18f fdg pet for mediastinal staging
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My Journal Presentation.Thanks the author for great research.TRANSCRIPT
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1818FF--FDG PET for Mediastinal Staging FDG PET for Mediastinal Staging
of Lungof Lung CCancerancer::
Which SUV Threshold Makes SenseWhich SUV Threshold Makes Sense??
Dirk HellwigDirk Hellwig et al. et al.
Department of Nuclear MedicineDepartment of Nuclear Medicine,, Saarland University Medical CenterSaarland University Medical Center,,HomburgHomburg//SaarSaar,, GermanyGermany
J Nucl Med J Nucl Med 2007;2007; 48:176148:1761––17661766
Resident: Apichaya Claimon, M.D.
Advisor: Pongpija Tuchinda, M.D.
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EEvaluation of mediastinal valuation of mediastinal LNLN involvementinvolvement
�� Mediastinoscopy Mediastinoscopy && ExcisionExcision
�� GGold standardold standard
�� SenSen 80%, Spec 100%80%, Spec 100%
�� InvasiveInvasive
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�� ContrastContrast--enhanced CT & MRIenhanced CT & MRI
�� UUse size criteria se size criteria
�� to differentiate between benign to differentiate between benign && malignantmalignant
�� But 21% of metastases are in normal sized LNBut 21% of metastases are in normal sized LN
�� 40%40% of enlarged of enlarged LNLN are are no malignancyno malignancy
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��1818FF--FDG PETFDG PET
�� TThe most accurate noninvasive modality for he most accurate noninvasive modality for
staging mediastinal staging mediastinal LNLN in lung cancerin lung cancer
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Aim of the studyAim of the study
�� To determine optimum SUV threshold To determine optimum SUV threshold
�� for for mediastinalmediastinal LN staging in patients with LN staging in patients with
NSCLC NSCLC
�� To compare diagnostic performance of To compare diagnostic performance of
SUV analysisSUV analysis with with visual interpretationvisual interpretation
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MATERIALS AND METHODSMATERIALS AND METHODS
�� Retrospective studyRetrospective study
�� PPatients with suspected atients with suspected NSCLCNSCLC
1818FF--FDG PET FDG PET
within 6 wkwithin 6 wk
MediastinoscopyMediastinoscopy
�� Total 95 Total 95 (75 men, 20 woman, age 62(75 men, 20 woman, age 62++9)9)
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1818FF--FDG PET LN evaluationFDG PET LN evaluation
�� Visual Visual
�� Compare with Compare with mediastinalmediastinal blood poolblood pool
�� 6 level (6 level (-- -- -- to + + +)to + + +)
�� SUV maxSUV max
�� 1.5 cm ROI 1.5 cm ROI
�� over visible LN over visible LN oror typical area of LN stationtypical area of LN station
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RESULTRESULT
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Total 95
Lung CA 80
(SCC 39, adeno 31,
unspecified NSCLC 4,
Carcinosarcoma 1,
SCLC 5)
Malig mesothelioma 2
Malig lymphoma 1
MFH 1
Benign 11
(TB 4,
after pneumonia 2,
silicosis 2,
sarcoidosis 1)
23/80 patient
mediastinal LN metastasis
(29%)
70/311 nodes
Positive
(23%)
Total 371 nodes biopsy
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1818FF--FDG PET in LN staging of lung cancerFDG PET in LN staging of lung cancer
�� unaffected lymph nodes unaffected lymph nodes ((N0N0))
�� peribronchialperibronchial or or hilarhilar lymph node involvement lymph node involvement ((N1N1))
�� ipsilateralipsilateral mediastinalmediastinal and and subcarinalsubcarinal involvement involvement ((N2N2))
�� contralateralcontralateral and and supraclavicularsupraclavicular involvement involvement ((N3N3))
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Comparison of SUVComparison of SUVmaxmax in mediastinal in mediastinal LNLN
�� SUVs were higher in metastatic lymph node stations (P < 0.01)SUVs were higher in metastatic lymph node stations (P < 0.01)
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�� TumorTumor--free LN with inflammatory changes free LN with inflammatory changes
had SUV = 2.7 + 2.0 had SUV = 2.7 + 2.0
(range, 0.8(range, 0.8––14.9; n = 146)14.9; n = 146)
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Diagnostic performanceDiagnostic performance
�� Using Visual InterpretationUsing Visual Interpretation
�� Using SUV Using SUV 2.52.5 as Cutoff Valueas Cutoff Value
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Using Visual InterpretationUsing Visual Interpretation
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Using Visual InterpretationUsing Visual Interpretation
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Using Visual InterpretationUsing Visual Interpretation
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Visual Interpretation Visual Interpretation vs.vs. SUV AnalysisSUV Analysis
AUCAUC
�� Visual Visual
0.9300.930++0.0220.022
�� SUV SUV
0.8990.899++0.0250.025
No significantNo significant
(P = 0.241)(P = 0.241)
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Determination of Determination of
Optimal SUV ThresholdOptimal SUV Threshold
Minimal FNR + FPR at SUV = 2.5
Highest diagnostic accuracy at SUV= 4.5
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CONCLUSIONCONCLUSION
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�� Human observationHuman observation has higher sensitivity has higher sensitivity
than than SUV analysisSUV analysis
�� But But SUVSUV has greater value in less has greater value in less
experience observerexperience observer
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�� SUV threshold = 2.5 is feasible SUV threshold = 2.5 is feasible
�� For differentiating benign from metastatic For differentiating benign from metastatic
mediastinalmediastinal lymph nodes in lung CA patientslymph nodes in lung CA patients
�� SenSen = 89%, Spec = 84%= 89%, Spec = 84%
�� False False -- : small metastasis: small metastasis
�� False + : LN inflammationFalse + : LN inflammation
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�� High NPV (96%) High NPV (96%)
�� if PET if PET ––veve ; can omit ; can omit mediastinoscopymediastinoscopy
�� Highest diagnostic accuracy at SUV Highest diagnostic accuracy at SUV >> 4.54.5
�� But SUV = 2.5 cannot applied to LN But SUV = 2.5 cannot applied to LN
metastasis in other tumor typesmetastasis in other tumor types
�� Because differ Because differ 1818FF--FDG uptakeFDG uptake
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Using Visual InterpretationUsing Visual Interpretation