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Lu F, Wang E, Liu H. Factors correlating the expression of PD-L1. BMC Cancer 2024; 24:642. [PMID: 38796458 PMCID: PMC11127358 DOI: 10.1186/s12885-024-12400-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Accepted: 05/20/2024] [Indexed: 05/28/2024] Open
Abstract
OBJECTIVE PD-L1 was an important biomarker in lung adenocarcinoma. The study was to confirm the most important factor affecting the expression of PD-L1 remains undetermined. METHODS The clinical records of 1045 lung adenocarcinoma patients were retrospectively reviewed. The High-Resolution Computed Tomography (HRCT) scanning images of all the participants were analyzed, and based on the CT characteristics, the adenocarcinomas were categorized according to CT textures. Furthermore, PD-L1 expression and Ki67 index were detected by immunohistochemistry. All patients underwent EGFR mutation detection. RESULTS Multivariate logistic regression analysis revealed that smoking (OR: 1.73, 95% CI: 1.04-2.89, p = 0.004), EGFR wild (OR: 1.52, 95% CI: 1.11-2.07, p = 0.009), micropapillary subtypes (OR: 2.05, 95% CI: 1.46-2.89, p < 0.0001), and high expression of Ki67 (OR: 2.02, 95% CI: 1.44-2.82, p < 0.0001) were independent factors which influence PD-L1 expression. In univariate analysis, tumor size > 3 cm and CT textures of pSD showed a correlation with high expression of PD-L1. Further analysis revealed that smoking, micropapillary subtype, and EGFR wild type were also associated with high Ki67 expression. Moreover, high Ki67 expression was observed more frequently in tumors of size > 3 cm than in tumors with ≤ 3 cm size as well as in CT texture of pSD than lesions with GGO components. In addition, multivariate logistic regression analysis revealed that only lesions with micropapillary components correlated with pSD (OR: 3.96, 95% CI: 2.52-5.37, p < 0.0001). CONCLUSION This study revealed that in lung adenocarcinoma high Ki67 expression significantly influenced PD-L1 expression, an important biomarker for immune checkpoint treatment.
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Affiliation(s)
- Fang Lu
- Department of Radiology, Huadong Hospital, Fudan University, Shanghai, 200040, China
| | - Ernuo Wang
- Department of Radiology, Huadong Hospital, Fudan University, Shanghai, 200040, China
| | - Haiquan Liu
- Department of Radiology, Huadong Hospital, Fudan University, Shanghai, 200040, China.
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Goto E, Takamochi K, Kishikawa S, Hayashi T, Ueda T, Hattori A, Fukui M, Matsunaga T, Suzuki K. Stepwise progression of invasive mucinous adenocarcinoma based on radiological and biological characteristics. Lung Cancer 2023; 184:107348. [PMID: 37619407 DOI: 10.1016/j.lungcan.2023.107348] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Revised: 08/09/2023] [Accepted: 08/17/2023] [Indexed: 08/26/2023]
Abstract
INTRODUCTION Invasive mucinous lung adenocarcinoma (IMA) has unique radiological findings and pathological characteristics. IMA is classified into solitary and pneumonic types; however, it is unclear whether these are biologically identical. METHODS A single-center retrospective analysis was performed for 70 IMA patients (solitary type [n = 38] and pneumonic type [n = 32]) who underwent pulmonary resection between January 2010 and December 2018. We compared clinical and biological characteristics between the two types. RESULTS The frequencies of genetic alternations such as EGFR, KRAS, BRAF, GNAS, ERBB2, TP53, NRG1, and MET were not different. Immunohistochemically, expression of MUC1 was significantly more common in the pneumonic type (5.0% versus 20.0%, p = 0.01) and diffuse MUC6 positive in the solitary type (39.0% versus 13.0%, p = 0.02). We further classified solitary types into those with or without ground-glass opacity (GGO) and pneumonic types into those with or without crazy-paving appearance (CPA), and evaluated their surgical outcomes. Five-year overall survival and relapse free survival rates were 95.8%/86.6%, 64.3%/70.7%, 74.6%/68.9%, and 50.0%/28.6% in patients with solitary type with GGO, solitary type without GGO, pneumonic type without CPA, and pneumonic type with CPA, respectively. CONCLUSIONS There were no differences in genetic alternations; however, mucin expression pattern was different. Surgical outcomes were different according to the presence of GGO in the solitary type and the presence of CPA in the pneumonic type. These findings suggested a stepwise progression from solitary to pneumonic IMA.
