Chest ACCP Career Connection
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

Guest Access | Sign In via User Name/Password
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF) Free
Right arrow Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Article Archive
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via ISI Web of Science (16)
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Kahn, D.
Right arrow Articles by Berbaum, K.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Kahn, D.
Right arrow Articles by Berbaum, K.
(Chest. 2004;125:494-501.)
© 2004 American College of Chest Physicians

The Utility of 99mTc Depreotide Compared With F-18 Fluorodeoxyglucose Positron Emission Tomography and Surgical Staging in Patients With Suspected Non-small Cell Lung Cancer*

Daniel Kahn, MD; Yusuf Menda, MD; Kemp Kernstine, MD, PhD, FCCP; David Bushnell, MD; Kelley McLaughlin, RN; Sara Miller, RN and Kevin Berbaum, PhD

* From the Nuclear Medicine Section (Drs. Kahn and Bushnell, and Ms. Miller), Iowa City VA Medical Center; and Departments of Radiology (Drs. Berbaum and Menda) and Surgery (Dr. Kernstine and Ms. McLaughlin), University of Iowa, Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA.

Correspondence to: Daniel Kahn, MD, Nuclear Medicine Section, 115, Iowa City VAMC, Iowa City, IA 52246; e-mail: daniel-kahn{at}uiowa.edu


   Abstract
TOP
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
 References
 
Study objectives: The findings from conventional imaging modalities, such as chest CT, are frequently unreliable in patients with lung cancer. This study was designed to compare the relative diagnostic accuracies and utility of the two most widely used functional imaging examinations, F-18–2-fluoro-2-deoxyglucose (FDG) positron emission tomography (PET) and 99mTc depreotide scintigraphy, for the diagnosis and staging of lung cancer.

Design: Prospective, experimental investigation.

Setting: Academic medical center.

Patients: One hundred sixty-six subjects with suspected lung cancer were enrolled in the study.

Interventions: Whole-body and single-photon emission CT imaging of the chest was performed after IV administration of 99mTc depreotide. Attenuation-corrected FDG PET imaging was performed after IV administration of FDG. Image findings were compared with the biopsy results or clinical follow-up.

Measurements and results: In 157 subjects with evaluable lung lesions, the sensitivities and specificities for detecting malignant disease (95% confidence intervals) of FDG PET are 96% (90 to 98%) and 71% (54 to 85%), and of 99mTc depreotide are 94% (88 to 98%) and 51% (34 to 68%). In the 139 subjects with available complete staging data, FDG PET correctly staged 76 of 139 patients (55%), and 99mTc depreotide correctly staged 63 of 139 patients (45%).

Conclusions: The sensitivity for detection of lung cancer in the primary lesion is equally high for FDG PET and 99mTc depreotide. The specificity is superior for FDG PET. The staging accuracy of FDG PET and 99mTc depreotide is similar, but when read with the chest CT neither scintigraphic examination is sufficiently accurate to stage patients with non-small cell lung cancer.

Key Words: lung cancer • positron emission tomography • scintigraphy • 99mTc depreotide


   Introduction
TOP
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 Conclusion
 References
 
Conventional imaging methods, such as chest CT, continue to play important roles in the detection of lung cancer and in tumor staging, but they often fail to distinguish between malignant and nonmalignant tumors in the lung or metastasis to the mediastinum.1 2 3 4 5 6 Definitive diagnosis and staging have traditionally depended on invasive techniques. However, even invasive procedures such as bronchoscopy and transbronchial or transthoracic biopsy have sensitivities of < 80% in certain settings,7 8 and may be associated with significant complications.9

The development of functional imaging examinations represents a significant advance in the diagnostic assessment of patients with lung cancer. F-18–2-fluoro-2-deoxyglucose (FDG) positron emission tomography (PET) is one such examination that takes advantage of increased glucose utilization by tumor cells to differentiate malignant from nonmalignant lesions.10 11 A recent summary12 of several studies involving > 2,000 patients reports that the sensitivity and specificity of FDG PET in the primary lung lesion were 96% and 74%, and that the sensitivity and specificity for the detection of tumor-bearing thoracic lymph nodes were 83% and 89%, respectively.

