Residual neck disease management in squamous-cell carcinoma of the head and neck treated with radiotherapy plus cetuximab

Purpose

Management of residual neck disease (RND) is one of the unsolved points after bio-radiotherapy (BRT) in loco-regional advanced squamous-cell carcinoma of the head and neck (SCCHN). The aims of the study were to characterize the radiological pattern of response by computed tomography (CT) and to assess the role of positron-emission tomography (PET)/CT in this setting for a better decision-making in the indication of neck dissection (ND).

Methods

We retrospectively reviewed 202 patients consecutively diagnosed with node-positive SCCHN (N1: 24; N2: 152; N3: 26) who had been treated with concomitant radiotherapy and cetuximab with or without previous induction chemotherapy between 2006 and 2013. Radiological evaluation after treatment was assessed by standard criteria using CT and in addition by PET/CT when RND was suspected in cases from 2010.

Results

There were 42 (21 %) patients who achieved complete response of the primary tumor persisting RND by CT. From this group, 24 patients were managed without PET/CT, leading to the performance of ND in 22 (92 %). On the other hand, 18 patients underwent PET/CT and ND was performed in only 6 (33 %). The overall survival was not different between both groups (p = 0.32). After histological examination and follow-up, PET/CT obtained a positive predictive value of 56 % and a negative predictive value of 89 %.

Conclusions

Radiological response after BRT is similar to that after treatment with chemo-radiotherapy, thereby validating in this scenario the accepted CT criteria to define complete response of the neck. However, when RND is suspected by CT, PET/CT is useful to prevent unnecessary ND.

     

Diagnostic performance of <Superscript>18</Superscript>F-fluorodeoxyglucose PET/CT and bone scintigraphy in breast cancer patients with suspected bone metastasis

Background

We prospectively compared the diagnostic accuracies of PET/CT and BS in patients with suspected bone metastases from breast cancer.

Methods

This single-institution prospective study included consecutive patients with suspected bone metastases from biopsy-proven breast cancer seen at Tokai University Hospital between September 2011 and March 2014. Inclusion criteria included suspicions for bone metastases (bone pain, elevated alkaline phosphatase, elevated tumor markers, or suspected bone metastases by BS). Two nuclear medicine physicians evaluated PET/CT and BS images.

Results

Thirty patients were initially enrolled in this study. Two were excluded from the analyses because they declined to undergo imaging during follow-up. PET/CT successfully detected bone metastases in all 10 patients finally diagnosed with the condition, whereas BS identified 2. The two methods were not highly concordant in detecting osseous metastases. In 19 of 28 paired studies (68 %), 2 (10 %) were positive for metastasis, and 17 (90 %) were negative. Nine occurrences (32 %) were discordant; of these, 2 were PET/CT positive and BS negative; 5 were PET/CT positive and BS equivocal; one was PET/CT negative and BS equivocal, and one was PET/CT equivocal and BS negative.

Conclusions

Our results indicated that PET/CT was superior to BS for the diagnosis of bone metastases. On the basis of the results of previous studies as well as ours, PET/CT could replace BS as the initial modality to detect bone metastases in patients suspected for the condition.

     

Radiotherapy volume delineation using 18F-FDG-PET/CT modifies gross node volume in patients with oesophageal cancer

Purpose

Evidence supporting the use of 18F-FDG-PET/CT in the segmentation process of oesophageal cancer for radiotherapy planning is limited. Our aim was to compare the volumes and tumour lengths defined by fused PET/CT vs. CT simulation.

Materials and methods

Twenty-nine patients were analyzed. All patients underwent a single PET/CT simulation scan. Two separate GTVs were defined: one based on CT data alone and another based on fused PET/CT data. Volume sizes for both data sets were compared and the spatial overlap was assessed by the Dice similarity coefficient (DSC).

