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1.  Hounsfield units upon PET/CT are useful in evaluating metastatic regional lymph nodes in patients with oesophageal squamous cell carcinoma 
The British Journal of Radiology  2012;85(1013):606-612.
Objectives
This study evaluated the usefulness of measurements of X-ray attenuation (in Hounsfield units) obtained from unenhanced CT images for attenuation correction of the positron emission tomography (PET) data from PET/CT in the assessment of regional lymph node metastasis in oesophageal squamous cell carcinoma.
Methods
17 patients with oesophageal squamous cell carcinoma underwent surgery after evaluation with PET/CT. After the excised lymph nodes were reviewed, we compared the histopathology and PET/CT findings, and analysed the lymph node metastasis. When 18-F fludeoxyglucose (FDG) uptake in the lymph nodes was focally prominent in comparison with background mediastinal activity (regardless of lymph node size), the lymph nodes were considered to be positive for malignancy by PET/CT. The mean Hounsfield units of mediastinal lymph nodes showing abnormally increased FDG uptake in PET/CT was retrospectively evaluated using images from the unenhanced CT component of PET/CT. Receiver operating characteristic (ROC) curve analysis was applied to determine the optimal cut-off value of mean Hounsfield units for detecting individual lymph node metastases.
Results
For depiction of malignant nodal groups in each lymph node group, the sensitivity, specificity and accuracy of PET/CT based on increased FDG uptake were 58.8%, 74.5% and 70.8%, respectively. For patients with nodal groups that were positive for uptake by PET/CT, the mean attenuation in lymph nodes as measured by CT was 48±13 HU for malignant nodes and 75±18 HU for benign nodes. This difference was statistically significant (p<0.001). Using ROC curve analysis, we determined the cut-off as 71 HU. When we excluded lymph nodes with attenuation higher than 71 HU from the nodes determined as malignant by PET/CT, the specificity and accuracy for detecting metastatic lymph nodes improved to 90.9% and 83.3%, respectively.
Conclusions
When interpreting lymph node metastasis in oesophageal squamous cell carcinoma using PET/CT, the assumption that any lymph node with mean HU>71 is benign can improve diagnostic accuracy.
doi:10.1259/bjr/73516936
PMCID: PMC3479874  PMID: 21304006
2.  Utility of 18F-fluoro-deoxyglucose emission tomography/computed tomography fusion imaging (18F-FDG PET/CT) in combination with ultrasonography for axillary staging in primary breast cancer 
BMC Cancer  2008;8:165.
Background
Accurate evaluation of axillary lymph node (ALN) involvement is mandatory before treatment of primary breast cancer. The aim of this study is to compare preoperative diagnostic accuracy between positron emission tomography/computed tomography with 18F-fluorodeoxyglucose (18F-FDG PET/CT) and axillary ultrasonography (AUS) for detecting ALN metastasis in patients having operable breast cancer, and to assess the clinical management of axillary 18F-FDG PET/CT for therapeutic indication of sentinel node biopsy (SNB) and preoperative systemic chemotherapy (PSC).
Methods
One hundred eighty-three patients with primary operable breast cancer were recruited. All patients underwent 18F-FDG PET/CT and AUS followed by SNB and/or ALN dissection (ALND). Using 18F-FDG PET/CT, we studied both a visual assessment of 18F-FDG uptake and standardized uptake value (SUV) for axillary staging.
Results
In a visual assessment of 18F-FDG PET/CT, the diagnostic accuracy of ALN metastasis was 83% with 58% in sensitivity and 95% in specificity, and when cut-off point of SUV was set at 1.8, sensitivity, specificity, and accuracy were 36, 100, and 79%, respectively. On the other hand, the diagnostic accuracy of AUS was 85% with 54% in sensitivity and 99% in specificity. By the combination of 18F-FDG PET/CT and AUS to the axilla, the sensitivity, specificity, and accuracy were 64, 94, and 85%, respectively. If either 18F-FDG PET uptake or AUS was positive in allixa, the probability of axillary metastasis was high; 50% (6 of 12) in 18F-FDG PET uptake only, 80% (4 of 5) in AUS positive only, and 100% (28 of 28) in dual positive. By the combination of AUS and 18F-FDG PET/CT, candidates of SNB were more appropriately selected. The axillary 18F-FDG uptake was correlated with the maximum size and nuclear grade of metastatic foci (p = 0.006 and p = 0.03).
Conclusion
The diagnostic accuracy of 18F-FDG PET/CT was shown to be nearly equal to ultrasound, and considering their limited sensitivities, the high radiation exposure by 18F-FDG PET/CT and also costs of the examination, it is likely that AUS will be more cost-effective in detecting massive axillary tumor burden. However, when we cannot judge the axillary staging using AUS alone, metabolic approach of 18F-FDG PET/CT for axillary staging would enable us a much more confident diagnosis.
doi:10.1186/1471-2407-8-165
PMCID: PMC2430574  PMID: 18541009
3.  Integrated FDG‐PET/CT does not make invasive staging of the intrathoracic lymph nodes in non‐small cell lung cancer redundant: a prospective study 
Thorax  2007;62(8):696-701.
