Shuji Adachi

Appropriate Sublobar Resection Choice for Ground Glass Opacity-Dominant Clinical Stage IA Lung Adenocarcinoma: Wedge Resection or Segmentectomy

BACKGROUND The purpose of this multicenter study was to characterize ground glass opacity (GGO)-dominant clinical stage IA lung adenocarcinomas and evaluate prognosis of these tumors after sublobar resection, such as segmentectomy and wedge resection. METHODS We evaluated 610 consecutive patients with clinical stage IA lung adenocarcinoma who underwent complete resection after preoperative high-resolution CT scanning and 18 F-fl uorodeoxyglucose PET/CT scanning and revealed 239 (39.2%) that had a . 50% GGO component. RESULTS GGO-dominant tumors rarely exhibited pathologic invasiveness, including lymphatic, vascular, or pleural invasion and lymph node metastasis. There was no significant difference in 3-year recurrence-free survival (RFS) among patients who underwent lobectomy (96.4%), segmentectomy (96.1%), and wedge resection (98.7%) of GGO-dominant tumors ( P = .44). Furthermore, for GGO-dominant T1b tumors, 3-year RFS was similar in patients who underwent lobectomy (93.7%), segmentectomy (92.9%), and wedge resection (100%, P = .66). Two of 84 patients (2.4%) with GGO-dominant T1b tumors had lymph node metastasis. Multivariate Cox analysis showed that tumor size, maximum standardized uptake value on 18 F-fl uorodeoxyglucose PET/CT scan, and surgical procedure did not affect RFS in GGO-dominant tumors. CONCLUSIONS GGO-dominant clinical stage IA lung adenocarcinomas are a uniform group of tumors that exhibit low-grade malignancy and have an extremely favorable prognosis. Patients with GGOdominant clinical stage IA adenocarcinomas can be successfully treated with wedge resection of a T1a tumor and segmentectomy of a T1b tumor.

Multicenter analysis of high-resolution computed tomography and positron emission tomography/computed tomography findings to choose therapeutic strategies for clinical stage IA lung adenocarcinoma.

OBJECTIVE The detection rates of small lung cancers, especially adenocarcinoma, have recently increased. An understanding of malignant aggressiveness is critical for the selection of suitable therapeutic strategies, such as sublobar resection. The objective of this study was to examine the malignant biological behavior of clinical stage IA adenocarcinoma and to select therapeutic strategies using high-resolution computed tomography, fluorodeoxyglucose-positron emission tomography/computed tomography, and a pathologic analysis in the setting of a multicenter study. METHODS We performed high-resolution computed tomography and fluorodeoxyglucose-positron emission tomography/computed tomography in 502 patients with clinical T1N0M0 adenocarcinoma before they underwent surgery with curative intent. We evaluated the relationships between clinicopathologic characteristics and maximum standardized uptake values on fluorodeoxyglucose-positron emission tomography/computed tomography, ground-glass opacity ratio, and tumor disappearance rate on high-resolution computed tomography and component of bronchioloalveolar carcinoma on surgical specimens, as well as between these and surgical findings. We used a phantom study to correct the serious limitation of any multi-institution study using positron emission tomography/computed tomography, namely, a discrepancy in maximum standardized uptake values among institutions. RESULTS Analyses of receiver operating characteristic curves identified an optimal cutoff value to predict high-grade malignancy of 2.5 for revised maximum standardized uptake values, 20% for ground-glass opacity ratio, 30% for tumor disappearance rate, and 30% for bronchioloalveolar carcinoma ratio. Maximum standardized uptake values and bronchioloalveolar carcinoma ratio, tumor disappearance rate, and ground-glass opacity ratio mirrored the pathologic aggressiveness of tumor malignancy, nodal metastasis, recurrence, and prognosis, including disease-free and overall survival. CONCLUSIONS Maximum standardized uptake value is a significant preoperative predictor for surgical outcomes. High-resolution computed tomography and fluorodeoxyglucose-positron emission tomography/computed tomography findings are important to determine the appropriateness of sublobar resection for treating clinical stage IA adenocarcinoma of the lung.

