Preoperative Staging Procedure Research Articles

Nodal size ranking as a predictor of mediastinal involvement in clinical early-stage non-small cell lung cancer.

In non-small cell lung cancer (NSCLC) patients, the recommended minimum requirement for an endoscopy-based mediastinal staging procedure is sampling the largest lymph node (LN) in right and left inferior paratracheal, and subcarinal stations. We aimed to analyze the percentage of cases where the largest LN in each mediastinal station was malignant in a cohort of NSCLC patients with mediastinal metastases diagnosed in the lymphadenectomy specimen. Furthermore, we investigated the sensitivity of a preoperative staging procedure in a hypothetical scenario where only the largest LN of each station would have been sampled.Prospective data of patients with mediastinal nodal metastases diagnosed in the lymphadenectomy specimens were retrospectively analyzed. The long-axis diameter of the maximal cut surface of all LNs was measured on hematoxylin and eosin-stained sections.Seven hundred seventy five patients underwent operation and 49 (6%) with mediastinal nodal disease were included. A total of 713 LNs were resected and 119 were involved. Sixty seven nodal stations revealed malignant LNs: in these, the largest LN was malignant in 39 (58%). In a “per patient” analysis, a preoperative staging procedure that sampled only the largest LN would have attained a sensitivity of 0.67; and if the largest and the second largest were sampled, sensitivity would be 0.87.In patients with NSCLC, nodal size ranking is not reliable enough to predict malignancy. In clinical practice, regardless of the preoperative staging method, systematic thorough sampling of all visible LNs is to be recommended over selective random samplings.

The Value of Staging Laparoscopy for Optimal Multidisciplinary Treatment in Patients with Gastric Cancer.

Introduction: Despite improvements in the conventional preoperative tools used for staging of gastric cancer, their accuracy still needs to be improved. Laparoscopy has the potential to visualize and characterize the tumor, the peritoneal cavity and the lymph nodes and thus to better select patients for the optimal treatment strategy. Material and Method: Patients with gastric cancer staged initially with contrast enhanced computer tomography and endoscopic ultrasound were also evaluated by laparoscopy and laparoscopic ultrasound in a distinct preoperative staging procedure. The perioperative data was recorded in a prospective database and was used to decide within the multidisciplinary team the optimal treatment protocol for each patient. The database was retrospectively reviewed for this study. Results: Among the 20 CT-scan M0 patients analyzed, peritoneal carcinomatosis was detected in 15% of the cases. In other 15% of patients laparoscopy upstaged the tumor and directed the patient towards neoadjuvant chemotherapy. Laparoscopic guided percutaneous core biopsies settled the definitive diagnosis in 3 further cases. In total, laparoscopic staging brought important information in 65% of cases and changed the treatment plan in 30% of patients. Conclusions: In the era of neoadjuvant chemotherapy, laparoscopy has the potential to overcome some of the limitations of the conventional staging methods and offers additional informations which finally change the treatment plan in as much as a third of patients with gastric cancer.

True Negative Predictive Value of Preoperative Staging Endosonography by Combined Endobronchial Ultrasound and Endoscopic Ultrasound in Non-Small Cell Lung Cancer