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Affiliation(s)
- Eisuke Goto
- Department of General Thoracic Surgery, Juntendo University School of Medicine, Japan
| | - Kazuya Takamochi
- Department of General Thoracic Surgery, Juntendo University School of Medicine, Japan.
| | - Satsuki Kishikawa
- Department of Human Pathology, Juntendo University School of Medicine, Japan
| | - Takuo Hayashi
- Department of Human Pathology, Juntendo University School of Medicine, Japan
| | - Takuya Ueda
- Department of General Thoracic Surgery, Juntendo University School of Medicine, Japan
| | - Aritoshi Hattori
- Department of General Thoracic Surgery, Juntendo University School of Medicine, Japan
| | - Mariko Fukui
- Department of General Thoracic Surgery, Juntendo University School of Medicine, Japan
| | - Takeshi Matsunaga
- Department of General Thoracic Surgery, Juntendo University School of Medicine, Japan
| | - Kenji Suzuki
- Department of General Thoracic Surgery, Juntendo University School of Medicine, Japan
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Xiao J, Li M, Du Q, Han H, Ge Y. The value of positron emission tomography computed tomography in predicting invasiveness of ground glass nodules: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2021; 100:e27507. [PMID: 34731135 PMCID: PMC8519196 DOI: 10.1097/md.0000000000027507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 09/03/2021] [Accepted: 09/23/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND The study was conducted to investigate the value of Positron emission tomography computed tomography (PET/CT) in predicting invasiveness of ground glass nodule (GGN) by the method of meta-analysis. METHODS Two researchers independently searched for published literature on PET/CT diagnosis of GGN as of November 30, 2020. After extracting the data, RevMan5.3 was used to evaluate the quality of the included literature. The Stata14 software was used to test the heterogeneity of the original study that met the inclusion criteria, to calculate the combined sensitivity, specificity, positive likelihood ratio and negative likelihood ratio, the prior probability and posttest probability. The summary receiver operator characteristic curve was drawn and the area under the curve was calculated. Using Deeks funnel plot to evaluate publication bias. RESULTS Five studies were finally included, including 298 GGN cases. The included studies had no obvious heterogeneity and publication bias. The combined sensitivity and specificity of PET/CT for predicting invasive adenocarcinoma presenting as GGN were 0.74 (95% confidence interval [CI]: 0.68-0.79), 0.82 (95% CI: 0.71-0.90), positive likelihood ratio and negative likelihood ratio were 4.1 (95% CI: 2.5-6.9), 0.32 (95% CI: 0.25-0.40), and the diagnostic odds ratio was 13 (95% CI: 7-26). The prior probability is 20%, the probability of GGN being invasive adenocarcinoma when PET/CT was negative was reduced to 7%, and the probability of GGN being invasive adenocarcinoma when PET/CT was positive was increased to 51%. The area under the curve of the summary receiver operator characteristic curve was 0.85. CONCLUSION PET/CT has high diagnostic accuracy for invasive adenocarcinoma presenting as GGN.
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Li Y, Wu X, Huang Y, Bian D, Jiang L. 18F-FDG PET/CT in lung adenosquamous carcinoma and its correlation with clinicopathological features and prognosis. Ann Nucl Med 2020; 34:314-321. [PMID: 32088884 DOI: 10.1007/s12149-020-01450-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Accepted: 02/11/2020] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Lung adenosquamous carcinoma (ASC) is a rare histological subtype of non-small cell lung cancer (NSCLC). Due to its rarity, the studies about 18F-FDG PET/CT in this kind of pulmonary tumor were quite limited. Thus, this study investigated 18F-FDG PET/CT findings in ASC and its correlation with clinicopathological features and clinical outcomes. METHODS Preoperative 18F-FDG PET/CT findings and parameters of maximum standard uptake value (SUVmax), metabolic tumor volume and total lesion glycolysis of primary lesion (MTV-P, TLG-P), combination of primary lesion and metastases (MTV-C, TLG-C), and clinicopathological features were retrospectively investigated in patients with ASC. Moreover, progression-free survival (PFS) was also analyzed. RESULTS All 41 patients (25 men; 16 women; age: 60 ± 7 years) had single ASC with the mean diameter of 33 ± 14 mm. Six lesions were located centrally and 35 peripherally. Serum tumor markers were abnormally increased sporadically. Twenty-two cases were at TNM stage I, 9 at II, and 10 at III. The primary tumors were FDG-avid in all cases, with the average SUVmax of 11.5 ± 6.0. SUVmax was significantly associated with tumor location, size, and TNM stage (P < 0.05). Forty-one lesions were subgrouped into 23 AC-predominant and 18 SCC-predominant lesions, and significant differences were observed for age, tumor size, and SUVmax in two groups (P < 0.05). The median PFS of 41 cases was 19 months, and 12-month and 24-month PFS rates were 72.1% and 36.1%, respectively. SUVmax, MTV-P, and TLG-C were significantly associated with PFS (P < 0.05). CONCLUSIONS ASC of the lung displayed high SUVmax on 18F-FDG PET/CT, which was associated with tumor location, size, TNM stage, and predominant histologic component. Moreover, metabolic parameters of 18F-FDG PET/CT were independent prognostic factors of this rare lung malignancy.
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Affiliation(s)
- Yuan Li
- Department of Nuclear Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, 200433, China
| | - Xiaodong Wu
- Department of Nuclear Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, 200433, China
- Medical College of Soochow University, Suzhou, 215123, China
| | - Yan Huang
- Department of Pathology, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, 200433, China
| | - Dongliang Bian
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, 200433, China
| | - Lei Jiang
- Department of Nuclear Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, 200433, China.
