BACKGROUND: Stage III non-small cell lung cancer (NSCLC) is a highly heterogeneous stage due to its subgroups (IIIA-IIIC) comprising both resectable and unresectable tumors. Accurate determination of the extent of the disease is essential for excluding stage IV and choosing the optimal treatment regimen. Whole body positron emission tomography and computed tomography scan (PET/CT) is recommended as an initial staging imaging in locally advanced NSCLC. Despite international guidelines for NSCLC diagnosis and treatment, they are not always adhered to due to various reasons. Even in such a groundbreaking study, the phase 3 trial PACIFIC investigating the efficacy of durvalumab as consolidation therapy in patients with stage III NSCLC PET/CT was not mandatory. With the premise that whole body PET/CT of the trunk is essential for diagnosing stage III NSCLC, we performed a retrospective study evaluating the relationship of the use of PET/CT versus conventional staging with CT of the chest and abdomen, in terms of survival. METHODS: This retrospective study of stage III NSCLC patients used the Czech lung cancer registry LUCAS, which was established in June 2018. As of the data export (up to February 9, 2022), a total of 703 patients were eligible for the analysis. Overall survival (OS) was compared using Kaplan-Meier analysis and a Cox regression model. Continuous variables were tested using the Mann-Whitney test, and categorical variables using the Pearson's Chi-square or Fisher's exact test. RESULTS: A total of 703 patients were included in the cohort with an average age of 69 years. PET/CT was performed on 354 patients, and conventional staging using chest and abdominal CT on 349 patients. The median OS among patients with PET/CT was 20.9 months [95% confidence interval (CI): 18.1-23.7], and it was statistically significantly higher (P<0.001) than among patients without PET/CT, where the median OS was 9.0 months (95% CI: 7.3-10.6). The observed effect of PET/CT was also statistically significant when comparing individual stages (IIIA, IIIB, IIIC). The multivariate Cox model confirmed the use of PET/CT as an independent prognostic factor. The most common reason for omission of PET/CT was the local or time unavailability of the examination. CONCLUSIONS: Omission of PET/CT can mean a significant decrement in survival for the patients in stage III NSCLC, likely due to poor staging and suboptimal treatment. Routine use of PET/CT is strictly recommended for the optimal management of stage III NSCLC patients even outside the high-income countries.

Department of Pneumology and Phthisiology Faculty of Medicine and University Hospital in Pilsen Charles University Pilsen Czech Republic

Department of Pneumology Bulovka Hospital 3rd Faculty of Medicine Charles University Prague Czech Republic

Department of Pulmonology University Hospital Motol 2nd Faculty of Medicine Charles University Prague Czech Republic

Department of Respiratory Diseases Faculty of Medicine and University Hospital Brno Masaryk University Brno Czech Republic

Department of Respiratory Medicine Thomayer Hospital 1st Faculty of Medicine Charles University Prague Czech Republic

Department of Respiratory Medicine University Hospital Olomouc Faculty of Medicine and Dentistry Palacky University Olomouc Czech Republic

Department of Social and Clinical Pharmacy Faculty of Pharmacy in Hradec Kralove Charles University Hradec Kralove Czech Republic

OAKS Consulting s r o Prague Czech Republic

Pulmonary Department University Hospital Hradec Kralove Faculty of Medicine in Hradec Kralove Charles University Hradec Kralove Czech Republic

Zobrazit více v PubMed

SVOD. SVOD Report - Diagnóza C34 – ZN průdušky - bronchu a plíce [Internet]. [cited 2023 Aug 8]. Available online: https://www.svod.cz/report.php?diag=C34

Sahiner I, Vural GU. Positron emission tomography/computerized tomography in lung cancer. Quant Imaging Med Surg 2014;4:195-206. PubMed PMC

Owens C, Hindocha S, Lee R, et al. The lung cancers: staging and response, CT, (18)F-FDG PET/CT, MRI, DWI: review and new perspectives. Br J Radiol 2023;96:20220339. 10.1259/bjr.20220339 PubMed DOI PMC

Farsad M. FDG PET/CT in the Staging of Lung Cancer. Curr Radiopharm 2020;13:195-203. 10.2174/1874471013666191223153755 PubMed DOI PMC

National Comprehensive Cancer Network. NSCLC and SCLC guideline (version 3.2023). [Internet]. 2005 [cited 2023 Aug 8]. Available online: https://www.nccn.org/guidelines/category_1

Vilstrup MH, Torigian DA. [18F]Fluorodeoxyglucose PET in Thoracic Malignancies. PET Clin 2014;9:391-420, v. 10.1016/j.cpet.2014.06.002 PubMed DOI

Volpi S, Ali JM, Tasker A, et al. The role of positron emission tomography in the diagnosis, staging and response assessment of non-small cell lung cancer. Ann Transl Med 2018;6:95. 10.21037/atm.2018.01.25 PubMed DOI PMC

Dondi F, Albano D, Bellini P, et al. Prognostic role of baseline (18)F-FDG pet/CT in stage I and stage ii non-small cell lung cancer. Clin Imaging 2023;94:71-8. 10.1016/j.clinimag.2022.11.014 PubMed DOI

