PET en Cáncer de PulmónCURSO DE ACTUALIZACIÓN EN

TOMOGRAFÍA POR EMISIÓN DE POSITRONES

SVMNViernes 17 enero 2014.

Hospital Clínico de Valencia

Antonio Martínez CaballeroUnidad PET-CT

Hospital Clínica Benidorm

Declaración de conflicto de intereses

• El autor declara que no existe conflicto de intereses relacionado con este trabajo o

cualquier situación en la que se pueda percibir que un beneficio o interés personal o privado

puede influir en el juicio emitido.

Esquema

• A. Conocimientos básicos CP

• B. Aplicaciones de PET en CP

• C. Actualización y Bibliografía

• D. Práctica en PET

PET-CT en Cáncer de Pulmón

Epidemiología de CP

• El Cáncer de pulmón es la causa mas frecuente de muerte relacionada con cáncer

• 3 millones de nuevos casos por año en el mundo, de los que 200.000 se producen en Europa. En España unos 20.000.

• En España la incidencia es de 77 casos /100.000 habit/año en varones y de 8 casos/100.000 habit/año en mujeres. La tasa de mortalidad es de 71 en varones y 6 mujeres.

• Sv5 global: 15%. (inluso tras cirugía en estadios precoces es baja, solo 50%)

• Tábaco: 80-90% en v; 60-80 m

Anatomía Patológica del CP

• >95% son de origen epitelial: carcinomas

– CP de células no-pequeñas (CPCNP): 80%

– CP de células pequeñas (CPCP): 15%

CPCNP :

– Ca. Epidermoide o Escamoso (35% de CP): Centrales, varones, fumadores

• Papilar, Cel. Claras, Cel. pequeña, Basaloide.

– Adenocarcinoma (30% de CP): Periféricos, Mujeres

• Acinar, Papilar, Bronquioloalveolar, Solido mucinoso, Subtipos mixtos.

– Ca. Cel. Grandes (10%).

– Ca. Adenoescamoso.

– Ca. pleomórfico, sarcomatoide, o sarcomatoso.

– Carcinoides

– Ca. tipo salivar.

– No clasificado

Diagnóstico

• Rx, TAC y PET

• Confirmacion con Citologia de Esputo y Broncoscopia en lesiones centrales y PAAF (con radioscopia o TAC) en perifericas

• Screening: TAC. Recomendación????– National Lung Screening Trial (NLST): TAC baja dosis, en

personas con alto riesgo de CP (fumador) reducen el riesgo de morir un 20% vs Rx.

– Revision*: F+ en ambos grupos, pocos eventos adversos.

*Nanavaty P. Cancer Control. 2014 Jan;21(1):9-14.

Técnicas Diagnósticas

BRONCOSCOPIA

T.N.M. 7ª Ed.

Novedades TNM 7ª ed• T1:

– T1a: <2 cm

– T1b: 2-3 cm

• T2:

– T2a: 3-5 cm

– T2b: 5-7 cm

• T3: >7 cm

• Nodulos adic. – Mismo lóbulo: de T4 a T3

– Lóbulo ipsilat: de M1 a T4

– Pleura afectada: de T4 a M1a

• “N” : N1, N2, N3 (línea media)

• “M”

• M1a:

• Nod. contralateral

• Pleura afectada

• M1b: MTX a distancia

Estadificación del cáncer de pulmón

Carcinoma oculto TX N0 M0

Estadio 0 TIS, Ca. in situ N0 M0

Estadio IIA T1a,b, N0 M0

IB T2a N0 M0

Estadio IIIIA

T1a, b N1 M0

T2a N1 M0

T2b N0 M0

IIBT2b N1 M0

T3 N0 M0

Estadio IIIIIIA

T1 ó T2 N2 M0

T3 N1, N2 M0

T4 N0, N1 M0

IIIBT4 N2 M0

Cualquier T N3 M0

Estadio IV Cualquier T Cualquier N M1a,b

Estadiaje “T”

• Debe ser por TAC

• PET-TAC ayuda en casos de atelectasia.

Estadiaje ganglionar “N”Regional Nodal Stations For

Lung Cancer Staging

Superior Mediastinal Nodes

• 1 Highest Mediastinal

• 2 Uper Paratracheal

• 3 Pre-vascular and

Retrotracheal

• 4 Lower Paratracheal

(includig Azygos Nodes)

Aortic Nodes

• 5 Subaortic (AP window)

• 6 Para-aortic

(ascending aorta or phrenic)

Inferior Mediastinal Nodes

• 7 Subcarinal

• 8 Paraesophageal

(below carina)

• 9 Pulmonary Ligament

N1 Nodes

• 10 Hiliar

• 11 Interlobar

• 12 Lobar

• 13 Segmental

• 14 Subsegmental

Mountain and Dresler. Chest 1997. American Joint Committee on Cancer (AJCC)

Estadiaje Mediastino CP

• Imagen.

