Hüseyin MELEK, Adalet DEMİR, Seyit İbrahim DİNÇER, Mehmet Zeki GÜNLÜOĞLU, Barış MEDETOĞLU, Hasan Volkan KARA

Küçük hücreli dışı akciğer kanserinde mediastinal evreleme stratejilerinin doğruluğu ve maliyeti

Amaç: Bu çalışmada küçük hücreli dışı akciğer kanseri (KHDAK)’nin mediastinal evrelemesinde pozitron emisyon tomografisi (PET) ve servikal mediastinoskopi (SM)’yi içeren çeşitli stratejilerin doğrulukları ve maliyetlerinin karşılaştırılması amaçlandı. Çalışma planı: Kasım 2004 - Şubat 2007 tarihleri arasında operabl KHDAK tanısı konulan 197 hastaya, (177 erkek, 20 kadın; ort. yaş 60.2 yıl; dağılım 30-84 yıl) mediastinal evreleme amacıyla toraks bilgisayarlı tomografi (BT)’si ve PET çekildi. Tüm hastalara SM yapıldı. Mediastinal lenf nodu metastazı (MLNM) saptanan 48 hasta kemo-radyoterapiye yönlendirildi. Kalan 149 hastaya torakotomi uygulanarak, akciğer rezeksiyonu ve sistematik mediastinal lenfatik diseksiyon yapıldı. Mediastinal lenf nodları histopatolojik olarak incelendi. Pozitron emisyon tomografisi ve SM’nin MLNM tespitine ilişkin duyarlılık, özgüllük ve doğruluk oranları hesaplandı. Mediastinal evreleme için PET veya SM’yi içeren üç strateji düzenlendi ve bu 197 hastanın sonuçları bu stratejilere uyarlandı. Strateji A; tüm hastalara PET çekilmesi, sadece PET’de metastaz varlığı bildirilen hastalara SM yapılması şeklinde düzenlendi. Strateji B (selektif PET-selektif SM); toraks BT’sinde T1N0 ş eklinde evrelenen K HDAK bulunan hastalara PET çekilmesi, mediastinal tutulum saptanmamışsa SM yapılmadan torakotomiye geçilmesi, diğer hastalara SM yapılması şeklinde düzenlendi. Strateji C (yüksek selektif SM); toraks BT’sinde T1N0 ş eklinde e vrelenmiş p eriferik s kuamöz h ücreli a kciğer k anserli hastalara başka evreleme işlemi olmadan direkt torakotomi, bu hastalar dışındaki tüm hastalara ise SM yapılması şeklinde düzenlendi. Her bir stratejinin doğruluğu ve sosyal güvenlik kurumu fiyatları ile maliyeti hesaplandı. Bulgular: Mediastinal evrelemede PET’nin duyarlılık, özgüllük, doğruluk oranı sırasıyla, %73, %75 ve %74, SM’nin duyarlılık, özgüllük ve doğruluk oranı ise sırasıyla %81, %100 ve %94 olarak hesaplandı. Tüm hastalara PET çekilmesi şeklindeki A stratejisi kullanılmış olsa idi mediastinal evrelemede elde edilecek duyarlılık, negatif prediktif değer (NPD) ve doğruluk oranlarının, sırasıyla, %66, %87 ve %90, toplam maliyetin de 332.330 TL olacağı hesaplandı. B stratejisine uyulsa oluşacak duyarlılık, NPD ve doğruluk oranları, yükselerek, sırasıyla, %81, %93 ve %94, toplam maliyet de düşerek 164.830 TL olacaktı. C stratejisi kullanılmış olsa idi, duyarlılık, NPD ve doğruluk oranları, B stratejisi için hesaplanan oranlarla aynı olacak iken, toplam maliyetin biraz daha düşeceği (140.250 TL) hesaplandı. Sonuç: Akciğer kanseri mediastinal evrelemesinde, evreleme stratejisinin, tüm hastalara PET çekilmesi, sadece PET’de metastaz varlığı bildirilen hastalara SM yapılması şeklinde oluşu durumunda yeterli doğruluk oranına erişilememektedir. Üstelik bu strateji, yüksek maliyete neden olmaktadır. Pozitron emisyon tomografisinin ve SM’nin selektif kullanımını içeren stratejiler ise tatminkar doğruluk oranıyla ve kabul edilebilir maliyetler ile uygulanabilir.

The accuracy and cost of mediastinal staging strategies for non-small cell lung cancer

Background: To compare the accuracies and costs of some strategies including positron emission tomography (PET) and cervical mediastinoscopy (CM) in the mediastinal staging of non-small cell lung cancer (NSCLC) was aimed. Methods: Thoracic computed tomography (CT) and PET was performed in 197 patients (177 males, 20 females; mean age 60.2 years; range 30 to 84 years) diagnosed with operable NSCLC between November 2004 and February 2007. Cervical mediastinoscopy was performed in all patients. Mediastinal lymphatic metastases (MLM) were detected in 48 patients, and these patients were directed to chemo-radiotherapy. The remaining 149 patients underwent lung resection and systematic mediastinal lymphatic dissection via thoracotomy was performed. The mediastinal lymph nodes were histopathologically examined. The sensitivity, specificity, and accuracy rates of PET and CM to detect MLM were calculated. Three mediastinal staging strategies, including PET and CM, were designed and the results of these 197 patients were adapted into these strategies. Strategy A; designed as to take PET scan from all patients and to perform CM to only patients with mediastinal uptake reported in their PET scan. Strategy B (selective PET-selective CM); was created as to take PET scan from patients with NSCLC staged as T1N0 according to t heir C T, i f no mediastinal uptake reported, performing thoracotomy without prior CM, and to perform CM to all other, PET scan had not been taken patients. Strategy C (high-selective CM); was designed as to perform directly thoracotomy without another staging procedure to patients with cancer in squamous cell type, located peripherally and staged as T1N0, according to their CT, and to perform CM to all other patients. The accuracy and the average cost according to the prices established by Social Security Organization of Turkey of each strategy were calculated. Results: The sensitivity, specificity, and accuracy rates of PET were determined as 73%, 75%, and 74%, respectively while sensitivity, specificity, and accuracy rates of CM were determined as 81%, 100%, and 94%, respectively. If strategy A that include to take PET scan from all patients had been followed up, sensitivity, negative predictive value (NPV) and accuracy rates that would be obtained were determined as 66%, 87% and 90%, respectively, and total cost that would be occurred was calculated as 332.330 TL. If B strategy had been applied, sensitivity, NPV and accuracy rates would increase as 81%, 93% and 94%, respectively, and total cost would decrease to 164.830 TL. If strategy C had been followed, sensitivity, NPV and accuracy rates would be same but total cost would slightly decreased (140.250 TL) when compared with B strategy. Conclusion: In mediastinal staging of lung cancer, sufficient accuracy rate could not been obtained when the staging strategy being as to take PET scan from all patients, and to perform CM to only patients with mediastinal uptake reported in their PET scan, furthermore, this strategy causes high cost. But, strategies include selective using of PET and CM can be applied with satisfactory accuracy rates and acceptable costs.

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