Differentiation Between Malignant and Benign Pleural Effusion in Patients With Extra-Pleural Primary Malignancies

Pleural Uptake Patterns in F18Fluorodeoxyglucose-Positron Emission Tomography (FDG-PET) Scans Improve the Identification of Malignant Pleural Effusions

BACKGROUND

The confirmation of malignant pleural effusions (MPE) requires an invasive procedure. Diagnosis can be difficult and may require repeated thoracentesis or biopsies. F18Fluorodeoxyglucose-Positron Emission Tomography (FDG-PET) can characterize the extent of malignant involvement in areas of increased uptake. Patterns of uptake in the pleura may be sufficient to obviate the need for further invasive procedures.

METHODS

This is a retrospective review of patients with confirmed malignancy and suspected MPE. Patients who underwent diagnostic thoracentesis with cytology and contemporaneous FDG-PET were identified for analysis. Some underwent confirmatory pleural biopsy. The uptake pattern on FDG-PET underwent blinded review and was categorized based on the pattern of uptake.

RESULTS

One hundred consecutive patients with confirmed malignancy, suspected MPE and corresponding FDG-PET scans were reviewed. MPE was confirmed in 70 patients with positive pleural fluid cytology or tissue pathology. Of the remaining patients, 15 had negative cytopathology, 14 had atypical cells and 1 had reactive cells. Positive uptake on FDG-PET was noted in 76 patients. The concordance of malignant histology and positive FDG-PET occurred in 58 of 76 patients (76%). Combining histologically confirmed MPE with atypical cytology, positive pleural FDG-PET uptake had a positive predictive value of 91% for MPE. An encasement pattern had a 100% PPV for malignancy.

CONCLUSION

Positive FDG-PET pleural uptake represents an excellent method to identify MPE, especially in patients with an encasement pattern. This may eliminate the need for additional invasive procedures in some patients, even when initial pleural cytology is negative.

Differentiating malignant and benign pleural effusion in patients with lung cancer: an 18F-FDG PET/CT retrospectively study

Rationale

To explore the clinical role of ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography (¹⁸F-FDG PET/CT) in differentiating malignant pleural effusion (MPE) from benign pleural effusion (BPE) in patients with lung cancer.

Methods

Over a 8-year period, we retrospectively reviewed PET/CT data of lung cancer patients with pleural effusion, with 237 participants enrolled for analysis. The nature of pleural effusion was confirmed using pleural cytology or biopsy. MPE versus BPE comparison and multiple regression analysis were performed. Receiver operating characteristic (ROC) curve analysis was used for evaluating the diagnostic performance.

Results

Of the 237 participants, 170 had MPEs and 67 had BPEs. Compared with BPEs, MPEs had higher pleural SUVmax and thicker pleura and were more common among non-small cell lung cancers, peripheral tumors, and women (p < 0.05). BPEs had larger and higher ¹⁸F-FDG uptake thoracic lymph nodes and more complications of pneumonia (p < 0.05) than MPEs. Multiple regression analysis was used to identify the pleural SUVmax (odds ratio, OR = 38.8), sex (OR = 0.033), and mediastinal lymphoid node size (OR = 0.86) as independent risk factors for MPEs. The sensitivity, specificity, and area under the ROC curve (AUC) in the combined ROC curve analysis by using the three factors were 95.3%, 95.5%, and 0.989, respectively.

Conclusion

¹⁸F-FDG PET/CT integrated imaging is an effective non-invasive method for differential diagnosis of MPE in patients with lung cancer. Pleural SUVmax combined with thoracic lymph nodes and sex has high diagnostic value.

DNA Methylation Analysis of the SHOX2 and RASSF1A Panel Using Cell-Free DNA in the Diagnosis of Malignant Pleural Effusion

Objectives

The differential diagnosis of pleural effusion (PE) is a common but major challenge in clinical practice. This study aimed to establish a strategy based on a PE-cell-free DNA (cfDNA) methylation detection system for the differential diagnosis of malignant pleural effusion (MPE) and benign pleural effusion (BPE).

Methods

A total of 104 patients with PE were enrolled in this study, among which 50 patients had MPE, 9 malignant tumor patients had PE of indefinite causes, and the other 45 patients were classified as benign controls. The methylation status of short stature homeobox 2 (SHOX2) and RAS association domain family 1, isoform A (RASSF1A) was detected using PE-cfDNA specimens by real-time fluorescence quantitative PCR. Total methylation (TM) was defined as the combination of the methylation levels of SHOX2 and RASSF1A. The electrochemiluminescence immunoassay was applied to evaluate the levels of multiple serum tumor markers.

Results

The PE-cfDNA methylation status of either SHOX2 or RASSF1A was much higher in MPE samples than in benign controls. The combination of SHOX2 and RASSF1A methylation in PE yielded a diagnostic sensitivity of 96% and a specificity of 100%, respectively. When compared with the corresponding serum tumor marker detection results, TM showed the highest diagnostic efficiency (AUC = 0.985). Furthermore, the combination of the SHOX2 and RASSF1A methylation panels using PE-cfDNA could apparently improve the differential diagnostic efficacy of BPE and MPE and could help compensate for the deficiency of cytology.

