| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Ann Thorac Surg 2002;73:259-266
© 2002 The Society of Thoracic Surgeons
a Nuclear Medicine Service, Department of Radiology, New York, NY, USA
b Thoracic Surgery Service, Department of Surgery, New York, NY, USA
c Department of Radiology, New York, NY, USA
d Biostatistics Service, Department of Biostatistics and Epidemiology, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
e Division of Thoracic Surgery, Toronto General Hospital, Toronto, Ontario, Canada
* Address reprint requests to Dr Akhurst, Nuclear Medicine Service, Department of Radiology, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10021, USA
e-mail: akhurstt{at}mskcc.org
Presented at the Thirty-seventh Annual Meeting of The Society of Thoracic Surgeons, New Orleans, LA, Jan 29–31, 2001.
 |
Abstract |
|---|
 Top Abstract IntroductionPatients and methodsResultsCommentAcknowledgmentsDiscussionReferences |
|---|
Methods. We reviewed our institutional experience with FDG-PET imaging followed by surgical staging of nonsmall cell lung cancer after induction therapy. A nuclear physician blinded to surgical findings reviewed the FDG-PET scans and assigned a clinical TNM stage. A thoracic surgeon assigned a pathologic TNM stage. Then the clinical TNM stage and the pathologic TNM stage were compared.
Results. Fifty-six patients (30 males and 26 females; median, age 60) with nonsmall cell lung cancer underwent chemotherapy (40 patients), chemoradiation (11 patients), or radiation alone (5 patients) followed by PET and operations. PET had a positive predictive value of 98% for detecting residual viable disease in the primary tumor. PET over-staged nodal status in 33% of patients, under staged nodal status in 15%, and was correct in 52%. PET correctly classified all patients with M1 disease.
Conclusions. Positron emission tomography after induction therapy accurately detects residual viable primary tumor, but not the involvement of mediastinal lymph nodes.
|
Introduction |
|---|
|
TopAbstractIntroductionPatients and methodsResultsCommentAcknowledgmentsDiscussionReferences |
|---|
To date, only one small study has addressed the accuracy of FDG-PET scanning after induction therapy for lung cancer [7]. In this study, 9 of 15 patients who had FDG-PET scans before and after chemotherapy underwent surgical resection if radiography showed they had partial (8 of 15) or minor (1 of 15) response on CT; the remaining patients received consolidative radiotherapy without surgical exploration. In the group of 9 patients who underwent surgical staging, PET was held to be 100% accurate in assessing mediastinal stage.
Possible justifications for obtaining a FDG-PET scan after induction therapy could include any or all of the following: (1) Overall restaging; (2) Assessment of response compared with a pretreatment scan; or (3) The documentation of the presence of residual viable tumor. Restaging is an important clinical issue in lung cancer patients because induction therapy followed by surgery for loco-regionally advanced NSCLC (ie, involvement of N2 nodes) may improve survival over an operation alone [8–11]. Operations after induction therapy for N2 disease appears most effective when there is pathologic evidence of response. In patients with N2 disease treated with induction chemotherapy followed by operation, with no residual mediastinal nodal disease being found, 5-year survival rates of 54% have been reported compared with a 5-year survival of 17% seen in all patients treated with induction therapy [12, 13]. It is therefore likely that curative operations should only be offered to those patients with objective evidence of response.
However, to date, response assessment has required surgical evaluation. Computed tomographic findings after induction therapy correlate poorly with pathologic findings, often underestimating the degree of response [14, 15]. In the absence of accurate radiographic imaging, and short of a thoracotomy, mediastinoscopy and mediastinotomy are currently the best means of staging the mediastinum. However, either procedure may be difficult to perform after induction therapy, whether it’s because of scarring by medical or radiation therapy or because of the performance of prior surgical procedures [16–18]. Therefore, an accurate noninvasive means of defining TNM status after induction therapy is needed and, if available, would represent an important therapeutic advance. The usefulness of FDG-PET in this setting has not been completely evaluated.
