Node Uptake Research Articles

Incidence of sarcoid-like reaction demonstrated on 18F-FDG PET-CT in head and neck cancer patients

Results SLR was diagnosed in 8/308 (2.6%) HNC patients. Of which 3 had mediastinal nodal uptake only, 2 had bilateral hilar nodal uptake only and 3 had both mediastinal and hilar uptake. All the 8 patients had primary HNC and deep cervical lymphadenopathy but no distant metastases, hence misinterpretation of SLR would have upstaged as M1 (metastasis positive). 4 cases were identified on scan for restaging of suspected recurrence, and 4 were for primary tumour staging. The mean SUVmax of SLR was 6.9 (range 2.4-9.6), and the mean SLR nodal size was 1.6cm in short axis (range 0.6-2.4cm), with no significant difference compared to active nodal diseases (P=0.33 and 0.23). Conclusion SLR was seen in 2.6% of HNC patients at 18F-FDG PET-CT examinations. 18F-FDG PET-CT plays a significant role in the management of HNC, and it is important to be aware of a possibility of SLR in order to avoid false-positive interpretation of metastasis.

(11)C-acetate PET/CT in pre-therapeutic lymph node staging in high-risk prostate cancer patients and its influence on disease management - a retrospective study.

BackgroundRadiation treatment with simultaneous integrated boost against suspected lymph node metastases may be a curative therapeutic option in patients with high-risk prostate cancer (>15% estimated risk of pelvic lymph node metastases according to the Cagiannos nomogram). 11C-acetate positron emission tomography/computed tomography (PET/CT) can be used for primary staging as well as for detection of suspected relapse of prostate cancer. The aims of this study were to evaluate the association between positive 11C-acetate PET/CT findings and the estimated risk of pelvic lymph node metastases and to assess the impact of 11C-acetate PET/CT on patient management in high-risk prostate cancer patients.MethodsFifty consecutive prostate cancer patients referred for primary staging with 11C-acetate PET/CT prior to radiotherapy with curative intention were enrolled in this retrospective study.ResultsAll patients showed increased 11C-acetate uptake in the prostate. Pelvic lymph node uptake was seen in 42% (21/50) of the patients, with positive external iliac lymph nodes in 71% (15/21) of these. The overall observed proportion of PET/CT-positive pelvic lymph nodes at patient level was higher than the average estimated risk, especially in low-risk groups (<15%). There was a significant association between observed proportion and estimated risk of pelvic lymph node metastases in groups with ≤45 and >45% estimated risk. Treatment strategy was altered due to 11C-acetate PET/CT findings in 43% (20/47) of the patients.ConclusionsThe observed proportion of 11C-acetate PET/CT findings suggestive of locoregional metastases was higher than the estimated risk, suggesting that the Cagiannos nomogram underestimates the risk for metastases. The imaging results with 11C-acetate PET/CT have a considerable impact on patient management.

Significance of Incidental Nasopharyngeal Uptake on (18)F-FDG PET/CT: Patterns of Benign/Physiologic Uptake and Differentiation from Malignancy.

The purpose of this study was to assess the significance of incidental nasopharyngeal uptake on 18F-FDG PET/CT and to identify image patterns useful in the differentiation between benign or physiologic activity and nasopharyngeal carcinoma. We retrospectively reviewed medical records of patients with nasopharyngeal uptakes on 18F-FDG PET/CT scans taken between January 2010 and July 2011. Patients with head and neck cancer, other metastatic head and neck lesions, or lymphoma were excluded. Total 177 patients were enrolled (Group A). PET images were reviewed for patterns of nasopharyngeal FDG uptake, presence/absence of cervical lymph node uptake and pattern of cervical node uptake. Diagnostic confirmation was made by pathology or clinical and radiological follow-up for 1 year or longer. Furthermore, initial PET/CT images of 48 patients with nasopharyngeal carcinoma (Group B) were reviewed for comparison with PET/CT images of Group A patients. All nasopharyngeal uptakes in Group A were confirmed to be benign. Group B showed significantly more intense FDG uptake (SUVmax of Group A 3.9 ± 1.4 vs. Group B 10.4 ± 4.6, p<0.001). and asymmetric nasopharyngeal uptake (asymmetric uptake of Group A 67.8% vs. Group B 89.6%). When SUVmax of 6.0 was used as cut off for detection of malignant nasopharyngeal uptake, the area under the ROC curve was 0.93 (95% confidence interval, 0.88-0.98), with a sensitivity of 88.1% and a specificity of 91.7%. Metastatic nodes in Group B showed higher SUVmax (Group A 2.3 ± 0.6 vs. Group B 7.1 ± 4.0, p<0.001) and larger size (short axis of Group A 5.3 ± 2.0 mm vs. Group B 13.1 ± 4.7 mm, p<0.001) than benign nodes of Group A. The majority of Group B cases demonstrated retropharyngeal lymph node uptake (70.8%), compared to only 2 cases in Group A. In patients without a history of underlying malignancy involving head and neck, incidental nasopharyngeal uptake on PET/CT does not indicate malignancy. However, if the nasopharyngeal uptake is intense (SUVmax≥6.0) or concomitant retropharyngeal lymph node uptake is present, the possibility of a malignant condition should be considered.

