Additional Value of FDG-PET/MRI Complementary to Sentinel Lymphonodectomy for Minimal Invasive Lymph Node Staging in Patients with Endometrial Cancer: A Prospective Study.

BACKGROUND: Lymph node metastases (LNM) are rare in early-stage endometrial cancer, but a diagnostic systematic lymphadenectomy (LNE) is often performed to achieve reliable N-staging. Therefore, this prospective study aimed to evaluate the benefit of [18F]-Fluorodeoxyglucose (FDG) PET/MRI complementary to SPECT/CT guided sentinel lymphonodectomy (SLNE) for a less invasive N-staging Methods: 79 patients underwent a whole-body FDG-PET/MRI, SLN mapping with 99mTc-Nanocolloid SPECT/CT and indocyanine green (ICG) fluoroscopy followed by LNE which served as ground truth. RESULTS: FDG-PET/MRI was highly specific in N-staging (97.2%) but revealed limited sensitivity (66.7%) due to missed micrometastases. In contrast, bilateral SLN mapping failed more often in patients with macrometastases. The combination of SLN mapping and FDG-PET/MRI increased the sensitivity from 66.7% to 77.8%. Additional SLN labeling with dye (ICG) revealed a complete SLN mapping in 80% (8/10) of patients with failed or incomplete SLN detection in SPECT/CT, reducing the need for diagnostic systematic LNE up to 87%. FDG-PET/MRI detected para-aortic LNM in three out of four cases and a liver metastasis. CONCLUSIONS: The combination of FDG-PET/MRI and SLNE can reduce the need for diagnostic systematic LNE by up to 87%. PET/MRI complements the SLN technique particularly in the detection of para-aortic LNM and occasional distant metastases.

Study on the diagnostic value of MDCT extramural vascular invasion in preoperative N staging of gastric cancer patients.

BACKGROUND: To explore the diagnostic value of multidetector computed tomography (MDCT) extramural vascular invasion (EMVI) in preoperative N Staging of gastric cancer patients. METHODS: According to the MR-defined EMVI scoring standard of rectal cancer, we developed a 5-point scale scoring system to evaluate the status of CT-detected extramural vascular invasion(ctEMVI), 0-2 points were ctEMVI-negative status, and 3-4 points were positive status for ctEMVI. Patients were divided into ctEMVI positive group and ctEMVI negative group. The correlation between ctEMVI and clinical features was analyzed. Receiver operating characteristic (ROC) curve was used to evaluate the diagnostic efficacy of ctEMVI for pathological metastatic lymph nodes and N staging, The sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) of pathological N staging using ctEMVI and short-axis diameter were generated and compared. RESULTS: The occurrence rate of lymphovascular invasion (LVI) and proportion of tumors with a greatest diameter > 6 cm in the ctEMVI positive group was higher than that in the ctEMVI negative group (P < 0.05). Spearman correlation analysis showed a positive correlation between ctEMVI and LVI, N stage, and tumor size (P < 0.05). For ctEMVI scores ≥ 3,The AUC of ctEMVI for diagnosing lymph node metastasis, N stage ≥ N2, and N3 stage were 0.857, 0.802, and 0.758, respectively. The sensitivity, NPV and accuracy of ctEMVI for diagnosing N stage ≥ N2 were superior to those of short-axis diameter (P < 0.05), while sensitivity, specificity, PPV, NPV, and accuracy of ctEMVI for diagnosing N3 stage were superior to those of short-axis diameter (P < 0.05). CONCLUSION: ctEMVI has important value in diagnosing metastatic lymph nodes and advanced N staging. As an important imaging marker, ctEMVI can be included in the preoperative imaging evaluation of patients, providing important assistance for clinical guidance and treatment.

Could the New pN Staging Classification Better Predict the Prognosis of Penile Cancer? A Population-Based Analysis.

BACKGROUND: The 8th edition of the American Joint Committee on Cancer (AJCC) has made new revisions to the N staging of penile cancer (PeCa). This study aimed to evaluate the prognostic value of the new N staging classification. METHODS: This cohort was included from the Surveillance, Epidemiology, and End Results (SEER) database (1988-2016). Overall survival (OS) and cancer-specific survival (CSS) were evaluated using Kaplan-Meier survival curve. The Cox proportional hazards model was employed to calculate hazard ratio (HR) and 95% confidence intervals (CI). RESULTS: Among the included 583 patients, 270 patients had only one positive inguinal lymph node (ILNP), 115 had two ILNPs, and 198 had 3 or more ILNPs. Kaplan-Meier analysis indicated that The OS and CSS of patients with ILNP = 2 were not statistically different from those with ILNP = 1 (p = 0.394; p = 0.760), but had OS and CSS benefit over those with ILNP ≥3 (p = 0.017; p = 0.020). Cox proportional hazards regression analysis indicated that patients with ILNP = 2 and ILNP = 1 have similar OS and CSS (HR = 0.80, p = 0.153; HR = 0.74, p = 0.148), but patients with ILNP ≥3 had worse OS and CSS than patients with ILNP = 2 (HR = 1.56, p = 0.007; HR = 1.86, p = 0.003). CONCLUSIONS: PeCa patients with only one or two lymph node metastases had similar survival outcomes. AJCC 8th edition pN staging has a better discriminative ability to predict the prognosis and can accurately stratify mortality risk in PeCa.

