The noninvasive staging of non-small cell lung cancer: the guidelines

Automatic definition of the central-chest lymph-node stations

PURPOSE

Lung cancer remains the leading cause of cancer death in the United States. Central to the lung-cancer diagnosis and staging process is the assessment of the central-chest lymph nodes. This assessment requires two steps: (1) examination of the lymph-node stations and identification of diagnostically important nodes in a three-dimensional (3D) multidetector computed tomography (MDCT) chest scan; (2) tissue sampling of the identified nodes. We describe a computer-based system for automatically defining the central-chest lymph-node stations in a 3D MDCT chest scan.

METHODS

Automated methods first construct a 3D chest model, consisting of the airway tree, aorta, pulmonary artery, and other anatomical structures. Subsequent automated analysis then defines the 3D regional nodal stations, as specified by the internationally standardized TNM lung-cancer staging system. This analysis involves extracting over 140 pertinent anatomical landmarks from structures contained in the 3D chest model. Next, the physician uses data mining tools within the system to interactively select diagnostically important lymph nodes contained in the regional nodal stations.

RESULTS

Results from a ground-truth database of unlabeled lymph nodes identified in 32 MDCT scans verify the system's performance. The system automatically defined 3D regional nodal stations that correctly labeled 96% of the database's lymph nodes, with 93% of the stations correctly labeling 100% of their constituent nodes.

CONCLUSIONS

The system accurately defines the regional nodal stations in a given high-resolution 3D MDCT chest scan and eases a physician's burden for analyzing a given MDCT scan for lymph-node station assessment. It also shows potential as an aid for preplanning lung-cancer staging procedures.

18F-FDG PET/CT imaging in oncology

Accurate diagnosis and staging are essential for the optimal management of cancer patients. Positron emission tomography with 2-deoxy-2-[fluorine-18]fluoro-D-glucose integrated with computed tomography (18F-FDG PET/CT) has emerged as a powerful imaging tool for the detection of various cancers. The combined acquisition of PET and CT has synergistic advantages over PET or CT alone and minimizes their individual limitations. It is a valuable tool for staging and restaging of some tumors and has an important role in the detection of recurrence in asymptomatic patients with rising tumor marker levels and patients with negative or equivocal findings on conventional imaging techniques. It also allows for monitoring response to therapy and permitting timely modification of therapeutic regimens. In about 27% of the patients, the course of management is changed. This review provides guidance for oncologists/radiotherapists and clinical and surgical specialists on the use of 18F-FDG PET/CT in oncology.

Activated carbon nanoparticles or methylene blue as tracer during video-assisted thoracic surgery for lung cancer can help pathologist find the detected lymph nodes

BACKGROUND

To assess whether using methylene blue (MB) or activated carbon nanoparticles as tracer can increase the detected number of lymph nodes in the systematic nodal dissected tissue during Video-Assisted Thoracic Surgery (VATS) for non-small cell lung cancer.

METHODS

Three groups of 20 patients each were obtained from randomization of 60 patients with NSCLC requiring VATS with systematic nodal dissection (SND) from February 2007 and December 2008, there were 17, 16, and 17 patients in group A (injection activated carbon nanoparticles), group B (injection MB), and group C (controls), respectively.

RESULTS

There was difference of the total number of dissected lymph nodes per patient among three groups (P < 0.001). The total number of dissected LNs and mediastinal nodes per patient in group A and group B was more than in group C (P < 0.001). There were 20, 18, and 14 metastatic LNs dissected in 6, 6, and 7 patients of group A, B, and C, respectively. There was difference of total number of dissected metastatic LNs per patient among three groups (P = 0.002).

CONCLUSIONS

MB can be as effective as activated carbon nanoparticles being tracer to increase the detected number of LNs in the systematic nodal dissected tissue during VATS for NSCLC.

Analysis of wait times and costs during the peri-diagnostic period for non-small cell lung cancer

PURPOSE

To determine the wait times and healthcare costs around the time of non-small cell lung cancer (NSCLC) diagnosis for a large, population-based cohort of patients.

METHODS

Data on baseline demographics, diagnostic and staging tests, timelines of investigations, and frequency of physician visits and hospital admissions were obtained from a provincial cancer registry and health administrative databases for 2852 patients, who were diagnosed with NSCLC from 1996 to 2000 in Manitoba, Canada. Dates between investigations were used to determine wait times surrounding diagnosis and fee codes for physician and hospital services were used to estimate costs.