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Akın Kabalak P, Yılmaz Ü, Ertürk H, Özmen Ö, Demiröz ŞM, Demirağ F, Kızılgöz D, Kavurgacı S, İnal Cengiz T. Prognostic significance of preoperative consolidation to maximum tumour diameter ratio and SUVmax in pathological stage I lung adenocarcinoma. CLINICAL RESPIRATORY JOURNAL 2019; 14:71-77. [PMID: 31688981 DOI: 10.1111/crj.13102] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Revised: 09/27/2019] [Accepted: 10/27/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Consolidation/tumour (C/T) ratio means the maximum diameter of the consolidation is divided by the maximum diameter of the tumour and it is predictive for pathologic subtypes and prognosis after resection of the tumour. The purpose of this study is to clarify impact of C/T ratio along with maximum standardized uptake value (SUV) in pathological stage I lung adenocarcinoma. METHODS Only patients with pathological stage I lung adenocarcinoma diagnosed by resection were included. Prognostic impact of C/T ratio and SUVmax were analysed by using regression analyses. RESULTS Totally 156 patients (121 males, 35 females) were evaluated retrospectively. Overall survival (OS) and progression free survival (PFS) were higher in patients with C/T ratio ≥0.5 (OS: 46.3 ± 23.7 vs 30.4 ± 14.6, P = 0.002 and PFS: 43.0 ± 25.4 vs 27.8 ± 15.8, P = 0.005). But PFS and OS curves did not reveal any significant differences with Kaplan-Meier method (P = 0.45 and P = 0.055 respectively). Resection type (limited vs anatomic) and C/T ratio were predictors for OS in multivariate analyses (resection type: HR: 2.21 (1.01-4.83), P = 0.045 and C/T ratio: HR: 0.44 (0.20-0.98), P = 0.045). For PFS, resection type and SUVmax had prognostic significance (resection type: HR: 3.56 (1.64-7.74), P = 0.001 and SUVmax: HR: 1.31 (0.82-2.99), P = .002). CONCLUSION In pathological stage 1 lung adenocarcinomas, SUVmax and surgery type are important predictors for recurrence rates. For early stage, adenocarcinoma patients with high SUVmax value, tumour size ≥3 cm and high grade subtype, C/T ratio should not be considered significant alone on survival and recurrence.
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Affiliation(s)
- Pınar Akın Kabalak
- Department of Chest Disease, Atatürk Chest Diseases and Thoracic Surgery Training and Research Hospital, Ankara, Turkey
| | - Ülkü Yılmaz
- Department of Chest Disease, Atatürk Chest Diseases and Thoracic Surgery Training and Research Hospital, Ankara, Turkey
| | - Hakan Ertürk
- Department of Radiology, Atatürk Chest Diseases and Thoracic Surgery Training and Research Hospital, Ankara, Turkey
| | - Özlem Özmen
- Department of Nuclear Medicine, Atatürk Chest Diseases and Thoracic Surgery Training and Research Hospital, Ankara, Turkey
| | - Şevki Mustafa Demiröz
- Department of Thoracic Surgery, Atatürk Chest Diseases and Thoracic Surgery Training and Research Hospital, Ankara, Turkey
| | - Funda Demirağ
- Department of Pathology, Atatürk Chest Diseases and Thoracic Surgery Training and Research Hospital, Ankara, Turkey
| | - Derya Kızılgöz
- Department of Chest Disease, Atatürk Chest Diseases and Thoracic Surgery Training and Research Hospital, Ankara, Turkey
| | - Suna Kavurgacı
- Department of Chest Disease, Atatürk Chest Diseases and Thoracic Surgery Training and Research Hospital, Ankara, Turkey
| | - Tuba İnal Cengiz
- Department of Chest Disease, Atatürk Chest Diseases and Thoracic Surgery Training and Research Hospital, Ankara, Turkey
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Lung Adenocarcinoma Manifesting as Ground-Glass Opacity Nodules 3 cm or Smaller: Evaluation With Combined High-Resolution CT and PET/CT Modality. AJR Am J Roentgenol 2019; 213:W236-W245. [PMID: 31361533 DOI: 10.2214/ajr.19.21382] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVE. The purpose of this study is to evaluate high-resolution CT (HRCT) combined with PET/CT for preoperative differentiation of invasive adenocarcinoma (IAC) from preinvasive lesions and minimally invasive adenocarcinoma (MIA) (the combination of which is hereafter referred to as preinvasive-MIA) in lung adenocarcinoma manifesting as ground-glass opacity nodules (GGNs) 3 cm or smaller. MATERIALS AND METHODS. We retrospectively analyzed the data of patients with lung adenocarcinoma with GGNs that were 3 cm or smaller between November 2011 and November 2018. The HRCT and PET/CT parameters for GGNs were compared to differentiate between IAC and preinvasive-MIA. Qualitative and quantitative parameters were analyzed using univariate and multivariate logistic regression models. The diagnostic performance of different parameters was compared using ROC curves and the McNemar test. RESULTS. The study enrolled 89 patients (24 men and 65 women) with lung adenocarcinoma who had a mean (± SD) age of 60.1 ± 8.1 years (range, 36-78 years). The proportions of mixed GGN type, polygonal or irregular shape, lobulated or spiculated edge, and dilated, distorted, or cutoff bronchial sign were higher for IAC GGNs than for preinvasive-MIA GGNs, and the attenuation value of the ground-glass opacity component on CT (CTGGO), maximum standardized uptake value, and the standardized uptake value (SUV) index (i.e., the ratio of the tumor maximum SUV to the liver mean SUV) for IAC GGNs were also higher (p = 0.001-0.022). Logistic regression analyses showed that the CTGGO and SUV index were independent predictors for IAC GGNs. The accuracy of CTGGO in combination with the SUV index for predicting IAC was 81.4% on a per-GGN basis and 85.4% on a per-patient basis. The combined HRCT and PET/CT modality had higher sensitivity and accuracy than did morphologic features, HRCT, and PET/CT measurement parameters alone (p < 0.001). CONCLUSION. The combined HRCT and PET/CT modality is an effective method to preoperatively identify IAC in lung adenocarcinoma manifesting as GGNs 3 cm or smaller.
