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Kagimoto A, Tsutani Y, Handa Y, Mimae T, Miyata Y, Okada M. Patient Selection of Sublobar Resection Using Visual Evaluation of Positron-Emission Tomography (PET) for Early-Stage Lung Adenocarcinoma. Ann Surg Oncol 2020; 28:2068-2075. [PMID: 32946014 DOI: 10.1245/s10434-020-09150-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 08/17/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND This study aimed to investigate the efficacy of the Deauville criteria (a 5-point visual scale criteria) in assessing the accumulation of [18F]-fluoro-2-deoxy-D-glucose (FDG) on positron-emission tomography (PET)/computed tomography (CT) for predicting prognosis of early-stage lung adenocarcinoma and selecting candidates for sublobar resection. METHODS This retrospective study included 648 patients undergoing curative resection for clinical N0 lung adenocarcinoma with a whole tumor size of 3 cm or smaller between April 2007 and March 2019. Accumulations of the FDG on PET/CT scans were scored using the Deauville criteria (Deauville score), and correlations between the Deauville score and prognosis were analyzed. RESULTS The recurrence-free survival (RFS) was significantly better for the patients with a Deauville score of 1 or 2 (n = 415, 5-year RFS, 92.6%) than for those with a score of 3 (n = 82, 5-year RFS, 72.7%; P < 0.001) or a score of 4 or 5 (n = 151, RFS, 70.8%; P < 0.001). The RFS did not differ significantly among the patients with Deauville scores of 1 and 2 who underwent wedge resection (n = 102, 5-year RFS, 90.5%), segmentectomy (n = 188, RFS, 95.1%; P = 0.355), and lobectomy (n = 125, RFS, 91.1%; P = 0.462). CONCLUSION The 5-point-scale evaluation of FDG accumulation on PET/CT was useful in predicting the prognosis for patients with early-stage lung adenocarcinoma. Lung adenocarcinoma patients with a whole tumor size of 3 cm or smaller and a Deauville score of 1 or 2 can be candidates for sublobar resection.
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Affiliation(s)
- Atsushi Kagimoto
- Department of Surgical Oncology, Hiroshima University Hospital, Hiroshima, Japan
| | - Yasuhiro Tsutani
- Department of Surgical Oncology, Hiroshima University Hospital, Hiroshima, Japan
| | - Yoshinori Handa
- Department of Surgical Oncology, Hiroshima University Hospital, Hiroshima, Japan
| | - Takahiro Mimae
- Department of Surgical Oncology, Hiroshima University Hospital, Hiroshima, Japan
| | - Yoshihiro Miyata
- Department of Surgical Oncology, Hiroshima University Hospital, Hiroshima, Japan
| | - Morihito Okada
- Department of Surgical Oncology, Hiroshima University Hospital, Hiroshima, Japan.
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Kagimoto A, Tsutani Y, Izaki Y, Handa Y, Mimae T, Miyata Y, Okada M. Prediction of Lymph Node Metastasis Using Semiquantitative Evaluation of PET for Lung Adenocarcinoma. Ann Thorac Surg 2020; 110:1036-1042. [DOI: 10.1016/j.athoracsur.2020.03.032] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 03/08/2020] [Accepted: 03/16/2020] [Indexed: 02/06/2023]
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Casanova R, Leblond AL, Wu C, Haberecker M, Burger IA, Soltermann A. Enhanced prognostic stratification of neoadjuvant treated lung squamous cell carcinoma by computationally-guided tumor regression scoring. Lung Cancer 2020; 147:49-55. [PMID: 32673826 DOI: 10.1016/j.lungcan.2020.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 06/19/2020] [Accepted: 07/02/2020] [Indexed: 11/15/2022]
Abstract
INTRODUCTION The amount of residual tumor burden after neoadjuvant chemotherapy is an important prognosticator, but for non-small cell lung carcinoma (NSCLC), no official regression scoring system is yet established. Computationally derived histological regression scores could provide unbiased and quantitative readouts to complement the clinical assessment of treatment response. METHODS Histopathologic tumor regression was microscopically assessed on whole cases in a neoadjuvant chemotherapy-treated cohort (NAC, n = 55 patients) of lung squamous cell carcinomas (LSCC). For each patient, the slide showing the least pathologic regression was selected for subsequent computational analysis and histological features were quantified: percentage of vital tumor cells (cTu.Percentage), total surface covered by vital tumor cells (cTu.Area), area of the largest vital tumor fragment (cTu.Size.max), and total number of vital tumor fragments (cTu.Fragments). A chemo-naïve LSCC cohort (CN, n = 104) was used for reference. For 23 of the 55 patients [18F]-Fluorodeoxyglucose (FDG) PET/CT measurements of maximum standard uptake value (SUVmax), background subtracted lesion activity (BSL) and background subtracted volume (BSV) were correlated with pathologic regression. Survival analysis was carried out using Cox regression and receiver operating characteristic (ROC) curve analysis using a 3-years cutoff. RESULTS All computational regression parameters significantly correlated with relative changes of BSV FDG PET/CT values after neoadjuvant chemotherapy. ROC curve analysis of histological parameters of NAC patients showed that cTu.Percentage was the most accurate prognosticator of overall survival (ROC curve AUC = 0.77, p-value = 0.001, Cox regression HR = 3.6, p = 0.001, variable cutoff < = 30 %). CONCLUSIONS This study demonstrates the prognostic relevance of computer-derived histopathologic scores. Additionally, the analysis carried out on slides displaying the least pathologic regression correlated with overall pathologic response and PET/CT values. This might improve the objective histopathologic assessment of tumor response in neoadjuvant setting.
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Affiliation(s)
- Ruben Casanova
- Institute of Pathology and Molecular Pathology, University Hospital Zurich, Switzerland.