Could the New pN Staging Classification Better Predict the Prognosis of Penile Cancer? A Population-Based Analysis

Background: The 8th edition of the American Joint Committee on Cancer (AJCC) has made new revisions to the N staging of penile cancer (PeCa). This study aimed to evaluate the prognostic value of the new N staging classification. Methods: This cohort was included from the Surveillance, Epidemiology, and End Results (SEER) database (1988–2016). Overall survival (OS) and cancer-specific survival (CSS) were evaluated using Kaplan–Meier survival curve. The Cox proportional hazards model was employed to calculate hazard ratio (HR) and 95% confidence intervals (CI). Results: Among the included 583 patients, 270 patients had only one positive inguinal lymph node (ILNP), 115 had two ILNPs, and 198 had 3 or more ILNPs. Kaplan–Meier analysis indicated that The OS and CSS of patients with ILNP = 2 were not statistically different from those with ILNP = 1 (p = 0.394; p = 0.760), but had OS and CSS benefit over those with ILNP ≥3 (p = 0.017; p = 0.020). Cox proportional hazards regression analysis indicated that patients with ILNP = 2 and ILNP = 1 have similar OS and CSS (HR = 0.80, p = 0.153; HR = 0.74, p = 0.148), but patients with ILNP ≥3 had worse OS and CSS than patients with ILNP = 2 (HR = 1.56, p = 0.007; HR = 1.86, p = 0.003). Conclusions: PeCa patients with only one or two lymph node metastases had similar survival outcomes. AJCC 8th edition pN staging has a better discriminative ability to predict the prognosis and can accurately stratify mortality risk in PeCa (AU)

Concordance between Clinical and Pathological T and N Stages in Polish Patients with Head and Neck Cancers.

BACKGROUND: The TNM (tumor, node, metastasis) staging system is important for the successful treatment of head and neck cancers (HNCs). This study aimed to evaluate the concordance between clinical and pathological T and N stages in patients with HNCs in Poland. METHODS: In this single-center retrospective study, clinical and pathological TNM staging data on 203 patients undergoing surgical treatment for HNC between 2011 and 2018 were collected and compared. The study group was classified as underdiagnosed, overdiagnosed, or correctly diagnosed with HNC based on pathological TNM staging. The concordance between clinical and pathological staging was evaluated using the kappa coefficient. RESULTS: Clinical and pathological TNM staging showed concordance in 59.9% of patients for primary tumor (T) and in 79.3% of patients for lymph node (N) classifications. Moderate agreement between the clinical and pathological stages was shown for stage T, while substantial agreement was revealed for stage N. The size and extent of the tumor were underestimated or overestimated in 73 of the 182 patients (40.1%), while lymph node involvement was downstaged in 11 of the 53 patients (20.7%). CONCLUSIONS: The disparities between clinical and pathological staging of HNC demonstrate the need for standardization in physical and pathological examinations, as well as radiographic imaging.

Efficacy of Lymph Node Location-Number Hybrid Staging System on the Prognosis of Gastric Cancer Patients.

BACKGROUND: Lymph node metastasis location and number significantly affects the prognosis of patients with gastric cancer (GC). This study was designed to examine a new lymph node hybrid staging (hN) system to increase the predictive ability for patients with GC. METHODS: This study analyzed the gastrointestinal treatment of GC at the Harbin Medical University Cancer Hospital from January 2011 to December 2016, and selected 2598 patients from 2011 to 2015 as the training cohort (hN) and 756 patients from 2016 as the validation cohort (2016-hN). The study utilized the receiver operating characteristic curve (ROC), c-index, and decision curve analysis (DCA) to compare the prognostic performance of the hN with the 8th edition of AJCC pathological lymph node (pN) staging for GC patients. RESULTS: The ROC verification of the training cohort and validation cohort based on each hN staging and pN staging showed that for each N staging, the hN staging had a training cohort with an AUC of 0.752 (0.733, 0.772) and a validation cohort with an AUC of 0.812 (0.780, 0.845). In the pN staging, the training cohort had an AUC of 0.728 (0.708, 0.749), and the validation cohort had an AUC of 0.784 (0.754, 0.824). c-Index and DCA also showed that hN staging had a higher prognostic ability than pN staging, which was confirmed in the training cohort and the verification cohort, respectively. CONCLUSION: Lymph node location-number hybrid staging can significantly improve the prognosis of patients with GC.

Establishment and validation of nomograms for predicting mesorectal lymph node staging and restaging.

