Preoperative Lymph Node Staging Research Articles

SC01.04 The Role of Mediastinoscopy in Induction Therapy of N2 NSCLC

SC01.04 The Role of Mediastinoscopy in Induction Therapy of N2 NSCLC

Clinically Node Negative, Pathologically Node Positive Rectal Cancer Patients Who Did Not Receive Neoadjuvant Therapy

PurposeNeoadjuvant chemoradiotherapy is the preferred standard of care for clinical stages II–III rectal cancer. It is uncertain whether clinically node negative (cN−) tumors found to be pathologically stage III could be optimally treated with surgery alone and avoid adjuvant treatments. The aim of our study was to define the outcomes of such patients. MethodsPatients undergoing radical surgery using total mesorectal excision (TME) techniques for rectal cancer (≤12 cm from the anal verge) with curative intent during 2000–2012 and found to have stage III disease on final pathology were identified from a prospectively maintained database. Patients were staged with abdominopelvic CT, transrectal endoscopic ultrasound, and/or pelvic MRI. Exclusion criteria were cN+ without neoadjuvant chemoradiotherapy, hereditary colorectal syndromes, inflammatory bowel diseases, lack of preoperative nodal staging, intraoperative radiotherapy, and follow-up <3 years. We compared cN−/pN+ patients according to the postoperative treatment received (group 1 if no further treatment, group 2 if any postoperative treatments), using ypN+ patients (neoadjuvant chemoradiotherapy + surgery) as controls (group 3). Oncological outcomes evaluated included overall survival (OS), disease-specific survival (DSS), disease-free survival (DFS), local recurrence (LR), and distant recurrence (DR). ResultsOut of 218 patients included in the study, 77 cN− patients underwent initial surgery with a pN+ surgical specimen. Eighteen of these patients received no postoperative treatment due to associated comorbidity, patient preference, or postoperative complications while the remaining 59 (group 2) patients received chemoradiotherapy (n = 21) or chemotherapy alone (n = 38), respectively, and group 3 included 141 patients. Distal, radial resection margins and TME grading when available were comparable among groups. cN−/pN+ patients treated with surgery alone were associated with significantly poorer cancer outcomes compared with cN−/pN+ patients who received any form of adjuvant therapy and to ypN+ patients. ConclusionTME surgery is not sufficient to optimize outcomes among rectal cancer patients believed to be node negative and found to be stage III based on specimen pathology.

18FDG-PET-CT improves specificity of preoperative lymph-node staging in patients with intestinal but not diffuse-type esophagogastric adenocarcinoma

IntroductionThe accuracy of preoperative lymph-node staging in patients with adenocarcinoma of the esophagogastric junction (AEG) or gastric cancer (GC) is low. The aim of this study was to assess the accuracy of [18F]fluorodeoxyglucose positron emission tomography/computed tomography (PET-CT) for lymph-node staging in patients with AEG or GC, with or without neoadjuvant treatment. Patients and methods221 consecutive patients with GC (n = 88) or AEG (n = 133) were evaluated. Initial staging included endoscopic ultrasound (EUS), multidetector spiral CT (MDCT) and PET-CT. PET-CT was performed for restaging in patients after neoadjuvant treatment (n = 94). Systematic lymphadenectomy was routinely performed with histopathological assessment of individual mediastinal and abdominal lymph-node stations. Preoperative staging from EUS, MDCT, and PET-CT was correlated with histopathological results. ResultsPET-CT showed a high specificity (91%) and positive predictive value (89%) for the preoperative detection of lymph-node metastases. In comparison, EUS was more sensitive (73% versus 50%, P < 0.01) but less specific (60%, P < 0.01). In patients with intestinal/mixed-type tumors, PET-CT improved the detection of extra-regional lymph-node metastases (P = 0.01) and distant metastases (P = 0.01) compared to CT alone. In contrast, lymph-node assessment by PET/CT after neoadjuvant treatment (32%, P < 0.01) and in diffuse-type cancers (24%, P < 0.01) is futile because of low sensitivities. ConclusionPET-CT does not improve the overall accuracy of N staging, but does improve specificity compared to EUS and MDCT in AEG and GC. We do not recommend routine PET-CT for the initial staging in patients with diffuse-type cancer or for restaging of lymph nodes after neoadjuvant treatment.

