Detection of extrapulmonary lesions with integrated PET/CT in the staging of lung cancer

Canadian Consensus Recommendations for the Management of Operable Stage II/III Non-Small-Cell Lung Cancer: Results of a Modified Delphi Process

The treatment paradigm for patients with stage II/III non-small-cell lung cancer (NSCLC) is rapidly evolving. We performed a modified Delphi process culminating at the Early-stage Lung cancer International eXpert Retreat (ELIXR23) meeting held in Montreal, Canada, in June 2023. Participants included medical and radiation oncologists, thoracic surgeons and pathologists from across Quebec. Statements relating to diagnosis and treatment paradigms in the preoperative, operative and postoperative time periods were generated and modified until all held a high level of consensus. These statements are aimed to help guide clinicians involved in the treatment of patients with stage II/III NSCLC.

Clinical value of PET/CT in identifying patients with oligometastatic/oligoprogressive disease among first-line tyrosine kinase inhibitor-treated advanced EGFR-mutant non-small cell lung cancer: Implications from survival comparisons

OBJECTIVE

Local therapy (LT) could potentially prolong the survival of patient with advanced epidermal growth factor receptor (EGFR)-mutant non-small cell lung cancer (NSCLC) receiving tyrosine kinase inhibitors (TKIs) and harboring oligometastatic/oligoprogressive disease (OMD/OPD). However, the optimal imaging method for identifying patients with OMD/OPD remains controversial. The objective of this study was to investigate the clinical value of incorporating PET/CT in detecting patients with OMD/OPD.

METHODS

Consecutive cases with metastatic EGFR-mutant NSCLC undergoing first-line EGFR-TKI treatment were retrospectively screened and those receiving baseline PET/CT and brain magnetic resonance imaging (MRI) or complete conventional imaging (CIM), including brain MRI, chest computed tomography (CT), abdomen ultrasound or CT and bone scintigraphy were included. OMD/OPD was defined as metastases/progressions documented at a maximum of five lesions and three organs, otherwise was defined as multiple metastatic/progressive disease (MMD/MPD). Progression-free survival (PFS) and overall survival (OS) were analyzed.

RESULTS

Of the 392 patients evaluated, baseline OMD was detected in 22.7% (53/233) of patients by PET/CT and in 18.2% (29/159) of patients by CIM (p = 0.171). Among the patients evaluated with baseline PET/CT, patients with OMD had longer PFS (p = 0.016) and tendency of improved OS (p = 0.058) than those with MMD. However, this result was not observed with patients evaluated using baseline CIM. With a median follow-up of 24.2 (range, 1.1-124.6) months, 297 patients had their first disease progression (FPD), of whom 164 (55.2%) had adequate imaging scans to analyze the tumor distributions at FPD comprehensively. OPD was detected in 63.0% (34/54) and 35.0% (39/110) of patients among the PET/CT and CIM assessed group (p = 0.003), respectively. Among the PET/CT assessed group, patients with OPD had significantly longer post-progressive overall survival (OS2) than those with MPD (p = 0.011). However, no significant difference of OS2 in the CIM assessed group was found.

CONCLUSION

Patients with OMD/OPD, evaluated by PET/CT but not CIM, generally had more favorable survival outcomes than those with MMD/MPD among patients with metastatic NSCLC undergoing first-line EGFR-TKI treatment.

ADVANCES IN KNOWLEDGE

PET/CT seems to affect the survival of patients under first-line EGFR-TKI treated metastatic NSCLC with OMD/OPD.

GOECP/SEOR radiotheraphy guidelines for non-small-cell lung cancer

Non-small cell lung cancer (NSCLC) is a heterogeneous disease accounting for approximately 85% of all lung cancers. Only 17% of patients are diagnosed at an early stage. Treatment is multidisciplinary and radiotherapy plays a key role in all stages of the disease. More than 50% of patients with NSCLC are treated with radiotherapy (curative-intent or palliative). Technological advances-including highly conformal radiotherapy techniques, new immobilization and respiratory control systems, and precision image verification systems-allow clinicians to individualize treatment to maximize tumor control while minimizing treatment-related toxicity. Novel therapeutic regimens such as moderate hypofractionation and advanced techniques such as stereotactic body radiotherapy (SBRT) have reduced the number of radiotherapy sessions. The integration of SBRT into routine clinical practice has radically altered treatment of early-stage disease. SBRT also plays an increasingly important role in oligometastatic disease. The aim of the present guidelines is to review the role of radiotherapy in the treatment of localized, locally-advanced, and metastatic NSCLC. We review the main radiotherapy techniques and clarify the role of radiotherapy in routine clinical practice. These guidelines are based on the best available evidence. The level and grade of evidence supporting each recommendation is provided.

