Clinical Role of F-18 Fluorodeoxyglucose Positron Emission Tomography Imaging in Patients with Lung Cancer and Suspected Malignant Pleural Effusion

doi:10.1378/chest.122.6.1918

Chest

Volume 122, Issue 6, December 2002, Pages 1918-1924

https://doi.org/10.1378/chest.122.6.1918 Get rights and content

Study objectives

The goals of this study were to determine the sensitivity, specificity, and predictive accuracy of F-18 fluorodeoxyglucose positron emission tomography (PET-FDG) imaging in detecting metastatic disease involvement of pleura and/or presence of malignant pleural effusion in patients with proven lung cancer. We wanted to compare efficacy of PET-FDG imaging to CT scanning in differentiating benign pleural effusion from malignant effusion and/or pleural involvement in patients with lung cancer.

Methods

We studied 35 patients with biopsy-proven lung cancer and abnormal findings on CT scanning for presence of pleural effusion (n = 34) and/or pleural thickening or nodular involvement (n = 4). The results of positron emission tomography and CT scanning were compared to pleural cytology (n = 31), histologic findings of pleural biopsy (n = 3), and/or clinical follow-up (n = 3) for at least 1 year for presence or absence of malignant pleural effusion.

Results

PET-FDG imaging correctly detected the presence of malignant pleural effusion and malignant pleural involvement in 16 of 18 patients and excluded malignant effusion or pleural metastatic involvement in 16 of 17 patients (sensitivity, specificity, and accuracy of 88.8%, 94.1%, and 91.4% respectively).

Conclusion

PET-FDG imaging is a highly accurate and reliable noninvasive test to differentiate malignant from benign pleural effusion and/or pleural involvement in patients with lung cancer and findings of suspected malignant pleural effusion on CT scanning.

Section snippets

Patient Population

We identified 35 consecutive patients with proven lung cancer who underwent PET-FDG imaging for suspected malignant pleural effusion or pleural metastases. All these patients either had conclusive pleural fluid cytology or clinical follow-up for at least 12 months, which confirmed the malignant or benign nature of etiology. Patients who did not have pleural cytology or definitive evidence of malignancy or benignity on follow-up were excluded from our study; therefore, patients with unsuccessful

Results

We studied 35 patients with radiographic findings of pleural effusion and/or pleural nodular involvement on chest radiography and/or CT with proven lung cancer at the time of study or previously. Of 35 patients, 18 patients had evidence of malignant effusion either on histology and clinical follow-up (n = 16) or clinical follow-up (n = 2), while 17 patients had either negative histology (n = 16) or clinical follow-up (n = 1) [Table 1].

Discussion

Pleural involvement is not an uncommon finding in patients with lung carcinoma. However, differentiation between benign and malignant effusion may be critical for accurate determination of the resectable status of the lung tumor. Most lung cancer patients may have potentially unresectable disease in the presence of malignant pleural effusions. Similarly it is very useful to diagnose the benign etiology of pleural effusion to prevent delay in the surgical treatment of resectable lung cancer.

Conclusion

In summary, PET-FDG may be a useful noninvasive diagnostic test for evaluation of pleural effusions in patients with lung cancer. Incorporation of PET-FDG imaging in the diagnostic algorithm used for differentiating benign from malignant effusion may improve the accuracy of staging of patients with lung cancer. PET-FDG may provide a useful alternate diagnostic method to invasive tests in patients with suspected malignant pleural effusion especially in patients with equivocal findings on CT or