Background
Staging of non‐small cell lung cancer (NSCLC) is important for determining choice of treatment and prognosis. The accuracy of FDG‐PET scans for staging of lymph nodes is too low to replace invasive nodal staging. It is unknown whether the accuracy of integrated FDG‐PET/CT scanning makes invasive staging redundant.
Methods
In a prospective study, the mediastinal and/or hilar lymph nodes in patients with proven NSCLC were investigated with integrated FDG‐PET/CT scanning. Pathological confirmation of all suspect lymph nodes was obtained to calculate the accuracy of the fusion images. In addition, the use of the standardised uptake value (SUV) in the staging of intrathoracic lymph nodes was analysed.
Results
105 intrathoracic lymph node stations from 52 patients with NSCLC were characterised. The prevalence of malignancy in the lymph nodes was 36%. The sensitivity of the integrated FDG‐PET/CT scan to detect malignant lymph nodes was 84% and its specificity was 85% (positive likelihood ratio 5.64, negative likelihood ratio 0.19). SUVmax, SUVmean and the SUVmax/SUVliver ratio were all significantly higher in malignant than in benign lymph nodes. The area under the receiver operating curve did not differ between these three quantitative variables, but the highest accuracy was found with the SUVmax/SUVliver ratio. At a cut‐off value of 1.5 for the SUVmax/SUVliver ratio, the sensitivity and specificity to detect malignant lymph node invasion were 82% and 93%, respectively.
Conclusion
The accuracy of integrated FDG‐PET/CT scanning is too low to replace invasive intrathoracic lymph node staging in patients with NSCLC. The visual interpretation of the fusion images of the integrated FDG‐PET/CT scan can be replaced by the quantitative variable SUVmax/SUVliver without loss of accuracy for intrathoracic lymph node staging.
doi:10.1136/thx.2006.072959
PMCID: PMC2117288  PMID: 17687098
4.  Implications of False Negative and False Positive Diagnosis in Lymph Node Staging of NSCLC by Means of 18F-FDG PET/CT 
PLoS ONE  2013;8(10):e78552.
Background
Integrated 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) is widely performed in hilar and mediastinal lymph node (HMLN) staging of non-small cell lung cancer (NSCLC). However, the diagnostic efficiency of PET/CT remains controversial. This retrospective study is to evaluate the accuracy of PET/CT and the characteristics of false negatives and false positives to improve specificity and sensitivity.
Methods
219 NSCLC patients with systematic lymph node dissection or sampling underwent preoperative PET/CT scan. Nodal uptake with a maximum standardized uptake value (SUVmax) >2.5 was interpreted as PET/CT positive. The results of PET/CT were compared with the histopathological findings. The receiver operating characteristic (ROC) curve was generated to determine the diagnostic efficiency of PET/CT. Univariate and multivariate analysis were conducted to detect risk factors of false negatives and false positives.
Results
The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of PET/ CT in detecting HMLN metastases were 74.2% (49/66), 73.2% (112/153), 54.4% (49/90), 86.8% (112/129), and 73.5% (161/219). The ROC curve had an area under curve (AUC) of 0.791 (95% CI 0.723-0.860). The incidence of false negative HMLN metastases was 13.2% (17 of 129 patients). Factors that are significantly associated with false negatives are: concurrent lung disease or diabetes (p<0.001), non-adenocarcinoma (p<0.001), and SUVmax of primary tumor >4.0 (p=0.009). Postoperatively, 45.5% (41/90) patients were confirmed as false positive cases. The univariate analysis indicated age > 65 years old (p=0.009), well differentiation (p=0.002), and SUVmax of primary tumor ≦4.0 (p=0.007) as risk factors for false positive uptake.
Conclusion
The SUVmax of HMLN is a predictor of malignancy. Lymph node staging using PET/CT is far from equal to pathological staging account of some risk factors. This study may provide some aids to pre-therapy evaluation and decision-making.
doi:10.1371/journal.pone.0078552
PMCID: PMC3808350  PMID: 24205256
5.  18F-FDG PET-CT for Staging of Conjunctival Melanoma 
The value of F-18 fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET-CT) for the evaluation of cutaneous melanoma has been demonstrated previously. However, there are few reports regarding the use PET-CT for the staging of conjunctival melanoma (CM). We report here a case, a 34-year-old male with a six-month history of a pigmented nodule at the palpebral conjunctiva of the left eye, and a firm left preauricular lymph node detected on physical examination. Biopsy of the ocular lesion confirmed CM, and fine needle aspiration cytology of the preauricular node was positive for malignancy. CT showed three pulmonary nodules. An 18F-FDG PET-CT was performed to restage the patient. The study showed hypermetabolic lesions in the left eye, and in the left preauricular node. The scan was negative for metastasis. These findings were important in guiding management of the disease in this patient. Future prospective studies should further evaluate the role of 18F-FDG PET-CT for the staging of CM.
doi:10.4103/1450-1147.113965
PMCID: PMC3745635  PMID: 23961257
Conjunctival melanoma; F-18 fluorodeoxyglucose positron emission tomography/computed tomography; positron emission tomography
6.  The Impact of 18F-FDG PET CT Prior to Chemoradiotherapy for Stage III/IV Head and Neck Squamous Cell Carcinoma 
ISRN Oncology  2012;2012:636379.