Conclusions

Our results indicated that SHOX2 and RASSF1A methylation panel detection could accurately classify BPE and MPE diseases and showed better diagnostic performance than traditional serum parameters. The SHOX2 and RASSF1A methylation detection of PE-cfDNA could be a potentially effective complementary tool for cytology in the process of differential diagnosis. In summary, PE-cfDNA could be used as a promising non-invasive analyte for the auxiliary diagnosis of MPE.

Derivation and validation of a 18F-FDG PET/CT scoring model to predict malignant pleural effusion

OBJECTIVE

To develop an 18F-fluorodeoxyglucose PET/computed tomography (CT) scoring model based on metabolic and radiologic findings of the pleura and fluid to identify malignant pleural effusion.

METHODS

The PET and CT findings from patients with pleural effusion in the derivation dataset were used to develop a scoring model. Then, the diagnostic accuracy of the predictive score was verified by the validation dataset.

RESULTS

Eight parameters independently predicting malignancy were retained in the scoring model, including pleural nodules or masses (4 points), focal pleural thickening (2 points), absence of pleural loculation (2 points), thickness of mediastinal pleura involvement ≥0.5 cm (2 points), maximum standardized uptake value (SUVmax) of mediastinal pleura involvement ≥2.3 (2 points), thickness of nonmediastinal pleura involvement ≥0.5 cm (1 point), SUVmax of nonmediastinal pleura involvement ≥3.0 (1 point) and fluid SUVmax ≥1.6 (1 point). The operating characteristics of the PET/CT score were 0.958 area under the curve (AUC), 88.6% sensitivity, 91.2% specificity, 10.09 positive likelihood ratio and 0.13 negative likelihood ratio, with 6 points as the threshold. These values in the validation dataset were 0.947, 91.7%, 88.4%, 7.91 and 0.094, respectively. No difference was found in AUCs between the derivation and validation datasets (z = 0.517, P = 0.697). The negative predictive value was 99.4% in the score from 0 to 2, and the positive predictive value was 98.3% for patients with score between 9 and 15.

CONCLUSIONS

The PET/CT scoring model is a valuable strategy to help physicians to distinguish malignant-benign pleural effusion and stratify patients who will benefit from invasive procedures.

Positron emission tomography-computed tomography (PET-CT) in suspected malignant pleural effusion. An updated systematic review and meta-analysis

The role of PET and integrated PET-CT in the diagnostic workup of suspected malignant pleural effusions is unknown. Earlier systematic reviews (published 2014 and 2015) both included pleural pathology without effusion, and reached contradictory conclusions. Five studies have been published since the latest review. This systematic review and meta-analysis aims to summarise the evidence of PET and integrated PET-CT in predicting pleural malignancy in patients suspected of having malignant pleural effusions. A meta-analysis based on a systematic literature search in Cochrane Library, Medline, EMBASE and Clinicaltrials.gov was performed. Diagnostic studies evaluating the performance of PET or PET-CT in patients with suspected malignant pleural effusion, using pleural fluid cytology or histopathology as the reference test, and presenting sufficient data for constructing a 2x2 table were included. The quality of the studies was assessed by the Quality Assessment of Diagnostic Accuracy Studies-2 score. Subgroup analyses on image modality, interpretation method and known malignancy status pre index-test application were planned. Seven studies with low risk of bias were included. The pooled ability to separate benign from malignant effusions varied with image modality, interpretation method and known malignancy status pre index-test application. In studies using PET-CT, visual/qualitative image analysis was superior to semi-quantitative with positive (LR + ) and negative likelihood ratio (LR-) of 9.9 (4.5-15.3) respectively 0.1 (0.1-0.2). There was considerable heterogeneity among studies. In conclusion, visual/qualitative image analysis of integrated PET-CT seems to add relevant information in the work-up of suspected malignant pleural effusions with LR + and LR- close to rigorous pre-set cut-offs of > 10 and < 0.1. However, the quality of evidence was low due to inter-study heterogeneity, and inability to assess meta-bias. Clinical Trial Registration: The protocol was uploaded to the PROSPERO database (CRD42020213319) on the 13th of October 2020.

Imaging features of extranodal involvement in paediatric Hodgkin lymphoma

Detecting extranodal disease in paediatric Hodgkin lymphoma is of great importance for both treatment and prognosis. Different imaging techniques can be used to identify these extranodal sites. This pictorial essay provides an overview of imaging features of extranodal disease manifestation in paediatric Hodgkin lymphoma.

