PET-positive Nodes Research Articles

Preoperative 18F-FDG PET/CT tumor markers outperform MRI-based markers for the prediction of lymph node metastases in primary endometrial cancer

ObjectivesTo compare the diagnostic accuracy of preoperative 18F-FDG PET/CT and MRI tumor markers for prediction of lymph node metastases (LNM) and aggressive disease in endometrial cancer (EC).MethodsPreoperative whole-body 18F-FDG PET/CT and pelvic MRI were performed in 215 consecutive patients with histologically confirmed EC. PET/CT-based tumor standardized uptake value (SUVmax and SUVmean), metabolic tumor volume (MTV), and PET-positive lymph nodes (LNs) (SUVmax > 2.5) were analyzed together with the MRI-based tumor volume (VMRI), mean apparent diffusion coefficient (ADCmean), and MRI-positive LN (maximum short-axis diameter ≥ 10 mm). Imaging parameters were explored in relation to surgicopathological stage and tumor grade. Receiver operating characteristic (ROC) curves were generated yielding optimal cutoff values for imaging parameters, and regression analyses were used to assess their diagnostic performance for prediction of LNM and progression-free survival.ResultsFor prediction of LNM, MTV yielded the largest area under the ROC curve (AUC) (AUC = 0.80), whereas VMRI had lower AUC (AUC = 0.72) (p = 0.03). Furthermore, MTV > 27 ml yielded significantly higher specificity (74%, p < 0.001) and accuracy (75%, p < 0.001) and also higher odds ratio (12.2) for predicting LNM, compared with VMRI > 10 ml (58%, 62%, and 9.7, respectively). MTV > 27 ml also tended to yield higher sensitivity than PET-positive LN (81% vs 50%, p = 0.13). Both VMRI > 10 ml and MTV > 27 ml were significantly associated with reduced progression-free survival.ConclusionsTumor markers from 18F-FDG PET/CT outperform MRI markers for the prediction of LNM. MTV > 27 ml yields a high diagnostic performance for predicting aggressive disease and represents a promising supplement to conventional PET/CT reading in EC.Key Points• Metabolic tumor volume (MTV) outperforms other 18F-FDG PET/CT and MRI markers for preoperative prediction of lymph node metastases (LNM) in endometrial cancer patients.• Using cutoff values for tumor volume for prediction of LNM, MTV > 27 ml yielded higher specificity and accuracy than VMRI> 10 ml.• MTV represents a promising supplement to conventional PET/CT reading for predicting aggressive disease in EC.

PSMA-PET guided dose-escalated volumetric arc therapy (VMAT) for newly diagnosed lymph node positive prostate cancer: Efficacy and toxicity outcomes at two years

Purpose/objectivesThere are no published reports of prostate specific membrane antigen (PSMA) positron emission tomography (PET) guided dose-escalated intensity-modulated radiation therapy (DE-IMRT) in newly diagnosed lymph node (LN) positive prostate cancer. We report early toxicity and efficacy outcomes with this approach. Materials/methodsPatients with newly diagnosed high-risk prostate cancer were staged using PSMA PET, computed tomography (CT) and bone scans. Patients with LN positive-only metastases were offered curative therapy using 3 months androgen deprivation therapy (ADT) followed by DE-IMRT (using volumetric arc therapy), and 3 years adjuvant ADT. All patients had fiducial marker insertion, with privately insured patients having spacer hydrogel insertion. PET and prostate magnetic resonance imaging were fused with the planning CT. We aimed to deliver 81 Gy in 45 fractions (Fx) to the prostate and PET-positive LNs, and 60 Gy in 45Fx to bilateral elective pelvic LNs. ResultsIn all, 46 patients were treated, with 83% Gleason 8–10, 67% T3/T4, median number of LNs 2 (range 1–6), and median PET-positive LN volume 1.14 cc (range 0.15–4.14). LNs were outside of standard contouring guidelines in 37% of patients. The mean PET-positive LN clinical target volume dose ranged from 73.3 to 85.9 Gy (median 83.6 Gy). With 24 months median follow-up, two year failure-free survival was 100%, and 2 year overall survival 95.7%. Acute grade 1 and 2 GI toxicity occurred in 48 and 11% of patients, and GU toxicity in 72 and 24%. Late grade 1, 2 and 3 GI toxicity occurred in 13, 2 and 0%, and GU toxicity 28, 13 and 4%. No toxicity was attributable to the high dose LN boost. ConclusionsPSMA PET-guided DE-IMRT up to 81 Gy to the prostate and involved LNs, and long term ADT, is a promising approach for newly diagnosed LN positive prostate cancer. LN contouring guidelines require re-evaluation in the era of PSMA PET imaging.

Feasibility of Dose Escalating [18F]fluciclovine Positron Emission Tomography Positive Pelvic Lymph Nodes During Moderately Hypofractionated Radiation Therapy for High-Risk Prostate Cancer

