Clinical Utility and Economic Impact of Conventional Transbronchial Needle Aspiration of Mediastinal Lymphadenopathies in Bronchogenic Carcinoma

ObjectivesTo analyse the clinical utility and economic impact of conventional transbronchial needle aspiration (TBNA) in patients with diagnosis of bronchogenic carcinoma (BC) and mediastinal lymphadenopathies in thoracic computed tomography (CT). To assess the predictive factors of valid aspirations.Patients and methodsRetrospective observational study between 2006 and 2011 of all TBNA performed in patients with final diagnosis of BC and accessible hilar or mediastinal lymphadenopathies on thoracic CT.ResultsWe performed TBNA on 267 lymphadenopathies of 192 patients. In 34.9% of patients, two or more lymph nodes were biopsied. Valid aspirations were obtained in 153 patients (79.7%) that were diagnostic in 124 patients (64.6%). Multivariate analysis showed that factors associated with valid or diagnostic results are the diameter of the lymph node and the number of lymph nodes explored. TBNA was the only endoscopic technique that provided the diagnosis of BC in 54 patients (28.1%). Staging mediastinoscopy was avoided in 67.6% of patients. The prevalence of mediastinal lymph node involvement was 74.4%, sensitivity of TBNA was 86.2% and negative predictive value was 63.6%. Including mediastinoscopy and other avoided diagnostic techniques, TBNA saved 451.57 € per patient.ConclusionsTBNA is a clinically useful, cost-effective technique in patients with BC and mediastinal or hilar lymphadenopathies. It should therefore be performed on a regular basis during diagnostic bronchoscopy of these patients.     

Real-time prediction of mediastinal lymph node malignancy by endobronchial ultrasound

ObjectiveTo evaluate the utility of different ultrasonographic (US) features in differentiating benign and malignant lymph node (LN) by endobronchial ultrasound (EBUS) and validate a score for real-time clinical application.MethodsA total of 208 mediastinal LNs acquired from 141 patients were analyzed. Six different US criteria were evaluated (short axis ≥10 mm, shape, margin, echogenicity, central hilar structure [CHS], and presence of hyperechoic density) by two observers independently. A simplified score was generated where the presence of margin distinction, round shape and short axis ≥10 mm were scored as 1, and heterogeneous echogenicity and absence of CHS were scored as 1.5. The score was evaluated prospectively for real-time clinical application in 65 LNs during EBUS procedure in 39 patients undertaken by two experienced operators. These criteria were correlated with the histopathological results and the sensitivity, specificity, and positive and negative predictive values (PPV and NPV) were calculated.ResultsBoth heterogenicity and absence of CHS had the highest sensitivity and NPV (≥90%) for predicting LN malignancy with acceptable inter-observer agreement (92% and 87% respectively). On real-time application, the sensitivity and specificity of the score >5 were 78% and 86% respectively; only the absence of CHS, round shape and size of LN were significantly associated with malignant LN.ConclusionsA combination of different US criteria can be useful for the prediction of mediastinal LN malignancy and valid for real-time clinical application.     

Significance of the Presence of Lymphocytes in the Cytological Analysis of Transbronchial Needle Aspiration

AimTo evaluate the clinical relevance of the presence of lymphocytes in transbronchial needle aspiration (TBNA) samples from pathological mediastinal lymph nodes in patients with suspected lung cancer.MethodsRetrospective observational study evaluating the negative predictive value (NPV) of TBNA samples with evidence of lymphocytes but no atypical cells.ResultsA total of 266 TBNA were performed in 252 patients with pathological mediastinal lymphadenopathy. One hundred and fifteen TBNA samples showed evidence of malignant cells (43%) and 94 (35%) samples were considered inadequate (absence of adequate cytological material or exclusive presence of bronchial epithelial cells). Out of the 57 TBNA samples remaining that contained lymphocytes without atypia (21%), 15 could not be confirmed. Thirty-two TBNA samples were confirmed with alternative diagnostic techniques and 10 were confirmed after clinical and radiological follow-up. The NPV of the 32 samples that were confirmed with alternative diagnostic techniques was 84%, which decreased to 76% when we included the 10 TBNA samples confirmed after clinical and radiological follow-up.ConclusionsThe presence of lymphocytes without atypia in TBNA samples does not rule out the neoplastic invasion of the lymph node analyzed.     

