Preoperative Staging Modalities Research Articles

Abstract PO5-26-07: Surgery for Invasive Lobular Carcinoma: A Patient Experience Survey from the Lobular Breast Cancer Alliance

Abstract The Lobular Breast Cancer Alliance (LBCA) is a nonprofit, patient advocacy organization committed to raising awareness and promoting research into invasive lobular carcinoma (ILC). While ILC accounts for 15% of breast cancers, knowledge about ILC remains limited. ILC’s hallmark is lack of E-cadherin, which results in non-cohesive formation and impacts accuracy of imaging tests and staging. Consequently, patients with ILC have higher rates of positive surgical margins, mastectomies, and axillary lymph node (LN) dissections. To understand the surgery experience of individuals with ILC, LBCA conducted an anonymous online survey from 6/21-7/2/23, distributed via the LBCA newsletter, social media, and partner organizations. Questions addressed pre-operative imaging, type of surgery, surgical margins, LN status, decision making about and patient experience with surgery. Analyses were limited to those respondents who had surgery. Study limitations include potential recall and selection bias. Results 1,482 individuals with a diagnosis of ILC completed the survey and 1,426 had undergone surgery. 76% were from North America, 11% from England, and 4% from Australia. Average age at diagnosis was 56 (range 31-86). At diagnosis, 38% were clinically stage 1; 37% stage 2; 17% stage 3; and 4% de novo metastatic. 75% had a mammogram that indicated dense breasts. Of 1,426 surgery respondents (SR), 95% reported that ILC was identified in only one breast at diagnosis. 80% had a pre-surgical MRI. MRI revealed larger tumors than seen on other imaging for 43% and revealed previously unseen contralateral ILC for 3%. 375 (26%) of SRs were diagnosed with ipsilateral disease and had a pre-surgical MRI that did not reveal new information about their ILC. Of these, post-surgical pathology reports indicated 16% had additional ipsilateral foci, 2% contralateral disease, and 40% had larger tumors than seen on pre-surgical imaging. 614 (43%) of SRs had one or more lumpectomy (L), 560 (39%) of SRs had a double mastectomy (DM), and 451 (32%) of SRs had a single mastectomy (SM). 123 (20%) of SRs who had one or more Ls, had a subsequent SM or DM. For those undergoing L (614), reasons for this choice included: recommendation from their care team (83%), wanted to keep their breast (25%), thought it was better for their overall survival (OS) (14%), and 13% indicated they wanted breasts but did not want reconstruction. Of the 560 women who had a DM, 60% indicated that they thought a DM would improve their OS, 50% were concerned about the risk of local recurrence, 47% doubted that imaging would detect future ILC tumors, and 45% noted concern that ILC is more likely to be bilateral. Of note, only 9% had ILC or ILC and another invasive breast cancer in both breasts at initial diagnosis and 31% who had a pre-surgical MRI changed their initial surgical treatment plan. Post surgery, pathology for DM group revealed larger tumors than seen on imaging (57%), and 6% had tumors found in a second breast that were not seen on imaging. For those 451 who had an SM, reasons for this choice included: 75% said it was what their care team recommended, 35% thought it would improve OS, 20% feared risk for local recurrence, and 15% doubted imaging would detect future ILC. Of 614 respondents who had L, 33% had positive margins at first surgery. Of those, 17% reported multiple Ls and M; and 24% reported clear margins were never achieved. Of the 1011 SM or DMs reported, 10% did not achieve clear margins after these surgeries. Conclusion The survey demonstrates the experience of a large cohort of women with ILC, reporting high rates of uncertainty about accuracy of imaging, high rates of repeat surgery, bilateral mastectomies, and positive margins. Patients are factoring concerns about potential extent of disease and future recurrence in their surgical decision making. These results support the need for improved pre-operative staging and imaging modalities specific to ILC. Citation Format: Laurie Hutcheson, Janice Axelrod, Tracy Cushing, Colleen Fitzwater, Rinath Jeselsohn, Gitte Joergensen, Maria Karsten, Miranda Kimm, Megan Kruse, Theresa Langdon, Julia Levine, Mason Mitchell-Daniels, Rita Mukhtar, Barbara Neilsen, Shani Paluch-Shimon, Therese Pross. Surgery for Invasive Lobular Carcinoma: A Patient Experience Survey from the Lobular Breast Cancer Alliance [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO5-26-07.

