Dual-Energy CT Material Decomposition: The Value in the Detection of Lymph Node Metastasis from Breast Cancer.

PURPOSE: To evaluate the diagnostic performance of a dual-energy computed tomography (DECT)-based material decomposition algorithm for iodine quantification and fat fraction analysis to detect lymph node metastases in breast cancer patients. MATERIALS AND METHODS: 30 female patients (mean age, 63.12 ± 14.2 years) diagnosed with breast cancer who underwent pre-operative chest DECT were included. To establish a reference standard, the study correlated histologic repots after lymphadenectomy or confirming metastasis in previous/follow-up examinations. Iodine concentration and fat fraction were determined through region-of-interest measurements on venous DECT iodine maps. Receiver operating characteristic curve analysis was conducted to identify the optimal threshold for differentiating between metastatic and non-metastatic lymph nodes. RESULTS: A total of 168 lymph nodes were evaluated, divided into axillary (metastatic: 46, normal: 101) and intramammary (metastatic: 10, normal: 11). DECT-based fat fraction values exhibited significant differences between metastatic (9.56 ± 6.20%) and non-metastatic lymph nodes (41.52 ± 19.97%) (p < 0.0001). Absolute iodine concentrations showed no significant differences (2.25 ± 0.97 mg/mL vs. 2.08 ± 0.97 mg/mL) (p = 0.7999). The optimal fat fraction threshold for diagnosing metastatic lymph nodes was determined to be 17.75%, offering a sensitivity of 98% and a specificity of 94%. CONCLUSIONS: DECT fat fraction analysis emerges as a promising method for identifying metastatic lymph nodes, overcoming the morpho-volumetric limitations of conventional CT regarding lymph node assessment. This innovative approach holds potential for improving pre-operative lymph node evaluation in breast cancer patients, offering enhanced diagnostic accuracy.

Treatment Strategies Guided by [18F]FDG-PET/CT in Patients with Locally Advanced Cervical Cancer and [18F]FDG-Positive Lymph Nodes.

BACKGROUND: Modern treatment guidelines for women with advanced cervical cancer recommend staging using 2-deoxy-2-[18F]fluoro-D-glucose positron emission computed tomography ([18F]FDG-PET/CT). However, the risk of false-positive nodes and therapy-related adverse events requires caution in treatment planning. Using data from the Netherlands Cancer Registry (NCR), we estimated the impact of [18F]FDG-PET/CT on treatment management in women with locally advanced cervical cancer, i.e., on nodal boosting, field extension, and/or debulking in cases of suspected lymph nodes. METHODS: Women diagnosed between 2009 and 2017, who received chemoradiotherapy for International Federation of Gynaecology and Obstetrics (2009) stage IB2, IIA2-IVB cervical cancer with an [18F]FDG-positive node, were retrospectively selected from the NCR database. Patients with pathological nodal examination before treatment were excluded. The frequency of nodal boosting, extended-field radiotherapy, and debulking procedures applied to patients with [18F]FDG-positive lymph nodes was evaluated. RESULTS: Among the 434 eligible patients with [18F]FDG-positive nodes, 380 (88%) received interventions targeting these lymph nodes: 84% of these 380 patients received nodal boosting, 78% extended-field radiotherapy, and 12% debulking surgery. [18F]FDG-positive nodes in patients receiving these treatments were more likely to be classified as suspicious than inconclusive (p = 0.009), located in the para-aortic region (p < 0.001), and larger (p < 0.001) than in patients who did not receive these treatments. CONCLUSION: While existing guidelines advocate [18F]FDG-PET/CT-guided treatment planning for the management of advanced cervical cancer, this study highlights that not all cases of [18F]FDG-positive nodes received an intervention, possibly due to the risk of false-positive results. Improvement of nodal staging may reduce suboptimal treatment planning.

Nodal staging with MRI after neoadjuvant chemo-radiotherapy for locally advanced rectal cancer: a fast and reliable method.

