Evaluation of Regional Node Involvement in The Staging of Non-small Cell Lung Cancer with F-18 FDG PET/CT

Öz

Öz Giriş ve Amaç: PET/BT’de küçük hücreli dışı akciğer kanserinin (KHDAK) nodal evrelemesi için mediastinal kan havuzu (MKH) aktivite eşik değerinin tanısal performansını değerlendirmek ve bölgesel nod tutulumunu değerlendirmede F-18 FDG-PET/BT'nin tanısal performansını artırabilecek değişkenleri incelemektir. Gereç ve Yöntemler: Endobronşiyal ultrason eşliğinde transbronşiyal iğne aspirasyonu ve F-18 FDG-PET/BT uygulanan KHDAK tanılı hastalar çalışmaya dahil edildi. Lenf nodu istasyonu ve lenf nodu evrelemesinin analizi, MKH eşik değeri ile diğer beş PET/BT parametresi histopatolojik sonuçlarla karşılaştırıldı. Bulgular: Çalışmaya 88 hasta dâhil edilmiş olup 250 lenf nodu istasyonundan patolojik örneklem yapıldı. PET/BT’de lenf nodu aktivitesinin MKH'dan yüksek olması %95.3 duyarlılık, %36.1 özgüllük, %33.1 pozitif öngörü değeri, %96.2 negatif öngörü değeri göstermiştir. İncelenen diğer beş PET/BT parametresinden nodal SUVmaks değeri ve lenf nodu/MKH SUVmaks oranı en tanısal parametrelerdi. Nodal SUVmaks için 3.8 eşik değeri %90.2 duyarlılık, %61.7 özgüllüközgüllük; lenf nodu/MKH SUVmaks oranı için 1.8 eşik değeri %90.1 duyarlılık, %60.5 özgüllük değeri göstermiştir. Sonuç: Nodal evrelemede MKH eşik değeri ile karşılaştırıldığında daha yüksek lenf nodu/MKH SUVmaks oranı eşik değeri ve diğer PET/BT değişkenlerinin kullanılması PET/BT'nin tanısal değerini artırabilir. Anahtar Kelimeler: Küçük hücreli dışı akciğer kanseri, PET/BT, FDG Abstract Aim: To evaluate the diagnostic performance of mediastinal blood pool activity(MBP) threshold for nodal staging of non-small cell lung cancer (NSCLC) on PET/CT and to examine the variables that may improve the diagnostic performance of 18F-FDG-PET/CT in evaluating regional lymph node involvement. Materials and Methods: Patients diagnosed with NSCLC who underwent endobronchial ultrasound guided transbronchial needle aspiration and 18F-FDG-PET/CT were included in the study. Analysis of lymph node station and lymph node staging, MBP threshold value and five other PET/CT parameters compared with histopathological results. Results: Eighty eight patients were included in the study and pathological samples were performed from 250 lymph node stations. The higher lymph node activity in PET/CT than MBP showed a sensitivity of 95.3%,a specificity of 36.1%,a positive prediction value of 33.1%, a negative prediction value of 96.2%.From the other five PET/CT parameters examined, nodal SUVmax value and lymph node/MBP SUVmax ratio were the most diagnostic parameters. The 3.8 threshold value for nodal SUVmax showed a sensitivity of 90.2%, a specificity of 61.7%,and the 1.8 threshold for lymph node/MBP SUVmax ratio showed a sensitivity of 90.1%, a specificity of 60.5%. Conclusion: Compared to MBP threshold value in the nodal staging, use of higher lymph node/MBP SUVmax ratio threshold value and other PET/CT variables may increase the diagnostic value of PET/CT. Keywords: Non-small cell lung cancer, PET/CT, FDG

Anahtar Kelimeler

• Non-small cell lung cancer
• PET/CT
• FDG

Küçük Hücreli Dışı Akciğer Kanseri Evrelemesinde Bölgesel Nod Tutulumunun F-18 FDG PET/BT ile Değerlendirilmesi