Preoperative carbohydrate antigen 19.9 level predicts lymph node metastasis in resectable adenocarcinoma of the head of the pancreas: a further plea for biological resectability criteria.

Lymph-nodal involvement (N+) represents an adverse prognostic factor after pancreatoduodenectomy (PD) for pancreatic adenocarcinoma (PDAC). Preoperative diagnostic and staging modalities lack sensitivity for identifying N+. This study aimed to investigate preoperative carbohydrate antigen 19.9 (CA 19.9) in predicting the N+ stage in resectable-PDAC (R-PDAC). Patients included in a multi-institutional retrospective database of PDs performed for R-PDAC from January 2000 to June 2021 were analysed. A preoperative laboratory value of CA 19.9 greater than 37U/l was used in univariate and multivariate logistic regression analysis to determine a possible association with N+. Additionally, different cut-offs of CA 19.9 related to the preoperative clinical T (cT) stage was assessed to evaluate the risk of N+. A total of 2034 PDs from thirteen centres were included in the study. CA 19.9 greater than 37U/l was significantly associated with higher N+ at univariate and multivariate analysis ( P <0.001). CA 19.9 levels greater than 37U/l were associated with N+ in 75.9%, 81.3%, and 85.7% of patients, respectively, in cT1, cT2, and cT3 tumours and with higher cut-off values for all cT stages. Lymph-nodal involvement is strongly related to preoperative CA 19.9 levels. Specially in patients staged as cT3 the CA 19.9 could represent a valid and easy tool to suspect nodal involvement. Due to these findings, R-PDAC patients with elevated CA 19.9 values should be considered in a more biologically advanced stage.

The performance of contrast-enhanced mammography and breast MRI in local preoperative staging of invasive lobular breast cancer

PurposeBreast MRI is considered the best modality for preoperative staging of invasive lobular carcinoma (ILC). However, contrast-enhanced mammography (CEM) shows comparable diagnostic performance to MRI, but evidence of CEM’s accuracy in women diagnosed with ILC is scant. We aimed to retrospectively evaluate CEM and MRI accuracy in preoperative staging of ILC. MethodsILC cases diagnosed between 2013 and 2021 were collected. For both modalities, tumour diameter was extracted from the reports. Bland-Altman plots were used to assess discrepancies between size measurements according to imaging and histopathological findings. CEM and MRI’s ability to detect multifocal/contralateral cancer was expressed as sensitivity, specificity, and diagnostic odds ratios (DORs). Pairwise comparison of women undergoing both CEM and MRI was not performed. Results305 ILC-cases fulfilled preset inclusion criteria. Mean age was 63.7 years. Preoperative staging was performed using MRI or CEM in 266 (87.2%) and 77 (25.2%) cases, respectively. MRI and CEM overestimated tumour size by 1.5 and 2.1 mm, respectively. Sensitivity to detect multifocal disease was higher for MRI than for CEM (86% versus 78%), but specificity was lower for MRI (79% versus 92%). For detection of contralateral breast cancer, sensitivity for MRI was 96% versus 88% for CEM, and specificity was 92% and 99%, respectively. For both indications, DOR was higher for CEM, but differences were non-significant (p = 0.56 and p = 0.78). ConclusionCEM and MRI overestimate ILC size with comparable systematic and random errors. MRI’s higher sensitivity for detection of multifocal/contralateral cancers is accompanied by lower specificity, but discriminative ability for both modalities was non-significant.

