Diagnostic Performance of Diffusion Weighted Imaging of Malignant and Benign Pulmonary Nodules and Masses: Comparison with Positron Emission Tomography

  • Usuda, Katsuo (Department of Thoracic Surgery, Kanazawa Medical University) ;
  • Sagawa, Motoyasu (Department of Thoracic Surgery, Kanazawa Medical University) ;
  • Motono, Nozomu (Department of Thoracic Surgery, Kanazawa Medical University) ;
  • Ueno, Masakatsu (Department of Thoracic Surgery, Kanazawa Medical University) ;
  • Tanaka, Makoto (Department of Thoracic Surgery, Kanazawa Medical University) ;
  • Machida, Yuichiro (Department of Thoracic Surgery, Kanazawa Medical University) ;
  • Maeda, Sumiko (Department of Thoracic Surgery, Kanazawa Medical University) ;
  • Matoba, Munetaka (Department of Radiology, Kanazawa Medical University) ;
  • Kuginuki, Yasuaki (Department of Radiology, Kanazawa Medical University) ;
  • Taniguchi, Mitsuru (Department of Radiology, Kanazawa Medical University) ;
  • Tonami, Hisao (Department of Radiology, Kanazawa Medical University) ;
  • Ueda, Yoshimichi (Department of Radiology, Kanazawa Medical University) ;
  • Sakuma, Tsutomu (Department of Thoracic Surgery, Kanazawa Medical University)
  • Published : 2014.06.15


Background: Diffusion-weighted imaging (DWI) makes it possible to detect malignant tumors based on the diffusion of water molecules. However, it is uncertain whether DWI has advantages over FDG-PET for distinguishing malignant from benign pulmonary nodules and masses. Materials and Methods: One hundred-forty-three lung cancers, 17 metastatic lung tumors, and 29 benign pulmonary nodules and masses were assessed in this study. DWI and FDG-PET were performed. Results: The apparent diffusion coefficient (ADC) value ($1.27{\pm}0.35{\times}10^{-3}mm^2/sec$) of malignant pulmonary nodules and masses was significantly lower than that ($1.66{\pm}0.58{\times}10^{-3}mm^2/sec$) of benign pulmonary nodules and masses. The maximum standardized uptake value (SUVmax: $7.47{\pm}6.10$) of malignant pulmonary nodules and masses were also significantly higher than that ($3.89{\pm}4.04$) of benign nodules and masses. By using optimal cutoff values for ADC ($1.44{\times}10^{-3}mm^2/sec$) and for SUVmax (3.43), which were determined with receiver operating characteristics curves (ROC curves), the sensitivity (80.0%) of DWI was significantly higher than that (70.0%) of FDG-PET. The specificity (65.5%) of DWI was equal to that (65.5%) of FDG-PET. The accuracy (77.8%) of DWI was not significantly higher than that (69.3%) of FDG-PET for pulmonary nodules and masses. As the percentage of bronchioloalveolar carcinoma (BAC) component in adenocarcinoma increased, the sensitivity of FDG-PET decreased. DWI could not help in the diagnosis of mucinous adenocarcinomas as malignant, and FDG-PET could help in the correct diagnosis of 5 out of 6 mucinous adenocarcinomas as malignant. Conclusions: DWI has higher potential than PET in assessing pulmonary nodules and masses. Both diagnostic approaches have their specific strengths and weaknesses which are determined by the underlying pathology of pulmonary nodules and masses.


Supported by : the Ministry of Education, Culture, Sports, Science and Technology


