Primary Staging Research Articles

An Updated Review on Imaging and Staging of Anal Cancer-Not Just Rectal Cancer.

This review discusses the histology, MR technique, diagnosis, staging, and treatment of anal cancer, with a particular focus on the differences in TNM staging between anal squamous-cell carcinoma (ASCC) and rectal adenocarcinoma. To conduct this updated review, a comprehensive literature search was performed using prominent medical databases, including PubMed and Embase. The search was limited to articles published within the last 10 years (2013-2023) to ensure their relevance to the current state of knowledge. (1) articles that provided substantial information on the diagnostic techniques used for ASCC, mainly focusing on imaging, were included; (2) studies reporting on emerging technologies; (3) English-language articles. articles that did not meet the inclusion criteria, case reports, or articles with insufficient data. The primary outcome of this review is to assess the accuracy and efficacy of different diagnostic modalities, including CT, MRI, and PET, in diagnosing ASCC. The secondary outcomes are as follows: (1) to identify any advancements or innovations in diagnostic techniques for ASCC over the past decade; (2) to highlight the challenges and limitations of the diagnostic process. ASCC is a rare disease; however, its incidence has been steadily increasing. Primary staging and assessment after chemoradiation therapy are commonly performed using MRI, which is considered to be the preferred imaging modality. CT and PET/CT are useful in evaluating lymph node metastases and distant metastatic disease. ASCC and rectal adenocarcinoma are the most common histological subtypes and are typically indistinguishable on MRI; therefore, a biopsy prior to imaging is necessary to stage the tumor accurately and determine the treatment approach.

Relationship between metalloproteinase-9 (MMP-9) expression and clinicopathology in colorectal cancer: a cross-sectional study.

According to the WHO's GLOBOCAN database, ~1,931,590 new colorectal cancer (CRC) cases and 915,607 CRC-related deaths occurred in 2020. The incidence of CRC in Indonesia is 8.6%, making it the fourth most common cancer. With CRC, matrix metalloproteinase-9 (MMP-9) has a role in tumour development and progression, such that patients with a higher MMP-9 expression had poorer survival. This study aimed to analyze the relationship between MMP-9 expression and clinicopathology in CRC patients. This was an analytic observational study with a cross-sectional research design. It was conducted from November 2021 to June 2022 with 52 patient tissue samples: these were subjected to MMP-9 immunohistochemistry stain, with the GeneTex (Irvine) MMP-9 monoclonal antibody. Patient data were collected with clinical variables based on medical records and histopathological examination by anatomy pathologists. Primary tumour location, cancer staging, and histopathology grading were associated with MMP-9 (P=0.016, P=0.001, P=0.049). The more proximal to the primary tumour, the higher the stage of cancer, and the higher the histopathological grade, thus the greater the expression of MMP-9. A significant relationship existed of primary tumour location, cancer staging, and histopathology grading with MMP-9 expression in CRC patients. MMP-9 expression could be a useful indicator for the clinical assessment of tumour biologic behaviour and prognosis in CRC patients.

PSMA PET/CT and PET/MRI in primary staging of prostate cancer and its effect on patient management

PSMA PET/CT and PET/MRI in primary staging of prostate cancer and its effect on patient management

Concordance of MRI With Pathology for Primary Staging of Rectal Cancer in Routine Clinical Practice: A Single Institution Experience

PurposeMRI is the preferred imaging modality for primary staging of rectal cancer, used to guide treatment. Patients identified with clinical stage I disease receive upfront surgical resection; those with clinical stage II or greater undergo upfront neoadjuvant therapy. Although clinical under-/over-staging may have consequences for patients and presents opportunities for organ preservation, the correlation between clinical and pathologic staging in routine clinical practice within a single institute has not been fully established. MethodsThis retrospective, Institutional Review Board-approved study, conducted at a National Cancer Institute-Designated Comprehensive Cancer Center with a multi-disciplinary rectal cancer disease center, included patients undergoing rectal MRI for primary staging January 1, 2018-August 30, 2020. Data collection included patient demographics, initial clinical stage via MRI report, pathologic diagnosis, pathologic stage, and treatment. The primary outcome was concordance of overall clinical and pathologic staging. Secondary outcomes included reasons for mismatched staging. ResultsA total 105 rectal adenocarcinoma patients (64 males, mean age 57 ± 12.7 years) had staging MRI followed by surgical resection. A total of 28 patients (27%) had mismatched under-/over- staging. Ten patients (10%) were understaged with mismatched T stage group (clinical stage I, pathologic stage II), five (5%) were understaged with mismatched N stage group (clinical stage I, pathologic stage III), and 13 (12%) were overstaged (clinical stage II-III, pathologic stage 0-I). Treatment matched concordance between clinical and pathologic stages was 86%. ConclusionMRI for primary rectal cancer staging has high concordance with pathology. Future studies to assess strategies for reducing clinically relevant understaging would be beneficial.

