Evaluation Of Solitary Pulmonary Nodules Research Articles

E33. Pet scanning for evaluation of solitary pulmonary nodule and staging of NSCLC

E33. Pet scanning for evaluation of solitary pulmonary nodule and staging of NSCLC

P-381 A comparison study between Tc-99m depreotide and computedtomographic study as tools for solitary pulmonary nodule evaluation

P-381 A comparison study between Tc-99m depreotide and computedtomographic study as tools for solitary pulmonary nodule evaluation

Occult lung infarction may induce false interpretation of 18F-FDG PET in primary staging of pulmonary malignancies

The aim of the present report is to describe abnormal (18)F-fluorodeoxyglucose (FDG) accumulation patterns in the pleura and lung parenchyma in a group of lung cancer patients in whom lung infarction was present at the time of positron emission tomography (PET). Between November 2002 and December 2003, a total of 145 patients (102 males, 43 females; age range 38-85 years) were subjected to whole-body FDG PET for initial staging (n=117) or restaging (n=11) of lung cancer or for evaluation of solitary pulmonary nodules (n=17). Of these patients, 24 displayed abnormal FDG accumulation in the lung parenchyma that was not consistent with the primary lesion under investigation (ipsilateral n=12, contralateral n=9 or bilateral n=3). Without correlative imaging, this additional FDG uptake would have been considered indeterminate in differential diagnosis. Of the 24 patients who were identified as having such lesions, six harboured secondary tumour nodules diagnosed as metastases, while in three the diagnosis of a synchronous second primary lung tumour was established. Additionally, nine patients were identified as having post-stenotic pneumonia and/or atelectasis (n=6) or granulomatous lung disease (n=3). In the remaining six (4% of all patients), a diagnosis of recent pulmonary embolism that topographically matched the additional FDG accumulation (SUV(max) range 1.4-8.6, mean 3.9) was made. Four of these six patients were known to have pulmonary embolism, and hence false positive interpretation was avoided by correlating the PET findings with those of the pre-existing diagnostic work-up. The remaining two patients were harbouring small occult infarctions that mimicked satellite nodules in the lung periphery. Based on histopathological results, the abnormal FDG accumulation in these two patients was attributed to the inflammatory reaction and tissue repair associated with the pathological cascade of pulmonary embolism. In patients with pulmonary malignancies, synchronous lung infarction may induce pathological FDG accumulation that can mimic active tumour manifestations. Identifying this potential pitfall may allow avoidance of false positive FDG PET interpretation.

Transthoracic Needle Biopsy of Thoracic Lesions

In the diagnostic evaluation of thoracic lesions, the image-guided transthoracic needle biopsy was developed, and its role was expanded with the development of cross-sectional detection and characterization of thoracic lesions and advances in biopsy needle design and techniques. Particularly for diagnostic evaluation of solitary pulmonary nodules, transthoracic needle biopsy has emerged as the invasive procedure of choice. This article covers the indication, the pre-procedure preparation, various guidance-modalities and techniques, and complications. (Tuberculosis and Respiratory Diseases 2004, 56:241-247) Comment : Perhaps a little more detail even though it is an abstract.

Depreotide Scanning in Sarcoidosis: A Pilot Stud

PURPOSE: Technetium-labeled depreotide (Tc-DP) is a novel radiopharmaceutical approved for use in the evaluation of solitary pulmonary nodules. Since Tc-DP binds to somatostatin receptors which are often present in inflammatory tissue, we hypothesized that Tc-DP nuclear scanning would be positive in patients with sarcoidosis.

Role of Bronchoscopy in the Evaluation of Solitary Pulmonary Nodule

Solitary pulmonary nodules (SPNs) are commonly encountered in clinical practice, and their diagnostic evaluation can be challenging. SPNs that cannot be easily classified as benign or malignant based on radiologic criteria and patient history must be evaluated by diagnostic testing to determine the likelihood that the lesion is malignant and thus requires additional specific treatment. Many of these nodules can be efficiently evaluated by bronchoscopy, particularly nodules that are larger than 2 cm in diameter, are located in the inner or middle lung zones, and are associated with a bronchus sign in a proximal bronchus. New imaging techniques, such as CT fluoroscopy, need to be studied additionally but show promise in improving yield. Bronchoscopy is safe, with little morbidity and mortality, making it an appealing alternative to more invasive procedures.