A Study of Patients With a Radiologic Diagnosis of Mesenteric Panniculitis and the Correlation With Malignancy

Introduction: Mesenteric panniculitis (MP), a “misty” or “hazy” mesentery and/or an unexplained mesenteric mass is an uncommon finding on computerized tomographic (CT) scanning. This finding in patients with prior cancer has been described, but its significance is poorly understood. We reviewed its association with malignancy, disease natural history; additional and follow-up imaging studies in a large group of patients with mesenteric abnormalities and either known history of cancer, or those with newly diagnosed cancers. Methods: CT scans showing “mesenteric panniculitis” or “misty mesentery” in patients with known or newly diagnosed cancer at North Shore University Health System were identified from January 2005-April 2010. Medical records were reviewed. Results of positron emission tomography (PET) were noted. In total, 359 patients (from 147,794 CT scans) had MP-like abnormalities. Of these patients, 81 had a known history of cancer and 19 had a new diagnosis of cancer. Results: Lymphomas were the most common cancers associated with MP (36%), with follicular lymphoma being the most common subtype (17/36), (Table 1). A variety of solid tumors were found, the most common being prostate (7) and renal cell cancer (6). CT follow-up was obtained in 71 patients. The CT was unchanged in 62, worsened in 7, and improved in 2 patients. PET scans were performed in 44 patients. Positive uptake in mesenteric lymph nodes was seen in 13 patients (29.6%). Positive uptake in the mesenteric mass was only seen in 2 patients (4.5%). Follow-up PET scanning showed no uptake in the mesenteric mass in both of these patients.Table 1Conclusion: Mesenteric changes suggestive of mesenteric panniculitis are seen in association with a variety of cancers. These changes generally remain stable on follow-up CT. Mesenteric uptake of fludeoxyglucose (FDG) during PET scanning does not occur in these lesions.

The effect of volume of interest definition on quantification of lymph node immune response to a monkeypox virus infection assessed by (18)F-FDG-PET.

Background2-deoxy-2-[18F]fluoro-D-glucose-positron emission tomography (18F-FDG-PET) is applied in the clinic for infection assessment and is under consideration for investigating the inflammatory/immune response in lymphoid tissue in animal models of viral infection. Assessing changes in 18F-FDG uptake of lymph nodes (LNs), primary lymphoid tissues targeted during viral infection, requires suitable methods for image analysis. Similar to tumor evaluation, reliable quantitation of the LN function via multiple 18F-FDG-PET sessions will depend how the volume of interest is defined. Volume of interest definition has a direct effect on statistical outcome. The current study objective is to compare for the first time agreement between conventional and modified VOI metrics to determine which method(s) provide(s) reproducible standardized uptake values (SUVs) for 18F-FDG uptake in the LN of rhesus macaques.MethodsMultiple 18F-FDG-PET images of LNs in macaques were acquired prior to and after monkeypox virus intravenous inoculation. We compared five image analysis approaches, SUVmax, SUVmean, SUVthreshold, modified SUVthreshold, and SUVfixed volume, to investigate the impact of these approaches on quantification of the changes in LN metabolic activity denoting the immune response during viral infection progression.ResultsThe lowest data repeatability was observed with SUVmax. The best correspondence was between SUVfixed volume and conventional and modified SUVthreshold. A statistically significant difference in the LN 18F-FDG uptake between surviving and moribund animals was shown using modified SUVthreshold and SUVfixed volume (adjusted p = 0.0037 and p = 0.0001, respectively).ConclusionsQuantification of the LN 18F-FDG uptake is highly sensitive to the method applied for PET image analysis. SUVfixed volume and modified SUVthreshold demonstrate better reproducibility for SUV estimates than SUVmax, SUVmean, and SUVthreshold. SUVfixed volume and modified SUVthreshold are capable of distinguishing between groups with different disease outcomes. Therefore, these methods are the preferred approaches for evaluating the LN function during viral infection by 18F-FDG-PET. Validation of multiple approaches is necessary to choose a suitable method to monitor changes in LN metabolic activity during progression of viral infection.Electronic supplementary materialThe online version of this article (doi:10.1186/s13550-014-0049-z) contains supplementary material, which is available to authorized users.