Pleural Empyema Menagement: A Brief Review of Litterature

Pleural empyema, defined as the presence of purulent material within the pleural space, is the consequence of a suppurative process involving the serous pleural layers. Thoracic empyema is a dynamic process, inflammatory in origin and taking place within a preformed space bordered by both the visceral and parietal pleura. It is a complex clinical entity, neither a sole clinical, laboratory, nor a radiological diagnosis. The primary therapeutic aim: ‘ubi pus evacua’ — if you find pus remove it—has not changed since the age of Celsus. Therefore, treatment of the acute empyema of the pleura is directed to early and complete evacuation of empirical fluid and content, achieving full re-expansion of the lungs and eradication of the infection using appropriate surgical procedures, antibiotics and other supportive procedures. The optimum method of treating empyema should be adjusted to the condition of the patient and the stage of the disease in which the patient is located. The method of treatment depends on the etiology (pneumonic or traumatic), the general condition of the patient and the stage of disease development. By reviewing the available literature, it can be concluded that treating the pleural empyemas is a demanding procedure, in which it is necessary for the treating physician to apply all of his knowledge, and that there is good cooperation with the patient.

PET Scan Contribution in Chest Tumor Management: A Systematic Review for Thoracic Surgeons

Aims and background

In the 90s, the introduction of positron emission tomography (PET) represented a milestone in the staging of thoracic tumors. In the last 10 years, PET scan has been widely adopted in thoracic oncology, showing high accuracy in diagnosis and staging and with promising issues in defining prognosis. The aim of this systematic review was to focus on the results and pitfalls of PET scan use in the modern management of chest tumors.

Methods and study design.

The literature search was performed on May 2010 in PubMed, Embase, and Cochrane according to PRISMA protocol. The search was restricted to publications in English, using in the same string the word “PET” with 9 different chest tumors; results were then filtered by eliminating technical articles, focusing only on papers in which surgery was considered as a potential diagnostic or therapeutic tool. From 6600 papers initially selected, 99 manuscripts were fully analyzed.

Results

Glucose uptake is a metabolic marker useful in the diagnosis and staging of chest tumors. In lung cancer screening, standard uptake value is helpful in defining the risk of malignancy of isolated pulmonary nodules. The addition of PET scan to conventional staging increases detection of nodal and distant metastases in lung cancer, esophageal cancer and malignant mesothelioma. In thymoma, a close relationship between standard uptake value, histology, and Masaoka stage has been advocated. This link between glucose uptake and prognosis suggests that PET translates biological tumor behavior into clinically detectable findings.

Conclusions

PET scan has a crucial role in thoracic oncology due to its impact on diagnosis, staging and prognosis. PET scan expresses the biological behavior of tumors, opening interesting perspectives in chest tumor management and improving detection and stage grouping in lung cancer. It anticipates the diagnosis in long-incubating diseases such as mesothelioma and increases biological knowledge of rare diseases, such as thymoma and other mediastinal tumors.

18F-fluorodeoxyglucose PET/CT findings in pleural effusions of patients with known cancer

Aim: Pleural effusion is common in cancer patients and to determine its malignant origin is of huge clinical significance. PET/CT with 18F-FDG is of diagnostic value in staging and follow-up, but its ability to differentiate between malignant and benign effusions is not precisely known. Patients, methods: We examined 50 PET/CT from 47 patients (29 men, 18 women, 60 ± 16 years) with pleural effusion and known cancer (24 NSCLC, 7 lymphomas, 5 breasts, 4 GIST, 3 mesotheliomas, 2 head and neck, 2 malignant teratoma, 1 colorectal, 1 oesophageal, 1 melanoma) for FDG uptake in the effusions using SUVmax. This was correlated to cytopathology performed after a median of 21 days (interquartile range –3 to 23), which included pH, relative distribution (macrophages, neutrophils, eosinophils, basophils, lymphocytes, plasmocytes), and absolute cell count. Results: Malignant cells were found in 17 effusions (34%) (6 NSCLC, 5 lymphomas, 2 breasts, 2 mesotheliomas, 2 malignant teratomas). SUV in malignant effusions were higher than in benign ones [3.7 (95%CI 1.8–5.6) vs. 1.7 g/ml (1.5–1.9), p = 0.001], with a correlation between malignant effuUntersion and SUV (Spearman coefficient ρ = 0.50, p = 0.001), but not with other cytopathological or radiological parameters (ROC area 0.83 ± 0.06). Using a 2.2-mg/l SUV threshold, 12 PET/CT studies were positive and 38 negative with sensitivity, specificity, positive and negative predictive values of 53%, 91%, 75% and 79%, respectively. For NSCLC only (n = 24), ROC area was 0.95 ± 0.04, 7 studies were positive and 17 negative with a sensitivity, specificity, positive and negative predictive values of 83%, 89%, 71 and 94%, respectively. Conclusion: PET/CT may help to differentiate the malignant or benign origin of a pleural effusion with a high specificity in patients with known cancer, in particular NSCLC.