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Utility of Metabolic Parameters on FDG PET/CT in the Classification of Early-Stage Lung Adenocarcinoma. Clin Nucl Med 2019; 44:560-565. [DOI: 10.1097/rlu.0000000000002591] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Li M, Wu N, Zhang L, Sun W, Liu Y, Lv L, Ren J, Lin D. Solid component proportion is an important predictor of tumor invasiveness in clinical stage T 1N 0M 0 (cT 1N 0M 0) lung adenocarcinoma. Cancer Imaging 2018; 18:18. [PMID: 29728140 PMCID: PMC5935978 DOI: 10.1186/s40644-018-0147-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 04/09/2018] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Preoperative tumor invasiveness in clinical stage T1N0M0 lung adenocarcinoma is critical for optimal surgical procedure. The aim of the present study was to evaluate the relationship between the ground-glass opacity component (GGOc) / solid component (Sc) proportion measured using three-dimensional (3D) computer-quantified computer tomography (CT) number analysis to explore radiographic features for invasiveness prediction in cT1N0M0 lung adenocarcinomas. METHODS A total of 375 surgically resected cT1N0M0 lung adenocarcinoma patients were included. The relativity between the GGOc/Sc proportion and lepidic growth pattern percentage was assessed using Spearman's rank analysis. Multiple logistic regression analysis was used to determine independent factors from radiographic features for tumor invasiveness. Prediction probability for tumor invasiveness was analysed using a receiver operating characteristic curve (ROC). RESULTS We found that the GGOc proportion was positively correlated with lepidic growth pattern percentage (r = 0.67, P < 0.01), while the Sc proportion was negatively correlated with it (r = - 0.74, P < 0.01). Multivariate analysis showed that tumor size and Sc proportion were identified as independent predictors for tumor invasiveness. The area under the ROC curve (AUC) of Sc proportion was 0.875, which was higher than that of tumor size (0.750) (P < 0.001), and had no significant difference with that of combination of these two factors (0.884) (P = 0.28). CONCLUSIONS The GGOc/Sc proportion measured using 3D computer-quantified CT number analysis reflects the lepidic growth pattern percentage in tumors, and the Sc proportion may be an important factor for the prediction of tumor invasiveness in cT1N0M0 lung adenocarcinoma.
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Affiliation(s)
- Meng Li
- Department of Diagnostic Radiology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ning Wu
- Department of Diagnostic Radiology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China. .,PET-CT Center, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Li Zhang
- Department of Diagnostic Radiology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wei Sun
- Department of Pathology, Beijing Cancer Hospital, Beijing, China
| | - Ying Liu
- PET-CT Center, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lv Lv
- Department of Diagnostic Radiology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jiansong Ren
- National Office for Cancer Prevention and Control, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Dongmei Lin
- Department of Pathology, Beijing Cancer Hospital, Beijing, China
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Fu L, Alam MS, Ren Y, Guan W, Wu H, Wang Q, Han Y, Zhou W, Li H, Wang Z. Utility of Maximum Standard Uptake Value as a Predictor for Differentiating the Invasiveness of T1 Stage Pulmonary Adenocarcinoma. Clin Lung Cancer 2018; 19:221-229. [DOI: 10.1016/j.cllc.2017.11.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2017] [Revised: 11/21/2017] [Accepted: 11/22/2017] [Indexed: 10/18/2022]
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10
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Lin LY, Zhang Y, Suo ST, Zhang F, Cheng JJ, Wu HW. Correlation between dual-energy spectral CT imaging parameters and pathological grades of non-small cell lung cancer. Clin Radiol 2018; 73:412.e1-412.e7. [DOI: 10.1016/j.crad.2017.11.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 11/02/2017] [Indexed: 02/07/2023]
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Wang XY, Zhao YF, Liu Y, Yang YK, Zhu Z, Wu N. Comparison of different automated lesion delineation methods for metabolic tumor volume of 18F-FDG PET/CT in patients with stage I lung adenocarcinoma. Medicine (Baltimore) 2017; 96:e9365. [PMID: 29390527 PMCID: PMC5758229 DOI: 10.1097/md.0000000000009365] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
The aim of the study was to investigate the suitable segmentation method in small, low uptake and heterogeneous nodules of stage I lung adenocarcinoma.133 stage I lung adenocarcinoma patients with F-FDG PET/CT scans were enrolled in this retrospective study. All lesions were divided into different groups according to nodule density, nodule size, and the maximum standard uptake value (SUVmax) level. Four different PET segmentation methods were performed, including percentage threshold of SUVmax (T42% and T42% × RC), gradient-based threshold (adaptive iterative algorithm, AT-AIA), and background-related threshold (adaptive thresholding at 40% SUVmax, AT40%) approaches. The MTVs were evaluated and compared with CT volume (CTV). Percentage volume error (%VE) compared to CTV was calculated and the correlations between MTVs and CTV were analyzed.AT-AIA had the highest accuracy in large, high uptake, and solid nodules (72.5%, 72.4%, and 65.6%, respectively). AT40% had the highest accuracy in small, low uptake and nonsolid nodules (56.6%, 56.1%, and 62.6%, respectively). In part-solid nodules, the accuracy of AT-AIA (60.0%) and AT40% (56.7%) were higher than that of T42% and T42% × RC. The MTV of AT-AIA was in excellent correlation with the CTV in solid nodules (R = 0.831, P < .001) and in high uptake nodules (R = 0.830, P < .001). The MTV of AT40% was in good correlation with the CTV in nonsolid nodules (R = 0.686, P = .003) and in part-solid nodules (R = 0.731, P < .001).AT40% showed best performance in small, low uptake, nonsolid and part-solid lesions. AT-AIA was suitable for large, high uptake, and solid lesions.