Introduction. To determine the value of a FDG-PET-CT scan in patients with locally advanced head and neck squamous cell carcinoma (HNSCC) prior to chemoradiotherapy. Materials and Methods. Consecutive patients with stage III or IV HNSCC who had undergone a staging FDG-PET-CT scan prior to chemoradiotherapy between August 2008 and April 2011 were included. Clinical details and conventional imaging (CT and/or MRI) were, retrospectively, reviewed, a TNM stage was assigned, and levels of cervical lymph node involvement were documented. This process was repeated with the addition of FDG-PET-CT. Radiotherapy plans were reviewed for patients with an alteration identified on TNM staging and/or nodal level identification with FDG-PET-CT and potential alterations in radiotherapy planning were documented. Results. 55 patients were included in the analysis. FDG-PET-CT altered the TNM stage in 17/55 (31%) of patients, upstaging disease in 11 (20%) and downstaging in 6 (11%); distant metastases were identified by FDG-PET-CT in 1 (2%) patient. FDG-PET-CT altered the lymph node levels identified in 22 patients (40%), upclassifying disease in 16 (29%) and downclassifying in 6 (11%). Radiotherapy plans were judged retrospectively to have been altered by FDG-PET-CT in 10 patients (18%). Conclusions. The use of FDG-PET-CT potentially impacts upon both treatment decisions and radiotherapy planning.
doi:10.5402/2012/636379
PMCID: PMC3324911  PMID: 22548190
7.  A Prospective Analysis of Positron Emission Tomography and Conventional Imaging for Detection of Stage IV Metastatic Melanoma in Patients Undergoing Metastasectomy 
Annals of surgical oncology  2004;11(8):731-738.
Background
Positron emission tomography with 2-deoxy-2-[18F]fluoro-d-glucose (FDG-PET) is available for evaluation of patients with melanoma. This study evaluates the potential of FDG-PET to improve on conventional imaging (CI) in patients with stage IV melanoma undergoing metastasectomy.
Methods
This was a prospective study comparing radiological evaluation of patients who underwent metastasectomy for palliation or cure. Patients underwent preoperative evaluation by physical examination, CI by computed tomography and/or magnetic resonance imaging, and FDG-PET. Independent observers performed three separate analyses of CI alone, FDG-PET alone, or FDG-PET read with knowledge of CI (FDG-PET + CI). Abnormalities were reported as benign or malignant and assessed by pathologic analysis or by clinical outcome determined by disease progression detected on serial evaluations.
Results
Ninety-four lesions were noted in 18 patients who underwent preoperative assessment, metastasectomy, and long-term follow up (median, 24 months). Lesion-by-lesion analysis for CI demonstrated a sensitivity of 76%, a specificity of 87%, a positive predictive value (PPV) of 86%, and a negative predictive value (NPV) of 76%. FDG-PET demonstrated a sensitivity of 79%, a specificity of 87%, a PPV of 86%, and an NPV of 80%. For FDG-PET + CI, the sensitivity was 88%, specificity was 91%, and PPV and NPV were 91% and 88%, respectively.
Conclusions
Combined use of FDG-PET and CI may be an accurate strategy to identify sites of disease in patients with stage IV melanoma being considered for metastasectomy. Interpreted independently, FDG-PET and CI seemed to be equivalent modalities. FDG-PET + CI had both the highest sensitivity on lesion-by-lesion analysis and the best accuracy on patient-by-patient analysis.
doi:10.1245/ASO.2004.01.023
PMCID: PMC2227906  PMID: 15249335
Melanoma; Cancer; FDG-PET; Imaging; Metastasectomy; Surgery
8.  Impact of FDG-PET/CT for the Detection of Unknown Primary Tumours in Patients with Cervical Lymph Node Metastases 
Objective: Because the detection of the primary tumour is of importance to optimize the patient’s management and allows a targeted therapy, the performance of hybrid positron emission tomography–computed tomography (PET/CT) using fluorodeoxyglucose (FDG) in the detection of primary tumors and unrecognized metastases with cervical lymph node metastases were evaluated in a retrospective study.
