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Chen WM, Chen M, Hsu JG, Lee TS, Shia BC, Wu SY. Use of Preoperative FDG PET/CT and Survival of Patients with Resectable Non-Small Cell Lung Cancer. Radiology 2022; 305:219-227. [PMID: 35727156 DOI: 10.1148/radiol.212798] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background The added value of preoperative PET/CT for the overall survival of patients with resectable non-small cell lung cancer (NSCLC) is unknown. Purpose To investigate the association of the use of preoperative PET/CT on survival of patients with resectable stage I-IIIB NSCLC. Materials and Methods In this retrospective study, patients with resectable stage I-IIIB NSCLC who underwent thoracic surgery from January 1, 2009, to December 31, 2018, from the Taiwan Cancer Registry were included. The last follow-up date was December 31, 2019. Patients were categorized into two groups according to whether they underwent preoperative metabolic imaging with fluorine 18 fluorodeoxyglucose PET/CT. Patients who did not undergo preoperative imaging were used as the control group. The primary outcome of interest was all-cause mortality. Patients in both groups were propensity score matched at a ratio of 1:1. Matching variables used were sex, age, histologic findings, American Joint Committee on Cancer clinical stage, cT stage, cN stage, current and past smoker history, adjuvant chemotherapy, adjuvant chemoradiation, Charlson comorbidity index, and hospital type. Survival curves were generated using the Kaplan-Meier method and compared using the log-rank test. Results In the matched cohort, 6754 patients (3349 men, mean age ± SD: 64 years ± 11) underwent PET/CT and 6754 did not (3362 men, mean age: 64 years ± 11). In adjusted analysis, patients with stage IIIA or IIIB NSCLC and preoperative PET/CT had a lower risk of death versus those without PET/CT (for stage IIIA: hazard ratio [HR] = 0.90 [95% CI: 0.79, 0.94], P = .02; for stage IIIB: HR = 0.80 [95% CI: 0.71, 0.90], P < .01). There was no improvement in a lower risk of death for patients with stage I-II NSCLC (after multivariable adjustment, the HR was 1.19 [95% CI: 0.89, 1.30], P = .65). Conclusion Use of preoperative PET/CT was associated with lower risk of death in patients with stage IIIA-IIIB non-small cell lung cancer compared with those without preoperative PET/CT. © RSNA, 2022 Online supplemental material is available for this article.
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Affiliation(s)
- Wan-Ming Chen
- From the Graduate Institute of Business Administration, College of Management (W.M.C., M.C., J.G.H., T.S.L., B.C.S., S.Y.W.), and Artificial Intelligence Development Center (B.C.S., S.Y.W.), Fu Jen Catholic University, Taipei, Taiwan; Big Data Center (W.M.C., S.Y.W.), Division of Radiation Oncology (S.Y.W.), and Cancer Center (S.Y.W.), Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, No. 111, Section 3, Hsing-Long Rd, Taipei 116, Taiwan; Department of Food Nutrition and Health Biotechnology (S.Y.W.) and Department of Healthcare Administration (S.Y.W.), College of Medical and Health Science, Asia University, Taichung, Taiwan; Centers for Regional Anesthesia and Pain Medicine, Taipei Municipal Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan (S.Y.W.); and Department of Management, College of Management, Fo Guang University, Yilan, Taiwan (S.Y.W.)
| | - Mingchih Chen
- From the Graduate Institute of Business Administration, College of Management (W.M.C., M.C., J.G.H., T.S.L., B.C.S., S.Y.W.), and Artificial Intelligence Development Center (B.C.S., S.Y.W.), Fu Jen Catholic University, Taipei, Taiwan; Big Data Center (W.M.C., S.Y.W.), Division of Radiation Oncology (S.Y.W.), and Cancer Center (S.Y.W.), Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, No. 111, Section 3, Hsing-Long Rd, Taipei 116, Taiwan; Department of Food Nutrition and Health Biotechnology (S.Y.W.) and Department of Healthcare Administration (S.Y.W.), College of Medical and Health Science, Asia University, Taichung, Taiwan; Centers for Regional Anesthesia and Pain Medicine, Taipei Municipal Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan (S.Y.W.); and Department of Management, College of Management, Fo Guang University, Yilan, Taiwan (S.Y.W.)
