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J Thorac Cardiovasc Surg 2006;132:215
© 2006 The American Association for Thoracic Surgery

Letter to the Editor

Reply to the Editor

Jeffrey L. Port, MD, David F. Yankelevitz, MD, Nasser K. Altorki, MD

Department of Cardiothoracic Surgery, Weill Medical College of Cornell University, New York, NY

Reply to the Editor:

We thank Drs Khandani and Detterbeck for their insightful comments on our article. Its main conclusion was that standard uptake values (SUVs) obtained from positron emission tomographic (PET) imaging were not useful for staging lung cancers smaller than 2 cm. We note that there was no disagreement with that conclusion, but rather the suggestion that visual inspection by experienced readers is now the accepted standard. A listing of some of the technical reasons why SUVs can be misleading is then given.

We agree that several recent articles have suggested that an expert reading may be equivalent to or better than a single cutoff for SUV. However, this is by no means a generally accepted standard. In fact, clinicians overwhelmingly continue to use the maximum SUV for differentiating benign from malignant lesions. This clinical practice is influenced by early PET reports, 1 Go in which a remarkably high accuracy of SUV was reported for differentiating benign from malignant nodules.

The problems outlined by Drs Khandani and Detterbeck regarding the limitations of the maximum SUV also affect the capability of experienced clinicians in making evaluations. Ultimately, anything that limits the ability to make quantitative assessments will also affect semiquantitative or nonquantitative assessments as well. The latest efforts in PET imaging include adding some form of gating to improve quantitative assessments, and likely there will again be discussion of whether this will become the new accepted standard. For now, the maximum SUV continues to be reported and to guide clinical practice. We look forward to improvements in PET technology and remain hopeful that the utility of PET for small lesions will improve; however, there are some fundamental limitations that we believe will continue to be problematic in the foreseeable future.


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  1. Patz Jr EF, Lowe VJ, Hoffman JM, Paine SS, Burrowes P, Coleman RE, et al. Focal pulmonary abnormalities. evaluation with F-18 fluorodeoxyglucose PET scanning. Radiology 1993;188:487-490.[Abstract/Free Full Text]

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Amir H. Khandani and Frank C. Detterbeck
J. Thorac. Cardiovasc. Surg. 2006 132: 214-215. [Extract] [Full Text] [PDF]



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