PurposeThe aim of this study was to report the treatment planning feasibility of dose escalation to suspicious lymph nodes (LNs) for a series of men who underwent pretreatment [18F]fluciclovine positron emission tomography (PET)/magnetic resonance imaging (MRI). Methods and MaterialsCases of men with prostate cancer who enrolled in a clinical trial of pretreatment [18F]fluciclovine PET who had suspicious LNs were selected. Pelvic LNs <1 cm were defined as positive based on [18F]fluciclovine-PET if their maximum standardized uptake value (SUVmax) was ≥1.3-fold greater than the reference blood pool SUVmean, and LNs ≥1 cm were defined as positive if the SUV was greater than the reference SUV bone marrow reference. For each case, a radiation treatment plan was generated to deliver 70 Gy to the prostate and proximal seminal vesicles, 60.2 Gy to the PET-positive LNs, and 50.4 Gy to the elective nodal regions, simultaneously in 28 fractions of 2.5 Gy, 2.15 Gy, and 1.8 Gy, respectively. Treatment planning goals were defined a priori. The resulting target volume and organ-at-risk dosimetry were compared with the original treatment plan. ResultsFour cases were identified, with between 1 and 5 [18F]fluciclovine PET–positive LNs each. Goals for the prostate and elective nodal target volumes were successfully met in all cases. The goal of covering more than 90% of the positive LN planning target volume by the prescription dose of 60.2 Gy was met in 3 of the 4 cases. This goal was not met in 1 case, but 100% of clinical target volume was covered by 60.2 Gy. The primary organ-at-risk tradeoff was that a small volume (0.5-8.2 cm3) of small bowel would receive ≥54 Gy in each case. ConclusionsThese preliminary results suggest that [18F]fluciclovine PET/MRI directed dose escalation of suspicious pelvic LNs is likely feasible in the setting of definitive radiation therapy. The potential clinical benefit of dose escalating [18F]fluciclovine PET–positive LNs should be investigated in a prospective clinical trial.

Transection of the arterial ligament for extended mediastinal lymph node dissection by video-assisted thoracoscopic surgery: invaluable technique for the right patient

Lung cancer remains the leading cause of cancer-related deaths worldwide, with non-small cell lung cancer (NSCLC) accounting for 85% of cases (1). Five-year survival is heavily dependent upon cancer stage and follows the tumor, node, and metastasis staging model (TNM), with lymph node (LN) metastasis being an important determinant of prognosis (2). Stage I NSCLC includes tumors less than 4 cm in diameter without metastasis to LNs. Published practice guidelines recommend preoperative staging with positron emission tomography (PET) or PET-computed tomography (CT), with subsequent preoperative pathologic tissue diagnosis for mediastinal staging in centrally located tumors, tumors >3 cm, and for enlarged or PET-positive LNs (2,3). Endobronchial ultrasonography (EBUS) with fine needle aspirate is the recommended first choice where available; if unavailable or if aspirate is negative in the setting of high suspicion for involved LNs, recommendations are to proceed with cervical mediastinoscopy.

Utility of EBUS-TBNA in PET-positive mediastinal lymph nodes in subjects with extra-thoracic malignancy.

Background/AimPatients with primary extra-thoracic malignancy (ETM) often have hyper-metabolic mediastinal lymph nodes (HM-MLN) in the PET-scan done for initial staging or post treatment follow-up. There is scant data on the etiology of HM-MLN in such patients, which can also be due to non-malignant causes. We used endobronchial ultrasound (EBUS) guided sampling to determine the etiology of HM-MLN in patients with ETM and study the relationship between PET-SUV values and a diagnosis of malignancy in this population.Materials and methods65 consecutive patients, from March 2013 to March 2017 with either known ETM for primary staging or post-treatment follow-up, with PET CT showing HM-MLN (SUV > 2.5) were included in the study.Results65 patients with ETM had EBUS-TBNA for HM-MLN. 20/65 (30.7%) were malignant, 45/65 (69.23%) were benign MLN. In patients with benign etiology of HM-MLN, 6/45 (13.3%) had necrotising granulomatous, 24/45 (53.3%) had non- necrotising granulomatous MLN and 15/45 (33.3%) had reactive MLN. We found discordance (i.e. primary ETM responded to treatment and a new HM-MLN was detected) in 21/65 (32.3%) patients with PET-CT done for initial ETM staging, and 44/65 (67.7%) with a post-treatment PET-CT. showed. Correlating SUV with diagnoses, the SUV values in EBUS-proven malignant MLN were 8.9 ± 4.1, while they were 10.2 ± 5.57 in benign MLN. There was no statistically significant difference between the SUV of benign and malignant MLNs.ConclusionThis study shows a significant incidence of EBUS-TBNA proven benign diagnoses 45/65 (69.2%) in ‘SUV-deemed-malignant MLN’ and a poor relationship between high SUV and malignant MLN, in patients with known ETM. The ETM related HM-MLN have a significant chance of being benign, and a tissue diagnosis is imperative as it impacts on the treatment plan and prognosis.

Nodal FDG-PET/CT uptake influences outcome and relapse location among esophageal cancer patients submitted to chemotherapy or radiochemotherapy.

Our aim was investigate whether lymph node uptake is associated with survival and regional relapses, and relapse patterns with respect to the radiotherapy fields in esophageal cancer (EC). The FDG-PET/CT image datasets of 56 patients were analyzed. All patients underwent definitive or neoadjuvant radio/chemotherapy (RCT). All patients suffering from persistent or recurrent local/regional-only disease after RCT were considered for salvage resection. Patients with adenocarcinoma without metastatic disease were considered for planned resection (usually within 3months of treatment). Patients with PET-positive lymph nodes before treatment had a worse overall survival and a shorter disease-free survival than those without PET-positive nodes. They also had worse node and metastatic relapse-free survival. N2 patients had statistically significant poorer outcomes than N1-N0 patients and a better survival if the involved nodes were closer to the esophageal tumor. Involved node location by PET/CT also affected global, nodal and metastatic relapses. In addition, an increment of SUVmax value increased relative risk of death and increased relative risk of node and metastatic relapses. The first site of relapse was metastatic recurrence and, second, local recurrence. The most frequent were "in-field" loco/regional recurrence. We observed a relationship between patients classified-N1 and out-field nodal recurrence (p = 0.024), and between patients-N2 and in-field nodal recurrence. The number of PET-positive nodes was an independent significant prognostic predictor for relapse (p < 0.001). Our study shows that only FDG-PET/CT can provide prognostic information in EC. Nodal PET/CT uptake influences outcome and relapse location among EC patients.

