Frank C Detterbeck1, Santiago Figueroa Almanzar1. 1. 1 Department of Surgery, Division of Thoracic Surgery, Yale University School of Medicine, New Haven, CT 06520-8062, USA ; 2 General University Hospital of Valencia, Avda, Tres Cruces 2, Valencia 46014, Spain.
Abstract
BACKGROUND: Although positron emission tomography (PET) imaging is widely recommended in the evaluation of patients with lung cancer, randomized controlled trials (RCTs) assessing this have demonstrated inconsistent results. We asked whether differences in the clinical context and endpoints could explain these discrepancies. METHODS: We used realist synthesis methods to analyze how contextual differences among RCTs affected the results. We focused on RCTs to minimize confounding yet permit evaluation of differences by comparing across studies. RESULTS: This analysis suggests that the impact of PET depends on the clinical setting. PET is of greatest benefit in identifying M1 disease in patients with a high chance of such involvement and when little traditional imaging [e.g., abdominal/pelvis computed tomography (CT) and bone scan] is used. Identification of N2,3 involvement by PET prior to resection is seen primarily when there is at least a moderate probability of such and the rate of invasive staging is high. The rate of N2 disease not identified preoperatively appears to increase if PET is used to avoid invasive mediastinal staging in clinical settings in which the risk of N2,3 involvement is moderately high. There is both a potential benefit in avoiding stage-inappropriate resection as well as a risk of missed (stage-appropriate) resection if PET findings are not evaluated carefully. CONCLUSIONS: A blanket recommendation for PET may be too simplistic without considering nuances of the clinical setting.
BACKGROUND: Although positron emission tomography (PET) imaging is widely recommended in the evaluation of patients with lung cancer, randomized controlled trials (RCTs) assessing this have demonstrated inconsistent results. We asked whether differences in the clinical context and endpoints could explain these discrepancies. METHODS: We used realist synthesis methods to analyze how contextual differences among RCTs affected the results. We focused on RCTs to minimize confounding yet permit evaluation of differences by comparing across studies. RESULTS: This analysis suggests that the impact of PET depends on the clinical setting. PET is of greatest benefit in identifying M1 disease in patients with a high chance of such involvement and when little traditional imaging [e.g., abdominal/pelvis computed tomography (CT) and bone scan] is used. Identification of N2,3 involvement by PET prior to resection is seen primarily when there is at least a moderate probability of such and the rate of invasive staging is high. The rate of N2 disease not identified preoperatively appears to increase if PET is used to avoid invasive mediastinal staging in clinical settings in which the risk of N2,3 involvement is moderately high. There is both a potential benefit in avoiding stage-inappropriate resection as well as a risk of missed (stage-appropriate) resection if PET findings are not evaluated carefully. CONCLUSIONS: A blanket recommendation for PET may be too simplistic without considering nuances of the clinical setting.
Authors: David S Ettinger; Wallace Akerley; Hossein Borghaei; Andrew C Chang; Richard T Cheney; Lucian R Chirieac; Thomas A D'Amico; Todd L Demmy; Apar Kishor P Ganti; Ramaswamy Govindan; Frederic W Grannis; Leora Horn; Thierry M Jahan; Mohammad Jahanzeb; Anne Kessinger; Ritsuko Komaki; Feng-Ming Kong; Mark G Kris; Lee M Krug; Inga T Lennes; Billy W Loo; Renato Martins; Janis O'Malley; Raymond U Osarogiagbon; Gregory A Otterson; Jyoti D Patel; Mary C Pinder-Schenck; Katherine M Pisters; Karen Reckamp; Gregory J Riely; Eric Rohren; Scott J Swanson; Douglas E Wood; Stephen C Yang; Miranda Hughes; Kristina M Gregory Journal: J Natl Compr Canc Netw Date: 2012-10-01 Impact factor: 11.908
Authors: Harm van Tinteren; Otto S Hoekstra; Egbert F Smit; Jan H A M van den Bergh; Ad J M Schreurs; Roland A L M Stallaert; Piet C M van Velthoven; Emile F I Comans; Fred W Diepenhorst; Paul Verboom; Johan C van Mourik; Pieter E Postmus; Maarten Boers; Gerrit J J Teule Journal: Lancet Date: 2002-04-20 Impact factor: 79.321
Authors: A F T Verhagen; G P Bootsma; V C G Tjan-Heijnen; G J van der Wilt; A L Cox; M H J Brouwer; F H M Corstens; W J G Oyen Journal: Lung Cancer Date: 2004-05 Impact factor: 5.705
Authors: Rosalie C Viney; Michael J Boyer; Madeleine T King; Patricia M Kenny; Christine A Pollicino; Jocelyn M McLean; Brian C McCaughan; Michael J Fulham Journal: J Clin Oncol Date: 2004-06-15 Impact factor: 44.544
Authors: Donna E Maziak; Gail E Darling; Richard I Inculet; Karen Y Gulenchyn; Albert A Driedger; Yee C Ung; John D Miller; Chu-Shu Gu; Kathryn J Cline; William K Evans; Mark N Levine Journal: Ann Intern Med Date: 2009-07-06 Impact factor: 25.391