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Single Pulmonary Nodule Charecterization : SUV’s Are They Trustworthy?

Single Pulmonary Nodule Charecterization : SUV’s Are They Trustworthy?. Hani A. Nabi, M.D., Ph.D. Department of Nuclear Medicine School of Medicine and Biomedical Science University at Buffalo State University of New York Buffalo, N.Y. USA.

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Single Pulmonary Nodule Charecterization : SUV’s Are They Trustworthy?

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  1. Single Pulmonary Nodule Charecterization: SUV’s Are They Trustworthy? Hani A. Nabi, M.D., Ph.D. Department of Nuclear Medicine School of Medicine and Biomedical Science University at Buffalo State University of New York Buffalo, N.Y. USA

  2. PET FDG Imaging in SPN35% of SPN are malignant. 40% of SPN are granuloma. Definition: Parenchymal lesions, well defined less than 4 cm. Benign Features: Central, concentric or stippled calcifications, stable for more than 2 years, patients younger than 35 years.

  3. PET FDG Features of a Benign SPN An SUV of less than 3.5 SUV: Mean Counts/pixel/sec x calibration factor Injected dose (mCi)/body weight (kg).

  4. PET FDG Imaging in SPN Author Patient Size Sens. Spec. (cm) Dewan, 1993 30 95 80 Gupta, 1993 34 0.6-3.0 95 86 Patz, 1993 51 1.2-6.0 100 89 MultiCenter 237 -- 96 90

  5. Semi-Quantitative Methods SUV Tumor to background ratios SUV versus visual interpretation SUV: prognostic significance

  6. SUV bw:mCi/g of tissuemCi injected/patient body weight (g)SUV bsa:mCi/g of tissuemCi injected/patient BSA in m2

  7. Standard Uptake Values of FDG Hypothesis FDG uptake, normalized to body weight, overestimates value in heavy patients.

  8. 44 patients with malignancies in abdomen or pelvis, 445-115 kg, studies 60-90 minutes following FDG injection.Mean SUV bsa normalized to mean SUV bw.J Nucl Med 94, 35:164-167.

  9. Results Mean SUV bw and bsa same = 3.42 SD of SUV bsa smaller Mean SUV bw varies widely with bw, tending to overestimate low to intermediate FDG uptake in heavy patients and underestimate intermediate--higher FDG uptake in light patients

  10. SUV, T:NT and Visual AnalysisJ Nucl Med 1994, 35:1771-76 107 patients with single pulmonary nodule; 67 malignancies and 27 benign. SUV bw were compared to visual interpretation by two independent readers. FDG uptake grade 1-5 (definitely tumor) based on mediastinal uptake (=3).

  11. Results SUV and visual analysis nearly identical. No difference between two readers. Probability of tumor high (0.93, CI 0.88-1.00) when FDG in tumor exceeded mediastinum.

  12. Effect of positioning of region of interest (ROI) in patients undergoing positron emission tomography (PET) with F-18 FDG and its influence in varying standardized uptake values (SUV)

  13. OBJECTIVES EVALUATE SUV’S AND HOW THEY ARE AFFECTED WHEN ROI’S ARE DRAWN IN DIFFERENT PLANES AND IN DIFFERENT AREAS OF THE SAME PLANE DETERMINE CLINICAL IMPORTANCE OF TUMOR/BKG RATIO OF SUV’S

  14. BEST VISUAL SLICES

  15. ROI’S ON SAME SLICE

  16. THREE ADJACENT PLANES

  17. VARIATION OF SUV’S OF TUMOR OVER 3 PLANES

  18. SUV’S OF TUMOR WITHIN ONE PLANE

  19. 7.88/3.74/13.32

  20. DISCUSSION SIGNIFICANT VARIATION (p < 0.009) WAS OBSERVED IN TUMORS OF ADJACENT PLANE WHERE SUV’S WERE >20 MINIMAL VARIATION WAS OBSERVED IN SUV’S WHEN ROI’S OF THE TUMOR WERE DRAWN ON ONE PLANE

