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Ospina AV, Bolufer Nadal S, Campo-Cañaveral de la Cruz JL, González Larriba JL, Macía Vidueira I, Massutí Sureda B, Nadal E, Trancho FH, Álvarez Kindelán A, Del Barco Morillo E, Bernabé Caro R, Bosch Barrera J, Calvo de Juan V, Casal Rubio J, de Castro J, Cilleruelo Ramos Á, Cobo Dols M, Dómine Gómez M, Figueroa Almánzar S, Garcia Campelo R, Insa Mollá A, Jarabo Sarceda JR, Jiménez Maestre U, López Castro R, Majem M, Martinez-Marti A, Martínez Téllez E, Sánchez Lorente D, Provencio M. Multidisciplinary approach for locally advanced non-small cell lung cancer (NSCLC): 2023 expert consensus of the Spanish Lung Cancer Group GECP. Clin Transl Oncol 2024; 26:1647-1663. [PMID: 38530556 PMCID: PMC11178633 DOI: 10.1007/s12094-024-03382-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 01/03/2024] [Indexed: 03/28/2024]
Abstract
INTRODUCTION Recent advances in the treatment of locally advanced NSCLC have led to changes in the standard of care for this disease. For the selection of the best approach strategy for each patient, it is necessary the homogenization of diagnostic and therapeutic interventions, as well as the promotion of the evaluation of patients by a multidisciplinary oncology team. OBJECTIVE Development of an expert consensus document with suggestions for the approach and treatment of locally advanced NSCLC leaded by Spanish Lung Cancer Group GECP. METHODS Between March and July 2023, a panel of 28 experts was formed. Using a mixed technique (Delphi/nominal group) under the guidance of a coordinating group, consensus was reached in 4 phases: 1. Literature review and definition of discussion topics 2. First round of voting 3. Communicating the results and second round of voting 4. Definition of conclusions in nominal group meeting. Responses were consolidated using medians and interquartile ranges. The threshold for agreement was defined as 85% of the votes. RESULTS New and controversial situations regarding the diagnosis and management of locally advanced NSCLC were analyzed and reconciled based on evidence and clinical experience. Discussion issues included: molecular diagnosis and biomarkers, radiologic and surgical diagnosis, mediastinal staging, role of the multidisciplinary thoracic committee, neoadjuvant treatment indications, evaluation of response to neoadjuvant treatment, postoperative evaluation, and follow-up. CONCLUSIONS Consensus clinical suggestions were generated on the most relevant scenarios such as diagnosis, staging and treatment of locally advanced lung cancer, which will serve to support decision-making in daily practice.
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Affiliation(s)
- Aylen Vanessa Ospina
- Head of the Oncology Department at the Hospital Universitario Puerta de Hierro. Full Professor of Medicine, Universidad Autónoma de Madrid, C/Manuel de Falla, 1 Majadahonda, 28222, Madrid, Spain.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Mariano Provencio
- Head of the Oncology Department at the Hospital Universitario Puerta de Hierro. Full Professor of Medicine, Universidad Autónoma de Madrid, C/Manuel de Falla, 1 Majadahonda, 28222, Madrid, Spain.
- Universidad Autónoma de Madrid, Ciudad Universitaria de Cantoblanco, 28049, Madrid, Spain.
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Lindquist KE, Cortas G, Hashemi Y, Rajabian N, Ehinger M. Endobronchial ultrasound-guided transbronchial fine needle aspiration of mediastinal lymphadenopathy: Diagnostic performance and clinical implications of the World Health Organization reporting system. Diagn Cytopathol 2024. [PMID: 38853534 DOI: 10.1002/dc.25365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 05/24/2024] [Accepted: 05/28/2024] [Indexed: 06/11/2024]
Abstract
INTRODUCTION Lymph node fine-needle aspiration cytology (LN-FNAC) is a common, rapid, minimally invasive and cost-effective diagnostic method. For mediastinal lymph nodes, endobronchial ultrasound (EBUS) guided LN-FNAC is a first-line investigation and has an indispensable role in the diagnosis and staging of patients with suspected lung cancer. Recently, a new WHO system has been proposed for classification of LN-FNAC heralding five different diagnostic categories; insufficient, benign, atypical, suspicious for malignancy and malignant. The aim of this study was to evaluate the diagnostic accuracy and risk of malignancy (ROM) of these categories in EBUS-guided LN-FNAC from mediastinal lymph nodes. METHOD We evaluated 2110 consecutive mediastinal lymph nodes during this one-year retrospective study. Corresponding radiological images and histologic material were used as ground truth to calculate accuracy, sensitivity, specificity and ROM. RESULTS The WHO system showed an overall accuracy of 93.7% with a sensitivity of 83.0% and a specificity of 97.5%. The positive predictive value was 92.3% and the negative predictive value 94.2%. The overall ROM for each category in the WHO classification system was 12.8% for the inadequate, 2.4% for the benign, 47.4% for the atypical, 81.0% for the suspicious for malignancy and 93.6% for the malignant category. CONCLUSION The results of the present study indicate that the new WHO system entails a high diagnostic accuracy regarding EBUS-guided LN-FNAC assessment of mediastinal lymph nodes and supports its integration into clinical practice. Application of the WHO system standardizes risk assessment thus facilitating communication between cytopathologists and clinicians and minimizes the need for histopathological analysis.
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Affiliation(s)
- Kajsa Ericson Lindquist
- Division of Pathology, Department of Clinical Sciences, Lund University, Lund, Sweden
- Department of Clinical Genetics, Pathology and Molecular Diagnostics, Office for Medical Services, Lund, Sweden
| | - Gaêlle Cortas
- Division of Pathology, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Yas Hashemi
- Division of Pathology, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Nilofar Rajabian
- Division of Pathology, Department of Clinical Sciences, Lund University, Lund, Sweden
- Department of Clinical Genetics, Pathology and Molecular Diagnostics, Office for Medical Services, Lund, Sweden
| | - Mats Ehinger
- Division of Pathology, Department of Clinical Sciences, Lund University, Lund, Sweden
- Department of Clinical Genetics, Pathology and Molecular Diagnostics, Office for Medical Services, Lund, Sweden
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Zhu Y, Cai Q, Wang Y, You N, Yip R, Lee DS, Taioli E, Flores R, Henschke CI, Yankelevitz DF. Pre-surgical assessment of mediastinal lymph node metastases in patients having ≥ 30 mm non-small-cell lung cancers. Lung Cancer 2021; 161:189-196. [PMID: 34624614 DOI: 10.1016/j.lungcan.2021.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 09/09/2021] [Accepted: 09/15/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Computed tomography (CT) and fluorodeoxyglucose-positron-emission-tomography (FDG-PET) measurements of mediastinal lymph nodes (MLNs) of patients with non-small-cell-lung-cancers (NSCLCs) ≤ 30 mm in maximum diameter are recommended for pre-surgical prediction of MLN metastases. METHODS We reviewed all patients at Mount Sinai Health System enrolled in the Initiative for Early Lung Cancer Research on Treatment (IELCART), prospective cohort between 2016 and 2020, who had pre-surgical FDG-PET and underwent surgery with MLN resection and/or pre-operative endobronchial ultrasound (EBUS) for a first primary NSCLC ≤ 30 mm in maximum diameter on pre-surgical CT. RESULTS Among 470 patients, none with part-solid (n = 63) or nonsolid (n = 23) NSCLCs had MLN metastases. Solid NSCLCs were identified in 384 patients, none in typical carcinoid (n = 48) or NSCLC ≤ 10 mm in maximum diameter (n = 47, including 8 typical carcinoids) had MLN metastases. Among the remaining 297 patients with solid NSCLCs 10.1-30.0 mm, 7 (2.4%) had MLN metastases. Area-under-the-curve (AUC) for predicting MLN metastases in solid NSCLCs 10.1-30.0 mm, using the CT maximum short-axis MLN diameter was 0.62 (95% CI:0.44-0.81, p = 0.18) and using the highest SUVmax of any MLN, AUC was 0.58 (95% CI:0.39-0.78,p = 0.41). Neither AUCs were significantly different from chance alone. Optimal cutoff for prediction of MLN metastases was ≥ 18.9 mm for CT maximum short-axis diameter [sensitivity 14.3% (95%CI:0.0%-57.9%); specificity 100.0% (95%CI:98.9%-100.0%)] and for highest SUVmax was ≥ 11.7 [sensitivity 14.3% (95%CI:0.0%-57.9%) and specificity 99.7% (95%CI:98.3%-100.0%)]. CONCLUSIONS CT and SUVmax had low sensitivity but high specificity for predicting MLN metastases in solid NSCLCs 10.1-30.0 mm. Clinical Stage IA NSCLCs ≤ 30 mm should be based on CT maximum tumor diameter and MLN maximum short-axis diameter ≤ 20 mm.