SESSION TITLE: Interventional Pulmonary Procedures SESSION TYPE: Original Investigation Slide PRESENTED ON: Wednesday, November 1, 2017 at 02:45 PM - 04:15 PM PURPOSE: Complete endosonographic mediastinal staging modalities have become a new standard in the pre-operative staging of non-small cell lung cancer in some centers. This study was performed to understand the value of mediastinal lymph node (LN) sampling and dissection at time of pulmonary resection in the setting of a negative pre-operative staging endosonography by combined EBUS & EUS. METHODS: This study consisted of a retrospective, single-institution, tertiary care referral center review of a prospectively maintained database between January 2009 and December 2014. Two hundred and thirty-two consecutive patients with non-small cell lung cancer with negative results on lymph node staging by combined endobronchial ultrasound (EBUS) and endoscopic ultrasound (EUS) fine needle aspiration (FNA) that subsequently underwent pulmonary resection or attempt at pulmonary resection were included. The endosonographic results were compared with the final pathological staging utilizing final pathology results of lymph nodes sampled during surgery. Chi-Square test was used for statistical analysis. A p-value of <0.05 was considered statistically significant. RESULTS: Twenty-five out of 232 patients with negative results on LN staging by combined EBUS / EUS - FNA had metastases in LNs sampled during pulmonary resection. 10 patients had N1 disease and 15 patients had N2 disease. The negative predictive value (NPV) of EBUS/EUS was 89.2% (p<0.01). Twenty-one out of these 25 patients who had surgical LN sampling at resection did not have the same station sampled pre-operatively by EBUS/ EUS. Therefore a direct comparison at surgical resection could not be made on these 21 patients. Eleven out of these 21 patients had Station 5 and Station 6 involvement and these stations are routinely difficult to sample using endoscopic modalities. If these 21 patients are omitted for comparison, only 4 out of 232 patients had false negative results by EBUS / EUS - FNA giving a true negative predictive value of 98.3% (p<0.01). 3 out of these 4 patients had N2 disease (Station 4L, 5 and 7) and 1 patient had N1 (Station 11R) disease detected at Pulmonary resection. CONCLUSIONS: Staging endosonography by combined EBUS & EUS in potentially resectable patients is associated with a high NPV. If pre-operative results of biopsy of a particular LN station by EBUS/EUS-FNA are negative, then sampling of the same station at surgery can potentially be omitted. LN stations not sampled by endosonography should be sampled at surgery. CLINICAL IMPLICATIONS: Can potentially change the practice and the way lymph node station sampling and dissection is done during pulmonary resection. This may reduce the operative time and avoid unnecessary dissection of the lymph nodes already biopsied at pre operative staging procedure. DISCLOSURE: The following authors have nothing to disclose: Pravachan Hegde, Vicky Thiffault, Vipul Jain, Akshatha Gowda, Pasquale Ferraro, Moishe Liberman No Product/Research Disclosure Information

18F-choline PET/CT for the assesment of pelvic lymph node metastases in high-risk prostate cancer patients.

61 Background: Assesment of pelvic lymph node involvement is a major dilemma due to poor diagnostic accuracy of conventional imaging such as computed tomography of the pelvis or magnetic resonance of the pelvis. Recently incorporation of new tools such as 18F-choline PET/CT address this issue, although there are few studies in this set of patients. To evaluate the 18-choline PET/CT diagnostic accuracy for staging of pelvic lymph node involvement in patients with high risk prostate cancer. Methods: Patients with diagnosis of high risk prostate cancer according to D’Amico risk assessment criteria where staged with a 18F-choline PET/CT prior to treatment with retropubic radical prostatectomy plus superextended bilateral lymph node dissection at our institution. 18F-choline PET/CT was compared with the results of pathological analisys of lymph nodes. We calculated sensitivity, specificity, positive and negative predictive value for 18F-choline PET/CT. Results: Between January 2012 and August 2014 a total of 36 patients met the following inclusion criteria: diagnosis of high prostate cancer (cT2c or more or PSA above 20 ng/ml or a gleason score 8-10), good performance status (ECOG 0-2) and a 18F-choline PET/CT as a preoperative staging procedure. Sensitivity, specificity, positive and negative predictive value were 64%, 92%, 77% and 85% respectively. Conclusions: 18F-choline PET/CT is a non invasive procedure that provides good information regarding pelvic lymph node involvement status that is better than the results of other techniques in published series, with a higher sensitivity in our group of patients. It is highly specific which means there is a very good chance that a patient with a normal study does not have lymph node metastases when analyzed.