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Affiliation(s)
| | | | | | - Yi-kun Yang
- Department of Thoracic Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | | | - Ning Wu
- PET/CT Center
- Department of Diagnostic Radiology
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Zhou J, Li Y, Zhang Y, Liu G, Tan H, Hu Y, Xiao J, Shi H. Solitary ground-glass opacity nodules of stage IA pulmonary adenocarcinoma: combination of 18F-FDG PET/CT and high-resolution computed tomography features to predict invasive adenocarcinoma. Oncotarget 2017; 8:23312-23321. [PMID: 28423576 PMCID: PMC5410306 DOI: 10.18632/oncotarget.15577] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 02/13/2017] [Indexed: 12/18/2022] Open
Abstract
To investigate the performance of combined 18F-FDG Positron Emission Tomography/Computed Tomography with high-resolution CT for differentiating invasive adenocarcinoma from adenocarcinoma in situ (pre-invasive lesion) or minimally invasive adenocarcinoma in stage IA lung cancer patients with solitary ground-glass opacity nodules. This retrospective study enrolled 58 consecutive stage IA pulmonary adenocarcinoma patients with solitary ground-glass opacity nodules. The characteristics and measurements of the ground-glass opacity nodules as pure ground-glass opacity nodules and mixed ground-glass opacity nodules in the pre-invasive or minimally invasive adenocarcinoma and invasive adenocarcinoma groups on Positron Emission Tomography/Computed Tomography and high-resolution CT were compared and analyzed. Ground-glass opacity nodules in the pre-invasive or minimally invasive adenocarcinoma group preferentially manifested as pure ground-glass opacity nodule (p < 0.01) compared to the invasive adenocarcinoma group. While cystic appearance was more common in the invasive adenocarcinoma group (p < 0.05). Significant differences were found in the diameter of the ground-glass opacity nodule itself and its solid component, and consolidation/tumor ratio between the two groups. The sensitivity in predicting invasive adenocarcinoma was higher with a combined consolidation/tumor ratio > 0.38 and SUVmax > 1.46 in mixed ground-glass opacity nodule when compared to those of SUVmax > 0.95 alone or consolidation/tumor ratio> 0.39 alone (both p > 0.05). For a mixed ground-glass opacity nodule combined consolidation/tumor ratio > 0.38 and SUVmax > 1.46 appears to better predict invasive adenocarcinoma in stage IA lung cancer patients with solitary ground-glass opacity nodules.
