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Stage T1 Non–Small Cell Lung Cancer: Preoperative Mediastinal Nodal Staging with Integrated FDG PET/CT—A Prospective Study¹

¹ From the Departments of Nuclear Medicine (B.T.K., J.Y.C.), Radiology and Center for Imaging Science (K.S.L., S.S.S.), Thoracic Surgery (Y.M.S., J.K.), and Medicine, Division of Pulmonary and Critical Care Medicine (O.J.K., H.K.), Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Ilwon-Dong, Kangnam-Ku, Seoul 135-710, Korea; and Biostatistics Units, Samsung Biomedical Research Institute, Samsung Medical Center, Seoul, Korea (S.K.). Received July 12, 2005; revision requested September 19; revision received September 23; accepted October 18; final version accepted, January 3, 2006. Address correspondence to K.S.L. (e-mail: kyungs.lee{at}samsung.com).

View larger version (136K): [in a new window]   Figure 1a: True-positive mediastinal lymph node metastasis at integrated PET/CT in 46-year-old man with adenocarcinoma of the lung. (a) Lung window view of transverse CT scan (2.5-mm collimation, 170 mA) at level of liver dome shows 28-mm nodule (arrow) with lobulated margin in right lower lobe. (b) Mediastinal window view of transverse unenhanced CT scan (5.0-mm collimation, 80 mA) at level of right bronchus intermedius shows 3.8-mm (short-axis diameter) lymph node (arrow) in subcarinal area (nodal station 7). Transverse (c) PET and (d) integrated PET/CT scans at level similar to b demonstrate node with markedly increased FDG uptake (maximum SUV, 7.9) (arrow) strongly suggesting malignant node, which proved to contain metastatic adenocarcinoma cells.

View larger version (88K): [in a new window]   Figure 1b: True-positive mediastinal lymph node metastasis at integrated PET/CT in 46-year-old man with adenocarcinoma of the lung. (a) Lung window view of transverse CT scan (2.5-mm collimation, 170 mA) at level of liver dome shows 28-mm nodule (arrow) with lobulated margin in right lower lobe. (b) Mediastinal window view of transverse unenhanced CT scan (5.0-mm collimation, 80 mA) at level of right bronchus intermedius shows 3.8-mm (short-axis diameter) lymph node (arrow) in subcarinal area (nodal station 7). Transverse (c) PET and (d) integrated PET/CT scans at level similar to b demonstrate node with markedly increased FDG uptake (maximum SUV, 7.9) (arrow) strongly suggesting malignant node, which proved to contain metastatic adenocarcinoma cells.

View larger version (104K): [in a new window]   Figure 1c: True-positive mediastinal lymph node metastasis at integrated PET/CT in 46-year-old man with adenocarcinoma of the lung. (a) Lung window view of transverse CT scan (2.5-mm collimation, 170 mA) at level of liver dome shows 28-mm nodule (arrow) with lobulated margin in right lower lobe. (b) Mediastinal window view of transverse unenhanced CT scan (5.0-mm collimation, 80 mA) at level of right bronchus intermedius shows 3.8-mm (short-axis diameter) lymph node (arrow) in subcarinal area (nodal station 7). Transverse (c) PET and (d) integrated PET/CT scans at level similar to b demonstrate node with markedly increased FDG uptake (maximum SUV, 7.9) (arrow) strongly suggesting malignant node, which proved to contain metastatic adenocarcinoma cells.

View larger version (86K): [in a new window]   Figure 1d: True-positive mediastinal lymph node metastasis at integrated PET/CT in 46-year-old man with adenocarcinoma of the lung. (a) Lung window view of transverse CT scan (2.5-mm collimation, 170 mA) at level of liver dome shows 28-mm nodule (arrow) with lobulated margin in right lower lobe. (b) Mediastinal window view of transverse unenhanced CT scan (5.0-mm collimation, 80 mA) at level of right bronchus intermedius shows 3.8-mm (short-axis diameter) lymph node (arrow) in subcarinal area (nodal station 7). Transverse (c) PET and (d) integrated PET/CT scans at level similar to b demonstrate node with markedly increased FDG uptake (maximum SUV, 7.9) (arrow) strongly suggesting malignant node, which proved to contain metastatic adenocarcinoma cells.

View larger version (108K): [in a new window]   Figure 2a: True-negative mediastinal lymph node metastasis at integrated PET/CT in 67-year-old man with adenocarcinoma of the lung. (a) Lung window view of transverse CT scan (2.5-mm collimation, 170 mA) at level of liver dome shows 10-mm nodule (arrow) with lobulated margin in right lower lobe. (b) Mediastinal window view of transverse unenhanced CT scan (5.0-mm collimation, 80 mA) at level of aortic arch shows 13-mm (short-axis diameter) lymph node (arrow) in right lower paratracheal area (nodal station 4R) with peripheral calcification. Transverse (c) PET and (d) integrated PET/CT scans at level similar to b demonstrate right lower paratracheal node showing increased FDG uptake (maximum SUV, 3.8) (arrow). Because there was calcification in this node, it was interpreted as benign and proved to be benign at histopathologic examination.

