Risk stratification of solitary pulmonary nodules by means of PET using (18)F-fluorodeoxyglucose and SUV quantification

Abstract

Purpose: (18)F-fluorodeoxyglucose (FDG) PET is the most accurate imaging modality in characterizing a solitary pulmonary nodule (SPN). Besides visual image interpretation, semiquantitative analysis using standardized uptake values (SUV) is performed to improve diagnostic accuracy. Mostly, an SUV threshold of 2.5 is applied to differentiate between benign and malignant lesions. In this study we analysed the use different SUV thresholds to predict the post-test probability of malignancy for the individual patient considering his pre-test probability. Furthermore, we investigated the prognostic value of SUV in SPN for survival.

Methods: This retrospective study included 140 consecutive patients who underwent FDG PET for evaluation of SPN. Visual interpretation was performed by two readers. For semiquantitative analysis, maximum SUV (SUV(max)) was measured in all SPN. A final diagnosis was obtained by pathological examination or follow-up of more than 2 years. In a nomogram, positive and negative predictive values (PPV and NPV) were plotted against the hypothetical SUV threshold to determine the optimum SUV threshold. Survival was analysed using the Kaplan-Meier method and log-rank test.

Results: The prevalence of malignancy was 57%. The FDG uptake in malignant SPNs was higher than in benign SPNs (SUV 9.7 +/- 5.5 vs 2.6 +/- 2.5, p < 0.01). More than 90% of SPNs with an SUV below 2.0 were benign (sensitivity, specificity, NPV of 96, 55 and 92%). The highest diagnostic accuracy was achieved with an SUV of 4.0 (sensitivity, specificity and accuracy of 85%). Visual interpretation achieved corresponding values of 94, 70 and 84%, respectively. In lung cancer higher FDG uptake (SUV(max) >or= 9.5) was associated with shorter survival (median survival 20 months) and low FDG uptake with longer survival (>75 months).

Conclusion: FDG PET allows assessment of the individual risk for malignancy in SPNs by considering tumoural SUV and pre-test probability. Higher FDG uptake in lung cancer as measured by SUV analysis is a prognostic factor. In patients with low FDG uptake in an SPN and increased risk during surgery omission of diagnostic thoracotomy may be warranted.