DOI: 10.1186/s13550-018-0359-7Pages: 1-10

Diagnostic implications of a small-voxel reconstruction for loco-regional lymph node characterization in breast cancer patients using FDG-PET/CT

1. Isala, Department of Nuclear Medicine

2. University of Twente, MIRA Institute for Biomedical Technology and Technical Medicine

3. Isala, Department of Medical Physics

4. Isala, Department of Surgery

5. Isala, Department of Pathology

Correspondence to:
Daniëlle Koopman
Tel: +31 38 424 5238




We evaluated the diagnostic implications of a small-voxel reconstruction for lymph node characterization in breast cancer patients, using state-of-the-art FDG-PET/CT. We included 69 FDG-PET/CT scans from breast cancer patients. PET data were reconstructed using standard 4 × 4 × 4 mm3 and small 2 × 2 × 2 mm3 voxels. Two hundred thirty loco-regional lymph nodes were included, of which 209 nodes were visualised on PET/CT. All nodes were visually scored as benign or malignant, and SUVmax and TBratio(=SUVmax/SUVbackground) were measured. Final diagnosis was based on histological or imaging information. We determined the accuracy, sensitivity and specificity for both reconstruction methods and calculated optimal cut-off values to distinguish benign from malignant nodes.


Sixty-one benign and 169 malignant lymph nodes were included. Visual evaluation accuracy was 73% (sensitivity 67%, specificity 89%) on standard-voxel images and 77% (sensitivity 78%, specificity 74%) on small-voxel images (p = 0.13). Across malignant nodes visualised on PET/CT, the small-voxel score was more often correct compared with the standard-voxel score (89 vs. 76%, p <  0.001). In benign nodes, the standard-voxel score was more often correct (89 vs. 74%, p = 0.04).

Quantitative data were based on the 61 benign and 148 malignant lymph nodes visualised on PET/CT. SUVs and TBratio were on average 3.0 and 1.6 times higher in malignant nodes compared to those in benign nodes (p <  0.001), on standard- and small-voxel PET images respectively. Small-voxel PET showed average increases in SUVmax and TBratio of typically 40% over standard-voxel PET. The optimal SUVmax cut-off using standard-voxels was 1.8 (sensitivity 81%, specificity 95%, accuracy 85%) while for small-voxels, the optimal SUVmax cut-off was 2.6 (sensitivity 78%, specificity 98%, accuracy 84%). Differences in accuracy were non-significant.


Small-voxel PET/CT improves the sensitivity of visual lymph node characterization and provides a higher detection rate of malignant lymph nodes. However, small-voxel PET/CT also introduced more false-positive results in benign nodes. Across all nodes, differences in accuracy were non-significant. Quantitatively, small-voxel images require higher cut-off values. Readers have to adapt their reference standards.

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  • Accepted: Jan 9, 2018
  • Online: Jan 16, 2018

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