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Affiliation(s)
- Yeqing Zhu
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Qiang Cai
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Department of Radiology, Shanxi Provincial People's Hospital, Taiyuan, Shanxi 030012 China
| | - Yong Wang
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Department of Radiology, Zhongshan Hospital, Xiamen University, Xiamen, Fujian, China
| | - Nan You
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rowena Yip
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Dong-Seok Lee
- Department of Thoracic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Emanuela Taioli
- Department of Thoracic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Institute for Translational Epidemiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Tisch Center Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Center for Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Raja Flores
- Department of Thoracic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Institute for Translational Epidemiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Tisch Center Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Claudia I Henschke
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Tisch Center Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Center for Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - David F Yankelevitz
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Tisch Center Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Center for Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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Wang Y, Zhu Y, Yip R, Lee DS, Flores RM, Kaufman A, Henschke CI, Yankelevitz DF. Pre-surgical assessment of mediastinal lymph node metastases in Stage IA non-small-cell lung cancers. Clin Imaging 2020; 68:61-67. [PMID: 32570011 DOI: 10.1016/j.clinimag.2020.06.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 05/27/2020] [Accepted: 06/12/2020] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Evaluation of sensitivity and specificity of CT and fluorodeoxyglucose-positron emission tomography for pre-surgical staging of mediastinal lymph node metastases (N2/N3) of non-small-cell-lung-cancers ≤30 mm. METHODS We reviewed a total of 263 patients from a prospective cohort study, who underwent resection including mediastinal lymph nodes, for first primary non-small-cell-lung-cancer ≤30 mm in maximum diameter on pre-surgical CT. Cutoff criteria for short-axis diameter on CT of the largest N2/N3 node of 10, 15, and 20 mm and positron emission uptake of 2.5, 3.0, and 4.0 were evaluated using Area-Under-the-Curve (AUC) assessment. Accuracy criterion was used to determine the optimal cutoffs. RESULTS Of 263 patients, 9 had nonsolid, 42 part-solid, and 212 solid non-small-cell-lung-cancers. Post-surgically, none of the 51 patients with nonsolid or part-solid cancers had mediastinal lymph node metastases. Among the 212 patients with solid cancers, 23 had N2 node metastases. For the 212 patients with solid cancers, the AUC for CT lymph node measurements was 0.67 (95% CI: 0.57-0.77), significantly higher (p = 0.001) than chance alone, while the AUC for SUVmax measurements, 0.56 (95% CI: 0.48-0.65), was not (p = 0.13). Optimal CT cutoff was >20 mm had low sensitivity of 30.4% (95% CI: 11.6%-49.2%) but high specificity of 99.5% (95% CI: 98.4%-100.0%). CONCLUSION Based on these results, clinical Stage IA for non-small-cell-lung-cancers with nonsolid, part-solid, or solid consistency should be based on pre-surgical CT maximum tumor diameter and lymph node short-axis measurements on CT ≤20 mm. Further prospective evaluation of these clinical Stage IA staging criteria is needed.
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Affiliation(s)
- Yong Wang
- Department of Radiology, Mount Sinai School of Medicine, NY, NY, USA; Department of Radiology, Zhongshan Hospital, Xiamen University, Xiamen, Fujian, China
| | - Yeqing Zhu
- Department of Radiology, Mount Sinai School of Medicine, NY, NY, USA; Department of Radiology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Rowena Yip
- Department of Radiology, Mount Sinai School of Medicine, NY, NY, USA
| | - Dong-Seok Lee
- Department of Thoracic Surgery, Mount Sinai School of Medicine, NY, NY, USA
| | - Raja M Flores
- Department of Thoracic Surgery, Mount Sinai School of Medicine, NY, NY, USA; Tisch Center Institute, Mount Sinai School of Medicine, NY, NY, USA; Center for Thoracic Oncology, Mount Sinai School of Medicine, NY, NY, USA
| | - Andrew Kaufman
- Department of Thoracic Surgery, Mount Sinai School of Medicine, NY, NY, USA; Tisch Center Institute, Mount Sinai School of Medicine, NY, NY, USA; Center for Thoracic Oncology, Mount Sinai School of Medicine, NY, NY, USA
| | - Claudia I Henschke
- Department of Radiology, Mount Sinai School of Medicine, NY, NY, USA; Tisch Center Institute, Mount Sinai School of Medicine, NY, NY, USA; Center for Thoracic Oncology, Mount Sinai School of Medicine, NY, NY, USA; Phoenix Veterans Affairs Health Care System, Phoenix, AZ, USA.
| | - David F Yankelevitz
- Department of Radiology, Mount Sinai School of Medicine, NY, NY, USA; Phoenix Veterans Affairs Health Care System, Phoenix, AZ, USA
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Atkins NK, Marjara J, Kaifi JT, Kunin JR, Saboo SS, Davis RM, Bhat AP. Role of Computed Tomography-guided Biopsies in the Era of Electromagnetic Navigational Bronchoscopy: A Retrospective Study of Factors Predicting Diagnostic Yield in Electromagnetic Navigational Bronchoscopy and Computed Tomography Biopsies. J Clin Imaging Sci 2020; 10:33. [PMID: 32547836 PMCID: PMC7294316 DOI: 10.25259/jcis_53_2020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Accepted: 05/20/2020] [Indexed: 12/26/2022] Open
Abstract
Objectives: Over 25% of the high-risk population screened for lung cancer have an abnormal computed tomography (CT) scan. Conventionally, these lesions have been biopsied with CT guidance with a high diagnostic yield. Electromagnetic navigational bronchoscopy (ENB) with transbronchial biopsy has emerged as a technology that improves the diagnostic sensitivity of conventional bronchoscopic biopsy. It has been used to biopsy lung lesions, due to the low risk of pneumothorax. It is, however, a new technology that is expensive and its role in the diagnosis of the solitary pulmonary nodule (SPN) is yet to be determined. The purpose of this study was to evaluate the diagnostic yield of CT-guided biopsy (CTB) following non-diagnostic ENB biopsy and identify characteristics of the lesion that predicts a low diagnostic yield with ENB, to ensure appropriate use of ENB in the evaluation of SPN. Materials and Methods: One hundred and thirty-five lung lesions were biopsied with ENB from January 2017 to August 2019. Biopsies were considered diagnostic if pathology confirmed malignancy or inflammation in the appropriate clinical and imaging setting. We evaluated lesions for several characteristics including size, lobe, and central/peripheral distribution. The diagnostic yield of CTB in patients who failed ENB biopsies was also evaluated. Logistic regression was used to identify factors likely to predict a non-diagnostic ENB biopsy. Result: Overall, ENB biopsies were performed in 135 patients with solitary lung lesions. ENB biopsies were diagnostic in 52% (70/135) of the patients. In 23 patients with solitary lung lesions, CTBs were performed following a non-diagnostic ENB biopsy. The CTBs were diagnostic in 87% of the patients (20/23). ENB biopsies of lesions <21.5 mm were non-diagnostic in 71% of cases (42/59); 14 of these patients with non-diagnostic ENB biopsies had CTBs, and 86% of them were diagnostic (12/14). ENB biopsies of lesions in the lower lobes were non- diagnostic in 59% of cases (35/59); 12 of these patients with non-diagnostic ENB biopsies had CTBs, and 83% were diagnostic (10/12). ENB biopsies of lesions in the outer 2/3 were non-diagnostic in 57% of cases (50/87); 21 of these patients with non-diagnostic ENB biopsies had CTBs, and 86% were diagnostic (18/21). Conclusion: CTBs have a high diagnostic yield even following non-diagnostic ENB biopsies. Lesions <21.5 mm, in the outer 2/3 of the lung, and in the lower lung have the lowest likelihood of a diagnostic yield with ENB biopsies. Although CTBs have a slightly higher pneumothorax rate, these lesions would be more successfully diagnosed with CTB as opposed to ENB biopsy, in the process expediting the diagnosis and saving valuable medical resources.
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Affiliation(s)
- Naomi K Atkins
- Departments of Radiology, University of Missouri, Columbia, Missouri, United States
| | - Jasraj Marjara
- Departments of Radiology, University of Missouri, Columbia, Missouri, United States
| | - Jussuf T Kaifi
- Departments of Cardiothoracic Surgery, University of Missouri, Columbia, Missouri, United States
| | - Jeffrey R Kunin
- Departments of Radiology, University of Missouri, Columbia, Missouri, United States
| | - Sachin S Saboo
- Department of Radiology, University of Texas Health Science Center, San Antonio, Texas, United States
| | - Ryan M Davis
- Departments of Radiology, University of Missouri, Columbia, Missouri, United States
| | - Ambarish P Bhat
- Departments of Radiology, University of Missouri, Columbia, Missouri, United States
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Junare PR, Jain S, Rathi P, Contractor Q, Chandnani S, Kini S, Thanage R. Endoscopic ultrasound-guided-fine-needle aspiration/fine-needle biopsy in diagnosis of mediastinal lymphadenopathy - A boon. Lung India 2020; 37:37-44. [PMID: 31898619 PMCID: PMC6961103 DOI: 10.4103/lungindia.lungindia_138_19] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background/Objectives: Evaluation of mediastinal lymphadenopathy (MLA) is a great diagnostic challenge considering the myriad of causes. In recent years, the role of endoscopic ultrasound (EUS) has been greatly extended in evaluation of MLA due to its safety, reliability, and accuracy. The present study details the role of EUS-guided-fine-needle aspiration/fine-needle biopsy (EUS-FNA/FNB) in MLA of unknown origin. Methods: Seventy-two patients (34 men) with MLA of unknown etiology were studied. Mediastinum was evaluated with linear echoendoscope and FNA/FNB was performed with 22-G needle and sent for cytology, histopathological, and mycobacterial growth indicator tube/GeneXpert evaluation. EUS-FNA/FNB diagnosis was based on cytology reporting by pathologists. Patients tolerated the procedure, and insertion of needle into the lesion was always successful without any complications. Results: EUS-FNA/FNB established a tissue diagnosis in 66/72 patients in first sitting, while six patients underwent repeat procedure. EUS-FNA diagnoses (after second sitting) were tuberculous lymphadenitis in 45/72 (62.5%), metastatic lymph nodes 12/72 (16.7%), reactive lymphadenopathy 6/72 (8.3%), sarcoidosis 4/72 (5.6%), and lymphoma 2/72 (2.8%), while it was nondiagnostic in 3/72 (4.1%) patients. Final diagnosis was based on combined clinical presentation, EUS-FNA/FNB result and clinicoradiological response to treatment on long-term follow-up of 6 months. Conclusion: EUS echo features along with EUS-FNA/FNB can diagnose MLA and surgical biopsy can be avoided.
