Improve Staging Accuracy Research Articles

An emerging evidence base for PET-CT in the management of childhood rhabdomyosarcoma: systematic review

IntroductionRhabdomyosarcoma (RMS) management depends on risk stratification at diagnosis and treatment response. Assessment methods include CT, MRI, bone scintigraphy, histological analysis and bone marrow biopsy. Advanced functional imaging (FI) has...

Incorporating surgical quality into the AJCC 7th edition improves staging accuracy in gastric cancer.

The staging of gastric cancer has become increasingly complex. With an emerging 15-node quality measure and a revised American Joint Committee on Cancer (AJCC) staging system, we evaluated the need for more intricate staging systems to predict survival outcomes in gastric cancer. The Surveillance, Epidemiology and End Results Program (SEER) database was used to identify 124,972 patients with gastric cancer between 2000 and 2010. Primary endpoints were 5-year disease-specific survival (DSS) and overall survival (OS). Analysis was performed on patients with ≥15 nodes evaluated. Multivariable regression with/without the inclusion of lymph node (LN) assessment and LN ratio were compared using the Akaike information criterion. The number of patients included in the final analysis was 12,096. The proportion of patients with an adequate lymphadenectomy increased markedly from 27 % in 2000 to 52 % in 2010. Overall 5-year DSS and OS was 61.9 and 48.8 %, respectively, for patients with ≥15 nodes examined, versus 57.7 and 39.9 %, respectively, for those with <15 sampled nodes (p < 0.0001). In patients with ≥15 nodes evaluated, the addition of LN evaluation and LN ratio to the existing staging model improved its ability to predict 5-year DSS and OS (p < 0.0001). LN evaluation and LN ratio were comparable in their ability to supplement the existing AJCC 7th edition (AJCC7) staging system. The inclusion of a minimum 15-LN quality measure improves the prognostic ability of the AJCC7 staging system, without adding significant complexity.

State-of-the-art molecular imaging in esophageal cancer management: implications for diagnosis, prognosis, and treatment.

Molecular imaging techniques are increasingly being used in addition to standard imaging methods such as endoscopic ultrasound (EUS) and computed tomography (CT) for many cancers including those of the esophagus. In this review, we will discuss the utility of the most widely used molecular imaging technique, (18)F-fluorodeoxyglucose ((18)F-FDG) positron emission tomography (PET). (18)F-FDG PET has a variety of potential applications ranging from improving staging accuracy at the time of initial diagnosis to assisting in radiation target volume delineation. Furthermore, (18)F-FDG PET can be used to evaluate treatment response after completion of neoadjuvant therapy or potentially during neoadjuvant therapy. Finally, we will also discuss other novel molecular imaging techniques that have potential to further improve cancer care.

Clinical significance of cytogenetic aberrations in bone marrow of patients with diffuse large B-cell lymphoma: prognostic significance and relevance to histologic involvement

BackgroundAlthough knowledge of the genetics of diffuse large B-cell lymphoma (DLBCL) has been increasing, little is known about the characteristics and prognostic significance of cytogenetic abnormalities and the clinical utility of cytogenetic studies performed on bone marrow (BM) specimens. To investigate the significance of isolated cytogenetic aberrations in the absence of histologic BM involvement, we assessed the implication of cytogenetic staging and prognostic stratification by a retrospective multicenter analysis of newly diagnosed DLBCL patients.MethodsWe analyzed cytogenetic and clinical data from 1585 DLBCL patients whose BM aspirates had been subjected to conventional karyotyping for staging. If available, interphase fluorescence in situ hybridization (FISH) data were also collected from patients.ResultsHistologic BM involvement were found in 259/1585 (16.3%) patients and chromosomal abnormalities were detected in 192 (12.1%) patients (54 patients with single abnormalities and 138 patients with 2 or more abnormalities). Isolated cytogenetic aberrations (2 or more abnormalities) without histologic involvement were found in 21 patients (1.3%). Two or more cytogenetic abnormalities were associated with inferior overall survival (OS) compared with a normal karyotype or single abnormality in both patients with histologic BM involvement (5-year OS, 16.5% vs. 52.7%; P < 0.001) and those without BM involvement (31.8% vs. 66.5%; P < 0.001). This result demonstrated that BM cytogenetic results have a significant prognostic impact that is independent of BM histology. The following abnormalities were most frequently observed: rearrangements involving 14q32, 19q13, 19p13, 1p, 3q27, and 8q24; del(6q); dup(1q); and trisomy 18. In univariate analysis, several specific abnormalities including abnormalities at 16q22-q24, 6p21-p25, 12q22-q24, and -17 were associated with poor prognosis. Multivariate analyses performed for patients who had either chromosomal abnormalities or histologic BM involvement, revealed IPI high risk, ≥ 2 cytogenetic abnormalities, and several specific chromosomal abnormalities, including abnormalities at 19p13, 12q22-q24, 8q24, and 19q13 were significantly associated with a worse prognosis.ConclusionsWe suggest that isolated cytogenetic aberrations can be regarded as BM involvement and cytogenetic evaluation of BM improves staging accuracy along with prognostic information for DLBCL patients.

