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Prospective Comparative Study of Integrated Positron Emission Tomography-Computed Tomography Scan Compared With Remediastinoscopy in the Assessment of Residual Mediastinal Lymph Node Disease After Induction Chemotherapy for Mediastinoscopy-Proven Stage IIIA-N2 Non–Small-Cell Lung Cancer: A Leuven Lung Cancer Group Study

Paul De Leyn, Sigrid Stroobants, Walter De Wever, Toni Lerut, Willy Coosemans, Georges Decker, Philippe Nafteux, Dirk Van Raemdonck, Luc Mortelmans, Kristiaan Nackaerts, Johan Vansteenkiste

From the Department of Thoracic Surgery, Department of Nuclear Medicine, Department of Radiology, and Department of Pneumology, University Hospitals Leuven, Gasthuisberg Leuven, Belgium

Address reprint requests to Paul De Leyn, MD, PhD, Department of Thoracic Surgery, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium; e-mail: Paul.Deleyn{at}uz.kuleuven.ac.be

PURPOSE: Mediastinal restaging after induction therapy for non–small-cell lung cancer remains a difficult and controversial issue. The goal of this prospective study was to compare the performance of integrated positron emission tomography (PET) –computed tomography (CT) and remediastinoscopy in the evaluation of mediastinal lymph node metastasis after induction chemotherapy.

PATIENTS AND METHODS: Thirty consecutive stage IIIA-N2 non–small-cell lung cancer patients surgically treated at our institution were entered onto this prospective study. N2 disease was proven by cervical mediastinoscopy, at which a mean number of 3.8 lymph node levels were biopsied. After completion of induction chemotherapy, the mediastinum was reassessed by integrated PET-CT and remediastinoscopy. All patients underwent thoracotomy with attempted complete resection and systematic nodal dissection.

RESULTS: PET-CT showed no evidence of nodal disease (N0) in 13 patients, Hilar nodal disease (N1) disease in three patients, and residual mediastinal disease (N2) in 14 patients. Remediastinoscopy was positive in only five patients. The preinduction involved lymph node level could be accurately re-evaluated in 18 patients. This was not the case in the other 12 because of extensive fibrosis and adhesions. In 17 patients, persistent N2 disease was found at thoracotomy. The sensitivity, specificity, and accuracy of PET-CT were 77%, 92%, and 83%, respectively. These parameters for remediastinoscopy were 29%, 100%, and 60%, respectively. Sensitivity (P < .0001) and accuracy (P = .012) were significantly better for PET-CT.

CONCLUSION: After a thorough staging mediastinoscopy, postinduction remediastinoscopy had a disappointing sensitivity because of adhesions and fibrosis. Integrated PET-CT yielded a better result than that obtained in previous studies with side-by-side PET and CT images.

Presented in part at the 11th World Conference on Lung Cancer of the International Association for the Study of Lung Cancer, Barcelona, Spain, July 3-6, 2005.

Author's disclosure of potential conflicts of interest and author contributions are found at the end of this article.

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Related Editorial

• Selection of Patients for Surgery After Induction Chemotherapy for N2 Non–Small-Cell Lung Cancer
  Peter Goldstraw
  JCO 2006 24: 3317-3318 [Full Text]

Related Correspondence

• Sensitivity of Remediastinoscopy: Influence of Adhesions, Multilevel N2 Involvement, or Surgical Technique?
  Paul Van Schil and Georgios Stamatis
  JCO 2006 24: 5338 [Full Text]

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