Does positron emission tomography offer ... - Semantic Scholar

ARTICLE IN PRESS doi:10.1510/icvts.2010.255901

Interactive CardioVascular and Thoracic Surgery 12 (2011) 806–811 www.icvts.org

Best evidence topic - Thoracic oncologic

Does positron emission tomography offer prognostic information in malignant pleural mesothelioma? Sumera Sharifa, Imran Zahida, Tom Routledgeb, Marco Scarcib,* Imperial College London, South Kensington Campus, London SW7 2AZ, UK b Department of Thoracic Surgery, Guy’s Hospital, London SE1 9RT, UK

a

Received 14 September 2010; received in revised form 17 December 2010; accepted 4 January 2011

Summary A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether positron emission tomography is useful in the diagnosis and prognosis of malignant pleural mesothelioma (MPM). Altogether 136 papers were found using the reported search, of which 15 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that fluorodeoxyglucose-positron emission tomography (FDG-PET) accurately differentiates benign from malignant pleural disease, helps detect recurrence and provides prognostic information in terms of staging, survival and mortality. Eleven studies evaluated the role of FDG-PET in the diagnosis and prognosis of MPM. Malignant disease had a higher standardised uptake value (SUV) (6.5"3.4 vs. 0.8"0.6; P-0.001) than benign pleural disease. Shorter median survival (9.7 vs. 21 months; Ps0.02) was associated with high SUV ()10) than low SUV (-10). PET accurately upstaged 13% and downstaged 27% of cases initially staged with computed tomography (CT). In patients undergoing chemotherapy, higher total glycolytic volume led to a lower median survival (4.9 vs. 11.5 months; Ps0.09), while a decline in FDG uptake was associated with a longer time to tumour progression (14 vs. 7 months; Ps0.02). Four studies observed the role of FDG-PET-CT in the diagnosis and prognosis of MPM. SUV was found to be higher in MPM compared to benign pleural disease (6.5 vs. 0.8; P-0.001). A higher SUVmax was observed in primary pleural lesions of metastatic (7.1 vs. 4.7; Ps0.003) compared to non-metastatic disease. Patients who underwent surgery had equivalent survival to those excluded based on scan results (20 vs. 12 months; Ps0.3813). One study compared the utility of PET and PET-CT in the diagnosis and prognosis of mesothelioma. PET-CT was found to be more accurate than PET in terms of staging (P-0.05) disease. Overall, PET accurately diagnoses MPM, predicts survival and disease recurrence. It can guide further management by predicting the response to chemotherapy and excluding surgery in patients with extrathoracic disease. Combined PET-CT has additional benefits in accurately staging disease. 䊚 2011 Published by European Association for Cardio-Thoracic Surgery. All rights reserved. Keywords: Malignant mesothelioma; Positron emission tomography; Diagnosis; Prognosis

1. Introduction A best evidence topic was constructed according to a structured protocol. This is fully described in ICVTS w1x.

additional diagnostic or prognostic information. You are unsure about the extent to which PET may have a role and resolve to check the literature yourself.

2. Three-part question

4. Search strategy

In wpatients with malignant pleural mesotheliomax is wpositron emission tomographyx superior to wcomputed tomography or magnetic resonance imagingx in terms of wdiagnostic, staging and prognostic data providedx.

Medline search 1950 to August 2010 was performed using OVIDSP interface. (exp MesotheliomayOR mesothelioma.mp) AND (exp Positron-Emission TomographyyOR positron emission tomography.mp. or PET.mp)

3. Clinical scenario You are at a multidisciplinary meeting and review a 55year-old male with a confirmed histological diagnosis of malignant pleural mesothelioma (MPM). You are asked whether positron emission tomography (PET) would provide *Corresponding author. Tel.: q44-75-15542899; fax: q44-20-71881016. E-mail address: [email protected] (M. Scarci). 䊚 2011 Published by European Association for Cardio-Thoracic Surgery

5. Search outcome One hundred and thirty-six papers were found using the reported search. From these, 15 papers provided the best evidence to answer the question. These are presented in Table 1. In addition, the reference list of each paper was searched.