Control of PET-Positive Lymph Nodes Treated with Definitive Chemoradiation in Locally Advanced Cervical Cancer

Pelvic and/or para-aortic lymph node (LN) involvement at diagnosis is a significant prognostic factor for cervical cancer. The optimal treatment technique for nodal disease has not been well established. We retrospectively reviewed the treatment and outcomes of patients with PET-positive LN metastases treated with definitive chemoradiation at our institution. Cervical cancer patients with PET-positive nodes treated with curative intent at our institution from 2006 to 2017 were identified. All patients received external beam radiotherapy with concurrent weekly cisplatin followed by brachytherapy. Patients with no follow-up imaging were excluded. Nodal treatment techniques (no boost [NB] vs. sequential boost [SEB] vs. simultaneously integrated boost [SIB]) were recorded. Total dose to each LN was converted to equivalent of 2-Gy (EQD2). Nodal control was assessed using follow-up PET/CT and/or CT imaging. Nodal failure was defined as persistence or increase in PET avidity or increase in size on CT. Nodal failure free rates were calculated using the maximum likelihood method. A total of 136 positive nodes from 43 patients were included in the analysis. Nodal distribution was as follows: 93 low pelvis (external iliac, internal iliac, obturator), 22 common iliac, 20 para-aortic, and 1 inguinal. The involved LN had a median pre-treatment size of 1.3 cm (range: 0.5-4.5 cm) and median standardized uptake value (SUV) of 7.8 (range: 2.3-19.2). A majority of the nodes were treated with intensity modulated radiation therapy with an SEB (45.6%) or SIB (45.6%) to a median cumulative EQD2 of 5448 cGy (range: 4425-6549 cGy). At a median follow up of 763 days, 9 of the 136 (6.6%) treated nodes in 6 of the 43 (14.0%) patients experienced failure: 6 low pelvic, 2 common iliac, and 1 para-aortic. The failed LN had a median size of 1.5 cm (range: 0.9-3.2 cm) and median SUV of 6.1 (range: 2.3-14.3). Median time from treatment initiation to nodal failure was 113 days (range: 85-447 days). The 1- and 2-year nodal failure free rates were 86.5% and 76.9% in the cohort of 43 patients, and 95.0% and 87.3% for all 136 metastatic LN. Crude control rates were 95.2% (59/62) in LN treated with SEB compared to 91.9% (57/62) in LN treated with SIB. There were no acute grade 3+ non-hematologic toxicities. Nine patients experienced late grade 3-5 toxicities, including fistula formation (n=4), small bowel obstruction (n=2), rectal bleeding (n=2), ureteral stricture (n=1), and vaginal stenosis (n=1). Concurrent chemoradiotherapy using either a sequential or simultaneous integrated boost provides excellent local control of PET-positive LN in cervical cancer patients and is well tolerated.

Optimal Target Delineation for Highly Conformal Photon and Proton Radiation Therapy Techniques in Breast Cancer with Regional Nodal Irradiation

Regional nodal irradiation (RNI) improves disease-free and distant disease-free survival in select women with breast cancer. For the most part, trials demonstrating this utilized 3-dimensional conformal radiotherapy (3D-CRT). Multiple atlases guide targeting using conformal techniques. We hypothesize that nodal failure patterns adequately covered by 3D-CRT may be under-covered with more conformal techniques. The Radiotherapy Comparative Effectiveness Consortium (RADCOMP), Radiation Therapy Oncology Group (RTOG), and the European Society for Radiotherapy and Oncology (ESTRO) breast cancer nodal atlases were utilized for contouring on a representative patient CT scan. 5mm PTV margins were applied. 3D-CRT, volumetric modulated arc therapy (VMAT), and pencil beam scanning proton (PBSPT) plans were prepared for each set of target volumes by two blinded dosimetrists. PET-positive lymph nodes of patients treated for breast cancer (2009-2017) were mapped (5 mm diameter brush at the center of the node) onto the representative patient utilizing anatomical landmarks. Lymph nodes were designated as adequately covered if they fell within the 95% isodose line. FDG-avid lymph nodes (n=389) were mapped from 102 patients with locally advanced (n=51; median 2, range 1-8 nodes) and metastatic (n=51; median 4, range 1-19 nodes) breast cancer: Axilla (AX) n=284, supraclavicular (SCV) n=60, internal mammary (IMN) n=45. With 3D-CRT (partially wide tangents, AP/PA SCV), coverage was excellent across all nodal levels (Table 1). With VMAT/PBSPT, overall coverage by 95% isodose was encouraging regardless of atlas: ESTRO (89%/88%), RTOG (93%/91%), and RADCOMP (98%/96%). At least 99% of level I and 94% level II lymph nodes were covered in all plans. Areas of under-coverage in level III, SCV, and IMN-SCV junction were identified in the ESTRO and RTOG atlases (Table 1). A greater than expected number of IMN nodes (n=45) were identified. The RADCOMP atlas improved coverage at the expense of slightly increased heart and lung doses (Table 1). Comprehensive target delineation, as detailed in the RADCOMP atlas is strongly recommended when utilizing conformal techniques for RNI to prevent under-coverage of areas of potential nodal failure.Abstract 111; Table 1Locoregional nodal coverage (%) by the 95% isodose line, lung V20 and heart dose.PlanTechniqueAll nodes (%)Level I Ax n (%)Level II Ax n (%)Level III Ax n (%)SCV n (%)IMN n (%)Left lung V20 (%)Heart Mean (cGy)3DPWT, AP/PA SCV379 (97%)161 (99%)86 (100%)36 (100%)56 (93%)40 (89%)44%987ESTROVMAT347 (89%)162 (100%)86 (100%)28 (78%)31 (52%)40 (89%)15.4%831ESTROPBSPT344 (88%)162 (100%)81 (94%)28 (78%)33 (55%)40 (89%)10.5%206RTOGVMAT362 (93%)160 (99%)86 (100%)33 (92%)45 (75%)38 (84%)16.7%853RTOGPBSPT354 (91%)160 (99%)81 (94%)31 (86%)43 (72%)39 (87%)10%204RADCOMPVMAT381 (98%)162 (100%)86 (100%)36 (100%)57 (95%)40 (89%)16.6%950RADCOMPPBSPT381 (98%)162 (100%)86 (100%)36 (100%)57 (95%)40 (89%)12.1%259 Open table in a new tab

