Preoperative Lymph Node Staging Research Articles

Diagnostic accuracy of 18F flucholine PET/CT for preoperative lymph node staging in newly diagnosed prostate cancer patients; a systematic review and meta-analysis

The purpose of the current study was to investiagte the diagnostic accuracy of F18 flucholine (FCH) positron emission tomography/CT (PET/CT) for pre-operative lymph node (LN) staging in newly diagnosed prostate cancer (PCa) patients using meta-analysis. PubMed and Embase from the earliest available date of indexing through December 31, 2018, were searched for studies evaluating the diagnostic performance of F18 FCH PET/CT for preoperative LN staging in newly diagnosed PCa. We determined the sensitivities and specificities across studies, calculated positive and negative likelihood ratios (LR + and LR-), and constructed summary receiver operating characteristic curves. Across seven studies (627 patients), the pooled sensitivity was 0.57 [95% confidence interval (CI) (0.42-0.70)] and a pooled specificity of 0.94 [95% CI (0.89-0.97)]. Likelihood ratio (LR) syntheses gave an overall positive likelihood ratio (LR+) of 10.2 (95% CI; 5.0-21.0) and negative likelihood ratio (LR-) of 0.46 (95% CI; 0.33-0.64). The pooled diagnostic odds ratio was 22 (95% CI; 9-54). F18 FCH PET/CT shows a low sensitivity and high specificity for the detection of metastatic LNs in patients with newly diagnosed PCa. Also, F18 FCH PET/CT is only useful for confirmation of LN metastasis (when positive) in PCa patients. F18 FCH PET/CT demonstrates low sensitivity but high specificity for diagnosis of metastatic LNs in patients with newly diagnosed PCa. Also, F18 FCH PET/CT is only useful for confirmation of LN metastasis (when positive) in PCa patients.

18F-FDG PET/CT in preoperative nodal staging of endometrial cancer: The role of radiomics to improve sensitivity in detecting nodal metastases

Objective: The introduction of SLN biopsy ultrastaging, able to identify micrometastatic deposits, increased false-negative PET/CT findings in nodal staging of endometrial cancer, as small metastatic lymph node (LN) lesions may remain undetected at visual analysis because of the limited spatial resolution of the PET technique. The aim of this study was to investigate the role of radiomics applied in women with endometrial cancer who underwent 18F-FDG PET scan, to evaluate whether imaging features computed on the primary tumor could improve sensitivity in detection of LN metastases.

Prognosis of upstaged N1 and N2 disease after curative resection in patients with clinical N0 non-small cell lung cancer.

Nodal upstaging occasionally occurs after curative resection in clinical N0 non-small cell lung cancer (NSCLC). The purpose of this study was to evaluate the prognosis of clinical N0 NSCLC (T1-2, tumor size 5 cm or smaller) after upstaging to pathologic N1 or N2. From 2005 to 2015, 676 consecutive patients were diagnosed with clinical T1-2N0 NSCLC and underwent curative resection. Among these, tumors were upstaged to N1 in 46 patients and to N2 in 24 patients. We analyzed the prognosis of upstaged tumors. For comparison of prognosis between nodal upstaging groups and others in the same stage, patients with preoperative pathologically proven N1 (n=31) and N2 (n=55) NSCLC were included in the study. A total of 70 patients (10.4%) had nodal upstaging after curative resection of clinical N0 NSCLC. Upstaging to N1 occurred in 46 patients and upstaging to N2 occurred in 24 patients. The 5-year disease-specific survival rate was not statistically different between the upstaged and non-upstaged N1/N2 groups in N1 disease (73.3% vs. 70.5%, P=0.247) or in N2 disease (58.9% vs. 50.7%, P=0.283). Multivariate analysis showed that nodal upstaging was not a significant prognostic factor in N1 or N2 NSCLC (hazard ratio =0.385, P=0.235; hazard ratio =0.677, P=0.458). Postoperative nodal upstaging from clinical T1-2N0 NSCLC was not a significant prognostic factor in the same stage. Therefore, surgical treatment of clinical T1-2N0 lung cancer diagnosed by imaging without preoperative pathologic lymph node staging can be a treatment option.

