Mediastinal Lymph Node Metastasis Research Articles

The value on SUV-derived parameters assessed on 18F-FDG PET/CT for predicting mediastinal lymph node metastasis in non-small cell lung cancer

PurposeTo explore valuable predictors for mediastinal lymph node metastasis in non-small cell lung cancer (NSCLC) patients, we analyzed the potential roles of standardized uptake value (SUV)-derived parameters from preoperative 18F-FDG PET/CT combined with clinical characteristics.MethodsData from 224 NSCLC patients who underwent preoperative 18F-FDG PET/CT scans in our hospital were collected. Then, a series of clinical parameters including SUV-derived features [SUVmax of mediastinal lymph node and primary-tumor SUVmax, SUVpeak, SUVmean, metabolic tumor volume (MTV) and total lesion glycolysis (TLG)] were evaluated. The best possible cutoff points for all measuring parameters were calculated using receiver operating characteristic curve (ROC) analysis. Predictive analyses were performed using a Logistic regression model to determine the predictive factors for mediastinal lymph node metastasis in NSCLC and lung adenocarcinoma patients. After multivariate model construction, data of another 100 NSCLC patients were recorded. Then, 224 patients and 100 patients were enrolled to validate the predictive model by the area under the receiver operating characteristic curve (AUC).ResultsThe mediastinal lymph node metastasis rates in 224 patients for model construction and 100 patients for model validation were 24.1% (54/224) and 25% (25/100), respectively. It was found that SUVmax of mediastinal lymph node ≥ 2.49, primary-tumor SUVmax ≥ 4.11, primary-tumor SUVpeak ≥ 2.92, primary-tumor SUVmean ≥ 2.39, primary-tumor MTV ≥ 30.88 cm3, and primary-tumor TLG ≥ 83.53 were more prone to mediastinal lymph node metastasis through univariate logistic regression analyses. The multivariate logistic regression analyses showed that the SUVmax of mediastinal lymph nodes (≥ 2.49: OR 7.215, 95% CI 3.326–15.649), primary-tumor SUVpeak (≥ 2.92: OR 5.717, 95% CI 2.094–15.605), CEA (≥ 3.94 ng/ml: OR 2.467, 95% CI 1.182–5.149), and SCC (< 1.15 ng/ml: OR 4.795, 95% CI 2.019–11.388) were independent predictive factors for lymph node metastasis in the mediastinum. It was found that SUVmax of the mediastinal lymph node (≥ 2.49: OR 8.067, 95% CI 3.193–20.383), primary-tumor SUVpeak (≥ 2.92: OR 9.219, 95% CI 3.096–27.452), and CA19-9 (≥ 16.6 U/ml: OR 3.750, 95% CI 1.485–9.470) were significant predictive factors for mediastinal lymph node metastasis in lung adenocarcinoma patients. The AUCs for the predictive value of the NSCLC multivariate model through internal and external validation were 0.833 (95% CI 0.769- 0.896) and 0.811 (95% CI 0.712–0.911), respectively.ConclusionHigh SUV-derived parameters (SUVmax of mediastinal lymph node and primary-tumor SUVmax, SUVpeak, SUVmean, MTV and TLG) might provide varying degrees of predictive value for mediastinal lymph node metastasis in NSCLC patients. In particular, the SUVmax of mediastinal lymph nodes and primary-tumor SUVpeak could be independently and significantly associated with mediastinal lymph node metastasis in NSCLC and lung adenocarcinoma patients. Internal and external validation confirmed that the pretherapeutic SUVmax of the mediastinal lymph node and primary-tumor SUVpeak combined with serum CEA and SCC can effectively predict mediastinal lymph node metastasis of NSCLC patients.

The Role Of Serum Uric Acid And Uric Acid To Albumin Ratio For Predicting Of Lymph Node Metastasis In Lung Cancer Treated Surgically By Vats.

In recent years, a correlation between prognosis of various cancers and inflammation has been emphasized in many studies. Uric acid which is a purine metabolite is one of the serum inflammation markers. Albumin is a major component of serum protein and it is used as a parameter reflecting nutritional status and cancer aggressiveness. Here, we have investigated whether preoperative serum uric acid levels, albumin levels, and uric acid to albumin ratio predict lymph node metastasis in non-small cell lung cancer treated surgically by VATS. The medical records of patients underwent VATS lobectomy-segmentectomy for non-small cell lung cancer between January 2015 and December 2020, were reviewed retrospectively. Cut-off values of preoperative serum uric acid, albumin and uric acid to albumin ratio were determined by Receiver Operating Characteristics (ROC) analysis. Groups with and without lymph node metastasis were created according to hilar and/or mediastinal lymph node metastasis. In addition, high and low groups were created according to preoperative uric acid levels and uric acid to albumin ratio. Pearson chi-square test was used investigate whether any significant correlation between the groups. A total of 115 patients were included in the study. Lymph node metastasis in N1 and N2 stations was detected in 11 and 18 patients, respectively. Cut-off values for uric acid and uric acid to albumin ratio were 5.97 mg/dL and 1.28x10-3, respectively. There was a statistically significant correlation between lymph node metastasis and high uric acid levels (p=0.008, OR: 3.2) and high uric acid to albumin ratio (p=0.03, OR: 2.6). Preoperative serum uric acid and uric acid to albumin ratio can predict the lymph node metastasis in non-small cell lung cancer treated surgically by video assisted thoracic surgery.

