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Communications to the Editor |

Prediction by Positron Emission Tomography Scanning of Survival in Non-small Cell Lung Cancer Prediction by Positron Emission Tomography Scanning of Survival in Non-small Cell Lung Cancer FREE TO VIEW

Angel López-Encuentra, MD, PhD
Author and Funding Information

Affiliations: Hospital Universitario 12 de Octubre Madrid, Spain,  Wake Forest University School of Medicine Winston-Salem, NC Johns Hopkins School of Medicine Baltimore, MD

Correspondence to: Angel López-Encuentra, MD, PhD, Pneumology Service, Hospital Universitario 12 de Octubre, Crrta. Andalucía 5.4 28041, Madrid, Spain



Chest. 2001;120(6):2113. doi:10.1378/chest.120.6.2113
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To the Editor:

In the work by Dunagan and coauthors (February 2001),1 a very interesting aspect is addressed regarding the utilization of positron emission tomography in patients with non-small cell lung cancer: its possible prognostic value. These authors consider surgical-pathologic staging as the “gold standard” of the classification.

For an accurate interpretation of their data, it would be important to know which procedure was used for intraoperative nodal staging: sampling or systematic nodal dissection?

Another aspect of interest would be the survival noted at 3 years after the surgery, depending on the stage (Table 5; Fig 1). Survival at 3 years for surgical-pathologic stages I, II, and III is 30.8%, 39.4%, and 30%, respectively, which differs to a great extent from the prognostic spectrum described in the 1997 International Staging System.2 How can that prognosis identity be explained among the three stages? Moreover, when considering the surgical-pathologic staging as the “gold standard,” how can these results on survival influence the possible overvaluation of positron emission tomography as a prognostic factor?

Dunagan, DP, Chin, R, McCain, TW, et al (2001) Staging by positron emission tomography predicts survival in patients with non-small cell lung cancer.Chest119,333-339. [PubMed] [CrossRef]
 
Mountain, CF Revisions in the International System for Staging Lung Cancer.Chest1997;111,1710-1717. [PubMed]
 

Prediction by Positron Emission Tomography Scanning of Survival in Non-small Cell Lung Cancer

To the Editor:

We greatly appreciate Dr. Lopez-Encuentra’s interest in our report. Dr. Lopez-Encuentra queries our method of mediastinal surgical staging. Intraoperative staging was performed primarily by mediastinal nodal sampling, with the surgical approach (mediastinoscopy, anterior mediastinotomy, thoracotomy), as determined appropriate for the selected site of nodal involvement. Bronchoscopic transbronchial needle aspiration (TBNA) was used to confirm mediastinal nodal metastasis of disease in patients who did not undergo surgical staging. In general, surgical staging was performed in patients with negative TBNA findings or nodes unamenable to this approach.

Dr. Lopez-Encuentra also correctly notes that our survival statistics at 3 years for surgical-pathologic stages II, III, and IV were similar. As noted, the number of patients with pathologic stages II (n = 13) and IV (n = 6) disease in our study was relatively small. We believe that the differences in survival rates, relative to those represented in the 1997 International Staging System, may be skewed by the small number of patients in each of these stages. The survival of our patients with stage III (n = 24) disease matches well with the 1997 International Staging System.

We share concerns regarding the potential for an overvaluation of positron emission tomography (PET) as a prognostic factor. Because CT more often overstaged (41%) and PET understaged (27%) the extent of pathologically confirmed disease, PET may be less likely to lead to the inappropriate denial of potentially curative surgery. Surgical-pathologic staging was used as a “gold standard” for determining the performance characteristics of PET only. Kaplan-Meier estimates of survival were based on staging by each modality, independent of the others. We believe that PET scanning is a promising, noninvasive method of staging non-small cell lung cancer (NSCLC) that also provides important prognostic information. As stated in our report, prospective, randomized, controlled trials are needed to confirm these findings, and to determine whether a PET-based management algorithm contributes to better outcomes in patients with NSCLC.


Figures

Tables

References

Dunagan, DP, Chin, R, McCain, TW, et al (2001) Staging by positron emission tomography predicts survival in patients with non-small cell lung cancer.Chest119,333-339. [PubMed] [CrossRef]
 
Mountain, CF Revisions in the International System for Staging Lung Cancer.Chest1997;111,1710-1717. [PubMed]
 
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