• Invasiva.

S E VPN VPP

TC 47-54 84-88 47-96 30-95

PET-TC 47-89 60-100 85-99 37-100

TBNA a ciegas 78 99 - -

EBUS-FNA 79-95 99-100 86-99 100

EUS 78-87 96-98 73-83 97-99

Mediastinoscopia 86 100 90 100

VAMLA 100 100 100 100

TEMLA 96 100 97 100

TBNA: punción aspiración transbronquial, EBUS: eco endobronquial, EUS: eco esofágica, VMLA: linfadenectomia mediastinica videoasistida, TEMLA: linfadenectomia mediastinica transcervical extendida.

Normativa SEPAR 2011 Arch Bronconeumol 2011;47:454-.

• TBNA y EBUS: – Med. Alto(2, 3P, y 4),

– Subcarinica (7)

– Hiliares (10)

– Lobares (11)

• EUS: – Paratraqueal inf. izda (4L)

– Subaortica (5)

– Med. Bajo (7, 8 y 9)

– Ocasionalmente: 4R,2R, y 2L

CT, bronchoscopic image and EBUS image of station 4R and 4L

EUS image of station 7, doppler signal station 5

MEDIASTINOSCOPIA

MEDIASTINOSCOPIA

VIDEOMEDIASTINOSCOPIA

“N” Estadiaje mediastino

• Puncionar todo ganglio sospechoso en PET (x 10-15% F+)• Puncionar todo ganglio >5 mm• Mejor EBUS vs TBNA, incluso en < 1cm, pero necesita 3

punciones por ganglio. Ahorra 55 % de Mediastinoscopias• La EUS evalúa hasta suprarrenales, tronco celiaco e higado.• La Videomediastinoscopia (Cirugía Torácica) es la prueba

mas frecuentemente usada para probar N2. Confirmada y tras TTo inducción se vuelve a utilizar el PET-CT para la Reestadificacion. Si N2 se hace negativo entonces cirugia.

Estadificación “N”

Si PET negativo en mediastino se acepta Cirugíasin pruebas invasivas,

EXCEPTO:

– Tumores de localización CENTRAL

– Tumores de BAJA actividad metabólica.

– Aparente afectación N1

– Ganglios en TAC >15 mm

“M” Estadiaje Extratorácico CP

S E VPN VPP

TC 18 98 89 71

PET-TC 92 98 98 89

EUS 85-93 100

EUS: eco esofágica.

Normativa SEPAR 2011

Estadiaje CPCP (Microcítico)

Validez de 7ª Edición de la AJCC2 categorías : según tumor incluido o no en un único campo de RT:

• Enfermedad Limitada (EL)Tumor confinado a un hemitórax y sus ganglios linfáticos regionales

(hiliares y mediastínicos homo y contralaterales y supraclaviculares ipsilaterales). Corresponde a estadios I-III A del TNM.

• Enfermedad Extendida (EE)Todos los tumores que excedan de los límites antes reseñados.

Corresponde a estadio IV y IIIB con derrame pleural del TNM.

CP de células pequeñas no es susceptible de Tto quirúrgico (excepto estadio I con estudio de extensión completo negativo)

BAplicaciones de PET en CP

Utilidad de PET en CP

1. Evaluación del nódulo pulmonar solitario2. Estadificación del CPCNP3. Valor pronóstico4. Re-estadificación del CPCNP5. Recurrencia6. Monitorizar Respuesta7. Planificación de radioterapia8. Guiar biopsia9. Carcinoma pulmonar microcítico

1. Nódulos Pulmonares

Caracterizar nódulos o masas

Metaanalisis (1) de 1474 lesiones:

• Se = 96.8%, E = 77.8%

• SUV >2.5: Se = 92%, E = 90%

• Visualmente: Se = 98%, E = 69% (2)

• Si < 1 cm es mas sensible el visual

(1) Gould. JAMA 2001.(2) Lowe. J Clin Oncol 1998

NoduloGUIA NCCN

• Evaluación Multidisciplinar

– Factores paciente: (edad, tabaco, exposiciones trabajo, infecciones…+ Factores radiologicos incluyendo FDG

• Nódulo >8mm “SOLIDO NO CALCIFICADO” PET• Maligno: SUV max > Pool sanguíneo mediastino.