The role of magnetic resonance imaging and magnetic resonance diffusion weighted image in preoperative staging of rectal cancer in comparison to postoperative histopathology

Background: With outstanding soft tissue contrast, functional imaging capabilities, and multiplanar capacity, high-resolution phased-array magnetic resonance imaging MRI is considered as a basic imaging modality for preoperative local staging of rectal cancer. And so MRI fills a void in clinical practice by allowing for precise local staging of rectal cancer prior to treatment decisions. The diffusion-weighted image used as enhancing utility for MRI in patients with rectal cancer. Objectives: The aim of work was to assess the role of MRI imaging including the (diffusion weighted imaging DWI and Apparent diffusion coefficient ADC map) in preoperative rectal cancer staging, in comparison to post-operative histopathology. Patients and methods: A total of 50 patients were included in the study, presented to South Valley University hospital and underwent MRI examination in MRI unit at South Valley University hospital. Results: Regarding the circumferential resection margin (CRM) infiltration, MRI diagnosed CRM involvement in 15 cases while rest 35 cases showing free CRM. From these positive cases only 13 were truly positive with histopathology, other two cases proved to be positive with histopathology not diagnosed by MRI. MRI showed MRF infiltration in only 18 cases. Histopathological assessment showed that MRF infiltration in only 15 cases and the rest 35 cases showing free MRF (agreement 83.3%). Conclusion: The results of this study demonstrate that preoperative MRI has a great value in achieving the best treatment strategy through accurate staging of rectal cancer, prediction of negative CRMs and involvement of the perirectal and pelvic LNs.

FDG-PET for preoperative evaluation of tumor invasion in ampullary cancer: A retrospective analysis.

Tumor invasion is the most significant prognostic factor in ampullary cancer and is thus a crucial factor in decision making for treatment. Endoscopic ultrasound can be performed to evaluate tumor invasion, but its diagnostic accuracy varies depending on the endoscopist. This study aimed to assess the usefulness of fluorodeoxyglucose positron emission tomography (FDG-PET) for preoperatively predicting tumor invasion in ampullary cancer. We retrospectively evaluated 44 patients with ampullary cancer (adenoma, n = 6; adenocarcinoma, n = 38) who underwent surgical resection. The SUVmax of the ampullary tumor site was assessed using FDG-PET, and the correlation among tumor invasion, lymph node metastasis, and other clinicopathological factors was evaluated. The SUVmax of the ampullary tumor site gradually increased depending on the extent of tumor invasion (p = 0.0075). Moreover, the SUVmax was significantly different between ≤T1a and ≥T1b, which is an indication for endoscopic papillectomy or surgical resection (p = 0.0015). The SUVmax of the ampullary section was significantly correlated with lymph node metastasis (p = 0.035). The SUVmax of the ampullary tumor site is correlated with tumor invasion and lymph node metastasis in ampullary cancer. Thus, FDG-PET can be a useful modality for preoperative staging and treatment strategy.

18F-fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) is accurate for high-grade prostate cancer bone staging when compared to bone scintigraphy.

In this study, we compared 18F-fluorodeoxyglucose (18F-FDG)-positron emission tomography/computed tomography (PET/CT) and bone scintigraphy accuracies for the detection of bone metastases for primary staging in high-grade prostate cancer (PCa) patients to determine if 18F-FDG-PET/CT could be used alone as a staging modality. Men with localized high-grade PCa (n=256, Gleason 8-10, International Society of Urological Pathology [ISUP] grades 4 or 5) were imaged with bone scintigraphy and 18F-FDG-PET/CT. We compared, on a per-patient basis, the accuracy of the two imaging modalities, taking inter-modality agreement as the standard of truth (SOT). 18F-FDG-PET/CT detected at least one bone metastasis in 33 patients compared to only 26 with bone scan. Of the seven false-negative bone scintigraphies, four (57.1%) were solitary metastases (monometastatic), three (42.9%) were oligometastatic (2-4 lesions), and none were plurimetastatic (>4 lesions). Compared to SOT, 18F-FDG-PET/CT showed higher sensitivity and accuracy than bone scintigraphy (100% vs. 78.8%, and 98.7% vs. 98.2%) for the detection of skeletal lesions. 18F-FDG-PET/CT appears similar or better than conventional bone scans to assess for bone metastases in patients newly diagnosed with high-grade PCa. Since intraprostatic FDG uptake is also a biomarker for failure of radical prostatectomy and that FDG-PET/CT has been shown to be accurate in detecting PCa lymph node metastasis, FDG-PET/CT has the potential to be used as the sole preoperative staging modality in high-grade PCa.

