Are There Any Additional Benefits to Performing Positron Emission Tomography/Computed Tomography Scans and Brain Magnetic Resonance Imaging on Patients with Ground-Glass Nodules Prior to Surgery?원문보기
Song, Jae-Uk
(Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine)
,
Song, Junwhi
(Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine)
,
Lee, Kyung Jong
(Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine)
,
Kim, Hojoong
(Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine)
,
Kwon, O Jung
(Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine)
,
Choi, Joon Young
(Department of Nuclear Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine)
,
Kim, Jhingook
(Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine)
,
Han, Joungho
(Department of Pathology, Samsung Medical Center, Sung)
,
Um, Sang-Won
Background: A ground-glass nodule (GGN) represents early-stage lung adenocarcinoma. However, there is still no consensus for preoperative staging of GGNs. Therefore, we evaluated the need for the routine use of positron emission tomography/computed tomography (PET)/computed tomography (CT) scans and...
Background: A ground-glass nodule (GGN) represents early-stage lung adenocarcinoma. However, there is still no consensus for preoperative staging of GGNs. Therefore, we evaluated the need for the routine use of positron emission tomography/computed tomography (PET)/computed tomography (CT) scans and brain magnetic resonance imaging (MRI) during staging. Methods: A retrospective analysis was undertaken in 72 patients with 74 GGNs of less than 3 cm in diameter, which were confirmed via surgery as malignancy, at the Samsung Medical Center between May 2010 and December 2011. Results: The median age of the patients was 59 years. The median GGN diameter was 18 mm. Pure and part-solid GGNs were identified in 35 (47.3%) and 39 (52.7%) cases, respectively. No mediastinal or distant metastasis was observed in these patients. In preoperative staging, all of the 74 GGNs were categorized as stage IA via chest CT scans. Additional PET/CT scans and brain MRIs classified 71 GGNs as stage IA, one as stage IIIA, and two as stage IV. However, surgery and additional diagnostic work-ups for abnormal findings from PET/CT scans classified 70 GGNs as stage IA, three as stage IB, and one as stage IIA. The chest CT scans did not differ from the combined modality of PET/CT scans and brain MRIs for the determination of the overall stage (94.6% vs. 90.5%; kappa value, 0.712). Conclusion: PET/CT scans in combination with brain MRIs have no additional benefit for the staging of patients with GGN lung adenocarcinoma before surgery.
Background: A ground-glass nodule (GGN) represents early-stage lung adenocarcinoma. However, there is still no consensus for preoperative staging of GGNs. Therefore, we evaluated the need for the routine use of positron emission tomography/computed tomography (PET)/computed tomography (CT) scans and brain magnetic resonance imaging (MRI) during staging. Methods: A retrospective analysis was undertaken in 72 patients with 74 GGNs of less than 3 cm in diameter, which were confirmed via surgery as malignancy, at the Samsung Medical Center between May 2010 and December 2011. Results: The median age of the patients was 59 years. The median GGN diameter was 18 mm. Pure and part-solid GGNs were identified in 35 (47.3%) and 39 (52.7%) cases, respectively. No mediastinal or distant metastasis was observed in these patients. In preoperative staging, all of the 74 GGNs were categorized as stage IA via chest CT scans. Additional PET/CT scans and brain MRIs classified 71 GGNs as stage IA, one as stage IIIA, and two as stage IV. However, surgery and additional diagnostic work-ups for abnormal findings from PET/CT scans classified 70 GGNs as stage IA, three as stage IB, and one as stage IIA. The chest CT scans did not differ from the combined modality of PET/CT scans and brain MRIs for the determination of the overall stage (94.6% vs. 90.5%; kappa value, 0.712). Conclusion: PET/CT scans in combination with brain MRIs have no additional benefit for the staging of patients with GGN lung adenocarcinoma before surgery.
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문제 정의
The major limitation was the potential for selection bias. This was the retrospective study of prospectively collected dataset performed on a small number of patients from a single center. Thus, these factors may limit the generalizability of our findings to other institutions or patient populations.
제안 방법
4% of patients, and approximately 35%–56% of these represented significant pathology unrelated to LCA22,23. Because more than 50% of the incidental thyroid and colonic uptake lesions on PET/CT during the initial NSCLC staging had a diagnosis with clinical significance, additional evaluations should be considered, although metastasis from LCA to the thyroid or colon is rare (less than 1%)24,25, and it in general, neither influences treatment decisions nor alters the prognosis. However, adrenal metastases from LCA are not uncommon.