Diagnostic Performance of Endosonography to Detect Mediastinal Lymph Node Metastasis in Patients with Radiological N1 Non-Small Cell Lung Cancer.

Guidelines recommend that non-small cell lung cancer (NSCLC) patients with suspected hilar lymph node (LN) metastases should undergo invasive mediastinal LN staging prior to surgical treatment via endosonography. We evaluated the diagnostic performance of endosonography for detecting occult mediastinal metastases (OMM) and determined the factors associated with OMM in NSCLC patients with radiological N1. Patients with confirmed primary NSCLC with radiological N1 who underwent endosonography for nodal staging assessment from January 2013 to December 2019 were retrospectively analyzed. The prevalence of OMM was found to be 83/279 (29.7%) and only 38.6% (32/83) were diagnosed via endosonography. However, five of them were confirmed as N3 by endosonography. The overall diagnostic sensitivity, negative predictive value, accuracy, and area under the curve of endosonography were 38.6%, 79.4%, 81.7%, and 0.69, respectively. In multivariable analysis, central tumor (adjusted odds ratio [aOR], 2.05; 95% confidence interval [CI], 1.15-3.68; p=0.016), solid tumor (aOR, 10.24; 95% CI, 1.32-79.49; p=0.026), and adenocarcinoma (aOR, 3.01; 95% CI, 1.63-5.55; p<0.001) were related to OMM in radiological N1 NSCLC patients. Although the sensitivity of endosonography for detecting OMM was only 40%, the prevalence of OMM was not low (30%) and some cases even turned out to be N3 diseases. Clinicians should be aware that OMM may be more likely in patients with central, solid, and adenocarcinomatous tumor when performing nodal staging in radiological N1 NSCLC via endosonography.

Selective Mediastinal Lymph Node Dissection Strategy for Clinical T1N0 Invasive Lung Cancer: A Prospective, Multicenter, Clinical Trial

IntroductionWe aimed to prospectively evaluate our previously proposed selective mediastinal lymph node (LN) dissection strategy for peripheral clinical T1N0 invasive NSCLC. MethodsThis is a multicenter, prospective clinical trial in China. We set six criteria for predicting negative LN stations and finally guiding selective LN dissection. Consolidation tumor ratio less than or equal to 0.5, segment location, lepidic-predominant adenocarcinoma (LPA), negative hilar nodes (stations 10–12), and negative visceral pleural invasion (VPI) were used separately or in combination as predictors of negative LN status in the whole, superior, or inferior mediastinal zone. LPA, hilar node involvement, and VPI were diagnosed intraoperatively. All patients actually underwent systematic mediastinal LN dissection. The primary end point was the accuracy of the strategy in predicting LN involvement. If LN metastasis occurred in certain mediastinal zone that was predicted to be negative, it was considered as an “inaccurate” case. ResultsA total of 720 patients were enrolled. The median number of LN dissected was 15 (interquartile range: 11–20). All negative node status in certain mediastinal zone was correctly predicted by the strategy. Compared with final pathologic findings, the accuracy of frozen section to diagnose LPA, VPI, and hilar node metastasis was 94.0%, 98.9%, and 99.6%, respectively. Inaccurate intraoperative diagnosis of LPA, VPI, or hilar node metastasis did not lead to inaccurate prediction of node-negative status. ConclusionsThis is the first prospective trial validating the specific mediastinal LN metastasis pattern in cT1N0 invasive NSCLC, which provides important evidence for clinical applications of selective LN dissection strategy.