More recently, other studies13 14 15 16 17 have reported that somatostatin analog scintigraphy can accurately detect lung cancer. 99mTc depreotide (NeoTect; Berlex Laboratories; Montville, NJ), one radiolabeled somatostatin analog, has been shown to accurately identify malignant solitary pulmonary lesions.18 To date, there have been no trials reporting the capacity of 99mTc depreotide to stage lung cancer, or whether this newer, more widely available agent can provide the same information as FDG PET. The purpose of the present study was to directly compare the diagnostic accuracies of FDG PET and Tc-99m depreotide for diagnosis and staging patients suspected of having lung cancer.


   Materials and Methods
TOP
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 Conclusion
 References
 
Patients
After signing an informed consent statement approved by our Institutional Review Board for the study of human subjects, 166 subjects (48 women and 118 men; median age, 68 years; range, 40 to 87 years) who had abnormal chest CT scan results and were suspected of having operable and potentially curable lung cancer were prospectively enrolled into the study. All were scheduled to have a definitive diagnosis made and tumor staging performed by surgical intervention.

FDG PET Imaging and Interpretation
Each patient underwent a FDG PET examination as part of their routine evaluation. After a 4-h fast, each patient received 10 to 15 mCi (370 to 555 megabecquerels) of FDG IV. All patients underwent imaging 60 min following FDG injection using a GE 4096 Plus PET (GE Medical Systems; Milwaukee, WI) scanning from the base of the brain to the level of the proximal thighs in multiple bed positions. This unit is a stand-alone PET unit (not a PET-CT device). Transmission scans using a 68Ge pin source were performed on all patients after the acquisition of the FDG, from which attenuation correction factors were calculated and used to correct the FDG emission data. The attenuation-corrected emission data were reconstructed with an iterative reconstruction algorithm using ordered subsets expectation maximization.

Images were evaluated separately and independently by two nuclear medicine specialists (each blinded to the 99mTc depreotide results) in three orthogonal planes on the computer monitor and compared with the chest CT scan. Differences of opinion were resolved by a third reader. Interpretation of the primary lesion was based on inspection of the attenuation-corrected images according to standard practice and the methods published by Lowe and coworkers.11 19 If the activity in the lesion was greater than the activity seen in the mediastinum, it was considered positive for malignancy. In the hilum and mediastinum, focal activity that was greater than surrounding "background" mediastinal activity was interpreted as malignant spread. Abnormalities were assigned (and then later correlated with the surgical and biopsy reports for comparison) to either the right or left superior (stations 1 and 2), inferior (stations 3, 4, 5, and 6) or subcarinal (stations 7 and 8) mediastinal region(s) and to the right or left hilar (stations 10 to 14) region(s). Focal increases in activity seen in locations not accounted for by the normal sites of FDG biodistribution were interpreted as extrathoracic metastatic disease. The FDG PET findings were then used to assign a tumor stage based on the American Joint Committee on Cancer/International Staging System (AJCC-ISS).20 21

99mTc Depreotide Imaging and Interpretation
99mTc depreotide examinations were performed within 3 weeks of the FDG PET examination. Vials of 99mTc depreotide containing 50 µg of the peptide were reconstituted according to package insert instructions. Twenty mCi (740 megabecquerels) of Tc-99m depreotide was injected IV, and whole-body anterior and posterior images were obtained 60 min later. Single-photon emission CT (SPECT) of the chest, including the upper abdomen with the adrenal glands, was then performed starting at 90 min after injection. Imaging was performed with a dual-detector gamma camera equipped with low-energy, high-resolution collimators (Prism 2000; Philips Medical Systems; Cleveland, OH). Two separate sets of images were generated from the data set of each examination, one optimized for the thorax, and the other for visualization of the adrenal glands.