In order to assess the accuracy of FDG-PET after induction therapy for lung cancer, we performed a retrospective review of the Memorial Sloan-Kettering Cancer Center experience in patients with NSCLC who had PET imaging after induction therapy and before intrathoracic surgical staging.
|
Patients and methods |
|---|
|
TopAbstractIntroductionPatients and methodsResultsCommentAcknowledgmentsDiscussionReferences |
|---|
FDG-PET scanning
All patients were instructed to fast for more than 6 hours before the intravenous injection of 370 to 555 MegaBequerels (MBq) of FDG. All patients had an uptake time of at least 45 minutes before commencement of imaging. All patients were studied on a dedicated state of the art whole body PET scanner, the GE Advance (GEMS, Milwaukee, WI), which has an axial field of view of 15 cm and a resolution of 4.5 mm in the center of the field of view for F-18. Post-emission transmission scans were performed on all patients allowing an iterative algorithm to be used for reconstruction.
Image analysis
The re-reading of the FDG scans was performed first in a blinded fashion by an experienced PET reader (T.A.), with later unblinding to all clinical data available before surgical staging. A second re-reading was performed in consultation with a thoracic radiologist (M.G.). Sites of abnormal CT (abnormal lesion in terms of size and position [lymph nodes > 1 cm in size]) and PET findings (visual estimation site of FDG uptake thought on balance to represent malignant tissue) were recorded, and a clinical TNM stage was assigned to each patient.
Surgical staging and data analysis
A final surgical-pathologic TNM stage was assigned to each patient by a thoracic surgeon (RD) based on all clinical data including operative findings and pathologic reports according to the International System for Staging Lung Cancer [19]. The two TNM stages were then compared. A separate analysis was performed stratified by the patient’s treatment.
|
Results |
|---|
|
TopAbstractIntroductionPatients and methodsResultsCommentAcknowledgmentsDiscussionReferences |
|---|
Fourteen of these 56 patients had also undergone a pretreatment FDG-PET scan. Forty-six patients had a posttreatment CT contemporaneous to the FDG-PET scan available for review, 9 had a pretreatment CT also available for review, and no CT was available for review in 10 patients. Because not all lesions were biopsied in all patients, T status could be compared in 51 patients (91%) and N status in 54 patients (96%); overall, 50 of the 56 patients (89%) were assessable for a clinical TNM stage and a pathologic TNM stage comparison. When the primary tumor (n = 5) or nodes were not sampled (n = 2), these data points were excluded from analysis.
Lung resection was performed in conjunction with other procedures in 20 patients, including chest wall resection (n = 9), mediastinoscopy (n = 9), or resection of a site of hematogenous spread (M1 disease) (n = 7), or a combination of these. In 6 patients, exploration with biopsy alone was performed because a R0 resection could not be achieved.
T staging
The FDG-PET was accurate in the detection of the presence or absence of disease in the primary site. Most of the errors in T staging (26 errors in 51 patients) related to under staging T4 disease (n = 8, 3 who had two primaries in the same lobe, 3 with direct mediastinal involvement, and 2 with vertebral involvement); as well as the distinction between T1 and T2 disease (n = 7). Subgroup analysis for those patients receiving chemotherapy alone or radiation therapy, with or without chemotherapy, did not reveal any obvious systematic error in clinical T staging attributable to the treatment. Data regarding the accuracy of FDG-PET in predicting viability of the primary tumor are presented in Table 1.
Three of 5 patients whose FDG-PET was falsely negative had been treated with combined chemoradiation. The positive and negative predictive values of the FDG scan for the presence of viable tumor were 98% and 29%, respectively.
|
|
|
In patients who were pathologically N0, PET over staged 12 of 28 patients; conversely, PET falsely called 6 patients with pathologic N1 and N2 disease N0. The PET staged 7 patients as N3, 3 of whom had N0 disease on unilateral mediastinal lymph node dissection; 2 of whom had N2 disease found during operation (Fig 2), and 2 who did not have mediastinal node dissection.
|
|
The influence of CT data
A nuclear medicine physician (TA) using available CT images and reports made an initial assessment of a clinical TNM stage. Re-review of the CT images by a thoracic radiologist (MG) did not significantly influence the accuracy of the clinical TNM stage assignment (data not shown) (Fig 3).
|
Comment |
|---|
|
TopAbstractIntroductionPatients and methodsResultsCommentAcknowledgmentsDiscussionReferences |
|---|
Unfortunately, based on this data, we cannot determine whether a change seen between PET scans performed before and after induction therapy will correlate with pathologic estimates of response or with survival. At the Memorial Sloan-Kettering Cancer Center, referrals for operation post induction administered outside the institution form a significant fraction of our surgical practice and therefore, most patients seen during this time interval have had a single posttreatment PET scan. We plan to develop a multicenter trial to determine the predictive value of PET imaging performed before and after induction therapy.
