Systematic review of the cost-effectiveness of positron-emission tomography in staging of non--small-cell lung cancer and management of solitary pulmonary nodules

The Prognostic Value of Positron Emission Tomography/Computed Tomography in Clinical Stage I Lung Cancer Patients: A Propensity-Match Analysis

Background: The application of positron emission tomography/computed tomography (PET/CT) helps provide accurate clinical staging for lung cancer patients. However, the effects and trends in early-stage lung cancer remain unclear. The aim of this study was to compare differences between clinical stage I lung cancer patients who received PET/CT for staging and those who did not. Methods: Data were obtained from the Taiwan Society of Cancer Registry. There were 6587 clinical stage I lung cancer patients between 2009 and 2014 analyzed in this study. We compared the characteristics of the PET/CT and no PET/CT groups. After propensity score matching, it resulted in both groups having 2649 patients. We measured the overall survival rates of all clinical stage I lung cancer patients and the overall survival rates of patients with PET/CT and without PET/CT. Results: The 1-, 3-, and 5-year survival rates of all clinical stage I lung cancer patients were 97.2%, 88.2%, and 79.0%, respectively. Patients with a larger tumor size tended to receive PET/CT for staging (stage Ib: 38.25% vs. 27.82%, p < 0.0001) and a larger resection (lobectomy: 74.62% vs. 66.61%, p < 0.0001). The 5-year survival rates were 79.8% in the PET/CT group and 78.2% in the no PET/CT group after propensity score matching (p = 0.6528). Conclusions: For clinical stage I lung cancer in Taiwan, patients with larger tumor sizes tend to have PET/CT for staging. Although PET/CT provided more precise clinical staging, these patients still received larger resections and had more pathological migration. However, there was no overall survival rate benefit after PET/CT.

Research on the Economics of Cancer-Related Health Care: An Overview of the Review Literature

We reviewed current literature reviews regarding economics of cancer-related health care to identify focus areas and gaps. We searched PubMed for systematic and other reviews with the Medical Subject Headings "neoplasms" and "economics" published between January 1, 2010, and April 1, 2020, identifying 164 reviews. Review characteristics were abstracted and described. The majority (70.7%) of reviews focused on cost-effectiveness or cost-utility analyses. Few reviews addressed other types of cancer health economic studies. More than two-thirds of the reviews examined cancer treatments, followed by screening (15.9%) and survivorship or end-of-life (13.4%). The plurality of reviews (28.7%) cut across cancer site, followed by breast (20.7%), colorectal (11.6%), and gynecologic (8.5%) cancers. Specific topics addressed cancer screening modalities, novel therapies, pain management, or exercise interventions during survivorship. The results indicate that reviews do not regularly cover other phases of care or topics including financial hardship, policy, and measurement and methods.

Diagnostic Performance of PET or PET/CT with Different Radiotracers in Patients with Suspicious Lung Cancer or Pleural Tumours according to Published Meta-Analyses

Purpose

Several meta-analyses have reported data about the diagnostic performance of positron emission tomography or positron emission tomography/computed tomography (PET or PET/CT) with different radiotracers in patients with suspicious lung cancer (LC) or pleural tumours (PT). This review article aims at providing an overview on the recent evidence-based data in this setting.

Methods

A comprehensive literature search of meta-analyses published in PubMed/MEDLINE and Cochrane Library database from January 2010 through March 2020 about the diagnostic performance of PET or PET/CT with different radiotracers in patients with suspicious LC or PT was performed. This combination of keywords was used: (A) “PET” OR “positron emission tomography” AND (B) “lung” OR “pulmonary” OR “pleur^∗” AND (C) meta-analysis. Only meta-analyses on PET or PET/CT in patients with suspicious LC or PT were selected.

Results

We have summarized the diagnostic performance of PET or PET/CT with fluorine-18 fluorodeoxyglucose (¹⁸F-FDG) and other radiotracers taking into account 17 meta-analyses. Evidence-based data demonstrated a good diagnostic performance of ¹⁸F-FDG PET or PET/CT for the characterization of solitary pulmonary nodules (SPNs) or pleural lesions with overall higher sensitivity than specificity. Evidence-based data do not support the routine use of dual time point (DTP) ¹⁸F-FDG PET/CT or fluorine-18 fluorothymidine (¹⁸F-FLT) PET/CT in the differential diagnosis of SPNs. Even if ¹⁸F-FDG PET/CT has high sensitivity and specificity as a selective screening modality for LC, its role in this setting remains unknown.