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Affiliation(s)
- Parmeshwar Ramesh Junare
- Department of Gastroenterology, Topiwala National Medical College and BYL Nair Charitable Hospital, Mumbai, Maharashtra, India
| | - Samit Jain
- Department of Gastroenterology, Topiwala National Medical College and BYL Nair Charitable Hospital, Mumbai, Maharashtra, India
| | - Pravin Rathi
- Department of Gastroenterology, Topiwala National Medical College and BYL Nair Charitable Hospital, Mumbai, Maharashtra, India
| | - Qais Contractor
- Department of Gastroenterology, Topiwala National Medical College and BYL Nair Charitable Hospital, Mumbai, Maharashtra, India
| | - Sanjay Chandnani
- Department of Gastroenterology, Topiwala National Medical College and BYL Nair Charitable Hospital, Mumbai, Maharashtra, India
| | - Sangeeta Kini
- Department of Gastroenterology, Topiwala National Medical College and BYL Nair Charitable Hospital, Mumbai, Maharashtra, India
| | - Ravi Thanage
- Department of Gastroenterology, Topiwala National Medical College and BYL Nair Charitable Hospital, Mumbai, Maharashtra, India
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Lee KA, Rangaswamy G, Lavan NA, Dunne M, Collins CD, Small C, Thirion P. ICORG 06-35: a prospective evaluation of PET-CT scan in patients with non-operable or non-resectable non-small cell lung cancer treated by radical 3-dimensional conformal radiation therapy: a phase II study. Ir J Med Sci 2019; 188:1155-1161. [PMID: 31062176 DOI: 10.1007/s11845-019-02019-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 04/09/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Radiotherapy (RT) is a key treatment modality in the curative treatment of patients with non-small cell lung cancer (NSCLC). Incorrect definition of the gross, or clinical, target volume is a common source of error which can lead to a reduced probability of tumour control. OBJECTIVE This was a pilot and a phase II study. The pilot evaluated the technical feasibility of integrating positron emission tomography-computed tomography (PET-CT) fusion. The primary outcome of the phase II study was to evaluate the safety of PET-CT scan-based RT by evaluating the rate of loco-regional recurrence outside the PET-CT planning target volume (PTV) but within conventional 3-D PTV. METHODS Patients underwent standard post-treatment follow-up, including repeated three monthly CT scans of the thorax. In case of loco-regional recurrence, three categories were considered, with only extra-PET scan PTV and intra-CT scan PTV recurrences considered as a failure. Our hypothesis was that the rate of these events would be < 10%. RESULTS Twelve patients were recruited; the study closed early due to poor recruitment. The primary endpoint of the pilot was met; it was feasible to deliver a PET-CT-based plan to ≥ 60% of patients. Two patients had intra-PET scan PTV recurrences, six had extra-PET scan PTV and extra-CT, and three patients had both. Another patient had extra-PET scan PTV and extra-CT as well as extra-PET scan PTV and intra-CT scan PTV recurrence. CONCLUSION/ADVANCES IN KNOWLEDGE PET-based planning has the potential to reduce radiation treatment volumes because of the avoidance of mediastinal lymph nodes that are PET negative.
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Affiliation(s)
- Karla A Lee
- St Luke's Radiation Oncology Network, Radiation Oncology, Dublin, Ireland. .,The Royal Marsden NHS Foundation Trust, Fulham Rd, London, SW3 6JJ, UK.
| | - Guhan Rangaswamy
- St Luke's Radiation Oncology Network, Radiation Oncology, Dublin, Ireland
| | - Naomi A Lavan
- St Luke's Radiation Oncology Network, Radiation Oncology, Dublin, Ireland
| | - Mary Dunne
- Clinical Trials, St Luke's Radiation Oncology Network, Dublin, Ireland
| | - Conor D Collins
- Department of Diagnostic Imaging St. Luke's Hospital and Department of Nuclear Medicine, Blackrock Clinic, Dublin, Ireland
| | - Cormac Small
- Radiation Oncology, Galway University Hospital, Galway, Ireland
| | - Pierre Thirion
- St Luke's Radiation Oncology Network, Radiation Oncology, Dublin, Ireland.,Cancer Trials Ireland, Dublin, Ireland
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Is SUVmax Helpful in the Differential Diagnosis of Enlarged Mediastinal Lymph Nodes? A Pilot Study. CONTRAST MEDIA & MOLECULAR IMAGING 2018; 2018:3417190. [PMID: 30510493 PMCID: PMC6230427 DOI: 10.1155/2018/3417190] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 09/02/2018] [Accepted: 09/20/2018] [Indexed: 12/16/2022]
Abstract
Objective To explore the diagnostic value of maximum standard uptake value (SUVmax) from 18F-FDG PET/CT images in enlarged mediastinal lymph nodes of unknown etiology. Methods We performed a retrospective study of patients with enlarged mediastinal lymph nodes on 18F-FDG PET/CT scans. SUVmax and the short axis and long axis of lymph nodes were recorded. These parameters were compared among the five commonest causes of mediastinal lymphadenopathy: lymphoma, metastatic disease, sarcoidosis, tuberculosis, and lymphadenitis. Histopathologic diagnosis was recorded as the final golden standard. Results A total of 94 patients (62 men and 32 women; age range 7-85 y) were included with final diagnoses of 42 patients with benign pathology and 52 patients with malignancies. The sensitivity, specificity, and the accuracy of PET/CT in diagnosis of the benign and malignant mediastinal lymph nodes were 94.2%, 73.8%, and 85.1%, respectively. The SUVmax of benign and malignant groups were 13.10 ± 5.21 and 12.59 ± 5.50, respectively, which had no statistical difference (P > 0.05). However, the long axis and the short axis of lymph nodes in the benign and malignant groups were 2.86 ± 1.02 cm, 1.77 ± 0.60 cm and 6.04 ± 3.83 cm, 3.95 ± 2.08 cm, respectively (P < 0.05). The diagnostic values of PET/CT were higher than those of the long or short axis. However, the specificity of PET/CT was lower (73.8%) than that from the long or short axis (90.5% and 92.9%, respectively), although no statistical difference existed. Among the five common causes of mediastinal lymphadenopathy, significant differences could be seen in SUVmax and in the long axis and the short axis of lymph nodes (P < 0.05). Conclusions SUVmax, a commonly used semiquantitative measurement, was not helpful for differentiation between benign and malignant lesions in patients with enlarged mediastinal lymph nodes in this study. Many benign lesions, such as sarcoidosis and tuberculosis, had high FDG uptake, possibly a trend that the size of the lymph nodes seems to have some diagnostic value.
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De Cecco CN, Burchett P, van Assen M, Ravenel J, Cooper SL, Li H, Bradshaw ML, Rieter WJ, Joseph Schoepf U, Gordon L. Rationale and design of a prospective study on the first integrated PET/dual-energy CT system for staging and image-based radiation therapy planning of lung cancer. Eur Radiol Exp 2018. [PMCID: PMC6092731 DOI: 10.1186/s41747-018-0047-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Wang H, Li QK, Auster M, Gong G. PET and CT features differentiating infectious/inflammatory from malignant mediastinal lymphadenopathy: A correlated study with endobronchial ultrasound-guided transbronchial needle aspiration. ACTA ACUST UNITED AC 2018; 5:7-13. [PMID: 31692939 PMCID: PMC6831101 DOI: 10.1016/j.jrid.2018.01.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Purpose: To explore the advantages of differentiating inflammatory from malignant thoracic lymph nodes by integrating their features on positron emission tomography (PET) and computed tomography (CT). Material and method: Following institutional review board approval, PET and CT parameters of thoracic lymph nodes were examined based on their pathologic diagnosis via endobronchial ultrasound-guided transbronchial needle aspiration. The standardized uptake value (SUV) of PET and CT findings of the long- and short-axis diameters, axial short to long diameter ratios (S/L), and measured nodal CT values of the lymph nodes were compared and analyzed statistically. Results: A total of 124 lymph nodes from 70 patients were studied. The inflammatory and malignant lymph nodes differed significantly in their SUV (P = 0.008), short-axis diameters (SAD, p < 0.001), long-axis diameters (LAD, p = 0.002) and S/L ratios (p < 0.001). They did not differ significantly in non-contrast enhanced CT values (p = 0.304). The sensitivities, specificities, positive predictive values, negative predictive values, diagnostic accuracies and diagnostic odds ratios (DOR) were: 1) elevated SUV alone - 95.31% (61/64), 20% (12/60), 55.96% (61/109), 80% (12/15), 58.87% (73/124), and 5; 2) combined SUV + SAD - 89.06%, 53.33%, 67.06%, 82.05%, 71.77%, and 9.31; 3) combined SUV + S/L ratio - 87.5%, 93.33%, 93.33%, 87.5%, 90.32%, and 98, respectively. Conclusion: Increased SUV, SAD, LAD, and S/L ratio are accurate PET/CT parameters to characterize inflammatory or malignant lymph nodes. SUV has high sensitivity but low specificity, low positive and negative predictive values, and low DOR. The SUV + SAD and SUV + S/L ratios have higher specificity, positive and negative predictive values, diagnostic accuracy and DOR.
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Affiliation(s)
- Haiyan Wang
- Shandong Medical Imaging Research Institute, Shandong University, Jingwu Road No.324, Jinan, Shandong 250021, China
| | - Qing Kay Li
- Department of Pathology, The Johns Hopkins University Bayview Medical Center, 4940 Eastern Avenue, Baltimore, MD 21224-2780, USA
| | - Martin Auster
- Imaging Department, The Johns Hopkins University Bayview Medical Center, 4940 Eastern Avenue, Baltimore, MD 21224-2780, USA
| | - Gary Gong
- Department of Radiology & Radiological Sciences, The Johns Hopkins University Hospital, Phipps B-125, 600 North Wolfe Street, Baltimore, MD 21287, USA
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Bhatt KM, Tandon YK, Graham R, Lau CT, Lempel JK, Azok JT, Mazzone PJ, Schneider E, Obuchowski NA, Bolen MA. Electromagnetic Navigational Bronchoscopy versus CT-guided Percutaneous Sampling of Peripheral Indeterminate Pulmonary Nodules: A Cohort Study. Radiology 2017; 286:1052-1061. [PMID: 29156147 DOI: 10.1148/radiol.2017170893] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Purpose To compare the diagnostic yield and complication rates of electromagnetic navigational bronchoscopic (ENB)-guided and computed tomography (CT)-guided percutaneous tissue sampling of lung nodules. Materials and Methods Retrospectively identified were 149 patients sampled percutaneously with CT guidance and 146 patients who underwent ENB with transbronchial biopsy of a lung lesion between 2013 and 2015. Clinical data, incidence of complications, and nodule pathologic analyses were assessed through electronic medical record review. Lung nodule characteristics were reviewed through direct image analysis. Molecular marker studies and pathologic analyses from surgical excision were reviewed when available. Multiple-variable logistic regression models were built to compare the diagnostic yield and complication rates for each method and for different patient and disease characteristics. Results CT-guided sampling was more likely to be diagnostic than ENB-guided biopsy (86.0% [129 of 150] vs 66.0% [99 of 150], respectively), and this difference remained significant even after adjustments were made for patient and nodule characteristics (P < .001). Age, American Society of Anesthesiologists class, emphysema grade, nodule size, and distance from pleura were not significant predictors of increased diagnostic yield. Intraprocedural time for physicians was significantly lower with CT-guided sampling (P < .001). Similar yield for molecular analyses was noted with the two approaches (ENB-guided sampling, 88.9% [32 of 36]; CT-guided sampling, 82.0% [41 of 50]). The two groups had similar rates of major complications (symptomatic hemorrhage, P > .999; pneumothorax requiring chest tube and/or admission, P = .417). Conclusion CT-guided transthoracic biopsy provided higher diagnostic yield in the assessment of peripheral pulmonary nodules than navigational bronchoscopy with a similar rate of clinically relevant complications. © RSNA, 2017 Online supplemental material is available for this article.