Effective cancer treatments lead to increased cancer cell death rate and a reduction in the metabolic signal of the cancerous lesion. Normal tissues also react to treatment with influx of metabolically active phagocytes and cytokines that lead to increased vascular permeability and vasodilatation, increasing the FDG available to the tissues in the region of the tumor. It is probable that the metabolic signals arising from malignant and the benign tissues may converge reducing the ability of PET to distinguish benign from malignant tissue.
Unfortunately, in our patients, FDG-PET imaging was unsatisfactory in the determination of the simple presence or absence of cancer in any mediastinal lymph node (see Table 3). It must be noted, that in this study, the presence or absence of pathologic N3 disease remained largely unconfirmed, as contralateral exploration was not routinely performed posttreatment. In this series, semiquantitative analysis using standardized uptake values was unable to differentiate benign from malignant nodes (data not shown). The PET was also unable to correctly differentiate stages IIIA and IIIB based on T stage because of inaccuracies in the assessment of T4 disease, a problem that may be overcome with the combined PET/CT machines that are currently being developed.
|
It is not surprising that there was a high degree of accuracy in the diagnosis of M1 stage with PET as these neoplasms are often resistant to therapy and likely to remain metabolically active. The accuracy of PET imaging in disease resistant to chemotherapy could be expected to resemble that seen in patients with untreated NSCLC.
The degree of over staging was worse for TNM than T or N alone, because of the nature of the TNM staging system, where any over call of T, N, or M status is likely to lead to up-staging of overall TNM status.
The influence of CT data
It was expected the addition of expert CT data would improve the diagnostic accuracy of FDG-PET imaging alone, however this proved not to be the case in this retrospective review, as many of the CTs were no longer available for review, and those that were, were often of poor quality. A prospective study using helically acquired CT data registered to the FDG-PET scan or ideally, a combined PET-CT machine should enable better characterization of T stage.
In spite of FDG-PETs excellent performance in the staging of untreated NSCLC, our experience with FDG-PET staging of lung cancer after induction therapy has been disappointing. In the absence of a clinical trial that proves otherwise, it currently appears that an isolated FDG scan even with a concurrent CT should not be relied upon to stage patients with NSCLC after induction therapy. Based on our data, surgical staging remains the only effective means of characterizing patients after induction therapy. Radiation either alone or in combination with chemotherapy may contribute to false positive N staging of NSCLC by FDG-PET, although this remains to be proven in a larger study group. Persistent FDG uptake in a primary tumor or a metastasis is strongly predictive of residual viable tumor and should not be ignored; however, we are unable to comment on PET findings that correlate well with a complete pathologic response. Future prospective studies are required to confirm these preliminary data, and to explore other questions, in particular, whether changes in PET imaging performed before and after treatment correlated with the degree of pathologic response and likelihood of long-term survival.
|
Acknowledgments |
|---|
|
TopAbstractIntroductionPatients and methodsResultsCommentAcknowledgmentsDiscussionReferences |
|---|
|
Discussion |
|---|
|
TopAbstractIntroductionPatients and methodsResultsCommentAcknowledgmentsDiscussionReferences |
|---|
Although the authors acknowledge the limitations of their retrospective review, the 56 patients in this study represent only one fifth of the 290 patients who underwent thoracotomy after induction treatment during this study period. What clinical or radiographic criteria were used in selecting these 56 patients for PET imaging at this juncture? Does this represent a selection bias that may strongly impact the results and conclusions of the study?
The fact that PET scanning did poorly in evaluating the T status of the primary tumor is expected. This is a physiologic test that has an inherent resolution no better than 4 to 5 mm. Even with the development of hybrid computed tomography (CT) PET scanners, it is unlikely that our attempts to conjoin a metabolic test with an anatomic surgical CT road map will be of much benefit in regard to the assessment of the primary tumor. Whether the tumor is a localized T1, T2, T3, or T4 lesion, en bloc resections remain our surgical dictum, and decisions regarding resectability will continue to be made in the operating room and not the nuclear medicine suite. The pathologist will continue to have the final word in regard to the T assignment. Similarly, trying to separate N1 nodal disease by PET from the primary lesion has little clinical value, as these nodes will be completely removed with the primary by an anatomic resection as consistently performed at Memorial Sloan-Kettering Cancer Center.