| | - Anne-Laure Leblond
- Institute of Pathology and Molecular Pathology, University Hospital Zurich, Switzerland
| | - Chengguang Wu
- Institute of Pathology and Molecular Pathology, University Hospital Zurich, Switzerland
| | - Martina Haberecker
- Institute of Pathology and Molecular Pathology, University Hospital Zurich, Switzerland
| | - Irene A Burger
- Department of Nuclear Medicine, University Hospital Zurich, Switzerland
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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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Giovacchini G, Picchio M, Schipani S, Landoni C, Gianolli L, Bettinardi V, Di Muzio N, Gilardi MC, Fazio F, Messa C. Changes in Glucose Metabolism during and after Radiotherapy in Non-Small Cell Lung Cancer. TUMORI JOURNAL 2018; 95:177-84. [DOI: 10.1177/030089160909500208] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Aims and background Evaluation of the metabolic response to radiotherapy in non-small cell lung cancer patients is commonly performed about three months after the end of radiotherapy. The aim of the present study was to assess with positron emission tomography/computed tomography (PET/CT) and [18F]fluorodeoxyglucose changes in glucose metabolism during and after radiotherapy in non-small cell lung cancer patients. Methods and study design In 6 patients, PET/CT scans with [18F]fluorodeoxyglucose were performed before (PET0), during (PET1; at a median of 14 days before the end of radiotherapy) and after the end of radiotherapy (PET2 and PET3, at a median of 28 and 93 days, respectively). The metabolic response was scored according to visual and semiquantitative criteria. Results Standardize maximum uptake at PET1 (7.9 ± 4.8), PET2 (5.1 ± 4.1) and PET3 (2.7 ± 3.1) were all significantly (P <0.05; ANOVA repeated measures) lower than at PET0 (16.1 ± 10.1). Standardized maximum uptake at PET1 was significantly higher than at both PET2 and PET3. There were no significant differences in SUVmax between PET2 and PET3. PET3 identified 4 complete and 2 partial metabolic responses, whereas PET1 identified 6 partial metabolic responses. Radiotherapy-induced increased [18F]fluorodeoxyglucose uptake could be visually distinguished from tumor uptake based on PET/CT integration and was less frequent at PET1 (n = 2) than at PET3 (n = 6). Conclusions In non-small cell lung cancer, radiotherapy induces a progressive decrease in glucose metabolism that is greater 3 months after the end of treatment but can be detected during the treatment itself. Glucose avid, radiotherapy-induced inflammation is more evident after the end of radiotherapy than during radiotherapy and does not preclude the interpretation of [18F]fluorodeoxyglucose images, particularly when using PET/CT.
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Affiliation(s)
| | - Maria Picchio
- Department of Nuclear Medicine, Scientific Institute San Raffaele, Milan, Italy
| | - Stefano Schipani
- Department of Radiation Oncology, Scientific Institute San Raffaele, Milan, Italy
| | - Claudio Landoni
- University of Milano-Bicocca, Milan, Italy
- Department of Nuclear Medicine, Scientific Institute San Raffaele, Milan, Italy
| | - Luigi Gianolli
- Department of Nuclear Medicine, Scientific Institute San Raffaele, Milan, Italy
| | | | - Nadia Di Muzio
- Department of Radiation Oncology, Scientific Institute San Raffaele, Milan, Italy
| | - Maria Carla Gilardi
- University of Milano-Bicocca, Milan, Italy
- Department of Nuclear Medicine, Scientific Institute San Raffaele, Milan, Italy
- Institute for Bioimaging and Molecular Physiology, National Research Council, Milan, Italy
| | | | - Cristina Messa
- University of Milano-Bicocca, Milan, Italy
- Department of Nuclear Medicine, San Gerardo Hospital, Monza, Italy
- Institute for Bioimaging and Molecular Physiology, National Research Council, Milan, Italy
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Garg PK, Singh SK, Prakash G, Jakhetiya A, Pandey D. Role of positron emission tomography-computed tomography in non-small cell lung cancer. World J Methodol 2016; 6:105-111. [PMID: 27018223 PMCID: PMC4804245 DOI: 10.5662/wjm.v6.i1.105] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Revised: 09/08/2015] [Accepted: 02/16/2016] [Indexed: 02/06/2023] Open
Abstract
Lung cancer is the leading cause of cancer-related mortality worldwide. Non-small cell carcinoma and small cell carcinoma are the main histological subtypes and constitutes around 85% and 15% of all lung cancer respectively. Multimodality treatment plays a key role in the successful management of lung cancer depending upon the histological subtype, stage of disease, and performance status. Imaging modalities play an important role in the diagnosis and accurate staging of the disease, in assessing the response to neoadjuvant therapy, and in the follow-up of the patients. Last decade has witnessed voluminous upsurge in the use of positron emission tomography-computed tomography (PET-CT); role of PET-CT has widened exponentially in the management of lung cancer. The present article reviews the role of 18-fluoro-deoxyglucose PET-CT in the management of non small cell lung cancer with emphasis on staging of the disease and the assessment of response to neoadjuvant therapy based on available literature.
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FDG PET/CT for assessing the resectability of NSCLC patients with N2 disease after neoadjuvant therapy. Ann Nucl Med 2015; 30:114-21. [DOI: 10.1007/s12149-015-1038-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 11/01/2015] [Indexed: 01/02/2023]
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Early assessment of metabolic response by 18F-FDG PET during concomitant radiochemotherapy of non-small cell lung carcinoma is associated with survival: a retrospective single-center study. Clin Nucl Med 2015; 40:e215-21. [PMID: 25546211 DOI: 10.1097/rlu.0000000000000615] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND PURPOSE We performed a retrospective single-center study to assess if midtreatment 18F-FDG PET/CT could predict local control and survival in patients with locally advanced non-small cell lung cancer treated with concurrent chemoradiotherapy. METHODS Thirty-one consecutive patients with unresectable or locally advanced lung cancer (T2-4 N0-3 M0) were treated with concurrent chemoradiotherapy in our center. Each patient received 18F-FDG PET/CT before treatment and at midtreatment time when a radiation therapy dose of 30 Gy was delivered. We assessed several PET/CT parameters as follows: SUV max, ΔSUV mean, ΔSUV max, variation of hypermetabolic tumor volume, and the variation of tumor total lesion glycolysis (ΔTLG). Univariate analysis was performed, and a stepwise procedure was used to define final multivariate model. RESULTS The ΔTLG was statistically correlated to overall survival (OS) (P = 0.035), progression-free survival (P = 0.023), and local control (P = 0.043) in univariate analysis. A decrease in TLG over 15% was statistically correlated to a better OS (P = 0.007; hazards ratio [HR], 7.439; 95% confidence interval [CI], 1.168-28.897) and progression-free survival (P = 0.010; HR, 5.695; 95% CI, 1.506-21.537) in univariate analysis. In multivariate analysis, ΔTLG superior to -15% was significantly correlated to a worse OS (P = 0.020; HR, 5.973; 95% CI, 1.324-26.953). CONCLUSIONS Early assessment of TLG response by 18F-FDG PET/CT during concomitant radiochemotherapy of non-small cell lung cancer might be associated with survival.
