Adrenal nodules at FDG PET/CT in patients known to have or suspected of having lung cancer: A proposal for an efficient diagnostic algorithm

Purpose: To develop an algorithm to maximize the diagnostic yield of positron emission tomography (PET)/computed tomography (CT) by using defined attenuation and standardized uptake value (SUV) criteria. Materials and Methods: An IRB-approved, HIPAA-compliant retrospective review with waiver of informed consent of data in 1388 consecutive patients who underwent PET/CT for known or suspected lung cancer was completed, and 187 adrenal nodules were identified in 147 patients. Nodules were defined histologically or by size change (malignant, n = 37) or stability for more than 1 year (benign, n = 58). Nodules not sampled for biopsy and with less than 1 year of follow-up were considered indeterminate (n = 92). Diameter, mean attenuation, SUV _max, and SUV ratio (nodule SUV _max/liver SUV _avg) were compared with t test and receiver operating characteristic analyses. Sensitivity, specificity, positive predictive value, and negative predictive value were calculated for diameter > 3 cm, mean attenuation > 10 HU, nodule SUV _max > 3.1, and SUV ratio > 1.0. These were also calculated for higher SUV _max and SUV ratio thresholds that were found to exclude all false-positives. Diagnostic accuracy was compared by using the McNemar test (P < .05). Results: In the study group of 147 patients (aged 42-88 years; mean, 65.5 years; 59 women), combined PET/CT with mean attenuation > 10 HU and SUV _max > 3.1 had 97.3% sensitivity and 86.2% specificity. Combined PET/CT with mean attenuation > 10 HU and SUV ratio > 1.0 had 97.3% sensitivity and 74.1% specificity. The accuracies of these threshold combinations (90.5% and 83.2%, respectively) were significantly different (P = .008). Applying a further cutoff of SUV ratio > 2.5 enabled identification of 22 of 37 metastatic lesions and exclusion of all fluorodeoxyglucose- avid benign nodules. Conclusion: Definitive identification of many metastases can be accomplished by applying an SUV ratio cutoff of greater than 2.5, allowing pragmatic management of adrenal nodules that initially test positive with the combined PET/CT criteria SUV _max > 3.1 and mean attenuation > 10 HU.