iwao F. Imprint Cytology for Detecting Metastasis of Lung Cancer in Mediastinal Lymph Nodes. Ann Thorac Surg 2004; 78:1190-3. [PMID: 15464468 DOI: 10.1016/j.athoracsur.2004.04.028] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/01/2004] [Indexed: 11/17/2022]
Abstract
BACKGROUND Lymph node metastasis of lung cancer has been evaluated with histologic examination. We studied the usefulness of cytologic diagnosis for detecting metastasis of lung cancer in mediastinal nodes. METHODS Five hundred twelve stations of mediastinal nodes in 157 patients with lung cancer were excised for staging of the disease through mediastinoscopy or thoracoscopy. Among them, 474 stations of mediastinal nodes in 151 patients were examined for metastasis both with imprint cytology and with hematoxylin-eosin histology independently. The final diagnostic decision was made by overall pathologic information, including cytology and histology. The diagnostic accuracies were compared between cytologic and histologic examinations. RESULTS Cytologic examination identified 66 positive stations and 2 suspicious stations in 45 patients, whereas histologic examination identified 61 positive stations in 42 patients. The final pathologic diagnosis was 70 positive stations and 1 suspicious station in 45 patients. The sensitivity, accuracy, and negative predictive value of cytologic examination for node metastasis were 95.7%, 99.4%, and 99.3%, respectively, and those of histologic examination were 87.1%, 98.1%, and 97.7%, respectively. On a patient basis the sensitivity, accuracy, and negative predictive value of cytologic examination were 100%, 100%, and 100%, respectively, whereas those of histologic examination were 93.8%, 98.0%, and 97.2%, respectively. An additional 3 patients (2.0%) who had contralateral mediastinal node metastasis diagnosed only with cytology were identified with upstaged disease. CONCLUSIONS Imprint cytology for detecting metastasis of lung cancer in mediastinal nodes has high sensitivity and accuracy and is no less useful than histologic examination.
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Affiliation(s)
- Kenichi Okubo
- General Thoracic SurgeryGifu National Hospital, Gifu, Japan.
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Cerfolio RJ, Ojha B, Bryant AS, Raghuveer V, Mountz JM, Bartolucci AA. The accuracy of integrated PET-CT compared with dedicated pet alone for the staging of patients with nonsmall cell lung cancer. Ann Thorac Surg 2004; 78:1017-23; discussion 1017-23. [PMID: 15337041 DOI: 10.1016/j.athoracsur.2004.02.067] [Citation(s) in RCA: 233] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/18/2004] [Indexed: 11/28/2022]
Abstract
BACKGROUND The treatment of patients with nonsmall cell lung cancer (NSCLC) is determined by the stage. We evaluated the accuracy of staging using integrated positron emission tomography (PET) and computed tomography (CT) and compared it with dedicated PET visually correlated with CT scan. METHODS A prospective blinded trial was performed on a consecutive series of patients with NSCLC. Patients underwent integrated PET-CT scanning with 2-[18F]-fluoro-2-deoxy-D-glucose (FDG-18). A radiologist assigned the T, N and M status. No sooner than 2 weeks the same radiologist read the dedicated PET alone, without the integrated CT images and a T, N and M status was assigned again. The most recent CT scan was available and visually correlated with both studies. All patients underwent biopsies of suspicious N2 or N3 lymph node or distant metastases and if negative, pulmonary resection with lymphadenectomy was performed. RESULTS There were 129 patients. Integrated PET-CT is a better predictor than PET for all stages of cancer and achieved statistical significance for stage I (52% versus 33%, p = 0.03) and for stage II (70% versus 36%, p = 0.04). It also is a better overall predictor for T status (70% versus 47%, p = 0.001) and the N status (78% versus 56%, p = 0.008). Nodal analysis shows that integrated PET-CT was more accurate for the total N2 nodes (96% versus 93%, p = 0.01) and for the total N1 nodes (90% versus 80%, p = 0.001). It was also more sensitive, specific, and had a higher positive predictive value for both N2 and N1 nodes (p < 0.05 for all). Integrated PET-CT is significantly more sensitive at the 4R, 5, 7, 10 L and 11 stations and more accurate at the 7 and 11 lymph nodes stations than dedicated PET. CONCLUSIONS Integrated PET-CT using FDG-18 better predicts stage I and II disease as well as the T and N status of patients with NSCLC when compared with dedicated PET alone. It is more accurate at some nodal stations but still only achieves an accuracy of 96% and 90% for the N2 and N1 nodes, respectively.
