[18F]‐fluorocholine positron‐emission/computed tomography for lymph node staging of patients with prostate cancer: preliminary results of a prospective study

Study Type – Diagnostic (case series)
Level of Evidence 4

OBJECTIVES

To evaluate prospectively [¹⁸F]‐fluorocholine positron‐emission/computed tomography (FCH PET/CT) for lymph node staging of prostate cancer before intended curative therapy, and to determine whether imaging 15 or 60 min after radiotracer injection is preferable.

PATIENTS AND METHODS

In all, 25 consecutive patients with newly diagnosed prostate cancer (Gleason score >6, and/or a prostate‐specific antigen level of >10 ng/mL, and/or T3 cancer) were scanned before lymphadenectomy. Each patient was assessed twice with imaging, at 15 and 60 min after the injection with FCH. Images were compared with the results of histopathological examination of the surgically removed lymph nodes. Maximum standardized uptake values (SUV_max) at 15 and 60 min were also compared.

RESULTS

Histopathologically, metastases were present in removed lymph nodes from three patients. FCH PET/CT showed a high radiotracer uptake in four patients, the former three and a fourth. The sensitivity, specificity, positive and negative predictive value of FCH PET/CT for patient based lymph node staging of prostate cancer were 100%, 95%, 75% and 100%, respectively; the corresponding 95% confidence intervals were 29.2–100%, 77.2–99.9%, 19.4–99.4% and 83.9–100%, respectively. Values of SUV_max at early and late imaging were not significantly different.

CONCLUSIONS

This small series supports the use of FCH PET/CT as a tool for lymph node staging of patients with prostate cancer. Values of SUV_max at early and late imaging did not differ. However, larger prospective studies are needed to validate these findings.     

Metachronous mediastinal lymph node metastasis from ascending colon cancer: A case report and literature review

IntroductionMetachronous mediastinal lymph node metastasis without pulmonary metastasis is extremely rare in colorectal cancer, which makes the clinical diagnosis difficult and treatment strategy unclear.Prsentation of caseA case was a 59-year-old man, who had undergone right hemicolectomy for ascending colon cancer 2 years and 8 months previously, presented with enlarged mediastinal lymph nodes. ¹⁸F-fluorodeoxyglucose (FDG) positron emission tomography revealed FDG was accumulated only into the mediastinal lymph nodes. Serum carcinoembryonic antigen (CEA) level was within the normal range. Six months later, the size and FDG uptake of the mediastinal lymph nodes had increased. We assumed a possibility that the mediastinal lymph nodes were metastasized from ascending colon cancer and so performed thoracoscopic-assisted resection of the mediastinal lymph nodes. Histopathological analysis revealed the resected lymph nodes were filled with moderately differentiated adenocarcinoma and a diagnosis of mediastinal lymph nodes metastasis from previously-resected ascending colon cancer was made. The patient was postoperatively followed for more than 1 year and 8 months without any sign of recurrence.DiscussionOnly 7 cases of metachronous mediastinal lymph node metastasis from colorectal cancer, including our case, have been reported in the English literature. It is difficult to clinically diagnose mediastinal lymph node metastasis.ConclusionWe report a rare case of metachronous mediastinal lymph node metastasis from ascending colon cancer with literature review. If the mediastinal lymph nodes are enlarged after colorectal cancer resection, we need to make a treatment strategy as well as a diagnostic approach considering the possibility of mediastinal lymph node metastasis.     

Oncological issues in staging mediastinal lymph node metastasis for left lung cancer

ObjectiveWe aimed to discuss the underlying oncological issues in staging of mediastinal lymph node metastasis in patients with left lung cancer who underwent extended radical lymphadenectomy (ERL).MethodsThis multi-institutional retrospective study analyzed 116 patients with left non-small-cell lung cancer who underwent bilateral paratracheal lymph node dissection (ERL) via median sternotomy. The clinicopathological records of patients with mediastinal lymph node metastasis were examined for prognostic factors, including age, sex, histology, tumor size, cN number, preoperative data, metastatic stations (number and distribution), pT, and adjuvant chemotherapy.ResultsMediastinal lymph node metastases were found in 43 patients, and right paratracheal lymph node metastases (pN3) were found in 13 patients. The 5-year overall survival rate was 25.2% in patients with pN3 tumors (n = 13) and 23.1% in patients with pN2 tumors (n = 30). The prognosis did not differ between patients with pN3 and pN2. Univariate analyses showed that histology, cN, and adjuvant chemotherapy were significant prognostic factors in patients with mediastinal lymph node metastasis. In these 43 patients, cN and adjuvant chemotherapy were significant independent prognostic factors in multivariate analysis.ConclusionsThe prognostic factors for left lung cancer with mediastinal lymph node metastasis were cN status and adjuvant chemotherapy, and not pN status (pN2 or pN3). We hope that the study results, which suggest that there may be no difference in prognosis between pN2 and pN3, would broaden the discussion of oncological issues in the staging of mediastinal lymph node metastasis of left lung cancer.     