The diagnostic accuracy of radiolabeled PSMA-ligand PET for tumour staging in newly diagnosed prostate cancer patients compared to histopathology: a systematic review and meta-analysis.

The current clinical recommendations posit the deployment of specific approved radiolabeled prostate-specific membrane antigen-ligand positron emission tomography (PSMA PET) for detecting metastatic prostate cancer during primary staging. Nevertheless, the precise efficacy of such ligands in localizing intraprostatic tumours (index tumour) and T-staging is not well established. Consequently, the objective of this inquiry is to ascertain the diagnostic accuracy of PSMA-PET in the tumour staging of newly diagnosed prostate cancer by means of a meta-analysis that integrates studies utilizing histological confirmation as the reference standard. In this study, we conducted a systematic literature search of the PubMed, Embase, Web of Science, and Cochrane Library databases using a predefined collection of search terms. These terms included 'PSMA PET', 'primary staging', and 'prostate cancer'. Subsequently, two independent reviewers evaluated all the studies based on predetermined inclusion criteria, extracted pertinent data, and assessed the quality of evidence. Any disparities were resolved by a third reviewer. A random effects Sidik-Jonkman model was applied to conduct a meta-analysis and estimate the diagnostic accuracy on a per-patient basis, along with 95% confidence intervals. Moreover, an appraisal regarding the likelihood of publication bias and the impact of small-study effects was performed utilizing both Egger's test and a graphical examination of the funnel plot. The present analysis comprised a total of twenty-three scientific papers encompassing 969 patients and involved their analysis by both qualitative and quantitative approaches. The results of this study demonstrated that the estimated diagnostic accuracy of PSMA PET/CT and PSMA PET/MRI, for the detection of intraprostatic tumours, regardless of the type of PSMA-ligand, was 86% (95% CI: 76-96%) and 97% (95% CI: 94-100%), respectively. Furthermore, the diagnostic accuracy for the detection of extraprostatic extension (EPE) was 73% (95% CI: 64-82%) and 77% (95% CI: 69-85%), while the diagnostic accuracy for the detection of seminal vesicle involvement (SVI) was 87% (95% CI: 80-93) and 90% (95% CI: 82-99%), respectively. The present investigation has demonstrated that PSMA PET/MRI surpasses currently recommended multiparametric magnetic resonance imaging (mpMRI) in terms of diagnostic accuracy as inferred from a notable data trajectory, whereas PSMA-PET/CT exhibited comparable diagnostic accuracy for intraprostatic tumour detection and T-staging compared to mpMRI. Nevertheless, the analysis has identified certain potential limitations, such as small-study effects and a potential for publication bias, which may impact the overall conclusions drawn from this study.

Can inflammatory indices predict sentinel lymph node status in patients with early-stage breast cancer?

Breast cancer research has focused on the early detection and treatment of breast cancer. Axillary lymph node status is essential for primary breast cancer staging, recurrence, and survival. The current quest for precision medicine is to identify predictive markers that offer the advantage of individualized treatment options. This study aimed to investigate the value of inflammatory indices in predicting positive sentinel nodes in breast cancer. We studied 602 patients with early-stage breast cancer who underwent sentinel lymph node biopsies (SLNB) at the Bülent Ecevit University General Surgery Clinic. We obtained data, including the clinical and demographic characteristics of the patients, such as age, histological type, and sentinel lymph nodes. Neutrophil, lymphocyte, platelet, and monocyte counts were obtained from preoperative complete blood count test data from the patient registry. The neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), lymphocyte-to-monocyte ratio (LMR), systemic inflammatory index (SII), and sentinel lymph node biopsy were analyzed. Sentinel LAP was negative in 391 (65%) patients and positive in 211 (35%). In the receiver operating characteristic curve analysis, no significant difference was found between SLNB positivity and negativity in terms of NLR, PLR, LMR, or SII. In contrast to previous research, NLR, PLR, LMR, or SII did not affect SLNB positivity prediction in our study.

Prostate MRI and PSMA-PET in the Primary Diagnosis of Prostate Cancer.

