Ce-CT versus integreted pet/ct in preoperative nodal staging of non–small cell lung cancer

Abstract

435N on-small cell lung cancer (NSCLC) accounts for approximately 75% to 85% of all newly diagnosed lung cancers (1). The optimal treatment of NSCLC relies on accurate disease staging, which is based on tumor size, regional nodal involvement, and the presence of metastasis. Correct evaluation of the presence or absence of metastases in mediastinal and hilar lymph nodes is a critical factor that may determine operability and long-term survival in patients with NSCLC. Surgical treatment can be expected in 70% of patients with N0 stage and up to 24% of patients with N2 stage; however, surgery is generally not indicated in patients with N3 stage cancer (2).Although computed tomography (CT) is the most commonly used noninvasive imaging modality for the pre-operative evaluation of tumor size and the extent of invasion into adjacent structures, a number of reviews and meta-analyses have shown the limited reliability of CT in lymph node staging (3). The CT criteria for lymph node tumor involvement rely on the size or shape of the lymph nodes. Usually, 1 cm is used as the size criterion predicting tumor involvement in lymph nodes. However, normal sized lymph nodes may show metastases upon histological examination, and nodal enlargement may be due to reactive hyperplasia or other benign conditions (2). Rapid advances in multi-detector CT scanners allow a more detailed analysis of the lung parenchyma and mediastinal structures. As a consequence, nodal staging may be enhanced with CT.Positron emission tomography (PET) with fluorine-18 fluorodeoxyglucose (FDG) has been reported to improve identification of nodal metastasis. FDG PET images may be more sensitive than CT because alterations in tissue metabolism generally precede anatomical changes (4). Integrated PET-CT provides information about anatomy and metabolism by combining morphological CT data and functional PET data (5). However, falsepositive PET-CT results in nodal staging have been shown in patients with co-existing inflammatory or infectious diseases, and PET-CT scanning may be unable to identify metastatic deposits in normal-sized lymph nodes because of its suboptimal spatial resolution (6, 7).Several retrospective and prospective studies have investigated the effectiveness of CT and PET-CT in pre-operative nodal staging of NSCLC (8-13). However, conflicting conclusions have been reported in these studies. Thus, the aim of our study was to retrospectively evaluate the effectiveness of integrated PET-CT in pre-operative staging of NSCLC in comparison with contrast enhanced CT (CE-CT) by using surgical and pathological findings as the reference standard. Materials and methods Patient populationFrom RESULTS Forty-eight of the 57 patients (84%) had no lymph node involvement (N0), five (9%) were found to have N1 disease, and four (7%) had N2 disease. There was a significant difference between CE-CT and PET-CT for nodal staging of N0 disease (P < 0.05). Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of hilar and mediastina...

Evaluation of the factors affecting the maximum standardized uptake value of metastatic lymph nodes in different histological types of non-small cell lung cancer on PET-CT

“…However, the sensitivity of PET-CT in mediastinal LN staging varies from 40–86.3% [ 5 - 12 ]; thus, there is a significant number of false-positive and false-negative findings in LN staging of lung cancer. The major reasons for the false-positive and false-negative findings in LN staging are lymph node involvement resulting from inflammatory diseases and microscopic metastases [ 5 - 12 ]. The ability of PET-CT to directly assess each lymph node station is limited; therefore, other approaches need to be explored to increase the accuracy of LN staging of NSCLC.…”

Limitations of 18F-2-Deoxy-d-Glucose Positron Emission Tomography in N1 Detection in Patients With Pathologic Stage II-N1 and Implications for Management

“…Among the articles, 11 matched the inclusion criteria of our study. The pooled sensitivity of our study and the cases in the literature was 41% (range, 17% to 93%) for detecting N1 disease (Table 4) [4][5][6][7][8][9][10][11][12][13][14][15].…”

“…In patients with pathologic N1 (pN1) disease, the preoperative FDG-PET detected pN1 disease in 24%, and the location and size of the tumor did not affect the ability of FDG-PET or FDG-PET/CT to detect pN1 disease. The reported sensitivity of FDG-PET in detecting pN1 disease has a wide range (17% to 93%) [4,5,[7][8][9][10][11][12][13][14][15][16], and this can partially be attributed to differences in methodology and the threshold SUVmax used to diagnose pN1 disease. For instance, when a SUV of 1.5 and higher is used to diagnose pN1 disease, the sensitivity is 96.9% with a specificity of 16.3%, whereas when 2.5 is used, the sensitivity of detecting pN1 disease is 48.5% with a specificity of 80.2% [8].…”

“…In fact, when the presence of pN1 disease will redirect patient therapy, endobronchial ultrasound or endoesophageal ultrasound and biopsy should be considered in the clinical staging algorithm. [7] 2012 PET/CT 1 6 17 Lin [9] 2012 PET/CT 10 18 56 Carrillo [8] 2012 PET/CT 16 33 48 Ceylan [10] 2012 PET/CT 3 5 60 Nakagawa [12] 2009 PET/CT 4 19 21 Bille [6] 2009 PET/CT 12 17 71 Turkmen [11] 2007 PET 3 14 21 Ebihara [13] 2006 PET 19 31 61 Cerfolio [14] 2004 PET/CT 14 15 93 Halter [15] 2004 …”

“…FDG-PET results were negative for lymph node involvement (N1) in these patients at diagnosis. The reported sensitivity of FDG-PET in detecting hilar lymph node metastasis (N1) has not been thoroughly investigated but has been reported to be 17% to 93% [4][5][6][7][8][9][10][11][12][13][14][15] and to predict worse survival when detected by FDG-PET before resection [4].The purpose of this study was to evaluate FDG-PET in the detection of N1 disease and to determine, as reported in the literature, if positive N1 on FDG-PET predicts poorer survival in patients with pathologic stage II-N1 NSCLC.…”