Table 4. Lung Cancer

StudyPatient Number/CharacteristicsProcedure ProtocolResultsConclusionsComments
Dewan et al. (1993)
Creighton University and Veterans Affairs Medical Center, Omaha, NE
Prospective study
30 subjects with solitary pulmonary nodules < 3 cm (10 benign and 20 malignant) on chest x-ray and CTChest FDG PET for all subjects with visual and semiquantitative (DUR) analysis of images by two independent blinded physicians; histologic confirmation in 29 subjectsSensitivity, specificity, positive and negative predictive values of PET (visual analysis): 95%, 80%, 90%, and 89%. Mean DUR values: > two for malignant lesions, < one for benign lesions; overlap in DUR between malignant and benign lesions.Further study is needed regarding the use of DUR indices, FDG PET is accurate in differentiating benign and malignant pulmonary nodules.Small study sample
Slosman et al. (1993)
Geneva University Hospital,
Geneva, Switzerland
Prospective study
36 subjects with proven lung cancer (n=21) or pulmonary mass of unknown origin (n=15)Chest FDG PET with visual and semiquantitative (TNTR) analysis, chest x-ray and CT, sputum cytologyCorrect identification by FDG PET in 29 (93.5%) of 31 subjects with malignant lesions and three (60%) of five subjects with benign lesions. 2 false-positive scans due to inflammatory processes; 2 false-negative scans likely due to small size.FDG PET is sensitive for detecting lung cancer and appears as an adjunct to conventional methods.Small study sample
Image interpretation not blinded
Hübner et al. (1995)
University of Tennessee Medical Center,
Knoxville, TN
Retrospective study
54 subjects with unknown primary lung masses (n=23), previous history of lung cancer (n=13), or extra pulmonary cancer with secondary chest mass (n=18)Dynamic chest FDG PET with visual and semiquantitative analysis (SUV) for all subjectsSensitivity, specificity, positive and negative predictive value of PET: 100%, 67%, 90%, and 100% in subjects with primary unknown lung masses; 83%, 80%, 62.5%, and 91% in subjects with suspected tumor recurrence; 87%, 83%, 93%, and 71% in subjects with suspected lung metastasis.Variation of FDG uptake in normal tissue and high FDG uptake in inflamed areas; may help differentiate benign and malignant lesions, confirm lung metastasis, and monitor therapy.Small study sample Image analysis not blinded
Duhaylongsod et al. (1995)
Duke University Medical Center,
Durham, NC
Prospective study
87 subjects with indeterminate lung lesions, 16 with previous lung cancer and resectionDynamic chest FDG PET with SUR analysis by blinded physicianSensitivity, specificity, and accuracy of PET using a SUR cutoff of > 2.5 for defining malignancy: 97%, 82%, and 92% overall; 100%, 81%, and 94% for lesions < 3 cm in diameter. False-positives in active infections with high FDG uptake.FDG PET is sensitive for detecting malignant lung masses and may be useful in distinguishing recurrence.Inclusion of 16 subjects with known resection for lung cancer
Miyauchi and Wahl (1996)
Univ. of Michigan Medical Center,
Ann Arbor, MI
Retrospective study
31 subjects with newly diagnosed lung lesions suspected to be NSCLC (n=16) or with primary breast cancer and no lung lesions (n=15)Dynamic chest FDG PET with SUV analysis for all subjectsMean SUVs significantly higher in posterior portions than in anterior and mid portions (.663-.804, .537-.595, and .515-.679) and significantly higher in lower lung field than in upper and middle lung fields (.712, .583, and .584).Regional differences in FDG uptake in normal lung tissue should be considered when interpreting PET, particularly in cases involving small lesions.Small study sample
Image analysis not blinded
Frank et al. (1995)
Creighton Cancer Center,
Omaha, NE
Prospective study
20 asymptomatic subjectsChest FDG PET with visual and DUR analyses for all subjects; CT for all subjectsSensitivity, specificity, and accuracy of PET using three as DUR cutoff for defining malignancy: 100%, 89.3%, and 92.5%. Sensitivity, specificity, and accuracy of CT: 67%, 85%, and 82%.FDG PET appears to be effective in detecting and following the progression of recurrent lung cancer.Small study sample
