Diagnóstico Nódulo Pulmonar - Society of Nuclear Medicine

November 2011
Value of PET/CT
Value of PET/CT
DiagnosisValor
of Pulmonary
do PET/CT Nodules
Diagnosis of Pulmonary Nodules
Core
Message for
Referring
Physicians
Diagnóstico
Nódulo
Pulmonar
Core Message for Referring Physicians
Informações para o Médico Solicitante
Background:
Practice Guideline
Background:
The prevalence of non-calcified pulmonary nod- Practice Guideline
Introdução:
The
non-calcified
pulmonary
ules prevalence
in smokers of
or ex
smokers is 23%
- 69%,nodbut
Ainprevalência
de
nódulos
pulmonares
não but
ules
smokers
or
ex
smokers
is
23%
69%,
only 1.4% - 2.7% have malignant nodules.
The
calcificados
fumantes
e ex-fumantes
é de The
only
1.4% Society
- em
2.7%
havepublished
malignant
nodules.
Fleischner
has
imaging
guide23%
69%,
mas
somente
1,4%
2,7%
são
Fleischner
Societywith
haspulmonary
published nodules
imagingthat
guidelines
for
patients
are
malignos.
A Fleischner
Society publicou
lines
for than
patients
with
pulmonary
nodulesorientathat are
smaller
8
mm
(1).
ções em imagens para pacientes com nódulos
smaller than 8 mm (1).
pulmonares menores que 8 mm (1).
PET/CT is more accurate that CT alone for char PET/CT
tem maior
acurácia
quealone
a CTfor
na charPET/CT
is more
accurate
that CT
acterizing
pulmonary
nodules,
resulting
in fewer
caracterização
do nódulo
pulmonar,
resultando
acterizing
pulmonary
nodules,
resulting
in
equivocal
findings,
anddehigher
specificity
(2).fewer
Low
em
um
menor
número
achados
equívocos,
equivocal
findings,
and
higher≥specificity
(2). Low
to
intermediate
risk
nodules
8
mm
should
be
etocom
maior especificidade
(2).
Nódulos
≥ 8 be
intermediate
risk nodules
≥ high-risk
8 mm should
evaluated
by
PET/CT,
whereas
nodules
mm com risco baixo a intermediário devem ser
evaluated
by PET/CT,
whereas high-risk nodules
should be com
biopsied
or excised.
avaliados
PET/CT,
enquanto que nódulos
should be biopsied or excised.
com alto risco devem ser biopsiados ou retirados
The sensitivity of PET/CT for lung cancer is >90%,
cirurgicamente.
The
sensitivity
of PET/CT
fornodules
lung cancer
is >90%,
so low
to intermediate
risk
that
are
metaso
A sensibilidade
do risk
PET/CT
parathat
câncer
de
low
to
intermediate
nodules
are
metabolically
inactive
can
be
followed
radiographically
pulmão
é > 90%,can
portanto
nódulos
de baixo a
bolically
be followed
radiographically
to ensureinactive
stability
resolution.
The
specificity of
intermediário
riscoorque
são inativos
metabolito
ensure
stability
or resolution.
The specificity
of
PET/CT
is
approximately
80%
because
inflammacamente podem ser seguidos radiologicamente
PET/CT
is approximately
80% because
inflammatory nodules
cansua
be estabilidade
metabolically
(3). PET
para
assegurar
ouactive
resolução.
A
tory
nodules
can
be
metabolically
active
(3). PET
especificidade
PET/CTfurther
é de aproximadamente
positive nodulesdarequire
investigation.
positive
nodules
require
further investigation.
80% porque
nódulos
inflamatórios
podem ser
PET/CT
with
18F-fluorodexoyglucose
(FDG) has
metabolicamente
ativos
(3).