Conclusions

Evidence-based data about the diagnostic performance of PET/CT with different radiotracers for suspicious LC or PT are increasing, with good diagnostic performance of ¹⁸F-FDG PET/CT. More prospective multicenter studies and cost-effectiveness analyses are warranted.

Diagnostic success of transthoracic needle biopsy and PET-CT for 1 to 2 cm solid indeterminate pulmonary nodules

OBJECTIVES

Among the nodule types, the most controversial group are indeterminate solid nodules from 1 to 2 cm in size with the first choice being transthoracic needle biopsy (TTNB) or positron emission tomography (PET-CT) or both methods together. However, no single diagnostic algorithm could be applied to all cases. This research discusses the diagnostic success of PET-CT and TTNB.

MATERIALS AND METHODS

407 Patients who referred to our hospital for any reason, with solid nodules with the size from 1 to 2 cmincidentally identified on the thoracic CT tests were investigated. Among the patients who underwent biopsy, 312 cases had PET-CT, and maximum SUV (SUVmax) values of the nodules were examined. Values of ≥2.5 were accepted as hypermetabolic.

RESULTS

The mean age of the patients was 61 ± 10.8 years. 84 patients were female (20.6%) and 323 were male (79.4%). For TTNB; sensitivity, specificity and accuracy rates of all cases, who were correctly diagnosed, were 76.9%, 83.3% and 78.9%, respectively (P < .001). The 2.5 SUVmax cutoff value had sensitivity of 91%, specificity of 35.6%, accuracy of 75% (P = .034). The cutoff value of 49 years of age, nodule size of 16.4 mm, gender and 2.5 SUVmax value had high accuracy for benign-malignant differentiation. No statistically significant difference was found in the upper lobe localization of nodule.

CONCLUSION

A positive result from TTNB is a reliable finding; however, a negative result is not definitive. The high negative predictive value of PET-CT is effective in preventing the unnecessary biopsies and surgical procedures.

Diagnostic Value of Plasma MicroRNAs for Lung Cancer Using Support Vector Machine Model

Aim: Small single-stranded non-coding RNAs (miRNAs) play an important role in carcinogenesis through degrading target mRNAs. However, the diagnostic value of miRNAs was not explored in lung cancers. In this study, a support-vector-machine (SVM) model for diagnosis of lung cancer was established based on plasma miRNAs biomarkers, clinical symptoms and epidemiology material.

Methods: The expressions of plasma miRNA were examined with SYBR Green-based quantitative real-time PCR.

Results: We identified that the expressions of 10 plasma miRNAs (miR-21, miR-20a, miR-210, miR-145, miR-126, miR-223, miR-197, miR-30a, miR-30d, miR-25), smoking status, fever, cough, chest pain or tightness, bloody phlegm, haemoptysis, were significantly different between lung cancer and control groups (P<0.05). The accuracies of the combined SVM, miRNAs SVM, symptom SVM, combined Fisher, miRNAs Fisher and symptom Fisher were 96.34%, 80.49%, 84.15%, 84.15%, 75.61%, and 80.49%, respectively; AUC of these six model were 0.976, 0.841, 0.838, 0.865, 0.750, and 0.801, respectively. The accuracy and AUC of combined SVM were higher than the other 5 models (P<0.05).

Conclusions: Our findings indicate that SVM model based on plasma miRNAs biomarkers may serve as a novel, accurate, noninvasive method for auxiliary diagnosis of lung cancer.

Cost-effectiveness analysis of positron-emission tomography-computed tomography in preoperative staging for nonsmall-cell lung cancer with resected monometastatic disease

BACKGROUND

The aim of this study was, from the Chinese healthcare perspective, to assess the cost-effectiveness of positron-emission tomography-computed tomography (PET-CT) with F-fluorodeoxyglucose (F-FDG) in preoperation staging for nonsmall-cell lung cancer (NSCLC) with resected monometastatic disease based on a retrospective study. This study was conducted from January 2017 to February 2019 at an academic hospital.

