Ann Thorac Surg 2008;86:1355-1357. doi:10.1016/j.athoracsur.2008.03.072
© 2008 The Society of Thoracic Surgeons
Case Reports
A Novel Approach to Positron Emission Tomography in Lung Cancer
Susan D. Moffatt-Bruce, MD, PhDa,*,
Stephen P. Povoski, MDb,
Suhail Sharif, MDb,
Nathan C. Hall, MD, PhDc,
Patrick Ross, Jr, MD, PhDa,
Morgan A. Johnsonb,
Edward W. Martin, Jr, MDb
a Division of Cardiothoracic Surgery, The Ohio State University, Columbus, Ohio
b Division of Surgical Oncology, Department of Surgery, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute and Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio
c Division of Nuclear Medicine, Department of Radiology, The Ohio State University, Columbus, Ohio
Accepted for publication March 14, 2008.
* Address correspondence to Dr Moffatt-Bruce, Division of Cardiothoracic Surgery, The Ohio State University, N839 Doan Hall, 410 West 10th Ave, Columbus, OH 43210 (Email: susan.moffatt-bruce{at}osumc.edu).
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Abstract
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18F-fluorodeoxyglucose positron emission tomography–computed tomography is integral to the staging of lung cancer. We describe the combined use of diagnostic preoperative 18F-fluorodeoxyglucose positron emission tomography–computed tomography, intraoperative 18F-fluorodeoxyglucose handheld gamma probe detection, and immediate postoperative 18F-fluorodeoxyglucose positron emission tomography–computed tomography patient and specimen imaging for improved staging and determination of adequacy of mediastinal lymph node dissection.
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Introduction
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Non-small cell lung cancer remains one of the most common causes of cancer deaths [1]. An accurate method of determining disease stage and adequacy of resection with minimal patient morbidity is necessary and is lacking to date [1, 2]. The approach of (1) preoperative 18F-fluorodeoxyglucose positron emission tomography–computed tomographic (18F-FDG PET–CT) imaging, (2) intraoperative 18F-fluorodeoxyglucose (18F-FDG) handheld gamma probe detection, and (3) postoperative patient and specimen 18F-FDG PET–CT imaging is described herein with the potential to accurately assess mediastinal lymph node involvement, direct the operative procedure, and allow immediate postoperative assessment of the surgical resection.
An 81-year-old man presented with a lung mass that was hypermetabolic on an 18F-FDG PET–CT scan (Siemens Biograph, Knoxville, TN) with a standardized uptake value of 13.6. The patient also had a thyroid nodule with a standardized uptake value of 18.2, which was biopsied and found to be benign. The patient was offered surgical resection based on stage IB disease. On the day of surgery, after having obtained informed consent, 26.11 mCi of 18F-FDG was intravenously injected 38 minutes prior to the start of surgery. The patient underwent a right thoracotomy. Sixty minutes from the time of incision, allowing sufficient time to reduce the blood pool of 18F-FDG, the handheld gamma probe detector (Neoprobe neo2000 unit [Neoprobe Corporation, Dublin, Ohio]) was used in the chest to evaluate the primary tumor and mediastinum. The primary tumor had a maximum sustainable count (counts per second) of 1,616 compared with the normal lung with a count of 989. Complete evaluation of the remaining lung parenchyma did not detect other elevated count readings. The mediastinum was evaluated with the handheld gamma probe detector with lymph node station 4 having 1,294 counts, station 7 having 1,255 counts, and station 9 having 1,220 counts. A right upper lobectomy was performed with a mediastinal lymph node dissection including stations 4R, 9R, and 7. Postoperatively, the specimen was evaluated with the handheld gamma probe detector; the tumor specimen had 228 counts, the unaffected lung parenchyma had 34 counts, and the excised mediastinal lymph nodes had 84 counts. The specimen underwent 18F-FDG PET–CT imaging prior to being sent to pathology, approximately 4.5 hours after the initial administration of 18F-FDG (Figs 1A,
1B). At the completion of the surgical procedure, the patient was extubated, taken to the recovery room, and underwent a repeat 18F-FDG PET–CT scan 6 hours after the initial 18F-FDG dose (Figs 1C, 1D). Postoperative imaging did not reveal any clinically significant hypermetabolic areas, although there was 18F-FDG pooling where the lymph node dissection had occurred. Ongoing studies to determine the best timing of the postoperative imaging so as to minimize confounding operative changes are underway. The patient tolerated the additional intraoperative and postoperative procedures. The final pathology revealed a 5.0 x 4.0 x 3.5 cm moderately differentiated adenosquamous lung cancer with all nodal stations negative for metastatic disease. Therefore, the pathology suggested that counts detected in the uninvolved lung parenchyma and lymph nodes reflected background activity. Studies are underway to determine the cut-off value of detectable counts that are clinically relevant.
