Clinicopathologic Significance of False-Positive Lymph Node Status on FDG-PET in Lung Cancer.

INTRODUCTION: 2-[18F] Fluoro-d-deoxyglucose (FDG) positron emission tomography (PET) is a relevant diagnostic procedure for staging lung cancer. However, accurate evaluation of lymph node metastases by PET is controversial because of false-positive FDG uptake. PATIENTS AND METHODS: A total of 245 patients with lung cancer were retrospectively analyzed. Standardized maximum uptake values (SUVmax) of the primary tumor and lymph nodes were compared to pathologic lymph node metastases to correlate PET findings with clinicopathologic variables and patient outcomes. RESULTS: The SUVmax values of metastatic lymph nodes were significantly higher than those of lymph nodes without metastases (P = .0036). When SUVmax ≥ 4 was defined as PET positive for metastasis, the sensitivity, specificity, and accuracy were 48.1%, 79.8%, and 73.1%, respectively. Multivariate logistic regression analysis showed that age > 75 years, bilateral hilar FDG uptake, and no lymph node swelling were significant factors related to false-positive lymph node metastases. Smoking status, FDG uptake in the primary tumor, and concurrent lung diseases were not significant factors. CONCLUSION: Metastatic lymph nodes show higher FDG uptake than false-positive lymph nodes, and older patient age, bilateral hilar FDG uptake, and no swollen nodes are associated with no metastases. Patients with lymph node metastases have worse survival than those with false-positive FDG-PET findings. However, abnormal FDG uptake in the lymph node is an important prognostic factor.

Prognostic impact of preoperative FDG-PET positive lymph nodes in lung cancer.

BACKGROUND: 2-[18F] Fluoro-D-deoxyglucose positron emission tomography (FDG-PET) is an appropriate diagnostic procedure for staging lung cancer. However, accurate evaluation of lymph node (LN) metastases by PET is controversial owing to false-positive/-negative FDG uptake results. The prognostic significance of both false-negative and false-positive LNs on FDG-PET remains to be determined. METHODS: A total of 235 patients with lung cancer were retrospectively analyzed. Maximum standardized uptake values (SUVmax) of the lymph nodes were compared with pathological LN metastases to correlate PET findings with clinicopathological variables and patients' outcomes. RESULTS: When SUVmax ≥ 4 was defined as PET-positive for LN metastasis, sensitivity, specificity, and accuracy were 46.0%, 79.5%, and 72.3%, respectively. False-negative cases and pathological n0 cases were significantly younger, had primary tumors that were smaller or lower SUVmax, and adenocarcinomas compared with false-positive and pathological n+ cases. The difference in survival time between patients with abnormal FDG uptake in the LN and those without was larger than that between pathological LN metastases and no pathological metastases in patients with adenocarcinoma. Multivariate analysis by the Cox proportional hazard model identified smoker, EGFR/ALK negative and LN positive on PET as significant adverse prognostic factors, rather than pathological n-stage. CONCLUSIONS: Abnormal FDG uptake in the LN is an important prognostic factor. Increased glucose metabolism on FDG-PET appears to be a more efficient postoperative prognostic marker than pathological n-stage in patients with lung cancer.

Thoracoscopic surgery using omental flap for bronchopleural fistula.

BACKGROUND: A bronchopleural fistula (BPF) can lead to empyema and death after pulmonary resection. A minor leakage from a BPF has been reported to be successfully closed endobronchially, although thoracoplasty is usually needed. CASE PRESENTATION: A case of successful thoracoscopic BPF closure using an omental flap in a 74-year-old man with emphysema who developed a BPF after right lower lobectomy for lung cancer is reported. Reoperation was performed to close the BPF using an omental flap. After successful closure of the BPF, the empyema resolved with intravenous antibiotics. CONCLUSIONS: Thoracoscopic single-stage omentoplasty without thoracotomy might be a useful treatment method when a BPF is diagnosed early.

Surgical outcomes in patients with small cell lung cancer: comparative analysis of computed tomograpy-detected patients with others.