OBJECTIVES: In patients with locally advanced rectal carcinoma (LARC), negative nodal status after neoadjuvant chemoradiotherapy (nCRT) may allow for rectum-sparing protocols rather than total mesorectal excision; however, current MRI criteria for nodal staging have suboptimal accuracy. The aim of this study was to compare the diagnostic accuracy of different MRI dimensional criteria for nodal staging after nCRT in patients with LARC. MATERIALS AND METHODS: Patients who underwent MRI after nCRT for LARC followed by surgery were retrospectively included and divided into a training and a validation cohort of 100 and 39 patients, respectively. Short-, long-, and cranial-caudal axes and volume of the largest mesorectal node and nodal status based on European Society of Gastrointestinal Radiology consensus guidelines (i.e., ESGAR method) were assessed by two radiologists independently. Inter-reader agreement was assessed in the training cohort. Histopathology was the reference standard. ROC curves and the best cut-off were calculated, and accuracies compared with the McNemar test. RESULTS: The study population included 139 patients (median age 62 years [IQR 55-72], 94 men). Inter-reader agreement was high for long axis (κ = 0.81), volume (κ = 0.85), and ESGAR method (κ = 0.88) and low for short axis (κ = 0.11). Accuracy was similar (p > 0.05) for long axis, volume, and ESGAR method both in the training (71%, 74%, and 65%, respectively) and in the validation (83%, 78%, and 75%, respectively) cohorts. CONCLUSION: Accuracy of the measurement of long axis and volume of the largest lymph node is not inferior to the ESGAR method for nodal staging after nCRT in LARC. CLINICAL RELEVANCE STATEMENT: In MRI restaging of rectal cancer, measurement of the long axis or volume of largest mesorectal lymph node after preoperative chemoradiotherapy is a faster and reliable alternative to ESGAR criteria for nodal staging. KEY POINTS: • Current MRI criteria for nodal staging in locally advanced rectal cancer after chemo-radiotherapy have suboptimal accuracy and are time-consuming. • Measurement of long axis or volume of the largest mesorectal lymph node on MRI showed good accuracy for assessment of loco-regional nodal status in locally advanced rectal cancer. • MRI measurement of the long axis and volume of largest mesorectal lymph node after chemo-radiotherapy could be a faster and reliable alternative to ESGAR criteria for nodal staging.

The efficacy of radiation therapy using the Quad Shot regimen in cutaneous metastasis from parotid gland cancer: A case report.

Cutaneous metastasis from malignant tumors can cause symptoms such as exudates, bleeding, and pain, which remarkably reduce patient's quality of life. Herein, we report a case in which radiation therapy using the Quad Shot regimen was effective in the treatment of cutaneous metastasis from parotid gland cancer.

Axillary management in patients with breast cancer and positive axilla at diagnosis. Experience in a Spanish university hospital with a 5-year follow-up.

Background: Axillary lymph node dissection (ALND) was the standard in breast cancer with axillary involvement until recently. Along with the number of metastatic nodes, axillary positivity was considered a main prognostic factor and scientific evidence shows that the administration of radiotherapy on ganglion areas decreases the risk of recurrence even in positive axilla. The objective of this study was to evaluate the axillary treatment in patients with positive axilla at diagnosis, the evolution of them over time, and to assess patient's follow-up with the aim of avoiding the morbidity associated with axillary dissection. Methods: A retrospective observational study of breast cancer patients diagnosed between 2010 and 2017 was performed. In total, 1,100 patients were studied, out of which 168 were women with clinically and histologically positive axilla at diagnosis. Seventy-six percent received primary chemotherapy and subsequent treatment with sentinel node biopsy, axillary dissection, or both. Patients with positive sentinel lymph node biopsy received either radiotherapy or lymphadenectomy depending on the year time they were diagnosed. Results: For 60 patients out of 168, neoadjuvant chemotherapy resulted in a complete pathological axillary response. Axillary recurrence was registered for six patients. No recurrence was detected in the biopsy group associated with radiotherapy. These results support the benefit of lymph node radiotherapy for patients with positive sentinel node biopsy after receiving primary chemotherapy. Conclusion: Sentinel node biopsy provides useful and reliable information about cancer staging and might prevent lymphadenectomy, leading to a decrease in morbidity. Pathological response to systemic treatment came out as the most important predictive factor of disease-free survival of breast cancer.

