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Chest

Volume 128, Issue 2, August 2005, Pages 698-703
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Clinical Investigations
The Impact of Positron Emission Tomography on Clinical Decision Making in a University-Based Multidisciplinary Lung Cancer Practice

https://doi.org/10.1378/chest.128.2.698Get rights and content

Introduction

Positron emission tomography (PET) scanning has gained increasing application as a diagnostic and staging tool in the evaluation of lung cancer. Although PET scanning has been demonstrated to be a cost-effective adjunct to lung cancer diagnosis, its global impact on clinical decision making has not been assessed

Study objectives

To evaluate the impact of the systematic use of PET scanning on clinical decision making

Design

Retrospective study

Setting

A university-based multidisciplinary lung cancer practice

Patients

All patients undergoing diagnostic or staging PET scans from December 31, 2000, to December 31, 2002

Interventions

None

Measurements and results

One hundred ninety-eight patients underwent PET for diagnosis (161 patients) or staging (37 patients). PET scan results and clinical outcomes were retrospectively reviewed to determine the frequency with which PET scan findings (1) upstaged patients, (2) downstaged patients, (3) changed the diagnostic workup, (4) altered therapy, (5) resulted in a significant additional diagnosis, and (6) triggered evaluations that ultimately proved fruitless. PET upstaged 32 of 198 patients (16.2%) and downstaged 12 patients (6.1%), facilitating curative resection in 4 patients. Overall, PET scan findings changed the stage in 44 patients (22.2%). PET scan findings changed diagnostic management in 105 of 198 patients (53%), among whom biopsy was deferred in 65 patients (61.9%) and was triggered or guided in 40 patients (38.1%). PET scan findings altered treatment decisions in 38 patients (19.2%), leading to neoadjuvant therapy in 6 patients and resection in 5 patients, and forestalling noncurative thoracotomy in 6 patients. PET scan findings prompted or redirected chemotherapy or radiotherapy in the remainder of the patients. Overall, PET scan findings changed management in 143 patients (72.2%). PET scan findings triggered additional diagnostic testing in 32 patients (16.2%), resulting in no new diagnosis in 16 patients (50%) and a critical change in management in 7 patients (21.9%). PET scan findings were solely responsible for a significant non-lung cancer diagnosis in eight patients (4%)

Conclusions

Systematically applied PET scanning has a significant impact on patient management, altering diagnostic or therapeutic interventions in 72.2% of patients, changing staging in 22.2% of patients, and identifying serious unsuspected diagnoses in 4.0% of patients, with potentially life-saving consequences in 2.0%

Section snippets

Patient Selection

The Stony Brook University Hospital Lung Cancer Evaluation Center (LCEC) is a multidisciplinary specialty practice composed of a dedicated pulmonologist (S.S.), a thoracic surgeon (T.V.B.), a medical oncologist, and a radiation oncologist. The spectrum of diagnoses for which patients are referred is outlined in Table 1. There are established algorithms for diagnostic evaluation by category. At the LCEC, diagnostic PET scanning is indicated for the following: noncalcified nodules (NCNs) that are

Patient Selection

Patients were included for analysis if there was either biopsy confirmation of diagnosis or ≥ 3 months of radiographic follow-up. Of the 405 patients enrolled during the study period, 43 were unevaluable due to a lack of adequate follow-up data. Of the remaining 362 patients, 253 met the established criteria for PET scanning, and 198 underwent PET scanning for diagnosis (161 patients) or staging (37 patients) [Table 1]. The reasons for noncompliance with diagnostic protocols are outlined in

Discussion

Several studies have been published to date that outline the impact of PET scanning on individual aspects of lung cancer care. Over the past decade, the overall sensitivity, specificity, and accuracy of PET scanning for the evaluation of solitary pulmonary nodules have averaged 96%, 88%, and 94%, respectively.2, 3, 4, 5 For nodal staging, the sensitivity has ranged between 67% and 100%, the specificity has ranged between 76% and 100%, the PPV has ranged between 64% and 96%, and the negative

Conclusions

Overall, systematically applied PET scanning had a significant impact on patient management. In our population, the results of PET scanning altered the diagnostic or therapeutic intervention in 72.2% of patients, changed staging in 22.2% of patients, triggered additional diagnostic testing in 16.2% of patients, and identified serious unsuspected diagnoses in 4.0% patients, with potentially life-saving consequences in 2.0% of patients. A definitive result (ie, a positive or negative result) in

References (23)

  • NC Gupta et al.

    Probability of malignancy in solitary pulmonary nodules using fluorine-18-FDG and PET

    J Nucl Med

    (1996)

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