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Table 1. Best evidence papers Author, date and country, Study type (level of evidence)

Patient group

Outcomes

Key results

Comments

Mavi et al., (2009), Mol Imaging Biol, USA, w2x

Single-centre experience, over seven years using 18F-FDG-PET (ns55)

SUVmax1 (%, 60 min post-FDG injection)

Group A: 5.0"2.2 Group B: 4.6"1.7 Group C: 1.6"0.4

Group A: Primary MPM (ns28)

SUVmax2 (%, 90 min post-FDG injection)

Group A: 5.8"2.8 Group B: 5.3"2.0 Group C: 1.4"0.3

Group B: Recurrent MPM (ns16)

DSUVmax (%)

Group A: 12.8"8.4 Group B: 13.8"9.2 Group C: –9.6"19.1

18F-FDG-PET uptake increases with time in MPM and decreases with time in benign pleural disease. Dualtime point imaging is therefore effective in differentiating benign from malignant pleural disease

Cohort study (level 2b)

Group C: Benign pleural disease (ns11)

Yamamoto et al., (2009), Nucl Med Commun, Japan, w3x

Single-centre experience using 18F-FDG-PET (ns33)


MPM (ns17) Benign pleural disease (ns16)


Mean SUVdelayed vs. SUVearly

MPM: 9.39"7.70 vs. 7.72"6.08 (P-0.001) Benign pleural disease: 3.27"3.26 vs. 2.92"2.45 (PsNS) MPM)benign pleural disease (P-0.01)

Detecting MPM on PET

Sensitivity, specificity and overall accuracy: 88%

Single-centre experience over five years using FDG-PET (ns63)

FDG uptake in primary tumour

Group A: ns59 one false-negative: stage 1a

Group A: PET prior surgery (ns60)

Median survival (months)

SUV-4 vs. SUV)4 24 vs. 14 (P-0.04)

Group B: PET postsurgery (ns3)

Hazard ratio (HR) for death

SUV)4 HRs3.3 (Ps0.03)

SUV

N0–N1: 5.3"2.1 N2: 8.6"3.4

Area under ROC (AUC) curve of SUV

N2: 78"10%

SUVmax calculation and its change over time were higher in MPM patients

18F-FDG uptake increased in all MPM cases over time There was no significant difference in benign pleural disease

PET is useful in predicting survival and mediastinal nodal metastases in patients with MPM AUC of 78% is useful in predicting mediastinal nodal disease. Patients with a higher SUV in the primary tumour are more likely to have mediastinal nodal metastases PET correctly identified six patients who had unresectable tumour because of extrathoracic disease

Flores et al., (2006), J Thorac Cardiovasc Surg, USA, w5x Cohort study (level 2b)

Single-centre experience over seven years using 18F-FDG-PET (ns137)


High SUV ()10) vs. low SUV (-10) 9.7 vs. 21 (Ps0.02)

Risk of death

High SUV ()10) HR: 1.9 (P-0.01) SUV HR: 1.05 (P-0.01)

There is a near linear correlation of increasing SUV with poor survival. SUV)10 is a risk factor for MPM High SUV has a 1.9 times greater risk of death than low SUV (-10) Each unit increase in SUV increases the risk of death by 5%

(Continued on next page)

Best Evidence Topic

Mean SUV SUVearly s PET 60 min post-18F-FDG injection SUVdelayed s PET 120 min post-18F-FDG injection

Flores, (2005), Lung Cancer, USA, w4x

Group AqB) Group C (P-0.0001) Group A vs. Group B (P)0.05)

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Table 1 (Continued) Author, date and country, Study type (level of evidence)

Patient group

Outcomes

Key results

Comments

Bernard et al., (1999), J Nucl Med, USA, w6x

Single-centre experience over two years of patients with MPM (ns22)

Mean SUV

Deceased vs. survivors 6.6"2.9 vs. 3.2"1.6


FDG-PET scan: seven patients died 5.3 months after scan

SUV correlating with duration of survival

High SUV ()4.03) vs. low SUV (F4.03)