A multi-institutional study of association of sonographic characteristics with cervical lymph node metastasis in unifocal papillary thyroid carcinoma.

Objective: Papillary thyroid carcinoma (PTC) is the most common pathological type of thyroid carcinoma, and is prone to cervical lymph node metastases (CLNM). We aim to evaluate the association between sonographic characteristics of PTC and CLNM before the initial surgery. Methods: Clinical information as well as ultrasonographic measurements and characteristics for 2376 patients from three hospitals were acquired in this retrospective cohort study. Univariate and multivariate logistic analysis were performed to predict CLNM in unifocal PTC patients. Receiver operating characteristic (ROC) curve was created to evaluate diagnostic performance. Results: Univariate analysis showed that gender, age, maximum tumor diameter and volume, cross-sectional and longitudinal aspect ratio, location, echogenicity, margin, and echogenic foci were independently associated with CLNM metastatic status (P < 0.05). Multivariate logistic analysis showed that gender, age, maximum tumor diameter and volume, cross-sectional aspect ratio (CSAR), location, echogenicity, margin, and echogenic foci were independent correlative factors; CSAR showed a significant difference for PTC2 to predict CLNM. The area under the curve (AUC) of the maximum tumor diameter, tumor volume, margin, and echogenic foci was 0.70, 0.69, 0.65, and 0.70, respectively. The multiple-variable linear regression model was constructed with an AUC of 0.77, a specificity of 73.4%, and a sensitivity of 72.3%. Kruskal-Wallis analysis for positive subgroups, maximum tumor diameter and volume, cross-sectional and longitudinal aspect ratio, margin, and echogenic foci showed statistical significance (P < 0.05). Conclusions: Younger age (< 55 years), male, larger tumor, and echogenic foci were high risk factors for CLNM in patients with unifocal PTC. CSAR had a more effective predictive value for CLNM in patients with larger thyroid tumors. A larger tumor with irregular and punctate echogenic foci was also more prone to the lateral neck, and both central and lateral neck metastasis.

Validating the screening criteria for bone metastases in treatment-naïve unfavorable intermediate and high-risk prostate cancer - the prevalence and location of bone- and lymph node metastases.

OBJECTIVE: The European Association of Urology (EAU) recommends a bone scan for newly diagnosed unfavorable intermediate- and high-risk prostate cancer. We aimed to validate the screening criteria for bone metastases in patients with treatment-naïve prostate cancer. METHODS: This single-center retrospective study included all patients with treatment-naïve unfavorable intermediate- or high-risk prostate cancer. All underwent MRI of the lumbar column (T2Dixon) and pelvis (3DT2w, DWI, and T2 Dixon). The presence and location of lymph node and bone metastases were registered according to risk groups and radiological (rad) T-stage. The risk of lymph node metastases was assessed by odds ratio (OR). RESULTS: We included 390 patients, of which 68% were high-risk and 32% were unfavorable intermediate-risk. In the high-risk group, the rate of regional- and non-regional lymph node metastases was 11% and 6%, respectively, and the rate of bone metastases was 10%. In the unfavorable intermediate-risk group, the rate of regional- and non-regional lymph node metastases was 4% and 0.8%, respectively, and the rate of bone metastases was 0.8%. Metastases occurred exclusively in the lumbar column in 0.5% of all patients, in the pelvis in 4%, and the pelvis and lumbar column in 3%. All patients with bone metastases had radT3-4, and patients with radT3-4 showed a four-fold increased risk of lymph node metastases (OR 4.48, 95% CI: 2.1-9.5). CONCLUSION: Bone metastases were found in 10% with high-risk prostate cancer and 0.8% with unfavorable intermediate-risk. Therefore, we question the recommendation to screen the unfavorable intermediate-risk group for bone metastases. KEY POINTS: • The rate of bone metastases was 10% in high-risk patients and 0.8% in the unfavorable intermediate-risk group. • The rate of lymph-node metastases was 17% in high-risk patients and 5% in the unfavorable intermediate-risk group. • No bone metastases were seen in radiologically localized disease.

Presence of Dendritic Cell Subsets in Sentinel Nodes of Breast Cancer Patients Is Related to Nodal Burden.

