Dual time point positron emission tomography/computed tomography scan in evaluation of intrathoracic lesions in an area endemic for histoplasmosis and with high prevalence of sarcoidosis.

BACKGROUND: We explored the role of dual time point fluorodeoxyglucose positron emission tomography/computed tomography (DTP PET/CT) scan in the differentiation of benign and malignant lung and mediastinal lesions. METHODS: We studied a sample of 72 consecutive patients who underwent DTP PET/CT scan for intrathoracic lesions. Information on demographics, initial and delayed maximum standardized uptake values (SUVmax) of lesions and final diagnosis were collected. Clinical criteria to diagnose benign lesions were defined as stability or regression of the lesion on follow-up after 2 years of initial detection. Sensitivity, specificity, predictive values and likelihood ratio and retention index were calculated using standard methods. RESULTS: Sixty-three (87%) patients had increased SUVmax in delayed scan (1 hour after initial scan). Among the patients with increased delayed uptake, 51 (80%) had malignant lesion and 12 (20%) had nonmalignant lesions. All 9 patients whose SUVmax decreased on delayed scan had nonmalignant lesions. The increased SUV on delayed scan was 100% sensitive in diagnosis of cancer but was only 42% specific. The positive predictive value was 80%, whereas the negative predictive value was 100%. Likelihood ratio for positive test was 1.75. CONCLUSIONS: All the lesions with decreased SUVmax in delayed PET scan were nonmalignant. This was true for both lung and mediastinal lesions. This could be a very helpful diagnostic finding in areas with high prevalence of benign conditions such as histoplasmosis and sarcoidosis. Multiple invasive diagnostic modalities could be prevented in a significant percentage of patients, with attendant decrease in morbidity and health care costs.

Surgical biopsy prevented with PET/CT scan in a young female with intrathoracic lymphadenopathy.

Intrathoracic lymphadenopathy is a common clinical problem encountered in Histoplasma endemic zones. It is challenging for clinicians to distinguish the infectious lesions from the neoplastic ones. Bronchoscopy with or without lung sampling and transbronchial needle aspiration (TBNA) is commonly the first diagnostic procedure employed. If non-diagnostic, the next step is usually surgical biopsy. In our experience, a significant number of patients who go for surgical biopsy are diagnosed with histoplasmosis. A positron emission tomography (PET) scan with dual-time imaging may help us distinguish benign from malignant lesions, thus obviating the need for surgical sampling. We report a case of a young female who presented with progressively increasing intrathoracic lymphadenopathy and was treated successfully based on dual-time PET scan results, without proceeding to surgical lung biopsy.