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Stamatis G. Staging of lung cancer: the role of noninvasive, minimally invasive and invasive techniques. Eur Respir J 2015; 46:521-31. [PMID: 25976686 DOI: 10.1183/09031936.00126714] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Accepted: 04/07/2015] [Indexed: 12/25/2022]
Abstract
Accurate staging and restaging of primary tumour and mediastinal nodes in patients with lung cancer is of significant importance. For primary tumours, computed tomography (CT) scans of the chest are recommended. Positron emission tomography (PET) imaging should be used in patients with curative intent treatment to evaluate metastatic disease. Diagnosis of the primary tumour should be performed using bronchoscopy or CT-guided transthoracic needle aspiration. In patients with enlarged mediastinal nodes and no distant metastasis, invasive staging of the mediastinum is required. For suspicious N2 or N3 disease, endoscopic needle techniques, such as endobronchial ultrasound and transbronchial needle aspiration, oesophageal ultrasound and fine needle aspiration, or a combination of both, are preferred to any surgical staging technique. In cases of suspicious nodes and negative results using needle aspiration techniques, invasive surgical staging using mediastinoscopy or video-assisted thoracic surgery should be performed. In central tumours or N1 nodes, preoperative invasive staging is indicated.Restaging after induction therapy remains a controversial topic. Today, neither CT, PET nor PET/CT scans are accurate enough to make final further therapeutic decisions for mediastinal nodal involvement. An invasive technique providing cytohistological information is still recommended.
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Affiliation(s)
- Georgios Stamatis
- Dept of Thoracic Surgery and Endoscopy, Ruhrlandklinik, West German Lung Center of the University Duisburg Essen, Essen, Germany
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Higher predictive value of tumour and node [18F]-FDG PET metabolic volume and TLG in advanced lung cancer under chemotherapy. Nucl Med Commun 2014; 35:908-15. [DOI: 10.1097/mnm.0000000000000145] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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van Gool MH, Aukema TS, Schaake EE, Rijna H, Codrington HE, Valdés Olmos RA, Teertstra HJ, van Pel R, Burgers SA, van Tinteren H, Klomp HM. 18F-Fluorodeoxyglucose Positron Emission Tomography versus Computed Tomography in Predicting Histopathological Response to Epidermal Growth Factor Receptor–Tyrosine Kinase Inhibitor Treatment in Resectable Non-Small Cell Lung Cancer. Ann Surg Oncol 2014; 21:2831-7. [DOI: 10.1245/s10434-014-3791-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Indexed: 12/17/2022]
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Rakheja R, Ko JP, Friedman K. Lung cancer: positron emission tomography/computed tomography and the new staging system. Semin Roentgenol 2013; 48:308-22. [PMID: 24034263 DOI: 10.1053/j.ro.2013.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Rajan Rakheja
- Division of Nuclear Medicine, New York University Langone Medical Center, New York, NY
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18F-FDG-PET evaluation of pathological tumour response to neoadjuvant therapy in patients with NSCLC. Nucl Med Commun 2013; 34:71-7. [PMID: 23086204 DOI: 10.1097/mnm.0b013e3283599999] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES The ability to identify potential responders to neoadjuvant treatment may improve patient selection or surgery and may help in the development of response criteria suitable for routine monitoring of response. The aim of this study was to evaluate the value of PET in predicting the pathological tumour response of non-small-cell lung cancer (NSCLC) to neoadjuvant therapy using a meta-analysis. METHODS All available published studies investigating the value of PET in predicting the pathological response of NSCLC to neoadjuvant therapy were collected. Pooled sensitivity and specificity data were obtained using statistical software. Subgroup analysis was performed to explore the sources of heterogeneity. RESULTS A total of 13 studies comprising 414 patients with NSCLC were included in the meta-analysis. Pooled sensitivity, specificity, positive predictive value and negative predictive value for PET-predicted response was 83% [95% confidence interval (CI); 76-89%], 84% (95% CI; 79-88%), 74% (95% CI; 67-81%) and 91% (95% CI; 87-94%), respectively. Significant heterogeneity (P<0.05) was observed. On the basis of our subgroup analyses, methodological quality could be responsible for this heterogeneity in our metaregression. The predictive value of PET in NSCLC patients with pathological response (considered the gold standard) was significantly higher than that of computed tomography (P<0.05). CONCLUSION PET scanning has an important role in predicting nonresponders to neoadjuvant therapy in cases of NSCLC, and the predictive value of PET for evaluating pathologically documented responses is superior to that of computed tomography. However, additional evaluations using prospective clinical trials will be required to assess the clinical benefit of this strategy.
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Jaklitsch MT, Gu L, Demmy T, Harpole DH, D'Amico TA, McKenna RJ, Krasna MJ, Kohman LJ, Swanson SJ, DeCamp MM, Wang X, Barry S, Sugarbaker DJ. Prospective phase II trial of preresection thoracoscopic mediastinal restaging after neoadjuvant therapy for IIIA (N2) non-small cell lung cancer: results of CALGB Protocol 39803. J Thorac Cardiovasc Surg 2013; 146:9-16. [PMID: 23768804 PMCID: PMC3704168 DOI: 10.1016/j.jtcvs.2012.12.069] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2012] [Revised: 12/07/2012] [Accepted: 12/18/2012] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Accurate pathologic restaging of N2 stations after neoadjuvant therapy in stage IIIA (N2) non-small cell lung cancer is needed. METHODS A prospective multi-institutional trial was designed to judge the feasibility of videothoracoscopy to restage the ipsilateral nodes in mediastinoscopy-proven stage IIIA (N2) non-small cell lung cancer after 2 cycles of platinum-based chemotherapy and/or 40 Gy or more of radiotherapy. The goals included biopsy of 3 negative N2 node stations or to identify 1 positive N2 node or pleural carcinomatosis. RESULTS Ten institutions accrued 68 subjects. Of the 68 subjects, 46 (68%) underwent radiotherapy and 66 (97%) underwent chemotherapy. Videothoracoscopy successfully met the prestudy feasibility in 27 patients (40%): 3 negative stations confirmed at thoracotomy in 7, persistent stage N2 disease in 16, and pleural carcinomatosis in 4. In 20 procedures (29%), no N2 disease was found, 3 stations were not biopsied because of unanticipated nodal obliteration. Thus, 47 videothoracoscopy procedures (69%, 95% confidence interval, 57%-80%) restaged the mediastinum. Videothoracoscopy was unsuccessful in 21 patients (31%) because the procedure had to be aborted (n = 11) or because of false-negative stations (n = 10). Of the 21 failures, 15 were right-sided, and 10 had a positive 4R node. The sensitivity of videothoracoscopy was 67% (95% confidence interval, 47%-83%), and the negative predictive value was 73% (95% confidence interval, 56%-86%) if patients with obliterated nodal tissue were included. The sensitivity was 83% (95% confidence interval, 63%-95%) and the negative predictive value was 64% (95% confidence interval, 31%-89%) if those patients were excluded. The specificity was 100%. One death occurred after thoracotomy. CONCLUSIONS Videothoracoscopy restaging was "feasible" in this prospective multi-institutional trial and provided pathologic specimens of the ipsilateral nodes. Videothoracoscopy restaging was limited by radiation and the 4R nodal station.
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Affiliation(s)
- Michael T Jaklitsch
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Mass 02115, USA.
