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Cancer screening with whole-body F-fluorodeoxyglucose positron-emission tomography
THE LANCET
Research letters
Cancer screening with whole-body 18F-fluorodeoxyglucose positron-emission tomography Seiei Yasuda, Akira Shohtsu
Because there is increased glycolysis in cancer cells, wholebody positron emission tomography (WB PET) with 18Ffluorodeoxyglucose can be used to detect cancers (figure). With its high sensitivity and ability non-invasively to survey the entire body, WB PET has potential for detecting cancers of many types with a single examination. We investigated the use of WB PET for cancer screening in individuals without symptoms. We studied members of a medical health club in Yamanashi, Japan, participating in a continuing cancerscreening programme that incorporates clinical, imaging, and immunochemical methods for the detection of cancers.1 45 to 60 min after the administration of 260 to 370 MBq of 18Ffluorodeoxyglucose, emission scanning was done for approximately 35 min. PET results were compared with the final screening outcome. Over 21 months, 1872 people participated in 2563 screening sessions. Cancers were found in 26 (1·4%). PET findings were positive in 15 (table). Positive patients, except for one person with lymphoma, were successfully treated. In one patient with breast cancer, microscopic metastasis was observed in a dissected lymph node, but lymph node metastasis was not observed in any other patient. All lung cancers were stage I. There were 11 false-negative findings by PET. Six were in the bladder or kidneys. There were three false-negative lung cancers: an 8-mm tubular adenocarcinoma, a 1·2-cm bronchioloalveolar adenocarcinoma, and a 1·5-cm bronchioloalveolar adenocarcinoma; these were not found by chest radiography. One scirrhous type breast cancer (stage I) and one small hepatoma were negative with PET. During the follow-up period, cancers were discovered in four people examined when they had symptoms: a 1-cm bladder cancer 5 months after screening, a 2-cm common bile duct cancer at 7 months, a superficial oesophageal cancer at 9 months, and a 1-cm malignant lymphoma of the upper pharynx at 13 months. Rigo et al2 stated that FDG PET was not suited to unselected screening because of the likelihood of falsepositives. Our study is the first dealing with a large number of people without symptoms. Although a substantial number of benign lesions such as chronic thyroiditis,3 sarcoidosis, Warthin’s tumour, thyroid adenoma, and colonic adenoma, were discovered, these subclinical lesions were thought to warrant further clinical examination. False-positive interpretations can be avoided if the potential sites and characteristics of non-malignant lesions are recognised in the interpretation of PET images. Our results show that PET can be used to detect a wide variety of cancers in resectable stages. Further studies are needed to determine whether cancers associated with hypometabolism are biologically less aggressive or more indolent than those associated with hypermetabolism. 1 2
Ide M, Suzuki Y. A window on Japan: medical health club with clinical PET. Eur J Nucl Med 1996; 23: 1677–79. Rigo P, Paulus P, Kaschten BJ, et al. Oncological application of positron emission tomography with fluorodeoxyglucose.
Vol 350 • December 20/27, 1997
Whole-body PET images of a 61-year-old woman On coronal tomographic images, high FDG accumulation was observed in the breast (left, arrow) and ascending colon (right, arrow). Surgery and endoscopic polypectomy confirmed the lesions to be a 2-cm breast cancer and a 1·8-cm ascending colonic adenoma. A No
Age/sex
Diagnosis
Tumour size
Lymph-node metastasis
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
66/M 49/M 55/F 55/F 65/M 45/M 53/M 40/F 48/F 61/F 44/F 48/M 36/M 65/M 52/F
Lung cancer Lung cancer Lung cancer Lung cancer Lung cancer Colon cancer Rectal cancer Colon cancer Breast cancer Breast cancer Breast cancer Thyroid cancer Gastric cancer Renal cancer Malignant lymphoma
1 cm 1·3 cm 1·3 cm 1·9 cm 2·4 cm 3·5 cm 4 cm 6 cm 1·3 cm 2 cm 1·8 cm 3 cm 3·5 cm 4 cm
– – – – – – – – – – + – – –
No
Age/sex
Diagnosis
Clinical stage or tumour size
Methods of detection
1 2 3 4 5 6 7 8 9 10 11
66/M 76/M 67/M 78/M 47/F 51/F 60/M 41/M 54/M 53/F 66/M
Prostatic cancer Prostatic cancer Prostatic cancer Prostatic cancer Lung cancer Lung cancer Lung cancer Renal cancer Renal cancer Breast cancer Hepatoma
B B C D 8 mm 1·1 cm 1·5 cm 1·5 cm 6 cm 1·5 cm 1·6 cm
PSA PSA PSA PSA CT CT CT US US PE, US US
B
CT=computer tomography, US=ultrasonography, PE=physical examination, PSA=prostate-specific antigen.
PET-positive cancers (A) and PET-negative cancers (B) 3
Eur J Nucl Med 1996; 23: 1641–74. Yasuda S, Shohtsu A, Ide M, et al. Diffuse FDG uptake in chronic thyroiditis. J Nucl Med 1997; 38 (suppl): 154P–155P.