A 58-Year-Old Man with a Painful Gluteal Mass as the First Presentation of Metastatic Adenocarcinoma of the Lung

Patient: Male, 58-year-old

Final Diagnosis: Metastatic lung adenocarcinoma

Symptoms: Gluteal mass

Medication:—

Clinical Procedure: —

Specialty: Oncology • Pulmonology

New revisions and current issues in the eighth edition of the TNM classification for non-small cell lung cancer

In the eighth edition of the TNM classification of lung cancer, the prognostic impact of tumor size is emphasized as a descriptor of all T categories. Especially in lung cancer where tumor size is 5 cm or less, the 1-cm cutoff point significantly differentiated the survival outcome. In addition, the new staging categories were assigned, namely, Tis (adenocarcinoma in situ) and T1mi (minimally invasive adenocarcinoma). Furthermore, the measurement of a radiological solid component size excluding the ground glass opacity component or pathological invasive size without a lepidic component was proposed for deciding the cT/pT categories for lung adenocarcinoma. The N descriptors were kept the same as in the eventh edition on the whole, however, quantification of nodal disease had a prognostic impact based on the number of nodal stations involved in the eighth edition, i.e. N1a as a single N1 station, N1b as a multiple N1 station, N2a1 as a single N2 station without N1 (skip metastasis), N2a2 as a single N2 station with N1 disease, and N2b as a multiple N2 station. In the M descriptors, subclassification was performed based on the location or numbers of distantly metastatic lesions, i.e. M1a as any intrathoracic metastases, M1b as a single distant metastatic lesion in one organ, and M1c as multiple distant metastases in either a single organ or multiple organs. Survival analysis of the eighth edition of the TNM classification clearly separated the distinct groups, however, unsolved issues still remain that should be discussed and further revised for the forthcoming TNM staging system.

Aberrant methylation of mutL homolog 1 is associated with increased risk of non-small cell lung cancer

BACKGROUND

Non-small cell lung cancer (NSCLC) is a common malignant tumor. DNA hypermethylation in the promoter region has been served as a potential molecular marker for several tumors. The goal of the current study was to assess the diagnostic ability of mutL homolog 1 (MLH1) promoter methylation in NSCLC.

METHODS

A total of 111 NSCLC patients' paired tissue samples were obtained to explore the association between MLH1 promoter methylation and NSCLC by methylation-specific polymerase chain reaction (MSP) method. Public databases including The Cancer Genome Atlas (TCGA) and Gene Expression Omnibus (GEO) were used to verify our findings.

RESULTS

Our results showed a significantly higher MLH1 methylation frequency in tumor tissue samples than their paired adjacent tissues (P = .008). ROC curve indicated that MLH1MSP assay was a sensitive but not a specific method in the diagnosis for NSCLC (sensitivity = 0.964, specificity = 0.135, AUC = 0.550). And the association between the methylation level and clinical characteristics has no statistical significance. TCGA cohort evinced a higher methylation probability in tumor group compared with nontumor group (the mean β value: -0.449 [-0.467, -0.437] vs -0.466 [-0.472, -0.437], P = .011), which was consistent with our results. Meanwhile, an inverse correlation between MLH1 methylation and MLH1 expression was detected in TCGA and GEO databases.

CONCLUSIONS

The MSP method for MLH1 methylation was a sensitive but not a specific diagnostic method for NSCLC.

The IASLC Lung Cancer Staging Project: Proposals for the Revision of the M Descriptors in the Forthcoming Eighth Edition of the TNM Classification of Lung Cancer

INTRODUCTION

The aim of this study is to analyze all metastatic (M) categories of the current tumor, node, and metastasis (TNM) classification of lung cancer with the objective of providing suggestions for modifications of the M component in the next edition of the TNM classification for lung cancer.

METHODS

The new International Association for the Study of Lung Cancer lung cancer database was created from 94,708 patients diagnosed as having lung cancer between 1999 and 2010. Including further patients submitted through the electronic data capture system to Cancer Research and Biostatistics until 2012, all together 1059 non-small-cell lung cancer cases were available for a detailed analysis of the clinical M categories. Overall survival was calculated using the Kaplan-Meier method, and prognosis was assessed using a Cox proportional hazards regression analysis.

RESULTS

No significant differences were found among the M1a (metastases within the chest cavity) descriptors. However, when M1b (distant metastases outside the chest cavity) were assessed according to the number of metastases, tumors with a single metastasis in a single organ had significantly better prognosis than those with multiple metastases in one or several organs.

CONCLUSIONS

In this revision of the TNM classification, cases with pleural/pericardial effusions, contralateral/bilateral lung nodules, contralateral/bilateral pleural nodules, or a combination of multiple of these parameters should continue to be grouped as M1a category. Single metastatic lesions in a single distant organ should be newly designated to the M1b category. Multiple lesions in a single organ or multiple lesions in multiple organs should be reclassified as M1c category. This new division can serve as a first step into providing rational definitions for an oligometastatic disease stage in non-small-cell lung cancer in the future.

Focal fluorine-18 fluorodeoxyglucose-avid parotid findings in patients with lung cancer: prevalence and characteristics

OBJECTIVE

Correct interpretation of incidental tumors is important to plan an appropriate treatment. We assessed the incidence and imaging characteristics of fluorine-18 fluorodeoxyglucose (F-FDG)-avid focal parotid findings (FPFs) in patients with lung cancer.