– Falsos + en infecciones-inflamaciones.– Falsos - Pequeños, baja densidad celular, y baja avidez de FDG como

Ca Broncoalveolar y T. Carcinoide

• Tras PET de malignidad: CONFIRMACION HISTOLOGICA PREVIO A CUALQUIER TRATAMIENTO NO QUIRURGICO.– Masas centrales: Broncoscopia– Nodulos perifericos (x fuera de 1/3): FNA-Transtorácica, EBUS-fna

2. Estadificacion “T”

PET/TC de estadificación de un varón de 58 años con carcinoma epidermoide pulmonar. Se evidencia el tumor central con atelectasia del lóbulo superior izquierdo. La intensa captación de 18F-FDG por el tumor (flecha) permite diferenciarlo del pulmón colapsado adyacente.

PET-TAC: N1-N2-N3

2. Estadificacion “N”

“M” NORMATIVA SEPAR

• Si dolor óseo: GGO, si dudosas lesiones PET, mayor S,E y VP

• Lesiones hepáticas y suprarrenales: TC/RM, si dudas PET (más resolutiva)

• Detecta metastasis ocultas en 8% en EST-I, 24% EST- III

• Mtx única en SRR o cerebro pueden extirparse.

• Ante estadio III o sospecha de mtx cerebral: ->RM.

Normativa SEPAR sobre estadificacion de cancer de pulmón. Arch Bronconeumol 2011;47:454-.

M1a: Malignant pleural effusion in right hemithorax.

Estadificación: “M”

M1b: pathological FDG uptake in the right adrenal gland with central necrosis

Costo-efectividad de estadiaje PETEstadiaje CPCNP: -EVITAR CIRUGIA INNECESARIA.

188 pac. con cirugia planificada, Randomizados a grupo-PET vs grupo no-PET

- 21% NO SE DEBIA HACER CIRUGIA POR ESTADIO AVANZADO. (1/5 Pts PREVENIR TORACOTOMIA INNECESARIA SI REALIZA PET.)

De Wever W,. Eur Radiol 2007;17:23–32.

QALY: München, Germany

Correcto estadiaje TNM 40% (31/77) para CT, y 60% (46/77) para PET/CT.

Resecabilidad: 84% correctamente por PET/CT; CT solo, 70%.

El incremento de coste-efectividad por Correcto estadiaje/pac: $3,508 PET/CT versus CT alone.

El incremento de coste-efectividad por Calidad vida-año-ganado: $79,878 PET/CT vs. CT alone,

- PET/CT para Estadiaje CPCNP es recomendado desde “economic point of view”

Schreyogg J. et al. J Nucl Med 2010;51:1668-75

3. Valor Pronóstico

99439. HSJ

Estudio de Ca. Pulmón

SUVmax = 23

4.Re-estadificación

• En N2, tto con QT+RT de inducción -> si remiten las adenopatías -> cirugía.

• PET-CT mejor que CT (VPN 75% vs 53%) (VPP 93% vs 66%), sobretodo N2 y Est III-A

• PET es negativo se plantea EBUS-FNA o cirugía para comprobar. (normativa SEPAR 2011 aunque VPN de EBUS = 20%)

Re-estadiaje.

-Si SUV max de ganglios N2 disminuye >50%, muy probable ->benignos.

Median percentage of change in the maxSUV of N2 lymph nodes in various stations on the basis of pathologic response.

Cerfolio et al. J Thorac Cardiovasc Surg. 2006;131(6):1229-.

5.Recurrencia

• Detección precoz de Recurrencia para ofrecer tratamiento de rescate.

• Tras cirugía, TAC de elección, pero necrosis, fibrosis, cicatrices dificultan. PET es mas específica.

• Tras QT-RT, el PET puede tener mas falsos +, por inflamación persistente. Pero es ideal para buscar M1 .

• Sens, Especif, Precision: 93%, 89%, 92%.

• SUV en tumores recurrentes es mayor que en cambiosbenignos post-Tto (Hellwig et al. 2006: 10.6+/-5.1 vs 2.1+/-0.6, p<0.001)

Recurrencia

Post-cirugía Post-RT

6. RESPUESTA A TTO

• La disminución de captacion de FDG precede a la disminución de tamaño.

• Precisa un estudio basal y otro tras el tratamiento para comparar.