BACKGROUND: Preoperative determination of lymph node (LN) status is crucial in treatment planning for rectal cancer. This study prospectively evaluated the risk factors for lymph node metastasis (LNM) at staging and restaging based on a node-by-node pairing between MRI imaging findings and histopathology and constructed nomograms to evaluate its diagnostic value. METHODS: From July 2021 to July 2022, patients with histopathologically verified rectal cancer who underwent MRI before surgery were prospectively enrolled. Histological examination of each LN status in the surgical specimens and anatomical matching with preoperative imaging. Taking histopathological results as the gold standard, federating clinical features from patients and LN imaging features on MRI-T2WI. Risk factors for LN metastasis were identified by multivariate logistic regression analysis and used to create a nomogram. The performance of the nomograms was assessed with calibration plots and bootstrapped-concordance index and validated using validation cohorts. RESULTS: A total of 500 target LNs in 120 patients were successfully matched with node-by-node comparisons. A total of 353 LNs did not receive neoadjuvant therapy and 147 LNs received neoadjuvant chemoradiotherapy (neoCRT). Characterization of LNs not receiving neoadjuvant therapy and multivariate regression showed that the short diameter, preoperative CEA level, mrT-stage, border contour, and signal intensity were associated with a high risk of LN metastasis (P < 0.05). The nomogram predicted that the area under the curve was 0.855 (95% CI, 0.794-0.916) and 0.854 (95% CI, 0.727-0.980) in the training and validation cohorts, respectively. In the neoadjuvant therapy group, short diameter, ymrT-stage, internal signal, and MRI-EMVI were associated with LN positivity (P < 0.05), and the area under the curves using the nomogram was 0.912 (95% CI, 0.856-0.968) and 0.915 (95% CI, 0.817-1.000) in two cohorts. The calibration curves demonstrate good agreement between the predicted and actual probabilities for both the training and validation cohorts. CONCLUSION: Our nomograms combined with preoperative clinical and imaging biomarkers have the potential to improve the prediction of nodal involvement, which can be used as an essential reference for preoperative N staging and restaging of rectal cancer.

The clinical value of regional lymphadenectomy for intrahepatic cholangiocarcinoma.

OBJECTIVE: The aim of this study was to explore the clinical value of lymph node dissection (LND) for intrahepatic cholangiocarcinoma (ICC). METHODS: Clinical and pathological data were collected from 147 ICC patients who attended two tertiary centers over the past 5 years. The patients were classified into two groups: the LND group (group A) and the no-performance LND (NLND) group (group B). Clinical and pathological parameters were compared between the two groups to analyze the impact of LND on the long-term survival time of ICC patients. RESULTS: Of the 147 patients, 54.4% (80) received LND and 42.5% (34/80) of these were found to have lymph node metastasis (LNM). LND did not increase postoperative complications (27.5%, P = 0.354), but postoperative hospital stays were longer (12.2 ± 6.3 d, P = 0.005) in group A compared with group B (20.9%, 9.5 ± 3.5 d). The 5-year survival rates of groups A and B are almost similar (21% vs 29%, P = 0.905). The overall survival rate of cN0 (diagnosis obtained by imaging) is better than pN1 (diagnosis obtained by histopathology), but lower than pN0 (all P < 0.05). Compared with NLND, the median survival time of LND patients with T1 has not significantly improved (29.3 vs 35.1 months, P = 0.762), but the patients with T2-4 has been significantly increased (29.0 vs 17.1 months, P = 0.040). Elevated CA19-9 level (HR = 1.764, 95% CI: 1.113-2.795, P = 0.016), vascular invasion (HR = 2.697, 95% CI: 1.103-6.599, P = 0.030), and T category (HR = 1.848, 95% CI: 1.059-3.224, P = 0.031) were independent risk factors for poor long-term survival time of the ICC patients (all P values < 0.05). CONCLUSION: ICC patients with cN0 may have LNM, and the long-term survival time of LNM patients is usually poor. We suggest that patients with ICC may require routine LND, especially those with T2-4 category.

Clinical application of nano-carbon to improve the accuracy of lymph node staging in patients with advanced gastric cancer receiving neoadjuvant chemotherapy: a prospective randomized controlled trial.

BACKGROUND: The significance of nano-carbon for lymph node staging in radical gastrectomy for gastric cancer (GC) has been confirmed, but studies on its application for GC patients treated with neoadjuvant chemotherapy (NCT) are rare. The purpose of this study was to explore the clinical value of using carbon nanoparticles suspension injections (CNS) to improve the accuracy of lymph node staging (N staging) of NCT for advanced GC. METHODS: 160 advanced GC patients receiving preoperative NCT were enrolled, according to the random number generated by computer, the enrolled patients were randomly divided into two groups: experimental group (n=80) and control group (n=80). The experimental group received endoscopic injection of CNS within 24 hours prior to NCT, while the control group received this within 24 hours post NCT and before D2 radical resection. SOX [oxaliplatin: 130 mg/(body surface area, BSA): m2, first day + S-1: (BSA: <1.25 m2, 40 mg each time; ≥1.25 to <1.5 m2, 50 mg each time; ≥1.5 m2, 60 mg each time), 2 times a day, for 2 weeks] was chosen as the NCT regimen, repeat every 3 weeks, 4 cycles were performed preoperative. Surgery was performed 3 weeks after the end of the 4 cycles of chemotherapy. The staining rate, metastasis rate, metastasis rate of stained lymph nodes, postoperative complication rate, and N staging of the two groups were analyzed and compared. RESULTS: A total of 3,197 lymph nodes were harvested in the experimental group, including 384 metastatic lymph nodes, 1,424 stained lymph nodes, and 210 metastatic stained lymph nodes. The total number of lymph nodes harvested in the control group was 2,565, including 244 metastatic lymph nodes, 796 stained lymph nodes, and 94 metastatic stained lymph nodes. Compared with the control group, a higher rate of stained lymph nodes, a higher total number of lymph nodes, and an increased number of metastatic lymph nodes were detected in the experimental group. CONCLUSIONS: The application of CNS before NCT in patients with advanced GC can minimize lymph node staging bias after NCT and improve its accuracy. TRIAL REGISTRATION: Chinese Clinical Trial Registry ChiCTR2100047407.

