The Department of Radiation Oncology, VU University Medical Center, Amsterdam, The Netherlands; The Department of Radiation Oncology, London Regional Cancer Program, London, ON, Canada; The Department of Epidemiology, Harvard School of Public Health, Boston, MA.
The Department of Radiation Oncology, VU University Medical Center, Amsterdam, The Netherlands.
Chest. 2014 Oct;146(4):1021-1028. doi: 10.1378/chest.13-2924.
The practice of treating a solitary pulmonary nodule (SPN) suspicious for stage I non-small cell lung cancer (NSCLC) with stereotactic ablative radiotherapy (SABR) in the absence of pathology is growing. In the absence of randomized evidence, the appropriate prior probability threshold of lung cancer of when such a strategy is warranted can be informed using decision analysis.
A decision tree and Markov model were constructed to evaluate the relative merits of surveillance, a PET scan-directed SABR strategy (without pathology), or a PET scan-biopsy-SABR strategy, when faced with an SPN at different prior probabilities for lung cancer. Diagnostic characteristics, as well as disease, treatment, and toxicity parameters, were extracted from the literature. Deterministic analysis and probabilistic sensitivity analyses were performed to inform the appropriate lung cancer prior probability threshold between treatment strategies.
In the reference case analysis, the prior probability threshold between surveillance and PET scan-biopsy-SABR was 17.0%; between PET scan-directed SABR and PET scan-biopsy-SABR, the threshold was 85.0%. The latter finding was confirmed on probabilistic sensitivity analysis (85.2%; 95% CI, 80.0% to 87.2%). This predicted lung cancer prior probability threshold was most sensitive to the diagnostic sensitivity of transthoracic biopsy (range, 77.2% to 94.0%) and the detection rate of false negatives on CT scan surveillance (range, 82.4% to 92.3%).
This model suggests that if there are concerns about morbidity related to biopsy for an SPN, a PET scan-directed SABR strategy is warranted when the prior probability of lung cancer exceeds a point estimate of 85%.
在没有病理学证据的情况下，对疑似 I 期非小细胞肺癌（NSCLC）的孤立性肺结节（SPN）采用立体定向消融放疗（SABR）进行治疗的做法正在增加。由于缺乏随机对照证据，当采用这种策略时，适当的肺癌先验概率阈值可以通过决策分析来确定。
构建决策树和马尔可夫模型，以评估在不同肺癌先验概率下，对 SPN 进行监测、PET 扫描引导的 SABR 策略（无病理学）或 PET 扫描活检-SABR 策略的相对优势。从文献中提取诊断特征以及疾病、治疗和毒性参数。进行确定性分析和概率敏感性分析，以确定治疗策略之间的适当肺癌先验概率阈值。
在参考病例分析中，监测与 PET 扫描活检-SABR 之间的先验概率阈值为 17.0%；PET 扫描引导的 SABR 与 PET 扫描活检-SABR 之间的阈值为 85.0%。概率敏感性分析（85.2%；95%CI，80.0%至 87.2%）证实了后一种发现。这一预测的肺癌先验概率阈值对经胸活检的诊断敏感性（范围为 77.2%至 94.0%）和 CT 扫描监测的假阴性检出率（范围为 82.4%至 92.3%）最为敏感。
该模型表明，如果对 SPN 活检的发病率存在担忧，且肺癌的先验概率超过 85%的点估计值，则 PET 扫描引导的 SABR 策略是合理的。