| | - Jeng-Guan Hsu
- From the Graduate Institute of Business Administration, College of Management (W.M.C., M.C., J.G.H., T.S.L., B.C.S., S.Y.W.), and Artificial Intelligence Development Center (B.C.S., S.Y.W.), Fu Jen Catholic University, Taipei, Taiwan; Big Data Center (W.M.C., S.Y.W.), Division of Radiation Oncology (S.Y.W.), and Cancer Center (S.Y.W.), Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, No. 111, Section 3, Hsing-Long Rd, Taipei 116, Taiwan; Department of Food Nutrition and Health Biotechnology (S.Y.W.) and Department of Healthcare Administration (S.Y.W.), College of Medical and Health Science, Asia University, Taichung, Taiwan; Centers for Regional Anesthesia and Pain Medicine, Taipei Municipal Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan (S.Y.W.); and Department of Management, College of Management, Fo Guang University, Yilan, Taiwan (S.Y.W.)
| | - Tian-Shyug Lee
- From the Graduate Institute of Business Administration, College of Management (W.M.C., M.C., J.G.H., T.S.L., B.C.S., S.Y.W.), and Artificial Intelligence Development Center (B.C.S., S.Y.W.), Fu Jen Catholic University, Taipei, Taiwan; Big Data Center (W.M.C., S.Y.W.), Division of Radiation Oncology (S.Y.W.), and Cancer Center (S.Y.W.), Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, No. 111, Section 3, Hsing-Long Rd, Taipei 116, Taiwan; Department of Food Nutrition and Health Biotechnology (S.Y.W.) and Department of Healthcare Administration (S.Y.W.), College of Medical and Health Science, Asia University, Taichung, Taiwan; Centers for Regional Anesthesia and Pain Medicine, Taipei Municipal Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan (S.Y.W.); and Department of Management, College of Management, Fo Guang University, Yilan, Taiwan (S.Y.W.)
| | - Ben-Chang Shia
- From the Graduate Institute of Business Administration, College of Management (W.M.C., M.C., J.G.H., T.S.L., B.C.S., S.Y.W.), and Artificial Intelligence Development Center (B.C.S., S.Y.W.), Fu Jen Catholic University, Taipei, Taiwan; Big Data Center (W.M.C., S.Y.W.), Division of Radiation Oncology (S.Y.W.), and Cancer Center (S.Y.W.), Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, No. 111, Section 3, Hsing-Long Rd, Taipei 116, Taiwan; Department of Food Nutrition and Health Biotechnology (S.Y.W.) and Department of Healthcare Administration (S.Y.W.), College of Medical and Health Science, Asia University, Taichung, Taiwan; Centers for Regional Anesthesia and Pain Medicine, Taipei Municipal Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan (S.Y.W.); and Department of Management, College of Management, Fo Guang University, Yilan, Taiwan (S.Y.W.)
| | - Szu-Yuan Wu
- From the Graduate Institute of Business Administration, College of Management (W.M.C., M.C., J.G.H., T.S.L., B.C.S., S.Y.W.), and Artificial Intelligence Development Center (B.C.S., S.Y.W.), Fu Jen Catholic University, Taipei, Taiwan; Big Data Center (W.M.C., S.Y.W.), Division of Radiation Oncology (S.Y.W.), and Cancer Center (S.Y.W.), Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, No. 111, Section 3, Hsing-Long Rd, Taipei 116, Taiwan; Department of Food Nutrition and Health Biotechnology (S.Y.W.) and Department of Healthcare Administration (S.Y.W.), College of Medical and Health Science, Asia University, Taichung, Taiwan; Centers for Regional Anesthesia and Pain Medicine, Taipei Municipal Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan (S.Y.W.); and Department of Management, College of Management, Fo Guang University, Yilan, Taiwan (S.Y.W.)
