Dual Time Point Positron Emission Tomography/Computed Tomography Scan in Evaluation of Intrathoracic Lesions in an Area Endemic for Histoplasmosis and With High Prevalence of Sarcoidosis

Importance Positron emission tomography (PET) with 18-fluorodeoxyglucose (FDG) is recommended for the non-invasive diagnosis of pulmonary nodules suspicious for lung cancer. In populations with endemic infectious lung disease, FDG-PET may not accurately identify malignant lesions. Objective To estimate the diagnostic accuracy of FDG-PET for pulmonary nodules suspicious for lung cancer in regions where infectious lung disease is endemic and compare the test accuracy in regions where infectious lung disease is rare. Data Sources and Study Selection Databases of MEDLINE, EMBASE and the Web of Science were searched from October 1, 2000, through April 28, 2014. Articles reporting information sufficient to calculate sensitivity and specificity of FDG-PET to diagnose lung cancer were included. Only studies that enrolled more than 10 participants with benign and malignant lesions were included. Database searches yielded 1923 articles, of which 257 were assessed for eligibility. Seventy studies were included in the analysis. Studies reported on a total of 8511 nodules; 5105 (60%) were malignant. Data Extraction and Synthesis Abstracts meeting eligibility criteria were collected by a research librarian and reviewed by 2 independent reviewers. Hierarchical summary receiver operating characteristic curves were constructed. A random-effects logistic regression model was used to summarize and assess the effect of endemic infectious lung disease on test performance. Main Outcome and Measures The sensitivity and specificity for FDG-PET test performance. Results Heterogeneity for sensitivity (I2=87%) and specificity (I2=82%) was observed across studies. The pooled (unadjusted) sensitivity was 89% (95% CI, 86%-91%) and specificity was 75% (95% CI, 71%-79%). There was a 16% lower average adjusted specificity in regions with endemic infectious lung disease (61% [95% CI, 49%-72%]) compared with nonendemic regions (77% [95% CI, 73%-80%]). Lower specificity was observed when the analysis was limited to rigorously conducted and well-controlled studies. In general, sensitivity did not change appreciably by endemic infection status, even after adjusting for relevant factors. Conclusions and Relevance The accuracy of FDG-PET for diagnosing lung nodules was extremely heterogeneous. Use of FDG-PET combined with computed tomography was less specific in diagnosing malignancy in populations with endemic infectious lung disease compared with nonendemic regions. These data do not support use of FDG-PET to diagnose lung cancer in endemic areas unless an institution achieves test performance accuracy similar to that found in nonendemic regions.

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“…Four of the ten studies were retrospective 10,25,28,29 and 7 studies 10,11,14,15,25,26,29 determined diagnosis with pathology only.…”

Section: Resultsmentioning

confidence: 99%

“…42,79 One study used a sodium iodide detector 38 and 3 studies created algorithms of staggered PET scans and changes in standard uptake values (dual-time point). 28,62,80 …”

Section: Resultsmentioning

confidence: 99%

Accuracy of FDG-PET to Diagnose Lung Cancer in Areas With Infectious Lung Disease

Deppen

Blume

Kensinger

et al. 2014

JAMA

152

119

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“…In a recent study of 72 patients with lung nodules, a delayed radionuclide uptake (1 hour after the initial scan) was highly associated with malignancy with an 80% positive predictive value and a 100% negative predictive value. 55 Application of this imaging technology can be helpful in the workup of lung nodules in patients who reside in endemic areas, sparing them invasive diagnostic procedures and potentially reducing morbidity and cost.…”

Section: Diagnosismentioning

confidence: 99%

Histoplasmosis: Up-to-Date Evidence-Based Approach to Diagnosis and Management

Hage

Azar

Bahr

et al. 2015

Semin Respir Crit Care Med

122

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Histoplasmosis is the most common endemic mycosis in the North America, Central America, and many countries of South America and also occurs in China, India, Southeast Asia, Africa, Australia, and Europe. Clinical syndromes are not specific and histoplasmosis often is overlooked in the evaluation of patients with community-acquired pneumonia, chronic cavitary pneumonia resembling tuberculosis or anaerobic infection, granulomatous inflammatory diseases such as sarcoidosis or Crohn disease, and malignancy. The diagnosis depends on understanding the geographic distribution, common clinical presentations, and tests used for diagnosis of histoplasmosis. While histoplasmosis resolves without treatment in most patients, treatment is indicated in all immunocompromised patients and those with progressive disseminated disease or chronic pulmonary disease. Treatment is appropriate in most patients with acute pulmonary disease but rarely in those with other pulmonary or mediastinal manifestations. The preferred agents include liposomal amphotericin B for more severe cases and itraconazole for milder cases and "step-down" therapy following response to amphotericin B.