Over the last years, prostate magnetic resonance imaging (MRI) has gained a key role in the primary diagnosis of clinically significant prostate cancer (csPCa). While a negative MRI can avoid unnecessary prostate biopsies and the overdiagnosis of indolent cancers, a positive examination triggers biopsy samples targeted to suspicious imaging findings, thus increasing the diagnosis of csPCa with a sensitivity and negative predictive value of around 90%. The limitations of MRI, including suboptimal positive predictive values, are fueling debate on how to stratify biopsy decisions and management based on patient risk and how to correctly estimate it with clinical and/or imaging findings. In this setting, "next-generation imaging" imaging based on radiolabeled Prostate-Specific Membrane Antigen (PSMA)-Positron Emission Tomography (PET) is expanding its indications both in the setting of primary staging (intermediate-to-high risk patients) and primary diagnosis (e.g., increasing the sensitivity of MRI or acting as a problem-solving tool for indeterminate MRI cases). This review summarizes the current main evidence on the role of prostate MRI and PSMA-PET as tools for the primary diagnosis of csPCa, and the different possible interaction pathways in this setting.

Atypical Uptake of 18<sup>F</sup>DG in White Adipose Tissue During PET/CT in Children

Positron emission tomography combined with computed tomography (PET/CT) with 18F-fluoro-deoxyglucose (18F-FDG) plays an important role in the management of cancer patients and is mainly used for primary staging, evaluation of treatment response and detection of disease recurrence. Due to non-specific nature of 18F-FDG uptake, a radiologist must be familiar with both physiological and atypical distribution of radiopharmaceuticals. Inappropriate patient preparation for the study and/or taking certain drugs can lead to abnormal 18F-FDG distribution. Our clinical case demonstrates an atypical uptake of 18F-FDG in white adipose tissue in a child treated with glucocorticoids for a long time.

Quantitative evaluation of primary lower extremity lymphedema staging using MRI: a preliminary study.

The staging of primary lower extremity lymphedema (LEL) is difficult yet vital in clinical work, and magnetic resonance imaging (MRI) can be used for quantitative assessment of primary LEL due to its high resolution for soft tissues. In this study, we evaluated the value of MRI-based soft tissue area measurements for staging primary LEL. A total of 90 consecutive patients with clinically diagnosed primary lower limb lymphoedema from January 2017 to December 2019 in Beijing Shijitan Hospital were enrolled retrospectively. Short time inversion recovery (STIR) sequence was applied to measure the total, muscle, bone, and subcutaneous areas in the upper 1/3 level of the bilateral lower calf. The difference between the affected and unaffected calf regarding the subcutaneous area was obtained, and (subcutaneous area)/(bone area) and (subcutaneous area)/(muscle area) were calculated. According to the International Society of Lymphology (ISL) clinical staging standard established in 2020, all patients were divided into stages I, II, and III, accordingly. Statistical analysis was performed to determine the validity of MRI measurements in staging LEL. There were 33 patients classified as stage I clinically, 44 patients as stage II, and 13 patients as stage III. There were significant differences in total, subcutaneous, the difference in subcutaneous area of limbs, subcutaneous/bone (S/B), and subcutaneous/muscle (S/M) between stage I and II as well as between stage I and III (P<0.001), but not between stage II and III (P=0.706, 0.329, and 0.229, respectively). A positive correlation was detected between the clinical stage and difference in subcutaneous area of limbs (rho =0.752, P<0.001), S/B (rho =0.747, P<0.001), S/M (rho =0.709, P<0.001), and subcutaneous (rho =0.723, P<0.001). For staging primary LEL, receiver operating characteristic (ROC) curves indicated that the difference in subcutaneous area of limbs had the best discrimination ability among parameters [area under the ROC curve (AUC) =0.950; 95% confidence interval (CI): 0.875-0.987; sensitivity: 95.45%; specificity: 84.85%], followed by S/B (AUC =0.930; 95% CI: 0.848-0.975; sensitivity: 77.27%; specificity: 93.94%) and S/M (AUC =0.895; 95% CI: 0.804-0.953; sensitivity: 77.27%; specificity: 90.91%). The ROC curves indicated that subcutaneous area (AUC =0.927; 95% CI: 0.844-0.974; sensitivity: 84.09%, specificity: 90.91%) and total (AUC =0.852; 95% CI: 0.753-0.923; sensitivity: 70.45%; specificity: 90.91%) also had discrimination ability between stage I and II. The measurement of the soft tissue area of the calf may be used as an auxiliary method for staging primary LEL. For patients with unilateral primary LEL, the difference in subcutaneous area of limbs could be a specific indicator to distinguish clinical stage I from II.