Prognostic significance of preoperative lymph node assessment for patients with stage pN0 esophageal squamous cell carcinoma after esophagectomy.

Accurate preoperative lymph node (LN) staging is important for surgical treatments of esophageal squamous cell carcinoma (ESCC). The aim of the study was to investigate the role of preoperative lymph nodes assessment by computed tomography (CT) scans in prognostic estimates and lymph nodes dissection strategy. A total of 233 stage pN0 ESCC patients who underwent radical esophagectomy from 2009 to 2016 were included, with the last follow-up time in 2018. Survival analysis was conducted to assess the relationship between preoperative clinical LN metastasis and the prognosis of patients with pN0 ESCC. Ninety-nine patients were classified as clinical positive LN metastasis by CT scans, but were confirmed as stage N0 by postoperative pathological examination, and survival analysis suggested that these patients had relatively poorer prognosis (P=0.027). Cox regression analysis indicated that the clinical LN metastasis on CT scans was an independent negative prognostic factor for patients with pN0 ESCC (P=0.031). The number of LNs dissected affected the prognosis of pN0 patients. Patients with positive LN metastasis on CT would have better prognosis when the number of dissected LNs was equal to or more than 15 LNs (P=0.036). Especially for patients with higher T stage, they were would obtain prognostic benefit with at least 17 LNs dissected (P=0.037). On the other hand, for those with negative LN metastasis on CT, at least 12 LNs dissected indicated better prognosis (P=0.019). Preoperative LN assessment for ESCC patients is critically important, the optimal LN dissection number should refer to the preoperative CT performance.

Endobronchial ultrasound-guided transbronchial needle aspiration mediastinal lymph node staging in malignant pleural mesothelioma.

Given poor survival of patients with malignant pleural mesothelioma (MPM) and extrapleural nodal metastasis, pre-operative mediastinal lymph node (LN) staging has been advocated. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) may be a useful pre-operative adjunct in patients with MPM. This study aims to assess performance of EBUS-TBNA for mediastinal LN staging in MPM. A retrospective chart review of patients with diagnosis of MPM referred to the mesothelioma program at a tertiary Canadian cancer center between January 1, 2012 and December 31, 2014 who received mediastinal LN staging with EBUS-TBNA. Forty-eight patients were included. Average age was 70 years (range, 48-84 years). Mesothelioma subtypes were as follows: epithelioid 34/48 (70.8%), sarcomatoid 4/48 (8.3%), biphasic 7/48 (14.6%) and other 3/48 (6.3%). Stage distribution was as follows: I 18.8%, II 10.4%, III 47.9%, and IV 22.9%. On average 3.4 LNs were sampled per patient (range, 1-5). The mean short axis of a sampled LN was 6.8±3.8 mm. Rapid on Site Evaluation (ROSE) was available in 75.0% (36/48) of the assessments. Prevalence of N2/N3 disease was 35.4% (17/48). EBUS-TBNA sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and diagnostic accuracy were: 16.7%, 100%, 100%, 68.8%, and 70.6%, respectively. EBUS-TBNA mediastinal LN staging prevented unnecessary surgery in 18.8% (9/48 patients) by detection of N2/N3 disease (8 patients) and metastatic secondary malignancy (1 patient). There were no EBUS-TBNA related complications. EBUS-TBNA mediastinal LN staging may impact significantly management of patients with MPM by detecting mediastinal metastatic disease, therefore, preventing morbidity and mortality of surgical management.

Integrated analysis of 18F-FDG PET/CT improves preoperative lymph node staging for patients with invasive bladder cancer.

