Chest

Chest

Volume 123, Issue 1, Supplement, January 2003, Pages 137S-146S
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Noninvasive Staging of Non-small Cell Lung Cancer*: A Review of the Current Evidence

https://doi.org/10.1378/chest.123.1_suppl.137SGet rights and content

Study objectives

To determine the test performance characteristics of CT scanning, positron emission tomography (PET) scanning, MRI, and endoscopic ultrasound (EUS) for staging the mediastinum, and to evaluate the accuracy of the clinical evaluation (ie, symptoms, physical findings, or routine blood test results) for predicting metastatic disease in patients in whom non-small cell lung cancer or small cell lung cancer is diagnosed.

Design, setting, and participants

Systematic searches of MEDLINE, HealthStar, and Cochrane Library databases to July 2001, and of print bibliographies. Studies evaluating the staging results of CT scanning, PET scanning, MRI, or EUS, with either tissue histologic confirmation or long-term clinical follow-up, were included. The performance of the clinical evaluation was compared against the results of brain and abdominal CT scans and radionuclide bone scans.

Measurement and results

Pooled sensitivities and specificities for staging the mediastinum were as follows: for CT scanning: sensitivity, 0.57 (95% confidence interval [CI], 0.49 to 0.66); specificity, 0.82 (95% CI, 0.77 to 0.86); for PET scanning: sensitivity, 0.84 (95% CI, 0.78 to 0.89); specificity, 0.89 (95% CI, 0.83 to 0.93); and for EUS: sensitivity, 0.78 (95% CI, 0.61 to 0.89); specificity, 0.71 (95% CI, 0.56 to 0.82). For the evaluation of brain metastases, the summary estimate of the negative predictive value (NPV) of the clinical neurologic evaluation was 0.94 (95% CI, 0.91 to 0.96). For detecting adrenal and/or liver metastases, the summary NPV of the clinical evaluation was 0.95 (95% CI, 0.93 to 0.96), and for detecting bone metastases, it was 0.90 (95% CI, 0.86 to 0.93).

Conclusions

PET scanning is more accurate than CT scanning or EUS for detecting mediastinal metastases. The NPVs of the clinical evaluations for brain, abdominal, and bone metastases are ≥ 90%, suggesting that routinely imaging asymptomatic lung cancer patients may not be necessary. However, more definitive prospective studies that better define the patient population and improved reference standards are necessary to more accurately assess the true NPV of the clinical evaluation.

Section snippets

Materials and Methods

The purpose of the present study is twofold, as follows: (1) to assess the performance characteristics of noninvasive imaging procedures for staging the mediastinum; and (2) to assess the negative predictive value (NPV) of the clinical evaluation for predicting extrathoracic metastases. The NPV is the probability that a negative result correctly indicates the absence of metastatic disease.

Results

Although some studies analyzed results by nodal station, which may increase the correlation between imaging abnormalities and pathology, clinical decisions are made based on the accurate staging of multiple lymph-node stations in the mediastinum. We therefore present results at the patient level, not at the nodal-station level.

Discussion

Patients presenting with newly diagnosed lung cancer need to be assessed for potential mediastinal and extrathoracic metastases. When selecting a test for staging the disease of a patient with known or suspected lung cancer, two issues need to be considered. First, one needs to select a test that will assess the patient for metastatic disease. This test should have a high sensitivity and specificity. Second, one needs to be able to interpret accurately the test results for an individual

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    This research was supported by a contract from the American College of Chest Physicians.

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    Copyright © 2003 The American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.