RESULTS

The median wait times from chest x-ray to chest computed tomography (CT) scan and from CT scan to definitive histological diagnosis were 8 (inter-quartile range 1-25) and 18 (inter-quartile range 3-42) days, respectively. At least 25% of patients waited more than 55 days from initial suspicion on chest x-ray to final diagnosis of NSCLC. The mean cost per case of NSCLC diagnosis was $6,978 (in Canadian dollars) where the majority of expenses was attributed to hospital admissions and repeated physician visits before a diagnosis was confirmed.

CONCLUSIONS

Despite clinical suspicion for NSCLC, a significant number of patients wait more than 8 weeks for a definitive diagnosis. Substantial costs are incurred by the Canadian universal healthcare system in the months surrounding diagnosis. Establishment of more efficient and cost-effective healthcare delivery in the peri-diagnostic time period may benefit the system as well as the patients.

Accuracy and sensitivity of computed tomography-guided percutaneous needle biopsy of pulmonary hilar lymph nodes

BACKGROUND

Because of their proximity to the pulmonary artery or vein, hilar lymph nodes are routinely biopsied with endobronchial or endoscopic ultrasonography (EUS)-guided fine-needle aspiration biopsy (FNAB). Computed tomography (CT)-guided percutaneous needle biopsy (PNB) allows the operator to acquire a larger core needle biopsy (CNB) when initial samples are inconclusive, when the suspected disease is not optimally diagnosed with FNAB, or when biomarkers are required. The purpose of this study was to retrospectively evaluate the sensitivity and accuracy of CT-guided PNB in patients with hilar adenopathy.

METHODS

The authors identified 80 patients who underwent 81 CT-guided PNBs of pulmonary hilar lesions from October 2002 through December 2006 and retrospectively reviewed their medical and imaging records. The PNB sensitivity and accuracy were calculated in each case, and each case was reviewed for complications, including pneumothorax and subsequent thoracostomy tube insertion.

RESULTS

PNB included FNAB and CNB in 81 (100%) and 14 (17%) procedures, respectively. Data on 69 PNB specimens (67 FNAB specimens and 13 CNB specimens) were available for statistical analysis. Overall, PNB had a sensitivity of 91.4% (95% confidence interval [CI], 81.0%-97.1%) and an accuracy rate of 92.8% (95% CI, 83.9%-97.1%). Pneumothoraxes occurred in 39 patients (48%), 26 (32%) of whom required thoracostomy tube insertion.

CONCLUSIONS

CT-guided PNB of pulmonary hilar lesions has high sensitivity and accuracy and represents a viable alternative for endobronchial ultrasound- or EUS-guided FNAB when larger biopsy samples are required for diagnosis or biomarker analysis. However, the procedure can result in high rates of pneumothorax.

Clinical impact of endoscopic ultrasound-fine needle aspiration of left adrenal masses in established or suspected lung cancer

INTRODUCTION

Correct lung cancer staging is pivotal for optimal allocation to surgical and nonsurgical treatment. A left adrenal gland (LAG) mass is found in 5 to 16%, and malignancy preclude surgery. Endoscopic ultrasound (EUS) is superior to other imaging procedures in visualizing LAG, but the impact of EUS-fine needle aspiration (FNA) on tumor, node, metastasis (TNM)-staging, treatment, and survival is unknown.

METHODS

The impact of EUS-FNA of the LAG on TNM staging, treatment, and survival was evaluated retrospectively in all patients (n = 40) referred to EUS during 2000-2006 for known or suspected lung cancer and where EUS disclosed an enlarged LAG. Conventional workup had preceded EUS.

RESULTS

EUS-FNA of an enlarged LAG altered the TNM staging in 70% (downstaged: 26 of 28 patients) and treatment in 48% (gained surgery 25%, avoided surgery 5%, surgically verified benign disease 5%, no cancer and no further workup 5%, and no cancer, control computed tomography, and then no further workup 8%). A malignant LAG lesion was found in 28% and was significantly associated with shorter survival.

CONCLUSION

EUS-FNA of an enlarged LAG in patients with known or suspected lung cancer had a significant impact on TNM staging, treatment, and survival. The impact of routine visualization of the LAG in lung cancer workup needs to be prospectively validated.

Skeletal morbidity in lung cancer patients with bone metastases: demonstrating the need for early diagnosis and treatment with bisphosphonates

BACKGROUND

The skeleton is one of the most frequent sites for metastases from non-small cell lung cancer (NSCLC), and skeletal-related events (SREs) can decrease quality of life (QOL). However, limited guidance exists regarding the diagnosis and treatment of bone metastases in patients with NSCLC.