Image interpretation not blinded
Lewis et al. (1994)
Guy's and St. Thomas' Hospital,
London, UK
Retrospective study
34 subjects with primary NSCLCFDG PET with visual interpretation by two physicians for all subjectsFDG uptake in primary tumors of all subjects and additional areas in 12 subjects, of whom 10 (29%) had confirmed metastasis; low to moderate FDG uptake in inflamed lymph nodes in two subjects. Unique data provided by PET resulted in treatment changes in 14 subjects (41%), of whom six (18%) were deemed inoperable.Standard thoracic PET would have missed metastasis in seven subjects, FDG PET improved assessment of lung cancer. A longer brain scanning time may have identified smaller lesions.Small study sample
Image interpretation not blinded
Rege et al. (1993b)
School of Medicine,
University of California,
Los Angeles CA
Retrospective study
16 subjects with known primary or metastatic pulmonary nodulesFDG PET using an FDG uptake ratio (not specified) for image analysis, thoracic CT with blinded analysisIncreased FDG uptake correctly identified malignant thoracic lesions in 14 subjects (87.5%) and detected extrathoracic metastasis in four subjects (25%). FDG uptake not increased in two cases CT correctly suggested malignant lung tumors in 14 subjects but missed two broncho genic carcinomas.FDG PET accurately detected primary and metastatic broncho genic carcinomas as well as extrathoracic metastasis.Small study sample
Insufficient description of FDG uptake ratio
Wahl et al. (1994)
University of Michigan Medical Center,
Ann Arbor, MI
Prospective study
23 subjects with newly diagnosed or suspected NSCLCFDG thoracic PET with visual and SUV analysis and enhanced CT for all subjects; blinded interpretation of CT and/or PET; digital anatometabolic fusion of CT and PET imagesMalignancy identified in 19 subjects with mediastinal involvement in 41%. Sensitivity, specificity, accuracy, positive and negative predictive values for staging of mediastinal disease: 64%, 44%, 52%, 44%, and 64% for CT alone; 82%, 81%, 81%, 75%, and 87% for PET alone or with fusion images.FDG PET superior to CT for staging mediastinal disease. Accuracy of interpretation can be improved with visual of digital fusion of CT and PET images.Small study sample
Chin et al. (1995)
Bowman Gray School of Medicine,
Wake Forest University,
Winston-Salem, NC
Prospective study
30 subjects with NSCLCFDG thoracic PET with visual and SUV analysis and enhanced CT for all subjects; histologic confirmation of mediastinal involvement in nine subjects; blinded PET and CT analysisCorrelation of surgical findings in 23 subjects with CT, 24 subjects with PET; correlation of CT and PET in 21 subjects. Sensitivity, specificity, accuracy, positive and negative predictive values in detecting stage N2 disease: 56%, 86%, 77%, 63%, and 82% for CT; 78%, 81%, 80%, 64%, and 89% for PET. Unsuspected metastasis of spine detected by PET in one case.Mediastinal FDG uptake correlates with extent of mediastinal involvement. FDG PET complements, rather than competes with, CT in the noninvasive evaluation of NSCLC.Small study sample
Sasaki et al. (1996)
Kyushu University,
Fukuoka, Japan
Prospective study
29 subjects with NSCLCFDG thoracic PET with visual and TMR analysis, enhanced CTSensitivity, specificity, accuracy, positive and negative predictive values for identifying mediastinal lymph node involvement: 65%, 87%, 82%, 61%, and 89% for CT; 76%, 98%, 93%, 93%, and 93% for PET. Sensitivity of PET: 100% in lesions with diameter of > 7 mm, 0% in lesions with diameter of < 7 mm.For detection of mediastinal lymph node metastasis of NSCLC, FDG PET is superior to CT.Small study sample
Image analysis not blinded
Scott et al. (1996)
Creighton University Medical Center and Omaha Veterans Affairs Medical Center,
Omaha, NE