Material and Methods: Twenty patients with cervical lymph node metastases of unknown primary tumors underwent staging with FDG-PET/CT. All underwent head and neck examinations, computed tomography (CT), and/or magnetic resonance imaging (MRI), panendoscopies, and biopsies of head and neck mucosal sites. The diagnostic accuracy of FDG-PET/CT in detecting primary tumors was compared with that of histopathology and clinical follow-up. The ability of FDG-PET/CT to detect distant metastases was also tested.
Results: PET/CT was positive with an increased FDG uptake suggesting the potential primary site in 45% of patients (9/20). PET/CT findings were true positive in 7, true negative in 10, false positive in 2, and false negative in 1 patients, resulting in a sensitivity of 87%, a specificity of 83%, an accuracy of 85%, a positive predictive value of 77% and a negative predictive value of 90%. Also, PET/CT showed distant metastases in seven patients.
Conclusion: FDG-PET/CT can be successfully used for the identification of the primary site and distant metastases in patients with cervical lymph node metastases from an unknown primary cancer.
Conflict of interest:None declared.
doi:10.4274/Mirt.344
PMCID: PMC3590973  PMID: 23487242
Neoplasms; unknown primary; lymphatic metastasis; neoplasm metastasis; Fluorodeoxyglucose F18; positron-emission tomography/computed tomography; head and neck neoplasms
9.  Contrast Enhanced Computed Tomography Characterization of Fluorodeoxygluocose-Avid Regional and Non-Regional Lymph Nodes in Patients with Suspicion of Metastatic Bladder Cancer 
Objective:
The objective of this study is to assess if size alone can predict the presence of metastatic disease within lymph nodes seen on contrast enhanced-computed tomography (CE-CT) in patients with suspicion of metastatic bladder cancer and also to evaluate the nodal distribution and morphological characteristics of fluorodeoxygluocose (FDG) avid lymph nodes on CE-CT.
Materials and Methods:
A retrospective analysis from 2002 to 2009 was performed on patients with suspicion of recurrent disease undergoing restaging FDG-positron emission tomography (PET)/CT. Standardized uptake value (SUVmax) adjusted for lean body mass was recorded in abnormal lymph nodes in the abdominopelvic region. Distribution, size, shape, presence of necrosis and clustering of the FDG-avid lymph nodes was assessed on CE-CT obtained within 4 weeks of the PET/CT. The abnormal nodes were then compared with non-FDG avid lymph nodes on the contralateral side serving as control.
Results:
A total of 103 lymph nodes were found to be FDG-avid in 14 patients on 17 PET/CT examinations. Overall, mean SULmax was 4.7 (range: 1.6-10.7), which is significantly higher than background of 1.5 (P < 0.05). Regional pelvic lymph nodes were FDG-avid in 93% of patients and metastatic extra-pelvic in 100% of patients. The overall average size of the FDG avid lymph nodes on CE-CT was 11 mm with a third of these measuring 3-8 mm. The average size of FDG-avid lymph nodes was 11 mm in the paraaortic region 13 mm in the common iliac 9 mm in the internal iliac and 13 mm in the external iliac regions. Nearly 88.4% of lymph nodes were round in shape, clustering was present in 68% and necrosis in 7% and average size of lymph nodes that served as controls was 6 mm with reniform morphology in 92% and absence of clustering and necrosis.
Conclusion:
Overlap in size exists between FDG-avid pathological and non-pathological lymph nodes seen on CE-CT in patients with metastatic bladder cancer. Other characteristic such as abnormal morphology and clustering are useful adjuncts in the evaluation of nodal metastatic disease.
doi:10.4103/2156-7514.124104
PMCID: PMC3935258  PMID: 24605261
Bladder cancer; contrast-enhanced imaging; fluorodeoxygluocose positron emission tomography/computed tomography
10.  Role and interpretation of FDG-PET/CT in HIV patients with fever of unknown origin: a prospective study 
Purpose of the study
Fever of unknown origin (FUO) is a challenging clinical entity in HIV patients. FDG-PET/CT is well validated in the work-up of FUO in HIV-negative patients but in HIV viremic patients, metabolism of HIV reactive lymph nodes could decrease its specificity. We prospectively evaluated the usefulness of FDG-PET/CT in FUO in HIV-positive patients and in particular whether HIV viremia impacts on FDG-PET/CT performance.
Methods
FDG-PET/CT was performed in 20 HIV patients with FUO and compared with FDG-PET/CT in 10 HIV viremic patients without FUO. Final diagnosis for FUO was based on histopathology, microbiology, or clinical and imaging follow-up. Mode of diagnosis, accordance of FDG-PET/CT with final diagnosis, localization of invasive diagnosis procedures was recorded in order to assess usefulness of FDG-PET/CT.