Impact of PET Staging in Limited-Stage Small-Cell Lung Cancer

Although positron emission tomography computed tomography (PET-CT) has been widely used for small-cell lung cancer (SCLC) staging, no study has examined the clinical impact of PET staging in limited-stage (LS) SCLC. We identified patients with LS-SCLC treated definitively with concurrent chemoradiation. Outcomes were assessed using the Kaplan-Meier approach, Cox regression, and competing risks method. We treated 54 consecutive LS-SCLC patients with concurrent chemoradiation from January 2002 to August 2010. Forty underwent PET, 14 did not, and all underwent thoracoabdominopelvic CT and magnetic resonance imaging neuroimaging. Most patient characteristics were balanced between the comparison groups, including age, race, sex, bone scanning, median dosage, and performance status. More number of PET-staged patients presented with nodal metastases (p = 0.05). Median follow-up was similar for PET-staged and non-PET-staged patients (p = 0.59). Median overall survival from diagnosis in PET-staged patients was 32 versus 17 months in patients staged without PET (p = 0.03), and 3-year survival was 47% versus 19%. Median time-to-distant failure was 29 versus 12 months (p = 0.04); median time-to-local failure was not reached versus 16 months (p = 0.04). On multivariable analysis, PET staging (odds ratio [OR] = 0.24; p = 0.04), performance status (OR = 1.89; p = 0.05), and N-stage (OR = 4.94; p < 0.01) were associated with survival. LS-SCLC patients staged with PET exhibited improved disease control and survival when compared with non-PET-staged LS-SCLC patients. Improved staging accuracy and better identification of intrathoracic disease may explain these findings, underscoring the value of PET-CT in these patients.

Prostate MRI: Who, when, and how? Report from a UK consensus meeting

The current pathway for men suspected of having prostate cancer [transrectal biopsy, followed in some cases by magnetic resonance imaging (MRI) for staging] results in over-diagnosis of insignificant tumours, and systematically misses disease in the anterior prostate. Multiparametric MRI has the potential to change this pathway, and if performed before biopsy, might enable the exclusion of significant disease in some men without biopsy, targeted biopsy in others, and improvements in the performance of active surveillance. For the potential benefits to be realized, the setting of standards is vital. This article summarizes the outcome of a meeting of UK radiologists, at which a consensus was achieved on (1) the indications for MRI, (2) the conduct of the scan, (3) a method and template for reporting, and (4) minimum standards for radiologists.

Reducing Morbidity of Pelvic and Retroperitoneal Lymphadenectomy

Lymphadenectomy is utilized in both pelvic and retroperitoneal oncological surgery as a means to eradicate locoregional disease, improve staging accuracy and guide adjuvant therapy. However, pelvic and retroperitoneal lymphadenectomy have the potential for morbidity including lymphatic injury, vascular injury, thromboembolic events and neurologic injury. Across the spectrum of urologic malignancies, the evidence supporting both the necessity and the extent of lymphadenectomy varies considerably. Awareness of the potential for injury and ways to avoid and manage the most common complications is necessary to decrease the morbidity associated with these procedures.

