Case of the Month—July 2004

Lung Cancer—Downgrading of Initial Staging by PET

History
A 59-year-old male presented with a 3-cm nodule in the lingular area of the lung on CT scan. A biopsy confirmed poorly differentiated non-small cell lung cancer (NSCLC). The CT scan also indicated a 2x4-cm soft tissue mass adjacent to the left adrenal gland suspicious for metastasis (Figure 1). Based on CT findings, the patient was assessed at Stage 4.

Figure 1.

CT suspicious for adrenal mass, thought to be Stage 4. PET led to a downgrading to Stage 1.

PET Finding
A PET study was requested for staging of the patient. This study showed a hypermetabolism corresponding to the lingular mass seen on CT and is consistent with malignancy (Figure 2, arrow). There is, however, no significant uptake corresponding to the soft tissue mass in the left adrenal region (Figure 3). Based on PET, the patient’s staging was downgraded to Stage 1.

Figure 2

Figure 3

Follow-Up
Biopsy of the left adrenal mass reveals benign mesothelial cells and benign ciliated columnar epithelial cells. No malignant cells were identified.

How Did PET Help?
PET findings downgraded the patient’s initial staging from Stage 4 to Stage 1. The patient’s management was altered from nonsurgical treatment to surgical resection.

Discussion
PET is often highlighted as a tool to correctly stage lymph node and distant metastasis, often leading to an upgrade of the patient’s staging. This case, however, illustrates a downgrading of the patient’s staging as an outcome of the PET.

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