Utility of the continuous intraoperative neuromonitoring in the prevention of the recurrent laryngeal nerve paralysis during thyroid surgery. A prospective observational study

BackgroundThe continuous intraoperative neuromonitoring (C-IONM) of the recurrent laryngeal nerve (RLN) could help reducing the incidence of nerve paralysis after thyroid surgery, in comparison with the mere anatomical visualization of the RLN. The objective is to assess the efficacy and utility of C-IONM as a predictive test for recurrent laryngeal nerve paralysis after thyroidectomy.MethodsA prospective observational study was performed in 248 patients who underwent thyroid surgery where C-IONM was applied, between September 2018 and December 2019, in a high-volume center. A previous and later laryngoscopy was performed, which allowed to evaluate the reliability of the C-IONM as a predictive test for recurrent paralysis. Sensitivity (SE), specificity (SP), positive predictive value (PPV), negative predictive value (NPV) were studied.ResultsA total number of 171 thyroidectomies, 62 hemithyroidectomies, 15 totalization thyroidectomies and 27 thyroidectomy with cervical dissections were performed. Postoperative laryngoscopy was altered in 40 patients (16.12%). The SE, SP, PPV and NPV values ​​were 65%, 94.7%, 70.2% and 93.4% respectively.ConclusionsC-IONM is a safe technique that provides real-time information about anatomical and functional integrity of the RLN and can improve the results of thyroid surgery.     

Performance of a new portable near-infrared spectroscopy device for detection of traumatic intracranial hematoma

IntroductionWe report results of a newly developed portable near-infrared spectroscopy (NIRS) based point-of-care device CEREBO® to detect traumatic intracranial hematoma (TICH).Materials and methodsPatients with alleged history of head injury visiting emergency room were enrolled. They were examined consecutively for the presence of TICH using CEREBO® and computed tomography (CT) scans.ResultsA total of 158 participants and 944 lobes were scanned, and 18% of lobes were found to have TICH on imaging with computed tomography of the head. 33.9% of the lobes could not be scanned due to scalp lacerations. The mean depth of hematoma was 0.8 (SD 0.5) cm and the mean volume of the hematoma was 7.8 (11.3) cc. The overall sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) of CEREBO® to classify subjects as hemorrhagic or non-hemorrhagic were 96% (CI 90 - 99%), 85% (CI 73 - 93%), 92% (CI 86 - 96%), 91% (CI 84 - 96%) and 93% (CI 82 - 98%) whereas to classify the lobes as hemorrhagic and non-hemorrhagic, the sensitivity, specificity, accuracy, PPV and NPV were 93% (CI 88 - 96%), 90% (CI 87 - 92%), 90% (CI 88 - 92%), 66% (CI 61 - 73%), and 98% (CI 97 - 99%) respectively. The sensitivity was highest at 100% (CI 92 - 100%) for the detection of extradural and subdural hematoma. The sensitivity for detecting intracranial hematoma including epidural, subdural, intracerebral and subarachnoid hematomas, of more than 2 cc was 97% (CI 93 - 99%) and the NPV was 100% (CI 99 - 100%). The sensitivity dropped for hematomas less than 2cc in volume to 84% (CI 71 - 92%) and the NPV was 99% (CI 98 - 99%). The sensitivity to detect bilateral hematomas was 94% (CI 74 - 99%).ConclusionThe performance of currently tested NIRS device for detection of TICH was good and can be considered for triaging a patient requiring a CT scan of the head after injury. The NIRS device can efficiently detect traumatic unilateral hematomas as well as those bilateral hematomas where the volumetric difference is greater than 2cc.     