Predicting T and N Staging of Resectable Gastric Cancer According to Whole Tumor Histogram Analysis About a Non-Cartesian k-Space Acquisition DCE-MRI: A Feasibility Study.

OBJECTIVE: To explore the feasibility of the whole tumor histogram analysis parameters derived from dynamic contrast-enhanced MRI (DCE-MRI) based on stack-of stars (StarVIBE) to predict T and N staging of resectable gastric cancer (GC). METHODS: Eighty-seven patients confirmed as GC by histopathology were enrolled in this prospective study. DCE-MRI were performed before surgery, and quantitative DCE parameters (Ktrans, Kep, Ve) and histogram metrics (Skewness, Kurtosis and Entropy) were measured by Omni-Kinetics software. Intraclass correlation coefficient (ICC) testing was used to determine the consistency of Ktrans, Kep and Ve values and histogram metrics values between two radiologists using Bland-Altman analysis. The quantitative DCE parameters or histogram metrics values between T stage or N stage were compared using ANOVA or Kruskal-Wallis testing. Receiver operating characteristic (ROC) analyses was performed to find out the best parameters for identifying T and N staging. RESULTS: There was statistical difference in Ktrans, Kep, Ve and entropy to identify T staging (P=0.015, 0.033, <0.001, and 0.007, respectively), and in pairwise comparisons of Ve values showed statistically difference between T1+2 and T3 group (P<0.001), T1+2 and T4 group (P<0.001). There were statistical differences in Ve to identify N staging (P=0.041). In ROC analysis, Ve was the best parameter for identifying T staging (AUC: 0.788, the sensitivity and specificity was 0.929 and 0.578, respectively) and N staging (AUC: 0.590, the sensitivity and specificity was 0.714 and 0.899, respectively). CONCLUSION: The whole tumor histogram analysis parameters derived from StarVIBE DCE-MRI may be able to quantitatively evaluate T and N staging of GC, so as to help clinical treatment decision optimization.

The role of lymph node dissection and a new N-staging system for intrahepatic cholangiocarcinoma: a study from the SEER database.

BACKGROUND: Although the National Comprehensive Cancer Network guidelines recommend routine lymph node dissection (LND) in intrahepatic cholangiocarcinoma (ICC), the role of LND remains controversial, and the node (N) stage is oversimplified. METHODS: Patients were identified from the Surveillance, Epidemiology, and End Results research data 18 (SEER 18). Propensity score matching (PSM) was used to reduce bias, and Kaplan-Meier curves and Cox proportional hazards models were used to compare overall survival (OS). The best cutoff values were found using X-tile software. RESULTS: Of 2037 patients included in SEER 18, 1147 underwent LND (56.3%); 389 (34.3%) had pathologically confirmed lymph node metastasis (LNM), and 316 (27.6%) had at least 6 LNDs. The median OS was worse for LND patients (34 months vs. 40 months, respectively), and this result remained after PSM. Male sex, age ≥60 years, tumor size > 5 cm, and LNM were independent prognostic risk factors for ICC. LNM ≥3 was associated with worse OS. CONCLUSIONS: Only a few LNDs met the requirements per the guidelines. LND does not improve OS in ICC, and the best approach to LND and a better N staging method should be explored further.

The influence of the number of lymph nodes removed on the accuracy of a newly proposed N descriptor classification in patients with surgically-treated lung cancer.

INTRODUCTION: The International Association for the Study of Lung Cancer has proposed a new classification of N descriptor based on the number of metastatic lymph nodes (LNs) stations, including skip metastasis. The aim of the study was to determine the effect of removed LNs on the adequacy of this new classification. MATERIALS AND METHODS: The material was collected retrospectively based on the database of the Polish Lung Cancer Group, including information on 8016 patients with non-small cell lung cancer operated in 23 thoracic surgery centers in Poland. The material covered the period from January 2005 to September 2015. We divided patients into two groups: ≤6LNs and >6LNs removed. RESULTS: In the whole group, an average of 13.4 nodes and 4.54 nodal stations were removed. 5-year survivals in the >6LNs group vs ≤ 6LNs group were: 62.3% and 55.1% (N0), 44.5% and 35.9% (N1a), 34.1% and 31,7% (N1b), 37.3% and 26.3% (N2a1), 32.4% and 26.7% (N2a2), 29.4% and 29.2% (N2b1), and 22.0% and 23.0% (N2b2), respectively. Comparing these groups, we detected significant differences at N0 (p < 0.001) and N2a1 (p = 0.022). In the ≤6LNs group, the survival curves for N2a1, N2a2, N2b1, and N2b2 overlapped (p > 0.05). In the >6LNs group, the survival curves were significantly different between grades, with survival for N2a1 better than N1b (p = 0.232). CONCLUSION: The proposed classification N descriptor is potentially better at differentiating patients into different stages. The accuracy of the classification depends on the number of lymph nodes removed. Therefore, the extent of lymphadenectomy has a significant impact on the staging of surgically-treated lung cancer.