PATIENTS AND METHODS

FPFs in PET-computed tomography reports of cancer patients were searched. Those with known parotid malignancies, lymphoma, and diffuse F-FDG uptake in the entire parotid gland were not included in the analysis.

RESULTS

FPFs were detected in 38/3120 cancer patients (1.23%), observed as a soft tissue mass with a mean diameter 1.6±0.5 cm (range 0.8-2.7 cm) and a mean maximum standardized uptake value of 7.7±3.7 (range 2.5-17.8). FPFs were observed in 23/604 (3.8%) patients with lung cancer, compared with 6/1366 (0.4%) with breast cancer and 5/842 (0.6%) with gastrointestinal malignancies. We assessed FPFs appearances in 23 patients with lung cancer (18 men, mean age 72.8±9.2); 20 (87%) were current or past smokers. There was no correlation between the stage or histopathological type of the lung cancer and the prevalence of parotid lesions. In four patients with histopathology, no malignancy was detected. For an additional 11 patients with available imaging and clinical follow-up (mean follow-up 15.5±13.5 months, range 3-42 months), FPFs were consistent with benign lesions.

CONCLUSION

FPFs were more prevalent among patients with lung cancer than in patients with other malignancies. As F-FDG avidity was moderate to high, FPFs may mimic distant metastases. It is important to consider FPFs in the interpretation of a focal parotid lesion as misinterpretation may result in denial of appropriate therapy.

2nd ESMO Consensus Conference in Lung Cancer: locally advanced stage III non-small-cell lung cancer

To complement the existing treatment guidelines for all tumour types, ESMO organises consensus conferences to focus on specific issues in each type of tumour. The 2nd ESMO Consensus Conference on Lung Cancer was held on 11-12 May 2013 in Lugano. A total of 35 experts met to address several questions on non-small-cell lung cancer (NSCLC) in each of four areas: pathology and molecular biomarkers, first-line/second and further lines of treatment in advanced disease, early-stage disease and locally advanced disease. For each question, recommendations were made including reference to the grade of recommendation and level of evidence. This consensus paper focuses on locally advanced disease.

A prospective study of the impact of fluorodeoxyglucose positron emission tomography with concurrent non-contrast CT scanning on the management of operable pancreatic and peri-ampullary cancers

BACKGROUND

The role of fluorodeoxyglucose (FDG) positron emission tomography (PET/CT) scanning in operable pancreas cancer is unclear. We, therefore, wanted to investigate the impact of PET/CT on management, by incorporating it into routine work-up.

METHODS

This was a single-institution prospective study. Patients with suspected and potentially operable pancreas, distal bile duct or ampullary carcinomas underwent PET/CT in addition to routine work-up. The frequency that PET/CT changed the treatment plan or prompted other investigations was determined. The distribution of standard uptake values (SUV) among primary tumours, and adjacent to biliary stents was characterised.

RESULTS

Fifty-six patients were recruited. The surgical plan was abandoned in 9 (16%; 95% CI: 6-26) patients as a result of PET/CT identified metastases. In four patients, metastases were missed and seven were inoperable at surgery, not predicted by PET/CT. Unexpected FDG uptake resulted in seven additional investigations, of which two were useful. Among primary pancreatic cancers, a median SUV was 4.9 (range 2-12.1). SUV was highest around the biliary stent in 17 out of 28 cases. PET/CT detected metastases in five patients whose primary pancreatic tumours demonstrated mild to moderate avidity (SUV < 5).

CONCLUSIONS

PET/CT in potentially operable pancreas cancer has limitations. However, as a result of its ability to detect metastases, PET/CT scanning is a useful tool in the selection of such patients for surgery.

Diagnostic evaluation for interventional bronchoscopists and radiologists in lung cancer practice

The global epidemic of lung cancer shows no signs of abating. It is generally accepted that accurate and cost-efficient diagnostic evaluation is the first important step to achieve the best outcomes of treatment. This is true in the context of disease confirmation, treatment planning, treatment monitoring, detection of and management of treatment failure or prognostication. Fortunately, major advances in the diagnostic evaluation of lung cancer have been made in the past three decades allowing more patients to get the appropriate treatment at the right time. This paper outlines how computed tomography, positron emission tomography/computed tomography and endobronchial ultrasound contribute to lung cancer management and discuss their strengths and weaknesses and their complimentary roles at different stages of lung cancer management. Due to financial constraint and reimbursement restrictions, not all clinically important advances in the diagnostic evaluation of lung cancer have been readily accepted into routine clinical care. This enforces the need to maintain ongoing dialogue between cancer clinicians, imaging specialists and health-care economists.

Using pet-ct to reduce futile thoracotomy rates in non-small-cell lung cancer: a population-based review

BACKGROUND

Combined positron-emission tomography and computed tomography (pet-ct) reduces futile thoracotomy (ft) rates in patients with non-small-cell lung cancer (nsclc). We sought to identify preoperative risk factors for ft in patients staged with pet-ct.

