Rationale and Objective
Coregistered SPECT and CT imaging (SPECT-CT) has potential for more precise evaluation of regional pulmonary function and may be useful for prediction of postoperative lung function in non−small cell lung cancer (NSCLC) patients. The purpose of the present study was to prospectively assess the capability of coregistered SPECT-CT using krypton-81m (Kr-81m) and technetium-99m−labeled macroaggregated albumin (Tc-99m MAA) for prediction of postoperative lung function of NSCLC patients compared with SPECT and planar imaging.
Materials and Methods
Sixty consecutive patients considered candidates for lung resection underwent 16-slice CT, ventilation and perfusion scintigraphy with SPECT examinations, and preoperative and postoperative measurement of FEV 1 %. In each subject, SPECT and CT data were automatically fused by using commercially available software. Each postoperative FEV 1 % value was predicted from uptakes of Kr-81m and Tc-99m MAA within total and resected lungs. Then, reproducibility coefficients and the limits of agreement between actual and each predicted postoperative lung function were statistically assessed.
Results
Reproducibility coefficients of SPECT-CT (Kr-81m: 5.1%, Tc-99m MAA: 5.2%) were smaller than those of SPECT and planar image using Kr-81m (SPECT: 7.4%, planar image: 12.1%) and using Tc-99m MAA (SPECT: 7.2%, planar image: 11.8%). The limits of agreement for SPECT-CT (Kr-81m: 3.3 ± 10.5%, Tc-99m MAA: 5.4 ± 11.0%) were also smaller than that of SPECT and planar image and small enough for clinical purposes.
Conclusions
Coregistered SPECT-CT using Kr-81m and Tc-99m MAA was able to more reproducibly and accurately predict postoperative lung function compared with SPECT and planar imaging.
Lung cancer continues to be the most common fatal malignancy ( ). In patients with non−small cell lung cancer (NSCLC), surgical resection offers the only realistic chance of cure. Most patients with lung cancer have a history of cigarette smoking, which brings risks for other conditions that may increase operative risks, including chronic obstructive pulmonary disease and coronary artery disease. Some of these patients have poor respiratory reserve so that surgery results in an unacceptable quality of life. Therefore, clinicians are frequently asked to evaluate the risks and feasibility of lung resection for patients with a combination of adverse conditions. Recently, predicted postoperative lung function and/or exercise testing has gained increasing importance in the evaluation of lung resection candidates ( ). An algorithm for functional assessment of lung resection candidates has been proposed by Wyser et al. ( ).
In current medical practice, it has been suggested that perfusion lung scan combined with spirometry can be useful for evaluation of the patient whose pulmonary function may not be adequate to tolerate resection as indicated by spirometry alone ( ). Reported correlation coefficients of predicted and actual postoperative lung function using this method vary between 0.51 and 0.92 ( ). In comparison with perfusion scintigraphy, ventilation scintigraphy is not commonly used for assessment of the degree of emphysema and prediction of postoperative lung function. However, some investigators have suggested the utility of ventilation scintigraphy as planar imaging or single-photon emission tomography (SPECT) for assessment of pulmonary emphysema and pulmonary thromboembolism and prediction of postoperative lung function ( ). In addition, a few investigators have suggested accurate assessment of regional ventilation abnormality by using krypton-81m (Kr-81m) gas similar to ultrafine aerosols with Tc-99m and/ or Tc-99m diethylenetriaminepentaacetic acid (DTPA) ( ). Although the use of ventilation and perfusion planar imaging and SPECT has been reported, they are not widely used for the assessment of lobectomy or segmentectomy because of the difficulty in interpreting the contribution of individual lobes to the overall findings, relatively longer data acquisition time, limited improvement of prediction error in candidate for lung resection, and higher costs compared with CT examination ( ).
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Materials and methods
Subjects
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Ventilation and Perfusion Scintigraphic Examination
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CT Examination
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Automated Coregistration of SPECT and CT Images
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Physiological Index and Outcome Measures
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Prediction of Postoperative Lung Function
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PredictedpostoperativeFEV1%=preoperativeFEV1%×(totallungactivity-summedradioactivityofROIsplacedovertheresectedlobe)÷totallungactivity Predicted
postoperative
FEV
1
%
=
preoperative
FEV
1
%
×
(
total
lung
activity-summed
radioactivity
of
ROIs
placed
over
the
resected
lobe
)
÷
total
lung
activity
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PredictedpostoperativeFEV1%=preoperativeFEV1%×(1-meanradioactivityofROIsplacedovertheresectedlobeonanteriorandposteriorimages/meantotallungactivityonanteriorandposteriorimages) Predicted
postoperative
FEV
1
%
=
preoperative
FEV
1
%
×
(
1-mean
radioactivity
of
ROIs
placed
over
the
resected
lobe
on
anterior
and
posterior
images
/
mean
total
lung
activity
on
anterior
and
posterior
images
)
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Image and Statistical Analysis of Ventilation and Perfusion SPECT-CTs
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Results
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Table 1
Patient characteristics
Age Mean (yr) 70 Range (yr) 45−85 Sex Male 30 Female 30 Operations Lobectomy 51 Bilobectomy 6 Pneumonectomy 3 Histological subtype Adenocarcinoma 46 Squamous cell carcinoma 8 Large cell carcinoma 4 Small cell carcinoma 2 Preoperative FEV 1 % Mean ± SD (%) 75.0 ± 17.3 Range (%) 43.0−110.0 Actual postoperative FEV 1 % Mean ± SD (%) 66.0 ± 13.7 Range (%) 39.0−93.0
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Table 2
Degree of Tumoral Misregistration on Each Axis for Ventilation and Perfusion SPECT-CT
x-axis y-axis z-axis Mean ± SD (mm), (range) Mean ± SD (mm), (range) Mean ± SD (mm), (range) Ventilation SPECT-CT 6.8 ± 2.8 (4−13) 6.8 ± 2.8 (4−14) 10.1 ± 4.5 ⁎ † (6−20) Perfusion SPECT-CT 7.3 ± 3.0 (4−16) 7.2 ± 3.1 (4−16) 10.6 ± 4.9 ⁎ † (6−24)
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Table 3
Correlation Between Actual and Predicted Postoperative FEV 1 % and Reproducibility Coefficient of Predicted Postoperative FEV 1 % on Each Method
Correlation Coefficient ( r ) Between Actual and Predicted Postoperative FEV 1 % Reproducibility Coefficient (%) SPECT-CT using Kr-81m 0.93 ⁎ 5.1 SPECT-CT using Tc-99m MAA 0.92 ⁎ 5.2 SPECT using Kr-81m 0.93 ⁎ 7.4 SPECT using Tc-99m MAA 0.92 ⁎ 7.2 Planar image using Kr-81m 0.89 ⁎ 12.1 Planar image using Tc-99m MAA 0.9 ⁎ 11.8
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Discussion
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Acknowledgments
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