Metastatic Malign Melanoma of Supraspinatus Muscle

Malignant melanoma, which occurs by malignant transformation of melanocytes that originate from the neural crest, is one of the most aggressive neoplasms of the skin, and it constitutes 4% of skin cancers (1). Malignant melanoma may spread to all organs, like skin, lungs, distant lymph nodes, pleura, liver, central nervous system, skeleton, subcutaneous sites, gastrointestinal tract, heart, adrenal glands, kidney, and thyroid gland, with different frequencies (2). The frequency of metastasis to the skeletal muscles in patients with malignant melanoma is very low (3). Here, we present a case of malignant melanoma that metastasized to the supraspinatus muscle who presented with shoulder pain. A 78-year-old female patient presented with unrelenting shoulder pain mimicking rotator cuff pathology. She had a 4-month history of pain, which was localized to the left shoulder and increased gradually. On physical examination, her shoulder movement was limited due to pain. The patient had a positive Neer sign. There was tenderness with palpation of the supraspinatus. A scar on the back of the patient was inspected. When her medical history had been questioned in more detail, she told us that she had a history of malignant melanoma on her back 30 years ago that was excised and caused no symptoms until that time. The patient also complained about exhaustion with daily activities. No lymph node enlargement in the cervical or axillary region was detected. Erythrocyte sedimentation rate was 24 mm/h (normal <20 mm/h), and other blood tests were normal. Shoulder magnetic resonance imaging (MRI) was performed. It revealed a mass showing contrast uptake in the supraspinatus muscle and contrast uptake in multiple lymph nodes in the axillary and supraclavicular regions (Figure 1). Thereafter, a positron emission tomography (PET) image was taken. The PET was consistent with multiple metastases to the subacromial region and axillary lymph nodes. The biopsy of the lesion confirmed the diagnosis of malignant melanoma. She was referred to an orthopedic surgeon. Malignant melanoma, which could have a large variation of aspects, can spread anywhere in the body, and it mostly often spreads loco-regionally into the skin, subcutaneous tissue, and lymph nodes, and then it goes into distant organs in the order of subcutaneous fat, lungs, liver, brain, bones, and intestines (3,4). Neighboring muscle tissue is also a target for malignant melanoma metastases. Malignant melanoma may

18F-FDG PET/CT for Staging and Detection of Extramedullary Organ Involvement in Chronic Myelomonocytic Leukemia

Chronic myelomonocytic leukemia (CMML) is a rare hematologic malignancy characterized by the accumulation of monocytes in the blood and bone marrow, dysplastic hematopoiesis, and potential leukemic involvement of organs. We report a case of leukemic involvement of cervical lymph nodes detected by 18F-FDG PET/CT. A 53-year-old woman with CMML and newly diagnosed cervical lymphadenopathy underwent whole-body PET/CT for evaluation of extramedullary disease. PET demonstrated marked tracer uptake in cervical lymph nodes. Histopathological evaluation revealed leukemic involvement. 18F-FDG PET/CT is a valuable tool enabling sensitive staging of CMML, particularly in case of extramedullary organ involvement.