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Affiliation(s)
- Kavita M Bhatt
- From the Departments of Radiology (K.M.B., Y.K.T., R.G., C.T.L., J.K.L., J.T.A., E.S., M.A.B.), Pulmonology (P.J.M.), and Quantitative Health Sciences (N.A.O.), Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195
| | - Yasmeen K Tandon
- From the Departments of Radiology (K.M.B., Y.K.T., R.G., C.T.L., J.K.L., J.T.A., E.S., M.A.B.), Pulmonology (P.J.M.), and Quantitative Health Sciences (N.A.O.), Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195
| | - Ruffin Graham
- From the Departments of Radiology (K.M.B., Y.K.T., R.G., C.T.L., J.K.L., J.T.A., E.S., M.A.B.), Pulmonology (P.J.M.), and Quantitative Health Sciences (N.A.O.), Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195
| | - Charles T Lau
- From the Departments of Radiology (K.M.B., Y.K.T., R.G., C.T.L., J.K.L., J.T.A., E.S., M.A.B.), Pulmonology (P.J.M.), and Quantitative Health Sciences (N.A.O.), Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195
| | - Jason K Lempel
- From the Departments of Radiology (K.M.B., Y.K.T., R.G., C.T.L., J.K.L., J.T.A., E.S., M.A.B.), Pulmonology (P.J.M.), and Quantitative Health Sciences (N.A.O.), Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195
| | - Joseph T Azok
- From the Departments of Radiology (K.M.B., Y.K.T., R.G., C.T.L., J.K.L., J.T.A., E.S., M.A.B.), Pulmonology (P.J.M.), and Quantitative Health Sciences (N.A.O.), Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195
| | - Peter J Mazzone
- From the Departments of Radiology (K.M.B., Y.K.T., R.G., C.T.L., J.K.L., J.T.A., E.S., M.A.B.), Pulmonology (P.J.M.), and Quantitative Health Sciences (N.A.O.), Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195
| | - Erika Schneider
- From the Departments of Radiology (K.M.B., Y.K.T., R.G., C.T.L., J.K.L., J.T.A., E.S., M.A.B.), Pulmonology (P.J.M.), and Quantitative Health Sciences (N.A.O.), Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195
| | - Nancy A Obuchowski
- From the Departments of Radiology (K.M.B., Y.K.T., R.G., C.T.L., J.K.L., J.T.A., E.S., M.A.B.), Pulmonology (P.J.M.), and Quantitative Health Sciences (N.A.O.), Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195
| | - Michael A Bolen
- From the Departments of Radiology (K.M.B., Y.K.T., R.G., C.T.L., J.K.L., J.T.A., E.S., M.A.B.), Pulmonology (P.J.M.), and Quantitative Health Sciences (N.A.O.), Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195
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12
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Akthar AS, Ferguson MK, Koshy M, Vigneswaran WT, Malik R. Limitations of PET/CT in the Detection of Occult N1 Metastasis in Clinical Stage I(T1-2aN0) Non-Small Cell Lung Cancer for Staging Prior to Stereotactic Body Radiotherapy. Technol Cancer Res Treat 2017; 16:15-21. [PMID: 26792491 PMCID: PMC5616110 DOI: 10.1177/1533034615624045] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Revised: 11/04/2015] [Accepted: 12/02/2015] [Indexed: 12/25/2022] Open
Abstract
PURPOSE/OBJECTIVES Patients receiving stereotactic body radiotherapy for stage I non-small cell lung cancer are typically staged clinically with positron emission tomography-computed tomography. Currently, limited data exist for the detection of occult hilar/peribronchial (N1) disease. We hypothesize that positron emission tomography-computed tomography underestimates spread of cancer to N1 lymph nodes and that future stereotactic body radiotherapy patients may benefit from increased pathologic evaluation of N1 nodal stations in addition to N2 nodes. MATERIALS/METHODS A retrospective study was performed of all patients with clinical stage I (T1-2aN0) non-small cell lung cancer (American Joint Committee on Cancer, 7th edition) by positron emission tomography-computed tomography at our institution from 2003 to 2011, with subsequent surgical resection and lymph node staging. Findings on positron emission tomography-computed tomography were compared to pathologic nodal involvement to determine the negative predictive value of positron emission tomography-computed tomography for the detection of N1 nodal disease. An analysis was conducted to identify predictors of occult spread. RESULTS A total of 105 patients with clinical stage I non-small cell lung cancer were included in this study, of which 8 (7.6%) patients were found to have occult N1 metastasis on pathologic review yielding a negative predictive value for N1 disease of 92.4%. No patients had occult mediastinal nodes. The negative predictive value for positron emission tomography-computed tomography in patients with clinical stage T1 versus T2 tumors was 72 (96%) of 75 versus 25 (83%) of 30, respectively ( P = .03), and for peripheral versus central tumor location was 77 (98%) of 78 versus 20 (74%) of 27, respectively ( P = .0001). The negative predictive values for peripheral T1 and T2 tumors were 98% and 100%, respectively; while for central T1 and T2 tumors, the rates were 85% and 64%, respectively. Occult lymph node involvement was not associated with primary tumor maximum standard uptake value, histology, grade, or interval between positron emission tomography-computed tomography and surgery. CONCLUSION Our results support pathologic assessment of N1 lymph nodes in patients with stage Inon-small cell lung cancer considered for stereotactic body radiotherapy, with the greatest benefit in patients with central and T2 tumors. Diagnostic evaluation with endoscopic bronchial ultrasound should be considered in the evaluation of stereotactic body radiotherapy candidates.
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Affiliation(s)
- Adil S. Akthar
- Department of Radiation and Cellular Oncology, The University of Chicago, Chicago, IL, USA
| | - Mark K. Ferguson
- Department of Surgery, The University of Chicago, Chicago, IL, USA
- Comprehensive Cancer Center, The University of Chicago, Chicago, IL, USA
| | - Matthew Koshy
- Department of Radiation and Cellular Oncology, The University of Chicago, Chicago, IL, USA
| | - Wickii T. Vigneswaran
- Department of Thoracic and Cardiovascular Surgery, Loyola University Health System, Maywood, IL, USA
| | - Renuka Malik
- Department of Radiation and Cellular Oncology, The University of Chicago, Chicago, IL, USA
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13
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Eldaboosy SA, Zeinnhom RA, Kanany H, Nour MO. The value of cervical mediastinoscopy in the diagnosis of mediastinal lesions. EGYPTIAN JOURNAL OF CHEST DISEASES AND TUBERCULOSIS 2015. [DOI: 10.1016/j.ejcdt.2015.03.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Abstract
In this review, we review the literature on the use of PET in radiation treatment planning, with an emphasis on describing our institutional methodology (where applicable). This discussion is intended to provide other radiation oncologists with methodological details on the use of PET imaging for treatment planning in radiation oncology, or other oncologists with an introduction to the use of PET in planning radiation therapy.
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15
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Shetty N, Noronha V, Joshi A, Rangarajan V, Purandare N, Mohapatra PR, Prabhash K. Diagnostic and Treatment Dilemma of Dual Pathology of Lung Cancer and Disseminated Tuberculosis. J Clin Oncol 2014; 32:e7-9. [DOI: 10.1200/jco.2012.46.0667] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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16
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Vyas KS, Davenport DL, Ferraris VA, Saha SP. Mediastinoscopy: trends and practice patterns in the United States. South Med J 2013; 106:539-44. [PMID: 24096946 DOI: 10.1097/smj.0000000000000000] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Historically, mediastinoscopy has been the gold standard for the staging of lung cancer. A practice gap exists as the result of a variation in knowledge concerning current trends and practice patterns of mediastinoscopy usage. In addition, there are regional variations in practice-based learning and patient care. Lessons learned during surgeries performed on patients with lung cancer and other advances such as positron emission tomography and endobronchial ultrasound could be universally applied to improve surgeons' management of patient care. The purpose of this study was to assess contemporary practices in the staging of lung cancer. METHODS We queried the Society of Thoracic Surgeons National Database for data regarding mediastinoscopy usage, yield, and variation, both by year and region. RESULTS Cases with mediastinoscopy, as a percentage of all cases performed in the database, have significantly decreased from 14.6% in 2006 to 11.4% in 2010 (P < 0.001). The 5-year median rate of mediastinoscopy in lung cancer patients at 163 centers was 15.3% (interquartile range 5.2%-31.7%), indicating significant variation among centers. The overall median center rate also decreased over time from 21.4% (2006) to 10.0% (2010). CONCLUSIONS With advances in minimally invasive procedures and imaging, mediastinoscopy usage has declined significantly. Our findings are likely to be relevant to both clinical practice and practice guidelines.