Results

The gross tumour volume (GTVtumour) and maximum tumour diameter were greater by PET/CT, and length of primary tumour was greater by CT, but differences were not statistically significant. However, the gross node volume (GTVnode) was significantly greater by PET/CT. The DSC analysis showed excellent agreement for GTVtumour, 0.72, but was very low for GTVnode, 0.25.

Conclusions

Our study shows that the volume definition by PET/CT and CT data differs. CT simulation, without taking into account PET/CT information, might leave cancer-involved nodes out of the radiotherapy-delineated volumes.

     

Watch the weathercock: changes in re-staging 18F-FDG PET/CT scan predict the probability of relapse in locally advanced non-small cell lung cancer

Introduction

Induction treatment is becoming the gold standard for locally advanced non-small cell lung cancers (LA-NSCLC). In contrast to baseline positron emission/computed tomography scan (PET/CT scan), re-staging PET/CT scan has been poorly studied in LA-NSCLC.

Materials and methods

We retrospectively explored the efficacy of re-staging PET/CT scan to diagnose response and to predict disease-free survival (DFS) in 55 induction-treated LA-NSCLC further treated with curative surgery or radiation but not with adjuvant therapy.

Results

Re-staging N status by PET/CT scan significantly correlated with pathological N status. Radiological or metabolic response in the re-staging PET/CT scan was associated with a significantly better DFS, which decreased from 25.8 to 19.3, to 11.2, and to 9.4 months in cN0, cN1, cN2, and cN3 patients, respectively.

Conclusion

Re-staging PET/CT scan helps to define response and consolidation treatment in induction-treated LA-NSCLC and predicts DFS. Further extended studies should confirm our results.

     

Analysis of positron emission tomography/computed tomography in patients to differentiate between malignant transformation of endometrioma and endometrioma

Purpose

Of those patients who undergo open surgery for a suspicion of malignant transformation of endometrioma (MTOE) due to solid nodule enhancement identified by contrast-enhanced magnetic resonance imaging (MRI), some benign endometrioma cases are included. The aim of this retrospective study was to determine the value and diagnostic accuracy of positron emission tomography/computed tomography (PET/CT) using 18-fluoro-2-deoxy-d-glucose (FDG) to differentiate between MTOE and endometrioma.

Patients and methods

We retrospectively analyzed 1599 consecutive patients who underwent laparoscopic surgery for the diagnosis of endometrioma preoperatively and 31 patients who underwent open surgery for a suspicion of MTOE preoperatively from January 2003 to December 2011. We analyzed the age, serum CA125 levels, and MRI findings of the patients and calculated the optimal cut-off value for PET/CT using receiver operating characteristic curve analysis.

Results

Of the 1,599 patients who underwent laparoscopic surgery for a suspicion of endometrioma preoperatively, malignancy was identified in one (0.062 %) patient. Of the 31 patients who underwent open surgery for a suspicion of MTOE preoperatively, 11 were diagnosed with endometrioma (false positive group) and 20 with MTOE stage I (positive group). Age, tumor size, presence of shading on MRI and maximum standardized uptake values (SUV_max) on PET/CT were significantly different between the two groups. A SUV_max cut-off >4.0 is capable of excluding endometrioma cases, with 75 % sensitivity and 100 % specificity (area under the curve 90 %).

Conclusion

PET/CT is a good diagnostic tool for MTOE using the optimal SUV_max cut-off of 4.0 (75 % sensitivity and 100 % specificity).

     

Response to chemotherapy estimates by FDG PET is an important prognostic factor in patients with Ewing sarcoma

Background

Response to chemotherapy is a prognostic factor in patients with Ewing sarcoma (ES); the role of FDG PET to predict response in these patients has not been thoroughly investigated. We evaluated the diagnostic accuracy and the potential of FDG PET to predict response to chemotherapy (CHT).

Materials and methods

We analyzed data of 50 patients with ES (median age 12.6 years). All patients were treated with neoadjuvant CHT, and underwent surgery for local control. All patients had ¹⁸F-FDG PET/CT at diagnosis and after induction CHT, prior to local control. We compared response assessed by histopathology with FDG PET using standard uptake values (SUVs).

