Value of [68Ga]Ga-Somatostatin Receptor PET/CT in the Grading of Pulmonary Neuroendocrine (Carcinoid) Tumours and the Detection of Disseminated Disease: Single Center Pathology-Based Analysis and Review of the Literature
Authors: Deleu Anne-Leen , Laenen Annouschka , Decaluwé Herbert , Weynand Birgit , Dooms Christophe , De Wever Walter , Jentjens Sander , Goffin Karolien , Vansteenkiste Johan , Laere Koen Van , De Leyn Paul , Nackaerts Kristiaan , Deroose Christophe 
Published: February 2022

Abstract
Background

Although most guidelines suggest performing a positron emission tomography/computed tomography (PET/CT) with somatostatin receptor (SSTR) ligands for staging of pulmonary carcinoid tumours (PC), only a limited number of studies have evaluated the role of this imaging tool in this specific patient population. The preoperative differentiation between typical carcinoid (TC) and atypical carcinoid (AC) and the extent of dissemination (N/M status) are crucial factors for treatment allocation and prognosis of these patients. Therefore we performed a retrospective analysis to assess the value of SSTR PET/CT in the tumour grading and the detection of lymph node involvement and distant metastases of PC with histopathology as gold standard, and compared this to [18F]FDG PET/CT in a subgroup of patients and to previous literature with group sizes of mostly 20-30 patients.
Methods

SSTR PET/CT scans performed between January 2007 and May 2020 in the context of PC were included. If available, [18F]FDG PET/CT images were also evaluated. The maximum standardized uptake (SUVmax) values of the primary tumour, of the pathologically examined hilar and mediastinal lymph nodes, as well as of the distant metastases, were recorded. Tumoural SUVmax values were related to the tumour type (TC versus AC) for both SSTR and [18F]FDG PET/CT in diagnosing and differentiating both tumour types. Nodal SUVmax values were compared to the pathological status (N+ versus N−) to evaluate the diagnostic accuracy of SSTR PET/CT in detecting lymph node involvement. Finally, a mixed model analysis of all pathologically proven distant metastatic lesions was performed.
Results

A total of 86 SSTR PET/CT scans performed in 86 patients with PC were retrospectively analyzed. [18F]FDG PET/CT was available in 46 patients. Analysis of the SUVmax values in the primary tumour showed significantly higher SSTR uptake in TC compared with AC (median SUVmax 18.4 vs 3.8; p=0.003) and significantly higher [18F]FDG uptake in AC compared to TC (median SUVmax 5.4 vs 3.5; p=0.038). Receiver operating characteristic (ROC) curve analysis resulted in an area under the curve (AUC) of 0.78 for the detection of TC on SSTR PET/CT and of 0.73 for the detection of AC on [18F]FDG PET/CT. A total of 267 pathologically evaluated hilar and mediastinal lymph nodes were analyzed. ROC analysis of paired SSTR/[18F]FDG SUVmax values for the detection of metastasis of TC in 83 lymph nodes revealed an AUC of 0.91 for SSTR PET/CT and of 0.74 for [18F]FDG PET/CT (difference 0.17; 95% confidence interval: -0.03 to 0.38; p = 0.10). In a sub-cohort of 10 patients with 12 lesions suspicious for distant metastases on SSTR PET/CT that were investigated with biopsies, a positive predictive value (PPV) of 100% was observed.
Conclusion

Our findings confirm the higher SSTR ligand uptake in TC compared to AC and vice versa for the [18F]FDG uptake. More importantly, we found a good diagnostic performance of SSTR PET/CT for the detection of hilar and mediastinal lymph node metastases of TC. Finally, a PPV of 100% for SSTR PET/CT was found in a small sub-cohort of patients with pathologically investigated distant metastatic lesions. Taken together, SSTR PET/CT has a very high diagnostic value in the TNM assessment of pulmonary carcinoids, particularly in TC, which underscores its position in European guidelines.