All images of the thorax and upper abdomen were evaluated (blinded from the FDG PET examination) separately and independently by two nuclear medicine physicians on the computer monitor of the camera in three orthogonal planes. The chest CT scan was visually compared with the 99mTc depreotide examination at the time of interpretation. Differences of opinion were resolved by a third reader. Focal areas of increased uptake compared with surrounding lung in the region of the CT scan abnormality were considered positive for malignancy; uptake less than or equal to adjacent or surrounding lung was interpreted as benign disease. In the hilum and mediastinum, focal activity that was greater than surrounding "background" mediastinal activity was interpreted as malignancy, with regional location determined in the same fashion as for the FDG PET examination. Focal increases in activity seen in locations unaccounted for by the normal biodistribution of the agent were interpreted as extrathoracic metastatic disease. As with the FDG PET interpretations, the 99mTc depreotide findings were used to stage the patients according to the AJCC-ISS.20 21

Statistical Analysis
Sensitivity, specificity, and positive and negative predictive values with 95% confidence intervals (CIs) were computed in the standard fashion. The McNemar test of symmetry for nonindependent frequencies was used to test for significant differences between the sensitivities and specificities of the imaging methods.22 A Student t test was used to assess significant differences between two methods of FDG PET interpretation in the primary lesions; p < 0.05 was considered significant.


   Results
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 Conclusion
 References
 
Primary Lung Lesion
Nine of the 166 subjects (5%) were excluded from analysis of the primary lesion because metastatic disease was proven before the biopsy of this lesion (n = 3), surgery was medically contraindicated (n = 2), or the patient refused any procedures to evaluate the lung lesion (n = 4). In the 157 subjects with complete data available, there were 122 malignant and 35 benign primary lesions. The median lesion size (average of the two longest dimensions on the chest CT) was 2.2 cm (range, 0.5 to 10.5 cm). Histopathology was used to determine the status in all 122 malignant lesions and in 23 of the benign lesions. Tissue for diagnosis was obtained by bronchoscopy (n = 48), fine-needle aspiration (n = 11), or open biopsy (n = 86). The benign nature of the lesion was confirmed with clinical follow-up in 12 subjects. In six subjects, the lesions were smaller or showed no change in size following repeat chest CT or chest radiograph obtained for at least 12 months (range, 12 to 17 months). The lesions resolved entirely in six other subjects.

The sensitivity, specificity, and positive and negative predictive values with 95% CIs of FDG PET and 99mTc depreotide for the diagnosis of the primary lung lesion in the 157 subjects are shown in Table 1 . The sensitivities of the two examinations are not statistically different, but the specificity of FDG PET was greater than that of 99mTc depreotide (McNemar test, p < 0.02). There were five false-negative FDG PET scan findings (lesion sizes, 0.5, 0.75, 1.5, 2, and 3 cm) and seven false-negative 99mTc depreotide scan findings (lesion sizes, 0.5, 0.75, 1.2, 1.5, 1.5, 1.5, and 4 cm). The results of both studies were false-negative in only two patients (lesion sizes, 0.5 cm and 0.75 cm, respectively). There were six cases of bronchoalveolar carcinoma in our series, three of which were undetected by FDG PET and two undetected by 99mTc depreotide. There were no subjects with carcinoid tumors in our series. In the 13 subjects with surgically proven granulomatous disease, results of both FDG PET and 99mTc depreotide were false-positive in 5 subjects (in 4 of these 5, both test results were false-positive). Examples of true-positive lesions with 99mTc and FDG are shown in Figures 1 , 2 .


View this table:
[in this window]
[in a new window]

  		Table 1.. Sensitivity, Specificity, and Negative and Positive Predictive Values for FDG PET and 99mTc Depreotide Compared With the Final Stage*

 


View larger version (77K):
[in this window]
[in a new window]
[Download PPT slide]
  		Figure 1.. A 60-year-old woman with adenocarcinoma of the right lung; congruent findings with 99mTc depreotide SPECT and FDG PET examinations in the primary cancer (top, A, B, C) and pretracheal lymph node (bottom, D, E, F). Top, A: CT demonstrating primary cancer in right lung. Top, B: Corresponding transaxial SPECT slice demonstrating abnormal 99mTc depreotide uptake in primary (long arrow) with normal uptake in vertebral body bone marrow (short arrow) and marrow in sternum (arrowhead). Top, C: Primary tumor seen in FDG PET examination (arrow). Bottom, D: Mediastinal CT window (inferior cut to top, A) showing lymphadenopathy (arrow) with corresponding abnormal uptake on 99mTc depreotide (bottom, E, long arrow) and FDG PET scans (bottom, F, arrow).