Cumulative survival at 12 months

17% vs. 86% (P-0.01)

High FDG uptake indicates shorter patient survival. Patients with lower SUVs tended to be at a lower stage and the extent of primary tumour involvement (T stage) also tended to be lower

Survival

PET volume (Ps0.008) SUVmax (Ps0.055)

PET volume was a significant predictor of survival. SUVmax trended towards significance only

Metabolic response

Responders vs. non-responders 40 vs. 60%

Median time to tumour progression

14 vs. 7 months (Ps0.02)

Early metabolic evaluation showed a good correlation between the decline in FDG uptake and the outcome of patients

Survival

Responders ) non-responders (Ps0.07) 87.5% alive at 15.1 months

No correlation was found between time to tumour progression and radiological response evaluated by CT

Median TGV on PET

Patients with PR: 30% of baseline value (range: 11–71%) Patients with SD: 71% of baseline value (range: 8–113%)

Fall in TGV was associated with improved patient survival unlike a fall in SUVmax

% Change in TGV compared with CT

69 (P-0.001)

Fall in TGV predictive of improved survival

Ps0.015

Magnitude of TGV% change and survival

Ps0.0036

TGV-60% superior to smaller change

HR: 0.22; Ps0.03

HR for 10% change in TGV post-chemo

0.64


Increased TGV vs. decreased TGV 4.9 vs. 11.5 (Ps0.09)

Fall in SUVmax and improved survival

Ps0.097

Nowak et al., (2010), Clin Cancer Res, Australia, w7x

Single-centre experience over three years using FDG-PET (ns93)


All patients had known MPM

Ceresoli et al., (2006), J Clin Oncol, Italy, w8x

Single-centre experience over one-year ns20 MPM patients undergoing permetrexed chemotherapy

Prospective cohort study (level 2b)

Metabolic response (MR): decrease of 25%y) in tumour FDG uptake as measured by SUV

Francis et al., (2007), J Nucl Med, Australia, w9x

Single-centre experience over two years MPM patients (ns23)


Patients underwent 18F-FDG-PET before and after one cycle of chemotherapy CT response: Partial response (PR) ns7 Stable disease (SD) ns13 Not measurable (NM) ns3 TGV: Increase ns4 Decrease ns18 Not evaluable ns1

Nanni et al., (2004), Cancer Biother Radiopharm, Italy, w10x

Single-centre experience over six months MPM patients (ns15)

PET stage corresponded to CT stage

60%


Staging (ns5) Post-therapy (ns10)

Upstaged by PET

13%

Downstaged by PET

27%

Change in management

20%

FDG-PET following CT

Semiquantitive 18F-FDG-PET using TGV may predict response to chemotherapy and patient survival after one cycle of treatment A 10% reduction in TGV after chemotherapy was associated with a 36% reduction in the risk of death

PET enabled accurate staging of MPM, altering management of three cases which included the exclusion of surgery in one case and alteration of chemotherapy in two



809

Table 1 (Continued) Author, date and country, Study type (level of evidence)

Patient group

Outcomes

Key results

Comments

Yan et al., (2009), Ann Thorac Surg, Australia, w11x

Single-centre experience over 23 years (ns456) FDG-PET

18-month survival

Preoperative PET vs. no preoperative PET 45 vs. 26% (P-0.012)


Preoperative PET (ns42) No preoperative PET (ns414)

Preoperative PET was strongly associated with 18-month survival in patients with MPM PET was used to exclude extrathoracic spread of disease

EPP (ns59) PyD (ns250) Pleurodesisybiopsy (ns147) Wilcox et al., (2009), Clin Lung Cancer, USA, w12x

Single-centre experience over six years using CT-PET (ns35)


Group A: EPP (ns8)

Upstaged following CT-PET

ns13

Survival (months)

Group A vs. Group B 20 vs. 12 (Ps0.3813)

Mortality rate

Group A: 80%, median follow-up 14 months

Group B: Excluded from surgery based on CT-PET results (ns14)

Integrated CT-PET is excellent for detecting nodal and distant metastases allowing accurate staging of patients with MPM to prevent futile attempts at resection