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。     

Role of FDG-PET/CT in evaluating surgical outcomes of operable breast cancer – Usefulness for malignant grade of triple-negative breast cancer

BackgroundThe aim of this study was to evaluate the significance of ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) for speculating the malignant level and prognostic value of operable breast cancers.MethodsOf 578 consecutive patients with primary invasive breast cancer who underwent curative surgery between 2005 and 2010, 311 patients (53.8%) who received FDG-PET/CT before initial therapy were examined.ResultsReceiver operating characteristics (ROC) curve analysis showed the cutoff value of the maximum standardized uptake value (SUV_max) to predict cancer recurrence was 3.8 in all patients and 8.6 in patients with the triple-negative subtype, respectively. In all patients, 3-year DFS rates were 98.8% for patients with a tumor of SUV_max ≤ 3.8 and 91.6% for patients with a tumor of SUV_max > 3.8 (p < 0.001). High value of SUV_max was significantly associated with large tumor size (p < 0.001), lymph node metastasis (p = 0.040), high nuclear grade (p < 0.001), lymphovascular invasion (p = 0.032), negative hormone receptor status (p < 0.001), and positive HER2 status (p = 0.014). Based on the results of multivariate Cox analysis in all patients, high SUV_max (p = 0.001) and negative hormone receptor status (p = 0.005) were significantly associated with poor prognosis. In patients with triple-negative subtype, 3-year DFS rates were 90.9% for patients with a tumor of SUV_max ≤ 8.6 and 42.9% for patients with a tumor of SUV_max > 8.6 (p = 0.002), and high SUV_max was the only significant independent prognostic factor (p = 0.047).ConclusionFDG-PET/CT is useful for predicting malignant behavior and prognosis in patients with operable breast cancer, especially the triple-negative subtype.     

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.     

Prediction of Mediastinal Lymph Node Metastasis in Papillary Thyroid Cancer

Because of the rarity of mediastinal lymph node metastasis, no evidence exists regarding risk factors indicating its presence. This study aimed to identify risk factors representing potential triggers of imaging for mediastinal lymph node metastasis. Carried out was an analysis of 392 consecutive patients with node-positive papillary thyroid cancer referred to a tertiary surgical center. Significant univariate associations (P ≤ 0.001) existed, after correction for multiple testing, between mediastinal lymph node metastasis and poor tumor differentiation (24% versus 2%), number of positive lymph nodes (mean 14.4 versus 7.3 nodes), and distant metastasis (43% versus 11%). Only nominally significant were age at first tumor diagnosis (47.7 versus 39.1 years; P = 0.042), extrathyroidal tumor extension (76% versus 53%; P = 0.044), and bilateral lymph node metastasis (81% versus 49%; P = 0.006). In the initial and optimized multivariate logistic regression models, which included all significant variables from the above analysis, only poor tumor differentiation (odds ratio 11.6–14.6) and distant metastasis (odds ratio 5.4–6.1) represented significant (P ≤ 0.005) predictors of mediastinal lymph node metastasis. These two variables featured excellent negative predictive values of 96%. Regarding prediction of mediastinal lymph node metastasis, poor tumor differentiation was more discriminatory than distant metastasis, as reflected in a better accuracy (94% versus 86%) and positive predictive value (42% versus 18%). We conclude that, subject to validation in independent series, patients with poorly differentiated papillary thyroid cancers, which are rare, should be ideal candidates for mediastinal imaging because 5 of 12 patients (42%) having this condition in the present investigation harbored mediastinal lymph node metastasis.     