BACKGROUND: Sentinel lymph nodes (SLNs) are both the first site where breast cancer (BC) metastases form and where anti-tumoral immunity develops. Despite being the most potent antigen-presenting cells, dendritic cells (DCs) located in a nodal tissue can both promote or suppress immune response against cancer in SLNs. METHODS: In SLNs excisions obtained from 123 invasive BC patients, we performed immunohistochemistry (IHC) for CD1a, CD1c, DC-LAMP, and DC-SIGN to identify different DCs populations. Then we investigated the numbers of DCs subsets in tumor-free, micrometastatic, and macrometastatic SLNs with the use of a light microscope. RESULTS: We observed that CD1c+ and DC-SIGN+ DCs were more numerous in SLNs with a larger tumor size. More abundant intratumoral DC-LAMP+ population was related to a higher number of metastatic lymph nodes. Conversely, more abundant CD1a+ DCs were associated with a decreasing nodal burden in SLNs and a lower number of involved lymph nodes. Moreover, densities of the investigated DC populations differed with respect to tumor grade, HER2 overexpression, hormone receptor status, and histologic type of BC. CONCLUSIONS: According to their subtype, DCs are associated with either lower or higher nodal burden in SLNs from invasive BC patients. These relationships appear to be dependent not only on the maturation state of DCs but also on the histological and biological characteristics of the tumor.

Evaluation of the Efficacy of Saracatinib-Loaded Nanoparticles in Lymphatic Metastases of HNSCC with the Aid of Bioluminescence Imaging.

Head and neck squamous cell carcinoma (HNSCC) remains a deadly disease despite concerted efforts to improve its diagnosis and treatment in recent decades. Metastasis of advanced HNSCC nearly always occurs first in neck lymph nodes before the development of distant metastasis. However, the development of preclinical animal models and therapeutic treatments for metastatic HNSCC is lagged from bench to clinic. In this protocol, we exemplify an orthotopic tongue tumor model that can recapitulate the cervical lymphatic metastases of HNSCC and the application to study the effect of novel saracatinib-loaded nanoparticles (Nano-Sar). By taking advantage of bioluminescence imaging (BLI), the present protocol reveals the strong anti-metastatic efficacy of Nano-Sar in the experimental setup. Collectively, the protocol with a novel metastatic mouse model shows great potential to evaluate treatments on metastatic diseases with the aid of bioluminescent technology.

The Lymphatic Spread of Lung Cancer: An Investigation of the Anatomy of the Lymphatic Drainage of the Lungs and Preoperative Mediastinal Staging.

The knowledge of lymphatic spread of lung cancer permitted the study of anatomy of lymphatic drainage of the lungs. The history of anatomy of lymphatic drainage of the lungs began in the 15th century. In the human, pulmonary lymph flows to the lymph nodes around the lobar bronchi and thence to extrapulmonary lymph nodes located around the main bronchi and trachea and its bifurcation (tracheobronchial lymph nodes). These send their efferents to a right and left mediastinal lymph trunks, which may join the thoracic duct, but usually drain opening directly into the brachiocephalic vein of their own side.

Evaluation of a streamlined sentinel lymph-node imaging protocol in early-stage oral cancer.

OBJECTIVE: Sentinel lymph-node (SLN) mapping for early-stage oral squamous cell carcinoma (OSCC) is comprehensive and consequently time-consuming and costly. This study evaluated the clinical value of several SLN imaging components and analyzed the accuracy for SLN identification using a streamlined SLN imaging protocol in early-stage OSCC. MATERIALS AND METHODS: This retrospective within-patient evaluation study compared both number and localization of identified SLNs between the conventional SLN imaging protocol and a streamlined imaging protocol (dynamic lymphoscintigraphy (LSG) for 10 min directly post-injection and SPECT-CT at ~ 2 h post-injection). LSG and SPECT-CT images of 77 early-stage OSCC patients, scheduled for SLN biopsy, were evaluated by three observers. Identified SLNs using either protocol were related to histopathological assessment of harvested SLNs, complementary neck dissection specimens and follow-up status. RESULTS: A total of 200 SLNs were identified using the streamlined protocol, and 12 additional SLNs (n = 212) were identified with the conventional protocol in 10 patients. Of those, 9/12 were identified on early static LSG and 3/12 on late static LSG. None of the additionally identified SLNs contained metastases; none of those in whom additional SLNs were identified developed regional recurrence during follow-up. Only inferior alveolar process carcinoma showed a higher rate of additionally identified SLNs with the conventional protocol (p = 0.006). CONCLUSION: Early dynamic LSG can be reduced to 10 min. Late static LSG may be omitted, except in those with a history of oncological neck treatment or with OSCC featuring slow lymphatic drainage. Early static LSG appeared to be contributory in most OSCC subsites.

