Preoperative evaluation of stage I and stage II non-small cell lung cancer

doi:10.1016/0003-4975(94)91673-X

The Annals of Thoracic Surgery

Volume 58, Issue 6, December 1994, Pages 1738-1741

https://doi.org/10.1016/0003-4975(94)91673-X Get rights and content

Abstract

The appropriate preoperative evaluation for occult metastasis in patients with potentially resectable lung cancer remains controversial. The records of 265 patients with stage I and II non-small cell lung cancers who underwent resection with curative intent were reviewed to determine if there was a survival benefit of negative preoperative scanning to detect metastases. A minimum of 5 years of follow-up was possible for all long-term survivors. Patients having preoperative bone scans, brain imaging, and abdominal imaging had no increased survival over those without such evaluation (using Kaplan-Meier survival curves). Additionally, no difference was found in the time to first recurrence between these groups, and the site of recurrence was independent of a negative preoperative scan for that location. These data, using patient outcome as the basis of our conclusion, support a policy of reserving expensive preoperative metastatic evaluations only for those patients with clinical evidence of metastatic disease.

References (24)

C Modini et al.
TNM staging in lung cancer: Role of computed tomography
J Thorac Cardiovasc Surg
(1982)
Y Ichinose et al.
Preoperative examination to detect distant metastasis is not advocated for asymptomatic patients with stages I and II non-small cell lung cancer
Chest
(1989)
JW Ramsdell et al.
Multiorgan scans for staging lung cancer
J Thorac Cardiovasc Surg
(1977)
DM White et al.
Usefulness outcome in evaluating the utility of nuclear scans of the bone, brain, and liver in bronchogenic carcinoma patients
Am J Med Sci
(1982)
RG Hooper et al.
Computed tomographic scanning of the brain in initial staging of bronchogenic carcinoma
Chest
(1984)
AG Little et al.
Clinical staging of patients with non-small cell lung cancer
Chest
(1990)
DL Quinn et al.
Staging of non-small cell bronchogenic carcinoma: relationship of the clinical evaluation to organ scans
Chest
(1986)
A Salvatierra et al.
Extrathoracic staging of broncogenic carcinoma
Chest
(1990)
PA Thomas et al.
Postoperative TINO non-small cell lung cancer squamous versus non-squamous recurrences
J Thorac Cardiovasc Surg
(1987)
EW Fordham et al.
The use of radionuclide scans in lung cancer: The case for routine multiorgan scans

RJ Kelly et al.

Efficacy of radionuclide scanning in patients with lung cancer

JAMA

(1979)

MV Merrick et al.

Bone scintigraphy in lung cancer: a reappraisal

Br J Radiol

(1986)

Cited by (17)