Results

Median SUV at diagnosis (SUV I) was 5 (range 1.2–17), and median SUV after neoadjuvant chemotherapy (SUV II) was 1.8 (range 0–8.4). Median SUV II/I ratio was 0.3 (range 0–1). SUV at diagnosis was significantly lower in patients with good histological response than in patients with poor histological response (median 3.8 vs. 7.2, p 0.02). We found a significant correlation between SUV II and outcome; the positive predictive value of an SUV II ≤ 2.5 for favorable response was 84.21 %, and the median SUV II was significantly higher in patients with disease progression (2.3 vs. 1.6, p = 0.04). In multivariate analysis, necrosis and SUV II were significant predictors of outcome.

Conclusions

¹⁸F-FDG PET demonstrates high diagnostic accuracy for response to initial chemotherapy in patients with ES and it correlates with outcome. The role of FDG PET in predicting response and outcome should be further investigated.

     

Utility of 18F-FDG-PET/CT in patients suspected of paraneoplastic neurological syndrome: importance of risk classification

Purpose

To assess the diagnostic impact of 18F-FDG-PET/CT in patients suspected of paraneoplastic neurological syndrome (PNS) based on our own pre-test risk classification (PRC).

Methods

A multicenter retrospective longitudinal study was conducted from 2006 to 2014. We designed a seven-point scoring system using the clinical syndrome characteristics [classical (CS) and non-classical syndromes (NCS)] and its location (central, peripheral, in the neuromuscular junction or combined), onconeural antibodies and tumor markers. Patients were classified as low (score 0–2), intermediate (3–4) and high (5–7) pre-test risk of PNS. FDG-PET/CT was classified as negative or positive. Final diagnosis according Graus’ criteria (definite, possible or no PNS) was established. Relations between clinical and metabolic variables with the final diagnosis were studied.

Results

73 patients were included, with a follow-up time of 33 months. Eleven (15 %) patients were finally diagnosed with neoplasm (8 invasive cancers). Ultimately, 13 (18 %) and 24 (33 %) subjects were diagnosed as definite or possible PNS. All the patients with final diagnosis of neoplasm had a CS (p = 0.005). PET/CT was helpful to diagnose 6/8 (75 %) invasive cancers. PET/CT findings were associated with the final diagnosis of neoplasm (p = 0.003) and the diagnosis of PNS attending to Graus’ criteria (p = 0.019). PRC showed significant association with the final diagnosis of neoplasm and PET/CT results. A majority of patients (10/11) diagnosed of neoplasm had intermediate/high-risk.

Conclusions

Our PRC seems to be a valid tool to select candidates for PET/CT imaging in this setting. PET/CT detected malignancy in a significant proportion of patients with invasive cancer.

     

Dosimetry study of <Superscript>18</Superscript>F-FMISO + PET/CT hypoxia imaging guidance on intensity-modulated radiation therapy for non-small cell lung cancer

Objectives

This study was to evaluate the feasibility of simultaneous integrated boost on tumor hypoxia area by studying the dosimetric change of hypoxia imaging guidance on intensity-modulated radiation therapy for non-small cell lung cancer (NSCLC).

Methods

Five NSCLC patients with large hypoxic volume participated in this study. FDG PET/CT images were fused with CT localization images to delineate gross tumor volume. FMISO PET/CT images were fused with CT localization images to delineate hypoxic biological target volume (BTV) (tissue maximum ratio ≥?1.3) by threshold. BTV was irradiated with 72, 78 and 84 Gy, respectively, 30 times. The dosimetry differences were compared in target volume and organ at risk between simultaneous integrated boost plans and conventional radiotherapy plans.

Results

Dosages on BTV of NSCLC hypoxic area were increased to 72, 78 and 84 Gy, respectively, by simultaneous integrated boost intensity-modulated radiation therapy. There was no obvious difference in dosage distributions on original target volume compared with those in conventional radiotherapy. Dosages on main organ at risk in chest met the dosimetric constraint, and there was no significant difference compared with those in conventional radiotherapy.