The Role of Ga-68-PSMA PET/CT in the Initial Staging of Prostate Cancer - A Single Center 4 Year Experience.

BACKGROUND: Recommended imaging modalities for prostate cancer staging have disappointing sensitivities, whereas [68Ga]-PSMA PET/CT (PET-PSMA) shows promising sensitivities and specificities in the initial management of prostate cancer. Recent studies have revealed that a significant change of management when PET-PSMA was used, with favorable negative predictive values. METHODS: In this retrospective study, we analyzed every PET-PSMA performed in our center for initial staging of intermediate and high-risk prostate cancer. Patients were divided into two groups based on whether imaging modalities other than PET-PSMA were performed. In patients submitted to radical prostatectomy, PET-PSMA findings were compared to histological analysis of the specimen. RESULTS: PET-PSMA results of 57 patients were gathered, with 77.2% (n=44) having performed CT scan or bone scan (BS) prior to PET-PSMA. Prostate cancer management strategy was changed in 61.4% (n=27), when PET-PSMA was performed following CT and BS. BS and CT results were consistent with PET-PSMA in 43.2% and 44.8%, respectively. In 30 cases, a curative strategy was used based on PET-PSMA findings. PET-PSMA revealed a negative predictive value of 95.2% in 23 patients submitted to radical prostatectomy with bilateral pelvic lymphadenectomy. Prostate SUV values on preoperative PET-PSMA correlated with initial PSA, ISUP grade, PC risk staging and presence of extraprostatic lesions. CONCLUSIONS: PET-PSMA is a key element for prostate cancer staging and management, with high diagnostic accuracy. More prospective studies need to be implemented to determine its role as a first-line staging tool.

Oncological therapy to Swedish men with metastatic penile cancer 2000-2015.

BACKGROUND: Penile cancer is an uncommon disease with poor prognosis when spread to more than one inguinal lymph node. Recommendations on chemo- and radiotherapy in treatment guidelines are based on low-grade evidence. There are to our knowledge no described population-based cohort with detailed information on given oncological treatment and survival data. The aim of this study is to investigate in detail how men with metastatic penile cancer have been treated with chemotherapy and radiotherapy over time, and how survival varies with N-stage and given treatment. MATERIAL AND METHODS: For this observational cohort study all men in Sweden diagnosed with penile cancer with lymph node- or distant metastases 2000-2015 were identified through the Swedish National Penile Cancer Register (NPECR). Medical records were retrieved and 325 men were confirmed to have metastatic penile cancer (Tany, c or pN1-3 and/or M1). Information on treatments was collected. Causes of death were retrieved from the National Cause of Death Register (CDR). RESULTS: Chemotherapy and/or radiotherapy were given to 172 (53%) of all men. The use of oncological treatments with curative intent increased significantly during the study period, from 30% of men with c/pN2-3 diagnosed 2000-2003 compared with 57% of men diagnosed 2012-2015. Ninety-three (29%) men received oncological treatments with curative intent of whom 85/93 (91%) had stage c/pN2-3M0. Survival decreased with higher N-stage, M1-stage, and absence of oncological treatment with curative intent. For men with c/pN3-stage, the engagement of pelvic lymph nodes was entailed with lower survival than pN3 based on extra-nodal extension (ENE). CONCLUSION: The use of oncological treatment was below recommendations in guidelines but increased during the study period. Treatment was given predominantly to men with c/pN2-3 and M1-disease. Survival was higher among men treated with curative intent; this could be due to patient selection bias.