How to optimize staging in early non-small cell lung cancer

The topic was discussed by Dr Johan Vansteenkiste, Leuven Belgium. PET is an exciting new imaging modality that has rapidly acquired a prominent position in evaluation of solitary pulmonary nodules (SPN) and staging of lung cancer. It is based on the principle that cancer cells have a higher rate of glycolysis and an increased cellular uptake of glucose due to increased number of transport proteins than non-neoplastic cells. The PET tracer, 18 fluoro-deoxyglucose (18 FDG) is taken up into cells and metabolically trapped and accumulates. 18 FDG is a positron emitter, and therefore, can be measured. Thus, PET provides evidence of metabolic activity of tumor cells and has opened up the relative new field of ‘molecular imaging’. PET has a sensitivity of approximately 90% and a specificity of 85 /90% for evaluating SPN, but the data available is based on nodules ]/1 cm in size [1]. The resolution limit of PET is thought to be 7 /8 mm. For nodules smaller than 1 cm, the sensitivity and specificity is unknown. The sensitivity and specificity of the CT scan for evaluating mediastinal lymph nodes for metastasis is 60 /70% each [2,3]. This means that 30 /40% of lymph nodes one cm or smaller will have microscopic metastasis (sensitivity) and 30 /40% of lymph nodes /1 cm in size will not contain metastases, but will only be reactive (specificity). In contrast, data presented and a published meta-analysis documents a sensitivity of 89% and specificity of 92% for PET evaluation of mediastinal nodes in patients with NSCLC [4]. A limitation of PET is that it lacks precise anatomic details. Studies have shown that the sensitivity and accuracy of PET is significantly improved when it is correlated with the CT scan. New scanners are just coming on the market that fuse the CT and PET images, thus giving better anatomic detail. It is likely that these new CT/PET scanners may replace the current PET scanners. They decrease the PET scan time from 60 to 30 min. False positive PET scans can occur in patients with tuberculosis, other granulomatous disease, sarcoidosis, and anthrasilicosis. Care must be taken to distinguish a malignancy adjacent to mediastinum from adjacent mediastinal nodal metastasis with the current scanners. False negative PET scans may occur in patients with carcinoid tumors and bronchoalveolar cell carcinoma because of the low metabolic activity. PET will also miss microscopic lymph node metastases (resolution size limitation). Dr Vansteenkiste recommended that PET evaluation of mediastinum be used as follows:

Radiologic evaluation of the solitary pulmonary nodule

The radiologic evaluation of solitary pulmonary nodules can be a complex process. Modalities, which can be used, include the chest radiograph, computed tomography, and positron emission tomography scanning. Interventional radiology can also play a role with image-guided transthoracic needle aspiration of indeterminate pulmonary nodules. The primary role of radiologic evaluation is to try to differentiate benign from malignant pulmonary nodules. The imaging findings that can be helpful in making this distinction as well as the limitations of each of the modalities are discussed. For the purpose of this review, solitary pulmonary nodule mimics such as skin or rib lesions, vascular malformations, and areas of rounded atelectasis are not discussed. Copyright 2002, Elsevier Science (USA). All rights reserved.

7. Survey of Results of Whole Body Imaging Using the PET/CT at the University of Pittsburgh Medical Center PET Facility

Purpose: At the University Of Pittsburgh Medical Center, over 100 oncology studies have been performed using a combined PET/CT scanner. The scanner is a prototype, which combines clinical PET and clinical CT imaging in a single unit. The sensitivity achieved using three-dimensional PET imaging as well as the use of the CT for attenuation correction and image fusion make the device ideal for clinical oncology. Clinical indications imaged on the PET/CT scanner include, but are not limited to, tumor staging, solitary pulmonary nodule evaluation, and evaluation of tumor reoccurrence in melanoma, lymphoma, colorectal cancer, lung cancer, pancreatic cancer, head and neck cancer, and renal cancer.Methods: For all studies, seven millicuries of F18-fluorodeoxyglucose is injected and a forty-five minute uptake period is allowed prior to positioning the patient in the scanner. A helical CT scan is acquired over the region, or regions of interest followed by a multi-bed whole body PET scan for the same axial extent. The CT scan is used to correct the PET data for attenuation. The entire imaging session lasts 1–1.5 hours depending on the number of beds acquired, and is generally well tolerated by the patient.Results and Conclusion: Based on our experience in over 100 studies, combined PET/CT imaging offers significant advantages, including more accurate localization of focal uptake, distinction of pathology from normal physiological uptake, and improvements in evaluating therapy. These benefits will be illustrated with a number of representative, fully documented studies.

