Traditional versus up-front [18F] fluorodeoxyglucose-positron emission tomography staging of non-small-cell lung cancer: a Dutch cooperative randomized study.
OBJECTIVE
We investigated whether application of positron emission tomography (PET) immediately after first presentation might simplify staging while maintaining accuracy, as compared with traditional strategy in routine clinical setting.


METHODS
At first presentation, patients with a provisional diagnosis of lung cancer without overt dissemination were randomly assigned to traditional work-up (TWU) according to international guidelines or early PET followed by histologic/cytologic verification of lesions, or imaging and follow-up. Patients with [18F] fluorodeoxyglucose (18FDG) -avid, noncentral tumors without suspicion of mediastinal or distant metastases on PET proceeded directly to thoracotomy. Follow-up in presumed benign lesions was at least 12 months. In patients treated with surgery or neoadjuvant therapy, the quality of staging was measured by comparing the clinical stage to the final stage (combination of peroperative staging and 6 months of follow-up). To investigate test substitution, we analyzed the number of (non)invasive tests to achieve clinical TNM staging, and its associated costs.


RESULTS
Between 1999 and 2001, 465 patients (233 TWU, 232 PET) were enrolled at 22 hospitals. The mean (standard deviation) number of procedures to finalize staging was equal in the TWU arm and the PET arm: 7.9 (2.0) v 7.9 (1.9), P = .90, respectively. Mediastinoscopies occurred significantly less often in the PET arm. Agreement between clinical and final stage was good in both arms (kappa = .85 v .78; P = .07). Costs did not differ significantly.


CONCLUSIONS
Up-front 18FDG-PET in patients with (suspected) lung cancer does not reduce the overall number of diagnostic test, but it maintains quality of TNM staging with the use of less invasive surgery.
Department of Pulmonology, VU University Medical Center, Amsterdam, The Netherlands.
Gerarda J M
GJ
Herder
Henk
H
Kramer
Otto S
OS
Hoekstra
Egbert F
EF
Smit
Jan
J
Pruim
Harm
H
van Tinteren
Emile F
EF
Comans
Paul
P
Verboom
Carin A
CA
Uyl-de Groot
Alle
A
Welling
Marinus A
MA
Paul
Maarten
M
Boers
Pieter E
PE
Postmus
Gerrit J
GJ
Teule
Harry J M
HJ
Groen
D000368:Aged; D002289:Carcinoma, Non-Small-Cell Lung / Q000000981:diagnostic imaging* / Q000628:therapy; D005260:Female; D019788:Fluorodeoxyglucose F18; D017048:Health Care Costs; D006801:Humans; D008175:Lung Neoplasms / Q000000981:diagnostic imaging* / Q000628:therapy; D008297:Male; D008875:Middle Aged; D020360:Neoadjuvant Therapy; D009367:Neoplasm Staging / Q000191:economics / Q000379:methods* / Q000592:standards; D011877:Radionuclide Imaging; D019275:Radiopharmaceuticals; D012680:Sensitivity and Specificity; D013997:Time Factors
D019275:Radiopharmaceuticals; D019788:Fluorodeoxyglucose F18