Implications of False Negative and False Positive Diagnosis in Lymph Node Staging of NSCLC by Means of 18F-FDG PET/CT

Abstract

BackgroundIntegrated 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) is widely performed in hilar and mediastinal lymph node (HMLN) staging of non-small cell lung cancer (NSCLC). However, the diagnostic efficiency of PET/CT remains controversial. This retrospective study is to evaluate the accuracy of PET/CT and the characteristics of false negatives and false positives to improve specificity and sensitivity.Methods219 NSCLC patients with systematic lymph node dissection or sampling underwent preoperative PET/CT scan. Nodal uptake with a maximum standardized uptake value (SUVmax) >2.5 was interpreted as PET/CT positive. The results of PET/CT were compared with the histopathological findings. The receiver operating characteristic (ROC) curve was generated to determine the diagnostic efficiency of PET/CT. Univariate and multivariate analysis were conducted to detect risk factors of false negatives and false positives.ResultsThe sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of PET/ CT in detecting HMLN metastases were 74.2% (49/66), 73.2% (112/153), 54.4% (49/90), 86.8% (112/129), and 73.5% (161/219). The ROC curve had an area under curve (AUC) of 0.791 (95% CI 0.723-0.860). The incidence of false negative HMLN metastases was 13.2% (17 of 129 patients). Factors that are significantly associated with false negatives are: concurrent lung disease or diabetes (p<0.001), non-adenocarcinoma (p<0.001), and SUVmax of primary tumor >4.0 (p=0.009). Postoperatively, 45.5% (41/90) patients were confirmed as false positive cases. The univariate analysis indicated age > 65 years old (p=0.009), well differentiation (p=0.002), and SUVmax of primary tumor ≦4.0 (p=0.007) as risk factors for false positive uptake.ConclusionThe SUVmax of HMLN is a predictor of malignancy. Lymph node staging using PET/CT is far from equal to pathological staging account of some risk factors. This study may provide some aids to pre-therapy evaluation and decision-making.

Parathyroid adenoma upstaging the lung cancer

“…NSCLC is vulnerable to surgery unless it is not beyond N 2 lymph nodes. All patients possessing intrapulmoner lesions without LN metastasis (N 0 ) or ipsilateral hiler nodes (N 1 ) can be treated surgically [2]. If N 2 lymph node is positive, neoadjuvant chemotherapy with/without surgery or chemoradiotherapy is proper [2].…”

“…However, the diagnostic efficiency is still keeping controversy because of lots of mostly benign pathologies stemming and rooting around this region by decreasing specificity creating false positive results [2]. Many of them are solitary and out of reach by ultrasound.…”

“…In non-small cell lung cancer (NSCLC),mediastinal staging is the most crucial aspect of the entity when deciding treatment planning and determining prognosis [1][2][3]. According to TNM staging, N 1 means ipsilateral peribronchial and/or hiler and intrapulmoner lymph nodes (LN) involvement, N 2 means ipsilateral mediastinal and/or subcarinal LN involvement, N 3 means contralateral mediastinal LN involvement.…”

18F‐fluorodeoxyglucose positron emission tomography/computed tomography in the evaluation of clinically node‐negative non‐small cell lung cancer

“…Then, studies with <100 patients were excluded to secure study quality. As shown in Table , seven reports have documented the usefulness of primary tumor SUVmax for the risk stratification of mediastinal ONM using a variety of cut‐off values . Li et al showed that tumor size and primary tumor SUVmax were independently associated with mediastinal ONM in patients with clinical stage I NSCLC .…”

Committee II: Guidelines for cytologic sampling techniques of lung and mediastinal lymph nodes

“…Though there is data to support the use of ultrasound echo‐texture characteristics to differentiate between malignant and benign lymph nodes, lymph nodes that are 0.5 cm or greater in short‐axis diameter on EBUS analysis should be considered for transbronchial needle aspiration (TBNA). Thorough evaluation of bilateral hila and mediastinum should be performed during the EBUS evaluation in light of the false‐negative rate of nuclear and radiologic staging . EBUS‐BNA of enlarged mediastinal/hilar lymph nodes should be performed in a systematic fashion, bearing in mind the laterality of the suspected primary lung lesion.…”