Perioperative chemotherapy in the management of high risk upper tract urothelial cancers.

Radical nephroureterectomy (RNU) remains the gold-standard in the treatment of invasive urothelial cancers of the upper tract (>pT2). However, there are stage-related, postoperative recurrence and cancer-specific death rates that are unacceptably high. Multimodality treatment regimens including neoadjuvant and adjuvant cisplatin-based systemic chemotherapy have been studied. While there is a paucity of Level 1 evidence to support either regimen, both have advantages and disadvantages. The provision of chemotherapy in the neoadjuvant setting is supported by extensive bladder cancer literature, but randomized controlled trials in the upper tract have not been completed. Neoadjuvant chemotherapy also risks overtreatment of patients due to the lack of accurate pre-operative staging modalities. On the other hand, adjuvant chemotherapy is supported by the findings of one prospective randomized trial, and eliminates the need for patient selection based on imperfect pre-operative modalities. However, the rigors of surgery and the renal function loss related to nephrectomy, may preclude the provision of adjuvant chemotherapy in a significant subset of patients. One may conclude that multimodal therapy is desirable for oncologic control, but the best means of providing such therapy requires further study.

CT Colonography in Preoperative Staging of Colon Cancer: Evaluation of FOxTROT Inclusion Criteria for Neoadjuvant Therapy.

The purpose of the present study is to evaluate the diagnostic performance of and interreader agreement for CT colonography (CTC) in the local staging of colon cancer, with emphasis given to the FOxTROT (Fluoropyrimidine, Oxaliplatin, and Targeted-Receptor pre-Operative Therapy [Panitumumab]) trial inclusion criteria, which propose a new tailored treatment paradigm for colon cancer that uses neoadjuvant therapy for patients with a high-risk of locoregional disease as determined by imaging. This biinstitutional retrospective study involved 89 patients (with 93 tumors) who had colon cancer and underwent presurgical CTC. Two radiologists reviewed the CTC studies for local staging, including measurement of the tumor beyond the muscularis propria on a true orthogonal plane. Histopathologic findings for surgical colectomy specimens served as the reference standard for local pathologic staging. The sensitivity, specificity, positive predictive value, and negative predictive value for local determination of the T category, N category, and extramural vascular invasion (EMVI) were calculated separately for each reader. High-risk T category tumors were the same as those as used in the FOxTROT trial. Interreader agreement was assessed using the kappa statistic. Thirty-five of 93 tumors (37.6%) were histologically classified as high-risk tumors (T3c, T3d, or T4 tumors). The interreader agreement was substantial (κ = 0.68) for classifying high-risk tumors with the use of CTC, moderate for differentiating N0 from N1 and N2 (κ = 0.44), and slight for detecting EMVI (κ = 0.15). The diagnostic statistics for CTC for the two readers were as follows: for detection of high-risk tumors, sensitivity was 65.7% and 82.9%, and specificity was 81.0% and 87.9%; for detection of N category-positive disease, sensitivity was 50.9% and 69.8%, and specificity was 50.0% and 72.5%; and for detection of EMVI, sensitivity was 18.2% and 66.7%, and specificity was 60.0% and 91.7%. The present study shows that CTC might be a feasible imaging modality for preoperative local staging of higher-risk colon cancers for which neoadjuvant chemotherapy is more suitable on the basis of the FOxTROT trial criteria. However, further studies are required to allow a better generalization of our results.

Preoperative Stating of Pelvic Lymph Nodes in Prostate Cancer Patients via Endorectal Magnetic Resonance Imaging.