Preoperative Lymph Node Staging by FDG PET/CT With Contrast Enhancement for Thyroid Cancer: A Multicenter Study and Comparison With Neck CT.

ObjectivesThe purpose of this study was to compare lymph node (LN) staging using 18F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) with contrast-enhancement (CE) PET/CT and contrast-enhanced neck CT (neck CT) in patients with thyroid cancer with level-by-level comparison with various factors.MethodsThis was a retrospective multicenter study. A total of 85 patients were enrolled. Patients who underwent a preoperative evaluation by CE PET/CT and neck CT for thyroid cancer were enrolled. The gold standard for LN was the combination of surgical pathology and clinical follow-up. We compared CE PET/CT with neck CT using a level-by-level method. Factors, including age, sex, camera, arm position, tumor size, extra-thyroidal extension, tumor location, number of primary tumors, primary tumor maximum standardized uptake value, and the interval from scan to operation were also analyzed.ResultsOverall accuracy was 81.2% for CE PET/CT and 68.2% for neck CT. CE PET/CT was more sensitive than neck CT (65.8% vs. 44.7%). Also, CE PET/CT showed higher negative predictive value (77.2% vs. 66.1%). CE PET/CT showed good agreement with the gold standard (weighted kappa [κ], 0.7) for differentiating N0, N1a, and N1b, whereas neck CT showed moderate agreement (weighted κ, 0.5). CE PET/CT showed better agreement for the number of levels involved with the gold standard (weighted κ, 0.7) than that of neck CT with the gold standard (weighted κ, 0.5). The accuracies for differentiating N0, N1a, and N1b were 81.2% for CE PET/CT and 68.2% for neck CT. Level-by-level analysis showed that CE PET/CT was more sensitive and has higher negative predictive value for detecting ipsilateral level IV and level VI LNs than neck CT. Other analyzed factors were not related to accuracies of both modalities.ConclusionCE PET/CT was more sensitive and reliable than neck CT for preoperative LN staging in patients with thyroid cancer.

Prospective evaluation of 68Gallium-prostate-specific membrane antigen positron emission tomography/computed tomography for preoperative lymph node staging in prostate cancer.

To assess the accuracy of 68Gallium-prostate-specific membrane antigen (68Ga-PSMA) positron emission tomography/computed tomography (PET/CT) for lymph node (LN) staging in intermediate- and high-risk prostate cancer (PCa). From April to October 2015, 30 patients with intermediate- (n = 3) or high-risk (n = 27) PCa were prospectively enrolled. Patients underwent preoperative 68Ga-PSMA PET/CT. Both visual and semi-quantitative analyses were undertaken. Subsequently, all patients underwent radical prostatectomy (RP) with an extended pelvic lymph node dissection. The sensitivity, specificity, and positive (PPV) and negative predictive value (NPV) for LN status of 68Ga-PSMA were calculated using histopathology as reference. Eleven patients (37%) had lymph node metastases (LNMs); 26 LNMs were identified in the 11 patients. Patient analysis showed that 68Ga-PSMA PET/CT had a sensitivity of 64% for the detection of LNMs, its specificity was 95%, the PPV was 88%, and the NPV was 82%. In total, 180 LN fields were analysed. In the LN-region-based analysis, the sensitivity of 68Ga-PSMA PET/CT for detection of LNMs was 56%, the specificity was 98%, the PPV was 90% and the NPV was 94%. The mean size of missed LNMs was 2.7 mm. Receiver-operating characteristic curve analysis showed a high accuracy of maximum standardized uptake value (SUVmax ) for the detection of LNMs, with an area under the curve of 0.915 (95% confidence interval 0.847-0.983); the optimum SUVmax was 2.0. In patients with intermediate- to high-risk PCa, 68Ga-PSMA PET/CT had a high specificity and a moderate sensitivity for LNM detection. 68Ga-PSMA PET/CT had the potential to replace current imaging for LN staging of patients with PCa scheduled for RP.

