title: High rate of detection of unsuspected distant metastases by pet in apparent stage III non-small-cell lung cancer: implications for radical radiation therapy.
abstract: OBJECTIVE
  Most radical radiotherapy (RT) candidates with non-small-cell lung cancer (NSCLC) have Stage III disease and ultimately die with distant metastases. We tested the hypothesis that positron emission tomography (PET) using 18-F fluorodeoxyglucose (FDG) would detect more unsuspected metastases in apparent Stage III disease than in Stages I-II.
  
  
  METHODS
  Staging FDG-PET was performed for 167 NSCLC patients, with Stage I-III by conventional workup, who were candidates for curative therapy with surgery (n = 8), radical chemo/RT or RT (n = 156), or preoperative chemo/RT (n = 3). Each patient was allocated a conventional "pre-PET stage" and a "post-PET stage" that relied on PET when discordance with conventional staging occurred.
  
  
  RESULTS
  Stage distribution pre-PET was n = 39 (Stage I), n = 28 (Stage II), and n = 100 (Stage III). In 32 patients (19%), PET detected distant metastasis, most commonly abdominal with 17 cases (adrenal, n = 7; liver, n = 4; other, n = 6). Other sites included lung (n = 10) and bone (n = 6). PET-detected metastasis increased with increasing pre-PET stage from I (7.5%) through II (18%) to III (24%, p = 0.016), and, in particular, was significantly higher in Stage III (p = 0.039). Biopsy confirmation was not routine, but progression occurred at PET-detected metastatic sites or other metastatic sites in all but 3 of the 32 patients by last review.
  
  
  CONCLUSIONS
  PET staging is recommended for radical RT candidates with NSCLC. The highest yield of unexpected distant metastases is observed in Stage III.
authors.affiliation: Department of Radiation Oncology, Peter MacCallum Cancer Institute, Melbourne, Victoria, Australia. mmanus@petermac.unimelb.edu.au
authors.forename: M P
authors.initials: MP
authors.lastname: MacManus
authors.forename: R J
authors.initials: RJ
authors.lastname: Hicks
authors.forename: J P
authors.initials: JP
authors.lastname: Matthews
authors.forename: A
authors.initials: A
authors.lastname: Hogg
authors.forename: A F
authors.initials: AF
authors.lastname: McKenzie
authors.forename: A
authors.initials: A
authors.lastname: Wirth
authors.forename: R E
authors.initials: RE
authors.lastname: Ware
authors.forename: D L
authors.initials: DL
authors.lastname: Ball
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002289:Carcinoma, Non-Small-Cell Lung / Q000000981:diagnostic imaging* / Q000473:pathology / Q000532:radiotherapy; D005260:Female; D019788:Fluorodeoxyglucose F18; D005500:Follow-Up Studies; D006801:Humans; D008175:Lung Neoplasms / Q000000981:diagnostic imaging* / Q000473:pathology / Q000532:radiotherapy; D008198:Lymph Nodes / Q000000981:diagnostic imaging / Q000473:pathology; D008207:Lymphatic Metastasis; D008297:Male; D008875:Middle Aged; D009362:Neoplasm Metastasis; D009367:Neoplasm Staging; D011446:Prospective Studies; D019275:Radiopharmaceuticals; D014055:Tomography, Emission-Computed
chemical_list: D019275:Radiopharmaceuticals; D019788:Fluorodeoxyglucose F18