Surgeons' assessment of symptoms suggesting extrathoracic metastases in patients with lung cancer. Canadian Lung Oncology Group

Pretreatment assessment for the optimal management of early-stage lung cancer

Optimal management of non-small cell lung cancer requires treatment approach to be tailored to both the particular disease stage and the overall health and functional status of the patient. Even though surgical resection by means of an anatomic lobectomy remains the treatment of choice with the goal of cure for early-stage lung cancer, it is an invasive procedure with associated morbidity and mortality. Although these risks continue to decrease in the modern era with improvements in surgical technique and perioperative management, the risks are elevated in patients with associated medical comorbidities. As a consequence, patients at potentially increased or high risk for surgical lobectomy need to be identified by a structured preoperative assessment. This has gained increasing importance, given the emergence of alternative treatment approaches such as minimally invasive surgery, less extensive pulmonary resection, and stereotactic body radiation therapy. We review the clinical approach to suspected early-stage lung cancer based on a tumor and patient-centered stratification of risk and benefit.

Study to prospectively evaluate reamed intramedually nails in patients with tibial fractures (S.P.R.I.N.T.): study rationale and design

BACKGROUND

Surgeons agree on the benefits of operative treatment of tibial fractures - the most common of long bone fractures - with an intramedullary rod or nail. Rates of re-operation remain high - between 23% and 60% in prior trials - and the two alternative nailing approaches, reamed or non-reamed, each have a compelling biological rationale and strong proponents, resulting in ongoing controversy regarding which is better.

METHODS/DESIGN

The objective of this trial was to assess the impact of reamed versus non-reamed intramedullary nailing on rates of re-operation in patients with open and closed fractures of the tibial shaft. The study to prospectively evaluate reamed intramedullary nails in tibial fractures (S.P.R.I.N.T) was a multi-center, randomized trial including 29 clinical sites in Canada, the United States and the Netherlands which enrolled 1200 skeletally mature patients with open (Gustilo Types I-IIIB) or closed (Tscherne Types 0-3) fractures of the tibial shaft amenable to surgical treatment with an intramedullary nail. Patients received a statically locked intramedullary nail with either reamed or non-reamed insertion. The first strategy involved fixation of the fracture with an intramedullary nail following reaming to enlarge the intramedullary canal (Reamed Group). The second treatment strategy involved fixation of the fracture with an intramedullary nail without prior reaming of the intramedullary canal (Non-Reamed Group). Patients, outcome assessors, and data analysts were blinded to treatment allocation. Peri-operative care was standardized, and re-operations before 6 months were proscribed. Patients were followed at discharge, 2 weeks post-discharge, and at 6 weeks, 3, 6, 9, and 12 months post surgery. A committee, blinded to allocation, adjudicated all outcomes.

DISCUSSION

The primary outcome was re-operation to promote healing, treat infection, or preserve the limb (fasciotomy for compartment syndrome after nailing). The primary outcome was a composite comprising the following re-operations: bone grafts, implant exchanges, and dynamizations, in patients with fracture gaps less than 1 cm post intramedullary nail insertion. Infections and fasciotomies were considered events irrespective of the fracture gap. We planned a priori to conduct a subgroup analysis of outcomes in patients with open and closed fractures. S.P.R.I.N.T is the largest collaborative trial evaluating alternative orthopaedic surgical interventions in patients with tibial shaft fractures. The methodological rigor will set new benchmarks for future trials in the field and its results will have important impact on patient care. The S.P.R.I.N.T trial was registered [ID NCT00038129] and received research ethics approval (REB#99-077).

Noninvasive staging of non-small cell lung cancer: ACCP evidenced-based clinical practice guidelines (2nd edition)

BACKGROUND

Correctly staging lung cancer is important because the treatment options and the prognosis differ significantly by stage. Several noninvasive imaging studies including chest CT scanning and positron emission tomography (PET) scanning are available. Understanding the test characteristics of these noninvasive staging studies is critical to decision making.

METHODS

Test characteristics for the noninvasive staging studies were updated from the first iteration of the lung cancer guidelines using systematic searches of the MEDLINE, HealthStar, and Cochrane Library databases up to May 2006, including selected metaanalyses, practice guidelines, and reviews. Study designs and results are summarized in evidence tables.