Nucleotide-guided mesorectal excision combined with endoluminal locoregional resection by transanal endoscopic microsurgery in the treatment of rectal tumors: technique and preliminary results

Endoluminal locoregional resection (ELRR) by transanal endoscopic microsurgery (TEM) is an alternative treatment option for T1N0 rectal cancer and for selected patients with small T2N0 rectal cancer after neoadjuvant radiochemotherapy (n-RCT). The N parameter may remain undefined after transanal surgery. This study aimed to evaluate the role of a modified sentinel lymph node technique to improve N staging that the authors named "nucleotide-guided mesorectal excision" (NGME). The study enrolled 41 patients (24 men and 17 women) with a mean age of 70.5 years. Preoperative staging identified dysplasia with no suspicion for cancer at imaging (n = 8), dysplasia with suspected malignancy at imaging (n = 15), no suspicion of malignancy at imaging after n-RCT (n = 2), cT1N0 (n = 6), cT2N0 (n = 6), cT3N0 (n = 3), and cT3N1 (n = 1). The patients underwent ELRR by TEM with NGME. Before surgery, 99m-technetium-marked nanocolloid was injected into the peritumoral submucosa. After resection, the residual defect was probed to detect residual radioactivity. If present, hot mesorectal fat was excised. With NGME, the mesorectal lymph node harvest increased from 0 to 10. Lymph nodes were isolated in the specimen or in hot mesorectal fat of 20 patients, 8 of whom had undergone n-RCT. The mean lymph node harvest was 2.75 ± 3.01 (range 1-10) in the irradiated patients and 2.91 ± 1.62 (range 1-6) in the nonirradiated patients (p = 0.87). The average number of lymph nodes in the irradiated patients was higher than in a previous historical series. The use of NGME during ELRR by TEM increases the lymph node harvest and may improve staging accuracy after transanal surgery.

Patterns of Myoinvasion in Endometrial Adenocarcinoma

Endometrial endometrioid adenocarcinoma (EEC) is the most common malignancy of the female genital tract, partly attributable to chronic estrogen exposure secondary to increased obesity rates. Tumor stage, which in most cases is based on depth of invasion (DOI), is of critical importance in determining if additional treatment is needed. However, the array of invasive morphologies within the spectrum of ECC can make the determination of DOI difficult. Several morphologic patterns of invasion have been described, including diffusely infiltrating irregular glands, "broad front" (or pushing border), adenoma malignum, adenomyosis-like, and microcystic, elongated, and fragmented glands. EEC may often contain a mixture of invasive patterns, which can further complicate evaluation of these common tumors. Recognition of these patterns may lead to more accurate staging, but perhaps more importantly, some patterns may be associated with adverse prognostic features. The purpose of this review is to highlight the various invasive patterns of EEC and note their unique pitfalls and prognostic implications in an effort to improve staging accuracy and treatment and follow-up for the thousands of women affected by this disease each year.