Results
FDG-PET/CT showed a different pattern in FUO and asymptomatic viremic patients. Reactive HIV lymph nodes in asymptomatic viremic patients were mostly peripheral with mean SUVmax of 6.5. In patients with FUO and underlying focal pathologies, hypermetabolic lymph nodes were central with mean SUVmax of 11.6. Presence of central lymph nodes with high FDG uptake in had a 100% specificity for focal pathology, even in viremic patients and absence of these had 100% negative predictive value. Lymph node biopsy in central hypermetabolic areas allowed identifying underlying disease in all FUO patients. For peripheral lymph nodes, a ROC curve was built in order to define the best cut-off of SUVmax for biopsy: SUVmax of 6–8 showed a sensitivity of 62.5% and specificity of 75%. Lymph nodes with SUVmax<4 had sensitivity of 0%.
Conclusions
FDG-PET/CT contributed to the diagnosis or exclusion of a focal etiology of the febrile state in 80% of HIV patients with FUO. Although number of patients was small, we could highlight several clear-cut features to help interpreting FDG-PET/CT in HIV patients with FUO. As in HIV-negative patients, we showed the usefulness of FDG-PET/CT in FUO in HIV patients even if they are viremic.
doi:10.7448/IAS.15.6.18107
PMCID: PMC3512434
11.  F18-fluorodeoxyglucose-positron emission tomography and computed tomography is not accurate in preoperative staging of gastric cancer 
Purpose
To investigate the clinical benefits of F18-fluorodeoxyglucose-positron emission tomography and computed tomography (18F-FDG-PET/CT) over multi-detector row CT (MDCT) in preoperative staging of gastric cancer.
Methods
FDG-PET/CT and MDCT were performed on 78 patients with gastric cancer pathologically diagnosed by endoscopy. The accuracy of radiologic staging retrospectively was compared to pathologic result after curative resection.
Results
Primary tumors were detected in 51 (65.4%) patients with 18F-FDG-PET/CT, and 47 (60.3%) patients with MDCT. Regarding detection of lymph node metastasis, the sensitivity of FDG-PET/CT was 51.5% with an accuracy of 71.8%, whereas those of MDCT were 69.7% and 69.2%, respectively. The sensitivity of 18F-FDG-PET/CT for a primary tumor with signet ring cell carcinoma was lower than that of 18F-FDG-PET/CT for a primary tumor with non-signet ring cell carcinoma (35.3% vs. 73.8%, P < 0.01).
Conclusion
Due to its low sensitivity, 18F-FDG-PET/CT alone shows no definite clinical benefit for prediction of lymph node metastasis in preoperative staging of gastric cancer.
doi:10.4174/jkss.2011.81.2.104
PMCID: PMC3204564  PMID: 22066108
Gastric cancer; 18F-FDG-PET/CT; MDCT; Preoperative staging
12.  Feasibility of FDG PET/CT to monitor the response of axillary lymph node metastases to neoadjuvant chemotherapy in breast cancer patients 
Purpose
The aim of this study was to assess the accuracy of 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT to visualize lymph node metastases before the start of neoadjuvant chemotherapy and to determine how often the visualization is sufficiently prominent to allow monitoring of the axillary response.
Methods
Thirty-eight patients with invasive breast cancer of >3 cm and/or lymph node metastasis underwent FDG PET/CT before neoadjuvant chemotherapy. The results of the FDG PET/CT were compared with those from ultrasonography with fine-needle aspiration (FNA) cytology or sentinel node biopsy. Patients suitable for response monitoring of the axilla were defined as having either a maximum standardized uptake value (SUVmax) ≥ 2.5 or a tumour to background ratio ≥5 in the most intense lymph node.
Results
The sensitivity and specificity of FDG PET/CT in detecting axillary involvement were 97 and 100%, respectively. No difference existed between the SUVmax of the primary tumour and that from the related most intense lymph node metastasis. Moreover, the mean tumour to background ratio was 90% higher in the lymph nodes compared to the primary tumour (p = 0.006). Ninety-three per cent of the patients had sufficient uptake in the lymph nodes to qualify for subsequent response monitoring of the axilla. A considerable distinction in metabolic activity was observed between the different subtypes of breast cancer. The mean SUVmax in lymph node metastases of oestrogen receptor (ER)-positive, triple-negative and human epidermal growth factor receptor 2 (HER2)-positive tumours was 6.6, 11.6 and 6.6, respectively.
Conclusion
The high accuracy in visualizing lymph node metastases and the sufficiently high SUVmax and tumour to background ratio at baseline suggest that it is feasible to monitor the axillary response with FDG PET/CT, especially in triple-negative tumours.
doi:10.1007/s00259-009-1343-2
PMCID: PMC2869017  PMID: 20130860
Breast cancer; Axillary lymph node metastasis; FDG-PET/CT; Neoadjuvant chemotherapy
13.  The application of PET-CT to post-mastectomy regional radiation therapy using a deformable image registration 
Background
To evaluate the utility of the preoperative PET-CT using deformable image registration (DIR) in the treatment of patients with locally advanced breast cancer and to find appropriate radiotherapy technique for further adequate treatment of axillary nodal area.