Lymph Node Size and Metastatic Infiltration in Colon Cancer

Background: Detection of metastatic lymph nodes in colon cancer is essential for determining stage and adjuvant treatment modalities. Lymph node size has been used as one possible criterion for nodal metastasis. Although enlarged regional lymph nodes are generally interpreted as metastases, few data are available that correlate lymph node size with metastatic infiltration in colon cancer.Methods: In a prospective morphometric study, the regional lymph nodes from 30 colon specimens from consecutive patients with primary colon cancer were analyzed. The lymph nodes were counted and the largest diameter of each lymph node was measured and analyzed for metastatic involvement by histological examination.Results: A total of 698 lymph nodes were present in the 30 specimens examined for this study. A mean number of 23 (range, 19–39) lymph nodes was found in each specimen. Of these nodes, 566 (81%) were tumor-free and 132 (19%) contained metastases. The mean diameter of the lymph nodes free of metastases was 3.9 mm, whereas those infiltrated by metastases averaged 5.9 mm in diameter (P< 0.0001). Of the tumor-free lymph nodes, 528 (93%) measured < 5 mm in diameter, whereas 70 (53%) lymph nodes containing metastases measured < 5 mm in diameter.Conclusions: Lymph node size is not a reliable indicator for lymph node metastasis in colon cancer. A careful histological search for small lymph node metastasis in the specimen should be undertaken to avoid false-negative node staging.     

Trends in axillary surgery and clinical outcomes among breast cancer patients with sentinel node metastasis

BackgroundThere is a lack of studies examining the long-term trend and survival of axillary surgery for breast cancer patients with sentinel node metastasis, especially for the patients with 3–5 node metastases.MethodsBreast cancer patients with 1–5 sentinel node metastases from the Surveillance, Epidemiology, and End Results (SEER) database from 2000 to 2016. Our study presented the trend of axillary surgery and assessed the long-term survival of sentinel lymph node biopsy (SLNB) alone vs axillary lymph node dissection (ALND) for those patients.ResultsOf the 41,996 patients diagnosed with T_1-2 breast cancer after lumpectomy and radiation included, 34,940 had 1-2 sentinel node metastases and 7056 had 3-5 sentinel node metastases. The percentage of patients undergoing SLNB alone increased from 22.4% in 2000 to 81.0% in 2016 for patients with 1–2 sentinel node metastases, and quadrupled from 5.2% in 2009 to 20.6% in 2016 for those with 3–5 sentinel node metastases. Completion of ALND did not benefit the long-term survival of 1–2 sentinel node metastasis patients (hazard ratio [HR] = 1.02, P = 0.539), but improved the long-term survival of 3–5 node metastasis patients (HR = 0.73, P < 0.001). Subgroup analysis demonstrated the inferiority of SLNB to ALND in all subgroups of 3–5 sentinel node metastases.ConclusionFor patients with T_1-2 breast cancer after lumpectomy and radiation, SLNB alone was an efficient and safe surgical choice for 1–2 sentinel node metastases but not for 3–5 sentinel node metastases. It is worth noting that for patients with 3–5 node metastasis, the proportion of omitted ALND quadrupled after 2009.     

The value of mediastinal staging with endobronchial ultrasound-guided transbronchial needle aspiration in patients with lung cancer

Objective: To evaluate the diagnostic yield, the learning curve and the safety of endobronchial ultrasound-guided transbronchial needle biopsy (EBUS-TBNA) in mediastinal staging of patients with lung cancer. Methods: Mediastinal staging was performed with EBUS-TBNA according to the Danish national guidelines in patients fulfilling one or more of the following criteria: (1) central tumour; (2) enlarged (>10 mm) mediastinal lymph nodes on computed tomography; or (3) positron emission tomography (PET)-positive mediastinal lymph nodes. The study period began in January 2006 when EBUS-TBNA was introduced in the department and ended in December 2007. All records were reviewed retrospectively. None of the four examiners had any previous experience with EBUS-TBNA or ultrasound when the study began. All examinations were performed under general anaesthesia. Patients without useful cytological material from the EBUS-TBNA were subjected to a supplementary standard cervical mediastinoscopy if the mediastinal lymph nodes were found to be enlarged (>10 mm), PET positive or if the examiner was insecure of the result of the EBUS-TBNA. Patients with mediastinal lymph node involvement, detected by EBUS-TBNA or standard cervical mediastinoscopy, were referred to oncological treatment, while those without mediastinal lymph node involvement underwent – if they were otherwise eligible for surgery – resection and systematic lymph node sampling either by thoracotomy or by video-assisted thoracoscopy. Final mediastinal staging was defined as positive if mediastinal lymph node involvement was detected by EBUS-TBNA, standard cervical mediastinoscopy or surgery, or defined as negative otherwise. Results: A total of 157 patients were included in the study. N2/N3 disease was found in 67 patients (42.6%). EBUS-TBNA missed the mediastinal spread in 10 patients. Five of the ten patients had lymph node metastases in station 5, 6 or 8 – out of reach of EBUS-TBNA or standard cervical mediastinoscopy. EBUS-TBNA had a sensitivity of 0.85 (0.74–0.93) and a negative predictive value of 0.90 (0.82–0.95). No complications occurred from EBUS-TBNA. The number of supplementary standard cervical mediastinoscopies decreased significantly in the study period. Conclusion: The results of this study suggest that staging of the mediastinum with EBUS-TBNA is safe and easy to learn – even without previous experience with ultrasound. The diagnostic yield of EBUS-TBNA is in accordance with the yield of standard cervical mediastinoscopy reported in the literature. We do not find any indications in the present study of the recommended necessity for mediastinoscopy in all EBUS-TBNA-negative patients.     