Video assisted thoracoscopic and open chest surgery in diagnosis and treatment of malignant pleural diseases

Parenchymal cancers of lung, breast, gastrointestinal tract and ovaries as well as lymphomas and mesotheliomas are among the most common cancer types causing malignant effusions, though almost all tumour types have been reported to cause a malignant effusion. The prognosis heavily depends on patients' response to systemic therapy however, regardless of the causing pathology and histopathologic form, malignant pleural disease is normally associated with a poor prognosis. To date, there are not sufficient data to allow accurate predictions of survival that would facilitate decision making for managing patients with malignant pleural diseases. Interventions are directed towards drainage of the effusion and, when appropriate, concurrent or subsequent pleurodesis or establishing long-term drainage to prevent re-accumulation. The rate of re-accumulation of the pleural effusion, the patient's prognosis, and the severity of the patient's symptoms should guide the subsequent choice of therapy. In contemporary medicine, not many cancers have managed to generate as intense debates concerning treatment, as malignant pleural mesothelioma. The relative advantages of surgery, radiation, chemotherapy and any combination of the three are continuously reassessed and reconsidered, even though not always based on scientific evidence. The aim of surgery in mesothelioma may be prolongation of life, in addition to palliation of symptoms. Longer recovery periods from more extensive surgical procedures could be justified, in carefully selected patients. Surgical options include: Video assisted thoracoscopic (VATS) pleurodesis, VATS partial pleurectomy (VATS PP)-both parietal and visceral; open pleurectomy decortication (PD)-with an extended option (EPD) and extrapleural pneumonectomy (EPP). Current evidence implies that EPD can be performed reliably in specialised centres with good results, both in terms of mortality and survival; however, no operation has yet been shown to be beneficial in a prospective randomized controlled clinical trial.

Pleural Metastasis in Head and Neck Cancer: Imaging Findings and Clinical Impact

OBJECTIVE

The aim of this study was to present the imaging findings of pleural metastases from head and neck cancer and correlate them with prognosis for overall survival, which to our knowledge have not received much attention in radiology literature.

METHODS

We reviewed 23 cases of head and neck cancer with pleural metastases that were seen on head and neck imaging. Computed tomography (CT), magnetic resonance imaging, and positron emission tomography/CT imaging findings were reviewed. The location and cell type of the primary cancer were studied. The effect of the pleural metastases on patient survival was analyzed.

RESULTS

Twelve (57%) of the 21 cases of pleural metastasis were missed initially on the neck CT but were visible in retrospect. Nine of 11 patients whom we had followed up for 1.5 years or longer have died, often within a few of months of presenting with pleural metastases.

CONCLUSIONS

The presence of pleural metastasis in head and neck cancer is an extremely poor prognostic indicator for survival. They are potentially missed on the neck CT. Given its significant clinical impact, head and neck radiologists should specifically look for pleural metastasis when reviewing imaging studies of patients with head and neck cancer.

The Role of 18F-FDG PET/CT Integrated Imaging in Distinguishing Malignant from Benign Pleural Effusion

Objective

The aim of our study was to evaluate the role of ¹⁸F-FDG PET/CT integrated imaging in differentiating malignant from benign pleural effusion.

Methods

A total of 176 patients with pleural effusion who underwent ¹⁸F-FDG PET/CT examination to differentiate malignancy from benignancy were retrospectively researched. The images of CT imaging, ¹⁸F-FDG PET imaging and ¹⁸F-FDG PET/CT integrated imaging were visually analyzed. The suspected malignant effusion was characterized by the presence of nodular or irregular pleural thickening on CT imaging. Whereas on PET imaging, pleural ¹⁸F-FDG uptake higher than mediastinal activity was interpreted as malignant effusion. Images of ¹⁸F-FDG PET/CT integrated imaging were interpreted by combining the morphologic feature of pleura on CT imaging with the degree and form of pleural ¹⁸F-FDG uptake on PET imaging.

Results

One hundred and eight patients had malignant effusion, including 86 with pleural metastasis and 22 with pleural mesothelioma, whereas 68 patients had benign effusion. The sensitivities of CT imaging, ¹⁸F-FDG PET imaging and ¹⁸F-FDG PET/CT integrated imaging in detecting malignant effusion were 75.0%, 91.7% and 93.5%, respectively, which were 69.8%, 91.9% and 93.0% in distinguishing metastatic effusion. The sensitivity of ¹⁸F-FDG PET/CT integrated imaging in detecting malignant effusion was higher than that of CT imaging (p = 0.000). For metastatic effusion, ¹⁸F-FDG PET imaging had higher sensitivity (p = 0.000) and better diagnostic consistency with ¹⁸F-FDG PET/CT integrated imaging compared with CT imaging (Kappa = 0.917 and Kappa = 0.295, respectively). The specificities of CT imaging, ¹⁸F-FDG PET imaging and ¹⁸F-FDG PET/CT integrated imaging were 94.1%, 63.2% and 92.6% in detecting benign effusion. The specificities of CT imaging and ¹⁸F-FDG PET/CT integrated imaging were higher than that of ¹⁸F-FDG PET imaging (p = 0.000 and p = 0.000, respectively), and CT imaging had better diagnostic consistency with ¹⁸F-FDG PET/CT integrated imaging compared with ¹⁸F-FDG PET imaging (Kappa = 0.881 and Kappa = 0.240, respectively).

Conclusion

¹⁸F-FDG PET/CT integrated imaging is a more reliable modality in distinguishing malignant from benign pleural effusion than ¹⁸F-FDG PET imaging and CT imaging alone. For image interpretation of ¹⁸F-FDG PET/CT integrated imaging, the PET and CT portions play a major diagnostic role in identifying metastatic effusion and benign effusion, respectively.

