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Ann Thorac Surg 1995;60:1582
© 1995 The Society of Thoracic Surgeons
Department of Radiology, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10021
This article by Valk and associates represents a valuable contribution to the growing literature on preoperative PET scanning for staging of non–small cell lung cancer. The particular strength of PET scanning appears to lie in the very sensitive detection of tumor-associated increased metabolic activity both in mediastinal disease and in distant metastases. The current article, which its authors describe as a field study of PET imaging, demonstrates an approximately 20% improvement in sensitivity, specificity, and accuracy of PET scanning over CT scanning in mediastinal staging (N stage) of non–small cell lung cancer. Even more impressively, PET scanning demonstrated evidence of distant metastases in 11% of patients. In 8 of these patients, CT scanning through the same region had been negative. Moreover, it appears that there may be a role for PET scanning in differentiation of metastatic disease from other abnormalities involving both the liver and adrenal glands.
These findings are extremely encouraging, but some caveats must be voiced, most of which are discussed in the Comment section of the article. In particular, the use of CT scanning for purposes of ``localization'' of PET findings suggest the possibility that PET may suffer in comparison with CT scanning as a ``stand alone'' examination for accurate anatomic imaging. Valk and associates only very peripherally discuss the important issue of local tumor extent (T disease) in non–small cell lung cancer, and the inherent deficiencies of PET scanning in determining local tumor involvement of contiguous anatomic structures (chest wall, bronchi, mediastinal structures, including vertebrae). Valk and associates indicate that PET scanning may permit elimination of routine abdominal and pelvic CT scanning in lung cancer staging. However, not all practitioners perform routine abdominal and pelvic CT scanning to stage lung cancer: at our institution, we routinely extend the staging chest CT to include the adrenal glands (at no additional charge).
Further confirmatory work needs to be done. Cooperative trials should be performed, in particular with the purpose in mind of determining whether PET scanning may conceivably act as a replacement for chest or abdominal and pelvic CT scanning or as a further adjunct to anatomic imaging in the accurate preoperative staging of non–small cell lung cancer. The quality of the CT scans in these studies must be as carefully controlled as the PET scans, and the time frame separating the scans must be short. To quote a review by Quint and colleagues [1], ``Until a better technology or algorithm presents itself, CT of the chest and the upper part of the abdomen will remain the standard examination for staging lung cancer.'' In the meantime, this article by Valk and associates represents an important step forward in the effective evaluation of the utility of PET scanning in staging N and M disease in this highly lethal neoplasm.
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