METHODS

A Markov model and 3 decision-tree models were designed to calculate the long-term medical costs, outcomes, and incremental cost-effectiveness ratios (ICERs) of the 2 diagnostic strategies (PET-CT and conventional CT). Model robustness was assessed in sensitivity analyses.

RESULTS

For the base-case analysis, preoperative PET-CT evaluation for NSCLC with resected monometastatic disease provided an additional 1.475, 2.129, and 2.412 life-years (LYs), in the time horizon of 10-, 20-, and 30-year, respectively, and the ICERs for the PET-CT group compared with the conventional CT group were $1153, $1393, and $1430 per LY, separately. The acceptability curves demonstrated that when the willingness-to-pay (WTP) thresholds ranged from $500 to $3000/LY, the probability of cost-effectiveness changed varied dramatically, and at WTP > $3000, the probability that the PET-CT group achieved cost-effectiveness was 100%. Sensitivity analyses suggested that the models we designed were robust.

CONCLUSION

Compared with conventional CT scan, preoperative F-FDG PET-CT evaluation for patients with resected monometastatic NSCLC is cost-effective from the Chinese healthcare perspective. Preoperative F-FDG PET-CT evaluation should be popularized for patients with resected monometastatic NSCLC.

PET/CT and brain MRI role in staging NSCLC: prospective assessment of the accuracy, reliability and cost-effectiveness

Aim:

To determine whether PET/CT and brain MRI used in staging NSCLC can be accurate, reliable and cost-effective tools. NSCLC represents 80–85% of lung cancer and adequate information on the initial tumor staging is critical for planning an optimal therapeutic strategy.

Patients & methods:

Data from 30 newly diagnosed NSCLC patients in Greece were collected and prospectively recorded. Patients with potential resectable disease were evaluated to ensure that there are no detectable metastases that would rule out the possibility of a curative surgery.

Results:

Divergence occurred in 50% of cases of staging with CT or PET/CT alone, while metastases undetectable by the CT were revealed using PET/CT. Unnecessary thoracotomies were avoided by 10% of patients and another 10% was operated on after chemotherapy with a better prognosis.

Conclusion:

PET/CT and brain MRI combined are reliable for correct staging, reducing avoidable thoracotomies, morbidity rates and costs.

Molecular imaging with positron emission tomography and computed tomography (PET/CT) for selecting first-line targeted treatment in metastatic breast cancer: a cost-effectiveness study

Our aim was to evaluate the potential cost-effectiveness of PET/CT with FES and ⁸⁹Zr-trastuzumab compared to pathology to select first-line targeted treatment in metastatic breast cancer (MBC) patients with non-rapidly progressive disease. A previously published and validated model was extended and adapted for this analysis. Two alternative scenarios were compared. In the care as usual pathway first-line targeted treatment of MBC patients was assigned on the basis of pathology results, while in the intervention pathway treatment selection was based on the results from the PET/CT imaging. Costs, life years gained (LYG) and incremental cost-effectiveness ratios (ICER) were calculated. More MBC lesions were detected in the intervention pathway than in the care as usual pathway. The diagnostic costs to evaluate the receptor status and the treatment costs were higher in the intervention strategy, as were total costs and total LYG. The ICER for replacing biopsies with PET/CT imaging with FES and ⁸⁹Zr-trastuzumab, assuming sensitivity of 77.1% and specificity of 80%, ranged from €71,000 to €77,000 per LYG. When assuming sensitivity of 80% and specificity of 76.7%, the ICER for replacing biopsies with PET/CT imaging with FES and ⁸⁹Zr-trastuzumab ranged from to €74,000 to €80,000 per LYG. The application of PET/CT with FES and ⁸⁹Zr-trastuzumab in first-line treatment selection for MBC patients has the potential to be a cost-effective intervention. Our analysis demonstrated that even a small increase in the sensitivity and the specificity of PET/CT can have a large impact on its potential cost-effectiveness.