Presurgical 68Ga-PSMA-11 Positron Emission Tomography for Biochemical Recurrence Risk Assessment: A Follow-up Analysis of a Multicenter Prospective Phase 3 Imaging Trial

BackgroundIn the initial staging of patients with high-risk prostate cancer (PCa), prostate-specific membrane antigen positron emission tomography (PSMA-PET) has been established as a front-line imaging modality. The increasing number of PSMA-PET scans performed in the primary staging setting might be associated with decreases in biochemical recurrence (BCR)-free survival (BCR-FS). ObjectiveTo assess the added prognostic value of presurgical PSMA-PET for BCR-FS compared with the presurgical Cancer of the Prostate Risk Assessment (CAPRA) and postsurgical CAPRA-Surgery (CAPRA-S) scores in patients with intermediate- to high-risk PCa treated with radical prostatectomy (RP) and pelvic lymph node dissection. Design, setting, and participantsThis is a follow-up study of the surgical cohort evaluated in the multicenter prospective phase 3 imaging trial (n = 277; NCT03368547, NCT02611882, and NCT02919111). Outcome measurements and statistical analysisEach 68Ga-PSMA-11-PET scan was read by three blinded independent readers. PSMA-PET prostate uptake (low vs high), PSMA-PET extraprostatic disease (N1/M1), and CAPRA and CAPRA-S scores were used to assess the risk of BCR. Patients were followed after RP by local investigators using electronic medical records. BCR was defined by a prostate-specific antigen (PSA) level increasing to ≥0.2 ng/ml after RP or initiation of PCa-specific secondary treatment (>6 mo after surgery). Univariate and multivariable Cox models, and c-statistic index were performed to assess the prognostic value of PSMA-PET and for a comparison with the CAPRA and CAPRA-S scores. Results and limitationsFrom December 2015 to December 2019, 277 patients underwent surgery after PSMA-PET. Clinical follow-up was obtained in 240/277 (87%) patients. The median follow-up after surgery was 32.4 (interquartile range 23.3–42.9) mo. Of 240 BCR events, 91 (38%) were observed. PSMA-PET N1/M1 was found in 41/240 (17%) patients. PSMA-PET prostate uptake, PSMA-PET N1/M1, and CAPRA and CAPRA-S scores were significant univariate predictors of BCR. The addition of PSMA-PET N1/M1 status to the presurgical CAPRA score improved the risk assessment for BCR significantly in comparison with the presurgical CAPRA score alone (c-statistic 0.70 [0.64–0.75] vs 0.63 [0.57–0.69]; p < 0.001). The C-index of the postsurgical model utilizing the postsurgical CAPRA-S score alone was not significantly different from the presurgical model combining the presurgical CAPRA score and PSMA-PET N1/M1 status (p = 0.19). ConclusionsPresurgical PSMA-PET was a strong prognostic biomarker improving BCR-FS risk assessment. Its implementation in the presurgical risk assessment with the CAPRA score improved the performance and reduced the difference with the reference standard (postsurgical CAPRA-S score). Patient summaryThe use prostate-specific membrane antigen positron emission tomography improved the assessment of biochemical recurrence risk in patients with intermediate- and high-risk prostate cancer who were treated with radical prostatectomy and pelvic lymph node dissection.

Surgical Staging of Differentiated Endometrial Cancer: An Analysis of Postoperative Outcome in a Gynecological Cancer Center in Sri Lanka.

Even though surgico-pathological staging is recommended in poorly differentiated endometrial cancer, management of differentiated endometrial cancer is controversial. Preoperative pelvic and abdominal Magnetic Resonance Imaging (MRI) is recommended in well-differentiatedendometrial cancer to identify patients with risk factors for regional metastasis. However, access to MRI is limited in Sri Lanka, and surgico-pathological staging is the primary staging method available for most patients with differentiated endometrial cancer. Our objective was to evaluate the outcome of surgical staging among differentiated endometrial cancer patients who underwent primary surgery at the gynecological cancer center of Apeksha Hospital Maharagama, Sri Lanka. A retrospective study was conducted using the ongoing electronic database at the gynecological cancer center of the National Cancer Institute (Apeksha Hospital) in Maharagama, Sri Lanka. Data from December 2019 to December 2020 were selected for analysis. During the study period, 112 patients with endometrial cancer underwent hysterectomy. This study included 90 patients with differentiated endometrial cancer (International Federation of Gynecology and Obstetrics [FIGO] Grade 1 and Grade 2), out of which pelvic lymph node dissection was performed in 78 (86.7%) cases. Among the 90 patients, 54 (60%) had medical comorbidities. It was reported that 35% (n=32) of the patients had myometrial invasion of more than 50% thickness. Furthermore, 13.8% of patients with deep myometrial invasion had lymph node metastasis, while only one patient (2%) in the superficial or no myometrial invasion group had lymph node metastasis. Therefore, the absence of deep myometrial invasion has a negative predictive value of around 98% for excluding pelvic lymph node metastasis. Approximately one in seven patients with deeply infiltrating differentiated endometrial cancer had lymph node metastasis. In limited resource settings where preoperative pelvic MRI is not readily available, implementing a policy of routine surgical pelvic lymph node assessment would be beneficial. This approach would aid in detecting stage IIIc disease and also help avoid unnecessary pelvic irradiation.