Conclusion

It is feasible in dosiology that the dosages in NSCLC hypoxic area were added to 72, 78 and 84 Gy by simultaneous integrated boost with the guidance of ¹⁸F-FMISO PET/CT.

     

Ductal carcinoma in situ and ductal carcinoma in situ with microinvasion: correlation of FDG uptake with histological and biological prognostic factors

Background

Several studies investigated the correlation between the intensity of fluorodeoxyglucose (FDG) uptake and some histological and biological characteristics in breast cancer. Ductal carcinoma in situ (DCIS) is generally thought to be a precursor lesion of invasive breast cancer. The aim of this study was to assess the correlation between FDG uptake values on positron emission tomography/computed tomography (PET/CT) with histological and biological prognostic factors in DCIS and ductal carcinoma in situ with microinvasion (DCIS-Mi).

Materials and methods

PET/CT images for initial staging of confirmed DCIS and DCIS-Mi patients, taken between July 2004 and December 2009, were reviewed retrospectively. Maximum standardized uptake values (SUVmax) and tumor background count density ratio on PET/CT were compared with tumor characteristics. Histological and biological prognostic factors included tumor size, nuclear grade, Van Nuys Prognostic Index, estrogen receptor, progesterone receptor, HER2, and Ki-67 index.

Results

In total, 87 lesions from 83 patients (all females; mean age 51 ± 9 years) were studied. The Van Nuys Prognostic Index group was 1 in 25 lesions, 2 in 36, and 3 in 26. On statistical analysis, significant differences in SUVmax and tumor background count density ratio were seen between the Van Nuys Prognostic Index groups and according to tumor size and HER2. The correlation between SUVmax and Ki-67 was significant. However, the correlation between tumor background count density ratio and Ki-67 was not statistically significant.

Conclusion

In DCIS and DCIS-Mi cases, significant correlations were found between increased FDG uptake and several histological and biological factors for poor prognosis (tumor size, Van Nuys Prognostic Index, and HER2).

     

Response to anti-PD1 therapy with nivolumab in metastatic sarcomas

Background

Manipulation of immune checkpoints such as CTLA4 or PD-1 with targeted antibodies has recently emerged as an effective anticancer strategy in multiple malignancies. Sarcomas are a heterogeneous group of diseases in need of more effective treatments. Different subtypes of soft tissue and bone sarcomas have been shown to express PD-1 ligand.

Methods

We retrospectively analyzed a cohort of patients (pts) with relapsed metastatic/unresectable sarcomas, who were treated with nivolumab provided under a patient assistance program from the manufacturer. Pts underwent CT or PET/CT imaging at baseline and after at least four doses of nivolumab; RECIST 1.1 criteria were used for response assessment.

Results

Twenty-eight pts with soft tissue (STS, N = 24) or bone sarcoma (N = 4), received IV nivolumab 3 mg/kg every 2 weeks from July 2015. Median age was 57 (24–78), male:female ratio was 14:14; the median number of nivolumab cycles was eight. Eighteen pts concomitantly received pazopanib at 400–800 mg daily. The most common side effect was grade 1–2 LFT elevations; grade 3–4 toxicity occurred in five patients (colitis, LFT elevations, pneumonitis). Twenty-four pts received at least four cycles. We observed three partial responses: one dedifferentiated chondrosarcoma, one epithelioid sarcoma and one maxillary osteosarcoma (last two patients on pazopanib); nine patients had stable disease including three leiomyosarcomas; 12 patients had progression of disease including 4 leiomyosarcoma. Clinical benefit (response + stability) was observed in 50% of the evaluable patients.

Conclusions

These data provide a rationale for further exploring the efficacy of nivolumab and other checkpoint inhibitors in soft tissue and bone sarcoma.