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Affiliation(s)
- Robert James Cerfolio
- Section of Thoracic Surgery, University of Alabama at Birmingham, and Division of Cardiothoracic Surgery, Department of Surgery, Birmingham Veterans Administration Hospital, Birmingham, Alabama 35294, USA.
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Abstract
Metabolic imaging with positron emission tomography (PET) using 18F-fluoro-2-deoxy-glucose (FDG) has been accepted as an important imaging modality in lung cancer. FDG PET may have important impacts on the management of lung-cancer patients, for instance by improvement of locoregional (mediastinal) and extrathoracic staging (unexpected metastases). Interesting findings have now been reported in the response assessment to induction therapy providing results of greater prognostic significance than that obtained by conventional imaging methods. In the field of thoracic irradiation, FDG PET may provide advantages in terms of reduced toxicity, treatment intensification, better local tumour control and increased survival.
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Affiliation(s)
- D Ukena
- Medizinische Universitätsklinik, Innere Medizin V, Universitätsklinikum des Saarlandes, D-66421 Homburg, Germany.
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Nomori H, Watanabe K, Ohtsuka T, Naruke T, Suemasu K, Uno K. The size of metastatic foci and lymph nodes yielding false-negative and false-positive lymph node staging with positron emission tomography in patients with lung cancer. J Thorac Cardiovasc Surg 2004; 127:1087-92. [PMID: 15052206 DOI: 10.1016/j.jtcvs.2003.08.010] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND We examined the sizes of lymph nodes and metastatic foci within the lymph nodes that affect false-positive and false-negative lymph node staging by positron emission tomography in lung cancer. METHODS Preoperative positron emission tomography and computed tomography scans were performed for 564 lymph node stations in 80 patients with peripheral-type lung cancer. The sizes of both the lymph nodes and the metastatic foci within the lymph nodes were measured, and these measurements were compared with those obtained with positron emission tomography scanning. To establish general sizes of metastatic foci within the lymph nodes, 277 metastatic lymph nodes in operative specimens previously resected from another 111 patients with lung cancer were examined as a control. RESULTS The sensitivity was significantly higher for positron emission tomography than for computed tomographic scanning (P =.026). The sizes of metastatic foci within lymph nodes that showed false-negative (n = 8) and true-positive (n = 28) with positron emission tomography ranged from 0.5 to 9 mm (3 +/- 1 mm) and from 4 to 18 mm (10 +/- 3 mm), respectively (P <.001). None of the metastatic foci smaller than 4 mm could be detected with positron emission tomography scanning. The review of the 277 previously resected metastatic lymph nodes showed that 89 (32%) had metastatic foci smaller than 4 mm. The sizes of true-positive (n = 28) and false-positive (n = 10) lymph nodes ranged from 6 to 15 mm (10 +/- 2 mm) and from 9 to 16 mm (12 +/- 2 mm), respectively (P <.01). None of the false-positive lymph nodes was smaller than 9 mm. CONCLUSIONS Although positron emission tomography was superior to computed tomography scanning in lymph node staging in lung cancer, positron emission tomography was unable to distinguish metastatic foci smaller than 4 mm, which were not unusual sizes for lymph node metastases in lung cancer. Positive lymph nodes with positron emission tomography smaller than 9 mm are likely to be true-positive rather than false-positive.