18F-FDG PET/CT在胆道系统恶性肿瘤中的应用

目的探讨~(18)F-FDG PET/CT诊断胆道系统恶性肿瘤的价值。方法回顾性分析34例临床疑似胆道恶性肿瘤患者的PET/CT影像资料,均获得术后病理结果,其中12例经手术切除淋巴结或淋巴结穿刺活检对18枚淋巴结获得病理诊断;与病理结果对照,计算PET/CT对胆道恶性病变原发灶、淋巴结转移的灵敏度、特异度、阳性预测值、阴性预测值及准确率。结果 34例中,31例为恶性病变,3例为良性病变。PET/CT诊断胆道恶性肿瘤原发灶的灵敏度100%(31/31),特异度66.67%(2/3),阳性预测值96.88%(31/32),阴性预测值100%(2/2),准确率97.06%(33/34)。胆道恶性病变原发灶最大标准摄取值(SUV_(max))为8.42±4.27;3例胆道良性疾病SUV_(max)分别为12.90、2.00及1.90。共18枚淋巴结获得病理结果,包括转移性淋巴结13枚,良性增生5枚。PET/CT诊断淋巴结转移的灵敏度76.92%(10/13),特异度60.00%(3/5),阳性预测值83.33%(10/12),阴性预测值50.00%(3/6),准确率72.22%(13/18)。结论 PET/CT对胆道系统恶性肿瘤的诊断具有重要价值。     

What Is the Comparative Ability of 18F-FDG PET/CT, 99mTc-MDP Skeletal Scintigraphy,and Whole-body MRI as a Staging Investigation to Detect Skeletal Metastases in Patients with Osteosarcoma and Ewing Sarcoma?

BackgroundSkeletal metastases of bone sarcomas are indicators of poor prognosis. Various imaging modalities are available for their identification, which include bone scan, positron emission tomography/CT scan, MRI, and bone marrow aspiration/biopsy. However, there is considerable ambiguity regarding the best imaging modality to detect skeletal metastases. To date, we are not sure which of these investigations is best for screening of skeletal metastasis.Question/purposeWhich staging investigation—¹⁸F-fluorodeoxyglucose positron emission tomography/CT (¹⁸F-FDG PET/CT), whole-body MRI, or ^99mTc-MDP skeletal scintigraphy—is best in terms of sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) in detecting skeletal metastases in patients with osteosarcoma and those with Ewing sarcoma?MethodsA prospective diagnostic study was performed among 54 of a total 66 consecutive osteosarcoma and Ewing sarcoma patients who presented between March 2018 and June 2019. The institutional review board approved the use of all three imaging modalities on each patient recruited for the study. Informed consent was obtained after thoroughly explaining the study to the patient or the patient’s parent/guardian. The patients were aged between 4 and 37 years, and their diagnoses were proven by histopathology. All patients underwent ^99mTc-MDP skeletal scintigraphy, ¹⁸F-FDG PET/CT, and whole-body MRI for the initial staging of skeletal metastases. The number and location of bone and bone marrow lesions diagnosed with each imaging modality were determined and compared with each other. Multidisciplinary team meetings were held to reach a consensus about the total number of metastases present in each patient, and this was considered the gold standard. The sensitivity, specificity, PPV, and NPV of each imaging modality, along with their 95% confidence intervals, were generated by the software Stata SE v 15.1. Six of 24 patients in the osteosarcoma group had skeletal metastases, as did 8 of 30 patients in the Ewing sarcoma group. The median (range) follow-up for the study was 17 months (12 to 27 months). Although seven patients died before completing the minimum follow-up, no patients who survived were lost to follow-up.ResultsWith the number of patients available, we found no differences in terms of sensitivity, specificity, PPV, and NPV among the three staging investigations in patients with osteosarcoma and in patients with Ewing sarcoma. Sensitivities to detect bone metastases for ¹⁸F-FDG PET/CT, whole-body MRI, and ^99mTc-MDP skeletal scintigraphy were 100% (6 of 6 [95% CI 54% to 100%]), 83% (5 of 6 [95% CI 36% to 100%]), and 67% (4 of 6 [95% CI 22% to 96%]) and specificities were 100% (18 of 18 [95% CI 82% to 100%]), 94% (17 of 18 [95% CI 73% to 100%]), and 78% (14 of 18 [95% CI 52% to 94%]), respectively, in patients with osteosarcoma. In patients with Ewing sarcoma, sensitivities to detect bone metastases for ¹⁸F-FDG PET/CT, whole-body MRI, and ^99mTc-MDP skeletal scintigraphy were 88% (7 of 8 [95% CI 47% to 100%]), 88% (7 of 8 [95% CI 47% to 100%]), and 50% (4 of 8 [95% CI 16% to 84%]) and specificities were 100% (22 of 22 [95% CI 85% to 100%]), 95% (21 of 22 [95% CI 77% to 100%]), and 95% (21 of 22 [95% CI 77% to 100%]), respectively. Further, the PPVs for detecting bone metastases for ¹⁸F-FDG PET/CT, whole-body MRI, and ^99mTc-MDP skeletal scintigraphy were 100% (6 of 6 [95% CI 54% to 100%]), 83% (5 of 6 [95% CI 36% to 100%]), and 50% (4 of 8 [95% CI 16% to 84%]) and the NPVs were 100% (18 of 18 [95% CI 82% to 100%]), 94% (17 of 18 [95% CI 73% to 100%]), and 88% (14 of 16 [95% CI 62% to 98%]), respectively, in patients with osteosarcoma. Similarly, the PPVs for detecting bone metastases for ¹⁸F-FDG PET/CT, whole-body MRI, and ^99mTc-MDP skeletal scintigraphy were 100% (7 of 7 [95% CI 59% to 100%]), 88% (7 of 8 [95% CI 50% to 98%]), and 80% (4 of 5 [95% CI 28% to 100%]), and the NPVs were 96% (22 of 23 [95% CI 78% to 100%]), 95% (21 of 22 [95% CI 77% to 99%]), and 84% (21 of 25 [95% CI 64% to 96%]), respectively, in patients with Ewing sarcoma. The confidence intervals around these values overlapped with each other, thus indicating no difference between them.ConclusionBased on these results, we could not demonstrate a difference in the sensitivity, specificity, PPV, and NPV between ¹⁸F-FDG PET/CT, whole-body MRI, and ^99mTc-MDP skeletal scintigraphy for detecting skeletal metastases in patients with osteosarcoma and Ewing sarcoma. For proper prognostication, a thorough metastatic workup is essential, which should include a highly sensitive investigation tool to detect skeletal metastases. However, our study findings suggest that there is no difference between these three imaging tools. Since this is a small group of patients in whom it is difficult to make broad recommendations, these findings may be confirmed by larger studies in the future.Level of EvidenceLevel II, diagnostic study.     