BACKGROUND: It is shown that low-dose computed tomography (CT) screening is useful for a reduction in lung-cancer-specific mortality in heavy smokers. However, the information about effectiveness according to the histological types of lung cancer has not been adequately investigated especially small cell lung cancer (SCLC). The present study was performed to see the clinical benefit of CT screening in patients with SCLC following thoracotomy. METHODS: We retrospectively reviewed the outcome in patients with early stage SCLC who initially underwent thoracotomy. The clinical stages and actuarial survival were estimated according to the three means of detection of SCLC: chest CT, radiographic screen, and symptomatically prompted cases. RESULTS: Sixty-nine patients (men/women, 63/6; mean age, 70 years) with SCLC underwent thoracotomy between 1991 and 2010 including chest CT (n = 13), radiographic screening (n = 39), and symptomatically prompted cases (n = 17). Pathological staging information included stage IA (n = 25), IB (n = 8), IIA (n = 13), IIB (n = 5), IIIA (n = 11), and IIIB (n = 7). Median survival time was 30.0 (95% confidence interval (CI): 22.0 to 57.0) months, with overall survival at 5 years of 34.3% (95% CI, 23.47 to 47.3). Nine patients (69%) with stage I were detected by CT which was significantly higher than those in other detection arms. However, there were no significant differences in the survival between CT and other detection arms. CONCLUSIONS: CT examination may be useful for detection in early stage SCLC potentially suitable for surgery, but the contribution to better clinical outcome in patients with SCLC remains unclear.

Risk analysis of pulmonary resection for elderly patients with lung cancer.

PURPOSE: The indications for pulmonary resection in elderly patients with lung cancer concomitant with another disease are unclear. We conducted this retrospective study to establish the risk factors of complications and survival to improve patient selection. METHODS: The subjects were 295 patients aged ≥ 75 years, who underwent pulmonary resection for lung cancer. We assessed comorbidity according to the Charlson comorbidity index (CCI) and examined risk factors for morbidity and the prognostic factors. RESULTS: Postoperative complications developed in 55 patients (morbidity 18.6 %). The median survival time was 59.3 months and the 5-year survival rate was 69.7 %. Multivariate logistic regression analyses selected smoking and thoracotomy as risk factors for complications, and a history of cerebrovascular disease, cancer stage, and thoracotomy as risk factors for a prolonged hospital stay (PHS). Video-assisted thoracic surgery (VATS) decreased the risk of morbidity and PHS, and influenced survival. Multivariate analysis with the Cox proportional hazard model identified CCI ≥ 2, morbidity, and PHS as unfavorable survival factors, in addition to age ≥ 80 and cancers that were non-adenocarcinoma or advanced. CONCLUSIONS: Although CCI ≥ 2 was associated with poorer survival, it was not necessarily a risk factor of postoperative complications or PHS. Performing VATS when possible could reduce the incidence of postoperative complications and PHS in elderly patients.

A randomized trial comparing adjuvant chemotherapy versus surgery alone for completely resected pN2 non-small cell lung cancer (JCOG9304).

The purpose of this study was to evaluate the efficacy of adjuvant chemotherapy with three courses of cisplatin and vindesine, in comparison to observation only, for N2 non-small cell lung cancer that had been completely resected. Patients with pathologically demonstrated mediastinal lymph node metastasis (N2), who had undergone complete resection, were randomized to observation or adjuvant chemotherapy (cisplatin 80 mg/m2 on day 1; vindesine 3 mg/m2 on days 1 and 8: x3 courses). Cycles started within 6 weeks after complete resection and were repeated every 4 weeks. This trial was terminated before accumulation of the planned numbers for registration because of a slow accrual rate. A total of 119 patients were randomized (59 patients in the adjuvant arm and 60 with surgery alone). The median survival was 36 months for both groups. Postoperative cisplatin with vindesine chemotherapy was not shown to be efficacious in cases of completely resected N2 non-small cell lung cancer in this setting of timing, dose and agents studied.