Lymph node staging in non-small cell lung cancer: evaluation by [18F]FDG positron emission tomography (PET)

BACKGROUND: A study was undertaken to investigate the accuracy of positron emission tomography (PET) with 2-[18F]-fluoro-2-deoxy-D- glucose (FDG) in the thoracic lymph node staging of non-small cell lung cancer (NSCLC). METHODS: Forty six patients with focal pulmonary tumours who underwent preoperative computed tomographic (CT) and FDG- PET scanning were evaluated retrospectively. Thirty two patients had NSCLC and 14 patients had a benign process. The final diagnosis was established by means of histopathological examination at thoracotomy, and the nodal classification in patients with lung cancer was performed by thorough dissection of the mediastinal nodes at surgery. RESULTS: FDG-PET was 80% sensitive, 100% specific, and 87.5% accurate in staging thoracic lymph nodes in patients with NSCLC, whereas CT scanning was 50% sensitive, 75% specific, and 59.4% accurate. The absence of lymph node tumour involvement was identified by FDG-PET in all 12 patients with NO disease compared with nine by CT scanning. Lymph node metastases were correctly detected by FDG-PET in three of five patients with N1 disease compared with two by CT scanning, in nine of 11 with N2 disease compared with six by CT scanning, an in all four with N3 nodes compared with two by CT scanning. CONCLUSIONS: FDG-PET provides a new and effective method for staging thoracic lymph nodes in patients with lung cancer and is superior to CT scanning in the assessment of hilar and mediastinal nodal metastases. With regard to resectability, FDG-PET could differentiate reliably between patients with N1/N2 disease and those with unresectable N3 disease.     

Effectiveness of positron emission tomography for the detection of melanoma metastases.

OBJECTIVE: The purpose of this study was to determine the sensitivity, specificity, and clinical utility of 18F 2-fluoro-2-deoxy-D-glucose (FDG) total-body positron emission tomography (PET) scanning for the detection of metastases in patients with malignant melanoma. SUMMARY BACKGROUND DATA: Recent preliminary reports suggest that PET using FDG may be more sensitive and specific for detection of metastatic melanoma than standard radiologic imaging studies using computed tomography (CT). PET technology is showing utility in the detection of metastatic tumors from multiple primary sites including breast, lung, lymphoma, and melanoma. However, little information is available concerning the general utility, sensitivity, and specificity of PET scanning of patients with metastatic melanoma. METHODS: One hundred three PET scans done on 76 nonrandomized patients having AJCC stage II to IV melanoma were prospectively evaluated. Patients were derived from two groups. Group 1 (63 patients) had PET, CT (chest and abdomen), and magnetic resonance imaging (MRI; brain) scans as a part of staging requirements for immunotherapy protocols. Group 2 (13 nonprotocol patients) had PET, CT, and MRI scans as in group 1, but for clinical evaluation only. PET scans were done using 12 to 20 mCi of FDG given intravenously. Results of PET scans were compared to CT scans and biopsy or cytology results. RESULTS: PET scanning for the detection of melanoma metastases had a sensitivity of 94.2% and a specificity of 83.3% compared to 55.3% and 84.4%, respectively, for CT scanning. Factors that produced false-positive PET scans were papillary carcinoma of the thyroid (1), bronchogenic carcinoma (1), inflamed epidermal cyst (1), Warthin's tumor of the parotid gland (1), surgical wound inflammation (2), leiomyoma of the uterus (1), suture granuloma (1), and endometriosis (1). The four false-negative scans were thought to be due to smaller (<0.3 to 0.5 cm) and diffuse areas of melanoma without a mass effect. CONCLUSIONS: PET scanning is extremely sensitive (94.2%) and very specific (83.3%) for identifying metastatic melanoma, particularly in soft tissues, lymph nodes, and the liver. A number of second primary or metastatic tumors and an inflammatory response can also be localized by PET. This observation mandates a close clinical correlation with positive PET and emphasizes the importance of establishing a tissue diagnosis. False-negative scans in the presence of metastases are rare (4% of scans). Metastases < or =5 mm in diameter may not image well. PET is superior to CT in detecting melanoma metastases and has a role as a primary strategy in the staging of melanoma.     