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MESH Headings
- Adenocarcinoma/diagnosis
- Adenocarcinoma/pathology
- Aged
- Carcinoma, Adenosquamous/diagnosis
- Carcinoma, Adenosquamous/pathology
- Carcinoma, Large Cell/diagnosis
- Carcinoma, Large Cell/pathology
- Carcinoma, Small Cell/diagnosis
- Carcinoma, Small Cell/pathology
- Carcinoma, Squamous Cell/diagnosis
- Carcinoma, Squamous Cell/pathology
- Carcinosarcoma/diagnosis
- Carcinosarcoma/pathology
- False Positive Reactions
- Female
- Fluorodeoxyglucose F18
- Humans
- Lung Neoplasms/diagnosis
- Lung Neoplasms/pathology
- Lymph Nodes/diagnostic imaging
- Lymph Nodes/pathology
- Lymphatic Metastasis
- Male
- Middle Aged
- Neoplasm Staging
- Predictive Value of Tests
- Prospective Studies
- Radiopharmaceuticals
- Sensitivity and Specificity
- Tomography, Emission-Computed
- Tomography, X-Ray Computed
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Affiliation(s)
- Hiroaki Nomori
- Department of Thoracic Surgery, Saiseikai Central Hospital, Tokyo, Japan.
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Annema JT, Hoekstra OS, Smit EF, Veseliç M, Versteegh MIM, Rabe KF. Towards a minimally invasive staging strategy in NSCLC: analysis of PET positive mediastinal lesions by EUS-FNA. Lung Cancer 2004; 44:53-60. [PMID: 15013583 DOI: 10.1016/j.lungcan.2003.10.013] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2003] [Revised: 10/20/2003] [Accepted: 10/24/2003] [Indexed: 02/04/2023]
Abstract
STUDY OBJECTIVE To asses the value of endoscopic ultrasound guided fine needle aspiration (EUS-FNA) in the nodal staging of patients with (suspected) non-small cell lung cancer (NSCLC) and a (18)FDG positron emission tomography (PET) scan suspect for N2/N3 mediastinal lymph node (MLN) metastases. BACKGROUND Due to the imperfect specificity of positron emission tomography, PET positive MLN should be biopsied in order to confirm or rule out metastasis. Currently, invasive surgical diagnostic techniques such as mediastinoscopy/-tomy are standard procedures to obtain MLN tissue. The minimally invasive technique of EUS-FNA has a high diagnostic accuracy (90-94%) for the analysis of MLN in patients with enlarged MLN on computed tomography of the chest (CT). DESIGN AND PATIENTS Thirty-six patients with proven n=26 or suspected n=10 non-small cell lung cancer and a PET scan suspect for N2/N3 lymph node metastases underwent EUS-FNA. When EUS-FNA did not confirm metastasis and the PET lesion was within reach of mediastinoscopy, a mediastinoscopy was performed. EUS-FNA negative patients with PET lesions beyond the reach of mediastinoscopy or those with a negative mediastinoscopy were referred for surgical resection of the tumour and MLN sampling or dissection. RESULTS EUS-FNA confirmed N2/N3 disease in 25 of the 36 patients (69%) and was highly suspicious in one. In the remaining 10 patients, one PET positive and one PET negative N2 metastasis was detected at thoracotomy. The PPV, NPV, sensitivity, specificity and accuracy of EUS-FNA in analysing PET positive MLN were 100%, 80%, 93%, 100% and 94%, respectively. No complications of EUS-FNA were recorded. CONCLUSIONS AND SIGNIFICANCE EUS-FNA yields minimally invasive confirmation of MLN metastases in 69% of the patients with potential mediastinal involvement at FDG PET. The combination of PET and EUS-FNA might qualify as a minimally invasive staging strategy for NSCLC.
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Affiliation(s)
- J T Annema
- Department of Pulmonary Medicine, Leiden University Medical Center, PO Box 9600, Albinusdreef 2, 2300 RC Leiden, The Netherlands.
