Evaluation of Pulmonary Lesions With FDG-PET: Comparison of Findings in Patients With and Without a History of Prior Malignancy

doi:10.1378/chest.109.4.982

Chest

Volume 109, Issue 4, April 1996, Pages 982-988

https://doi.org/10.1378/chest.109.4.982 Get rights and content

Study objective

The purpose of this study was to evaluate the accuracy of positron emission tomography (PET) using F-18-fluorodeoxyglucose (FDG) in differentiating benign from malignant pulmonary lesions both in patients with and without a history of prior malignancy.

Design

Forty-eight consecutive patients with pulmonary lesions suspicious for malignancy underwent FDG-PET scanning. Group 1 included 27 patients without and group 2 included 21 patients with a history of malignancy. Pathologic proof of diagnosis was obtained for 32 patients and 16 patients were followed up clinically and radiographically for at least 6 months. The standard uptake ratio (SUR) and the lesion to background (L/B) ratio were determined in 45 patients.

Setting

Vanderbilt University Medical Center.

Results

In group 1, the average SUR and L/B ratio for malignant lesions (n=14) were 8.9 ±4.9 and 20.6 ± 14.2, respectively. For benign lesions (n=12), the average SUR was 3.3±3.2 and L/B ratio was 5.2±5.5. In group 2, the average SUR and L/B ratio for malignant lesions were not significantly different from group 1. Using either a SUR greater than 2.5 or L/B ratio greater than 5 as an cutoff level to differentiate benign and malignant lesions, the sensitivity and negative predictive value in both groups were 100%. There were five false-positive studies in group 1 and one in group 2, including tuberculosis (n=2), a granulomatous lesion (n=l), an inflammatory lesion (n=l), a schwannoma (n=l), and a fibrous mesothelioma (n=l). The overall accuracy was 88%, 81% in group 1, and 95% in group 2.

Conclusion

FDG-PET can identify malignant pulmonary lesions both in patients without and with a history of prior malignancy with a high sensitivity and negative predictive value for lesions greater than 1 cm (100% in this study). High FDG uptake by some inflammatory processes and benign tumors may cause false-positive results. Semiquantitative evaluation using SUR or L/B ratio provides similar accuracy.

Section snippets

Patient Population

This study includes 48 consecutive patients who underwent an FDG-PET scan for clinical evaluation of a pulmonary lesion. There were 36 men and 12 women ranging from 33 to 88 years of age. Thirty patients had a pathologic diagnosis of the suspicious lesion within 6 weeks of the PET scan. Tissue was obtained by thoracotomy (n=22), endobronchial biopsy (n=4), pleural biopsy (n=l), mediastinoscopy (n=1), and fine-needle aspiration (n=2); 2 patients had evidence of malignancy by pleural cytologic

Results

Patients were divided in two groups based on whether they had a history of prior malignancy. There were 27 patients with new pulmonary lesions and no history of malignancy (group 1) and 21 patients with a history of prior malignancy (group 2). The prior malignancies in patients from group 2 were the following: Hodgkin's disease (n=l), melanoma (n=4), carcinoma of the colon (n=9), breast (n=2), cervix (n=2), lung (n=2), and kidney (n=l). All patients had surgical treatment of their primary

Discussion

PET provides a unique opportunity to study physiologic processes. Previous studies have demonstrated the usefulness of FDG-PET in the evaluation of pulmonary lesions.14, 15, 16 In this study, we compared the accuracy of FDG-PET to differentiate malignant from benign lesions in patients without and with a history of prior malignancy using two different parameters for semiquantitative measurements.

The two groups of patients were compared first using the SUR that requires attenuation correction of

Conclusion

FDG-PET is an accurate imaging modality to differentiate malignant from benign pulmonary lesions both in patients with and without a history of prior malignancy. The interpretation was equivalent using either the SUR or the L/B ratio, and the overall accuracy was 88%. Owing to its high sensitivity and negative predictive value for pulmonary lesions greater than 1 cm, FDG-PET can exclude the presence of a malignant lesion with great certainty, preventing further evaluation of some patients with

ACKNOWLEDGMENTS

The authors thank Nancy Buchheimer for excellent technical assistance and John Bobbitt for preparation of the figures.