Pros: should a patient with stage IA non-small cell lung cancer undergo invasive mediastinal staging?

Mediastinal lymph node involvement is an important prognostic factor in patients with non-small cell lung cancer (NSCLC). The American and European guidelines for preoperative mediastinal lymph node staging agree in which situations a pre-surgical exploration of the mediastinum is required in order to avoid futile pulmonary resections (1,2). Invasive mediastinal staging with cyto-histological confirmation is indicated when computed tomography (CT) shows enlarged mediastinal or hilar lymph nodes, when positron emission tomography (PET) shows an increase uptake in the mediastinum or hilum, when the tumour is centrally located and when the tumour size is more than 3 cm, especially in adenocarcinoma with high 18F-Fluorodeoxyglucose (FDG) uptake. In general, a minimally invasive technique (endobronchial or endoesophageal ultrasound fine needle aspiration) is indicated of first choice, but when negative, a surgical exploration of the mediastinum (mainly a video mediastinoscopy) is required. In some particular situation, like clinical (c) staged N1 tumours, with normal mediastinum on imaging techniques, it was suggested to proceed directly to surgical resection when preoperative endosonography was negative. However, this issue has been analyzed, concluding that in cN1 NSCLC, endosonography alone has an unsatisfactory sensitivity to detect mediastinal involvement and, therefore, a confirmatory video mediastinoscopy is mandatory when endoscopic techniques show a negative result (3). Although stage cIA NSCLC is the main situation in which invasive mediastinal staging might be omitted, this paper will analyze the established indications and other particular situations in which performing a pre-surgical mediastinal staging in this group of patients can add a benefit in terms of accurate staging.

Standardized visual reading of F18-FDG-PET in patients with non-small cell lung cancer scheduled for preoperative thoracic lymph node staging

ObjectivesRoutine visual assessment of positron emission tomography (PET) for thoracic lymph node (LN) staging in patients with non-small cell lung cancer (NSCLC) is limited by a lack of reliable assessment criteria. This study evaluates the accuracy and inter-rater agreement of a standardized approach with unified windowing and a PET-based visual score. Materials and methodsThis retrospective analysis included pretherapeutic FDG-PET data of 86 patients with NSCLC. After standardized windowing (threshold: 2×liver SUVmean) the LN uptake was assessed visually by three independent readers with varying levels of experience using a 4-step score (1, LN uptake≤mediastinal blood pool structures (MBPS); 2, MBPS<LN<liver; 3, liver≤LN<‘black’; 4, LN appears ‘black’). ROC analyses and respective areas under the curve (AUC) based on histology/cytology as standard of reference. Agreement was analyzed with Cohen’s kappa (κ, pairwise) and Fleiss’ κ (overall). Subgroup analyses separated between hilar vs. mediastinal LNs, adenocarcinoma vs. squamous cell carcinoma and grading G1/2 vs. G3/4. ResultsFifty-four of the 278LNs (19.4%) were malignant (optimal cut-off to differentiate benign vs. malignant, score >3). The inexperienced (n=1), advanced (n=1), and expert readers (n=1) achieved similar accuracies of 93.5%, 91.4% and 92.1%, respectively (P>0.05 each). Cohen’s κ ranged from 0.92 to 0.96 and Fleiss’ κ was 0.93. ROC-analyses showed no significant differences between attendant readers within any subgroup (AUC, 0.92–0.96). ConclusionApplying unified windowing, the introduced PET-score achieved highly accurate and robust LN assessment. This approach may shorten learning curves of inexperienced readers, facilitate multicenter trials, and improve comparability of future studies.

