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OBJECTIVES To assess the false-negative (FN) rate of positron emission tomography (PET)-chest computed tomography (CT) scan in clinical non-central cIA and cIB non-small-cell lung cancer (NSCLC) for mediastinal staging. METHODS Between January 2007 and December 2010, 402 patients with potentially operable NSCLC were assessed by thoracic CT scan and 18-fluoro-2-deoxy-d-glucose PET-CT for mediastinal staging and to detect extrathoracic metastases, of which 153 surgically treated patients (79 cIA and 74 cIB cases) were prospectively included in the study. Central tumours were excluded on the basis of CT scan criteria, defined as contact with the intrapulmonary main bronchi, pulmonary artery, pulmonary veins or the origin of the first segmental branches. CT scan was considered negative if lymph nodes were <1 cm at the smaller diameter. 18FDG PET-CT was considered negative when the high maximum standard uptake value (SUVmax) was <2.5. Non-invasive surgical staging was carried out in this group, and curative resection plus systematic mediastinal dissection was performed except in the event of unexpected oncological contraindication. RESULTS Composite non-invasive staging (CT scan, PET-CT) showed a negative predictive value (NPV) of 92% (CI 83.6–96.8) in the cIA group and 85% (CI 74–92) in the cIB group. There were 6 of 79 (7.6%) false-negatives (FNs) in cIA and 11 of 74 (14.8%) in cIB. Multilevel pN2 were detected in four cases, all of them in the cIB group. The most frequently involved N2 was subcarinal (two cases) in cIA and right lower paratracheal (R4) and seven (five cases) in cIB. Occult (pN2) lymph nodes were more frequent in tumour sizes ≥5 cm (pT2b, nine cases, four FNs, P = 0.03), pN1, adenocarcinoma [excluding minimally invasive adenocarcinoma (MIA) and lepidic predominant growth (LPA)] (P = 0.029) and female patients, but no other risk factors for mediastinal metastases were identified (age, clinical stage, tumour location, central or peripheral, P > 0.05). Multilevel pN2 was significantly more frequent in the cIB group (P < 0.03). In pT ≤ 1 cm (T1a), NPV was significantly better (NPV = 100%, P < 0.05) than the other subgroups studied (IA > 1 cm and IB). CONCLUSIONS Composite results for non-invasive mediastinal staging (CT scan, PET-CT) showed 11% of FNs in cI stage (7.6% in non-central cIA and 14.8% in cIB). In tumours ≤1 cm, NPV makes surgical staging unnecessary. In women with adenocarcinoma and non-central cIB, however, the high FN rate makes invasive staging necessary, particularly in pT2b to decrease the incidence of unexpected pN2 in thoracotomy. [ABSTRACT FROM PUBLISHER]

Abstract: Objective: To study the outcomes of broncho±angioplastic sleeve lobectomy (SL) versus pneumonectomy (PN), and the PN:SL ratio after an aggressive policy of parenchyma-sparing surgery to improve postoperative complications rate and long-term quality of life (QoL). Methods: A prospective study was conducted in 490 patients with non-small cell lung cancer between 2005 and 2009. All patients not suitable for standard lobectomy were scheduled for SL, if possible, or for PN; eight patients with functional impairment were directly scheduled for SL. Results: Of 76 procedures, 21 (4%) were PN and 55 (11%) SL (29 bronchoplastic, seven bronchovascular, seven angioplastic; 11 extended to more than one lobe). There were no surgical, oncological or physiological preoperative differences between the groups. The 5-year PN:SL ratio was 1:2.6 (2005: 1:2.1; 2006: 1:2.6; 2007: 1:3.6; 2008: 1:3; 2009: 1:3.5). SL and PN mortality were 2 (3.6%) and 1 (5%), respectively. Postoperative complications occurred in 18 (32%) SL and 7 (33%) PN patients. pN1 (p =0.04), vascular reconstruction and upper-left SL were risk factors for postoperative complications of SL (p =0.03) but were not detected as a mortality risk. Overall 5-year survival was 61% for SL and 31% for PN. Survival at 5 years was significantly higher for SL (p =0.03, Kaplan–Meier). Age <70 years and SL were positive factors for long-term survival. In multivariate modelling, both remained positive factors. Surviving PN patients experienced significantly greater loss of respiratory function and lower QoL than those who avoided this surgery (preoperative score, PN vs SL: 52 vs 51; 3 months, 41 vs 43; and 6 months, 42 vs 51, p =0.04). The adjuvant treatment complement was higher in SL at 34 (62%) than at PN 10 (47%). The side effects of this treatment were more frequent in patients with more extirpated parenchyma (p =0.04). Conclusions: Parenchyma-sparing procedures can reduce the PN rate to less than 10%. A PN:SL index lower than 1:1.5 as a quality standard in a specialised thoracic unit should encourage the use of broncho-angioplastic procedures and improve patient outcomes. Long-term survival, QoL, postoperative lung function test and tolerance of adjuvant therapies are significantly better after SL than PN intervention. [Copyright &y& Elsevier]

Abstract: Objective: This study sought to assess the real incidence of pN2 among patients with non-small-cell lung cancer (NSCLC) (cN0) with negative mediastinal uptake of 2-deoxy-2-(18F)-fluoro-o-glucose (FDG). Methods: During 30 consecutive months (January 2007–May 2009), all patients with NSCLC scheduled for surgery in our unit had a preoperative FDG-positron emission tomography (PET)/computed tomography (CT) in our institution, after a dedicated chest CT (n =259). Only patients with both FDG-PET/CT and negative dedicated chest CT scan (N1 and N2 nodes <1cm) were prospectively included (n =125). Patients with cN1/cN2/cN3 and patients who had undergone preoperative chemo-radiotherapy were excluded. No invasive surgical staging was carried out in this group and curative resection plus systematic mediastinal dissection was performed except in the event of unexpected oncological contraindication. All variables were collected prospectively and, when pathological information was obtained, all the cases were carefully reviewed. Results: Mediastinal assessment by FDG-PET/CT, negative predictive value (NPV) was 85.6%, confidence interval (CI): [77–91]; false negatives (FNs) for mediastinal lymph nodes involvement was 14.4% (18 cases). The pN2 stations most frequently involved were: 4R (six cases), seven (six cases) and five (five cases). Multiple-level pN2 occurred in six (4.8%) cases. Occult (pN2) lymph nodes were more frequent in women (p <0.01), adenocarcinoma (p <0.05) and pN1 (p <0.05). Pathological N2 prevalence for pN1 was 34 (27.7%). Considering pathological staging as the gold standard, the agreement was 70% and 47.5% for stage IA and IB (Kappa''s index: 0.72 and 0.76) and, in all patients, 47% (Kappa''s index: 0.27). In general, down-staging is more frequent than up-staging. Conclusions: Mediastinal staging of NSCLC by FDG-PET/CT showed a considerable incidence of FNs. NPV is lower than previously reported and the preoperative mediastinal staging by 18FDG-PET/CT may jeopardise the accurate treatment for early stage NSCLC patients. [Copyright &y& Elsevier]