Download Non-small cell lung cancer

Value of PET/CT
Non-small cell lung cancer
Core Message for Referring Physicians
Background:
There are about 215,000 new cases of
lung cancer in the United States each year. Lung
cancer is the second most common cause of cancer and the leading cause of cancer death in men
and women. Non–small cell lung cancer accounts
for 80% of all lung cancers. Accurate staging at
the time of diagnosis is crucial, because patients
with resectable disease have a better prognosis.
Patients usually are not surgical candidates if
they have metastases to ipsilateral supraclavicular or contralateral medisatinal nodes, pulmonary
metastases to another lobe or lung, or distant
metastatic disease.
Practice Guidelines:
American College of Chest Surgeons:
PET to evaluate for mediastinal and extra thoracic staging should be considered in patients with clinical 1A lung cancer and should be performed in patients with clinical IB–IIIB
lung cancer being treated with curative intent (5).
National Comprehensive Cancer Network
PET scan can play a role in the evaluation and more accurate staging of stage I–IV disease (6).
Case Example 1:
Figure 1A. A 67-year-old man with newly diagnosed
adenocarcinoma. Anterior maximal intensity projection
(MIP) shows the primary tumor in the left upper lobe
(arrow) plus multiple left mediastinal and right hilar
(arrowhead) lymph node metastases.
PET has been shown to improve staging
compared to CT alone. Pieterman and colleagues
reported that PET increased sensitivity for mediastinal lymph node metastases from 75% to
91%. Furthermore, 11% of patients were found to
have distant metastases (1).
A meta-analysis by Gould reported the
sensitivity and specificity of PET in the mediastinum to be 85% and 90% (2). Mediastinal lymph
node biopsy often is not performed in patients
with negative PET and negative CT, but biopsy is
important to confirm positive findings.
The introduction of integrated PET/CT
in 2001 improved staging accuracy compared
to PET alone, CT alone, and separate PET and CT
read side by side. Lardinois reported that PET/
CT provided additional information in 41% of
patients, with increased accuracy for T stage as
well as N stage (3). De Wever reported that PET/CT
detected distant metastases in 92% of patients
and was more accurate than PET or CT alone (4).
Case Example 2:
Figure 1B. Fused transaxial PET/CT images show the primary tumor (arrowhead) plus left para
aortic (thin arrow) and left paratracheal (thick arrow) mediastinal lymph node metastases.
Reimbursement
CMS Coverage Policy
PET and PET/CT are approved by the Centers
for Medicare and Medicaid Services for diagnosis, staging and restaging of non-small
cell lung cancer. Monitoring response during
treatment is only covered when patients are
participating in a clinical research trial or
have been registered with the National Oncologic PET Registry (9).
PET/CT is also recommended by NCCN as part of modern 3-dimensional conformal RT techniques (6). PET/CT is preferable to CT alone for the gross tumor volume (GTV) delineation in
cases with significant atelectasis.
PET/CT can be used to evaluate response to radiation and chemotherapy performed in the
neoadjuvant setting or for curative intent. Eschmann reported that 5-year survival was 60% in
patients who showed >60% decrease in FDG uptake following neoadjuvant chemotherapy, but
only15% when the decrease was less than 60% (7).
Nahmias found that a 50% decrease in FDG uptake between 1 week and 3 weeks after initiation of chemotherapy was predicative of survival >6 months (8).
References
1. Pieterman RM. Preoperative staging of non-small-cell lung cancer with positron-emission tomography. N Engl J Med. 2000
Jul 27;343(4):254–61.
2. Gould MK. Test performance of positron emission tomography and computed tomography for mediastinal staging in patients
with non-small-cell lung cancer: a meta-analysis. Ann Intern Med. 2003;139:879–892.
3. Lardinois D. Staging of non-small-cell lung cancer with integrated positron-emission tomography and computed tomography.
N Engl J Med. 2003 Jun 19;348(25):2500–7.
4. De Wever W Detection of extrapulmonary lesions with integrated PET/CT in the staging of lung cancer. J.Eur Respir J. 2007
May;29(5):995–1002.
5. Alberts WM. Clinical Practice Guidelines (2nd Edition) Executive Summary: ACCP Evidence-Based Diagnosis and Management
of Lung. Cancer Chest. 2007;132;1–19.
6. NCCN Practice Guidelines in Oncology. Non-Small Cell Lung Cancer v.1.2009. Available at: http://www.nccn.org/professionals/
physician_gls/PDF/nscl.pdf.
7. Eschmann SM. Repeat 18F-FDG PET for monitoring neoadjuvant chemotherapy in patients with stage III non-small cell lung
cancer. Lung Cancer. 2007 Feb;55(2):165–71.
8. Nahmias C. Time course of early response to chemotherapy in non-small cell lung cancer patients with 18F-FDG PET/CT. J Nucl
Med. 2007 May;48(5):744–51
9. CMS Publication 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, Section 220.6). Available at:
http://www.cms.hhs.gov/manuals/downloads/ncd103c1_part4.pdf.