Öz

Evaluation of Regional Node Involvement in The Staging of Non-small Cell Lung Cancer with F-18 FDG PET/CT Küçük Hücreli Dışı Akciğer Kanseri Evrelemesinde Bölgesel Nod Tutulumunun F-18 FDG PET/BT ile Değerlendirilmesi Mutlay KESKİN1*, Haydar ASLAN1 1Mersin Şehir Eğitim ve Araştırma Hastanesi Nükleer Tıp Kliniği Mersin, Türkiye e-mail: [e-mail], [e-mail], ORCID: 0000-0003-2528-8648 ORCID: 0009-0001-0232-6712 *Sorumlu Yazar/Corresponding Author: Mutlay Keskin Gönderim Tarihi / Received: Kabul Tarihi / Accepted: DOI: Öz Giriş ve Amaç: PET/BT’de küçük hücreli dışı akciğer kanserinin (KHDAK) nodal evrelemesi için mediastinal kan havuzu (MKH) aktivite eşik değerinin tanısal performansını değerlendirmek ve bölgesel nod tutulumunu değerlendirmede F-18 FDG-PET/BT'nin tanısal performansını artırabilecek değişkenleri incelemektir. Gereç ve Yöntemler: Endobronşiyal ultrason eşliğinde transbronşiyal iğne aspirasyonu ve F-18 FDG-PET/BT uygulanan KHDAK tanılı hastalar çalışmaya dahil edildi. Lenf nodu istasyonu ve lenf nodu evrelemesinin analizi, MKH eşik değeri ile diğer beş PET/BT parametresi histopatolojik sonuçlarla karşılaştırıldı. Bulgular: Çalışmaya 88 hasta dâhil edilmiş olup 250 lenf nodu istasyonundan patolojik örneklem yapıldı. PET/BT’de lenf nodu aktivitesinin MKH'dan yüksek olması %95.3 duyarlılık, %36.1 özgüllük, %33.1 pozitif öngörü değeri, %96.2 negatif öngörü değeri göstermiştir. İncelenen diğer beş PET/BT parametresinden nodal SUVmaks değeri ve lenf nodu/MKH SUVmaks oranı en tanısal parametrelerdi. Nodal SUVmaks için 3.8 eşik değeri %90.2 duyarlılık, %61.7 özgüllüközgüllük; lenf nodu/MKH SUVmaks oranı için 1.8 eşik değeri %90.1 duyarlılık, %60.5 özgüllük değeri göstermiştir. Sonuç: Nodal evrelemede MKH eşik değeri ile karşılaştırıldığında daha yüksek lenf nodu/MKH SUVmaks oranı eşik değeri ve diğer PET/BT değişkenlerinin kullanılması PET/BT'nin tanısal değerini artırabilir. Anahtar Kelimeler: Küçük hücreli dışı akciğer kanseri, PET/BT, FDG Abstract Aim: To evaluate the diagnostic performance of mediastinal blood pool activity(MBP) threshold for nodal staging of non-small cell lung cancer (NSCLC) on PET/CT and to examine the variables that may improve the diagnostic performance of 18F-FDG-PET/CT in evaluating regional lymph node involvement. Materials and Methods: Patients diagnosed with NSCLC who underwent endobronchial ultrasound guided transbronchial needle aspiration and 18F-FDG-PET/CT were included in the study. Analysis of lymph node station and lymph node staging, MBP threshold value and five other PET/CT parameters compared with histopathological results. Results: Eighty eight patients were included in the study and pathological samples were performed from 250 lymph node stations. The higher lymph node activity in PET/CT than MBP showed a sensitivity of 95.3%,a specificity of 36.1%,a positive prediction value of 33.1%, a negative prediction value of 96.2%.From the other five PET/CT parameters examined, nodal SUVmax value and lymph node/MBP SUVmax ratio were the most diagnostic parameters. The 3.8 threshold value for nodal SUVmax showed a sensitivity of 90.2%, a specificity of 61.7%,and the 1.8 threshold for lymph node/MBP SUVmax ratio showed a sensitivity of 90.1%, a specificity of 60.5%. Conclusion: Compared to MBP threshold value in the nodal staging, use of higher lymph node/MBP SUVmax ratio threshold value and other PET/CT variables may increase the diagnostic value of PET/CT. Keywords: Non-small cell lung cancer, PET/CT, FDG