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Broderick SR, Patterson GA. Performance of integrated positron emission tomography/computed tomography for mediastinal nodal staging in non-small cell lung carcinoma. Thorac Surg Clin 2013; 23:193-8. [PMID: 23566971 DOI: 10.1016/j.thorsurg.2013.01.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Integrated positron emission tomography (PET)/CT is routinely used for mediastinal nodal staging of non-small cell lung carcinoma in centers throughout the world. This modality is the most accurate noninvasive means by which to identify metastatic disease in mediastinal lymph nodes. This article reviews the evidence supporting the use of PET/CT and discusses the clinical applicability of this modality.
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Affiliation(s)
- Stephen R Broderick
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, 3108 Queeny Tower, One Barnes-Jewish Hospital Plaza, St Louis, MO 63110-1013, USA.
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Broderick SR, Crabtree TD. Restaging after induction therapy for non-small-cell lung cancer. Lung Cancer Manag 2012. [DOI: 10.2217/lmt.12.33] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
SUMMARY Select patients with stage IIIa-N2 non-small-cell lung cancer will benefit from treatment with induction chemoradiotherapy followed by surgical resection. The identification of patients with residual N2 disease may allow for selection of those patients most likely to benefit from resection. The optimal strategy for restaging of mediastinal lymph nodes following induction therapy is controversial. Noninvasive, imaging-based strategies are largely ineffective. Minimally invasive approaches such as endobronchial ultrasound-transbronchial needle aspiration and endoscopic ultrasound-guided fine needle aspiration may identify residual nodal disease, but require surgical confirmation of negative results. Repeat mediastinoscopy may be effective at centers that specialize in this technique, but in the authors opinion its use cannot be broadly recommended. A thoughtful and minimally invasive approach to initial staging of N2 nodes is recommended, reserving mediastinoscopy for restaging whenever possible.
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Affiliation(s)
- Stephen R Broderick
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, MO, USA
| | - Traves D Crabtree
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, MO, USA
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Massaccesi M, Calcagni ML, Spitilli MG, Cocciolillo F, Pelligrò F, Bonomo L, Valentini V, Giordano A. ¹⁸F-FDG PET-CT during chemo-radiotherapy in patients with non-small cell lung cancer: the early metabolic response correlates with the delivered radiation dose. Radiat Oncol 2012; 7:106. [PMID: 22781363 PMCID: PMC3410758 DOI: 10.1186/1748-717x-7-106] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2012] [Accepted: 07/10/2012] [Indexed: 12/25/2022] Open
Abstract
Background To evaluate the metabolic changes on 18 F-fluoro-2-deoxyglucose positron emission tomography integrated with computed tomography (18 F-FDG PET-CT) performed before, during and after concurrent chemo-radiotherapy in patients with locally advanced non-small cell lung cancer (NSCLC); to correlate the metabolic response with the delivered radiation dose and with the clinical outcome. Methods Twenty-five NSCLC patients candidates for concurrent chemo-radiotherapy underwent 18 F-FDG PET-CT before treatment (pre-RT PET-CT), during the third week (during-RT PET-CT) of chemo-radiotherapy, and 4 weeks from the end of chemo-radiotherapy (post-RT PET-CT). The parameters evaluated were: the maximum standardized uptake value (SUVmax) of the primary tumor, the SUVmax of the lymph nodes, and the Metabolic Tumor Volume (MTV). Results SUVmax of the tumor and MTV significantly (p=0.0001, p=0.002, respectively) decreased earlier during the third week of chemo-radiotherapy, with a further reduction 4 weeks from the end of treatment (p<0.0000, p<0.0002, respectively). SUVmax of lymph nodes showed a trend towards a reduction during chemo-radiotherapy (p=0.06) and decreased significantly (p=0.0006) at the end of treatment. There was a significant correlation (r=0.53, p=0.001) between SUVmax of the tumor measured at during-RT PET-CT and the total dose of radiotherapy reached at the moment of the scan. Disease progression free survival was significantly (p=0.01) longer in patients with complete metabolic response measured at post-RT PET-CT. Conclusions In patients with locally advanced NSCLC, 18 F-FDG PET-CT performed during and after treatment allows early metabolic modifications to be detected, and for this SUVmax is the more sensitive parameter. Further studies are needed to investigate the correlation between the metabolic modifications during therapy and the clinical outcome in order to optimize the therapeutic strategy. Since the metabolic activity during chemo-radiotherapy correlates with the cumulative dose of fractionated radiotherapy delivered at the moment of the scan, special attention should be paid to methodological aspects, such as the radiation dose reached at the time of PET.
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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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Siekiera J, Małkowski B, Jóźwicki W, Jasiński M, Wronczewski A, Pietrzak T, Chmielowska E, Petrus A, Kamecki K, Mikołajczak W, Kraśnicki K, Chłosta P, Drewa T. Can We Rely on PET in the Follow-Up of Advanced Seminoma Patients? Urol Int 2012; 88:405-9. [DOI: 10.1159/000337056] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2011] [Accepted: 01/21/2012] [Indexed: 11/19/2022]
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Collaud S, Lardinois D, Tischler V, Steinert HC, Stahel R, Weder W. Significance of a new fluorodeoxyglucose-positive lesion on restaging positron emission tomography/computed tomography after induction therapy for non-small-cell lung cancer. Eur J Cardiothorac Surg 2011; 41:612-6. [PMID: 22219415 DOI: 10.1093/ejcts/ezr109] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Restaging of patients with locally advanced non-small-cell lung cancer (NSCLC) is of paramount importance, since only patients with down-staging after induction therapy will benefit from surgery. In this study, we assessed the aetiology of new (18)fluoro-2-deoxy-d-glucose (FDG)-positive focal abnormalities on restaging positron emission tomography/computed tomography (PET/CT) in patients with a good response after induction chemotherapy in the primary tumour and lymph nodes. METHODS Between 2004 and 2008, 31 patients with histological proven stage III NSCLC had a PET/CT prior and after induction chemotherapy. Their medical charts were retrospectively reviewed. RESULTS Restaging PET/CT revealed a new FDG-positive lesion in 6 of 31 (20%) patients. The initial clinical stage of the disease was IIIA N2 in four and IIIB T4 in two patients. The maximal standard uptake value in the primary tumour (P = 0.043) and in the initially involved mediastinal nodes (P = 0.068) decreased after induction treatment in all patients. The new PET/CT findings were located in an ipsilateral cervical lymph node in two patients, a contralateral mediastinal in one patient and an ipsilateral mammary internal lymph node in one patient. Two other patients had a lesion on the contralateral lung. Malignant lymph node infiltrations were excluded following fine-needle puncture, intraoperative biopsy or follow-up PET/CT. Contralateral pulmonary lesions were diagnosed as benign following mini thoracotomy and pulmonary wedge resection. CONCLUSIONS New solitary FDG-positive lesions on restaging PET/CT after induction chemotherapy for NSCLC are not rare in good responders to chemotherapy. In our experience, all these lesions were not associated with malignancy.
