Original Articles
Detection of extrathoracic metastases by positron emission tomography in lung cancer

Presented at the Thirty-fourth Annual Meeting of The Society of Thoracic Surgeons, New Orleans, LA, Jan 26–28, 1998.
https://doi.org/10.1016/S0003-4975(98)00675-4Get rights and content

Abstract

Background. Accurate staging of non–small cell lung cancer is essential for treatment planning. We evaluated in a prospective study the role of whole-body 2-[18F]fluoro-2-deoxy-d-glucose (FDG) positron emission tomography (PET) in mediastinal nodal staging with a positive predictive value of 96%. The study was continued to further evaluate the value of whole-body FDG PET in detecting unexpected extrathoracic metastases (ETMs) in patients qualifying for surgical treatment by conventional staging.

Methods. One hundred patients underwent clinical evaluation, chest and upper abdominal computed tomography scan, mediastinoscopy (lymph nodes greater than 1 cm on computed tomography), and routine laboratory tests. In 94 patients with stage IIIa or less and 6 with suspected N3 a whole-body FDG PET was performed. If clinical signs of ETMs were present additional diagnostic methods were applied. All findings in the FDG PET were confirmed histologically or radiologically.

Results. Unexpected ETMs were detected in 13 (14%) of 94 patients (stage IIIa or less) at 14 sites. In addition 6 of 94 patients were restaged up to N3 after PET. The suspected N3 disease (stage IIIb) on computed tomography was confirmed by PET in all 6 patients. There was no false positive finding of ETM. Weight loss was correlated with the occurrence of ETM: more than 5 kg, 5 of 13 patients (38%); more than 10 kg, 4 of 6 patients (67%). Pathologic laboratory findings were not predictive for ETM.

Conclusions. Whole-body FDG PET improves detection of ETMs in patients with non–small cell lung cancer otherwise elegible for operation. In 14% of patients (stage IIIa or less), ETMs were detected, and in total, 20% of the patients were understaged.

Section snippets

Patients

Between February 1994 and September 1997 we performed FDG PET in 107 patients with NSCLC diagnosed by cytology or histology. Only patients who qualified for surgical therapy were included in the study. All patients who underwent neoadjuvant therapy were excluded.

In 2 patients definitive histologic diagnosis revealed small cell lung cancer, and 5 patients were excluded because of incomplete data. Preoperative staging included history, physical examination, and blood tests as well as chest x-ray

Histologic examination of the primary tumor

Of the 100 patients with NSCLC, 53 had squamous cell carcinoma, 38 had adenocarcinoma, and 9 had large cell carcinoma. In women the distribution was as follows: 5 had squamous cell carcinoma (25% of female patients), 14 had adenocarcinoma (70%), and 1 had large cell carcinoma (5%). In men 48 squamous cell carcinomas (60% of male patients), 24 adenocarcinomas (30%), and 8 large cell carcinomas (10%) were found.

Extrathoracic metastases

Unexpected ETM were detected at 14 sites in 13 (14%) of the patients, who were stage

Comment

Our prospective study in patients with NSCLC was originally designed to evaluate the role of FDG PET for mediastinal N staging. Use of FDG PET for mediastinal N staging is limited with respect to the exact anatomic differentiation of N1/N2 in the hilar region. However, N3 stage is detected reliably.

In this previously published study a high accuracy in detecting malignant lesions in the mediastinum could be achieved. This might be related to our highly qualified team of nuclear physicians and a

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