RA07.07: THE ROLE OF 18F-FLUORODEOXYGLUCOSE POSITRON-EMISSION TOMOGRAPHY ON SURVIVAL OF PATIENTS FOLLOWING NEOADJUVANT CHEMOTHERAPY AND SURGERY FOR ESOPHAGEAL CANCER

Abstract Background The occurrence of lymph node metastases (LNMs) is a critical factor for postoperative survival in patients with esophageal cancer. Generally F-fluorodeoxyglucose positron-emission tomography (FDG-PET) has a low sensitivity and a relatively high rate of false-negative for detecting LNMs. However, the role of FDG-PET in predicting the outcome is still unclear. The aim of this study is to assess the role of FDG-PET in predicting survival in patients with resectable thoracic esophageal squamous cell carcinoma (TESCC) treated with neoadjuvant chemotherapy (NAC). Methods Seventy-three patients with TESCC received NAC followed by surgery, and underwent FDG-PET before NAC in our hospital between January 2012 and November 2016. The number of PET-positive lymph nodes (LNs) and the maximum standardized uptake value (SUVmax) of the LNs were prospectively evaluated. The results of FDG-PET were compared with the pathological results and the prognosis. Results 15 patients had no PET-positive LNs, 23 had one, 15 had two and 20 patients had three or more positive LNs. A significantly high proportion of the PET-positive LNs ≧3 group had ≧3 pathological LNMs than the PET-positive LNs ≦2 group (70.0 vs. 22.6%, P &lt; 0.001). The PET-positive LNs ≧3 group also had a significantly lower 3-year overall survival rate (47.9 vs. 71.9%, P = 0.018). Univariate Cox's proportional hazard regression analyses revealed the PET-positive LNs ≧3 status (Hazard ratio = 2.68 [1.14–6.28], P = 0.024) and the SUVmax of the LNs ≧8 status (Hazard ratio = 2.45 [1.06–5.65], P = 0.036) were significant prognostic factors. On the other hand, the SUVmax of the primary tumor was not a significant prognostic factor. Conclusion We identified the PET-positive LNs ≧3 status and the SUVmax of the LNs ≧8 status in patients with resectable TESCC before NAC as potential adverse prognostic factors for survival. Disclosure All authors have declared no conflicts of interest.

The diagnostic accuracy of fluorodeoxyglucose-positron emission tomography/computed tomography and sentinel node biopsy in the prediction of pelvic lymph node metastasis in patients with endometrial cancer: A retrospective observational study.

According to the sentinel node biopsy (SNB), systematic pelvic lymph node dissection (PLND) may not be needed for patients with early-stage endometrial cancer. On the other hand, imaging technology including fluorodeoxyglucose-positron emission tomography/computed tomography (FDG PET/CT) has been developing worldwide. The aim of this study was to evaluate the combined diagnostic accuracy of FDG PET/CT and SNB in the prediction of pelvic lymph node metastasis in endometrial cancer patients.One hundred twenty-one patients with endometrial cancer underwent FDG PET/CT before hysterectomy and received SNB followed by systematic PLND. Univariate and multivariate analyses were performed to compare the diagnostic accuracy of FDG PET/CT and SNB in the prediction of pelvic node metastasis to the ultimate histologic status.FDG PET/CT had lower sensitivity (36.8% versus 57.9%, P = .1) and a higher specificity (96.4% versus 84.8%, P < .01) than SNB. The kappa statistics of FDG PET/CT and SNB were 0.37 (95% CI, 0.15–0.59) and 0.72 (95% CI, 0.53–0.90), respectively. The sensitivity of SNB was significantly higher than that of FDG PET/CT in all hemi-pelvises (HPs) in which the short axis of the largest metastatic lymph node was <5 mm in diameter (72.7% versus 18.2%, P = .01). In contrast, the sensitivity of FDG PET/CT was higher than that of SNB in all HPs in which the short axis of the largest metastatic lymph node was ≥5 mm in diameter (62.5% versus 37.5%, P = .2); however, the difference was not statistically significant. When the combined diagnosis of FDG PET/CT and SNB was made, the sensitivity and specificity were 84.2% and 82.1%, respectively.SNB was more useful for detecting lymph node metastasis than FDG PET/CT, especially in patients with small metastatic lymph nodes. The combined diagnosis of FDG PET/CT and SNB improves the sensitivity; PET-positive nodes should be dissected regardless of SNB status and HPs in which SNB was not detected should be dissected systematically regardless of FDG PET/CT status.