Preoperative intrathoracic lymph node staging in patients with non-small-cell lung cancer: accuracy of integrated positron emission tomography and computed tomography

Objective: To evaluate the accuracy of integrated positron emission tomography with ¹⁸F-fluoro-2-deoxy-d-glucose (FDG) and computed tomography (PET/CT) in preoperative intrathoracic lymph node staging in patients with non-small-cell lung cancer (NSCLC) and to ascertain the role of invasive staging in verifying positron emission tomography (PET)/computed tomography (CT) results. Methods: Retrospective, single institution study of consecutive patients with suspected or pathologically proven, potentially resectable NSCLC undergoing integrated PET/CT scanning in the same PET centre. Lymph node staging was pathologically confirmed on tissue specimens obtained at mediastinoscopy and/or thoracotomy. Statistical evaluation of PET/CT results was performed on a per-patient and per-nodal-station bases. Results: A total of 1001 nodal stations (723 mediastinal, 148 hilar and 130 intrapulmonary) were evaluated in 159 patients. Nodes were positive for malignancy in 48 (30.2%) out of 159 patients (N1 = 17; N2 = 30; N3 = 1) and 71 (7.1%) out of 1001 nodal stations (N1 = 24; N2 = 46; N3 = 1). At univariate analysis, lymph node involvement was significantly associated (p < 0.05) with the following primary tumour characteristics: increasing diameter, maximum standardised uptake value >9, central location and presence of vascular invasion. PET/CT staged the disease correctly in 128 out of 159 patients (80.5%), overstaging occurred in nine patients (5.7%) and understaging in 22 patients (13.8%). The overall sensitivity, specificity, positive and negative predictive values, and accuracy of PET/CT for detecting metastatic lymph nodes were 54.2%, 91.9%, 74.3%, 82.3% and 80.5% on a per-patient basis, and 57.7%, 98.5%, 74.5%, 96.8% and 95.6% on per-nodal-station basis. With regard to N2/N3 disease, PET/CT accuracy was 84.9% and 95.3% on a per-patient basis and on per-nodal-station basis, respectively. Referring to nodal size, PET/CT sensitivity to detect malignant involvement was 32.4% (12/37) in nodes <10 mm, and 85.3% (29/34) in nodes ≥10 mm. Conclusion: Our data show that integrated PET/CT provides high specificity but low sensitivity and accuracy in intrathoracic nodal staging of NSCLC patients and underscore the continued need for surgical staging.     

Improved staging using intraoperative ultrasound for mediastinal lymphadenectomy in non-small lung cancer surgery

BackgroundExtent of lymph node involvement in patients with non-small cell lung cancer (NSCLC) is the cornerstone of staging and influences both multimodality treatment and final outcome. The aim of this study was to investigate accuracy and characteristics of intraoperative ultrasound guided systematic mediastinal nodal dissection in patients with resected NSCLC.MethodsFrom January 2008 to June 2013, 244 patients undergoing intraoperative surgical staging after radical surgery for NSCLC were included in prospective study. The patients were divided in two groups according to systematic mediastinal nodal dissection: 124 patients in intraoperative ultrasound nodal dissection guided group and 120 in standard nodal dissection group. The lymph nodes were mapped by their number and station and histopathologic evaluation was performed.ResultsOperating time was prolonged for 10 min in patients with ultrasound guided mediastinal nodal dissection, but number and stations of evaluated lymph nodes were significantly higher (p < 0.001) in the same group. Skip nodal metastases were found in 24% of patients without N1 nodal involvement. Twelve (10%) patients were upstaged using US guided mediastinal lymphadenectomy. In US guided group 5-year survival rate was 59% and in the group of standard systematic mediastinal lymphadenectomy 43% (p = 0.001) Standard staging system seemed to be improved in ultrasound guided mediastinal lymphadenectomy patients. Complication rate showed no difference between analyzed groups.ConclusionHigher number and location of analyzed mediastinal nodal stations in patients with resected NSCLC using ultrasound is suggested to be of great oncological significance. Our results indicate that intraoperative ultrasound may have important staging implications.     