Anahtar Kelimeler

• Küçük hücreli dışı akciğer kanseri
• PET/BT
• FDG

Kaynakça

1. World Health Organization. The top 10 causes of death. 2018. Available at: www.who.int/news-room/fact-sheets/detail/the-top-10-causes-ofdeath. [Accessed 12 March 2019].
2. 2. American Cancer Society. Non-small cell lung cancer survival rates, by stage. 2017. Available at:https://www.cancer.org/cancer/non-small-celllung-cancer/detection-diagnosis-staging/survival-rates.html. [Accessed 12 March 2019].
3. 3. Chansky K, Detterbeck FC, Nicholson AG, Rusch VW, Vallières E, Groome P, et al. The IASLC Lung Cancer Staging Project: External Validation of the Revision of the TNM Stage Groupings in the Eighth Edition of the TNM Classification of Lung Cancer. J Thorac Oncol. 2017 Jul;12(7):1109-1121.
4. 4. Van Schil PE, Yogeswaran K, Hendriks JM, Lauwers P, Faivre-Finn C. Advances in the use of surgery and multimodality treatment for N2 non-small cell lung cancer. Expert Rev Anticancer Ther. 2017 Jun;17(6):555-561.
5. 5. Donington J, Schumacher L, Yanagawa J. Surgical Issues for Operable Early-Stage Non-Small-Cell Lung Cancer. J Clin Oncol. 2022 Feb 20;40(6):530-538.
6. 6. Baldwin DR. Imaging in lung cancer: recent advances in PET-CT and screening. Thorax. 2011 Apr;66(4):275-7.
7. 7. Vilmann P, Clementsen PF, Colella S, Siemsen M, De Leyn P, Dumonceau JM, et al., Combined endobronchial and esophageal endosonography for the diagnosis and staging of lung cancer: European Society of Gastrointestinal Endoscopy (ESGE) Guideline, in cooperation with the European Respiratory Society (ERS) and the European Society of Thoracic Surgeons (ESTS). Endoscopy. 2015 Jun;47(6):545-59.
8. 8. Lung cancer: diagnosis and management. London: National Institute for Health and Care Excellence (NICE); 2023 Jul 26. PMID: 31211540.

