What is the best way to diagnose and stage malignant pleural mesothelioma?

Our plain-English summary of What is the best way to diagnose and stage malignant pleural mesothelioma?, by I. Zahid, S. Sharif, T. Routledge, et al (Interactive Cardiovascular and Thoracic Surgery, 2011).

The study

• Authors: I. Zahid, S. Sharif, T. Routledge, M. Scarci
• Journal: Interactive Cardiovascular and Thoracic Surgery
• Published: 2011;12(2):254-9
• Type of article: Review
• Cited by: 37 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was which diagnostic modality [computed tomography (CT), positron emission tomography (PET), combination PET/CT and magnetic resonance imaging (MRI)] provides the best diagnostic and staging information in patients with malignant pleural mesothelioma (MPM). Overall, 61 papers were found using the reported search, of which 14 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results are tabulated. We conclude that fluorodeoxyglucose (FDG)-PET is superior to MRI and CT but inferior to PET-CT, in terms of diagnostic specificity, sensitivity and staging of MPM. Four studies reported outcomes using FDG-PET to diagnose MPM. PET diagnosed MPM with high sensitivity (92%) and specificity (87.9%). Mean standardised uptake value (SUV) was higher in malignant than benign disease (4.91 vs. 1.41, P<0.0001). Lymph node metastases were detected with higher accuracy (80% vs. 66.7%) compared to extrathoracic disease. Three studies assessed the utility of PET-CT to diagnose MPM. Mean SUV was higher in malignant than benign disease (6.5 vs. 0.8, P<0.001). MPM was diagnosed with high sensitivity (88.2%), specificity (92.9%) and accuracy (88.9%). PET-CT had low sensitivity for stage N2 (38%) and T4 (67%) disease. CT-guided needle biopsy definitively diagnosed MPM after just one biopsy (100% vs. 9%) much more often than a 'blind' approach. CT had a lower success rate (92% vs. 100%) than thoracoscopic pleural biopsy but was equivalent to MRI in terms of detection of lymph node metastases (P=0.85) and visceral pleural tumour (P=0.64). CT had a lower specificity for stage II (77% vs. 100%, P<0.01) and stage III (75% vs. 100%, P<0.01) disease compared to PET-CT. Overall, the high specificity and sensitivity rates seen with open pleural biopsy make it a superior diagnostic modality to CT, MRI or PET for diagnosing patients with MPM.

In plain English

This article was a 'best evidence topic', a structured review of published studies. The authors asked which method (CT, PET, PET-CT or MRI) best diagnoses and stages malignant pleural mesothelioma. A Medline search covering 1950 to August 2010 found 61 papers, of which 14 were judged best evidence. In one reviewed FDG-PET study, sensitivity was 92% and specificity was 75%. In one PET-CT study, specificity was 92.9% and sensitivity was 88.2%. Another study reported low PET-CT sensitivity for T4 (67%) and N2 (38%) disease. In a 54-patient study, PET-CT was more accurate than CT, PET or MRI for stage II and III tumours. One biopsy study found that CT-guided needle biopsy gave a definitive diagnosis on the first biopsy in 100% of cases (five of five patients), compared with 9% for a 'blind' approach. In that study, open pleural biopsy was 95% sensitive and 100% specific. The authors concluded that PET-CT was superior to FDG-PET, MRI and CT for detection and staging. They added that surgical pleural biopsy still gave the most accurate definitive diagnosis but is more invasive.

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: Best evidence topic: a structured literature review of published studies. Nearly all of the 14 selected studies were single-centre retrospective cohort studies; one was a prospective cohort study.
• Who was studied: The review drew on 61 papers found by a Medline search covering 1950 to August 2010. Of these, 14 were selected as the best evidence. They were studies of patients with suspected or confirmed malignant pleural mesothelioma, ranging from 15 to 65 patients each, from the USA, Japan, Turkey, the UK, Italy and Switzerland, published 1998 to 2010.
• Exposure: The review compared diagnostic and staging methods, not asbestos exposure. The methods were FDG-PET, PET-CT, CT, MRI, FDG gamma-camera coincidence imaging, and biopsy or thoracoscopy. Asbestos exposure appeared only in the review's hypothetical clinical scenario of a retired plumber.
• Main results:
  • In the reviewed study by Bernard et al., FDG-PET diagnosed malignant pleural mesothelioma with a sensitivity of 92%.
  • In the same Bernard et al. study, FDG-PET had a specificity of 75%.
  • In the reviewed study by Yildrim et al., FDG-PET-CT identified malignant pleural mesothelioma with a specificity of 92.9% and a sensitivity of 88.2%.
  • In the reviewed study by Erasmus et al. (29 patients), PET-CT had low sensitivity for T4 disease (67%) and N2 disease (38%).
  • In the reviewed study by Attanoos and Gibbs, CT-guided closed biopsy made a definitive diagnosis after one biopsy in 100% of cases, compared with 9% for 'blind' closed biopsy.
  • In the Attanoos and Gibbs study, the CT-guided closed percutaneous biopsy group had 5 patients. The 100% figure therefore represents five of five.
  • In the same Attanoos and Gibbs study, open pleural biopsy was 95% sensitive and 100% specific for malignant pleural mesothelioma.
  • In the reviewed study by Gerbaudo et al. (15 patients), FDG gamma-camera coincidence imaging had greater sensitivity than CT (97% vs. 83%) and greater accuracy (94% vs. 82%). Specificity was the same for both (80% vs. 80%).
  • In the reviewed study by Heelan et al. (65 patients), CT was inferior to MRI at detecting disease invading the diaphragm. The areas under the ROC curve were 0.55 for CT and 0.82 for MRI, with P equal to 0.01.
  • In the reviewed study by Plathow et al. (54 patients), PET-CT was more accurate than CT, PET and MRI for stage II tumours: 100% vs. 77% vs. 86% vs. 80%, P less than 0.01. The review text also reports stage III accuracies of 100% vs. 75% vs. 83% vs. 90%.
  • In the reviewed study by Nanni et al. (15 patients), PET upstaged disease in 13% of patients and downstaged it in 27%, compared with CT. This led to a change in management protocol for 20% of patients.
• The authors' conclusion: The authors concluded that the reviewed studies showed PET-CT to be superior to FDG-PET, MRI and CT in specificity and sensitivity for detecting and staging malignant pleural mesothelioma. They also concluded that surgical pleural biopsy still provides the most accurate definitive diagnosis, although it is more invasive than PET-CT.

Topics

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

Medical terms in this study, explained in our Lexicon: Pleural Mesothelioma, Thoracic Surgery, Staging, PET-CT, Needle Biopsy, Biopsy, Pleural Biopsy.

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