Original ResearchLung CancerAppropriate Sublobar Resection Choice for Ground Glass Opacity-Dominant Clinical Stage IA Lung Adenocarcinoma: Wedge Resection or Segmentectomy

BACKGROUND The purpose of this multicenter study was to characterize ground glass opacity (GGO)-dominant clinical stage IA lung adenocarcinomas and evaluate prognosis of these tumors after sublobar resection, such as segmentectomy and wedge resection. METHODS We evaluated 610 consecutive patients with clinical stage IA lung adenocarcinoma who underwent complete resection after preoperative high-resolution CT scanning and 18 F-fl uorodeoxyglucose PET/CT scanning and revealed 239 (39.2%) that had a . 50% GGO component. RESULTS GGO-dominant tumors rarely exhibited pathologic invasiveness, including lymphatic, vascular, or pleural invasion and lymph node metastasis. There was no significant difference in 3-year recurrence-free survival (RFS) among patients who underwent lobectomy (96.4%), segmentectomy (96.1%), and wedge resection (98.7%) of GGO-dominant tumors ( P = .44). Furthermore, for GGO-dominant T1b tumors, 3-year RFS was similar in patients who underwent lobectomy (93.7%), segmentectomy (92.9%), and wedge resection (100%, P = .66). Two of 84 patients (2.4%) with GGO-dominant T1b tumors had lymph node metastasis. Multivariate Cox analysis showed that tumor size, maximum standardized uptake value on 18 F-fl uorodeoxyglucose PET/CT scan, and surgical procedure did not affect RFS in GGO-dominant tumors. CONCLUSIONS GGO-dominant clinical stage IA lung adenocarcinomas are a uniform group of tumors that exhibit low-grade malignancy and have an extremely favorable prognosis. Patients with GGOdominant clinical stage IA adenocarcinomas can be successfully treated with wedge resection of a T1a tumor and segmentectomy of a T1b tumor.

Oncologic outcomes of segmentectomy compared with lobectomy for clinical stage IA lung adenocarcinoma: propensity score-matched analysis in a multicenter study.

OBJECTIVE Our objective was to compare the oncologic outcomes of lobectomy and segmentectomy for clinical stage IA lung adenocarcinoma. METHODS We examined 481 of 618 consecutive patients with clinical stage IA lung adenocarcinoma who underwent lobectomy or segmentectomy after preoperative high-resolution computed tomography and F-18-fluorodeoxyglucose positron emission tomography/computed tomography. Patients (n = 137) who underwent wedge resection were excluded. Lobectomy (n = 383) and segmentectomy (n = 98) as well as surgical results were analyzed for all patients and their propensity score-matched pairs. RESULTS Recurrence-free survival (RFS) and overall survival (OS) were not significantly different between patients undergoing lobectomy (3-year RFS, 87.3%; 3-year OS, 94.1%) and segmentectomy (3-year RFS, 91.4%; hazard ratio [HR], 0.57; 95% confidence interval [CI], 0.27-1.20; P = .14; 3-year OS, 96.9%; HR, 0.49; 95% CI, 0.17-1.38; P = .18). Significant differences in clinical factors such as solid tumor size (P < .001), maximum standardized uptake value (SUVmax) (P < .001), and tumor location (side, P = .005; lobe, P = .001) were observed between both treatment groups. In 81 propensity score-matched pairs including variables such as age, gender, solid tumor size, SUVmax, side, and lobe, RFS and OS were similar between patients undergoing lobectomy (3-year RFS, 92.9%, 3-year OS, 93.2%) and segmentectomy (3-year RFS, 90.9%; 3-year OS, 95.7%). CONCLUSIONS Segmentectomy is suitable for clinical stage IA lung adenocarcinoma, with survivals equivalent to those of standard lobectomy.