• CRITERIO: reducción de la masa tumoral evaluada por la TAC– criterios RECIST, “Response evaluation criteria in solid tumors”. Medir en el plano axial el

diámetro mayor de las masas tumorales

– respuesta completa (sin evidencia de tumor), respuesta parcial (una 30% reducción del tamaño tumoral), enfermedad estable (sin modificación) y enfermedad progresiva (incremento del 20% del tamaño)

• Organización Europea para Investigación y Tratamiento del Cáncer: criterios EORTC:

RESP. METABOLICA PARCIAL -> DESCENSO >25% TRAS 2 CICLOS

• Criterios PERCIST: RMP -> DESCENSO DE SUL >30% (en lesión más intensa)

RESPUESTA

AdeCa. Respuesta a Tto: RMC.

RESPUESTA A TTOERLOTINIB

• Benz M. J Nucl Med 2011.

• 22 pac. Estadio IIIB-IV. PET previo y a 2 semanas de iniciar Erlotinib. Criterios PERCIST. 5 focos.

• Si PMD (progresión). OS (superv global): 87 d

• Si SMD (estable) OS: 828 d

RM Parcial Progresión

7. Planificacion RT

• Permite cálculo de las dosis de radiación y volumen tumoral a tratar.

• PET permite delimitar perfectamente dentro de la imagen anatómica del tumor cuáles son las zonas de actividad maligna y su intensidad.

• Mayor eficacia en los tratamientos aplicados y evita el daño en tejidos sanos peritumorales (IMRT).

• Puede de cambiar el volumen tumoral a tratar hasta en en 30-60% de casos, respecto a CT (Greco et al. Lung Cancer 2007)

• 36% de pacientes puede disminuir el GTV por atelectasias y neumonias post-obstructivas (Spratt DE et al. Clin Nucl Med 2010).

• No hay un método “gold standard” para delimitar volúmenes tumorales automaticamente. Sin embargo, debería validarse uno para CPCNP. (Shirai K Int J Mol Imaging. 2012)

Delimitación de volumen de tratamiento en RT:Autocontorno a partir del 40% del SUVmax en región de interés.

PLANIFICACIÓN RT

8. Biopsia guiada PET

• Permite escoger el mejor sitio a puncionar.

• Especialmente en Recurrencias de neoplasias tratadas y grandes lesiones con Necrosis asociada.

• Limitado en nódulos pequeños.

Axial fused PET/CT (top right) and CT (bottom right) images at the level of the upper lungs, with a sagittal fused PET/CT image (middle) and an MIP image (on left), from a PET study of a 71-year-old lady with a large right upper lobe mass. Bronchoscopic evaluation and two CT-guided biopsies failed to reveal malignancy. PET scan clearly shows a large malignant right upper lung mass with a large ‘cold’ central necrotic area(arrows) and intense FDG uptake peripherally. A third CT-guided biopsy from the periphery of the mass based on the PET findings confirmed NSCLC

9. CP.Microcitico

• PET-TAC cambia manejo de pac. en 28-30% casos

• NCCN Recomienda PET-CT si sospecha ENF. LIMITADA para detectar metastasis a distancia

• Detección de áreas tumorales o no-tumorales para campos de RT (Atelectasia)

• Comparado a CPCNP la relacion de SUVmax y pronostico es mas compleja (van der Leest C. Lung Cancer. 2012)

CPCP

ENF. LIMITADA

MESOTELIOMA MALIGNO

• UTILIDAD DE PET:– Caracterizar benigno vs maligno: S y E = 90%, 95%

– Variantes hipocaptantes (F-): epiteloide

– F+ tras pleurodesis con talco.

– identificar metástasis extratorácicas ocultas que excluyen al paciente para cirugía (22-50% casos).

– Determinar el lugar adecuado para biopsia pleural.

– SUV alto peor pronóstico.

– Valoración de respuesta a QT, mejor que RECIST.

Mesotelioma

21-year-old man with malignant mesothelioma epithelioid type, diagnosed after biopsies of pleura, pericardium, and mediastinal mass.PET/CT maximum-intensity-projection anterior image shows large FDG-avid mass in mediastinum with maximum standardized uptake value of 10.9.

CActualizaciónBibliografía

CIRUGIA. NOVEDADES

• Naidoo R, et al. J Thorac Dis 2013 Oct;5 (Suppl 5):S593-S606.Dep. Cardiothoracic Surgery. Brisbane, Australia

• The role of surgery continues to evolve and in the last ten years there have been a number of significant changes in the surgical management of lung cancer. These changes extend across the entire surgical spectrum of lung cancer management including diagnosis, staging, treatment and pathology.