MP79-09 PROSPECTIVE EVALUATION OF 68GA-PSMA POSITRON EMISSION TOMOGRAPHY/COMPUTERIZED TOMOGRAPHY FOR PREOPERATIVE LYMPH NODE STAGING IN PROSTATE CANCER

You have accessJournal of UrologyProstate Cancer: Staging II1 Apr 2016MP79-09 PROSPECTIVE EVALUATION OF 68GA-PSMA POSITRON EMISSION TOMOGRAPHY/COMPUTERIZED TOMOGRAPHY FOR PREOPERATIVE LYMPH NODE STAGING IN PROSTATE CANCER Pim van Leeuwen, Louise Emmeett, Francis Ting, Warick Delprado, and Phillip Stricker Pim van LeeuwenPim van Leeuwen More articles by this author , Louise EmmeettLouise Emmeett More articles by this author , Francis TingFrancis Ting More articles by this author , Warick DelpradoWarick Delprado More articles by this author , and Phillip StrickerPhillip Stricker More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.2007AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Conventional imaging techniques are inadequate for lymph node staging in prostate cancer (PC). To assess the accuracy of 68Ga-PSMA positron emission tomography/computerized tomography (PET/CT) for lymph node (LN) staging in intermediate and high-risk PC. Secondly, to validate the automated standardized maximum uptake value (SUV max) for the detection of PC using 68Ga-PSMA PET/CT. METHODS From March to October 2015, 30 patients with intermediate (n=3) or high-risk (n=27) PC were prospectively enrolled. Patients underwent preoperative 68Ga-PSMA PET/CT. Both visual and semi quantitative analysis was undertaken. Subsequently, all patients underwent a radical prostatectomy with an extended pelvic lymph node dissection (eLND). Sensitivity, specificity, positive and negative predictive value (PPV and NPV) for LN status of 68Ga-PSMA were calculated using histopathology as reference. RESULTS Eleven of 30 patients (37%) had histologically proven LNMs. Overall, 536 LNs were resected, with 26 harbouring metastases (4.9%). On a patient analysis, 68Ga-PSMA PET/CT has a sensitivity of 64% for the detection of LNMs, specificity was 95%, PPV was 88%, and NPV was 82%. In total, 180 LN fields were analyzed. For the LN-region-based analysis, the sensitivity of 68Ga-PSMA PET/CT for detection of LNMs was 56%, specificity was 98%, PPV was 90% and NPV was 94%. Mean size of missed LNMs was 2.7mm. Receiver operating characteristic (ROC) analysis demonstrated high accuracy of SUV for the detection of LNMs, AUC 0.937 (95%CI 0.888-0.985), this means that a cutoff value of SUVmax 2.0 would have a 4% false-positive rate and would detect 92% of LNMs (sensitivity). For detecting intraprostatic PC, AUC 0.905 (95%CI 0.885-0.925), this means that a cutoff value of SUVmax 3.0 would have a 10% false-positive rate but would detect only 73% of cancer cases (sensitivity). CONCLUSIONS In patients with intermediate to high-risk PC, 68Ga-PSMA PET/CT has a high specificity and a moderate sensitivity for LNM detection. Therefore, 68Ga-PSMA PET/CT has the potential to replace current imaging modalities in PC staging in the future. However, due to its moderate sensitivity for small LNs (<5mm) it should not replace eLND as a staging technique. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e1038 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Pim van Leeuwen More articles by this author Louise Emmeett More articles by this author Francis Ting More articles by this author Warick Delprado More articles by this author Phillip Stricker More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Impact of EUS-FNA for preoperative para-aortic lymph node staging in patients with pancreatobiliary cancer