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Schmidt‐Hansen M, Baldwin DR, Hasler E, Zamora J, Abraira V, Roqué i Figuls M. PET-CT for assessing mediastinal lymph node involvement in patients with suspected resectable non-small cell lung cancer. Cochrane Database Syst Rev 2014; 2014:CD009519. [PMID: 25393718 PMCID: PMC6472607 DOI: 10.1002/14651858.cd009519.pub2] [Citation(s) in RCA: 87] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND A major determinant of treatment offered to patients with non-small cell lung cancer (NSCLC) is their intrathoracic (mediastinal) nodal status. If the disease has not spread to the ipsilateral mediastinal nodes, subcarinal (N2) nodes, or both, and the patient is otherwise considered fit for surgery, resection is often the treatment of choice. Planning the optimal treatment is therefore critically dependent on accurate staging of the disease. PET-CT (positron emission tomography-computed tomography) is a non-invasive staging method of the mediastinum, which is increasingly available and used by lung cancer multidisciplinary teams. Although the non-invasive nature of PET-CT constitutes one of its major advantages, PET-CT may be suboptimal in detecting malignancy in normal-sized lymph nodes and in ruling out malignancy in patients with coexisting inflammatory or infectious diseases. OBJECTIVES To determine the diagnostic accuracy of integrated PET-CT for mediastinal staging of patients with suspected or confirmed NSCLC that is potentially suitable for treatment with curative intent. SEARCH METHODS We searched the following databases up to 30 April 2013: The Cochrane Library, MEDLINE via OvidSP (from 1946), Embase via OvidSP (from 1974), PreMEDLINE via OvidSP, OpenGrey, ProQuest Dissertations & Theses, and the trials register www.clinicaltrials.gov. There were no language or publication status restrictions on the search. We also contacted researchers in the field, checked reference lists, and conducted citation searches (with an end-date of 9 July 2013) of relevant studies. SELECTION CRITERIA Prospective or retrospective cross-sectional studies that assessed the diagnostic accuracy of integrated PET-CT for diagnosing N2 disease in patients with suspected resectable NSCLC. The studies must have used pathology as the reference standard and reported participants as the unit of analysis. DATA COLLECTION AND ANALYSIS Two authors independently extracted data pertaining to the study characteristics and the number of true and false positives and true and false negatives for the index test, and they independently assessed the quality of the included studies using QUADAS-2. We calculated sensitivity and specificity with 95% confidence intervals (CI) for each study and performed two main analyses based on the criteria for test positivity employed: Activity > background or SUVmax ≥ 2.5 (SUVmax = maximum standardised uptake value), where we fitted a summary receiver operating characteristic (ROC) curve using a hierarchical summary ROC (HSROC) model for each subset of studies. We identified the average operating point on the SROC curve and computed the average sensitivities and specificities. We checked for heterogeneity and examined the robustness of the meta-analyses through sensitivity analyses. MAIN RESULTS We included 45 studies, and based on the criteria for PET-CT positivity, we categorised the included studies into three groups: Activity > background (18 studies, N = 2823, prevalence of N2 and N3 nodes = 679/2328), SUVmax ≥ 2.5 (12 studies, N = 1656, prevalence of N2 and N3 nodes = 465/1656), and Other/mixed (15 studies, N = 1616, prevalence of N2 to N3 nodes = 400/1616). None of the studies reported (any) adverse events. Under-reporting generally hampered the quality assessment of the studies, and in 30/45 studies, the applicability of the study populations was of high or unclear concern.The summary sensitivity and specificity estimates for the 'Activity > background PET-CT positivity criterion were 77.4% (95% CI 65.3 to 86.1) and 90.1% (95% CI 85.3 to 93.5), respectively, but the accuracy estimates of these studies in ROC space showed a wide prediction region. This indicated high between-study heterogeneity and a relatively large 95% confidence region around the summary value of sensitivity and specificity, denoting a lack of precision. Sensitivity analyses suggested that the overall estimate of sensitivity was especially susceptible to selection bias; reference standard bias; clear definition of test positivity; and to a lesser extent, index test bias and commercial funding bias, with lower combined estimates of sensitivity observed for all the low 'Risk of bias' studies compared with the full analysis.The summary sensitivity and specificity estimates for the SUVmax ≥ 2.5 PET-CT positivity criterion were 81.3% (95% CI 70.2 to 88.9) and 79.4% (95% CI 70 to 86.5), respectively.In this group, the accuracy estimates of these studies in ROC space also showed a very wide prediction region. This indicated very high between-study heterogeneity, and there was a relatively large 95% confidence region around the summary value of sensitivity and specificity, denoting a clear lack of precision. Sensitivity analyses suggested that both overall accuracy estimates were marginally sensitive to flow and timing bias and commercial funding bias, which both lead to slightly lower estimates of sensitivity and specificity.Heterogeneity analyses showed that the accuracy estimates were significantly influenced by country of study origin, percentage of participants with adenocarcinoma, (¹⁸F)-2-fluoro-deoxy-D-glucose (FDG) dose, type of PET-CT scanner, and study size, but not by study design, consecutive recruitment, attenuation correction, year of publication, or tuberculosis incidence rate per 100,000 population. AUTHORS' CONCLUSIONS This review has shown that accuracy of PET-CT is insufficient to allow management based on PET-CT alone. The findings therefore support National Institute for Health and Care (formally 'clinical') Excellence (NICE) guidance on this topic, where PET-CT is used to guide clinicians in the next step: either a biopsy or where negative and nodes are small, directly to surgery. The apparent difference between the two main makes of PET-CT scanner is important and may influence the treatment decision in some circumstances. The differences in PET-CT accuracy estimates between scanner makes, NSCLC subtypes, FDG dose, and country of study origin, along with the general variability of results, suggest that all large centres should actively monitor their accuracy. This is so that they can make reliable decisions based on their own results and identify the populations in which PET-CT is of most use or potentially little value.
