Usefulness of Lung Perfusion Scintigraphy Before Lung Cancer Resection in Patients with Ventilatory Obstruction

doi:10.1016/j.athoracsur.2006.05.041

The Annals of Thoracic Surgery

Volume 82, Issue 5, November 2006, Pages 1828-1834

Presented at the Poster Session of the Forty-second Annual Meeting of The Society of Thoracic Surgeons, Chicago, IL, Jan 30–Feb 1, 2006.

https://doi.org/10.1016/j.athoracsur.2006.05.041 Get rights and content

Background

The study was conducted to evaluate the efficacy of preoperative lung perfusion scintigraphy performed by planar acquisition and single-photon emission computed tomography (SPECT) in predicting postoperative pulmonary function of patients with resectable lung cancer and obstructive ventilatory defect.

Methods

The study enrolled 39 patients (mean age, 67 ± 2.1 years). All patients underwent preoperative and postoperative pulmonary function tests. Cut-off values for postoperative forced expiratory volume in 1 second (FEV₁) were 65% of the predicted value for pneumonectomy and 45% for lobectomy. A semiquantitative analysis of planar and SPECT lung perfusion scintigraphy images was performed preoperatively to estimate postoperative predicted FEV₁ (FEV₁ppo). Relationships between FEV₁ppo and measured postoperative FEV₁ were tested by the Pearson correlation and Bland Altman agreement tests.

Results

Twenty-eight lobectomies and 11 pneumonectomies were performed. The FEV₁ppo estimated by mean planar lung scintigraphy was 1.85 ± 0.38 L, with a Pearson correlation coefficient to the measured FEV₁ of 0.8632 (p < 0.001). The mean FEV₁ppo estimated by SPECT was 1.78 ± 0.31 L, with a Pearson coefficient to the measured FEV₁ of 0.8527 (p < 0.001). Both values showed a more significant correlation with postoperative measured FEV₁ after lobectomy (p < 0.001) than after pneumonectomy (p = 0.045). The Bland Altman test confirmed satisfactory agreement of FEV₁ppo estimated by both planar lung scintigraphy and SPECT with FEV₁ measured by spirometry.

Conclusions

Both planar lung scintigraphy and SPECT can accurately predict postoperative FEV₁ and can therefore be considered reliable tools in establishing operability of patients with lung cancer and ventilatory obstruction.

Section snippets

Patients and Methods

A prospective study was conducted on 39 patients (31 men, 8 women) with a mean age of 67 ± 2.1 who had anatomic resection for lung cancer between January 2004 and January 2005. The ethics committee of the Tor Vergata University approved the study, and written informed consent was obtained from all recruited patients.

Preoperative and postoperative (60 ± 22 days) pulmonary function tests were performed according to the American Thoracic Society guidelines [4]. The preoperative evaluation included

Results

Of 39 operated patients, 28 subjects underwent lobectomy and 11 had pneumonectomy. Histologic diagnosis was squamous cell carcinoma in 22 patients, adenocarcinoma in 11, and large cell carcinoma in 6. Preoperative and postoperative data of each patient are summarized in Table 1. The overall mean preoperative FEV₁% was 59.41% ± 5.44%, with a mean of 61.54% ± 3.2% in patients undergoing a pneumonectomy and 58.57% ± 6.6% in those undergoing a lobectomy. Correlations are listed in Table 2.

The mean

Comment

Prediction of postsurgical pulmonary function is crucial in limiting morbidity and mortality after lung resection in patients with ventilatory obstruction, making accurate preoperative evaluation the key to successful outcome [2, 3, 4, 6, 7, 10, 11]. Measurement of ventilatory indexes, including FEV₁, diffusing capacity of the lungs for carbon monoxide, and maximal oxygen uptake, usually represents the first step of this evaluation process, although the usefulness of each of these indexes

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Cited by (30)