• Positron Emission Tomography (PET) scanning and ultrasound (EBUS) have redefined traditional staging paradigms, and surgical techniques, including video-assisted thoracoscopy (VATS), robotic surgery and uniportal surgery, are now accepted as standard of care in many centers.

• The changing pathology of lung cancer, with more peripheral tumours and an increase in adenocarcinomas has important implications for the Thoracic surgeon.

• Screening, using Low-Dose CT scanning, is having an impact, with not only a higher percentage of lower stage cancers detected, but also redefining the role of sublobar resection.

• The incidence of pneumonectomy has reduced as have the rates of "exploratory thoracotomy". In general, lung resection is considered for stage I and II patients with a selected role in more advanced stage disease as part of a multimodality approach

RT. NOVEDADES

• Fay M, et al. J Thorac Dis. 2013 Oct;5(Suppl 5):S551-S555.

• Recent advances in radiotherapy for thoracic tumours.

• Source

• Division of Oncology, Royal Brisbane and Women's Hospital, Queensland Health, Brisbane, Australia; ; School of Medicine, University of Queensland, Brisbane, Australia; ; Visiting Scientist, Preclinical Molecular Imaging, Eberhard Karls Universität Tübingen, Germany;

• Abstract

• Radiation Oncology technology has continued to advance at a rapid rate and is bringing significant benefits to patients. This review outlines some of the advances in technology and radiotherapy treatment of thoracic cancers including brachytherapy, stereotactic radiotherapy, tomotherapy and intensity modulated radiotherapy.

• The importance of functional imaging with PET and management of movement are highlighted. Most of the discussion relates to non-small cell lung cancer but management of mesothelioma and small cell lung cancer are also covered. This technology has substantial benefits to patients in terms of decreasing toxicity both in the short and longer term.

Li J. Surg Oncol. 2013 Sep;22(3):151-5. Department of Oncology,, Jinan 250031, PR China

Meta-analysis: accuracy of 18FDG PET-CT for distant metastasis staging in lung cancer patients.

BACKGROUND:

We undertook a meta-analysis to evaluate the accuracy of (18)FDG PET-CT for diagnosis of distant metastases in lung cancer patients.

METHODS:

Studies about (18)FDG PET-CT for diagnosis of distant metastases in patients with lung cancer were systematically searched in the MEDLINE and EMBASE databases. We calculated sensitivities, specificities, positive likelihood ratios and negative likelihood ratios, and constructed summary receiver operating characteristic curves using bivariate regression models for (18)FDG PET-CT.

RESULTS:

Across 9 studies (780 patients), the sensitivity, specificity, positive likelihood ratio and negative likelihood ratio

of (18)FDG PET-CT were 0.93 (95% confidence interval [CI] = 0.88-0.96), 0.96 (95% CI = 0.95-0.96), 28.4

(95% CI = 14.0-57.5), and 0.08 (95% CI = 0.02-0.37), respectively. Overall weighted area under the curve was 0.98 (95% CI = 0.96-0.99).

CONCLUSION:

(18)FDG PET-CT has excellent diagnostic performance for diagnosis of distant metastases in patients with lung cancer.

M1-METAANALISIS-PET.2013

PET vs MEDIASTINOCOPIADarling GE, et al J Thorac Oncol. 2011 Aug;6(8):1367-72.

Positron emission tomography-computed tomography compared with invasive mediastinal staging in non-small cell lung cancer: results of mediastinal staging in the early lung positron emission tomography trial.

. University of Toronto, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.

INTRODUCTION:

Patients with non-small cell lung cancer (NSCLC) require careful preoperative staging to define resectability for potential cure. Fluorodeoxyglucose positron emission tomography combined with computed tomography (FDG PET-CT) is widely used to stage NSCLC. If the mediastinum is positive on PET-CT examination, some practitioners conclude that the patient is inoperable and refer the patient for nonsurgical treatment.

METHODS:

In this analysis of a previously reported trial comparing PET-CT with conventional imaging in the diagnostic work-up of patients with clinical stage I, II, or IIIA NSCLC, we determined the accuracy of PET-CT in mediastinal staging compared with invasive mediastinal staging either by mediastinoscopy alone or by mediastinoscopy combined with thoracotomy.

RESULTS:

All 149 patients had mediastinal nodal staging at mediastinoscopy alone (14), thoracotomy alone (64), or both (71). The sensitivity of PET-CT was 70% (95% confidence interval [CI], 48-85%), and specificity was 94% (95% CI, 88-97%). Of 22 patients with a PET-CT interpreted as positive for mediastinal nodes, 8 did not have tumor. The positive predictive value and negative predictive value were 64% (95% CI, 43-80%) and 95% (95% CI, 90-98%), respectively. Based on PET-CT alone, eight patients would have been denied potentially curative surgery if the mediastinal abnormalities detected by PET-CT had not been evaluated with an invasive mediastinal procedure.