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Fig 1. The right upper lobectomy specimen (A) underwent postoperative specimen 18F-fluorodeoxyglucose positron emission tomography-computed tomographic (18F-FDG PET/CT) scanning 4.5 hours after the initial 18F-FDG dose (B). The preoperative 18F-FDG positive lesion (C) was successfully resected, as determined by repeat 18F-FDG PET/CT scan (D). The 18F-FDG positive thyroid nodule seen in (C) and (D) was biopsied preoperatively and found to be benign.
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Comment
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Lung cancer is the leading cause of cancer deaths in the Western hemisphere [1]. A critical determinant of survival and therapy is the extent of disease including mediastinal lymph node status [1, 2]. Preoperatively, lung cancer patients are generally imaged with a thoracic and upper abdomen 18F-FDG PET–CT scan. Often mediastinal nodes found on 18F-FDG PET–CT scans are not accessible by cervical mediastinoscopy, or they are only mildly hypermetabolic and therefore indeterminate. No study to date reliably stages lymph nodes, and a complete mediastinal lymphadenectomy is not without morbidity. A method whereby mediastinal lymph nodes could be assessed both preoperatively and intraoperatively would improve our ability to best treat and minimize morbidity for our patients.
Preoperative and postoperative 18F-FDG PET–CT patient and specimen imaging combined with intraoperative 18F-FDG gamma probe detection is a novel way to ensure adequate staging and resection of lung cancer patients. Although a variety of radiopharmaceuticals have been developed for PET imaging of cancer, only 18F-FDG has been approved for human use by the United States Food and Drug Administration. The physical properties of 18F-FDG make this molecule useful for intraoperative and perioperative imaging because it becomes trapped after phosphorylation within cells metabolizing glucose, and it emits 511 keV photons that can be detected with gamma probes and imaging devices [3]. In addition, 18F-FDG accumulation in tumor tissue is based on high cellular uptake, glycolytic rate, and subsequent trapping, thereby making it a reasonable tumor imaging tracer.
Diagnostic preoperative 18F-FDG PET–CT imaging in combination with intraoperative 18F-FDG gamma probe detection has been widely used for detection of tumor burden and recurrences in patients with colorectal carcinoma [4–6]. Other groups have used this technology to differentiate normal from melanoma-bearing tissue [7]. The feasibility of intraoperative gamma probe detection combined with diagnostic perioperative 18F-FDG PET–CT scanning has been limitedly evaluated in cases of lymphoma, head and neck cancer, thyroid cancer, and breast cancer [3, 8]. To date, perioperative imaging and intraoperative procedures have been well-tolerated by patients and operating room staff [3, 5].
The prevalence of lung cancer combined with a 5-year survival of only 15% mandates that we find innovative ways to improve staging and treatment of lung cancer. The combined use of preoperative and postoperative 18F-FDG PET–CT imaging with intraoperative 18F-FDG gamma probe detection for tumor and lymph node assessment is a novel way to advance our current treatment regimens for lung cancer.
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References
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Abstract
Introduction