Head-to-head comparison of lung perfusion with dual-energy CT and SPECT-CT
2020, Diagnostic and Interventional Imaging
Citation Excerpt :
Both techniques are also required as a part of the diagnostic work up prior to lobe reduction surgery or radiation therapy for lung cancer. Pulmonary scintigraphy as a functional modality is indicated for perfusion defect imaging or relative lobar perfusion to anticipate post-operative lung function [2,3]. Then CT as a morphological modality is indicated for pulmonary vessel imaging or resection management before volume reduction surgery [4,5].
To compare the quantitative and qualitative lung perfusion data acquired with dual energy CT (DECT) to that acquired with a large field-of-view cadmium-zinc-telluride camera single-photon emission CT coupled to a CT system (SPECT-CT).
A total of 53 patients who underwent both dual-layer DECT angiography and perfusion SPECT-CT for pulmonary hypertension or pre-operative lobar resection surgery were retrospectively included. There were 30 men and 23 women with a mean age of 65.4 ± 17.5 (SD) years (range: 18–88 years). Relative lobar perfusion was calculated by dividing the amount (of radiotracer or iodinated contrast agent) per lobe by the total amount in both lungs. Linear regression, Bland-Altman analysis, and Pearson's correlation coefficient were also calculated. Kappa test was used to test agreements in morphology and severity of perfusion defects assessed on SPECT-CT and on DECT iodine maps with a one-month interval. Wilcoxon rank sum test was used to compare the sharpness of perfusion defects and radiation dose among modalities.
Strong correlations for relative lobar perfusion using linear regression analysis and Pearson's correlation coefficient (r = 0.93) were found. Bland-Altman analysis revealed a −0.10 bias, with limits of agreement between [−6.01; 5.81]. With respect to SPECT- CT as standard of reference, the sensitivity, specificity, PPV, NPV, accuracy for lobar perfusion defects were 89.4% (95%  CI: 82.6−93.4%), 96.5% (95% CI: 92.1−98.5%), 95.6% (95% CI:  90.9−97.8%), 91.4% (95% CI: 85.6−94.9%) and 93.0% (95% CI:  87.6−96.1%) respectively. High level of agreement was found for morphology and severity of perfusion defects between modalities (Kappa = 0.84 and 0.86 respectively) and on DECT images among readers (Kappa = 0.94 and 0.89 respectively). A significantly sharper delineation of perfusion defects was found on DECT images (P < 0.0001) using a significantly lower equivalent dose of 4.1 ± 2.3 (SD) mSv (range: 1.9–11.85 mSv) compared to an equivalent dose of 5.3 ± 1.1 (SD) mSv (range: 2.8–7.3 mSv) for SPECT-CT, corresponding to a 21.2% dose reduction (P = 0.0004).
DECT imaging shows strong quantitative correlations and qualitative agreements with SPECT-CT for the evaluation of lung perfusion.
Evaluation of pulmonary perfusion SECT-CT in the prediction of postoperative pulmonary function
2019, Medecine Nucleaire
L’objectif de notre étude était d’évaluer les performances de la tomographie d’émission monophotonique couplée à la tomodensitométrie (TEMP-TDM) de perfusion pulmonaire avec analyse quantitative semi-automatique dans le bilan d’opérabilité des cancers pulmonaires.
Trente-cinq patients ont bénéficié d’une scintigraphie de perfusion pulmonaire préopératoire (en acquisition planaire et TEMP-TDM) d’août 2016 à décembre 2017. Les volumes expiratoires maximaux en une seconde (VEMS) postopératoires prédits (VEMSpopp) par chacune des 2 méthodes ont été comparés entre eux et au VEMS postopératoire (VEMSpop) à 3 mois. Nous avons également évalué la reproductibilité inter-observateur du logiciel de segmentation semi-automatique et la concordance des données simulant des réductions du temps d’acquisition de 30 et 50 %.
Pour les trente lobectomies et 5 pneumonectomies, les deux méthodes étaient concordantes entre elles avec un coefficient de corrélation à 0,827 IC 95 % [0,686–0,909]. Elles sous-estimaient le VEMSpop qui était en moyenne de 69 %, soit une différence moyenne respective de −8 et −6,77 % (p < 0,001) pour la TEMP-TDM et la scintigraphie planaire. La reproductibilité inter-observateur du logiciel de segmentation en TEMP-TDM était excellente au niveau pulmonaire et lobaire. La participation fonctionnelle lobaire, après amputation de 30 à 50 % du temps d’acquisition, présentait des écarts absolus < 3 % par rapport aux données natives.
