Preoperative staging of mesothelioma by 18F-fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography fused imaging and mediastinoscopy compared to pathological findings after extrapleural pneumonectomy
Friday, September 19th, 2008.
European Journal of Cardio-Thoracic Surgery. 2008 Nov;34(5):1090-6. Epub 2008 Sep 16. [Link]
Sørensen JB, Ravn J, Loft A, Brenøe J, Berthelsen AK; Nordic Mesothelioma Group.
Aaseboe U, Billing B, Bjørck T, Brodin O, Brunsvig P, Forsløw U, Frank H, Hansen O, Harving H, Hillerdal G, Jakobsen KD, Johansson A, Ladegaard L, Lindh B, Melgaard P, Mygind N, Månsson T, Palshof T, Sundstrøm S, Sørensen P, Vigander T.
Department of Oncology, Finsen Centre/National University Hospital, Copenhagen, Denmark. jens.benn.soerensen@rh.regionh.dk
Abstract
Objectives: Extrapleural pneumonectomy (EPP) in MPM may be confined with both morbidity and mortality and careful preoperative staging identifying resectable patients is important. Staging is difficult and the accuracy of preoperative CT scan, 18F-FDG PET/CT scan (PET/CT), and mediastinoscopy is unclear. The objectives were to compare these staging techniques to each other and to surgical–pathological findings.
Methods: Patients had epithelial subtype MPM, age ≤70 years, and lung function test allowing pneumonectomy. Preoperative staging after 3–6 courses of induction chemotherapy included conventional CT scan, PET/CT, and mediastinoscopy. Surgical–pathological findings were compared to preoperative findings.
Results: Forty-two consecutive patients were without T4 or M on CT scan. PET/CT showed inoperability in 12 patients (29%) due to T4 (7 patients) and M1 (7 patients). Among 30 patients with subsequent mediastinoscopy, including 10 with N2/N3 on PET/CT, N2 were histologically verified
in 6 (20%). Among 24 resected patients, T4 occurred in 2 patients (8%), and N2 in 4 (17%), all being PET/CT negative. PET/CT accuracy of T4 and N2/N3 compared to combined histological results of mediastinoscopy and EPP showed sensitivity, specificity, positive predictive value, negative predictive value, and positive and negative likelihood ratios of 78% and 50%, 100% and 75%, 100% and 50%, 94% and 75%, not applicable and 5.0, and 0.22 and 0.67, respectively.
Conclusions: Non-curative surgery is avoided in 29% out of 42 MPM patients by preoperative PET/CT and in further 14% by mediastinoscopy. Even though both procedures are valuable, there are false negative findings with both, urging for even more accurate staging procedures.
Keywords: Mesothelioma; Staging; PET/CT scan; Mediastinoscopy; Extrapleural pneumonectomy
Glossary
- staging
- the process of finding out whether cancer has spread and if so, how far. There is more than one system for staging. The TNM system, described below, is one used often. The TNM system for staging gives three key pieces of information: T refers to the size of the Tumor N describes how far the cancer has spread to nearby Nodes M shows whether the cancer has spread (Metastasized) to other organs of the body Letters or numbers after the T, N, and M give more details about each of these factors. To make this information somewhat clearer, the TNM descriptions can be grouped together into a simpler set of stages, labeled with Roman numerals. In general, the lower the number, the less the cancer has spread. A higher number means a more serious cancer.
- scan
- a study using either x-rays or radioactive isotopes to produce images of internal body organs.
- oncology
- (on-call-o-jee) the branch of medicine concerned with the diagnosis and treatment of cancer.
- morbidity
- a measure of the new cases of a disease in a population; the number of people who have a disease.
- mortality
- a measure of the rate of death from a disease within a given population.
- mediastinoscopy
- (me-dee-as-tin-OS-ko-pee) examination of the chest cavity using a lighted tube replaced under the chest bone (sternum). This allows the doctor to see the lymph nodes in this area and remove samples to check for cancer.
- chemotherapy
- (key-mo-THER-uh-pee) treatment with drugs to destroy cancer cells. Chemotherapy is often used with surgery or radiation to treat cancer when the cancer has spread, when it has come back (recurred), or when there is a strong chance that it could recur.
- CT scan
- computed tomography (tom-og-ruh-fee), an imaging test in which many x-rays are taken of a part of the body to produce cross-sectional pictures of internal organs. Except for the injection of a dye (needed in some but not all cases), this is a painless procedure that can be done in an outpatient clinic. It is often referred to as a "CT" or "CAT" scan.
- mesothelioma
- a tumor derived from mesothelial tissue, such as the peritoneum (lining the abdomen) or pleura (lining the lungs). More on mesothelioma.
- extrapleural pneumonectomy
- (EPP) surgery to remove the pleura, diaphragm, pericardium, and entire lung involved with the tumor. You can view a web cast from Brigham and Women's Hospital in Boston of this procedure being done by Dr. David Sugarbaker: see the extrapleural pneumonectomy (EPP) web cast here.