     

Yttrium-90 (Y-90) Resin Microsphere Therapy for Patients with Unresectable Hepatocellular Carcinoma: a Single-Center Experience

Background/Aim

Selective intraarterial radionuclide therapy (SIRT) with yttrium-90 (Y-90) resin microspheres presently has successful results in primary or metastatic inoperable liver tumors. This procedure, which is also known as radioembolisation, delivers high doses of radiation selectively to hepatic tumors while minimum healthy liver exposure. The aim of this study was to present our clinical experience of radiomicrosphere therapy for the treatment of patients with unresectable hepatocellular carcinoma (HCC).

Methods

We performed 40 Y-90 microsphere therapies in 28 patients (5 females, 23 males; mean age ± SD 48 ± 8) with HCC during the period from April 2008 through December 2016. Pretreatment Tc-99m microaggregated albumin (MAA) scintigraphy was performed to all patients in order to detect eligibility for SIRT. All patients had pre- and post-biochemical tests (hemogram and serologic tests) and imaging methods (CT or MRI or PET/CT) at regular intervals to detect any possible complication and determine response rates.

Results

The mean shunting to the lungs on MAA scan was 6.5% and the mean ± SD administered dose of Y-90 was 1.55 ± 0.32 GBq in all patients. The estimated doses to the target tumors, normal liver parenchyma and lungs were 105.7 ± 55.3, 25.5 ± 8.2 and 5.8 ± 1.7 Gy, respectively. No significant complication was observed during or early after (first week) the treatment procedure and it was well tolerated by all the patients. Only one patient developed a treatment-related gastroduodenal ulcer 3 weeks after the treatment. In control imaging tests (MRI or FDG PET/CT) performed 2.5 months after the treatment, we observed complete response in 2 (7%) patients, partial response in 10 (36%) patients, stable disease in 5 (18%) patients and progressive disease in 11 (39%) patients.

Conclusion

According to our clinical experience, we can conclude that Y-90 microsphere therapy is a safe and effective treatment option for the patients with unresectable HCC without any serious side effects.

     

The prognostic value of volume-based parameters using <Superscript>18</Superscript>F-FDG PET/CT in gastric cancer according to HER2 status

Background

We aimed to find the clinical value of metastatic tumor burden evaluated with F18-FDG PET/CT in gastric cancer patients, considering the human epidermal growth factor receptor 2 (HER2) status.

Methods

We retrospectively reviewed 124 patients with locally advanced or metastatic gastric cancer at Yonsei Cancer Center between January 2006 and December 2014 who had undergone baseline FDG PET/CT before first-line chemotherapy. We measured the maximum standardized uptake value from the primary tumor (SUV_max) and whole-body (WB) PET/CT parameters, including WB SUV_max, WB SUV_mean, WB metabolic tumor volume (WB MTV), and WB total lesion glycolysis (WB TLG), in all metabolically active metastatic lesions (SUV threshold ≥2.5 or 40% isocontour for ≤2.5), and we determined their association with patient survival outcomes.

Results

SUV_max was higher in HER2-positive gastric cancers (median 12.1, range 3.4–34.6) compared to HER-2 negative (7.4, 1.6–39.1, P < 0.001). Among all patients, WB TLG > 600, which is indicative of a high metastatic tumor burden, showed worse progression-free survival (PFS) [hazard ratio (HR), 2.003; 95% CI, 1.300–3.086; P = 0.002] and overall survival (OS) (HR, 3.001; 95% CI, 1.950–4.618; P < 0.001) than did WB TLG ≤ 600. Among HER2-positive gastric cancer patients treated with trastuzumab, higher metabolic tumor burden predicted worse OS, but not PFS.

Conclusions

HER2-positive gastric cancers had higher SUV_max compared to HER2-negative gastric cancers. In both HER2-negative patients and -positive patients receiving trastuzumab, FDG PET/CT volume-based parameters may have a role in further stratifying the prognosis of stage IV gastric cancer.

