DOI: 10.1007/s00259-018-4016-1Pages: 1-10

Performance of FDG-PET/CT in solitary pulmonary nodule based on pre-test likelihood of malignancy: results from the ITALIAN retrospective multicenter trial

1. Istituto Oncologico Veneto IOV - IRCCS, SSD Medicina Nucleare e Imaging Molecolare

2. Università degli Studi di Napoli Federico II, Dipartimento di Scienze Biomediche Avanzate

3. Università degli Studi di Salerno, Dipartimento di Medicina, Chirurgia e Odontoiatria “Scuola Medica Salernitana”

4. Centro Interuniversitario di Ricerca per lo Sviluppo Sostenibile

5. Struttura Complessa di Medicina Nucleare, Ospedale San Giuseppe Moscati

6. Università degli Studi di Bologna, Servizio di Medicina Nucleare, Policlinico S. Orsola Malpighi

7. Università di Milano Bicocca, Unità di Medicina Nucleare, Ospedale San Gerardo

8. Ospedale Humanitas, Unità di Medicina Nucleare, Cancer Center

9. Medicina Futura IOS, Unità di Medicina Nucleare, Dipartimento delle Immagini

10. Unità di Medicina Nucleare, Dipartimento delle Immagini, SDN-IRCCS

11. Centro di Riferimento Oncologico della Basilicata-IRCCS

12. Ospedale Universitario Integrato di Verona, Unità di Medicina Nucleare, Dipartimento delle Immagini

13. Università Cattolica del Sacro Cuore, Istituto di Medicina Nucleare

14. Ospedale di Bolzano, Dipartimento di Medicina Nucleare

15. Università Tor Vergata, Dipartimento di Biomedicina e Prevenzione

16. Servizio di Medicina Nucleare, IRCCS Neuromed

17. Ospedale del Mare, Struttura Complessa di Medicina Nucleare

Correspondence to:
Laura Evangelista




The aim of this study was to determine the performance of 18F-FDG-PET/CT in patients with solitary pulmonary nodule (SPN), stratifying the risk according to the likelihood of pulmonary malignancy.


FDG-PET/CT of 502 patients, stratified for pre-test cancer risk, were retrospectively analyzed. FDG uptake in SPN was assessed by a 4-point scoring system and semiquantitative analysis using the ratio between SUVmax in SPN and SUVmean in mediastinal blood pool (BP) and between SUVmax in SPN and SUVmean in liver (L). Histopathology and/or follow-up data were used as standard of reference.


SPN was malignant in 180 (36%) patients, benign in 175 (35%), and indeterminate in 147 (29%). The 355 patients with a definitive SPN nature (malignant or benign) were considered for the analysis. Considering FDG uptake ≥ 2, sensitivity, specificity, positive (PPV) and negative (NPV) predictive values, and accuracy were 85.6%, 85.7%, 86%, 85.2%, and 85.6% respectively. Sensitivity and PPV were higher (P < 0.05) in intermediate and high-risk patients, while specificity and NPV were higher (P < 0.05) in low-risk patients. On receiver operating characteristic curve analysis, the cut-offs for better discrimination between benign and malignant SPN were 1.56 (sensitivity 81% and specificity 87%) and 1.12 (sensitivity 81% and specificity 86%) for SUVmax/SUVmeanBP and SUVmax/SUVmeanL respectively. In intermediate and high-risk patients, including the SUVmax/SUVmeanBP, the specificity shifted from 85% and 50% to 100%.


Visual FDG-PET/CT has an acceptable performance in patients with SPN, but accuracy improves when SUVratios are considered, particularly in patients with intermediate and high risk of malignancy.

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  • Accepted: Apr 9, 2018
  • Online: May 7, 2018

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