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Positron emission tomography-computed tomography (PET-CT) in suspected malignant pleural effusion. An updated systematic review and meta-analysis
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Citation Excerpt :
Studies where authors did not reply were excluded due to missing information. In total, 18 studies [8–9,13,27–28,30,40,26,43–52] were included in the review. Their characteristics are shown in Table 1.
The role of PET and integrated PET-CT in the diagnostic workup of suspected malignant pleural effusions is unknown. Earlier systematic reviews (published 2014 and 2015) both included pleural pathology without effusion, and reached contradictory conclusions. Five studies have been published since the latest review. This systematic review and meta-analysis aims to summarise the evidence of PET and integrated PET-CT in predicting pleural malignancy in patients suspected of having malignant pleural effusions.
A meta-analysis based on a systematic literature search in Cochrane Library, Medline, EMBASE and Clinicaltrials.gov was performed. Diagnostic studies evaluating the performance of PET or PET-CT in patients with suspected malignant pleural effusion, using pleural fluid cytology or histopathology as the reference test, and presenting sufficient data for constructing a 2x2 table were included. The quality of the studies was assessed by the Quality Assessment of Diagnostic Accuracy Studies-2 score. Subgroup analyses on image modality, interpretation method and known malignancy status pre index-test application were planned.
Seven studies with low risk of bias were included. The pooled ability to separate benign from malignant effusions varied with image modality, interpretation method and known malignancy status pre index-test application. In studies using PET-CT, visual/qualitative image analysis was superior to semi-quantitative with positive (LR + ) and negative likelihood ratio (LR-) of 9.9 (4.5–15.3) respectively 0.1 (0.1–0.2). There was considerable heterogeneity among studies.
In conclusion, visual/qualitative image analysis of integrated PET-CT seems to add relevant information in the work-up of suspected malignant pleural effusions with LR + and LR- close to rigorous pre-set cut-offs of > 10 and < 0.1. However, the quality of evidence was low due to inter-study heterogeneity, and inability to assess meta-bias.
Clinical Trial Registration: The protocol was uploaded to the PROSPERO database (CRD42020213319) on the 13th of October 2020.
Diagnosis and management of pleural metastases and malignant effusion in breast cancer
2018, The Breast: Comprehensive Management of Benign and Malignant Diseases
Pleural metastases and malignant pleural effusion may occur with metastatic breast cancer. Presentation can vary widely from an incidental finding on imaging to a large effusion with severe dyspnea. Any pleural effusion in a breast cancer patient can be suspected to be a malignant effusion until proven otherwise. The focus of the clinician should be to provide the most efficient, accurate diagnosis with the least risk of complication and pain for the patient. This chapter reviews diagnosis and management of malignant pleural and pericardial effusions.
Pitfalls and Limitations in Non-Small Cell Lung Cancer Staging
2015, Seminars in Roentgenology
Citation Excerpt :
Typically, thoracentesis is performed to differentiate benign from malignant effusions. When FDG-PET/CT is performed as part of the staging algorithm, negative results on FDG-PET/CT study and thoracentesis are useful to confirm the absence of pleural metastases.22,23,24 Schaffler et al22 reported FDG-PET/CT to have a sensitivity, specificity, positive predictive value, NPV, and accuracy of 100%, 71%, 63%, 100%, and 80%, respectively, in the detection of M1a pleural disease.
Accuracy of fluorodeoxyglucose-PET imaging for differentiating benign from malignant pleural effusions: A meta-analysis
2015, Chest
The role of fluorodeoxyglucose (FDG)-PET imaging for diagnosing malignant pleural effusions is not well defined. The aim of this study was to summarize the evidence for its use in ruling in or out the malignant origin of a pleural effusion or thickening.
A meta-analysis was conducted of diagnostic accuracy studies published in the Cochrane Library, PubMed, and Embase (inception to June 2013) without language restrictions. Two investigators selected studies that had evaluated the performance of FDG-PET imaging in patients with pleural effusions or thickening, using pleural cytopathology or histopathology as the reference standard for malignancy. Subgroup analyses were conducted according to FDG-PET imaging interpretation (qualitative or semiquantitative), PET imaging equipment (PET vs integrated PET-CT imaging), and/or target population (known lung cancer or malignant pleural mesothelioma). Study quality was assessed using Quality Assessment of Diagnostic Accuracy Studies-2. We used a bivariate random-effects model for the analysis and pooling of diagnostic performance measures across studies.
Fourteen non-high risk of bias studies, comprising 407 patients with malignant and 232 with benign pleural conditions, met the inclusion criteria. Semiquantitative PET imaging readings had a significantly lower sensitivity for diagnosing malignant effusions than visual assessments (82% vs 91%; P = .026). The pooled test characteristics of integrated PET-CT imaging systems using semiquantitative interpretations for identifying malignant effusions were: sensitivity, 81%; specificity, 74%; positive likelihood ratio (LR), 3.22; negative LR, 0.26; and area under the curve, 0.838. Resultant data were heterogeneous, and spectrum bias should be considered when appraising FDG-PET imaging operating characteristics.
The moderate accuracy of PET-CT imaging using semiquantitative readings precludes its routine recommendation for discriminating malignant from benign pleural effusions.
Positron Emission Tomography
2015, Murray and Nadel's Textbook of Respiratory Medicine: Volume 1,2, Sixth Edition
Diagnostic performance of Fluorine-18-Fluorodeoxyglucose positron emission tomography in the assessment of pleural abnormalities in cancer patients: A systematic review and a meta-analysis
2014, Lung Cancer
Citation Excerpt :
In particular in malignant pleural abnormalities a higher increase of SUV in delayed 18F-FDG-PET imaging was reported compared to benign pleural abnormalities [18]. Overall possible sources of false-negative (small malignant lesions or with low proliferative index) and false-positive results (mainly inflammatory lesions) of 18F-FDG-PET or PET/CT should be kept in mind [13–20]. The diagnostic performance results of 18F-FDG-PET or PET/CT in the eight included studies in the meta-analysis are presented in Table 3 and Figs. 1 and 2.
To systematically review and meta-analyze published data about the diagnostic performance of Fluorine-18-Fluorodeoxyglucose (¹⁸F-FDG) positron emission tomography (PET) and PET/computed tomography (PET/CT) in the assessment of pleural abnormalities in cancer patients.
A comprehensive literature search of studies published through June 2013 regarding the role of ¹⁸F-FDG-PET and PET/CT in evaluating pleural abnormalities in cancer patients was performed. All retrieved studies were reviewed and qualitatively analyzed. Pooled sensitivity, specificity, positive and negative likelihood ratio (LR+ and LR−) and diagnostic odd ratio (DOR) of ¹⁸F-FDG-PET or PET/CT on a per patient-based analysis were calculated. The area under the summary ROC curve (AUC) was calculated to measure the accuracy of these methods in the assessment of pleural abnormalities. Sub-analyses considering ¹⁸F-FDG-PET/CT and patients with lung cancer only were carried out.
Eight studies comprising 360 cancer patients (323 with lung cancer) were included. The meta-analysis of these selected studies provided the following results: sensitivity 86% [95% confidence interval (95%CI): 80–91%], specificity 80% [95%CI: 73–85%], LR+ 3.7 [95%CI: 2.8–4.9], LR− 0.18 [95%CI: 0.09–0.34], DOR 27 [95%CI: 13–56]. The AUC was 0.907. No significant improvement considering PET/CT studies only and patients with lung cancer was found.
¹⁸F-FDG-PET and PET/CT demonstrated to be useful diagnostic imaging methods in the assessment of pleural abnormalities in cancer patients, nevertheless possible sources of false-negative and false-positive results should be kept in mind. The literature focusing on the use of ¹⁸F-FDG-PET and PET/CT in this setting remains still limited and prospective studies are needed.

