Deppen S, et al. Annals of Thoracic Surgery 2011;92:

Transcription

1 Deppen S, et al. Annals of Thoracic Surgery 2011;92:

2 mor_his-mortality-histoplasmosis

3 Baddley, John W., et al. Emerging Infectious Diseases 2011; 17(9): DOI:

4 Countries with deaths attributed to Histoplasmosis sp.

5 N=211 consecutive patients with FDG PET/CT referred for a clinically suspicious nodule. SUV > 2.5 or if uptake described as moderate (similar to liver) or intense (greater than liver) defined a positive FDG PET/CT result. Deppen S, et al. Annals of Thoracic Surgery 2011;92:

6 In all 211 patients (high risk & indeterminate): Sensitivity of PET/CT = 92% (CI, 86% - 95%) Specificity of PET/CT = 40% (CI, 25% - 56%) 24 benign nodules (60%) were FP on FDG PET/CT 22/43 (51%) of benign nodules were granulomas Deppen S, et al. Annals of Thoracic Surgery 2011;92:

7 In 113 patients with indeterminate lung lesions: 65% were due to cancer Sensitivity of PET/CT = 89% (CI: 80% - 95%) Specificity of PET/CT = 40% (CI: 25% - 57%) 24 benign lesions (60%) were FP on FDG PET/CT 22/43 (51%) of benign nodules were granulomas Deppen S, et al. Annals of Thoracic Surgery 2011;92:

8 Overall accuracy of PET/CT = 81% (about the same as CT): Positive LR = 1.5 (prev. published values average about 7.1 Gould et al, JAMA 2001) Negative LR = 0.2 (prev. published values average 0.06 Gould, et al, JAMA 2001) Deppen S, et al. Annals of Thoracic Surgery 2011;92:

9 Deppen S, et al. Annals of Thoracic Surgery 2011;92:

10 Pretest probability is key: In a pt with 40% pre-test prob of LC: +FDG PET/CT gives a post-test prob of LC of 55% -FDG PET/CT gives a post-test prob of LC of 12% Thus: there is NO IMPACT ON CARE by PET/CT with these results! In other areas: +FDG PET/CT gives a post-test prob of LC of 84% -FDG PET/CT gives a post-test prob of LC of 4% Deppen S, et al. Annals of Thoracic Surgery 2011;92:

11 Deppen S, et al. Annals of Thoracic Surgery 2011;92:

12 Accuracy of FDG PET/CT based on lesion size: Deppen S, et al. Annals of Thoracic Surgery 2011;92:

13 Croft, et al, (Iowa) reported similar results prior to PET/CT days in 2002, thus adding CT part of PET/CT does not improve results in the fungal belt. N=90 patients with SPNs Sens 93%, Spec 40%, PPV 88%, NPV 55% These investigators attributed their results to high prevalence of pulmonary fungal infections also (6/9, 67%) 82% of the general population of Iowa has a positive skin test for histoplasmosis Croft DR, et al. Lung Cancer 2002;36:

14 43% of the PET/CT scans were performed at Vanderbilt; 57% of patients came with PET or PET/CT from outside hospitals PET or PET/CT results were taken from the reports Results similar between Vanderbilt (97% sens, 44% spec) and outside hospitals (86% & 25%) 46% of FP scans were due to granulomas Deppen S, et al. Annals of Thoracic Surgery 2011;92:

15 Case 1: A 62 year-old female Relapsed nodular sclerosing Hodgkin lymphoma (stage IV) Restaging following autologous stem cell transplantation

16 62 year-old female Relapsed nodular sclerosing Hodgkin lymphoma (stage IV) Restaging following autologous stem cell transplantation

17 Lobulated, intense LUL nodule. Lung cancer? Lymphoma? Biopsy recommended.

18 Biopsy: Granulomatous lymphohistiocytic infiltrate with necrosis

19 Case 2: 21 year-old male Recurrent SCC of the right lateral tongue Restaging prior to further surgery

20 A 21 year-old male with recurrent SCC of the right lateral tongue Restaging prior to further surgery

21 Cavitary GGO with solid central nodule. Little uptake. Diagnosis?

22 Biopsy: Adenocarcinoma

23 Conclusions: Are the results of the NLST definitive - have the results proven that low-dose annual CT screening in high risk subjects decreases chance of death due to lung cancer? Maybe. More time is needed to see if the curves diverge or if the initial results might be due to overdiagnosis and/or lead time bias. Lung cancer screening is NOT approved for routine clinical use, and should only be done as part of a well-designed clinical trial (NCCN guidelines 2011).

24 Conclusions: FDG PET/CT scanning for lung nodules is of limited benefit in high endemic areas for fungal infections (most of the US) in terms of deciding to bx/resect or not (clinical risk factors and CT are still standard of care) FDG PET/CT is still useful for: Staging/restaging of lung cancer IAW ACCP guidelines Directing biopsy to high yield and/or more accessible targets