9. 9. De Leyn P, Dooms C, Kuzdzal J, Lardinois D, Passlick B, Rami-Porta R, et al., Revised ESTS guidelines for preoperative mediastinal lymph node staging for non-small-cell lung cancer. Eur J Cardiothorac Surg. 2014 May;45(5):787-98.
10. 10. Billé A, Pelosi E, Skanjeti A, Arena V, Errico L, Borasio P, et al., Preoperative intrathoracic lymph node staging in patients with non-small-cell lung cancer: accuracy of integrated positron emission tomography and computed tomography. Eur J Cardiothorac Surg. 2009 Sep;36(3):440-5.
11. 11. Dinnes J, Ferrante di Ruffano L, Takwoingi Y, Cheung ST, Nathan P, Matin RN, et al., Cochrane Skin Cancer Diagnostic Test Accuracy Group. Ultrasound, CT, MRI, or PET-CT for staging and re-staging of adults with cutaneous melanoma. Cochrane Database Syst Rev. 2019 Jul 1;7(7):CD012806.
12. 12. Serra Fortuny M, Gallego M, Berna L, Montón C, Vigil L, Masdeu MJ, et al., FDG-PET parameters predicting mediastinal malignancy in lung cancer. BMC Pulm Med. 2016 Dec 8;16(1):177.
13. 13. Kuo WH, Wu YC, Wu CY, Ho KC, Chiu PH, Wang CW, et al., Node/aorta and node/liver SUV ratios from (18)F-FDG PET/CT may improve the detection of occult mediastinal lymph node metastases in patients with non-small cell lung carcinoma. Acad Radiol. 2012 Jun;19(6):685-92.
14. 14. Mallorie A, Goldring J, Patel A, Lim E, Wagner T. Assessment of nodal involvement in non-small-cell lung cancer with 18F-FDG-PET/CT: mediastinal blood pool cut-off has the highest sensitivity and tumour SUVmax/2 has the highest specificity. Nucl Med Commun. 2017 Aug;38(8):715-719.
15. 15. El-Sherief AH, Lau CT, Wu CC, Drake RL, Abbott GF, Rice TW. International association for the study of lung cancer (IASLC) lymph node map: radiologic review with CT illustration. Radiographics. 2014 Oct;34(6):1680-91.
16. 16. Evison M, Morris J, Martin J, Shah R, Barber PV, Booton R, et al., Nodal staging in lung cancer: a risk stratification model for lymph nodes classified as negative by EBUS-TBNA. J Thorac Oncol. 2015 Jan;10(1):126-33.
17. 17. Moloney F, Ryan D, McCarthy L, McCarthy J, Burke L, Henry MT, et al., Increasing the accuracy of 18F-FDG PET/CT interpretation of "mildly positive" mediastinal nodes in the staging of non-small cell lung cancer. Eur J Radiol. 2014 May;83(5):843-7.
18. 18. Hwangbo B, Kim SK, Lee HS, Lee HS, Kim MS, Lee JM, et al., Application of endobronchial ultrasound-guided transbronchial needle aspiration following integrated PET/CT in mediastinal staging of potentially operable non-small cell lung cancer. Chest. 2009 May;135(5):1280-1287.
19. 19. Billiet C, De Ruysscher D, Peeters S, Decaluwé H, Vansteenkiste J, Dooms C, et al., Patterns of Locoregional Relapses in Patients with Contemporarily Staged Stage III-N2 NSCLC Treated with Induction Chemotherapy and Resection: Implications for Postoperative Radiotherapy Target Volumes. J Thorac Oncol. 2016 Sep;11(9):1538-49.
20. 20. Guarize J, Casiraghi M, Donghi S, Casadio C, Diotti C, Filippi N, et al., EBUS-TBNA in PET-positive lymphadenopathies in treated cancer patients. ERJ Open Res. 2017 Oct 23;3(4):00009-2017.
21. 21. Liu A, Qian L, Zhong Y, Lu X, Zhao Y. Endobronchial ultrasound guided transbronchial needle aspiration combining with immunohistochemistry and genotype in lung cancer: A single-center, 55 cases retrospective study. Ann Med Surg (Lond). 2017 Jul 25;23:1-7.
22. 22. Cho J, Choe JG, Pahk K, Choi S, Kwon HR, Eo JS, et al., Ratio of Mediastinal Lymph Node SUV to Primary Tumor SUV in 18F-FDG PET/CT for Nodal Staging in Non-Small-Cell Lung Cancer. Nucl Med Mol Imaging. 2017 Jun;51(2):140-146.
23. 23. Lee AY, Choi SJ, Jung KP, Park JS, Lee SM, Bae SK. Characteristics of Metastatic Mediastinal Lymph Nodes of Non-Small Cell Lung Cancer on Preoperative F-18 FDG PET/CT. Nucl Med Mol Imaging. 2014 Mar;48(1):41-6.
24. 24. Stamatis G. Staging of lung cancer: the role of noninvasive, minimally invasive and invasive techniques. Eur Respir J. 2015 Aug;46(2):521-31.
25. 25. Pak K, Kim K, Kim MH, Eom JS, Lee MK, Cho JS, et al., A decision tree model for predicting mediastinal lymph node metastasis in non-small cell lung cancer with F-18 FDG PET/CT. PLoS One. 2018 Feb 27;13(2):e0193403.
26. 26. Jalil BA, Yasufuku K, Khan AM. Uses, limitations, and complications of endobronchial ultrasound. Proc (Bayl Univ Med Cent). 2015 Jul;28(3):325-30.
27. 27. von Bartheld MB, van Breda A, Annema JT. Complication rate of endosonography (endobronchial and endoscopic ultrasound): a systematic review. Respiration. 2014;87(4):343-51.
28. 28. Evison M, Crosbie P, Navani N, Callister M, Rintoul RC, Baldwin D, et al., How should performance in EBUS mediastinal staging in lung cancer be measured? Br J Cancer. 2016 Oct 11;115(8):e9.