Palliative surgery for malignant superior vena cava obstruction resistant to immunotherapy: a case report

A disease progression pattern in a limited number of sites, called oligoprogression, is relatively common in patients with lung cancer during immunotherapy. It is controversial how to manage clinically problematic oligoprogressive lesions, such as superior vena cava (SVC) obstruction resistant to immunotherapy. We present a case of a 43-year-old man who presented with facial swelling and pain in the right shoulder. Contrast-enhanced computed tomography (CT) revealed a tumor at the apex of the right lung, pulmonary and pleural nodules, and swollen mediastinal lymph nodes. A swollen mediastinal lymph node directly invaded into the SVC. Pathological diagnosis of the lymph node revealed adenocarcinoma. On the basis of these findings, the patient was diagnosed with lung adenocarcinoma with SVC obstruction (cT3N2M1c; stage IVB). First-line chemotherapy with carboplatin, pemetrexed, and pembrolizumab reduced the size of the primary tumor, pulmonary and pleural metastases, and most mediastinal lymph node metastases after four cycles of treatment, but one lesion invading the SVC increased. Therefore, surgical resection of the lesion and vascular replacement were performed. At present, 22 months have passed since the surgery, and maintenance therapy with pemetrexed and pembrolizumab is ongoing, without disease progression nor any adverse events. The clinical course of the case presented here suggests that palliative surgery may be an effective management option for a clinically problematic lesion, such as SVC obstruction, which increases during immunotherapy.

A Case of Mediastinal Lymph Node Metastasis from a Colorectal Liver Metastasis Successfully Treated by Surgical Resection

A Case of Mediastinal Lymph Node Metastasis from a Colorectal Liver Metastasis Successfully Treated by Surgical Resection

Adjuvant treatments for locally advanced differentiated thyroid cancer: a nationwide survey in Japan.

The role of adjuvant external-beam radiotherapy (EBRT) for locally advanced differentiated thyroid cancer (DTC) is controversial because of the lack of prospective data. To prepare for a clinical trial, this study investigated the current clinical practice of adjuvant treatments for locally advanced DTC. A survey on treatment selection criteria for hypothetical locally advanced DTC was administered to representative thyroid surgeons of facilities participating in the Japan Clinical Oncology Group Radiation Therapy Study Group. Of the 43 invited facilities, surgeons from 39 (91%) completed the survey. For R1 resection or suspected residual disease, 26 (67%) facilities administered high-dose (100-200 mCi) radioactive iodine (RAI), but none performed EBRT. For R2 resection or unresectable primary disease, 26 (67%) facilities administered high-dose RAI and 7 (18%) performed adjuvant treatments, including EBRT. For complete resection with nodal extra-capsular extension, 13 (34%) facilities administered high-dose RAI and 1 (3%) performed EBRT. For unresectable mediastinal lymph node metastasis, 31 (79%) facilities administered high-dose RAI and 5 (13%) performed adjuvant treatments, including EBRT. Adjuvant EBRT was not routinely performed mainly because of the lack of evidence for efficacy (74%). Approximately 15% of the facilities routinely considered adjuvant EBRT for DTC with R2 resection or unresectable primary or lymph node metastasis disease. Future clinical trials will need to optimize EBRT for these patients.

Construction of a predictive model of abdominal lymph node metastasis in thoracic esophageal squamous cell carcinoma and preliminary analysis of its effect on target for postoperative radiotherapy.

To investigate the influencing factors of abdominal lymph node metastasis in thoracic esophageal squamous cell carcinoma (TESCC), and to construct its predictive model, in order to analyze the targets for postoperative radiotherapy. From January 2008 to December 2014, the clinicopathological data of 479 patients who underwent radical resection for esophageal cancer in the Fourth Hospital of Hebei Medical University were collected and retrospectively analyzed. The influencing factors of postoperative abdominal lymph node metastasis were analyzed, and a predictive model was constructed based on their independent influencing factors. Receiver operating characteristic (ROC) curve was utilized to analyze the predictive value of this model; in the meantime, the postoperative locoregional recurrence (LRR) of this group was analyzed. The postoperative pathology of all patients showed that the lymph node metastasis rate (LNR) was 39.7%, of which the abdominal lymph node metastasis rate was 22.0%. Logistic regression analysis revealed that the patient's lesion location, pN stage, vascular invasion, LND and mediastinal lymph node metastasis were independent risk factors for the positive rate of abdominal lymph nodes after surgery (P = 0.000, 0.000, 0.033, 0.000, 0.000). The probability of abdominal lymph node metastasis was Y = ex/(1 + ex), and X = -5.502 + 1.569 × lesion location + 4.269 × pN stage + 1.890 × vascular invasion + 1.950 × LND-4.248 × mediastinal lymph node metastasis. The area under the ROC curve (AUC) of this model in predicting abdominal lymph node metastasis was 0.962 (95% CI, 0.946-0.977). This mathematical model had a high predictive value for the occurrence of abdominal lymph node metastasis (P = 0.000), and the sensitivity and specificity of prediction were 94.6% and 88.3% respectively. The overall survival rate was significantly higher (X2 = 29.178, P = 0.000), while abdominal lymph node recurrence rate was lower in patients with negative abdominal lymph nodes than in those with negative lymph nodes (1.4%&7.7%, X2 = 12.254, P = 0.000). The lesion location, pN stage, vascular invasion, LND and mediastinal lymph node metastasis are independent influencing factors of abdominal lymph node metastasis in patients with TESCC. The mathematical model constructed by these indicators can accurately predict abdominal lymph node metastasis, which can help clinicians to choose the targets for postoperative radiotherapy.