METHODS

Data on the burden of skeletal morbidity and the diagnosis and treatment of bone metastases in patients with NSCLC were obtained from reviewing the published literature (PubMed) and presentations and abstracts from recent oncology congresses.

RESULTS

Bone metastases are common but underdiagnosed in patients with NSCLC. Most NSCLC patients with bone metastases develop > or =1 SRE during their lifetimes. As survival improves with new treatment modalities, the prevalence of SREs is likely to increase. Direct costs of SREs and their subsequent supportive care are approximately $28,000 per patient. Although bone metastases often are not diagnosed until after the onset of symptoms, early treatment can delay the onset of potentially debilitating SREs. In patients with NSCLC and other solid tumors (n=773), zoledronic acid (ZOL; 4 mg via 15-min infusion every 3 weeks) delayed the median time to first on-study SRE by >80 days compared with placebo (p=0.009). Moreover, ZOL significantly reduced the ongoing risk of SREs by 32% versus placebo (p=0.016).

CONCLUSIONS

Skeletal morbidity is an important concern in patients with NSCLC. The incidence of SREs is expected to increase as survival improves in this setting. Prevention of SREs with therapies such as ZOL may preserve patients' QOL and possibly reduce healthcare costs.

Natural Orifice Trans-Luminal Endoscopic Surgery in the esophagus

As limited as are the studies regarding peritoneal Natural Orifice Trans-Luminal Endoscopic Surgery, mediastinal transluminal experiments are certainly in their infancy. The authors evaluate the parallel development of minimally invasive thoracic surgery with regard to its counterpart in peritoneal laparoscopy to NOTES. Transesophageal interventions by both endosonographic and direct visualization are examined in the context of minimally invasive surgery and mediastinal NOTES. Techniques of viscerotomy creation, visualization, and closure are examined with particular emphasis on mediastinal structures. The state of current interventions is examined. Finally, current morbidity (including infectious complications) and survival outcomes are examined in those animals that have undergone transesophageal exploration.

Multidisciplinary Evaluation of Patients With Suspected Lung Cancer

Lung cancer diagnosis and treatment has evolved to require the input and expertise of multiple diverse medical and surgical specialties. The approach to lung cancer patients requires the adherence to a few principles that include thorough use of staging modalities to assure the proper treatment for each patient, and an understanding of the limitations and advantages of each of these modalities. Evidence is continuing to emerge that supports the notion that diagnostic workup and treatment of lung cancer patients is best done within the context of a multidisciplinary team devoted to this purpose.

Video-assisted surgery for lung cancer. State of the art and personal experience

This paper reviews the role of videothoracoscopy in lung cancer, highlighting its utility in definitive staging, diagnosis, and treatment. We show exploratory videothoracoscopy to be the perfect technique for last-minute staging, looking for tumor invasion, especially parietal T3 and vascular T4 (due to videopericardioscopy), management of solitary pulmonary nodules, and the possibility of radical treatment with video-assisted thoracoscopic lobectomy. We perform an overview of the literature and analyze our experience of 1,381 patients with lung cancer. In 1,277 of them, the final decision on resectability was made by exploratory videothoracoscopy, including 91 by videopericardioscopy (only 30 were considered non-resectable on videopericardioscopy). Solitary pulmonary nodules were diagnosed in 382 cases (190 were cancer), and we performed 260 major lung resections by video-assisted thoracoscopic surgery (22 pneumonectomies, 238 lobectomies/bilobectomies).

18F-FDG PET/CT in mediastinal lymph node staging of non-small-cell lung cancer in a tuberculosis-endemic country: consideration of lymph node calcification and distribution pattern to improve specificity

PURPOSE

The aim of the study was to assess the accuracy of (18)F-fluorodeoxyglucose (FDG) PET/CT in mediastinal lymph node staging of patients with non-small-cell lung cancer (NSCLC) in a region with a high prevalence of granulomatous disease.

METHODS

Between March 2004 and February 2006, all patients with NSCLC underwent FDG PET/CT and contrast-enhanced thoracic CT, and subsequent surgical resection. PET/CT and contrast-enhanced CT images of 182 patients (126 men and 56 women; mean age 60.7 years) with NSCLC were acquired. Mediastinal node staging was determined using the American Joint Committee on Cancer (AJCC) staging system. Surgical and histological findings served as the reference standard.

