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Borgheresi A, Agostini A, Pierpaoli L, Bruno A, Valeri T, Danti G, Bicci E, Gabelloni M, De Muzio F, Brunese MC, Bruno F, Palumbo P, Fusco R, Granata V, Gandolfo N, Miele V, Barile A, Giovagnoni A. Tips and Tricks in Thoracic Radiology for Beginners: A Findings-Based Approach. Tomography 2023; 9:1153-1186. [PMID: 37368547 DOI: 10.3390/tomography9030095] [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: 05/05/2023] [Revised: 06/03/2023] [Accepted: 06/12/2023] [Indexed: 06/29/2023] Open
Abstract
This review has the purpose of illustrating schematically and comprehensively the key concepts for the beginner who approaches chest radiology for the first time. The approach to thoracic imaging may be challenging for the beginner due to the wide spectrum of diseases, their overlap, and the complexity of radiological findings. The first step consists of the proper assessment of the basic imaging findings. This review is divided into three main districts (mediastinum, pleura, focal and diffuse diseases of the lung parenchyma): the main findings will be discussed in a clinical scenario. Radiological tips and tricks, and relative clinical background, will be provided to orient the beginner toward the differential diagnoses of the main thoracic diseases.
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Affiliation(s)
- Alessandra Borgheresi
- Department of Clinical, Special and Dental Sciences, University Politecnica delle Marche, Via Tronto 10/a, 60126 Ancona, Italy
- Department of Radiology, University Hospital "Azienda Ospedaliero Universitaria delle Marche", Via Conca 71, 60126 Ancona, Italy
| | - Andrea Agostini
- Department of Clinical, Special and Dental Sciences, University Politecnica delle Marche, Via Tronto 10/a, 60126 Ancona, Italy
- Department of Radiology, University Hospital "Azienda Ospedaliero Universitaria delle Marche", Via Conca 71, 60126 Ancona, Italy
- Italian Society of Medical and Interventional Radiology (SIRM), SIRM Foundation, 20122 Milan, Italy
| | - Luca Pierpaoli
- School of Radiology, University Politecnica delle Marche, Via Tronto 10/a, 60126 Ancona, Italy
| | - Alessandra Bruno
- School of Radiology, University Politecnica delle Marche, Via Tronto 10/a, 60126 Ancona, Italy
| | - Tommaso Valeri
- School of Radiology, University Politecnica delle Marche, Via Tronto 10/a, 60126 Ancona, Italy
| | - Ginevra Danti
- Department of Radiology, Azienda Ospedaliero-Universitaria Careggi, 50134 Florence, Italy
| | - Eleonora Bicci
- Department of Radiology, Azienda Ospedaliero-Universitaria Careggi, 50134 Florence, Italy
| | - Michela Gabelloni
- Nuclear Medicine Unit, Department of Translational Research, University of Pisa, 56126 Pisa, Italy
| | - Federica De Muzio
- Department of Medicine and Health Sciences V. Tiberio, University of Molise, 86100 Campobasso, Italy
| | - Maria Chiara Brunese
- Department of Medicine and Health Sciences V. Tiberio, University of Molise, 86100 Campobasso, Italy
| | - Federico Bruno
- Italian Society of Medical and Interventional Radiology (SIRM), SIRM Foundation, 20122 Milan, Italy
- Department of Diagnostic Imaging, Area of Cardiovascular and Interventional Imaging, Abruzzo Health, Unit 1, 67100 L'Aquila, Italy
| | - Pierpaolo Palumbo
- Italian Society of Medical and Interventional Radiology (SIRM), SIRM Foundation, 20122 Milan, Italy
- Department of Diagnostic Imaging, Area of Cardiovascular and Interventional Imaging, Abruzzo Health, Unit 1, 67100 L'Aquila, Italy
| | - Roberta Fusco
- Medical Oncology Division, Igea SpA, 80013 Naples, Italy
| | - Vincenza Granata
- Division of Radiology, Istituto Nazionale Tumori IRCCS Fondazione Pascale-IRCCS di Napoli, 80131 Naples, Italy
| | - Nicoletta Gandolfo
- Diagnostic Imaging Department, Villa Scassi Hospital-ASL 3, 16149 Genoa, Italy
| | - Vittorio Miele
- Italian Society of Medical and Interventional Radiology (SIRM), SIRM Foundation, 20122 Milan, Italy
- Department of Radiology, Azienda Ospedaliero-Universitaria Careggi, 50134 Florence, Italy
| | - Antonio Barile
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, 67100 L'Aquila, Italy
| | - Andrea Giovagnoni
- Department of Clinical, Special and Dental Sciences, University Politecnica delle Marche, Via Tronto 10/a, 60126 Ancona, Italy
- Department of Radiology, University Hospital "Azienda Ospedaliero Universitaria delle Marche", Via Conca 71, 60126 Ancona, Italy
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Ramamoorthy E, Garg M, Singh P, Aggarwal AN, Gupta N. Role of Diffusion-Weighted Magnetic Resonance Imaging for Characterization of Mediastinal Lymphadenopathy. Diagnostics (Basel) 2023; 13:diagnostics13040706. [PMID: 36832194 PMCID: PMC9955495 DOI: 10.3390/diagnostics13040706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 12/21/2022] [Accepted: 02/07/2023] [Indexed: 02/16/2023] Open
Abstract
BACKGROUND To assess the diagnostic performance of diffusion-weighted (DW) magnetic resonance imaging (MRI) in the characterization of mediastinal lymph nodes and compare them with morphological parameters. METHODS A total of 43 untreated patients with mediastinal lymphadenopathy underwent DW and T2 weighted MRI followed by pathological examination in the period from January 2015 to June 2016. The presence of diffusion restriction, apparent diffusion coefficient (ADC) value, short axis dimensions (SAD), and T2 heterogeneous signal intensity of the lymph nodes were evaluated using receiver operating characteristic curve (ROC) and forward step-wise multivariate logistic regression analysis. RESULTS The ADC of malignant lymphadenopathy was significantly lower (0.873 ± 0.109 × 10-3 mm2/s) than that of benign lymphadenopathy (1.663 ± 0.311 × 10-3 mm2/s) (p = 0.001). When an ADC of 1.0955 × 10-3 mm2/s was used as a threshold value for differentiating malignant from benign nodes, the best results were obtained with a sensitivity of 94%, a specificity of 96%, and an area under the curve (AUC) of 0.996. A model combining the other three MRI criteria showed less sensitivity (88.9%) and specificity (92%) compared to the ADC-only model. CONCLUSION The ADC was the strongest independent predictor of malignancy. The addition of other parameters failed to show any increase in sensitivity and specificity.
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Affiliation(s)
- Eniyavel Ramamoorthy
- Department of Radio Diagnosis and Imaging, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Mandeep Garg
- Department of Radio Diagnosis and Imaging, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
- Correspondence:
| | - Paramjeet Singh
- Department of Radio Diagnosis and Imaging, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Ashutosh N. Aggarwal
- Department of Pulmonary Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Nalini Gupta
- Department of Cytology, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
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Archer JM, Truong MT, Shroff GS, Godoy MCB, Marom EM. Imaging of Lung Cancer Staging. Semin Respir Crit Care Med 2022; 43:862-873. [PMID: 35815631 DOI: 10.1055/s-0042-1753476] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Lung cancer is a leading cause of cancer-related mortality worldwide. Imaging is integral in accurate clinical staging to stratify patients into groups to predict survival and determine treatment. The eighth edition of the tumor, node, and metastasis (TNM-8) staging system proposed by the International Association for the Study of Lung Cancer in 2016, accepted by both the Union for International Cancer Control and the American Joint Committee on Cancer, is the current standard method of staging lung cancer. This single TNM staging is used for all histologic subtypes of lung cancer, including nonsmall cell lung cancer, small cell lung cancer, and bronchopulmonary carcinoid tumor, and it addresses both clinical and pathologic staging. Familiarity with the strengths and limitations of imaging modalities used in staging, the nuances of TNM-8, its correct nomenclature, and potential pitfalls are important to optimize patient care. In this article, we discuss the role of computed tomography (CT) and positron emission tomography/CT in lung cancer staging, as well as current imaging recommendations pertaining to TNM-8.