Value of integrated positron emission tomography revised using a phantom study to evaluate malignancy grade of lung adenocarcinoma: a multicenter study.

The malignant biological behavior of small‐sized lung adenocarcinomas remains obscure, although understanding this feature is important for selecting appropriate treatment. In the current study, the authors evaluated malignancy grades of small adenocarcinomas using fluorodeoxyglucose‐positron emission tomography/computed tomography (PET/CT) in addition to high‐resolution CT (HRCT) and pathological analysis in a multicenter setting.

Multiphase ECG-triggered 3D contrast-enhanced MR angiography: utility for evaluation of hilar and mediastinal invasion of bronchogenic carcinoma.

The purpose of this study was to evaluate the usefulness of cardiac synchronized magnetic resonance angiography [electrocardiographically (ECG)‐triggered MRA] for improving image quality and detection of hilar and mediastinal invasion of bronchogenic carcinoma. Fifty patients, suspected of having hilar or mediastinal invasion of bronchogenic carcinoma, underwent contrast‐enhanced computed tomography and MR imaging including conventional and ECG‐triggered MRA. Twenty patients subsequently also underwent surgical resection. Vascular enhancement‐to‐background ratio (VBR), vascular enhancement‐to‐tumor ratio (VTR), signal‐to‐noise ratio (SNR), contrast‐to‐noise ratio (CNR) and image quality scores of thoracic vessels obtained with both MRA techniques were determined and compared. In addition, the diagnostic accuracy of tumor invasion of pulmonary vessels was compared. VBRs and VTRs of both MRA techniques were not significantly different. ECG‐triggered MRA significantly improved SNRs and CNRs (P < 0.05). Two readers judged that overall image quality of ECG‐triggered MRA was better than that of conventional MRA (κ ≥ 0.41). In conclusion, ECG‐triggered MRA improves the image quality and the detection of hilar and mediastinal invasion of bronchogenic carcinoma. J. Magn. Reson. Imaging 2001;13:215–224.

Clinical utility of Gd-DTPA-enhanced magnetic resonance imaging in lung cancer

Magnetic resonance (MR) imaging has both advantages and disadvantages in its application in lung cancer staging. Because of its ability to provide superior contrast resolution and to display structures in many planes, MR imaging is better than computed tomography (CT) for the detection of mediastinal and chest wall invasion. MR imaging also is more sensitive than CT for detection of hilar and mediastinal lymph node enlargement. Multiplanar T1− and T2-weighted images are optimal for differentiating lymph nodes from large vessels without the need for contrast enhancement; in these cases administration of Gd-DTPA provides no more information than plain MR images. MR studies should be used for examining patients with suspected mediastinal or chest wall invasion and those who have equivocal hilar or mediastinal adenopathy. The shortening effect of Gd-DTPA on the T1 value results in a high signal. This effect is dependent upon both the perfusion and diffusion of the contrast agent and the amount of extracellular fluid. The distribution of Gd-DTPA is similar to that of iodinated water-soluble contrast media. Gd-DTPA examination should be tailored to provide information regarding blood flow, vascularity, and permeability, none of which is easily appreciated on CT or plain MR images. Applications for which Gd-DTPA enhancement may be helpful include differentiating between malignant and benign pulmonary masses, differentiating between hilar lung cancer and peripheral postobstructive atelectasis or pneumonia, determining therapeutic effect after radiation therapy, and differentiating between recurrent or residual tumor and radiation pneumonitis.