PET
com
nódulos
PET/CT
with to18F-fluorodexoyglucose
(FDG)
has
been
shown
be
cost-effective
for
characterpositivos requerem investigação posterior.
been
shown
to
be
cost-effective
for
characterlung nodules
≥ 8 mm when18risk-estimates
izingPET/CT
com fluordeoxiglicoseF (FDG) tem
izing
lung
nodules
≥
8 mmmorphological
when risk-estimates
baseddemonstrado
on clinical ser
versus
paramsido
custo-efetiva na caracterbased
on conflicting,
clinical pulmonares
versus
morphological
paramização
de
nódulos
≥ 8 mm quando
eters are
or when
indeterminate
nodarefound
conflicting,
or
when
indeterminate
aeters
estimativa
deinrisco
baseada
em parâmetros
ules
are
high-risk
individuals
(4). nodules are versus
found inmorfológicos
high-risk individuals
(4). ou
clínicos
são conflitantes,
SNM
recommends
that
18F-FDG
PET/CT
should
quando nódulos indeterminados são achados
em
SNM
recommends
that
18F-FDG
PET/CT
should
routinely bedeobtained
in (4).
the diagnostic work-up of
indivíduos
alto risco
be obtainednodule
in the
diagnostic
of
18
solitary
(5).
will imroutinely
SNMpulmonary
recomenda
que
FDGFImaging
PET/CTwork-up
deve
ser
solitary
pulmonary
nodule
(5).
Imaging
will
imrotineiramente
realizado
na pesquisa
diagnóstiprove health care
outcomes,
mostly by
avoiding
prove
health pulmonar
care
outcomes,
mostly
avoiding
ca
do nódulo
solitário
(5). and
Abyrealização
futile
surgeries
in low-risk
patients
enabling
futile
surgeries
in low-risk
patients
andresultados
enabling
do
método
de imagem
irá melhorar
os
curative
surgeries
in high-risk
patients.
curative
in high-risk
patients.
da
saúde,surgeries
principalmente
evitando
cirurgias
desnecessárias em pacientes de baixo risco e
permitindo cirurgias curativas em pacientes de
alto risco.
Orientações
Práticas: of Chest Surgeons:
American College
American College
College of Chest
Chest Surgeons:
Surgeons:
American
In patients with aoflow
to moderate pre test probability of malignancy (5% - 60%) and an
In
patients
with
a
low
to
moderate
pre test probability de
of malignancy
(5% risco
- 60%)
an
indeterminate
Em pacientesSPN
comthat
probabilidade
baixo a fluorodeoxyglucose
moderado
(5%and
-(FDG)
60%)
measures pré-teste
at least 8detomalignidade
10 mm in diameter,
eindeterminate
um nódulo pulmonar
solitário
indeterminado
de 8 fluorodeoxyglucose
a 10 mm de diâmetro,(FDG)
a
SPN that
measures
at least 8que
to tenha
10 mmnoinmínimo
diameter,
positron emission tomography (PET) should be performed to characterize the nodule.
tomografia
por emissão
de pósitrons
(PET)
com fluordeoxiglicose
deve ser feita
para a caracterpositron emission
tomography
(PET)
should
be performed to(FDG)
characterize
the nodule.
When
the pre-test probability of malignancy is moderate to high (>60%), and the nodule
ização
do nódulo.
When the
pre-test probability
ofdemalignancy
is moderate
to high
(>60%),
and
nodule
is hypermetabolic
Quando
a probabilidade
pré-teste
malignidade
moderada
a alta
(> 60%),
e o the
nódulo
é
by FDG PET,
surgical
diagnosis isé de
preferred
when
clinically
appropriate
(6).
is
hypermetabolic
by
FDG
PET,
surgical
diagnosis
is
preferred
when
clinically
appropriate
(6).
hipermetabólico a FDG PET, o diagnóstico cirúrgico é preferível quando apropriado clinicamente (6).
Case1:Example 1:
Caso
Case Example 1:
47-year-old
man
with
incidental
1.5
cm nodule
discovered
on chest x-ray.
PET/CT
showed
high
Homem
de 47man
anos,with
comincidental
um nódulo1.5
incidental
de 1,5
cm diagnosticado
umPET/CT
RX de tórax.