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Affiliation(s)
- Stéphane Collaud
- Division of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland.
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O'Brien MER, Myerson JS, Coward JIG, Puglisi M, Trani L, Wotherspoon A, Sharma B, Cook G, Ashley S, Gunapala R, Chua S, Popat S. A phase II study of ¹⁸F-fluorodeoxyglucose PET-CT in non-small cell lung cancer patients receiving erlotinib (Tarceva); objective and symptomatic responses at 6 and 12 weeks. Eur J Cancer 2011; 48:68-74. [PMID: 22119198 DOI: 10.1016/j.ejca.2011.10.033] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2011] [Revised: 10/25/2011] [Accepted: 10/26/2011] [Indexed: 01/14/2023]
Abstract
BACKGROUND The aim of this study was to assess if (18)F-fluorodeoxyglucose (FDG) Positron Emission Tomography (PET)-CT scanning could minimise the time non-responding patients were exposed to erlotinib (Tarceva). METHODS Patients were selected for clinical factors that would predict response to erlotinib. A FDG PET-CT and diagnostic contrast-enhanced (traditional) CT scan were carried out at baseline, and then a FDG PET-CT at 6 weeks and a traditional CT at 12 weeks were repeated. The primary end-point was rate of early progression in patients after 6 weeks, of which a minimum 12 out of 35 were required to make the study worthwhile. The responses at 6 (PET-CT) and 12 weeks (traditional CT) were compared and correlated with symptomatic response at both these time points. RESULTS Forty seven patients were recruited with 38 and 33 patients assessable by FDG PET-CT at 6 weeks and traditional CT at 12weeks, respectively. There was good correlation between Partial response (PR) at both time points and all 10 patients who had a PR at 12 weeks had a PR at 6 weeks. Of the 13 patients with progressive disease (PD) at 12 weeks, seven had PD at 6 weeks and could have had their treatment stopped early. No evaluable patient with stable disease (SD) (8/38) or PD (9/38) on FDG PET-CT at 6 weeks went on to have a later response. Symptomatic response at 6 or 12 weeks did not correlate well with objective response on scanning at either time point. CONCLUSIONS The primary end-point of this study was met as >12 (15/38) patients could have stopped treatment early on the basis of the FDG PET-CT scan result. A FDG PET-CT evaluable response of SD or PD at 6 weeks does predict future lack of response. No correlation was found between response and symptomatic response at either 6 or 12 weeks.
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Affiliation(s)
- M E R O'Brien
- Royal Marsden Hospital, Downs Road, Sutton, Surrey SM2 5PT, United Kingdom
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Delappe E, Dunphy M. 18F-2-Deoxy-d-Glucose positron emission tomography-computed tomography in lung cancer. Semin Roentgenol 2011; 46:208-23. [PMID: 21726705 DOI: 10.1053/j.ro.2011.02.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Eithne Delappe
- Department of Radiology, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA
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Rebollo-Aguirre AC, Ramos-Font C, Villegas Portero R, Cook GJR, Llamas Elvira JM, Romero Tabares A. Is FDG-PET suitable for evaluating neoadjuvant therapy in non-small cell lung cancer? Evidence with systematic review of the literature. J Surg Oncol 2010; 101:486-94. [PMID: 20213693 DOI: 10.1002/jso.21525] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Neoadjuvant therapy response assessment is crucial in patients with non-small cell lung cancer (NSCLC). FDG-PET has emerged as a valuable tool for defining therapy response assessment in other tumours. AIM To systematically review publications appearing in the literature describing induction therapy response assessment with FDG-PET in NSCLC. METHODS We performed a bibliographic search and selected only prospective studies in order to include the highest levels of evidence. RESULTS Nine of 497 potentially relevant publications were selected. The ranges of sensitivity, specificity, positive predictive value and negative predictive value for primary tumour response assessment were 80-100%, 0-100%, 42.9-100%, and 66.7-100%, respectively. Pooling data for N2 restaging after neoadjuvant response the overall sensitivity was 63.8% (95% CI, 53.3-73.7%) and overall specificity was 85.3% (95% CI, 80.4-89.4%). CONCLUSION The results of the analysis do not support the use of FDG-PET as the only re-assessment tool for mediastinal lymph node evaluation for routine clinical use. FDG-PET seems to predict primary tumour response to induction therapy but it could not be shown by pooling analysis.
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A Systematic Review of Restaging After Induction Therapy for Stage IIIa Lung Cancer: Prediction of Pathologic Stage. J Thorac Oncol 2010; 5:389-98. [PMID: 20186025 DOI: 10.1097/jto.0b013e3181ce3e5e] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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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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Abstract
Esophageal cancer is the third most common malignancy of the alimentary tract. The incidence of esophageal cancer has steadily increased over the past three decades. Almost all therapeutic modalities for esophageal cancer are associated with a considerable mortality and morbidity. Consequently, there has been growing concern regarding effective management of esophageal cancer. 18F-fluorodeoxyglucose positron emission tomography (18F-FDG PET) is playing an increasing role in the management of esophageal cancer, offering potential advantages in the accuracy of disease assessment at a number of decision points in the management pathway. This review evaluates the critical role of FDG-PET in (i) diagnosis, (ii) preoperative staging, (iii) monitoring of response to neoadjuvant therapy, (iv) assessment of recurrence and (v) prediction of prognosis of esophageal cancer. We have also compared diagnostic performance of FDG-PET and other current technologies such as computed tomography scan and endoscopic ultrasonography based on available evidence.
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Cerfolio RJ, Bryant AS, Talati AA, Cerfolio RM, Winokur TS. Change in maximum standardized uptake value on repeat positron emission tomography after chemoradiotherapy in patients with esophageal cancer identifies complete responders. J Thorac Cardiovasc Surg 2009; 137:605-9. [DOI: 10.1016/j.jtcvs.2008.11.016] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2008] [Revised: 10/03/2008] [Accepted: 11/11/2008] [Indexed: 12/22/2022]
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Kerrou K. [Contribution of PET/CT for staging and prognosis of non-small cell lung carcinoma. Assessment of the pathological response]. REVUE DE PNEUMOLOGIE CLINIQUE 2009; 65:49-55. [PMID: 19306785 DOI: 10.1016/j.pneumo.2008.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2008] [Accepted: 08/17/2008] [Indexed: 05/27/2023]
Affiliation(s)
- K Kerrou
- Service de médecine nucléaire, hôpital Tenon, 4, rue de la Chine, 75020 Paris, France.