La TEMP-TDM ne s’est pas avérée statistiquement supérieure aux planaires, le VEMSpop étant difficile à prévoir compte tenu de facteurs confondants. Pourtant, cet examen pourrait avoir un intérêt avant lobectomie et en cas d’hétérogénéité de la perfusion. Facilement réalisable, cette méthode est très reproductible, y compris sur les données simulant une diminution du temps d’acquisition de 50 %.
The aim of our study was to evaluate the performances of pulmonary perfusion single photon emission computed tomography-computed tomography (SPECT-CT) with semi-automatic analysis for preoperative assessment for lung cancer.
Thirty-five patients underwent preoperative lung perfusion scintigraphy (planar and SPECT-CT acquisition) from august 2016 to December 2017. Predicted postoperative forced expiratory volume in one second (ppoFEV1 and FEV1) by both methods were compared between each other and with the actual FEV1 measured 3 months after surgery. We also evaluated interobserver reproductibility of SPECT-CT semi-automatic segmentation software and the concordance of the data simulating reductions of 30 and 50% of acquisition time.
For 30 lobectomies and 5 pneumonectomies, the mean ppoFEV1 was 69%, a difference with actual ppoFEV1 of −8% for SPECT-CT and −6.77% for planar (P < 0,001). Both methods were well correlated, correlation coefficient was 0,827, 95% CI [0.686–0.909] but underestimated the actual poppFEV1. For SPECT-CT, interobserver reproducibility was excellent for pulmonary and lobar evaluation. The lobar functions, without 30 and 50% of the time acquisition, had absolute difference < 3% in comparison to native data.
We did not prove SPECT-CT superiority on planar scintigraphy, actual FEV1 being difficult to predict because of confounding factors. But this exam could be useful before lobectomy and in cases of heterogeneous perfusion. Easily made, this method is reproducible even on data simulating a reduction of 50% of time acquisition.
Preoperative evaluation of the lung function before lobular resection using lung perfusion tomoscintigraphy with computed tomography: A pilot feasibility study
2016, Medecine Nucleaire
Évaluer la faisabilité en routine clinique de la tomoscintigraphie de perfusion pulmonaire couplée au scanner pour prédire la fonction pulmonaire postopératoire avant lobectomie.
Vingt-deux patients avec un volume expiratoire maximal par seconde (VEMS) ou une diffusion libre du monoxyde de carbone (DLCO) inférieure ou égale à 80 % ayant bénéficié d’une tomoscintigraphie pulmonaire couplée au scanner (TEMP/TDM) de perfusion et de ventilation préopératoire étaient inclus. Les images planaires étaient obtenues à partir des données de tomoscintigraphie. Les données de la perfusion pulmonaire et lobaire ont été évaluées et le VEMS postopératoire prédit calculé selon une méthode de simple calcul, selon la scintigraphie planaire, puis selon la TEMP/TDM.
Le VEMS préopératoire moyen était de 62 % (±3,96). Les données de la scintigraphie planaire et de la TEMP/TDM étaient corrélées pour l’évaluation pulmonaire à 0,992 (p = 0,01) et à 0,73 (p = 0,01) pour l’évaluation lobaire selon le test de Pearson. Le Bland-Altman évalue une moyenne des différences pour l’évaluation pulmonaire à 0,59 à droite et −0,59 à gauche et à −1,83 pour l’évaluation lobaire avec des limites d’agrément, respectivement, à 4,39 et −3,2 ; 3,2 et −4,4 ; 15,4 et −19,06.
La prédiction de la fonction respiratoire avant lobectomie par la tomoscintigraphie couplée au scanner de perfusion pulmonaire est réalisable en routine. Nous avons trouvé une excellente corrélation des données de la TEMP/TDM avec l’imagerie planaire au niveau pulmonaire. Par contre, il existe une forte dispersion entre les résultats des deux modalités au niveau lobaire avec une tendance à sous-estimer la perfusion lobaire pour les images planaires. En considérant qu’une évaluation basée sur une image lobaire anatomique sera plus fiable, nous proposons de réaliser une TEMP/TDM pour la quantification de la fonction pulmonaire avant résection lobaire.
Evaluate the feasibility of lung singe photon emission computed tomography with computed tomography (SPECT-CT) before lobular resection in order to obtain an accurate predictive respiratory function for patients with pulmonary disease undergoing surgery.
We included retrospectively 22 patients with a forced expiratory volume in 1 second (FEV1) or with a diffusing capacity for carbon monoxide (DLCO) under 80 %. They all underwent a SPECT-CT lung perfusion and ventilation scan. Planar imaging were extracted from the SPECT-CT data. Lung and lobular perfusion data were then evaluated. FEV1 was then predicted by the simple calculation method, then by the planar and the SPECT-CT lung scintigraphy.