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Chest

Study objectives

Methods

Results

Conclusion

Section snippets

Patient Population

Results

Discussion

Conclusion

References (20)

Transudative pleural effusions: false reassurance against malignancy [Letter]

Chest

Prospective comparison of radiologic thoracoscopic, and pathologic staging in patients with early non-small cell lung cancer

Ann Thorac Surg

Staging non-small cell lung cancer by whole-body positron emission tomographic imaging

Ann Thorac Surg

Diagnostic efficacy of PET-FDG imaging in solitary pulmonary nodules

Chest

Routine video-assisted thoracoscopy prior to thoracotomy

Chest

Thoracic computed tomography in patients with suspected malignant pleural effusions

Clin Radiol

Thoracoscopy for diagnosis of pleural disease

Ann Intern Med

Focal pulmonary abnormalities: evaluation with F-18 fluoro-deoxyglucose PET scanning

Radiology

Positron emission tomography of lung tumors and mediastinal lymph nodes using [F-18] fluoro-deoxyglucose

Ann Thorac Surg

Glucose utilization in vivo by human pulmonary neoplasms

Cancer

Cited by (114)

Positron emission tomography-computed tomography (PET-CT) in suspected malignant pleural effusion. An updated systematic review and meta-analysis

Diagnosis and management of pleural metastases and malignant effusion in breast cancer

Pitfalls and Limitations in Non-Small Cell Lung Cancer Staging

Accuracy of fluorodeoxyglucose-PET imaging for differentiating benign from malignant pleural effusions: A meta-analysis

Positron Emission Tomography

Diagnostic performance of Fluorine-18-Fluorodeoxyglucose positron emission tomography in the assessment of pleural abnormalities in cancer patients: A systematic review and a meta-analysis

Chest

Clinical Investigations: CancerClinical Role of F-18 Fluorodeoxyglucose Positron Emission Tomography Imaging in Patients with Lung Cancer and Suspected Malignant Pleural Effusion

Study objectives

Methods

Results

Conclusion

Section snippets

Patient Population

Results

Discussion

Conclusion

Chest

Ann Thorac Surg

Ann Thorac Surg

Chest

Chest

Thoracic computed tomography in patients with suspected malignant pleural effusions

Clin Radiol

Thoracoscopy for diagnosis of pleural disease

Ann Intern Med

Focal pulmonary abnormalities: evaluation with F-18 fluoro-deoxyglucose PET scanning

Radiology

Positron emission tomography of lung tumors and mediastinal lymph nodes using [F-18] fluoro-deoxyglucose

Ann Thorac Surg

Glucose utilization in vivo by human pulmonary neoplasms

Cancer

Clinical Investigations: Cancer
Clinical Role of F-18 Fluorodeoxyglucose Positron Emission Tomography Imaging in Patients with Lung Cancer and Suspected Malignant Pleural Effusion