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Role of positron emission tomography-computed tomography in non-small cell lung cancer · PDF file 2017-05-06 · Lung cancer is the leading cause of cancer-related mortality worldwide

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  • Pankaj Kumar Garg, Saurabh Kumar Singh, Gaurav Prakash, Ashish Jakhetiya, Durgatosh Pandey

    Pankaj Kumar Garg, Department of Surgery, University College of Medical Sciences and Guru Teg Bahadur Hospital, University of Delhi, Delhi 110095, India

    Pankaj Kumar Garg, Ashish Jakhetiya, Durgatosh Pandey, Department of Surgical Oncology, Dr BRA Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi 110029, India

    Saurabh Kumar Singh, Department of Pulmonary Medicine, Gajra Raja Medical College and Jaya Arogya Group of Hospitals, Gwalior 474009, India

    Gaurav Prakash, Clinical Hematology and Bone Marrow Trans­ plant unit, Department of Internal Medicine, Post­Graduate Institute of Medical Education and Research, Chandigarh 160012, India

    Author contributions: Garg PK conceptualized the study; Garg PK and Singh SK searched the literature, analyzed the retrieved literature, and wrote the initial draft; Prakash G, Jakhetiya A and Pandey D provided critical inputs in literature search and analysis, and drafting the manuscript; all the authors read the final draft and approved it.

    Conflict-of-interest statement: There is no conflict of interest associated with any of the author.

    Open-Access: This article is an open­access article which was selected by an in­house editor and fully peer­reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY­NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non­commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non­commercial. See: http://creativecommons.org/ licenses/by­nc/4.0/

    Correspondence to: Dr. Pankaj Kumar Garg, Department of Surgery, University College of Medical Sciences and Guru Teg Bahadur Hospital, University of Delhi, Dilshad Garden, Delhi 110095, India. [email protected] Telephone: +91­11­22592536 Fax: +91­11­22590495

    Received: June 23, 2015 Peer-review started: June 23, 2015 First decision: August 16, 2015 Revised: September 8, 2015 Accepted: February 14, 2016 Article in press: February 16, 2016 Published online: March 26, 2016

    Abstract Lung cancer is the leading cause of cancer-related mortality worldwide. Non-small cell carcinoma and small cell carcinoma are the main histological subtypes and constitutes around 85% and 15% of all lung cancer respectively. Multimodality treatment plays a key role in the successful management of lung cancer depending upon the histological subtype, stage of disease, and performance status. Imaging modalities play an impor- tant role in the diagnosis and accurate staging of the disease, in assessing the response to neoadjuvant therapy, and in the follow-up of the patients. Last de- cade has witnessed voluminous upsurge in the use of positron emission tomography-computed tomography (PET-CT); role of PET-CT has widened exponentially in the management of lung cancer. The present article reviews the role of 18-fluoro-deoxyglucose PET-CT in the management of non small cell lung cancer with emphasis on staging of the disease and the assessment of response to neoadjuvant therapy based on available literature.

    Key words: Positron emission tomography; Diagnostic imaging; Neoplasm staging; Carcinoma; Non-small-cell lung cancer; Lung neoplasms

    © The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.

    Core tip: The evidence is evolving for the role of po- sitron emission tomography-computed tomography

    MINIREVIEWS

    105 March 26, 2016|Volume 6|Issue 1|WJM|www.wjgnet.com

    Role of positron emission tomography-computed tomography in non-small cell lung cancer

    Submit a Manuscript: http://www.wjgnet.com/esps/ Help Desk: http://www.wjgnet.com/esps/helpdesk.aspx DOI: 10.5662/wjm.v6.i1.105

    World J Methodol 2016 March 26; 6(1): 105-111 ISSN 2222-0682 (online)

    © 2016 Baishideng Publishing Group Inc. All rights reserved.

    World Journal of MethodologyW J M

  • (PET-CT) in the management of non-small cell lung cancer (NSCLC). Available literature supports the use of PET-CT in the staging of NSCLC to have better disease staging (assessment of mediastinal and extra-thoracic disease). Detection of abnormal mediastinal nodes at various basins is the potential advantage of PET-CT for better targeted biopsy and it may lead to reduction in futile surgical interventions. The role of PET-CT in the prediction and assessment of response to neoadjuvant therapy needs further studies.