METHODS

We retrospectively reviewed all patients referred to the BC Cancer Agency during 2009-2010 who underwent pet-ct and thoracotomy for nsclc. Patients with clinical N2 disease were excluded. An ft was defined as any of a benign lesion; an exploratory thoracotomy; pathologic N2 or N3, stage iiib or iv, or inoperable T3 or T4 disease; and recurrence or death within 1 year of surgery.

RESULTS

Of the 108 patients who met the inclusion criteria, ft occurred in 27. The main reason for ft was recurrence within 1 year (14 patients) and pathologic N2 disease (10 patients). On multivariate analysis, an Eastern Cooperative Oncology Group performance status greater than 1, a pet-ct positive N1 status, a primary tumour larger than 3 cm, and a period of more than 16 weeks from pet-ct to surgery were associated with ft. N2 disease that had been negative on pet-ct occurred in 21% of patients with a pet-ct positive N1 status and in 20% of patients with tumours larger than 3 cm and non-biopsy mediastinal staging only. The combination of pet-ct positive N1 status and a primary larger than 3 cm had 85% specificity, and the presence of either risk factor had 100% sensitivity, for ft attributable to N2 disease.

CONCLUSIONS

To reduce ft attributable to N2 disease, tissue biopsy for mediastinal staging should be considered for patients with pet-ct positive N1 status and with tumours larger than 3 cm even with a pet-ct negative mediastinum.

Minimally invasive mediastinal staging of non-small-cell lung cancer: emphasis on ultrasonography-guided fine-needle aspiration

BACKGROUND

Mediastinal staging in patients with non-small-cell lung cancer (NSCLC) is crucial in dictating surgical vs nonsurgical treatment. Cervical mediastinoscopy is the "gold standard" in mediastinal staging but is invasive and limited in assessing the posterior subcarinal, lower mediastinal, and hilar lymph nodes. Less invasive approaches to NSCLC staging have become more widely available.

METHODS

This article reviews several of these techniques, including noninvasive mediastinal staging of NSCLC, endobronchial ultrasound (EBUS) and fine-needle aspiration (FNA), endoscopic ultrasound (EUS) and FNA, and the combination of EBUS/EUS.

RESULTS

Noninvasive mediastinal staging with computed tomography and positron-emission tomography scans has significant false-negative and false-positive rates and requires lymph node tissue confirmation. FNA techniques, with guidance by EBUS and EUS, have become more widely available. The combination of EBUS-FNA and EUS-FNA of mediastinal lymph nodes can be a viable alternative to surgical mediastinal staging. Current barriers to the dissemination of these techniques include initial cost of equipment, lack of access to rapid on-site cytology, and the time required to obtain sufficient skills to duplicate published results.

CONCLUSIONS

Within the last decade, these approaches to NSCLC staging have become more widely available. Continued study into these noninvasive techniques is warranted.

Modern diagnostic and therapeutic interventional radiology in lung cancer

Imaging has an important role in the multidisciplinary management of primary lung cancer. This article reviews the current state-of-the-art imaging modalities used for the evaluation, staging and post-treatment follow-up and surveillance of lung cancers, and image-guided percutaneous techniques for biopsy to confirm the diagnosis and for local therapy in non-surgical candidates.

Clinical significance of incidental findings on staging positron emission tomography for oesophagogastric malignancies

INTRODUCTION

The aim of this retrospective study was to determine the clinical significance of incidental findings detected on positron emission tomography (PET) in patients undergoing staging of oesophagogastric malignancies.

METHODS

Patients with oesophagogastric malignancies who underwent PET between June 2007 and May 2012 were included in the study. PET was performed according to hospital protocol. All imaging was interpreted by two consultant radiologists in nuclear medicine. Incidental findings that were unrelated to the primary malignancy were recorded and patients were recommended to have further investigations (imaging, endoscopy and biopsy).

RESULTS

Overall, 333 patients (240 male, 93 female; mean age: 67 years) with upper gastrointestinal malignancies were eligible for inclusion in the study. Eighty-nine of these patients had PET demonstrating one or more incidental findings. Two patients were found to have a second primary malignancy. One patient had a distant metastasis of his primary cancer and six patients had a premalignant lesion.

CONCLUSIONS

In this study, incidental findings were discovered in 26.7% of patients with known oesophagogastric cancer. A second primary cancer or premalignant lesion was found in 8.4% of patients with incidental findings. Patients with these findings should be investigated to rule out further malignancy. There were a high proportion of false positive results in our study. It is recommended that each patient is considered on an individual basis and assessed with simultaneous PET and computed tomography.