  21. PROBLEMS WITH SUV’S UPTAKE TIME GLUCOSE LEVEL PARTIAL VOLUME EFFECT PATIENT SIZE ROI EFFECT ? NODULE SIZE?

  22. SUV’s and Nodule Size JNM 2002, 43(5): 156, Coronado et al. Compared SUVs amongst nodules < 1.5 cm - > 3.0 cm 45 patients with SPNs SUV > mean 21 SPNs 1.5cm or less ( 2.79) 18 SPNs 1.6-3.0cm (4.88) 7 SPNs 3.0cm or greater (5.16) 32/45 FDG positive 27/30 proven neoplasia

  23. Nodules 1.5cm or less (21) 04cm-1.5cm (mean 0.97cm) 11 malignant, 4 FN, 10TN FN : 1.0cm , FDG+ but SUVs less 3.5 Nodules 1.5 cm or less had lower SUV’s, a cutoff value of 2.0 might be more appropriate.

  24. Journal of Hematology & Oncology 2008 1:13

  25. Khalaf et al Retrospective Study (2 centers) Criteria for enrollment: Positive CT for SPN Positive FDG PET Histopathological Biopsy 173/420 patients fulfilled above criterion

  26. Linear regression equation fitted to all nodules malignant and benign nodules

  27. < 1.0cm 1.1 – 2.0 cm

  28. < 1.0cm 1.1 – 2.0 cm 2.1 – 3.0 cm > 3.0 cm

  29. Relationship between SUV’s and nodules 1.5 cm or less SUV max cutoff 2.5 useful in the evaluation of nodules 1cm or greater, has minimal or no value in SPN < 1.0 cm

  30. Occurrence of neoplasia in single pulmonary nodules (SPN) with no visual FDG uptake or FDG uptake SUV’s less than 2.5 established by long term clinical follow-up. Hani A. Nabi, M.D., Ph.D L. Li, M.D., Ph.D, John Baker, Ph.D Department of Nuclear Medicine School of Medicine and Biomedical Science University at Buffalo State University of New York Buffalo, N.Y. USA

  31. Objective Prognostic significance of FDG PET negative (visual or SUV less than 2.5) SPN.

  32. Patients and Methods Retrospective review of all FDG SPN patients referred by a single pulmonary group from 2000—2004. One hundred twenty-eight (128) patients (68 females, 60 males, mean age 63 years, 56% between 51-70 years) fulfilled criteria for negative scans. Mean follow-up 29.3 months (8-52 months).

  33. Patients and Methods 72 (56%) were current or former tobacco users. 8 (6.2%) occupational exposure. 14 (11%) history of cancer, other than lung.

  34. Results 8% 12% 20% 59%

  35. Results (no FDG uptake) 76 patients (59%) had no visual uptake. 21 had biopsy. 6 (7.9%) were malignant. 70/76 (92%) were negative on clinical follow-up of at least 18 months.

  36. Results 31.5m 12.3m Stable Follow-up

  37. Results (SUVs < 2.5 cm) 52 patients (41%) had FDG uptake less than 2.5 34 had biopsy. 23/52 (44%) malignant. 29/52 were negative for malignancy on follow-up of at least 18 months.

  38. Results Nodule types

  39. 92% Results 55.8% 44.2% 8% Comparison of benign and malignant nodule number between FDG uptake and no FDG uptake

  40. Benign and malignant SUV uptake 1.84 1.88 Benign Malignant

  41. Results The difference in proportion in malignancy between the no-FDG uptake and FDG uptake groups is statistically significant. Likelihood ratio Chi-square = 23.6. P < 0.001.

  42. Conclusion SPN with no visual FDG uptake have a relatively low likelihood of malignancy (7.9%) compared to lesions with FDG SUV less than 2.5 (44%). This study confirmed our previous work (JNM 2006, 47:173) that there is no predetermined fixed value of SUV cutoff that is accurately able to diagnose malignancy in small pulmonary nodules.

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