Diagnostic Ability of FDG-PET/CT in the Detection of Malignant Pleural Effusion

We investigated the role of F-18 fluorodeoxyglucose (FDG)-positron emission tomography (PET)/computed tomography (CT) for the differential diagnosis of malignant and benign pleural effusion. We studied 36 consecutive patients with histologically proven cancer (excluding malignant mesothelioma) who underwent FDG-PET/CT for suspected malignant pleural effusion. Fourteen patients had cytologically proven malignant pleural effusion and the other 22 patients had either negative cytology or clinical follow-up, which confirmed the benign etiology. We examined the maximum standardized uptake values (SUV max) of pleural effusion and the target-to-normal tissue ratio (TNR), calculated as the ratio of the pleural effusion SUV max to the SUV mean of the normal tissues (liver, spleen, 12th thoracic vertebrae [Th12], thoracic aorta, and spinalis muscle). We also examined the size and density (in Hounsfield units) of the pleural effusion and pleural abnormalities on CT images. TNR (Th12) and increased pleural FDG uptake compared to background blood pool were significantly more frequent in cases with malignant pleural effusion (P < 0.05 for both). The cutoff TNR (Th12) value of >0.95 was the most accurate; the sensitivity, specificity, and accuracy for this value were 93%, 68%, and 75%, respectively. FDG-PET/CT can be a useful method for the differential diagnosis of malignant and benign pleural effusion.

Accuracy of fluorodeoxyglucose-PET imaging for differentiating benign from malignant pleural effusions: a meta-analysis

BACKGROUND

The role of fluorodeoxyglucose (FDG)-PET imaging for diagnosing malignant pleural effusions is not well defined. The aim of this study was to summarize the evidence for its use in ruling in or out the malignant origin of a pleural effusion or thickening.

METHODS

A meta-analysis was conducted of diagnostic accuracy studies published in the Cochrane Library, PubMed, and Embase (inception to June 2013) without language restrictions. Two investigators selected studies that had evaluated the performance of FDG-PET imaging in patients with pleural effusions or thickening, using pleural cytopathology or histopathology as the reference standard for malignancy. Subgroup analyses were conducted according to FDG-PET imaging interpretation (qualitative or semiquantitative), PET imaging equipment (PET vs integrated PET-CT imaging), and/or target population (known lung cancer or malignant pleural mesothelioma). Study quality was assessed using Quality Assessment of Diagnostic Accuracy Studies-2. We used a bivariate random-effects model for the analysis and pooling of diagnostic performance measures across studies.

RESULTS

Fourteen non-high risk of bias studies, comprising 407 patients with malignant and 232 with benign pleural conditions, met the inclusion criteria. Semiquantitative PET imaging readings had a significantly lower sensitivity for diagnosing malignant effusions than visual assessments (82% vs 91%; P = .026). The pooled test characteristics of integrated PET-CT imaging systems using semiquantitative interpretations for identifying malignant effusions were: sensitivity, 81%; specificity, 74%; positive likelihood ratio (LR), 3.22; negative LR, 0.26; and area under the curve, 0.838. Resultant data were heterogeneous, and spectrum bias should be considered when appraising FDG-PET imaging operating characteristics.

CONCLUSIONS

The moderate accuracy of PET-CT imaging using semiquantitative readings precludes its routine recommendation for discriminating malignant from benign pleural effusions.

Diagnostic accuracy of 18F-FDG-PET and PET/CT in the differential diagnosis between malignant and benign pleural lesions: a systematic review and meta-analysis

RATIONALE AND OBJECTIVES

To systematically review and meta-analyze published data about the diagnostic accuracy of fluorine-18-fluorodeoxyglucose ((18)F-FDG) positron emission tomography (PET) and PET/computed tomography (CT) in the differential diagnosis between malignant and benign pleural lesions.

METHODS AND MATERIALS

A comprehensive literature search of studies published through June 2013 regarding the diagnostic performance of (18)F-FDG-PET and PET/CT in the differential diagnosis of pleural lesions was carried out. All retrieved studies were reviewed and qualitatively analyzed. Pooled sensitivity, specificity, positive and negative likelihood ratio (LR+ and LR-) and diagnostic odds ratio (DOR) of (18)F-FDG-PET or PET/CT in the differential diagnosis of pleural lesions on a per-patient-based analysis were calculated. The area under the summary receiver operating characteristic curve (AUC) was calculated to measure the accuracy of these methods. Subanalyses considering device used (PET or PET/CT) were performed.

RESULTS

Sixteen studies including 745 patients were included in the systematic review. The meta-analysis of 11 selected studies provided the following results: sensitivity 95% (95% confidence interval [95%CI]: 92-97%), specificity 82% (95%CI: 76-88%), LR+ 5.3 (95%CI: 2.4-11.8), LR- 0.09 (95%CI: 0.05-0.14), DOR 74 (95%CI: 34-161). The AUC was 0.95. No significant improvement of the diagnostic accuracy considering PET/CT studies only was found.

