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The optimal treatment for early stage non-small cell lung cancer (stage I–IIIA) is surgical resection. This requires accurate staging to prevent inappropriate surgery. Despite conventional staging (CS) with CT chest and abdomen, bone isotope scan and brain imaging, the 5-year survival is only 50%, with the majority of the deaths being due to lung cancer recurrence.
This randomised, adequately powered, study compares CS (n=162) with the use of positron emission tomography (PET)-CT and brain imaging (PET) (n=167) to determine the proportion of patients in whom disease was correctly upstaged (as confirmed by biopsy or other tests) prior to surgery (mediastinoscopy followed by resection).
PET was superior to CS; it led to confirmed upstaging of disease in 13.8% of cases compared with 6.8% in the CS group. However, eight patients in the PET group were incorrectly upstaged and could have been denied surgery compared with only one in the CS group. The majority were due to false-positive mediastinal nodes. PET led to less understaging in 14.9% compared with 29.6% in CS, as confirmed by findings at mediastinoscopy, node sampling at resection or recurrence within 1 year. There was no difference in death rate over 3 years, with almost a third dying mainly from lung cancer recurrence.
This study adds to other open studies and two randomised studies that suggest that a PET-CT strategy can identify advanced disease and reduce futile thoracotomy. It highlights that resection should only be excluded after sampling of suspect PET hot mediastinal nodes, as a failure to do this would have denied 5% the chance of surgical cure. This study did not assess cost-effectiveness, but PET-CT did reduce the need for other tests, 51 compared with 81 tests, to confirm the preoperative staging. This study supports the UK strategy of providing adequate PET-CT resources to ensure optimal staging prior to surgical resection.
▶ Maziak DE, Darling GE, Inculet RI, et al. Positron emission tomography in staging early lung cancer. Ann Intern Med 2009;151:221–8.