     

Predictive and prognostic value of FDG-PET/CT imaging and different response evaluation criteria after primary systemic therapy of breast cancer

Objectives

(1) To predict pathological complete remission (pCR) and survival after primary systemic therapy (PST) in patients diagnosed with breast cancer by using two different PET/CT based scores: a simplified PERCIST-based PET/CT score (Method 1) and a combined PET/CT score supplemented with the morphological results of the RECIST system (Method 2) and (2) to assess the effect of different breast carcinoma subtypes on tumor response and its evaluation.

Methods

Eighty-eight patients were enrolled in the study who underwent PET/CT imaging before and after PST. PET/CTs were evaluated by changes in maximum Standardized Uptake Value (SUVmax) and tumor size. Method 1 and 2 were applied to predict pathological complete remission (pCR). Kaplan–Meier analyses for survival were performed. Classification into biological subtypes was performed based on the pre-therapeutic tumor characteristics.

Results

A total of 30/88 patients showed pCR (34.1 %). Comparing pCR/non-pCR patient groups, significant differences were detected by changes in SUVmax (p < 0.001) and tumor size (p < 0.001) regarding the primary breast lesions. To predict pCR, Method 2 had higher sensitivity (72.4 % vs. 44.8 %) and negative predictive value (57.9 % vs. 45.8 %) with lower false negativity rate (16 vs. 32) than Method 1. pCR rate was higher in Her2-positive and triple negative tumors. Despite the significant differences detected between the biological subtypes regarding changes in primary tumor SUVmax (p = 0.007) and size (p = 0.015), the subtypes only had significant impact on response evaluation with Method 2 and not with Method 1. In our study, neither clinical nor pathological CR were predictors of longer progression-free survival.

Conclusions

Our results suggest that combined PET/CT criteria are more predictive of pCR. The effect of biological subtypes is significant on pCR rate as well as on the changes in FDG-uptake and morphological tumor response. Response evaluation with combined criteria was also able to reflect the differences between the biological behavior of breast tumor subtypes.

     

Diagnostic accuracy of <Superscript>18</Superscript>F–FDG PET/CT and MR imaging in patients with adenoid cystic carcinoma

Background

The aim of this study was to evaluate the value of 18F–FDG PET/CT (PET/CT) and MRI for local and/or whole-body restaging of adenoid cystic carcinoma of the head and neck (ACC).

Methods

Thirty-six patients with ACC underwent conventional MRI of the head and neck and a whole-body PET/CT and were analysed with regards to detection of a local tumor recurrence, lymph node or distant metastases. A consensus interpretation of all available imaging data was used as reference standard. Sensitivity, specificity, diagnostic accuracy, positive and negative predictive values were calculated for MRI and PET/CT.

Results

The sensitivity of PET/CT and MRI was 96% (89%), specificity 89% (89%), PPV 96% (96%), NPV 89% (73%) and accuracy 94% (89%) for detection of local tumors. Additionally, PET/CT revealed lymph node metastases in one patient and distant metastases in 9/36 patients. In three patients secondary primaries were found.

Conclusions

Whole-body PET/CT in addition to MRI of the head and neck improves detection of local tumour and metastastic spread in ACC.

     

Integration of radiotherapy and chemotherapy for abdominal lymph node recurrence in gastric cancer

Purpose

Abdominal lymph node (ALN) recurrence in gastric cancer (GC) is rare and usually unresectable. We investigated the effects of integration of radiotherapy (RT) and chemotherapy against ALN recurrence in GC.

Methods

We retrospectively categorized GC patients with ALN recurrence treated between 2005 and 2013 into two groups: those treated with integration of RT and chemotherapy (RCT) and those who received systemic chemotherapy only (CT). The median follow-up period after ALN recurrence for all patients was 20 months.

