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Correspondence |

Impact of Positron Emission Tomography on Clinical Decision Making FREE TO VIEW

Gustavo A. Heresi, MD; Peter J. Mazzone, MD, MPH, FCCP; James K. Stoller, MD, MS, FCCP
Author and Funding Information

Cleveland Clinic Foundation, Cleveland, OH

Correspondence to: Gustavo A. Heresi, MD, Department of Pulmonary, Allergy and Critical Care Medicine/A90, 9500 Euclid Ave, Cleveland, OH 44195; e-mail: heresig@ccf.org



Chest. 2006;130(1):300-301. doi:10.1378/chest.130.1.300-a
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To the Editor:

We read with interest the article by Sachs and Bilfinger (August 2005)1 on the impact of positron emission tomography (PET) on clinical decision making in an academic lung cancer center and wish to comment regarding the consistency of the data and also on the generalizability of the findings. In calculating the false-positive rate of PET for the primary site, the authors grouped together both positive and indeterminate results (ie, any nonzero standardized uptake value [SUV]). This grouping was undertaken to “subject PET scan to the most rigorous standard of accuracy.” However, to calculate the positive predictive value (PPV) of PET, they considered only positive results (ie, >2.5 SUV), thus quoting a PPV of 87.3%. We suggest that this estimate of PPV is confusing, because if one calculates the PPV using the provided false-positive rate, the PPV of PET is 63.3%. Recognizing that these different estimates reflect different inclusion criteria, we submit that the lower estimates for the false-positive rate and PPV warrant mention.

Also, according to Table 1, the number of patients who had an indication for PET scan and did not actually receive a scan was 65. However, according to the numbers provided in the text of the article, only 55 patients did not undergo PET scanning. Because only patients who underwent PET were analyzed, this discordance does not impact the overall results. Yet, we believe that the reader should be aware of this discordance and that this warrants discussion regarding reasons (eg, was there an overlap in indications for PET scans in some patients).

Finally, the authors report that PET upstaged 32 patients (16% of the case series), mostly due to detecting N2 disease and extrathoracic malignancy. Current wisdom suggests that PET is not the “gold standard” for detecting mediastinal disease.23 In this context, mediastinoscopy is performed routinely at many institutions, whether or not the PET scan result is positive. Thus, the impact of this PET finding may not be as high as stated. An alternative, prospective way to evaluate the true impact of PET would be to prospectively ask the clinician to commit to a course of action without knowledge of the PET results and then see if the management and/or course changes when PET results are provided. Such a prospective means of evaluation has been used to assess other clinical questions4 when randomizing to testing or not is unrealistic. We suggest that the impact on mediastinal staging of PET is predicated on institutional practice regarding the use of PET and routine mediastinoscopy; thus, we submit that generalizability of the results may vary by practice.

The authors have no conflicts of interest to disclose.

Sachs, A, Bilfinger, TV (2005) The impact of positron emission tomography on clinical decision making in a university-based multidisciplinary lung cancer practice.Chest128,698-703
 
Gonzalez-Stawinski, GV, Lemaire, A, Merchant, F, et al A comparative analysis of positron emission tomography and mediastinoscopy in staging non-small cell lung cancer.J Thorac Cardiovasc Surg2003;126,1900-1905
 
Silvestri, GA, Tanoue, LT, Mitchell, ML, et al The noninvasive staging of non-small cell lung cancer: the guidelines.Chest2003;123(suppl),147S-156S
 
Stoller, JK, Rankin, JA, Reynolds, HY The impact of bronchoalveolar lavage cell analysis on clinicians’ diagnostic reasoning about interstitial lung disease.Chest1987;92,839-843
 

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Tables

References

Sachs, A, Bilfinger, TV (2005) The impact of positron emission tomography on clinical decision making in a university-based multidisciplinary lung cancer practice.Chest128,698-703
 
Gonzalez-Stawinski, GV, Lemaire, A, Merchant, F, et al A comparative analysis of positron emission tomography and mediastinoscopy in staging non-small cell lung cancer.J Thorac Cardiovasc Surg2003;126,1900-1905
 
Silvestri, GA, Tanoue, LT, Mitchell, ML, et al The noninvasive staging of non-small cell lung cancer: the guidelines.Chest2003;123(suppl),147S-156S
 
Stoller, JK, Rankin, JA, Reynolds, HY The impact of bronchoalveolar lavage cell analysis on clinicians’ diagnostic reasoning about interstitial lung disease.Chest1987;92,839-843
 
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