Preoperative intrathoracic lymph node staging in patients with non-small-cell lung cancer: accuracy of integrated positron emission tomography and computed tomography

• Published in: European journal of cardio-thoracic surgery 2009-09, Vol.36 (3), p.440-445
• Main Authors: Billé, Andrea, Pelosi, Ettore, Skanjeti, Andrea, Arena, Vincenzo, Errico, Luca, Borasio, Piero, Mancini, Maurizio, Ardissone, Francesco
• Format: Article
• Language: English
• Subjects: Adult; Aged; Aged, 80 and over; Biological and medical sciences; Carcinoma, Non-Small-Cell Lung - diagnosis; Carcinoma, Non-Small-Cell Lung - pathology; Carcinoma, Non-Small-Cell Lung - secondary; Carcinoma, Non-Small-Cell Lung - surgery; Cardiology. Vascular system; Female; Fluorodeoxyglucose F18; Humans; Lung Neoplasms - diagnosis; Lung Neoplasms - pathology; Lung Neoplasms - surgery; Lymph node staging; Lymphatic Metastasis; Male; Mediastinoscopy; Medical sciences; Middle Aged; Neoplasm Staging; Non-small-cell lung cancer; PET/CT; Pneumology; Positron-Emission Tomography - methods; Radiopharmaceuticals; Retrospective Studies; Sensitivity and Specificity; Surgery (general aspects). Transplantations, organ and tissue grafts. Graft diseases; Surgery of the heart; Tomography, X-Ray Computed - methods; Tumors of the respiratory system and mediastinum
• ISSN: 1010-7940; 1873-734X
• DOI: 10.1016/j.ejcts.2009.04.003

Objective: To evaluate the accuracy of integrated positron emission tomography with 18F-fluoro-2-deoxy-d-glucose (FDG) and computed tomography (PET/CT) in preoperative intrathoracic lymph node staging in patients with non-small-cell lung cancer (NSCLC) and to ascertain the role of invasive staging in verifying positron emission tomography (PET)/computed tomography (CT) results. Methods: Retrospective, single institution study of consecutive patients with suspected or pathologically proven, potentially resectable NSCLC undergoing integrated PET/CT scanning in the same PET centre. Lymph node staging was pathologically confirmed on tissue specimens obtained at mediastinoscopy and/or thoracotomy. Statistical evaluation of PET/CT results was performed on a per-patient and per-nodal-station bases. Results: A total of 1001 nodal stations (723 mediastinal, 148 hilar and 130 intrapulmonary) were evaluated in 159 patients. Nodes were positive for malignancy in 48 (30.2%) out of 159 patients (N1 = 17; N2 = 30; N3 = 1) and 71 (7.1%) out of 1001 nodal stations (N1 = 24; N2 = 46; N3 = 1). At univariate analysis, lymph node involvement was significantly associated (p ≪ 0.05) with the following primary tumour characteristics: increasing diameter, maximum standardised uptake value >9, central location and presence of vascular invasion. PET/CT staged the disease correctly in 128 out of 159 patients (80.5%), overstaging occurred in nine patients (5.7%) and understaging in 22 patients (13.8%). The overall sensitivity, specificity, positive and negative predictive values, and accuracy of PET/CT for detecting metastatic lymph nodes were 54.2%, 91.9%, 74.3%, 82.3% and 80.5% on a per-patient basis, and 57.7%, 98.5%, 74.5%, 96.8% and 95.6% on per-nodal-station basis. With regard to N2/N3 disease, PET/CT accuracy was 84.9% and 95.3% on a per-patient basis and on per-nodal-station basis, respectively. Referring to nodal size, PET/CT sensitivity to detect malignant involvement was 32.4% (12/37) in nodes ≪10 mm, and 85.3% (29/34) in nodes ≥10 mm. Conclusion: Our data show that integrated PET/CT provides high specificity but low sensitivity and accuracy in intrathoracic nodal staging of NSCLC patients and underscore the continued need for surgical staging.