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“…In these numerous studies, attempts have been made to qualify and quantify the impact of the length of the injection-to-scan time interval on differentiating malignant processes from benign processes. As one might expect, the findings reported amongst these various investigators have been highly variable, with some supporting the use of delayed phase and dual-time-point diagnostic 18 F-FDG PET imaging approaches [66-77,81-84,86,87,91-93,95-100,103-108,110,111,113,114,117-122,124-128,131,133,134,136,138,141,143,146,149,152,153,155,157,160-163,165,167,169], and with others not [65,78,89,90,94,101,102,109,115,116,123,129,130,132,135,137,139,140,147,148,150,151,156,158,164,166,168]. …”

Section: Discussionmentioning

confidence: 99%

18F-FDG PET/CT oncologic imaging at extended injection-to-scan acquisition time intervals derived from a single-institution 18F-FDG-directed surgery experience: feasibility and quantification of 18F-FDG accumulation within 18F-FDG-avid lesions and background tissues

et al. 2014

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Background18F-fluorodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) is a well-established imaging modality for a wide variety of solid malignancies. Currently, only limited data exists regarding the utility of PET/CT imaging at very extended injection-to-scan acquisition times. The current retrospective data analysis assessed the feasibility and quantification of diagnostic 18F-FDG PET/CT oncologic imaging at extended injection-to-scan acquisition time intervals.Methods18F-FDG-avid lesions (not surgically manipulated or altered during 18F-FDG-directed surgery, and visualized both on preoperative and postoperative 18F-FDG PET/CT imaging) and corresponding background tissues were assessed for 18F-FDG accumulation on same-day preoperative and postoperative 18F-FDG PET/CT imaging. Multiple patient variables and 18F-FDG-avid lesion variables were examined.ResultsFor the 32 18F-FDG-avid lesions making up the final 18F-FDG-avid lesion data set (from among 7 patients), the mean injection-to-scan times of the preoperative and postoperative 18F-FDG PET/CT scans were 73 (±3, 70-78) and 530 (±79, 413-739) minutes, respectively (P < 0.001). The preoperative and postoperative mean 18F-FDG-avid lesion SUVmax values were 7.7 (±4.0, 3.6-19.5) and 11.3 (±6.0, 4.1-29.2), respectively (P < 0.001). The preoperative and postoperative mean background SUVmax values were 2.3 (±0.6, 1.0-3.2) and 2.1 (±0.6, 1.0-3.3), respectively (P = 0.017). The preoperative and postoperative mean lesion-to-background SUVmax ratios were 3.7 (±2.3, 1.5-9.8) and 5.8 (±3.6, 1.6-16.2), respectively, (P < 0.001).Conclusions18F-FDG PET/CT oncologic imaging can be successfully performed at extended injection-to-scan acquisition time intervals of up to approximately 5 half-lives for 18F-FDG while maintaining good/adequate diagnostic image quality. The resultant increase in the 18F-FDG-avid lesion SUVmax values, decreased background SUVmax values, and increased lesion-to-background SUVmax ratios seen from preoperative to postoperative 18F-FDG PET/CT imaging have great potential for allowing for the integrated, real-time use of 18F-FDG PET/CT imaging in conjunction with 18F-FDG-directed interventional radiology biopsy and ablation procedures and 18F-FDG-directed surgical procedures, as well as have far-reaching impact on potentially re-shaping future thinking regarding the “most optimal” injection-to-scan acquisition time interval for all routine diagnostic 18F-FDG PET/CT oncologic imaging.

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Dual Time Point Positron Emission Tomography/Computed Tomography Scan in Evaluation of Intrathoracic Lesions in an Area Endemic for Histoplasmosis and With High Prevalence of Sarcoidosis

Cited by 24 publications

References 18 publications

Accuracy of FDG-PET to Diagnose Lung Cancer in Areas With Infectious Lung Disease

Accuracy of FDG-PET to Diagnose Lung Cancer in Areas With Infectious Lung Disease

Histoplasmosis: Up-to-Date Evidence-Based Approach to Diagnosis and Management

18F-FDG PET/CT oncologic imaging at extended injection-to-scan acquisition time intervals derived from a single-institution 18F-FDG-directed surgery experience: feasibility and quantification of 18F-FDG accumulation within 18F-FDG-avid lesions and background tissues

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