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Cerfolio RJ, Bryant AS. Restaging After Neo-Adjuvant Chemoradiotherapy for N2 Non–Small Cell Lung Cancer. Thorac Surg Clin 2008; 18:417-21, vii. [DOI: 10.1016/j.thorsurg.2008.08.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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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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Herth FJF, Annema JT, Eberhardt R, Yasufuku K, Ernst A, Krasnik M, Rintoul RC. Endobronchial ultrasound with transbronchial needle aspiration for restaging the mediastinum in lung cancer. J Clin Oncol 2008; 26:3346-50. [PMID: 18519953 DOI: 10.1200/jco.2007.14.9229] [Citation(s) in RCA: 173] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
PURPOSE To investigate the sensitivity and accuracy of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for restaging the mediastinum after induction chemotherapy in patients with non-small-cell lung cancer (NSCLC). PATIENTS AND METHODS One hundred twenty-four consecutive patients with tissue-proven stage IIIA-N2 disease who were treated with induction chemotherapy and who had undergone mediastinal restaging by EBUS-TBNA were reviewed. On the basis of computed tomography, 58 patients were classified as having stable disease and 66 were judged to have had a partial response. All patients subsequently underwent thoracotomy with attempted curative resection and a lymph node dissection regardless of EBUS-TBNA findings. RESULTS Persistent nodal metastases were detected by using EBUS-TBNA in 89 patients (72%). Of the 35 patients in whom no metastases were assessed by EBUS-TBNA, 28 were found to have residual stage IIIA-N2 disease at thoracotomy. The majority (91%) of these false negative results were due to nodal sampling error rather than detection error. Overall sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of EBUS-TBNA for mediastinal restaging after induction chemotherapy were 76%, 100%, 100%, 20%, and 77%, respectively. CONCLUSION EBUS-TBNA is a sensitive, specific, accurate, and minimally invasive test for mediastinal restaging of patients with NSCLC. However, because of the low negative predictive value, tumor-negative findings should be confirmed by surgical staging before thoracotomy.
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Affiliation(s)
- Felix J F Herth
- Department of Internal Medicine, Pneumology and Critical Care Medicine, Thoraxklinik, University of Heidelberg, Amalienstr 5, D-69126, Heidelberg, Germany.
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Poettgen C, Theegarten D, Eberhardt W, Levegruen S, Gauler T, Krbek T, Stamatis G, Teschler H, Kuehl H, Bockisch A, Stuschke M. Correlation of PET/CT findings and histopathology after neoadjuvant therapy in non-small cell lung cancer. Oncology 2008; 73:316-23. [PMID: 18497503 DOI: 10.1159/000134474] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2007] [Accepted: 10/31/2007] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Prediction of histopathological response with PET/CT scans after neoadjuvant chemoradiotherapy is limited by confounding factors which have been evaluated in this analysis. METHODS (18)F-2-fluoro-2-deoxy-D-glucose (FDG)-PET/CT findings [standard uptake value (SUV), residual tumor volume] were correlated with histopathological parameters of the resection specimens (tumor cell density, necrosis, scar, macrophage infiltration) in patients with locally advanced non-small cell lung cancer (stage IIIA/IIIB) after neoadjuvant induction chemotherapy (platinum-based doublet) and concurrent chemoradiotherapy (cisplatin/vinorelbine/45 Gy). RESULTS Sixty patients [40 male/20 female, median age 56 years (34-78)] completed induction therapy, 46 patients (stage IIIA/IIIB: 16/30; squamous cell carcinoma 41%, adenocarcinoma 48%, large cell carcinoma 11%) were resected. Pathologic complete response of the primary tumor was observed in 19 patients (41%) with a broad range of SUV(mean) (0.4-9.8, mean 3.0) after neoadjuvant therapy. A high rate of histopathological complete remissions (44%) was observed in tumors with a postinduction SUV >2.5 and volumes larger than the median (7.9 cm(3)) before resection. SUV(mean) was positively correlated with the macrophage score (r = 0.39, p = 0.007) and tumor cell density (r = 0.32, p = 0.03). CONCLUSIONS These observations suggest that postinduction FDG uptake should be interpreted with caution in larger residual tumor volumes, since high SUV levels may be due to macrophage infiltration and not viable tumor tissue.
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Affiliation(s)
- Christoph Poettgen
- Department of Radiotherapy, University of Duisburg-Essen, Essen, Germany.
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Abstract
Anatomically based technologies (computed tomography scans, magnetic resonance imaging, and so on) are in routine use in radiotherapy for planning and assessment purposes. Even with improvements in imaging, however, radiotherapy is still limited in efficacy and toxicity in certain applications. Further advances may be provided by technologies that image the molecular activities of tumors and normal tissues. Possible uses for molecular imaging include better localization of tumor regions and early assay for the radiation response of tumors and normal tissues. Critical to the success of this approach is the identification and validation of molecular probes that are suitable in the radiotherapy context. Recent developments in molecular-imaging probes and integration of functional imaging with radiotherapy are promising. This review focuses on recent advances in molecular imaging strategies and probes that may aid in improving the efficacy of radiotherapy.
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Mirzaei S, Prosch H, Knoll P, Mostbeck G. Non-small Cell Lung Cancer. Cancer Imaging 2008. [DOI: 10.1016/b978-012374212-4.50030-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Cerfolio RJ, Bryant AS. When is it best to repeat a 2-fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography scan on patients with non-small cell lung cancer who have received neoadjuvant chemoradiotherapy? Ann Thorac Surg 2007; 84:1092-7. [PMID: 17888953 DOI: 10.1016/j.athoracsur.2007.05.050] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2007] [Revised: 05/13/2007] [Accepted: 05/14/2007] [Indexed: 01/02/2023]
Abstract
BACKGROUND The ideal time to repeat a 2-fluoro-2-deoxy-D-glucose (FDG) positron emission tomography (PET)/computed tomography (CT) scan to accurately restage a patient after neoadjuvant chemoradiotherapy for non-small cell lung cancer (NSCLC) is unknown. METHODS This retrospective cohort study used a prospective database of patients who underwent neoadjuvant chemoradiotherapy, an initial and repeat FDG-PET/CT scan, and pathologic staging. The accuracy of the clinical stage suggested by repeat FDG-PET/CT was compared with the actual pathologic stage. Receiver operating characteristic (ROC) curves were used to determine when it was most accurate to repeat the FDG-PET/CT after the completion of the last dose of chest radiation. RESULTS The study comprised 109 patients, 93 of whom patients received 60 Gy (or higher) of radiotherapy. The median time to restaging was 24 days (range, 2 to 88 days). ROC analysis showed the optimal time to restage patients was 26 days for overall staging (area under the curve [AUC], 0.88) and 29 days for N2 restaging (AUC, 0.82). The accuracy for overall stage was 3 (38%) of 8 for patients for less than 10 days, 28 (72%) of 39 for patients between 11 and 20 days, 42 (88%) of 49 between 21 and 30 days, and 8 (62%) of 13 for 31 days or more. The accuracy for these time intervals for the restaging of the N2 lymph node was 50% (1/2) 40% (2/5), 88% (7/8), and 100% (3/3), respectively. CONCLUSIONS The optimal time to perform a repeat FDG-PET/CT scan after the completion of neoadjuvant chemotherapy and high-dose radiotherapy to maximize its accuracy for restaging patients with NSCLC is about 1 month after the last dose of radiation.