The aim of this study was to evaluate the diagnostic sensitivity, specificity and accuracy of endorectal magnetic resonance imaging (e-MRI), as a preoperative staging modality in the diagnosis of lymph node metastasis (LNM) in patients with prostate cancer (PCa). Retrospectively, we analyzed data from N=168 patients who underwent radical prostatectomy (RP) between 2004 and 2013 at two tertiary medical centres. Prior to RP all patients underwent an e-MRI. Inclusion criteria were: PSA levels >20 ng/ml or Gleason score >7. Examinations were performed on a closed 1.0-T system combined with an endorectal body phased-array coil, imaging results were correlated with histopathology. 10.7% (N=18 patients) had histologically-proven LNM. e-MRI was true-positive in N=6 (33.3%) and false-negative N=12 patients (66.6%). N=150 (89.3%) patients without LNM e-MRI were true-negative in 96% and false-positive in 4%. Sensitivity was 96%, specificity was 33%, accuracy was 64.5%. e-MRI can be considered a useful preoperative staging modality in diagnosis of LNM.

ESSR Consensus Document for Detection, Characterization, and Referral Pathway for Tumors and Tumorlike Lesions of Bone.

AbstractBenign bone tumors are rare but are more common than primary malignant bone tumors. The early accurate diagnosis and reliable differentiation of these rare benign tumors and tumor mimickers from the even rarer malignant tumors with subsequent appropriate treatment or watchful waiting is crucial for the clinical outcome. Bone tumors are often a source of diagnostic and therapeutic uncertainty. Thus this European Society of Musculoskeletal Radiology consensus document is intended to help radiologists in their decision making and support discussion among clinicians who deal with patients with suspected or proven bone tumors. Evaluating these tumors starts with a patient history and physical examination. Radiography is the principal imaging modality and often can reliably diagnose a benign bone tumor by providing information about localization, matrix, aggressiveness, size, and (potential) multiplicity. In a significant number of cases, additional imaging is not necessary. Potentially malignant entities recognized by radiography should be referred for magnetic resonance imaging, which also serves as a preoperative local staging modality, with specific technical requirements. Indeterminate tumors, or tumors in which therapy depends on histology results, should be biopsied. For biopsy, we strongly recommend referral to a specialist regional sarcoma treatment center (RSTC), where a multidisciplinary tumor team, including a specialist pathologist, radiologist, and sarcoma surgeon, are involved. Additional staging modalities are entity specific and should be performed according to the recommendations of the RSTC.

Diagnostic Accuracy and Impact of Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography in Preoperative Staging of Cutaneous Malignant Melanoma: Results of a Prospective Study in Indian Population.

The aim of the study was to evaluate the diagnostic accuracy of positron emission tomography/computed tomography (PET/CT) in staging patients with primary cutaneous malignant melanoma (CMM). We further compared the performance of PET/CT with conventional imaging (CI) (CT and ultrasonography [USG]) and assessed the impact of PET/CT on disease management. This was a single institution, prospective, double-blinded study, recruiting a total of 70 treatment naïve patients. The sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) of PET/CT for N staging were 86%, 96%, 80%, and 97%, respectively. The sensitivity, specificity, NPV, and PPV of PET/CT for M staging were 87%, 100%, 93%, and 100%, respectively. The diagnostic accuracy of the PET/CT was superior to CI for N staging (90% vs. 84% for CT and 80% for USG) and M staging (95% vs. 90% for CT). No statistically significant difference was noted between PET/CT and CI for N staging (PET/CT vs. CT, P = 0.125; PET/CT vs. USG, P-0.063) or M staging (PET/CT vs. CT, P = 0.125). PET/CT upstaged 23% of patients with clinically localized disease and 58% of patients with clinically palpable regional nodes. To conclude, fluorodeoxyglucose PET/CT is a highly sensitive and specific imaging modality for preoperative staging of primary CMMs. PET/CT impacts disease management in significant number of patients and should be especially recommended in all patients with clinically palpable regional nodes.

Using Ultrasonography to Evaluate the Relationship between Capsular Invasion or Extracapsular Extension and Lymph Node Metastasis in Papillary Thyroid Carcinomas.