Mean FEV1 was equal to 62 % (±3.96). We estimate the Pearson's linear correlation coefficient between planar imaging and SPECT-CT for lung evaluation at 0.992 (P = 0.01) and for lobar evaluation at 0.73 (P = 0.01). Bland-Altman found a mean absolute differences between the two methods (planar – SPECT-CT) at 0.59 on the right and −0.59 on the left lung for lung evaluation and at −1.83 for the lobar evaluation with agreement limits respectively at 4.39 and −3,2; 3.2 and −4.4; 15.4 and −19.06.
Quantification pulmonary perfusion with SPECT-CT is feasible. We found excellent agreement between planar imaging and SPECT-CT at pulmonary level. Contrariwise, there is a consequential spreading at lobular level with a tendency to underestimate lobular perfusion with planar imaging. Therefore, considering anatomical-based imaging can be more accurate, we propose, when possible, to use SPECT-CT for lobular functional evaluation. With this new technique, preoperative evaluation of the lung function before lobular resection using lung scintigraphy can become valuable.
Improved prediction of lobar perfusion contribution using technetium-99m-labeled macroaggregate of albumin single photon emission computed tomography/computed tomography with attenuation correction
2014, Journal of Thoracic and Cardiovascular Surgery
Citation Excerpt :
Several approaches are possible for the calculation of the ppoFEV1: the segment technique, radionuclide scanning technique, and quantitative CT.21,27 The recommendations for the preoperative workup include the use of perfusion scintigraphy (American College of Chest Physicians, British Thoracic Society, European Respiratory Society) for planned pneumonectomy and the use of segment counting or quantitative CT for planned lobectomy.14-16 Several investigators have agreed that ventilation scintigraphy, perfusion scintigraphy, quantitative CT, and segment counting perform similarly in estimating postoperative lung function in both the long and the short term after pneumonectomy, with good correlation to the actual FEV1.7,8,15,24 However, at present, no guideline has incorporated perfusion scintigraphy in planned lobectomy, likely because until the advent of SPECT/CT, the lobar anatomy could not be delineated using perfusion scintigraphy.
Lung cancer resection can require removal of an entire lobe and, at times, bilobectomy or pneumonectomy. Many patients will also have significantly compromised lung function that requires limiting the extent of surgery or could preclude surgery altogether. The preoperative assessment should include predicted postoperative forced expiratory volume in 1 second (ppoFEV1), because a ppoFEV1 of <40% predicts significantly increased perioperative morbidity. The ppoFEV1 can be estimated by multiplying the preoperative FEV1 by the residual perfused territory percentage, as predicted on planar perfusion scintigraphy (PPS). However, ppoFEV1 using PPS has shown variable correlation with spirometry-measured postoperative FEV1.
We propose an improved method for assessing regional lung perfusion in preoperative lung surgery patients. Patients undergo single photon emission computed tomography/computed tomography (SPECT/CT) imaging with attenuation correction using the conventional perfusion agent, technetium-99m–labeled macroaggregate of albumin. The CT image provides information for manual segmentation of each lobe. These segmentations are applied to the SPECT images to determine lobar perfusion. This proposed method was compared with PPS.
This technique was evaluated in 17 patients. As expected, the perfusion contributions of the right and left lungs, calculated from SPECT/CT, correlated closely with those obtained from PPS (Pearson r = 0.995). However, the lobar perfusion contributions obtained by PPS and SPECT/CT were significantly different, by 2 methods of comparison (Hotelling's P = 1.7 × 10⁻⁶ and P = 1.7 × 10⁻⁴).
This new SPECT/CT technique provides an anatomically more accurate assessment of lobar perfusion. This technique can refine which patients should be operative candidates and allow better prediction of postoperative function in contrast to the anatomically inaccurate planar scintigraphic predictions, which often underestimate the postoperative FEV1. This new technique is expected to have a significant effect on the resectability of patients with lung cancer.
Vibration response imaging versus perfusion scan in lung cancer surgery evaluation
2014, Journal of Thoracic and Cardiovascular Surgery