1499 TARGETED BIOPSY FINDINGS IN SELECTION OF MEN FOR ACTIVE SURVEILLANCE: DO EPSTEIN CRITERIA STILL APPLY?

You have accessJournal of UrologyProstate Cancer: Localized (VII)1 Apr 20131499 TARGETED BIOPSY FINDINGS IN SELECTION OF MEN FOR ACTIVE SURVEILLANCE: DO EPSTEIN CRITERIA STILL APPLY? Jim Hu, Edward Chang, Geoffrey Sonn, Shyam Natarajan, Daniel Margolis, Malu Macairan, Patricia Lieu, Jiaoti Huang, and Leonard Marks Jim HuJim Hu Los Angeles, CA More articles by this author , Edward ChangEdward Chang Los Angeles, CA More articles by this author , Geoffrey SonnGeoffrey Sonn Los Angeles, CA More articles by this author , Shyam NatarajanShyam Natarajan Los Angeles, CA More articles by this author , Daniel MargolisDaniel Margolis Los Angeles, CA More articles by this author , Malu MacairanMalu Macairan Los Angeles, CA More articles by this author , Patricia LieuPatricia Lieu Los Angeles, CA More articles by this author , Jiaoti HuangJiaoti Huang Los Angeles, CA More articles by this author , and Leonard MarksLeonard Marks Los Angeles, CA More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.2978AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Epstein's criteria from 1994 (Gleason grade ≤6, < 3 cores positive, <50% of any core) have been widely used to identify men with very low risk prostate cancer (CaP). Despite these rigorous criteria, 20-30% of active surveillance (AS) candidates undergoing subsequent radical prostatectomy harbor more aggressive disease. Multiparametric magnetic resonance imaging (MRI)-ultrasound fusion biopsy enables identification and targeting of suspicious lesions and may improve staging accuracy. Herein, we describe outcomes of confirmatory fusion biopsy for AS. METHODS Of 134 men meeting Epstein's criteria on initial biopsy (mean 13 cores sampled) enrolled in the UCLA AS program, 106 underwent confirmatory fusion biopsy a median of 11 months after initial diagnosis (Figure). Suspicious MRI targets (mean diameter 10.9 mm) were found on 83 (78.3%) men (mean = 1.7 targets per patient). Targets were biopsied at 3mm intervals of the longest axis in addition to 12 systematic cores. A mean of 16 total cores were sampled per subject. Men were considered to exceed Epstein's criteria based on Gleason grade or amount of cancer; however multiple cores sampled per target were considered one core to avoid artifactual over-counting of positive cores. RESULTS At re-biopsy, mean age was 64 years, median PSA 4.1 (interquartile range [IQR] 2.4-6.2, median prostate volume 42.5 cc (IQR 31.4-56.9). Confirmatory biopsy identified cancer in 70 men (66%). It resulted in reclassification beyond Epstein criteria for 38 (35.9%) men, 26 (24.5%) due to upgrading to Gleason ≥7 disease and 12 (11.3%) due to greater CaP volume (3 due to ≥50% maximal involvement and 9 due to >2 core positivity). CONCLUSIONS MR-US fusion biopsy presents a novel way to identify and monitor men eligible for AS. This technology yields higher reclassification compared to the 22% to 27% reclassification with conventional ultrasound guided confirmatory biopsy. This high re-classification rate calls into question the use of Epstein criteria in the era of targeted biopsies. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e614-e615 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jim Hu Los Angeles, CA More articles by this author Edward Chang Los Angeles, CA More articles by this author Geoffrey Sonn Los Angeles, CA More articles by this author Shyam Natarajan Los Angeles, CA More articles by this author Daniel Margolis Los Angeles, CA More articles by this author Malu Macairan Los Angeles, CA More articles by this author Patricia Lieu Los Angeles, CA More articles by this author Jiaoti Huang Los Angeles, CA More articles by this author Leonard Marks Los Angeles, CA More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Imaging Follicular Lymphoma Using Positron Emission Tomography With [18F]Fluorodeoxyglucose: To What Purpose?