In patients with pancreatobiliary cancer, para-aortic lymph node (PALN) metastasis is considered to be the involvement beyond the regional lymph nodes, namely, distant metastasis. Effective methods for preoperative PALN staging, however, are not established. This study aimed to compare the diagnostic capability for PALN metastasis between EUS-FNA and (18)F-fluorodeoxyglucose positron emission tomography with CT (PET/CT). We performed a prospective, nonrandomized, single-center trial. Between December 2010 and March 2014, 208 patients with pancreatobiliary cancer without apparent distant metastasis except for PALNs were assessed for study eligibility before surgery. Among them, 52 consecutive patients with PALN enlargement were enrolled in the study. (18)F-Fluorodeoxyglucose PET/CT and EUS-FNA were performed sequentially as a single combined procedure to evaluate PALN metastases. The primary outcome was to compare the diagnostic capability of EUS-FNA and PET/CT for PALN metastasis. Of 71 enlarged PALNs in the 52 patients, 30 (42.3%) were finally diagnosed as metastases in 21 patients (40.4%). Of the 21 patients with PALN metastases, preoperative EUS-FNA or PET/CT made a correct diagnosis in 20 (95.2%) or 12 (57.1%), respectively. EUS-FNA had higher sensitivity and specificity for the diagnosis of PALN metastasis (sensitivity, 96.7% [29/30]; 95% confidence interval, 82.2%-99.9%; specificity, 100% [39/39]; 95% confidence interval, 91.0%-100%) than PET/CT. EUS-FNA is superior to PET/CT for preoperative PALN staging in patients with pancreatobiliary cancer. Because of the clinical benefit of EUS-FNA to reduce unnecessary surgery, it should be part of the standard preoperative examination for patients with pancreatobiliary cancer. (UMIN clinical trials registry number: 000006408.).

559 Prospective evaluation of 68Ga-PSMA positron emission tomography/computerized tomography for preoperative lymph node staging in prostate cancer

559 Prospective evaluation of 68Ga-PSMA positron emission tomography/computerized tomography for preoperative lymph node staging in prostate cancer

Preoperative axillary lymph node staging by ultrasound-guided cytology using a four-level sonographic score.

BackgroundThe staging of axillary lymph nodes is critical to the management and prognosis of breast cancer, the most frequent cancer in females. Neoadjuvant therapy and lymph node dissection are recommended when malignant cells invade the lymph nodes. Therefore the pre-operative examination of these lymph nodes is crucial to treatment.MethodsIn this study, we examined the effectiveness of cytology through ultrasound-guided fine needle aspiration (USG-FNA) and ultrasound (US) imaging using an established classification system in correctly identifying lymph node status compared to the final histological results after surgery.ResultsCytology by USG-FNA and US classification were found to be promising methods of axillary lymph node staging.ConclusionsUS and CB offer minimally invasive techniques to pre-operatively examine these lymph nodes in patients with primary breast cancer.

Validation of 3 T MRI including diffusion-weighted imaging for nodal staging of newly diagnosed intermediate- and high-risk prostate cancer

To prospectively validate 3T magnetic resonance imaging (MRI) including diffusion-weighted imaging (DWI) for preoperative lymph node (LN) staging in a clinical setting, in intermediate- and high-risk prostate cancer (PCa) patients using laparoscopic extended LN dissection (ePLND) as the reference standard. Between August 2011 and May 2013, 40 newly diagnosed intermediate and high-risk PCa patients underwent preoperative LN staging with 3T MRI DWI using histopathology of ePLND as the reference standard. The sensitivity, specificity, and accuracy of MRI DWI were calculated. A subgroup analysis of proven LN-positive patients was made to investigate differences in PSA, Gleason score, number, and size of LN metastases, estimated risk of LN involvement, and if curative treatment was indicated, between the true-positive and the false-negative groups. A total of 728 LN were harvested from six anatomical regions per patient (external, obturator, internal) with a mean number of 18 LNs per patient (range 11-40). Twenty patients had histologically proven LN-positive disease. MRI DWI was true positive in 11 patients, false negative in nine patients, false positive in two patients, and true negative in 18 patients, resulting in 90% specificity, 55% sensitivity, and 72.5% accuracy. The true-positive patients had significantly more involved LNs (mean 6.9 versus 2.7, p=0.017), with larger diameter (mean 12.3 versus 5.2mm, p=0.048) and fewer were treated with curative intent (six versus nine, p=0.03), compared with the false-negative group. MRI DWI LN staging has a low sensitivity but high specificity. The true-positive patients have a considerably higher burden of LN metastases compared to false-negative patients.