RESULTS

The pooled sensitivity and specificity of CT scanning for identifying mediastinal lymph node metastasis were 51% (95% confidence interval [CI], 47 to 54%) and 85% (95% CI, 84 to 88%), respectively, confirming that CT scanning has limited ability either to rule in or exclude mediastinal metastasis. For PET scanning, the pooled estimates of sensitivity and specificity for identifying mediastinal metastasis were 74% (95% CI, 69 to 79%) and 85% (95% CI, 82 to 88%), respectively. These findings demonstrate that PET scanning is more accurate than CT scanning. If the clinical evaluation in search of metastatic disease is negative, the likelihood of finding metastasis is low.

CONCLUSIONS

CT scanning of the chest is useful in providing anatomic detail, but the accuracy of chest CT scanning in differentiating benign from malignant lymph nodes in the mediastinum is poor. PET scanning has much better sensitivity and specificity than chest CT scanning for staging lung cancer in the mediastinum, and distant metastatic disease can be detected by PET scanning. With either test, abnormal findings must be confirmed by tissue biopsy to ensure accurate staging.

Detecting extrathoracic metastases in patients with non-small cell lung cancer: Is routine scanning necessary?

There is controversy over whether to scan extrathoracic sites for metastases in patients with non-small cell lung cancer (NSCLC). We tested the efficiency of clinical factors to determine whether metastasis has occurred, and whether routine scanning for NSCLC is required. Nine hundred and forty five patients scanned for extrathoracic metasates were included. Clinical factors indicating metastasis were determined using multivariate analysis. Of the 945 cases, 377 (39.9%) had metastasis. Bone metastases were determined by focal skeleton pains, elevated serum alkaline phosphatase levels, adenocarcinoma, KPS</=70, sensitivity of 90.6, specificity of 12.7, PPV of 16.3, NPV of 87.8, and silent metastases rate (SMR) of 9.4%. Brain metastases were determined by neurological symptoms, adenocarcinoma, hematocrite <40 for men and <35 for women, KPS</=70, sensitivity of 89.9, specificity of 7.9, PPV of 9.2, NPV of 88.3, and SMR of 10.1%. Abdominal metastases were determined by abdominal pain/tension, hepatomegaly, elevated GGT levels, serum LDH levels >500 IU, a N2 or N3 case, KPS</=70, sensitivity of 95.9, specificity of 7.1, PPV of 13.3, NPV of 92.1 and SMR of 4.1%. Of the 224 patients with stage I and II disease, 73 had metastasis with a rate of 10.9% silent metastasis. We concluded that routine scanning of NSCLC for staging is necessary.

Le bilan préopératoire du cancer bronchique

INTRODUCTION

The overall prognosis of non-small cell carcinoma of the bronchus (NSCLC) remains poor on account of frequently late diagnosis and associated co-morbidity preventing the optimal treatment of the tumour. Surgical resection remains the best curative treatment for limited stage disease.

STATE OF THE ART

The pre-operative assessment should determine whether the extent of the tumour permits complete resection and whether the physiological state of the patient would tolerate the curative resection required. The ultimate goal is to improve 5-year survival. In the case of initial inoperability the assessment should determine whether pre-operative oncological treatment might make an advanced tumour operable (e.g. stage IIIA), or whether targeted medical treatment might improve the patient sufficiently to tolerate an intervention initially judged too risky. The rapid development of the technical modalities available for the assessment requires a continuous review of the current practice guidelines. Positron emission tomography has considerably augmented the accuracy of classical radiological assessment. Nevertheless staging by imaging alone remains imprecise to the extent that invasive examinations are still necessary to provide histological proof of the clinical stage of NSCLC. The techniques for assessing mediastinal invasion are developing rapidly and becoming more accurate and less invasive. Mediastinoscopy enhanced by modern video technology, ultrasound guided endoscopic biopsies and thoracoscopy are complimentary rather than competing techniques. The functional assessment should estimate the operative risk of the proposed pulmonary resection, identify the targeted actions aimed at reducing this risk or, in the absence of such actions, suggest less invasive but less well validated surgical techniques or even palliative treatments. When the operative risk cannot be reduced its precise estimation at least allows the patient to decide whether the risk seems acceptable in relation to the chances of a cure.