RESULTS

A total of 182 patients with 778 mediastinal node stations were evaluated. Sensitivity and specificity of contrast-enhanced CT were 36% and 80% on a per-patient basis and 23% and 92% on a per-node station basis. Sensitivity and specificity of PET/CT were 81% and 73% on a per-patient basis and 75% and 85% on a per-node station basis. After lymph nodes with calcification and bilateral hilar distribution were considered benign, sensitivity and specificity of PET/CT were 75% and 89% on a per-patient basis and 66% and 96% on a per-node station basis.

CONCLUSION

This prospective study suggests that FDG PET/CT can more accurately stage mediastinal lymph nodes than CT. Considering lymph node calcification and distribution pattern could improve specificity at the cost of a decrease in sensitivity.

Analysis of HLA class I and II alleles regarding to lymph node and distant metastasis in patients with non-small cell lung cancer

The aim of this study was to investigate the relation of HLA alleles in patients with non-small cell lung cancer (NSCLC). The incidence of class I and II HLA alleles of 63 patients with NSCLC were prospectively compared with the incidence of class I and II HLA alleles with 88 healthy controls. The number of cases with stage I and II (early stage) was 12 and there were 51 cases with stage III and IV (advanced stage). Metastasis rates of the regional lymph node in patients were as follow; N(0): n=10; N(1): n=13; N(2): n=26 and N(3): n=14. Lymph node metastasis was detected by pathological staging in 15 cases and by clinical staging in 48 cases. Lymph node metastasis was searched in all patients by a helical thorax CT. All distant metastasis were investigated by thorax CT, abdominal CT, brain CT or MRI and bone scintigraphy, and distant organ metastasis was detected in 25 cases. The patients and healthy controls were typed for HLA class I and II alleles. HLA-A2 was an independent risk factor for both critical lymph node (N(2 and 3)) involvement and distant metastasis. HLA-B44, -CW6 and -CW7 frequencies appear to be significant in controls compared to patients. HLA-A2 frequency was higher in patients with advanced stage than early stage, while HLA-A26, -B35 and -CW4 frequencies were more expressed in patients with early stage than in patients with advanced stage. Compared with controls, frequency of HLA-DRB1*07, -DQ02 and -DQ07 were lower expressed in patients. Compared patients with advanced stage, HLA-DRB1*07 was higher in patients with early stage. HLA-A2 was an independent risk factor for lymph node and distant metastasis, and the allele was significantly higher in patients with critical lymph node for surgery and distant metastasis. HLA-A26 appeared to be a significance protective allele against to metastases.

CT, MRI and ultrasound scanning rates: evaluation of cancer diagnosis, staging and surveillance in Ontario

OBJECTIVE

To examine practice patterns and rates of computed tomography (CT), magnetic resonance imaging (MRI), and abdominal ultrasound (AUS) during staging, treatment and surveillance for cancer patients.

METHODS

Using Ontario Health Insurance Plan billing data linked to the Ontario Cancer Registry, we determined rates of CT, MRI, and AUS by body site for breast, colorectal, lung, lymphoma, and prostate cancer, from 1998 to 2002. Rates of scans were additionally examined by region of patient residence and time from cancer diagnosis.

RESULTS

The frequency of imaging increased in nearly all scans and tumors over the study period. Rates of peri-diagnosis scans varied substantially by region, ranging from 1.7-fold variation (CT for lung cancer) to 50-fold variation (MRI for breast cancer). For breast cancer, there is possible over-utilization of CT, but overall rates of scanning appear reasonable for the other four cancers.

CONCLUSIONS

Considerable regional variation in imaging rates suggests utilization guidelines should be developed or knowledge transfer initiatives are needed to improve compliance to existing guidelines. In breast cancer, there appears to be over-utilization of imaging. Further studies are necessary to determine utilization for each stage, the reason scans were obtained, and the impact of scans on patient outcomes.

[I Brazilian consensus of endoscopic ultrasonography]

BACKGROUND

In the last 20 years, several papers have focused on demonstrating the impact of endoscopic ultrasonography findings on the management of different clinical scenarios in digestive disease. This fact is an indirect evidence of the difficulty of popularization of the method. On other hand, the limited availability of endoscopic ultrasonography in Brazil is a direct evidence of this limitation. This was the rationale for the organization of a consensus meeting on endoscopic ultrasonography. It was aimed to identify the best evidence that support the use of endoscopic ultrasonography in gastroenterology.