 


View larger version (130K):
[in this window]
[in a new window]
[Download PPT slide]
  		Figure 2.. Coronal SPECT views of same patient, slicing from posterior to anterior top left to bottom right. Top, A: 99mTc depreotide demonstrating primary cancer (long arrow), normal uptake in vertebral bone marrow (arrowhead), and mediastinal lymph node (short arrow). Bottom, B: FDG PET demonstrating abnormal uptake in tumor (long arrow), normal cardiac activity (arrowhead), and mediastinal lymph node abnormality (short arrow). R = right; L = left.

 
For comparison, standardized uptake values (SUVs) were available in 121 malignant lesions and the same 35 benign lesions. In the malignant lesions, the mean SUV ± SD was 9.31 ± 6.14; in the benign lesions, it was 1.67 ± 1.55. These values are significantly different (Student t test, p < 0.0001). Using a threshold SUV of 2.5 (< 2.5 is benign, >= 2.5 is malignant), the sensitivity and specificity of FDG PET for malignancy in the primary lesion were 90% and 80%, respectively.

Combining the results of both tests and interpreting a lesion as malignant when either scan result is positive yields a sensitivity and specificity of 98% (95% CI, 96 to 100%) and 49% (95% CI, 32 to 66%), respectively. The combined test sensitivity is not significantly different from FDG PET alone (McNemar test, p = 0.08), but is significantly greater than 99mTc depreotide (McNemar test, p = 0.02). The specificity of combining the examinations is significantly lower compared with FDG PET (McNemar test, p = 0.005) but not different from 99mTc depreotide (McNemar test, p = 0.32).

Hilar and Mediastinal Lymph Nodes
Complete results of mediastinal and hilar lymph node stations were available in 128 of the 166 patients (77%). Results were obtained by systematic sampling of the paratracheal and hilar nodal stations in 108 of these subjects (mediastinoscopy/intraoperative sampling during thoracotomy), including 14 patients in whom the primary lesion later proved to be benign. The remaining 20 patients with benign primary lesions were not surgically staged but were classified as negative (N0). The hilum and mediastinum results in 38 patients with cancer were eliminated because they refused surgery or it was medically contraindicated (n = 12), had inoperable disease including stage IV (n = 19), had metastatic tumor to the lung from another organ (n = 4), or had inadequate tissue sampling performed (n = 3). In the 128 subjects, the node stage was as follows: N0 (n = 97), N1 (n = 6), N2 (n = 19), and N3 (n = 6).

The sensitivity, specificity, and predictive values in the hilum and mediastinum of the two examinations compared to histopathologic results are shown in Table 1 . No statistically significant difference was detected between the two examinations (McNemar test, p = 0.10 sensitivities, p = 0.16 specificities).

Whole-Body Final Stage
A final pathologic stage was assigned according to the AJCC-ISS20 21 in 139 subjects. In 134 of 139 patients, biopsy results determined the final stage. In five patients, surgery was not indicated as metastatic lung cancer was confirmed using MRI (n = 3), CT (n = 1), or bone scintigraphy (n = 1). Final staging data were unavailable in 27 of the 166 subjects (16%), as patients refused surgery (n = 21), were unavailable for follow-up (n = 2), or were proven to have metastatic disease to the lung (n = 4) from another organ (uterine, bladder, colon, and kidney). For the imaging stage, when FDG PET or 99mTc depreotide results were positive in the primary lesion, the chest CT scan was used to determine the tumor (T1–4) stage. N1, N2, and N3 disease as well as distant lesions (M1) were determined directly and only from the respective nuclear medicine scan.

The relationships between FDG PET, 99mTc depreotide, and final stage are depicted in Tables 2 , 3 . FDG PET correctly staged 76 of 139 cases (55%), and 99mTc depreotide correctly staged 63 of 139 cases (45%). When either FDG PET or 99mTc depreotide misstaged cases, the other scan usually did not correctly stage the tumor (Tables 4 , 5 ).