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Affiliation(s)
- Mia Schmidt‐Hansen
- Royal College of Obstetricians and GynaecologistsNational Guideline Alliance27 Sussex PlRegent's ParkLondonUKNW1 4RG
| | - David R Baldwin
- Nottingham University Hospitals, NHS Trust, Nottingham City HospitalDepartment of Respiratory MedicineHucknall RoadNottinghamUKNG5 1PB
| | - Elise Hasler
- Royal College of Obstetricians and GynaecologistsNational Guideline Alliance27 Sussex PlRegent's ParkLondonUKNW1 4RG
| | - Javier Zamora
- Ramon y Cajal Institute for Health Research (IRYCIS), CIBER Epidemiology and Public Health (CIBERESP), Madrid (Spain) and Queen Mary University of LondonClinical Biostatistics UnitCtra. Colmenar km 9,100MadridMadridSpain28034
| | - Víctor Abraira
- Ramon y Cajal Institute for Health Research (IRYCIS), CIBER Epidemiology and Public Health (CIBERESP) and Cochrane Collaborating CentreClinical Biostatistics UnitCrta Colmenar Km 9.1MadridMadridSpain28034
| | - Marta Roqué i Figuls
- CIBER Epidemiología y Salud Pública (CIBERESP)Iberoamerican Cochrane Centre ‐ Biomedical Research Institute Sant Pau (IIB Sant Pau)Sant Antoni Maria Claret 171Edifici Casa de ConvalescènciaBarcelonaCatalunyaSpain08041
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Silvestri GA, Gonzalez AV, Jantz MA, Margolis ML, Gould MK, Tanoue LT, Harris LJ, Detterbeck FC. Methods for staging non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2013; 143:e211S-e250S. [PMID: 23649440 DOI: 10.1378/chest.12-2355] [Citation(s) in RCA: 936] [Impact Index Per Article: 85.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Correctly staging lung cancer is important because the treatment options and prognosis differ significantly by stage. Several noninvasive imaging studies and invasive tests are available. Understanding the accuracy, advantages, and disadvantages of the available methods for staging non-small cell lung cancer is critical to decision-making. METHODS Test accuracies for the available staging studies were updated from the second iteration of the American College of Chest Physicians Lung Cancer Guidelines. Systematic searches of the MEDLINE database were performed up to June 2012 with the inclusion of selected meta-analyses, practice guidelines, and reviews. Study designs and results are summarized in evidence tables. RESULTS The sensitivity and specificity of CT scanning for identifying mediastinal lymph node metastasis were approximately 55% and 81%, respectively, confirming that CT scanning has limited ability either to rule in or exclude mediastinal metastasis. For PET scanning, estimates of sensitivity and specificity for identifying mediastinal metastasis were approximately 77% and 86%, respectively. These findings demonstrate that PET scanning is more accurate than CT scanning, but tissue biopsy is still required to confirm PET scan findings. The needle techniques endobronchial ultrasound-needle aspiration, endoscopic ultrasound-needle aspiration, and combined endobronchial ultrasound/endoscopic ultrasound-needle aspiration have sensitivities of approximately 89%, 89%, and 91%, respectively. In direct comparison with surgical staging, needle techniques have emerged as the best first diagnostic tools to obtain tissue. Based on randomized controlled trials, PET or PET-CT scanning is recommended for staging and to detect unsuspected metastatic disease and avoid noncurative resections. CONCLUSIONS Since the last iteration of the staging guidelines, PET scanning has assumed a more prominent role both in its use prior to surgery and when evaluating for metastatic disease. Minimally invasive needle techniques to stage the mediastinum have become increasingly accepted and are the tests of first choice to confirm mediastinal disease in accessible lymph node stations. If negative, these needle techniques should be followed by surgical biopsy. All abnormal scans should be confirmed by tissue biopsy (by whatever method is available) to ensure accurate staging. Evidence suggests that more complete staging improves patient outcomes.
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Affiliation(s)
| | - Anne V Gonzalez
- Montreal Chest Institute, McGill University Health Centre, Montreal, QC, Canada
| | - Michael A Jantz
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Florida, Gainesville, FL
| | | | - Michael K Gould
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Lynn T Tanoue
- Section of Pulmonary and Critical Care Medicine, New Haven, CT
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