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Accuracy of PET for Diagnosis of Solid Pulmonary Lesions with ¹⁸F-FDG Uptake Below the Standardized Uptake Value of 2.5

¹ Division of Nuclear Medicine, Department of Radiology, School of Medicine, Tokyo Women's Medical University, Tokyo, Japan; ² First Department of Medicine, School of Medicine, Tokyo Women's Medical University, Tokyo, Japan; ³ First Department of Surgery, School of Medicine, Tokyo Women's Medical University, Tokyo, Japan; and ⁴ Department of Surgical Pathology, School of Medicine, Tokyo Women's Medical University, Tokyo, Japan

Correspondence: For correspondence or reprints contact: Chisato Kondo, MD, Division of Nuclear Medicine, Department of Radiology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo 162-8666, Japan. E-mail: pkondou{at}rad.twmu.ac.jp

Benign and malignant pulmonary lesions usually are differentiated by ¹⁸F-FDG PET with a semiquantitative ¹⁸F-FDG standardized uptake value (SUV) of 2.5. However, the frequency of malignancies with an SUV of <2.5 is significant, and pulmonary nodules with low ¹⁸F-FDG uptake often present diagnostic challenges. Methods: Among 360 consecutive patients who underwent ¹⁸F-FDG PET to evaluate pulmonary nodules found on CT, we retrospectively analyzed 43 who had solid pulmonary lesions (excluding lesions with ground-glass opacity, infiltration, or benign calcification) with an SUV of <2.5. The uptake of ¹⁸F-FDG was graded by a visual method (absent, faint, moderate, or intense) and 2 semiquantitative methods (SUV and contrast ratio [CR]). Final classification was based on histopathologic findings or at least 6 mo of clinical follow-up. Results: We found 16 malignant (diameter, 8–32 mm) and 27 benign (7–36 mm) lesions. When faint visual uptake was the cutoff for positive ¹⁸F-FDG PET results, the receiver-operating-characteristic (ROC) analysis correctly identified all 16 malignancies and yielded false-positive results for 10 of 27 benign lesions. Sensitivity was 100%, specificity was 63%, and the positive and negative predictive values were 62% and 100%, respectively. When an SUV of 1.59 was the cutoff for positive ¹⁸F-FDG PET results, the ROC analysis revealed 81% sensitivity, 85% specificity, and positive and negative predictive values of 77% and 89%, respectively. At a cutoff for positive ¹⁸F-FDG PET results of a CR of 0.29, the ROC analysis revealed 75% sensitivity, 82% specificity, and positive and negative predictive values of 71% and 85%, respectively. The areas under the curve in ROC analyses did not differ significantly among the 3 analyses (visual, 0.84; SUV, 0.81; and CR, 0.82). Analyses of intra- and interobserver variabilities indicated that visual and SUV analyses were quite reproducible, whereas CR analysis was poorly reproducible. Conclusion: These results suggested that for solid pulmonary lesions with low ¹⁸F-FDG uptake, semiquantitative approaches do not improve the accuracy of ¹⁸F-FDG PET over that obtained with visual analysis. Pulmonary lesions with visually absent uptake indicate that the probability of malignancies is very low. In contrast, the probability of malignancy in any visually evident lesion is about 60%.

Key Words: lung cancer • PET • ¹⁸F-FDG • pulmonary nodules • CT

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