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Affiliation(s)
- J Matthew Archer
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Mylene T Truong
- Department of Thoracic Imaging, University of Texas Monroe Dunaway Anderson Cancer Center, Houston, Texas
| | - Girish S Shroff
- Department of Thoracic Imaging, University of Texas Monroe Dunaway Anderson Cancer Center, Houston, Texas
| | - Myrna C B Godoy
- Department of Thoracic Imaging, University of Texas Monroe Dunaway Anderson Cancer Center, Houston, Texas
| | - Edith M Marom
- Department of Diagnostic Radiology, Tel Aviv University, Chaim Sheba Medical Center, Ramat Gan, Israel
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Numan RC, Berge MT, Burgers JA, Klomp HM, van Sandick JW, Baas P, Wouters MW. Pre- and postoperative care for stage I-III NSCLC: Which quality of care indicators are evidence-based? Lung Cancer 2016; 101:120-128. [PMID: 27794400 DOI: 10.1016/j.lungcan.2016.05.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2016] [Revised: 05/16/2016] [Accepted: 05/29/2016] [Indexed: 10/21/2022]
Abstract
Identification of evidenced-based Quality of Care (QoC) indicators for lung cancer care is essential to quality improvement. The aim of this review was to identify evidence-based quality indicators for the pre- and postoperative care of stage I-III Non Small Cell Lung Cancer (NSCLC) provided by the lung physician. To obtain these indicators, a search in PubMed, Embase and the Cochrane library database was performed. English literature published between 1980 and 2012 was included and search terms regarding 'lung neoplasms', 'quality of care', 'pathology', 'diagnostic methods', 'preoperative and postoperative treatment' were used. The potential indicators were categorized as structure, process or outcome measures and the indicators supported by literature with high evidence level were selected. Five QoC indicators were identified. The use of the positron emission tomography-computed tomography (PET-CT) results in more accurate mediastinal staging compared to the CT scan. Endoscopic Ultrasound-Fine Needle Aspiration and Endobronchial Ultrasound-Fine Needle Aspiration are sensitive diagnostic tools for mediastinal staging and reduce futile thoracotomies. Pathological conformation of lung cancer can best be obtained by a combination of cytological and histological diagnostics used during bronchoscopy. For patients with clinical stage III NSCLC, preoperative multimodality treatment (i.e. preoperative chemoradiation) results in superior survival and increased mediastinal downstaging compared to single modality treatment (i.e. preoperative chemotherapy or radiotherapy). After surgery, the addition of chemotherapy results in a significant survival benefit for patients with pathological stage II and III NSCLC. These five QoC indicators can be used for benchmarking and ultimately quality improvement of lung cancer care.
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Affiliation(s)
- Rachel C Numan
- Department of Surgical Oncology, Netherlands Cancer Institute/Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands.
| | - Martijn Ten Berge
- Department of Surgical Oncology, Leids Universitair Medisch Centrum, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Jacobus A Burgers
- Department of Thoracic Oncology, Netherlands Cancer Institute/Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| | - Houke M Klomp
- Department of Surgical Oncology, Netherlands Cancer Institute/Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| | - Johanna W van Sandick
- Department of Surgical Oncology, Netherlands Cancer Institute/Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| | - Paul Baas
- Department of Thoracic Oncology, Netherlands Cancer Institute/Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| | - Michel W Wouters
- Department of Surgical Oncology, Netherlands Cancer Institute/Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
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Zhang Y, Qin Q, Li B, Wang J, Zhang K. Magnetic resonance imaging for N staging in non-small cell lung cancer: A systematic review and meta-analysis. Thorac Cancer 2015; 6:123-32. [PMID: 26273348 PMCID: PMC4448484 DOI: 10.1111/1759-7714.12203] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Accepted: 10/31/2014] [Indexed: 12/16/2022] Open
Abstract
Background Lymph node staging in non-small cell lung cancer (NSCLC) is essential for deciding appropriate treatment. This study systematically reviews the literature regarding the diagnostic performance of magnetic resonance imaging (MRI) in lymph node staging of patients with NSCLC, and determines its pooled sensitivity and specificity. Methods PubMed and Embase databases and the Cochrane library were used to search for relevant studies. Two reviewers independently identified the methodological quality of each study. A meta-analysis of the reported sensitivity and specificity of each study was performed. Results Nine studies were included. These studies had moderate to good methodological quality. Pooled sensitivity, specificity, positive likelihood ratio (LR+), negative likelihood ratio (LR−) and diagnosis odds ratio (DOR) for per-patient based analyses (7 studies) were 74%, 90%, 7.5, 0.26, and 36.7, respectively, and those for per-lymph node based analyses (5 studies) were 77%, 98%, 42.24, 0.21, and 212.35, respectively. For meta-analyses of quantitative short time inversion recovery imaging (STIR) and diffusion-weighted imaging (DWI), pooled sensitivity and specificity were 84% and 91%, and 69% and 93%, respectively. Pooled LR+ and pooled LR− were 8.44 and 0.18, and 8.36 and 0.36, respectively. The DOR was 56.29 and 27.2 respectively. Conclusion MRI showed high specificity in the lymph node staging of NSCLC. Quantitative STIR has greater DOR than quantitative DWI. Large, direct, and prospective studies are needed to compare the diagnostic power of STIR versus DWI; consistent diagnostic criteria should be established.
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Affiliation(s)
- Yuanyuan Zhang
- Department of Radiation Oncology, Shandong Cancer Hospital, School of Medicine and Life Sciences, University of Jinan-Shandong Academy of Medical Sciences Jinan, Shandong Province, China
| | - Qin Qin
- Department of Radiation Oncology, Shandong Cancer Hospital, Shandong University Jinan, Shandong Province, China
| | - Baosheng Li
- Department of Radiation Oncology, Shandong Cancer Hospital, School of Medicine and Life Sciences, University of Jinan-Shandong Academy of Medical Sciences Jinan, Shandong Province, China ; Department of Radiation Oncology, Shandong Cancer Hospital, Shandong University Jinan, Shandong Province, China
| | - Juan Wang
- Department of Radiation Oncology, Shandong Cancer Hospital, School of Medicine and Life Sciences, University of Jinan-Shandong Academy of Medical Sciences Jinan, Shandong Province, China
| | - Kun Zhang
- Department of Radiology, Hohhot First Hospital Hohhot, Inner Mongolia, China
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Hong YJ, Hur J, Lee HJ, Kim YJ, Hong SR, Suh YJ, Choi BW. Respiratory dynamic magnetic resonance imaging for determining aortic invasion of thoracic neoplasms. J Thorac Cardiovasc Surg 2014; 148:644-50. [DOI: 10.1016/j.jtcvs.2013.12.060] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2013] [Revised: 07/31/2013] [Accepted: 12/12/2013] [Indexed: 11/25/2022]
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Wu LM, Xu JR, Gu HY, Hua J, Chen J, Zhang W, Haacke EM, Hu J. Preoperative mediastinal and hilar nodal staging with diffusion-weighted magnetic resonance imaging and fluorodeoxyglucose positron emission tomography/computed tomography in patients with non–small-cell lung cancer: Which is better? J Surg Res 2012; 178:304-14. [DOI: 10.1016/j.jss.2012.03.074] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2012] [Revised: 03/19/2012] [Accepted: 03/30/2012] [Indexed: 12/25/2022]
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Mennini ML, Catalano C, Del Monte M, Fraioli F. Computed tomography and magnetic resonance imaging of the thoracic lymphatic system. Thorac Surg Clin 2012; 22:155-60. [PMID: 22520282 DOI: 10.1016/j.thorsurg.2011.12.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Several radiographic diagnostic techniques are currently available to assess the potential involvement of mediastinal lymph nodes in thoracic oncology. In particular, computed tomography and magnetic resonance imaging have been repeatedly validated; these techniques allow adequate imaging with a reasonable accuracy. The morphologic information provided by these techniques is crucial to stage lung cancer and plan treatment. These techniques are also extremely useful to evaluate other disorders and differentiate malignancy from benign disease.