Surgeon decision-making for management of positive sentinel lymph nodes in the post-Multicenter Selective Lymphadenectomy Trial II era: A survey study.

BACKGROUND AND OBJECTIVES: Completion lymph node dissection (CLND) did not improve melanoma-specific survival for patients with sentinel lymph node (SLN)-positive melanoma in the second Multicenter Selective Lymphadenectomy Trial (MSLT-II). We assessed surgeons' awareness of MSLT-II and its impact on CLND recommendations. METHODS: An anonymous online cross-sectional survey of the Society of Surgical Oncology membership evaluated surgeon thresholds in offering CLND using patient scenarios and clinicopathologic characteristics ranking. RESULTS: Of the 2881 e-mails delivered, 146 surgeons (5.1%) completed all seven scenarios. Most (129 of 131, 98%) were aware of MSLT-II and 125 (95%) found it practice-changing. Specifically, 52% (65 of 125) always, 40% usually, 6% rarely, and 3% never offered CLND before MSLT-II. Meanwhile, 4% always, 9% usually, 78% rarely, and 8% never offer CLND now, after MSLT-II (p < .0001). The most important clinicopathologic factors in determining CLND recommendations were extracapsular extension, number of positive SLN, and SLN tumor deposit size, while primary tumor mitotic index and nodal basin location were the least important. Surgical oncology fellowship training, melanoma patient volume, and academic center practice also influenced CLND recommendations. CONCLUSIONS: Most surgeon respondents are aware of MSLT-II, but its application in practice varies according to several clinicopathologic and surgeon factors.

New Developments in Imaging for Sentinel Lymph Node Biopsy in Early-Stage Oral Cavity Squamous Cell Carcinoma.

Sentinel lymph node biopsy (SLNB) is a diagnostic staging procedure that aims to identify the first draining lymph node(s) from the primary tumor, the sentinel lymph nodes (SLN), as their histopathological status reflects the histopathological status of the rest of the nodal basin. The routine SLNB procedure consists of peritumoral injections with a technetium-99m [99mTc]-labelled radiotracer followed by lymphoscintigraphy and SPECT-CT imaging. Based on these imaging results, the identified SLNs are marked for surgical extirpation and are subjected to histopathological assessment. The routine SLNB procedure has proven to reliably stage the clinically negative neck in early-stage oral squamous cell carcinoma (OSCC). However, an infamous limitation arises in situations where SLNs are located in close vicinity of the tracer injection site. In these cases, the hotspot of the injection site can hide adjacent SLNs and hamper the discrimination between tracer injection site and SLNs (shine-through phenomenon). Therefore, technical developments are needed to bring the diagnostic accuracy of SLNB for early-stage OSCC to a higher level. This review evaluates novel SLNB imaging techniques for early-stage OSCC: MR lymphography, CT lymphography, PET lymphoscintigraphy and contrast-enhanced lymphosonography. Furthermore, their reported diagnostic accuracy is described and their relative merits, disadvantages and potential applications are outlined.

Morphological consistency of desmoplastic reactions between the primary colorectal cancer lesion and associated metastatic lesions.

Some preceding studies show that a desmoplastic reaction (DR) at the invasive front of a primary tumor (DRprimary) is a promising prognostic indicator, and its histologic classification is an independent prognostic factor in patients with colorectal cancer (CRC). Although DR is observed in metastatic lesions, such as those in lymph nodes (DRLN) and the liver (DRliver), the association between DRprimary and DR of metastatic lesions is unclear. We investigated whether DRLN and DRliver could be categorized in the same manner as DRprimary and examined the features and prognostic implications of DRLN and DRliver. In this study, we evaluated 363 patients with metastases to lymph nodes and 45 patients with synchronous liver metastases who underwent curative resection. DRLN and DRliver statuses were classified as mature, intermediate, or immature, based on keloid-like collagen and myxoid stroma appearances in the metastatic lesions. Overall, 109, 106, and 148 patients had mature, intermediate, and immature DRLN, respectively; in total, 5, 21, and 19 patients had mature, intermediate, and immature DRliver, respectively. DRLN and DRprimary (spearman's rho = 0.43, P < 0.0001) and DRliver and DRprimary (spearman's rho = 0.40, P = 0.0069) were each significantly correlated. The 5-year relapse-free survival (RFS) after surgery was 67.7% for mature/intermediate DRLN and 52.9% for immature DRLN; the 5-year RFS after hepatectomy was 11.5% for mature/intermediate DRliver and 5.6% for immature DRliver. In conclusion, DRLN and DRliver may be classified in the same manner as DRprimary; morphological consistency of DR was observed between primary and metastatic lesions.