Methods
Sixty-five breast cancer patients who had level II, III axillary or supraclavicular lymph node metastasis on 18F-FDG PET-CT and received postoperative radiotherapy after modified radical mastectomy were enrolled. One radiation oncologist contoured normal organs (axillary vessels, clavicular head, coracoids process and humeral head) and involved lymph nodes on PET-CT and simulation CT slices. After contouring, deformable image registration of PET-CT on simulation CT was carried out. To evaluate the performance of the DIR, Dice similarity coefficient (DSC) and Center of mass (COM) were used. We created two plans, one was the historically designed three field plan and the other was the modified plan based on the location of axillary lymph node, and we compared the doses that irradiated the axillary lymph nodes.
Results
The DSCs for axillary artery, axillary vein, clavicular head, coracoids process and humeral head were 0.43 ± 0.15, 0.39 ± 0.20, 0.85 ± 0.10, 0.72 ± 0.20 and 0.77 ± 0.20, respectively. The distances between the COMs of axillary artery, axillary vein, clavicular head, coracoids process and humeral head in simulation CT and from PET-CT were 13.0 ±7.1, 20.2 ± 11.2, 4.4 ± 6.3, 3.7 ± 6.7, and 9.5 ± 25.0 mm, respectively. In the historically designed plan, only 57.7% of level II lymph nodes received more than 95% of prescribed dose and the coverage was improved to 70.0% with the modified plan (p < 0.01). For level III lymph nodes, the volumes received more than 95% of prescribed dose were similar in both plans (96.8 % vs 97.9%, p = 0.35).
Conclusion
Deformable image registration of PET-CT on simulation CT was helpful in the identification of the location of the preoperatively involved axillary lymph node. Historically designed three-field plan was not adequate to treat the axillary level II lymph node area. Novel treatment technique based on the location of axillary lymph node from PET-CT using DIR can result in more adequate coverage of nodal area.
doi:10.1186/1748-717X-8-104
PMCID: PMC3698158  PMID: 23621896
Breast cancer; Deformable image registration (DIR); Radiotherapy; PET-CT
14.  RISK OF SUBCLINICAL MICROMETASTATIC DISEASE IN THE SUPRACLAVICULAR NODAL BED ACCORDING TO THE ANATOMIC DISTRIBUTION IN PATIENTS WITH ADVANCED BREAST CANCER 
Purpose
To determine the anatomic distribution of gross supraclavicular nodes within the supraclavicular fossa using 2-deoxy-2-[F-18] fluoro-d-glucose (FDG) positron emission tomography/computed tomography (PET/CT) scans, and to evaluate likely coverage of specific regions of the supraclavicular fossa using standard radiation fields.
Methods and Materials
We identified 33 patients with advanced or metastatic breast cancer who had a PET/CT scan demonstrating hypermetabolic supraclavicular lymph nodes in 2005. The locations of the involved lymph nodes were mapped onto a single CT set of images of the supraclavicular fossa. These lymph nodes were also mapped onto the treatment-planning CT dataset of 4 patients treated in our institution (2 patients with biopsy-proven supraclavicular nodes and 2 patients with clinically negative supraclavicular nodes).
Results
We were able to determine the distribution of 52 supraclavicular lymph nodes in 32 patients. Of 32 patients, 28 (87%) had a history of metastatic disease, and 2 patients had isolated nodal recurrences. Five patients had supraclavicular nodes posterior to the vertebral body transverse process, and several lymph nodes were in close proximity to the medial field border, raising the possibility of geographic miss in these areas.
Conclusions
In patients with locally advanced disease, increased coverage of the supraclavicular fossa medially and posteriorly may be warranted.
doi:10.1016/j.ijrobp.2007.10.025
PMCID: PMC3385870  PMID: 18164831
Positron emission tomography; Computed tomography; Breast cancer; Supraclavicular nodes
15.  Positron emission tomography-computed tomography for staging and follow-up of pediatric nasopharyngeal carcinoma 
Purpose
While evaluations of FDG PET-CT in adult patients with NPC have documented advantages and disadvantages of the technique compared with conventional imaging, to our knowledge, no such studies have been performed with pediatric patients. In this investigation, we studied the utility of FDG PET-CT in children with NPC.
Methods
Eighteen children with biopsy-proven NPC who underwent FDG PET-CT and MRI were studied (total 38 pairs of imagings). All baseline and follow-up FDG PET-CT and MRI studies were independently reviewed for restaging of disease.
Results
The concordance between FDG PET-CT and MRI in T, N, and overall staging was 29%, 64%, and 43%, respectively. Compared with MRI, FDG PET-CT yielded lower T and overall staging and showed less cervical and retropharyngeal lymphadenopathy. The concordance between follow-up FDG PET-CT and MRI was 79% overall and 100% 9 months after therapy. In patients who achieved complete remission, FDG PET-CT showed disease clearance 3-6 months earlier than MRI. There were no false positive or false negative FDG PET-CT scans during follow-up.
