Korean J Radiol.  2019 Mar;20(3):513-521. 10.3348/kjr.2018.0409.

Solitary Nodular Invasive Mucinous Adenocarcinoma of the Lung: Imaging Diagnosis Using the Morphologic-Metabolic Dissociation Sign

• Cha MJ
• Lee KS
• Kim TJ
• Kim HS
• Kim TS
• Chung MJ
• Kim BT
• Kim YS

• KMID: 2438282
• DOI: http://doi.org/10.3348/kjr.2018.0409

Abstract

OBJECTIVE
To evaluate the efficacy of the morphologic-metabolic (M-M) dissociation sign based on computed tomography (CT) and fluorine-18-fluorodeoxyglucose positron emission tomography (PET)/CT in discriminating invasive mucinous adenocarcinoma (IMA) from invasive non-mucinous adenocarcinomas (ADCs) of the lung.
MATERIALS AND METHODS
The Institutional Review Board approved this retrospective study. Among surgically resected solitary pulmonary nodule (SPN)-type ADCs (< 3 cm in diameter), 35 patients with IMAs and 329 with invasive non-mucinous ADCs were included. Morphologic malignancy was established if the tumor with lobulated or spiculated margin on CT presented a tumor shadow disappearance rate of < 0.5. The M-M dissociation sign was determined when a malignant-morphologic nodule on CT showed maximum standardized uptake value (SUVmax) < 3.5 on PET/CT.
RESULTS
Among 35 IMAs (size: 21 ± 7 mm, SUVmax: 1.8 ± 2.0) and 329 invasive non-mucinous ADCs (size: 21 ± 6 mm, SUVmax: 4.6 ± 4.2), the M-M dissociation sign was observed in 54% of IMAs (19/35) and 10% of invasive non-mucinous ADCs (34/329) (p < 0.001). The diagnostic performance of the sign in discriminating IMA from invasive non-mucinous ADCs showed a sensitivity of 54.3% (95% confidence interval [CI], 36.7-71.2), specificity 89.7% (95% CI, 85.9-92.7), positive predictive value 35.8% (95% CI, 26.5-46.5), and negative predictive value 94.9% (95% CI, 92.8-96.4). Multivariate analyses revealed metabolic benignity (odds ratio [OR] 2.99; 95% CI, 1.01-8.93; p = 0.047) and M-M dissociation sign (OR 6.35; 95% CI, 2.76-14.62; p < 0.001) to be significant predictors of SPN-type IMAs.
CONCLUSION
Identification of the absence of M-M dissociation sign is an accurate indicator for excluding IMA from SPN-type lung ADCs.

Keyword

Lung; Invasive mucinous adenocarcinoma; Dissociation; CT; PET/CT

MeSH Terms

Adenocarcinoma
Adenocarcinoma, Mucinous*
Diagnosis*
Ethics Committees, Research
Fluorodeoxyglucose F18
Humans
Lung*
Mucins*
Multivariate Analysis
Positron-Emission Tomography
Positron-Emission Tomography and Computed Tomography
Retrospective Studies
Sensitivity and Specificity
Solitary Pulmonary Nodule
Fluorodeoxyglucose F18
Mucins

Figure

• 

  Fig. 1 Flow chart of patient selection.ADC = adenocarcinoma, CT = computed tomography, IMA = invasive mucinous adenocarcinoma, Nov. = November, PET = positron emission tomography, Sep. = September, SPN = solitary pulmonary nodule

• 

  Fig. 2 IMA with positive M-M dissociation sign in 43-year-old woman.A. Lung window image of transverse CT scan obtained at level of liver dome shows 30-mm-sized nodule with lobulated or spiculated margin (arrow) in right lower lobe (TDR = 1.34%). B. PET/CT image demonstrates scant 18F-FDG uptake (arrow) within tumor and with SUVmax of 2.2. FDG = fluorodeoxyglucose, M-M = morphologic-metabolic, SUVmax = maximum standardized uptake value, TDR = tumor shadow disappearance rate, 18F = fluorine-18

• 

  Fig. 3 IMA with positive M-M dissociation sign in 52-year-old woman.A. Lung window image of transverse CT scan obtained at level of left atrium shows 27-mm-sized nodule with lobulated or spiculated margin (arrow) in left lower lobe (TDR = 28.99%). Additionally, note internal cavitation or bubble lucency within tumor. B. PET/CT image demonstrates scant 18F-FDG uptake (arrow) within tumor and with SUVmax of 3.0.

• 

  Fig. 4 Invasive non-mucinous adenocarcinoma with negative M-M dissociation sign in 60-year-old man.A. Lung window image of transverse CT scan obtained at level of right bronchus intermedius shows 24-mm-sized lobulated and spiculated nodule (arrow) in right middle lobe (TDR = 35.31%). Additionally, note internal cavitation or bubble lucency within tumor. B. PET/CT image demonstrates hot 18F-FDG uptake (arrow) within tumor and with SUVmax of 12.9.

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