CONCLUSIONS

(18)F-FDG-PET and PET/CT demonstrated to be accurate diagnostic imaging methods in the differential diagnosis between malignant and benign pleural lesions; nevertheless, possible sources of false-negative and false-positive results should be kept in mind.

Diagnostic imaging in the preoperative management of lung cancer

Surgical resection is the accepted standard of care for patients with non-small cell lung cancer (NSCLC). Several imaging modalities play central roles in the detection and staging of the disease. The aim of this review is to evaluate the utility of computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET) and PET/CT for NSCLC staging. Radiographic staging refers to the use of CT as a non-invasive diagnostic technique. However, while the vast majority of patients undergo only CT, CT is a notoriously inaccurate means of tumor and nodal staging in many situations. PET/CT clearly improves the staging, particularly nodal staging, compared to CT or PET alone. In addition, as a result of the increased soft-tissue contrast, MRI is superior to CT for distinguishing between tissue characteristics. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), which is a minimally invasive technique, also has pathological diagnostic potential. Extensive research and the resultant improvements in the understanding of genetics, histology, molecular biology and oncology are transforming our understanding of lung cancer, and it is clear that imaging modalities such as CT, MRI, PET and PET/CT will have an important role in its preoperative management. However, thoracic surgeons should also be aware of the limitations of these techniques.

Treatment of complicated pleural effusions in 2013

The incidence of pleural infection seems to be increasing worldwide. Despite continued advances in the management of this condition, morbidity and mortality have essentially remained static over the past decade. This article summarizes the current evidence and opinions on the epidemiology, etiology, and management of complicated pleural effusions caused by infection, including empyema. Although many parallels may be drawn between children and adults in such cases, most trials, guidelines, and series regard pediatric patient groups and those more than 18 years of age as separate entities. This review focuses mainly on the treatment of adult disease.

Predictive value of F-18 FDG PET/CT for malignant pleural effusion in non-small cell lung cancer patients

BACKGROUND

The purpose of this study was to evaluate the accuracy of F-18 fluorodeoxyglucose positron emission tomography/computed tomography (F-18 FDG PET/CT) imaging in the detection of malignant pleural effusion and pleural metastasis in patients with non-small cell lung cancer (NSCLC).

MATERIALS AND METHODS

We analyzed F-18 FDG PET/CT images of 33 lung cancer patients with pleural effusion. We used 2 categorical parameters to differentiate malignant from benign pleural effusion: i) quantitative parameters using maximum standardized uptake value (SUVmax of effusion and pleura, and the following ratios: lesion to aorta (L/Ao), to cerebellum (L/Cbl), to liver (L/Liv), to nonlesion (L/NL), and to primary lung cancer (L/Prim)) and ii) various parameters determined by PET and CT scans (uptake at the pleural region, Hounsfield unit, size, and morphology of any solid abnormality).

RESULTS

Malignant pleural effusions showed significantly higher L/Prim values than benign pleural effusions. The presence of pleural abnormality on CT and pleural region uptake on PET images were found to be significantly more frequent in cases of malignant pleural disease. These parameters could differentiate malignant and benign pleural effusion according to receiver operating characteristic (ROC) analyses. There were no statistical differences between L/Prim, pleural abnormality on CT, and pleural region uptake on PET images. Abnormal pleural region uptake on PET images was the most accurate parameter identifying malignant pleural effusion by logistic regression analysis.

CONCLUSIONS

Our results suggest that F-18 FDG PET/CT can be used as a reliable and noninvasive method for the differentiation of malignant and benign pleural disease in patients with NSCLC.

Diagnosis and treatment of malignant pleural effusion: a systematic literature review and new approaches

Malignant pleural effusion is a frequent complication in many types of tumors, and its presence indicates short expected survival. This review updates the current knowledge about diagnosis and management of malignant pleural effusion. In recent years, progress has been made in diagnosis through the use of new pathologic and radiologic approaches, such as the introduction of positron emission tomography-computed tomography, immunohistochemical marker combinations, and genetic studies to identify malignant cells. Treatment is always palliative. New promising drugs have been tested, but, awaiting randomized studies, talc pleurodesis is still the treatment of choice, although doubts remain about its safety. A long-term indwelling pleural catheter could be a valid alternative to talc pleurodesis in selected patients with trapped lung syndrome (a lung that fails to reexpand after drainage of pleural effusion) and short life expectancy. However, the correct treatment depends on several factors such as performance status, expected survival, presence of lung reexpansion following pleural drainage and comorbidities.

[What is the role of FDG-PET in thoracic oncology in 2010?]

18F-Fluorodeoxyglucose-Positron Emission Tomography (FGD-PET) has been considered to have a major impact on the management of lung malignancies since the beginning of this century. Its value has been demonstrated by many publications, meta-analysis and European/American/Japanese recommendations. PET combined with computed tomography has provided useful information regarding the diagnosis and staging of lung cancer and allows for the delivery of adaptive radiotherapy. In its more common uses, PET has been shown to be cost-effective. With the widespread use of new radiotracers, PET will play an increasing role in the evaluation of response to treatment.