The role of positron emission tomography in the diagnosis, staging and response assessment of non-small cell lung cancer

Lung cancer is a common disease and the leading cause of cancer-related mortality, with non-small cell lung cancer (NSCLC) accounting for the majority of cases. Following diagnosis of lung cancer, accurate staging is essential to guide clinical management and inform prognosis. Positron emission tomography (PET) in conjunction with computed tomography (CT)-as PET-CT has developed as an important tool in the multi-disciplinary management of lung cancer. This article will review the current evidence for the role of ¹⁸F-fluorodeoxyglucose (FDG) PET-CT in NSCLC diagnosis, staging, response assessment and follow up.

Cost-effectiveness of lung cancer screening and treatment methods: a systematic review of systematic reviews

BACKGROUND

Due to extensive literature in the field of lung cancer and their heterogeneous results, the aim of this study was to systematically review of systematic reviews studies which reviewed the cost-effectiveness of various lung cancer screening and treatment methods.

METHODS

In this systematic review of systematic reviews study, required data were collected searching the following key words which selected from Mesh: "lung cancer", "lung oncology", "lung Carcinoma", "lung neoplasm", "lung tumors", "cost- effectiveness", "systematic review" and "Meta-analysis". The following databases were searched: PubMed, Cochrane Library electronic databases, Google Scholar, and Scopus. Two reviewers (RA and A-AS) evaluated the articles according to the checklist of "assessment of multiple systematic reviews" (AMSTAR) tool.

RESULTS

Overall, information of 110 papers was discussed in eight systematic reviews. Authors focused on cost-effectiveness of lung cancer treatments in five systematic reviews. Targeted therapy options (bevacizumab, Erlotinib and Crizotinib) show an acceptable cost-effectiveness. Results of three studies failed to show cost-effectiveness of screening methods. None of the studies had used the meta-analysis method. The Quality of Health Economic Studies (QHES) tool and Drummond checklist were mostly used in assessing the quality of articles. Most perspective was related to the Payer (64 times) and the lowest was related to Social (11times). Most cases referred to Incremental analysis (82%) and also the lowest point of referral was related to Discounting (in 49% of the cases). The average quality score of included studies was calculated 9.2% from 11.

CONCLUSIONS

Targeted therapy can be an option for the treatment of lung cancer. Evaluation of the cost-effectiveness of computerized tomographic colonography (CTC) in lung cancer screening is recommended. The perspective of the community should be more taken into consideration in studies of cost-effectiveness. Paying more attention to the topic of Discounting will be necessary in the studies.

The role of PET/CT as a prognosticator and outcome predictor in lung cancer

Positron emission tomography/computed tomography (PET/CT) is an important imaging tool for management of lung cancer and can be utilized in diagnosis, staging, restaging, treatment planning and evaluating treatment response. In the past decade PET/CT has proven to be beneficial for the prediction of prognosis and outcome. PET findings before and after treatment, the quantitative PET parameters such as standardized uptake value (SUV), metabolic tumor volume (MTV), and total lesion glycolysis (TLG) as well as delayed PET/CT imaging can be used to determine patient prognosis and outcome. Other tracers such as hypoxia and proliferation marker tracers may be used for prognostication. The prognostic factors derived from PET/CT imaging help early development of risk-adapted treatment strategies, which provides cost-effective treatment and leads to improved patient management. Here, we discuss findings of studies related to application of PET/CT in lung cancer as well as some technical updates on quantitative PET/CT in lung cancer.

Use of [(18)F]Fluoro-2-deoxy-d-glucose Positron Emission Tomographic Imaging in the National Lung Screening Trial

BACKGROUND

Positron emission tomography (PET) is a diagnostic tool for lung cancer evaluation. No studies have ascertained practice patterns and determined the appropriateness of PET imaging in a large group of US patients with screen-detected lung nodules.

METHODS

We analyzed participants in the National Lung Screening Trial (NLST) with positive screening test results and identified individuals with a PET scan performed prior to lung cancer diagnosis (diagnostic PET). Appropriate scan was defined as one performed in a patient with a nodule ≥ 0.8 cm. Logistic regression was used to assess factors associated with diagnostic PET scan use and appropriateness of PET scan use.