Prognostic value of MRI-determined cervical lymph node size in nasopharyngeal carcinoma.

OBJECTIVES: To investigate the prognostic value of magnetic resonance imaging (MRI)-determined cervical lymph node (CLN) size in nasopharyngeal carcinoma (NPC). METHODS: We retrospectively reviewed 2066 patients with NPC treated with intensity-modulated radiotherapy, and randomly divided them into two groups, in a 1:1 ratio. One group was used for training (the training group), and the other one was for internal validation (the validation group). All patients had undergone MRI examination and the maximal axial diameters (MAD) of the axial plane of all positive nodes had been measured and recorded. RESULTS: Of 683 patients with CLN metastases in the training group (n = 1033), MAD = 4 cm was associated with worse OS (64.7% vs 84.6%, P < .001), DFS (55.9% vs 76.3%, P = .001), and DMFS (67.6% vs 86.1%, P = .001). Multivariate analysis showed that MAD = 4 cm was a significant negative prognostic factor for OS (HR = 2.058; P = .025), DFS (HR = 1.727; P = .049), and DMFS (HR = 2.034; P = .036). When MRI-determined MAD = 4 cm was classified as N3 in the N classification, the OS, DFS, DMFS, and RRFS survival curves were well separated. The OS, DFS, DMFS, and RRFS concordance indexes were not statistically different between the proposed N staging system and the UICC/AJCC staging system in the training group, or between the training group and the validation group (all P = .05). CONCLUSION: MAD = 4 cm on axial MRI slices can be recommended as a prognostic factor in future versions of the UICC/AJCC NPC staging system.

The value of multidetector-row computed tomography in lymph node staging of gastric cancer: a preliminary Vietnamese study.

INTRODUCTION: Gastric cancer (GC) is the fourth most common malignant disease in the world, following breast cancer, colorectal cancer, and lung cancer. This study aimed to evaluate the usefulness of multidetector-row computed tomography (MDCT) in identifying the metastatic lymph node of GC. MATERIAL AND METHODS: A cross-sectional study was performed after receiving approval by the institutional review board. A total of 88 patients with GC, who underwent radical gastrectomy, were examined by MDCT. Categorical variables were compared using Fisher's exact test. The discriminating ability of lymph node size was determined according to an area under the receiver operating curve(AUROC) analysis, and the optimal cut-off point was determined. RESULTS: The proportion of metastatic lymph node patients in the proximal group (32.3%) was significantly higher than that in the distal group (18.4%). T categorisation and lymph node sizes were significantly different between the non-metastatic lymph node and metastatic lymph node groups. The AUROC for lymph node size was 0.738, with an optimal cut-off point of 7.5 mm,producing a sensitivity of 71.5% and a specificity of 70.5%. CONCLUSIONS: MDCT displayed medium accuracy for the determination of metastatic lymph nodes and N categorisation. Based on our findings, although MDCT is generally the first choice for preoperative assessments in GC patients, other diagnostic modalities should supplement MDCT in order to achieve more precise N staging.

Histologically Confirmed Diagnostic Efficacy of 18F-rhPSMA-7 PET for N-Staging of Patients with Primary High-Risk Prostate Cancer.

18F-rhPSMA-7 (radiohybrid prostate-specific membrane antigen [PSMA]) is a novel ligand for PET imaging. Here, we present data from a retrospective analysis using PET/CT and PET/MRI examinations to investigate the efficacy of 18F-rhPSMA-7 PET for primary N-staging of patients with prostate cancer (PC) compared with morphologic imaging (CT or MRI) and validated by histopathology. Methods: Data from 58 patients with high-risk PC (according to the D'Amico criteria) who were staged with 18F-rhPSMA-7 PET/CT or PET/MRI at our institution between July 2017 and June 2018 were reviewed. The patients had a median prescan prostate-specific antigen value of 12.2 ng/mL (range, 1.2-81.6 ng/mL). The median injected activity of 18F-rhPSMA-7 was 327 MBq (range, 132-410 MBq), with a median uptake time of 79.5 min (range, 60-153 min). All patients underwent subsequent radical prostatectomy and extended pelvic lymph node dissection. The presence of lymph node metastases was determined by an experienced reader independently for both the PET and the morphologic datasets using a template-based analysis on a 5-point scale. Patient-level and template-based results were both compared with histopathologic findings. Results: Lymph node metastases were present in 18 patients (31.0%) and were located in 52 of 375 templates (13.9%). Receiver-operating-characteristic analyses showed 18F-rhPSMA-7 PET to perform significantly better than morphologic imaging on both patient-based and template-based analyses (areas under curve, 0.858 vs. 0.649 [P = 0.012] and 0.765 vs. 0.589 [P < 0.001], respectively). On patient-based analyses, the sensitivity, specificity, and accuracy of 18F-rhPSMA-7 PET were 72.2%, 92.5%, and 86.2%, respectively, and those of morphologic imaging were 50.0%, 72.5%, and 65.5%, respectively. On template-based analyses, the sensitivity, specificity, and accuracy of 18F-rhPSMA-7 PET were 53.8%, 96.9%, and 90.9%, respectively, and those of morphologic imaging were 9.6%, 95.0%, and 83.2%, respectively. Conclusion:18F-rhPSMA-7 PET is superior to morphologic imaging for N-staging of high-risk primary PC. The efficacy of 18F-rhPSMA-7 is similar to published data for 68Ga-PSMA-11.