Abstracts and Case Studies From the College of American Pathologists 2014 Annual Meeting (CAP '14)

Abstracts and Case Studies From the College of American Pathologists 2014 Annual Meeting (CAP '14)

Targeted delivery of docetaxel to the metastatic lymph nodes: A comparison study between nanoliposomes and activated carbon nanoparticles

The objective of this study is to compare the targeting ability of activated carbon nanoparticles and nanoliposomes, which are used as carriers for delivering docetaxel (DTX) to the metastatic lymph nodes. In this study, we first prepared the DTX-loaded activated carbon nanoparticles (DTX-AC-NPs) by modifying the activated carbon with nitric acid oxidation and absorbing DTX in the concentrated nitro-oxide nanocarbon. We then prepared DTX-loaded nanoliposomes (DTX-LPs) by the proliposome method. The physiochemical properties of DTX-AC-NPs and DTX-LPs were carefully evaluated in vitro. The metastatic lymph node uptake and the injection site retention were investigated by analyzing the DTX concentration in metastatic lymph nodes and injection sites. The result showed that DTX-AC-NPs and DTX-LPs with suitable and stable physicochemical properties could be used for in vivo lymph node targeting studies. DTX-AC-NPs significantly increased DTX-AUC(0–24) and prolonged DTX-retention in metastatic lymph nodes compared to DTX-LPs and non-modified activate carbon in vivo. This study demonstrated activated carbon nanoparticles may be potential intralymphatic drug delivery system to preferentially target regional metastatic lymph nodes.

Preoperative mediastinal lymph node staging for non-small cell lung cancer: 2014 update of the 2007 ESTS guidelines.

Accurate preoperative staging and restaging of mediastinal lymph nodes in patients with potentially resectable non-small cell lung cancer (NSCLC) is of paramount importance. In 2007, the European Society of Thoracic Surgeons (ESTS) published an algorithm on preoperative mediastinal staging integrating imaging, endoscopic and surgical techniques. Over the last years more evidence of the different mediastinal staging technique has become available. Therefore, a revision of the ESTS guidelines was needed. In case of CT-enlarged or PET-positive mediastinal lymph nodes, tissue confirmation is indicated. Endosonography (EBUS/EUS) with fine needle aspiration is the first choice (when available) since it is minimally invasive and has a high sensitivity to rule in mediastinal nodal disease. If negative, surgical staging with nodal dissection or biopsy is indicated. Video-assisted mediastinoscopy is preferred over mediastinoscopy. The combined use of endoscopic staging and surgical staging results in the highest accuracy. When there are no enlarged lymph nodes on CT and when there is no uptake in lymph nodes on PET or PET-CT, direct surgical resection with systematic nodal dissection is indicated for tumors ≤3 cm located in the outer third of the lung. In central tumors or N1 nodes, preoperative mediastinal staging is indicated. The choice between endoscopic staging with EBUS/EUS and fine needle aspiration or video-assisted mediastinoscopy depends on local expertise to adhere to minimal requirements for staging. For tumors larger than 3 cm, preoperative mediastinal staging is advised, mainly in adenocarcinoma with high SUV uptake.

Negative predictive value (NPV) of FDG PET-CT for nodal disease in clinically node-negative early stage lung cancer (AJCC 7 th ed T1-2aN0) and identification of risk factors for occult nodal (pN1-N2) metastasis: implications for SBRT

Non-surgical methods are increasingly employed in the management of early stage lung cancer, but do not afford histological confirmation of nodal status. We sought to assess the incidence, pattern, and predictors of occult nodal involvement (pN1-pN2) in non-small cell lung cancer (NSCLC) patients with negative nodal uptake on fluorodeoxyglucose (FDG) positron emission tomography-computed tomography (PET-CT) in early stage lung cancer (clinical stage I AJCC 7 th edition). All patients treated surgically over a 3-year period at Dartmouth Hitchcock Medical Center who were AJCC 7th ed. clinical stage I by pre-operative PET-CT were included in this analysis. The agreement between the clinical stage based on PET-CT and true stage based on pathologic dissection was assessed. Multivariate logistic regression was used to analyze predictors of occult nodal metastasis. Of 144 clinically node-negative patients, 125 were pathologically nodenegative. For all 144 patients, the negative predictive values (NPVs) of PET-CT were 92% for mediastinal disease, 90% for N1 disease, and 87% for overall nodal metastases. The NPVs for mediastinal metastases were 95% in T1 disease and 87% in T2 disease. In multivariate analysis, tumor size (adjusted OR: 3.28, 95% CI: 1.41-7.57), central tumor location (adjusted OR: 7.3, 95% CI: 2.22-24.3), and age at surgery (adjusted OR: 0.95, 95% CI: 0.92-0.98) were significant predictors of occult nodal metastasis. The NPV of PET-CT in nodal staging has implications for the non-surgical treatment of lung cancer, such as stereotactic body radiotherapy, where routine pathologic nodal staging is not performed. Our data suggest PET-CT more accurately rules out the presence of nodal disease in smaller, peripherally located primary tumors.