Magnetic resonance imaging of cervical carcinoma using an endorectal surface coil

IntroductionThe objective of this trial is to investigate the diagnostic value of magnetic resonance imaging (MRI) with an endorectal surface coil for precise local staging of patients with histologically proven cervical cancer by comparing the radiological, clinical, and histological results. Materials and methodsWomen with cervical cancer were recruited for this trial between February 2007, and September 2010. All the patients were clinically staged according to the FIGO classification and underwent radiological staging by MRI that employed an endorectal surface coil. The staging results after surgery were compared to histopathology in all the operable patients. ResultsA total of 74 consecutive patients were included in the trial. Forty-four (59.5%) patients underwent primary surgery, whereas 30 (40.5%) patients were inoperable according to FIGO and underwent primary radiochemotherapy. The mean age of the patients was 50.6 years. In 11 out of the 44 patients concordant staging results were obtained by all three staging modalities. Thirty-two of the 44 patients were concordantly staged by FIGO and histopathological examination, while only 16 were concordantly staged by eMRI and histopathological examination. eMRI overstaged tumors in 14 cases and understaged them in 7 cases. ConclusionseMRI is applicable in patients with cervical cancer, yet of no benefit than staging with FIGO or standard pelvic MRI. The most precise preoperative staging procedure still appears to be the clinical examination.

Maximum standardized uptake value on PET/CT in preoperative assessment of lymph node metastasis for thoracic esophageal squamous cell carcinoma

The presence of lymph node metastasis is an important prognostic factor for patients with esophageal cancer. Accurate assessment of lymph nodes in thoracic esophageal carcinoma is essential for selecting appropriate treatment and forecasting disease progression. Positron emission tomography combined with computed tomography (PET/CT) is becoming an important tool in the workup of esophageal carcinoma. Here, we evaluated the effectiveness of the maximum standardized uptake value (SUVmax) in assessing lymph node metastasis in esophageal squamous cell carcinoma (ESCC) prior to surgery. Fifty-nine surgical patients with pathologically confirmed thoracic ESCC were retrospectively studied. These patients underwent radical esophagectomy with pathologic evaluation of lymph nodes. They all had 18F-FDG PET/CT scans in their preoperative staging procedures. None had a prior history of cancer. The pathologic status and PET/CT SUVmax of lymph nodes were collected to calculate the receiver operating characteristic (ROC) curve and to determine the best cutoff value of the PET/CT SUVmax to distinguish benign from malignant lymph nodes. Lymph node data from 27 others were used for the validation. A total of 323 lymph nodes including 39 metastatic lymph nodes were evaluated in the training cohort, and 117 lymph nodes including 32 metastatic lymph nodes were evaluated in the validation cohort. The cutoff point of the SUVmax for lymph nodes was 4.1, as calculated by ROC curve (sensitivity, 80%; specificity, 92%; accuracy, 90%). When this cutoff value was applied to the validation cohort, a sensitivity, a specificity, and an accuracy of 81%, 88%, and 86%, respectively, were obtained. These results suggest that the SUVmax of lymph nodes predicts malignancy. Indeed, when an SUVmax of 4.1 was used instead of 2.5, FDG-PET/CT was more accurate in assessing nodal metastasis.

Prognostic significance of a positive axillary lymph node fine‐needle aspirate in patients with invasive breast carcinoma

Image-guided axillary lymph node fine-needle aspirates (FNAs) correlate well with pathologic lymph node staging in cases of invasive breast carcinoma. The objective of this study was to determine the prognostic significance of a positive lymph node. Consecutive cases of nonmetastatic (M0) invasive breast carcinoma evaluated by image-guided FNA were identified (4-year period, median follow-up of 51 months). "Positive" and "nonpositive" groups were compared using Kaplan-Meier survival analysis. Multivariate Cox regression was used to correct for clinicopathologic and treatment factors. A total of 142 cases was included, 70 with positive axillary FNA and 72 with a nonpositive result. FNA-positive and nonpositive cases did not differ in patient age, tumor subtype, or hormone receptor status. Positive FNA was significantly associated with advanced T and N pathologic stage, and with HER2 (human epidermal growth factor receptor 2) positivity. FNA-positive patients were more likely to undergo mastectomy and to receive chemotherapy. Kaplan-Meier analysis showed that positive FNA is associated with poor prognosis, both with respect to disease-free survival (89% nonpositive versus 73% positive at 5 years, P < .001) and overall survival (94% versus 81%, respectively, at 5 years, P = .01). Multivariate analysis showed that when correcting for other variables, FNA positivity was not independently significant. Positive axillary lymph node FNA is associated with poor prognosis on univariate analysis. By contrast, overall nodal staging is independently significant on multivariate analysis. The prognostic significance of axillary FNA likely results from its ability to predict for nodal status. Axillary FNA has utility as a preoperative staging procedure.