Citation Excerpt :
More complex techniques have been investigated, such as single-photon emission CT. Mineo and colleagues18 recently reported correlations of 0.83 to 0.85. These authors studied the pulmonary function of 39 patients and compared prediction using single-photon emission CT before surgery with measurements after surgery.
Ventilation/perfusion scan is a standard procedure in high-risk surgical patients to predict pulmonary function after surgery. Vibration response imaging is a technique that could be used in these patients. The objective of our study was to compare this imaging technique with the usual scanning technique for predicting postoperative forced expiratory volume.
We assessed 48 patients with lung cancer who were candidates for lung resection. Forced spirometry, vibration response imaging, and ventilation/perfusion scan were performed in patients before surgery, and spirometry was performed after intervention.
We included 48 patients (43 men; mean age, 64 years) undergoing lung cancer surgery (32 lobectomies/16 pneumonectomies). On comparison of both techniques, for pneumonectomy, we found a concordance of 0.84 (95% confidence interval, 0.76-0.92) and Bland–Altman limits of agreement of −0.33 to +0.45, with an average difference of 0.064. By comparing postoperative spirometry with vibration response imaging, we found a concordance of 0.66 (95% confidence interval, 0.38-0.93) and Bland–Altman limits of agreement of −0.60 to +0.33, with an average difference of −0.13.
The 2 techniques presented good concordance values. Vibration response imaging shows non-negligible confidence intervals. Vibration response imaging may be useful in preoperative algorithms in patients before lung cancer surgery.
Vibration response imaging in prediction of pulmonary function after pulmonary resection
2012, Annals of Thoracic Surgery
Citation Excerpt :
We measured the postoperative FEV1 or Dlco at 4 to 6 weeks after the operation because the ppoFEV1 or ppoDlco was reported to be fairly accurate 1 month after major pulmonary resection, but the actual values were underestimated more than 3 months postoperatively [18]. The correlation between the ppoFEV1 using a scan and the postoperative FEV1 has been variable, with correlative figures ranging between r = 0.67 and 0.9 [4, 19–24]. This study showed a significant correlation between the ppoFEV1 using a scan and the postoperative FEV1 (r = 0.83), similar to previous studies.
Vibration response imaging (VRI) is a new technique that captures lung sounds generated by the flow of air through the lungs. It predicts postoperative values for an intended lung resection. In this study, we measured the predicted postoperative pulmonary function as determined by a perfusion lung scan and the VRI, and compared with results from the postoperative pulmonary function.
This study was performed prospectively in patients who were candidates for major pulmonary resection. Each patient underwent a pulmonary function test, perfusion scintigraphy, and VRI within 1 week before operation. Postoperative lung function was measured at 4 to 6 weeks.
The study enrolled 44 patients. There were no significant differences for predicted postoperative forced expiratory volume in 1 second (ppoFEV₁) and predicted postoperative diffusion capacity of the lung for carbon monoxide (ppoDlco) between scan and VRI. Both ppoFEV₁ and ppoDlco using a scan and VRI predicted the postoperative results well, respectively. The postoperative FEV₁ was correlated with ppoFEV₁ using a scan (r = 0.83, p < 0.001), and the ppoFEV₁ using a VRI (r = 0.83, p < 0.001). The postoperative Dlco was correlated with the ppoDlco using a scan (r = 0.85, p < 0.001), and the ppoDlco using a VRI (r = 0.80, p < 0.001).
The VRI was highly predictive of postoperative FEV₁ and Dlco for lung resection.

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Original articleGeneral thoracicUsefulness of Lung Perfusion Scintigraphy Before Lung Cancer Resection in Patients with Ventilatory Obstruction

Background

Methods

Results

Conclusions

Section snippets

Patients and Methods

Results

Comment

Clin Chest Med

Chest

Chest

Clin Chest Med

Ann Thorac Surg

Lung Cancer

Respir Med

Am J Med

Thorac Surg Clin

Chest

Semin Thorac Cardiovasc Surg

Relationship between pulmonary function and lung cancer surgical outcome

Eur Respir J

Original article
General thoracic
Usefulness of Lung Perfusion Scintigraphy Before Lung Cancer Resection in Patients with Ventilatory Obstruction