Background:Previous studies have demonstrated that ultrasonography is the recommended imaging modality for preoperative staging of papillary thyroid carcinomas (PTCs). However, only a few studies have kept watch on preoperative evaluation of capsular invasion (CI) or extracapsular extension (ECE) and cervical lymph node metastasis using preoperative ultrasonography. This study aimed to investigate the relationship between the CI or ECE and the cervical lymph node metastasis in PTCs using preoperative ultrasonography and postoperative pathology in Chinese patients.Methods:The data of preoperative ultrasonography and postoperative pathology of 166 patients who had a definitive diagnosis of PTCs from October 2011 to July 2014 at Xuanwu Hospital, Beijing were collected and reviewed. Preoperative ultrasonic parameters of thyroid nodules were compared with those of postoperative pathological diagnoses. All the patients were divided into bilateral PTCs group (n = 42, 78 nodules) and unilateral PTCs group (n = 124, 124 nodules), and the data of the nodule sizes, CI or ECE, and cervical lymph node metastasis by preoperative ultrasonography were compared between two groups.Results:A total of 202 nodules of 166 patients which were confirmed by preoperative ultrasonography and postoperative pathology were analyzed. Hypoechogenicity (n = 201, 99.5%) and irregular margins (n = 167, 82.7%) were the main ultrasonic characteristics of PTCs. A significant moderate agreement between preoperative ultrasonic examination and postoperative pathology for CI or ECE (κ = 0.622, P < 0.001) was observed. The diagnostic sensitivity was 92.0%, and specificity was 71.1%. In bilateral PTCs group, 81.0% had CI or ECE, and 61.9% had cervical lymph node metastasis. In unilateral PTCs group, 76.6% had CI or ECE, and 58.1% had cervical lymph node metastasis. There were no significant differences in the incidence of CI or ECE and cervical lymph node metastasis between two groups (all P > 0.05).Conclusions:Ultrasonography was proved to be a valuable method for preoperative diagnosis of PTCs. Hypoechogenicity and irregular margins were strongly associated with PTCs. CI or ECE in unilateral PTCs strongly implied the cervical lymph node metastasis. Therefore, the cervical lymph nodes should be carefully examined by ultrasonography in patients with PTCs.

Ratio of lymph node to primary tumor SUVmax multiplied by maximal tumor diameter on positron emission tomography/integrated computed tomography may be a predictor of mediastinal lymph node malignancy in lung cancer.

Positron emission tomography/integrated computed tomography (PET/CT) provides the most accurate imaging modality for preoperative lung cancer staging. However, the diagnostic accuracy of maximum standardized uptake value (SUVmax) for mediastinal (N2) lymph nodes (LN) is unclear. We compared SUVmax, the ratio of LN to primary tumor SUVmax (SUVn/t), and SUVn/t multiplied by maximal tumor diameter (SUVindex) in terms of their abilities to predict mediastinal LN malignancy.We retrospectively analyzed 170 mediastinal LN stations from 73 consecutive patients who underwent systemic LN resection and PET/CT within 27 days. The SUVmax of the primary tumors was >2.0 and the SUVmax of the mediastinal LN stations ranged from 2.0 to 7.0 on PET/CT. Receiver-operating characteristic curves (ROCs) of SUVmax, SUVn/t, and SUVindex were calculated separately and the areas under the curves (AUCs) were used to assess the abilities of the parameters to predict LN malignancy. The optimal cutoff values were calculated from each ROC curve and the diagnostic abilities were also compared. The diagnostic accuracies of the 3 methods were also assessed separately in smoking and nonsmoking patients.Twenty-eight LN stations were malignancy-positive and the remaining 142 were malignancy-negative. The AUCs for SUVindex, SUVn/t, and SUVmax were 0.709, 0.590, and 0.673, respectively, and the optimal cutoff values for SUVindex, SUVn/t, and SUVmax were 1.11, 0.34, and 3.6, respectively. The differences between SUVindex and SUVn/t were significant, but there was no significant difference between SUVindex and SUVmax. There were no significant differences between smokers and nonsmokers in the AUCs for any of the methods for predicting LN malignancy (P values >0.05).SUVindex may be a predictor of mediastinal LN malignancy in lung cancer patients.