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Affiliation(s)
- Krishna S Vyas
- From the College of Medicine, and the Department of Surgery, University of Kentucky, Lexington
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Karunamurthy A, Cai G, Dacic S, Khalbuss WE, Pantanowitz L, Monaco SE. Evaluation of endobronchial ultrasound-guided fine-needle aspirations (EBUS-FNA): Correlation with adequacy and histologic follow-up. Cancer Cytopathol 2013; 122:23-32. [DOI: 10.1002/cncy.21350] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2013] [Revised: 06/05/2013] [Accepted: 06/24/2013] [Indexed: 12/23/2022]
Affiliation(s)
| | - Guoping Cai
- Department of Pathology; Yale University School of Medicine; New Haven Connecticut
| | - Sanja Dacic
- Department of Pathology; University of Pittsburgh Medical Center; Pittsburgh Pennsylvania
| | - Walid E. Khalbuss
- Department of Pathology; University of Pittsburgh Medical Center; Pittsburgh Pennsylvania
| | - Liron Pantanowitz
- Department of Pathology; University of Pittsburgh Medical Center; Pittsburgh Pennsylvania
| | - Sara E. Monaco
- Department of Pathology; University of Pittsburgh Medical Center; Pittsburgh Pennsylvania
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18
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Koksal D, Demirag F, Bayiz H, Ozmen O, Tatci E, Berktas B, Aydoğdu K, Yekeler E. The correlation of SUVmax with pathological characteristics of primary tumor and the value of Tumor/ Lymph node SUVmax ratio for predicting metastasis to lymph nodes in resected NSCLC patients. J Cardiothorac Surg 2013; 8:63. [PMID: 23557204 PMCID: PMC3622559 DOI: 10.1186/1749-8090-8-63] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2012] [Accepted: 03/26/2013] [Indexed: 12/25/2022] Open
Abstract
Background We aimed to investigate the correlation of maximum standardized uptake value (SUVmax) with pathological characteristics of primary tumor and to determine a Tumor/ Lymph node (T/LN) SUVmax ratio predicting metastasis to lymph nodes in NSCLC patients. Methods Eighty-one NSCLC patients who had PET/CT examination at initial staging and subsequently underwent surgical resection were retrospectively evaluated. There were 100 PET/CT positive mediastinal or hilar lymph node stations. Pathological characteristics of the tumor such as largest tumor diameter, tumor histology, differentiation, number of mitosis, degree of stromal inflammation, necrosis; etiology of PET/CT positive lymph node stations; SUVmax of primary tumor and positive lymph node stations were recorded. A T/LN SUVmax ratio was calculated for each lymph node station. Results SUVmax of the primary tumor was positively correlated with the largest tumor diameter (p = 0.001, r = 0.374), number of mitosis (p < 0.001, r = 0.405), and postoperative pathological stage (p = 0.007, r = 0.298). Patients with squamous cell carcinoma had a statistically significant higher mean SUVmax, number of mitosis and advanced N stages compared to adenocarcinoma. The etiology of 100 PET/CT positive lymph node stations were metastasis in 14, anthracosis in 40, reactive in 39, granulomatous in 4, and silicosis in 3 patients. A T/LN SUVmax ratio of 5 or lower was suggestive for a malignant lymph node with a sensitivity of 92.8% and specificity of 47%. Conclusions SUVmax of a primary tumor is related to certain pathological characteristics, such as largest diameter, histology, and number of mitosis. A T/LN SUVmax ratio lower than 5 predicts the metastasis to lymph nodes with a high sensitivity.
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Affiliation(s)
- Deniz Koksal
- Chest Diseases Clinic, Ataturk Chest Diseases and Chest Surgery Education and Research Hospital, Ankara, Turkey.
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Cerci JJ, Takagaki TY, Trindade E, Morgado R, Morabito F, Musolino RS, Soares Junior J, Meneghetti JC. A tomografia por emissão de pósitrons com 2-[18F]-fluoro-2-desoxi-D-glicose é custo-efetiva em pacientes com câncer de pulmão não pequenas células no Brasil. Radiol Bras 2012. [DOI: 10.1590/s0100-39842012000400004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJETIVO: Comparar a acurácia e a custo-efetividade do estadiamento metabólico (EM) com o FDG-PET em relação ao estadiamento convencional (EC) no estadiamento inicial de pacientes com câncer de pulmão não pequenas células (CPNPC). MATERIAIS E MÉTODOS: Noventa e cinco pacientes com diagnóstico inicial de CPNPC foram estadiados antes do início do tratamento. Os resultados do EC e EM foram comparados quanto a definição do tratamento e incidência de toracotomia fútil em cada estratégia. RESULTADOS: O EM com FDG-PET classificou 48,4% dos pacientes como estádio mais avançado e 5,3% como menos avançado. O resultado do EM modificaria o tratamento em 41% dos pacientes. A toracotomia foi considerada fútil em 47% dos pacientes com EC e em 19% dos casos com EM. O custo das toracotomias fúteis em oito pacientes no EM foi de R$ 79.720, enquanto em 31 pacientes no EC seria de R$ 308.915. Apenas esta economia seria mais que suficiente para cobrir os custos de todos os exames de FDG-PET nos 95 pacientes (R$ 126.350) ou de FDG-PET/CT (R$ 193.515). CONCLUSÃO: O EM com FDG-PET tem maior acurácia que o EC em pacientes com CPNPC. A FDG-PET e FDG-PET/CT são custo-efetivas e sua utilização se justifica economicamente na saúde pública no Brasil.
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Chang CF, Rashtian A, Gould MK. The use and misuse of positron emission tomography in lung cancer evaluation. Clin Chest Med 2012; 32:749-62. [PMID: 22054883 DOI: 10.1016/j.ccm.2011.08.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
This article discusses the potential benefits and limitations of positron emission tomography (PET) for characterizing lung nodules, staging the mediastinum, identifying occult distant metastasis, determining prognosis and treatment response, guiding plans for radiation therapy, restaging during and after treatment, and selecting targets for tissue sampling. The key findings from the medical literature are presented regarding the capabilities and fallibilities of PET in lung cancer evaluation, including characterization of pulmonary nodules and staging in patients with known or suspected non-small-cell lung cancer. The discussion is limited to PET imaging with fluorodeoxyglucose.
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Affiliation(s)
- Ching-Fei Chang
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Keck School of Medicine of USC, 2020 Zonal Avenue, IRD Room 723, Los Angeles, CA 90033, USA
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21
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The role of positron emission tomography for non-small cell lung cancer. Pract Radiat Oncol 2011; 1:282-8. [DOI: 10.1016/j.prro.2011.01.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2010] [Revised: 01/11/2011] [Accepted: 01/18/2011] [Indexed: 01/02/2023]
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Ibeas P, Cantos B, Gasent JM, Rodríguez B, Provencio M. PET-CT in the staging and treatment of non-small-cell lung cancer. Clin Transl Oncol 2011; 13:368-77. [DOI: 10.1007/s12094-011-0670-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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23
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UyBico SJ, Wu CC, Suh RD, Le NH, Brown K, Krishnam MS. Lung cancer staging essentials: the new TNM staging system and potential imaging pitfalls. Radiographics 2011; 30:1163-81. [PMID: 20833843 DOI: 10.1148/rg.305095166] [Citation(s) in RCA: 110] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Lung cancer is the leading cause of cancer-related deaths worldwide, with a dismal 5-year survival rate of 15%. The TNM (tumor-node-metastasis) classification system for lung cancer is a vital guide for determining treatment and prognosis. Despite the importance of accuracy in lung cancer staging, however, correct staging remains a challenging task for many radiologists. The new 7th edition of the TNM classification system features a number of revisions, including subdivision of tumor categories on the basis of size, differentiation between local intrathoracic and distant metastatic disease, recategorization of malignant pleural or pericardial disease from stage III to stage IV, reclassification of separate tumor nodules in the same lung and lobe as the primary tumor from T4 to T3, and reclassification of separate tumor nodules in the same lung but not the same lobe as the primary tumor from M1 to T4. Radiologists must understand the details set forth in the TNM classification system and be familiar with the changes in the 7th edition, which attempts to better correlate disease with prognostic value and treatment strategy. By recognizing the relevant radiologic appearances of lung cancer, understanding the appropriateness of staging disease with the TNM classification system, and being familiar with potential imaging pitfalls, radiologists can make a significant contribution to treatment and outcome in patients with lung cancer.
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Affiliation(s)
- Stacy J UyBico
- Department of Radiology, University of California, Los Angeles, CA, USA
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Aristei C, Falcinelli L, Palumbo B, Tarducci R. PET and PET-CT in radiation treatment planning for lung cancer. Expert Rev Anticancer Ther 2010; 10:571-84. [PMID: 20397922 DOI: 10.1586/era.09.195] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
This review analyzes PET images in radiotherapy treatment planning for lung cancer patients and discusses the most controversial current issues. Computed tomography images are commonly used to assess location and extension of target volumes and organs at risk in radiotherapy treatment planning. Although PET is more sensitive and specific, contouring on PET images is difficult because tumor margins are indistinct, due to heterogeneous (18)fluorodeoxyglucose uptake distribution and limited spatial resolution. The best target delineation criteria have not yet been established. In non-small-cell lung cancer, PET appears to improve sparing of organs at risk and reduce the risk of toxicity; prescribed doses can be increased. Data are scarce on small-cell lung cancer.
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Affiliation(s)
- Cynthia Aristei
- Radiation Oncology Section, Department of Surgical, Radiological and Odontostomatological Sciences, University of Perugia, Ospedale Santa Maria della Misericordia, Sant'Andrea delle Fratte, 06156 Perugia, Italy.