Prognostic value of metabolic tumor volume and total lesion glycolysis from ¹8F-FDG PET/CT in lymph node metastases and risk stratification of endometrial carcinoma.

OBJECTIVE: To investigate the prognostic value of metabolic tumor volume (MTV) and total lesion glycolysis (TLG), measured by preoperative ¹8F-fluorodeoxyglucose positron emission tomography/computed tomography (¹8F-FDG PET/CT), in risk stratification of patients with endometrial carcinoma (EC). METHODS: The patients with pathological diagnosis of EC who underwent preoperative ¹8F-FDG PET/CT imaging were retrospectively selected for analysis of the prognostic values of PET parameters in risk classification and lymph node metastases (LNMs). Receiver-operating-characteristic analysis was used to analyze the correlation of PET parameters cutoff values with deep myometrial invasion (MI), lymphovascular space involvement and LNM for prognostic values in risk stratification. RESULTS: The sensitivity, specificity, positive predictive value, negative predictive value and accuracy for detection of LNM are 83.3%, 99.7%, 90.9%, 99.5% and 99.2%, respectively. The MTV and TLG of primary lesion of EC in the patients with LNM are notably higher than those in patients without LNM, p<0.010. The MTV and TLG of the EC primary lesions in high-risk patients are significantly higher than those in low-risk patients (p<0.010), but the maximum standardized uptake value (SUVmax) is not. The MTV and TLG of primary lesions were superior to SUVmax for predicting of deep MI, LNM and high-risk of EC (p<0.005). CONCLUSION: MTV and TLG of primary lesions are more valuable in predicting risk stratification of EC patients. Preoperative ¹8F-FDG PET/CT imaging is useful in predicting the LNM of EC and may help guide pelvic lymphadenectomy to avoid unnecessary pelvic lymphadenectomy in EC patients with low-risk stratification.

A Prospective Study of Sentinel Lymph Node Mapping for Endometrial Cancer: Is It Effective in High-Risk Subtypes?

BACKGROUND: The efficacy of sentinel lymph node (SLN) mapping for high-risk endometrial cancer remains unclear. This prompted us to evaluate the sensitivity, negative predictive value (NPV), and false-negative (FN) rate of cervical injection of indocyanine green (ICG) SLN mapping in patients with endometrial cancer. MATERIALS AND METHODS: This prospective interventional study was performed at a single university teaching hospital. Consecutive patients with early-stage endometrial cancer who underwent laparoscopic surgical staging were included. Cervical injection of ICG and near-infrared SLN identification and biopsy were performed for all study patients followed by systematic pelvic lymphadenectomy, whereas para-aortic lymphadenectomy was performed in all patients with high-risk histologies. SLN detection rates, sensitivity, NPV, and FN rates were calculated. RESULTS: Between July 2016 and July 2018, 131 patients were enrolled. The overall SLN detection rate was 93.1%, with a bilateral detection rate of 61.8%. Four positive SLNs were identified in four patients. Lymph node metastasis was observed in four additional patients without positive SLNs. These four patients belonged to a group of patients with a high-risk subtype. Three of the four patients had isolated para-aortic node metastases. In low-risk endometrial cancers, the sensitivity of the SLN technique to identify nodal metastatic disease was 100% (95% confidence interval [CI] 31.0-100), with an NPV and FN rate of 100% (95% CI 95.1-100) and 0%, respectively. In high-risk endometrial cancers, the sensitivity, NPV, and FN rate were 20% (95% CI 1.0-70.1), 83.3% (95% CI 61.8-94.5), and 80%, respectively. CONCLUSION: Cervical injection of ICG and SLN mapping yielded a low sensitivity and a high FN rate for the identification of node metastasis in endometrial cancer with high-risk histologies. IMPLICATIONS FOR PRACTICE: The efficacy of sentinel lymph node (SLN) mapping for high-risk endometrial cancer remains unclear. This study enrolled 131 patients with early-stage endometrial cancer who underwent cervical injection of indocyanine green SLN mapping followed by systematic pelvic lymphadenectomy and para-aortic lymphadenectomy. The key result was that SLN mapping yielded a low sensitivity and a high false-negative rate for the identification of node metastasis in endometrial cancer with high-risk histologies. The SLN strategy in these patients may increase the risk of missed diagnosis of isolated para-aortic node metastases and seems to be unacceptable in clinical practice.