METHODS

A panel of experts on endoscopic ultrasonography was selected based on the files of the Gastroenterology and Endoscopy Societies and on the registries of endoscope manufacturers. Two members of the meeting selected the relevant topics that were transformed into questions. The topics and the questions were debated among the experts five months before the consensus meeting. The experts were asked to perform systematic reviews in order to answer the questions so it could be possible to grade the answers based on the strength of the evidence. During the two days of the meeting the answers were presented, debated and voted. Consensus was reached when a minimum of 70% of the voters were in agreement. The final consensus report was submitted to the experts' evaluation and approval.

RESULTS

Seventy nine questions were debated by the experts at the pre-Consensus meeting. As the result of this debate 85 questions came out and were assigned to the members of the panel. During the Consensus meeting 22 experts debated and voted 85 answers. Consensus was reached for several clinical scenarios for which the impact of endoscopic ultrasonography findings were supported by level 1 evidences: differential diagnosis of subepithelial lesions and thickening of gastric folds, staging and diagnosis of unresectable esophageal cancer, indirect signs of peritoneal involvement of gastric cancer, MALT gastric lymphoma and rectal cancer staging, diagnosis of common bile duct and gallbladder stones, diagnosis of chronic pancreatitis and differential diagnosis of a solid mass in chronic pancreatitis, differential diagnosis of the pancreatic cyst, prediction of the results of the endoscopic treatment of esophageal varices and diagnosis and staging of non-small cell lung cancer.

CONCLUSIONS

There are the highest levels of evidences that support the indication of endoscopic ultrasonography for several digestive diseases and even for non-small cell lung cancer.

Immunohistochemical markers associated with brain metastases in patients with nonsmall cell lung carcinoma

BACKGROUND

To the authors' knowledge, there are no reliable markers able to identify patients with nonsmall cell lung cancer (NSCLC) that will develop metastases to the brain. The authors investigated associations between immunohistochemical markers and the development of brain metastases in patients with NSCLC.

METHODS

This was a hospital-based, case-control study of patients who were newly diagnosed with NSCLC between 1989 and 2003, developed brain metastases, and had pathology material available from both the primary NSCLC and the brain metastases. These patients were compared with a control group of patients who had NSCLC and no evidence of brain metastases. NSCLC was examined for expression levels of Ki-67, caspase-3, vascular endothelial growth factor A (VEGF-A), VEGF-C, E-cadherin, and epidermal growth factor receptor (EGFR) in 54 surgical pathology specimens using immunohistochemistry, and associations were evaluated between those markers and the development of brain metastases.

RESULTS

Brain metastases developed after a median of 12.5 months (range, 1.7-89.4 months) after the diagnosis of NSCLC. A significantly increased risk of developing brain metastases was associated with patients with NSCLC who had primary tumors with high Ki-67 levels (adjusted odds ratio [OR] of 12.2; 95% confidence interval [95% CI], 2.4-70.4 [P < .001]), low caspase-3 expression (adjusted OR of 43; 95% CI, 5.3 to >100 [P < .001]), high VEGF-C expression (adjusted OR of 14.6; 95% CI, 2.0 to >100 [P < .001]), and low E-cadherin (adjusted OR of 3.6; 95% CI, 0.9-16.4 [P = .05]). No significant risk was associated with VEGF-A or EGFR expression. High Ki-67 expression also was associated with a shorter overall survival (P = .04).

CONCLUSIONS

The results of the current study indicated that patients with NSCLC who had high Ki-67 expression, low caspase-3 expression, high VEGF-C expression, and low E-cadherin expression in their tumors may benefit from close surveillance because they may have an increased risk of developing brain metastases.

Positron Emission Tomography (PET) radiotracers in oncology--utility of 18F-Fluoro-deoxy-glucose (FDG)-PET in the management of patients with non-small-cell lung cancer (NSCLC)

PET (Positron Emission Tomography) is a nuclear medicine imaging method, frequently used in oncology during the last years. It is a non-invasive technique that provides quantitative in vivo assessment of physiological and biological phenomena. PET has found its application in common practice for the management of various cancers.Lung cancer is the most common cause of death for cancer in western countries.This review focuses on radiotracers used for PET scan with particular attention to Non Small Cell Lung Cancer diagnosis, staging, response to treatment and follow-up.

Non-small cell lung cancer: whole-body MR examination for M-stage assessment--utility for whole-body diffusion-weighted imaging compared with integrated FDG PET/CT

PURPOSE

To prospectively and directly compare the capability of whole-body diffusion-weighted (DW) imaging, whole-body magnetic resonance (MR) imaging with and that without DW imaging, and integrated fluorine 18 fluorodeoxyglucose (FDG) positron emission tomography (PET)/computed tomography (CT) for M-stage assessment in non-small cell lung cancer (NSCLC) patients.