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Monaco SE, Schuchert MJ, Khalbuss WE. Diagnostic difficulties and pitfalls in rapid on-site evaluation of endobronchial ultrasound guided fine needle aspiration. Cytojournal 2010; 7:9. [PMID: 20607094 PMCID: PMC2895875 DOI: 10.4103/1742-6413.64385] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2010] [Accepted: 04/24/2010] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND One of the novel techniques utilizing fine needle aspiration (FNA) in the diagnosis of mediastinal and lung lesions is the endobronchial ultrasound (EBUS)-guided FNA. In this study, we describe five cases which had a discrepancy between on-site evaluation and final diagnosis, or a diagnostic dilemma when rendering the preliminary diagnosis, in order to illustrate some of the diagnostic difficulties and pitfalls that can occur in EBUS FNA. METHODS A total of five EBUS FNA cases from five patients were identified in our records with a discrepancy between the rapid on-site evaluation (ROSE) and final diagnosis, or that addressed a diagnostic dilemma. All of the cases had histological confirmation or follow-up. The cytomorphology in the direct smears, cell block, and immunohistochemical stains were reviewed, along with the clinical history and other available information. RESULTS Two cases were identified with a nondefinitive diagnosis at ROSE that were later diagnosed as malignant (metastatic signet-ring cell adenocarcinoma and metastatic renal cell carcinoma (RCC)) on the final cytological diagnosis. Three additional cases were identified with a ROSE and final diagnosis of malignant (large cell neuroendocrine carcinoma (LCNEC) and two squamous cell carcinomas), but raised important diagnostic dilemmas. These cases highlight the importance of recognizing discohesive malignant cells and bland neoplasms on EBUS FNA, which may lead to a negative or a nondefinitive preliminary diagnosis. Neuroendocrine tumors can also be difficult due to the wide range of entities in the differential diagnosis, including benign lymphocytes, lymphomas, small and nonsmall cell carcinomas, and the lack of immunohistochemical stains at the time of ROSE. Finally, the background material in EBUS FNAs may be misleading and unrelated to the cells of interest. CONCLUSIONS This study illustrates the cytomorphology of five EBUS FNA cases that address some of the diagnostic challenges witnessed while examining these specimens during ROSE. Many of the difficulties faced can be attributed to the baseline cellularity of the aspirates, the bronchial contamination, the difficulty identifying neoplasms with bland cytology, the wide spectrum of diseases that can occur in the mediastinum with overlapping cytomorphologic features, the mismatch between the background material and the cell populations present, and the overall unfamiliarity with these types of specimens.
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Affiliation(s)
- Sara E Monaco
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Tascı E, Tezel C, Orki A, Akın O, Falay O, Kutlu CA. The role of integrated positron emission tomography and computed tomography in the assessment of nodal spread in cases with non-small cell lung cancer. Interact Cardiovasc Thorac Surg 2010; 10:200-3. [DOI: 10.1510/icvts.2009.220392] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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Prévost A, Papathanassiou D, Jovenin N, Menéroux B, Cuif-Job A, Bruna-Muraille C, Domange-Testard A, Liehn JC. [Comparison between PET(-FDG) and computed tomography in the staging of lung cancer. Consequences for operability in 94 patients]. REVUE DE PNEUMOLOGIE CLINIQUE 2009; 65:341-349. [PMID: 19995654 DOI: 10.1016/j.pneumo.2009.08.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2008] [Revised: 05/29/2009] [Accepted: 08/03/2009] [Indexed: 05/28/2023]
Abstract
INTRODUCTION Lung cancer, a major application of FDG/PET-CT, has recently been introduced in daily practice in France. The authors retrospectively studied its impact on the management of this disease. METHODS The results of PET-CT and conventional assessment (brain imaging, chest and abdominal CT and possibly bone scintigraphy) were compared in 94 patients, referred for the staging of non-small cell lung cancer, or the assessment of a solitary lung lesion. The impact of thoracic lymph node involvement on the operability of patients was studied in 44 patients. RESULTS PET-CT revealed metastases in 20% of the patients without metastases found by conventional imaging and modified the stage of the disease in 28% of the cases. It changed the indication of surgical treatment in 19% of the cases and led to induction chemotherapy in two patients. In addition, two synchronous cancers were discovered. Regarding lymph node involvement, PET-CT remains of diagnostic value regardless of the scanner results. CONCLUSION The impact of PET-CT in assessing non-small cell lung cancer was confirmed in the authors' practice. Its interest and the consequences in some patients misclassified with conventional assessment have been demonstrated.
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Affiliation(s)
- A Prévost
- Département d'oncologie médicale, institut Jean-Godinot, 1, rue du Général-Koenig, BP 171, 51056 Reims cedex, France.
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Şanlı M, Isik AF, Zincirkeser S, Elbek O, Mete A, Tuncozgur B, Elbeyli L. Reliability of positron emission tomography–computed tomography in identification of mediastinal lymph node status in patients with non–small cell lung cancer. J Thorac Cardiovasc Surg 2009; 138:1200-5. [DOI: 10.1016/j.jtcvs.2009.03.035] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2008] [Revised: 02/24/2009] [Accepted: 03/23/2009] [Indexed: 10/20/2022]
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Zimmermann FB, Geinitz H, Schill S, Thamm R, Nieder C, Schratzenstaller U, Molls M. Stereotactic hypofractionated radiotherapy in stage I (T1-2 N0 M0) non-small-cell lung cancer (NSCLC). Acta Oncol 2009; 45:796-801. [PMID: 16982542 DOI: 10.1080/02841860600913210] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Stereotactic Radiotherapy has the potential to produce high local control rates with low risk of severe lung toxicity. From December 2000 to January 2006, 68 inoperable patients (median age 76 years) with stage I NSCLC received definitive hSRT. A mean total dose of 37.5 Gy (24-40 Gy; 60%-isodose) in 3-5 fractions was applied. Immobilisation was carried out by means of a vacuum couch and low pressure foil (Medical Intelligence, Schwab München, Germany). Staging procedures were thoracic and abdominal CT-scan, FDG-PET and CT or MRI of the brain in all patients. Clinical target volume was the tumor as seen in lung windowing of CT and in FDG-PET. Organ movements (6-22 mm) and patient positioning in the couch (3-12 mm) were added as safety margin for the definition of the planning target volume (PTV), that was enclosed by the 60%-isodose. We observed four (6%) local tumor recurrences, resulting in an actuarial local tumor control rate of 96%, 88% and 88% after 1, 2 and 3 year follow-up. Nineteen patients died, with eight patients due to cancer (12%), two to local tumor progression alone. Cancer-specific survival is 96%, 82% and 73% at 1, 2 and 3 years. Eleven patients died from comorbidities, making a 53% overall 3-year survival. Fifty five percent of the patients were affected by mild acute and subacute side effects, with only 3% experiencing pneumonitis III degrees . Late effects were pneumonitis III degrees in 1%, rib fractures in 3%, and benign pleural effusion in 2 patients. Hypofractionated SRT is safe even in elderly patients with stage I NSCLC and significantly reduced lung capacity. It leads to high local control rates and should be offered to patients not amenable for curative resection.
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Affiliation(s)
- Frank B Zimmermann
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University, Munich, FRG.
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Hwangbo B, Kim SK, Lee HS, Lee HS, Kim MS, Lee JM, Kim HY, Lee GK, Nam BH, Zo JI. Application of Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration Following Integrated PET/CT in Mediastinal Staging of Potentially Operable Non-small Cell Lung Cancer. Chest 2009; 135:1280-1287. [DOI: 10.1378/chest.08-2019] [Citation(s) in RCA: 126] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Nomori H, Ohba Y, Yoshimoto K, Shibata H, Shiraishi K, Mori T. Positron emission tomography in lung cancer. Gen Thorac Cardiovasc Surg 2009; 57:184-91. [PMID: 19367450 DOI: 10.1007/s11748-008-0371-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2008] [Indexed: 11/28/2022]
Abstract
Recent advances in positron emission tomography (PET) with 2-deoxy-2-fluoro [F-18]-D: -glucose (FDG) has enabled not only the diagnosis and staging of lung cancer but also the prediction of its malignancy grade. However, FDG-PET has been known to have several pitfalls for imaging of lung cancer. For the effective clinical use of FDG-PET in lung cancer, we reviewed the pitfalls of using FDG-PET in the diagnosis of pulmonary nodules, semiquantitative analysis of FDG-uptake, N-staging, prediction of tumor aggressiveness, prognostic significance, and prediction of pathological response after chemoradiotherapy.
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Affiliation(s)
- Hiroaki Nomori
- Department of Thoracic Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, 860-8556, Japan.
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Use of PET and PET/CT for Radiation Therapy Planning: IAEA expert report 2006–2007. Radiother Oncol 2009; 91:85-94. [DOI: 10.1016/j.radonc.2008.11.008] [Citation(s) in RCA: 304] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2008] [Revised: 11/03/2008] [Accepted: 11/07/2008] [Indexed: 11/18/2022]
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Mac Manus M, Hicks RJ. The use of positron emission tomography (PET) in the staging/evaluation, treatment, and follow-up of patients with lung cancer: a critical review. Int J Radiat Oncol Biol Phys 2008; 72:1298-306. [PMID: 19028270 DOI: 10.1016/j.ijrobp.2008.08.022] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2008] [Revised: 08/17/2008] [Accepted: 08/20/2008] [Indexed: 11/25/2022]
Affiliation(s)
- Michael Mac Manus
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, and University of Melbourne, Melbourne, Australia
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Radiographic Staging of Mediastinal Lymph Nodes in Non–Small Cell Lung Cancer Patients. Thorac Surg Clin 2008; 18:349-61. [DOI: 10.1016/j.thorsurg.2008.07.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Miele E, Spinelli GP, Tomao F, Zullo A, De Marinis F, Pasciuti G, Rossi L, Zoratto F, Tomao S. 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). JOURNAL OF EXPERIMENTAL & CLINICAL CANCER RESEARCH : CR 2008; 27:52. [PMID: 18928537 PMCID: PMC2579910 DOI: 10.1186/1756-9966-27-52] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/19/2008] [Accepted: 10/17/2008] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- Evelina Miele
- Department of Experimental Medicine University of Rome Sapienza viale Regina Elena 324, Rome, Italy.
