Donna E. Maziak, MDCM; Gail E. Darling, MD; Richard I. Inculet, MD; Karen Y. Gulenchyn, MD; Albert A. Driedger, MD; Yee C. Ung, MD; John D. Miller, MD; Chu-Shu Gu, MSc; Kathryn J. Cline, BSc; William K. Evans, MD; Mark N. Levine, MD, MSc
Among patients with early-stage nonâ€“small cell lung cancer (NSCLC), preoperative imaging tests are important in defining surgical candidates.
To assess whether whole-body positron emission tomography and computed tomography (PET-CT) plus cranial imaging correctly upstages cancer in more patients with NSCLC than does conventional staging plus cranial imaging.
Randomized clinical trial with recruitment from June 2004 to August 2007. The centralized, computer-generated, variable block size randomization scheme was stratified by treatment center and cancer stage. Participants, health care providers, and outcome assessors were not blinded to imaging modality assignment.
8 hospitals and 5 PET-CT centers in academic institutions.
Eligible patients were older than 18 years; had histologic or cytologic proof of stage I, II, or IIIA NSCLC on the basis of chest radiography and thoracic CT; and had a tumor considered to be resectable.
PET-CT or conventional staging (abdominal CT and bone scan). All patients also had cranial imaging using CT or magnetic resonance imaging.
The primary outcome was correct upstaging, thereby avoiding stage-inappropriate surgery. Secondary outcomes were incorrect upstaging and incorrect understaging.
170 patients were assigned to PET-CT and 167 to conventional staging. Eight patients (3 who had PET-CT and 5 who had conventional staging) did not have planned surgery. Disease was correctly upstaged in 23 of 167 PET-CT recipients and 11 of 162 conventional staging recipients (13.8% vs. 6.8%; difference, 7.0 percentage points [95% CI, 0.3 to 13.7 percentage points]), thereby sparing these patients from surgery. Disease was incorrectly upstaged in 8 PET-CT recipients and 1 conventional staging recipient (4.8% vs. 0.6%; difference, 4.2 percentage points [CI, 0.5 to 8.6 percentage points]), and it was incorrectly understaged in 25 and 48 patients, respectively (14.9% vs. 29.6%; difference, 14.7 percentage points [CI, 5.7 to 23.4 percentage points]). At 3 years, 52 patients who had PET-CT and 57 patients who had conventional staging had died.
The relatively small sample and the fact that some patients did not have planned surgery limited the ability to determine precise differences in clinical outcomes that were attributable to testing strategies.
Preoperative staging with PET-CT and cranial imaging identifies more patients with mediastinal and extrathoracic disease than conventional staging, thereby sparing more patients from stage-inappropriate surgery, but the strategy also incorrectly upstaged disease in more patients.
Ontario Ministry of Health and Long-Term Care, Canadian Institutes of Health Research, and Cancer Care Ontario.
Imaging tests may help identify patients with lung cancer who are candidates for curative surgical resection.
This randomized trial compared 2 preoperative imaging strategies for patients with early non–small cell lung cancer: whole-body positron emission tomography and computed tomography (PET-CT) plus cranial imaging versus conventional staging plus cranial imaging. The PET-CT strategy identified more patients with mediastinal and extrathoracic disease that precluded surgery but also incorrectly upstaged disease in more patients.
A PET-CT–based imaging strategy may help identify advanced disease and prevent futile thoracotomy in patients with non–small cell lung cancer, but it also has false-positive results that incorrectly upstage disease in some patients.
PET-CT = positron emission tomography and computed tomography.
CS = conventional staging; HR = hazard ratio; PET-CT = positron emission tomography and computed tomography.
The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of the ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets will constitute copyright infringement.
Maziak DE, Darling GE, Inculet RI, Gulenchyn KY, Driedger AA, Ung YC, et al. Positron Emission Tomography in Staging Early Lung Cancer: A Randomized Trial. Ann Intern Med. 2009;151:221–228. doi: 10.7326/0003-4819-151-4-200908180-00132
Download citation file:
Published: Ann Intern Med. 2009;151(4):221-228.
Hematology/Oncology, Lung Cancer, Pulmonary/Critical Care.
Results provided by:
Copyright © 2019 American College of Physicians. All Rights Reserved.
Print ISSN: 0003-4819 | Online ISSN: 1539-3704
Conditions of Use