Preoperative 18F-fluoro-2-deoxy-D-glucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) is controversial to assess lymph node (LN) staging in patients with invasive bladder cancer. We proposed to use the maximum standardized uptake value (SUVmax) associated with axial-based LN size to improve the detection of regional LN metastasis. From May 2015 to May 2017, we prospectively included patients with urothelial bladder cancer who underwent radical cystectomy with extended pelvic LN dissection. All patients underwent preoperative 18F-FDG PET/CT staging before surgery. The gold standard comparator was the pathological examination of resected LNs. The data were reported on a regional per area- and patient-based model according to SUVmax values and axial-based LN size criteria. In total, 1012 LNs were identified in 61 patients with clinically localized invasive bladder cancer who underwent radical cystectomy and extended pelvic LN dissection. Loco-regional involvement of 24 LN areas was confirmed in 17 patients. In per area analysis, diagnostic accuracy of PET/CT and CT alone were respectively 84% and 78% (p = 0.039). On patient-based analysis, combined PET/CT correctly classified pelvic LN status in 5/61 (+ 8%) additional patients using optimal thresholds compared to CT alone, with accuracies of 82% and 74%, respectively (p = 0.13). Combining SUVmax and axial-based LN size criteria using 18F-FDG PET/CT improved the diagnostic accuracy for preoperative LN staging in patients with invasive bladder cancer, in per area analysis. • Combining metabolical and morphological features using18F-FDG PET/CT improves the detection of malignant lymph node in patients with bladder cancer. • 18 F-FDG PET/CT may help for initial staging of patients with muscle invasive bladder cancer.

Role of EBUS TBNA in Staging of Lung Cancer: A Clinician's Perspective.

The treatment of non-small cell lung cancer (NSCLC) includes surgical resection with curative intent in early-stage disease and chemoradiation in the advanced stage disease. Therefore, an accurate preoperative mediastinal lymph node staging is required not only to offer the appropriate treatment but also to avoid unnecessary invasive procedures including thoracotomy. The mediastinal lymph nodes can be sampled using several techniques including mediastinoscopy, surgery (open or video-assisted thoracoscopic surgery), endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA), or endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA). Currently, EBUS-TBNA/EUS-FNA is the preferred modality for sampling mediastinal lymph nodes because of its minimally invasive nature and high diagnostic yield. In this review, we discuss the utility of endosonographic procedures in mediastinal lymph node staging of NSCLC.

Significance of MRI in rectal carcinoma therapy optimization - correlation of preoperative T- and N-staging with definitive histopathological findings.

In past decades, both prognosis and therapy of rectal cancer patients showed significant improvement, on the other hand, the incidence of rectal carcinoma continues to have a rising tendency. According to current UICC classification, patients in stage II rectal cancer or higher are indicated for neoadjuvant chemoradiotherapy (nCRT). Magnetic resonance imaging (MRI) is currently the most common diagnostic method used for preoperative staging of rectal cancer. Several studies already pointed out the inaccuracy of preoperative lymph node staging in patients with rectal cancer. The present study analyzed overall accuracy of MRI staging of rectal cancer and thus its accuracy in neoadjuvant therapy indication, by comparing preoperative MRI staging with definitive histopathologic results from resected tumors. This study evaluated cases of 92 patients with rectal tumor that underwent MRI examination followed by surgical resection. Tumors included in the analysis were ranging from T1 to T3b according to TNM staging, with free circumferential resection margin (CRM), distance form mesorectal fascia more than 5 mm, negative intersphincteric plane and also negative extramural venous invasion (EMVI), while the N stage was not decisive. In all cases both N-staging and T-staging were evaluated histologically and compared with preoperative MRI results. Significant difference in preoperative and postoperative N-staging was shown in 51 patients (61.45%). In majority of cases MRI lead to overstaging, which was observed in 44 cases (53.1 %), with complete negativity of lymph nodes proven by histological examination in 34 cases. On the other hand, understaging of lymph nodes was observed only in 7 cases (7.4 %). The T-staging did not show significant differences. Results from this study confirm that MRI plays an important role in T-staging of rectal tumors, however, there are admittedly issues in N-staging of tumors, which should lead to reevaluation of neoadjuvant therapy indication in patients with positive lymph nodes according to MRI examination. Based on the results of this study, we see the future of preoperative staging of rectal tumors in precise T-staging together with accurate assessment of CRM and distance of tumor from mesorectal fascia as well as evaluation of intersphinteric plane and EMVI.

MRI‑based neoadjuvant therapy indication in middle and low rectal cancer.