Furosemide diminishes ¹⁸F-fluoroethylcholine uptake in prostate cancer in vivo.

(18)F-Fluoroethylcholine ((18)F-FECh) is excreted via the urinary system with high activity accumulation in the urinary bladder. Furosemide and oral hydration can be administered concomitantly to reduce urinary activity to provide better detectability of retroperitoneal and pelvic lesions. Currently it is unknown if there is any effect of furosemide on (18)F-FECh uptake in organs, tissues and tumour lesions and the extent to which image quality along the urinary tract may be improved by furosemide. We retrospectively analysed 217 (18)F-FECh PET/CT examinations from 213 patients with known prostate cancer (PCa), performed either with oral hydration (109) or furosemide 20mg together with oral hydration (108). Maximum (18)F-FECh uptake in different organs, tissues, lymph nodes and osseous metastases was quantified in terms of standardized uptake value (SUV) in a volume of interest and compared between the two groups. To characterize the impact of furosemide on lesion detectability a three-point rating scale was used to assess the presence of focal activity spots in the ureters and of perivesicular artefacts. Patient characteristics and distribution of tumour lesions were well balanced between the two groups. Overall, SUVmax values from normal organs were increased after furosemide compared to the values in patients scanned without furosemide. Significant changes were observed in the salivary glands, liver, spleen, pancreas, kidneys, gluteus muscle and perirenal fat. SUVmax values were significantly decreased after furosemide in lymph node metastases (SUVmax 4.81 ± 2.68 vs. 6.48 ± 4.22, p = 0.0006), but not in osseous metastases. Evaluation of image quality along the urinary tract revealed significantly better depiction of the perivesicular space and significantly less focal tracer accumulation in the ureters in patients receiving furosemide, but the number of detected lymph nodes was not significantly different. Furosemide administration reduced choline uptake in tumour lesions, especially significant in pelvic lymph node metastases. Although furosemide administration improved image quality, optimal image quality may also be obtained by adequate hydration without the risk of diminishing choline uptake in PCa lesions. Therefore a controlled hydration protocol seems more appropriate than administration of furosemide.

Radiochemical pharmacokinetic profile of P10 peptide with antifungal properties.

Paracoccidioidomycosis (PCM) is a chronic granulomatous disease that is caused by the thermally dimorphic fungus Paracoccidioides brasiliensis. It is endemic in some countries of Latin America and can cause a high-burden fungal infection with significant morbidity and mortality. The peptide P10, which demonstrates immune protection against experimental PCM, was radiolabeled with a radioisotope and evaluated in vivo. The radiolabeling was conducted to trace the pharmacokinetics of the molecule in principal organs and tissues. This was achieved with high radiochemical purity. Biodistribution and scintigraphic imaging showed fast blood clearance that was mainly renal; however, hepatobiliar excretion was also, with marked uptake in cervical lymph nodes. This profile may be useful for the development of a prophylactic drug or vaccine for patients exposed to PCM.

A patient with progressive dyspnoea and a new heart murmur

A 74-year-old man was referred to the outpatient clinic of the cardiology department with progressive dyspnoea and a new heart murmur. Physical examination of the chest wall showed a hard immobile and painless sternal swelling at the level of the angulus of Ludovici. There was an increase of the velocities across the pulmonary valve (continuous Doppler) on echocardiography as a result of the RVOT and pulmonary trunk stenosis.Computed tomography (CT) of the chest revealed a mass in the anterior mediastinum which had grown through the sternum into the skin, as well as an external compression of the ascending aorta, the truncus pulmonalis and the pericardium. Anatomo-pathological examination revealed a non-small-cell lung carcinoma. PET CT showed another nodule with FDG uptake in the right kidney, suspected for metastasis, and an uptake in a right paratracheal lymph node. The tumour was staged as a cT4cN2M1b.Palliative radiochemotherapy was started. The patient had a good clinical and radiographic response, but relapsed a few months later.