Group B: 79%, median follow-up four months

Group C: Parietal pleurectomy (ns2) Group D: Excluded from surgery based on functional statusypatient preference (ns11) Yildirim et al., (2009), J Thorac Oncol, Turkey, w13x

Single-centre experience over two years using 18F-FDG-PET-CT (ns31)

MPM: 15 Benign asbestos-related pleural effusion (BAPE) and diffuse pleural thickening (DPE): 13 Sensitivity: 88.2% Specificity: 92.9% Overall accuracy: 90.3% 90.3%

Observational pilot study (level 2b)

Malignant disease: MPM (ns17)

DPE (ns5)

Mean SUVmax

MPM vs. benign disease 6.5"3.4 vs. 0.8"0.6 (P-0.001)

Single-centre experience over three years diagnosed MPM using 18F-FDGPET-CT (ns46)

Detection of metastases

Nine patients (eight previously undetected)

Mean SUVmax of primary pleural lesions

Metastases vs. no metastases: 7.1 vs. 4.7 (Ps0.003)

Survival (months)

4 vs. 8 (P-0.05)

Single-centre experience over four years (ns25) 18F-FDG-PET-CT post-multimodality therapy for MPM

Mean SUVmax of recurrent disease

8.9"4.0

Detection of recurrence:

ns17 (sensitivity 94%)

Recurrence ns18 No recurrence ns7

Identification of no recurrence

ns7 (specificity 100%)

Single-centre study experience of epithelial MPM diagnosed using PETyPET-CT (ns54)

PET: Accuracy of staging (%)

Stage II: 86 Stage III: 83

Benign disease: BAPE (ns9)

Lee et al., (2009), Mol Imaging Biol, Australia, w14x Retrospective cohort study (level 2b)

Tan et al., (2010), J Thorac Oncol, UK, w15x Retrospective cohort study (level 2b)

Plathow et al., (2008), Invest Radiol, Germany, w16x

Metastases (ns9) No metastases (ns37)

18F-FDG-PETyCT imaging is a highly accurate and reliable non-invasive test to differentiate MPM from benign pleural disease

Patients with extrathoracic metastases had a significantly higher SUVmax in the primary pleural lesion at all stages of disease prevention 18-FDG-PET-CT is useful in diagnosing disease recurrence after multimodality therapy for MPM

PET and PET-CT enables detection of newly found distant


Best Evidence Topic

Detected by FDGPET-CT

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Table 1 (Continued) Author, date and country, Study type (level of evidence) Cohort study (level 2b)

Patient group

Outcomes

Key results

Comments

Sensitivity and specificity (%)

Stage II: 100 and 84.6 Stage III: 83 and 100 Stage IV: 100 and 100

metastases and therefore can prevent unnecessary surgery in some cases

PET-CT: Accuracy of staging (%)

100 Stage II and III: PET-CT vs. MRIyPET (P-0.05) PET-CT vs. CT (P-0.01)

Sensitivity and specificity

All stages: 100%

SUV, standardised uptake value; FDG-PET, fluorodeoxyglucose-positron emission tomography; MPM, malignant pleural mesothelioma; TGV, total glycolytic volume; CT, computed tomography.