The aim of this study was to evaluate the indication of neoadjuvant therapy in patients with middle and low rectal cancer based on MRI examination. In spite of noticeable advances in the diagnosis of rectal cancer, the optimal treatment remains highly debated. Current guidelines advise the use of neoadjuvant therapy in UICC stage II patients or higher. However, in clinical praxis, there is gradual implementation of new criterions and variables used in rectal cancer stage evaluation, the fact of which influences the treatment choice. The most important emerging variables taken currently into account are the distance from mesorectal fascia, circumferential resection margin, extramural venous invasion and intersphincteric plane, all of which can be evaluated using the MRI examination. The accuracy of MRI staging was compared with definite histopathological results from resected tumors. Patient data were prospectively collected between the years 2013 and 2018 at 3rd Surgical Clinic, Faculty of Medicine, Comenius University in Bratislava, Slovakia. Data from 101 patients were gathered and divided into two groups, according to the localization of tumor within rectum, while 9 patients were excluded from the study because of benign lesion diagnosis based upon final histopathologic evaluation. In 92 evaluated patients, no significant change was noted between MRI and histopathological T-staging. However, in N-staging, significant differences were noted between preoperative MRI staging and postoperative histopathological staging. The results of this study demonstrate inefficient preoperative lymph node staging, suggesting overtreatment of rectal cancer patients. Although the use of neoadjuvant therapy has led to great advances in modern cancer treatment, it is connected with a number of side effects and therefore should be indicated only for patients who can benefit from this treatment (Tab. 1, Fig. 3, Ref. 16).

The diagnostic accuracy of CT and MRI for the detection of lymph node metastases in gallbladder cancer: A systematic review and meta-analysis

BackgroundLymph node metastases (LNM) are an ominous prognostic factor in gallbladder cancer (GBC) and, when present, should preclude surgery. However, uncertainty remains regarding the optimal imaging modality for pre-operative detection of LNM and international guidelines vary in their recommendations. The purpose of this study was to systematically review the diagnostic accuracy of computed tomography (CT) versus magnetic resonance imaging (MRI) in the detection of LNM of GBC. MethodsA literature search of studies published until November 2017 concerning the diagnostic accuracy of CT or MRI regarding the detection of LNM in GBC was performed. Data extraction and risk of bias assessment was performed independently by two reviewers. The sensitivity of CT and MRI in the detection of LNM was reviewed. Additionally, estimated summary sensitivity, specificity and diagnostic accuracy of MRI were calculated in a patient based meta-analysis. ResultsNine studies including 292 patients were included for narrative synthesis and 5 studies including 158 patients were selected for meta-analysis. Sensitivity of CT ranged from 0.25 to 0.93. Estimated summary diagnostic accuracy parameters of MRI were as follows: sensitivity 0.75 (95% CI 0.6 – 0.85), specificity 0.83 (95% CI 0.74 – 0.90), LR + 4.52 (95% CI 2.55–6.48) and LR- 0.3 (95% CI 0.15 – 0.45). Small (<10 mm) LNM were most frequently undetected on pre-operative imaging. Due to a lack of data, no subgroup analysis comparing the diagnostic accuracy of CT versus MRI could be performed. ConclusionThe value of current imaging strategies for the pre-operative assessment of nodal status in GBC remains unclear, especially regarding the detection of small LNM. Additional research is warranted in order to establish uniformity in international guidelines, improve pre-operative nodal staging and to prevent futile surgery.

Diagnostic Accuracy of F-18 FDG PET/CT for Preoperative Lymph Node Staging in Newly Diagnosed Bladder Cancer Patients: A Systematic Review and Meta-Analysis

Aims: We aimed to assess the diagnostic accuracy of F-18 fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) for preoperative lymph node (LN) staging in newly diagnosed bladder cancer (BC) patients through a systematic review and meta-analysis. Patients and Methods: MEDLINE, Embase, and the Cochrane Library database, from the earliest available date of indexing through June 30, 2017, were searched for studies evaluating the diagnostic performance of F-18 FDG PET/CT for preoperative LN staging in newly diagnosed BC. We determined the sensitivities and specificities across studies, calculated positive and negative likelihood ratios (LR+ and LR–), and constructed summary receiver operating characteristic curves. Results: Across 14 studies (785 patients), the pooled sensitivity was 0.57 (95% CI: 0.49–0.64) and the pooled specificity was 0.92 (95% CI: 0.87–0.95). The LR syntheses gave an overall LR+ of 7.4 (95% CI: 4.4–12.3) and an LR– of 0.47 (95% CI: 0.39–0.56). The pooled diagnostic odds ratio was 16 (95% CI: 9–28). Conclusions: F-18 FDG PET/CT shows a low sensitivity and high specificity for the detection of metastatic LNs in patients with newly diagnosed BC.