Study on intralymphatic-targeted hyaluronic acid-modified nanoliposome: Influence of formulation factors on the lymphatic targeting

In this study, hyaluronic acid-modified docetaxel-loaded liposomes were prepared to evaluate the lymphatic targeting after subcutaneous administration, and formulation factors affecting the lymphatic targeting were examined, including free hyaluronic acid, molecular weight, hyaluronic acid-density and particle diameter. The high molecular weight hyaluronic acid-modified docetaxel-loaded liposomes (HA-LPs) and low molecular weight hyaluronic acid-modified docetaxel-loaded liposomes (LMWHA-LPs) were prepared via electrostatic attraction. The physicochemical properties and in vitro drug release were evaluated. The lymphatic drainage and the lymph node uptake were investigated by pharmacokinetics and distribution recovery of docetaxel in lymph nodes, injection site and plasma. The lymphatic targeting ability of optimized Cy7-loaded LMWHA-LPs (LMWHA-LPs/Cy7) was evaluated by near-infrared fluorescence imaging technique. The result showed that HA-LPs and LMWHA-LPs with suitable and stable physicochemical properties could be used for in vivo lymphatic targeting studies. Hyaluronic acid-modified liposome significantly increased the docetaxel recovery in lymph nodes, and displayed higher AUC(0-24h) and longer retention time compared to unmodified liposomes in vivo. In contrast, the presence of free hyaluronic acid hindered the lymphatic drainage and increased the plasma-drug concentration. Importantly, LMWHA-modification improved lymphatic drainage and lymph node uptake of liposomes compared with HA-modification. And Lymph node uptake of LMWHA-LPs depended mainly on LMWHA-density instead of particle size. The results of in vivo imaging showed that LMWHA-LPs/Cy7 significantly located in the lymphatic system. And both DTX-loaded and Cy7-loaded LMWHA-LPs had similar and stable lymphatic target level. Our investigation showed that LMWHA-LPs were a highly promising lymphatic targeting carrier for chemotherapy drugs and diagnostic fluorescence agents.

Limitations of somatostatin scintigraphy in primary small bowel neuroendocrine tumors

BackgroundSomatostatin receptor scintigraphy (SRS; octreoscan) is used in neuroendocrine tumors to locate the primary tumor site and delineate the extent of disease. SRS has decreased sensitivity for small bowel neuroendocrine tumors (SBNETs). The reasons for SRS nonlocalization are not clear. We sought to determine factors that correlate with successful primary tumor localization by SRS in patients with resected SBNETs, and also identify factors that confound interpretation of SRS reports. MethodsRecords of patients with resected SBNETs were reviewed for SRS results, tumor size, multifocality, N, and M status. Somatostatin receptor 2 (SSTR2) expression was analyzed in resected tumors by quantitative polymerase chain reaction. SRS reports were reviewed and categorized as localizing the primary tumor or not. A nuclear medicine physician independently reviewed available images. ResultsOf 37 patients with preoperative SRS, the primary tumor was localized in 37%. Of all the factors tested, only small tumor size correlated significantly with SRS nonlocalization. Overexpression of SSTR2 was not significantly different between tumors that were or were not localized by SRS, regardless of tumor size. There were three instances where the SRS report did not agree with the nuclear medicine physician's interpretation as to whether SRS localized the primary tumor. In each case, uptake in mesenteric nodes was a confounding factor. ConclusionsSBNETs <2 cm are most likely to be missed by SRS. SSTR2 expression did not correlate with SRS nonlocalization of the primary tumor. Uptake in mesenteric nodes may help indicate an SBNET primary but can also interfere with its visualization within the small bowel.

Ipilimumab-Induced Immunomediated Adverse Events

A 42-year-old woman underwent resection of a high-risk melanoma of the right thigh. Adjuvant treatment with ipilimumab was then started within a phase III randomised, double-blind clinical trial. F-FDG PET/CT scan showed intense uptake in mediastinal hilar lymph nodes, bilaterally, and in rectus abdominis muscle. Biopsy at the abdominal wall revealed a chronic granulomatous inflammation. After oral steroid treatment, all the areas of abnormal tracer uptake disappeared. Ipilimumab can induce inflammatory immunomediated reactions that should be taken into account to avoid misinterpretation.

