Elsevier

The Lancet Oncology

Volume 2, Issue 11, November 2001, Pages 659-666
The Lancet Oncology

Review
Positron emission tomography in the diagnosis and staging of lung cancer: a systematic, quantitative review

https://doi.org/10.1016/S1470-2045(01)00555-1Get rights and content

Summary

Lung cancer is the cause of 32% of all male cancer deaths and 25% of all female cancer deaths. Because the prognosis depends on early diagnosis and staging, continuous evaluation of the diagnostic tools available is important. The aim of this study was to assess the diagnostic value of dedicated positron emission tomography (PET) and gamma-camera PET in the diagnostic investigation of non-small-cell lung cancer (NSCLC). A systematic literature search was carried out in the MEDLINE and EMBASE databases and the Cochrane Controlled Trials Register. We identified 55 original works on the diagnostic performance of PET with fluorodeoxyglucose in the investigation of NSCLC. For diagnosis of NSCLC, the mean sensitivities and specificities were, respectively, 0·96 (SE 0·01) and 0·78 (0·03) for dedicated PET, and 0·92 (0·04) and 0·86 (0·04) for gamma-camera PET. In the mediastinal staging of NSCLC, the results were 0·83 (0·02) and 0·96 (0·01) for dedicated PET and 0·81 (0·04) and 0·95 (0·02) for gamma-camera PET. We conclude that dedicated PET could be a valuable tool in the diagnosis and staging of NSCLC. However, studies of populations with a lower prevalence of NSCLC are recommended.

Section snippets

Assessment of methodological quality

The search strategy retrieved about 300 references. Of these, 190 were relevant for the purpose of this study, and we reviewed these to assess eligibility for further analysis. Articles selected for inclusion met the following criteria: original work assessing the diagnostic performance of FDGPET in the investigation of lung cancer; adequate description of methods and results; and a study population of more than ten patients. A total of 55 studies met these criteria (46 with dedicated PET and

Data analysis

Most studies describe only sensitivity and specificity (nosographic probabilities), because these are most important ways of assessing the diagnostic performance of a new test. But in the interpretation of the test result, positive and negative predictive values (diagnostic probabilities) are important to the clinician. Nosographic probabilities are deemed to be relatively independent of the disease prevalence, whereas diagnostic probabilities depend on the prevalence of the disease in the

Descriptive analysis

Of the 55 articles eligible for further analysis, 46 addressed dedicated PET (see Webtable 1 on The Lancet Oncology website http://oncology.thelancet.com)15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60 and nine gammacamera PET (see Webtable 2, as above).61, 62, 63, 64, 65, 66, 67, 68, 69 Of these studies, 19 were not eligible for the quantitative analysis, owing

Discussion

From this systematic assessment of the present evidence on PET in the diagnosis and staging of NSCLC, we found that there were no randomised studies, and many of the existing studies had several flaws in the methodology. Nevertheless, the conclusions of the studies were quite consistent and apparently independent of the methodological quality.

Before reaching any conclusions, we shall discuss the following three questions, which are the backbone of the process of evidence-based decision-making.14

Conclusion

Introduction of PET as a routine diagnostic tool in the investigation of NSCLC would make it possible - with one examination - to decide whether a pulmonary nodule is malignant or benign, and to identify the stage of a potential cancer. This can be done with higher accuracy than with the current non-invasive methods. If PET is applied to a population of patients with a high prevalence of NSCLC, the PET result will in most cases be valid enough for decisions to be made on the future management

Search strategy and selection criteria

This study was initiated in June 1999 with a comprehensive computer search through the MEDLINE and EMBASE databases (Silverplatter, WinSPIRS 4·0) of the medical literature published after 1993. The search strategy was a combination of free text (PET and lung and cancer) and systematic search terms from Thesaurus (tomographyemission-computed; emission-tomography and lungneoplasm; carcinoma-non-small-cell lung; carcinomasmall-cell; lung-cancer). To avoid missing relevant literature, the

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