Factors associated with false-positive staging of lung cancer by positron emission tomography

BACKGROUND: Positron emission tomography imaging is gaining popularity as a noninvasive staging tool in non-small cell lung cancer. Nonmalignant processes can also affect radio-tracer uptake. This study seeks to identify factors associated with false-positive staging of mediastinal metastases. METHODS: A retrospective review was performed of 100 patients with early stage non-small cell lung cancer referred for positron emission tomography scan evaluation. All had pathologic confirmation of their disease. Positron emission tomography scans, radiology records, operative reports, and pathology results were reviewed. Patients with positron emission tomography scans interpreted as positive for mediastinal involvement and negative pathology at operation were selected. RESULTS: Seven patients were found to have a false-positive positron emission tomography evaluation for mediastinal metastases. All but 1 patient had a concurrent inflammatory process or an anatomic factor associated with the false positive. The sensitivity and specificity in detecting involved mediastinal nodes was 87.5% and 90.7%, respectively. The negative predictive value was 95.8%. CONCLUSIONS: Although positron emission tomography has been established as an accurate modality to stage non-small cell lung cancer, false-positive evaluation of mediastinal metastases can occur in the setting of concurrent inflammatory lung diseases or for centrally located tumors. Pathologic evaluation of mediastinal disease should be pursued whenever suggested by a positive positron emission tomography scan especially in the face of those factors described.     

Comparative efficacy of positron emission tomography with FDG and computed tomographic scanning in preoperative staging of non-small cell lung cancer

OBJECTIVE: To determine the sensitivity, specificity, and accuracy of positron emission tomography with 2-fluorine-18-fluorodeoxyglucose (PET-FDG) in the preoperative staging (N and M staging) of patients with lung cancer. The authors wanted to compare the efficacy of PET scanning with currently used computed tomography (CT) scanning. MATERIALS AND METHODS: Results of whole-body PET-FDG imaging and CT scans were compared with histologic findings for the presence or absence of lymph node disease or metastatic sites. Sampling of mediastinal lymph nodes was performed using mediastinoscopy or thoracotomy. RESULTS: PET-FDG imaging was significantly more sensitive, specific, and accurate for detecting N disease than CT. PET changed N staging in 35% and M staging in 11% of patients. CT scans helped in accurate anatomic localization of 6/57 PET lymph node abnormalities. CONCLUSION: PET-FDG is a reliable method for preoperative staging of patients with lung cancer and would help to optimize management of these patients. Accurate lymph node staging of lung cancer may be ideally performed by simultaneous review of PET and CT scans.     

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.     

Impact of F18-fluorodeoxyglycose positron emission tomography/computed tomography on the management of resectable pancreatic tumours

Background: Positron emission tomography/computed tomography (PET/CT) using F18‐fluorodeoxyglucose has been shown to be valuable in the management of malignant disease. The aim of this study is to investigate the impact of this technique on the management of patients with resectable pancreatic tumours. Methods: Thirty‐six patients with 37 potentially resectable pancreatic tumours on diagnostic CT imaging underwent PET/CT scans. Operative findings, histological reports and/or clinical follow‐up served as standard of reference. The impact of PET/CT on patient management was estimated by calculating the percentage of patients whose treatment plan was altered due to PET/CT. Results: Pancreatic adenocarcinoma was diagnosed in 30 patients, neuroendocrine tumours in 3, mass‐forming pancreatitis in 3 and serous cystadenoma in 1. The median standard uptake (max) value was 5.0 (range 2.2–12.0). Sensitivity and specificity of detecting extrapancreatic metastatic disease were 73% and 100%, respectively. Three occult liver metastases were detected at laparotomy following negative PET/CT. PET/CT findings influenced the management of 8 (22%) patients – 3 with liver metastases, 3 with bone metastases, 1 with lymph node metastases and 1 by identifying the benign appearance of the pancreatic tumour. Conclusion: PET/CT achieves a significant diagnostic impact in detecting extrapancreatic metastatic disease. F18‐fluorodeoxyglucose PET/CT appears to be useful in assessing suspicious pancreatic masses.     

PET, CT, and MRI with Combidex for mediastinal staging in non-small cell lung carcinoma.