Metastases to the thyroid presenting as a metabolically inactive incidental thyroid nodule with stable size in 15 months

Though the thyroid gland has a rich vascular supply, incidence of metastatic disease from distant organs is rare. Here we present an unusual case of metastases to the thyroid with several interesting features. A 63-year-old male with history of adenocarcinoma of the right lobe lung (5 years prior to presentation), treated with surgery and chemotherapy, followed by new adenosquamous lung cancer in the left lobe of the lung (one year prior to presentation), treated surgically followed by adjuvant chemotherapy, was referred to Endocrinology section for evaluation of an incidental thyroid nodule on CT chest. Ultrasound (US) of the thyroid revealed a complex, predominantly hypoechoic lesion measuring 1.8 cm within the lower pole of the right thyroid lobe and a subcentimeter lesion in the left lobe of the thyroid. Review of prior CT chests showed that the lesion in the right lobe was stable for 15 months, with no evidence of a hypermetabolic lesion on PET scan. The subcentimeter lesion was not seen on prior CT scans. US guided fine needle aspiration (FNA) and pathology of the lobectomy of the thyroid confirmed adenosquamous carcinoma. Interesting features in this case are that the thyroid metastases occurred without any evidence of synchronous lesions elsewhere, the size was stable over 15 months, and the lesions were metabolically inactive.

Methods for staging non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines

BACKGROUND

Correctly staging lung cancer is important because the treatment options and prognosis differ significantly by stage. Several noninvasive imaging studies and invasive tests are available. Understanding the accuracy, advantages, and disadvantages of the available methods for staging non-small cell lung cancer is critical to decision-making.

METHODS

Test accuracies for the available staging studies were updated from the second iteration of the American College of Chest Physicians Lung Cancer Guidelines. Systematic searches of the MEDLINE database were performed up to June 2012 with the inclusion of selected meta-analyses, practice guidelines, and reviews. Study designs and results are summarized in evidence tables.

RESULTS

The sensitivity and specificity of CT scanning for identifying mediastinal lymph node metastasis were approximately 55% and 81%, respectively, confirming that CT scanning has limited ability either to rule in or exclude mediastinal metastasis. For PET scanning, estimates of sensitivity and specificity for identifying mediastinal metastasis were approximately 77% and 86%, respectively. These findings demonstrate that PET scanning is more accurate than CT scanning, but tissue biopsy is still required to confirm PET scan findings. The needle techniques endobronchial ultrasound-needle aspiration, endoscopic ultrasound-needle aspiration, and combined endobronchial ultrasound/endoscopic ultrasound-needle aspiration have sensitivities of approximately 89%, 89%, and 91%, respectively. In direct comparison with surgical staging, needle techniques have emerged as the best first diagnostic tools to obtain tissue. Based on randomized controlled trials, PET or PET-CT scanning is recommended for staging and to detect unsuspected metastatic disease and avoid noncurative resections.

CONCLUSIONS

Since the last iteration of the staging guidelines, PET scanning has assumed a more prominent role both in its use prior to surgery and when evaluating for metastatic disease. Minimally invasive needle techniques to stage the mediastinum have become increasingly accepted and are the tests of first choice to confirm mediastinal disease in accessible lymph node stations. If negative, these needle techniques should be followed by surgical biopsy. All abnormal scans should be confirmed by tissue biopsy (by whatever method is available) to ensure accurate staging. Evidence suggests that more complete staging improves patient outcomes.

The correlation of SUVmax with pathological characteristics of primary tumor and the value of Tumor/ Lymph node SUVmax ratio for predicting metastasis to lymph nodes in resected NSCLC patients

Background

We aimed to investigate the correlation of maximum standardized uptake value (SUVmax) with pathological characteristics of primary tumor and to determine a Tumor/ Lymph node (T/LN) SUVmax ratio predicting metastasis to lymph nodes in NSCLC patients.

Methods

Eighty-one NSCLC patients who had PET/CT examination at initial staging and subsequently underwent surgical resection were retrospectively evaluated. There were 100 PET/CT positive mediastinal or hilar lymph node stations. Pathological characteristics of the tumor such as largest tumor diameter, tumor histology, differentiation, number of mitosis, degree of stromal inflammation, necrosis; etiology of PET/CT positive lymph node stations; SUVmax of primary tumor and positive lymph node stations were recorded. A T/LN SUVmax ratio was calculated for each lymph node station.

Results

SUVmax of the primary tumor was positively correlated with the largest tumor diameter (p = 0.001, r = 0.374), number of mitosis (p < 0.001, r = 0.405), and postoperative pathological stage (p = 0.007, r = 0.298). Patients with squamous cell carcinoma had a statistically significant higher mean SUVmax, number of mitosis and advanced N stages compared to adenocarcinoma. The etiology of 100 PET/CT positive lymph node stations were metastasis in 14, anthracosis in 40, reactive in 39, granulomatous in 4, and silicosis in 3 patients. A T/LN SUVmax ratio of 5 or lower was suggestive for a malignant lymph node with a sensitivity of 92.8% and specificity of 47%.

Conclusions

SUVmax of a primary tumor is related to certain pathological characteristics, such as largest diameter, histology, and number of mitosis. A T/LN SUVmax ratio lower than 5 predicts the metastasis to lymph nodes with a high sensitivity.

