Using pet-ct to Reduce Futile Thoracotomy Rates in Non-Small-Cell Lung Cancer: A Population-Based Review

Background: Combined positron-emission tomography and computed tomography (PET-CT) reduces futile thoracotomy (FT) rates in patients with non-small-cell lung cancer (NSCLC). We sought to identify preoperative risk factors for FT in patients staged with PET-CT. Methods: We retrospectively reviewed all patients referred to the BC Cancer Agency during 2009–2010 who underwent PET-CT and thoracotomy for NSCLC. Patients with clinical N2 disease were excluded. An FT was defined as any of a benign lesion; an exploratory thoracotomy; pathologic N2 or N3, stage IIIB or IV, or inoperable T3 or T4 disease; and recurrence or death within 1 year of surgery. Results: Of the 108 patients who met the inclusion criteria, FT occurred in 27. The main reason for FT was recurrence within 1 year (14 patients) and pathologic N2 disease (10 patients). On multivariate analysis, an Eastern Cooperative Oncology Group performance status greater than 1, a PET-CT positive N1 status, a primary tumour larger than 3 cm, and a period of more than 16 weeks from PET-CT to surgery were associated with FT. N2 disease that had been negative on PET-CT occurred in 21% of patients with a PET-CT positive N1 status and in 20% of patients with tumours larger than 3 cm and non-biopsy mediastinal staging only. The combination of PET-CT positive N1 status and a primary larger than 3 cm had 85% specificity, and the presence of either risk factor had 100% sensitivity, for FT attributable to N2 disease. Conclusions: To reduce FT attributable to N2 disease, tissue biopsy for mediastinal staging should be considered for patients with PET-CT positive N1 status and with tumours larger than 3 cm even with a PET-CT negative mediastinum.