Value of Presurgical 18F-FDG PET/CT Radiomics for Predicting Mediastinal Lymph Node Metastasis in Patients with Lung Adenocarcinoma.

Objective: The aim of this study was to develop a 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) radiomic model for predicting mediastinal lymph node metastasis (LNM) in presurgical patients with lung adenocarcinoma. Methods: The study enrolled 320 patients with lung adenocarcinoma (288 internal and 32 external cases) and extracted 190 radiomic features using the LIFEx package. Optimal radiomic features to build a radiomic model were selected using the least absolute shrinkage and selection operator algorithm. Logistic regression was used to build the clinical and complex (combined radiomic and clinical variables) models. Results: Ten radiomic features were selected. In the training group, the area under the receiver operating characteristic curve of the complex model was significantly higher than that of the radiomic and clinical models [0.924 (95% CI: 0.887-0.961) vs. 0.863 (95% CI: 0.814-0.912; p = 0.001) and 0.838 (95% CI: 0.783-0.894; p = 0.000), respectively]. The sensitivity, specificity, accuracy, and positive and negative predictive values of the radiomic model were 0.857, 0.790, 0.811, and 0.651 and 0.924, respectively, which were better than that of visual evaluation (0.539, 0.724, 0.667, and 0.472 and 0.775, respectively) and PET semiquantitative analyses (0.619, 0.732, 0.697, and 0.513 and 0.808, respectively). Conclusions: 18F-FDG PET/CT radiomics showed good predictive performance for LNM and improved the N-stage accuracy of lung adenocarcinoma.

Mathematical models for intraoperative prediction of metastasis to regional lymph nodes in patients with clinical stage I non-small cell lung cancer.

It remains challenging to determine the regions of metastasis to lymph nodes during operation for clinical stage I non-small cell lung cancer (NSCLC). This study aimed to establish intraoperative mathematical models with nomograms for predicting the hilar-intrapulmonary node metastasis (HNM) and the mediastinal node metastasis (MNM) in patients with clinical stage I NSCLC. The clinicopathological variables of 585 patients in a derivation cohort who underwent thoracoscopic lobectomy with complete lymph node dissection were retrospectively analyzed for their association with the HNM or the MNM. After analyzing the variables, we developed multivariable logistic models with nomograms to estimate the risk of lymph node metastasis in different regions. The predictive efficacy was then validated in a validation cohort of 418 patients. It was confirmed that carcinoembryonic antigen (>5.75 ng/mL), CYFRA211 (>2.85 ng/mL), the maximum diameter of tumor (>2.75 cm), tumor differentiation (grade III), bronchial mucosa and cartilage invasion, and vascular invasion were predictors of HNM, and carcinoembryonic antigen (>8.25 ng/mL), CYFRA211 (>2.95 ng/mL), the maximum diameter of tumor (>2.75 cm), tumor differentiation (grade III), bronchial mucosa and cartilage invasion, vascular invasion, and visceral pleural invasion were predictors of MNM. The validation of the prediction models based on the above results demonstrated good discriminatory power. Our predictive models are helpful in the decision-making process of specific therapeutic strategies for the regional lymph node metastasis in patients with clinical stage I NSCLC.

Correlation analysis between unenhanced and enhanced CT radiomic features of lung cancers presenting as solid nodules and their efficacy for predicting hilar and mediastinal lymph node metastases.

If hilar and mediastinal lymph node metastases occur in solid nodule lung cancer is critical for tumor staging, which determines the treatment strategy and prognosis of patients. We aimed to develop an effective model to predict hilar and mediastinal lymph node metastases by using texture features of solid nodule lung cancer. Two hundred eighteen patients with solid nodules on CT images were analyzed retrospectively. The 3D tumors were delineated using ITK-SNAP software. Radiomics features were extracted from unenhanced and enhanced CT images based on AK software. Correlations between radiomics features of unenhanced and enhanced CT images were analyzed with Spearman rank correlation analysis. According to pathological findings, the patients were divided into no lymph node metastasis group and lymph node metastasis group. All patients were randomly divided into training group and test group at a ratio of 7:3. Valuable features were selected. Multivariate logistic regression was used to build predictive models. Two predictive models were established with unenhanced and enhanced CT images. ROC analysis was used to estimate the predictive efficiency of the models. A total of 7 categories of features, including 107 features, were extracted. There was a high correlation between the 7 categories of features from unenhanced CT images and enhanced CT images (all r > 0.7, p < 0.05). Among them, the shape features had the strongest correlation (mean r = 0.98). There were 5 features in the enhanced model and the unenhanced model, which had important predicting significance. The AUCs were 0.811 and 0.803, respectively. There was no significant difference in the predictive performance of the two models (DeLong's test, p = 0.05). Our study models achieved higher accuracy for predicting hilar and mediastinal lymph node metastasis of solid nodule lung cancer and have some value in promoting the staging accuracy of lung cancer. Our results show that CT radiomics features have potential to predict hilar and mediastinal lymph node metastases in solid nodular lung cancer. In addition, enhanced and unenhanced CT radiomics models had comparable predictive power in predicting hilar and mediastinal lymph node metastases.

