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Characterization of the Solitary Pulmonary Nodule: 18F-FDG PET Versus Nodule-Enhancement CT

Jared A. Christensen1, Mark A. Nathan1, Brian P. Mullan1, Thomas E. Hartman1, Stephen J. Swensen1 and Val J. Lowe1

1 All authors: Department of Radiology, Mayo Clinic, 200 First St. SW, Rochester, MN 55905.


Figure 1
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  		Fig. 1A —69-year-old man with indeterminate right lower lobe pulmonary nodule. Axial nodule-enhancement CT unenhanced image shows irregular 18 x 13 mm nodule in right lower lobe.

 

Figure 2
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  		Fig. 1B —69-year-old man with indeterminate right lower lobe pulmonary nodule. Axial nodule-enhancement CT contrast-enhanced image shows peak nodule enhancement of 53 H. Histology of resected nodule showed grade 2 squamous cell lung carcinoma, confirming nodule-enhancement CT result as true-positive for malignancy.

 

Figure 3
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  		Fig. 2A —61-year-old woman with indeterminate right lower lobe pulmonary nodule. Axial nodule-enhancement CT unenhanced image shows lobulated 22 x 18 mm nodule in right lower lobe.

 

Figure 4
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  		Fig. 2B —61-year-old woman with indeterminate right lower lobe pulmonary nodule. Axial nodule-enhancement CT contrast-enhanced image shows peak nodule enhancement of 10 H, supporting benign cause for this nodule. Histology of resected nodule showed hamartoma, confirming nodule-enhancement CT result as true-negative for malignancy.

 

Figure 5
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  		Fig. 3A —57-year-old woman with history of breast carcinoma and new right middle lobe pulmonary nodule. Axial unenhanced CT image shows 12-mm nodule in right middle lobe.

 

Figure 6
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  		Fig. 3B —57-year-old woman with history of breast carcinoma and new right middle lobe pulmonary nodule. Anterior maximum-intensity-projection image from whole-body 18F-FDG PET shows focus of intense hypermetabolism in inferior right lung that correlates with right middle lobe nodule and was, therefore, highly suspicious for malignancy. Histology of resected nodule showed metastatic grade 4 breast carcinoma, confirming 18F-FDG PET result as true-positive for malignancy.

 

Figure 7
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  		Fig. 4A —41-year-old woman with indeterminate right lower lobe pulmonary nodule. Axial nodule-enhancement CT unenhanced image shows 13-mm nodule in right lower lobe.

 

Figure 8
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  		Fig. 4B —41-year-old woman with indeterminate right lower lobe pulmonary nodule. Axial nodule-enhancement CT contrast-enhanced image shows peak nodule enhancement of 28 H. This degree of enhancement is suspicious for malignancy.

 

Figure 9
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  		Fig. 4C —41-year-old woman with indeterminate right lower lobe pulmonary nodule. Anterior maximum-intensity-projection image from whole-body 18F-FDG PET does not show increased metabolic activity in inferior right lung to correlate with this nodule, supporting benign cause. Histology from biopsy of this nodule showed inflammatory nodule with predominantly histiocytic reaction. This would confirm nodule-enhancement CT as false-positive and 18F-FDG PET as true-negative for malignancy.

 

Figure 10
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  		Fig. 5A —71-year-old woman with indeterminate left lower lobe pulmonary nodule. Axial lung-window CT image shows somewhat spiculated 8 x 5 mm nodule in left lower lobe. Nodule-enhancement CT showed peak nodule enhancement of 55 H.

 

Figure 11
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  		Fig. 5B —71-year-old woman with indeterminate left lower lobe pulmonary nodule. Anterior maximum-intensity-projection image from whole-body 18F-FDG PET fails to show increased metabolic activity within this nodule. Histology of resected nodule revealed grade 2 lung adenocarcinoma. This would confirm nodule-enhancement CT result as true-positive and 18F-FDG PET as false-negative for malignancy.

 

Figure 12
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  		Fig. 6 —Proposed algorithm for evaluation of newly found solitary pulmonary nodules. SUV = standardized uptake value.

 

Figure 13
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  		Fig. 7 —67-year-old woman with enlarging 8 x 7 mm left lower lobe pulmonary nodule first detected on low-dose screening chest CT. Axial 18F-FDG PET image shows focus of increased metabolic activity in posterior left lung base (arrowhead) correlating with location of nodule. During blinded, qualitative review, two experienced nuclear radiologists independently interpreted this nodule as malignant; however, measured standardized uptake value maximum was 1.7, below 2.5 threshold for malignancy and favoring benign cause. Histology of resected nodule revealed grade 2 adenocarcinoma.

 

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