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Citation Excerpt :
Leptomeningeal metastases have been reported to exhibit intraspinal hypermetabolism,26 and this was confirmed in 2 patients in our study. The FDG-PET can distinguish malignant from benign pulmonary lesions27 and appears to be highly sensitive in identifying systemic lymphoma.28 Spinal cord lymphoma was FDG-PET hypermetabolic in most (57%) of our patients, but these findings may have been lower than expected given the concomitant use of corticosteroid use in this patient group.
To report and compare spinal cord [¹⁸F]-fluorodeoxyglucose–positron emission tomography (FDG-PET) metabolism in 51 patients with active myelopathy.
We retrospectively identified patients from January 1, 2001, through December 31, 2011, with active myelopathy in whom FDG-PET was performed. Inclusion criteria were (1) intramedullary myelopathy, (2) neoplastic/inflammatory etiology, and (3) FDG-PET performed after myelopathy onset. Exclusion criteria were (1) extramedullary myelopathy, (2) radiation-associated myelopathy, (3) no pathological confirmation of neoplasm, and (4) inactive myelopathy. Diagnostic categories of nonsarcoid inflammatory, neoplastic, and neurosarcoid were based on their final myelopathic diagnosis. Two radiologists who independently assessed FDG-PET for spinal cord hypermetabolism and maximum standardized uptake value (SUVmax) were blinded to the underlying etiology.
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Spinal cord FDG-PET hypermetabolism in patients with active myelopathy may be reliably detected and was more common in neoplastic than in inflammatory myelopathies in this study. Future investigation of spinal cord FDG-PET is indicated to assess its potential contributions in evaluating active myelopathies.
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Sixty-three (87%) patients had increased SUVmax in delayed scan (1 hour after initial scan). Among the patients with increased delayed uptake, 51 (80%) had malignant lesion and 12 (20%) had nonmalignant lesions. All 9 patients whose SUVmax decreased on delayed scan had nonmalignant lesions. The increased SUV on delayed scan was 100% sensitive in diagnosis of cancer but was only 42% specific. The positive predictive value was 80%, whereas the negative predictive value was 100%. Likelihood ratio for positive test was 1.75.
All the lesions with decreased SUVmax in delayed PET scan were nonmalignant. This was true for both lung and mediastinal lesions. This could be a very helpful diagnostic finding in areas with high prevalence of benign conditions such as histoplasmosis and sarcoidosis. Multiple invasive diagnostic modalities could be prevented in a significant percentage of patients, with attendant decrease in morbidity and health care costs.
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Chest

Clinical Investigations: Lung CancerEvaluation of Pulmonary Lesions With FDG-PET: Comparison of Findings in Patients With and Without a History of Prior Malignancy

Study objective

Design

Setting

Results

Conclusion

Section snippets

Patient Population

Results

Discussion

Conclusion

ACKNOWLEDGMENTS

Int J Radiat Oncol Biol Phys

Chest

Cancer statistics, 1991

CA

Lung cancer

Versuche and uberlebeudem carcinomgewebe (methoden)

Biochem Z

Elevated levels of glucose transport and transporter messenger RNA are induced by rats or src oncogenes

Science

Physiochemical properties and isoenzyme composition of hexokinase from normal and malignant human tissues

J Natl Cancer Inst

Hexokinase, differentiation, and growth rates of transplanted tumors

Cancer Res

Molecular events leading to enhanced glucose transport in Rous sarcoma virus-transformed cells

Fed Proc

A fluorinated glucose analog, 2-fluoro-2-deoxy-D-glucose [18F]: nontoxic tracer for rapid tumor detection

J Nucl Med

Metabolic trapping as a principle of radiopharmaceutical design: some factors responsible for the biodistribution of [18F]2-deoxy-2-fluoro-D-glucose

J Nucl Med

18F-2-deoxy-2-fluoro-D-glucose uptake into human tumor xenografts: feasibility studies for cancer imaging with positron emission tomography

Cancer

Differential diagnosis of lung cancer with positron emission tomography: a prospective study

J Nucl Med

Glucose utilization in vivo by human neoplasm

Cancer

Clinical Investigations: Lung Cancer
Evaluation of Pulmonary Lesions With FDG-PET: Comparison of Findings in Patients With and Without a History of Prior Malignancy