Positron emission tomography (PET) with [F]fluorodeoxyglucose (FDG) is not as well established for use in follicular lymphoma (FL) as it is for Hodgkin lymphoma (HL) and diffuse large B-cell lymphoma (DLBCL). The likely reason is that the clinical benefit of functional imaging is less well defined in FL, which is often an incurable, remitting, and relapsing condition for which treatment is aimed at disease control and prolonging survival. FL is almost always FDG avid. In one study, FDG uptake was seen in all but seven of 140 patients (5%), and disease was limited to the bone marrow or the skin. PET could therefore be a useful tool to stage FL. This might be particularly important in the distinction between early-stage localized disease, which is potentially curable with involved-field radiotherapy (IFRT), and advanced disease, which is incurable and treated with chemotherapy. Several retrospective studies have indicated that PET detects more lesions than computed tomography (CT), with a potential to alter management through upstaging or changing the size of the radiotherapy field. Management changes were indicated because of additional disease findings on PET in 18% to 29% of patients with FL; this increased to 45% to 50% when only patients with limited-stage disease as determined by CT were considered. This suggests that there might be a rationale for using PET for imaging of patients with limited-stage disease to avoid futile IFRT. The outcome of IFRT for localized FL staged by PET has not yet been reported; therefore, it is not known whether the improved staging accuracy will result in improved outcome. Indolent lymphomas tend to have lower uptake than aggressive lymphomas. One study showed that using receiver operating characteristic analysis, an optimal threshold for the standardized uptake value (SUV) of 10 allowed aggressive lymphomas to be distinguished from indolent lymphomas in 69 patients who underwent biopsy with sensitivity and specificity of 71% and 81%, respectively. Higher uptake has also been observed in patients with indolent lymphomas who undergo transformation. Thus, there may be a rationale for using PET to identify the most appropriate site for biopsy in patients with FL at diagnosis and with suspected transformation. More recently, interest has turned to the role of PET in response assessment after chemotherapy and radioimmunotherapy. Reports suggested that patients with PET-positive scans had worse outcomes than patients with PET-negative scans in untreated and relapsed/refractory disease. These studies, however, involved heterogeneous groups with respect to stage, treatment, and the timing of PET scans. Last year, Journal of Clinical Oncology published a study that reported the results of postinduction PET-CT scans in 122 patients with FL who were enrolled onto the Primary Rituximab and Maintenance (PRIMA) trial. Patients were treated with rituximab plus six cycles of cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) or rituximab plus eight cycles of cyclophosphamide, vincristine, and prednisone (R-CVP) and randomly assigned to observation or 2 years of maintenance rituximab. Patients with PET-positive scans after induction had significantly worse outcomes than patients with PET-negative scans. Progression-free survival (PFS) rates were 32.9% and 70.7% (P .001), and overall survival (OS) rates were 78.5% and 96.5% (P .0011) for patients with PET-positive and PET-negative scans, respectively, with a median follow-up of 42 months. There was a significant difference in PFS for patients according to PET status in the observation but not in the maintenance arm, probably because of better outcomes and inadequate patient numbers in the maintenance arm. PET-based response assessment was more predictive than conventional response assessment using international working criteria (IWC). In the multivariate Cox analyses, both PET-based and IWCbased responses were significant, but the IWC was only significant for progressive disease or stable disease (7% of patients) versus the remainder of the study patients. Within the IWC-defined responders (93%), PET was positive in 38% of patients with partial response and 18% of patients with complete response or complete response unconfirmed. The study was limited by its retrospective nature and the PET methodology. The PET-CT result was the interpretation by the local investigator of an imaging report that did not make reference to standardized criteria for PET reporting, which had not been developed at that time. Reports were given by more than 40 physicians, and acquisition parameters for PET were not specified. Despite these drawbacks, the study presented the first evidence that PET-CT might be a useful therapeutic end point in FL and identified a cohort of patients with less favorable outcome treated in a clinical trial. JOURNAL OF CLINICAL ONCOLOGY E D I T O R I A L VOLUME 30 NUMBER 35 DECEMBER 1

Editorial Comment

Meticulous extended pelvic lymph node dissection (PLND) requires surgical experience and is time consuming. The concept of sentinel lymph node dissection (SLND) is compelling in terms of limiting time requirements and decreasing the risk of complications while potentially improving staging accuracy and even the chances of survival. In contrast to radio-guided studies alone, the added injection of fluorescing dye in the present study enables additional visualization of afferent lymphatic vessels.

United States Military Cancer Institute Clinical Trials Group (USMCI GI-01) Randomized Controlled Trial Comparing Targeted Nodal Assessment and Ultrastaging With Standard Pathological Evaluation for Colon Cancer

Our randomized controlled trial previously demonstrated improved staging accuracy with targeted nodal assessment and ultrastaging (TNA-us) in colon cancer (CC). Our objective was to test the hypothesis that TNA-us improves disease-free survival (DFS) in CC. In this randomized trial, targeted nodal assessment and ultrastaging resulted in enhanced lymph node diagnostic yield associated with improved staging accuracy, which was further associated with improved disease-free survival in early colon cancer. Clinical parameters of the control (n = 94) and TNA-us (n = 98) groups were comparable. Median (interquartile range) lymph node yield was higher in the TNA-us arm: 16 (12-22) versus 13 (10-18); P = 0.002. Median follow-up was 46 (29-70) months. Overall 5-year DFS was 61% in the control arm and 71% in the TNA-us arm (P = 0.11). Clinical parameters of node-negative patients in the control (n = 51) and TNA-us (n = 55) groups were comparable. Lymph node yield was higher in the TNA-us arm: 15 (12-21) versus 13 (8-18); P = 0.03. Five-year DFS differed significantly between groups with node-negative CC (control 71% vs TNA-us 86%; P = 0.04). Survival among stage II CC alone was higher in the TNA-us group, 83% versus 65%; P = 0.03. Adjuvant chemotherapy use was nearly identical between groups. TNA-us stratified CC prognosis; DFS differed significantly between ultrastaged and conventionally staged node-negative patients [control pN0 72% vs TNA-us pN0(i-) 87%; P = 0.03]. Survival varied according to lymph node yield in patients with node-negative CC [5-year DFS: <12 lymph nodes = 57% vs 12+ lymph nodes = 85%; P = 0.011] but not in stage III CC. TNA-us is associated with improved nodal diagnostic yield and enhanced staging accuracy (stage migration), which is further associated with improved DFS in early CC. This study is registered at clinicaltrials.gov under the registration number: NCT01623258.

