PET-CT in Clinical Adult Oncology: II. Primary Thoracic and Breast Malignancies

Our plain-English summary of PET-CT in Clinical Adult Oncology: II. Primary Thoracic and Breast Malignancies, by M.F. Covington, B.R. Koppula, G.C. Fine, et al (Cancers, 2022).

The study

• Authors: M.F. Covington, B.R. Koppula, G.C. Fine, A.E. Salem, R.H. Wiggins, J.M. Hoffman, K.A. Morton
• Journal: Cancers
• Published: 2022;14(11)
• Type of article: Review
• Cited by: 12 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Positron emission tomography combined with x-ray computed tomography (PET-CT) is an advanced imaging modality with oncologic applications that include staging, therapy assessment, restaging, and surveillance. This six-part series of review articles provides practical information to providers and imaging professionals regarding the best use of PET-CT for the more common adult malignancies. The second article of this series addresses primary thoracic malignancy and breast cancer. For primary thoracic malignancy, the focus will be on lung cancer, malignant pleural mesothelioma, thymoma, and thymic carcinoma, with an emphasis on the use of FDG PET-CT. For breast cancer, the various histologic subtypes will be addressed, and will include 18F fluorodeoxyglucose (FDG), recently Food and Drug Administration (FDA)-approved 18F-fluoroestradiol (FES), and 18F sodium fluoride (NaF). The pitfalls and nuances of PET-CT in breast and primary thoracic malignancies and the imaging features that distinguish between subcategories of these tumors are addressed. This review will serve as a resource for the appropriate roles and limitations of PET-CT in the clinical management of patients with breast and primary thoracic malignancies for healthcare professionals caring for adult patients with these cancers. It also serves as a practical guide for imaging providers, including radiologists, nuclear medicine physicians, and their trainees.

In plain English

This article was a narrative review, the second in a six-part series, written by radiologists at the University of Utah for doctors and imaging staff. It described how PET-CT scans, mainly using the tracer FDG, are used for lung cancer, malignant pleural mesothelioma, thymic tumors and breast cancer. It reported no new patient study. Its example images came from deidentified teaching files from clinical cases at the University of Utah, 2004 to 2022. Asbestos appeared only as background: the review stated that malignant pleural mesothelioma is associated with prior asbestos exposure in 70% of cases, and it listed asbestos among occupational risk factors for lung cancer. Drawing on other studies and guidelines, the review stated that mesothelioma typically shows intense activity on FDG PET-CT. It also stated that the scan may under-stage mediastinal or lymph node disease and is best used to look for distant spread. It warned that inflammation after talc pleurodesis can look like calcified pleural plaques with mesothelioma. The authors concluded that FDG PET-CT staging of mesothelioma should be reserved for patients considered for surgery or with suspected progression after induction chemotherapy.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Narrative review (second article of a six-part review series) on clinical use of PET-CT in primary thoracic malignancies and breast cancer; no original patient data
• Who was studied: No study population. Illustrative images were taken from deidentified teaching files of clinical cases at the University of Utah, 2004 to 2022
• Exposure: Asbestos exposure was not studied. It was mentioned as background: malignant pleural mesothelioma described as associated with prior asbestos exposure in 70% of cases, and asbestos listed among occupational carcinogens that are risk factors for lung cancer
• Main results:
  • The review stated that malignant pleural mesothelioma is typically intensely hypermetabolic (shows strong FDG uptake) on FDG PET-CT
  • The review stated that hypermetabolic pleural thickening in mesothelioma is typically associated with calcified pleural plaques. It added that this appearance can be mimicked by inflammation after talc pleurodesis, empyema, other pleural inflammatory disease or other subpleural cancers
  • Citing other work, the review stated that FDG PET-CT may under-stage mediastinal or nodal disease in mesothelioma and is typically best used to assess distant metastases
  • The review reported that NCCN guidelines endorse FDG PET-CT staging of mesothelioma only for patients being considered for surgery. It also stated that PET-CT should be done before contemplated talc pleurodesis
  • In an illustrative case of a patient who had undergone talc pleurodesis, the review noted that the inflammatory reaction to talc could be confused with calcified pleural plaques and mesothelioma without the appropriate history
  • In one illustrative case, a 53-year-old male mining worker with long occupational silica exposure had an FDG-avid lung mass. The mass was attributed to progressive massive fibrosis and was stable for years. The review stated that pneumoconiosis can mimic primary lung cancer
• The authors' conclusion: The authors concluded that FDG PET-CT staging of malignant pleural mesothelioma is best reserved for patients considered for surgery or for suspected progression despite induction chemotherapy, recognizing that it may under-stage mediastinal or nodal disease

Topics

Medical terms in this study, explained in our Lexicon: PET-CT, Staging, Lung Cancer, Pleural Mesothelioma, Carcinoma, Histological Subtype.

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• Newest therapeutic strategies impacting on rarest thoracic malignancies: The clinical case report of biphasic pleural mesothelioma — F. Pellicioli, L. Sala, et al. (2024)
• Low-dose computed tomography screening for lung cancer and pleural mesothelioma in an asbestos-exposed population: baseline results of a prospective, nonrandomized feasibility trial--an Alpe-adria Thoracic Oncology Multidisciplinary Group Study (ATOM 002) — G. Fasola, O. Belvedere, et al. (2007)
• Scientific Advances in Thoracic Oncology 2016 — R.A. Soo, E.C.A. Stone, et al. (2017)
• New applications of magnetic resonance imaging for thoracic oncology — Y. Ohno (2014)

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