BACKGROUND: To determine the relative utility of positron emission tomography (PET), computed tomography (CT), and magnetic resonance imaging with Combidex (MRI-C) in the non-invasive staging of non-small cell lung cancer (NSCLC) mediastinal lymph nodes (MLN), we compared the three tests' individual performance with surgical mediastinal sampling. In contrast to prior studies, cytology was not used. METHODS: The MLN were evaluated using PET and CT in 64 NSCLC patients. MRI-C was performed in 9 of these patients. MLN with a PET standard uptake value greater than or equal to 2.5, or greater than 1 cm in the short axis by CT or lack of MRI-C signal change were considered positive for metastatic disease. All MLN were sampled and subjected to standard pathologic analysis. PET, CT, and MRI-C scans were interpreted blinded to the histopathological results. Sensitivity, specificity, and accuracy for each scan type to appropriately stage MLN was determined using pathologic results as the standard. RESULTS: Thirty patients had stage I disease, 8 stage II, 9 stage IIIA, 7 stage IIIB, and 10 stage IV. Two-hundred-and-thirty MLN were sampled. Sixteen patients had metastatic mediastinal disease. Compared to the pathological results, PET, CT, and MRI-C had a sensitivity, specificity, and accuracy of 70%, 86%, 84%; 65%, 79%, 76%; 86%, 82%, and 83%, respectively. PET and MRI-C were statistically more accurate than CT (p<0.001). In cases where PET and CT did not identify MLN involvement with NSCLC, 8% (2/25) were pathologically positive. CONCLUSIONS: PET and MRI-C are statistically more accurate than CT. However, the differences are small and may not be clinically relevant. No technique was sensitive or specific enough to change the current recommendation to perform mediastinoscopy for MLN staging in NSCLC.     

Positron emission tomography in the initial staging of esophageal cancer

OBJECTIVE: To assess the value of positron emission tomography (PET) compared with computed tomography (CT) in the initial staging of esophageal cancer. DESIGN: Case series. SETTING: Tertiary care veterans hospital. PATIENTS: Patients with newly diagnosed esophageal cancers from January 1996 through May 2001 who underwent both CT and PET scanning within 4 weeks were included in the study (n = 24). Only patients who underwent pathological or radiographic follow-up were included. MAIN OUTCOME MEASURES: The sensitivity, specificity, and negative and positive predictive values of CT and PET were determined based on a criterion standard of pathological staging in 16 patients (67%) and follow-up imaging in 8 patients (33%). RESULTS: For staging regional lymph node involvement, CT and PET scans showed no statistically significant difference in sensitivity (57% and 71%, respectively) and specificity (71% and 86%, respectively). For detection of metastatic disease, CT and PET showed no significant difference in sensitivity (83% and 67%, respectively) and specificity (75% and 92%, respectively). There was no significant difference in clinical decision making when the results of both tests were discordant. CONCLUSIONS: There was no significant difference between the 2 imaging modalities in the initial staging of esophageal cancer. The CT scan was a sensitive indicator of distant metastases, whereas PET was more specific. It is unclear what additional role PET scanning should have in the initial screening of patients.     

Fluorodeoxyglucose positron emission tomography integrated with computed tomography to determine resectability of primary lung cancer

PURPOSE: Fluorodeoxyglucose positron emission tomography integrated with computed tomography (FDGPET/CT) was evaluated as a routine staging technique for primary lung cancer. MATERIALS AND METHODS: We prospectively compared FDG-PET/CT in determining clinical stage and surgical indication with conventional staging not including positron emission tomography (PET). A total of 50 consecutive patients diagnosed with primary lung cancer by cytological or histological examination were studied; 20 of them underwent surgery. RESULTS: Discrepancies between the two staging methods were observed in 14 patients (28%). The stage assigned by PET increased in 12 cases (24%) and decreased in 2 (4%). PET staging was accurate in eight cases with otherwise undetected distant metastases (M1) but was incorrect in six cases, including five where it overdiagnosed nodal metastases (N). Two clinical N3 patients (4%) would have missed a chance of surgery if the surgical indication had been determined by PET staging alone. According to our criteria for surgery, other patients were assigned correctly to surgery by PET staging. The maximum standard uptake value (maxSUV) of all primary lesions ranged from 0 to 23.0 (mean +/- SD, 8.0 +/- 4.4). The mean maxSUV among surgical cases (5.8 +/- 3.6) was significantly smaller than among nonsurgical cases (9.5 +/- 4.2) (P < 0.05). CONCLUSION: Staging examination including FDG-PET/CT and brain magnetic resonance imaging ordinarily can determine the clinical stage and resectability of primary lung cancer. False-positive findings in regional lymph nodes, possibly reflecting past infectious disease, are the most important remaining problem.     