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Affiliation(s)
- Jun Zhou
- Department of Nuclear Medicine, Zhongshan Hospital, Fudan University, Shanghai, China 200032.,Nuclear Medicine Institute of Fudan University, Shanghai, China 200032.,Shanghai Institute of Medical Imaging, Shanghai, China 200032
| | - Yanli Li
- Department of Nuclear Medicine, Zhongshan Hospital, Fudan University, Shanghai, China 200032.,Nuclear Medicine Institute of Fudan University, Shanghai, China 200032.,Shanghai Institute of Medical Imaging, Shanghai, China 200032
| | - Yiqiu Zhang
- Department of Nuclear Medicine, Zhongshan Hospital, Fudan University, Shanghai, China 200032.,Nuclear Medicine Institute of Fudan University, Shanghai, China 200032.,Shanghai Institute of Medical Imaging, Shanghai, China 200032
| | - Guobing Liu
- Department of Nuclear Medicine, Zhongshan Hospital, Fudan University, Shanghai, China 200032.,Nuclear Medicine Institute of Fudan University, Shanghai, China 200032.,Shanghai Institute of Medical Imaging, Shanghai, China 200032
| | - Hui Tan
- Department of Nuclear Medicine, Zhongshan Hospital, Fudan University, Shanghai, China 200032.,Nuclear Medicine Institute of Fudan University, Shanghai, China 200032.,Shanghai Institute of Medical Imaging, Shanghai, China 200032
| | - Yan Hu
- Department of Nuclear Medicine, Zhongshan Hospital, Fudan University, Shanghai, China 200032.,Nuclear Medicine Institute of Fudan University, Shanghai, China 200032.,Shanghai Institute of Medical Imaging, Shanghai, China 200032
| | - Jie Xiao
- Department of Nuclear Medicine, Zhongshan Hospital, Fudan University, Shanghai, China 200032.,Nuclear Medicine Institute of Fudan University, Shanghai, China 200032.,Shanghai Institute of Medical Imaging, Shanghai, China 200032
| | - Hongcheng Shi
- Department of Nuclear Medicine, Zhongshan Hospital, Fudan University, Shanghai, China 200032.,Nuclear Medicine Institute of Fudan University, Shanghai, China 200032.,Shanghai Institute of Medical Imaging, Shanghai, China 200032
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Umakoshi H, Iwano S, Yokoi K, Ito S, Ito R, Kawaguchi K, Fukui T, Naganawa S. FDG PET/CT Overcomes Discordance Between Clinical and Pathologic TNM Classification of Small-size Primary Lung Cancer: Influence on Postoperative Prognosis. Clin Lung Cancer 2017; 19:e37-e45. [PMID: 28666761 DOI: 10.1016/j.cllc.2017.05.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 05/26/2017] [Accepted: 05/30/2017] [Indexed: 10/19/2022]
Abstract
INTRODUCTION We aimed to determine the concordance between the clinical stage (c-stage) and pathologic stage (p-stage) for patients with small-size lung cancer. Additionally we searched for prognostic factors other than the TNM stage. PATIENTS AND METHODS We retrospectively reviewed the preoperative multidetector computed tomography (CT) and positron emission tomography/CT reports, surgical records, and pathologic reports of patients with primary lung cancer ≤ 3 cm. The Union for International Cancer Control TNM seventh edition classification of c-stage and p-stage were compared. The tumors were classified into multiple subgroups by concordance or discordance between the c-stage and p-stage. Disease-free survival (DFS) was assessed using survival analysis to assess the tumor characteristics that were predictive of prognosis. RESULTS A total of 289 surgically resected primary lung cancers were evaluated. The concordance between c-stage and p-stage was 65.4%, with moderate reproducibility (kappa coefficient, 0.467). The upstaging rate from c-stage I to p-stage II-IV was 9.4%, and these patients had significantly worse DFS than those with a concordant stage I classification (P < .001). The main reason for upstaging was an underestimation of metastases to the hilar lymph nodes (n = 7) or mediastinal lymph nodes (n = 11). A multivariate Cox proportional hazards model showed that the significant predictive factors for DFS were p-stage (hazard ratio, 1.342; P = .003) and maximum standardized uptake value on positron emission tomography/CT (hazard ratio, 12.162; P = .001). CONCLUSION The concordance rate between c-stage and p-stage for small primary lung cancers had moderate reproducibility. Discordance between c-stage I and p-stage II-IV significantly affected DFS. The maximum standardized uptake value of the primary lesion was an independent prognostic factor, and combining it with c-stage might improve the prediction of therapeutic outcomes.
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Affiliation(s)
- Hiroyasu Umakoshi
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shingo Iwano
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Kohei Yokoi
- Department of Thoracic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shinji Ito
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Rintaro Ito
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Koji Kawaguchi
- Department of Thoracic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takayuki Fukui
- Department of Thoracic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shinji Naganawa
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Koo HJ, Sung YS, Shim WH, Xu H, Choi CM, Kim HR, Lee JB, Kim MY. Quantitative Computed Tomography Features for Predicting Tumor Recurrence in Patients with Surgically Resected Adenocarcinoma of the Lung. PLoS One 2017; 12:e0167955. [PMID: 28068363 PMCID: PMC5221878 DOI: 10.1371/journal.pone.0167955] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Accepted: 11/23/2016] [Indexed: 12/13/2022] Open
Abstract
Purpose The purpose of this study was to determine if preoperative quantitative computed tomography (CT) features including texture and histogram analysis measurements are associated with tumor recurrence in patients with surgically resected adenocarcinoma of the lung. Methods The study included 194 patients with surgically resected lung adenocarcinoma who underwent preoperative CT between January 2013 and December 2013. Quantitative CT feature analysis of the lung adenocarcinomas were performed using in-house software based on plug-in package for ImageJ. Ten quantitative features demonstrating the tumor size, attenuation, shape and texture were extracted. The CT parameters obtained from 1-mm and 5-mm data were compared using intraclass correlation coefficients. Univariate and multivariable logistic regression methods were used to investigate the association between tumor recurrence and preoperative CT findings. Results The 1-mm and 5-mm data were highly correlated in terms of diameter, perimeter, area, mean attenuation and entropy. Circularity and aspect ratio were moderately correlated. However, skewness and kurtosis were poorly correlated. Multivariable logistic regression analysis revealed that area (odds ratio [OR], 1.002 for each 1-mm2 increase; P = 0.003) and mean attenuation (OR, 1.005 for each 1.0-Hounsfield unit increase; P = 0.022) were independently associated with recurrence. The receiver operating curves using these two independent predictive factors showed high diagnostic performance in predicting recurrence (C-index = 0.81, respectively). Conclusion Tumor area and mean attenuation are independently associated with recurrence in patients with surgically resected adenocarcinoma of the lung.