Histopathologic Criteria for Local Excision of Colorectal Cancer: Multivariate Analysis

Background: Local treatment of colorectal cancer, including endoscopic removal of colonic polyps and transanal resection of rectal tumors, has become widely accepted. However, risk factors predicting the presence of lymph node metastasis have not been fully investigated. To determine the criteria for local excision of colorectal cancer, histopathologic factors independently predicting the lymph node metastasis were investigated.Methods: We performed a retrospective histopathologic study on 335 patients who underwent resection of colorectal cancer and dissection of regional lymph nodes between 1982 and 1996. Features of node-positive tumors (n = 150) were compared with those of node-negative tumors (n = 185), with special reference to the histopathologic findings of the resected tumor. Multivariate analysis was done using the stepwise logistic regression test.Results: Node-positive tumors, when compared with node-negative tumors, were characterized by tumor larger than 6 cm (42% vs. 22%), serosal invasion (88% vs. 56%), lymphatic invasion (32% vs. 5%), venous invasion (9% vs. 2%), and histology other than well-differentiated (66% vs. 29%). Multivariate analysis showed that factors independently associated with lymph node metastasis were serosal invasion, lymphatic invasion, and histologic type. When these three risk factors were negative, lymph node metastasis was rare (5%). When one, two, or three factors were positive, the frequency of lymph node metastasis was 38%, 66%, and 85%, respectively.Conclusions: In colorectal cancer, factors independently associated with lymph node metastasis are serosal invasion, lymphatic invasion, and histologic type. When these three parameters are favorable, local treatment of colorectal cancer does not require additional lymph node dissection.     

Feasibility and reliability of sentinel lymph node biopsy after neoadjuvant chemotherapy in breast cancer patients with positive axillary nodes at initial diagnosis: An up-to-date meta-analysis of 3,578 patients

PurposeNeoadjuvant chemotherapy (NACT) is increasingly adopted in the therapy of breast cancer (BC) patients with positive axillary nodes (cN+), but the reliability and feasibility of sentinel lymph node biopsy (SLNB) following NACT are still controversial. The objective of the present study is to conduct an updated meta-analysis on this issue.MethodsA literature search was performed using PubMed, Cochrane, Embase, and Web of Science to identify papers published from January 1, 2000 to October 22, 2020 to research SLNB after NACT in BC patients. Studies that met the quality standard were enrolled for this meta-analysis.ResultsA total of 3578 participants from 27 trials were included in this meta-analysis. The pooled estimate of the identification rate (IR) for SLNB was 91 %, and the false negative rate (FNR) was 15 %. The pooled negative prediction value (NPV), accuracy, specificity, and sensitivity were 82 %, 89 %, 97 %, and 85 %, respectively. In subgroup analysis, the application of dual mapping could clearly decrease the FNR. The FNR was significantly high in the luminal types, and it declined as more sentinel lymph nodes (SLNs) were removed.ConclusionSLNB following NACT is now technically feasible for BC with cN+. However, it must be emphasized that the FNR is unacceptable high.     