Extraintestinal Endosonography
2019, Clinical Gastrointestinal Endoscopy
The use of endoscopic ultrasound (EUS) has grown over the last 25 years, and it is now a well-established diagnostic method for luminal and extraluminal disorders. This chapter discusses EUS applications relating to extraintestinal structures, organs, and lesions. The objectives of this chapter are to review the utility of EUS for evaluating the mediastinum in both benign and malignant disease processes, including the detection of mediastinal lymph node metastases in lung cancer. Mass lesions in the paragastric and retroperitoneal organs (excluding the bile duct, gallbladder, and pancreas) are reviewed, including detection of lesions of the adrenal gland, liver, and kidneys. Ascites and pleural fluid are examined along with unusual extraintestinal lesions.
Extraintestinal Endosonography (including Celiac Block)
2011, Clinical Gastrointestinal Endoscopy, Second Edition
Noninvasive staging of non-small cell lung cancer: ACCP evidenced-based clinical practice guidelines (2nd edition)
2007, Chest
Citation Excerpt :
Finally, the lack of prospective randomized trials and outcome studies in the area of extrathoracic staging is striking. Two retrospective studies showed that scanning asymptomatic patients with early NSCLC did not help to predict recurrences postoperatively or to improve survival.118, 119 The only prospective randomized trial120 showed no statistical difference in recurrence rates or survival in a group of patients who were randomized to undergo bone scintigraphy and CT scans of the head, liver, and adrenal glands, compared with the group assigned to undergo CT scans of the chest and mediastinoscopy, followed by thoracotomy when appropriate.
Correctly staging lung cancer is important because the treatment options and the prognosis differ significantly by stage. Several noninvasive imaging studies including chest CT scanning and positron emission tomography (PET) scanning are available. Understanding the test characteristics of these noninvasive staging studies is critical to decision making.
Test characteristics for the noninvasive staging studies were updated from the first iteration of the lung cancer guidelines using systematic searches of the MEDLINE, HealthStar, and Cochrane Library databases up to May 2006, including selected metaanalyses, practice guidelines, and reviews. Study designs and results are summarized in evidence tables.
The pooled sensitivity and specificity of CT scanning for identifying mediastinal lymph node metastasis were 51% (95% confidence interval [CI], 47 to 54%) and 85% (95% CI, 84 to 88%), respectively, confirming that CT scanning has limited ability either to rule in or exclude mediastinal metastasis. For PET scanning, the pooled estimates of sensitivity and specificity for identifying mediastinal metastasis were 74% (95% CI, 69 to 79%) and 85% (95% CI, 82 to 88%), respectively. These findings demonstrate that PET scanning is more accurate than CT scanning. If the clinical evaluation in search of metastatic disease is negative, the likelihood of finding metastasis is low.
CT scanning of the chest is useful in providing anatomic detail, but the accuracy of chest CT scanning in differentiating benign from malignant lymph nodes in the mediastinum is poor. PET scanning has much better sensitivity and specificity than chest CT scanning for staging lung cancer in the mediastinum, and distant metastatic disease can be detected by PET scanning. With either test, abnormal findings must be confirmed by tissue biopsy to ensure accurate staging.
Seeking a home for a PET, part 2: Defining the appropriate place for positron emission tomography imaging in the staging of patients with suspected lung cancer
2004, Chest
Citation Excerpt :
A more detailed look at the false-negative (FN) rate of the clinical evaluation suggests an explanation for the discrepancy in these viewpoints. In patients with stage I and II NSCLC, a negative clinical evaluation carries a FN rate of approximately 5%, as has been shown consistently in several studies12,16,17 using different approaches to this issue. However, in patients with clinical stage III (cIII) NSCLC, the FN rate of a clinical evaluation is approximately 15 to 30%.12,13,17
In patients who have a high likelihood of having lung cancer, there is little role for positron emission tomography (PET) imaging for diagnosis of the primary lesion. The primary impact of PET imaging is in extrathoracic staging, but it should not replace a clinical evaluation by a physician experienced in lung cancer. PET imaging is most useful for confirmation of the presumed extrathoracic stage in patients with intermediate stages of lung cancer. The role of PET imaging is limited in patients with strong clinical signs of metastatic disease, or in patients with a clinical stage I lung cancer and a negative clinical evaluation. With regard to intrathoracic staging, PET imaging has a definite role in communities in which mediastinoscopy is not available, whereas the impact is limited in institutions in which invasive mediastinal staging is available. The data suggest that a positive PET result in the mediastinum should be confirmed by biopsy. A mediastinoscopy is also reasonable in patients with clinical stage III lung cancer who have no mediastinal PET uptake. It is unclear and controversial whether a biopsy is needed in patients with clinical stage II lung cancer who have no PET uptake in the mediastinum.
Extra-thoracic staging of lung cancer
2003, European Journal of Radiology
Non-small-cell lung cancer: Practice patterns of extrathoracic imaging
1999, Academic Radiology
The purpose of this study was to identify practice patterns of extrathoracic imaging in patients newly diagnosed with non-small-cell lung cancer.
The authors retrospectively reviewed the charts of 125 patients (71 men, 54 women; mean age, 67 years) from five hospitals (25 patients each) with newly diagnosed non-small-cell lung cancer. Charts were reviewed for cancer cell type, evidence of metastatic disease, and performance and results of extrathoracic imaging, including computed tomography (CT) and magnetic resonance (MR) imaging of the brain, bone scanning, and abdominal CT.
Of 125 patients, 77 (62%) underwent extrathoracic imaging. These patients included 64 (64%) of 100 patients with clinical symptoms or laboratory signs of metastatic disease and 13 (52%) of 25 patients with no such indications. Extrathoracic imaging did not differ according to cancer cell type: It was performed for 30 (60%) of 50 patients with squamous cell carcinoma, 26 (60%) of 43 patients with adenocarcinoma, and 16 (73%) of 22 patients with non-small-cell lung cancer that was not further characterized. Brain CT or MR imaging, bone scanning, or abdominal CT were performed in only 48%, 39%, and 30% of patients, respectively. Brain CT or MR images or bone scans revealed metastatic disease in seven of 20 and nine of 22 patients with clinical symptoms or laboratory signs of disease, respectively. These examinations revealed disease in four of 40 and two of 27 patients without such symptoms or signs, respectively (P < .05). No significant differences emerged among the practice patterns at the five participating hospitals.
No consensus was found on performance of extrathoracic imaging in patients with newly diagnosed non-small-cell lung cancer.

View all citing articles on Scopus

View full text

Original articlePreoperative evaluation of stage I and stage II non-small cell lung cancer

Abstract

J Thorac Cardiovasc Surg

Chest

J Thorac Cardiovasc Surg

Am J Med Sci

Chest

Chest

Chest

Chest

J Thorac Cardiovasc Surg

The use of radionuclide scans in lung cancer: The case for routine multiorgan scans

Efficacy of radionuclide scanning in patients with lung cancer

JAMA

Bone scintigraphy in lung cancer: a reappraisal

Br J Radiol

Original article
Preoperative evaluation of stage I and stage II non-small cell lung cancer