Figure 8. 18F-FDG scan in a patient with a primary lung cancer involving the right apex (arrow). The mediastinum is normal and the patient is a surgical candidate. (Courtesy of ADAC Labs and Dr. J.-F. Gaillard, HIA Val de Grace, Paris, France.)

Lung cancer

Lung cancer is now the most common single cause of cancer related death in both sexes, having recently overtaken breast cancer in women. In the United States there are in excess of 160,000 new cases annually and survival at 5 years is approximately

The most important contributions of nuclear medicine to the management of patients with lung cancer are in the evaluation of solitary pulmonary nodules and in staging of confirmed disease using PET imaging with 18F-FDG; both indications can often be performed with a single examination.

Most series have shown the sensitivity of PET to be of the order of 95% in diagnosing cancer in a solitary pulmonary nodule; quantitative assessment with the standardized uptake value (SUV) > 2.5 has a specificity greater than 90%. (The SUV is an index of lesion uptake and is calculated as decay-corrected lesion activity divided by the injected activity/body weight).

Once the presence of non-small cell lung cancer (NSCLC) has been confirmed, an evaluation of the mediastinum for locoregional metastatic involvement is required to plan therapy. CT has a sensitivity of60-70% and specificity of65-75% in defining mediastinal involvement, and mediastinoscopy an accuracy of 89%. Metastatic involvement has been shown to be present in 13% of nodes <1 cm on CT and in only 36% in nodes >2 cm, so current staging techniques have significant limitations.

FDG imaging can improve patient management. Sensitivity and specificity in detecting mediastinal disease has been reported as 90-95% and up to 95%, respectively. The commonest cause of false positive uptake is granulomatous disease. Prospective comparisons of conventional staging (CT, ultrasonography, bone scanning, and, when indicated, needle biopsies) with FDG PET have shown that PET improves the rate of detection of local and distant metastases in patients with NSCLC. In jurisdictions where PET is readily available, it has become the investigation of choice (Fig. 8). In addition to evaluating mediastinal involvement the ability of PET to provide whole body images will define that group of patients who present with Stage IV disease (Fig. 9).

Using these criteria for staging patients with NSCLC, several groups have shown changes in management based on the PET images; one recent study has shown

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