Sunlight may increase the FDG uptake value in primary tumors of patients with non-small cell lung cancer

Currently, positron emission tomography with computerized tomography (PET-CT) is the most sensitive technique for detecting extracranial metastases in non-small cell lung cancer (NSCLC). It has been reported that there is a correlation between the maximal standardized uptake value (SUV(max)) of primary tumors and prognosis in patients with NSCLC. The effect of sunlight exposure on PET-CT SUV(max) value is not known. Therefore, we aimed to evaluate the effect of sunlight exposure on PET-CT SUV(max) value in patients with NSCLC. A total of 290 patients with NSCLC from two different regions of Turkey (Kayseri, n=168 and Adana, n=122) that have different climate and sunlight exposure intensity, were included in the study. Age, gender, histology of cancer, cancer stage, smoking status, comorbidity and SUV(max) of the primary tumor area at the time of staging were evaluated as prognostic factors. In the multivariate analysis, we detected that the region was the only independent factor affecting SUV(max) (P=0.019). We identified that warmer climate and more sunlight exposure significantly increases the SUV(max) value of the primary tumor area in patients with NSCLC. Further studies are warranted to clarify the issue.

The role of positron emission tomography/computed tomography in radiation therapy planning for patients with lung cancer

Positron emission tomography (PET)/computed tomography (CT) has rapidly assumed a critical role in the management of patients with locoregionally advanced lung cancers who are candidates for definitive radiation therapy (RT). Definitive RT is given with curative intent, but can only be successful in patients without distant metastasis and if all gross tumor is contained within the treated volume. An increasing body of evidence supports the use of PET-based imaging for selection of patients for both surgery and definitive RT. Similarly, the use of PET/CT images for accurate target volume definition in lung cancer is a dynamic area of research. Most available evidence on PET staging of lung cancer relates to non-small cell lung cancer (NSCLC). In general clinical use, (18)F-fluorodeoxyglucose (FDG) is the primary radiopharmaceutical useful in NSCLC. Other tracers, including proliferation markers and hypoxia tracers, may have significant roles in future. Much of the FDG-PET literature describing the impact of PET on actual patient management has concerned candidates for surgical resection. In the few prospective studies where PET was used for staging and patient selection in NSCLC candidates for definitive RT, 25%-30% of patients were denied definitive RT, generally because PET detected unsuspected advanced locoregional or distant metastatic disease. PET/CT and CT findings are often discordant in NSCLC but studies with clinical-pathological correlation always show that PET-assisted staging is more accurate than conventional assessment. In all studies in which "PET-defined" and "non-PET-defined" RT target volumes were compared, there were major differences between PET and non-PET volumes. Therefore, in cases where PET-assisted and non-PET staging are different and biopsy confirmation is unavailable, it is rational to use the most accurate modality (namely PET/CT) to define the target volume. The use of PET/CT in patient selection and target volume definition is likely to lead to improvements in outcome for patients with NSCLC.

Mediastinal staging of lung cancer: novel concepts

Clinical TNM staging is the standard method used to decide treatment for patients with non-small-cell lung cancer. Although integrated fluorodeoxyglucose (FDG) PET CT increases the accuracy of staging, it only guides direct tissue sampling. Histological assessment of mediastinal lymph nodes has traditionally been done with mediastinoscopy, a surgical procedure. Endobronchial and oesophageal ultrasound-guided lymph node sampling have been assessed as additions or alternatives to mediastinoscopy. We review endosonography and surgical staging, and show that both have a place in the mediastinal staging of lung cancer. We conclude that mediastinal tissue staging should preferentially start with a complete endosonographic assessment. A surgical mediastinoscopy should be reserved for those in whom the endosonography result is negative. Further refinement of this recommendation is likely in the near future because data suggest that the confirmatory mediastinoscopy is particularly useful for patients with enlarged or FDG-avid lymph nodes.

Integrated PET/CT in non small cell lung cancer staging--clinical and pathological agreement

INTRODUCTION

Integrated PET/CT has become a fundamental tool in the preoperative assessment of non small lung cancer (NSCLC) providing useful anatomical and metabolic information to characterize tumoral lesions and to detect unsuspected metastatic disease.

AIM

To compare the agreement between clinical and pathological staging before and after the use of PET/CT.

MATERIAL AND METHODS

Retrospective study of patients with NSCLC who underwent potentially curative surgery throughout 10.5 years. Cohen's kappa coefficient was used to evaluate staging agreement.

RESULTS

One hundred and fifty patients were evaluated, 78% males, with a mean age of 65 (±9.6) years. Thirteen percent were submitted to neoadjuvant chemotherapy. PET/CT was performed in 41%. Global agreement between clinical and pathological staging was 51% (kappa=0.3639). There was a statistically significant difference between the staging results in patients who underwent PET/CT, when compared to the subgroup who did not (p=0.003). For those with PET/CT false negatives occurred in less 39%, false positives in more 12% and clinical and pathological staging coincided in more 27%. The overall results reflected an improvement in the agreement between clinical and pathological staging in the PET/CT subgroup (67%, kappa=0.5737 vs 40%, kappa=0.2292). PET/CT accuracy was enhanced when patients re-staged after neoadjuvant therapy were excluded and a substantial staging agreement was obtained for those who had the exam only for staging purposes (73%, kappa=0.6323).