MATERIALS AND METHODS

The institutional review board approved this study; informed consent was obtained from patients. A total of 203 NSCLC patients (109 men, 94 women; mean age, 72 years) prospectively underwent whole-body DW imaging, whole-body MR imaging, and FDG PET/CT. Final diagnosis of the M-stage in each patient was determined on the basis of results of all radiologic and follow-up examinations. Two chest radiologists and two nuclear medicine physicians independently assessed all examination results and used a five-point visual scoring system to evaluate the probability of metastases. Final diagnosis based on each of the methods was made by consensus of two readers. Receiver operating characteristic (ROC) analysis was used to compare the capability for M-stage assessment among whole-body DW imaging, whole-body MR imaging with and that without DW imaging, and PET/CT on a per-patient basis. Sensitivity, specificity, and accuracy were compared with the McNemar test.

RESULTS

Area under ROC curve (A(z)) values of whole-body MR imaging with DW imaging (A(z) = 0.87, P = .04) and integrated FDG PET/CT (A(z) = 0.89, P = .02) were significantly larger than that of whole-body DW imaging (A(z) = 0.79). Specificity and accuracy of whole-body MR imaging with (specificity, P = .02; accuracy, P < .01) and that without DW imaging (specificity, P = .02; accuracy, P = .01) and integrated FDG PET/CT (specificity, P < .01; accuracy, P < .01) were significantly higher than those of whole-body DW imaging.

CONCLUSION

Whole-body MR imaging with DW imaging can be used for M-stage assessment in NSCLC patients with accuracy as good as that of PET/CT.

Does positron emission tomography prevent nontherapeutic pulmonary resections for clinical stage IA lung cancer?

BACKGROUND

The American College of Surgeons Oncology Group (ACOSOG) Z0050 trial demonstrated that positron emission tomography (PET) prevents nontherapeutic thoracotomies in a substantial fraction of patients with known or suspected non-small cell lung cancer (NSCLC). However, the benefit of PET in clinical stage IA patients has been questioned due to the lower prevalence of metastases and poor ability to discriminate benign from malignant lung lesions. This study evaluates whether PET prevents nontherapeutic pulmonary resections in clinical stage IA patients by finding advanced disease or by declaring a nodule as benign.

METHODS

We reanalyzed all patients with clinical stage IA NSCLC from ACOSOG Z0050. The clinical, PET, and pathologic stages were compared for this prospective cohort.

RESULTS

One hundred twenty-two clinical stage IA patients were evaluated and 78.7% (96 of 122; 95% confidence interval [CI], 70.4 to 85.6) were eventually shown to have cancer. PET correctly showed 7.4% (9 of 122; 95% CI, 3.4 to 13.5) of patients to have advanced disease (stages IIIA to IV). However, due to a high false positive rate, the positive predictive value for advanced disease was only 33.3% (9 of 27; 95% CI, 16.5 to 54.0). The negative predictive value of PET to predict benign lesions was only 57% (16 of 28; 95% CI, 37.2 to 75.5). Thus, 43% (12 of 28; 95% CI, 24.5 to 62.8) of patients with a PET negative primary lesion actually had cancer, and all of these had resectable disease (stages IA to IIB).

CONCLUSIONS

In clinical stage IA lung cancer patients, PET prevents nontherapeutic pulmonary resections less than 10% of the time. If a strategy of no surgery and serial computed tomographic scans is chosen for PET negative lesions, over 40% of patients with NSCLC will have surgery delayed. A prospective trial comparing PET versus resection for clinical stage IA lesions would clarify the value of PET for these patients.

[Imaging and PET/CT of lung cancer]

Lung cancer is one of the most frequently occurring cancer in the world. Imaging plays a critical role for screening, diagnosing, staging, and following patients. Although morphologic imaging such as chest X-ray and CT are still useful for these purpose, major limitations occur in the proper evaluation of diagnosing and staging. Metabolic imaging using PET significantly increases the accuracy of staging. This paper will review the role of imaging in patients suspected or diagnosed with lung cancer.

