title: Can FDG-PET reduce the need for mediastinoscopy in potentially resectable nonsmall cell lung cancer?
abstract: BACKGROUND
  Few fluoro-deoxy-glucose (FDG)-positron emission tomography (PET) nonsmall cell lung cancer (NSCLC) trials have had sufficient patients to adequately evaluate PET for mediastinal staging. We question whether once PET is performed, is mediastinoscopy necessary?
  
  
  METHODS
  We performed a 5-year retrospective analysis of operable patients with known or suspicious NSCLC. Standard PET techniques were used. Inclusion criteria were (1) surgical mediastinal nodal sampling by mediastinoscopy within 31 days of the PET and (2) definitive diagnosis.
  
  
  RESULTS
  There were 237 patients who met the evaluation criteria; ninety-nine patients with NSCLC and 138 with suspicious lesions (137 men and 100 women; aged 20 to 88 years). The PETs were performed from 0 to 29 days before mediastinoscopy (median, 7 days). The standardized uptake value for the primary lesion was 0 to 24.6 (7.9+/-5.0). Nine primary lesions had no FDG uptake (1 benign, 8 NSCLCs). Seventy-one patients (31%) had mediastinal PET positive disease, and 44 patients (19%) had histologic positive mediastinal disease; N2 41 patients (17%) and N3 9 patients (4%). In 6 patients (3%), the initial frozen sections were negative, but PET positivity encouraged further biopsies that were positive for cancer. The PET sensitivity was 82%, specificity 82%, accuracy 82%, negative predictive value 95%, and positive predictive value was 51%. All primary lesions with a standardized uptake value less than 2.5 and a negative mediastinal PET were negative histologically (n = 29). Logistic regression analysis resulted in 100% specificity for PET in this group.
  
  
  CONCLUSIONS
  In NSCLC PET may reduce the necessity for mediastinoscopy when the primary lesion standardized uptake value is less than 2.5 and the mediastinum is PET negative. Accepting this approach in our patient population, the need for mediastinoscopy would have been reduced by 12%.
authors.affiliation: Department of Biostatistics, College of Public Health, University of Iowa, and Iowa City Veterans Administration Medical Center, USA. kemp-kernstine@uiowa.edu
authors.forename: Kemp H
authors.initials: KH
authors.lastname: Kernstine
authors.forename: Kelley A
authors.initials: KA
authors.lastname: Mclaughlin
authors.forename: Yusuf
authors.initials: Y
authors.lastname: Menda
authors.forename: Nicholas P
authors.initials: NP
authors.lastname: Rossi
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Kahn
authors.forename: David L
authors.initials: DL
authors.lastname: Bushnell
authors.forename: Michael M
authors.initials: MM
authors.lastname: Graham
authors.forename: Carl K
authors.initials: CK
authors.lastname: Brown
authors.forename: Mark T
authors.initials: MT
authors.lastname: Madsen
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002289:Carcinoma, Non-Small-Cell Lung / Q000000981:diagnostic imaging* / Q000473:pathology / Q000601:surgery; D005260:Female; D019788:Fluorodeoxyglucose F18; D006801:Humans; D008175:Lung Neoplasms / Q000000981:diagnostic imaging* / Q000473:pathology / Q000601:surgery; D008198:Lymph Nodes / Q000000981:diagnostic imaging* / Q000473:pathology / Q000601:surgery; D008207:Lymphatic Metastasis; D008297:Male; D008481:Mediastinoscopy; D008875:Middle Aged; D009367:Neoplasm Staging; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D014055:Tomography, Emission-Computed
chemical_list: D019788:Fluorodeoxyglucose F18