It is recognized that a wide variety of factors can contribute to a false positive PET image. What criteria did you use in this study to determine that a site was in fact positive? Were standard uptake value(s) (SUVs) or visual response scores, or both, used?
A PET’s inability to accurately characterize N2 and N3 nodes is certainly a disappointment and the key "take-home" message of this article. Patients with persistent or progressive mediastinal nodal disease after induction therapy are unlikely to benefit from an open thoracotomy. Consistent and appropriate selection of patients who will and will not benefit from a thoracotomy is our continuing surgical quest. Redo mediastinoscopies can be performed with low morbidity, although often tedious the second time around. It would have been our hope that PET scanning could minimize the need for repeat mediastinal explorations, however, Dr Downey’s data does not absolve us of these difficult management decisions.
Did the size of the metastatic focus within the mediastinal nodes or the subtype histology of the lesions contribute to these poor results? In the article you describe, 7 patients were PET positive for N3 disease, but none of these patients had subsequent sampling of these nodes. Have these patients been followed up and have they recurred in these PET-predicted sites?
Finally, in your study, PET imaging correctly identified 10 patients with metastatic disease. Were correlative radiographs done of these sites and did they subsequently have patterns of failure at these sites? With PET’s ability to detect distant mets, do you continue to use bone scans in your practice?
Once again, I enjoyed your article and thank the Society for the opportunity to discuss it at this plenary session.
DR RICHARD H. FEINS (Rochester, NY): I would just like to ask Dr Downey if there was a time factor in terms of when the scans were done following neoadjuvant treatment, and if there is a time factor, how would that potentially impact the ability of PET to determine recurrence in patients who have been treated? Thank you.
DR ERIC VALLIERES (Seattle, WA): Doctor Downey, 8% of your patients, despite re-imaging, including PET, ended up with exploration only. What were the findings at thoracotomy in these patients, and how was that missed on PET scan?
DR SCOTT SWANSON (Boston, MA): Did you compare PET head to head with CAT scan? In other words, did PET add anything over simply re-analyzing a CAT scan in this study?
DR DOWNEY: I would like to thank Dr Walsh for his comments. Of his questions, I would like to answer the ones regarding the selection criteria, that is, how we came up with 56 patients, the question about tissue confirmation for N3 and M1 disease, about histologies, and about bone scan. The two questions regarding the more detailed aspects of PET imaging, specifically, what were the criteria for defining a lesion as positive on PET scan and also the influence of the size of the lesion on the accuracy of PET scan, I would like to refer to my colleague, Dr Timothy Akhurst, after I have answered the first five questions.
First, regarding the selection criteria, this was our consecutive experience with 56 patients, but it does represent a subgroup of patients within the overall group of 290 patients who were seen and operated on at Memorial Sloan-Kettering Cancer Center after induction therapy during this time interval. The decision to obtain a PET scan after medical therapy for the lung cancer and prior to operation was made at the discretion of the operating surgeon. The reasons why one patient and not another may have had a PET scan is difficult to reconstruct in retrospect. There were no specific recommendations or selection criteria during that time for an individual patient to receive a PET scan. This points out the need for prospective studies in which the decisions for moving forward on a pattern of care may be more readily apparent.
Second, regarding histology, all patients had histologic-proven nonsmall cell carcinoma, excluding bronchoalveolar cancer. We did not do subgroup analysis for individual histologies such as squamous cell cancer versus adenocarcinoma.
Third, regarding the histological confirmation of disease at M1 sites or within N3 nodes, looking at the M1 sites first, there were 10 patients who by PET criteria had evidence for M1 disease. All 10 patients had either concurrent or subsequent pathological confirmation of disease within that site or had evidence for progression of disease within that site by radiographic criteria. The high number of patients with M1 disease during the time period of this study reflects the fact that we had an open protocol within our institution for induction therapy for patients with a solitary site of metastatic disease to be followed by complete resection of all sites of disease. This protocol has been presented in abstract form.
