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Impact of Computer-Aided CT and PET Analysis on Non-invasive T Staging in Patients with Lung Cancer and Atelectasis

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Abstract

Purpose

Tumor delineation within an atelectasis in lung cancer patients is not always accurate. When T staging is done by integrated 2-deoxy-2-[18F]fluoro-d-glucose ([18F]FDG)-positron emission tomography (PET)/X-ray computer tomography (CT), tumors of neuroendocrine differentiation and slowly growing tumors can present with reduced FDG uptake, thus aggravating an exact T staging. In order to further exhaust information derived from [18F]FDG-PET/CT, we evaluated the impact of CT density and maximum standardized uptake value (SUVmax) for the classification of different tumor subtypes within a surrounding atelectasis, as well as possible cutoff values for the differentiation between the primary tumor and atelectatic lung tissue.

Procedures

Seventy-two patients with histologically proven lung cancer and adjacent atelectasis were investigated. Non-contrast-enhanced [18F]FDG-PET/CT was performed within 2 weeks before surgery/biopsy. Boundaries of the primary within the atelectasis were determined visually on the basis of [18F]FDG uptake; CT density was quantified manually within each primary and each atelectasis.

Results

CT density of the primary (36.4 Hounsfield units (HU) ± 6.2) was significantly higher compared to that of atelectatic lung (24.3 HU ± 8.3; p < 0.01), irrespective of the histological subtype. The discrimination between different malignant tumors using density analysis failed. SUVmax was increased in squamous cell carcinomas compared to adenocarcinomas. Irrespective of the malignant subtype, a possible cutoff value of 24 HU may help to exclude the presence of a primary in lesions below 24 HU, whereas a density above a threshold of 40 HU can help to exclude atelectatic lung.

Conclusion

Density measurements in patients with lung cancer and surrounding atelectasis may help to delineate the primary tumor, irrespective of the specific lung cancer subtype. This could improve T staging and radiation treatment planning (RTP) without additional application of a contrast agent in CT, or an additional magnetic resonance imaging (MRI), even in cases of lung tumors of neuroendocrine differentiation or in slowly growing tumors with less avidity to [18F]FDG.

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Author information

Authors and Affiliations

  1. Department of Nuclear Medicine, University Hospital Heidelberg, INF 400, 69120, Heidelberg, Germany

    Paul Flechsig, Ramin Rastgoo, Clemens Kratochwil, Uwe Haberkorn & Frederik L. Giesel

  2. Translational Lung Research Center Heidelberg, Member of the German Center for Lung Research DZL, Heidelberg, Germany

    Paul Flechsig, Hans-Ulrich Kauczor, Uwe Haberkorn & Frederik L. Giesel

  3. Medical Faculty, Department of Diagnostic and Interventional Radiology, University Dusseldorf, 40225, Dusseldorf, Germany

    Ole Martin

  4. Department of Biostatistics, German Cancer Research Center, Heidelberg, Germany

    Tim Holland-Letz

  5. Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany

    Alexander Harms

  6. Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany

    Hans-Ulrich Kauczor

  7. Clinical Cooperation Unit, Department of Nuclear Medicine, DKFZ, Heidelberg, Germany

    Uwe Haberkorn & Frederik L. Giesel

  8. Department of Radiology, Columbia University Medical Centre, New York Presbyterian Hospital, New York, NY, USA

    Frederik L. Giesel

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  1. Paul Flechsig
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  9. Frederik L. Giesel
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Correspondence to Paul Flechsig.

Ethics declarations

The study was approved by the institutional review board and conducted according to the guidelines of the institutional review board and to good clinical practice according to the ethical principles that have their origin in the Declaration of Helsinki. In this retrospective analysis, the requirement of informed consent was waived by the institutional review board.

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The authors declare that they have no conflict of interest.

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Flechsig, P., Rastgoo, R., Kratochwil, C. et al. Impact of Computer-Aided CT and PET Analysis on Non-invasive T Staging in Patients with Lung Cancer and Atelectasis. Mol Imaging Biol 20, 1044–1052 (2018). https://doi.org/10.1007/s11307-018-1196-9

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  • DOI: https://doi.org/10.1007/s11307-018-1196-9

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