VIEWPOINT AND CONCLUSIONS

In the future the pre-operative assessment of NSCLC should improve the detection of micro-metastases in order to optimise the choice of induction and adjuvant therapies. The increasing use of induction chemotherapy before surgical resection can only increase the importance of a detailed assessment for the selection of patients and the evaluation of results.

Should mediastinoscopy actually be incorporated into the FDG PET strategy for patients with non-small cell lung carcinoma?

BACKGROUND

Incorporating mediastinoscopy (MS) into the PET-based strategy for non-small cell lung carcinoma (NSCLC) patients might be cost-effective because MS can allow unnecessary thoracotomies to be avoided. The objective of our study was to assess the cost-effectiveness of incorporating MS into a PET strategy for NSCLC patients.

METHODS

To determine life expectancy (LE), quality adjusted life years (QALY), and the incremental cost-effectiveness ratio (ICER), a decision-tree sensitivity analysis was designed for histopathologically confirmed NSCLC patients with M0 disease, based on the three competing strategies of chest CT only vs. PET + CT vs. PET + CT + MS. A simulation of 1000 NSCLC patients was created using baselines of other relevant variables in regard to sensitivity, specificity, mortality, LE, utilities and cost from published data. One-way sensitivity analyses were performed to determine the influences of mediastinal metastasis prevalence on LE, QALY and ICER.

RESULTS

The LE and QALY per patient in the CT only strategy, PET + CT strategy and PET + CT + MS strategy were 4.79 and 4.35, 5.33 and 4.93 and 5.68 and 5.33 years, respectively, with a 20% prevalence of mediastinal metastasis. The ICERs were 906.6 yen x 10(3) (7555 US dollars)/QALY/patient at a 20% mediastinal metastasis prevalence, and 2194 yen x 10(3) (18,282 US dollars)/QALY/patient at a 50% prevalence, but exceeded 5280 yen x 10(3) (44,000 US dollars)/QALY/ patient at 80%.

CONCLUSIONS

Our study quantitatively showed the CT + PET + MS strategy in place of the PET + CT strategy in managing NSCLC patients to be cost-effective. MS should be incorporated into the PET + CT strategy for NSCLC patients except in those highly suspected of having mediastinal disease on chest CT or PET.

Current state of imaging for lung cancer staging

Proper selection and interpretation of imaging studies is essential to provide optimal treatment to patients who have lung cancer. The following combines the recommendations of the American College of Chest Physicians [74] and the authors' current clinical practice guidelines: --All patients who have known or suspected lung cancer should undergo a CT of the chest and upper abdomen. --An FDG-PET study should be performed, if available. --Mediastinoscopy should be performed in all patients except those who have peripheral small (<2 cm) tumors and no evidence of N2 disease on CT or PET imaging. --MRI should be performed for tumors of the superior sulcus to define the relationship of the tumor to adjacent neurovascular structures. --Patients who have neurologic signs or symptoms should undergo a brain imaging study (CT or MRI). --Screening for extrathoracic disease is not necessary in asymptomatic patients who have clinical stage I or II disease.

Seeking a home for a PET, part 2: Defining the appropriate place for positron emission tomography imaging in the staging of patients with suspected lung cancer

In patients who have a high likelihood of having lung cancer, there is little role for positron emission tomography (PET) imaging for diagnosis of the primary lesion. The primary impact of PET imaging is in extrathoracic staging, but it should not replace a clinical evaluation by a physician experienced in lung cancer. PET imaging is most useful for confirmation of the presumed extrathoracic stage in patients with intermediate stages of lung cancer. The role of PET imaging is limited in patients with strong clinical signs of metastatic disease, or in patients with a clinical stage I lung cancer and a negative clinical evaluation. With regard to intrathoracic staging, PET imaging has a definite role in communities in which mediastinoscopy is not available, whereas the impact is limited in institutions in which invasive mediastinal staging is available. The data suggest that a positive PET result in the mediastinum should be confirmed by biopsy. A mediastinoscopy is also reasonable in patients with clinical stage III lung cancer who have no mediastinal PET uptake. It is unclear and controversial whether a biopsy is needed in patients with clinical stage II lung cancer who have no PET uptake in the mediastinum.