Regarding the 7 patients with evidence for N3 disease by PET, none of those patients had, as Dr Walsh said, biopsy of N3 nodes, and this points out one limitation of our study. Of the 7 patients, 5 of them had mediastinal lymph node dissection ipsilateral to the site of the primary tumor. Three patients who had ipsilateral mediastinal lymph node dissections had no evidence of any disease in any sampled lymph node. Two patients who had ipsilateral mediastinal lymph node dissections had involved N2 nodes. There were 2 patients who had no lymph nodes sampled at all. Both of these patients had evidence for inoperability at thoracotomy prior to the time at which mediastinal lymph node dissection would be performed. We do not have long-term follow-up on these 7 patients to find out whether they did or did not progress within the N3 nodes, and I think this points out, again, the need for prospective studies with an attempt to provide tissue characterization of all sites of FDG uptake if at all possible.
Finally, regarding the use of a bone scan, this is an area that is clearly in evolution. I can not, based on the information that is available, make a recommendation as to whether or not PET scan replaces or complements bone imaging at this time. This will be answered hopefully in part by the completion of the American College of Surgeons oncology group protocol Z50, which will allow us to state whether or not PET imaging detects more sites of disease than bone scan.
I would like to ask Dr Akhurst to answer the two questions regarding the details of PET imaging.
DR AKHURST: I would like to thank Dr Walsh for his question. All interpretations of an imaging study are exactly that, interpretations of all information available to the reader at the time a report is generated. The information available at the time of the generation of the data for this study included treatment given, and in most cases a CT performed at some point prior to the PET studies. In terms of individual lesions, any area of increased FDG uptake, is potentially abnormal if it is (1) usually not seen in that anatomical site, or (2) hypermetabolic in comparison to normal.
Receiver operator characteristic curves (ROC) are statistical devices used to establish accuracy of interpretation of data, and have been applied in medical imaging to compare accuracy of various tests as well as to establish thresholds to optimize accuracy of data interpretation. Previous ROC analysis in untreated lung cancer patients has shown that for mediastinal nodes a SUV of 4.4 was a useful cut-off to distinguish benign from malignant nodes. In the same report, it was noted that SUV-based reporting performed no better than visual interpretation of the images [20]. This is not surprising, as there has to be a subjective decision to draw a region of interest around a lesion before the SUV is generated. Although an SUV is an objective number, there is then a significant subjective element inherent in SUV-based data. The same group reported their initial experience in lung cancer restaging posttherapy, and for their analysis used a visual scale with nodes whose activity was greater than mediastinal blood pool considered positive for the presence of malignancy [21]. This is not an unreasonable approach, as a component of the signal seen by the camera in a given tissue is due to intravascular FDG, and is therefore related to the fact that the tissues are viable. If one assumes that the non-nodal mediastinal tissues have a similar proportion of their mass as blood pool as the mediastinal nodes, we could consider any nodal activity greater than blood pool as suspicious for malignancy.
In this study the PET reader knew that therapy had been given previously, and was therefore expecting that the degree of hypermetabolism of any cancer would be reduced in comparison to that seen in untreated lung cancer. It was therefore assumed that a threshold of 4.4 for the presence of malignancy in mediastinal nodes would be inappropriate for this analysis. Each area seen on this study was subjectively interpreted on its own merits, as described above, but broadly speaking, lesions with an SUV of greater than 2.5 were considered more suspicious than lesions less than 2.5, a level that approximates the typical SUV of the mediastinal blood pool [22]. The semiquantitative analysis we performed did not assist in the correct assignment of malignancy, as there was considerable overlap of benign and malignant nodes seen in terms of their SUV.
DR DOWNEY: Regarding Dr Feins’ question about the time factor, some of these patients had their treatments initiated outside Memorial Sloan-Kettering Cancer Center and then came at varying times after completion of treatment to be considered for surgical resection. Others had induction therapy initiated and completed at Memorial Sloan-Kettering Cancer Center. For our patients, the average length of time for the PET scan to be performed was within 2 to 3 weeks after the completion of induction therapy. For the patients who presented at variable times afterward, the time interval could be as long as 2 to 3 months. We did not analyze this as a separate factor. We do think that a lot of the false positives and false negatives that we see are due to time-dependent changes that may resolve after the completion of induction therapy, and this will need to be sorted out in future studies.