The PROCAINA (PROstate CAncer INdication Attitudes) Project (Part I): a survey among Italian radiation oncologists on postoperative radiotherapy in prostate cancer

Radiotherapy (RT) has an established role in the postoperative treatment of prostate cancer patients with extracapsular extension, positive surgical margins or a detectable post-operative prostate-specific antigen (PSA). Despite the large number of patients treated with postoperative RT, some issues about optimal technique, doses, volumes, timing and association with androgen deprivation are still subject of debate. The aim of this survey was to determine the patterns of choice of Italian radiation oncologists in two different clinical cases of postoperative prostate cancer patients. During the 2010 National Congress of the Italian Association of Radiation Oncology (AIRO), four clinical cases were presented to the attending radiation oncologists. Two of them were cases of postoperative prostate cancer, differing in T stage of the primary tumour according to the TNM classification, preoperative staging procedures, preoperative PSA (iPSA), Gleason score of biopsies and definitive pathological specimen after surgery and postoperative PSA. For each clinical case, the radiation oncologists were asked to: (a) give indication to new pre-treatment procedures for staging; b) give indication to postoperative treatment; (c) to define specifically, where indicated, the total dose, type of fractionation, treatment volumes, type of technique, type of image-guided setup control; (d) indicate whether adjuvant hormonal therapy should be prescribed; (e) define criteria that mostly influenced the prescription. A descriptive statistical analysis was then performed. A total of 300 questionnaires were distributed amongst radiation oncologists attending the congress; 128 were completed and considered for this analysis (41%). Some important differences were shown in prescribing and performing postoperative radiotherapy, and some significant differences with international guidelines and data available from the literature were also reviewed and discussed. Despite the results of clinical trials, significant differences still exist among Italian radiation oncologists in deciding postoperative treatment in prostate cancer patients. These patients probably deserve a more uniform approach based on updated, detailed and evidence-based recommendations.

Role of High-Resolution Ultrasound and PET/CT Imaging for Preoperative Characterization of Sentinel Lymph Nodes in Cutaneous Melanoma

The purpose of our study was the comparison of high-resolution ultrasound (HRUS) and positron emission tomography combined with computerised tomography (PET/CT) in the preoperative characterization and identification of subclinical nodal metastases focusing on sentinel lymph nodes (SLN) in melanoma patients. Patients with cutaneous melanoma (CM) who received sentinel lymph node biopsy at the Department of Dermatology and Allergy, University of Bonn, between January 2009 and January 2011 had been evaluated with a retrospective computer-aided search concerning preoperative staging procedures. A combination of PET/CT and HRUS had been performed preoperatively in 20 of 123 patients. A total of 59 SLNs had been removed in those 20 patients followed by histopathologic examination. HRUS correctly identified two of 17 positive SLNs whereas PET/CT imaging identified none. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of HRUS were 11.8 % (95 % confidence interval [CI] = 3.3–34.3), 100 % (95 % CI = 91.6–100.0), 100.0 % (95 % CI = 34.2–100.0), and 73.7 % (95 % CI = 61.0–83.3), respectively. On the basis of this limited study cohort, HRUS had a better value than PET/CT in preoperative identification of positive SLNs, suggesting a possible diagnostic superiority of HRUS in general characterization of peripheral nodal disease in CM.

