Michelle Dusart

Endobronchial ultrasound and value of PET for prediction of pathological results of mediastinal hot spots in lung cancer patients

SUMMARY In the staging of lung cancer with positron emission tomography (PET) positive mediastinal lymph nodes, tissue sampling is required. The performance of transbronchial needle aspiration (TBNA) using linear endobronchial ultrasound (real-time EBUS-TBNA) under local anaesthesia and the value of PET for prediction of pathological results were assessed in that setting. The number of eluded surgical procedures was evaluated. All consecutive patients with suspected/proven lung cancers and FDG-PET positive mediastinal adenopathy were included. If no diagnosis was reached, further surgical sampling was required. Lymph node SUVmax (maximum standardized uptake value) was assessed in patients whose PET was performed in the leading centre. One hundred and six patients were included. The average number of TBNA samples per patient was 4.9+/-1.1. The prevalence of lymph node metastasis was 58%. Sensitivity, accuracy and negative predictive value of EBUS-TBNA in the staging of mediastinal hot spots were 95, 97 and 91%. Patients without malignant lymph node involvement showed lower SUVmax (respective median values of 3.7 and 10.0; p<0.0001). Surgical procedures were eluded in 56% of the patients. Real-time EBUS-TBNA should be preferred over mediastinoscopy as the first step procedure in the staging of PET mediastinal hot spots in lung cancer patients. In case of negative EBUS, surgical staging procedure should be undertaken. The addition of SUVmax cut-off may allow further refinement but needs validation.

Endobronchial ultrasound and positron emission tomography positive mediastinal lymph nodes

Positron emission tomography with 18F-fluoro-2-deoxy-d-glucose (FDG-PET) is more accurate than computed tomography for staging of mediastinal (hilar) lymph nodes. In the case of positive findings, tissue sampling of lymph nodes is required. The diagnostic/staging yield of transbronchial needle aspiration (TBNA) following endobronchial ultrasound (EBUS) localisation was assessed in this particular clinical setting. The number of avoided surgical procedures was evaluated. All consecutive patients referred for staging and/or diagnosis of mediastinal FDG-PET positive lesions were included. Data were prospectively collected. TBNA sampling of lymph nodes was performed after EBUS localisation. If no diagnosis was reached, further surgical sampling or adequate follow-up was performed. From January 2003 to June 2004, 33 patients were included. The average number of TBNA samples per patient was 4.2±1.5. Cytological or histological diagnoses were obtained in 27 (82%) of the patients, of which 78% were obtained after previous EBUS localisation. In 25 (76%) of the 33 patients, surgical staging procedures were suppressed. In conclusion, transbronchial needle aspiration after endobronchial ultrasound localisation should be considered as a primary method of evaluation of lymph nodes positive by positron emission tomography with 18F-fluoro-2-deoxy-d-glucose, and may replace the majority of surgical mediastinal staging/diagnostic procedures.

Has Cox-2 a prognostic role in non-small-cell lung cancer? A systematic review of the literature with meta-analysis of the survival results

Cyclooxygenase-2 (COX-2) is overexpressed in lung cancer, especially in adenocarcinoma (ADC). Our aim was to determine the prognostic value of COX-2 on survival in patients with lung cancer. Studies evaluating the survival impact of COX-2 in lung cancer, published until December 2005, were selected. Data for estimation of individual hazard ratios (HR) for survival were extracted from the publications and combined in a pooled HR. Among 14 eligible papers, all dealing with non-small-cell lung cancer, 10 provided results for meta-analysis of survival data (evaluable studies). Cyclooxygenase-2 positivity was associated with reduced survival, improved survival or no statistically significant impact in six, one and seven studies, respectively. Combined HR for the 10 evaluable studies (1236 patients) was 1.39 (95% confidence intervals (CI): 0.97–1.99). In stage I lung cancer (six evaluable studies, 554 patients), it was 1.64 (95% CI: 1.21–2.24). No significant impact was shown in ADC. A slight detrimental effect on survival in patients with lung cancer is associated with COX-2 expression, but the statistical significance is not reached. This effect is statistically significant in stage I, suggesting that COX-2 expression could be useful at early stages to distinguish those with a worse prognosis.

Clinical value of FDG-PET/CT for the diagnosis of human immunodeficiency virus-associated fever of unknown origin: a retrospective study.

AimThe aim of this study was to evaluate retrospectively the usefulness of [18F]fluorodeoxyglucose (FDG)-PET/computed tomography (CT) in patients affected by human immunodeficiency virus and suffering from fever of unknown origin (HIV-associated FUO). Material and methodsTen patients (six males, four females, age 24–48 years) suffering from HIV-associated FUO were studied by FDG-PET/CT. Final diagnosis was established either by microbiological or histopathological analysis or by a more than 6-month follow-up. FDG-PET/CT was regarded as ‘helpful for diagnosis’ when the abnormal uptake pointed to the organ or location where the cause of fever was thereafter identified. ResultsNine out of 10 FDG-PET/CT were abnormal and the cause of fever was further demonstrated by other diagnostic procedures. An infectious process (tuberculosis) was diagnosed in six patients and a neoplasm in three (two lymphomas, one Kaposis sarcoma). FDG-PET/CT directly suggested sites for biopsy in six patients (tuberculous lymphadenitis and neoplasm). The only patient with normal FDG-PET/CT suffered from drug-induced fever. ConclusionFDG-PET/CT is a valuable tool in patients with HIV-associated FUO. FDG-PET/CT was categorized as ‘helpful for diagnosis’ in nine out of the 10 patients we studied. Adding the CT anatomical landmarks to the PET findings allowed an accurate and easy localization of the sites to be punctured in the six patients in whom histopathological diagnosis was needed.