A Meta-Analysis And Systematic Review Of Accuracy Of Endoscopic Ultrasound For N Staging Of Gastric Cancers.

BACKGROUND: Endoscopic ultrasonography (EUS) is widely used as a staging modality for gastric cancer. However, the results of studies on the use of EUS for N staging in gastric cancer vary. This study aimed at studying the overall diagnostic accuracy of EUS for N staging of gastric cancer. METHODS: Published studies were identified through searching the MEDLINE, Web of Science, EMBASE, SpringerLink and ScienceDirect databases. A bivariate random effect model was used to estimate the sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), and diagnostic odds ratio (DOR). A hierarchical summary receiver operating characteristic curves (HSROC) based on the pooled data was also computed. RESULTS: Fifty studies (5223 patients) were included in this analysis. The pooled sensitivity, specificity, PLR, NLR and DOR of EUS for N staging were 0.82 (95% CI 0.78 to 0.85), 0.68 (0.63 to 0.73), 2.6 (2.2 to 3.0), 0.27 (0.22 to 0.32), and 10 (8 to 12), respectively. The area under the HSROC was 0.83. CONCLUSION: The EUS may provide a clinically useful tool to guide physicians in the N staging of gastric cancer. However, physicians must note that the EUS has a relatively low specificity.

[The effect of standardized lymphectomy and sampling of resected lymph nodes on TNM staging of resectable pancreatic head cancer].

Objective: To examine the effect of standardized lymphectomy and sampling of resected lymph nodes (LN) on TNM staging of resectable pancreatic head cancer. Methods: Consecutive patients with resectable pancreatic head cancer who received standard pancreatoduodenctomy at Department of General Surgery in Beijing Hospital from December 2017 to November 2018 were recruited as study group. After operation, the surgeon sampled lymph nodes from the fresh specimen following the Japanese Gastric Cancer Guidelines.Thirty-three cases were recruited in the study group and the mean age was (59.8±15.2) years.Pathologic reports from December 2015 to November 2016 were taken as control group, containing 29 cases with age of (57.0±13.0) years. Number of lymph nodes, standard-reaching ratio and positive nodes ratio were compared between two groups. According to the seventh edition and eighth edition of TNM staging, the changes of N staging and TNM staging were analysed. The quantitative data conforming to normal distribution were tested by independent sample t test, the quantitative data not conforming to normal distribution were tested by rank sum test, and the enumeration data were analysed by χ(2) test. Results: The basal data of the two groups were comparable (all P>0.05) . The number of lymph nodes sampled in the study group was 23.27±8.87, significantly more than in control group (12.86±5.90, t=0.653, P=0.000) .Ratio of cases with more than 15 nodes was 81.8% (27/33) in the study group and 34.5% (10/29) in the control group with statistical significance (χ(2)=14.373, P=0.000) . In the study group, the positive lymph node ratios of No. 17a+17b, 14a+14b, 8a+8p LN were 36.4% (12/33) , 30.3% (10/33) and 9.1% (3/33) respectively. The positive lymph node ratio in No.14a+14b LN was higher than in No.8 LN (χ(2)=4.694, P=0.030) . According to the change in N staging system in the AJCC eighth edition, 2 cases (6.1%, 2/33) changed from ⅠB to ⅡA, 7 cases (21.2%, 7/33) from ⅡA to ⅠB and 5 cases (15.2%, 5/33) changed from ⅡB to Ⅲ (25.0%, 5/20) . Conclusions: No.14 LN should be treated as the first station rather than second station because of the anatomic character and higher metastatic ratio. Standardised lymphectomy and sampling may increase the number of LN resected and improve the TNM staging of resectable pancreatic head cancer.

The value of mediastinoscopy in N staging of clinical N2 lung cancer.

BACKGROUND: To determine the value of mediastinoscopy in N staging of lung cancer with clinical N2 disease. METHODS: We retrospectively reviewed 87 patients who received mediastinoscopy for known or suspected lung cancer, including 83 cervical mediastinoscopies and 4 parasternal mediastinoscopies. All patients were clinically staged N2 for enlarged ipsilateral mediastinal and/or subcarinal lymph nodes (short axis >1.0 cm) on computed tomography scan. RESULTS: Of the 87 patients, 61 cases proved to be N2 disease by mediastinoscopy; the other 26 mediastinoscopy-negative patients underwent thoracotomy for lung resection and mediastinal lymph node dissection in the same operation. Final pathologic N staging was consistent with mediastinoscopic sampling and surgical dissection in 24 patients, and N2 disease was found in 2 patients (false-negative by mediastinoscopy). The sensitivity, specificity, and accuracy of mediastinoscopy were 96.8%, 100%, and 97.7%, respectively. Among all 87 mediastinoscopic procedures, there was no mortality and only 1 complication (1.1%). CONCLUSIONS: Mediastinoscopy is a highly effective and safe procedure for the mediastinal staging of lung cancer with clinical N2 disease.

Diffusion-weighted imaging and loco-regional N staging of patients with colorectal liver metastases.

