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FDG-PET in Addition to Conventional Work-Up in Non–Small-Cell Lung Cancer

Comprehensive Cancer Centre Amsterdam, Amsterdam, the Netherlands

Egbert F. Smit, Otto S. Hoekstra

Departments of Pulmonology and Nuclear Medicine, Free University Medical Center, Amsterdam, The Netherlands

To the Editor:

With great interest we read the recent article by Viney et al,¹ which reported on the results of a randomized controlled trial (RCT) of the role of positron emission tomography (PET) in the management of operable non–small-cell lung cancer (NSCLC). Earlier, the results of the PLUS study² were reported, a second RCT on the role of PET in NSCLC. Both studies were presented at the 36th Annual Meeting of the American Society of Clinical Oncology in New Orleans, LA, May 20-23, 2000. Since that time, the results of these studies have often been presented as being at variance. A closer look at the study of Viney et al reveals that the major difference between their study and the PLUS study is the definition of the term "avoided/futile thoracotomy." Whereas in the PLUS study objective criteria were applied (ie, benign disease, T4 lesion, macroscopic mediastinal–lymph-node involvement, distant metastatic disease at follow-up, or exploratory thoracotomy for any other reason), in the study of Viney et al a very pragmatic approach was followed by taking the surgeon’s initiative as the correct diagnosis-therapy decision (gold standard). There is no posterior evaluation of the appropriateness of the thoracotomy because no systematic follow-up information is available. In addition, no differentiation in stage IIIA patients is made, whereas, at the time when both studies were active, stage IIIA/N2 was considered inoperable by international consensus.³ Finally, no results are given for the conventional work-up, and therefore the quality cannot be evaluated.

In randomized studies of diagnostic interventions, two aspects are of major importance: the transparent definition of the end point and the quality of conventional work-up. Unlike therapy trials where the patients’ situation is directly affected by the intervention and its effect as such measurable, the justification for a diagnostic device is a worthwhile change in therapy decision based on additional information. Justification of that change in management should come from either histology or—in case histology is not available—from some other measure of proof, like information from follow-up. Moreover, because standards of conventional work-up may differ between centers and countries, to be able to interpret the results it is important to describe how good the (standard) results are, and not to rely on the surgeon’s opinion only. In this respect, the results of the study of Viney et al leave us with many questions and too few data to compare with our results.

Authors’ Disclosures of Potential Conflicts of Interest

The authors indicated no potential conflicts of interest.

REFERENCES

1. Viney RC, Boyer MJ, King MT, et al: Randomized controlled trial of the role of positron emission tomography in the management of stage I and II non–small-cell lung cancer. J Clin Oncol 22:2357-2362, 2004[Abstract/Free Full Text]

2. van Tinteren H, Hoekstra OS, Smit EF, et al: Effectiveness of positron emission tomography in the pre-operative assessment of patients with suspected non-small cell lung cancer: The ‘PLUS’ multi-centre randomised trial. Lancet 359:1388-1393, 2002[CrossRef][Medline]

3. Ettinger DS, Cox JD, Ginsberg RJ, et al: NCCN non-small-cell lung cancer practice guidelines: The National Comprehensive Cancer Network. Oncology (Huntingt) 10:81-111, 1996 (suppl 11)

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