Accuracy of Multidetector-Row Computed Tomography in the Preoperative Diagnosis of Lymph Node Metastasis in Patients with Gastric Cancer

Background/Aims: Preoperative lymph node staging in gastric cancer patients is important. The aim of this study was to assess the diagnostic accuracy of computed tomography (CT) in assessing lymph nodes in patients with gastric cancer. Methods: A total of 56 patients had undergone standardized gastric resection with lymphadenectomy between October 2013 and June 2015 were reviewed retrospectively. The short axis diameter of the largest lymph node per station was recorded when reviewing the preoperative CT images. Diagnostic accuracy was calculated by comparing CT with histopathological findings. Results: In 518 stations dissected at surgery, 56 included lymph nodes with metastasis. Among them, lymph nodes were visualized on preoperative CT in 26 stations. No lymph node was detected in 382 stations among 462 infiltration-negative stations. The cutoff of 12 mm had the highest accuracy rate of 0.896. Conclusion: The accuracy of CT in the preoperative diagnosis of lymph node metastasis in patients with gastric cancer remains poor. Therefore, surgeons should pay attention to the visibility of lymph nodes on CT. Detection of lymph nodes on CT can be utilized for a more accurate diagnosis such as fine-needle aspiration biopsy.

Diagnostic Efficacy of 68Gallium-PSMA Positron Emission Tomography Compared to Conventional Imaging for Lymph Node Staging of 130 Consecutive Patients with Intermediate to High Risk Prostate Cancer

Current standard imaging techniques are insufficient to reliably detect lymph node metastases in prostate cancer. Recently ligands of PSMA (prostate specific membrane antigen) were introduced in PET (positron emission tomography) of prostate cancer. Thus the aims of this retrospective analysis were to 1)investigate the diagnostic efficacy of (68)Ga-PSMA-PET imaging for lymph node staging in patients with prostate cancer scheduled for radical prostatectomy and 2) compare it to morphological imaging (computerized tomography and magnetic resonance tomography) with histopathological evaluation as the standard of reference. A total of 130 patients with intermediate to high risk prostate cancer were staged with (68)Ga-PSMA-PET/magnetic resonance tomography or PET/computerized tomography from December 2012 to November 2014 before radical prostatectomy and template pelvic lymph node dissection. Histopathological findings of resected tissue were statistically correlated with the results of (68)Ga-PSMA-PET and morphological imaging in a patient and template based manner. Lymph node metastases were found in 41 of 130 patients (31.5%). On patient based analysis the sensitivity, specificity and accuracy of (68)Ga-PSMA-PET were 65.9%, 98.9% and 88.5%, and those of morphological imaging were 43.9%, 85.4% and 72.3%, respectively. Of 734 dissected lymph node templates 117 (15.9%) showed metastases. On template based analysis the sensitivity, specificity and accuracy of (68)Ga-PSMA-PET were 68.3%, 99.1% and 95.2%, and those of morphological imaging were 27.3%, 97.1% and 87.6%, respectively. On ROC analysis (68)Ga-PSMA-PET performed significantly better than morphological imaging alone on patient and template based analyses (p = 0.002 and <0.001, respectively). In patients with intermediate to high risk prostate cancer preoperative lymph node staging with (68)Ga-PSMA-PET proved to be superior to standard routine imaging. Thus it has the potential to replace current standard imaging for this indication if confirmed by prospective studies.

Axillary ultrasound and fine-needle aspiration in preoperative staging of axillary lymph nodes in patients with invasive breast cancer.

ObjectiveTo propose an algorithm to determine the necessity for ultrasonography-guided fine-needle aspiration (US-FNA) in preoperative axillary lymph node staging of patients with invasive breast cancer.Materials and MethodsProspective study developed at National Cancer Institute. The study sample included 100 female patients with breast cancer referred for axillary staging by US-FNA.ResultsThe overall US-FNA sensitivity was set at 79.4%. The positive predictive value was calculated to be 100%, and the negative predictive value, 69.5%. The US-FNA sensitivity for lymph nodes with normal sonographic features was 0%, while for indeterminate lymph nodes it was 80% and, for suspicious lymph nodes, 90.5%. In the assessment of invasive breast tumors stages T1, T2 and T3, the sensitivity was respectively 69.6%, 83.7% and 100%. US-FNA could avoid sentinel node biopsy in 54% of cases.ConclusionAxillary ultrasonography should be included in the preoperative staging of all patients with invasive breast cancer. The addition of US-FNA in cases of lymph nodes suspicious for malignancy may prevent more than 50% of sentinel lymphadenectomies, significantly shortening the time interval to definitive therapy.