Consistency and prognostic value of preoperative staging and postoperative pathological staging using 18F-FDG PET/MRI in patients with non-small cell lung cancer.

In recent years, positron emission tomography/magnetic resonance imaging (PET/MRI) has been clinically used as a method to diagnose non-small cell lung cancer (NSCLC). This study aimed to evaluate the concordance of staging and prognostic ability of NSCLC patients using thin-slice computed tomography (CT) and 18F-fluorodeoxyglucose (FDG) PET/MRI. This retrospective study was performed on consecutive NSCLC patients who underwent both diagnostic CT and 18F-FDG PET/MRI before surgery between November 2015 and May 2019. The cTNM staging yielded from PET/MRI was compared with CT and pathological staging, and concordance was investigated, defining pathological findings as reference. To assess the prognostic value of disease-free survival (DFS) and overall survival (OS), we dichotomized the typical prognostic factors and TNM classification staging (Stage I vs. Stage II or higher). Kaplan-Meier curves derived by the log-rank test were generated, and univariate and multivariate analyses were performed to identify the factors associated with DFS and OS. A total of 82 subjects were included; PET/MRI staging was more consistent (59 of 82) with pathological staging than with CT staging. There was a total of 21 cases of CT and 11 cases of PET/MRI that were judged as cStage I, but were actually pStage II or pStage III. CT tended to judge pN1 or pN2 as cN0 compared to PET/MRI. There was a significant difference between NSCLC patients with Stage I and Stage II or higher by PET/MRI staging as well as prognosis prediction of DFS by pathological staging (P < 0.001). In univariate analysis, PET/MRI, CT, and pathological staging (Stage I or lower vs. Stage II or higher) all showed significant differences as prognostic factors of recurrence or metastases. In multivariate analysis, pathological staging was the only independent factor for recurrence (P = 0.009), and preoperative PET/MRI staging was a predictor of patient survival (P = 0.013). In NSCLC, pathologic staging was better at predicting recurrence, and preoperative PET/MRI staging was better at predicting survival. Preoperative staging by PET/MRI was superior to CT in diagnosing hilar and mediastinal lymph-node metastases, which contributed to the high concordance with pathologic staging.

Intraoperative ultrasound: "Alternative eye" in lymph nodal dissection in non-small cell lung cancer.

Staging of the mediastinum lymph nodes involvement in patients with non-small cell lung cancer (NSCLC) is an important prognostic factor determining the most appropriate multimodality treatment plan. The objective of this study is to assess ultrasound characteristics of mediastinal lymph nodes metastasis and effectiveness of intraoperative ultrasound-guided mediastinal nodal dissection in patients with resected NSCLC. All patients undergoing video-assisted thoracoscopic surgery lobectomy and pulmonary lymphadenectomy from November 2020 to March 2022 at the thoracic surgery department of the Vanvitelli University of Naples underwent intraoperative ultrasound-guided mediastinal lymph nodal dissection. This study evaluates whether individual B-mode features and a compounding thereof can be used to accurately and reproducibly predict lymph node malignancy. Intraoperative ultrasound, during systematic mediastinal lymph node dissection, is helpful in preventing lesion to mediastinal structures. Pathological nodal sonographic characteristics are round shape, short-axis diameter, echogenicity, margin, the absence or presence of coagulation necrosis sign, and the absence or presence of central hilar structure, increased color Doppler flow, the absence or presence of calcification, and nodal conglomeration. Operating time was not substantially prolonged. The procedure is simple, safe and highly accurate. Ultrasonic techniques allow surgeons to detect the relationship between lymph nodes and surrounding large blood vessels during biopsy, improving the safety and simplicity of the operation, increasing the number of harvested lymph nodes, and reducing the risk of intraoperative injury; it is a fast, easily reproducible, and inexpensive method.

The IASLC Proposed Grading System Accurately Predicts Prognosis and Mediastinal Nodal Metastasis in Patients With Clinical Stage I Lung Adenocarcinoma.

