Mediastinal Lymph Node Staging With FDG-PET Scan in Patients With Potentially Operable Non-small Cell Lung Cancer: A Prospective Analysis of 50 Cases

doi:10.1378/chest.112.6.1480

Chest

Volume 112, Issue 6, December 1997, Pages 1480-1486

https://doi.org/10.1378/chest.112.6.1480 Get rights and content

Study objective

To compare the performance of CT, radio-labeled ¹⁸F-fluoro-2-deoxy-D-glucose positron emission tomography (FDG-PET) blinded to CT, and FDG-PET visually correlated with CT, in the detection of N2 metastatic mediastinal lymph nodes (MLN) in patients with non-small cell lung cancer (NSCLC) and to hypothesize how PET could influence our actual mediastinal staging procedures.

Setting

Tertiary university hospital.

Patients and methods

In 50 patients with potentially operable NSCLC, thoracic CT, PET, and invasive surgical staging were performed. Blinded prospective interpretation was performed for each test and compared with surgical pathology results. Abnormalities on each of these staging examinations were recorded on a standard MLN map.

Results

The sensitivity, specificity, and accuracy in detecting N2 disease of CT was 67%, 59%, and 64%, respectively. Results of PET blinded to CT were significantly better (p=0.004): 67%, 97%, and 88%, respectively. For PET visually correlated with CT, this was 93%, 97%, and 96%, respectively. In 22 patients, both CT and PET were normal, and this was correct in all cases.

Conclusions

PET was significantly more accurate than CT in the MLN staging in NSCLC. Both examinations were complementary, since visual correlation with the anatomic information on CT improved the reader's ability to discriminate between hilar vs subaortic MLN FDC uptake, and between paramediastinal tumor vs tracheobronchial MLN FDG uptake. If the results can be confirmed in larger numbers of patients, PET could reduce the need for invasive surgical staging remarkably.

Section snippets

Materials and Methods

Patients were eligible if they had suspected or biopsy specimen-proved NSCLC, potentially operable after standard staging for distant metastases.²⁶ Exclusion criteria were diabetes mellitus, treatment with oral corticosteroids, ischemic cardiomyopathy, direct mediastinal invasion by the primary tumor, and obvious bulky mediastinal adenopathies. We tried to include all eligible patients, although this was not always possible due to schedule limitations in admission to the hospital, or in the

Results

The records of 50 patients, treated between September 1995 and April 1996, were analyzed prospectively. Their mean age was 65 years (range, 40 to 83 years). There were 32 squamous cell tumors, 10 adenocarcinomas, and 8 large cell carcinomas. Thirty-one tumors were localized in the upper lobes (18 right, 13 left) and 15 were localized in the lower lobes (10 right, 5 left). Two tumors were in the right intermediate bronchus, and one in the right middle lobe and left main stem bronchus each.

Discussion

The optimal treatment of patients with potentially operable NSCLC depends on the preoperative mediastinal stage. Resection is worthwhile in patients with so-called “unforeseen N2,” found at thoracotomy after normal preoperative mediastinoscopy.1, 2, 3, 4, 5, 6 Patients with a preoperative abnormal mediastinoscopy are preferably entered in a multimodality treatment, including induction chemotherapy and surgery or radiotherapy.29, 30

Surgical techniques, either cervical mediastinoscopy³¹ or

APPENDIX

The Leuven Lung Cancer Group consists of pulmonary oncologists (J. Vansteenkiste, K. Nackaerts, M. Demedts), thoracic surgeons (G. Deneffe, P. De Leyn, T. Lerut), radiation oncologists (J. Menten, L. Van Uytsel, E. Van der Schueren), and other coworkers from the Departments of Pulmonology (B. Buyse, M. Decamer, M. Delcroix, A. Vandeneeckhout, G. Verleden), Thoracic Surgery (D. Van Raemdonck, W. Coosemans), Radiation Oncology (K. Haustermans, P. Lambin, W. Van den Bogaert, E. Van Limbergen),

ACKNOWLEDGMENT

The authors thank G. Bormans for the supply of the FDG, and S. Vleugels and W. Costermans for their dedicated assistance in PET image acquisition and processing.

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^†: For a full listing of the members of the Leuven Lung Cancer Group, see the Appendix

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Chest

Clinical Investigations: CancerMediastinal Lymph Node Staging With FDG-PET Scan in Patients With Potentially Operable Non-small Cell Lung Cancer: A Prospective Analysis of 50 Cases

Study objective

Setting

Patients and methods

Results

Conclusions

Section snippets

Materials and Methods

Results

Discussion

APPENDIX

ACKNOWLEDGMENT

J Thorac Cardiovasc Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Lung Cancer

Surg Clin North Am

Chest

Chest

Chest

Ann Thorac Surg

Lung Cancer

Ann Thorac Surg

Chest

J Thorac Cardiovasc Surg

Five year survival in resected T3/N2 lung cancer

Acta Chir Belg

Results of radical treatment of stage IIIa non-small cell carcinoma of the lung

Eur J Cardiothorac Surg

Surgery for non-small cell lung cancer with unsuspected metastasis to ipsilateral mediastinal or subcarinal nodes (N2 disease)

Eur J Cardiothorac Surg

Prognostic significance of computed tomography in resected N2 lung cancer

Ann Thorac Surg

Clinical Investigations: Cancer
Mediastinal Lymph Node Staging With FDG-PET Scan in Patients With Potentially Operable Non-small Cell Lung Cancer: A Prospective Analysis of 50 Cases