  1. Ebright MI, Zakowski MF, Martin J, et al (2002). Clinical pattern and pathologic stage but not histologic features predict outcome for bronchioloalveolar carcinoma. Ann Thorac Surg, 74, 1640-7.
  2. Cheran SK, Nielsen ND, Patz EF (2004). False-negative findings for primary lung tumors on FDG positron emission tomography. Staging and prognostic implications. AJR, 182, 1129-32.
  3. Chun EJ, Lee HJ, Kang WJ, et al (2009). Differentiation between malignancy and inflammation in pulmonary ground-glass nodules: The feasibility of integrated 18F-FDG PET/CT. Lung Cancer, 65, 180-6.
  4. Desprechins B, Stadnik T, Koerts G, et al (1999). Use of diffusion-weighted MR imaging in differential diagnosis between intracerebral necrotic tumors and cerebral abscesses. Am J Neuroradiol, 20, 1252-7.
  5. Ding XP, Zhang J, Li BS, et al (2012). Feasibility of shrinking field radiation therapy thorough 18F-FDG PET/CT after 40Gy for stage III non-small cell lung camcers. Asian Pac J Cancer Prev, 13, 319-23.
  6. Ebisu T, Tanaka C, Umeda M, et al (1996). Discrimination of brain abscess from necrotic or cystic tumors by diffusion-weighted echo planar imaging. Magn Reson Imaging, 14, 1113-6.
  7. Feuerlein S, Pauls S, Juchems MS, et al (2009). Pitfalls in abdominal diffusion-weighted imaging. How predictive is restricted water diffusion for malignancy. AJR, 193, 1070-6.
  8. Fornasa F, Pinali L, Gasparini A, Toniolli E, Montemezzi S (2011). Diffusion-weighted magnetic resonance imaging in focal breast lesions. Analysis of 78 cases with pathological correlation. Radiol med, 116, 264-75.
  9. Goo JM, Im JG, Do KH, et al (2000). Pulmonary tuberculoma evaluated by means of FDG PET. Findings in 10 cases. Radiology, 216, 117-21.
  10. Gould MK, Maclean CC, Kuschner WG, Rydzak CE, Owens DK (2001). Accuracy of positron emission tomography for diagnosis of pulmonary nodules and mass lesions. A meta-analysis. JAMA, 285, 914-24.
  11. Koike N, Cho A, Nasu K, et al (2009). Role of diffusion-weighted magnetic resonance imaging in the differential diagnosis of focal hepatic lesions. World J gastroenterol, 15, 5805-12.
  12. Higashi K, Ueda Y, Seki H, et al (1998). Fluorine-18-FDG PET imaging is negative in bronchioloalveolar lung carcinoma. J Nucl Med, 39, 1016-20.
  13. Higashiyama M, Kodama K, Yokouchi H, et al (1999). Prognostic value of bronchiolo-alveolar carcinoma component of small lung adenocarcinoma. Ann Thorac Surg, 68, 2069-73.
  14. International Union Against Cancer (2009). TNM classification of malignant tumours. 7th ed. NY, Wiley-Liss, 138-46.
  15. Komori T, Narabayashi I, Matsumura K, et al (2007). 2-fluorine-18 fluoro-2-deoxy-D-glucose positron emission tomography/ computed tomography versus whole-body diffusion-weighted MRI for detection of malignant lesions. Initial experience. Ann Nucl Med, 21, 209-15.
  16. Kwee TC, Takahara T, Ochiai R, et al (2010). Complementary roles of whole-body diffusion-weighted MRI and 18F-FDG PET. The state of the art and potential application. J Nucl Med, 51, 1549-58.
  17. Le Bihan D, Breton E, Lallemand D, et al (1988). Separation of diffusion and perfusion in intravoxel incoherent motion MR imaging. Radiology, 168, 497-505.
  18. Lowe, VJ, Fletcher JW, Gobar L, et al (1998). Prospective investigation of positron emission tomography in lung nodules. J Clin Oncol, 16, 1075-84.
  19. Mori T, Nomori H, Ikeda K, et al (2008). Diffusion-weighted magnetic resonance imaging for diagnosing malignant pulmonary nodules/masses. Comparison with positron emission tomography. J Thoracic Oncol, 3, 358-64.
  20. Nomori H, Watanabe K, Ohtsuka T, et al (2004). Evaluation of F-18 fluorodeoxyglucose (FDG) PET scanning for pulmonary nodules less than 3cm in diameter, with special reference to the CT images. Lung cancer, 45, 19-27.
  21. Mutlu H, Buyukcelik A, Erden A, et al (2013). Staging with PET-CT in patients with locally advanced non small cell lung cancer is superior to conventional staging methods in terms of survival. Asian Pac J Cancer Prev, 14, 3743-6.
  22. Nasu K, Kuroki Y, Minami M (2012). Diffusion-weighted imaging findings of mucinous carcinoma arising in the ano-rectal region. Comparison of apparent diffusion coefficient with that of tubular adenocarcinoma. Jpn J Radiol, 30, 120-7.
  23. Nomori H, Mori T, Ikeda K, et al (2008). Diffusion-weighted magnetic resonance imaging can be used in place of positron emission tomography for N staging of non-small cell lung cancer with fewer false-positive results. J Thoracic Cardiovasc Surg, 135, 816-22.
  24. Ohba Y, Nomori H, Mori T, et al (2009). Is diffusion-weighted magnetic resonance imaging superior to positron emission tomography with fludeoxyglucose F 18 in imaging non-small cell lung cancer? J Thorac Cardiovasc Surg, 138, 439-45.
  25. Ohno Y, Koyama H, Yoshikawa T, et al (2012). Diffusion-weighted MRI versus 18F-FDG PET/CT: performance as predictors of tumor treatment response and patient survival in patients with non-small cell lung cancer receiving chemoradiotherapy. AJR, 198, 75-82.
  26. Read WL, Page NC, Tierney RM, Piccirillo JF, Govindan R (2004). The epidemiology of bronchioloalveolar carcinoma over the past two decades: analysis of the SEER database. Lung Cancer, 45, 137-42.
  27. Satoh Y, Ichikawa T, Motosugi U, et al (2011). Diagnosis of peritoneal disseminatiom. Comparison of 18F-FDG PET/CT, diffusion-weighted MRI, and contrast-enhanced MDCT. AJR, 196, 447-53.
  28. Tien RD, Felsberg GJ, Friedman H, Brown M, MacFall J (1994). MR imaging of high-grade cerebral gliomas. Value of diffusion-weighted echoplanar pluse sequences. AJR, 162, 671-7.
  29. Sorensen AG, Buonanno FS, Gonzalez RG, et al (1996). Hyperacute stroke. Evaluation with combined multisection diffusion-weighted and hemodynamically weighted echo-planar MR imaging. Radiology, 199, 391-401.
  30. Szafer A, Zhong J, Gore JC (1995). Theoretical model for water diffusion in tissues. Magn Reson Med, 33, 697-712.
  31. Takahara T, Imai Y, Yamashita T, et al (2004). Diffusion weighted whole body imaging with background body signal suppression (DWIBS). Technical improvement using free breathing, STIR and high resolution 3D display. Radiat Med, 22, 275-82.
  32. Tondo F, Saponaro A, Stecco A, et al (2011). Role of diffusion-weighted imaging in the differential diagnosis of benign and malignant lesions of the chest-mediastinum. Radiol Med, 116, 720-33.
  33. Travis WD, Garg K, Franklin WA, et al (2005). Evolving concepts in the pathology and computed tomography imaging of lung adenocarcinoma and bronchioloalveolar carcinoma. J Clin Oncol, 23, 3279-87
  34. Tsushima Y, Tateishi U, Uno H, et al (2008). Diagnostic performance of PET/CT in differentiation of malignant and benign non-solid solitary pulmonary nodules. Ann Nucl Med, 22, 571-7.
  35. Usuda K, Zhao XT, Sagawa M, et al (2011). Diffusion-weighted imaging is superior to PET in the detection and nodal assessment of lung cancers. Ann Thorac Surg, 91, 1689-95.
  36. Uto T, Takehara Y, Nakamura Y, et al (2009). Higher sensitivity and specificity for diffusion-weighted imaging of malignant lung lesions without apparent diffusion coefficient quantification. Radiology, 252, 247-54.
  37. Wu LM, Hu J, Gu HY, Hua J, Xu JR (2013). Can diffusion-weighted magnetic resonance imaging (DW-MRI) alone be used as a reliable sequence for the preoperative detection and characterisation of hepatic metastases? A meta-analysis. Eur J Cancer, 49, 572-84.
  38. Wu LM, Xu JR, Gu HY, et al (2012). Preoperative mediastinal and hilar nodal staging with diffusion-weighted magnetic resonance imaging and fluorodeoxyglucose positron emission tomography/computed tomography in patients with non-small-cell lung cancer: which is better? J Surg Res, 178, 304-14.
  39. Wu LM, Xu JR, Hua J, et al (2013). Can diffusion-weighted imaging be used as a reliable sequence in the detection of malignant pulmonary nodules and masses? Magn Reson Imaging, 31, 235-46.