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Affiliation(s)
- Maria Luisa Mennini
- Department of Radiological Sciences, Sapienza University of Rome, Policlinico Umberto I, V.le Regina Elena 324, Roma 00161, Italy
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Ridene I, Ben Miled-M'rad K, Zidi A, Hantous-Zannad S, Baccouche I. [Small-cell lung carcinoma: CT imaging features]. ACTA ACUST UNITED AC 2011; 92:3-7. [PMID: 21352720 DOI: 10.1016/j.jradio.2010.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2009] [Revised: 03/18/2010] [Accepted: 03/22/2010] [Indexed: 11/26/2022]
Abstract
Small cell lung carcinoma (SCLC) typically is central in location. It is a very aggressive tumor characterized by its propensity for invasion of mediastinal structures, frequently, the ipsilateral pulmonary artery, multifocal nodal metastases and high frequency of distant metastases at initial presentation. CT is very sensitive and effective for local and regional staging. Combined with other diagnostic modalities, especially PET imaging, it allows whole body imaging for accurate staging, which is mandatory for therapeutic management. The different CT imaging features of SCLC and its more specific imaging characteristics will be reviewed in this article.
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Affiliation(s)
- I Ridene
- Service d'imagerie médicale, hôpital Abderrahmane Mami, 2080 Ariana, Tunisie.
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Alper F, Turkyilmaz A, Kurtcan S, Aydin Y, Onbas O, Acemoglu H, Eroglu A. Effectiveness of the STIR turbo spin-echo sequence MR imaging in evaluation of lymphadenopathy in esophageal cancer. Eur J Radiol 2010; 80:625-8. [PMID: 20800403 DOI: 10.1016/j.ejrad.2010.08.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2010] [Revised: 07/27/2010] [Accepted: 08/02/2010] [Indexed: 11/18/2022]
Abstract
PURPOSE We have investigated the utility of the STIR TSE sequence in the differentiation of benign from malignant mediastinal lymph nodes in patients with esophageal cancer. PATIENTS AND METHODS This study included 35 consecutive patients who were diagnosed as esophageal cancer and were undergone surgery. STIR TSE sequences were obtained as the ECG trigger. The signal intensity of the benign and malign lymph nodes, normal esophagus, and pathologic esophagus can be calculated on STIR sequence. RESULTS Pathologically, the number of total lymph nodes in 35 operated cases was 482. Approximately 152 lymph nodes were detected with MR imaging. Of these, 28 were thought to be malignant, and 124 were thought to be benign, although 32 were malignant and 120 were benign according pathological results. The ratio of benign lymph node intensity value to normal esophagus intensity value was 0.73±0.3. The ratio of malignant lymph node intensity value to normal esophagus intensity value ratio was 2.03±0.4. According to these results, the sensitivity of MR was 81.3%, the specificity was 98.3%. CONCLUSION We think that if motionless images can be obtained with MRI, we may be able to differentiate benign lymph nodes from malignant ones.
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Affiliation(s)
- Fatih Alper
- Atatürk University, School of Medicine, Department of Radiology, Erzurum, Turkey.
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Metastases in mediastinal and hilar lymph nodes in patients with non-small cell lung cancer: quantitative assessment with diffusion-weighted magnetic resonance imaging and apparent diffusion coefficient. J Comput Assist Tomogr 2010; 34:1-8. [PMID: 20118713 DOI: 10.1097/rct.0b013e3181a9cc07] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To evaluate diffusion-weighted magnetic resonance (DW-MR) imaging for detection of metastases in lymph nodes by using quantitative analysis. METHODS Seventy patients with non-small cell lung cancer were examined with DW and short inversion time inversion recovery (STIR) turbo-spin-echo MR imaging. Apparent diffusion coefficient of each lung cancer and lymph node was calculated from DW-MR images. Difference of the apparent diffusion coefficient in a lung cancer and a lymph node was calculated (D1). From STIR turbo-spin-echo MR images, ratios of signal intensity in a lymph node to that in a 0.9% saline phantom was calculated (lymph node-saline ratio [LSR1]). For quantitative analysis, the threshold value for a positive test was determined on a per node basis and tested for ability to enable a correct diagnosis on a per patient basis. Results of quantitative analyses of DW- and STIR-MR images were compared on a per patient basis with McNemar testing. RESULTS Mean D1 in the lymph node group with metastases was lower than that in the group without metastases (P < 0.001). When an D1 of 0.24 x 10(-3) mm2/s was used as the positive test threshold, sensitivity, specificity, and accuracy were 69.2%, 100%, and 94.0%, respectively, on a per patient basis. There was no significant difference (P > 0.05) between quantitative analyses of DW-MR images and STIR-MR images. CONCLUSIONS Quantitative analysis of DW-MR images enables differentiation of lymph nodes with metastasis from those without.
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Rusch VW, Bains MS. Nael Martini: a leader in thoracic surgical oncology. Ann Thorac Surg 2010; 89:1006-9. [PMID: 20172188 DOI: 10.1016/j.athoracsur.2009.11.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2009] [Revised: 10/07/2009] [Accepted: 11/24/2009] [Indexed: 11/18/2022]
Abstract
Nael Martini was one of the leading academic general thoracic surgeons of the late 20th century. His most notable contributions related to the surgical and multimodality treatment of lung cancer.
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Affiliation(s)
- Valerie W Rusch
- Thoracic Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York 10065, USA.
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Mediastinal lymph nodes in patients with non-small cell lung cancer: preliminary experience with diffusion-weighted MR imaging. J Thorac Imaging 2009; 23:157-61. [PMID: 18728541 DOI: 10.1097/rti.0b013e318166d2f5] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVES The purpose of our study was to describe our preliminary experience of evaluating mediastinal lymph node metastases with diffusion-weighted magnetic resonance (MR) imaging in patients with non-small cell lung cancer. MATERIALS AND METHODS Forty-two consecutive patients with non-small cell lung cancer underwent preoperative diffusion-weighted MR imaging using a non-breath-hold short inversion time inversion recovery-echo planar imaging sequence with a high b value of 1000 s/mm2. An experienced thoracic radiologist prospectively evaluated each study for mediastinal lymph node metastases on a per-patient basis. On diffusion-weighted MR imaging, mediastinal lymph node metastasis was defined as a focus of low signal intensity at the site of a visible lymph node on corresponding T2-weighted image. The MR results were correlated with histopathologic findings. RESULTS Diffusion-weighted MR imaging demonstrated mediastinal lymph node metastasis in 4 (80%) of 5 patients with pathologically proven metastasis and accurately identified 36 (97%) of 37 patients without mediastinal lymph node metastasis. Thus, 40 (95%) of 42 patients were accurately diagnosed. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of diffusion-weighted MR imaging for mediastinal lymph node metastasis were 80%, 97%, 80%, 97%, and 95%, respectively. CONCLUSIONS Our preliminary results show that diffusion-weighted MR imaging has a high negative predictive value for excluding mediastinal lymph node metastases from non-small cell lung cancer and has the potential to be a reliable alternative non-invasive imaging method for the preoperative staging of mediastinal lymph node in patients with non-small cell lung cancer.