Surgical sentinel lymph node biopsy in early breast cancer. Could it be avoided by performing a preoperative staging procedure? A pilot study

SummaryBackgroundThe aim of this pilot trial was to study the feasibility of sentinel node percutaneous preoperative gamma probe-guided biopsy as a valid preoperative method of assessment of nodal status compared to surgical sentinel lymph node biopsy.Material/MethodsThis prospective study enrolled 10 consecutive patients without evidence of axillary lymph node metastases at preoperative imaging. All patients underwent sentinel node occult lesion localization (SNOLL) using radiotracer intradermic injection that detected a “hot spot” corresponding to the sentinel node in all cases. Gamma probe over the skin detection with subsequent ultrasonographically guided needle biopsy of the sentinel node were performed. The percutaneous needle core histopathological diagnosis was compared to the results of the surgical biopsy.ResultsPreoperative sentinel node identification was successful in all patients.ConclusionsThe combination of preoperative gamma probe sentinel node detection and ultrasound-guided biopsy could represent a valid alternative to intraoperative sentinel node biopsy in clinically and ultrasonographically negative axillary nodes, resulting in shorter duration of surgery and lower intraoperative risks.

Staging of muscle-invasive bladder cancer: can computerized tomography help us to decide on local treatment?

To assess the power of multi-detector row computerized tomography (MDCT) in daily routine as a basic staging procedure for the decision on local treatment of patients with bladder cancer. We retrospectively analysed 276 patients who had undergone radical cystectomy between 2004 and 2008 and correlated the MDCT findings with pathological findings, number of removed lymph nodes and type of urinary diversion. Accuracy of MDCT in predicting pathological tumour stage was 49% (kappa coefficient, 0.23; P < 0.001). Overstaging occurred in 23.4%, and understaging occurred in 24.7%. Accuracy in predicting lymph node metastases was 54% (kappa coefficient, 0.04; P = 0.297). Overstaging and understaging occurred in 8.3 and 29.4%, respectively. Significantly more ileal conduits were performed in patients with high postoperative pathological tumour stages (P = 0.04) and positive lymph nodes (P = 0.013). In contrast, there was no correlation between preoperative CT tumour/nodal stage and the number of removed lymph nodes (P = 0.44 and P = 0.732, respectively), and between preoperative tumour stage and type of urinary diversion (P = 0.126). MDCT as a preoperative staging procedure has a low accuracy in predicting the correct tumour and nodal stage, and therefore, it has little impact on decision-making for local treatment of muscle-invasive bladder cancer during radical cystectomy.

The value of axillary ultrasound with fine needle aspiration as a pre-operative staging procedure in breast cancer: Northern Irish experience

In our unit sentinel lymph node biopsy (SLNB) is performed without intra-operative pathological nodal assessment. If node biopsies are positive the patients have to return at a later date for a complete axillary node clearance (ANC). We conducted a retrospective study to ascertain if the use of pre-operative ultrasound assessment of the axilla with fine needle aspiration (FNA) sampling could identify patients with nodal metastases and therefore identify patients who should proceed primarily to ANC. Our study showed that 40 patients out of 119 had nodal metastases, and ultrasound correctly identified 19 of those patients.

343 Value of axillary ultrasound as a pre-operative staging procedure in breast cancer – a pilot study

343 Value of axillary ultrasound as a pre-operative staging procedure in breast cancer – a pilot study

Neuroendocrine gastroenteropancreatic tumors: ESMO Clinical Recommendation for diagnosis, treatment and follow-up

Neuroendocrine gastroenteropancreatic tumors : ESMO clinical recommendation for diagnosis, treatment and follow-up

18Fluorodeoxyglucose Positron Emission Tomography in the Diagnosis and Staging of Lung Cancer: A Systematic Review