RESULTS

Diagnostic PET imaging was performed in 1,556 of 14,195 patients (11%) with positive screen results; 331 of these (21%) were inappropriate. PET scan use by endemic fungal disease area was comparable although patients from the Northeast/Southeast were twice as likely as the West to have a diagnostic PET. Trial arm, older age, sex, nodule size ≥ 0.8 cm, upper lobe location, and spiculated margin were variables positively associated with use. Trial arm, older age, and spiculated margin were positively associated with appropriate use. Only 561 diagnostic PETs (36%) were recommended by a radiologist and 284 PETs performed for nodules < 0.8 cm (86%) were ordered despite no recommendation from a radiologist.

CONCLUSIONS

PET imaging was differentially used in the NLST and inappropriately used in many cases against radiologist recommendations. These data suggest PET imaging may be overused in the lung cancer screening population and may contribute to excess health-care costs.

PET/CT imaging in lung cancer: indications and findings

The use of PET/CT imaging in the work-up and management of patients with lung cancer has greatly increased in recent decades. The ability to combine functional and anatomical information has equipped PET/CT to look into various aspects of lung cancer, allowing more precise disease staging and providing useful data during the characterization of indeterminate pulmonary nodules. In addition, the accuracy of PET/CT has been shown to be greater than is that of conventional modalities in some scenarios, making PET/CT a valuable noninvasive method for the investigation of lung cancer. However, the interpretation of PET/CT findings presents numerous pitfalls and potential confounders. Therefore, it is imperative for pulmonologists and radiologists to familiarize themselves with the most relevant indications for and limitations of PET/CT, seeking to protect their patients from unnecessary radiation exposure and inappropriate treatment. This review article aimed to summarize the basic principles, indications, cancer staging considerations, and future applications related to the use of PET/CT in lung cancer.

Cost-effectiveness analysis of strategies introducing integrated ¹⁸F-FDG PET/CT into the mediastinal lymph node staging of non-small-cell lung cancer

OBJECTIVE

The aim of the study was to establish the most cost-effective strategy for using integrated 18F-fluorodeoxyglucose PET and computed tomography (CT) for mediastinal lymph node staging (N-staging) of preoperative non-small-cell lung cancer (NSCLC).

PATIENTS AND METHODS

Four N-staging decision models for operative NSCLC, model A (CT only), model B (PET/CT for negative CT), model C (CT and PET/CT for all), and model D (PET/CT only), were constructed according to the Chinese edition of NCCN Clinical Practice Guidelines in Oncology Non-Small-Cell Lung Cancer and China NSCLC N-staging practices. Data including the parameters for decision models, life expectancy, and expenditures were retrieved from the literature, from websites of PET Reservation Centers, and on consultation with experts. On the basis of model A, incremental cost-effectiveness ratios were calculated for the other three models. Robustness of the result was evaluated by univariate sensitivity analysis.

RESULTS

Life expectancy (years) was 2.60 for model A, 2.57 for model B, 2.67 for model C, and 2.66 for model D. The probabilities for improper therapy due to wrong staging were 36.78, 13.00, 8.91, and 12.95%, respectively. Surgical mortality rates were 1.87, 1.01, 1.13, and 1.24%, respectively. Model C, for which the incremental cost-effectiveness ratio (37 960 CNY/year) was lower than that of model D (65 175 CNY/year) and 2012 GDP per capita in China (38 459 CNY), was cost-effective and optimal, and this result was robust.

CONCLUSION

Model C was the most cost-effective strategy for NSCLC N-staging in the China mainland. Introduction of model C into Chinese N-staging protocols for NSCLC would be helpful for treatment selection, for reducing surgical mortality rates, and for extending life expectancy.

Budget impact from the incorporation of positron emission tomography - computed tomography for staging lung cancers

OBJECTIVE

To estimate the budget impact from the incorporation of positron emission tomography (PET) in mediastinal and distant staging of non-small cell lung cancer.

METHODS

The estimates were calculated by the epidemiological method for years 2014 to 2018. Nation-wide data were used about the incidence; data on distribution of the disease´s prevalence and on the technologies’ accuracy were from the literature; data regarding involved costs were taken from a micro-costing study and from Brazilian Unified Health System (SUS) database. Two strategies for using PET were analyzed: the offer to all newly-diagnosed patients, and the restricted offer to the ones who had negative results in previous computed tomography (CT) exams. Univariate and extreme scenarios sensitivity analyses were conducted to evaluate the influence from sources of uncertainties in the parameters used.

