Test Performance of Positron Emission Tomography and Computed Tomography for Mediastinal Staging in Patients with Non–Small-Cell Lung Cancer

A Meta-Analysis

  1. Michael K. Gould, MD, MS;
  2. Ware G. Kuschner, MD;
  3. Chara E. Rydzak, BA;
  4. Courtney C. Maclean, BA;
  5. Anita N. Demas, MD;
  6. Hidenobu Shigemitsu, MD;
  7. Jo Kay Chan, BS; and
  8. Douglas K. Owens, MD, MS
  1. From Veterans Affairs Palo Alto Health Care System, Palo Alto, and Stanford University School of Medicine, Stanford, California.

    Abstract

    Purpose: To compare the diagnostic accuracy of computed tomography (CT) and positron emission tomography (PET) with 18-fluorodeoxyglucose (FDG) for mediastinal staging in patients with non–small-cell lung cancer and to determine whether test results are conditionally dependent (the sensitivity and specificity of FDG-PET depend on the presence or absence of enlarged mediastinal lymph nodes on CT).

    Data Sources: Computerized search of MEDLINE, EMBASE, BIOSIS, and CancerLit through March 2003 and reference lists of retrieved studies and review articles.

    Study Selection: Studies in any language that examined FDG-PET for mediastinal staging in patients with known or suspected non–small-cell lung cancer, enrolled at least 10 participants (including at least 5 participants with mediastinal metastasis), and provided enough data to permit calculation of sensitivity and specificity for identifying lymph node involvement.

    Data Extraction: One reviewer (of non-English-language studies) or 2 reviewers (of English-language studies) independently evaluated studies for inclusion, rated methodologic quality, and abstracted relevant data.

    Data Synthesis: Thirty-nine studies met inclusion criteria. Methodologic quality varied, but few aspects of study quality affected diagnostic accuracy. The authors constructed summary receiver-operating characteristic curves for CT and FDG-PET. Positron emission tomography with 18-fluorodeoxyglucose was more accurate than CT for identifying lymph node involvement (P < 0.001). For CT, median sensitivity and specificity were 61% (interquartile range, 50% to 71%) and 79% (interquartile range, 66% to 89%), respectively. For FDG-PET, median sensitivity and specificity were 85% (interquartile range, 67% to 91%) and 90% (interquartile range, 82% to 96%), respectively. Fourteen studies provided information about the conditional test performance of CT and FDG-PET. Positron emission tomography with 18-fluorodeoxyglucose was more sensitive but less specific when CT showed enlarged lymph nodes (median sensitivity, 100% [interquartile range, 90% to 100%]; median specificity, 78% [interquartile range, 68% to 100%]) than when CT showed no lymph node enlargement (median sensitivity, 82% [interquartile range, 65% to 100%]; median specificity, 93% [interquartile range, 92% to 100%]; P = 0.002).

    Conclusions: Positron emission tomography with 18-fluorodeoxyglucose is more accurate than CT for mediastinal staging. Positron emission tomography with 18-fluorodeoxyglucose is more sensitive but less specific when CT shows enlarged mediastinal lymph nodes.

    Article and Author Information

    • Disclaimer: The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.

    • Acknowledgments: The authors thank Jean-Dominique Delcroix, PhD, Eran Geller, MD, MS, Eric Hsiao, MD, and Annette Langer-Gould, MD, for reviewing non-English-language studies; James Fletcher, MD, Ann Leung, MD, and George Segall, MD, for helping to develop criteria for the technical quality of CT and FDG-PET; Christopher Stave, MLS, and Elaine Alligood, MLS, for assisting with literature searches; and Dena Bravata MD, MS, Lincoln Moses, PhD, and Trevor Hastie, PhD, for providing statistical advice.

    • Grant Support: Drs. Gould and Owens received Research Career Development Awards from the Veterans Affairs Health Services Research and Development Service. This study was also supported by Veterans Affairs Cooperative Study 27, “18-F-Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) Imaging for Management of Patients with Solitary Pulmonary Nodules.”

    • Potential Financial Conflicts of Interest: None disclosed.

    • Requests for Single Reprints: Michael K. Gould, MD, MS, Pulmonary Section (111P), Veterans Affairs Palo Alto Health Care System, 3801 Miranda Avenue, Palo Alto, CA 94304; e-mail, gould{at}stanford.edu.

    • Current Author Addresses: Drs. Gould and Kuschner: Veterans Affairs Palo Alto Health Care System (111P), 3801 Miranda Avenue, Palo Alto, CA 94304.

    • Ms. Rydzak: 201 Rawson Road #3, Brookline, MA 02445.

    • Ms. Maclean: 2614 Cedar Creek Drive, Durham, NC 27705.

    • Dr. Demas: 2330 Post Street, Suite 460, San Francisco, CA 94115.

    • Dr. Shigemitsu: Veterans Affairs Medical Center (111), 1030 Jefferson Avenue, Memphis, TN 38104.

    • Ms. Chan and Dr. Owens: Center for Primary Care and Outcomes Research, 117 Encina Commons, Stanford, CA 94305-6019.

    • Author Contributions: Conception and design: M.K. Gould, D.K. Owens.

    • Analysis and interpretation of the data: M.K. Gould, W.G. Kuschner, C.E. Rydzak, C.C. Maclean, H. Shigemitsu, D.K. Owens.

    • Drafting of the article: M.K. Gould, D.K. Owens.

    • Critical revision of the article for important intellectual content: M.K. Gould, W.G. Kuschner, C.E. Rydzak, C.C. Maclean, A.N. Demas, H. Shigemitsu, D.K. Owens.

    • Final approval of the article: M.K. Gould, W.G. Kuschner, C.E. Rydzak, C.C. Maclean, A.N. Demas, H. Shigemitsu, D.K. Owens.

    • Statistical expertise: M.K. Gould, D.K. Owens.

    • Obtaining of funding: M.K. Gould, D.K. Owens.

    • Administrative, technical, or logistic support: C.E. Rydzak, A.N. Demas, J.K. Chan.

    • Collection and assembly of data: M.K. Gould, W.G. Kuschner, C.E. Rydzak, C.C. Maclean, A.N. Demas, J.K. Chan.

    Summary for Patients

    • Summaries for Patients:Detecting Spread of Non–Small-Cell Lung Cancer within the Chest Ann Intern Med December 2, 2003 139:I-18
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    1. Ann Intern Med December 2, 2003 vol. 139 no. 11 879-892
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