Primary Tumor Staging for Oral Cancer and a Proposed Modification Incorporating Perineural Invasion: An International Multicenter Study.

The objective of this study isto determine if the incorporation of perineural invasion (PNI) into the T-classification would improve the prognostic performance of TNM-8. An international, multicenter study of 1049 patients with oral cavity squamous cell carcinoma that weretreated from 1994 to 2018 is performed. Various classification models aredeveloped within each T-category and evaluated using the Harrel-concordance index (C-index), Akaike-information criterion (AIC), and visual inspection. Stratification into distinct prognostic categories, with internal validation, isperformed using bootstrapping analysis (SPSS and R-software). Through multivariate analysis, PNI issignificantly associated with disease-specific survival (p < 0.001). PNI integration into the staging system results in a significantly improved model compared with the current T category alone (lower AIC, p < 0.001). The PNI-integrated model issuperior in predicting differential outcomes between T3 and T4 patients. A new model for T-classification of oral cavity squamous cell carcinoma is proposed, which is based on incorporating PNI into the staging system. These data can be used for future evaluations of the TNM staging system.

Co-Expression of Immunohistochemical Markers MRP2, CXCR4, and PD-L1 in Gallbladder Tumors Is Associated with Prolonged Patient Survival.

Gallbladder cancer (GBC) is a rare pathology in Western countries. However, it constitutes a relevant health problem in Asia and Latin America, with a high mortality in middle-aged Chilean women. The limited therapeutic options for GBC require the identification of targetable proteins with prognostic value for improving clinical management support. We evaluated the expression of targetable proteins, including three epithelial tumor markers, four proteins associated with multidrug and apoptosis resistance, and eleven immunological markers in 241 primary gallbladder adenocarcinomas. We investigated correlations between tumor marker expression, the primary tumor staging, and GBC patients' survival using automated immunohistochemistry, a semi-automatic method for image analysis, univariate and multivariate statistical analyses, and machine learning algorithms. Our data show a significant association between the expression of MRP2 (p = 0.0028), CXCR4 (p = 0.0423), and PD-L1 (p = 0.0264), and a better prognosis for patients with late-stage primary tumors. The expression of the MRP2/CXCR4/PD-L1 cluster of markers discriminates among short-, medium-, and long-term patient survival, with an ROC of significant prognostic value (AUC = 0.85, p = 0.0012). Moreover, a high MRP2/CXCR4/PD-L1 co-expression is associated with increased survival time (30 vs. 6 months, p = 0.0025) in GBC patients, regardless of tumor stage. Hence, our results suggest that the MRP2/CXCR4/PD-L1 cluster could potentially be a prognostic marker for GBC.

The Diagnostic Value of PSMA PET/CT in Men with Newly Diagnosed Unfavorable Intermediate-Risk Prostate Cancer.

Our objective was to determine the diagnostic value of prostate-specific membrane antigen (PSMA) PET/CT in staging men with newly diagnosed unfavorable intermediate-risk prostate cancer (PCa). Methods: Patients with newly diagnosed unfavorable intermediate-risk PCa, in whom PSMA PET/CT was performed as a primary staging modality, were retrospectively studied. PSMA PET/CT was performed at several diagnostic centers and reported by expert nuclear medicine physicians within 2 high-volume PCa centers. A multivariate logistic regression analysis, taking into account clinical, biochemical, pathologic, and radiologic variables, was performed to identify potential independent predictors for metastatic disease on PSMA PET/CT. Results: In total, 396 men with newly diagnosed unfavorable intermediate-risk PCa were studied. Metastatic disease was observed in 37 (9.3%) men, of whom 29 (7.3%) had molecular imaging locoregional lymph node metastases (miN1) and 16 (4.0%) had distant metastases (miM1). A radiologic tumor stage of at least T3 on MRI (odds ratio, 2.72 [95% CI, 1.27-5.83]; P = 0.01) and more than 50% positive prostate biopsies (odds ratio, 3.87 [95% CI, 1.74-8.62]; P = 0.001) were found to be independently associated with metastatic disease on PSMA PET/CT. Conclusion: Given that metastatic disease was observed in nearly 1 in 10 men with newly diagnosed unfavorable intermediate-risk PCa, PSMA PET/CT is considered to be of diagnostic value within this population. Further stratification using the radiologic tumor stage and the percentage of positive prostate biopsies could aid in identifying those patients at risk of having metastatic disease on PSMA PET/CT.