RESULTS

The incorporation of PET-CT in SUS would imply the need for additional resources of 158.1 BRL (98.2 USD) million for the restricted offer and 202.7 BRL (125.9 USD) million for the inclusive offer in five years, with a difference of 44.6 BRL (27.7 USD) million between the two offer strategies within that period. In absolute terms, the total budget impact from its incorporation in SUS, in five years, would be 555 BRL (345 USD) and 600 BRL (372.8 USD) million, respectively. The costs from the PET-CT procedure were the most influential parameter in the results. In the most optimistic scenario, the additional budget impact would be reduced to 86.9 BRL (54 USD) and 103.8 BRL (64.5 USD) million, considering PET-CT for negative CT and PET-CT for all, respectively.

CONCLUSIONS

The incorporation of PET in the clinical staging of non-small cell lung cancer seems to be financially feasible considering the high budget of the Brazilian Ministry of Health. The potential reduction in the number of unnecessary surgeries may cause the available resources to be more efficiently allocated.

Systematic Review of the Quality of Economic Evaluations in the Otolaryngology Literature

Objective

To evaluate the quality of economic evaluations published in the otolaryngology—head and neck surgery literature, which will identify methodologic weaknesses that can be improved on in future studies. A secondary objective is to identify factors that may be associated with higher quality economic evaluations.

Data Sources

Ovid Medline (including PubMed), Embase, and the National Health Services Economic Evaluation databases.

Review Methods

A systematic search was performed of the aforementioned databases according to PRISMA guidelines. The search was performed using otolaryngology key terms combined with the term cost. A manual search of 36 otolaryngology journals was also performed. Included studies were graded using the Quality of Health Economics Studies instrument, a 16-item checklist providing a total quality score of 100.

Results

Fifty studies were identified, and the mean quality rating was 54.7/100 (SD = 30.9). The most commonly omitted methodology components were a lack of discussion of limitations and biases, failure to address the negative outcomes of examined interventions, and a lack of a robust sensitivity analysis. Higher quality economic evaluations were associated with a higher journal impact factor (correlation coefficient r = 0.62, P = .0001), having an author with a PhD in health economics ( r = 0.56, P = .0001), and having authors who have published prior economic evaluations ( r = 0.46, P = .001).

Conclusion

Results from this study have demonstrated that there are several methodological domains that can be improved on when publishing economic evaluations in the otolaryngology literature. Authors should follow recommended methodological and reporting guidelines to optimize the transparency and accuracy of the overall conclusions.

Cost-effectiveness of PET and PET/computed tomography: a systematic review

The development of clinical diagnostic procedures comprises early-phase and late-phase studies to elucidate diagnostic accuracy and patient outcome. Economic assessments of new diagnostic procedures compared with established work-ups indicate additional cost for 1 additional unit of effectiveness measure by means of incremental cost-effectiveness ratios when considering the replacement of the standard regimen by a new diagnostic procedure. This article discusses economic assessments of PET and PET/computed tomography reported until mid-July 2014. Forty-seven studies on cancer and noncancer indications were identified but, because of the widely varying scope of the analyses, a substantial amount of work remains to be done.

Cost effectiveness of a 92-gene assay for the diagnosis of metastatic cancer

OBJECTIVES

To estimate the clinical and economic trade-offs involved in using a molecular assay (92-gene assay, CancerTYPE ID) to aid in identifying the primary site of difficult-to-diagnose metastatic cancers and to explore whether the 92-gene assay can be used to standardize the diagnostic process and costs for clinicians, patients, and payers.

METHODS

Four decision-analytic models were developed to project the lifetime clinical and economic impact of incorporating the 92-gene assay compared with standard care alone. For each model, total and incremental costs, life-years, quality-adjusted life-years (QALYs), incremental cost-effectiveness ratios (ICERs), and the proportion of patients treated correctly versus incorrectly were projected from the payer perspective. Model inputs were based on published literature, analyses of SEER (Surveillance Epidemiology and End RESULTS) data, publicly available data, and interviews with clinical experts.

RESULTS

In all four models, the 92-gene assay increased the proportion of patients treated correctly, decreased the proportion of patients treated with empiric therapy, and increased quality-adjusted survival. In the primary model, the ICER was $50,273/QALY; thus, the 92-gene assay is therefore cost effective when considering a societal willingness-to-pay threshold of $100,000/QALY. These findings were robust across sensitivity analyses.