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An YS, Sun JS, Park KJ, Hwang SC, Park KJ, Sheen SS, Lee S, Lee KB, Yoon JK. Diagnostic performance of (18)F-FDG PET/CT for lymph node staging in patients with operable non-small-cell lung cancer and inflammatory lung disease. Lung 2008; 186:327-36. [PMID: 18670805 DOI: 10.1007/s00408-008-9109-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2008] [Accepted: 07/01/2008] [Indexed: 11/28/2022]
Abstract
As (18)F-fluorodeoxyglucose (FDG) is taken up by inflammatory lymph nodes, it could be falsely interpreted as metastasis. Therefore, we evaluated the diagnostic ability of positron emission tomography/computed tomography (PET/CT) for lymph node staging of lung cancer when inflammatory lung disease coexisted. Patients with operable non-small-cell lung cancer and FDG-avid lymph nodes were retrospectively classified into two groups; those with inflammatory lung disease (ILD) and those without it (NILD). Receiver operating characteristic (ROC) curve analysis was performed for maximum standardized uptake value (SUVmax), pattern of FDG uptake, maximum Hounsfield unit, and size, and then the areas under the ROC curves (AUCs) were compared between subgroups. There were 124 patients (ILD/NILD = 38/86) and 396 FDG-avid lymph nodes (ILD/NILD = 140/256). The average number of FDG-avid lymph nodes was greater in ILD (3.7 vs. 2.9, p = 0.039), whereas the proportion of metastasis was higher in NILD (25.4% vs. 11.4%, p = 0.002). With all N1-N3 lymph nodes and the NILD group, the AUC values of all four parameters were significantly greater than 0.5 (p < 0.05), and SUVmax was the most valuable parameter for lymph node metastasis. However, in the ILD group, only the AUC value of SUVmax was significantly greater than 0.5. These results were reproduced when analyses were performed with N1-N2 lymph nodes. In conclusion, SUVmax was the most valuable PET/CT parameter for assessment of lymph node metastasis in patients with operable non-small-cell lung cancer. In addition, it was the only valuable parameter when inflammatory lung disease coexisted.
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Affiliation(s)
- Young-Sil An
- Department of Nuclear Medicine, Ajou University School of Medicine, San 5, Wonchon-dong, Yeongtong-gu, Suwon 443-721, South Korea
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Nomori H, Mori T, Ikeda K, Kawanaka K, Shiraishi S, Katahira K, Yamashita Y. 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 Thorac Cardiovasc Surg 2008; 135:816-22. [PMID: 18374761 DOI: 10.1016/j.jtcvs.2007.10.035] [Citation(s) in RCA: 108] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2007] [Revised: 10/23/2007] [Accepted: 10/31/2007] [Indexed: 01/12/2023]
Abstract
OBJECTIVE One of the deficiencies of positron emission tomography for N staging in lung cancer is a false-positive result caused by concurrent lymphadenitis. Recently, diffusion-weighted magnetic resonance imaging has been reported to be able to image tumors of body organs. The aim of this study is to examine the usefulness of diffusion-weighted magnetic resonance imaging for N staging of non-small cell lung cancer compared with positron emission tomography-computed tomography. METHODS Both positron emission tomography-computed tomography and diffusion-weighted magnetic resonance imaging were prospectively used in 88 patients before surgical intervention for non-small cell lung cancer to examine 734 lymph node stations. The diagnostic results of positron emission tomography-computed tomography and diffusion-weighted magnetic resonance imaging were compared. The diameters of the metastatic foci within lymph nodes were measured on hematoxylin and eosin-stained sections to compare the detectable size of metastatic foci between positron emission tomography-computed tomography and diffusion-weighted magnetic resonance imaging. RESULTS The accuracy of N staging in the 88 patients was 0.89 with diffusion-weighted magnetic resonance imaging, which was significantly higher than the value of 0.78 obtained with positron emission tomography-computed tomography (P = .012), because of less overstaging in the former. Among the 734 lymph node stations examined pathologically, 36 had metastases, and the other 698 did not. Although there was no significant difference in the diagnosis of the 36 metastatic lymph node stations between the 2 methods, diffusion-weighted magnetic resonance imaging was more accurate for diagnosing the 698 nonmetastatic stations than positron emission tomography-computed tomography because of fewer false-positive results (P = .002). The detectable size of metastatic foci within lymph nodes was 4 mm in both positron emission tomography-computed tomography and diffusion-weighted magnetic resonance imaging. CONCLUSIONS Diffusion-weighted magnetic resonance imaging can be used in place of positron emission tomography-computed tomography for N staging of non-small cell lung cancer with fewer false-positive results compared with positron emission tomography-computed tomography.
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Affiliation(s)
- Hiroaki Nomori
- Department of Thoracic Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan.
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Könemann S, Weckesser M. PET and PET/CT in radiotherapy. Recent Results Cancer Res 2008; 170:243-253. [PMID: 18019631 DOI: 10.1007/978-3-540-31203-1_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Affiliation(s)
- S Könemann
- Universitätsklinikum Münster, Klinik und Poliklinik für Strahlentherapie und Radioonkologie, Germany
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40
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Chiles C, Aquino SL. Imaging of Thoracic Malignancies. Oncology 2007. [DOI: 10.1007/0-387-31056-8_29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Rodríguez Fernández A, Bellón Guardia M, Gómez Río M, Ramos Font C, Sánchez-Palencia Ramos A, Llamas Elvira J, Pedraza Muriel V. Estadificación del cáncer de pulmón de células no pequeñas. Utilidad de la imagen estructural (TAC) y funcional (FDG-PET). Rev Clin Esp 2007; 207:541-7. [DOI: 10.1157/13111571] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Inoue M, Okumura M, Minami M, Shiono H, Sawabata N, Utsumi T, Ohno Y, Sawa Y. Cardiopulmonary co-morbidity: a critical negative prognostic predictor for pulmonary resection following preoperative chemotherapy and/or radiation therapy in lung cancer patients. Gen Thorac Cardiovasc Surg 2007; 55:315-21. [PMID: 17867276 DOI: 10.1007/s11748-007-0140-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Preoperative therapy is an optional strategy for locally advanced lung cancer, although the indication for pulmonary resection is often marginal, when considering the survival benefit and perioperative risks. The aim of the present study was to identify prognostic predictors by assessing clinical factors including pre-thoracotomy co-morbidity. METHODS This was a retrospective analysis of 54 patients who underwent complete resection after preoperative therapy was performed. RESULTS The overall 5-year survival rate was 38%. In patients without cardiopulmonary co-morbidity the 5-year survival rate was 49%, whereas it was 0% for those who had associated cardiopulmonary co-morbidity (P = 0.004). When analyzing only those who died from lung cancer, the group without cardiopulmonary comorbidity showed a tendency for longer survival than those in the co-morbidity group (P = 0.092). The 5-year survival rate for patients--evaluated with a Charlson Co-morbidity Index (CCI)--with a CCI score of 0, was 45%, which tended to be better than that for those with a CCI score of 1-2 (P = 0.066). Furthermore, patients with a normal prethoracotomy level of carcinoembryonic antigen (CEA) had a 5-year survival rate of 44%, which was better than the 22% for patients with elevated CEA (P = 0.013). The 5-year survival rate for patients without lymph node metastasis was 52%, whereas it was 14% for those with residual node involvement (P = 0.002). Lymph node metastasis and cardiopulmonary co-morbidity were shown to be independent poor prognostic predictors by multivariate analysis. CONCLUSION In addition to nodal status, preoperative cardiopulmonary co-morbidity should be noted when considering the operative indications following preoperative therapy for lung cancer patients.
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Affiliation(s)
- Masayoshi Inoue
- Department of Surgery, Division of Thoracic and Cardiovascular Surgery, Osaka University Graduate School of Medicine, E1-2-2 Yamadaoka, Suita, Osaka 565-0871, Japan
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Spiro SG, Buscombe J, Cook G, Eisen T, Gleeson F, O'Brien M, Peake MD, Rowell NP, Seymour R. Ensuring the right PET scan for the right patient. Lung Cancer 2007; 59:48-56. [PMID: 17850919 DOI: 10.1016/j.lungcan.2007.07.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2007] [Revised: 07/25/2007] [Accepted: 07/26/2007] [Indexed: 10/22/2022]
Abstract
Guidelines issued by the National Institute for Clinical Excellence (NICE) in the England and Wales recommend that rapid access to (18)F-deoxyglucose positron emission tomography (FDG-PET) is made available to all appropriate patients with non-small-cell lung cancer (NSCLC). The clinical evidence for the benefits of PET scanning in NSCLC is substantial, showing that PET has high accuracy, sensitivity and specificity for disease staging, as well as pre-therapeutic assessment in candidates for surgery and radical radiotherapy. Moreover, PET scanning can provide important information to assist in radiotherapy treatment planning, and has also been shown to correlate with responses to treatment and overall outcomes. If the government cancer waiting time targets are to be met, rapid referral from primary to secondary healthcare is essential, as is early diagnostic referral within secondary and tertiary care for techniques such as PET. Studies are also required to explore new areas in which PET may be of benefit, such as surveillance studies in high-risk patients to allow early diagnosis and optimal treatment, while PET scanning to identify treatment non-responders may help optimise therapy, with benefits both for patients and healthcare resource use. Further studies are needed into other forms of lung cancer, including small-cell lung cancer and mesothelioma. In conclusion, PET scanning has the potential to improve the diagnosis and management of lung cancer for many patients. Further studies and refinement of guidelines and procedures will maximise the benefit of this important technique.
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Affiliation(s)
- Stephen G Spiro
- Department of Respiratory Medicine, University College Hospital, UCLH NHS Foundation Trust, London WC1E 6AU, United Kingdom.