Contribution of positron emission tomography in pleural disease

INTRODUCTION

Positron emission tomography (PET) now plays a clear role in oncology, especially in chest tumours. We discuss the value of metabolic imaging in characterising pleural pathology in the light of our own experience and review the literature.

BACKGROUND

PET is particularly useful in characterising malignant pleural pathologies and is a factor of prognosis in mesothelioma. Metabolic imaging also provides clinical information for staging lung cancer, in researching the primary tumour in metastatic pleurisy and in monitoring chronic or recurrent pleural pathologies.

CONCLUSIONS

PET should therefore be considered as a useful tool in the diagnosis of liquid or solid pleural pathologies.

Thoracic complications and emergencies in oncologic patients

Oncology patients often experience urgent or emergent medical complications that are a direct or indirect result of the underlying malignant condition and are first identified or clarified on radiologic imaging studies. The aim of this review is to identify, discuss, and illustrate some of the major thoracic complications in patients with primary intrathoracic or extrathoracic neoplasms; particular focus is placed on issues in which radiologic imaging may have a significant impact on patient management, including superior vena cava (SVC) syndrome, post-obstructive pneumonia, diaphragmatic paralysis, pleural effusions, pericardial disease, tracheo-esophageal fistula, deep venous thrombosis, and pulmonary embolism.

The utility of multi-detector computed tomography in the diagnosis of malignant pleural effusion in the patients with ovarian cancer

PURPOSE

The purpose of this study was to retrospectively assess possible clinical predictors of malignant pleural effusion in patients with ovarian cancer.

MATERIALS AND METHODS

This review was performed on 38 ovarian cancer patients that showed pleural effusion in a CT scan and who underwent thoracocentesis before treatment. CT scans were obtained using a 4-channel multi-detector CT scanner. Fisher's exact test was used to determine the probability of malignant pleural effusion as a function of; amount of ascites, lymph node enlargement, amount of pleural effusion, pleural nodules, and pleural thickening.

RESULTS

Sixteen (42.1%) of the 38 patients had malignant pleural effusion and malignant pleural effusion amounts were greater than those with nonmalignant effusion. Pleural nodules were more frequently found in the malignant pleural effusion group (eight [50%] patients) than in the nonmalignant group (zero [0%] patient) (p<0.001). Supradiaphragmatic lymph node enlargement (with short axis diameter 1cm or more) was more frequent in malignant group (12 [75%] patients) than in the nonmalignant group (two [9.1%] patients) (p<0.001).

CONCLUSION

The probability of malignant pleural effusion in patients with ovarian cancer was found to be correlated with the amount of pleural effusion, the presence of pleural nodules, and supradiaphragmatic lymph node enlargement.

Diagnosis and management of malignant pleural effusions

Malignant pleural effusions (MPEs) complicate the clinical course of patients with a broad array of malignancies, which are most often due to lymphomas or carcinomas of the breast, lung, gastrointestinal tract or ovaries. Patients may present with a MPE as the initial manifestation of a cancer or develop an effusion during the advanced phases of a known malignancy. In either circumstance, the median survival after presentation with a MPE is 4 months. Effusions may result from direct pleural invasion (MPE) or indirect effects (paraneoplastic effusions), such as impairment of fluid efflux from the pleural space by lymphatic obstruction or pleural effects of cancer radiation or drug therapy. Because only 50% of patients with cancer who develop a pleural effusion during their clinical course have a MPE, careful evaluation of the effusion to establish its aetiology is required to direct therapy. Management is palliative with interventions directed towards decreasing the volume of intrapleural fluid and the severity of associated symptoms.

Recent advances in the diagnosis and management of malignant pleural effusions

Malignant pleural effusions (MPEs) are an important complication for patients with intrathoracic and extrathoracic malignancies. Median survival after diagnosis of an MPE is 4 months. Patients can present with an MPE as a complication of far-advanced cancer or as the initial manifestation of an underlying malignancy. Common cancer types causing MPEs include lymphomas, mesotheliomas, and carcinomas of the breast, lung, gastrointestinal tract, and ovaries. However, almost all tumor types have been reported to cause MPEs. New imaging modalities assist the evaluation of patients with a suspected MPE; however, positive cytologic or tissue confirmation of malignant cells is necessary to establish a diagnosis. Even in the presence of known malignancy, up to 50% of pleural effusions are benign, underscoring the importance of a firm diagnosis to guide therapy. Rapidly evolving interventional and histopathologic techniques have improved the diagnostic yield of standard cytology and biopsy. Management of an MPE remains palliative; it is critical that the appropriate management approach is chosen on the basis of available expertise and the patient's clinical status. This review summarizes the pathogenesis, diagnosis, and management of MPE. Studies in the English language were identified by searching the MEDLINE database (1980-2007) using the search terms pleura, pleural, malignant, pleurodesis, and thoracoscopy.

