Original article
General thoracic
Improving the Inaccuracies of Clinical Staging of Patients with NSCLC: A Prospective Trial

Presented at the Forty-first Annual Meeting of The Society of Thoracic Surgeons, Tampa, FL, Jan 24–26, 2005.
https://doi.org/10.1016/j.athoracsur.2005.04.019Get rights and content

Background

Clinical stage affects the care of patients with nonsmall cell lung cancer.

Methods

This is a prospective trial on patients with suspected resectable nonsmall cell lung cancer. All patients underwent integrated positron emission tomographic scanning and computed tomographic scanning, and all suspicious metastatic sites were investigated. A, T, N, and M status was assigned. If N2, N3 and M1 were negative, patients underwent thoracotomy and complete thoracic lymphadenectomy.

Results

There were 383 patients. The accuracy of clinical staging using positron emission tomographic scanning and computed tomographic scanning was 68% and 66% for stage I, 84% and 82% for stage II, 74% and 69% for stage III, and 93% and 92% for stage IV, respectively. N2 disease was discovered in 115 patients (30%) and was most common in the subcarinal lymph node (30%). Unsuspected N2 disease occurred in 28 patients (14%) and was most common in the posterior mediastinal lymph nodes (subcarinal, 38%; posterior aortopulmonary, 15%). It was found in 9% of patients who were clinically staged I (58% in the posterior mediastinal lymph nodes) and in 26% of patients clinically staged II (86% in posterior mediastinal lymph nodes).

Conclusions

Despite integrated positron emission tomographic scanning and computed tomographic scanning, clinical staging remains relatively inaccurate for patients with nonsmall cell lung cancer. Recent studies suggest adjuvant therapy for stage Ib and II nonsmall cell lung cancer; thus the impact on preoperative care is to find unsuspected N2 disease. Unsuspected N2 disease is most common in posterior mediastinal lymph nodes inaccessible by mediastinoscopy. Thus one should consider endoscopic ultrasound fine-needle aspiration, especially for patients clinically staged as I and II, even if the nodes are negative on positron emission tomographic scanning and computed tomographic scanning.

Section snippets

Patient Selection

Patients who presented to one surgeon (RJC) between September 2002 and August 1, 2004 with an indeterminate pulmonary nodule or a biopsy proven NSCLC and underwent integrated FDG-PET/CT scanning at our institution and CT scanning were eligible to participate in this study. Patients were excluded if they were less than 19 years of age, had a history of type I diabetes, or received preoperative chemotherapy or radiation. All patients were clinically staged using the T, N, and M classification

Patient Characteristics and Overall Staging

There were 383 patients (227 men) with primary nonsmall cell lung cancer. The patient characteristics for these patients are shown in Table 2. As shown in Figure 1, 184 of the 383 patients (48%) were clinically staged as N2 positive and 199 (52%) were staged as N2 negative. Eighty-seven patients were pathologically confirmed to have N2 disease, and 97 of the patients were found to be false positives on clinical staging modalities. Twenty-eight patients (14%) had unsuspected N2 disease. Table 3

Comment

Despite the addition of the FDG-PET scan and integrated FDG-PET/CT scans, the clinical stage of patients with NSCLC only correctly predicts the actual stage (the positive predictive value) in approximately 50% of the patients. In addition, we found a relatively low accuracy for both FDG-PET/CT and CT scan in this prospective study at each stage. Toloza and colleagues [14] in 2003 reported similar findings for CT scans. They found computed tomography to have a sensitivity of only 57% and a

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Copyright © 2005 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.