Sentinel lymph node surgery after neoadjuvant chemotherapy in patients with T2 to T4, N0 and N1 breast cancer

BackgroundHistological status of axillary lymph nodes is an important prognostic factor in patients receiving surgery for breast cancer (BC). Sentinel lymph node (SLN) biopsy (B) has rapidly replaced axillary lymph node dissection (ALND), and is now the standard of care for axillary staging in patients with clinically node-negative (N0) operable BC. The aim of this study is to compare pretreatment lymphoscintigraphy with a post primary systemic treatment (PST) scan in order to reduce the false-negative rates for SLNB.MethodsIn this single-institution study we considered 170 consecutive T2-4 N0-1 M0 BC patients treated with anthracycline-based PST. At the time of incisional biopsy, we performed sentinel lymphatic mapping. After PST, all patients repeated lymphoscintigraphy with the same methodology. During definitive surgery we performed further sentinel lymphatic mapping, SLNB and ALND.ResultsThe SLN was removed in 158/170 patients giving an identification rate of 92.9% (95% confidence interval (CI) = 88.0–96.3%) and a false-negative rate of 14.0% (95% CI = 6.3–25.8%). SLNB revealed a sensitivity of 86.0% (95% CI = 74.2–93.7%), an accuracy of 94.9% (95% CI = 90.3–97.8%) and a negative predictive value of 92.7% (95% CI = 86.1–96.8%).ConclusionIdentification rate, sensitivity and accuracy are in accordance with other studies on SLNB after PST, even after clinically negative node conversion following PST. This study confirms that diagnostic biopsy and neoadjuvant chemotherapy maintain breast lymphatic drainage unaltered.     

Performance of models predicting residual lymph node disease in melanoma patients following sentinel lymph node biopsy

BackgroundAmong melanoma patients with a tumor-positive sentinel node biopsy (SNB), approximately 20% harbor disease in non-sentinel nodes (nSN), as determined by a completion lymph node dissection (CLND). CLND lacks a survival benefit and has high morbidity. This study assesses predictive factors for nSN metastasis and validates five models predicting nSN metastasis.MethodsPatients with invasive melanoma were identified from the BC Cancer Agency (2005–2015). Clinicopathological data were collected from 296 patients who underwent a CLND after a positive SNB. Multivariate analysis was completed to assess predictive variables in the study population. Five models were externally validated using overall model performance (Brier score [calibration and discrimination]) and discrimination (area under the ROC curve [AUC]).ResultsSeventy-three patients had nSN metastasis at the time of CLND. The variable most predictive of nSN involvement was lymphovascular invasion (odds ratio [OR] 3.99; 95% confidence interval [CI] 1.67–9.54; p = 0.002). The highest discrimination was Lee et al. (2004) (AUC 0.68 [95% CI 0.61–0.75]), Rossi et al. (2018) (AUC 0.68 [95% CI 0.57–0.77]), and Bertolli et al. (2019) (AUC 0.68 [95% CI 0.60–0.75]). Rossi et al. (2018) had the lowest overall model performance (Brier score 0.44). Rossi et al. (2018) and Bertolli et al. (2019) had the ability to stratify patients to a risk of nSN involvement up to 99% and 95%, respectively.ConclusionBertolli et al. (2019) had amongst the highest overall model performance, was the most clinically meaningful and is recommended as the preferred model for predicting nSN metastasis.     

Detection of mediastinal lymph node metastasis from lung cancer with positron emission tomography (PET) using 11C-methionine]

Twenty-five patients with primary non-small cell lung cancer underwent the positron emission tomography (PET) using 11C-methionine to detect the mediastinal lymph node metastasis. We introduced the positron angiography to recognize precisely the anatomical orientation of the mediastinal lymph nodes. The 11C-uptake of the lymph node was expressed with distribution absorption ratio (DAR). A total 107 lymph nodes were examined. The average DAR in metastatic lymph nodes (n = 28) was 3.89 while that of non-metastatic nodes (n = 79) was 2.38 indicating a significant difference (p < 0.001). The most adequate threshold for detection of metastasis was 3.3 with sensitivity of 100%, and specificity of 87.3% and overall accuracy of 89.7%. Metastasis of squamous cell carcinoma was diagnosed more accurately than that of adenocarcinoma. Thus, PET using 11C-methionine may offer a new method to detect the mediastinal lymph node metastasis from lung cancer.     

Level III axillary lymph nodes involvement in node positive breast cancer received neoadjuvant chemotherapy