Somatostatin Receptor Targeted PET-CT and Its Role in the Management and Theranostics of Gastroenteropancreatic Neuroendocrine Neoplasms

Somatostatin receptor (SSTR) agonist-based Positron Emission Tomography-Computed Tomography (PET-CT) imaging is nowadays the mainstay for the assessment and diagnostic imaging of neuroendocrine neoplasms (NEN), especially in well-differentiated neuroendocrine tumors (NET) (World Health Organization (WHO) grade I and II). Major clinical indications for SSTR imaging are primary staging and metastatic workup, especially (a) before surgery, (b) detection of unknown primary in metastatic NET, (c) patient selection for theranostics and appropriate therapy, especially peptide receptor radionuclide therapy (PRRT), while less major indications include treatment response evaluation on and disease prognostication. Dual tracer PET-CT imaging using SSTR targeted PET tracers, viz. [68Ga]Ga-DOTA-Tyr3-Octreotate (DOTA-TATE) and [68Ga]Ga-DOTA-NaI3-Octreotide (DOTA-NOC), and fluorodeoxyglucose (FDG), have recently gained widespread acceptance for better assessment of whole-body tumor biology compared to single-site histopathology, in terms of being non-invasive and the ability to assess inter- and intra-tumoral heterogeneity on a global scale. FDG uptake has been identified as independent adverse risk factor in various studies. Recently, somatostatin receptor antagonists have been shown to be more sensitive and specific in detecting the disease. The aim of this review article is to summarize the clinical importance of SSTR-based imaging in the clinical management of neuroendocrine and related tumors.

18F]FDG PET/MRI in children suffering from lymphoma: does MRI contrast media make a difference?

ObjectivesEvaluate the influence of an MRI contrast agent application on primary and follow-up staging in pediatric patients with newly diagnosed lymphoma using [18F]FDG PET/MRI to avoid adverse effects and save time and costs during examination.MethodsA total of 105 [18F]FDG PET/MRI datasets were included for data evaluation. Two different reading protocols were analyzed by two experienced readers in consensus, including for PET/MRI-1 reading protocol unenhanced T2w and/or T1w imaging, diffusion-weighted imaging (DWI), and [18F]FDG PET imaging and for PET/MRI-2 reading protocol an additional T1w post contrast imaging. Patient-based and region-based evaluation according to the revised International Pediatric Non-Hodgkin’s Lymphoma (NHL) Staging System (IPNHLSS) was performed, and a modified standard of reference was applied comprising histopathology and previous and follow-up cross-sectional imaging. Differences in staging accuracy were assessed using the Wilcoxon and McNemar tests.ResultsIn patient-based analysis, PET/MRI-1 and PET/MRI-2 both determined a correct IPNHLSS tumor stage in 90/105 (86%) exams. Region-based analysis correctly identified 119/127 (94%) lymphoma-affected regions. Sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy for PET/MRI-1 and PET/MRI-2 were 94%, 97%, 90%, 99%, 97%, respectively. There were no significant differences between PET/MRI-1 and PET/MRI-2.ConclusionsThe use of MRI contrast agents in [18F]FDG PET/MRI examinations has no beneficial effect in primary and follow-up staging of pediatric lymphoma patients. Therefore, switching to a contrast agent–free [18F]FDG PET/MRI protocol should be considered in all pediatric lymphoma patients.Clinical relevance statementThis study gives a scientific baseline switching to a contrast agent–free [18F]FDG PET/MRI staging in pediatric lymphoma patients. This could avoid side effects of contrast agents and saves time and costs by a faster staging protocol for pediatric patients.Key Points• No additional diagnostic benefit of MRI contrast agents at [18F]FDG PET/MRI examinations of pediatric lymphoma primary and follow-up staging• Highly accurate primary and follow-up staging of pediatric lymphoma patients at MRI contrast–free [18F]FDG PET/MRI

Exploring the impact of remoteness on people with head and neck cancer: Utilisation of a state-wide dataset.