Invited Commentary

Faris and associates [1Faris N. Yu X. Sareen S. et al.Preoperative evaluation of lung cancer in a community health care setting.Ann Thorac Surg. 2015; 100: 394-400Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar] report on lung cancer care delivery in a 2-hospital health system that provides care for patients across several Southern states. Their overall findings and conclusions mirror those revealed through analyses of national cancer registries—there are significant gaps in the quality of lung cancer care. The authors plan to bridge this gap with a multidisciplinary team of thoracic oncology experts and systems engineers. An important limitation of this study is that the denominator consists of patients selected to undergo pulmonary resection. The authors recognize this limitation and intend to evaluate all patients with suspected or confirmed non-small cell lung cancer in the future. This key aspect of their future plans deserves emphasis—the authors intend to pursue a disease-based rather than treatment-based approach to quality improvement. A disease-based approach to quality improvement is impactful in two ways. First, by moving “proximally” on the cancer care continuum, more individuals can reap the potential benefits of quality improvement. A simple, linear conceptualization of the cancer care continuum is prevention, screening, diagnosis/staging, treatment, and survivorship/end-of-life care. More “proximal” aspects of the care continuum have a larger denominator. For example, up to 94 million former or current smokers are eligible to undergo evidence-based smoking cessation or lung cancer screening, or both. By contrast, there are approximately 240,000 newly diagnosed lung cancer patients each year, of which approximately 50,000 undergo surgical therapy. Ensuring high-quality prevention and screening will affect a greater number of people than those undergoing surgical therapy. However, impact cannot and should not be judged by numbers alone. Moving “proximally” on the cancer care continuum can reveal other important detrimental departures from optimal care. For instance, patients with suspected or confirmed non-small cell lung cancer should undergo rigorous preoperative nodal staging. Many would agree that an overstaged patient falsely presumed to have locally advanced disease and deprived a curative-intent resection is a significant departure from optimal care. Evaluating only surgical patients precludes an understanding of how many patients are inappropriately denied an opportunity for a cure. Moving “proximally” towards a disease-based approach to quality improvement allows for such efforts to better realize their potential of positively influencing individuals and the general population. Preoperative Evaluation of Lung Cancer in a Community Health Care SettingThe Annals of Thoracic SurgeryVol. 100Issue 2PreviewWe examined the presurgical evaluation of suspected lung cancer patients in a community-based health care system to establish current benchmarks of care that will lay the groundwork for an evidence-based quality improvement project. Full-Text PDF

Sentinel lymph node biopsy in oral and oropharyngeal squamous cell carcinoma: current status and unresolved challenges.

Because imaging with ultrasound, computed tomography, magnetic resonance imaging or positron emission tomography is unreliable for preoperative lymph node staging of early-stage oral and oropharyngeal squamous cell carcinoma (OSCC), elective neck dissection has been typically performed. The targeted sampling of sentinel lymph nodes (SLN) identified by lymphoscintigraphy and detected by gamma probe has become an effective alternative for the selection of patients for regional nodal resection. With careful consideration to technique, high SLN detection rates have been reported. Advanced techniques including intraoperative handheld gamma camera imaging and freehand single photon emission computed tomography (SPECT) are expected to increase surgical confidence in these procedures. This review gives an update on SLN biopsy in patients with OSCC including clinical standards and controversial aspects.