Usefulness of Radial Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration for the Diagnosis of Mediastinal Lymph Nodes

IntroductionTransbronchial needle aspiration (TBNA) is a bronchoscopic technique that has been shown to be useful for sampling mediastinal lymph nodes. The yield of this technique can be increased by using endobronchial ultrasound (EBUS) to guide needle placement. The aim of the present study was to compare the yield of EBUS-guided TBNA to that of conventional TBNA in the analysis of mediastinal lymph nodes.Patients and MethodsAll patients undergoing either EBUS-guided or conventional TBNA for the diagnosis of mediastinal lymph nodes between January 2006 and May 2007 were studied consecutively. Histology results were used as a reference standard in patients treated surgically. In cases in which surgery was not indicated, the results of cytology or of clinical follow-up of at least 6 months duration were used.ResultsTBNA was performed in 117 patients and a total of 143 lymph nodes were punctured (mean shortest [SD] diameter, 17.9 [8] mm). The samples obtained were diagnostic in 58 patients (49.6%) and in 70 lymph nodes (49.0%). For paratracheal and hilar stations, the yield of EBUS-guided TBNA was superior to that of conventional TBNA (59.2% compared to 34.1%, P=.02).ConclusionsRadial EBUS guidance increases the diagnostic yield of TBNA in paratracheal and hilar lymph node stations.     

扩散加权成像诊断乳腺浸润性导管癌腋窝淋巴结转移

目的评价DWI对乳腺浸润性导管癌(IDC)腋窝转移性淋巴结的诊断价值。方法回顾性分析115例病理证实的IDC患者的MRI,选取154枚淋巴结,根据手术及病理确定其性质,测量并比较转移与非转移淋巴结的ADC值,确定诊断转移淋巴结的ADC值界值,计算其敏感度、特异度、阳性预测值、阴性预测值及准确率。结果 154枚淋巴结中,87枚存在转移,其ADC值[(0.921±0.161)×10-3 mm2/s]明显低于非转移淋巴结[(1.167±0.199)×10-3 mm2/s),P0.001]。以ADC值为1.005×10-3 mm2/s作为转移淋巴结的诊断界值,其敏感度为80.46%,特异度为88.06%,阳性预测值为89.74%,阴性预测值为77.63%,准确率为83.77%。结论 DWI结合ADC值对鉴别乳腺IDC转移与非转移性腋窝淋巴结是有价值的功能影像学方法。     