Endobronchial ultrasound and value of PET for prediction of pathological results of mediastinal hot spots in lung cancer patients

SUMMARY

In the staging of lung cancer with positron emission tomography (PET) positive mediastinal lymph nodes, tissue sampling is required. The performance of transbronchial needle aspiration (TBNA) using linear endobronchial ultrasound (real-time EBUS-TBNA) under local anaesthesia and the value of PET for prediction of pathological results were assessed in that setting. The number of eluded surgical procedures was evaluated. All consecutive patients with suspected/proven lung cancers and FDG-PET positive mediastinal adenopathy were included. If no diagnosis was reached, further surgical sampling was required. Lymph node SUVmax (maximum standardized uptake value) was assessed in patients whose PET was performed in the leading centre. One hundred and six patients were included. The average number of TBNA samples per patient was 4.9+/-1.1. The prevalence of lymph node metastasis was 58%. Sensitivity, accuracy and negative predictive value of EBUS-TBNA in the staging of mediastinal hot spots were 95, 97 and 91%. Patients without malignant lymph node involvement showed lower SUVmax (respective median values of 3.7 and 10.0; p<0.0001). Surgical procedures were eluded in 56% of the patients. Real-time EBUS-TBNA should be preferred over mediastinoscopy as the first step procedure in the staging of PET mediastinal hot spots in lung cancer patients. In case of negative EBUS, surgical staging procedure should be undertaken. The addition of SUVmax cut-off may allow further refinement but needs validation.

Impact of staging transesophageal EUS on treatment and survival in patients with non-small-cell lung cancer

BACKGROUND

Transesophageal EUS-guided FNA (EUS-FNA) is safe, accurate, and cost effective in staging patients with non-small-cell lung cancer (NSCLC). However, the impact of EUS-FNA on patient survival has not been demonstrated.

OBJECTIVE

To determine the impact of metastatic disease in mediastinal lymph nodes as determined by EUS staging on treatment choice and survival in patients with NSCLC.

DESIGN

Retrospective analysis of prospectively collected data.

SETTING

Tertiary university-based referral center.

PATIENTS

Patients with biopsy-proven NSCLC who underwent staging EUS-FNA. The relationship between the EUS nodal status and patient survival was evaluated. Cox proportional hazards models were used to determine the significance of EUS nodal status and patient characteristics on patient survival.

MAIN OUTCOMES MEASUREMENTS

Impact of EUS-FNA on therapy and survival in patients with NSCLC.

RESULTS

Of 125 patients with NSCLC, EUS-FNA confirmed metastatic disease in 46% of the patients. Patients who were node positive were more likely to receive chemotherapy and/or radiation therapy and were less likely to undergo surgery compared with patients who were node negative (P< .0001). Patients with N2 or N3 disease by EUS-FNA had a shorter survival time than patients who were node negative (P= .004). Adjusting for age, race, and sex, EUS-FNA was the most important predictor of survival of patients with NSCLC in this cohort of patients (hazard ratio 2.34, 95% CI 1.31-4.21).

LIMITATIONS

Lack of surgical reference standard in all patients and referral to a tertiary center.

CONCLUSIONS

Patients with node-positive NSCLC as detected by EUS-FNA have a shorter survival time compared with patients who were node negative. They are more likely to receive neoadjuvant therapy and less likely to receive surgery. Preoperative EUS-FNA is a minimally invasive technique that provides important prognostic information in patients with NSCLC.

[Silent brain metastasis in the initial staging of lung cancer: evaluation by computed tomography and magnetic resonance imaging]

OBJECTIVE

Brain metastases are common in patients with lung cancer and influence both prognosis and treatment decisions. The aim of this study was to evaluate the incidence of silent brain metastasis during the initial staging of lung cancer using cranial computed tomography (CT) and magnetic resonance imaging (MRI).

PATIENTS AND METHODS

We performed a retrospective analysis of lung cancer patients with no neurologic signs or symptoms who were evaluated by cranial CT, MRI, or both at the time of diagnosis. Results were checked using data obtained during systematic monitoring of progression. The incidence of brain metastasis was analyzed by sex, age, histology, and TNM stage.

RESULTS

Silent brain metastasis was detected in 8.3% of the 169 patients with lung cancer. The detection rate was 7.9% in the cranial CT group and 11.3% in the cranial MRI group. The percentage of false positives and false negatives was 0% and 1.9%, respectively. Cranial MRI performed better than CT in detecting multiple brain metastases (72.8% vs 50%) and metastases smaller than 1 cm (36.3% vs 16.7%). The incidence of brain metastasis was lower in patients aged over 70 years and higher in patients with adenocarcinoma (20% compared to 5.3% to 5.9% for other histologic subtypes, P=.01). No association was found with TNM stage.

