Lung Cancer Staging: the Value of PET Depends on the Clinical Setting

Overview

Journal J Thorac Dis

Publisher AME Publishing Company

Specialty Pulmonary Medicine

Date 2015 Jan 16

PMID 25589964

Citations 2

Authors

Frank C Detterbeck

Santiago Figueroa Almanzar

Affiliations

Soon will be listed here.

Abstract

Background: Although positron emission tomography (PET) imaging is widely recommended in the evaluation of patients with lung cancer, randomized controlled trials (RCTs) assessing this have demonstrated inconsistent results. We asked whether differences in the clinical context and endpoints could explain these discrepancies.

Methods: We used realist synthesis methods to analyze how contextual differences among RCTs affected the results. We focused on RCTs to minimize confounding yet permit evaluation of differences by comparing across studies.

Results: This analysis suggests that the impact of PET depends on the clinical setting. PET is of greatest benefit in identifying M1 disease in patients with a high chance of such involvement and when little traditional imaging [e.g., abdominal/pelvis computed tomography (CT) and bone scan] is used. Identification of N2,3 involvement by PET prior to resection is seen primarily when there is at least a moderate probability of such and the rate of invasive staging is high. The rate of N2 disease not identified preoperatively appears to increase if PET is used to avoid invasive mediastinal staging in clinical settings in which the risk of N2,3 involvement is moderately high. There is both a potential benefit in avoiding stage-inappropriate resection as well as a risk of missed (stage-appropriate) resection if PET findings are not evaluated carefully.

Conclusions: A blanket recommendation for PET may be too simplistic without considering nuances of the clinical setting.

Citing Articles

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Farjah F, Detterbeck F Transl Lung Cancer Res. 2015; 4(4):365-72.

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Serum neuron specific enolase levels correlate with patient prognosis for advanced lung cancer.

Xue F, Zhu L, Wang L, Wang Q Int J Clin Exp Med. 2015; 8(6):9498-504.

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References

Fischer B, Lassen U, Mortensen J, Larsen S, Loft A, Bertelsen A . Preoperative staging of lung cancer with combined PET-CT. N Engl J Med. 2009; 361(1):32-9. DOI: 10.1056/NEJMoa0900043. View

Viney R, Boyer M, King M, Kenny P, Pollicino C, McLean J . Randomized controlled trial of the role of positron emission tomography in the management of stage I and II non-small-cell lung cancer. J Clin Oncol. 2004; 22(12):2357-62. DOI: 10.1200/JCO.2004.04.126. View

Maziak D, Darling G, Inculet R, Gulenchyn K, Driedger A, Ung Y . Positron emission tomography in staging early lung cancer: a randomized trial. Ann Intern Med. 2009; 151(4):221-8, W-48. DOI: 10.7326/0003-4819-151-4-200908180-00132. View

Wong G, Greenhalgh T, Westhorp G, Pawson R . Realist methods in medical education research: what are they and what can they contribute?. Med Educ. 2011; 46(1):89-96. DOI: 10.1111/j.1365-2923.2011.04045.x. View

Verhagen A, Bootsma G, Tjan-Heijnen V, van der Wilt G, Cox A, Brouwer M . FDG-PET in staging lung cancer: how does it change the algorithm?. Lung Cancer. 2004; 44(2):175-81. DOI: 10.1016/j.lungcan.2003.11.007. View

Cerfolio R, Bryant A, Ojha B, Eloubeidi M . Improving the inaccuracies of clinical staging of patients with NSCLC: a prospective trial. Ann Thorac Surg. 2005; 80(4):1207-13. DOI: 10.1016/j.athoracsur.2005.04.019. View

van Tinteren H, Hoekstra O, Smit E, van den Bergh J, Schreurs A, Stallaert R . Effectiveness of positron emission tomography in the preoperative assessment of patients with suspected non-small-cell lung cancer: the PLUS multicentre randomised trial. Lancet. 2002; 359(9315):1388-93. DOI: 10.1016/s0140-6736(02)08352-6. View

Ettinger D, Akerley W, Borghaei H, Chang A, Cheney R, Chirieac L . Non-small cell lung cancer. J Natl Compr Canc Netw. 2012; 10(10):1236-71. DOI: 10.6004/jnccn.2012.0130. View

Wong G, Greenhalgh T, Westhorp G, Buckingham J, Pawson R . RAMESES publication standards: realist syntheses. BMC Med. 2013; 11:21. PMC: 3558331. DOI: 10.1186/1741-7015-11-21. View

10.