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Affiliation(s)
- Robert James Cerfolio
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham School of Public Health, Birmingham, Alabama 35294, USA.
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de Geus-Oei LF, van der Heijden HFM, Corstens FHM, Oyen WJG. Predictive and prognostic value of FDG-PET in nonsmall-cell lung cancer: a systematic review. Cancer 2007; 110:1654-64. [PMID: 17879371 DOI: 10.1002/cncr.22979] [Citation(s) in RCA: 121] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
For several years, molecular imaging with (18)F-fluorodeoxyglucose positron emission tomography (FDG-PET) has become part of the standard of care in presurgical staging of patients with nonsmall-cell lung cancer (NSCLC), focusing on the detection of malignant lesions at early stages, early detection of recurrence, and metastatic spread. Currently, there is an increasing interest in the role of FDG-PET beyond staging, such as the evaluation of biological characteristics of the tumor and prediction of prognosis in the context of treatment stratification and the early assessment of tumor response to therapy. In this systematic review, the literature on the value of the evolving applications of FDG-PET as a marker for prediction (ie, therapy response monitoring) and prognosis in NSCLC is addressed, divided in sections on the predictive value of FDG-PET in locally advanced and advanced disease, the prognostic value of FDG-PET at diagnosis, after induction treatment, and in recurrent disease. Furthermore, the background and recommendations for the application of FDG-PET for these indications will be discussed.
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Affiliation(s)
- Lioe-Fee de Geus-Oei
- Department of Nuclear Medicine, Radboud University Nijmegen Medical Center, Nijmegen, Netherlands.
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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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Abstract
Imaging techniques play a vital role in the diagnosis, staging, and follow-up of patients who have lung cancer. For this purpose, PET has become an important adjunct to conventional imaging techniques such as chest radiography, CT, ultrasonography, and MR imaging. The ability of PET to differentiate the metabolic properties of tissues allows more accurate assessment of undetermined lung lesions, mediastinal lymph nodes, or extrathoracic abnormalities, tumor response after induction treatment, and detection of disease recurrence.
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Affiliation(s)
- Jokke Wynants
- Respiratory Oncology Unit (Pulmonology), Leuven Lung Cancer Group, University Hospital Gasthuisberg, Catholic University, Herestraat 49, B-3000, Leuven, Belgium.
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The role of integrated computed tomography positron-emission tomography in esophageal cancer: staging and assessment of therapeutic response. Semin Radiat Oncol 2007; 17:29-37. [PMID: 17185195 DOI: 10.1016/j.semradonc.2006.09.005] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Computed tomography (CT) and endoscopy/endoscopic ultrasonography are usually performed to initially stage patients with esophageal cancer, to determine primary tumor response, and to detect nodal and distant metastases after preoperative therapy. Positron-emission tomography (PET) with [18F]-fluoro-2-deoxy-D-glucose and integrated CT-PET are useful in the initial staging of patients with esophageal cancer as well as in the prediction of pathologic response, disease-free interval, and overall survival after preoperative therapy. Importantly, integrated CT-PET imaging decreases the number of futile attempts at surgical resection, mainly because of the detection of occult distant metastases. The following sections review the use of integrated CT-PET imaging in determining the T, N, and M descriptors of the American Joint Commission on Cancer's 2002 guidelines for pathologic and clinical staging at initial diagnosis and after chemoradiation therapy in those patients being considered for surgical resection.
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Abstract
PURPOSE OF REVIEW The aim of this review is to analyze recent evidence for optimal treatment of elderly patients with non-small cell lung cancer, focusing on surgery, and possibly to foresee the future strategies to apply in these patients. RECENT FINDINGS Surgery in elderly patients affected by non-small cell lung cancer is safe and feasible when careful preoperative respiratory and cardiac studies have been carried out and the disease has been properly staged. The surgical treatment is not to be denied in elderly patients due to age per se, but when a major contraindication to surgery has been recognized. Long term survival for elderly patients with early stage lung cancer treated by anatomical pulmonary resection is comparable to the survival rate of younger patients. Pneumonectomy, extended surgical procedure or preoperative induction chemotherapy are major risk factors for an increased postoperative morbidity and mortality rate. When co-morbidities are present or a patient is 80 years or older, there is evidence that a non-anatomical resection can be performed without affecting long-term results. SUMMARY Due to the aging of the general population, elderly patients will become a large percentage of the cases of non-small cell lung cancer to be treated. Implementing preoperative cardiologic studies and redefining selective respiratory criteria specifically could dramatically improve results.
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Affiliation(s)
- Lorenzo Spaggiari
- Division of Thoracic Surgery, European Institute of Oncology, Milan, Italy.
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Abstract
PURPOSE OF REVIEW Positron emission tomography (PET) has become a major adjunct to structural imaging for nonsmall cell lung cancer. Established indications are the differential diagnosis of lung nodules, as well as mediastinal lymph node and extrathoracic staging. RECENT FINDINGS More details for small or faint pulmonary nodules became available--information of interest in the era of lung cancer screening trials, in which PET might help to reduce unwanted invasive procedures for benign findings. The strength of PET in mediastinal staging (its high negative predictive value) was confirmed in a randomized study, in which PET reduced the number of invasive procedures without loss of accuracy in staging. Isolated positive lesions that are decisive for radical compared with palliative treatment should be confirmed by other tests, as they may be benign or due to second primary cancer. PET with integrated computed tomography (CT) may guide modern radiotherapy, by improving radiation fields. Integrated PET-CT is a promising tool in the indication for surgery in stage IIIA-N2 patients after induction treatment. Predictive values for lymph node downstaging become in acceptable ranges and PET response in the primary tumor could be clearly linked to pathologic response and survival. SUMMARY In recent years, PET has seen further refinements in established indications and definition of new indications.
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Affiliation(s)
- Johan Vansteenkiste
- Respiratory Oncology Unit, Department Pulmonology and Leuven Lung Cancer Group, University Hospital Gasthuisberg, Leuven, Belgium.