View this table:
[in this window]
[in a new window]

  		Table 2.. Comparison of FDG PET Stage With Final Stage in 139 Subjects

 

View this table:
[in this window]
[in a new window]

  		Table 3.. Comparison of 99mTc Depreotide Stage With Final Stage in 139 Subjects

 

View this table:
[in this window]
[in a new window]

  		Table 4.. 99mTc Depreotide Results in Misstaged FDG PET Cases

 

View this table:
[in this window]
[in a new window]

  		Table 5.. FDG Results in Misstaged 99mTc Depreotide Cases

 
Surgical (Final Stage Less Than IIIB) vs Nonsurgical (Final Stage IIIB or IV) Disease
We also evaluated the ability of each scan to separate surgical (n = 112) from nonsurgical (n = 27) disease. To detect nonsurgical disease, FDG PET had a sensitivity of 63% (95% CI, 42 to 80%) and a specificity of 84% (95% CI, 76 to 90%), whereas 99mTc depreotide had a sensitivity of 52% (95% CI, 32 to 71%) and a specificity of 86% (95% CI, 78 to 91%). Neither the sensitivities (McNemar test, p = 0.32) or specificities (p = 0.55) of these two modalities differed significantly. To detect nonsurgical disease, chest CT alone had a sensitivity of 92% (95% CI, 85 to 96%) and a specificity of 33% (95% CI, 17 to 54%).

Distant Sites of Abnormal 99mTc Depreotide or FDG PET Uptake
There were 22 patients with distant sites of abnormal uptake seen (imaging stage IV) with either FDG PET alone (n = 10), 99mTc depreotide alone (n = 5), or both scans (n = 7). In 8 of these 22 patients, stage IV disease was confirmed before thoracotomy. In three of the eight patients, the sites of distant disease had already been detected with CT or bone scans prior to FDG PET or 99mTc depreotide imaging. In the remaining 14 of 22 stage IV patients, thoracotomy with curative intent was performed because the positive FDG PET or 99mTc depreotide findings could not be confirmed before surgery. Clinical follow-up was performed in this group. After clinical follow-up, disease was confirmed in 2 of 14 patients by bone scan and CT scans 1 month and 5 months after surgery, respectively. False-positive findings were seen in 9 of the 14 patients based on biopsy results in 2 patients and clinical follow-up (range, 6 to 31 months) in 7 patients. In 3 of the 14 patients, the scan findings could not be confirmed as the patients were unavailable for follow-up. Therefore, 5 patients before thoracotomy and 2 patients after thoracotomy (total of 7 patients [5%]) of 139 patients had otherwise unsuspected disease first detected with 99mTc depreotide alone (n = 1), FDG PET alone (n = 2), or both (n = 4). Nine of 139 patients (6%) with abnormal distant sites detected only by 99mTc depreotide (n = 4), FDG PET (n = 4), or both (n = 1) had false-positive findings.


   Discussion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
Conclusion
 References
 
Noninvasive testing results from patients with suspected lung cancer are frequently unreliable. Conventional imaging techniques have a limited diagnostic accuracy since interpretation relies principally on lesion size and other nonspecific findings.3 For this reason, newer imaging methods that do not rely solely on lesion size have been evaluated in patients with lung cancer.

We have found that FDG PET and 99mTc depreotide scans are equally sensitive for the detection of lung cancer at the primary lesion site, but the specificity is lower for 99mTc depreotide compared with FDG PET. Further, we confirm the finding of Lowe and coworkers11 that there is no diagnostic advantage to using SUVs over visual inspection when assessing the primary lung lesion. The negative predictive values of the tests are reasonably high given the high prevalence of patients with cancer (78%) referred from our thoracic surgery clinics. Had the prevalence of disease been lower (eg, 45%) as might be the case if patients were referred from our pulmonary medicine clinics, the negative predictive values increase to 96% for FDG PET and 91% for 99mTc depreotide. Thus, when considering our reported predictive values, it is important to be aware that values will vary in other centers depending on the prevalence of cancer in the referral population. If both examinations are performed and results are required to be negative to interpret a lesion as benign, despite the high prevalence of cancer in our series, only two malignant primaries in 122 of our patients (1.6%) with lung cancer would have been missed. This indicates that if the FDG PET and 99mTc depreotide imaging findings in the region of the primary are negative, the patient is very unlikely to have lung cancer. As has been reported in other trials,11 23 inflammatory diseases (particularly granulomatous disease) or misinterpreted areas of normal radiotracer accumulation were responsible for the false-positive findings in our series of patients. Our results with FDG PET are similar to the results of several studies12 24 that have demonstrated high sensitivity with more modest specificity in the primary lesion. Though few published data are available regarding 99mTc depreotide scanning, the sensitivity determined from our trial is similar but the specificity is lower than reported in other trials. Blum and coworkers reported a sensitivity and specificity of 93% and 88%, respectively, for the diagnosis of malignancy25 and later reported values of 97% and specificity 73% from a larger multicenter trial.18