PS01.214: METASTATIC YIELD OF SUPERIOR MEDIASTINAL LYMPHADENECTOMY AND ASSOCIATION WITH PET IN INTRATHORACIC OESOPHAGEAL CARCINOMA TREATED WITH MINIMALLY INVASIVE OESOPHAGECTOMY

Abstract Background Lymph node status in oesophageal carcinoma is an important prognostic factor and predictor of survival. However, specific metastatic distribution patterns, especially for superior mediastinal lymph nodes, are not defined; they may be dependent on tumour location, histology and use of neoadjuvant treatment. Consensus for an optimal surgical strategy with regards to superior mediastinal lymphadenectomy (SML) has therefore not been formed. We aim to assess the metastatic yield of superior mediastinal nodes in intra-thoracic oesophageal cancer while correlating results with preoperative PET-CT. Methods Data from 39 consecutive 2-stage and 3-stage fully Minimally Invasive Oesophagectomies (MIO) performed by a single surgical team for intra-thoracic oesophageal or gastro-oesophageal junction carcinoma (Siewert I/II) between September 2016 and December 2017 were analysed. In n = 7 (18%), SML was performed. Of these n = 1 was for mid-oesophageal adenocarcinoma (ACA) and n = 6 were for squamous cell carcinoma (SCC) (5 for mid-oesophageal and 1 for distal oesophageal, which had a 2-stage procedure). Histological superior mediastinal nodal analysis was correlated with pre-operative PET-CT. Results Median total lymph node count was 45 (IQR, 37–68), with median SML count of 8 (IQR, 5–22). Of 7 SML’s, n = 1 (14.2%) revealed metastasis in 1/5 right paratracheal nodes. The patient had 3-stage MIO with no neo-adjuvant treatment for mid-oesophageal SCC. Final staging was pT3N2(6/45)M0. Preoperative PET-CT showed low avidity in right paratracheal nodes. Of the rest, 5 had negative PET-CT and 1 showed PET-positive paratracheal nodes, not confirmed histologically. The latter patient had neoadjuvant chemoradiotherapy for distal oesophageal ACA. Conclusion Although a small sample-sized study it demonstrates that PET-CT has a role in identifying metastatic superior mediastinal nodes. It can aid in the decision of resecting avid nodes but it should be born in mind that PET could have false positive results due to surrounding inflammation not uncommonly found in the lungs. False positivity (not confirmed histologically) may be also attributed to complete pathological lymph node response post neo-adjuvant treatment. SML’s role is not as clear in distal oesophageal/GOJ cancer compared to mid-oesophageal, but PET-CT seems a useful adjunct. In the West, SML shows a low metastatic yield for intra-thoracic oesophageal cancer. Disclosure All authors have declared no conflicts of interest.

Outcome after PSMA PET/CT based salvage radiotherapy in patients with biochemical recurrence after radical prostatectomy: a bi-institutional retrospective analysis.

Prostate-specific membrane antigen positron emission tomography/computed tomography (PSMA PET/CT) detects prostate cancer recurrence at low PSA levels. Radiotherapy with dose escalation to the former prostate bed has been associated with improved biochemical recurrence-free survival (BRFS). Thus, we hypothesized that PSMA PET/CT-guided salvage radiotherapy leads to improved BRFS. Methods: A total of 204 consecutive patients were referred for salvage radiotherapy following radical prostatectomy. PSMA PET/CT scans were performed and patients with PSA persistence (109 patients) or evidence of distant metastases (5 patients) were excluded from this analysis. Thus, the following analysis is based on a total of 90 patients who underwent PSMA PET/CT prior to radiotherapy due to biochemical recurrence and received salvage radiotherapy. In case of PET-positive findings, antiandrogen therapy was commenced before initiation of radiotherapy. BRFS (PSA ≤ 0.2 ng/ml) was defined as the study endpoint. Results: PET-positive lesions were detected in 42/90 (47%) patients: 24/42 (27%) fossa recurrence only, 12/42 (13%) pelvic lymph nodes only and 6/42 (7%) fossa and pelvic lymph node recurrence. Median PSA before radiotherapy was 0.44 (0.11 - 6.24). Cumulatively, a total dose of 70.0 Gy (67.2 - 72 Gy) was delivered to local macroscopic tumor, 66 Gy (59.4 - 70.2 Gy) to the prostatic fossa, 60.8 Gy (54 - 66 Gy) to PET-positive lymph nodes and 50.4 Gy (45 - 50.4 Gy) to the lymphatic pathways. After a median follow-up of 23 months, BRFS was 78%. Antiandrogen therapy was ongoing in 4 patients at last follow-up. No significant difference in BRFS between PET-positive (74%) vs. PET-negative patients (82%; p>0.05) was observed at last follow-up. Two patients had late genitourinary toxicity grade 3 and no patient had gastrointestinal toxicity ≥ 3 (NCI-CTCAE v4.03). Conclusion: PSMA PET/CT-guided salvage radiotherapy is an effective and safe local treatment option. No difference in BRFS between PET-positive and PET-negative patients was observed, indicating effective targeting of PET-positive lesions. PSMA PET/CT when readily available should be offered to patients with PSA recurrence for treatment individualization.

Clinical impact of fluorine-18-fluorodeoxyglucose positron emission tomography/computed tomography in patients with resectable pancreatic cancer: diagnosing lymph node metastasis and predicting survival.

To evaluate the diagnostic accuracy of fluorine-18-fluorodeoxyglucose PET/computed tomography (F-FDG PET/CT) for lymph node (LN) metastasis and the prognostic significance of F-FDG PET/CT LN parameters in patients with resectable pancreatic cancer. Patients with resectable pancreatic cancer who underwent staging F-FDG PET/CT between May 2007 and September 2016 were retrospectively enrolled and analyzed through medical record and image re-evaluation. The diagnostic accuracy of F-FDG PET/CT in predicting LN metastasis was evaluated and compared with that of contrast-enhanced abdominal computed tomography (CECT). Prognostic variables, including LN parameters assessed by F-FDG PET/CT [standardized uptake value (SUV)LN and LN/tumor SUV ratio], that affect disease-free survival (DFS) and overall survival (OS) were evaluated by regression analysis. When predicting LN metastasis, F-FDG PET/CT showed greater sensitivity, positive predictive value, negative predictive value, and accuracy than CECT. Among prognostic factors affecting DFS, PET-positive LN (P=0.008), and LN/tumor SUV ratio (P=0.003) were found to be significant by regression analysis. Among the variables affecting OS, lymphovascular invasion (P=0.018) and the LN/tumor SUV ratio (P=0.046) were found to be significant. F-FDG PET/CT showed higher diagnostic accuracy in predicting LN metastasis than CECT in patients with resectable pancreatic cancer. Only the LN/tumor SUV ratio of F-FDG PET/CT was an independent prognostic variable in both DFS and OS.

