FDG-PET/CT for pretherapeutic lymph node staging in non-small cell lung cancer: A tailored approach to the ESTS/ESMO guideline workflow. (July 2021)

• Record Type: Journal Article
• Authors: Rogasch, Julian M.M.; Frost, Nikolaj; Bluemel, Stephanie; Michaels, Liza; Penzkofer, Tobias; von Laffert, Maximilian; Temmesfeld-Wollbrück, Bettina; Neudecker, Jens; Rückert, Jens-Carsten; Ochsenreither, Sebastian; Böhmer, Dirk; Amthauer, Holger; Furth, Christian
• Is Part Of: Lung cancer. Volume 157(2021)
• Page Start: 66
• Page End: 74
• Publication Date: 2021-07
• Subjects: 95 %-CI 95 %-confidence interval -- ADC adenocarcinoma -- AS analog PET/CT scanner -- DS digital PET/CT scanner -- EBUS-TBNA endobronchial ultrasound-guided transbronchial needle aspiration -- ESMO European Society for Medical Oncology -- ESTS European Society of Thoracic Surgeons -- FDG fluorodeoxyglucose -- FWHM full width at half maximum -- HU Houndsfield units -- IASLC International Association for the Study of Lung Cancer -- LN lymph node -- MBPS mediastinal blood pool structures -- MIP maximum intensity projection -- NOS NSCLC subtype, not otherwise specified -- NPV negative predictive value -- OSEM ordered subset expectation maximization -- PET/CT positron emission tomography/computed tomography -- PSF point spread function -- RF risk factor(s) -- SCC squamous cell carcinoma -- SiPM silicon photomultipliers -- SOR standard of reference -- SUV standardized uptake value -- TOF time of flight; FDG-PET/CT -- Non-small cell lung cancer -- Mediastinal lymph nodes -- Guideline -- Accuracy; Lungs -- Cancer -- Periodicals; Lung Neoplasms -- Abstracts; Lung Neoplasms -- Periodicals; Poumons -- Cancer -- Périodiques; Lungs -- Cancer; Periodicals; Electronic journals; Electronic journals; 616.99424
• DOI: 10.1016/j.lungcan.2021.05.003
• Languages: English
• ISSNs: 0169-5002

Abstract

Highlights: Risk factors for missed pN2 defined by current guidelines may be overcautious. In current analysis, missed pN2 was always associated with adenocarcinoma subtype. Most EBUS-TBNA procedures in patients with mediastinal negative PET/CT were confirmatory. The proposed modified workflow could have avoided 82 % of these procedures. In this analysis, additional cases of missed pN2 disease would have remained rare. Abstract: Objectives: In patients with NSCLC, current ESTS and ESMO guidelines recommend invasive lymph node (LN) staging with EBUS-TBNA even if FDG-PET/CT is negative for mediastinal LNs if at least one of three risk factors is present (cN1, non-peripheral primary or primary >3 cm). Modified workflows to avoid unnecessary invasive procedures were evaluated. Materials and methods: Monocentric retrospective analysis of pretherapeutic FDG-PET/CT in 247 patients with NSCLC (62 % male; age, 68 [43–88] years) using an analog or digital PET/CT scanner. PET windowing was standardized. LNs were positive if 'LN uptake > mediastinal blood pool' or short axis >10 mm. Surgery or EBUS-TBNA served as reference for diagnostic accuracy per LN station. In all patients with negative mediastinal LNs by PET/CT, LN histology from surgery was available. Results: Among 700 L N stations analyzed, 180 were malignant. Sensitivity and specificity of PET/CT per LN station were 93 % and 71 %. Following current guidelines, 76 patients with mediastinal negative PET/CT required confirmatory invasive staging. Only 5/76 patients had unexpected pN2 (all had adenocarcinoma). In a modified approach, confirmatory invasive staging was confined to patients with mediastinal negative PET/CT who showed all three risk factors. Using this modification, EBUS-TBNA could have been omitted in 62 (82 %) of the 76 patients who required EBUS-TBNA based on current recommendation. Among these 62 patients, only one patient had unsuspected pN2 (single-level) while the remaining 61 of 62 omitted EBUS-TBNA were deemed unnecessary because mediastinal LNs were confirmed to be negative. No multi-level pN2 would have been missed. Conclusion: In the current analysis, 82 % of EBUS-TBNA procedures in patients with mediastinal negative PET/CT could have been omitted by modifying the current guideline workflow as proposed (i.e., restricting EBUS-TBNA in patients with cN0/1 to those with all three risk factors). This was consistent with different PET/CT scanners. Prospective confirmation is required.