CONCLUSIONS

Use of the 92-gene assay for diagnosing metastatic tumors of uncertain origin is associated with reduced misdiagnoses, increased survival, and improved quality of life. Incorporating the assay into current practice is a cost-effective approach to standardizing diagnostic methods while improving patient care. Limitations of this analysis are the lack of data availability and resulting modeling simplifications, although sensitivity analyses showed these to not be key drivers of results.

Approach to a solid solitary pulmonary nodule in two different settings-"Common is common, rare is rare"

A new solid solitary pulmonary nodule (SPN) is a common feature in the daily practice of physicians, pulmonologists and thoracic surgeons. The etiology and consequently the diagnostic approach is very different in various parts of the world. Identification of malignant nodules is the universal goal to proceed to a potential curable therapy. In countries with a low incidence of inflammatory disease and a high incidence of lung cancer the diagnostic work up includes a positron emission tomography (PET) scan or PET-computer tomography (CT) as a main pillar. In countries with a high incidence of inflammatory and infectious disease and a low incidence in lung cancer this diagnostic work up needs to be adapted. In these settings a PET scan has a limited role and tissue diagnosis, whether with a trans-thoracic, trans-bronchial biopsy or a video-assisted wedge resection is the most targeted approach to determine or exclude malignancy. The evaluation of a solid SPN in the two different situations is outlined in our algorithm. Recommendations stress the value of clinical judgement in different settings, determination of probabilities of malignancy, cost-effective use of diagnostic tools and evaluation of various management alternatives according to the risk profile and the patients preferences.

Cost-effectiveness of Fluorine-18-Fluorodeoxyglucose positron emission tomography in tumours other than lung cancer: A systematic review

AIM: To systematically review published data on the cost-effectiveness of Fluorine-18-Fluorodeoxyglucose positron emission tomography (FDG-PET) or PET/computed tomography (PET/CT) in tumours other than lung cancer.

METHODS: A comprehensive literature search of studies published in PubMed/MEDLINE, Scopus and Embase databases through the 10^th of October in 2013 was carried out. A search algorithm based on a combination of the terms: (1) “PET” or “ PET/computed tomography (PET/CT)” or “positron emission tomography”; and (2) “cost-effectiveness” or “cost-utility” or “cost-efficacy” or “technology assessment” or “health technology assessment” was used. Only cost-effectiveness or cost-utility analyses in English language were included. Exclusion criteria were: (1) articles not within the field of interest of this review; (2) review articles, editorials or letters, conference proceedings; and (3) outcome evaluation studies, cost studies or health technology assessment reports. For each included study, information was collected concerning basic study, type of tumours evaluated, perspective/type of study, results, unit and comparison alternatives.

RESULTS: Sixteen studies were included. Head and neck tumours were evaluated in 4 articles, lymphoma in 4, colon-rectum tumours in 3 and breast tumours in 2. Only one article was retrieved for melanoma, oesophagus and ovary tumours. Cost-effectiveness results of FDG-PET or PET/CT ranged from dominated to dominant.

CONCLUSION: Literature evidence about the cost-effectiveness of FDG-PET or PET/CT in tumours other than lung cancer is still limited. Nevertheless, FDG-PET or PET/CT seems to be cost-effective in selective indications in oncology (staging and restaging of head and neck tumours, staging and treatment evaluation in lymphoma).

Plasma and EBC microRNAs as early biomarkers of non-small-cell lung cancer

Lung cancer is a major cause of death in Western countries. Current screening methods are invasive and still lead to a high percentage of false positives. There is, therefore, a need to find biomarkers that increase the probability of detecting lung cancer early. MicroRNAs (miRNAs) are stable molecules in blood plasma and exhaled breath condensate (EBC). We quantified miRNA-21 and miRNA-486 expression from plasma and EBC samples from patients with a diagnosis of non-small-cell lung cancer (NSCLC) and controls. miRNA-21 was significantly higher in plasma and in EBC of the NSCLC patients and miRNA-486 was significantly lower. This difference indicates a significantly improved diagnostic value, and suggests that these miRNAs could be clinically used as a first-line screening test in high-risk subjects.