AMSTERDAMThe use of positron-emission tomography (PET) scans to
stage patients with nonsmall-cell lung cancer (NSCLC) could
prevent as many as one in five unnecessary thoracotomies, according
to research presented at the ASCO meeting.
As many as 50% of patients with NSCLC undergo surgery unnecessarily,
Dutch investigators pointed out, for reasons such as disease
metastases unknown at time of surgery. The multi-institutional study
tested the ability of PET scans to accurately determine the stage of
disease and to prevent futile thoracotomies.
Thoracotomy was considered futile if disease was found to be benign
or far advanced at the time of surgery, or if patients had recurrent
disease or died within 1 year of surgery.
Adding PET to Work-up
Prior to mediastinoscopy or thoracotomy, 96 patients with potentially
resectable NSCLC were randomized to a conventional work-up, and 92
received a conventional work-up plus PET scan. Most patients
underwent mediastinoscopy, but some with small tumors went directly
We found that the number of futile thoracotomies was halved
when we included PET in the workup, reported Harm van Tinteren,
MD, from the Comprehensive Cancer Center, Amsterdam. In a large
number of patients, noncurative thoracotomies were avoided. In short,
PET scans stage tumors more accurately than CT scans.
Futile thoracotomies were noted in 39 of 96 patients in the
conventional work-up group (41%), and 19 of 92 patients in the PET
arm (21%), for a statistically significant relative reduction of 51%,
The reduction was evident in three different phases. Preoperatively,
the major contrast was seen in the occurrence of upstaging due to
PET: 25 patients were upstaged in the PET arm, vs 11 in the
conventional arm; 7 unexpected distant metastases and 18 positive
lymph nodes were seen on PET and later confirmed. This might
suggest a better yield, Dr. van Tinteren commented.
Surgery itself proved more futile in the conventional arm than in the
PET arm, due either to extensive disease that was considered
inoperable (12 vs 6) or to the presence of benign lesions (7 vs 2).
There was no difference in the number of nonfutile thoracotomies
according to group, he further reported.
Fewer Relapses With PET
Because PET scans more accurately determined which patients would
benefit from surgery, only 4 patients in the PET group relapsed after
surgery, compared with 14 patients in the conventional work-up group.
Furthermore, the study included a cost analysis, which showed that
the cost of using PETwhile more expensive up frontwas
a wash because of the savings realized by reducing
unnecessary surgery, Dr. van Tinteren added. We concluded that
PET reduces futile thoracotomies by 50% without additional cost.
At a press conference, it was pointed out that a Southwest Oncology
Group (SWOG) survey found that 85% of group investigators currently
use PET scans. SWOG concluded that PET scanning is becoming rapidly
available in the United States, even to community physicians.
A national lung cancer trial is now assessing the usefulness of PET
scanning for accurate restaging after chemotherapy but prior to
surgery. While PET scanning has become standard for the staging of
NSCLC, its role in restaging is still unsettled.