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.     

Scanning with 18F-FDG-PET/CT for Detection of Pelvic Nodal Involvement in Inguinal Node-Positive Penile Carcinoma

Background

Penile carcinoma patients with inguinal lymph node involvement (LNI) have an increased risk for pelvic nodal involvement with or without distant metastases.

Objective

To evaluate the diagnostic accuracy of fluorine-18 fluorodeoxyglucose (18F-FDG) positron emission tomography (PET) with computed tomography (CT; 18F-FDG PET/CT) scanning in determining further metastatic spread in patients with tumour-positive inguinal nodes.

Design, setting, and participants

Eighteen patients with penile squamous cell carcinoma with unilateral or bilateral cytologically tumour-positive inguinal disease underwent whole-body 18F-FDG-PET/CT scanning for tumour staging.

Measurements

Images were blindly assessed by two nuclear medicine physicians. All scans were evaluated for pelvic nodal involvement per basin and for distant metastases. Histopathology (when available), radiologic imaging, and clinical follow-up (with a minimum of 1 yr) served as a reference standard. The diagnostic value of PET/CT scanning for predicting pelvic nodal involvement was evaluated using standard statistical methods.

Results and limitations

The reference was available in 28 of the 36 pelvic basins. Of the 11 tumour-positive pelvic basins, 10 were correctly predicted by PET/CT scan, as were all 17 tumour-negative pelvic basins. PET/CT scan showed a sensitivity of 91%, a specificity of 100%, a diagnostic accuracy of 96%, a positive predictive value of 100%, and a negative predictive value of 94% in detecting pelvic nodal involvement. Additionally, PET/CT scans showed distant metastases in five patients. In four patients, the presence of distant metastases could be confirmed, while in one patient, no radiologic confirmation was found for that particular lesion. A potential limitation is that the diagnostic accuracy of PET/CT scanning was calculated on 28 pelvic basins only. Furthermore, no comparison was made with conventional CT scans, as not all patients had undergone contrast-enhanced CT scans.

Conclusions

PET/CT scanning appears promising for detecting pelvic lymph node metastases with great accuracy, and it identifies distant metastases in penile carcinoma patients with inguinal LNI. In our practice, PET/CT scanning has become part of routine staging in such patients.     

Role of positron emission tomography in mediastinal lymphatic staging of non-small cell lung cancer.

OBJECTIVE: Positron emission tomography (PET) is used increasingly in staging of non-small cell lung cancer (NSCLC) as a non-invasive tool. The role of the PET in mediastinal lymphatic staging of NSCLC is not clear. We aimed to demonstrate the efficacy of PET in determining mediastinal lymphatic metastasis by comparing the results of PET with mediastinoscopy. PATIENTS AND METHODS: We performed PET preoperatively in 170 patients with clinically operable NSCLC between 2004 and 2006. Stations defined as metastasis by PET (SUV(max) >2.5) were recorded. Mediastinoscopy was performed initially in all patients and a total of 687 stations which can be reached with mediastinoscope were sampled (mean 4.04). Forty-three patients with mediastinal metastasis were referred to the oncology clinic for chemotherapy while lung resection and complete mediastinal lymphatic dissection through thoracotomy was performed in the remaining 127 patients. Involvement of mediastinal lymph nodes was verified to compare the sensitivity and specificity of mediastinoscopy and the related PET results. RESULTS: Histopathologic classification of the tumors revealed 79 squamous carcinomas and 58 adenocarcinomas. False positivity rate of PET was 26% (95% CI: 14-38), false negativity was 25% (95% CI: 18-33), sensitivity was 74% (95% CI: 63-86), specificity was 73% (95% CI: 66-82) and accuracy was 74% in mediastinal staging. Negative predictive value of mediastinoscopy was 94% (95% CI: 89-98), positive predictive value 100%, sensitivity 84% (95% CI: 74-94), specificity 100% and accuracy was 95%. CONCLUSION: PET results do not provide acceptable accuracy rates. Mediastinoscopy still remains the gold standard for mediastinal staging of NSCLC, although it cannot reach to all the mediastinal stations.     