Prospective study
FDG thoracic PET with visual and SUV analysis by interpreters blinded to all findings except CT, enhanced CT with blinded analysis, and histologic confirmation for all subjectsSensitivity, specificity, accuracy, positive and negative predictive values: For identifying mediastinal involvement: 67%, 83%, 78%, 67%, and 83% for CT; 100%, 100%, 100%, 100%, and 100% for PET. For localizing level of nodal involvement: 60%, 94%, 89%, 60%, and 94% for CT; 100%, 98%, 99%, 91%, 100% for PET complemented by CT anatomic data. PET identified scalene node metastasis not seen by CT in two subjects.A combination of CT and FDG PET may be best noninvasive approach for identifying lymph node involvement of NSCLC.Small study sample
Valk et al. (1995)
Northern California PET Imaging Center and Radiologic Associates of Sacramento,
Sacramento, CA
Prospective study
99 subjects with histologically proven NSCLC referred for stagingFDG thoracic, abdominal, and whole-body PET with visual analysis for all subjects and SUV analysis for lesions > 2 cm, blinded analysis of mediastinal scans; CT with blinded analysis for all subjects; surgical staging in 76 subjectsSensitivity, specificity, accuracy, positive and negative predictive values in diagnosing mediastinal disease (N2): 63%, 73%, 70%, 54%, and 79% for CT; 83%, 94%, 91%, 88%, and 92% for PET. False-negative PET results due to microscopic disease or failure to resolve nodes from primary tumor. PET detected unsuspected distant metastasis in 11 subjects (11%).FDG PET more accurate than CT in detecting mediastinal lymph node metastasis and allows detection of distant metastasis.Small study sample
Selection bias
Contrast not used in all CT studies
Bury et al. (1996a)
CHU Sart Tilman,
Liege, Belgium
Prospective study
61 subjects with newly diagnosed NSCLCFDG PET with visual analysis, thoracic and abdominal CT, and bone scan for all subjectsFinal staging: I or II (n=24), IIIa (n=13), IIIb (n=5), IV (n=19). PET correctly identified all primary tumors (four false with CT), changed N stage in 13 subjects (all wrong with CT), and changed M stage in six subjects (not identified with CT). PET correctly detected 10 unsuspected distant metastatic lesions in five subjects but falsely identified three lesions in three subjects.Compared with conventional imaging with CT and bone scanning, FDG PET improves noninvasive diagnostic accuracy of NSCLC staging.Small study sample
Image analysis not blinded
No statistical analysis of findings
Sazon et al. (1996)
VA Medical Center West Los Angeles,
Los Angeles, CA
Prospective study
107 subjects with abnormal chest roentgenograms, including 82 with malignancy (73 with NSCLC, five with SCLC, four with lung metastasis) and 25 with nonmalignant chest diseasesFDG whole-body PET with visual analysis by blinded physicians and enhanced CT with blinded analysis for all subjectsSensitivity and specificity: For predicting malignancy of chest abnormalities, 100% and 52% (due to number of nonmalignant chest disorders) for PET; for identifying mediastinal involvement, 81% and 56% for CT, 100% and 100% for PET. Mediastinal involvement correct by PET regardless of node size or presence of concomitant pulmonary inflammation. Distant metastasis also identified with PET in one patient.For mediastinal staging of lung cancer, FDG PET effective.Mainly male study population
Histologic confirmation in less than 30% of subjects
Kubota et al. (1993)
Tohoku University,
Sendai, Japan
Prospective study
18 subjects with lung cancer 11C-MET PET with blinded TMR analysis for tumor metabolic data and CT for tumor volume data before and after treatment for all subjectsThree groups identified: Group A: 10 subjects, no regrowth of residual tumor, significant decrease in MET uptake and in tumor volume after treatment. Group B: five subjects, early local recurrence, small decrease in MET uptake but small or large decrease in tumor volume. Group C: three subjects, late recurrence, large decrease in MET uptake (similar to that in Group A) but slight decrease in tumor volume. 11C-MET may be useful in determining the presence of viable tumor cells after treatment of lung cancer but plays a supplemental role to CT for evaluating treatment response.Small study sample