The International Association for the Study of Lung Cancer (IASLC) recently proposed a new grading system for lung adenocarcinoma (LUAD). We aimed to validate the prognostic performance of the grading system and explore its role in guiding the strategy of lymph node (LN) dissection. We retrospectively reviewed 1029 patients with clinical stage I LUAD who underwent surgery between 2011 and 2013. The association between mediastinal nodal metastasis and grading system was evaluated. To investigate the value of the grading system in guiding LN dissection strategies, 3 pathologists evaluated the feasibility of identifying the grading system using frozen section (FS). The differences in prognosis between all neighboring grades were highly significant based on the grading system ( P <0.001). Notably, almost no grade 1 LUAD (1.4%) had pN2 disease, whereas higher rates were found in grade 2 LUAD (9.6%) and grade 3 LUAD (18.3%) ( P <0.001). Multivariate logistic regression analysis revealed that higher tumor grade was an independent predictor of mediastinal nodal metastasis ( P =0.002). Moreover, limited mediastinal LN dissection had equivalent prognosis in grade 1 LUAD, but significantly worse prognosis in grade 2 and grade 3 LUAD than systematic mediastinal LN dissection. The overall accuracy of using intraoperative FS to identify the IASLC grading system was 85.4% (κ=0.765) with substantial agreement. The IASLC grading system could accurately stratify prognosis and predict mediastinal nodal metastasis in patients with clinical stage I LUAD. FS was feasible for identifying the IASLC grading system.

Preoperative prediction of mediastinal lymph node metastasis in non-small cell lung cancer based on 18F-FDG PET/CT radiomics

To establish and verify a 2-[18F]-fluoro-2-deoxy-d-glucose (FDG) positron-emission tomography (PET)/computed tomography (CT)-based radiomics nomogram to predict mediastinal lymph node metastasis (LNM) in non-small cell lung cancer (NSCLC) patients preoperatively. This retrospective study enrolled 155 NSCLC patients (primary cohort, n=93; validation cohort, n=62). For each patient, 2,704 radiomic features were extracted from the primary lung cancer regions. Four procedures including the Mann-Whitney U-test, Spearman's correlation analysis, minimum redundancy-maximum relevance (mRMR), and least absolute shrinkage and selection operator (LASSO) binary logistic regression were utilised for determining essential features and establishing a radiomics signature. After that, a nomogram was established. The nomogram's potential was assessed based on its discrimination, calibration, and clinical usefulness. The radiomics signature and nomogram predictive performances were evaluated with respect to the area under the receiver operating characteristic curve (AUC), specificity, accuracy, and sensitivity. The radiomics signature composed of eight selected features had good discriminatory performance of LNM versus non-LNM groups an AUC of 0.851 and 0.826 in primary and validation cohorts, respectively. The nomogram also indicated good discrimination with an AUC of 0.869 and 0.847 in the primary and validation cohorts, respectively. Furthermore, good calibration was demonstrated utilising the nomogram. An 18F-FDG PET/CT-based radiomics nomogram that integrates the radiomics signature and age was promoted to predict mediastinal LNM within NSCLC patients, which could potentially facilitate individualised therapy for mediastinal LNM before treatment. The nomogram was beneficial in clinical practice, as illustrated by decision curve analysis.

240. PERIOPERATIVE OUTCOME AND SURGICAL TECHNIQUE OF TRANSMEDIASTINAL ESOPHAGECTOMY FOR ESOPHAGOGASTRIC JUNCTION CANCER

Abstract We started performing mediastinal lymph node dissection by a laparoscopic transhiatal approach (LTHA) in 2009. To date, 463 patients had undergone our method during various esophageal surgical procedures, including esophagogastric junction cancer (EGJC). Furthermore, we started performing single-port mediastinoscopic cervical approach in 2014, and developed a simple technique for transmediastinal esophagectomy (TME) without thoracic approach (350 cases). Fifty four patients with EGJC were treated by TME. Left single-port mediastinoscopic cervical approach was performed with pneumomediastinum. Mainly for advanced SCC, upper mediastinal lymph node dissection including recurrent laryngeal nerve LNs was performed with intraoperative monitoring using NIM system. Next, LTHA was performed for en bloc mediastinal lymph node dissection. The esophageal hiatus was opened, and working space was secured by Long Retractors. The posterior plane of the pericardium was extended. The posterior side of LNs was then separated. Finally, while lifting LNs like a membrane, they were resected from bilateral mediastinal pleura. Reconstruction with narrow gastric conduit was performed through substernal tract. Patients with EGJC performed TME were analyzed (n = 54, SCC/Adeno/Others = 29/23/2). Upper mediastinal lymph node metastasis was found in 9 cases (SCC/Adeno = 5/4), middle mediastinal lymph node metastasis was found in 5 cases (SCC/Adeno = 3/2), and all of them had advanced tumors. Their perioperative outcome were compared with those performed the right thoracotomy (n = 41). The operative time and bleeding were decreased by TME. The number of resected mediastinal lymph nodes, pR0 rate, and mediastinal recurrence in the two groups were not different. In 92.6% of patients treated by TME, extubation was performed at 0 POD. Postoperative respiratory complications was decreased by TME (TME:7.4%, thoracotomy:17.1%). This procedure, TME, resulted in a good surgical view, safe en-bloc mediastinal lymph node dissection, and the decrease of postoperative respiratory complications in patients with EGJC.