Regarding the R2 resections, these were for the usual reasons for finding unresectable disease within the chest, such as unsuspected invasion of a structure, such as the aorta, or a small malignant effusion or pleural implantation, which is at this point difficult to predict based on either CT or PET criteria.
Finally, in response to Dr Swanson’s question regarding comparison of CT scans, our studies should be considered an examination of utility of PET. This was not a fair comparison to CT scans, because a lot of the CT scans were performed at other institutions and were available only to us at this point as scanned-in PACS images, which are often suboptimal. A head-to-head comparison would need state-of-the-art PET scanning and state-of-the-art CT scan images. Thank you very much.
|
References |
|---|
|
TopAbstractIntroductionPatients and methodsResultsCommentAcknowledgmentsDiscussionReferences |
|---|
This article has been cited by other articles:
|
|
 |
|
  T. Tanvetyanon, E. A. Eikman, E. Sommers, L. Robinson, D. Boulware, and G. Bepler Computed Tomography Response, But Not Positron Emission Tomography Scan Response, Predicts Survival After Neoadjuvant Chemotherapy for Resectable Non-Small-Cell Lung Cancer J. Clin. Oncol., October 1, 2008; 26(28): 4610 - 4616. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
F. J.F. Herth, J. T. Annema, R. Eberhardt, K. Yasufuku, A. Ernst, M. Krasnik, and R. C. Rintoul Endobronchial Ultrasound With Transbronchial Needle Aspiration for Restaging the Mediastinum in Lung Cancer J. Clin. Oncol., July 10, 2008; 26(20): 3346 - 3350. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. De Waele, M. Serra-Mitjans, J. Hendriks, P. Lauwers, J. Belda-Sanchis, P. Van Schil, and R. Rami-Porta Accuracy and survival of repeat mediastinoscopy after induction therapy for non-small cell lung cancer in a combined series of 104 patients Eur. J. Cardiothorac. Surg., May 1, 2008; 33(5): 824 - 828. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. E. Van Schil and M. De Waele A second mediastinoscopy: how to decide and how to do it? Eur. J. Cardiothorac. Surg., April 1, 2008; 33(4): 703 - 706. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 F. Wang, Z. Wang, W. Yao, H. Xie, J. Xu, and L. Tian Role of 99mTc-Octreotide Acetate Scintigraphy in Suspected Lung Cancer Compared with 18F-FDG Dual-Head Coincidence Imaging J. Nucl. Med., September 1, 2007; 48(9): 1442 - 1448. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 L. A. Robinson, J. C. Ruckdeschel, H. Wagner Jr, and C. W. Stevens Treatment of Non-small Cell Lung Cancer-Stage IIIA: ACCP Evidence-Based Clinical Practice Guidelines (2nd Edition) Chest, September 1, 2007; 132(3_suppl): 243S - 265S. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. De Leyn, D. Lardinois, P. E. Van Schil, R. Rami-Porta, B. Passlick, M. Zielinski, D. A. Waller, T. Lerut, and W. Weder ESTS guidelines for preoperative lymph node staging for non-small cell lung cancer Eur. J. Cardiothorac. Surg., July 1, 2007; 32(1): 1 - 8. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. De Leyn, S. Stroobants, W. De Wever, T. Lerut, W. Coosemans, G. Decker, P. Nafteux, D. Van Raemdonck, L. Mortelmans, K. Nackaerts, et al. Prospective Comparative Study of Integrated Positron Emission Tomography-Computed Tomography Scan Compared With Remediastinoscopy in the Assessment of Residual Mediastinal Lymph Node Disease After Induction Chemotherapy for Mediastinoscopy-Proven Stage IIIA-N2 Non-Small-Cell Lung Cancer: A Leuven Lung Cancer Group Study J. Clin. Oncol., July 20, 2006; 24(21): 3333 - 3339. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 R. J. Cerfolio, A. S. Bryant, and B. Ojha Restaging patients with N2 (stage IIIa) non-small cell lung cancer after neoadjuvant chemoradiotherapy: A prospective study J. Thorac. Cardiovasc. Surg., June 1, 2006; 131(6): 1229 - 1235. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