Conclusions
FDG PET-CT may underestimate tumor extent and regional lymphadenopathy compared with MRI at the time of diagnosis, but it helps to detect metastasis and clarify ambiguous findings. FDG PET-CT is sensitive and specific for follow-up and enables earlier determination of disease remission. FDG PET-CT is a valuable imaging modality for the evaluation of and monitoring NPC in pediatric patients.
doi:10.1007/s00259-012-2091-2
PMCID: PMC3531235  PMID: 22532252
positron emission tomography; magnetic resonance imaging; nasopharyngeal carcinoma; child
16.  FDG-PET/CT of sarcoidosis and sarcoid reactions following antineoplastic treatment 
SpringerPlus  2013;2:113.
Sarcoidosis or sarcoid reactions, which appear as FDG-avid lesions in oncologic patients, need to be differentiated from disseminated malignancies. We aimed to promote awareness of development of sarcoidosis or sarcoid reactions after antineoplastic therapy to avoid diagnostic errors with FDG-PET/CT findings and assess the utility of FDG-PET/CT for follow-up. We retrospectively reviewed radiological reports of FDG-PET/CT scans performed between January 2009 and December 2011. Among oncologic patients with more than 2 FDG-PET/CT scans, those with nearly symmetrical increases in FDG uptake in the hilar or mediastinal lymph nodes were identified, and those with known sarcoidosis, concurrent diagnoses of sarcoidosis with malignancy, or histopathologically proven malignancies were excluded. Then, only those cases were selected for which sarcoidosis or sarcoid reactions were diagnosed. Four of 376 oncologic cases met the criteria. At 9 months to 6 years after antineoplastic therapy, abnormal FDG uptakes were observed in the hilar, mediastinal, abdominal, pelvic, and inguinal nodes, and/or spleen and lung parenchyma with SUVmax up to 17.7. On the basis of these findings, 1 patient received anticancer chemotherapy because of tumor recurrence suspicion. A gradual decrease in FDG uptake was observed on subsequent PET/CT scans. Sarcoidosis or sarcoid reactions should be considered in differential diagnosis of oncologic patients who have developed FDG-avid lesions any time after antineoplastic therapy. FDG-PET/CT can be used for follow-up in nondiagnostic situations to detect decreases in FDG uptake due to presence of sarcoidal granulomas.
doi:10.1186/2193-1801-2-113
PMCID: PMC3610027  PMID: 23543853
FDG; PET; Sarcoid reactions; Sarcoidosis; Malignancy; Cancer; Lymphadenopathy
17.  Positron emission tomography scanning is not superior to whole body multidetector helical computed tomography in the preoperative staging of colorectal cancer 
Gut  2006;55(7):1007-1011.
Background
The role of positron emission tomography with the glucose analogue [18F] fluoro‐2‐deoxy‐D‐glucose (FDG‐PET) in the initial staging of disease in patients with primary colorectal cancer (CRC) has not been adequately assessed.
Aims
To evaluate the additional value of FDG‐PET as a staging modality, complementary to routine multidetector row computed tomography (MDCT) in patients with CRC.
Methods
Forty four patients with CRC underwent preoperative MDCT and FDG‐PET. The accuracy of intraoperative macroscopic staging was also investigated compared with histopathological diagnosis. All FDG‐PET images were evaluated with respect to detectability of the primary tumour, lymph node involvement, and distant metastases. Both MDCT and FDG‐PET diagnoses and treatment plan were compared with surgical and histopathological results.
Results
Thirty seven patients underwent surgery. Tumour detection rate was 95% (42/44) for MDCT, 100% (44/44) for FDG‐PET, and 100% (37/37) for intraoperative macroscopic diagnosis. Pathological diagnosis of T factor was T1 in five, T2 in four, T3 in 24, and T4 in four cases. Concordance rate with pathological findings of T factor was 57% (21/37) for MDCT and 62% (23/37) for macroscopic diagnosis. Lymph node involvement was pathologically positive in 19 cases. Regarding N factor, overall accuracy was 62% (23/37) for MDCT, 59% (22/37) for FDG‐PET, and 70% (26/37) for macroscopic diagnosis. For all 44 patients, FDG‐PET findings resulted in treatment changes in only one (2%) patient.
Conclusion
FDG‐PET is not superior to routine MDCT in the initial staging of primary CRC.
doi:10.1136/gut.2005.076273
PMCID: PMC1856325  PMID: 16361308
positron emission tomography; colorectal surgery; spiral computed tomography; colorectal neoplasms; neoplasm staging
18.  PET/MRI in head and neck cancer: initial experience 
Purpose
To evaluate the feasibility of PET/MRI (positron emission tomography/magnetic resonance imaging) with FDG (18F-fluorodeoxyglucose) for initial staging of head and neck cancer.