What are the implications of the revised N staging system for surgery?

Malignant pleural mesothelioma has a poor prognosis and an average survival of 12–18 months despite treatment. One of the unique features of this malignancy is development of diffuse nodules inside the pleural cavity which lead to an irregular lymph node metastasis pattern in the chest cavity. Lymph node staging of mesothelioma was the same as Lung Cancer lymph node staging. It was recently revised to include unique intrathoracic involvement sites (internal mammary, peridiaphragmatic, pericardial fat pad and intercostal lymph nodes) in mesothelioma and ipsilateral mediastinal and intrapulmonary lymph nodes were grouped as N1. The preoperative invasive lymph node staging is inadequate and almost 40% are understaged in clinical N0 patients and 30% in N1 patients. Invasive mediastinal staging with cervical mediastinoscopy, endobronchial ultrasound or endoscopic ultrasound are used, however pericardial, posterior intercostal and internal mammary lymph nodes are inaccessible. Invasive preoperative mediastinal staging is important to stratify patients for appropriate treatment. The number and sites of potential lymph node involvement in mesothelioma is much higher and widespread than lung cancer. Thus, the technique and principles of lymphadenectomy or sampling in lung cancer is obviously not enough in mesothelioma. Long term survival difference is less than 10% in patients with bronchopulmonary or ipsilateral mediastinal and extrapleural lymph node involvement compared with those without lymph node involvement. The revised N staging system emphasizes the importance of preoperative invasive mediastinal staging, broadens surgical indications without dramatic improvements in survival.

Comparison of 68Ga-PSMA-11 PET-CT with mpMRI for preoperative lymph node staging in patients with intermediate to high-risk prostate cancer

BackgroundTo evaluate the diagnostic value of 68Ga-PSMA-11 PET-CT with multiparametric magnetic resonance imaging (mpMRI) for lymph node (LN) staging in patients with intermediate- to high-risk prostate cancer (PCa) undergoing radical prostatectomy (RP) with pelvic lymph node dissection (PLND).MethodsWe retrospectively identified 42 consecutive patients with intermediate- to high-risk PCa according to D′Amico and without concomitant cancer. Preoperative 68Ga-PSMA-11 PET-CT, pelvic mpMRI and subsequent robot assisted laparoscopic RP with PLND were performed in all patients.ResultsAmong 42 patients assessed, the preoperative PSA value, Gleason score, pT stage and intraprostatic PCa volume of patients with LN metastases were all significantly higher than those without metastases (P = 0.029, 0.028, 0.004, respectively). The average maximum standardized uptake value (SUV) of 68Ga-PSMA-11 PET-CT positive PCa of patients with or without LN metastases were 13.10 (range 6.12–51.75) and 7.22 (range 5.4–11.2), respectively (P < 0.001). 68Ga-PSMA-11 PET-CT and pelvic mpMRI had the ability of succeed on preoperative definite accurate diagnosis and accurate localization of primary PCa in all 42 patients. Fifteen patients (35.71%) had a pN1 stage. 51 positive LN were found. Both 68Ga-PSMA-11 PET-CT and pelvic mpMRI displayed brillient patient-based and region-based sensitivity, specificity, negative predictive value and positive predictive value. There was no statistical difference for the detection of LNMs according to the diameter of the LNMs between 68Ga-PSMA-11 PET-CT and mpMRI in this study.ConclusionsBoth 68Ga-PSMA-11 PET-CT and mpMRI performed great value for LN staging in patients with intermediate- to high-risk PCa undergoing RP with PLND. However, despite excellent performance of 68Ga-PSMA-11 PET-CT, it cannot replace mpMRI that remains excellent for lymph node staging.