Results

Of 53 patients, 31 and 22 were in the RCT and CT groups, respectively. Isolated distant failure (DF; 35.5%) without local progression (LP) was the dominant pattern of failure (POF) in the RCT group (median DF-free period, 26 months). LP followed by DF (31.8%) was the dominant POF in the CT group; LP (median LP-free period, 8 months) occurred 10 months earlier than DF (median DF-free period, 18 months). RCT patients had significantly longer median progression-free survival (PFS) compared to CT patients (25 vs. 8 months; P = 0.021). On multivariate analysis, treatment (CT vs. RCT) was an independent prognostic factor for PFS (hazard ratio 2.085; 95% confidence interval 1.073–4.050; P = 0.013).

Conclusions

Integration of RT and chemotherapy achieved long-term local control and prolonged PFS in GC patients with ALN recurrence. Local RT is feasible for treating isolated ALN recurrences.

     

CT scan prior to radiotherapy in unresectable,locally advanced,non-small cell carcinoma of the lung: is it always necessary?

Purpose

There is broad consensus regarding evaluating response to chemotherapy (CHT) by means of computerized tomography (CT) in patients with localized or locally advanced non-small cell lung carcinoma (NSCLC). We present a study comparing the usefulness of CT versus chest X-ray (XR) and clinical findings when indicating radiotherapy (RT) following CHT.

Methods

Ninety-eight of 150 subjects with unresectable locally advanced NSCLC were blindly and independently evaluated by XR and CT, with pairs of chest XR and CT (before and after CHT). A null hypothesis (H0) was established of the conditioned probability of detecting progression by CT and not by XR of 10 % or more, with a statistical power of 80 %.

Results

Sensitivity, specificity, positive and negative predictive value of XR versus CT were 98, 89, 99, and 80 % respectively. A 4 % (p = 0.0451) probability of improvement of CT versus XR was calculated, enabling the H0 to be ruled out.

Conclusion

The CT failed to prove to be significantly superior to the chest XR + clinical picture in indicating a change in treatment approach in patients with unresectable locally advanced NSCLC after CHT.

     

Breast sentinel lymph node navigation with three-dimensional computed tomography–lymphography: a 12-year study

Purpose

To evaluate the utility of three-dimensional (3D) computed tomography (CT)?lymphography (LG) breast sentinel lymph node navigation in our institute.

Patients and methods

Between 2002 and 2013, we preoperatively identified sentinel lymph nodes (SLNs) in 576 clinically node-negative breast cancer patients with T1 and T2 breast cancer using 3D CT–LG method. SLN biopsy (SLNB) was performed in 557 of 576 patients using both the images of 3D CT–LG for guidance and the blue dye method.

Results

Using 3D CT–LG, SLNs were visualized in 569 (99 %) of 576 patients. Of 569 patients, both lymphatic draining ducts and SLNs from the peritumoral and periareolar areas were visualized in 549 (96 %) patients. Only SLNs without lymphatic draining ducts were visualized in 20 patients. Drainage lymphatic pathways visualized with 3D CT–LG (549 cases) were classified into four patterns: single route/single SLN (355 cases, 65 %), multiple routes/single SLN (59 cases, 11 %) single route/multiple SLNs (62 cases, 11 %) and multiple routes/multiple SLNs (73 cases, 13 %). SLNs were detected in 556 (99.8 %) of 557 patients during SLNB.

Conclusion

CT–LG is useful for preoperative visualization of SLNs and breast lymphatic draining routes. This preoperative method should contribute greatly to the easy detection of SLNs during SLNB.

     

Overall survival and prognostic factors in patients with spinal metastases from lung cancer treated with and without epidermal growth factor receptor tyrosine kinase inhibitors

Background

Evaluation of the prognosis in patients with spinal metastases is important in decision making regarding surgical treatment. The purpose of this study was to investigate overall survival in patients with spinal metastases from lung cancer by histological subtype, and to investigate prognostic factors in patients treated with and without epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs).