Lung cancer is the leading cause of cancer-related death in industrialized countries. The overall mortality rate for lung cancer is high, and early diagnosis provides the best chance for survival. Diagnostic tests guide lung cancer management decisions, and clinicians increasingly use diagnostic imaging in an effort to improve the management of patients with lung cancer. This systematic review, an expansion of a health technology assessment conducted in 2001 by the Institute for Clinical and Evaluative Sciences, evaluates the accuracy and utility of 18fluorodeoxyglucose positron emission tomography (PET) in the diagnosis and staging of lung cancer. Through a systematic search of the literature, we identified relevant health technology assessments, randomized trials, and meta-analyses published since the earlier review, including 12 evidence summary reports and 15 prospective studies of the diagnostic accuracy of PET. PET appears to have high sensitivity and reasonable specificity for differentiating benign from malignant lesions as small as 1 cm. PET appears superior to computed tomography imaging for mediastinal staging in non-small cell lung cancer (NSCLC). Randomized trials evaluating the utility of PET in potentially resectable NSCLC report conflicting results in terms of the relative reduction in the number of noncurative thoracotomies. PET has not been studied as extensively in patients with small-cell lung cancer, but the available data show that it has good accuracy in staging extensive- versus limited-stage disease. Although the current evidence is conflicting, PET may improve results of early-stage lung cancer by identifying patients who have evidence of metastatic disease that is beyond the scope of surgical resection and that is not evident by standard preoperative staging procedures. Further trials are necessary to establish the clinical utility of PET as part of the standard preoperative assessment of early-stage lung cancer.

O-107 The role of axillary ultrasound (US) and fine needle aspiration cytology (FNAC) as pre-operative axillary staging procedure in patients with operable breast cancer

O-107 The role of axillary ultrasound (US) and fine needle aspiration cytology (FNAC) as pre-operative axillary staging procedure in patients with operable breast cancer

P1-091: Preoperative staging procedures using 18F-FDG-Positron Emission Tomography-Computed Tomography fused imaging (PET-CT-Scan) and Mediastinoscopy compared to Surgical-Pathological findings in Malignant Pleural Mesothelioma undergoing Extrapleural Pneumonectomy

P1-091: Preoperative staging procedures using 18F-FDG-Positron Emission Tomography-Computed Tomography fused imaging (PET-CT-Scan) and Mediastinoscopy compared to Surgical-Pathological findings in Malignant Pleural Mesothelioma undergoing Extrapleural Pneumonectomy

M14-01: Mediastinal staging of NSCLC and 18FDG PET

M14-01: Mediastinal staging of NSCLC and 18FDG PET

170 Role of preoperative staging procedures using conventional CT scan, FDG-PET-CT-scan fused imaging, and mediastinoscopy compared to surgical-pathological findings in malignant pleural mesothelioma (MPM) undergoing extrapleural pneumonectomy

170 Role of preoperative staging procedures using conventional CT scan, FDG-PET-CT-scan fused imaging, and mediastinoscopy compared to surgical-pathological findings in malignant pleural mesothelioma (MPM) undergoing extrapleural pneumonectomy

Prediction of cervical involvement in endometrial cancer by hysteroscopy

This study evaluated the ability of hysteroscopy to preoperatively predict cervical involvement in endometrial cancer. The records of 110 surgically staged consecutive endometrial cancer patients treated at our institution from 1997 to 2003 were retrospectively analyzed. Data on demographics, preoperative staging procedures, surgical pathology reports, and adjuvant treatments were retrieved. Fourteen (12.7%) patients had cervical involvement (stage II) according to the surgical pathology report, of whom nine (8.1%) had stage IIA and five (4.6%) had stage IIB. Clinical evaluation by speculoscopy and palpation had failed to reveal any indication of cervical involvement. Preoperative diagnostic hysteroscopy procedures were included. None of the hysteroscopy procedures revealed any suspicious lesion in the cervical canal. Hysteroscopy and clinical examination fail to adequately predict cervical involvement in endometrial carcinoma. Fractional D&C appears to be the best method until a more effective alternative becomes available.