CONCLUSION

Inclusion of PET/CT in NSCLC preoperative assessment improved the accuracy of the clinical staging, with a good level of agreement with pathological staging.

[Role of imaging techniques in the TNM classification of non-small cell bronchogenic carcinoma]

The Seventh Edition of the TNM Classification for non-small cell bronchogenic carcinomas include a series of changes in the T and M descriptor, in particular a re-classification of malignant pleural and pericardial effusions and of separated tumour nodes, new tumour size cut-off values and sub-divisions of the T1-T2 and M1 categories. We review these corrections that led to the changes in the staging system that affects stages II-III. Furthermore, we describe and illustrate the role of the different imaging techniques in tumour staging (CT, PET, PET-CT and MRI), highlighting their respective indications, advantages and disadvantages, as well their complementary function.

The management impact of clinically significant incidental lesions detected on staging FDG PET-CT in patients with non-small cell lung cancer (NSCLC): an analysis of 649 cases

To evaluate FDG PET-CT in the detection of unexpected pre-malignancy or second malignancy at the initial staging of patients with histologically proven non-small cell lung cancer (NSCLC) and its impact on management.

METHODS

Staging FDG PET-CT scans acquired between February 2006 and July 2010 in 649 patients (M=389; F=260) with NSCLC were reviewed for the presence of unexpected pre-malignancy or second primary. A "True-Positive" lesion represented a second primary or pre-malignant lesion. A "False-Positive" lesion was due to benign causes or an atypical site of metastasis from NSCLC.

RESULTS

77 (12%) patients were identified on PET-CT as having a potential pre-malignancy or second primary. 39 out of 77 (51%) patients had diagnostic verification where histopathology served as reference standard in 33 patients (85%) and the rest had endoscopy and progress PET-CT scans. 20 patients (3.1%) had a second primary (n=11) or pre-malignant lesions comprising dysplastic colorectal polyps (n=9), and additional therapy and/or management change for the index tumour was instigated in 17 patients (85%). In patients with a second primary, 3 (27%) patients had a high impact change in management from an initial curative intent to palliative.

CONCLUSION

Staging FDG PET-CT is highly valuable in identifying second primary cancers or pre-malignant lesions in patients with NSCLC. When a second primary is detected on PET-CT, there is a high impact change in management in 27% of patients.

SEPAR guidelines for lung cancer staging

The latest tumour, lymph node and metastasis (TNM) classification by the International Association for the Study of Lung Cancer (IASLC), based on the analysis of patients from all over the world, has incorporated changes in the descriptors, especially those regarding tumor size, while proposing new group staging. A new lymph node map has also been developed with the intention of facilitating the classification of the "N" component. SEPAR recommends using this new classification. As for the procedures recommended for staging, in addition to the generalized use of computed tomography (CT), it points to the role of positron emission tomography (PET) or image fusion methods (PET/CT), which provide a better evaluation of the mediastinum and extrathoracic metastases. Endobronchial ultrasound (EBUS) and esophageal ultrasound (EUS) for obtaining cytohistological samples have been incorporated in the staging algorithm, and it emphasizes the importance of precise re-staging after induction treatment in order to make new therapeutic decisions. Comment is made on the foreseeable incorporation in the near future of molecular staging, and systematic lymph node dissection is recommended with the intention of making a more exact surgical-pathological classification.

Focal leptomeningeal metastasis following curative surgery for lung cancer: case report

A 58-year-old woman presented with 4 lesions of pulmonary adenocarcinoma which were curatively resected. No adjuvant therapy was needed because the lesions were all in the early stage. Magnetic resonance (MR) imaging of the brain, taken 10 months after the curative surgery, disclosed focal enhancement along the right central sulcus. Cerebrospinal fluid examination was normal. The lesion remained stable for 16 months, then began to spread out. She underwent open biopsy and the histological diagnosis was leptomeningeal metastasis from adenocarcinoma. She was treated with gefitinib at first because the lesion expressed epidermal growth factor receptor domain mutation. However, the lesion continued to enlarge, so she underwent whole cranial irradiation which was not effective. She died 2 years 10 months after the first detection of the metastasis. Early histological diagnosis is important even though the MR imaging lesion is not likely to be metastasis after curative surgery of the primary lesions.

Efficacy of conventional whole-body ¹⁸F-FDG PET/CT in the incidental findings of parotid masses

OBJECTIVE

The objective of this study was to evaluate the incidence of incidental parotid masses with conventional whole-body ¹⁸F-deoxyglucose (FDG) PET/CT and assess the ability of PET/CT to characterize these unexpected parotid lesions.