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Verhagen AFT, Bootsma GP, Tjan-Heijnen VCG, van der Wilt GJ, Cox AL, Brouwer MHJ, Corstens FHM, Oyen WJG. FDG-PET in staging lung cancer. Lung Cancer 2004; 44:175-81. [PMID: 15084382 DOI: 10.1016/j.lungcan.2003.11.007] [Citation(s) in RCA: 112] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2003] [Revised: 11/12/2003] [Accepted: 11/17/2003] [Indexed: 01/08/2023]
Abstract
BACKGROUND In patients with lung cancer, positron emission tomography (PET) using fluor-18-fluorodesoxyglucose (FDG) may be used both to detect extrathoracic metastases (ETM) and for mediastinal lymph node staging (MLS), potentially reducing the need for mediastinoscopy. We assessed the added value of FDG-PET in detecting ETM and focused on the reliability of FDG-PET and mediastinoscopy for MLS. PATIENTS AND METHODS In 72 consecutive patients with non-small cell lung cancer, the impact of adding FDG-PET to full conventional clinical staging was prospectively analyzed. The predictive value of FDG-PET findings and tumor location for pathologic mediastinal lymph node status were assessed in a logistic regression analysis. RESULTS Unexpected extrathoracic metastases were detected by FDG-PET in 15% of patients. In MLS overall negative and positive predictive values were 71 and 83% for FDG-PET, and 92 and 100% for mediastinoscopy. However, the negative predictive value of FDG-PET was only 17% in case of FDG-PET positive N1 nodes and/or a centrally located primary tumor, whereas it was 96% in case of FDG-PET negative N1 nodes and a non-centrally located primary tumor. CONCLUSION By incorporating FDG-PET in clinical staging, 15% of patients with lung cancer are upstaged due to unexpected extrathoracic metastases. In case of a negative mediastinal FDG-PET, mediastinoscopy can only be omitted in the presence of a non-centrally located primary tumor and without FDG-PET positive N1 nodes.
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Affiliation(s)
- A F T Verhagen
- Department of Cardio-thoracic surgery (414), University Medical Center Nijmegen, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands.
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Kelly RF, Tran T, Holmstrom A, Murar J, Segurola RJ. Accuracy and Cost-Effectiveness of [18F]-2-Fluoro-Deoxy-D-Glucose-Positron Emission Tomography Scan in Potentially Resectable Non-small Cell Lung Cancer. Chest 2004; 125:1413-23. [PMID: 15078754 DOI: 10.1378/chest.125.4.1413] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVES This retrospective study of patients who were referred for surgical resection of non-small cell lung cancer (NSCLC) assessed the accuracy and cost-effectiveness of positron emission tomography (PET) with radiolabeled [18F]-2-fluoro-deoxy-D-glucose (FDG) in staging mediastinal lymph nodes (MLNs). DESIGN From January 2001 to September 2002, 90 patients with suspected or proven NSCLC who had been referred for curative resection were retrospectively reviewed. All patients were without evidence of metastatic disease. Sixty-nine of the 90 patients had undergone thoracic FDG-PET imaging as part of their evaluation and are the focus of this study. Sensitivity, specificity, accuracy, and positive and negative predictive values for metastasis to the MLN were calculated for CT scanning vs FDG-PET scanning. Four algorithms for staging MLN with mediastinoscopy and/or FDG-PET scan were compared. MEASUREMENTS AND RESULTS Sixty-nine patients underwent preoperative CT and FDG-PET scans, and 32 of 69 patients underwent mediastinoscopy. Fifty-seven patients underwent thoracotomy with complete mediastinal lymphadenectomy. Sensitivity, specificity, accuracy, and positive and negative predictive values for CT scans and FDG-PET scans were 46%, 86%, 78%, 43%, and 87%, and 62%, 98%, 91%, 89% and 92%, respectively. Mediastinoscopy was accurate in 32 of 32 patients (100%). Routine mediastinoscopy remains the most economically reasonable strategy with excellent sensitivity. Selective FDG-PET imaging improved the sensitivity of noninvasive staging for patients with normal MLNs on CT scans. CONCLUSIONS Selective use of FDG-PET imaging improves staging accuracy compared to CT scanning alone and makes it a cost-effective adjunct to the preoperative staging of NSCLC. However, in patients with adenocarcinoma and MLNs of < 1 cm, FDG-PET scanning cannot yet replace mediastinoscopy.
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Abstract
The staging of lung cancer is a continuously progressing field, with advances in technology not only improving prognostic accuracy, but fundamentally changing pre-operative investigation algorithms. Noninvasive staging is currently undergoing revolutionary developments with the advent of Positron Emission Tomography, whereas Video-Assisted Thoracic Surgery has already been established as an essential, minimally invasive diagnostic tool for invasive histological staging. Molecular staging may transform future lung cancer staging, promising extremely accurate substaging, and potentially prompting a revision of our anatomically based conceptualization of lung cancer spread. This review presents an appraisal of current lung cancer staging modalities, and presents an overview of recent developments in molecular staging.