Combined contrast-enhanced computed tomography and 18-fluoro-2-deoxy-D-glucose-positron emission tomography in the diagnosis and staging of non-small cell lung cancer

We present the current optimal uses and limitations of positron emission tomography/computed tomography (PET/CT) as it relates to the diagnosis and staging of non-small cell lung cancer (NSCLC). PET/CT demonstrates increased accuracy in the workup of solitary pulmonary nodules for malignancy compared with CT alone, and we discuss its benefits and limitations. We review pitfalls in measured standardized uptake values of lung lesions caused by respiratory artifacts, the lower sensitivity for detection of small lung nodules on non-breath-hold CT, and the benefits of obtaining an additional diagnostic CT for the maximum sensitivity of lung nodule detection. There are limitations of quantitatively comparing separate PET/CT examinations from different facilities with standardized uptake values. As for staging, we describe how PET/CT supplements clinical tumor-nodes-metastases (ie, TNM) staging, as well as mediastinoscopy, endobronchial ultrasound, and endoscopic ultrasound, which are the gold standard pathologic staging methods. We touch on the 7th edition TNM staging system based on the work by the International Association for the Study of Lung Cancer, an anatomically based staging method.     

PET/CT Fusion Scan Enhances CT Staging in Patients with Pancreatic Neoplasms

Background  The role of fusion positron emission tomography/computed tomography scans (PET/CT) in staging of patients with pancreatic neoplasms (PN) is poorly defined. PET/CT may serve as an adjunct to standard imaging by increasing occult metastases detection. The purpose of this study was to assess the additional value, in relation to computed tomography (CT), of PET/CT imaging for patients with PN. Methods  Eighty-two patients with potentially resectable PN underwent staging with PET/CT and CT of the chest and abdomen. Sensitivity of diagnosing pancreatic cancer by PET/CT avidity was evaluated. The sensitivity of detecting metastases was compared between PET/CT, standard CT, and the combination of PET/CT and CT. The impact of PET/CT on patient management was estimated by calculating the percentage of patients whose treatment plan was altered due to PET/CT. Results  The sensitivity and specificity of PET/CT in diagnosing pancreatic cancer were 89% and 88%, respectively. Sensitivity of detecting metastatic disease for PET/CT alone, standard CT alone, and the combination of PET/CT and CT were 61%, 57%, and 87%, respectively. Findings on PET/CT influenced the clinical management in seven patients (11%), two with a supraclavicular lymph node (LN), two occult liver lesions, two peritoneal implants, and one peri-esophageal LN. Conclusion  This study evaluated PET/CT in the initial work-up of patients with PN. PET/CT increased sensitivity (87%) for detection of metastatic disease when combined with standard CT. In invasive cancer, PET/CT changed the management in 11% of our patients. PET/CT should be considered in the initial work-up of patients with potentially resectable pancreatic lesions.     

Anti-CEA immunoscintigraphy and computed tomographic scanning in the preoperative evaluation of mediastinal lymph nodes in lung cancer.

BACKGROUND: Thoracic computed tomography (CT) provides most of the staging information needed before operation for lung cancer and can reduce the number of exploratory thoracotomies. In recent years a new immunoscintigraphic technique with anti-carcinoembryonic antigen (CEA) monoclonal antibodies has been shown to be effective in lung cancer staging. This study compares the yields of CT scans and immunoscintigraphy in the preoperative evaluation of the medistinal lymph nodes of patients with non-small cell lung cancer. METHODS: One hundred and thirty one patients believed on clinical grounds to have a operable non-small cell lung cancer were photoscanned with the indium-111 labelled F(ab')2 fragments of the antibody FO23C5. Both planar and single photoemission computed tomography (SPECT) thoracic views were recorded. CT scan of the thorax, abdomen, and brain were obtained in all patients. Seventy of the patients eventually underwent surgery, an additional seven underwent mediastinoscopy or mediastinotomy, and a further 10 had both cervical exploration and thoracotomy. Pathological evaluation of the mediastinal nodes was available in all 87 patients, but in only 80 of them was the diagnosis of lung cancer eventually confirmed. RESULTS: The diagnostic accuracy of planar immunoscintigraphy, SPECT immunoscintigraphy, and CT scanning for N2 disease was 76%, 74%, and 71%, respectively. The corresponding sensitivity and specificity rates were 45%, 77%, 64% and 88%, 72%, and 74%. These were not significantly different. CONCLUSIONS: This study shows that anti-CEA immunoscintigraphy has no advantage over conventional CT scanning in assessing mediastinal lymphoadenopathy in patients with lung cancer. CT scanning remains the gold standard test in these patients.     