ObjectiveTo investigate the incidence, associated factors and prognosis of level III node involvement for breast cancer with positive axillary lymph nodes after neoadjuvant chemotherapy.MethodsA consecutive series of 521 node positive T_0–2 invasive breast cancer cases were included in this retrospective study. Axillary node metastases were proved by ultrasound guided needle biopsy (NB) if ultrasonographic abnormal node was detected or by sentinel node biopsy (SNB) if no abnormal node was detected. After 4 to 8 cycles of neoadjuvant chemotherapy (NCT）, axillary lymph nodes dissection included level III lymph nodes were completed for each case.ResultsThe pathologic complete response rate of axillary nodes was 31.1% (90/289) in NB positive subgroup. The incidence of residual positive level III lymph nodes were 9.0% (47/521). Multivariate analysis showed that node NB positivity (OR = 2.212, 95% CI: 1.022–4.787, P = 0.044), clinical tumor size >2 cm before NCT (OR = 2.672, 95% CI: 1.170–6.098, P = 0.020), and primary tumor non-response to neoadjuvant chemotherapy (OR = 1.718, 95% CI: 1.232–2.396, P = 0.001) were independent predictors of level III lymph nodes positivity. At median follow-up time of 30 months, the distant disease-free survival (DDFS) rate of level III node positive group was much lower than that of level III negative group (p = 0.011).ConclusionsAbout 9% of node positive T_0–2 breast cancer will have residual positive node in level III region after neoadjuvant chemotherapy. Node positivity proved by NB, large tumor size, and primary tumor non-response to neoadjuvant chemotherapy are independent predictors of level III lymph nodes positivity.     

Prospective Analysis of Accuracy of Positron Emission Tomography,Computed Tomography,and Endoscopic Ultrasonography in Staging of Adenocarcinoma of the Esophagus and the Esophagogastric Junction

Background: Exact preoperative staging of esophageal cancer is essential for accurate prognosis and selection of appropriate treatment modalities.Methods: Forty-two patients with adenocarcinoma of the esophagus or the esophagogastric junction suitable for radical esophageal resection were staged with positron emission tomography (PET), spiral computed tomography (CT), and endoscopic ultrasonography (EUS).Results: Diagnostic sensitivity for the primary tumor was 83% for PET and 67% for CT; for local peritumoral lymph node metastasis, it was 37% for PET and 89% for EUS; and for distant metastasis, it was 47% for PET and 33% for CT. Diagnostic specificity for local lymph node metastasis was 100% with PET and 54% with EUS, and for distant metastasis, it was 89% for PET and 96% for CT. Accuracy for locoregional lymph node metastasis was 63% for PET, 66% for CT, and 75% for EUS, and for distant metastasis, it was 74% with PET and 74% with CT. Of the 10 patients who were considered inoperable during surgery, PET identified 7 and CT 4. The false-negative diagnoses of stage IV disease in PET were peritoneal carcinomatosis in two patients, abdominal para-aortic cancer growth in one, metastatic lymph nodes by the celiac artery in four, and metastases in the pancreas in one. PET showed false-positive lymph nodes at the jugulum in three patients.Conclusions: The diagnostic value of PET in the staging of adenocarcinoma of the esophagus and the esophagogastric junction is limited because of low accuracy in staging of paratumoral and distant lymph nodes. PET does, however, seem to detect organ metastases better than CT.     

Similarities and differences in fluorodeoxyglucose positron emission tomography/computed tomography findings in spondyloarthropathy,polymyalgia rheumatica and rheumatoid arthritis

ObjectivesWe assessed fluorine-18 (¹⁸F)-labelled fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) findings in patients with seronegative spondyloarthritis (SpA), polymyalgia rheumatica (PMR), and rheumatoid arthritis (RA).MethodsWe studied 53 patients with SpA (n = 21), PMR (n = 16), or RA (n = 16) admitted to our hospital between 2006 and 2011. Disease activity in the ischial tuberosities, greater trochanters, spinous processes, vertebral bodies, and sacroiliac joints (SIJ) were evaluated by determining FDG accumulation using maximum standardized uptake values (SUV_max) and FDG scores.ResultsSUV_max for ischial tuberosities was significantly higher in PMR than SpA or RA. SUV_max for greater trochanters and spinous processes was significantly higher in PMR than RA (P < 0.001) and significantly higher in SpA than in PMR or RA for SIJ (P = 0.01). No significant difference in vertebral scores was observed among groups (P = 0.488). FDG scores yielded similar results. X-ray findings were consistent with PET/CT findings in 3/15 (20%) patients with sacroiliitis, whereas magnetic resonance imaging findings were consistent with PET/CT findings in 4/7 (57.1%) patients.ConclusionsPET/CT detection of inflammation in the ischial tuberosities, greater trochanters, and spinous processes discriminated between PMR and RA, but not between SpA and PMR. PET/CT findings can distinguish SpA from RA and PMR and are useful for the early diagnosis of sacroiliitis.