Cervical Mediastinoscopy Versus Computed Tomography for Detecting Enlarged Mediastinal Lymph Nodes in Non-Cancerous Lung Diseases

Cervical mediastinoscopy (CM) is considered to be the gold standard for evaluating mediastinal lymph nodes. The aim of this study was to determine the diagnostic yield of computed tomography (CT) and CM for detecting enlarged mediastinal lymph nodes in non-malignant pulmonary diseases. We retrospectively investigated the correlation and differentiation between chest CT and CM findings in terms of sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV), in 30 patients with granulomatous lung disease diagnosed by CM and isolated enlarged lymph nodes seen on CT scans. Biopsy tissues from the lymph nodes in stations right, 1, 2, 3, 4, and 7, were obtained for pathological examination. The 30 patients comprised 11 men (mean age 47.1 ± 18.4 years) and 19 women (mean age 44.2 ± 14.0 years). Radiological examination showed that the diagnostic value of stations 2 and 4 was particularly high. Thus, when CM is used for diagnostic purposes, the small lymph nodes in station 1, obtained by careful dissection of the higher mediastinal region, can be helpful. Generally, there is no absolute consistency between the findings of CM and CT. For this reason, obtaining samples from each station regardless of CT findings is recommended.     

ROC曲线法分析99mTc-MIBI显像对甲状腺肿瘤的诊断效能

目的用ROC曲线法分析99mTc-MIBI显像对鉴别甲状腺结节良恶性的诊断效能。方法选择甲状腺99mTcO4-显像＂冷＂或＂凉＂结节患者59例共75个结节行99mTc-MIBI显像,其中确诊良性结节58个（良性组）,恶性结节17个（恶性组）,对结果进行半定量和ROC曲线法分析,并对两种方法进行比较。结果恶性组和良性组5min时靶/非靶（T/N）比值分别为1.63±1.09、0.86±0.36,1h分别为1.59±1.05、0.88±0.29,恶性组T/N比值均显著高于良性组。半定量法显示5min时诊断灵敏度47.06%（8/17）、特异度93.10%（54/58）,准确率82.67%（62/75）;1h时诊断灵敏度52.94%（9/17）、特异度94.83%（55/58）,准确率85.33%（64/75）。ROC法曲线下面积5min、1h时均为0.86,以5min时0.99为界值,诊断灵敏度88.24%、特异度75.86%、准确率78.67%。以1h时0.93为界值,诊断灵敏度88.24%、特异性79.31%、准确率81.33%。两种界值灵敏度、特异度比较差异有统计学意义。结论 99mTc-MIBI显像对鉴别甲状腺肿瘤良恶性有诊断价值;采用ROC曲线分析法可提高99mTc-MIBI显像对鉴别甲状腺＂冷＂、＂凉＂结节良恶性的诊断效能。     

Routine postoperative upper gastrointestinal fluoroscopy after laparoscopic sleeve gastrectomy: Is there still a utility?

PurposeTo assess the performance of routine esophagogastric transit studies (OGT) performed between day 2 (D2) and day 4 (D4) following sleeve gastrectomy for the diagnosis of gastric fistula.Patients and methodsSingle center study including 736 patients undergoing surgery for sleeve gastrectomy including 32 of whom developed gastric fistula. Seven hundred and twenty OGT on D2 and 86 abdominal and pelvic CT scans were performed to investigate for a fistula and whether or not a blood collection was present. Sensitivity, specificity, positive and negative predictive values, Youden index (YI) and dosimetry were calculated for both investigations.ResultsThe sensitivity and specificity of OGT for the diagnosis of fistula were 7% and 98% respectively with a PPV of 18%, an NPV of 96% and YI of 0.06. The mean DSP was 5500 μGy.m². Sensitivity, specificity, positive and negative predictive values and Youden index for CT were 55%, 100%, 100%, 81%, 0.55, respectively for the presence of a fistula; and 96%, 86%, 78%, 98%, 0.83 for the presence of a non-blood collection and; 100%, 86%, 78%, 100%, 0.86 for the presence of a non-blood collection and/or fistula. The mean DLP was 3700 mGy.cm.ConclusionBecause of its very poor sensitivity for the diagnosis of gastric fistula, the OGT on D2 needs to be reconsidered. CT performed on clinical suspicion appears to be a better diagnostic tool.     

