. Step 3 of 40
Clinical Stem 2
A patient with pulmonary nodules 1 year after curative intent resection of primary lung adenocarcinoma

Answer C
This patient with pathologic stage IIB has a higher risk of recurrence than if she had limited IA disease. A goal of surveillance imaging is to detect lung cancer recurrence or second primary lung cancer early enough to warrant curative retreatment. Studies to date do not show that surveillance PET-CT improves overall survival. Current ACCP, NCCN, ESMO and NICE guidelines do not recommend PET-CT for routine surveillance after curative intent treatment, but PET-CT was shown to be useful for restaging patients after adjuvant therapy.

Several studies, including one randomized trial, show that PET-CT after resection leads to earlier detection of a greater number of asymptomatic recurrences compared with more traditional imaging, although many false positive findings are detected.

Recurrences of NSCLC during the first four years after curative intent resection seem to gather at specific times. There is an initial surge 9 months after surgery, followed by two smaller surges at the end of two and four years, respectively. These recurrences may not be detected by regularly scheduled imaging studies.
Surveillance radiologic imaging recommendation strategies do not currently take into account prognostic factors associated with recurrence risk. These factors are relevant to designing a personalized surveillance strategy as part of a patient-centric approach to lung cancer diagnosis and treatment.
References:
  1. Calman L, Beaver K, Hind D, et al. Survival benefits from follow-up of patients with lung cancer: a systematic review and meta-analysis. J Thorac Oncol. 2011;6:1993-2004.
  2. Rubins J, Unger M, Colice GL, American College of Chest P. Follow-up and surveillance of the lung cancer patient following curative intent therapy: ACCP evidence-based clinical practice guideline (2nd edition). Chest. 2007;132(3 Suppl):355S-367S
  3. Monteil J, Vergnenegre A, Bertin F, et al. Randomized follow-up study of resected NSCLC patients: conventional versus 18F-DG coincidence imaging. Anticancer Res. 2010;30:3811-3816.
  4. Cho S, Lee EB. A follow-up of integrated positron emission tomography/computed tomography after curative resection of non-small-cell lung cancer in asymptomatic patients. J Thorac Cardiovasc Surg. 2010;139:1447-1451.
  5. Takenaka D, Ohno Y, Koyama H, et al. Integrated FDG-PET/CT vs. standard radiological examinations: comparison of capability for assessment of postoperative recurrence in non-small cell lung cancer patients. Eur J Radiol. 2010;74:458-464.
  6. Demicheli R, Fornili M, Ambrogi F, et al. Recurrence dynamics for non-small-cell lung cancer: effect of surgery on the development of metastases. J Thorac Oncol. 2012;7:723-730.
Each fictitious clinical case scenario is based on a conglomerate of real patient data. Cases have been modified to avoid any possibility for patient identification and to help meet educational objectives. Any resemblance to real persons, living or deceased, is purely coincidental.

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