Tu1648 Evaluating the Efficacy of a New FDA Approved EUS Core Biopsy Needle and Different Fine Needle Biopsy (FNB) Techniques to Yield the Best Core Specimen in a Live Porcine Model

Tu1647 Impact of EUS-FNA for Preoperative Para-Aortic Lymph Node Staging in Patients With Pancreato-Biliary Neoplasm Akira Kurita*, Yuzo Kodama, Tsutomu Chiba Gastroenterology and Hepatology, Kyoto University, Kyoto, Japan; Department of Gastroenterology and Hepatology, Kitano Hospital, Osaka, Japan Background: In patients with pancreato-biliary neoplasms, para-aortic lymph node (PALN) metastasis is highly associated with their poor prognosis. However, effective methods for preoperative PALN staging has not been established yet. Objective: To compare the diagnostic ability of 18 F-fluorodeoxyglucose positron-emission tomography with computed tomography (PET/CT), endoscopic ultrasonography (EUS), and EUS-guided fine needle aspiration (EUS-FNA) as to PALN metastasis.Design, Setting, and Patients: Prospective, nonrandomized single center trial performed in 1 referral hospital in Japan. Between December 2010 and March 2014, a total of 208 patients with preoperative pancreato-biliary neoplasms were assessed for study eligibility. Of all them, consecutive 52 patients were enrolled in this study. Intervention: PET/CT, EUS, and EUS-FNA were performed sequentially as a single combined procedure. Main Outcomes Measure: Primary outcome was to compare the diagnostic ability of PET/CT, EUS, and EUS-FNA. Results: Of all 208 patients with a operable pancreato-biliary neoplasm, 52 patients with 71 nodes, 20 patients (38.5%) with 29 nodes (40.8%) had malignant lymph nodes. EUS-FNA revealed the highest sensitivity and specificity for the diagnosis of PALN (sensitivity 96.6% [28/29]; 95% confidence interval, 82.2%-99.9%, and specificity 100% [40/40]; 95% confidence interval, 91.2%-100%) in the three modalities. Of all 20 patients with PALN metastases, preoperative EUS-FNA or PET/CT could make correct diagnosis in 19 (36.5%) or 14 (26.9%) patients, respectively. This indicated that 5 more patients could have avoided unnecessary laparotomy by using EUS-FNA as compared to PET/CT. Conclusions: EUS-FNA is an ideal diagnostic modality for preoperative PALN staging in patients with pancreato-biliary neoplasms. From its significant clinical benefits of reducing unnecessary surgery, EUS-FNA should be added to the standard preoperative examinations for pancreato-biliary neoplasms. Diagnostic values for PALN staging by each modality AB544 Sensitivity 95% CI GASTROI Specificity 95% CI NTESTINAL Positive Predictive Value ENDOSCOPY Negative Predictive Value Volume 81, No Accuracy

Tu1647 Impact of EUS-FNA for Preoperative Para-Aortic Lymph Node Staging in Patients With Pancreato-Biliary Neoplasm

Tu1647 Impact of EUS-FNA for Preoperative Para-Aortic Lymph Node Staging in Patients With Pancreato-Biliary Neoplasm

Topographic distribution and characteristics of normal gastric regional lymph nodes on diffusion-weighted magnetic resonance imaging.

Current lack of recognition of normal gastric regional lymph nodes (GRLNs) and inherent defect of morphological imaging limit the accuracy of preoperative nodal (N) staging of gastric cancer. To map the distribution of normal GRLNs and evaluating the characteristics of GRLNs with diffusion-weighted imaging (DWI) in healthy population. Forty-nine enrolled healthy volunteers were divided into two age groups and underwent conventional magnetic resonance imaging (MRI) and DWI examinations. The characteristics of GRLNs in 14 regional stations, including short axis diameter (SD), short-to-long axis diameter ratio (SLR), signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), and apparent diffusion coefficient (ADC), were recorded and compared between age groups and among different stations. The normal GRLNs were mainly distributed in station 7 in both age groups, followed by stations 3, 8, and 9. The SLR was lower in the young group than in the old group (P = 0.034) while SD, SNR, CNR, and ADC were significantly higher in the young group compared to the old group, P = 0.045, 0.041, 0.037, and 0.042, respectively. SD was different among stations in both age groups (P = 0.002, 0.001), especially bigger in station 8, and the SNRs and CNRs of stations 8 and 9 were relatively high in the old group (P = 0.031, 0.035), while there was no difference in ADC value. Better understanding of the appearances of normal GRLNs on conventional MRI and DWI may help to build more appropriate imaging criteria for GRLN assessment in gastric cancer.