Time-Dependent Trends in Lymph Node Yield and Impact on Adjuvant Therapy Decisions in Colon Cancer Surgery: An International Multi-Institutional Study

Lymph node yield (LNY) and accuracy of nodal assessment are critical to staging and treatment planning in colon cancer (CC). A nationally agreed upon 12-node minimum is a quality standard in CC. The impact of this quality measure on LNY and impact on therapeutic decisions are evaluated in two international, multi-center, prospective trials comprising a well-characterized cohort assembled over 8 years (2001-2009) with long-term follow-up. Quality adherence through increased LNY improves staging accuracy and impacts adjuvant therapy decisions. Retrospective analysis of prospective data to assess time-dependent LNY, the dependent variable in multivariate linear regression analysis adjusted for age, gender, body-mass-index (BMI), tumor size/stage/grade, anatomic location and surgery date. Two-hundred-forty-five patients with non-metastatic CC, median age 70 years, BMI 26 kg/m(2), tumor size 4.0 cm, and LNY 17 nodes were studied. Seventy-two percent had T3 (70 %)/T4 (2 %) tumors. Adherence to the 12-node minimum was 70 %(2001-2002), 81 % (2003-2004), 90 % (2005-2006), 94 % (2007-2008). LNY significantly increased over time (Median LNY: 2001-2004 = 15 vs. 2005-2008 = 17; P < 0.001) on multivariate analysis controlling for tumor size (P < 0.001), and right-sided tumor location (P < 0.001). Adjuvant therapy administration and indication for chemotherapy according to LNY (<12 vs. 12 + LNs = 33 % vs. 39 %; P = 0.48) and time period (2001-2004 vs. 2005-2008 = 39 % vs. 37 %; P = 0.89) remained unchanged. Despite the independent predictors of nodal yield (tumor location and size), year of study still had a significant impact on nodal yield. Despite increased quality adherence and LNY over time, there appears to be a delayed impact on adjuvant therapy decisions once quality standard adherence takes effect.

FDG-PET and Hodgkin Lymphoma: Are We Ready for a Functional Tumor Volume Definition?