A Multicenter Trial With a Somatostatin Analog 99mTc Depreotide in the Evaluation of Solitary Pulmonary Nodules

The affinity of various malignant neoplasms including small cell and non-small cell lung cancer for peptide analogs of somatostatin has been well documented. Depreotide is such an analog and can be complexed with technetium-99m ((99m)Tc depreotide) for optimal imaging properties. Using this radiopharmaceutical, solitary pulmonary nodules (SPN) were previously evaluated in a successful phase II/III trial. The results of the larger multicenter phase III study using (99m)Tc depreotide to differentiate malignant and benign etiologies in SPN are now presented. Patients with SPN </= 6 cm on chest radiograph were referred for evaluation. One hundred fourteen individuals who had an absence of a benign pattern of calcification on CT scan, age > 30 years, and no demonstrable radiographic stability for the prior 2 years were studied. All underwent single-photon emission CT (SPECT) with (99m)Tc depreotide and subsequent tissue histologic examination. Three nuclear medicine specialists blinded to histologic findings examined the SPECT images and scored them as positive or negative based on the presence or absence of activity in the radiographic region of the SPN. The final result was determined by the majority score, which was then compared with the histologic result. Of the 114 individuals studied, 88 had a histologic result compatible with malignant neoplasm. (99m)Tc depreotide scintigraphy correctly identified 85 of this group, with three false-negative determinations compared with histology. There were seven false-positive determinations, including six granulomas and one hamartoma. (99m)Tc depreotide scintigraphy correctly excluded malignancy in 19 of 26 patients with benign histologic findings. The sensitivity of this method was 96.6% with a specificity of 73.1%. (99m)Tc depreotide scintigraphy is a safe and useful method for the noninvasive evaluation of SPN with a sensitivity and accuracy comparable to that reported for fluorine-18 fluorodeoxyglucose positron emission tomography.

CT Evaluation of Solitary Pulmonary Nodule: Value of Additional HRCT Scan

Purpose : The aim of our study was to evaluate the usefulness of high-resolution CT scans in addition to helical CT for characterizing a solitary pulmonary nodule. Materials and Methods : Our study included 49 patients with a solitary pulmonary nodule ; in each patient this was evaluated by both additional high-resolution CT and helical scanning. Images were evaluated by three independent observers, each of whom read them twice : initially with helical CT images only and then with helical images plus high-resolution CT images. After analysis, the observers recorded the following : histologic diagnosis, benignancy or malignancy of a nodule, and confidence in their diagnosis (three scales). Results : In differentiating benign and malignant nodules, the accuracy of helical scans only was 75% (110/147 readings) whereas that of helical plus high-resolution CT scans was 82% (121/147readings) (p=0.001). Correct histologic diagnosis was made in 47% of cases (69/147 readings) when helical scans only had been evaluated and in 48% of cases (71/147 readings) for which both helical and high-resolotion CT scans were available (p=0.815). Diagnosis was more often highly confident on the basis of additional high-resolution CT scans (25%) than helical scans only (5%) (p= 0.001). Conclusion : By enhancing differential diagnostic accuracy between benign and malignant nodules and by increasing confidence in the histologic diagnosis of apulmonary nodule, additional high-resolution CT scans are valuable for the evaluation of a solitary pulmonary nodule.

PP69. Cost effectiveness of FDG-PET in the evaluation of solitary pulmonary nodules

PP69. Cost effectiveness of FDG-PET in the evaluation of solitary pulmonary nodules

Likelihood of Malignancy in a Solitary Pulmonary Nodule: Comparison of Bayesian Analysis and Results of FDG-PET Scan

To compare the probability of cancer in a solitary pulmonary nodule using standard criteria with Bayesian analysis and result of 2-[F-18] fluoro-2-deoxy-D-glucose-positron emission tomographic (FDG-PET) scan. A university hospital and a teaching Veteran Affairs Medical Center. Retrospective analysis of 52 patients who had undergone both CT scan of the chest and a FDG-PET scan for evaluation of a solitary pulmonary nodule. FDG-PET scan was classified as abnormal or normal. Utilizing Bayesian analysis, the probability of cancer using "standard criteria" available in the literature, based on patient's age, history of previous malignancy, smoking history, size and edge of nodule, and presence or absence of calcification were calculated and compared to the probability of cancer based on an abnormal or normal FDG-PET scan. Histologic study of the nodules was the gold standard. The likelihood ratios for malignancy in a solitary pulmonary nodule with an abnormal FDG-PET scan was 7.11 (95% confidence interval [CI], 6.36 to 7.96), suggesting a high probability for malignancy, and 0.06 (95% CI, 0.05 to 0.07) when the PET scan was normal, suggesting a high probability for benign nodule. FDG-PET scan as a single test alone was more accurate than the standard criteria and standard criteria plus PET scan in correctly classifying nodules as malignant or benign. FDG-PET scan as a single test was a better predictor of malignancy in solitary pulmonary nodules than the standard criteria using Bayesian analysis. FDG-PET scan can be a useful adjunct test in the evaluation of solitary pulmonary nodules.