HIMEDIC Imaging Centre at Lake Yamanaka, Hirano, Yamanashi 401-05, Japan (S Yasuda)
1819
Research letters
Cancer screening with whole-body 18F-fluorodeoxyglucose positron-emission tomography Seiei Yasuda, Akira Shohtsu
Because there is increased glycolysis in cancer cells, wholebody positron emission tomography (WB PET) with 18Ffluorodeoxyglucose can be used to detect cancers (figure). With its high sensitivity and ability non-invasively to survey the entire body, WB PET has potential for detecting cancers of many types with a single examination. We investigated the use of WB PET for cancer screening in individuals without symptoms. We studied members of a medical health club in Yamanashi, Japan, participating in a continuing cancerscreening programme that incorporates clinical, imaging, and immunochemical methods for the detection of cancers.1 45 to 60 min after the administration of 260 to 370 MBq of 18Ffluorodeoxyglucose, emission scanning was done for approximately 35 min. PET results were compared with the final screening outcome. Over 21 months, 1872 people participated in 2563 screening sessions. Cancers were found in 26 (1·4%). PET findings were positive in 15 (table). Positive patients, except for one person with lymphoma, were successfully treated. In one patient with breast cancer, microscopic metastasis was observed in a dissected lymph node, but lymph node metastasis was not observed in any other patient. All lung cancers were stage I. There were 11 false-negative findings by PET. Six were in the bladder or kidneys. There were three false-negative lung cancers: an 8-mm tubular adenocarcinoma, a 1·2-cm bronchioloalveolar adenocarcinoma, and a 1·5-cm bronchioloalveolar adenocarcinoma; these were not found by chest radiography. One scirrhous type breast cancer (stage I) and one small hepatoma were negative with PET. During the follow-up period, cancers were discovered in four people examined when they had symptoms: a 1-cm bladder cancer 5 months after screening, a 2-cm common bile duct cancer at 7 months, a superficial oesophageal cancer at 9 months, and a 1-cm malignant lymphoma of the upper pharynx at 13 months. Rigo et al2 stated that FDG PET was not suited to unselected screening because of the likelihood of falsepositives. Our study is the first dealing with a large number of people without symptoms. Although a substantial number of benign lesions such as chronic thyroiditis,3 sarcoidosis, Warthin’s tumour, thyroid adenoma, and colonic adenoma, were discovered, these subclinical lesions were thought to warrant further clinical examination. False-positive interpretations can be avoided if the potential sites and characteristics of non-malignant lesions are recognised in the interpretation of PET images. Our results show that PET can be used to detect a wide variety of cancers in resectable stages. Further studies are needed to determine whether cancers associated with hypometabolism are biologically less aggressive or more indolent than those associated with hypermetabolism. 1 2
Ide M, Suzuki Y. A window on Japan: medical health club with clinical PET. Eur J Nucl Med 1996; 23: 1677–79. Rigo P, Paulus P, Kaschten BJ, et al. Oncological application of positron emission tomography with fluorodeoxyglucose.
Vol 350 • December 20/27, 1997
Whole-body PET images of a 61-year-old woman On coronal tomographic images, high FDG accumulation was observed in the breast (left, arrow) and ascending colon (right, arrow). Surgery and endoscopic polypectomy confirmed the lesions to be a 2-cm breast cancer and a 1·8-cm ascending colonic adenoma. A No
Age/sex
Diagnosis
Tumour size
Lymph-node metastasis
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
66/M 49/M 55/F 55/F 65/M 45/M 53/M 40/F 48/F 61/F 44/F 48/M 36/M 65/M 52/F
Lung cancer Lung cancer Lung cancer Lung cancer Lung cancer Colon cancer Rectal cancer Colon cancer Breast cancer Breast cancer Breast cancer Thyroid cancer Gastric cancer Renal cancer Malignant lymphoma
1 cm 1·3 cm 1·3 cm 1·9 cm 2·4 cm 3·5 cm 4 cm 6 cm 1·3 cm 2 cm 1·8 cm 3 cm 3·5 cm 4 cm
– – – – – – – – – – + – – –
No
Age/sex
Diagnosis
Clinical stage or tumour size
Methods of detection
1 2 3 4 5 6 7 8 9 10 11
66/M 76/M 67/M 78/M 47/F 51/F 60/M 41/M 54/M 53/F 66/M
Prostatic cancer Prostatic cancer Prostatic cancer Prostatic cancer Lung cancer Lung cancer Lung cancer Renal cancer Renal cancer Breast cancer Hepatoma
B B C D 8 mm 1·1 cm 1·5 cm 1·5 cm 6 cm 1·5 cm 1·6 cm
PSA PSA PSA PSA CT CT CT US US PE, US US
B
CT=computer tomography, US=ultrasonography, PE=physical examination, PSA=prostate-specific antigen.
PET-positive cancers (A) and PET-negative cancers (B) 3
Eur J Nucl Med 1996; 23: 1641–74. Yasuda S, Shohtsu A, Ide M, et al. Diffuse FDG uptake in chronic thyroiditis. J Nucl Med 1997; 38 (suppl): 154P–155P.
HIMEDIC Imaging Centre at Lake Yamanaka, Hirano, Yamanashi 401-05, Japan (S Yasuda)
1819