Positron emission tomography with f18-fluorodeoxyglucose in the staging and preoperative evaluation of malignant pleural mesothelioma

Our plain-English summary of Positron emission tomography with f18-fluorodeoxyglucose in the staging and preoperative evaluation of malignant pleural mesothelioma, by D.B. Schneider, C. Clary-Macy, S. Challa, et al (The Journal of Thoracic and Cardiovascular Surgery, 2000).

The study

• Authors: D.B. Schneider, C. Clary-Macy, S. Challa, K.C. Sasse, S.H. Merrick, R. Hawkins, G. Caputo, D. Jablons
• Journal: The Journal of Thoracic and Cardiovascular Surgery
• Published: 2000;120(1):128-33
• Cited by: 83 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Objectives: The purpose of this study was to evaluate the utility of positron emission tomography with F18-fluorodeoxyglucose in the preoperative evaluation and staging of malignant mesothelioma in patients who were candidates for aggressive combined modality therapy.

Methods: Eighteen consecutive patients with biopsy-proven malignant mesothelioma underwent positron emission tomographic scanning. The results of positron emission tomographic imaging were compared with results obtained by computed tomography, mediastinoscopy, thoracoscopy, and pathologic examination of surgical specimens. All patients fasted and received an average of 14.5 +/- 2.7 mCi of F18-fluorodeoxyglucose for positron emission tomographic scanning. Attenuation-corrected whole-body and regional emission images of the chest and upper abdomen were acquired and formatted into transaxial, coronal, and sagittal images.

Results: All primary malignant mesotheliomas accumulated F18-fluorodeoxyglucose, and the mean standardized uptake value was 7. 6 (range, 3.33-14.85; n = 9). There were no false-negative results of positron emission tomography. Identification of occult extrathoracic metastases by positron emission tomography was the basis for excluding two patients from surgical therapy. There were two false-positive results of positron emission tomography: increased F18-fluorodeoxyglucose uptake in the contralateral chest that was negative by thoracoscopic biopsy (n = 1) and increased abdominal F18-fluorodeoxyglucose uptake after partial colectomy for diverticular disease (n = 1).

Conclusions: Positron emission tomography can identify malignant pleural mesothelioma and appears to be a useful noninvasive staging modality for patients being considered for aggressive combined modality therapy.

In plain English

This study reviewed the records of 18 consecutive patients with malignant pleural mesothelioma in San Francisco who had PET scans with the tracer F18-fluorodeoxyglucose (FDG) between 1997 and 1999. PET results were compared with CT scans and with biopsy and surgical findings. A history of asbestos exposure was documented in 13 (72%) patients. All 18 tumors took up FDG. PET showed lymph node uptake in 4 patients, and cancer was confirmed in all 4. CT showed enlarged nodes in only 2 of these 4. Among 16 patients whose results could be checked, PET correctly showed whether cancer had spread in 14 and CT in 8. PET found hidden spread outside the chest that excluded 2 patients from surgery. PET gave 2 false-positive results, one of them a benign asbestos-related plaque, and it missed chest wall or diaphragm invasion in 2 patients. The authors concluded that PET appears useful for staging. They noted the retrospective design, the small size, that lymph nodes were not sampled in every patient, and that earlier talc pleurodesis may have raised FDG uptake.

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: Retrospective review of a consecutive series of patients (diagnostic imaging study comparing FDG-PET with CT and pathology)
• Who was studied: 18 consecutive patients with malignant pleural mesothelioma referred for treatment at the University of California/Mount Zion Medical Center, San Francisco, scanned 1997 to 1999. Median age was 68 years (range 43 to 83), 14 men and 4 women. Cell type was epithelial or mixed in 17 and sarcomatous in 1. Eight scans were done at the UCSF PET center and 10 at 4 other centers.
• Exposure: The study evaluated a diagnostic test, not an asbestos exposure: PET scanning after an intravenous dose of 14.5 plus or minus 2.7 mCi of F18-fluorodeoxyglucose (FDG). A history of asbestos exposure was recorded in 13 of 18 patients, but no fiber types are named.
• Main results:
  • A history of asbestos exposure was documented in 13 (72%) of the 18 patients.
  • All 18 primary mesotheliomas accumulated FDG. The Results section gives a mean standardized uptake value of 7.5 plus or minus 4.2. The abstract gives 7.6 (range 3.33 to 14.85, n = 9), and the Methods say uptake values were available only for the last 9 patients.
  • PET showed increased uptake in mediastinal lymph nodes in 4 patients, and lymph node metastases were confirmed by pathology in all 4.
  • CT showed enlarged lymph nodes in only 2 of the 4 patients with documented lymph node metastases.
  • Among the 16 patients with pathologic or other confirmation, PET correctly predicted the presence or absence of metastatic disease in 14 patients.
  • Among the same 16 patients, CT correctly predicted the presence or absence of metastatic disease in only 8.
  • Across all 18 patients, PET correctly identified the presence or absence of metastatic disease in 16 (89%).
  • In the 16 confirmed patients, PET had 2 false-positive results and CT had 4. (From the authors' table: PET 5 true positive, 9 true negative, 0 false negative; CT 3 true positive, 5 true negative, 4 false negative.)
  • PET found previously undetected spread outside the chest (axillary and cervical lymph nodes, bone), which was the basis for excluding 2 patients from surgery.
  • One false-positive PET result, uptake in the opposite side of the chest, proved on biopsy to be a benign asbestos-related plaque. The other was abdominal uptake after a partial colectomy for diverticulitis.
  • PET did not predict spread through the diaphragm or invasion of the chest wall in 2 patients.
• The authors' conclusion: The authors concluded that PET appears to be a useful imaging method for evaluating and staging malignant mesothelioma, and that it may improve the selection of patients for aggressive multimodality therapy.
• Limitations the authors state:
  • The study had a retrospective design and a small sample size, and mediastinal lymph nodes were not sampled in every patient.
  • Because lymph nodes were not completely dissected in every patient, the exact sensitivity and specificity of PET could not be determined.
  • About half the patients had talc pleurodesis before PET scanning, which may have falsely raised FDG uptake.

Topics

The National Library of Medicine indexes this study under subjects our site covers: Mesothelioma.

Medical terms in this study, explained in our Lexicon: Staging, Pleural Mesothelioma, Malignant Mesothelioma, Biopsy, Mediastinoscopy, Thoracoscopy, Thoracoscopic Biopsy.

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• Good vibrations and the power of positron thinking: positron emission tomography and endoscopic ultrasound in staging of mesothelioma-two case reports — C.P. Carden, J.S. Myerson, et al. (2008)
• Integrated positron emission tomography-computed tomography does not accurately stage intrathoracic disease of patients undergoing trimodality therapy for malignant pleural mesothelioma — J. Pilling, J.A. Dartnell, et al. (2010)
• Clinical implications of 18F-fluorodeoxyglucose positron emission tomography/computed tomography at delayed phase for diagnosis and prognosis of malignant pleural mesothelioma — Y. Abe, K. Tamura, et al. (2012)
• Prognostic and predictive role of [18 F]fluorodeoxyglucose positron emission tomography (FDG-PET) in patients with unresectable malignant pleural mesothelioma (MPM) treated with up-front pemetrexed-based chemotherapy — P.A. Zucali, E. Lopci, et al. (2017)

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