INTRODUCTION: Diffusion-weighted MRI (DWI) contributes to N staging of rectal cancers and diagnosis of colorectal liver metastases (CLM). About 15% of CLM patients have loco-regional lymph node (LN) metastases that impact prognosis and treatment strategy. This retrospective study is the first one to evaluate quantitative ADC measurement as a tool to identify metastatic LNs in patients with liver metastases from colorectal cancer. METHODS: All consecutive patients undergoing surgery for CLM between 2008 and 2015 were considered. Inclusion criteria were: intraoperative retrieval of at least one LN; LN ≥ 5 mm; DWI performed ≤2 months before surgery. The ADC and ADCratio (ADCLN/ADCCLM) were computed by two radiologists for all the LNs. RESULTS: Among 555 patients operated for CLM, 32 met the inclusion criteria. Fifty-six LNs were analyzed and 28 were metastatic. ADC and ADCratio in metastatic LNs were lower than in benign LNs (ADC = 1.37 vs. 1.83 × 10-3 mm2/s, p < 0.001; ADCratio = 1.26 vs. 1.73, p < 0.001). The optimal cut-off value for ADC was 1.48 x 10-3 mm2/s (AUC = 0.85, p < 0.001, sensitivity/specificity/accuracy 79%/93%/86% in per LN-analysis and 94%/86%/91% in per-patient analysis). The optimal cut-off for ADCratio was 1.15 (AUC = 0.80, p < 0.001, sensitivity/specificity/accuracy 69%/93%/81% and 76%,93%/84%). Excellent inter- and intra-operators' agreements were observed. CONCLUSION: In patients with CLM, ADC values < 1.48 x 10-3 mm2/s can be postulated as a cut-off to distinguish metastatic LNs.

Prognostic factors of radical gastrectomy for stage Ⅲ gastric cancer and predictive value of metastatic lymph node ratio for prognosis: a report of 995 cases / 中华消化外科杂志