CONCLUSIONS:

PET-CT assessment of the mediastinum is associated with a clinically relevant false-positive rate. Our study confirms the need for pathologic confirmation of mediastinal lymph node abnormalities detected by PET-CT.

Pronostico: MTV - TLG

Chunga HWet al J Cancer Res Clin Oncol. 2014 Jan;140(1):89-98. FDG PET/CT metabolic tumor volume and total lesion glycolysis predict prognosis in patients with advanced lung adenocarcinoma.

Seoul, Korea

PURPOSE:

We investigated fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT)-assessed metabolictumor volume (MTV) and total lesion glycolysis (TLG) as prognostic factors in lung adenocarcinoma patients.

METHODS:

This retrospective study included 106 patients (19 stage I/II and 87 stage III/IV lung adenocarcinoma) who underwent FDG PET/CT before

treatment. Standardized uptake value (SUV), MTV, and TLG (MTV × mean SUV) of each malignant lesion were measured. Whole

MTV and whole TLG were the summation of all the MTV and TLG values in each patient. Survival analysis and FDG PET/CT parametersregarding epidermal growth factor receptor (EGFR) gene mutation status were evaluated.

RESULTS:

Univariate survival analysis of stage III/IV patients identified high whole MTV (≥90), high whole TLG (≥600), and stage IV as significantpredictors of poor progression-free survival. For overall survival, high whole MTV (≥90), high whole TLG (≥600), EGFR mutation-negative, and stage IV were significant poor prognostic predictors. After multivariate survival analysis, high whole MTV (P = 0.001), highwhole TLG (P = 0.027), and stage IV (P = 0.006) were independent predictors of poor progression-free survival. High whole MTV (P < 0.001), high whole TLG (P = 0.001), and EGFR mutation-negative (P = 0.001) were independent prognostic predictors for pooroverall survival. In a survival analysis of stage I/II patients, none was an independent prognostic predictor. No significant differenceswere found in FDG PET/CT parameters for EGFR mutation-negative and EGFR mutation-positive patients.

CONCLUSIONS:

Assessment of MTV and TLG by FDG PET/CT in advanced lung adenocarcinoma patients provides useful information regarding prognosis.

Independiente de estadio

PET 4D-(RESPIR GATED)Guerra L et al. Eur J Nucl Med Mol Imaging. 2012 Sep;39(9):1381-90.

Respiratory gated PET/CT in a European multicentre retrospective study: added diagnostic value in detection and characterization of lung lesions.

Source Nuclear Medicine, San Gerardo Hospital, Via Pergolesi 33, 20900 Monza, Italy.

PURPOSE: The aim of our work is to evaluate the added diagnostic value of respiratory gated (4-D) positron emission tomography/computed tomography (PET/CT) in lung lesion detection/characterization in a large patient population of a multicentre retrospective study.

METHODS: The data of 155 patients (89 men, 66 women, mean age 63.9 ± 11.1 years) from 5 European centres and submitted to standard (3-D) and 4-D PET/CT were retrospectively analysed. Overall, 206 lung lesions were considered for the analysis (mean ± SD lesions dimension 14.7 ± 11.8 mm). Maximum standardized uptake values (SUV(max)) and lesion detectability were assessed for both 3-D and 4-D PET/CT studies; 3-D and 4-D PET/CT findings were compared to clinical follow-up as standard reference.

RESULTS:

Mean ± SD 3-D and 4-D SUV(max) values were 5.2 ± 5.1 and 6.8 ± 6.1 (p < 0.0001), respectively, with an average percentage increase of 30.8 %. In 3-D PET/CT, 86 of 206 (41.7 %) lesions were considered positive, 70 of 206 (34 %) negative and 50 of 206 (24.3 %) equivocal, while in 4-D PET/CT 117 of 206 (56.8 %) lesions were defined as positive, 80 of 206 (38.8 %) negative and 9 of 206 (4.4 %) equivocal. In 34 of 50 (68 %) 3-D equivocal lesions follow-up data were available and the presence of malignancy was confirmed in 21 of 34 (61.8 %) lesions, while in 13 of 34 (38.2 %) was excluded. In 31 of these 34 controlled lesions, 20 of 34 (58.8 %) and 11 of 34 (32.4 %) were correctly classified by 4-D PET/CT as positive and negative, respectively; 3 of 34 (8.8 %) remained equivocal. With equivocal lesions classified as positive, the overall accuracy of 3-D and 4-D was 85.7 and 92.8 %, respectively, while the same figures were 80.5 and 94.2 % when equivocal lesions were classified as negative.