Abstract 5187 IntroductionTumor Volume (TV) is an important independent prognostic factor in patients with Hodgkin Lymphoma (HL) and can be calculated manually using Contrast Enhanced Computed Tomography (CT) scan as proposed by Gobbi et al. (Gobbi PG et al, JCO, 2001; Gobbi PG et al, Cancer 2004). Definition of CT based TV (CT-TV) however is difficult to assess being time consuming and complex procedure.Differently from CT, FDG-PET scan allows a better identification of tumor sites in HL and improves staging accuracy (Rigacci et al, Ann Hematol, 2007). Availability of digitalized images with PET makes it feasible to try to explore a PET based method to define TV (PET-TV). Patients and methodsWe performed a pilot study to compare CT-TV and PET-TV on a series of phantoms and on a series of patients, to “optimize” the calculation of PET-TV in humans and to compare the new PET-TV with CT-TV. For the first part of the study 12 fillable objects characterized by different known volumes (VL) (range 0.5–1700 ml), shape and complexity were filled with a solution of water and FDG and then acquired with PET/CT. For the second part of the study 20 patients with HL, for whom both baseline CT and PET were available, were identified. Patients had a median age of 34 years, 6 had stage I, 11 had stage II (2 with Bulky and 2 with subdiaphragmatic disease), 3 had stage III or IV. For both parts of the study CT-VL and PET-VL were calculated separately and blindly by a radiologist and a nuclear medicine physician. CT-VL was defined manually on CT as originally reported. For definition of PET-VL a semiautomatic segmentation software (PET VCAR - Volume Computer Assisted Reading - GE) was used; volume contouring was defined automatically using different SUV thresholds (35-40-45-50-55-60%) or semiautomatically using an operator aided approach. ResultsWhen used on phantoms both CT and PET allowed an accurate definition of VL with an overall difference with actual VL of +4% and +1%, respectively. The automatic approach for calculation of PET-VL was feasible with the best PET threshold for segmentation identified at 45%. Both CT and PET had the worst results with very small VL (<1.2 cm3) whose impact on global VL however is not significant. Dividing the VLs in “small”(range 0.5–26.5 cm3) and “big”(range 70–1700 cm3) CT-VL was –28% and +4% and PET–VL was +4% and +1%, respectively.On patients CT-TV ranged from 13 to 840 ml. Regarding PET an automatic approach using 45% threshold defined with phantoms was first used but didn't allow sometimes to include all visible tumor; being the optimal threshold for patients variable an operator visual assessment evaluation was required.Final PET-TV ranged from 29 to 536 ml. Overall using CT-TV as comparator, the use of PET allowed the identification of lower TV (median −11%: −47% to + 86%); in 12/18 PET-TV was lower than CT-TV with differences ranging from −9% to – 47%. In 6 patients PET-TV was greater than CT-TV (+1% to +86). In patient with lower PET-TV than CT-TV, this was mainly due to the presence of “hot” and “cold” areas within the tumor (especially big mediastinal masses) that cannot be read by CT and takes PET-TV closer to a “functional volume”(FV) rather than an anatomical volume only. In one case with the PET-TV higher than CT-TV, PET also included extranodal sites (bone and tonsils) that were not identifiable at CT. Finally TV calculation time/patient was 10 minutes (5 to 15) with PET, much less than with CT. Conclusions:PET can be used to define VL in phantoms and TV in patients with HL. Although a fully automated method is feasible and effective in phantoms, a semiautomated approach must be used for PET-TV assessment in humans. With such approach PET-TV evaluation is feasible, easy and quick to assess. The use of PET-TV allows the identification of a new concept of “functional volume” (FV) that partially correlates with CT-TV but probably describes different aspects of the tumor. The clinical and prognostic relevance of FV in patients with HL must be further investigated. Disclosures:No relevant conflicts of interest to declare.

Use of Restaging Bladder Tumor Resection for Bladder Cancer Among Medicare Beneficiaries

To evaluate the use and effectiveness of restaging bladder tumor resection using population-based data. Restaging bladder tumor resection improves staging accuracy and the response to intravesical therapy. However, its use outside of a tertiary care setting, and its subsequent clinical implications, are unknown. We identified 62 016 patients diagnosed with bladder cancer between 1992 and 2005 using SEER-Medicare data. Restaging bladder tumor resection was defined as 2 or more resections occurring within 60 days of diagnosis. Using multivariable models, we assessed the relationship between the use of restaging resection and cancer-specific survival. Restaging resection was performed in only 3064 (4.9%) of newly diagnosed bladder cancer patients, but was most common among those with high grade (7.7% vs 2.0% in low grade, P < .001) and stage (8.8% in T2 vs 2.8% in Ta/Tis, P < .001) disease. Compared to patients with muscle-invasive cancers who did not undergo restaging at diagnosis, restaging resection was associated with improved 5-year cancer-specific mortality among pathologically staged patients (20.4% vs 28.0%, P = .02), while clinically staged patients trended toward improved mortality (28.2% vs 31.9%, P = .07). Restaging transurethral resection for bladder cancer is relatively uncommon and associated with improved survival among patients with muscle invasive bladder cancer. Greater use of restaging warrants further investigation as a simple means of improving outcomes among patients suspected of having muscle invasive disease.