PET/CT
47-year-old
cm nodule
discovered
on chest em
x-ray.
showed
high
FDG
uptake.
Biopsy
showed
poorly
differentiated
lung
cancer.
mostrou alta captação de FDG. A biópsia mostrou câncer de pulmão pouco diferenciado.
FDG uptake. Biopsy showed poorly differentiated lung cancer.
Case2:Example 2:
Caso
Case Example 2:
84 year-old man with chronic cough and 1.5 cm nodule on chest x-ray. PET /CT showed no FDG
84 year-old
with chronic
cough eand
cm de
nodule
onnochest
x-ray.
/CT showed
no FDG
Homem
84man
anos,
tosse crônica
um 1.5
nódulo
1,5tocm
RX
tórax.PET
PET/CT
não mostrou
uptake.deBiopsy
wascom
deferred.
The nodule
had grown
2 cm
12 de
months
later.
Biopsy
showed a
uptake.
Biopsy
was
deferred.
The
nodule
had
grown
to
2
cm
12
months
later.
Biopsy
showed
a
captação
fungus. de FDG. A biópsia não foi realizada. O nódulo cresceu para 2 cm 12 meses após. A biópsia
fungus. infecção fúngica.
mostrou
Diagnóstico do Nódulo Pulmonar
Um critério quantitativo foi proposto para aumentar a acurácia do PET/
CT. O standardized uptake value (SUV) é uma relação da concentração de
FDG no nódulo em comparação com a média de concentração no organismo. Um SUV de 2,5 vem sendo usado para diferenciar os nódulos entre
benignos e malignos. Muitas variáveis, entretanto, afetam o cálculo do
SUV, limitando a sua acurácia e reprodutibilidade. Vem sendo sugerido
que um aumento ou a não modificação no valor do SUV quando medido em
dois momentos entre 60 e 120 minutos após a injeção de FDG melhoram
a sua acurácia. Apesar do apelo de um simples valor numérico, a maioria
dos médicos confia na avaliação visual da atividade metabólica usando
um modelo de decisão binária de captação detectável versus captação não
detectável de FDG.
Referências
1. MacMahon H, et al. Guidelines for management of small pulmonary
nodules detected on CT scans: A statement from the Fleischner
Society. Radiology 2005;237:395-400.
2. Pauls S, et al. Performance of integrated FDG-PET/CT for differentiating benign and malignant lung lesions--results from a large prospective clinical trial. Mol Imaging Biol. 2008 Mar-Apr;10(2):121-8.
3. Ung YC, et al. 18Fluorodeoxyglucose positron emission tomography in
the diagnosis and staging of lung cancer: a systematic review. J Natl
Cancer Inst 2007 Dec 5;99(23):1753-6
4. Gould MK, et al. Cost-effectiveness of alternative management strategies for patients with solitary pulmonary nodules. Ann Intern Med.
2003 May 6;138(9):724-35.
5. Fletcher JW, et al. Recommendations on the use of 18F-FDG PET in
oncology. J Nucl Med. 2008 Mar;49(3):480-508.
6. Alberts WM. Chest 2007;132;1-19 Clinical Practice Guidelines (2nd
Edition) Executive Summary: ACCP Evidence-Based Diagnosis and
Management of Lung Cancer.
7. Alkhawaldeh K, et al. Impact of dual-time-point 18F-FDG PET imaging
and partial volume correction in the assessment of solitary pulmonary
nodules. Eur j Nucl Med Mol Imaging 2008;35:246-252.
8. CMS Publication 100-03, Medicare National Coverage Determinations
Manual, Chapter 1, Part 4, Section 220.6). Available at http://www.
cms.hhs.gov/manuals/downloads/ncd103c1_part4.pdf
“The translation of PETPROs was approved by SNM, but the Brazilian SNM
assumes sole responsibility for the accuracy of the translation - A tradução
da PETPROs foi aprovada pela SNM, a SBBMN assume total responsabilidade pela precisão desta tradução.”
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