Pawson R, Greenhalgh T, Harvey G, Walshe K . Realist review--a new method of systematic review designed for complex policy interventions. J Health Serv Res Policy. 2005; 10 Suppl 1:21-34. DOI: 10.1258/1355819054308530. View

11.

Kozower B, Meyers B, Reed C, Jones D, Decker P, Putnam Jr J . Does positron emission tomography prevent nontherapeutic pulmonary resections for clinical stage IA lung cancer?. Ann Thorac Surg. 2008; 85(4):1166-9. DOI: 10.1016/j.athoracsur.2008.01.018. View

12.

Darling G, Maziak D, Inculet R, Gulenchyn K, Driedger A, Ung Y . Positron emission tomography-computed tomography compared with invasive mediastinal staging in non-small cell lung cancer: results of mediastinal staging in the early lung positron emission tomography trial. J Thorac Oncol. 2011; 6(8):1367-72. DOI: 10.1097/JTO.0b013e318220c912. View

13.

Pozo-Rodriguez F, Martin de Nicolas J, Sanchez-Nistal M, Maldonado A, Garcia de Barajas S, Calero-Garcia R . Accuracy of helical computed tomography and [18F] fluorodeoxyglucose positron emission tomography for identifying lymph node mediastinal metastases in potentially resectable non-small-cell lung cancer. J Clin Oncol. 2005; 23(33):8348-56. DOI: 10.1200/JCO.2004.00.6361. View

14.

Silvestri G, Gould M, Margolis M, Tanoue L, McCrory D, Toloza E . Noninvasive staging of non-small cell lung cancer: ACCP evidenced-based clinical practice guidelines (2nd edition). Chest. 2007; 132(3 Suppl):178S-201S. DOI: 10.1378/chest.07-1360. View

15.

Morgensztern D, Waqar S, Subramanian J, Gao F, Govindan R . Improving survival for stage IV non-small cell lung cancer: a surveillance, epidemiology, and end results survey from 1990 to 2005. J Thorac Oncol. 2009; 4(12):1524-9. DOI: 10.1097/JTO.0b013e3181ba3634. View

16.

Gould M, Kuschner W, Rydzak C, Maclean C, Demas A, Shigemitsu H . Test performance of positron emission tomography and computed tomography for mediastinal staging in patients with non-small-cell lung cancer: a meta-analysis. Ann Intern Med. 2003; 139(11):879-92. DOI: 10.7326/0003-4819-139-11-200311180-00013. View

17.

Morgensztern D, Ng S, Gao F, Govindan R . Trends in stage distribution for patients with non-small cell lung cancer: a National Cancer Database survey. J Thorac Oncol. 2009; 5(1):29-33. DOI: 10.1097/JTO.0b013e3181c5920c. View

18.

Dietlein M, Weber K, Gandjour A, Moka D, Theissen P, Lauterbach K . Cost-effectiveness of FDG-PET for the management of potentially operable non-small cell lung cancer: priority for a PET-based strategy after nodal-negative CT results. Eur J Nucl Med. 2000; 27(11):1598-609. DOI: 10.1007/s002590000376. View

19.

Herder G, Kramer H, Hoekstra O, Smit E, Pruim J, van Tinteren H . Traditional versus up-front [18F] fluorodeoxyglucose-positron emission tomography staging of non-small-cell lung cancer: a Dutch cooperative randomized study. J Clin Oncol. 2006; 24(12):1800-6. DOI: 10.1200/JCO.2005.02.4695. View

20.

Morgensztern D, Goodgame B, Baggstrom M, Gao F, Govindan R . The effect of FDG-PET on the stage distribution of non-small cell lung cancer. J Thorac Oncol. 2008; 3(2):135-9. DOI: 10.1097/JTO.0b013e3181622c2c. View