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Malignant and Benign Diffuse Pleural Disease : Utility Offdg PET in Differential Diagnosis and Comparison with CT 1

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Malignant and Benign Diffuse Pleural Disease : Utility Offdg PET in Differential Diagnosis and Comparison with CT 1 J Korean Radiol Soc 1997; 37 : 641 - 649 Malignant and Benign Diffuse Pleural Disease : Utility ofFDG PET in Differential Diagnosis and Comparison with CT 1 Kyung Soo Lee, M.D., Jung-Eun Cheon, M.D., Byung-Tae Kim, M.D.2 Yookyung Kim, M.D., Duk 、^J oo Ro, Ph.D., 0 Jung Kwon, M.D.3, ChongH. Rhee, M.D.3 Purpose : To assess the utility of 2-[18F] f1 uoro-2-deoxy-D-glucose (FDG) PET in differentiating malignant and benign diffuse pleural disease, and to compare it with CT. Materials and Methods : Both FDG PET and CT scans were performed in 20 con­ secutive patients with diffuse pleural disease(13 malignant and seven benign cases). In FDG PET, peak standardized uptake value (SUV) as well as visual assessment of abnor­ mally increased uptake in the pleura was evaluated. The results were compared with CT findings. Results : With only visual assessment of PET images, sensitivity, specificity, and accuracy for malignancy were 92 %, 43 %, and 75 %, respectively. With peak SUV of 4.8 or more, the corresponding figures were 100 %, 57 %, and 85 %, respectively, and on CT interpretation, were 100 %, 57 %, and 85 %, respectively. Tuberculous empyema simulated malignant pleural disease both on FDG PET (3/6 patients with peak SUV more than 4.8) and CT (3/6 patients) Conclusion : For the differentiation of malignant and benign diffuse pleural dis­ ease, FDG PET and CT are equally accurate. Combined visual and quantitative assessments of PET images enhance discriminatory ability. Tuberculous empyema simulates malignant pleural disease both on FDG PET and CT. Index Words : Emission CT Fluorine Pleura, CT Pleura, diseases Pleura, neoplasms Because diffuse pleural abnormalities usually in­ pleural disease is even more difficult because a specific volve various degrees of pleural thickening, calcifi­ diagnosis is often hard to make on the basis of clinical cation and effusion, there is an overlap of radiologic criteria, thoracentesis, and percutaneous pleural bi­ findings of different benign and malignant pleural dis­ opsy findings. eases(l). The differentiation ofmalignant from benign CT can play a major role in distinguishing malignant from benign pleural disease. Features that favor the 'Departments of Radiology. Samsung Medical Center. College of Medicine. former include circumferentiaL nodular and parietal SungKyunKwan University 2Departments of Nuclear Medicine. Samsung Medical Center. College of Medi­ pleural thickening of more than 1 cm, and mediastinal cine. SungKyunKwan University pleural involvement. Although specificity of the 'Departments of Pulmonary Medicine. Samsung Medical Center. College of findings was high(88 - 100 %), their sensitivity was Medicine. SungKyunKwan University This research was supported in part by Samsung lnstitutional Biomedical Re­ relatively low(36 - 56 %) (2). search grant C-95-028 It has been recognized that the increased rate of Received June 16. 1997; Accepted September 5. 1997 Address reprint requests to: Kyung Soo Lee. M.D .• Department of Radiology. glucose metabolism seen in human cancers may serve Samsung Medical Center 1 50. lrwon-Dong. Kangnam-Ku SeouI135-230. South as a useful target for positron emission tomographic Korea. Tel. 82-2-3410-251 1. 2518 FAX.82-2-341O-2559 (PET) metabolic imaging with radiolabeled glucose e-mail. [email protected] - 641 - Kyung Soo Lee, et al : Malignant and Benign Diffuse Pleural Disease ana10gues such as 2-[18Fl fluoro-2-deoxy-D-g1ucose b100d glucose 1eve1 ranged from 70 to 113 (mean, 88) (FDG) . Severa1 recent studies have reported the diag­ mg/dL and image acquisition started just after injec­ nostic applicability of FDG PET to thoracic imaging for tion. A Hanning filter was used for image reconstruc­ the differentiation of ma1ignant from benign disease tion, resulting in a practica1 reso1ution of 9.0mm. Im­ (3 - 8) age processing and reconstruction were performed The aims of this study were to assess the utility of with an Apollo 735 computer system(Hew1ett Packard, FDG PET in differentiating between ma1ignant and be Rockville, Md이)ι). Photon at야tem뻐 tion was corrected by nign diffuse p1eura1 diseases, and to compare it with the use of a transmission scan obtained with two CT. 68Gef'8Ga pin sources (10 mCi each) 20 mins before the injection ofFDG. On images obtained 40-60 minutes after injection, Materials and Methods we visually constructed over the 1esion a region of This study invo1ved 20 consecutive patients interest (ROI) showing the most active FDG uptake. diagnosed on chest CT as suffering from diffuse p1eura1 The size of an ROI varied from nine to 41 pixels; each disease. Ten were men and ten were women, and their pixe1 was 1. 95 mm in size, in 128 X 128 array. ages ranged from 18 to 74 years(mean + standard devi Standardized uptake va1ue(SUV), normalized for ation, 51. 