Outcome after PSMA PET/CT based radiotherapy in patients with biochemical persistence or recurrence after radical prostatectomy

BackgroundPSMA PET/CT visualises prostate cancer residual disease or recurrence at lower PSA levels compared to conventional imaging and results in a change of treatment in a remarkable high number of patients. Radiotherapy with dose escalation to the former prostate bed has been associated with improved biochemical recurrence-free survival. Thus, it can be hypothesised that PSMA PET/CT-based radiotherapy might improve the prognosis of these patients.MethodsOne hundred twenty-nine patients underwent PSMA PET/CT due to biochemical persistence (52%) or recurrence (48%) after radical prostatectomy without evidence of distant metastases (February 2014–May 2017) and received PSMA PET/CT-based radiotherapy. Biochemical recurrence free survival (PSA ≤ 0.2 ng/ml) was defined as the study endpoint.ResultsPatients with biochemical persistence were significantly more often high-risk patients with significantly shorter time interval before PSMA PET/CT than patients with biochemical recurrence. Patients with biochemical recurrence had significantly more often no evidence of disease or local recurrence only in PSMA PET/CT, whereas patients with biochemical persistence had significantly more often lymph node involvement. Seventy-three patients were started on antiandrogen therapy prior to radiotherapy due to macroscopic disease in PSMA PET/CT. Cumulatively, 70 (66–70.6) Gy was delivered to local macroscopic tumor, 66 (63–66) Gy to the prostate fossa, 61.6 (53.2–66) Gy to PET-positive lymph nodes and 50.4 (45–52.3) Gy to lymphatic pathways. Median PSA after radiotherapy was 0.07 ng/ml with 74% of patients having a PSA ≤ 0.1 ng/ml. After a median follow-up of 20 months, median PSA was 0.07 ng/ml with ongoing antiandrogen therapy in 30 patients. PET-positive patients without antiandrogen therapy at last follow-up (45 patients) had a median PSA of 0.05 ng/ml with 89% of all patients, 94% of patients with biochemical recurrence and 82% of patients with biochemical persistence having a PSA ≤ 0.2 ng/ml. Post-radiotherapy PSA ≤ 0.1 ng/ml and biochemical recurrence vs. persistence were significantly associated with a PSA ≤ 0.2 ng/ml at last follow-up.ConclusionsPSMA PET/CT-based radiotherapy is an effective local salvage treatment option with significant PSA response in patients with biochemical recurrence or persistence after radical prostatectomy leading to deferral of long-term ADT or systemic therapy.

Sarcoid-Like Mediastinal Lymphadenopathy in Gynecologic Malignancy.

Noncaseating granulomas are seen surrounding tumors with varying frequency, possibly as part of an immune response to tumor cells. However, data about the association of sarcoid with gynecologic malignancy is sparse. We performed a search of our institutional database for all EBUS-TBNA biopsies conducted within the past five years that revealed granulomatous inflammation. All adult female patients with a history of gynecologic malignancy were included. Patients with a history of sarcoidosis or fungal or mycobacterial infection were excluded. All patients with evidence of malignant cells on TBNA specimen were excluded. Our results revealed 65 patients with histologic diagnosis of a noncaseating granuloma on EBUS-TBNA. Five patients (7.69%) had a history of gynecologic malignancy. Two patients had evidence of PET-positive nodes on surveillance scans, which led directly to the examination. Our findings suggest that distant malignancies may cause granulomatous lymphadenitis, through yet undefined mechanisms. As such, patients with evidence of mediastinal lymphadenopathy could benefit from routine sampling and histologic examination to define the pathology in the correct clinical context.

Detection level and pattern of positive lesions using PSMA PET/CT for staging prior to radiation therapy

BackgroundTo determine the potential role of 68Ga-PSMA positron emission tomography/computed tomography (PET/CT) in radiotherapy (RT) planning for prostate cancer (PCa).MethodsOne hundred twenty-nine patients (pts) with 68Ga-PSMA PET/CT were retrospectively analysed. Potentially influencing factors (androgen deprivation therapy, amount of 68Ga-PSMA-HBED-CC, PSA doubling time ≤/> 10 months, PSA before PET/CT, T−/N-category and Gleason score) were evaluated by logistic regression analysis. The detection rate of PSMA PET/CT was compared to contrast enhanced CT and its impact on RT management analysed.ResultsOne hundred twenty-nine patients (pts) (20 at initial diagnosis, 49 with PSA relapse and 60 with PSA persistence after radical prostatectomy) received PSMA PET/CT prior to RT. The majority of pts. (71.3%) had PET-positive findings (55.1% of pts. with PSA recurrence, 75% of pts. with PSA persistence and 100% of newly diagnosed pts). Median PSA before PET/CT in pts. with pathological findings (n = 92) was 1.90 ng/ml and without (n = 37) 0.30 ng/ml. PSA level at time of PET/CT was the only factor associated with PET-positivity. In pts. with a PSA ≤ 0.2 ng/ml, the detection rate of any lesion was 33.3%, with a PSA of 0.21–0.5 ng/ml 41.2% and with a PSA of 0.51–1.0 ng/ml 69.2%, respectively. Regarding the anatomic distribution of lesions, 42.2% and 14.7% of pts. with relapse or persistence had pelvic lymph node and distant metastases. In pts. at initial diagnosis the detection rate of pelvic lymph nodes and distant metastases was 20% and 10%. 68Ga-PSMA PET/CT had a high detection rate of PCa recurrence outside the prostatic fossa in pts. being considered for salvage RT (22.4% PET-positive pelvic lymph nodes and 4.1% distant metastases). Compared to CT, PSMA PET/CT had a significantly higher sensitivity in diagnosing rates of local recurrence/primary tumour (10.1% vs. 38%), lymph nodes (15.5% vs. 38.8%) and distant metastases (5.4% vs. 14.0%). This resulted in a modification of RT treatment in 56.6% of pts.ConclusionsThe detection of PCa is strongly associated with PSA level at time of 68Ga-PSMA PET/CT. PSMA PET/CT differentiates between local, regional and distant metastatic disease with implications for disease management. PSMA PET/CT allows for tumour detection in post-prostatectomy pts. with PSA ≤ 0.5 ng/ml considered for salvage RT.