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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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Endobronchial Ultrasound-Guided Fine-Needle Aspiration of Mediastinal Lymph Nodes: A Single Institution's Early Learning Curve. Ann Thorac Surg 2008; 86:1104-9; discussion 1109-10. [DOI: 10.1016/j.athoracsur.2008.06.042] [Citation(s) in RCA: 84] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2008] [Revised: 06/10/2008] [Accepted: 06/11/2008] [Indexed: 12/25/2022]
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Whitson BA, Groth SS, Maddaus MA. Recommendations for optimal use of imaging studies to clinically stage mediastinal lymph nodes in non-small-cell lung cancer patients. Lung Cancer 2008; 61:177-85. [DOI: 10.1016/j.lungcan.2007.12.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2007] [Revised: 11/27/2007] [Accepted: 12/16/2007] [Indexed: 12/25/2022]
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Rankin SC. The role of positron emission tomography in staging of non-small cell lung cancer. Target Oncol 2008. [DOI: 10.1007/s11523-008-0085-6] [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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Erasmus JJ, Sabloff BS. CT, positron emission tomography, and MRI in staging lung cancer. Clin Chest Med 2008; 29:39-57, v. [PMID: 18267183 DOI: 10.1016/j.ccm.2007.11.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Lung cancer is a common malignancy and remains the leading cause of cancer-related deaths in both men and women in the United States. Imaging plays an important role in the detection, diagnosis, and staging of the disease as well as in assessing response to therapy and monitoring for tumor recurrence after treatment. This article reviews the staging of the two major histologic categories of lung cancer-non-small-cell lung carcinoma (NSCLC) and small-cell lung carcinoma-and emphasizes the appropriate use of CT, MRI, and positron emission tomography imaging in patient management. Also discussed are proposed revisions of the International Association for the Study of Lung Cancer's terms used to describe the extent of NSCLC in terms of the primary tumor, lymph nodes, and metastases descriptors.
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Affiliation(s)
- Jeremy J Erasmus
- Division of Diagnostic Imaging, University of Texas, MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 0371, Houston, TX 77030, USA.
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Ugalde P, Miro S, Fréchette E, Deslauriers J. Correlative anatomy for thoracic inlet; glottis and subglottis; trachea, carina, and main bronchi; lobes, fissures, and segments; hilum and pulmonary vascular system; bronchial arteries and lymphatics. Thorac Surg Clin 2008; 17:639-59. [PMID: 18271174 DOI: 10.1016/j.thorsurg.2007.04.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Because it is relatively inexpensive and universally available, standard radiographs of the thorax should still be viewed as the primary screening technique to look at the anatomy of intrathoracic structures and to investigate airway or pulmonary disorders. Modern trained thoracic surgeons must be able to correlate surgical anatomy with what is seen on more advanced imaging techniques, however, such as CT or MRI. More importantly, they must be able to recognize the indications, capabilities, limitations, and pitfalls of these imaging methods.
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Affiliation(s)
- Paula Ugalde
- Department of Thoracic Surgery, Centre de Pneumologie de Laval, 2725 Chemin Sainte-Foy, Québec, QC G1V 4G5, Canada
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Truong MT, Munden RF, Movsas B. Imaging to optimally stage lung cancer: conventional modalities and PET/CT. J Am Coll Radiol 2007; 1:957-64. [PMID: 17411738 DOI: 10.1016/j.jacr.2004.07.007] [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] [Indexed: 01/02/2023]
Abstract
Accurately staging patients with lung cancer is important in determining treatment options and prognoses. Staging allows the distinction of patients who are candidates for surgical resection from those with inoperable disease who may be treated with chemotherapy and/or radiation therapy. Conventional imaging plays an essential role in the noninvasive and invasive methods of the evaluation and staging of patients with non-small-cell lung cancer (NSCLC). Imaging modalities used for staging include chest radiography, chest computed tomography (CT), abdominal CT, brain CT or magnetic resonance imaging, bone scans, and (18)F-2-deoxy-d-glucose positron emission tomography (PET). Recently, PET/CT, the integration of the functional data of PET with the anatomic data of CT, has emerged as a modality to potentially change the way patients are evaluated. This article reviews current recommendations regarding the staging of patients with NSCLC and addresses the role of PET/CT.
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Affiliation(s)
- Mylene T Truong
- Department of Diagnostic Radiology, University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030, USA.
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Renck DV, Araújo DBD, Gomes NH, Mendonça R. Comparação entre tomografia computadorizada e mediastinoscopia na avaliação do envolvimento ganglionar mediastínico no carcinoma brônquico não de pequenas células. Radiol Bras 2007. [DOI: 10.1590/s0100-39842007000100005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJETIVO: Avaliar o rendimento da tomografia computadorizada torácica, em relação à mediastinoscopia, na detecção de metástases ganglionares mediastinais em pacientes portadores de carcinoma brônquico analisando o rendimento dessa e identificando as regiões mais problemáticas. MATERIAIS E MÉTODOS: Analisamos 195 pacientes portadores de carcinoma brônquico, buscando-se comparar os achados entre tomografia computadorizada torácica e mediastinoscopia com biópsia. RESULTADOS: Em relação às metástases nodais mediastinais, 33,9% tinham doença metastática ganglionar peribrônquica e/ou hilar ipsilateral, 46,1% possuíam metástases mediastinais ipsilaterais e/ou subcarinais e 20% apresentavam doença metastática mediastinal e/ou hilar contralateral, escalênica ou supraclavicular. As regiões com melhores valores de sensibilidade foram traqueobrônquica direita, paratraqueal direita alta e paratraqueal esquerda alta. As regiões nodais com melhores resultados de especificidade foram paratraqueal esquerda alta, paratraqueal direita alta e regiões traqueobrônquicas. CONCLUSÃO: A tomografia computadorizada torácica mostrou-se importante ferramenta diagnóstica na detecção de anormalidades em gânglios mediastinais; entretanto, a natureza neoplásica desses gânglios deve ser conferida por mediastinoscopia, ou até mesmo por toracotomia, a fim de que a correta decisão quanto ao tratamento possa ser tomada.
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Affiliation(s)
- Décio Valente Renck
- Universidade Católica de Pelotas; Universidade Federal de Pelotas; Santa Casa de Misericórdia de Pelotas
| | - Daniel Brito de Araújo
- Hospital do Servidor Público Estadual de São Paulo; Sociedade Brasileira de Clínica Médica
| | - Nilton Haertel Gomes
- Universidade Católica de Pelotas; Universidade Federal de Pelotas; Santa Casa de Misericórdia de Pelotas
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Ohno Y, Koyama H, Nogami M, Takenaka D, Yoshikawa T, Yoshimura M, Ohbayashi C, Sugimura K. STIR turbo SE MR imaging vs. coregistered FDG-PET/CT: Quantitative and qualitative assessment of N-stage in non-small-cell lung cancer patients. J Magn Reson Imaging 2007; 26:1071-80. [PMID: 17896365 DOI: 10.1002/jmri.21106] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
PURPOSE To conduct a prospective comparison of the accuracy of short inversion time (TI) inversion-recovery (STIR) turbo spin-echo (SE) imaging and coregistered 2-[fluorine-18] fluoro-2-deoxy-D-glucose (FDG)-positron emission tomography (PET) with computed tomography (CT) (coregistered FDG-PET/CT) to assess the N-stage in non-small-cell lung cancer (NSCLC) patients. MATERIALS AND METHODS A total of 115 consecutive NSCLC patients prospectively underwent CT, STIR turbo SE imaging, and FDG-PET, as well as surgical and pathological examinations. All STIR turbo SE images were obtained with a 0.9% saline phantom, which was placed alongside the chest wall of each patient, and coregistered FDG-PET/CTs were reconstructed using commercially available software. For quantitative assessments, the ratio of signal intensity (SI) of each lymph node to that of 0.9% saline phantom (lymph node-saline ratio [LSR]) and maximal standardized uptake value (SUV(max)) of each lymph node were calculated. Feasible threshold values were determined by using the receiver operating characteristic (ROC) curve-based positive test, and diagnostic capabilities of N-stage were compared by McNemar's test on a per patient basis. RESULTS When feasible, threshold values were adopted, quantitative sensitivity (90.1%) and accuracy (92.2%) of STIR turbo SE imaging were significantly higher than those of quantitative and qualitative sensitivities (76.7% and 74.4%) and accuracies (83.5% and 82.6%) of coregistered FDG-PET/CT on a per patient basis (P < 0.05). CONCLUSION STIR turbo SE imaging is at least as valid as coregistered FDG-PET/CT for quantitative and qualitative assessment of the N-stage for NSCLC patients.