A retrospective analysis of preoperative staging modalities for oral squamous cell carcinoma.

An accurate preoperative assessment of cervical lymph node status is a prerequisite for individually tailored cancer therapies in patients with oral squamous cell carcinoma. The detection of malignant spread and its treatment crucially influence the prognosis. The aim of the present study was to analyze the different staging modalities used among patients with a diagnosis of primary oral squamous cell carcinoma between 2008 and 2015. An analysis of preoperative staging findings, collected by clinical palpation, ultrasound, and computed tomography (CT), was performed. The results obtained were compared with the results of the final histopathological findings of the neck dissection specimens. A statistical analysis using McNemar's test was performed. The sensitivity of CT for the detection of malignant cervical tumor spread was 74.5%. The ultrasound obtained a sensitivity of 60.8%. Both CT and ultrasound demonstrated significantly enhanced sensitivity compared to the clinical palpation with a sensitivity of 37.1%. No significant difference was observed between CT and ultrasound. A combination of different staging modalities increased the sensitivity significantly compared with ultrasound staging alone. No significant difference in sensitivity was found between the combined use of different staging modalities and CT staging alone. The highest sensitivity, of 80.0%, was obtained by a combination of all three staging modalities: clinical palpation, ultrasound and CT. The present study indicates that CT has an essential role in the preoperative staging of patients with oral squamous cell carcinoma. Its use not only significantly increases the sensitivity of cervical lymph node metastasis detection but also offers a preoperative assessment of local tumor spread and resection borders. An additional non-invasive cervical lymph node examination increases the sensitivity of the tumor staging process and reduces the risk of occult metastasis.

Soft Tissue Tumors in Adults: ESSR-Approved Guidelines for Diagnostic Imaging.

Soft tissue sarcomas are rare, but early, accurate diagnosis with subsequent appropriate treatment is crucial for the clinical outcome. The ESSR guidelines are intended to help radiologists in their decision-making and support discussion among clinicians who deal with patients with suspected or proven soft tissue tumors. Potentially malignant lesions recognized by ultrasound should be referred for magnetic resonance imaging (MRI), which also serves as a preoperative local staging modality, with specific technical requirements and mandatory radiological report elements. Radiography may add information about matrix calcification and osseous involvement. Indeterminate lesions, or lesions in which therapy is dependent on histology results, should be biopsied. For biopsy, we strongly recommend referral to a specialist sarcoma center, where an interdisciplinary tumor group, with a specialized pathologist, radiologist, and the surgeon are involved. In sarcoma, a CT scan of the chest is mandatory. Additional staging modalities are entity-specific. There are no evidence-based recommendations for routine follow-up in surgically treated sarcomas. However, we would recommend regular follow-up with intervals dependent on tumor grade, for 10 years after the initial diagnosis.

P-094 FDG PET/CT as a preoperative staging modality for early gastric cancer

P-094 FDG PET/CT as a preoperative staging modality for early gastric cancer

Abstract OT3-5-01: A prospective, randomized trial of sentinel lymph node biopsy versus no additional staging in patients with T1-T2 invasive breast cancer and negative axillary ultrasound

