Role of integrated 18-fluorodeoxyglucose position emission tomography-computed tomography in patients surveillance after multimodality therapy of malignant pleural mesothelioma

Our plain-English summary of Role of integrated 18-fluorodeoxyglucose position emission tomography-computed tomography in patients surveillance after multimodality therapy of malignant pleural mesothelioma, by C. Tan, S. Barrington, S. Rankin, et al (Journal of Thoracic Oncology, 2010).

The study

• Authors: C. Tan, S. Barrington, S. Rankin, D. Landau, J. Pilling, J. Spicer, P. Cane, L. Lang-Lazdunski
• Journal: Journal of Thoracic Oncology
• Published: 2010;5(3):385-8
• Cited by: 29 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Introduction: To investigate the role of 18-fluorodeoxyglucose positron emission tomography-computed tomography (18-FDG-PET-CT) in the surveillance of patients after multimodality treatment of malignant pleural mesothelioma.

Methods: Retrospective study of patients who had chemotherapy, radical surgery, extrapleural pneumonectomy or pleurectomy/decortication, and radiotherapy for mesothelioma in our unit. PET-CT was performed after multimodality therapy to evaluate response to treatment or when disease recurrence was suspected. 18-FDG-PET scans were acquired from skull base to upper thigh with low-dose CT scans for attenuation correction and image fusion.

Results: Forty-four patients had extrapleural pneumonectomy (21) or pleurectomy/decortication (23) between January 2004 and July 2008. Twenty-five patients had PET-CT performed after multimodality therapy. This was performed in 11 patients in whom disease recurrence was suspected at a median of 9 (range, 6-16) months after treatment. PET-CT correctly diagnosed recurrent disease in eight patients and missed microscopic recurrence in one. Surveillance PET-CT was performed in 14 asymptomatic patients at a median of 11 (range, 7-13) months after treatment. It showed unsuspected recurrences in four patients. The standard uptake value max of recurrent mesothelioma was 8.9 +/- 4.0 (4-18.4). PET-CT had a sensitivity of 94%, a specificity of 100%, and the positive and negative predictive values of 100 and 88%, respectively.

Conclusions: 18-FDG-PET-CT is useful in diagnosing disease recurrence after multimodality therapy for malignant pleural mesothelioma. We propose a prospective study to fully assess its value in this group of patients.

In plain English

This retrospective study from Guy's and St Thomas' Hospital in London asked whether PET-CT scanning with the tracer 18-FDG could detect the return of malignant pleural mesothelioma after combined treatment with chemotherapy, radical surgery (extrapleural pneumonectomy or pleurectomy/decortication) and radiotherapy. Of 44 patients treated between January 2004 and July 2008, 25 had PET-CT afterwards. In 11 the scan was done because recurrence was suspected, and in 14 it was routine surveillance of patients without symptoms. The article does not report asbestos exposure. In the suspected group, PET-CT correctly found recurrence in eight patients and missed microscopic recurrence in one. In the symptom-free group, the results section reports unsuspected recurrence in nine patients, while the abstract says four. Overall, PET-CT identified 17 of 18 patients with recurrence (sensitivity 94%) and all seven without disease (specificity 100%). The positive and negative predictive values were 100% and 88%. The authors concluded that PET-CT could be a useful tool, particularly when CT had failed to identify recurrence. They described this as a small retrospective study and called for a prospective one.

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 study of patients identified from a hospital departmental database
• Who was studied: 44 patients (40 men, 4 women; median age 62) treated with multimodality therapy for malignant pleural mesothelioma at Guy's and St Thomas' Hospital, London, between January 2004 and July 2008. 21 had extrapleural pneumonectomy and 23 had pleurectomy/decortication. 25 of the 44 had PET-CT after treatment.
• Exposure: Not an asbestos exposure study; the article gives no information on asbestos exposure. Patients had chemotherapy, radical surgery (extrapleural pneumonectomy or pleurectomy/decortication) and radiotherapy, followed by 18-FDG PET-CT scanning.
• Main results:
  • Among 11 patients scanned because recurrence was suspected (median 9 months, range 6 to 16, after surgery), PET-CT correctly identified recurrence in eight and missed microscopic recurrence in one.
  • Among 14 patients without symptoms scanned for surveillance (median 11 months, range 7 to 13, after surgery), the results section reports unsuspected recurrence in nine.
  • In the surveillance group, in six of 11 patients whose earlier CT showed no recurrence, PET-CT showed recurrence in four, all with local disease inside the chest.
  • In two surveillance patients whose CT was suspicious for recurrence, PET-CT showed no FDG uptake in the suspicious areas.
  • Beyond local disease in the chest, PET-CT found recurrence in the other lung in two patients, peritoneal spread in four, bone spread in two and a supraclavicular lymph node in one.
  • PET-CT missed recurrence in one patient who developed a small pleural effusion on the opposite side 12 months after left extrapleural pneumonectomy. Biopsies of small pleural nodules confirmed recurrent mesothelioma.
  • Across all 25 scanned patients, PET-CT correctly identified recurrence in 17 of 18 (sensitivity 94%) and correctly identified 7 of 7 as having no residual disease (specificity 100%).
  • The positive predictive value was 100% and the negative predictive value was 88%.
  • The mean SUVmax (a measure of tracer uptake) of recurrent disease was 8.9, range 4 to 18.4. The authors stated that an SUVmax above 4 seemed to distinguish recurrence from postoperative change in their patients.
• The authors' conclusion: The authors concluded that, in their preliminary experience in 25 patients, 18-FDG-PET-CT could be a useful tool to identify recurrent disease after multimodality therapy, particularly when CT failed to discriminate or identify recurrence. They proposed a prospective study.
• Limitations the authors state:
  • The authors described the study as small and retrospective, and said PET-CT should be assessed further in a prospective study.
  • Patients were treated under two different protocols with different relapse patterns, which the authors said may affect PET-CT accuracy because it may detect recurrence better at some sites than others.
  • The authors noted that previous talc pleurodesis or sarcoid-like reactive lymph node enlargement can affect PET-CT accuracy for recurrence in the mediastinum.
  • The authors stated that metastatic deposits need to be 5 to 10 mm in size to be resolved with PET.

Topics

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

Medical terms in this study, explained in our Lexicon: Multimodal Therapy, Pleural Mesothelioma, PET-CT, Chemotherapy, Extrapleural Pneumonectomy (EPP), Pleurectomy/Decortication (P/D), Mesothelioma, PET Scan.

Related studies

• 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)
• Patterns of disease progression on 18F-fluorodeoxyglucose positron emission tomography-computed tomography in patients with malignant pleural mesothelioma undergoing multimodality therapy with pleurectomy/decortication — A. Bille, S. Chicklore, et al. (2013)
• The role of fluorodeoxyglucose-positron emission tomography/computed tomography in differentiating between benign and malignant adrenal lesions — P. Ozcan Kara, T. Kara, et al. (2011)
• 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)
• Clinical value of fluorodeoxyglucose-positron emission tomography/computed tomography in differentiation of malignant mesothelioma from asbestos-related benign pleural disease: an observational pilot study — H. Yildirim, M. Metintas, et al. (2009)
• 18-Fluorodeoxyglucose positron emission tomography as a tool for response prediction in solid tumours — D.J. De Maeseneer, B. Lambert, et al. (2010)

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