6. Results Eleven studies evaluated the role of PET in MPM. Mavi et al. w2x reported greater 18F-fluorodeoxyglucose (FDG) uptake over time with both primary MPM (DSUVmaxs12.8" 8.4%) and recurrent MPM (DSUVmaxs13.8"9.2%) but lower uptake in benign pleural disease (DSUVmaxs–9.6"19.1%). Malignant disease had higher SUVmax (5.0"2.2 vs. 1.6"0.4, P-0.0001) than benign disease. Yamamoto et al. w3x observed large increases in delayed (120 min post-18F-FDG injection) compared to early (60 min post-18F-FDG injection) standardised uptake valve (SUV) measurements in malignant (7.72"6.08 vs. 9.39"7.70, P-0.001) but not in benign disease (2.92"2.45 vs. 3.27"3.26, PsNS). Mean SUV was higher in malignant disease (P-0.01). MPM was detected with a sensitivity, specificity and overall accuracy of 88%. Flores w4x observed higher SUV in N2 disease (8.6"3.4) than N0–N1 disease (5.3"2.1). The area under the receiver operating curve (AUC) of SUV was a strong predictor of N2 disease (78"10%). SUV of -4 was associated with a longer survival than a SUV of )4 (24 vs. 14 months; P-0.04), with the latter having a hazard ratio (HR) for death of 3.3 (Ps0.03). In 2006, Flores et al. w5x assessed survival in 137 patients with MPM over seven years. A high SUV ()10) was associated with a shorter survival (9.7 vs. 21 months; Ps0.02) and 1.9 times greater death risk (P-0.01) than low SUV (-10). Bernard et al. w6x analysed 22 patients with MPM and reported higher mean SUV in deceased patients (6.6"2.9 vs. 3.2"1.6) compared to those that survived. The cumulative survival at 12 months in patients who had high SUVs ()4.03) was lower than those who had a low SUV (F4.03) (17% vs. 86%; P-0.01). Nowak et al. w7x reported PET to be a significant predictor of survival (Ps0.008) in patients with MPM and SUVmax to trend towards significance only (Ps0.055). Ceresoli et al. w8x evaluated response to chemotherapy using FDG-PET. Responders (G25% reduction in FDG uptake) had a longer median time to tumour progression (14 vs. 7 months; Ps0.02) and longer survival (Ps0.07) than non-responders. Similarly, Francis et al. w9x observed the role of serial 18F-FDG-PET in assessing the response to chemotherapy after one cycle. Patients with a partial response had a lower median total glycolytic volume

(TGV) (30% vs. 71% of baseline) compared to those with stable disease. Reduction in TGV was predictive of improved survival (Ps0.015). Nanni et al. w10x compared 18F-FDG-PET to computed tomography (CT) and found 60% concordance in staging disease. However, 13% of patients were upstaged and 27% downstaged by PET, leading to a change in management in 20%. Yan et al. w11x reported greater 18-month survival in patients with preoperative compared to postoperative FDG-PET (45% vs. 26%; P-0.012). Four studies evaluated the combination of PET-CT in the diagnosis and prognosis of mesothelioma. Wilcox et al. w12x observed that 13 patients were upstaged following the use of PET-CT. There was no significant difference in survival between patients who had extrapleural pneumonectomy (ns8) and those excluded from surgery based on scan results (ns14) (20 vs. 12 months; Ps0.3812). Yildrim et al. w13x reported 18F-FDG-PET-CT detected MPM (ns17) and benign pleural disease (ns14) with high sensitivity (88.2%), specificity (92.9%) and overall accuracy (90.3%). The mean SUVmax was higher in MPM than benign pleural disease (6.5"3.4 vs. 0.8"0.6; P-0.001). Lee et al. w14x detected metastases in nine patients with MPM of which eight had previously been undetected. The primary pleural lesions in patients with metastases had higher mean SUVmax (7.1 vs. 4.7; Ps0.003) and shorter survival (four vs. eight months; P-0.05) than those of non-metastatic disease. Recently, Tan et al. w15x reported the use of 18FFDG-PET-CT in diagnosing disease recurrence postmultimodality therapy for MPM. Seventeen of 18 cases were detected (sensitivity 94%) and in seven patients no recurrence was identified (specificity 100%). The mean SUVmax of recurrent disease was 8.9"4.0. One study compared the accuracies of PET and PET-CT in diagnosing and staging MPM. In 2008, Plathow et al. w16x analysed the accuracy of PET in staging 54 patients with epithelial MPM. For stage II disease PET had an accuracy of 86% with sensitivity and specificity of 100% and 84.6%, respectively. For stage III disease, PET had similar accuracy of 83% with sensitivity and specificity of 83% and 100%, respectively. PET-CT was found to be more accurate than PET (P-0.05) and was observed to have 100% sensitivity and specificity for all disease stages.