Abstract Background: The American College of Surgeons Oncology Group Z0011 prospective randomized trial demonstrated no local control or survival advantage with more extensive axillary surgery, even in the setting of known axillary disease. These results convincingly showed that axillary surgery provides little, if any, therapeutic benefit. Given that axillary surgery is not associated with local control or survival benefit, the current role of sentinel lymph node (SLNB) is limited to staging the axilla (in other words, SLNB provides staging information but is not therapeutic). Objectives: In this randomized, controlled non-inferiority trial we aim to determine the utility of axillary ultrasound (AUS) as a pre-operative staging modality for patients with clinically node-negative invasive breast cancer with the hope that it will be a minimally invasive replacement for SLNB. 1. Primary Objective: To assess whether axillary recurrence rates for patients randomized to Arm 1 (no SLNB) is equivalent to axillary recurrence rates for patients randomized to Arm 2 (SLNB). 2. Secondary Objective: To assess disease-free survival in Arm 1 vs. Arm 2. 3. Tertiary Objective: To assess overall survival in Arm 1 vs. Arm 2. Study Design: A randomized non-inferiority trial comparing no further axillary staging versus SLNB in women with clinical T1-T2, N0 M0 breast cancer and negative AUS. Following a negative AUS, four hundred sixty women will be randomized in a 1:1 fashion to no further axillary staging or SLNB. Subjects will be monitored for local-regional and distant recurrence per NCCN guidelines. We have recruited 28 study participants. Eligibility Criteria: To be eligible the patient must be 18-y.o. or older; female; have tissue-diagnosis of invasive breast cancer; cT1-2N0M0 cancer; negative AUS; ECOG &amp;lt;/=2; available for follow-up; candidate for SLNB. A patient is ineligible if pregnant or lactating; has concurrent invasive bilateral breast malignancies or multicentric disease or is considered a poor surgical candidate. Statistical Methods: Power analysis: A power analysis was performed to determine the accrual goal. The power analysis is based on axillary recurrence, our primary endpoint. We expect an axillary recurrence rate of 1% in patients undergoing SLNB. By assuming a noninferiority limit of 2% difference, our sample size will allow us 80% power at 1-sided 0.1 significance level to assure such a noninferiority. Data analysis: Longer-term formal data analysis for the study will be performed following the intent-to-treat (ITT) principle. Demographic and clinical characteristics of the sample, as well as efficacy, complication rates and loss to follow-up will be summarized using descriptive statistics. The balance of demographic and baseline clinical characteristics between two arms will be compared using t-test, Mann-Whitney rank-sum test, or Chi-square test as appropriate. The differences in OS and DFS between treatment arms will be compared using log-rank test. Citation Format: Natalia S Tucker, William E Gillanders, Timothy Eberlein, Rebecca Aft, Julie Margenthaler, Feng Gao, Catherine Appleton, Imran Zoberi, Ademuyiwa Foluso, Amy Cyr. A prospective, randomized trial of sentinel lymph node biopsy versus no additional staging in patients with T1-T2 invasive breast cancer and negative axillary ultrasound [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr OT3-5-01.

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

MRI in local staging of rectal cancer: an update

Preoperative imaging for staging of rectal cancer has become an important aspect of current approach to rectal cancer management, because it helps to select suitable patients for neoadjuvant chemoradiotherapy and determine the appropriate surgical technique. Imaging modalities such as endoscopic ultrasonography, computed tomography, and magnetic resonance imaging (MRI) play an important role in assessing the depth of tumor penetration, lymph node involvement, mesorectal fascia and anal sphincter invasion, and presence of distant metastatic diseases. Currently, there is no consensus on a preferred imaging technique for preoperative staging of rectal cancer. However, high-resolution phased-array MRI is recommended as a standard imaging modality for preoperative local staging of rectal cancer, with excellent soft tissue contrast, multiplanar capability, and absence of ionizing radiation. This review will mainly focus on the role of MRI in preoperative local staging of rectal cancer and discuss recent advancements in MRI technique such as diffusion-weighted imaging and dynamic contrast-enhanced MRI.

Imaging techniques for the evaluation of ovarian cancer

Women with ovarian cancer often present at advanced stage of disease. The outcome depends mainly on the stage of disease at first diagnosis, but also on the quality of treatment. For individualised tumour treatment, detailed assessment of tumour extension using modern imaging is crucial. Ultrasound remains the initial and most important imaging method for ovarian cancer detection. Although increasing evidence shows that ultrasound is an accurate technique to stage and follow up ovarian cancer, it requires an experienced examiner capable of examining both the pelvis and the abdomen. Computed tomography is the most commonly used imaging modality for preoperative staging and follow up. Magnetic resonance imaging remains a second-line imaging method for solving problems, mainly in the pelvis. Positron emission tomography combined with computed tomography is the optimal imaging technique for suspected recurrence, particularly in women with rising CA 125 levels, but negative results of conventional imaging methods.