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Affiliation(s)
- Yoshiharu Ohno
- Department of Radiology, Kobe University Graduate School of Medicine, Kobe, Japan
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Kazawa N, Kitaichi M, Hiraoka M, Togashi K, Mio N, Mishima M, Wada H. Small cell lung carcinoma: Eight types of extension and spread on computed tomography. J Comput Assist Tomogr 2006; 30:653-61. [PMID: 16845299 DOI: 10.1097/00004728-200607000-00017] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to classify the types of tumor extension and spread of small cell lung carcinoma (SCLC) and to recognize the unusual types of spread pattern of SCLC on computed tomography (CT) including multidetector row CT (MDCT) using contrast-enhanced material. MATERIALS AND METHODS Sixty-eight cases (53 men and 15 women aged 54-83 years old) of pathologically proven SCLC were examined mainly by contrast-enhanced CT scan. In surgically treated 7 cases, CT-pathologic correlations were performed. RESULTS Eight types of extension and spread were recognized by the examinations of chest CT. The type of central mass + mediastinal extension (n = 20 [29.4%]) was the most common manifestation. The types of central perihilar mass (n = 12 [17.6%]), peripheral mass + mediastinal extension (n = 14 [20.6%]), and peripheral mass (n = 7 [10.3%]) were frequently observed. The primary site of SCLC was in peripheral lung tissue in 21 of 68 cases (30.9%) in this study. Unusual CT manifestations, such as the types of lymphangitic spread (n = 6 [8.8%]), pleural dissemination (n = 4 [5.9%]), lobar replacement (n = 3 [4.4%]), pneumonialike air-space infiltrative spread (n = 2 [2.9%]) were recognized in our study. Stenosis of trachea and main bronchus caused by peribronchial extension were commonly noted. In the advanced cases with mediastinal extension, we observed the extension of SCLC to superior vena cava (n = 22), main pulmonary artery (n = 18), pulmonary vein (n = 11), and thoracic aortic wall (n = 7). Peri-and intracardial invasions were also observed in 9 cases. CONCLUSIONS Computed tomography including MDCT analysis revealed 8 types of extension and spread of SCLC including unusual forms in 68 SCLC cases. Peribronchial extension and great vessel wall involvement, such as superior vena cava, main pulmonary artery, and peri-/intra-cardial extension, were commonly observed in advanced stage.
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Affiliation(s)
- Nobukata Kazawa
- Department of Radiology, Kyoto University Hospital, Shogoin Kawaharamachi 54 Sakyo, Kyoto-City, Kyoto Prefecture Japan.
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Abstract
Computed tomography (CT) is still the cornerstone of imaging studies in the preoperative staging and post- therapeutic evaluation of lung cancer. The most recent developments in multidetector technology have dramatically improved the temporal and spatial resolution of CT. In the mean time, magnetic resonance imaging (MRI) has not become a routine examination in lung imaging and is today only used as a problem-solving tool in patients in whom CT remains equivocal. This article will describe the current tools developed in the multidetector CT era for evaluating the lung, and state-of-the-art MR examination of the chest. Then, the role of CT and MRI in nodule detection, the distinction between benign and malignant nodules, and the benefit of CT and MRI in the staging and post-therapeutic evaluation of lung cancer will be covered.
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Affiliation(s)
- François Laurent
- Laboratoire de Physiologie Cellulaire Respiratoire, Université Bordeaux 2, and INSERM E356, Bordeaux.
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Abstract
OBJECTIVE Elective nodal irradiation (ENI) of regional lymphatics has been a foundational paradigm for radiation oncologists in the treatment of nonsmall-cell lung cancer (NSCLC), but its utility has recently been called into question. This review summarizes the controversies surrounding ENI and reviews the therapeutic options available to treat regional lymphatics in NSCLC. METHODS Local failure after conventional radiotherapy (RT) occurs in 40% to 80% of patients fueling the investigation of more aggressive RT regimens. As the dose is increased and accelerated the volume of normal lung tissue treated becomes a limiting factor. Thus elimination of ENI followed by further dose escalation has become a commonly pursued solution. When ENI is excluded, treatment is restricted to clinically positive disease and negative lymph node stations are left untreated. RESULTS Radiographic and surgical data suggest our ability to determine the true extent of disease is imperfect and therefore the elimination of ENI likely leaves microscopic NSCLC untreated. CONCLUSIONS At our institution we have concluded that the prophylactic treatment of regional lymph nodes is best reserved for patients most likely to achieve local control and are designing treatment protocols including chemotherapy to take advantage of this improvement in local control.
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Affiliation(s)
- Daniel T Chang
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
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Munden RF, Swisher SS, Stevens CW, Stewart DJ. Imaging of the Patient with Non–Small Cell Lung Cancer. Radiology 2005; 237:803-18. [PMID: 16251391 DOI: 10.1148/radiol.2373040966] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Lung cancer is the most common type of cancer and is the leading cause of cancer deaths in the United States for both men and women. Even though the 5-year survival rate of patients with lung cancer remains dismal at 14% for all cancer stages, treatments are improving and newer agents for lung cancer appear promising. Therefore, an accurate assessment of the extent of disease is critical to determine whether the patient is treated with surgical resection, radiation therapy, chemotherapy, or a combination of these modalities. Radiologic imaging plays an important role in the staging evaluation of the patient; however, radiologists need to be aware that there are also important differences in what each specialist needs from imaging to provide appropriate treatment. This article reviews the role of imaging in patients with non-small cell lung cancer, with an emphasis on the radiologic imaging findings relevant for each specialty.
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Affiliation(s)
- Reginald F Munden
- Division of Diagnostic Imaging, Department of Diagnostic Radiology, University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030, USA.
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Seo JS, Kim YJ, Choi BW, Choe KO. Usefulness of magnetic resonance imaging for evaluation of cardiovascular invasion: evaluation of sliding motion between thoracic mass and adjacent structures on cine MR images. J Magn Reson Imaging 2005; 22:234-41. [PMID: 16028243 DOI: 10.1002/jmri.20378] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
PURPOSE To determine the feasibility and usefulness of magnetic resonance imaging (MRI) for evaluating cardiovascular invasion of a thoracic mass by demonstrating the sliding motion between the mass and adjacent structures. MATERIALS AND METHODS Twenty-six patients (17 males and nine females, mean age = 49 years) were included in this study. They all had thoracic masses with equivocal cardiovascular invasion on chest CT scan and/or MRI that were surgically confirmed. The pathologic diagnoses were teratoma/thymic tumor (N = 12), lung cancer (N = 9), and other thoracic tumor (N = 5). Conventional T1/T2, contrast-enhanced, and breathheld ECG-gated cine MRI using a steady-state free precession (SSFP) technique was performed. The results were compared to the surgical reports. RESULTS The cine MR images showed the presence of sliding motion in 39 structures in 20 patients, which were surgically confirmed as not being invaded, and 15 structures in six patients with the absence of sliding motion noted as tumor invasion. Therefore, the accuracy of the cine MR images was 94.4% (51/54) for evaluating cardiovascular invasion of a thoracic mass. CONCLUSION MRI can provide additional information and improve the accuracy of preoperative staging for predicting cardiovascular invasion of a thoracic mass by evaluating the sliding motion.