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Affiliation(s)
- Hyun Jung Koo
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, Seoul, Korea
| | - Yu Sub Sung
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, Seoul, Korea
| | - Woo Hyun Shim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, Seoul, Korea
| | - Hai Xu
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, Seoul, Korea
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Chang-Min Choi
- Department of Oncology, Asan Medical Center, Seoul, Korea
- Pulmonary and Critical Care Medicine, Asan Medical Center, Seoul, Korea
| | - Hyeong Ryul Kim
- Thoracic and Cardiovascular Surgery, Asan Medical Center, Seoul, Korea
| | - Jung Bok Lee
- Clinical Epidemiology and Biostatistics, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Mi Young Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, Seoul, Korea
- * E-mail:
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Shimamoto H, Iwano S, Umakoshi H, Kawaguchi K, Naganawa S. Evaluation of locoregional invasiveness of small-sized non-small cell lung cancers by enhanced dual-energy computed tomography. Cancer Imaging 2016; 16:18. [PMID: 27455976 PMCID: PMC4960863 DOI: 10.1186/s40644-016-0077-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2016] [Accepted: 07/19/2016] [Indexed: 12/26/2022] Open
Abstract
Background To investigate the correlation between iodine-related attenuation of dual-energy computed tomography (DE-CT) and the histopathological invasiveness of surgically resected primary non-small cell lung cancers (NSCLCs) ≤ 3 cm in diameter. Methods We selected 63 consecutive NSCLC lesions from 60 patients (32 males, 28 females; age range, 39–85 years; mean age, 68 years). After injection of iodinated contrast media, arterial phases were scanned using 140-kVp and 80-kVp tube voltages. Three-dimensional iodine-related attenuation (3D-IRA) of primary tumors at the arterial phase was computed using “lung nodule” application software. The corrected 3D-IRA normalized to the patient’s body weight and contrast medium concentration was then calculated. Single-factor analysis of variance (ANOVA) was used for comparison among tumor differentiation grade groups. Univariate and multivariate logistic regression analysis was used for the correlation between locoregional invasive tumor and clinical factors. Results Resected tumors were histopathologically classified into well-differentiated (G1; n = 24), moderately-differentiated (G2; n = 28), and poorly-differentiated (G3; n = 11) groups by degree of tumor differentiation. The mean ± standard deviation of the 3D-IRA was 56.1 ± 22.6 HU in G1 tumours, 48.5 ± 23.9 HU in G2 tumours, and 28.4 ± 15.8 HU in G3 tumours; significant differences were observed between groups by ANOVA. (p = 0.005). Univariate logistic analysis showed that the 3D-IRA and corrected 3D-IRAs were significantly correlated with locoregional invasive tumors (p = 0.002 and p < 0.001, respectively). Multivariate logistic analysis revealed that only the corrected 3D-IRA was significantly correlated with tumor invasiveness (p = 0.003), while gender, clinical size, and solid/subsolid type were not (p = 0.950, p = 0.057 and p = 0.456, respectively). Conclusions The 3D-IRA of small-sized NSCLCs was significantly associated with and invasiveness. Low 3D-IRA tumors tended to have greater invasiveness than high 3D-IRA tumors.
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Affiliation(s)
- Hironori Shimamoto
- Department of Radiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Shingo Iwano
- Department of Radiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan.
| | - Hiroyasu Umakoshi
- Department of Radiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Koji Kawaguchi
- Department of Thoracic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Shinji Naganawa
- Department of Radiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
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Impact of Thin-Section Computed Tomography-Determined Combined Pulmonary Fibrosis and Emphysema on Outcomes Among Patients With Resected Lung Cancer. Ann Thorac Surg 2016; 102:440-7. [PMID: 27157056 DOI: 10.1016/j.athoracsur.2016.03.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Revised: 02/25/2016] [Accepted: 03/07/2016] [Indexed: 11/21/2022]
Abstract
BACKGROUND There is only limited information on the clinical impact of combined pulmonary fibrosis and emphysema (CPFE) on postoperative and survival outcomes among patients with resected lung cancer. METHODS In a retrospective analysis, data were reviewed from 685 patients with resected lung cancer between 2006 and 2011. The clinical impact of thin-section computed tomography (TSCT)-determined emphysema, fibrosis, and CPFE on postoperative and survival outcomes was evaluated. RESULTS The emphysema group comprised 32.4% of the study population, the fibrosis group 2.8%, and the CPFE group 8.3%. The CPFE group had a more advanced pathologic stage and higher prevalence of squamous cell carcinoma as compared with the normal group without emphysema or fibrosis findings on TSCT. The incidence of postoperative complications was significantly higher in the CPFE group. Overall, the 30-day mortality in the CPFE group was 5.3%. Cancer recurrence at pathologic stage I and death due to either cancer or other causes were significantly higher in the CPFE group. Survival curves indicated that a finding of CPFE was associated with worse overall survival for patients with any stage disease. Multivariate analysis suggested that pathologic stage and CPFE were independent factors associated with worse overall survival. The adjusted hazard ratio of overall survival for the CPFE group versus the normal group was 2.990 (95% confidence interval: 1.801 to 4.962). CONCLUSIONS Among patients with resected lung cancer, the presence of TSCT-determined CPFE might predict worse postoperative and survival outcomes.
