Value of PET/CT

Diagnosis of Pulmonary Nodules

Core Message for Referring Physicians

Background: Practice Guideline

The prevalence of non-calcified pulmonary nod-
ules in smokers or ex smokers is 23% - 69%, but American College of Chest Surgeons:
only 1.4% - 2.7% have malignant nodules. The In patients with a low to moderate pre test probability of malignancy (5% - 60%) and an
Fleischner Society has published imaging guide- indeterminate SPN that measures at least 8 to 10 mm in diameter, fluorodeoxyglucose (FDG)
lines for patients with pulmonary nodules that are positron emission tomography (PET) should be performed to characterize the nodule.
smaller than 8 mm (1). When the pre-test probability of malignancy is moderate to high (>60%), and the nodule
PET/CT is more accurate that CT alone for char- is hypermetabolic by FDG PET, surgical diagnosis is preferred when clinically appropriate (6).
acterizing pulmonary nodules, resulting in fewer Case Example 1:
equivocal findings, and higher specificity (2). Low

to intermediate risk nodules 8 mm should be
evaluated by PET/CT, whereas high-risk nodules
should be biopsied or excised.

The sensitivity of PET/CT for lung cancer is >90%,

so low to intermediate risk nodules that are meta-
bolically inactive can be followed radiographically
to ensure stability or resolution. The specificity of
PET/CT is approximately 80% because inflamma- 47-year-old man with incidental 1.5 cm nodule discovered on chest x-ray. PET/CT showed high
tory nodules can be metabolically active (3). PET FDG uptake. Biopsy showed poorly differentiated lung cancer.
positive nodules require further investigation.
Case Example 2:
PET/CT with 18F-fluorodexoyglucose (FDG) has

been shown to be cost-effective for character-
izing lung nodules 8 mm when risk-estimates
based on clinical versus morphological param-
eters are conflicting, or when indeterminate nod-
ules are found in high-risk individuals (4).

SNM recommends that 18F-FDG PET/CT should

routinely be obtained in the diagnostic work-up of
solitary pulmonary nodule (5). Imaging will im-
prove health care outcomes, mostly by avoiding
futile surgeries in low-risk patients and enabling
curative surgeries in high-risk patients.
84 year-old man with chronic cough and 1.5 cm nodule on chest x-ray. PET /CT showed no FDG
uptake. Biopsy was deferred. The nodule had grown to 2 cm 12 months later. Biopsy showed a
fungus.

Reimbursement
CMS Coverage Policy
PET and PET/CT are approved by the Centers
for Medicare and Medicaid Services (CMS)
for characterization of solitary pulmonary
nodules not exceeding 4 cm to determine
the likelihood of malignancy. Claims should
include evidence of the initial detection of
a primary lung nodule, usually by computed
tomography (8).
Quantitative criteria have been suggested to improve the accuracy of PET/CT. The standardized
uptake value (SUV) is a ratio of the concentration of FDG in the nodule compared to the average
concentration in the body. An SUV of 2.5 has been used to differentiate benign from malignant
nodules. Many variables, however, affect the measurement of SUV, limiting its accuracy and
reproducibility. It has been suggested that an increase or no change in SUV when measured
at two time points between 60 to 120 minutes improves accuracy (7). Despite the appeal of a
simple numerical measurement, most physicians rely on visual assessment of metabolic activ-
ity using a binary decision model of detectable versus no detectable FDG uptake.
References
1. MacMahon H, et al. Guidelines for management of small pulmonary nodules detected on CT scans: A statement from the
Fleischner Society. Radiology 2005;237:395-400.
2. Pauls S, et al. Performance of integrated FDG-PET/CT for differentiating benign and malignant lung lesions--results from a
large prospective clinical trial. Mol Imaging Biol. 2008 Mar-Apr;10(2):121-8.
3. Ung YC, et al. 18Fluorodeoxyglucose positron emission tomography in the diagnosis and staging of lung cancer: a systematic
review. J Natl Cancer Inst 2007 Dec 5;99(23):1753-6
4. Gould MK, et al. Cost-effectiveness of alternative management strategies for patients with solitary pulmonary nodules. Ann
Intern Med. 2003 May 6;138(9):724-35.
5. Fletcher JW, et al. Recommendations on the use of 18F-FDG PET in oncology. J Nucl Med. 2008 Mar;49(3):480-508.
6. Alberts WM. Chest 2007;132;1-19 Clinical Practice Guidelines (2nd Edition) Executive Summary: ACCP Evidence-Based
Diagnosis and Management of Lung Cancer.
7. Alkhawaldeh K, et al. Impact of dual-time-point 18F-FDG PET imaging and partial volume correction in the assessment of
solitary pulmonary nodules. Eur j Nucl Med Mol Imaging 2008;35:246-252.
8. CMS Publication 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, Section 220.6). Available at
http://www.cms.hhs.gov/manuals/downloads/ncd103c1_part4.pdf