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Noninvasive Staging of Non-small Cell Lung Cancer^*

ACCP Evidenced-Based Clinical Practice Guidelines (2nd Edition)

^* From the Department of Medicine (Dr. Silvestri), Medical University of South Carolina, Charleston, SC; the Department of Medicine (Dr. Gould), Veterans Affairs Palo Alto Health Care System, Palo Alto, CA; the Department of Medicine (Dr. Margolis), University of Pennsylvania, Philadelphia, PA; the Departments of Medicine (Dr. Tanoue) and Surgery (Dr. Detterbeck), Yale University, New Haven, CT; and the Departments of Medicine (Dr. McCrory) and Surgery (Dr. Toloza), Duke University Medical Center, Durham, NC.

Correspondence to: Gerard A. Silvestri, MD, FCCP, Professor of Medicine, Medical University of South Carolina, Department of Pulmonary and Critical Care Medicine, 171 Ashley Ave, Room 812-CSB, Charleston, SC 29425-2220; e-mail: silvestri{at}musc.edu

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.

Key Words: CT scan • lung cancer • mediastinum • metastases • noninvasive • positron emission tomography • staging

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