Our findings suggest that FDG PET may be marginally more accurate than 99mTc depreotide in the hilar and mediastinal regions, though the difference between them was not statistically different. Several investigators have reported that FDG PET is a relatively accurate method for assessing the status of the mediastinal lymph node regions. A large meta-analysis26 reported that the average sensitivity and specificity for malignancy were approximately 80% and 90%, respectively. The sensitivity is similar but the specificity is lower in our series compared with the meta-analysis, though similar to the specificity values reported by other groups of investigators.27 28 29 We suspect that the somewhat reduced specificity seen in our group of patients is related to conditions such as bacterial pulmonary infection, granulomatous disease, and other active inflammatory conditions of the chest that are important known causes of false-positive scan findings. To our knowledge, this is the first reported study that examines lymph node staging in a large series of patients undergoing 99mTc depreotide scintigraphy. In this direct comparison between FDG PET and 99mTc depreotide, we found that these tests performed similarly in the hilum and mediastinum.

A combined PET-CT unit was not available for use in this trial. Likewise, a combined SPECT-CT unit was not available to scan patients after receiving 99mTc depreotide. It is certainly possible that tumor staging would have been improved had PET-CT (or SPECT-CT) been utilized, particularly with regard to questions of chest wall invasion by the primary, properly interpreting midline nodal findings as N2 vs N3, and the potential to reduce false-positive distant findings by more precise localization. Preliminary evidence in a very small study30 suggests that the accuracy of PET-CT in this patient group is superior to that of FDG-PET alone. If this finding is confirmed, undoubtedly FDG PET-CT will become an even more important tool for staging patients, especially in the assessment of distant metastatic disease. However, until the results from future trials with adequate subject numbers are available, it is unclear if these newer and more expensive technologies will offer a significant advantage to patients with newly diagnosed non-small cell lung cancer.

However, because node stage alone does not alone determine appropriateness of definitive surgery, we have presented data based on overall or final stage. Our data indicate that neither FDG PET nor 99mTc depreotide, when interpreted in combination with the chest CT scan, can be reliably used alone to accurately stage patients with non-small cell lung cancer. Only approximately one half of the patients with suspected lung cancer were correctly staged using either of the nuclear medicine examinations. Since there was no predictable pattern of false-negative or false-positive scan findings for either scan when evaluating sites distant from the primary lesion, we are unable to recommend that both examinations be performed in order to enhance staging accuracy. Of major importance, neither test appears to reliably separate surgical candidates from nonsurgical (stage IIIB and IV) candidates.

FDG PET reportedly will detect unsuspected distant metastatic disease in approximately 10 to 15% of patients.23 31 32 While greatly impacting patient management, the likelihood of detecting unsuspected disease in our series is approximately the same with either examination (5%). Unexpected scan findings distant from the primary tumor should generally lead to further diagnostic investigation. Given the false-positive rate of unsuspected findings in 6% of our subjects, we believe that special care must be taken to confirm the findings of either examination with other imaging modalities or biopsy.


   Conclusion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
References
 
Our findings demonstrate that FDG PET and 99mTc depreotide have equally high sensitivities for the detection of lung cancer in the primary lesion. Therefore, since the likelihood of non-small cell lung cancer is low (particularly when the prevalence of cancer in the population is not > 50%) when either test result is negative, test selection should be based on other variables such as availability and convenience (99mTc depreotide, unlike FDG PET, uses standard nuclear medicine gamma cameras and an easily compounded radiopharmaceutical), and cost. The two imaging examinations are comparable but distinctly less accurate when evaluating for evidence of metastatic spread of cancer. For this reason FDG PET or 99mTc depreotide must be used with caution for this purpose.


   Acknowledgements
 
The authors thank Mitchell Thomas, CNMT; Jenifer Swearingen, RN; Amy Nibaur, RN; Dennis Sass, RN; Craig Larson, PA-C; John Richmond, CNMT; and Nicholas Rossi, MD, for assisting with this project.