T. Bunyaviroch and R. E. Coleman PET Evaluation of Lung Cancer J. Nucl. Med., March 1, 2006; 47(3): 451 - 469. [Full Text] [PDF]
|
|
|
|
|
|
M. De Waele, J. Hendriks, P. Lauwers, P. Ortmanns, W. Vanroelen, A.-M. Morel, P. Germonpre, and P. Van Schil Nodal status at repeat mediastinoscopy determines survival in non-small cell lung cancer with mediastinal nodal involvement, treated by induction therapy Eur. J. Cardiothorac. Surg., February 1, 2006; 29(2): 240 - 243. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
L. K. Shankar and D. C. Sullivan Functional Imaging in Lung Cancer J. Clin. Oncol., May 10, 2005; 23(14): 3203 - 3211. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 O. Birim, A. P. Kappetein, T. Stijnen, and A. J.J.C. Bogers Meta-Analysis of Positron Emission Tomographic and Computed Tomographic Imaging in Detecting Mediastinal Lymph Node Metastases in Nonsmall Cell Lung Cancer Ann. Thorac. Surg., January 1, 2005; 79(1): 375 - 382. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
D. Hellwig, T. P. Graeter, D. Ukena, T. Georg, C.-M. Kirsch, and H.-J. Schafers Value of F-18-fluorodeoxyglucose positron emission tomography after induction therapy of locally advanced bronchogenic carcinoma J. Thorac. Cardiovasc. Surg., December 1, 2004; 128(6): 892 - 899. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. J. Cerfolio, A. S. Bryant, T. S. Winokur, B. Ohja, and A. A. Bartolucci Repeat FDG-PET After Neoadjuvant Therapy is a Predictor of Pathologic Response in Patients With Non-Small Cell Lung Cancer Ann. Thorac. Surg., December 1, 2004; 78(6): 1903 - 1909. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 L. Schrevens, N. Lorent, C. Dooms, and J. Vansteenkiste The Role of PET Scan in Diagnosis, Staging, and Management of Non-Small Cell Lung Cancer Oncologist, November 1, 2004; 9(6): 633 - 643. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
D. G. Pfister, D. H. Johnson, C. G. Azzoli, W. Sause, T. J. Smith, S. Baker Jr, J. Olak, D. Stover, J. R. Strawn, A. T. Turrisi, et al. American Society of Clinical Oncology Treatment of Unresectable Non-Small-Cell Lung Cancer Guideline: Update 2003 J. Clin. Oncol., January 15, 2004; 22(2): 330 - 353. [Full Text] [PDF]
|
|
|
|
|
|
G. V. Gonzalez-Stawinski, A. Lemaire, F. Merchant, E. O'Halloran, R. E. Coleman, D. H. Harpole, and T. A. D'Amico A comparative analysis of positron emission tomography and mediastinoscopy in staging non-small cell lung cancer J. Thorac. Cardiovasc. Surg., December 1, 2003; 126(6): 1900 - 1904. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
W. A. Weber, V. Petersen, B. Schmidt, L. Tyndale-Hines, T. Link, C. Peschel, and M. Schwaiger Positron Emission Tomography in Non-Small-Cell Lung Cancer: Prediction of Response to Chemotherapy by Quantitative Assessment of Glucose Use J. Clin. Oncol., July 15, 2003; 21(14): 2651 - 2657. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. J. Cerfolio, B. Ojha, S. Mukherjee, A. H. Pask, C. S. Bass, and C. R. Katholi Positron emission tomography scanning with 2-fluoro-2-deoxy-D-glucose as a predictor of response of neoadjuvant treatment for non-small cell carcinoma J. Thorac. Cardiovasc. Surg., April 1, 2003; 125(4): 938 - 944. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
D. Lardinois, A. Schallberger, D. Betticher, and H.-B. Ris Postinduction video-mediastinoscopy is as accurate and safe as video-mediastinoscopy in patients without pretreatment for potentially operable non-small cell lung cancer Ann. Thorac. Surg., April 1, 2003; 75(4): 1102 - 1106. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
L. Kostakoglu and S. J. Goldsmith 18F-FDG PET Evaluation of the Response to Therapy for Lymphoma and for Breast, Lung, and Colorectal Carcinoma J. Nucl. Med., February 1, 2003; 44(2): 224 - 239. [Abstract] [Full Text] [PDF]
|
|
| ||