Machine learning classification of mediastinal lymph node metastasis in NSCLC: a multicentre study in a Western European patient population

Background[18F] FDG PET-CT has an important role in the initial staging of lung cancer; however, accurate differentiation between activity in malignant and benign intrathoracic lymph nodes on PET-CT scans can be challenging. The purpose of the current study was to investigate the effect of incorporating primary tumour data and clinical features to differentiate between [18F] FDG-avid malignant and benign intrathoracic lymph nodes.MethodsWe retrospectively selected lung cancer patients who underwent PET-CT for initial staging in two centres in the Netherlands. The primary tumour and suspected lymph node metastases were annotated and cross-referenced with pathology results. Lymph nodes were classified as malignant or benign. From the image data, we extracted radiomic features and trained the classifier model using the extreme gradient boost (XGB) algorithm. Various scenarios were defined by selecting different combinations of data input and clinical features. Data from centre 1 were used for training and validation of the models using the XGB algorithm. To determine the performance of the model in a different hospital, the XGB model was tested using data from centre 2.ResultsAdding primary tumour data resulted in a significant gain in the performance of the trained classifier model. Adding the clinical information about distant metastases did not lead to significant improvement. The performance of the model in the test set (centre 2) was slightly but statistically significantly lower than in the validation set (centre 1).ConclusionsUsing the XGB algorithm potentially leads to an improved model for the classification of intrathoracic lymph nodes. The inclusion of primary tumour data improved the performance of the model, while additional knowledge of distant metastases did not. In patients in whom metastases are limited to lymph nodes in the thorax, this may reduce costly and invasive procedures such as endobronchial ultrasound or mediastinoscopy procedures.

Association of Fluorodeoxyglucose Positron Emission Tomography Radiomics Features with Clinicopathological Factors and Prognosis in Lung Squamous Cell Cancer.

To evaluate the role of fluorine-18 fluorodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) radiomics features (RFs) for predicting clinicopathological factors (CPFs) and prognosis in patients with resected lung squamous cell cancer (LSCC). Patients with early-stage (stage I-III) LSCC who underwent 18F-FDG PET/CT before surgical resection between August 2012 and February 2020 were analyzed. Patients who received neoadjuvant chemotherapy or radiotherapy were excluded from the study. The maximum standard uptake value (SUVmax) and RFs were extracted from PET images for primary tumors. The diagnostic performances of PET parameters in groups of tumor differentiation, stage, and mediastinal lymph node metastasis (MLNM) status were evaluated. The study endpoints were overall survival (OS) and progression-free survival (PFS). Univariate and multivariate analyses were performed with RFs, SUVmax, and CPFs to find independent predictors of PFS and OS. A total of 77 patients (5 female, 72 male) were included in the study. SUVmax and GLCM entropy were independently associated with tumor differentiation. The only parameter with significant diagnostic performance for MLNM was GLZLM-SLZGE. Tumor diameter and NGLDM busyness were independently associated with the stage. MLNM and tumor differentiation were found to be independent predictors of PFS. NGLDM contrast and MLNM were independently associated with OS. Using radiomic features in addition to CPFs to predict disease recurrence and shorter overall survival can guide precision medicine in patients with LSCC.

Application of transverse cervical artery flap in laryngeal function preservation surgery of hypopharyngeal carcinoma