   Footnotes
 
Abbreviations: AJCC-ISS = American Joint Committee on Cancer/International Staging System; CI = confidence interval; FDG = F-18–2-fluoro-2-deoxyglucose; PET = positron emission tomography; SPECT = single-photon emission CT; SUV = standardized uptake value

This work was perfomed at the Iowa City VA Medical Center and the University of Iowa, Roy J. and Lucille A. Carver College of Medicine.

Research support was provided in part by Berlex Laboratories, Inc.

Received for publication May 27, 2003. Accepted for publication September 5, 2003.


   References
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
 References
 

  1. Marom, EM, Erasmus, JJ, Patz, EF (2000) Lung cancer and positron emission tomography with fluorodeoxyglucose. Lung Cancer 28,187-202[CrossRef][ISI][Medline]
  2. Goldsmith, SJ, Kostakoglu, L Role of nuclear medicine in the evaluation of the solitary pulmonary nodule. Semin Ultrasound CT MR 2000;21,129-138[CrossRef][ISI][Medline]
  3. Webb, WR, Gatsouris, S, Zerhouni, EA, et al CT and MR imaging in staging non-small cell bronchogenic carcinoma: report of the Radiology Diagnostic Oncology Group. Radiology 1992;182,319-323[Abstract/Free Full Text]
  4. Farrell, MA, McAdams, HP, Herndon, JE, et al Non-small cell lung cancer: FDG PET for nodal staging in patients with stage I disease. Radiology 2000;215,886-890[Abstract/Free Full Text]
  5. Mac Manus, MP, Hicks, RJ, Ball, DL, et al F-18 fluorodeoxyglucose positron emission tomography staging in radical radiotherapy candidates with nonsmall cell lung carcinoma: powerful correlation with survival and high impact on treatment. Cancer 2001;92,886-895[CrossRef][ISI][Medline]
  6. Deslauriers, J, Gregoire, J Clinical and surgical staging of non-small cell lung cancer. Chest 2000;117,96S-103S[Abstract/Free Full Text]
  7. Salathe, M, Soler, M, Bolliger, CT, et al Transbronchial needle aspiration in routine fiberoptic bronchoscopy. Respiration 1992;59,5-8[Medline]
  8. Schenk, DA, Bower, JH, Bryan, CL, et al Transbronchial needle aspiration staging of bronchogenic carcinoma. Am Rev Respir Dis 1986;134,146-148[ISI][Medline]
  9. Kazerooni, EA, Lim, FT, Mikhail, A, et al Risk of pneumothorax in CT-guided transthoracic needle aspiration biopsy of the lung. Radiology 1996;198,371-375[Abstract/Free Full Text]
  10. Dewan, NA, Gupta, NC, Redepenning, LS, et al Diagnostic efficacy of PET-FDG imaging in solitary pulmonary nodules: potential role in evaluation and management. Chest 1993;104,997-1002[Abstract/Free Full Text]
  11. Lowe, VJ, Fletcher, JW, Gobar, L, et al Prospective investigation of positron emission tomography in lung nodules. J Clin Oncol 1998;16,1075-1084[Abstract]
  12. Ho, I, O’Doherty, MJ, Maisey, MN Positron emission tomography in lung cancer. Semin Nucl Med 2002;32,240-271[CrossRef][ISI][Medline]
  13. Krenning, EP, Kwekkeboom, DJ, Bakker, WH, et al Somatostatin receptor scintigraphy with [111In-DTPA-D-Phe1]- and [123I-Tyr3]-octreotide: the Rotterdam experience with more than 1000 patients. Eur J Nucl Med 1993;20,716-731[ISI][Medline]
  14. Kwekkeboom, DJ, Kho, GS, Lamberts, SW, et al The value of octreotide scintigraphy in patients with lung cancer. Eur J Nucl Med 1994;21,1106-1113[ISI][Medline]
  15. Kwekkeboom, DJ, Krenning, EP, Bakker, WH, et al Radioiodinated somatostatin analog scintigraphy in small-cell lung cancer. J Nucl Med 1991;32,1845-1848[Abstract/Free Full Text]
  16. O’Byrne, KJ, Carney, DN Somatostatin and the lung. Lung Cancer 1993;10,151-172[CrossRef][ISI][Medline]