METHODS

Fifty eight incidental findings of parotid masses with routine FDG PET/CT whole-body scan were reviewed in this retrospective analysis, which were selected from the patients without any known or suspected parotid disease in our PET center, from June 2005 to May 2009. 51 cases were operated or underwent a biopsy after a short-term PET/CT study; the remaining 7 cases had a follow-up. Parotid mass that showed both noncontrast CT (irregular shape and blurry border) and PET malignant features (high FDG uptake, SUV(max) > 3.0) was considered as positive for malignancy. Correlation of FDG PET/CT with histology or follow-up outcome was performed.

RESULTS

Fifty eight unexpected findings of parotid masses accounted for 0.3% of the total cases in 4 years, including 11 (19.0%) malignant tumors and 47 (81.0%) benign lesions. 13 lesions manifested single nodule with malignant CT features and intense FDG activity, of which 6 were proved to be malignant; thus, sensitivity and positive predictive values were 54.5% (6 of 11) and 46.2% (6 of 13), respectively. 45 lesions showed either single nodule with benign CT features, or a low FDG uptake (SUV(max) ≤ 3.0), of which 40 were true negatives; therefore, specificity and negative predictive values were 85.1% (40 of 47) and 88.9% (40 of 45), respectively. All parotid masses except 9 benign and 1 malignant showed a high FDG uptake. Compared with SUV only, combined interpretation of PET and CT results displayed a lower sensitivity (90.9-54.5%), but a higher specificity (19.1-85.1%) and a higher overall accuracy.

CONCLUSIONS

Whole-body FDG-PET/CT at the time of surveying the entire body condition is helpful for detecting the asymptomatic parotid masses. Combined noncontrast CT is an essential evidence for improving the diagnostic accuracy of FDG-PET/CT for parotid masses.

Diagnostic efficacy of PET/CT plus brain MR imaging for detection of extrathoracic metastases in patients with lung adenocarcinoma

We aimed to evaluate prospectively the efficacy of positron emission tomography (PET)/computed tomography (CT) plus brain magnetic resonance imaging (MRI) for detecting extrathoracic metastases in lung adenocarcinoma. Metastatic evaluations were feasible for 442 consecutive patients (M:F=238:204; mean age, 54 yr) with a lung adenocarcinoma who underwent PET/CT (CT, without IV contrast medium injection) plus contrast-enhanced brain MRI. The presence of metastases in the brain was evaluated by assessing brain MRI or PET/CT, and in other organs by PET/CT. Diagnostic efficacies for metastasis detection with PET/CT plus brain MRI and with PET/CT only were calculated on a per-patient basis and compared from each other. Of 442 patients, 88 (20%, including 50 [11.3%] with brain metastasis) had metastasis. Regarding sensitivity of overall extrathoracic metastasis detection, a significant difference was found between PET/CT and PET/CT plus brain MRI (68% vs. 84%; P=0.03). As for brain metastasis detection sensitivity, brain MRI was significantly higher than PET/CT (88% vs. 24%; P<0.001). By adding MRI to PET/CT, brain metastases were detected in additional 32 (7% of 442 patients) patients. In lung adenocarcinoma patients, significant increase in sensitivity can be achieved for detecting extrathoracic metastases by adding dedicated brain MRI to PET/CT and thus enhancing brain metastasis detection.

Diagnosis, staging and treatment of patients with non-small cell lung cancer for the surgeon

This article covers the risk factors, diagnostic tools, staging methods/modalities and treatment for patients with non-small cell lung cancer (NSCLC). Also presented is the new 7th edition American Joint Cancer Committee (AJCC) TNM classification for staging of NSCLC and a recommended treatment algorithm.

Positron emission tomography in mantle cell lymphoma

Mantle cell lymphoma (MCL) is a rare but aggressive non-Hodgkin lymphoma subtype with a poor prognosis; most patients relapse despite initial response to therapy. Response was traditionally evaluated by computed tomography (CT), but the introduction of [(18)F]Fluorine-Deoxyglucose Positron Emission Tomography (PET) changed response assessment in aggressive lymphoma. However, the value of PET-evaluation in MCL has not been studied yet. Therefore, PET- and CT-findings were investigated in 37 patients with MCL (239 scans) and categorised following standardised response criteria for CT-evaluation (IWC-criteria), PET-evaluation (EORTC-criteria) and combined PET/CT-evaluation (IWC + PET-criteria). FDG-PET showed a high sensitivity for the detection of deposits of MCL and a higher FDG-uptake was shown in patients with the more aggressive blastoid-variant of MCL versus common MCL. However, routine use of PET for end-of-treatment response assessment in MCL cannot be recommended because CT- and PET-based designation systems had equivalent prognostic value. PET-based end-of-treatment response assessment only provided additional information over CT-based response assessment in a subpopulation of patients with highly FDG-avid MCL. PET allowed early detection of preclinical relapse during post-therapy surveillance, but the therapeutic consequences of such information are currently unclear.

PET/CT for staging and monitoring non small cell lung cancer

Correct staging of non small cell lung cancer (NSCLC) is vital for appropriate management. Initial staging is usually performed with computerised tomography (CT), but increasingly functional imaging using integrated positron emission tomography and CT (PET/CT) is being used to provide more accurate staging, guide biopsies, assess response to therapy and identify recurrent disease.