Échographie endobronchique et ganglions TEP positives dans le cancer broncho-pulmonaire

INTRODUCTION In bronchial carcinoma when positron emission tomography with 18-fluorodeoxyglucose (FDG-PET) shows increased emission in the mediastinal lymph nodes, confirmation by tissue biopsy is necessary. In this particular situation we have evaluated the use of real time lymph node aspiration under endobronchial ultrasound control. METHODS Consecutive patients referred for staging and/or diagnosis of PET positive mediastinal nodes in the setting of suspected or confirmed bronchial carcinoma were included. The results of lymph node aspiration, performed under local anaesthesia in out-patients, were collected and if non-diagnostic surgical exploration was performed. RESULTS 20 patients were studied between December 2004 and September 2005. The average number of ultrasound guided needle aspirations per patient was 4.8 +/- 1.2. Cytological or histological confirmation of malignancy was obtained by needle biopsy in 12 patients. The 8 negative cases were confirmed by surgical biopsy. In this preliminary series the sensitivity, specificity and negative predictive value of ultrasound guided aspiration of PET positive nodes was 100%. CONCLUSION Endobronchial ultrasound with needle aspiration should be considered a primary method of investigation of PET positive mediastinal lymph nodes.Resume Introduction Dans le cancer broncho-pulmonaire, lorsque la tomographie en emission de positons au 18-fluorodesoxyglucose (TEP-FDG) montre une captation accrue au niveau ganglionnaire mediastinal, une confirmation par un prelevement tissulaire est necessaire. Nous avons evalue dans cette presentation particuliere la ponction ganglionnaire sous controle echographique endobronchique en temps reel. Methodes Les patients adresses consecutivement pour le bilan et/ou le diagnostic de ganglions TEP positifs dans le cadre d’un cancer broncho-pulmonaire suspecte ou confirme ont ete inclus. Les resultats des ponctions des ganglions, realisees sous anesthesie locale, en ambulatoire, ont ete collectes et en l’absence de diagnostic, une exploration chirurgicale etait requise. Resultats Entre decembre 2004 et septembre 2005, 20 patients ont ete inclus. Le nombre moyen de ponctions ganglionnaires sous controle echographique par patient etait de 4,8 =/- 1,2. Chez 12 patients, la confirmation cytologique ou histologique d’atteinte neoplasique etait obtenue par l’aiguille. Les 8 observations negatives etaient confirmees par l’exploration chirurgicale. Dans cette serie preliminaire, la sensibilite, specificite et valeur predictive negative de la ponction echo-guidee des ganglions TEP positifs etaient de 100 %, 100 % et 100 %. Conclusions L’echographie endobronchique avec ponction doit etre consideree comme une technique primaire d’exploration des ganglions TEP positifs.

Assigning statistical significance to tumor changes in patient monitoring using FDG pet

In PET-based patient monitoring, tumor changes can be assessed using standardized uptake values (SUV), tumor volume (V), or total lesion glycolysis (TLG). We studied the impact of the SUV, V and TLG estimation methods on the interpretation of tumor changes between 2 PET scans. We also propose a bootstrap approach to assign statistical significance to the observed tumor changes. In 17 tumor changes, the SUV variations were the least dependent on the estimation method compared to the V or TLG changes. In 16/17 cases, SUV changes were significant. In 2 out of these 16 significant cases, at least one SUV index suggested non significant change. Testing the significance of tumor feature changes might reduce errors in interpreting tumor changes.

244. Evaluation of breast metastasis FDG-F18 uptake according to primary lesions histology

It is known that primary lesions of lobular invasive carcinoma (Ici) concentrate the glucose analogue FDG-F18 lesser than the primary ductal invasive (dci) ones. To our knowledge, at present, there is no evidenee that the SUVs of secondary lesions in lobular invasive carcinoma are lower than those in ductal invasive carcinoma. 66 investigations (for 58 patients) realized between July 2001 and March 2002 were retrospectively reviewed. 4 patients were examined for initial staging and 54 patients for recurrence suspicion (clinical suspicion, radiological suspicion or elevated serum markers). 42 patients (72%) had a ductal carcinoma histology, 11 patients (19%) had a lobular one, 4 (7%) had a mixed one and one had another histology. 136 lesions were described on the FDG-F18 PETscan. 67/136 (49%) were also described by conventional imaging or by biopsy and 37/136 (27%) are still on follow-up. 32/136 (24%) were never investigated (in 69% of these cases, the prove of their nature would not have changed the therapeutic strategy). 95 of the 136 lesions were quantified (SUVbwmax measurements). 74/95 (77%) of these lesions were secondary ductal ones, 11/95 (11%) were secondary lobular ones and 9/95(9%) were secondary mixed ones. Results The F-test was significant for the comparison SUVdci /SUVIci (p=0.04). SUV values of ductal secondary lesions were higher than those of lobular secondary lesions; SUV values of mixed carcinoma were intermediate between ductal and lobular ones. Yet the Student test was non significant (probably due to the too low number of patients). Nevertheless, it seems worth trying to test prospectively the hypothesis on a greater number of patients. Currently 99 additional patents were available at on update of an result will be available for the meeting.