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Affiliation(s)
- Alan D L Sihoe
- Department of Surgery, Prince of Wales Hospital, Hong Kong, China
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71
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Botta DM, Head HD. Non-small cell lung cancer: an update. ACTA ACUST UNITED AC 2004; 60:492-8. [PMID: 14972212 DOI: 10.1016/s0149-7944(03)00133-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Donald M Botta
- Department of Surgery, University of Tennessee College of Medicine, Chattanooga Unit, Chattanooga, Tennessee, USA
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72
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Abstract
The diagnostic approach to patients who have mediastinal masses should include thorough preoperative imaging. Once limited to plain radiographic techniques, the radiologist now has a wide variety of imaging modalities to aid in the evaluation of the mediastinum. CT is the imaging modality of choice for evaluating a suspected mediastinal mass or a widened mediastinum, and it provides the most useful information for the diagnosis, treatment, and evaluation of postoperative complications.
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Affiliation(s)
- Dorith Shaham
- Department of Radiology, Hadassah University Hospital, Ein-Kerem, Jerusalem 91120, Israel.
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Reed CE, Harpole DH, Posther KE, Woolson SL, Downey RJ, Meyers BF, Heelan RT, MacApinlac HA, Jung SH, Silvestri GA, Siegel BA, Rusch VW. Results of the American College of Surgeons Oncology Group Z0050 trial: the utility of positron emission tomography in staging potentially operable non-small cell lung cancer. J Thorac Cardiovasc Surg 2004; 126:1943-51. [PMID: 14688710 DOI: 10.1016/j.jtcvs.2003.07.030] [Citation(s) in RCA: 234] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES The American College of Surgeons Oncology Group undertook a trial to ascertain whether positron emission tomography with 18F-fluorodeoxyglucose could detect lesions that would preclude pulmonary resection in a group of patients with documented or suspected non-small cell lung cancer found to be surgical candidates by routine staging procedures. METHODS A total of 303 eligible patients registered from 22 institutions underwent positron emission tomography after routine staging (computed tomography of chest and upper abdomen, bone scintigraphy, and brain imaging) had deemed their tumors resectable. Positive findings required confirmatory procedures. RESULTS Positron emission tomography was significantly better than computed tomography for the detection of N1 and N2/N3 disease (42% vs 13%, P =.0177, and 58% vs 32%, P =.0041, respectively). The negative predictive value of positron emission tomography for mediastinal node disease was 87%. Unsuspected metastatic disease or second primary malignancy was identified in 18 of 287 patients (6.3%). Distant metastatic disease indicated in 19 of 287 patients (6.6%) was subsequently shown to be benign. By correctly identifying advanced disease (stages IIIA, IIIB, and IV) or benign lesions, positron emission tomography potentially avoided unnecessary thoracotomy in 1 of 5 patients. CONCLUSIONS In patients with suspected or proven non-small cell lung cancer considered resectable by standard staging procedures, positron emission tomography can prevent nontherapeutic thoracotomy in a significant number of cases. Use of positron emission tomography for mediastinal staging should not be relied on as a sole staging modality, and positive findings should be confirmed by mediastinoscopy. Metastatic disease, especially a single site, identified by positron emission tomography requires further confirmatory evaluation.
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Affiliation(s)
- Carolyn E Reed
- Hollings Cancer Center, Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston 29425, USA.