Prospective Study of Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration in Non-Small Cell Lung Cancer Stadification: How Many Passes Are Adequate for PET Positive and Negative Lymph Nodes?

SESSION TITLE: Rapid Session: Interventional Procedures SESSION TYPE: Original Investigation Slide PRESENTED ON: Sunday, October 29, 2017 at 03:15 PM - 04:15 PM PURPOSE: It is recommended in the absence of rapid on-site evaluation (ROSE) in patients suspected of having lung cancer and undergoing endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for diagnosis, that a minimum of 3 separate needle passes be performed per sampling site (Ungraded Consensus-Based Statement).1 However it is still unclear if there is a difference between PET-positive lymph nodes (LN) and those PET negative. The purpose of the present study was to elucidate the number of passes needed for PET positive or negative LN. METHODS: A prospective study was performed from 2012 to 2017 at the Bellvitge University Hospital, 103 patients with diagnosed NSCLC were recruited. The patients underwent 3 passes of EBUS-TBNA in 150 lymph nodes found during the procedure that were bigger than 5 mm. The 3 passes were studied by ROSE and by cell block, each pass separately. LN were divided by PET results. The results of the passes and the final diagnosis were analyzed. RESULTS: A total of 103 patients were selected, 85,7% of them were male with an average age of 66.9 years. All of them have been diagnosed of non-small cell lung cancer (NSCLC) prior to the test performance, 34,3% were adenocarcinoma and 65,7% squamous cell carcinoma. ROC analysis and Sensitivity has been assessed for each of the two groups of LN (PET + and PET-) and the results were compared for each pass. We observed that in PET positive LN there is a significant improvement in the sensitivity if 3 passes were performed, while in PET negative LN there is no significant difference in the diagnostic yield between one or three passes. There is no significant difference if the LN were <10 mm or >10 mm. There is neither significant difference if the tumor was an Adenocarcinoma. CONCLUSIONS: In NSCLC stadification by EBUS-TBNA, we recommend three passes in those PET-positive LN and only one in those PET-negative even if ROSE is available. CLINICAL IMPLICATIONS: This study suggest that three passes per PET-positive LN and one for PET-negative LN are necessary to obtain satisfactory results for NSCLC stratification with ROSE available. DISCLOSURE: The following authors have nothing to disclose: Noelia Cubero, Melisa Masis, Rosa Lopez Lisbona, Marta Diez-Ferrer, Antoni Rosell No Product/Research Disclosure Information

68Ga-PSMA PET/CT and Volumetric Morphology of PET-Positive Lymph Nodes Stratified by Tumor Differentiation of Prostate Cancer.

68Ga-prostate-specific membrane antigen (PSMA) PET/CT is a new method to detect early nodal metastases in patients with biochemical relapse of prostate cancer. In this retrospective investigation, the dimensions, volume, localization, and SUVmax of nodes identified by 68Ga-PSMA were correlated to their Gleason score (GS) at diagnosis. Methods: All PET/CT images were acquired 60 ± 10 min after intravenous injection of 68Ga-PSMA (mean dose, 176 MBq). In 147 prostate cancer patients (mean age, 68 y; range, 44-87 y) with prostate-specific antigen relapse (mean prostate-specific antigen level, 5 ng/mL; range, 0.25-294 ng/mL), 362 68Ga-PSMA PET-positive lymph nodes (LNs) were identified. These patients were classified on the basis of their histopathology at primary diagnosis into either low- (GS ≤ 6, well differentiated), intermediate- (GS = 7, moderately differentiated), or high-GS cohorts (GS ≥ 8, poorly differentiated prostate cancer). Using semiautomated LN segmentation software (Fraunhofer MEVIS), we measured node volume and short-axis dimensions (SADs) and long-axis dimensions based on CT and compared with the SUVmax Nodes demonstrating uptake of 68Ga-PSMA with an SUVmax of 2.0 or more were considered PSMA-positive, and nodes with an SAD of 8 mm or more were considered positive by morphologic criteria. Results: Mean SUVmax was 13.5 (95% confidence interval [CI], 10.9-16.1), 12.4 (95% CI, 9.9-14.9), and 17.8 (95% CI, 15.4-20.3) within the low-, intermediate-, and high-GS groups, respectively. The morphologic assessment of the 68Ga-PSMA-positive LN demonstrated that the low-GS cohort presented with smaller 68Ga-PSMA-positive LNs (mean SAD, 7.7 mm; n = 113), followed by intermediate- (mean SAD, 9.4 mm; n = 122) and high-GS cohorts (mean SAD, 9.5 mm; n = 127). On the basis of the CT morphology criteria, only 34% of low-GS patients, 56% of intermediate-GS patients, and 53% of high-GS patients were considered CT positive. Overall, 68Ga-PSMA imaging led to a reclassification of stage in 90 patients (61%) from cN0 to cN1 over CT. Conclusion:68Ga-PSMA PET is a promising modality in biochemical recurrent prostate cancer patients for N staging. Conventional imaging underestimates LN involvement compared with PSMA molecular staging score in each GS cohort. The sensitivity of 68Ga-PSMA PET/CT enables earlier detection of subcentimeter LN metastases in the biochemical recurrence setting.