Cited by

  1. Recurrence and Metastasis of Lung Cancer Demonstrate Decreased Diffusion on Diffusion-Weighted Magnetic Resonance Imaging vol.15, pp.16, 2014,
  2. Diagnostic Significance of Apparent Diffusion Coefficient Values with Diffusion Weighted MRI in Breast Cancer: a Meta-Analysis vol.15, pp.19, 2014,
  3. Diagnostic Performance of Diffusion - Weighted Imaging for Multiple Hilar and Mediastinal Lymph Nodes with FDG Accumulation vol.16, pp.15, 2015,
  4. Diffusion Weighted Imaging Can Distinguish Benign from Malignant Mediastinal Tumors and Mass Lesions: Comparison with Positron Emission Tomography vol.16, pp.15, 2015,
  5. Apparent diffusion coefficient values of diffusion-weighted imaging for distinguishing focal pulmonary lesions and characterizing the subtype of lung cancer: a meta-analysis vol.26, pp.2, 2016,
  6. Use of diffusion-weighted magnetic resonance imaging to distinguish between lung cancer and focal inflammatory lesions: a comparison of intravoxel incoherent motion derived parameters and apparent diffusion coefficient vol.57, pp.11, 2016,
  7. Is it better to include necrosis in apparent diffusion coefficient (ADC) measurements? The necrosis/wall ADC ratio to differentiate malignant and benign necrotic lung lesions: Preliminary results vol.46, pp.4, 2017,
  8. Non-Gaussian diffusion imaging for malignant and benign pulmonary nodule differentiation: a preliminary study vol.58, pp.1, 2017,
  9. Diagnostic Performance of DWI With Multiple Parameters for Assessment and Characterization of Pulmonary Lesions: A Meta-Analysis vol.210, pp.1, 2018,
  10. Fluorine 18–FDG PET/CT and Diffusion-weighted MRI for Malignant versus Benign Pulmonary Lesions: A Meta-Analysis pp.1527-1315, 2018,
  11. Usefulness of both PET/CT with F18-FDG and whole-body diffusion-weighted imaging in cancer screening: a preliminary report pp.1864-6433, 2018,
  12. Diffusion-weighted MRI in solitary pulmonary lesions: associations between apparent diffusion coefficient and multiple histopathological parameters vol.8, pp.1, 2018,
  13. FDG-PET/CT and diffusion-weighted imaging for resected lung cancer: correlation of maximum standardized uptake value and apparent diffusion coefficient value with prognostic factors vol.35, pp.5, 2018,