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Cerfolio RJ, Bryant AS. The Role of Integrated Positron Emission Tomography-Computerized Tomography in Evaluating and Staging Patients with Non-Small Cell Lung Cancer. Semin Thorac Cardiovasc Surg 2007; 19:192-200. [DOI: 10.1053/j.semtcvs.2007.07.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2007] [Indexed: 11/11/2022]
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Kimura H, Yasufuku K, Ando S, Yoshida S, Ishikawa A, Wada Y, Fujisawa T. Indications for mediastinoscopy and comparison of lymph node dissections in candidates for lung cancer surgery. Lung Cancer 2007; 56:349-55. [PMID: 17466405 DOI: 10.1016/j.lungcan.2007.01.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2006] [Revised: 12/09/2006] [Accepted: 01/15/2007] [Indexed: 11/18/2022]
Abstract
A prospective phase II study of indications for surgery, using video-assisted mediastinoscopy (VAM) to detect mediastinal lymph node metastasis was conducted in patients with resectable primary lung cancer of clinical stages I-IIIA. According to the indication criteria for VAM, Group A patients had primary tumor resection and lymph node sampling without VAM. Patients without detected metastasis by VAM underwent thoracotomy and systematic lymph node dissection (Group B). Cases with mediastinal lymph node involvement confirmed by VAM were treated with chemotherapy followed by radiotherapy (Group D) or by thoracotomy (Group C) with extended dissection of mediastinal lymph nodes via median sternotomy. Of the 359 eligible patients, 209 underwent VAM (Group V) and 150 had thoracotomy without VAM (Group A). Of the VAM patients, 158 were negative for mediastinal involvement and underwent thoracotomy (Group B). Fifty-one patients had metastases and were given chemotherapy or chemo-radiotherapy. After two courses of chemotherapy, 22 patients with partial response (PR) or stable disease (SD) but reduced tumor markers received surgery with mediastinal lymph node dissection (Group C). The 2- and 5-year survival rates were 93.0 and 88.5% for Group A, and 89.5 and 61.5% for Group B, while the 2-year rate in Group C was 60.3%. In stage IA patients, Group A 2- and 5-year survival rates were 98.6 and 95.1%, the respective Group B rates being 96.3 and 89.9%. The more favorable Group A outcomes indicated both successful selection by these criteria of patients not requiring mediastinal examination, and the superfluity of complete lymph node dissection in early stage cancer.
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Affiliation(s)
- Hideki Kimura
- Division of Thoracic Diseases, Chiba Cancer Center, 666-2 Nitona-cho, Chuo-ku, Chiba 260-8717, Japan.
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Kobayashi M, Okubo K, Morikawa H, Hayatsu E. Evaluation of Mediastinal Node Metastasis in Lung Cancer by FDG-PET. ACTA ACUST UNITED AC 2007. [DOI: 10.2482/haigan.47.233] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Le Péchoux C, Ferreira I, Bruna A, Roberti E, Besse B, Bretel JJ. Cancers bronchiques : la radiothérapie prophylactique des aires ganglionnaires a-t-elle encore une place ? Cancer Radiother 2006; 10:354-60. [PMID: 17035060 DOI: 10.1016/j.canrad.2006.09.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The use of conformal radiotherapy in lung cancer has considerably evolved with the advent of improved staging technologies and methods of radiation delivery. Patients with limited disease, inoperable for medical reasons, may be treated with conformal radiotherapy alone; patients with more advanced disease are treated with combined chemo-radiotherapy. If local control may be improved by radiotherapy dose escalation according to several studies, toxicity and more particularly pulmonary toxicity seems to be related to radiation volume. Thus the use of elective nodal irradiation is being questioned. Data for early stage (stage I) non-small-cell lung cancer treated with conformal radiotherapy or stereotactic hypofractionated radiotherapy strongly supports the use of smaller fields that do not incorporate elective nodal regions; local control and survival rates approach those of surgical series. In locally advanced non-small cell lung cancer, eliminating elective nodal irradiation allows to maximize tumor dose and minimize normal tissue toxicity in combined modality treatments; results are encouraging. The use of staging modalities such as positron emission tomography and eventually oesophageal ultrasonography is increasing, allowing to encompass the tumor volume with more accuracy. Several studies have confirmed that involved-field irradiation results into a regional nodal rate of less than 10%. Further larger-scale studies would be needed to definitely establish "no elective nodal irradiation" as a standard in non-small cell lung cancer. There are very few data concerning small cell lung cancer.
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Affiliation(s)
- C Le Péchoux
- Département de Radiothérapie, Institut Gustave-Roussy, 39, Rue Camille-Desmoulins, Villejuif, France.
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Nestle U, Kremp S, Grosu AL. Practical integration of [18F]-FDG-PET and PET-CT in the planning of radiotherapy for non-small cell lung cancer (NSCLC): The technical basis, ICRU-target volumes, problems, perspectives. Radiother Oncol 2006; 81:209-25. [PMID: 17064802 DOI: 10.1016/j.radonc.2006.09.011] [Citation(s) in RCA: 180] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2006] [Revised: 09/05/2006] [Accepted: 09/22/2006] [Indexed: 11/20/2022]
Abstract
The value of positron emission tomography using [18F]-fluoro-deoxy-glucose (FDG-PET) for pretherapeutic evaluation of patients with non-small cell lung cancer (NSCLC) is beyond doubt. Due to the increasing availability of PET and PET-CT scanners the method is now widely available, and its technical integration has become possible for radiotherapy planning systems. Due to the depiction of malignant tissue with high diagnostic accuracy, the use of FDG-PET in radiotherapy planning of NSCLC is very promising. However, by uncritical application, PET could impair rather than improve the prognosis of patients. Therefore, in the present paper we give an overview of technical factors influencing PET and PET-CT data, and their consequences for radiotherapy planning. We further review the relevant literature concerning the diagnostic value of FDG-PET and on the integration of FDG-PET data in RT planning for NSCLC. We point out the possible impact in gross tumor volume (GTV) definition and describe methods of target volume contouring of the primary tumor, as well as concepts for the integration of diagnostic information on lymph node involvement into the clinical target volume (CTV), and the possible implications of PET data on the definition of the planning target volume (PTV). Finally, we give an idea of the possible future use of tracers other than [18F]-FDG in lung cancer.
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Affiliation(s)
- Ursula Nestle
- Department of Nuclear Medicine, Saarland University Medical Centre, Hamburg/Saar, Germany.
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Ebihara A, Nomori H, Watanabe K, Ohtsuka T, Naruke T, Uno K, Kuwahira I, Eguchi K. Characteristics of Advantages of Positron Emission Tomography over Computed Tomography for N-staging in Lung Cancer Patients. Jpn J Clin Oncol 2006; 36:694-8. [PMID: 17068084 DOI: 10.1093/jjco/hyl092] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE We analyzed the characteristics of advantages of positron emission tomography (PET) over computed tomography (CT) for N-staging in lung cancer patients. METHODS Preoperative PET and CT scans were performed for 2057 lymph node stations in 205 patients with peripheral-type lung cancer. The advantages of PET over CT for N-staging were analyzed among lymph node locations and histological subtypes. RESULTS The pathological N-stages were N0 in 143 patients, N1 in 31, N2 in 24 and N3 in 7. PET was able to diagnose N0, N2 and N3 diseases more accurately than CT (P=0.03, 0.01 and 0.02, respectively), but there was no significant difference between the two modalities for N1 disease. In the upper mediastinal lymph node stations, both false-negative and false-positive were significantly less frequent with PET than with CT (P=0.001). In the lower mediastinal and supra clavicle lymph nodes, PET showed a lower frequency of false-negative than CT (P=0.04 and 0.003, respectively), but there was no significant difference in the frequency of false-positive between the two modalities. Among histological types, PET could stage adenocarcinoma with less frequent false-negative and squamous cell carcinoma with less frequent false-positive than CT (P=0.02 and 0.005, respectively). CONCLUSION For N-staging, PET was superior to CT for the following: (1) more accurate for N0, N2 and N3 diseases but not for N1; (2) lower frequency of false-positive in the upper mediastinal nodes; and (3) lower frequencies of false-negative in adenocarcinoma and false-positive in squamous cell carcinoma. Recognizing these advantages of PET could make the N-staging of lung cancer more accurate.
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Affiliation(s)
- Akinori Ebihara
- Department of Internal Medicine, Saiseikai Central Hospitaol, Tokyo, Japan
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Bryant AS, Cerfolio RJ, Klemm KM, Ojha B. Maximum Standard Uptake Value of Mediastinal Lymph Nodes on Integrated FDG-PET-CT Predicts Pathology in Patients with Non-Small Cell Lung Cancer. Ann Thorac Surg 2006; 82:417-22; discussion 422-3. [PMID: 16863739 DOI: 10.1016/j.athoracsur.2005.12.047] [Citation(s) in RCA: 116] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2005] [Revised: 12/11/2005] [Accepted: 12/13/2005] [Indexed: 11/23/2022]
Abstract
BACKGROUND Positron emission tomography (PET) scans often help direct biopsies of mediastinal lymph nodes in patients with non-small cell lung cancer (NSCLC), but the maximum standard uptake value (maxSUV) of individual nodes has not been evaluated. METHODS This is a prospective study of consecutive patients with NSCLC, all of whom underwent integrated fluorodeoxyglucose-positron emission-computed tomography (FDG-PET-CT) and had biopsy or resection of their mediastinal lymph nodes. RESULTS There were 397 patients. One-hundred and forty-three patients had N2 disease and 1,252 N2 nodes were pathologically examined. The median maxSUV of the nodes that had metastatic disease were the following: for the 2R node, 10.4 (range, 0-18.6); for 4R, 8.6 (range, 0-18.3); for 5, 8.9 (range, 0-26.3); for 6, 7.6 (range, 0-19.6); for 7, 7.7 (range, 0-14); for 8 and 9, 5.4 (range, 0-8.9). The median maxSUV for all of the N2 nodes that were benign was 0 (range, 0-18.8) (p < 0.05 for all stations except for nodes 8 and 9). When a maxSUV of 5.3 is used the accuracy of integrated FDG-PET-CT for each N2 nodal station is maximized and is at least 92% for each. CONCLUSIONS The maxSUV of individual mediastinal lymph nodes is a predictor of malignancy. There is overlap between false and true positives. Definitive biopsies are required to prove cancer irrespective of the maxSUV value. However, when a maxSUV of 5.3 is used instead of the traditional value of 2.5, the accuracy for FDG-PET-CT for each N2 nodal station increases to at least 92%.
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Affiliation(s)
- Ayesha S Bryant
- Department of Surgery, Emory University, Atlanta, Georgia, USA.
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