"We should...stop performing routine PET scans for all patients with advanced cancer," Dr. Jelle Ruurda of University Medical Center Utrecht told Reuters Health by email. "FDG-PET/CT has limited additive value, but staging laparoscopy (SL) adds considerably to the staging process."
A guideline revision is under way, according to Dr. Ruurda. "Usually this takes a very long time," he said, "but we intend to have it revised on this topic within half a year."
As reported in JAMA Surgery, Dr. Ruurda and colleagues analyzed outcomes of 394 patients (mean age, 67.6; 65% men) with locally advanced gastric cancer. All underwent an FDG-PET/CT and/or SL in addition to initial staging, and most underwent both.
The treatment intent changed from curative to palliative in 65 patients (16%) based on the additional FDG-PET/CT and SL findings. FDG-PET/CT detected distant metastases in 12 (3%), and SL detected peritoneal or locally nonresectable disease in 73 (19%), with an overlap of seven patients (2%).
FDG-PET/CT had a sensitivity of 33% and specificity of 97% in detecting distant metastases.
Secondary findings (mainly gastrointestinal) on FDG/PET were detected in 83 patients (22%), which led to additional examinations in 60 (16%). A second primary tumor was confirmed in seven of the 83 patients (8%) - three colon, two lung, and two prostate cancers - but follow-up was not reported for most of this group.
SL had a sensitivity for detection of macroscopically peritoneal metastases of 82% and specificity of 78%. It also resulted in a complication requiring reintervention in three patients (0.8%), but no postoperative mortality.
The mean diagnostic delay overall was 19 days.
Dr. Eric Nakakura of the University of California, San Francisco, coauthor of a related editorial, commented in an email to Reuters Health, "The typical CT scan done in the emergency department is a low-resolution picture, just like one taken by a disposable camera. You see a general picture of the target, but nothing is really that clear."
"Once you identify something is amiss, you absolutely need the best imaging possible--the professional camera with megapixel resolution, telephoto lens, and high-tech lighting--a high resolution CT," he said. "This is not automatic, and most clinicians don't realize this. I am surprised that most clinicians think a CT is a CT. But you need to specify you want a multiphase, high-resolution CT in order to get it."
"Also, most clinicians don't realize a PET-CT typically includes a noncontrast CT, (which) is like a low-resolution black and white photo that provides limited detail," he said. "It does require a bit of communication and resources to get a concomitant multiphase, high-resolution CT (megapixel resolution, a telephoto lens, and high-tech flash) with the PET... I'm surprised that that medical world is completely oblivious to this problem, or doesn't really care to point it out."
Further, he added, "Most clinicians don't look at the CT images themselves; they rely on the written reports. Therefore, they have no clue if the picture is low-resolution or fuzzy because the reports don't comment on it. This is a big problem in how we assess our patients, and I hoped to point it out in this commentary."
SOURCE: https://bit.ly/3BMEmFt and https://bit.ly/3mJPxub JAMA Surgery, online October 27, 2021.
By Marilynn Larkin
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