CONCLUSIONS

The incidence of silent brain metastasis is high in patients under 70 years of age, particularly in patients with adenocarcinomas, even in initial stages. This should be taken into consideration when planning staging procedures. Cranial MRI seems to be more accurate than cranial CT for detecting multiple metastases and small metastases.

Ultrasound vs. CT in detecting chest wall invasion by tumor: a prospective study

BACKGROUND

Lung cancer is one of the leading causes of cancer-related deaths worldwide. Accurate staging is important for patient management and clinical research. The recognition of chest wall involvement preoperatively is important for staging and surgical planning. Multiple modalities are available to assess the chest wall involvement preoperatively, including CT scanning, MRI, and ultrasound (US) examination. The purpose of this study was to evaluate the sensitivity and specificity of the US examination in determining the chest wall involvement of lung cancer compared to that of CT scan and surgery.

METHODS

A total of 136 patients with clinical suspicion of chest wall involvement were recruited. Ninety patients met the inclusion criteria and underwent CT scanning, transthoracic US, and surgical exploration. A final determination regarding chest wall involvement was made after reviewing the final pathology results and surgical staging.

RESULTS

Chest wall invasion by tumor was noted in 26 patients during surgery and final pathologic examination of the tissue. Of these patients, US correctly identified 23 patients tumor invasion, while CT scanning identified 11 patients with tumor invasion. There were 3 false-positive results and 3 false-negative results with US examination, compared to 15 false-negative results and no false-positive results with CT scanning.

CONCLUSIONS

US has better sensitivity (89%) and specificity (95%) in assessing chest wall involvement by a lung tumor compared to CT scan examination (sensitivity, 42%; specificity, 100%).

Detecting extrathoracic metastases in patients with non-small cell lung cancer: Is routine scanning necessary?

There is controversy over whether to scan extrathoracic sites for metastases in patients with non-small cell lung cancer (NSCLC). We tested the efficiency of clinical factors to determine whether metastasis has occurred, and whether routine scanning for NSCLC is required. Nine hundred and forty five patients scanned for extrathoracic metasates were included. Clinical factors indicating metastasis were determined using multivariate analysis. Of the 945 cases, 377 (39.9%) had metastasis. Bone metastases were determined by focal skeleton pains, elevated serum alkaline phosphatase levels, adenocarcinoma, KPS</=70, sensitivity of 90.6, specificity of 12.7, PPV of 16.3, NPV of 87.8, and silent metastases rate (SMR) of 9.4%. Brain metastases were determined by neurological symptoms, adenocarcinoma, hematocrite <40 for men and <35 for women, KPS</=70, sensitivity of 89.9, specificity of 7.9, PPV of 9.2, NPV of 88.3, and SMR of 10.1%. Abdominal metastases were determined by abdominal pain/tension, hepatomegaly, elevated GGT levels, serum LDH levels >500 IU, a N2 or N3 case, KPS</=70, sensitivity of 95.9, specificity of 7.1, PPV of 13.3, NPV of 92.1 and SMR of 4.1%. Of the 224 patients with stage I and II disease, 73 had metastasis with a rate of 10.9% silent metastasis. We concluded that routine scanning of NSCLC for staging is necessary.

Virtual Mediastinoscopy for Safer and More Accurate Mediastinal Exploration

PURPOSE

Virtual endoscopy can theoretically produce images of hollow organs from computed tomographic scanning by discriminating walls with the air space. We produced virtual images of the mediastinum (ie, virtual mediastinoscopy based on positron emission tomography and computed tomography scanning data to visualize lymph nodes and great vessels similar to cervical mediastinoscopy).

DESCRIPTION

Virtual images from 5 patients with positive mediastinal positron emission tomography findings were produced using computer software designed for virtual endoscopy. Visualization of lymph nodes and vessels was done based on positron emission tomography-computed tomography and enhanced computed tomographic scanning data, respectively.

EVALUATION

Virtual mediastinoscopy clearly showed three-dimensional relationships between active nodes and surrounding structures. Great vessels, such as the innominate artery and azygos vein, which require assessment during a mediastinoscopy, were visualized in virtual movies. Further, perspective views in the craniocaudal direction based on surgeon-orientation, simulated actual views were obtained during cervical video mediastinoscopy.

CONCLUSIONS

Virtual mediastinoscopy provided realistic images of the mediastinal anatomy, and has the potential to make cervical mediastinoscopy and other mediastinal explorations safer, as well as more accurate.