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Affiliation(s)
- Jae Seung Seo
- Department of Radiology and Research Institute of Radiological Science, Yonsei University College of Medicine, Shinchon Severance Hospital, #134 Shinchon-dong Seodaemoon-ku, Seoul 129-572, Korea
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Abstract
Radiologic evaluation is an important component of the clinical staging evaluation of lung cancer and can greatly influence whether the patient is treated with surgical resection, radiation therapy, chemotherapy, or a combination of these modalities. In addition to staging, the radiologic evaluation of the patient undergoing treatment and subsequent follow-up is important to the clinician for assessing treatment effects and complications. This article discusses the imaging of patients with non-small cell lung cancer and its use in management of these patients.
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Affiliation(s)
- Reginald F Munden
- Division of Diagnostic Imaging, Department of Radiology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA.
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Erasmus JJ, Truong MT, Munden RF. CT, MR, and PET imaging in staging of non-small-cell lung cancer. Semin Roentgenol 2005; 40:126-42. [PMID: 15898410 DOI: 10.1053/j.ro.2005.01.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Affiliation(s)
- Jeremy J Erasmus
- Department of Diagnostic Radiology, University of Texas, MD Anderson Cancer Center, Houston, TX 77030, USA.
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Finke NM, Aubry MC, Tazelaar HD, Aughenbaugh GL, Lohse CM, Pankratz VS, Deschamps C. Autopsy results after surgery for non-small cell lung cancer. Mayo Clin Proc 2004; 79:1409-14. [PMID: 15544020 DOI: 10.4065/79.11.1409] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To determine the percentage of metastatic and unexpected residual lung cancer at autopsy in patients considered for curative resection of non-small cell lung cancer during a time when computed tomography was available as a preoperative staging tool. MATERIAL AND METHODS Clinical data and surgical and autopsy slides of all patients who underwent curative resection of nonsmall cell lung cancer at the Mayo Clinic in Rochester, Minn, between 1985 and 1999 and who underwent autopsy within 30 days of surgery were reviewed retrospectively for the presence of residual or metastatic disease. RESULTS The study group consisted of 25 men and 7 women, with a mean age of 70 years. A pulmonary metastasis was identified at surgery in 1 patient (3%). Metastases were found in an additional 5 patients (16%) at autopsy, 1 of whom had 2 sites involved. These sites included the liver in 2 and lung, epicardium, adrenal gland, and kidney in 1 each. The average diameter of metastases was 1.6 cm. No factor studied was found to be significantly associated with the presence of unrecognized metastatic disease at autopsy. CONCLUSION The advent of computed tomography as a staging tool has decreased the percentage of patients with undiagnosed metastatic disease at surgery; however, preoperative understaging in lung cancer remains a problem.
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Affiliation(s)
- Nicole M Finke
- Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, Minn 55905, USA
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Abstract
Proper selection and interpretation of imaging studies is essential to provide optimal treatment to patients who have lung cancer. The following combines the recommendations of the American College of Chest Physicians [74] and the authors' current clinical practice guidelines: --All patients who have known or suspected lung cancer should undergo a CT of the chest and upper abdomen. --An FDG-PET study should be performed, if available. --Mediastinoscopy should be performed in all patients except those who have peripheral small (<2 cm) tumors and no evidence of N2 disease on CT or PET imaging. --MRI should be performed for tumors of the superior sulcus to define the relationship of the tumor to adjacent neurovascular structures. --Patients who have neurologic signs or symptoms should undergo a brain imaging study (CT or MRI). --Screening for extrathoracic disease is not necessary in asymptomatic patients who have clinical stage I or II disease.
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Affiliation(s)
- Michael S Kent
- Department of Surgery, Weill Medical College, Cornell University, 525 East 68th Street, Suite K707, New York, NY 10021, USA
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Affiliation(s)
- Abid Irshad
- Department of Radiology, Medical University of South Carolina, Charleston, SC, USA.
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Ohno Y, Hatabu H, Takenaka D, Higashino T, Watanabe H, Ohbayashi C, Yoshimura M, Satouchi M, Nishimura Y, Sugimura K. Metastases in Mediastinal and Hilar Lymph Nodes in Patients with Non–Small Cell Lung Cancer: Quantitative and Qualitative Assessment with STIR Turbo Spin-Echo MR Imaging. Radiology 2004; 231:872-9. [PMID: 15163823 DOI: 10.1148/radiol.2313030103] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To evaluate short inversion time inversion-recovery (STIR) turbo spin-echo (TSE) magnetic resonance (MR) imaging for detection of metastases in lymph nodes by using quantitative and qualitative analyses. MATERIALS AND METHODS One hundred ten patients (68 men and 42 women) with non-small cell lung cancer who ranged in age from 36 to 82 years (mean age, 64 years) were examined with respiratory-triggered STIR TSE MR imaging. Ratios of signal intensity in a lymph node to that in a 0.9% saline phantom (lymph node-saline ratios [LSRs]) for all lymph nodes were classified into three groups according to nodal short-axis diameter. LSRs of each group were compared by using pathologic diagnosis as the standard of reference. For quantitative analysis, the LSR threshold value for a positive test was determined on a per-node basis and tested for ability to enable a correct diagnosis on a per-patient basis. For qualitative analysis, signal intensities of lymph nodes were assessed by using a five-point visual scoring system. Results of quantitative and qualitative analyses were compared on a per-patient basis with McNemar testing. RESULTS In 110 patients, 92 of 802 lymph nodes were pathologically diagnosed as containing metastases, while 710 lymph nodes did not contain metastases. Mean LSR in the lymph node group with metastasis was higher than that in the group without metastasis (P <.05). When an LSR of 0.6 was used as the positive-test threshold at quantitative analysis, sensitivity was 93% (37 of 40 patients) and specificity was 87% (61 of 70 patients) on a per-patient basis. With a score of 4 as the positive-test threshold at qualitative analysis, sensitivity was 88% (35 of 40 patients) and specificity was 86% (60 of 70 patients) on a per-patient basis. There was no significant difference (P >.05) between results of quantitative and those of qualitative analysis. CONCLUSION Quantitative and qualitative analyses of STIR TSE MR images enable differentiation of lymph nodes with metastasis from those without. Qualitative analysis can substitute for quantitative analysis of STIR TSE MR imaging data.
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Affiliation(s)
- Yoshiharu Ohno
- Department of Radiology, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan.
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Rocha AT, McCormack M, Montana G, Schreiber G. Association between lower lobe location and upstaging for early-stage non-small cell lung cancer. Chest 2004; 125:1424-30. [PMID: 15078755 DOI: 10.1378/chest.125.4.1424] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVE To identify factors associated with a misclassification of the true disease stage by comparing the differences between the clinical and pathologic stage of patients with early-stage non-small cell lung cancer (NSCLC). DESIGN A prospective cohort study. SETTING A multidisciplinary thoracic oncology clinic at a university-affiliated Veterans Affairs medical center. PATIENT POPULATION One hundred nine male veterans with clinical stage I/II NSCLC who had undergone thoracotomy with systematic lymph node dissection. METHODS Prospective data were collected on all patients between September 1997 and April 2002. Logistic regression analysis was used to establish the odds ratio (OR) for predictors of changes in stage. RESULTS A stage misclassification was found in 35.8% of patients (39 of 109 patients) after thoracotomy with lymph node dissection, and all but one patient were upstaged. Unsuspected nodal involvement (N stage) resulted in the upstaging of 16.5% of the patients, a change in tumor stage (T stage) resulted in the upstaging of 13.8% of the patients, a change in both stages resulted in the upstaging of 2.7% of patients, and the designation of metastatic disease resulted in the upstaging of 1.9% of the patients. The rate of unsuspected mediastinal lymph node involvement (pathologic stage N2) was 8.3% (9 of 109 patients), despite negative mediastinoscopy findings. Complete anatomic resection was performed in all patients. Advanced disease was found in 8.3% of the patients (9 of 109 patients) [stage IIIB or IV]. Having the primary tumor in a lower lobe location was the only statistically significant factor associated with upstaging (OR, 3.56; 95% confidence interval, 1.4 to 9.1). The effect of location was robust after controlling for tumor size and the prior performance of mediastinoscopy. Patient age, smoking history, weight loss, tumor size, and tumor histology were all found not to be associated with upstaging. CONCLUSION A lower lobe tumor location in patients with early-stage NSCLC appears to be associated with upstaging after surgery. We conclude that a tumor location in a lower lobe deserves special attention.