Endoscopic ultrasound in lung cancer patients with a normal mediastinum on computed tomography

BACKGROUND: Computed tomography (CT) is the most common method of staging lung cancer. We have previously shown endoscopic ultrasound guided fine-needle aspiration (EUS-FNA) to be highly accurate in staging patients with nonsmall cell lung cancer (NSCLC) who have enlarged mediastinal lymph nodes on CT scan. In this study we report the accuracy and yield of EUS-FNA in staging patients without enlarged mediastinal lymph nodes by CT. METHODS: Patients with NSCLC and CT scan showing no enlarged mediastinal lymph nodes (> 1 cm for all nodes except > 1.2 cm for subcarinal) in the mediastinum underwent EUS. Fine needle aspiration was performed on at least one lymph node, if present, in the upper mediastinum, aortopulmonary window, subcarinal, and periesophagus regions. Each specimen was evaluated with on-site cytopathology and confirmed with complete cytopathologic examination. RESULTS: Sixty-nine patients without enlarged mediastinal lymph nodes were evaluated. Endoscopic ultrasound detected malignant mediastinal lymph nodes in 14 of 69 patients as well as other advanced (American Joint Committee on Cancer [AJCC] stage III/IV) in 3 others (1 left adrenal, and 2 with mediastinal invasion of tumor) for a total of 17 of 69 (25%, 95% confidence interval: 16% to 34%) patients. Eleven additional patients were found to have advanced disease by bronchoscopy (2), mediastinoscopy (2), and thoracotomy with mediastinal lymph node dissection (7). The sensitivity of EUS for advanced mediastinal disease was 61% (49% to 75%), and the specificity was 98% (95% to 100%). CONCLUSIONS: Endoscopic ultrasound guided fine needle aspiration can detect advanced mediastinal disease and avoid unnecessary surgical exploration in almost one of four patients who have no evidence of mediastinal disease on CT scan. In addition to previously reported results in patients with enlarged lymph nodes on CT, these data suggest that all potentially operable patients with nonmetastatic NSCLC may benefit from EUS staging.     

Transcervical extended mediastinal lymphadenectomy--the new operative technique and early results in lung cancer staging.

OBJECTIVE: Mediastinal staging is one of the most important problems in thoracic surgery. Although the pathological examination is a generally accepted standard, none of the currently used techniques enables complete removal of all lymph node stations of the mediastinum. The aim of the study is to present a new technique of transcervical extended mediastinal lymphadenctomy (TEMLA) and to analyze its value in lung cancer staging. METHODS: In the prospective study of consecutive group of non-small cell lung cancer (NSCLC) patients, operated on between January and August 2004, we evaluated the usefulness of this original technique of bilateral mediastinal lymphadenectomy, assessing its accuracy and safety. The operations were performed through the transcervical approach, were videomediastinoscopy-assisted, with sternum elevation. Lymph node stations 1, 2R, 2L, 3a, 4R, 4L, 5, 6, 7 and 8 were removed. In patients without mediastinal metastases thoracotomy with pulmonary resection was performed and mediastinum searched for any missed lymph nodes. RESULTS: There were 83 patients operated on with the TEMLA technique. The mean number of nodes removed was 43 (range: 26-85). The sensitivity, specificity and accuracy of the presented method in detecting mediastinal node metastases were: 90, 100, and 96%, respectively, whereas the positive and negative predictive values were: 100 and 95%, respectively. CONCLUSIONS: The TEMLA technique is a safe and highly accurate method of mediastinal staging in NSCLC.     