儿童和青少年可逆性后部脑病综合征的MRI特征和病因分析

目的分析儿童和青少年可逆性后部脑病综合征（PRES）的临床资料和MRI特征,探讨其病因、发病机制及MRI表现与成人的异同。方法回顾性分析8例PRES患儿的临床资料及MR扫描结果。结果 8例患儿均有基础性疾病,其中系统性红斑狼疮2例,急性淋巴细胞性白血病1例,硬皮病1例,肾病综合征3例,原发性癫痫1例;均接受糖皮质激素、免疫抑制剂或细胞毒性药物治疗。MRI表现为以顶枕叶皮层下白质为主的片状对称性长T1长T2信号、T2-FLAIR序列呈高信号灶,部分病灶累及皮层;颞叶、额叶、基底节区、脑干或小脑亦可见信号相同的小片状病灶。经有效治疗后,患儿神经系统症状均消失,其中4例复查头颅MRI,可见脑内病灶均消失。结论使用糖皮质激素、免疫抑制剂及细胞毒性药物可能是引起儿童和青少年PRES重要原因,其特征性MRI表现有助于临床诊断PRES。     

Utility of Breast Sentinel Lymph Node Biopsy Using Day-Before-Surgery Injection of High-Dose 99mTc-Labeled Sulfur Colloid

Background: In sentinel lymph node SLN biopsy for breast cancer, many centers use same-day preoperative injection of technetium ^99mTc-labeled sulfur colloid and intraoperative injection of blue dye for localization of SLNs. Same-day sulfur colloid injections can be problematic because of the variability in sulfur colloid migration times, which can lead to ineffective use of operating room time, and low SLN-to-background radioactivity ratios. We examined the utility of day-before-surgery injections of high dose ^99mTc-labeled sulfur colloid injections.Methods: The day before surgery, high-dose ^99mTc-labeled sulfur colloid was injected peritumorally, and a lymphoscintigram was obtained. Intraoperatively, after injection of blue dye, a gamma probe was used to localize SLNs. Nodes that were stained blue or were highly radioactive were considered SLNs and were removed.Results: Lymphoscintigraphy demonstrated drainage in 107 patients 91%. Transcutaneous localization of the SLN was possible in 104 patients 89%. In three patients, all of whom had no drainage demonstrated on lymphoscintigraphy, no SLN was identified at surgery 97.5% success rate for SLN identification. A mean of 2.3 SLNs per patient were identified. Twenty-five patients 21% had at least one histologically positive SLN. In 23 of these patients, the positive SLN was the SLN with the most radioactivity, and in the remaining two patients, the positive SLN was both blue-stained and hot.Conclusion: Day-before-surgery injection of high-dose ^99mTc-labeled sulfur colloid results in high rates of transcutaneous and intraoperative identification of SLNs. The delay between injection and surgery did not appear to promote significant passage of sulfur colloid to second-echelon nodes.Presented at the 54th Annual Meeting of the Society of Surgical Oncology, Washington, DC, March 15-18, 2001.     

CT指导介入治疗下腔静脉Budd-Chiari综合征

目的评估CT对下腔静脉型Budd-Chiari综合征(BCS)介入治疗的临床指导价值。方法收集于我院接受介入治疗的329例下腔静脉型BCS患者,所有患者术前均接受CT检查,并根据CT诊断结果制定介入治疗方案。以DSA治疗结果为金标准,评估CT诊断的准确率、敏感度、特异度、阳性预测值和阴性预测值。结果 DSA示下腔静脉不完全闭塞型BCS 108例,下腔静脉完全闭塞型221例;CT诊断下腔静脉不完全闭塞型99例,下腔静脉完全闭塞型230例。与DSA结果相比,CT诊断15例假阴性,6例假阳性。CT术前制定是否破膜的准确率、敏感度、特异度、阳性预测值及阴性预测值分别为94.19%、97.29%、86.11%、93.49%及93.94%,CT术前制定介入治疗方法的准确率、敏感度、特异度、阳性预测值及阴性预测值分别为97.55%、100%、92.52%、96.49%和100%。结论 CT诊断下腔静脉型BCS准确率较高,且有助于制定介入治疗方案。     

The transcervical extended mediastinal lymphadenectomy versus cervical mediastinoscopy in non-small cell lung cancer staging.