Preoperative Clinical Lymph Node Staging is Valuable in Selecting Patients With Pathological IIIA-N2 Non–small Cell Lung Cancer Benefiting From Postoperative Radiation Therapy

Preoperative Clinical Lymph Node Staging is Valuable in Selecting Patients With Pathological IIIA-N2 Non–small Cell Lung Cancer Benefiting From Postoperative Radiation Therapy

Validity of the updated European Society of Thoracic Surgeons staging guideline in lung cancer patients

ObjectiveThe European Society of Thoracic Surgeons (ESTS) has proposed a revised preoperative lymph node staging guideline for patients with potentially resectable non–small cell lung cancer (NSCLC). We aimed to assess the validity of this revised ESTS guideline and survival results in our patient cohort. MethodsA total of 571 patients with potentially resectable NSCLC seen between January 2004 and November 2013 were included in the study. The preoperative mediastinal staging was performed by video-assisted cervical mediastinoscopy or video-assisted mediastinoscopic lymphadenectomy in all patients except those with peripheral cT1N0 nonadenocarcinoma tumors. Resection via thoracotomy or video-assisted thoracoscopic surgery was done in patients with no mediastinal lymph node metastasis. Surgical pathological results were compared with the ESTS staging guideline, and the validity of the guideline was tested. ResultsIn this series, mediastinal lymph node metastasis was revealed preoperatively in 266 patients (46.6%). A total of 305 patients underwent anatomic lung resection. The sensitivity, specificity, positive and negative predictive values, and accuracy of the guidelines were calculated as 95.0%, 100%, 100%, 94.6%, and 97.2%, respectively. ConclusionsThe ESTS revised preoperative lymph node staging guidelines for patients with NSCLC seem to be effective and valid, and may provide high survival following resectional surgery.

Gamma probe and ultrasound guided fine needle aspiration cytology of the sentinel node (GULF) trial - overview of the literature, pilot and study protocol

BackgroundSentinel node (SN) biopsy (SNB) detects clinically occult metastases of breast cancer and melanoma in 20–30%. Wound infections, seroma and lymph edema occur in up to 10%. Targeted ultrasound (US) of the SN, (with fine needle aspiration cytology (FNAC) if appropriate) has been investigated as a minimally invasive alternative, but reported sensitivity rates are too low to replace SNB. Our hypothesis is that the use of a handheld gamma probe concomitant with US may improve sensitivity.Our aim is to provide an overview of the current literature on preoperative nodal staging of clinical N0 melanoma patients, report on a pilot, and present a study protocol for a minimally invasive alternative to the SNB: Gamma probe and Ultrasound guided Fine needle aspiration cytology of the sentinel node (GULF trial).MethodsThe GULF trial is a multicenter open single arm observational trial. Newly diagnosed cT1b-4N0M0 cutaneous melanoma or cT1-3N0M0 breast cancer patients, aged >18 years, presenting for SNB are eligible. 120 patients will be included for preoperative targeted gamma probe guided US and FNAC of the SN. Afterwards all patients proceed to surgical SNB. Primary endpoint is the sensitivity of FNAC. Secondary endpoints include SN identification rate and the histopathological compatibility of Core Needle Biopsy and FNAC vs. SNB. Secondary endpoints were investigated in a pilot with 10 FNACs and marker placements, and 10 FNACs combined with Core Needle Biopsy.ResultsA pilot in 20 patients showed that SN identification rate was 90%, supporting the feasibility of this technique.DiscussionThere is broad experience with US (in combination with FNAC) prior to SNB, but sensitivity and specificity are too low to completely abandon SNB. Promising alternative techniques potentially will replace SNB in the future but more evidence is needed in the form of prospective studies. Accurate identification of the SN for US-FNAC has been proven feasible in our pilot. When adequate sensitivity can be reached, US-FNAC provides a minimally invasive alternative for the surgical SNB procedure.Trial registrationThe GULF trial is registered in the Netherlands Trial Registry (NTR), ID: NRT5193. May 1st 2015.

MTE15.02 Lymph Node Mapping in Lung Cancer

MTE15.02 Lymph Node Mapping in Lung Cancer

ED10.02 The Role of Surgery in Stage III NSCLC

ED10.02 The Role of Surgery in Stage III NSCLC

ED08.01 Surgery of Early-Stage NSCLC

ED08.01 Surgery of Early-Stage NSCLC

MTE05.01 Where is the Place of Surgery for N2 Disease?

MTE05.01 Where is the Place of Surgery for N2 Disease?