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Port JL, Kent MS, Korst RJ, Keresztes R, Levin MA, Altorki NK. Positron emission tomography scanning poorly predicts response to preoperative chemotherapy in non-small cell lung cancer. Ann Thorac Surg 2004; 77:254-9; discussion 259. [PMID: 14726072 DOI: 10.1016/s0003-4975(03)01457-7] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The ability to accurately predict pathologic response to preoperative chemotherapy may have a significant impact on the treatment strategy for non-small cell lung cancer (NSCLC). The purpose of this study was to examine the accuracy of positron emission tomography (PET) scanning in predicting the pathologic response to preoperative chemotherapy in the primary tumor and draining lymph nodes. METHODS A total of 25 patients were enrolled in two separate phase II trials investigating induction chemotherapy for NSCLC. All patients underwent pre-treatment and post-treatment PET scans followed by surgical resection. A significant PET scan response was defined as a reduction in the standard uptake value by 50% or more. We defined a major pathologic response as either no disease or microscopic disease only in the primary tumor. The percentage change in standard uptake value was then calculated and correlated with pathologic response in the primary tumor. In addition, the presence or absence of nodal metastases as determined by the postchemotherapy PET scan was compared with final pathologic nodal stage. RESULTS The positive and negative predictive values for PET detection of major pathologic response in the primary tumor were 43% and 100%, respectively. Positron emission tomography did not accurately predict nodal status in 52% of patients. The positive and negative predictive values of PET to detect node-positive disease were 73% and 64%, respectively. For N2 disease the positive predictive value of PET scans was less than 20%. CONCLUSIONS Positron emission tomography scanning does not reliably predict pathologic response to preoperative chemotherapy in NSCLC in either the primary tumor or the draining lymph nodes.
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Affiliation(s)
- Jeffrey L Port
- Department of Cardiothoracic Surgery, Weill-Cornell Medical Center, New York, New York 10021, USA
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75
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Johnston MR. Induction therapy for stage III lung cancer. Lung Cancer 2003; 42 Suppl 2:S53-7. [PMID: 14644537 DOI: 10.1016/j.lungcan.2003.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Michael R Johnston
- University of Toronto, Toronto General Hospital, 200 Elizabeth Street, Suite 10 EN-230, Toronto, Ont, Canada M5G 2C4.
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Cerfolio RJ, Ojha B, Bryant AS, Bass CS, Bartalucci AA, Mountz JM. The role of FDG-PET scan in staging patients with nonsmall cell carcinoma. Ann Thorac Surg 2003; 76:861-6. [PMID: 12963217 DOI: 10.1016/s0003-4975(03)00888-9] [Citation(s) in RCA: 101] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND To assess the role of flourodeoxyglucose-positron-emission tomography (FDG-PET) scan in staging patients with nonsmall cell lung cancer (NSCLC). METHODS We prospectively studied 400 patients with NSCLC. Each patient underwent a computed tomography (CT) scan of the chest and upper abdomen, other conventional staging studies and had a FDG-PET scan within 1 month before surgery. All suspicious N2 lymph nodes by either chest CT or by FDG-PET scan were biopsied. Patients that were N2 and M1 negative underwent pulmonary resection and complete thoracic lymphadenectomy. RESULTS The FDG-PET had a higher sensitivity (71% vs 43%, p < 0.001), positive predictive value (44% vs 31%, p < 0.001), negative predictive value (91% vs 84%, p = 0.006), and accuracy (76% vs 68%, p = 0.037) than CT scan for N2 lymph nodes. Similarly, FDG-PET had a higher sensitivity (67% vs 41%, p < 0.001), but lower specificity (78% vs 88%, p = 0.009) than CT scan for N1 lymph nodes. FDG-PET led to unnecessary mediastinoscopy in 38 patients. FDG-PET was most commonly falsely negative in the subcarinal (#7) station and the aortopulmonary window lymph node (#5, #6) stations. It accurately upstaged 28 patients (7%) with unsuspected metastasis and it accurately downstaged 23 patients (6%). CONCLUSIONS The FDG-PET scan allows for improved patient selection. It more accurately stages the mediastinum, however there are many false positives lymph nodes and it may be more likely to miss N2 disease in the #5, #6, and #7 stations. A positive FDG-PET scan means a tissue biopsy is indicated in that location.
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Naunheim KS. What's new in general thoracic surgery. J Am Coll Surg 2003; 197:88-96. [PMID: 12831929 DOI: 10.1016/s1072-7515(03)00380-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Keith S Naunheim
- Division of Cardiothoracic Surgery, St. Louis University Health Sciences Center, MO 63110, USA
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