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Cerfolio RJ, Bryant AS, Ojha B. Restaging patients with N2 (stage IIIa) non-small cell lung cancer after neoadjuvant chemoradiotherapy: a prospective study. J Thorac Cardiovasc Surg 2006; 131:1229-35. [PMID: 16733150 DOI: 10.1016/j.jtcvs.2005.08.070] [Citation(s) in RCA: 95] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2005] [Revised: 08/24/2005] [Accepted: 08/30/2005] [Indexed: 12/14/2022]
Abstract
BACKGROUND The accuracy of restaging in patients with stage IIIa non-small cell lung cancer after neoadjuvant chemoradiotherapy is unknown. METHODS A prospective trial of patients with biopsy-proven N2 disease who underwent initial clinical staging with mediastinoscopy, integrated positron emission tomography/computed tomography (PET/CT), and CT. Patients then were clinically restaged by the same imaging techniques 4 to 12 weeks after their induction chemoradiation therapy and then underwent definitive pathologic staging. RESULTS Ninety-three patients had their lymph nodes pathologically restaged. Repeat PET/CT after neoadjuvant therapy missed residual N2 disease in 13/65 (20%) patients and falsely suggested it in 7 of 28 (25%). It was more accurate than repeat CT for restaging at all pathologic stages (stage 0, 92% vs 39%, P = .03; and stage I 89% vs 36%, P = .04). When the maximum standardized uptake value of the primary tumor is decreased by 75% or more, it is highly likely (likelihood ratio, +LR, 6.1) the patient is a complete responder; when it decreased by 55% or more, it is highly likely (+LR, 9.1) the patient is a partial responder. When the maximum standardized uptake value of the N2 node initially involved with metastatic cancer is decreased by more than 50%, it is highly likely (+LR, 7.9) the node is now benign. CONCLUSION Repeat integrated PET/CT is superior to repeat CT for the restaging of patients with stage IIIa non-small cell lung cancer. The percent decrease in the maximum standardized uptake value of the primary and of the involved lymph node is predictive of pathology; however, nodal biopsies are required since a persistently high maximum standardized uptake value does not equate to residual cancer.
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Affiliation(s)
- Robert James Cerfolio
- Division of Thoracic Surgery, University of Alabama at Birmingham, and Department of Surgery, Birmingham Veterans Administration Hospital, Birmingham, Ala 35294, USA.
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De Leyn P, Stroobants S, De Wever W, Lerut T, Coosemans W, Decker G, Nafteux P, Van Raemdonck D, Mortelmans L, Nackaerts K, Vansteenkiste J. Prospective comparative study of integrated positron emission tomography-computed tomography scan compared with remediastinoscopy in the assessment of residual mediastinal lymph node disease after induction chemotherapy for mediastinoscopy-proven stage IIIA-N2 Non-small-cell lung cancer: a Leuven Lung Cancer Group Study. J Clin Oncol 2006; 24:3333-9. [PMID: 16849747 DOI: 10.1200/jco.2006.05.6341] [Citation(s) in RCA: 143] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
PURPOSE Mediastinal restaging after induction therapy for non-small-cell lung cancer remains a difficult and controversial issue. The goal of this prospective study was to compare the performance of integrated positron emission tomography (PET)--computed tomography (CT) and remediastinoscopy in the evaluation of mediastinal lymph node metastasis after induction chemotherapy. PATIENTS AND METHODS Thirty consecutive stage IIIA-N2 non-small-cell lung cancer patients surgically treated at our institution were entered onto this prospective study. N2 disease was proven by cervical mediastinoscopy, at which a mean number of 3.8 lymph node levels were biopsied. After completion of induction chemotherapy, the mediastinum was reassessed by integrated PET-CT and remediastinoscopy. All patients underwent thoracotomy with attempted complete resection and systematic nodal dissection. RESULTS PET-CT showed no evidence of nodal disease (N0) in 13 patients, Hilar nodal disease (N1) disease in three patients, and residual mediastinal disease (N2) in 14 patients. Remediastinoscopy was positive in only five patients. The preinduction involved lymph node level could be accurately re-evaluated in 18 patients. This was not the case in the other 12 because of extensive fibrosis and adhesions. In 17 patients, persistent N2 disease was found at thoracotomy. The sensitivity, specificity, and accuracy of PET-CT were 77%, 92%, and 83%, respectively. These parameters for remediastinoscopy were 29%, 100%, and 60%, respectively. Sensitivity (P < .0001) and accuracy (P = .012) were significantly better for PET-CT. CONCLUSION After a thorough staging mediastinoscopy, postinduction remediastinoscopy had a disappointing sensitivity because of adhesions and fibrosis. Integrated PET-CT yielded a better result than that obtained in previous studies with side-by-side PET and CT images.
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Affiliation(s)
- Paul De Leyn
- Department of Thoracic Surgery, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium.
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Mawlawi O, Erasmus JJ, Pan T, Cody DD, Campbell R, Lonn AH, Kohlmyer S, Macapinlac HA, Podoloff DA. Truncation artifact on PET/CT: impact on measurements of activity concentration and assessment of a correction algorithm. AJR Am J Roentgenol 2006; 186:1458-67. [PMID: 16632745 DOI: 10.2214/ajr.05.0255] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVE Discrepancy between fields of view (FOVs) in a PET/CT scanner causes a truncation artifact when imaging extends beyond the CT FOV. The purposes of this study were to evaluate the impact of this artifact on measurements of 18F-FDG activity concentrations and to assess a truncation correction algorithm. MATERIALS AND METHODS Two phantoms and five patients were used in this study. In the first phantom, three inserts (water, air, bone equivalent) were placed in a water-filled cylinder containing 18F-FDG. In the second phantom study, a chest phantom and a 2-L bottle fitted with a bone insert were used to simulate a patient's torso and arm. Both phantoms were imaged while positioned centrally (baseline) and at the edge of the CT FOV to induce truncation. PET images were reconstructed using attenuation maps from truncated and truncation-corrected CT images. Regions of interest (ROIs) drawn on the inserts, simulated arm, and background water of the baseline truncated and truncation-corrected PET images were compared. In addition, extremity malignancies of five patients truncated on CT images were reconstructed with and without correction and the maximum standard uptake values (SUVs) of the malignancies were compared. RESULTS Truncation artifact manifests as a rim of high activity concentration at the edge of the truncated CT image with an adjacent low-concentration region peripherally. The correction algorithm minimizes these effects. Phantom studies showed a maximum variation of -5.4% in the truncation-corrected background water image compared with the baseline image. Activity concentration in the water insert was 6.3% higher while that of air and bone inserts was similar to baseline. Extremity malignancies showed a consistent increase in the maximum SUV after truncation correction. CONCLUSION Truncation affects measurements of 18F-FDG activity concentrations in PET/CT. A truncation-correction algorithm corrects truncation artifacts with small residual error.
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Affiliation(s)
- Osama Mawlawi
- Department of Imaging Physics, M. D. Anderson Cancer Center, 1515 Holcombe Blvd., Box 56, Houston, TX 77030, USA.
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Preoperative Chemo-Radiation-Induced Ulceration in Patients with Esophageal Cancer: A Confounding Factor in Tumor Response Assessment in Integrated Computed Tomographic-Positron Emission Tomographic Imaging. J Thorac Oncol 2006. [DOI: 10.1097/01243894-200606000-00016] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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