title: Detection of underlying malignancy in patients with paraneoplastic neurological syndromes: comparison of 18F-FDG PET/CT and contrast-enhanced CT.
abstract: OBJECTIVE
  To determine the value of combined (18)F-FDG PET/CT with diagnostic contrast-enhanced CT (CECT) in detecting primary malignancies and metastases in patients with paraneoplastic neurological syndromes (PNS) and to compare this with CECT alone.
  
  
  METHODS
  PET/CT scans from 66 patients with PNS were retrospectively evaluated. Two blinded readers initially reviewed the CECT portion of each PET/CT scan. In a second session 3 months later, the readers analysed the combined PET/CT scans. Findings on each study were assessed using a four-point-scale (1 normal/benign; 2 inconclusive, further diagnostic work-up may be necessary; 3 malignant; 4 inflammatory). Sensitivity and specificity for malignant findings were calculated for PET/CT and CECT. Interreader agreement was determined by calculating Cohen's kappa. Pooled data from clinical follow-up (including histopathology and follow-up imaging, median follow-up 20.0 months) served as the reference gold standard.
  
  
  RESULTS
  Both readers classified 12 findings in ten patients (15%) as malignant on the PET/CT scans (two patients had two primary tumours). One such imaging finding (suspected thymic cancer) was false-positive (i.e. benign histology). The most common tumours were bronchial carcinoma (n = 3), lymph node metastases of gynaecological tumours (n = 3) and tonsillar carcinoma (n = 2). Three of 12 findings (25%) were not detected by CECT alone (cervical carcinoma, lymph node metastasis and tonsillar carcinoma). In a per-patient analysis, sensitivity and specificity for malignant findings were 100% and 90% for PET/CT and 78% and 88% for CECT. In 24% (reader 1) and 21% (reader 2) of the patients, the PET/CT findings were inconclusive. Of these findings, 57% (reader 1) and 56% (reader 2) were only diagnosed with PET (e.g. focal FDG uptake of the thyroid, gastrointestinal tract and ovaries). On follow-up, none of these findings corresponded to malignancy. Overall agreement between the two readers was excellent with a Cohen's kappa of 0.95 ± 0.04 (p < 0.001) for PET/CT and 0.97 ± 0.03 (p < 0.001) for CECT alone.
  
  
  CONCLUSIONS
  In this cohort of patients with PNS, PET/CT exhibited improved detection of underlying malignancy versus CECT alone. While hybrid imaging produces a greater number of inconclusive findings, sensitivity is increased for the detection of head and neck and gynaecological malignancies as well as metastatic lymph node involvement.
authors.affiliation: Institute for Clinical Radiology, Ludwig-Maximilians-University Hospital Munich, Marchioninistrasse 15, 81377 Munich, Germany. nicolai.schramm@med.uni-muenchen.de
authors.forename: N
authors.initials: N
authors.lastname: Schramm
authors.forename: A
authors.initials: A
authors.lastname: Rominger
authors.forename: C
authors.initials: C
authors.lastname: Schmidt
authors.forename: J N
authors.initials: JN
authors.lastname: Morelli
authors.forename: C
authors.initials: C
authors.lastname: Schmid-Tannwald
authors.forename: F G
authors.initials: FG
authors.lastname: Meinel
authors.forename: M F
authors.initials: MF
authors.lastname: Reiser
authors.forename: C
authors.initials: C
authors.lastname: Rist
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003287:Contrast Media; D005260:Female; D019788:Fluorodeoxyglucose F18; D006801:Humans; D008297:Male; D008875:Middle Aged; D064847:Multimodal Imaging; D009362:Neoplasm Metastasis; D015588:Observer Variation; D020361:Paraneoplastic Syndromes, Nervous System / Q000000981:diagnostic imaging* / Q000473:pathology; D049268:Positron-Emission Tomography; D012189:Retrospective Studies; D014057:Tomography, X-Ray Computed; D055815:Young Adult
chemical_list: D003287:Contrast Media; D019788:Fluorodeoxyglucose F18