Proposal for Bailout Procedure Negative Results Follow-up Paper State-of-the-art Best Evidence Topic Nomenclature Historical Pages

w1x Sharif S, Zahid I, Routledge T, Scarci M Does positron emission tomography offer prognostic information in malignant pleural mesothelioma? Interact CardioVasc Thorac Surg 2011;12:806–811. w2x Zahid I, Sharif S, Routledge T, Scarci M. What is the best way to diagnose and stage malignant pleural mesothelioma? Interact CardioVasc Thorac Surg 2011;12:254–259. w3x Kao SC, Yan TD, Lee K, Burn J, Henderson DW, Klebe S, Kennedy C, Vardy J, Clarke S, van Zandwijk N, McCaughan BC. Accuracy of diagnostic biopsy for the histological subtype of malignant pleural mesothelioma. J Thorac Oncol 2011 Jan 24. wEpub ahead of printx.

ESCVS Article

References

Institutional Report

Authors: Stefano Cafarotti, Department of Thoracic Surgery, Catholic University, Rome, Italy; Venanzio Porziella, Stefano Margaritora, Pierluigi Granone doi:10.1510/icvts.2010.255901A We have read with great interest the article by Sharif et al. w1x reporting on the role of positron emission tomography-computed tomography (PETCT) imaging in the diagnosis and prognosis of malignant pleural mesothelioma (MPM). There are many diagnostic modalities to identify patients with MPM. Currently, there is no consensus as to which single modality should be used to confirm diagnosis prior to surgery. Increasingly, PET-CT is playing a crucial role in the assessment of patients with known or suspected MPM due to its capacity for: 1. differentiation from benign pleural diseases, 2. high sensitivity in preoperative staging for the selection of appropriate surgical candidates, 3. post-treatment surveillance for recurrence, 4. evaluation of therapeutic response. PET-CT seems to be superior to other imaging modalities in detecting more extensive disease involvement, and in identifying unsuspected occult distant metastases. However, surgical or radiological pleural biopsy still provides the most accurate definitive diagnosis in MPM, as reported by the authors themselves in another published paper w2x, although it is a more invasive procedure than PET-CT. If indeed it is true that PET-CT increases the accuracy of overall staging in patients with MPM and significantly improves the selection of patients for curative surgical resection, it is also true that histological confirmation is required and mandatory due to the evidence that histological subtype is an established prognostic factor in malignant pleural mesothelioma w3x. The current diagnostic gold standard is principally based on light microscopic examination of hematoxylin-eosin and immunohistochemical stains of large tissue sections or cellular tissue. Indeed pathological diagnosis of MPM and classification of histological findings into one of the three subtypes (epithelial, sarcomatoid, biphasic) are necessary to evaluate the impact on prognosis. In conclusion, to achieve accurate diagnosis of MPM, obtaining cellular or large tissue samples in the initial examination is recommended. The integration of PET-CT and biopsy offers the best way to diagnose and stage MPM.