  17. Bombardieri, E, Crippa, F, Cataldo, I, et al Somatostatin receptor imaging of small cell lung cancer (SCLC) by means of 111In-DTPA octreotide scintigraphy. Eur J Cancer 1995;31A,184-188[CrossRef][ISI][Medline]
  18. Blum, J, Handmaker, H, Lister-James, J, et al A multicenter trial with a somatostatin analog 99mTc depreotide in the evaluation of solitary pulmonary nodules. Chest 2000;117,1232-1238[Abstract/Free Full Text]
  19. Lowe, VJ, Hoffman, JM, DeLong, DM, et al Semiquantitative and visual analysis of FDG-PET images in pulmonary abnormalities. J Nucl Med 1994;35,1771-1776[Abstract/Free Full Text]
  20. Beahrs OH. Hensen DE, Hutter RVP, et al, eds. American Joint Committee on Cancer. Lung. In: Manual for staging cancer, 4th ed. Philadelphia, PA: Lippincott, 1992;115–121
  21. Park, BJ, Louie, O, Altorki, N Staging and the surgical management of lung cancer. Radiol Clin North Am 2000;38,545-561[CrossRef][ISI][Medline]
  22. McNemar, Q Psychological statistics 4th ed. 1969,54-58 Wiley. New York, NY:
  23. Pieterman, RM, van Putten, JWG, Meuzelaar, JJ, et al Preoperative staging of non-small cell lung cancer with positron emission tomography. N Engl J Med 2000;343,254-261[Abstract/Free Full Text]
  24. Gould, MK, Maclean, CC, Kuschner, WG, et al Accuracy of PET for diagnosis of pulmonary nodules and mass lesions: a meta-analysis. JAMA 2001;285,914-919[Abstract/Free Full Text]
  25. Blum, JE, Handmaker, H, Rinne, NA The utility of a somatostatin-type receptor binding peptide radiopharmaceutical (P829) in the evaluation of solitary pulmonary nodules. Chest 1999;115,224-232[Abstract/Free Full Text]
  26. Dwamena, BA, Sonnad, SS, Angobaldo, JO, et al Metastases from non-small cell lung cancer: mediastinal staging in the 1990s; meta-analytic comparison of PET and CT. Radiology 1999;213,530-536[Abstract/Free Full Text]
  27. Wahl, RL, Quint, LE, Greenough, RL, et al Staging of mediastinal non-small cell lung cancer with FDG PET, CT and fusion images: preliminary prospective examination. Radiology 1994;191,371-377[Abstract/Free Full Text]
  28. Albes, JM, Lietzenmayer, R, Schott, U, et al Improvement of non-small-cell lung cancer staging by means of positron emission tomography. Thorac Cardiovasc Surg 1999;47,42-47[ISI][Medline]
  29. Dunagan, D, Chin, R, McCain, T, et al Staging by positron emission tomography predicts survival in patients with non-small cell lung cancer. Chest 2001;119,333-339[Abstract/Free Full Text]
  30. Hany, TF, Steinert, HC, Buck, A, et al PET diagnostic accuracy: improvement with in-line PET-CT system; initial results. Radiology 2002;225,575-581[Abstract/Free Full Text]
  31. Marom, EM, McAdams, HP, Erasmus, JJ, et al Staging non-small cell lung cancer with whole-body PET. Radiology 1999;212,803-809[Abstract/Free Full Text]
  32. Weder, W, Schmid, RA, Bruchhaus, H Detection of extrathoracic metastases by PET in lung cancer. Ann Thorac Surg 1998;66,886-893[Abstract/Free Full Text]



This article has been cited by other articles:


Home page
 ImagingHome page
D R Baldwin, J D Birchall, R H Ganatra, and K S Pointon
Evaluation of the solitary pulmonary nodule: clinical management, role of CT and nuclear medicine
Imaging, October 1, 2004; 16(1): 22 - 36.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF) Free
Right arrow Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Article Archive
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via ISI Web of Science (16)
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Kahn, D.
Right arrow Articles by Berbaum, K.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Kahn, D.
Right arrow Articles by Berbaum, K.

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS