Positron emission tomography with 2-[18f]fluoro-2-deoxy-D-glucose: can it be used to accurately stage the mediastinum in non-small cell lung cancer as an alternative to mediastinoscopy?

See related article on page 1900. L ast year national health care costs rose 10%. Health care providers and third-party payers are under increasing pressure to reduce costs yet maintain or even improve quality. So can adding an additional test, such as positron emission tomography (PET), to an already expensive evaluation, such as lung cancer assessment, reduce cost and improve quality? It could, if it reduces unnecessary tests and surgery and accurately directs treatment. Simply, PET is expensive. The high quality, 3-dimensional reconstruction capability, in-computer software systems cost $1.5 to $2.0 million; computed tomography combined systems PET/CT are more than $2.0 million (Sue Ann Halliday, ImageMed Group, LLC, and Barry Siegel, Washington University, St Louis, Mo, personal communications). To provide appropriate space in most medical centers costs an additional $1.5 to $2.0 million. The radiopharmaceutical contrast is also expensive. For the study of lung cancer, most centers use fluorodeoxyglucose F 18 (FDG). It has a brief shelf life, the half-life being 110 minutes. For in-house production, a cyclotron is used that costs $1.0 to $2.0 million. A practical alternative, purchase of commercially made FDG, is approximately $300 to $450 per dose. Thus the initial cost for a complete in-house system is $4 to $6 million dollars. This total does not include the costs of the technicians, partor full-time physicists, nurses, and nuclear radiologists appropriately trained to run, operate, and maintain the equipment and to read the resultant images. The per-study cost for an ear lobes to pelvis single-patient study in most medical centers is $2800 to $3500, nearly 7 times the cost of a chest/upper abdominal computed tomogram. The use of PET and the conclusions we make are dependent on two assumptions. First, staging matters. Identifying the state of biologic progression or stage to determine the prognosis and management is important to success in treatment. Second, ideally selected treatment can improve survival and reduce the hindrance of the disease, ultimately reducing the cost of care. Presumably PET should help to discriminate patients who have limited disease, those most effectively treated with surgery. Generally and not to be completely inclusive, we have learned a number of things about the use of FDG-PET in the clinical evaluation of lung cancer: 1. It is useful in diagnosis and staging, though it neither diagnoses nor excludes the presence of malignancy. 2. It can discriminate less suitable candidates for surgical resection, estimated to be 20% to 25% of potential surgical patients. 3. It may provide helpful prognostic information in additional to the staging information. In medical centers that wish to provide complete and accurate staging for their patients and who do not have an accomplished surgeon who can perform mediastinoscopy or thoracoscopy, is PET an alternative to a thoracic surgical investigation? When reviewing clinical PET research, we must make sure that we understand the differences among the studies. First, the machines used for positron acquisition From the Division of Cardiothoracic Surgery, The University of Iowa Hospitals and Clinics, Iowa City, Iowa.