    Garg PK, Singh SK, Prakash G, Jakhetiya A, Pandey D. Role of positron emission tomography­computed tomography in non­ small cell lung cancer. World J Methodol 2016; 6(1): 105­111 Available from: URL: http://www.wjgnet.com/2222­0682/full/ v6/i1/105.htm DOI: http://dx.doi.org/10.5662/wjm.v6.i1.105

    INTRODUCTION As per GLOBOCAN 2012 data, lung cancer is the leading cause of cancer related death worldwide; an estimated 1.8 million new lung cancer cases occurred in 2012, accounting for about 13% of total cancer diagnoses[1]. Non-small cell lung carcinoma (NSCLC) and small cell lung carcinoma are the main histological subtypes and constitutes around 85% and 15% of all lung cancer respectively[2]. Multimodality treatment is the key to successful management of lung cancer depending upon the histological subtype, stage of the disease, and perfor- mance status of the patient. Imaging modalities play an important role in the diagnosis and accurate staging of the disease, in assessing the response to the neoadjuvant therapy, and in the follow-up of the patients. The role of positron emission tomography-computed tomography (PET-CT) has widened exponentially during the last decade in the management of solid tumors, and lung cancer is no exception to this trend. In the present article, we review the role of 18-fluoro-deoxyglucose (FDG) PET-CT in the management of NSCLC with emphasis on the staging of the disease and the assessment of the response to neoadjuvant therapy.

    ROLE OF FDG PET-CT IN THE STAGING OF LUNG CANCER Accurate staging is essential in formulating an opti- mal management plan for the patient, predicting the prognosis of the disease, and to evaluate and compare the results of various clinical studies by providing a uniform staging terminology across the centers. Staging of NSCLC incorporates assessment of primary tumor, regional lymph nodes and distant sites. Being a whole- body imaging technique, PET-CT has proved to be an enticing option to assess the loco-regional extent and distant sites in a single non-invasive examination. Moreover, combination of functional and anatomical imaging in a PET-CT examination provides greater

    accuracy in the disease staging.

    Primary tumor A radiologic imaging is required in the assessment of extent of primary tumor. Contrast enhanced computed tomography (CECT) of the chest is traditionally consi- dered the standard imaging modality for delineation of anatomical extent of the primary tumor (Figure 1). At times, magnetic resonance imaging (MRI) is also needed in case of superior sulcus involvement or mediastinal involvement (assessing the relation to heart or great vessels). Because of poor spatial resolution, PET-CT does not offer much advantage over conventional CT/MRI. However, PET-CT has been shown to be superior to CT/ MRI in assessing tumor size when there is associated post-obstructive atelectasis or consolidation[3]. Pawaroo et al[4], in their study of 59 patients of NSCLC, showed that PET was better than CT with either soft-tissue or lung windows in delineating primary NSCLC if surroun- ding collapse or consolidation is present. They cautioned that PET may not be reliable for assessment of alveolar cell carcinoma owing to low FDG accumulation. This is to be highlighted that accurate primary tumor is useful for radiotherapy planning if consolidation or collapse surrounds the primary tumor.

    Another potential advantage of PET-CT over the conventional imaging is its ability to diagnose pleural disease. Though presence of malignant pleural disease confers a M1 disease and precludes curative surgery; post-obstructive pneumonia related benign effusion should not be erroneously diagnosed as malignant. Conventional imaging modalities like CT and MRI are able to detect pleural thickening or nodularity; however, they are limited in their capacity to differentiate malig- nant from benign growths with a reasonable amount of certainty[5]. In an analysis of FDG PET-CT images of 33 lung cancer patients with pleural effusion, Kim et al[6] suggested that FDG PET/CT can be used as a reliable and noninvasive method for the differentiation of malignant and benign pleural disease in patients with NSCLC. Similar results were also reported by Gupta et al[7], they reported PET-FDG imaging is a highly accurate and reliable noninvasive test to differentiate malignant from benign pleural effusion and/or pleural involvement in patients with lung cancer (sensitivity, specificity, and accuracy of 88.8%, 94.1% and 91.4% respectively).

    This is also worth mentioning here that thoracocentesis may not prove to be futile in up to 30%-40% cases of malignant pleural effusion[8]. In malignant pleural effusion, 18F-FDG PET was found to have a sensitivity of 88.8%, a specificity of 94.1%, a positive predictive value of 94.1%, a negative predictive value 88.8% and an accuracy of 91.4%[9]. Schaffler et al[10], evaluated the accuracy of fluorine 18F-FDG PET-CT in differentiation of pleural malignancy and cancer unrelated pleural disease in patients with NSCLC and o

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