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Non-small cell lung cancer

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					                                                             Value of PET/CT
                                               Non-small cell lung cancer
                                         Core Message for Referring Physicians
Background:                                           Practice Guidelines:
           There are about 215,000 new cases of
lung cancer in the United States each year. Lung      American College of Chest Surgeons:
cancer is the second most common cause of can-            PET to evaluate for mediastinal and extra thoracic staging should be considered in pa-
cer and the leading cause of cancer death in men      tients with clinical 1A lung cancer and should be performed in patients with clinical IB–IIIB
and women. Non–small cell lung cancer accounts        lung cancer being treated with curative intent (5).
for 80% of all lung cancers. Accurate staging at      National Comprehensive Cancer Network
the time of diagnosis is crucial, because patients       PET scan can play a role in the evaluation and more accurate staging of stage I–IV dis-
with resectable disease have a better prognosis.      ease (6).
Patients usually are not surgical candidates if
they have metastases to ipsilateral supraclavicu-     Case Example 1:
lar or contralateral medisatinal nodes, pulmonary     

metastases to another lobe or lung, or distant
metastatic disease.

          PET has been shown to improve staging                                       Figure 1A. A 67-year-old man with newly diagnosed
compared to CT alone. Pieterman and colleagues                                        adenocarcinoma. Anterior maximal intensity projection
reported that PET increased sensitivity for me-                                       (MIP) shows the primary tumor in the left upper lobe
diastinal lymph node metastases from 75% to                                           (arrow) plus multiple left mediastinal and right hilar
91%. Furthermore, 11% of patients were found to                                       (arrowhead) lymph node metastases.
have distant metastases (1).

           A meta-analysis by Gould reported the
sensitivity and specificity of PET in the mediasti-
num to be 85% and 90% (2). Mediastinal lymph
node biopsy often is not performed in patients        Case Example 2:
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        Figure 1B. Fused transaxial PET/CT images show the primary tumor (arrowhead) plus left para
and was more accurate than PET or CT alone (4).       aortic (thin arrow) and left paratracheal (thick arrow) mediastinal lymph node metastases.
                                                PET/CT is also recommended by NCCN as part of modern 3-dimensional conformal RT tech-
Reimbursement                                   niques (6). PET/CT is preferable to CT alone for the gross tumor volume (GTV) delineation in
                                                cases with significant atelectasis.
CMS Coverage Policy
                                                PET/CT can be used to evaluate response to radiation and chemotherapy performed in the
PET and PET/CT are approved by the Centers
for Medicare and Medicaid Services for di-
                                                neoadjuvant setting or for curative intent. Eschmann reported that 5-year survival was 60% in
agnosis, staging and restaging of non-small     patients who showed >60% decrease in FDG uptake following neoadjuvant chemotherapy, but
cell lung cancer. Monitoring response during    only15% when the decrease was less than 60% (7).
treatment is only covered when patients are
participating in a clinical research trial or   Nahmias found that a 50% decrease in FDG uptake between 1 week and 3 weeks after initia-
have been registered with the National On-      tion of chemotherapy was predicative of survival >6 months (8).
cologic PET Registry (9).
                                                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.