Living in regional/rural areas can impact outcomes for people with head and neck cancer (HNC). Using a comprehensive state-wide dataset, the impact of remoteness on key service parameters and outcomes for people with HNC was examined. Retrospective quantitative analysis of routinely collected data held within the Queensland Oncology Repository. Quantitative methods (descriptive statistics, multivariable logistic regression and geospatial analysis). All people diagnosed with HNC in Queensland, Australia. The impact of remoteness was examined in 1991 people (1171 metropolitan, 485 inner-regional, 335 rural) with HNC cancer diagnosed between 2013 and 2015. This paper reports key demographics and tumour characteristics (age, gender, socioeconomic status, First Nations status, co-morbidities, primary tumour site and staging), service use/uptake (treatment rates, attendance at multidisciplinary team review and timing to treatment) and post-acute outcomes (readmission rates, causes of readmission and 2-year survival). In addition to this, the distribution of people with HNC across QLD, distances travelled and patterns of readmission were also analysed. Regression analysis revealed remoteness significantly (p < 0.001) impacted access to MDT review, receiving treatment, and time to treatment commencement, but not readmission or 2-year survival. Reasons for readmission did not differ by remoteness, with dysphagia, nutritional inadequacies, gastrointestinal disorders and fluid imbalance indicated in the majority of readmissions. Rural people were significantly (p < 0.0001) more likely to travel to care and to readmit to a different facility than provided primary treatment. This study provides new insights into the health care disparities for people with HNC residing in regional/rural areas.

Head-to-head comparison of 68Ga-PSMA-11 PET with 99mTc-MDP bone scan for detection of bone disease in patients with prostate cancer with biochemical progression during ADT: A single center prospective study.

e17072 Background: 68Ga-PSMA-11 PET/CT (PSMA-PET) was approved by the U.S. Food and Drug Administration in patients with prostate cancer (PCa) at primary staging or biochemical recurrence. A head-to-head comparison between PSMA-PET and conventional imaging (99mTc-MDP bone scan [BS] and CT) in men with advanced prostate cancer was not performed. We aimed to compare the detection rate of bone disease for PSMA-PET vs BS in men with PCa and with biochemical progression during androgen deprivation therapy (ADT). Methods: This was a prospective single-center, open-label, single-arm, head-to-head comparison, prospective phase 2 study (NCT04928820). A sample size of 102 men was required to achieve an 80.3% power to detect a difference of 12% positivity rate of bone disease in favor of PSMA-PET vs BS (35% vs 23%). Men with i) biopsy-proved PCa, ii) who had rising PSA levels on 2 successive occasions ≥1 week apart, iii) were receiving treatment with hormonal therapy, iii) and had an absolute PSA value ≥1 ng/ml were eligible. Men who were enrolled received PSMA-PET and bone scan within 30 days. The primary endpoint was detection rate of bone disease for PSMA-PET vs BS. Secondary endpoint was the number of bone lesions detected by PSMA-PET vs BS. Number of lesions was categorized into: 0 vs 1 vs 2 vs 3 vs 4 vs 5 vs &gt; 5. A p value &lt; 0.05 was considered statistically significant. Results: 22 men were enrolled between July 8, 2021 and June 9, 2022. The median patients age was 71 years (range: 56-94). The median time between scans was 12 days (range: 1-29). The median PSA value was 9.5 ng/ml (range: 1.2 – 1717). 11/22 (11%) patients had hormone-sensitive PCa, while 11/22 (50%) had castration-resistant PCa prior to receiving the scans. The positivity rate for bone disease was equal for PSMA-PET and BS in all cases: 7/22 (32%) patients had negative scans on both imaging modalities and 15 (68%) had ≥1 bone lesion detected on both imaging modalities (p = 1.00). In 15/22 (68%) men, both imaging modalities showed equal number of bone lesions: 0 lesions in 7/22 (32%) men and &gt; 5 lesions in 8/22 (36%) men. In 3/22 (14%) men BS showed higher number of lesions, while in 4/22 (18%) men PSMA-PET showed higher number of lesions. No statistical difference was noticed between PSMA-PET and BS in number of bone lesions detected (p &gt; 0.05). The trial was terminated early since these preliminary results gave already a 95% confidence interval of 81-100% for equivalent positivity rate of bone disease between PSMA-PET and BS. Conclusions: In this prospective study of patients with prostate cancer with rising PSA levels under hormonal therapy, 68Ga-PSMA-11 PET and 99mTc-MDP bone scan had similar detection rate for bone disease. Further studies investigating similar comparison between PSMA-PET and BS in clinically-relevant selected patient population are warranted. Clinical trial information: NCT04928820 .