265 Assessing the optimal extent of salvage lymph node dissection in patients with single pelvic nodal uptake at [11c]-choline pet/ct scan from recurring prostate cancer

265 Assessing the optimal extent of salvage lymph node dissection in patients with single pelvic nodal uptake at [11c]-choline pet/ct scan from recurring prostate cancer

Two patients with intestinal failure requiring home parenteral nutrition, a NOD2 mutation and tuberculous lymphadenitis

BackgroundMutations in the NOD2 gene are a significant risk factor to acquire intestinal failure requiring home parenteral nutrition. Tuberculous lymphadenitis is the main manifestation of extrapulmonary tuberculosis. Defects in the innate immunity, including NOD2 mutations, may increase the risk for acquiring infections caused by M. tuberculosis. An association of intestinal failure, mutations in the NOD2 gene and tuberculous lymphadenitis has not been described before.Case presentationWe report of two patients with intestinal failure secondary to mesenteric ischemia. Both patients presented with fever and weight loss while receiving long term home parenteral nutrition. Both of them were found to have mutations in the NOD2 gene. Catheter related infections were ruled out. FDG-PET-CT scans initially obtained in search for another infectious focus that would explain the symptoms unexpectedly showed high FDG uptake in mediastinal lymph nodes. Direct or indirect evidence proved or was highly suggestive for tuberculous lymphadenitis. Intravenous tuberculostatic therapy was started and led to a reversal of symptoms and to resolution of the lesions by FDG-PET-CT.ConclusionMutations in the NOD2 gene may put patients both at an increased risk for acquiring M. tuberculosis infections as well as at an increased risk of intestinal failure after extensive intestinal resection. Thus we suggest to specifically include reactivated and opportunistic infections in the differential diagnosis of suspected catheter related infection in patients with intestinal failure who carry mutations in their NOD2 gene.

Revised ESTS guidelines for preoperative mediastinal lymph node staging for non-small-cell lung cancer

Accurate preoperative staging and restaging of mediastinal lymph nodes in patients with potentially resectable non-small-cell lung cancer (NSCLC) is of paramount importance. In 2007, the European Society of Thoracic Surgeons (ESTS) published an algorithm on preoperative mediastinal staging integrating imaging, endoscopic and surgical techniques. In 2009, the International Association for the Study of Lung Cancer (IASLC) introduced a new lymph node map. Some changes in this map have an important impact on mediastinal staging. Moreover, more evidence of the different mediastinal staging technique has become available. Therefore, a revision of the ESTS guidelines was needed. In case of computed tomography (CT)-enlarged or positron emission tomography (PET)-positive mediastinal lymph nodes, tissue confirmation is indicated. Endosonography [endobronchial ultrasonography (EBUS)/esophageal ultrasonography (EUS)] with fine-needle aspiration (FNA) is the first choice (when available), since it is minimally invasive and has a high sensitivity to rule in mediastinal nodal disease. If negative, surgical staging with nodal dissection or biopsy is indicated. Video-assisted mediastinoscopy is preferred to mediastinoscopy. The combined use of endoscopic staging and surgical staging results in the highest accuracy. When there are no enlarged lymph nodes on CT and when there is no uptake in lymph nodes on PET or PET-CT, direct surgical resection with systematic nodal dissection is indicated for tumours ≤ 3 cm located in the outer third of the lung. In central tumours or N1 nodes, preoperative mediastinal staging is indicated. The choice between endoscopic staging with EBUS/EUS and FNA or video-assisted mediastinoscopy depends on local expertise to adhere to minimal requirements for staging. For tumours >3 cm, preoperative mediastinal staging is advised, mainly in adenocarcinoma with high standardized uptake value. For restaging, invasive techniques providing histological information are advisable. Both endoscopic techniques and surgical procedures are available, but their negative predictive value is lower compared with the results obtained in baseline staging. An integrated strategy using endoscopic staging techniques to prove mediastinal nodal disease and mediastinoscopy to assess nodal response after induction therapy needs further study.