OBJECTIVE: To compare the diagnostic yield of the transcervical extended mediastinal lymphadenectomy (TEMLA) and the cervical mediastinoscopy (CM) in detecting metastatic mediastinal lymph nodes in NSCLC patients. METHODS: Prospective, randomized, single-blind clinical study. RESULTS: There were 41 NSCLC patients enrolled in the study; 21 were randomized to the TEMLA group and 20 to the cervical mediastinoscopy group. The TEMLA revealed mediastinal metastases in 7 patients, and mediastinoscopy in 3. In the TEMLA group one patient out of the 14 with negative nodes was finally found unfit for surgery, and in the remaining 13 lung resections with mediastinal dissection were performed. In the mediastinoscopy group one patient out of the 17 with negative nodes was finally found unfit for surgery and another one refused surgery, so in 15 of them lung resections with mediastinal dissection were performed. In no patient in the TEMLA group did the pathological examination of the operative specimen reveal metastatic lymph nodes, whereas in the mediastinoscopy group metastatic nodes were found in 5 patients. The number of false negative results was significantly greater in the mediastinoscopy group (5 vs 0, p=0.019), and the difference was the reason for terminating the randomization before reaching the initially planned number of 100 patients. The sensitivity of mediastinoscopy was 37.5% and its negative predictive value was 66.7%, compared to 100% and 100% in the TEMLA group. The comparison of the time of the operation, blood loss, complications, postoperative pain and the use of analgetics has shown significant differences between groups only regarding the operative time and the pain intensity, being greater in the TEMLA group. CONCLUSIONS: 1. The sensitivity and the NPV of the TEMLA in detecting mediastinal metastases in NSCLC are significantly greater than those of cervical mediastinoscopy. 2. The invasiveness of TEMLA and mediastinoscopy does not significantly differ, except for the postoperative pain.     

Staging of non-small cell lung cancer: clinical value of positron emission tomography and mediastinoscopy

We report about a MEDLINE research from 2000 to 2005 with the key words 'positron emission tomography AND/OR mediastinoscopy'. The search identified 448 potential studies. Out of the published data sensitivity, specificity, positive and negative predictive value, and accuracy for mediastinal lymph node staging by FDG-PET ranged from 58%-94%, 76%-96%, 43%-95%, 56%-98% to 74%-91%, respectively. With corresponding values of 80%-96%, 100%, 100%, 92%-97%, and 94%, respectively, for mediastinoscopy. FDG-PET improved the rate of detection of local and distant metastases in 12% to 62% and changed the management of treatment in 8% to 60% of patients with NSCLC. Our study shows that in the diagnostic strategy of patients with NSCLC, additional FDG-PET can prevent non-therapeutic thoracotomy in a significant number of cases. If FDG-PET imaging and CT scan is negative for mediastinal lymph node involvement routinely mediastinoscopy can be omitted and thoracotomy can immediately be performed. In patients with negative FDG-PET scan, but positive CT scan, histologic verification by invasive methods can individually be considered. Patients with positive FDG-PET scan mediastinoscopy still remain a reliable standard for exact lymph node staging. By incorporating FDG-PET in clinical staging unnecessary exploratory thoracotomies, and mediastinoscopy, can be omitted.     

Routine contrast enema prior to stoma reversal seems only required following treatment for necrotizing enterocolitis: An evaluation of the diagnostic accuracy of the contrast enema

IntroductionContrast enemas are often made prior to stoma reversal in order to detect distal intestinal strictures distal of the stoma. If untreated these strictures can cause obstruction which might necessitate redo-surgery. However, the value of contrast enemas is unclear. Therefore, we aim to evaluate the contrast enema's diagnostic accuracy in detecting strictures in children with a stoma.MethodsYoung children (≤3 years) treated with a stoma between 1998 and 2018 were retrospectively included. The STARD criteria were followed. Patients treated for anorectal malformations and those that died before stoma reversal were excluded. Surgical identification of strictures during reversal or redo-surgery within three months was used as gold standard. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and area under the curve (AUC) reflected diagnostic accuracy.ResultsIn 224 included children, strictures were found during reversal in 10% of which 95% in patients treated for necrotizing enterocolitis. Contrast enema was performed in 68% of all patients and detected 92% of the strictures. In the overall cohort, the sensitivity was 100%, specificity 98%, PPV 88% and NPV 100% whilst the AUC was 0.98. In patients treated for NEC, the sensitivity was 100%, specificity 97%, PPV 88% and NPV 100% whilst the AUC was 0.98.ConclusionStrictures prior to stoma reversal seem to be mainly identified in patients treated for NEC and not in other diseases necessitating a stoma. Moreover, the contrast enema shows excellent diagnostic accuracy in detecting these strictures. For this reason we advise to only perform contrast enemas in patients treated for NEC.Level of EvidenceII     