Methods

The data from 135 patients diagnosed with spinal metastases from lung cancer were retrospectively evaluated. The 88 patients with adenocarcinoma were divided into two groups according to whether the lung cancer was treated with or without EGFR-TKIs—the EGFR-TKI group (n = 43) and the non-EGFR-TKI group (n = 45).

Results

The overall median survival time was 11.3 months for those with adenocarcinoma, 5.3 months for squamous cell carcinoma, and 3.9 months for small cell carcinoma. Overall survival in the EGFR-TKI group (median 21.4 months) was significantly longer than in the non-EGFR-TKI group (median 6.1 months). In univariate analysis, poor performance status was a poor prognostic factor in the non-EGFR-TKI group. However, performance status and other variables were not significant prognostic factors in the EGFR-TKI group.

Conclusions

Median overall survival was longer in patients with spinal metastases from lung cancer treated with EGFR-TKIs compared with those treated without EGFR-TKIs. Poor performance status or other prognostic factors were not associated with poor overall survival in the group treated with EGFR-TKIs.

     

Impact of pathologic diagnosis of internal mammary lymph node metastasis in clinical N2b and N3b breast cancer patients

Purpose

To analyze the prognostic role of pathologic confirmation of internal mammary lymph nodes (IMNs) for breast cancer patients who received neoadjuvant chemotherapy.

Methods

Of the patients who were treated with neoadjuvant chemotherapy, surgery, and radiation therapy between 2009 and 2013, 114 women had suspicious IMNs and FNAB was attempted. Clinical IMN metastasis was diagnosed by 18F-FDG PET/CT positivity or pathologic confirmation (N = 70). Patients were divided into the FNAB(+) or FNAB(?) IMN group.

Results

The pathologic confirmation rate was 57% (40 of 70 patients). Rates were 74% in US-positive, 70% in MRI-positive, and 55% in PET-positive patients. Nodal stage was cN2b (6%) or cN3b (94%). Five-year progression-free survival (PFS) was significantly worse in patients with FNAB(+) IMN metastasis than FNAB(?) IMN metastasis (61% vs. 87%, P = 0.03). FNAB(+) IMN patients showed worse distant metastasis and regional recurrence-free survival without statistical significance (69% vs. 86%, P = 0.06, and 81% vs. 96%, P = 0.06). With median follow-up of 50.5 months (13.0–97.0 months), overall survival at 5 years was 77%, and PFS was 72%.

Conclusions

Patients with FNAB-proven IMN metastasis had worse treatment outcomes compared to patients with clinically diagnosed IMN metastasis in cN2b/N3b breast cancer.

     

Prostate-specific membrane antigen in breast cancer: a comprehensive evaluation of expression and a case report of radionuclide therapy

Purpose

Prostate-specific membrane antigen (PSMA), a protein product of the folate hydrolase 1 (FOLH1) gene, is gaining increasing acceptance as a target for positron emission tomography/computer tomography (PET/CT) imaging in patients with several cancer types, including breast cancer. So far, PSMA expression in breast cancer endothelia has not been sufficiently characterized.

Methods

This study comprised 315 cases of invasive carcinoma of no special type (NST) and lobular breast cancer (median follow-up time 9.0 years). PSMA expression on tumor endothelia was detected by immunohistochemistry. Further, vascular mRNA expression of the FOLH1 gene (PSMA) was investigated in a cohort of patients with invasive breast cancer provided by The Cancer Genome Atlas (TCGA).

Results

Sixty percent of breast cancer cases exhibited PSMA-positive endothelia with higher expression rates in tumors of higher grade, NST subtype with Her2-positivity, and lack of hormone receptors. These findings were confirmed on mRNA expression levels. The highest PSMA rates were observed in triple-negative carcinomas (4.5 × higher than in other tumors). Further, a case of a patient with metastatic breast cancer showing PSMA expression in PET/CT imaging and undergoing PSMA radionuclide therapy is discussed in detail.

Conclusions

This study provides a rationale for the further development of PSMA-targeted imaging in breast cancer, especially in triple-negative tumors.