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Affiliation(s)
- Ana T Rocha
- Division of Pulmonary Medicine, Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA
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Rankin S. The role of imaging in screening, diagnosis and staging of Non-Small Cell Lung Cancer (NSCLC). EJC Suppl 2004. [DOI: 10.1016/j.ejcsup.2003.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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Chern MS, Wu MH, Chang CY. CT and MRI for staging of locally advanced non-small cell lung cancer. Lung Cancer 2003; 42 Suppl 2:S5-8. [PMID: 14644528 DOI: 10.1016/j.lungcan.2003.08.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Ming-Sheng Chern
- Department of Radiology, Taipei Veterans General Hospital, National Yang-Ming University, No 201, Section 2, Shih-Pai Road, Taipei, Taiwan
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Abstract
This article reviews the contribution of diagnostic imaging to the intrathoracic staging of non-small cell lung cancer. The principle features of the current staging system are discussed along with the relative roles of the various imaging modalities in the evaluation of the primary tumour and metastatic disease. The emerging role of positron emission tomography with fluorodeoxyglucose (FDG-PET) as a clinically useful, potentially cost effective, complementary imaging technique is also reviewed.
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39
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Munden RF, Erasmus JJ. Thoracic Imaging Techniques for Non-Small Cell and Small Cell Lung Cancer. Lung Cancer 2003. [DOI: 10.1007/0-387-22652-4_3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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40
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Takenaka D, Ohno Y, Hatabu H, Ohbayashi C, Yoshimura M, Ohkita Y, Sugimura K. Differentiation of metastatic versus non-metastatic mediastinal lymph nodes in patients with non-small cell lung cancer using respiratory-triggered short inversion time inversion recovery (STIR) turbo spin-echo MR imaging. Eur J Radiol 2002; 44:216-24. [PMID: 12468071 DOI: 10.1016/s0720-048x(02)00271-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To differentiate between metastatic and non-metastatic lymph nodes in patients with non-small cell lung cancer using respiratory-triggered short inversion time inversion recovery (STIR) turbo spin-echo (SE) MR imaging. METHODS AND PATIENTS One hundred and forty mediastinal lymph nodes were detected in 25 patients with non-small cell lung cancer who underwent respiratory-triggered STIR turbo SE imaging. Ratios of signal intensity of lymph nodes to 0.9% saline phantoms (lymph node-saline ratio) were compared by Student's t-test using the pathological diagnosis as the gold standard. The threshold value of the lymph node-saline ratio was determined for a positive test, and tested for its capability to provide a differential diagnosis. RESULTS One hundred and forty lymph nodes were diagnosed and classified into two groups: metastatic lymph node (n=21) and non-metastatic lymph node (n=119). The mean lymph node-saline ratio in the non-metastatic lymph node group (0.42+/-0.01; mean+/-standard error) was significantly lower than that of the metastatic lymph node group (0.77+/-0.02, P<0.0001). When 0.6 was adapted as the threshold for a positive test, sensitivity, specificity, and accuracy for differentiating metastatic lymph node from non-metastatic lymph node per lymph nodes were 100, 96, and 96%, and sensitivity, specificity, and accuracy for differentiating metastatic lymph node from non-metastatic lymph node per patients were 100, 75, and 88%, respectively. CONCLUSIONS Both metastatic and non-metastatic lymph nodes in patients with non-small cell lung cancer were well differentiated using respiratory-triggered STIR turbo SE imaging.
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Affiliation(s)
- Daisuke Takenaka
- Department of Radiology, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan
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Abstract
Since publication of the Radiologic Diagnostic Oncology Group Report in 1991, the clinical application of pulmonary magnetic resonance (MR) imaging to patients with lung cancer has been limited. Computed tomography has been much more widely available for staging of lung cancer in clinical situations. Currently, ventilation and perfusion scintigraphy is the only modality that demonstrates pulmonary function while 2-[fluorine-18]-fluoro-2-deoxy-D-glucose positron emission tomography is the only modality that reveals biological glucose metabolism of lung cancer. However, recent advancements in MR imaging have made it possible to evaluate morphological and functional information in lung cancer patients more accurately and quantitatively. Pulmonary MR imaging may hold significant potential to substitute for nuclear medicine examinations. In this review, we describe recent advances in MR imaging of lung cancer, focusing on (1) characterization of solitary pulmonary nodules; (2) differentiation from secondary change; evaluation of (3) medastinal invasion, (4) chest wall invasion, (5) lymph node metastasis, and (6) distant metastasis; and (7) pulmonary functional imaging. We believe that further basic studies, as well as clinical applications of newer MR techniques, will play an important role in the management of patients with lung cancer.
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Affiliation(s)
- Yoshiharu Ohno
- Department of Radiology, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan.
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Affiliation(s)
- J Martin
- Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA
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Vansteenkiste JF, Stroobants SG. The role of positron emission tomography with 18F-fluoro-2-deoxy-D-glucose in respiratory oncology. Eur Respir J 2001; 17:802-20. [PMID: 11401078 DOI: 10.1183/09031936.01.17408020] [Citation(s) in RCA: 83] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In the past 5 yrs, positron emission tomography (PET) with 18F-fluoro-2-deoxy-D-glucose (FDG) has become an important imaging modality in lung cancer patients. At this time, the indication of FDG-PET as a complimentary tool to computed tomography in the diagnosis and staging of nonsmall cell lung cancer has gradually gained more widespread acceptance and also reimbursement in many European countries. This review focuses on the data of FDG-PET in the diagnosis of lung nodules and masses, and in locoregional and extrathoracic staging of nonsmall cell lung cancer. Emphasis is put on the potential clinical implementation of the currently available FDG-PET data. The use of FDG-PET in these indications now needs further validation in large-scale multicentre randomized studies, focusing mainly on treatment outcome parameters, survival and cost-efficacy. Interesting findings with 18F-fluoro-2-deoxy-D-glucose-positron emission tomography have also been reported for the evaluation of response to radio- or chemotherapy, in radiotherapy planning, recurrence detection and assessment of prognosis. Finally, a whole new field of application of positron emission tomography in molecular biology, using new radiopharmaceuticals, is under extensive investigation.
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Affiliation(s)
- J F Vansteenkiste
- Respiratory Oncology Unit, Dept of Pulmonology, University Hospital Gasthuisberg, Catholic University Leuven, Belgium
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Ohno Y, Adachi S, Motoyama A, Kusumoto M, Hatabu H, Sugimura K, Kono M. Multiphase ECG-triggered 3D contrast-enhanced MR angiography: utility for evaluation of hilar and mediastinal invasion of bronchogenic carcinoma. J Magn Reson Imaging 2001; 13:215-24. [PMID: 11169827 DOI: 10.1002/1522-2586(200102)13:2<215::aid-jmri1032>3.0.co;2-2] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
The purpose of this study was to evaluate the usefulness of cardiac synchronized magnetic resonance angiography [electrocardiographically (ECG)-triggered MRA] for improving image quality and detection of hilar and mediastinal invasion of bronchogenic carcinoma. Fifty patients, suspected of having hilar or mediastinal invasion of bronchogenic carcinoma, underwent contrast-enhanced computed tomography and MR imaging including conventional and ECG-triggered MRA. Twenty patients subsequently also underwent surgical resection. Vascular enhancement-to-background ratio (VBR), vascular enhancement-to-tumor ratio (VTR), signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR) and image quality scores of thoracic vessels obtained with both MRA techniques were determined and compared. In addition, the diagnostic accuracy of tumor invasion of pulmonary vessels was compared. VBRs and VTRs of both MRA techniques were not significantly different. ECG-triggered MRA significantly improved SNRs and CNRs (P < 0.05). Two readers judged that overall image quality of ECG-triggered MRA was better than that of conventional MRA (kappa > or = 0.41). In conclusion, ECG-triggered MRA improves the image quality and the detection of hilar and mediastinal invasion of bronchogenic carcinoma.