No statistical analysis of study data
Hebert et al. (1996)
Duke University Medical Center,
Durham, NC
Prospective study
20 subjects with histologically confirmed NSCLCFDG PET; visual analysis with correlation of PET images and chest x-ray (XR) and CT images; calculation of uptake ratios; PET before radiotherapy in all subjects and after therapy in 12 subjectsPretherapy: Increased FDG uptake in 19 (95%) of 20 lesions; good correlation between area of FDG uptake and XR/CT volume in 13 subjects; area of FDG uptake > XR/CT volume in two subjects, < XR/CT volume in three subjects, and present in one lesion not seen on XR or CT. Posttherapy: Difficult to assess response by XR or CT; correlation of PET with clinical evidence good in four subjects with complete response but inconsistent in eight subjects with partial or no response.FDG PET appears to be useful for detecting and delineating lung cancers poorly defined by chest x-ray or CT. FDG PET ability to distinguish between radiation necrosis and tumor recurrence unclear.Small study sample
Unblended image analysis
Hübner et al. (1996)
University of Tennessee Medical Center,
Knoxville, TN
Retrospective study
52 subjects, 26 with malignant lung tumors and 26 age and gender matched controls with nonmalignant lesionsFDG PET with visual, SUV, and Patlak analyses blinded to all findings but radiographic data required for scanner positioning; CT with blinded analysis in 21 subjects with malignant lesions and 19 with benignSensitivity and specificity of PET: 100% and 73%, respectively, with visual interpretation and SUVs using no preselected cut-of threshold; 81% and 81%, respectively, with SUV using a cutoff of 3.8 to differentiate between malignant and benign lesions; 85% and 85%, respectively, with Patlak using a cutoff of .025 minute-1 to differentiate between malignant and benign lesions.Interpretation of FDG PET images can be facilitated using data from SUV analysis or the accumulation rate, as determined by Patlak analysis.Small study sample
Steinert et al. (1997)
University Hospital,
Zürich, Switzerland
Prospective study
47 subjects with suspected or newly diagnosed NSCLCFDG PET with independent blinded visual analysis, spiral or conventional CT with independent blindedSensitivity, specificity, positive predictive value, negative predictive value, and accuracy for staging of N2 and N3 mediastinal disease: 89%, 99%, 96%, 97%, and 96%, respectively for FDG PET; 57%, 94%, 76%, 87%, and 85%, respectively, for CT.For nodal staging of NSCLC, FDG PET appears to be superior to CT.Small study sample
Bury et al. (1996b)
CHU Sart Tilman,
Liege, Belgium
Prospective study
50 subjects with newly diagnosed NSCLCFDG PET with independent visual analysis and thoracic CT for all subjects; pathologic confirmation with thoracotomy in 46 patientsInvolvement of hilar or mediastinal lymph nodes in 58% of cases. Sensitivity and specificity for staging lymph node involvement: 90% and 86% for FDG PET; 72% and 81% for CT.In the mediastinal staging of NSCLC, FDG PET is more accurate than CT.Small study sample
Image analysis not blinded

NOTE: DUR, differential uptake ratio; TNTR, tumor-to-normal-tissue ratio; SUV, standardized uptake value; Kpat, Patlak value; NSCLC, nonsmall cell lung cancer; ACTH, adrenocorticotropic hormone; TMR, tumor-to-muscle ratio; SCLC, small cell lung cancer; NSCLC, nonsmall cell lung cancer.

From: Positron Emission Tomography (PET) for Oncologic Applications

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Minnesota Health Technology Assessments [Internet].
Minnesota Health Technology Advisory Committee.
St. Paul (MN): Minnesota Department of Health; 1995-2001.

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