View larger version (95K): [in a new window]   Figure 2b: True-negative mediastinal lymph node metastasis at integrated PET/CT in 67-year-old man with adenocarcinoma of the lung. (a) Lung window view of transverse CT scan (2.5-mm collimation, 170 mA) at level of liver dome shows 10-mm nodule (arrow) with lobulated margin in right lower lobe. (b) Mediastinal window view of transverse unenhanced CT scan (5.0-mm collimation, 80 mA) at level of aortic arch shows 13-mm (short-axis diameter) lymph node (arrow) in right lower paratracheal area (nodal station 4R) with peripheral calcification. Transverse (c) PET and (d) integrated PET/CT scans at level similar to b demonstrate right lower paratracheal node showing increased FDG uptake (maximum SUV, 3.8) (arrow). Because there was calcification in this node, it was interpreted as benign and proved to be benign at histopathologic examination.

View larger version (79K): [in a new window]   Figure 2c: True-negative mediastinal lymph node metastasis at integrated PET/CT in 67-year-old man with adenocarcinoma of the lung. (a) Lung window view of transverse CT scan (2.5-mm collimation, 170 mA) at level of liver dome shows 10-mm nodule (arrow) with lobulated margin in right lower lobe. (b) Mediastinal window view of transverse unenhanced CT scan (5.0-mm collimation, 80 mA) at level of aortic arch shows 13-mm (short-axis diameter) lymph node (arrow) in right lower paratracheal area (nodal station 4R) with peripheral calcification. Transverse (c) PET and (d) integrated PET/CT scans at level similar to b demonstrate right lower paratracheal node showing increased FDG uptake (maximum SUV, 3.8) (arrow). Because there was calcification in this node, it was interpreted as benign and proved to be benign at histopathologic examination.

View larger version (99K): [in a new window]   Figure 2d: True-negative mediastinal lymph node metastasis at integrated PET/CT in 67-year-old man with adenocarcinoma of the lung. (a) Lung window view of transverse CT scan (2.5-mm collimation, 170 mA) at level of liver dome shows 10-mm nodule (arrow) with lobulated margin in right lower lobe. (b) Mediastinal window view of transverse unenhanced CT scan (5.0-mm collimation, 80 mA) at level of aortic arch shows 13-mm (short-axis diameter) lymph node (arrow) in right lower paratracheal area (nodal station 4R) with peripheral calcification. Transverse (c) PET and (d) integrated PET/CT scans at level similar to b demonstrate right lower paratracheal node showing increased FDG uptake (maximum SUV, 3.8) (arrow). Because there was calcification in this node, it was interpreted as benign and proved to be benign at histopathologic examination.

View larger version (172K): [in a new window]   Figure 3a: False-negative mediastinal lymph node metastasis at integrated PET/CT in 55-year-old woman with adenocarcinoma of the lung. (a) Lung window view of transverse CT scan (2.5-mm collimation, 170 mA) shows 25-mm nodule (arrow) with lobulated and spiculated margins in left upper lobe. (b) Mediastinal window view of transverse unenhanced CT scan (5.0-mm collimation, 80 mA) at level of azygos arch shows 8-mm (short-axis diameter) lymph node (arrow) in paraaortic area (nodal station 6). Transverse (c) PET and (d) integrated PET/CT scans at level similar to b demonstrate paraaortic node (arrow) showing little FDG uptake (maximum SUV = 2.0). Node was interpreted as benign and proved to be malignant at histopathologic examination of dissected nodes.

View larger version (74K): [in a new window]   Figure 3b: False-negative mediastinal lymph node metastasis at integrated PET/CT in 55-year-old woman with adenocarcinoma of the lung. (a) Lung window view of transverse CT scan (2.5-mm collimation, 170 mA) shows 25-mm nodule (arrow) with lobulated and spiculated margins in left upper lobe. (b) Mediastinal window view of transverse unenhanced CT scan (5.0-mm collimation, 80 mA) at level of azygos arch shows 8-mm (short-axis diameter) lymph node (arrow) in paraaortic area (nodal station 6). Transverse (c) PET and (d) integrated PET/CT scans at level similar to b demonstrate paraaortic node (arrow) showing little FDG uptake (maximum SUV = 2.0). Node was interpreted as benign and proved to be malignant at histopathologic examination of dissected nodes.

View larger version (87K): [in a new window]   Figure 3c: False-negative mediastinal lymph node metastasis at integrated PET/CT in 55-year-old woman with adenocarcinoma of the lung. (a) Lung window view of transverse CT scan (2.5-mm collimation, 170 mA) shows 25-mm nodule (arrow) with lobulated and spiculated margins in left upper lobe. (b) Mediastinal window view of transverse unenhanced CT scan (5.0-mm collimation, 80 mA) at level of azygos arch shows 8-mm (short-axis diameter) lymph node (arrow) in paraaortic area (nodal station 6). Transverse (c) PET and (d) integrated PET/CT scans at level similar to b demonstrate paraaortic node (arrow) showing little FDG uptake (maximum SUV = 2.0). Node was interpreted as benign and proved to be malignant at histopathologic examination of dissected nodes.

View larger version (86K): [in a new window]   Figure 3d: False-negative mediastinal lymph node metastasis at integrated PET/CT in 55-year-old woman with adenocarcinoma of the lung. (a) Lung window view of transverse CT scan (2.5-mm collimation, 170 mA) shows 25-mm nodule (arrow) with lobulated and spiculated margins in left upper lobe. (b) Mediastinal window view of transverse unenhanced CT scan (5.0-mm collimation, 80 mA) at level of azygos arch shows 8-mm (short-axis diameter) lymph node (arrow) in paraaortic area (nodal station 6). Transverse (c) PET and (d) integrated PET/CT scans at level similar to b demonstrate paraaortic node (arrow) showing little FDG uptake (maximum SUV = 2.0). Node was interpreted as benign and proved to be malignant at histopathologic examination of dissected nodes.