Prediction of pathologic node-negative clinical stage IA lung adenocarcinoma for optimal candidates undergoing sublobar resection

OBJECTIVE Patients with pathologic node-negative early lung cancer may be optimal candidates for sublobar resection. We aimed to identify predictors of pathologic lymph node involvement in clinical stage IA lung adenocarcinoma. METHODS The data from a multicenter database of 502 patients with completely resected clinical stage IA lung adenocarcinoma were retrospectively analyzed to determine the relationship between the lymph node metastasis status and tumor size on high-resolution computed tomography (HRCT) or maximum standardized uptake value (SUVmax) on [18F]-fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography (FDG-PET/CT). Revised SUVmax was used to correct interinstitutional discrepancies. RESULTS In multivariate analyses, either a solid tumor size on HRCT (P = .001) or an SUVmax on FDG-PET/CT (P = .049) was an independent predictor of lymph node metastasis. The predictive criteria of pathologic node-negative early lung cancer were a solid tumor size of less than 0.8 cm or an SUVmax of less than 1.5. Patients who met the predictive criteria of pathologic node-negative disease had less pathologic invasiveness, such as lymphatic, vascular, or pleural invasion (P < .001), and better disease-free survival (P < .0001) than those who did not, and 86 (40.4%) of the 213 patients with T1b (2-3 cm) tumors met the predictive criteria. CONCLUSIONS Either a solid tumor size or an SUVmax was a significant independent predictor of nodal involvement in clinical stage IA lung adenocarcinoma. The pathologic node-negative status criteria of a solid tumor size of less than 0.8 cm on HRCT or an SUVmax of less than 1.5 on FDG-PET/CT may be helpful for avoiding systematic lymphadenectomy for clinical stage IA lung adenocarcinoma, even in cases of T1b (2-3 cm) tumor.

Contrast-enhanced MR perfusion imaging and MR angiography: utility for management of pulmonary arteriovenous malformations for embolotherapy

OBJECTIVE The purpose of this study was to assess the capability of MR perfusion imaging and angiography (MRA) for management of pulmonary arteriovenous malformation (PAVM). METHODS AND PATIENTS Eight patients, having 15 PAVMs underwent pulmonary angiography (PAG), CT, MR perfusion imaging and MRA. For the pretherapeutic management, MRA was compared with PAG and CT regarding detectability and diameter of vasculature. For post-therapeutic management, the change in size of aneurysmal sac, any residual contrast-enhancement and the blood supply within the sac were evaluated. RESULTS All PAVMs with aneurysmal sac, feeding artery and draining vein diameters of equal to or more than 3 mm, were identified and measured with similar results by all modalities. On follow-up studies, 7 (58.4%) out of 12 treated PAVMs showed a decrease in size and residual contrast-enhancement. The residual contrast-enhancement was considered as bronchial artery-to-pulmonary artery collateral flow by MR perfusion imaging. CONCLUSION MR perfusion imaging and MRangiography are useful for management of PAVMs over 3 mm in diameter.

Mucinous Carcinoma of the Breast: MRI Features of Pure and Mixed Forms with Histopathologic Correlation

OBJECTIVE The purpose of this study was to describe the MRI features of the pure and mixed forms of mucinous carcinoma of the breast and the histopathologic correlation. MATERIALS AND METHODS Seventeen pure and three mixed mucinous tumors of the breast were examined with T2-weighted MRI and triple-phase dynamic MRI. MR images were reviewed for evaluation of the signal intensity and enhancement patterns of tumors and for correlation with the histopathologic findings. RESULTS The presence of very high signal intensity on T2-weighted images was a common feature of pure and mixed mucinous tumors. Fourteen pure tumors and one mixed tumor had very high signal intensity, and three pure and two mixed tumors had very high signal intensity and isointensity on T2-weighted images. The enhancement pattern during the early phase varied with the cellularity of pure tumors and with the distribution of nonmucinous components in mixed tumors. Hypocellular pure mucinous tumors had a typical pattern of gradual enhancement. CONCLUSION Hypercellular pure mucinous tumors exhibit strong early enhancement and may be difficult to differentiate from mixed mucinous tumors. The distinction between the pure and mixed forms of mucinous carcinoma is important because mixed mucinous carcinoma more frequently undergoes lymph node metastasis and has a poorer prognosis than does pure mucinous carcinoma.