CONCLUSION:

The respiratory gated PET/CT technique is a valuable clinical tool in diagnosing lung lesions, improving quantification and confidence in reporting, reducing 3-D undetermined findings and increasing the overall accuracy in lung lesion detection and characterization.

RM-PET vs PET-CT. ESTADIAJEYi CA. Cancer. 2013 May 15;119(10):1784-91.

Co-registered whole body magnetic resonance imaging-positron emission tomography (MRI-PET) versus PET-CT plus brain MRI in staging resectable lung cancer: comparisons of clinical effectiveness in a randomized trial.

Seoul, Korea.

BACKGROUND:

The objective of this study was to assess whether coregistered whole brain (WB) magnetic resonance imaging-positron emission tomography (MRI-PET) would increase the number of correctly upstaged patients compared with WB PET-computed tomography (PET-CT) plus dedicated brain MRI in patients with nonsmall cell lung cancer (NSCLC).

METHODS:

From January 2010 through November 2011, patients with NSCLC who had resectable disease based on conventional staging were assigned randomly either to coregistered MRI-PET or WB PET-CT plus brain MRI (ClinicalTrials.gov trial NCT01065415). The primary endpoint was correct upstaging (the identification of lesions with higher tumor, lymph node, or metastasis classification, verified with biopsy or other diagnostic test) to have the advantage of avoiding unnecessary thoracotomy, to determine appropriate treatment, and to accurately predict patient prognosis. The secondary endpoints were over staging and under staging compared with pathologic staging.

RESULTS:

Lung cancer was correctly upstaged in 37 of 143 patients (25.9%) in the MRI-PET group and in 26 of 120 patients (21.7%) in the PET-CT plus brain MRI group (4.2% difference; 95% confidence interval, -6.1% to 14.5%; P = .426). Lung cancer was over staged in 26 of 143 patients (18.2%) in the MRI-PET group and in 7 of 120 patients (5.8%) in the PET-CT plus brain MRI group (12.4% difference; 95% confidence interval, 4.8%-20%; P = .003), whereas lung cancer was under staged in 18 of 143 patients (12.6%) and in 28 of 120 patients (23.3%), respectively (-10.7% difference; 95% confidence interval, -20.1% to -1.4%; P = .022).

CONCLUSIONS:

Although both staging tools allowed greater than 20% correct upstaging compared with conventional staging methods, coregistered MRI-PET did not appear to help identify significantly more correctly upstaged patients than PET-CT plus brain MRI in patients with NSCLC.

DUAL POINT-NODULOSMETAANALISIS

Zhang L, et al Acta Radiol. 2013 Sep;54(7):770-7.

Dual time point 18FDG-PET/CT versus single time point 18FDG-PET/CT for the differential diagnosis of pulmonary nodules: a

meta-analysis.

BACKGROUND: Lung cancer is one of the most common cancer types in the world. An accurate diagnosis of lung cancer is crucial for early treatment and management.

PURPOSE: To perform a comprehensive meta-analysis to evaluate the diagnostic performance of dual time point 18F-fluorodexyglucose position emission tomography/computed tomography (FDG-PET/CT) and single time point 18FDG-PET/CT in the diagnosis of pulmonary nodules.

MATERIAL AND METHODS: PubMed (1966-2011.11), EMBASE (1974-2011.11), Web of Science (1972-2011.11), Cochrane Library (-2011.11), and four Chinese databases - CBM (1978-2011.11), CNKI (1994-2011.11), VIP (1989-2011.11), and Wanfang Database (1994-2011.11) - were searched. Summary sensitivity, summary specificity, summary diagnostic odds ratios (DOR), and summary positive likelihood ratios (LR+) and negative likelihood ratios (LR-) were obtained using Meta-Disc software. Summary receiver-operating characteristic (SROC) curves were used to evaluate the diagnostic performance of dual time point 18FDG-PET/CT and single time point 18FDG-PET/CT.