Staging non-small cell lung cancer

Patients with newly diagnosed non-small cell lung cancer (NSCLC) need accurate tumor staging in order to direct appropriate therapy and establish prognosis; the tumor is usually staged using the TNM system. The major imaging modalities currently used for staging this disease are thoracic computed tomography (CT) (including the adrenal glands) and whole body fluorodeoxyglucose (FDG)-positron emission tomography (PET) scanning. CT is generally most useful in evaluating the T stage, i.e. local spread of the neoplasm, whereas PET is most helpful in assessing the N and M stages, i.e. regional and distant tumor spread, respectively. Integrated CT-PET imaging adds information compared to the use of either modality alone. PET findings frequently lead to upstaging the disease and thus prevent unindicated surgeries. Magnetic resonance imaging (MRI) is helpful in evaluating local extent of disease in patients with superior sulcus tumors and possible brachial plexus involvement. Staging accuracy using any of these imaging techniques is imperfect; therefore, pathologic confirmation of positive findings is recommended, whenever possible, before denying a patient potentially curative therapy.

Fluorine-18 Fluorodeoxyglucose PET/CT Patterns of Extranodal Involvement in Patients with Non-Hodgkin Lymphoma and Hodgkin's Disease

Lymphoma may originate in extranodal sites. Extranodal lymphoma may also be secondary to and accompany nodal disease. Fluorine-18 fluorodeoxyglucose (18F-FDG) imaging has an essential role in the staging of lymphoma, in monitoring the response to therapy, and in detection of recurrence. The introduction of 18F-FDG PET/CT hybrid imaging allows for accurate localization of disease and may be specifically beneficial for the detection of unexpected extranodal sites of disease or exclusion of disease in the presence of nonspecific extranodal CT findings. Accurate staging and localization often dictate the appropriate treatment strategy in patients with lymphoma. Therefore, at any stage in the course of the disease, the potential presence of extranodal disease should be considered when interpreting 18F-FDG PET/CT studies in patients with non-Hodgkin lymphoma and Hodgkin's disease.

A prospective study of PET/CT in initial staging of small-cell lung cancer: comparison with CT, bone scintigraphy and bone marrow analysis

BACKGROUND

Small-cell lung cancer (SCLC) accounts for 15%-20% of all lung cancer cases. Accurate and fast staging is mandatory when choosing treatment, but current staging procedures are time consuming and lack sensitivity.

PATIENTS AND METHODS

A prospective study was designed to examine the role of combined positron emission tomography/computed tomography (PET/CT) compared with standard staging (CT, bone scintigraphy and immunocytochemical assessment of bone marrow biopsy) of patients with SCLC. Thirty-four consecutive patients were included. Twenty-nine patients received initial PET/CT.

RESULTS

PET/CT caused change of stage in 5/29 (17%). Excluding patients with unconfirmed findings or pleural effusion, the sensitivity for accurate staging of patients with extensive disease was the following: for standard staging 79%, PET 93% and PET/CT 93%. Specificity was 100%, 83% and 100%, respectively.

CONCLUSION

The results from this first study on PET/CT in SCLC indicates that PET/CT can simplify and perhaps even improve the accuracy of the current staging procedure in SCLC. A larger clinical trial, preferably with consequent histological confirmation in case of discordance, however, is warranted.

[Other malignant tumors of the pleura]

Malignant tumors of the pleura are most often diffuse, nethertheless they are sometimes localized. There is an overlap of the radiologic features of the benign and malignant pleural lesions. The differential diagnosis may be difficult, even on histological sample. Imaging allows the diagnosis of pleural involvement, suggests the malignity, guides percutaneous or thoracoscopic biopsies of the pleura, defines extent of the tumor and follows the course of the disease. We will describe the malignant pleural tumors: pleural metastases, pleural involvement of broncho-pulmonary cancer, of lymphoma and leukaemia. Then the rare pleural tumors will be described: malignant pleural fibroma, sarcoma, histiocytoma and hemangiopericytoma.

[18-Fluoro-deoxy-glucose (15FDG) positon emission tomography (PET) for the evaluation of malignant pleural disease]

Use of 18FDG-PET for malignant tumors of the pleura raises certain technical difficulties because of the small size of the tumors and their diffuse distribution, but hybrid PET/CT machines offer a better localization of FDG uptake. FDG-PET can discriminate between malignant and benign pleural tumors FDG uptake in the pleura is the best diagnostic criteria of malignancy. The presence of FDG uptake in pleural effusion is less discriminate between benign and malignant disease. For mesotheliomas, FDG-PET can difference malignant tumors from benign tumors of the pleura on the basis of the SUV value (<or > 2). It does not enable detection of mediastinal node involvement and regional extension but is effective in detecting extra-thoracic regional spread not identified with other imaging methods. FDG-PET can thus affect the therapeutic strategy. The intensity of uptake has prognostic value. SUV<4 associated with an epithelial tumor is a sign of good prognosis at three years. SUV > 4 associated with a non-epithelial tumor is a sign of poor prognosis. For mesotheliomas, FDG uptake can be used to assess the effect of chemotherapy and determine whether patients are good responders or not.