The critical role of EBUS-TBNA cytology in the staging of mediastinal lymph nodes in lung cancer patients: A correlation study with positron emission tomography findings.

The sensitivity and specificity of positron emission tomography (PET) have been significantly improved for the identification of malignancies in recent years; however, it is still necessary to confirm PET findings in a lymph node (LN) by direct tissue sampling. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is the most commonly used approach for diagnosing and staging mediastinal LNs, particularly in lung cancer patients with locally advanced disease. Despite this fact, evidence-based studies of EBUS-TBNA cytology and PET findings are still suboptimal. The electronic database at the Johns Hopkins Medical Institutions and the pathology archives were searched to identify patients with mediastinal lymphadenopathy who had both EBUS-TBNA mediastinal LN sampling and a PET scan over a 14-month period. Patients suspected of having lung cancer and patients with a history of lung cancer were included in this study. Cytological diagnoses and follow-up surgical LN diagnoses were reviewed and correlated with PET scan findings. A total of 140 LNs from 79 patients, including 86 PET-positive LNs and 54 PET-negative LNs, were included. The most frequently sampled LNs were 4R and 7. The average size of PET-positive and PET-negative LNs was 1.2 and 1.6 cm, respectively. Among PET-positive LNs, 41.9% were malignant, 41.9% showed reactive changes or granulomatous inflammation, and 9.3% were nondiagnostic by EBUS-TBNA. However, among PET-negative LNs, 74.1% showed reactive changes or granulomatous inflammation, 7.4% were malignant, and 18.5% were nondiagnostic by EBUS-TBNA. The data demonstrate that EBUS-TBNA cytology improves the diagnostic accuracy of mediastinal LNs and clinical staging. Furthermore, EBUS-TBNA may identify additional malignant LNs (7.4%), and this highlights the risk for false-negative findings with PET scanning in isolation. Cancer Cytopathol 2017;125:717-25. © 2017 American Cancer Society.

MP53-12 STANDARD OF CARE VERSUS METASTASIS-DIRECTED THERAPY FOR NODAL OLIGORECURRENT PROSTATE CANCER FOLLOWING MULTIMODALITY TREATMENT: A CASE-CONTROL STUDY

You have accessJournal of UrologyProstate Cancer: Advanced (including Drug Therapy) III1 Apr 2017MP53-12 STANDARD OF CARE VERSUS METASTASIS-DIRECTED THERAPY FOR NODAL OLIGORECURRENT PROSTATE CANCER FOLLOWING MULTIMODALITY TREATMENT: A CASE-CONTROL STUDY Thomas Steuber, Vidit Sharma, Piet Ost, Karel Decaestecker, Thomas Zilli, Barbara A Jereczek-Fossa, Cordula Jilg, and R. Jeffrey Karnes Thomas SteuberThomas Steuber More articles by this author , Vidit SharmaVidit Sharma More articles by this author , Piet OstPiet Ost More articles by this author , Karel DecaesteckerKarel Decaestecker More articles by this author , Thomas ZilliThomas Zilli More articles by this author , Barbara A Jereczek-FossaBarbara A Jereczek-Fossa More articles by this author , Cordula JilgCordula Jilg More articles by this author , and R. Jeffrey KarnesR. Jeffrey Karnes More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1663AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES There are several retrospective series regarding metastasis-directed therapy (MDT), in the form of either salvage lymphadenectomy (sPLND) or stereotactic body radiotherapy (SBRT), to PET-positive lymph node recurrences after initial radical prostatectomy (RP) and postoperative radiotherapy (PORT). However, these studies are single arm studies without a control group of patients not receiving MDT, which is still considered standard of care (SOC). We pooled data from 5 institutions and performed a retrospective case-control study to assess the influence of MDT to pelvic lymph node metastasis on cancer-specific survival (CSS). METHODS The SOC-cohort consisted of 2270 men who underwent RP+PORT (adjuvant or salvage) between 1996-2013 at a single institution (Hamburg) and experienced subsequent biochemical failure managed with systemic treatment administered at physicians′ discretion. The MDT-cohort comprised 227 patients treated with RP+PORT between 1996-2013 who experienced a biochemical recurrence (BCR) followed by a Choline or PSMA PET-detected nodal recurrence. This recurrence was managed with either sPLND (n= 150) or SBRT (n= 77). In case of further systemic progression, systemic treatment was administered at physicians′ discretion. Disease characteristics and the impact of MDT on cancer-specific survival (CSS) was assessed using Cox proportional hazard models. CSS was measured from time of BCR following RP+PORT. A propensity-score matched pair analysis between SOC and MDT patients was performed based on known prognostic factors at initial diagnosis (PSA prior to RP, year of RP, RP Gleason Grade, age, pN-status and pT stage). RESULTS In total, 384 were matched (187:187) with a median follow-up of 64.2 months. Type of treatment (SOC vs. MDT), age at RP, RP Gleason Grade and margin status were significantly associated with cancer-specific survival in multivariate analysis (all p<0.05). After matched-pair analysis, 10 year CSS was 79.4% (95% CI 66.5-88.2)for SOC and 98.8% (95% CI 91.4-98.8) for MDT(p= 0.002). CONCLUSIONS MDT to pelvic nodal recurrences of PCa is associated with improved CSS compared to SOC. These data should be considered hypothesis-generating and inform future randomized trials in this setting. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e717-e718 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Thomas Steuber More articles by this author Vidit Sharma More articles by this author Piet Ost More articles by this author Karel Decaestecker More articles by this author Thomas Zilli More articles by this author Barbara A Jereczek-Fossa More articles by this author Cordula Jilg More articles by this author R. Jeffrey Karnes More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...