840 Transthoracal needle aspiration biopsy (TNAB) as a first bioptic procedure in evaluation of solitary pulmonary nodules (SPN) suspected to be malignant

840 Transthoracal needle aspiration biopsy (TNAB) as a first bioptic procedure in evaluation of solitary pulmonary nodules (SPN) suspected to be malignant

Evaluation of solitary pulmonary nodules with dynamic contrast-enhanced MR imaging - A promising technique?

Abstract The evaluation of a solitary pulmonary nodule (SPN) is one of the most frequently encountered challenges in thoracic radiology. In addition to a “state-of-the-art” evaluation of SPNs with CT and biopsy techniques, recently the assessment of the enhancement characteristics with iodinized contrast agents has shown its potential to improve the characterization of SPNs. We investigated whether dynamic contrast-enhanced MRI is suitable to assess the degree and kinetics of MR contrast enhancement and whether this technique could help in the noninvasive specification of SPNs. We studied prospectively 21 patients with SPNs. T1-weighted and proton density-weighted spoiled gradient-echo breath-hold images (2D-FLASH) were obtained before and after the administration of Gd-DTPA in a standard dosage of 0.1 mmol/kg body weight. The maximum enhancement and the initial velocity of contrast uptake were assessed and correlated with pathohistological findings. To quantify contrast enhancement, we used the relative signal intensity increase (Srel) and the recently introduced enhancement factor (EF) and contrast uptake equivalent (CE). Dynamic contrast-enhanced MRI proved to be well suited for the assessment of the contrast enhancement characteristics of SPNs. Significant differences were found in the degree and kinetics of contrast enhancement for specific types of nodules. Malignant neoplastic SPNs enhanced stronger and faster than benign neoplastic SPNs. The strongest and fastest enhancement, however, was found in a benign type of nodules where histology revealed inflammatory/fibrous lesions. These differences in contrast enhancement between the different pathohistological groups were more significant when EF and CE rather than Srel was used for the quantification of contrast enhancement. The results of this study indicate a potential role for dynamic contrast-enhanced MRI in the preoperative noninvasive evaluation of SPNs using EF and CE as contrast uptake assessment parameters.

CT reconstruction algorithm selection in the evaluation of solitary pulmonary nodules.

We have observed a significant CT artifact in the evaluation of lung nodules that occurred with the use of high-spatial-frequency reconstruction algorithms. We have seen this lead to a false-positive diagnosis of calcification in a small uncalcified lung nodule. Because of the seriousness of misinterpretation of benign calcification in an uncalcified nodule, we reviewed the various effects of several reconstruction algorithms on different scanners. Using high-spatial-frequency, smoothing, and intermediate reconstruction algorithms, we studied standardized cylinders in a CT reference phantom and lung nodules in eight patients. Algorithms on four CT scanners were analyzed. We found peripheral edge enhancement artifact on some CT images of phantom cylinders and uncalcified lung nodules. The images with edge enhancement artifact were obtained from two scanners with the use of high-spatial-frequency algorithms (Picker 1200 SX and GE HiSpeed Advantage). Use of high-spatial-frequency reconstruction algorithms for the analysis of lung nodules with thin-section CT may lead to an erroneous diagnosis of calcification.