Clinical impact of FDG PET-CT in patients with potentially operable metastatic colorectal cancer

To assess the clinical impact of 2-[(18)F]-fluoro-2-deoxy-d-glucose (FDG) positron-emission tomography-computed tomography (PET-CT) in patients with potentially resectable metastatic colorectal cancer. One hundred and two patients with potentially resectable metastatic colorectal cancer underwent FDG PET-CT in addition to conventional imaging over an 18-month period. The findings were compared to conventional imaging, with histological or clinico-radiological validation. The impact on subsequent management was evaluated using information from clinico-radiological databases. Of 102 patients (mean age 67 years, range 27-85 years), 94 had liver, five had isolated lung, and three had limited peritoneal metastases. In 31 patients (30%) PET-CT had a major impact on subsequent management, by correctly clarifying indeterminate lesions on conventional imaging as inoperable metastatic disease in 16 patients, detecting previously unsuspected metastatic disease in nine patients, identifying occult second primary tumours in three patients, and correctly down-staging three patients. PET-CT had a minor impact in 12 patients (12%), no impact in 49 cases (48%), and a potentially negative impact in 10 cases (10%). Following PET-CT, 36 (35%) patients were no longer considered for surgery. Of those remaining operative 45 of 66 (68%) underwent potentially curative metastatic surgery. In this cohort PET-CT saved 16 futile laparotomies. FDG PET-CT has a valuable role in selected patients with metastatic colorectal cancer by improving staging accuracy and characterizing indeterminate lesions and helps triage patients to the appropriate treatment.

Estadificación de los linfomas no hodgkinianos: estudio prospectivo de la tomografía por emisión de positrones/tomografía computarizada (PET/TC) frente a la PET y a la TC

Background and objective To prospectively analyze the diagnostic accuracy of PET/CT in non-Hodgkin's lymphoma (NHL) and to evaluate the most appropriate study protocol of this technique. Patients and method Seventy-six biopsy proven NHL patients were enrolled in this prospective study for 3 years. Patients initially underwent a low-dose CT without intravenous contrast, then a PET emission scan and finally a full-dose CT with intravenous contrast. For every patient, two modalities of PET/CT images were reconstructed: a low-dose unenhanced PET/CT and a full-dose enhanced PET/CT. Each modality was evaluated by either of two pairs of readers, different for each modality. Enhanced CT and PET images were evaluated by an independent radiologist and nuclear medicine physician respectively. Results Agreement between reference standard and techniques was as follows: 52.2% of patients with enhanced CT (κ = 0.458), 46% with PET (κ = 0.335), 75% with low-dose unenhanced PET/CT (κ = 0.664) and 76.8% with full-dose enhanced PET/CT (κ = 0.679), with p < 0.001. Although all techniques underestimated the stage in comparison to gold standard, the lowest percentage was for full-dose enhanced PET/CT (20.3%). Conclusions PET/CT improved staging accuracy of NHL, being full-dose enhanced PET/CT the most accurate technique in our study.

Cytoskeletal staining in rectal cancer: problems

Dear Editor: I read the recent publication “Cytokeratin staining for complete remission in rectal cancer after chemoradiation” by Gonullu et al. (Int J Colorectal Dis. 2010; 25: 805–809) with great interest. Gonullu et al. concluded that “cytokeratin IHC offers a means of improving staging accuracy and thus provides useful information for prognosis and treatment decisions for patients with rectal cancer who had a clinical CR after CRT.” The problems of the techniques “falsenegative and/or false-positive results (Painter et al. Toxicol Patho. 2010; 38: 131–141)” should be mentioned. In a recent study on immostaining of sentinel lymph node mapping in colorectal cancer, false negative seems to be very clinically important (Sommariva et al. Eur J Surg Oncol. 2010;36:130–134). A mucinous histology seem to interfere with the reliability of staging (Sommariva et al. Eur J Surg Oncol. 2010;36:130–134). Nevertheless, the reported sensitivity and specificity of the cytokeratin staining in diagnosis of malignancy are about 80% and 75%, which cannot be considered good (Golijianin et al. J Urol. 2000; 164: 1922–1925). Many factors including tissue type, fixation time, quality control on specimen collection and frozen sectioning, and antibody specificity are mentioned for their impact on the result of IHC (Painter et al. Toxicol Pathol. 2010; 38: 131–141). How to solve the basic diagnostic problems and control of quality of the whole IHC process is required before implementation of the staining technique for real usage

Primary Adenocarcinoma of the Rete Testis: Improved Staging Accuracy With CT-PET

A case of adenocarcinoma of the rete testis in a 54-year-old man is presented. Most such patients harbor metastatic disease, even in clinically localized presentations. CT-PET may provide improved diagnostic sensitivity over conventional CT in this setting.