Remon J, Soria JC, Peters S, et al. Early and locally advanced non-small-cell lung cancer: an update of the ESMO Clinical Practice Guidelines focusing on diagnosis, staging, systemic and local therapy. Ann Oncol 2021;32:1637-42. 10.1016/j.annonc.2021.08.1994 PubMed DOI

Cao JQ, Rodrigues GB, Louie AV, et al. Systematic review of the cost-effectiveness of positron-emission tomography in staging of non--small-cell lung cancer and management of solitary pulmonary nodules. Clin Lung Cancer 2012;13:161-70. 10.1016/j.cllc.2011.09.002 PubMed DOI

Kukava S, Baramia M. Place and Role of PET/CT in the Diagnosis and Staging of Lung Cancer. In: Jeremić B. editor. Advances in Radiation Oncology in Lung Cancer. Cham: Springer International Publishing; 2022:85-111.

Mielgo-Rubio X, Rojo F, Mezquita-Pérez L, et al. Deep diving in the PACIFIC: Practical issues in stage III non-small cell lung cancer to avoid shipwreck. World J Clin Oncol 2020;11:898-917. 10.5306/wjco.v11.i11.898 PubMed DOI PMC

Antonia SJ, Villegas A, Daniel D, et al. Durvalumab after Chemoradiotherapy in Stage III Non-Small-Cell Lung Cancer. N Engl J Med 2017;377:1919-29. 10.1056/NEJMoa1709937 PubMed DOI

McLoud TC. The role of PET scanning in the evaluation of lung carcinoma. Cancer Imaging 2003;3:83-4.

Hadique S, Jain P, Hadi Y, et al. Utility of FDG PET/CT for assessment of lung nodules identified during low dose computed tomography screening. BMC Med Imaging 2020;20:69. 10.1186/s12880-020-00469-0 PubMed DOI PMC

Hicks RJ, Kalff V, MacManus MP, et al. (18)F-FDG PET provides high-impact and powerful prognostic stratification in staging newly diagnosed non-small cell lung cancer. J Nucl Med 2001;42:1596-604. PubMed

Gregory DL, Hicks RJ, Hogg A, et al. Effect of PET/CT on management of patients with non-small cell lung cancer: results of a prospective study with 5-year survival data. J Nucl Med 2012;53:1007-15. 10.2967/jnumed.111.099713 PubMed DOI

Bissonnette JP, Sun A, Grills IS, et al. Non-small cell lung cancer stage migration as a function of wait times from diagnostic imaging: A pooled analysis from five international centres. Lung Cancer 2021;155:136-43. 10.1016/j.lungcan.2021.03.017 PubMed DOI

Sharma R, Tripathi M, D'Souza M, et al. The importance of 18F-FDG PET/CT, CT and X-rays in detecting primary stage III A lung cancer and the incidence of extra thoracic metastases. Hell J Nucl Med 2009;12:22-5. PubMed

Fischer B, Lassen U, Mortensen J, et al. Preoperative staging of lung cancer with combined PET-CT. N Engl J Med 2009;361:32-9. 10.1056/NEJMoa0900043 PubMed DOI

Chen WM, Chen M, Hsu JG, et al. Use of Preoperative FDG PET/CT and Survival of Patients with Resectable Non-Small Cell Lung Cancer. Radiology 2022;305:219-27. 10.1148/radiol.212798 PubMed DOI

Greenspan BS. Role of PET/CT for precision medicine in lung cancer: perspective of the Society of Nuclear Medicine and Molecular Imaging. Transl Lung Cancer Res 2017;6:617-20. 10.21037/tlcr.2017.09.01 PubMed DOI PMC

Vella M, Meyer CS, Zhang N, et al. Association of Receipt of Positron Emission Tomography-Computed Tomography With Non-Small Cell Lung Cancer Mortality in the Veterans Affairs Health Care System. JAMA Netw Open 2019;2:e1915828. 10.1001/jamanetworkopen.2019.15828 PubMed DOI PMC

van Tinteren H, Hoekstra OS, Smit EF, et al. Effectiveness of positron emission tomography in the preoperative assessment of patients with suspected non-small-cell lung cancer: the PLUS multicentre randomised trial. Lancet 2002;359:1388-93. 10.1016/S0140-6736(02)08352-6 PubMed DOI

Krákorová G. Diagnostic and therapeutic guidelines for stage III non-small-cell lung cancer. Onkologie 2016;10:11-4. 10.36290/xon.2016.004 DOI

John A, Yang B, Shah R. Clinical Impact of Adherence to NCCN Guidelines for Biomarker Testing and First-Line Treatment in Advanced Non-Small Cell Lung Cancer (aNSCLC) Using Real-World Electronic Health Record Data. Adv Ther 2021;38:1552-66. 10.1007/s12325-020-01617-2 PubMed DOI PMC

Sterbis E, Liang R, Trivedi P, et al. Lack of Adherence to Guideline-Based Imaging Before Subsequent Radiation in Patients with Non-Small Cell Lung Cancer: Impact on Patient Outcomes. J Nucl Med 2023;64:75-81. 10.2967/jnumed.122.264131 PubMed DOI PMC