Role of Bronchoscopy in the Evaluation of Solitary Pulmonary Nodule

Mehta, Atul C. M.B., B.S., F.C.C.P., F.A.C.P.; Kathawalla, Salim A. M.D.; Chan, Choong-Chee M.D.; Arroliga, Alejandro M.D., F.C.C.P. Author Information

PET-FDG Imaging and Transthoracic Needle Lung Aspiration Biopsy in Evaluation of Pulmonary Lesions: A Comparative Risk-Benefit Analysis

Positron emission tomography (PET) utilizing 2-[fluorine-18]-fluoro-2-deoxy-D-glucose (FDG) has been demonstrated to be highly accurate in differentiating benign from malignant pulmonary nodules. Transthoracic fine-needle aspiration biopsy (TTNA) is generally the initial procedure of choice in the evaluation of peripheral lesions suspected to be malignant. Our objective was to determine whether PET-FDG imaging, a noninvasive test, was equally efficacious as TTNA in the evaluation of lung lesions suspected to be malignant. Thirty-three patients with 35 lung lesions who had undergone both PET-FDG imaging and TTNA were retrospectively selected from an ongoing prospective study of PET-FDG imaging in the evaluation of solitary pulmonary nodules. Diagnostic efficacy was determined by calculating sensitivity, specificity, positive and negative predictive value, and overall predictive accuracy for both PET-FDG imaging and TTNA in differentiating benign from malignant lesions. Complication rate also was documented for the two tests. The PET imaging correctly identified all 26 malignant lesions, including 21 lesions diagnosed by TTNA and 7 of the 9 benign lung lesions. The TTNA was positive for malignancy in 21 lung lesions and missed the diagnosis of malignancy in 5 lesions. Diagnostic sensitivity, specificity, positive and negative predictive value, and overall predictive accuracy was 100, 78, 93, 100, and 94% for PET imaging and 81, 100, 100, 64, and 86 for TTNA, respectively. Pneumothorax was documented in 16 patients (46%), and 9 patients (26%) required a chest tube. There were no complications with PET imaging. We conclude that PET imaging of the lung is as efficacious as TTNA, with less risk, and offers an alternate noninvasive option in the evaluation and management of lung lesions suspected to be malignant.

Evaluation of solitary pulmonary nodules with dynamic contrast-enhanced MR imaging--a promising technique.

The evaluation of a solitary pulmonary nodule (SPN) is one of the most frequently encountered challenges in thoracic radiology. In addition to a "state-of-the-art" evaluation of SPNs with CT and biopsy techniques, recently the assessment of the enhancement characteristics with iodinized contrast agents has shown its potential to improve the characterization of SPNs. We investigated whether dynamic contrast-enhanced MRI is suitable to assess the degree and kinetics of MR contrast enhancement and whether this technique could help in the noninvasive specification of SPNs. We studied prospectively 21 patients with SPNs. T1-weighted and proton density-weighted spoiled gradient-echo breath-hold images (2D-FLASH) were obtained before and after the administration of Gd-DTPA in a standard dosage of 0.1 mmol/kg body weight. The maximum enhancement and the initial velocity of contrast uptake were assessed and correlated with pathohistological findings. To quantify contrast enhancement, we used the relative signal intensity increase (S(rel)) and the recently introduced enhancement factor (EF) and contrast uptake equivalent (CE). Dynamic contrast-enhanced MRI proved to be well suited for the assessment of the contrast enhancement characteristics of SPNs. Significant differences were found in the degree and kinetics of contrast enhancement for specific types of nodules. Malignant neoplastic SPNs enhanced stronger and faster than benign neoplastic SPNs. The strongest and fastest enhancement, however, was found in a benign type of nodules where histology revealed inflammatory/fibrous lesions. These differences in contrast enhancement between the different pathohistological groups were more significant when EF and CE rather than S(rel) was used for the quantification of contrast enhancement. The results of this study indicate a potential role for dynamic contrast-enhanced MRI in the preoperative noninvasive evaluation of SPNs using EF and CE as contrast uptake assessment parameters.

Primary Adenoid Cystic Carcinoma of Salivary Gland with Metastatic to the Lung

A 22-year old female visited CNUH due to palpable neck mass. Cytologic examination of a fine needle aspiration was performed and the result was Pap class II. Routine chest x-ray shows solitary pulmonary nodule. For rule-out malignancy, FNA at neck mass was repeated and pathologic finding was dysplasia. She was admitted to MI department for evaluation of solitary pulmonary nodule and percutaneous needle aspiration was done. Pathologic diagnosis was adenoid cystic carcinoma. Thereafter, the lesions were treated by excisional biopsy of submandibular gland mass with left supraomohyoid neck dissection and wedge resection of right lower lobe at ENT department and thoracic and cardiovascular surgery department, respectively. Final diagnosis was adenoid cystic carcinoma arising in submandibular gland with solitary lung metastasis. According to TMN staging system, surgical staging is stage IV of T2N0M1. Clinical follow-up to postoperative 13 months in this case showed that she is alive and well without evidence of recurrence.