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Ito R, Iwano S, Kishimoto M, Ito S, Kato K, Naganawa S. Correlation between FDG-PET/CT findings and solid type non-small cell cancer prognostic factors: are there differences between adenocarcinoma and squamous cell carcinoma? Ann Nucl Med 2015; 29:897-905. [PMID: 26342592 DOI: 10.1007/s12149-015-1025-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 08/12/2015] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The maximum standardized uptake value (SUVmax) of FDG-PET/CT is commonly used as an indicator to evaluate the invasiveness and prognosis of non-small-cell lung cancers (NSCLC). We investigated the correlation between SUVmax and tumor invasiveness or postoperative recurrence of solid type NSCLC and compared squamous cell carcinoma (SCC)/adenosquamous carcinoma (ASC) to adenocarcinoma (AC). METHODS A retrospective review of preoperative PET/CT, thin-section CT, and postoperative pathological records obtained over a 5-year period was conducted. Solid type NSCLC tumors on thin-section CT with confirmed diagnosis from surgical resection (diameter ≤3 cm) were included. Multivariate logistic regression was used to evaluate the correlation between tumor characteristics and pathological prognostic factors or postoperative recurrence. RESULTS 150 patients (111 males, 39 females; mean age 67 years; 106 cases of AC, 36 cases of SCC, and 8 cases of ASC) were included. SUVmax was significantly correlated with pleural involvement (p = 0.047), lymphatic permeation (p = 0.003), lymph node metastasis (p = 0.027), and tumor invasiveness (p < 0.001). Receiver operating characteristic analysis indicated an optimal SUVmax threshold of 5.0 for tumor invasiveness. Histopathological type was significantly correlated with pleural involvement (p = 0.042), but not with other types of invasiveness. Twenty-nine patients experienced postoperative recurrence. SUVmax was significantly correlated with tumor recurrence (p = 0.004), but size and histopathological type were not (p = 0.502 and p = 0.351, respectively). CONCLUSION SUVmax of the primary lesion in solid type NSCLC was significantly correlated with tumor invasiveness and postoperative recurrence. No differences in tumor invasiveness were observed between solid type AC and SCC/ASC. However, in solid type AC, SUVmax of the primary lesion was more significantly correlated with recurrence.
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Affiliation(s)
- Rintaro Ito
- Department of Radiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Shingo Iwano
- Department of Radiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan.
| | - Mariko Kishimoto
- Department of Radiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Shinji Ito
- Department of Radiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Katsuhiko Kato
- Department of Radiological and Medical Laboratory Sciences, Nagoya University Graduate School of Medicine, 1-1-20 Daiko-Minami, Higashi-ku, Nagoya, 461-8673, Japan
| | - Shinji Naganawa
- Department of Radiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
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Iwano S, Ito R, Umakoshi H, Ito S, Naganawa S. Evaluation of lung cancer by enhanced dual-energy CT: association between three-dimensional iodine concentration and tumour differentiation. Br J Radiol 2015; 88:20150224. [PMID: 26329466 DOI: 10.1259/bjr.20150224] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE To investigate the correlation between iodine concentration of dual-energy CT (DECT) and histopathology of surgically resected primary lung cancers. METHODS We reviewed the medical records, post-operative pathological records and pre-operative DECT images of patients who underwent surgical lung resection for primary lung cancer. After injection of iodinated contrast media, arterial and delayed phases were scanned using 140- and 80-kV tube voltages. Three-dimensional iodine concentration (iodine volume) of primary tumours was calculated using lung nodule application software. RESULTS A total of 60 patients (37 males and 23 females; age range, 39-84 years; mean age, 69 years) with 62 lung cancers were analysed. The resected tumours were histopathologically classified into well-differentiated (G1; n = 20), moderately differentiated (G2; n = 29), poorly differentiated (G3; n = 9) and undifferentiated (G4; n = 4) groups by degree of tumour differentiation (DTD). The mean ± standard deviation of iodine volume at the delayed phase was 59.6 ± 18.6 HU in G1 tumours, 46.5 ± 11.3 HU in G2 tumours, 34.3 ± 15.0 HU in G3 tumours and 28.8 ± 6.4 HU in G4 tumours; significant differences were observed between groups (p < 0.001). Univariate logistic regression analysis showed that iodine volumes both at the early and delayed phases were significantly correlated with DTD (p = 0.006 and p = 0.001, respectively), whereas gender, body weight and tumour size were not (p = 0.084, p = 0.062 and p = 0.391, respectively). CONCLUSION The iodine volume of lung cancers was significantly associated with their DTD. High-grade tumours tended to have lower iodine volumes than low-grade tumours. ADVANCES IN KNOWLEDGE Iodine volume measured by DECT could be a valuable functional imaging method to estimate differentiation of primary lung cancer.
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Affiliation(s)
- Shingo Iwano
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Rintaro Ito
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroyasu Umakoshi
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shinji Ito
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shinji Naganawa
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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