Development and external validation of a multivariable [68Ga]Ga-PSMA-11 PET-based prediction model for lymph node involvement in men with intermediate or high-risk prostate cancer

PurposeTo develop and evaluate a lymph node invasion (LNI) prediction model for men staged with [68Ga]Ga-PSMA-11 PET.MethodsA consecutive sample of intermediate to high-risk prostate cancer (PCa) patients undergoing [68Ga]Ga-PSMA-11 PET, extended pelvic lymph node dissection (ePLND), and radical prostatectomy (RP) at two tertiary referral centers were retrospectively identified. The training cohort comprised 173 patients (treated between 2013 and 2017), the validation cohort 90 patients (treated between 2016 and 2019). Three models for LNI prediction were developed and evaluated using cross-validation. Optimal risk-threshold was determined during model development. The best performing model was evaluated and compared to available conventional and multiparametric magnetic resonance imaging (mpMRI)-based prediction models using area under the receiver operating characteristic curves (AUC), calibration plots, and decision curve analysis (DCA).ResultsA combined model including prostate-specific antigen, biopsy Gleason grade group, [68Ga]Ga Ga-PSMA-11 positive volume of the primary tumor, and the assessment of the [68Ga]Ga-PSMA-11 report N-status yielded an AUC of 0.923 (95% CI 0.863–0.984) in the external validation. Using a cutoff of ≥ 17%, 44 (50%) ePLNDs would be spared and LNI missed in one patient (4.8%). Compared to conventional and MRI-based models, the proposed model showed similar calibration, higher AUC (0.923 (95% CI 0.863–0.984) vs. 0.700 (95% CI 0.548–0.852)—0.824 (95% CI 0.710–0.938)) and higher net benefit at DCA.ConclusionsOur results indicate that information from [68Ga]Ga-PSMA-11 may improve LNI prediction in intermediate to high-risk PCa patients undergoing primary staging especially when combined with clinical parameters. For better LNI prediction, future research should investigate the combination of information from both PSMA PET and mpMRI for LNI prediction in PCa patients before RP.

Clinicopathological Profile of Ampulla of Vater and Pancreas Malignancies at Cipto Mangunkusumo Hospital in 2015-2019

Background&#x0D; Malignancies of ampulla of vater and pancreas are often difficult to distinguish. Malignancies in ampulla of vater include malignancies in major duodenal papilla, distal common bile duct and pancreatic duct opening (Wirsung). The origin of the primary tumor, histopathological diagnosis and staging play a role in therapy and prognosis. WHO Classification of tumors of the digestive system, 2019 made changes in tumor staging following the system of the American Joint Committee on Cancer (AJCC), 8th edition. This study was conducted to determine types of pancreatic and ampullary malignancies, demographic distribution, location, profile, histomorphology and tumor staging changes in the 7th edition of the AJCC to 8th edition of the AJCC in the WHO Classification of tumors of the digestive system, 2019. The aim to determine clinicopathological profile of malignancies of ampulla of vater and pancreas as well as tumor staging changes based on AJCC edition 8.&#x0D; Methods&#x0D; Observational descriptive study on pancreatic and ampulla vater malignancy resection preparations at Department of Anatomic Pathology FKUI/RSCM, period January 2015 to December 2019 that met the inclusion criteria. Demographic evaluation, tumor location, histopathological profile and patient staging changes were carried out based on the 8th edition of AJCC.&#x0D; Results&#x0D; There were 27 cases of adenocarcinoma in ampulla of vater, 10 cases of pancreatic ductal adenocarcinoma, 1 case of mucinous cystic neoplasm with adenocarcinoma focus, 1 case of serous cystadenocarcinoma, 7 cases of PanNET, 2 cases of PanNEC, 3 cases of SPN, 1 case of MiNEN. Changes in pT were present in 29 cases. Changes in pN were present in 6 cases.&#x0D; Conclusion&#x0D; The diagnosis and pathological staging are in accordance with the 2019 WHO digestive system tumor classification. Tumor differentiation, presence or absence of lymphovascular invasion, perineural invasion and lymph node metastases and incision margin status are important histopathological parameters.