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Affiliation(s)
- Y Ohno
- Department of Radiology, Kobe University School of Medicine, Chuo-ku, Kobe 650-0017, Japan.
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Liengswangwong V, Bonner JA. Point: the potential importance of elective nodal irradiation in the treatment of non-small cell lung cancer. Semin Radiat Oncol 2000; 10:308-14. [PMID: 11040331 DOI: 10.1053/srao.2000.9279] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Patients who receive radiation therapy for non-small cell lung cancer (NSCLC) will require accurate targeting of the grossly involved primary and nodal disease. However, the treatment of grossly uninvolved elective nodal sites that may harbor microscopic occult disease is controversial. In simple terms, physicians are guided by 1 of 2 paradigms when they decide about the use of elective nodal irradiation in NSCLC. First, one may consider that high doses of radiation therapy for the primary and grossly involved lymph nodes represents the most important aspect of treatment and that elective irradiation of potential occult micrometastasis is not necessary because it may limit the doses that can be given to the gross disease. Additionally, this line of thought often includes the belief that most or all patients with occult micrometastasis are not curable. Alternatively, one may consider that the evidence for a dose response, for grossly involved NSCLC, beyond 60 Gy is very limited and that the omission of elective nodal irradiation obviates the chance for cure in many patients. These small deposits of tumor in regional nodes are common, are amenable to low doses of radiation (50 Gy), and treatment of these lesions does result in cures. This review focuses on this latter paradigm and the available evidence to support it.
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Affiliation(s)
- V Liengswangwong
- Department of Radiation Oncology, The University of Alabama at Birmingham, Birmingham, AL 35233-6832, USA
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Takamochi K, Nagai K, Yoshida J, Suzuki K, Ohde Y, Nishimura M, Takahashi K, Nishiwaki Y. The role of computed tomographic scanning in diagnosing mediastinal node involvement in non-small cell lung cancer. J Thorac Cardiovasc Surg 2000; 119:1135-40. [PMID: 10838529 DOI: 10.1067/mtc.2000.105830] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVES The reliability of computed tomographic scanning in evaluating mediastinal node involvement is controversial because of the high false result rate. We attempted to identify significant factors responsible for false-positive and false-negative scans. METHODS From August 1992 through April 1997, 401 patients with lung cancer who underwent major lung resection and systematic lymph node dissection were enrolled in this study. We retrospectively examined mediastinal node size, tumor location, maximum tumor dimension, the presence or absence of obstructive pneumonia, atelectasis, pulmonary fibrosis, and lymph node calcification on contrast-enhanced computed tomographic scans. We identified clinical and radiologic factors responsible for the false results by using univariate and multivariable analysis. RESULTS Central tumor location proved to be a significant factor of false-positive scans. Elevated carcinoembryonic antigen level and larger tumor dimension were significant factors of false-negative scans. In patients with a peripheral tumor smaller than 40 mm and normal levels of serum carcinoembryonic antigen, sensitivity, specificity, positive predictive value, and negative predictive value were 6%, 93%, 8%, and 90%, respectively. The reliability of computed tomographic scanning in this low-risk subgroup was high in detecting N0-1 disease but low in diagnosing N2 disease. CONCLUSION It is not possible to accurately diagnose N2 disease by using lymph node size on computed tomographic scanning alone, especially in patients with a central tumor, an elevated serum carcinoembryonic antigen level, or a tumor of 40 mm or larger. A preoperative invasive staging procedure is indicated in these populations and may not be indicated in the population with normal computed tomographic scan results without any of these risk factors.
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Affiliation(s)
- K Takamochi
- Division of Thoracic Oncology, National Cancer Center Hospital East, Chiba, Japan.
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Abstract
Over the past years, positron emission tomography (PET) with fluoro-2-deoxy-D-glucose (FDG) has emerged as an important imaging modality. In the thorax, FDG-PET has been shown to differentiate benign from malignant pulmonary lesions and stage lung cancer. Preliminary studies have shown its usefulness in assessing tumor recurrence, and assisting in radiotherapy planning. FDG-PET is often more accurate than conventional imaging studies, and has been proven to be cost-effective in evaluating lung cancer patients. This review will discuss the current applications of FDG-PET as compared with conventional imaging in diagnosing, staging, and following patients with lung cancer.
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Affiliation(s)
- E M Marom
- Department of Radiology, Duke University Medical Center, Durham, NC 27710, USA.
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Takamochi K, Nagai K, Suzuki K, Yoshida J, Ohde Y, Nishiwaki Y. Clinical predictors of N2 disease in non-small cell lung cancer. Chest 2000; 117:1577-82. [PMID: 10858386 DOI: 10.1378/chest.117.6.1577] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
OBJECTIVES To identify clinical or radiologic predictors of mediastinal lymph node involvement in patients with non-small cell lung cancer, and to define the indications of preoperative mediastinoscopy. METHODS From August 1992 through April 1997, 387 patients with lung cancer (290 adenocarcinoma and 97 squamous cell carcinoma) underwent surgical resection. We retrospectively measured all mediastinal lymph node sizes both in the shortest and longest axes on contrast-enhanced CT scan to determine the optimal size criteria. Using multivariate logistic regression analysis, we identified clinical or radiologic predictors of N2 disease. RESULTS We could not identify reliable size criteria for nodal involvement. We found two significant predictive factors of N2 disease on the basis of multivariable analysis: maximum tumor dimension and serum carcinoembryonic antigen (CEA) concentrations. The lymph node size did not prove to be a significant factor. Among 50 patients with serum CEA concentrations < 5.0 ng/mL and maximum tumor dimension < 20 mm, pathologic N2 disease was proven only in three patients (6%), regardless of the lymph node size on CT scan. Among 140 patients with serum CEA concentrations > or = 5.0 ng/mL and maximum tumor dimension > or = 20 mm, approximately one third (n = 46) showed N2 disease. CONCLUSION Serum CEA concentrations and maximum tumor dimension were more valuable in predicting N2 disease than the lymph node size on CT scan. Mediastinoscopy is indicated in patients with serum CEA concentrations > or = 5.0 ng/mL and maximum tumor dimension > or = 20 mm, and not indicated in patients with serum CEA concentrations < 5.0 ng/mL and maximum tumor dimension < 20 mm.
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Affiliation(s)
- K Takamochi
- Division of Thoracic Oncology, National Cancer Center Hospital East, Chiba, Japan.
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Abstract
The necessity for a compulsive attitude toward preoperative assessment of lung cancer is to be emphasized, since rational treatment and prognosis depend largely on the stage of disease at the time of diagnosis. In the preoperative setting, the techniques used should be sequential, logical, and help to identify patients suitable for treatment with curative intent. With regard to the primary tumor (T status), the accuracy of CT or MRI to predict the need for extended resections is limited. Similarly, all noninvasive methods to determine the nodal status (N) are valuable, but mediastinoscopy has a greater sensitivity and specificity than either CT or MRI. The role of routine organ screening for the detection of distant occult metastasis in the asymptomatic patient is still controversial. Ultimately, the prognosis of the resected patient with lung cancer is based on complete intraoperative staging, which can be done by either systematic node sampling or complete lymphadenectomy. At present, neither of these techniques has been shown to improve the quality of staging or survival.
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Affiliation(s)
- J Deslauriers
- Centre de pneumologie de l'Hôpital Laval, Sainte-Foy, Quebec, Canada
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