The histologic classification of adenocarcinoma followed the International Association for the Study of Lung Cancer/American Thoracic Society/European Respiratory Society classification15. Each patient was assigned a final TNM stage based on the clinical, surgical, and pathologic data, together with an additional diagnostic work-up to evaluate the abnormal findings on PET/CT, and follow-up information according to the revised International System for Staging Lung Cancer9. All of the patients who underwent surgical resection were followed from the day of surgery, using a previously described method16.
If a GGN was less than 10 mm in diameter and did not possess a solid portion, it was observed for at least 3 months to determine if it would resolve on its own. If the lesion remained stable, the CT examination was repeated after 6 months and then annually thereafter for a pure GGN, with follow-up examinations repeated every 3 months for the first year and every 6 months thereafter for a part-solid GGN. An increase or decrease in the size of a GGN was defined as a change of ≥2 mm from the size in the initial CT scan6.
In the final stage, as determined by surgery and additional diagnostic work-up for the incidentally abnormal findings on PET/CT scan, four cases were upstaged to IB (three patients were changed from T1b to T2a) and IIA (one patient with visceral pleural involvement) following surgery, compared to the preoperative staging assessed by both chest CT alone and the combined staging modalities including chest CT, PET/CT, and brain MRI. However, three cases were downstaged to IA from stage IIIA (one with a false-positive mediastinal lesion confirmed by surgery) and from stage IV (two cases with a benign adrenal adenoma confirmed by an adrenal CT scan), as assessed by the combined modalities (Table 4).
An increase or decrease in the size of a GGN was defined as a change of ≥2 mm from the size in the initial CT scan6. Surgical resections were planned for growing GGNs, those that showed new development, and those in which the internal solid portion grew, during the follow-up examination.
However, there is as yet no consensus for preoperative staging of GGNs. Therefore, we retrospectively evaluated the need for the routine use of PET/CT and brain MRI for the detection of mediastinal and distant metastases in patients with GGN lung adenocarcinoma with a diameter of 3 cm or less on chest CT scans.
대상 데이터
Of the enrolled 72 patients with 74 pathologically confirmed malignant GGNs, 70 had a solitary GGN and two had two nodules. The median GGN diameter was 18 mm on chest CT scans.
This study included 35 pure and 39 part-solid GGNs. The median longitudinal diameter of solid component in patients with part-solid GGN was 7 mm (IQR, 5–14) (Table 2).
This study was a retrospective analysis of prospectively collected dataset at the Samsung Medical Center (a 1,960-bed university-affiliated, tertiary referral hospital in Seoul, South Korea) between May 2010 and December. In total, 72 patients with 74 pathology-proven adenocarcinomas, who had undergone surgical resection for curative intent, were included (Figure 1).
성능/효과
In conclusion, PET/CT and brain MRI have no additional benefit for the staging of patients with GGN lung adenocarcinoma prior to surgery. Therefore, routine PET/CT scans and brain MRIs do not seem to be mandatory for staging GGNs, considering the indolent nature of GGNs and the need for unwarranted additional tests for false-positive interpretation with PET/CT and brain MRI.
In our study, an incidental uptake on PET/CT was detected in 10 cases, including the thyroid (n=7, 9.7% but only 3 [4.2%] in focal uptake), adrenal gland (n=2, 2.8%), and colon (n=1, 1.4%). Among them, only two cases were confirmed to be thyroid cancer.
In contrasts, we performed both PET/CT and brain MRI in all of our enrolled patients, and could determine the clinical roles of PET/CT and brain MRI in staging GGN lung adenocarcinomas, compared to previous studies17-19. Our study showed that there were no statistically significant differences for the determination of overall stage in patients with ground-glass nodular lung adenocarcinomas, between chest CT alone and a combination of modalities including chest CT, PET/CT, and brain MRI. Therefore, the patients with GGN lung adenocar-cinomas with stage IA on chest CT scan seems to be suitable for omitting PET/CT scans and brain MRIs to avoid increasing cost caused by the unwarranted additional tests for false-positive interpretation by PET/CT or brain MRI, considering low prevalence of mediastinal nodal and distant metastases3,4,20.
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