ARTICLE IN PRESS
Interactive CardioVascular and Thoracic Surgery 12 (2011) 806–811
? 2011 Published by European Association for Cardio-Thoracic Surgery
Best evidence topic - Thoracic oncologic
Does positron emission tomography offer prognostic information
in malignant pleural mesothelioma?
Sumera Sharif , Imran Zahid , Tom Routledge , Marco Scarci *
Imperial College London, South Kensington Campus, London SW7 2AZ, UK
Department of Thoracic Surgery, Guy’s Hospital, London SE1 9RT, UK
Received 14 September 2010; received in revised form 17 December 2010; accepted 4 January 2011
A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether positron
emission tomography is useful in the diagnosis and prognosis of malignant pleural mesothelioma (MPM). Altogether 136 papers were found
using the reported search, of which 15 represented the best evidence to answer the clinical question. The authors, journal, date and
country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that
fluorodeoxyglucose-positron emission tomography (FDG-PET) accurately differentiates benign from malignant pleural disease, helps detect
recurrence and provides prognostic information in terms of staging, survival and mortality. Eleven studies evaluated the role of FDG-PET in
the diagnosis and prognosis of MPM. Malignant disease had a higher standardised uptake value (SUV) (6.5"3.4 vs. 0.8"0.6; P-0.001) than
benign pleural disease. Shorter median survival (9.7 vs. 21 months; Ps0.02) was associated with high SUV ()10) than low SUV (-10). PET
accurately upstaged 13% and downstaged 27% of cases initially staged with computed tomography (CT). In patients undergoing chemotherapy,
higher total glycolytic volume led to a lower median survival (4.9 vs. 11.5 months; Ps0.09), while a decline in FDG uptake was associated
with a longer time to tumour progression (14 vs. 7 months; Ps0.02). Four studies observed the role of FDG-PET-CT in the diagnosis and
prognosis of MPM. SUV was found to be higher in MPM compared to benign pleural disease (6.5 vs. 0.8; P-0.001). A higher SUV
observed in primary pleural lesions of metastatic (7.1 vs. 4.7; Ps0.003) compared to non-metastatic disease. Patients who underwent
surgery had equivalent survival to those excluded based on scan results (20 vs. 12 months; Ps0.3813). One study compared the utility of
PET and PET-CT in the diagnosis and prognosis of mesothelioma. PET-CT was found to be more accurate than PET in terms of staging
(P-0.05) disease. Overall, PET accurately diagnoses MPM, predicts survival and disease recurrence. It can guide further management by
predicting the response to chemotherapy and excluding surgery in patients with extrathoracic disease. Combined PET-CT has additional
benefits in accurately staging disease.
? 2011 Published by European Association for Cardio-Thoracic Surgery. All rights reserved.
Keywords: Malignant mesothelioma; Positron emission tomography; Diagnosis; Prognosis
A best evidence topic was constructed according to a
structured protocol. This is fully described in ICVTS w1x.
2. Three-part question
Inwpatients with malignant pleural mesotheliomaxiswpos-
itron emission tomographyx superior to wcomputed tomog-
wdiagnostic, staging and prognostic data providedx.
3. Clinical scenario
You are at a multidisciplinary meeting and review a 55-
year-old male with a confirmed histological diagnosis of
malignant pleural mesothelioma (MPM). You are asked
whether positron emission tomography (PET) would provide
*Corresponding author. Tel.: q44-75-15542899; fax: q44-20-71881016.
E-mail address: email@example.com (M. Scarci).
additional diagnostic or prognostic information. You are
unsure about the extent to which PET may have a role and
resolve to check the literature yourself.
4. Search strategy
Medline search 1950 to August 2010 was performed using
(exp MesotheliomayOR mesothelioma.mp) AND (exp Posi-
tron-Emission TomographyyOR positron emission tomogra-
phy.mp. or PET.mp)
5. Search outcome
One hundred and thirty-six papers were found using the
reported search. From these, 15 papers provided the best
evidence to answer the question. These are presented in
Table 1. In addition, the reference list of each paper was
ARTICLE IN PRESS
S. Sharif et al. / Interactive CardioVascular and Thoracic Surgery 12 (2011) 806–811
Proposal for Bail-
7. Clinical bottom line
PET is useful diagnostic tool to identify and stage MPM
and differentiate it from benign pleural disease. The above
studies have found PET to be useful in the prediction of
survival, determination of mortality risk and detection of
metastases and recurrent disease. However, the combina-
tion of PET-CT produced superior diagnostic results than
PET alone, highlighting the need for further prospective
studies to refine the role of PET and PET-CT in different
settings of MPM.
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eComment: What is the best way to diagnose and stage malignant
Authors: Stefano Cafarotti, Department of Thoracic Surgery, Catholic
University, Rome, Italy; Venanzio Porziella, Stefano Margaritora,Pierluigi
We have read with great interest the article by Sharif et al. w1x reporting
on the role of positron emission tomography-computed tomography (PET-
CT) imaging in the diagnosis and prognosis of malignant pleuralmesothelioma
There are many diagnostic modalities to identify patients with MPM.
Currently, there is no consensus as to which single modality should be used
to confirm diagnosis prior to surgery. Increasingly, PET-CT is playing a crucial
role in the assessment of patients with known or suspected MPM due to its
capacity for: 1. differentiation from benign pleural diseases, 2. high sensi-
tivity in preoperative staging for the selection of appropriate surgical
candidates, 3. post-treatment surveillance for recurrence, 4. evaluation of
PET-CT seems to be superior to other imaging modalities in detecting more
extensive disease involvement, and in identifying unsuspected occult distant
metastases. However, surgical or radiological pleural biopsy still provides
the most accurate definitive diagnosis in MPM, as reported by the authors
themselves in another published paper w2x, although it is a more invasive
procedure than PET-CT. If indeed it is true that PET-CT increases the accuracy
of overall staging in patients with MPM and significantly improves the
selection of patients for curative surgical resection, it is also true that
histological confirmation is required and mandatory due to the evidence
that histological subtype is an established prognostic factor in malignant
pleural mesothelioma w3x. The current diagnostic gold standard is principally
based on light microscopic examination of hematoxylin-eosin and immuno-
histochemical stains of large tissue sections or cellular tissue. Indeed
pathological diagnosis of MPM and classification of histological findings into
one of the three subtypes (epithelial, sarcomatoid, biphasic) are necessary
to evaluate the impact on prognosis.
In conclusion, to achieve accurate diagnosis of MPM, obtaining cellular or
large tissue samples in the initial examination is recommended. The integra-
tion of PET-CT and biopsy offers the best way to diagnose and stage MPM.
w1x Sharif S, Zahid I, Routledge T, Scarci M Does positron emission tomog-
raphy offer prognostic information in malignant pleural mesothelioma?
Interact CardioVasc Thorac Surg 2011;12:806–811.
w2x Zahid I, Sharif S, Routledge T, Scarci M. What is the best way to
diagnose and stage malignant pleural mesothelioma? Interact Cardio-
Vasc Thorac Surg 2011;12:254–259.
w3x Kao SC, Yan TD, Lee K, Burn J, Henderson DW, Klebe S, Kennedy C,
Vardy J, Clarke S, van Zandwijk N, McCaughan BC. Accuracy of
diagnostic biopsy for the histological subtype of malignant pleural
mesothelioma. J Thorac Oncol 2011 Jan 24. wEpub ahead of printx.