RESULTS: The inclusion criteria were fulfilled by eight articles, with a total of 415 patients and 430 pulmonary nodules. Compared with the gold standard (pathology or clinical follow-up), the summary sensitivity of dual time point 18FDG-PET/CT was 79% (95%CI, 74.0-84.0%), and its summary specificity was 73% (95%CI, 65.0-79.0%); the summary LR+ was 2.61 (95%CI, 1.96-3.47), and the summary LR- was 0.29 (95%CI, 0.21-0.41); the summary DOR was 10.25 (95%CI, 5.79-18.14), and the area under the SROC curve (AUC) was 0.8244. The summary sensitivity for single time point 18FDG-PET/CT was 77% (95%CI, 71.9-82.3%), and its summary specificity was 59% (95%CI, 50.6-66.2%); the summary LR+ was 1.97 (95%CI, 1.32-2.93), and the summary LR- was 0.37 (95%CI, 0.29-0.49); the summary DOR was 6.39 (95%CI, 3.39-12.05), and the AUC was 0.8220.

CONCLUSION: The results indicate that dual time point 18FDG-PET/CT and single time point 18FDG-PET/CT have similar accuracy in the differential diagnosis of pulmonary nodules. Dual time point 18FDG-PET/CT appears to be more specific than single time point 18FDG-PET/CT.

DPráctica diaria

PET EN HCB

40% Dx de NPS, 30% Extension, 15% Recurrencia, 10% Planif. RT, 5% V. Respuesta

Nódulo

Falso negativo. El analisis histologico evidencio un carcinoma bronquioalveolar

Falso negativo. El analisis histologico demostró T. Carcinoide

Pitfalls

Granulomatous infection mimicking pulmonary metastasis.Transthoracic needle aspiration biopsy revealed no malignant cells. Fungal elements morphologically consistent with blastomyceswere identified.

Truong et al. Radiol Clin North Am. 2014

Pitfalls

Injection of radiotracer with microembolism mimicking pulmonary metastasis. A 38-year-old man withteratoma presents for staging evaluation. Axial PET/CT (A) shows a focal area of FDG avidity in the right lowerlobe (arrow) suspicious for pulmonary metastasis. However, no corresponding pulmonary nodule is seen on CT(B). This potential pitfall is due to an accumulation of FDG within a thrombus following injection of the radiotracer.The thrombus is embolized into the right lower lobe pulmonary artery. Iatrogenic microembolism occurswhen abnormal FDG accumulation in the lung has no counterpart detectable on CT. Truong et al. Radiol Clin North Am. 2014

ESTADIAJE 1

T2a (>3 <=5 cm) N2 (subcarinal) M0

III-A

ESTADIAJE 2

Ca. Epidermoide Extensión.-Masa LSI >7cm (T3), atelectasia, -Adenopatia nivel 5. (N2)-Supraclavicular (N3)-Adenopatia hilio hepatico (M1)

Pitfalls N

Mediastinal brown fat mimicking adenopathy.

Truong et al. Radiol Clin North Am. 2014

Pitfalls N

Mediastinal hematoma following mediastinoscopy mimicking adenopathyMediastinoscopy was performed 2 weeks earlier for lung cancer staging.

Truong et al. Radiol Clin North Am. 2014

Pitfall M

Truong et al. Radiol Clin North Am. 2014

Pitfalls M

Talc pleurodesis mimicking pleural metastasis. A 69-year-old man with lung cancer presents for staging.By clinical history, the patient had recurrent spontaneous pneumothoraces requiring talc pleurodesis 2 years earlier. Note the inflammatory reaction incited by talc can result in persistent increased FDG uptake even years after pleurodesis.

Truong et al. Radiol Clin North Am. 2014

DUAL POINT vp

Representative case of adenocarcinoma and mediastinal lymph node metastasis (lymph node 7) in subcarinal area: chest CT (A), early imaging (B), and delayed imaging (C). CT images show nodule in right lung with no significant mediastinallymph node swelling. Early imaging shows strong accumulation in nodule and faint accumulation in lymph node 7. PET showsincreased uptake in lung nodule (early SUV 6.85, delayed SUV 10.01, RI SUV 46.1%) and uptake in lymph node 7 (early SUV 3.49, delayed SUV 5.08, RI SUV 45.6%).

Pitfalls fp

—59-year-old man with indeterminate 0.8-cm-diameter pulmonary nodule in right middle lobePathology report showed granulomatous inflammation composed of clustered epithelioid histiocytes with Langhans' giant cells. Special stain revealed acid-fast bacilli.8F-FDG PET image shows initial maximal standard uptake value of nodule (arrow) was 2.4.FDG PET image acquired 1 hour after A shows delayed maximal standard uptake value of nodule (arrow) increased to 3.5. (RI 45%)

Dual-Point

SUV MAX 4.5

SUV MAX 5.3

(RI 15%)

FIN