8 ::t 15.6). These patients were consensually injected dose and body weight, was obtained in each se1ected by an experienced chest radio1ogist and a pixe1 using the previous1y described method(lO). The pu1mono1ogist aware of their name, age, sex, clinica1 maximum pixe1 va1ue of SUV in ROI was chosen as data, and radiographic findings but who did not take peakSUV(IL 12). part in image ana1ysis. On CT, p1eura1 thickening was PET scans were interpreted independent1y by two seen; this extended for 8cm craniocaudally and 5 cm qualified nuclear medicine physicians, who were 1aterally, and in the p1eura was over 3mm thick(9). blinded to patho1ogic results, but aware ofCT findings. P1eura1 effusion and/or calcification was a1so present. Because diffuse p1eura1 uptake was expected on PET, We excluded those patients with metastatic diffuse the pattern of abnormally increased uptake was p1eura1 disease originating from overt 1ung cancer, subclassified visually as smooth linear, nodu1ar, or in­ since cancer in these patients may easily be recognized terrupted. Increased uptake was considered to have byCTscans. occurred when the presumed 1esion showed more up­ All patho1ogic specimens were obtained by p1eura1 take than the mediastinum. Because spatia1 reso1ution biopsy(n= 10), open thoracotomy including decorti­ ofincreased uptake on PET was not satisfactory, the 10- cation(n=6), and video-assisted thoracoscopic sur cation of increased uptake (such as parietaL fissuraL or gery(n=4), and were reviewed by one patho1ogist. Ma mediastinaI) was not specified. When increased uptake 1ignant vs. benign disease was histo1ogically deter­ was detected in other areas including the 1ung, medias­ mined on the basis of standard architectura1 and tina1 node, chest waU, or extrathoracic area, the 10- cyto1ogic features. P1eura1 metastasis occurred in cation of the uptake was recorded. Initially, the PET eleven patients(from presumed 1ung carcinoma in four, scans were assessed visually, images were reviewed in and from unknown primary sites in seven); two were axiaL coronaL and sagitta1 p1anes, using an interactive suffering from malignant mesothelioma, and seven video disp1ay system. Inclusion criteria of 3 mm or from benign diffuse p1eura1 disease (tubercu1ous em­ more ofp1eura1 thickness, as seen on axia1 CT scans, did pyema, 6 cases; nontuberculous empyema, 1 case). not thus preclude interpretation of a PET scan of 9 mm in reso1ution. When FDG uptake of the p1eura11esion Image Acquisition and Interpretation of FDG was higher than that of the mediastinum, it was PET regarded as ma1ignant. In cases of a clash of opinion be­ All FDG PET scans were obtained with a GE tween the two observers, decisions on malignancy Advance™ PET scanner(GE Medica1 Systems, were reached by consensus. Interpretations were a1so Mi1waukee, Wis). This unit has 4.2건5-mrr따t based on an assessment of uptake semiquantitation, plane않s(18 direct p1anes and 17 cross p1anes), provides using peak SUV . full-width at ha1f maximum of 4.2mm both in direct and cross p1anes, and its 10ngitudina1 field of view is Image Acquisition and Interpretation of CT 15.2cm. Intravenous injection of 10 mCi (370 MBq) of All CT scanning was performed with a GE HiSpeed FDG was performed after an overnight fast of at 1east Advantage scanner(GE Medica1 Systems, Milwaukee, four hours. Just before FDG injection, the patients’ Wis). Helica1 scans(thickness, lOmm; tab1e feed, 10 - 642 - J Korean Radiol Soc 1997; 37 : 641 - 649 mm/sec) were obtained through the thorax after intra­ defined as p1eura1 thickening bordering the medias­ venous administration of 100 mL of Iopamiro(30 % of tinum, and a distinction between viscera1 and parieta1 Iopamid 이， Bracco, Mi1an, Ita1y). Additiona1 thin-sec­ p1eura1 thickening was made on1y in the presence of tion (l-mm collimation) CT scans were obtained p1eura1 effusion. The contour of p1eura1 thickening through the thorax at 20-mm interva1s. Image data was characterized as smooth, irregu1ar, or nodu1ar, and were reconstructed using bone a1gorithms. All scans parieta1 p1eura1 invo1vement was further characterized were photographed with both mediastina1 (window according to whether it was circumferentiaI(defined as width, 400 HU; window 1evel, 30 HU) and 1ung win­ invo1vement ofthe entire perimeter ofthe hemithorax, dow(window width, 1,500 HU; window 1evel, - 700 including the mediastinum, or p1eura1 rind), and on the HU) basis ofwidth ofthickening and 1ength of craniocauda1 CT scans were ana1yzed by two chest radio1ogists extension. Mediastina1 nodes were considered who did not participate in the se1ection ofpatients, and enlarged if they were greater than lOmm in short-axis decisions concerning CT findings were reached by diameter, and were recorded following the American consensus. The scans were assessed on the basis of 10- Thoracic Society 1ymph node mapping system(13) cation, type and extent of p1eura1 thickening, the pres­ After ana1yzing the CT findings of each patient, the ence of p1eura1 effusion, p1eura1 calcification, disease process ofthe p1eura was considered malignant extrap1eura1 invasion and mediastina1 adenopathy, if one or more of the following findings was present: and coexisting pu1monary parenchyma1 abnorma1ities, circumferential, nodu1ar or parieta1 p1eura1 thickening as recommended in a previous study(2).
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