Comparison of Integrated Positron Emission Tomography/Computed Tomography and Mediastinoscopy in Mediastinal Staging of Non-Small Cell Lung Cancer: Analysis of 212 Patients

Background : Mediastinal staging is crucial to determine the prognosis and treatment options for patients with non-small cell lung cancer (NSCLC). In this study, we compared the results of integrated positron emission tomography-computerised tomography (PET/CT) with those of mediastinoscopy in mediastinal staging of NSCLC patients. Methods : PET/CT and mediastinoscopy was performed on 250 consecutive patients diagnosed with NSCLC between September 2005 and March 2008. Thirty-eight patients were excluded from the study. Standard cervical mediastinoscopy was performed in all patients, and simultaneous extended cervical mediastinoscopy was performed in 52 patients with left sided lesions. Patients with negative mediastinoscopy underwent resection. The pathological results were correlated with PET/CT findings.

Results : A total of 212 patients (199 male, 13 female; mean age: 58.3 years) were evaluated. In PET/CT analysis 60 true-positive, 45 false-positive, 103 true-negative and 4 false-negative patients were found. The rate of PET/CT positivity of mediastinal lymph nodes was 49.5%. The sensitivity, specificity, positive and negative predictive values and accuracy for PET/CT were 93.8%, 69.6%, 57.1%, 96.3% and 76.9% respectively. The incidence of N2 disease in NSCLC patients with negative mediastinal lymph node uptake on PET/CT was 3.7% (4 of 107). In univariate analysis, right upper lobe tumours were significantly (p < 0.05) more associated with occult N2 disease.

Conclusions : In patients with positive mediastinal lymph node uptake on PET/CT invasive mediastinal staging appears necessary for exact staging. Mediastinoscopy can be omitted in NSCLC patients with negative mediastinal uptake on PET/CT in regions where the rate of PET/CT positivity of mediastinal lymph nodes is high.     

Prediction of final tumor response to preoperative chemotherapy by Tc‐99m MIBI imaging at the middle of chemotherapy in malignant bone and soft tissue tumors: Comparison with Tl‐201 imaging

The aim of this study was to assess the predictive power of ^99mTc‐MIBI scintigraphy performed in the middle of chemotherapy, for the final tumor response to chemotherapy, and compare it to that of ²⁰¹Tl in malignant bone and soft tissue tumors (MBST). Sixty‐eight patients with MBST underwent ^99mTc‐MIBI and ²⁰¹Tl scintigraphies at 15 min after tracer injection before the first, and after the third, chemotherapy cycles. After five cycles of chemotherapy and tumor resection, therapeutic effect was assessed by histopathology. Less than 90% and ≥90% necrosis were judged as poor and good response to chemotherapy, respectively. Tracers uptake ratios were calculated by dividing the lesion count density by that of the background. ^99mTc‐MIBI perfusion index was also calculated. The % reduction of the perfusion index (ΔPI) and uptake ratios (ΔUR) calculated by 100 × [(prechemotherapy value ? postchemotherapy value)/prechemotherapy value] were compared with histologic response. The sensitivity, specificity, and accuracy for the prediction of effective chemotherapy in ^99mTc‐MIBI imaging were 80%, 95%, 88% in ΔUR, and 74%, 74%, 74% in ΔPI, respectively. The area under the receiver operator characteristic curve (A_z) of the ^99mTc‐MIBI‐ΔUR (0.923) was significantly higher than that of ΔPI (0.809, p = 0.025) but only marginally higher than that of the ²⁰¹Tl‐ΔUR (0.865, p = 0.079). A_z in ²⁰¹Tl (0.865) was not significantly different from that of ΔPI (0.809, p = 0.35). ^99mTc‐MIBI imaging performed in the middle of chemotherapy well predicts the final tumor response to chemotherapy in patients with malignant bone and soft tissue tumors. © 2007 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 26:411–418, 2008