The noninvasive staging of non-small cell lung cancer: the guidelines

Correctly staging lung cancer is extremely important because the treatment options and the prognosis differ significantly by stage. Several noninvasive imaging studies are available to aid in identifying disease both within and outside of the chest. Chest CT scanning is useful in providing anatomic detail that better identifies the location of the tumor, its proximity to local structures, and whether or not lymph nodes in the mediastinum are enlarged. Unfortunately, the accuracy of chest CT scanning in differentiating benign from malignant lymph nodes in the mediastinum is unacceptably low. Whole-body positron emission tomography (PET) scanning provides functional information on tissue activity and has much better sensitivity and specificity than chest CT scanning for staging lung cancer in the mediastinum. In addition, metastatic disease can be detected by PET scan. Still, positive findings of PET scans can occur from nonmalignant etiologies (eg, infections), so that tissue sampling to confirm the suspected malignancy must be performed. The clinical evaluation tool, which is composed of a thorough history and physical examination, remains the best predictor of metastatic disease. If the findings from the clinical evaluation are negative, then imaging studies such as a CT scan of the head, a bone scan, or an abdominal CT scan are unnecessary, and the search for metastatic disease is complete. If signs, symptoms, or findings from the physical examination suggest the presence of malignancy, then sequential imaging, starting with the most appropriate study based on the clues obtained by the clinical evaluation, should be performed. Abnormalities detected by all of the aforementioned imaging studies are not always cancer. Unless overwhelming evidence of metastatic disease is present on an imaging study, in situations in which it will make a difference in treatment, all abnormal scan findings require tissue confirmation of malignancy so that patients are not precluded from having potentially curative surgery.

Effectiveness of positron emission tomography in the preoperative assessment of patients with suspected non-small-cell lung cancer: the PLUS multicentre randomised trial

BACKGROUND

Up to 50% of curative surgery for suspected non-small-cell lung cancer is unsuccessful. Accuracy of positron emission tomography (PET) with 18-fluorodeoxyglucose (18FDG) is thought to be better than conventional staging for diagnosis of this malignancy. Up to now however, there has been no evidence that PET leads to improved management of patients in routine clinical practice. We did a randomised controlled trial in patients with suspected non-small-cell lung cancer, who were scheduled for surgery after conventional workup, to test whether PET with 18FDG reduces number of futile thoracotomies.

METHODS

Before surgery (mediastinoscopy or thoracotomy), 188 patients from nine hospitals were randomly assigned to either conventional workup (CWU) or conventional workup and PET (CWU+PET). Patients were followed up for 1 year. Thoracotomy was regarded as futile if the patient had benign disease, explorative thoracotomy, pathological stage IIIA-N2/IIIB, or postoperative relapse or death within 12 months of randomisation. The primary outcome measure was futile thoracotomy. Analysis was by intention to treat.

FINDINGS

96 patients were randomly assigned CWU and 92 CWU+PET. Two patients in the CWU+PET group did not undergo PET. 18 patients in the CWU group and 32 in the CWU+PET group did not have thoracotomy. In the CWU group, 39 (41%) patients had a futile thoracotomy, compared with 19 (21%) in the CWU+PET group (relative reduction 51%, 95% CI 32-80%; p=0.003).

INTERPRETATION

Addition of PET to conventional workup prevented unnecessary surgery in one out of five patients with suspected non-small-cell lung cancer.

Toward less futile surgery in non-small cell lung cancer? A randomized clinical trial to evaluate the cost-effectiveness of positron emission tomography

Non-small cell lung cancer can be cured if the patient is medically operable and the tumor resectable. Current diagnostic strategies are aimed to detect tumor deposits that preclude resection with curative intent. However, these strategies are rather inefficient, resulting in a large number of futile invasive procedures. In the early 1990s positron emission tomography (PET) showed promising results at its introduction in the clinic, especially in oncology. A large number of accuracy studies have reported that PET is superior to conventional imaging. However, whether PET ultimately improves patient outcome should ideally be assessed by means of a randomized controlled trial. No such design has been applied to evaluate PET in oncology so far. The PLUS study was designed to compare the current strategy of conventional methods with a strategy where PET was added after completion of noninvasive techniques. Patients considered operable by the physician at this point were then randomly assigned to PET and further consequences or to standard procedures of mediastinoscopy or thoracotomy. Primary outcome events were futile thoracotomies. The trial randomized 188 patients from nine hospitals in 1 year. Patient enrollment has been stopped and data collection is in progress. The results will be published in 2001. Control Clin Trials 2001;22:89-98