Original Article
Differentiation of malignant from benign heart and pericardial lesions using positron emission tomography and computed tomography

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Abstract

Objective

To assess the feasibility of 18F-FDG PET-CT for the differentiation of malignancy from benign lesions of the heart and the pericardium.

Methods

A total of 23 cases (malignancy:benign = 13:10) with cardiac and pericardial lesions, confirmed by pathology or on clinical grounds, were analyzed in this study. All lesions were evaluated semi-quantitatively using maximum standard uptake values (SUVmax) and SUVmax lesion/blood, and the density of the heart and pericardium lesions and the relation with surrounding tissues were evaluated. The differences of SUVmax and SUVmax lesion/blood between benign and malignant lesions were analyzed by the Mann-Whitney test. Subsequently, the diagnostic sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) were calculated for CT and PET-CT, respectively.

Results

The maximum SUV showed significant difference between malignancy (avg ± SD 6.5) and benign (avg ± SD 1.5) (Z = −3.601, P < .01), the SUVmax lesion/blood of malignancy and benign were avg ± SD 3.4 and avg ± SD 0.9, respectively, also with a significant difference (Z = −3.600, P < .01). In this pilot study, the optimal cutoff value to separate benign vs malignant lesions of SUVmax was 3.5-4.0 and the cutoff for SUVmax lesion/blood was 1.3-2.0. The sensitivity, specificity, accuracy, PPV, and NPV of CT and PET-CT were 76.9%(10/13), 100.0%(10/10), 87.0%(20/23), 100.0%(10/10), 76.9%(10/13) and 100.0%(13/13), 90.0%(9/10), 95.7%(22/23), 92.9%(13/14), 100.0%(9/9), respectively.

Conclusion

18F-FDG PET-CT appears promising for correctly differentiating benign vs malignant cardiac and pericardial lesions.

Introduction

Computed tomography (CT) can be used to identify morphological alterations associated with disease. Conventional CT images cannot detect differences in metabolic status, and, therefore, are of little use for distinguishing malignant from benign myocardial or pericardial lesions. Positron emission tomography (PET)-CT can convey both anatomical information (lesion structure) and metabolic status,1, 2, 3, 4 However, the role of PET-CT in the differential diagnosis of cardiac and pericardial lesions has not previously been reported. In this study, a total of 23 cardiac or pericardial lesions were retrospectively reviewed to explore whether it was feasible to differentiate the benign vs malignant nature of cardiac or pericardial lesions by PET-CT.

Section snippets

Patients

The clinical data of patients seen between August 2007 and 2009 that correspond with the following criteria were retrospectively reviewed. The inclusive criteria were: (1) The cardiac or pericardial lesions were histologically proven, and lipoma was confirmed by MRI; (2) the complete clinical data of all patients were collected; and (3) all patients had undergone a PET/CT scan. Finally, a total of 23 patients were included in this study (14 males, 9 females, age range 16-86, mean age 55).

Of the

Criteria for Differentiating Malignant and Benign Cardiac or Pericardial Lesions by PET

  • (1)

    Lesion SUVmaxand SUVmaxof lesion/blood of cardiac and pericardiallesions (Table 1; Figure 1, 2) The benign lesions had SUVmax values from 0.5 to 7.4 (median 1.5), while the malignant lesions had SUVmax values between 4.1 and 21.2 (median 6.5). The difference in SUVmax between benign and malignant lesions was statistically significant (Z = −3.601, P < .01). The lesion/blood SUVmax values for benign and malignant lesions were 0.9 and 3.4, respectively, and again the difference was also

The Advantages of Fasting

Fasting before 18F-FDG PET is a suitable method to depress normal myocardial FDG uptake. Minimizing myocardial FDG uptake should decrease false-positive results and increase the detection rate because a decrease in the background uptake should facilitate the detection of FDG-avid juxtacardiac masses (Figure 7). In normal myocardium, metabolism is primarily oxidative and utilizes various admixtures of free fatty acids, glucose, and lactate. Under fasting conditions, plasma insulin levels fall,

Limitations

Due to the diversity of cardiac and pericardial lesions and the variability in clinical symptoms, it is difficult to perform a comprehensive analysis and summary of clinical conditions. Additional research with inclusion of larger numbers of patients should be undertaken to elucidate them.

Because it reduces influence of the background and individual difference, SUVmax of lesion/blood was a better indicator in distinguishing benign from malignant lesions compared with SUVmax.

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