Peripheral small-sized (2 cm or less) non-small cell lung cancer with mediastinal lymph node metastasis; clinicopathologic features and patterns of nodal spread

Objective: The diagnosis of small-sized (2 cm or less) non-small cell lung cancer (NSCLC) has increased with the development of computed tomography (CT), whereas unexpected extensive multiple-level mediastinal involvement has been occasionally detected in this small-sized lung cancer. To establish the optimal surgical strategy, we retrospectively analyzed the clinicopathologic features, efficacy of preoperative investigations and lobe specific patterns of nodal spread in small-sized NSCLC with mediastinal involvement. Methods: Among 1550 resected lung cancer cases between 1981 and 2000, 267 (17.2%) had peripheral small-sized NSCLC. Of these, 29 patients (10.8%) with mediastinal lymph node involvement who underwent pulmonary resection and systematic nodal dissection were reviewed. Results: Among 29 patients, 27 patients (93.1%) were adenocarcinoma, and 51.7% (15/29) showed no lymph node enlargement on CT (cN0). Surgical pathology revealed multiple-level mediastinal involvement in 65.5% (19/29) of all patients and 60.0% (9/15) of cN0 patients. All of right upper lobe tumors (n=11) showed multiple-level involvement. Thallium-201 single photon emission computed tomography (201Tl-SPECT) was positive for increased focal uptake in the mediastinum in 72.7% (8/11) of patients. Conclusions: The vast majority of cases were adenocarcinoma, and two thirds of them showed multiple-level mediastinal involvement, even in cN0 patients. We thus recommend to perform systematic nodal dissection or meticulous sampling for accurate intrathoracic staging, especially for right upper lobe tumor. 201Tl-SPECT appears to be more sensitive preoperative investigation for mediastinal metastasis compared with CT scan.     

The Value of Radiographic and Computed Tomography in the Staging of Lung Carcinoma

A prospective double-blind study was undertaken to compare computed tomography (CT) and conventional radiographic tomography (RT) in the staging of lung carcinoma. Seventy-five patients had CT and RT of the mediastinum and hilum prior to operation. The presence or absence of metastasis to lymph nodes documented at the time of operation was the standard applied to the studies. CT correctly predicted the presence or absence of mediastinal lymphadenopathy in most cases (sensitivity 91%, specificity 94%), while RT was less helpful (sensitivity 61%, specificity 86%). Metastatic mediastinal lymph nodes in those patients with false negative CT and RT studies averaged only 0.8 cm in diameter, probably accounting for the negative radiographic findings. Both CT and RT had poor predictive values in detecting hilar lymphadenopathy (sensitivity 73% and 47%, specificity 87% and 72%, respectively).The predictive value of CT in the evaluation of mediastinal lymphadenopathy equaled that of mediastinoscopy or mediastinotomy. When CT of the mediastinum demonstrates no lymphadenopathy, invasive staging can be deferred for definitive thoracotomy. Since false positive values were seen with both CT and RT scans of the mediastinum (4% and 8%, respectively), invasive staging will still be necessary in those patients with positive studies.     

Fluorodeoxyglucose positron emission tomography improves preoperative staging of resectable lung metastasis

OBJECTIVE: F-18 fluorodeoxyglucose positron emission tomography (FDG-PET) is now a procedure of proven clinical value in the staging of primary lung cancer. This study evaluated the role of PET in the preoperative assessment of resectable lung metastases. METHODS: Eighty-six patients with previously treated malignancy and proven or suspected lung metastases, deemed resectable at computed tomography scan, were investigated with 89 preoperative PET procedures. Primary tumor sites were: gastrointestinal in 32 cases, sarcoma in 13, urologic in 14, breast in 8, head and neck in 7, gynecologic in 5, thymus in 5, other in 5. Seventy lung resections were performed in 68 patients of whom only 54 proved to be lung metastasis, 7 were primary lung tumors, and 9 were benign lesions. RESULTS: In 19 cases (21%) lung surgery was excluded on the basis of PET scan results due to extrapulmonary metastases (11 cases), primary site recurrence (2), mediastinal adenopathy (2), or benign disease (4). All mediastinal node metastases (7 cases) were detected by PET with a sensitivity, accuracy, and negative predictive value for mediastinal staging of 100%, 96%, and 100%, respectively, versus 71%, 92%, and 95% of the computed tomography scan. In the group of patients who underwent lung resection, PET sensitivity for detection of lung metastasis was 87%. CONCLUSIONS: PET scan proved to be a valuable staging procedure in patients with clinically resectable lung metastasis and changed the therapeutic management in a high proportion of cases.