To explore the value and limitation of transverse cervical artery flap in laryngeal function preservation surgery of hypopharyngeal carcinoma. Between January 2013 and December 2019, 18 male patients with hypopharyngeal carcinoma were admitted. The patients' age ranged from 48 to 77 years, with a median age of 65 years. The disease duration ranged from 3 to 8 months (mean, 5 months). All patients were diagnosed as squamous cell carcinoma by biopsy before operation. According to the American Joint Committee on Cancer (AJCC) guidelines (2017, 8th ed), TNM staging was T2N0M0 in 9 cases, T2N1M0 in 2 cases, and T3N0M0 in 7 cases, and cTNM staging was stage Ⅱ in 9 cases and stage Ⅲ in 9 cases. The lesions of 15 cases were located in the piriform fossa of hypopharynx on one side, among which the esophageal entrance was involved in 4 cases. The lesions of 3 cases were located in the posterior wall of the hypopharynx with esophageal entrance involvement. After partial pharyngo- laryngectomy and bilateral neck lymph node dissection, the hypopharyngeal and laryngeal defects were repaired with transverse cervical artery flaps, the size of the flap ranged from 4 cm×3 cm to 6 cm×4 cm. The accompanying vein of transverse cervical artery (7 cases), external jugular vein (6 cases), and combination of both (5 cases) served as venous reflux. Retrograde external jugular venous reflux exercise was performed in 2 flaps with venous reflux obstruction during operation. The incisions at donor sites were directly sutured or via relaxed incision sutured. Radiotherapy and chemotherapy were supplemented within 3 months after operation. Tracheal cannula with air bag was used to prevent patients from aspiration in the early postoperative stage. The operation time was 4-6 hours, with an average of 4.5 hours. All patients were followed up 1-5 years (mean, 2 years and 6 months). Postoperative pathological examination showed that 7 cases had cervical lymph node metastases on the affected side, and there was no lymph node metastasis in cervical region Ⅴ; the remaining 11 cases had no lymph node metastasis. After operation, 16 flaps survived successfully, and 2 flaps with external jugular vein reflux were covered with white pseudomembrane, no flap necrosis was found after the pseudomembrane fell off. Four cases had no obvious accidental aspiration after operation; 14 cases had obvious accidental aspiration, of which 13 cases were significantly reduced at 3 months after operation, and 1 case still had obvious accidental aspiration at 6 months after operation, and the accidental aspiration decreased significantly after pulling out the gastric tube. All patients had no aspiration pneumonia. One case developed upper mediastinal lymph node metastasis at 1 year and 2 months after operation, and died of recurrence and pulmonary infection at 1 year and 3 months after operation. No recurrence or metastasis was found in the remaining 17 cases during follow-up. Tracheal cannula was successfully removed in 7 cases at 2-5 months after operation. Different degrees of accidental aspiration in 11 patients were confirmed by esophagography, so the tracheal cannula was retained. All patients had pronunciation function after operation. All incisions at the donor sites healed by first intention, and the shoulder joint function was normal. Using transverse cervical artery flap to repair the hypopharyngeal and laryngeal defects during hypopharyngeal carcinoma surgery in patients without lymph node metastasis in cervical region Ⅴ, can achieve good results of laryngeal function preservation. In cases with suspected lymph node metastasis in cervical region Ⅴ or venous dysplasia of accompanying vein of transverse cervical artery, there is a risk of tumor recurrence or flap necrosis, and the repair method needs to be cautiously employed.

Potential factors of cytokeratin fragment 21-1 and cancer embryonic antigen for mediastinal lymph node metastasis in lung cancer.

Objective: Lung cancer is a common malignant tumor, characterized by being difficult to detect and lacking specific clinical manifestations. This study aimed to find out the risk factors of mediastinal lymph node metastasis and explore the correlation between serum tumor markers and mediastinal lymph node metastasis and lung cancer prognosis. Methods: A retrospective study of 3,042 lung cancer patients (330 patients with mediastinal lymph node metastasis and 2,712 patients without mediastinal lymph node metastasis) collected from the First Affiliated Hospital of Nanchang University from April 1999 to July 2020. The patients were divided into two groups, namely, mediastinal lymph node metastasis group and non-mediastinal lymph node metastasis group. Student’s t test, non-parametric rank sum test and chi-square test were used to describe whether there is a significant difference between the two groups. We compared the serum biomarkers of the two groups of patients, including exploring serum alkaline phosphatase (ALP), calcium hemoglobin (HB), alpha-fetoprotein (AFP), carcinoembryonic antigen (CEA), CA125, CA-199, CA -153, cytokeratin fragment 19 (CYFRA 21-1), total prostate specific antigen (TPSA), neuron-specific enolase (NSE) levels and the incidence and prognosis of lung cancer mediastinal lymph node metastasis. Binary logistic regression analysis was used to determine its risk factors, and receiver operating curve (ROC) analysis was used to evaluate its diagnostic value for mediastinal lymph node metastasis. Results: Binary logistic regression analysis showed that carcinoembryonic antigen and CYFRA 21-1 were independent risk factors for mediastinal lymph node metastasis in patients with lung cancer (p < 0.001 and p = 0.002, respectively). The sensitivity and specificity of CEA for the diagnosis of mediastinal lymph node metastasis were 90.2 and 7.6%, respectively; CYFRA 21-1 were 0.6 and 99.0%, respectively. Conclusion: Serum CEA and CYFRA 21-1 have predictive value in the diagnosis of mediastinal lymph node metastasis in patients with lung cancer.