Protocol

w1x Dunning J, Prendergast B, Mackway-Jones K. Towards evidence-based medicine in cardiothoracic surgery: best BETS. Interact CardioVasc Thorac Surg 2003;2:405–409. w2x Mavi A, Basu S, Cermik TF, Urhan M, Bathaii M, Thiruvenkatasamy D, Houseni M, Dadparvar S, Alavi A. Potential of dual time point FDG-PET imaging in differentiating malignant from benign pleural disease. Mol Imaging Biol 2009;11:369–378. w3x Yamamoto Y, Kameyama R, Togami T, Kimura N, Ishikawa S, Yamamoto Y, Nishiyama Y. Dual time point FDG PET for evaluation of malignant pleural mesothelioma. Nucl Med Commun 2009;30:25–29. w4x Flores R. The role of PET in the surgical management of malignant pleural mesothelioma. Lung Cancer 2005;49(Suppl 1):S27–S32. w5x Flores RM, Akhurst T, Gonen M, Zakowski M, Dycoco J, Larson SM, Rusch VW. Positron emission tomography predicts survival in malignant pleural mesothelioma. J Thorac Cardiovasc Surg 2006;132:763–768. w6x Be ´nard F, Sterman D, Smith RJ, Kaiser LR, Albelda SM, Alavi A. Prognostic value of FDG PET imaging in malignant pleural mesothelioma. J Nucl Med 1999;40:1241–1245. w7x Nowak AK, Francis RJ, Philips MJ, Miliward MJ, van der Schaaf AA, Boucek J, Musk AW, McCoy MJ, Segal A, Robins P, Byrne MJ. A novel prognostic model for malignant meosthelioma incorporating quantitative FDG-PET imaging with clinical parameters. Clin Cancer Res 2010;16:2409–2417. w8x Ceresoli G, Chiti A, Zucali PA, Rodari M, Lutman RF, Salamina S, Incarbone M, Alloisio M, Santoro A. Early response evaluation in malignant pleural mesothelioma by positron emission tomography with w18Fxfluorodeoxyglucose. J Clin Oncol 2006;24:4587–4593. w9x Francis RJ, Byrne MJ, van der Schaaf AA, Boucek JA, Nowak AK, Phillips M, Price R, Patrikeos AP, Musk AW, Millward MJ. Early prediction of response to chemotherapy and survival in malignant pleural mesothelioma using a novel semiautomated 3-dimensional volume-based analysis of serial 18F-FDG PET scans. J Nucl Med 2007;48:1449–1458. w10x Nanni C, Castellucci P, Farsad M, Pinto C, Moretti A, Pettinato C, Marengo M, Boschi S, Franchi R, Martoni A, Monetti N, Fanti S. Role of 18F-FDG PET for evaluating malignant pleural mesothelioma. Cancer Biother Radiopharm 2004;19:149–154. w11x Yan TD, Boyer M, Tin MM, Sim J, Kennedy C, McLean J, Bannon PG, McCaughan BC. Prognostic features of long-term survivors after surgical management of malignant pleural mesothelioma. Ann Thorac Surg 2009;87:1552–1557. w12x Wilcox BE, Subramaniam RM, Peller PJ, Aughenbaugh GL, Nichols III FC, Aubry MC, Jett JR. Utility of integrated computed tomography-positron emission tomography for selection of operable malignant pleural mesothelioma. Clin Lung Cancer 2009;10:244–248. w13x Yildirim H, Metintas M, Entok E, Ak G, Ak I, Dundar E, Erginel S. Clinical value of fluorodeoxyglucose-positron emission tomographyycomputed tomography in differentiation of malignant mesothelioma from asbestos-related benign pleural disease. J Thorac Oncol 2009;4:1480–1484. w14x Lee ST, Ghanem M, Herbertson RA, Berlangieri SU, Byrne AJ, Tabone K, Mitchell P, Knight SR, Feigen M, Scott AM. Prognostic value of 18F-FDG

eComment: What is the best way to diagnose and stage malignant pleural mesothelioma?

Work in Progress Report

References

New Ideas

PET is useful diagnostic tool to identify and stage MPM and differentiate it from benign pleural disease. The above studies have found PET to be useful in the prediction of survival, determination of mortality risk and detection of metastases and recurrent disease. However, the combination of PET-CT produced superior diagnostic results than PET alone, highlighting the need for further prospective studies to refine the role of PET and PET-CT in different settings of MPM.

PETyCT in patients with malignant pleural mesothelioma. Mol Imaging Biol 2009;11:473–479. w15x Tan C, Barrington S, Rankin S, Landau D, Pilling J, Spicer J, Cane P, Lang-Lazdunski L. Role of integrated 18-fluorodeoxyglucose positron emission tomography-computed tomography in patients surveillance after multimodality therapy of malignant pleural mesothelioma. J Thorac Oncol 2010;5:385–388. w16x Plathow C, Staab A, Schmaehl A, Aschoff P, Zuna I, Pfannenberg C, Peter SH, Eschmann S, Klopp M. Computed tomography, positron emission tomographyycomputed tomography and magnetic resonance imaging for staging of limited pleural mesothelioma. Invest Radiol 2008;43:737–744.

Editorial

7. Clinical bottom line

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Brief Case Report Communication