Objective To investigate the prognostic factors of radical gastrectomy for stage Ⅲ gastric cancer and predictive value of metastatic lymph node ratio for prognosis.Methods The retrospective case-control study was conducted.The clinicopathological data of 995 patients with stage Ⅲ gastric cancer who were admitted to the Zhongshan Hospital of Fudan University between January 2003 and December 2014 were collected.There were 690 males and 305 females,aged from 20 to 75 years,with an average age of 61 years.After clinical staging according to results of preoperative accessory examinations,patients with early gastric cancer underwent D1+ lymphadenectomy,patients with advanced gastric cancer underwent D2 lymphadenectomy and patients with serosa invasion underwent D2+ lymphadenectomy.Observation indicators:(1) treatment situations;(2) follow-up and survival situations;(3) prognostic factors analysis after operation;(4) stratified analysis:① stratified analysis of tumor pathological N staging;② stratified analysis of number of lymph node dissected;③ stratified analysis of tumor pathological TNM staging;(5) receiver operating characteristic (ROC) curve.Patients were followed up using outpatient examination and telephone interview to detect postoperative survival up to January 2016.The overall survival time was from the operation data to last follow-up or time of death.Measurement data with normal distribution were represented as Mean±SD.The survival rate and curve were respectively calculated and drawn by the Kaplan-Meier method and Log-rank test was used for survival analysis.The COX proportional hazard model was used for univariate and multivariate analysis.The ROC curve and area under curve (AUC) were used to check the accuracy of number of positive lymph nodes and metastatic lymph node ratio for prognosis.Comparison of the AUC was analyzed by the Z test.Results (1) Treatment situations:of 995 patients underging gastrectomy,677 underwent distal gastrectomy,85 underwent proximal gastrectomy,233 underwent total gastrectomy.There were 117 undergoing D1+ lymphadenectomy and 878 undergoing D2 lymphadenectomy or D2+ lymphadenectomy.The number of lymph node dissected,number of positive lymph nodes,metastatic lymph node ratio were 27± 12,10± 9 and 0.41±0.28,respectively.(2) Follow-up and survival situations:995 patients were followed up for (35± 32)months.During the follow-up,the 1-,3-,5-year overall survival rates were 77.9％,47.8％,36.2％.(3) Prognostic factors analysis after operation:results of univariate analysis showed that sex,tumor histological type,vascular embolus,degree of tumor invasion,tumor pathological N staging,number of lymph node dissected,metastatic lymph node ratio,tumor pathological TNM staging were related factors affecting prognosis of radical gastrectomy for stage Ⅲ gasteric cancer (hazard ratio =0.817,1.486,1.268,2.173,1.957,1.737,3.357,2.169,95％ confidence interval:0.686-0.973,1.059-2.086,1.074-1.497,1.195-3.954,1.480-2.588,1.390-2.170,2.476-4.602,1.740-2.704,P＜0.05).Results of multivariate analysis showed that sex,tumor histological type,tumor pathological N staging,number of lymph node dissected,metastatic lymph node ratio,tumor pathological TNM staging were independent factors affecting prognosis of radical gastrectomy for stage Ⅲ gastric cancer (hazard ratio =0.805,1.476,0.237,1.475,3.811,3.600,95％ confidence interval:0.673-0.963,1.049-2.087,0.083-0.678,1.140-1.909,2.259-6.428,1.317-9.839,P＜0.05).(4) Stratified analysis:of the 995 patients,the postoperative l-,3-,5-year overall survival rates were 93.7％,69.6％,60.5％ in the patients with metastatic lymph node ratio ≤ 0.1,86.9％,60.6％,44.3％ in the patients with 0.1 ＜ metastatic lymph node ratio ≤0.4 and 64.3％,28.9％,21.0％ in the patients with metastatic lymph node ratio ＞ 0.4,showing a statistically significant difference (x2 =121.300,P＜0.05).There were statistically significant differences between patients with metastatic lymph node ratio ≤0.1 and patients with 0.1＜ metastatic lymph node ratio ≤0.4,between patients with metastatic lymph node ratio ≤0.1 and patients with metastatic lymph node ratio ＞0.4 (x2=7.580,65.320,P＜0.05).There was a statistically significant difference between patients with 0.1 ＜ metastatic lymph node ratio ≤0.4 and patients with metastatic lymph node ratio＞0.4 (x2 =80.806,P＜0.05).① Stratified analysis of tumor pathological N staging:the average metastatic lymph node ratio was 0.09 in the 132 stage N1 patients,who were divided into the patients with metastatic lymph node ratio ≤ 0.1 and ＞ 0.1.The postoperative 1-,3-,5-year overall survival rates were 92.2％,68.6％,59.1％ in the 108 patients with metastatic lymph node ratio ≤ 0.1 and 79.2％,32.8％,21.9％ in the 24 patients with metastatic lymph node ratio ＞0.1,respectively,showing a statistically significant difference (x2 =14.499,P＜0.05).The average metastatic lymph node ratio was 0.23 in the 265 stage N2 patients,who were divided into the patients with metastatic lymph node ratio ≤0.2 and ＞0.2.The postoperative 1-,3-,5-year overall survival rates were 92.3％,73.8％,61.0％ in the 138 patients with metastatic lymph node ratio ≤0.2 and 76.5％,40.1％,22.2％ in the 127 patients with metastatic lymph node ratio ＞0.2,respectively,showing a statistically significant difference (x2 =42.536,P＜0.05).The average metastatic lymph node ratio was 0.56 in the 598 stage N3 patients,who were divided into the patients with metastatic lymph node ratio ≤0.4 and ＞0.4.The postoperative 1-,3-,5-year overall survival rates were 88.5％,62.8％,47.0％ in the 194 patients with metastatic lymph node ratio ≤ 0.4 and 64.3％,29.8％,21.0％ in the 404 patients with metastatic lymph node ratio ＞0.4,respectively,showing a statistically significant difference (x2 =51.860,P＜ 0.05).② Stratified analysis of number of lymph node dissected:7 of 117 patients with the number of lymph node dissected ＜ 15 had metastatic lymph node ratio ≤0.1,who were divided into patients with metastatic lymph node ratio ≤0.4 and ＞0.4.The postoperative 1-,3-,5-year overall survival rates were 78.2％,40.0％,28.6％ in the 44 patients with metastatic lymph node ratio ≤0.4 and 78.1％,18.7％,12.9％ in the 73 patients with metastatic lymph node ratio＞0.4,respectively,showing a statistically significant difference (x2 =4.727,P＜0.05).③ Stratified analysis of tumor pathological TNM staging:of 262 patients with stage Ⅲa gastric cancer,the postoperative 1-,3-,5-year overall survival rates were 88.5％,65.0％,54.3％ in the 230 patients with metastatic lymph node ratio ≤0.4 and 77.5％,35.4％,29.5％ in the 32 patients with metastatic lymph node ratio ＞0.4,respectively,showing a statistically significant difference (x2 =6.132,P＜0.05).Of 296 patients with stage Ⅲb gastric cancer,the postoperative 1-,3-,5-year overall survival rates were 84.4％,60.7％,42.7％ in the 200 patients with metastatic lymph node ratio ≤ 0.4 and 59.9％,26.8％,21.7％ in the 96 patients with metastatic lymph node ratio ＞0.4,respectively,showing a statistically significant difference (x2 =23.699,P＜0.05).Of 437 patients with stage Ⅲ c gastric cancer,the postoperative 1-,3-,5-year overall survival rates were 84.7％,59.9％,38.7％ in the 133 patients with metastatic lymph node ratio ≤0.4 and 64.0％,27.9％,18.3％ in the 304 patients with metastatic lymph node ratio ＞0.4,respectively,showing a statistically significant difference (x2=36.215,P＜ 0.05).(5) ROC curve:ROC curves of postoperative overall survival rates in patients with stage Ⅲ gastric cancer were drawn using the number of positive lymph nodes and metastatic lymph node ratio,of which AUC were 0.619 (95％ confidence interval:O.588-0.649) and 0.706 (95％ confidence interval:0.677-0.734),showing a statistically significant difference (Z=8.842,P＜0.05).Conclusions Sex,tumor histological type,tumor pathological N staging,number of lymph node dissected,metastatic lymph node ratio,tumor pathological TNM staging are independent factors affecting prognosis of radical gastrectomy for stage Ⅲ gastric cancer.There is different prognosis of patients with different metastatic lymph node ratios in the subgroup of the same tumor pathological TNM staging,number of lymph node dissected,tumor pathological TNM staging.Compared with tumor pathological N staging,metastatic lymph node ratio has a more accurate predictive value for prognosis.