Prognostic value of metabolic tumor volume and total lesion glycolysis from ¹⁸F-FDG PET/CT in lymph node metastases and risk stratification of endometrial carcinoma / 부인종양

OBJECTIVE: To investigate the prognostic value of metabolic tumor volume (MTV) and total lesion glycolysis (TLG), measured by preoperative ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography (¹⁸F-FDG PET/CT), in risk stratification of patients with endometrial carcinoma (EC). METHODS: The patients with pathological diagnosis of EC who underwent preoperative ¹⁸F-FDG PET/CT imaging were retrospectively selected for analysis of the prognostic values of PET parameters in risk classification and lymph node metastases (LNMs). Receiver-operating-characteristic analysis was used to analyze the correlation of PET parameters cutoff values with deep myometrial invasion (MI), lymphovascular space involvement and LNM for prognostic values in risk stratification. RESULTS: The sensitivity, specificity, positive predictive value, negative predictive value and accuracy for detection of LNM are 83.3%, 99.7%, 90.9%, 99.5% and 99.2%, respectively. The MTV and TLG of primary lesion of EC in the patients with LNM are notably higher than those in patients without LNM, p<0.010. The MTV and TLG of the EC primary lesions in high-risk patients are significantly higher than those in low-risk patients (p<0.010), but the maximum standardized uptake value (SUVmax) is not. The MTV and TLG of primary lesions were superior to SUVmax for predicting of deep MI, LNM and high-risk of EC (p<0.005). CONCLUSION: MTV and TLG of primary lesions are more valuable in predicting risk stratification of EC patients. Preoperative ¹⁸F-FDG PET/CT imaging is useful in predicting the LNM of EC and may help guide pelvic lymphadenectomy to avoid unnecessary pelvic lymphadenectomy in EC patients with low-risk stratification.

Can MR textural analysis improve the prediction of extracapsular nodal spread in patients with oral cavity cancer?

OBJECTIVE: To explore the utility of MR texture analysis (MRTA) for detection of nodal extracapsular spread (ECS) in oral cavity squamous cell carcinoma (SCC). METHODS: 115 patients with oral cavity SCC treated with surgery and adjuvant (chemo)radiotherapy were identified retrospectively. First-order texture parameters (entropy, skewness and kurtosis) were extracted from tumour and nodal regions of interest (ROIs) using proprietary software (TexRAD). Nodal MR features associated with ECS (flare sign, irregular capsular contour; local infiltration; nodal necrosis) were reviewed and agreed in consensus by two experienced radiologists. Diagnostic performance characteristics of MR features of ECS were compared with primary tumour and nodal MRTA prediction using histology as the gold standard. Receiver operating characteristic (ROC) and regression analyses were also performed. RESULTS: Nodal entropy derived from contrast-enhanced T1-weighted images was significant in predicting ECS (p = 0.018). MR features had varying accuracy: flare sign (70%); irregular contour (71%); local infiltration (66%); and nodal necrosis (64%). Nodal entropy combined with irregular contour was the best predictor of ECS (p = 0.004, accuracy 79%). CONCLUSION: First-order nodal MRTA combined with imaging features may improve ECS prediction in oral cavity SCC. KEY POINTS: • Nodal MR textural analysis can aid in predicting extracapsular spread (ECS). • Medium filter contrast-enhanced T1 nodal entropy was strongly significant in predicting ECS. • Combining nodal entropy with irregular nodal contour improves predictive accuracy.