Methods
The study group comprised 20 patients (16 men, 4 women) aged between 52 and 81 years (median 64 years) with histologically proven squamous cell carcinoma of the head and neck region. The patients underwent a PET scan on a conventional scanner and a subsequent PET/MRI examination on a whole-body hybrid system. FDG was administered intravenously prior to the conventional PET scan (267–395 MBq FDG, 348 MBq on average). The maximum standardized uptake values (SUVmax) of the tumour and of both cerebellar hemispheres were determined for both PET datasets. The numbers of lymph nodes with increased FDG uptake were compared between the two PET datasets.
Results
No MRI-induced artefacts where observed in the PET images. The tumour was detected by PET/MRI in 17 of the 20 patients, by PET in 16 and by MRI in 14. The PET/MRI examination yielded significantly higher SUVmax than the conventional PET scanner for both the tumour (p < 0.0001) and the cerebellum (p = 0.0009). The number of lymph nodes with increased FDG uptake detected using the PET dataset from the PET/MRI system was significantly higher the number detected by the stand-alone PET system (64 vs. 39, p = 0.001).
Conclusion
The current study demonstrated that PET/MRI of the whole head and neck region is feasible with a whole-body PET/MRI system without impairment of PET or MR image quality.
doi:10.1007/s00259-012-2248-z
PMCID: PMC3510405  PMID: 23053322
PET/MRI; Head and neck cancer
19.  Comparison between 18F-Fluorodeoxyglucose Positron Emission Tomography and Sentinel Lymph Node Biopsy for Regional Lymph Nodal Staging in Patients with Melanoma: A Review of the Literature 
Aim. to compare 18F-Fluorodeoxyglucose positron emission tomography (FDG-PET) to sentinel lymph node biopsy (SLNB) for regional lymph nodal staging in patients with melanoma. Methods. We performed a literature review discussing original articles which compared FDG-PET to SLNB for regional lymph nodal staging in patients with melanoma. Results and Conclusions. There is consensus in the literature that FDG-PET cannot replace SLNB for regional lymph nodal staging in patients with melanoma.
doi:10.1155/2011/912504
PMCID: PMC3253490  PMID: 22242204
20.  Prognostic value of 18F-fluorodeoxyglucose positron emission tomography, computed tomography and magnetic resonance imaging in oral cavity squamous cell carcinoma with pathologically positive neck lymph node 
Radiation Oncology Journal  2012;30(4):173-181.
Purpose
To evaluate the prognostic value of preoperative neck lymph node (LN) assessment with 18F-fluorodeoxyglucose positron emission tomography (18F-FDG PET), computed tomography (CT), and magnetic resonance imaging (MRI) in oral cavity squamous cell carcinoma (OSCC) patients with pathologically positive LN.
Materials and Methods
In total, 47 OSCC patients with pathologically positive LN were retrospectively reviewed with preoperative 18F-FDG PET and CT/MRI. All patients underwent surgical resection, neck dissection and postoperative adjuvant radiotherapy and/or chemotherapy between March 2002 and October 2010. Histologic correlation was performed for findings of 18F-FDG PET and CT/MRI.
Results
Thirty-six (76.6%) of 47 cases were correctly diagnosed with neck LN metastasis by 18F-FDG PET and 32 (68.1%) of 47 cases were correctly diagnosed by CT/MRI. Follow-up ranged from 20 to 114 months (median, 56 months). Clinically negative nodal status evaluated by 18F-FDG PET or CT/MRI revealed a trend toward better clinical outcomes in terms of overall survival, disease-free survival, local recurrence-free survival, regional nodal recurrence-free survival, and distant metastasis-free survival rates even though the trends were not statistically significant. However, there was no impact of neck node standardized uptake value (SUVmax) on clinical outcomes. Notably, SUVmax showed significant correlation with tumor size in LN (p < 0.01, R2 = 0.62). PET and CT/MRI status of LN also had significant correlation with the size of intranodal tumor deposit (p < 0.05, R2 = 0.37 and p < 0.01, R2 = 0.48, respectively).
Conclusion
18F-FDG PET and CT/MRI at the neck LNs might improve risk stratification in OSCC patients with pathologically positive neck LN in this study, even without significant prognostic value of SUVmax.
doi:10.3857/roj.2012.30.4.173
PMCID: PMC3546285  PMID: 23346536
Oral cavity squamous cell carcinoma; Neck lymph node; Magnetic resonance imaging; X-ray computed tomography; 18F-FDG PET; Prognostic value
21.  Evaluation of mediastinal lymph nodes using 18F-FDG PET-CT scan and its histopathologic correlation 
Annals of Thoracic Medicine  2011;6(1):11-16.
AIMS AND OBJECTIVES:
To determine the efficacy of integrated 18F-fluorodeoxy glucose positron emission tomography-computed tomography (18F-FDG PET-CT) in the evaluation and characterization of mediastinal lymph nodes into benign and malignant pathology.
METHODS:
Thirty-five patients with mediastinal lymphadenopathies without primary neoplastic or infective lung pathologies were included in the study. The lymph nodes were detected on contrast-enhanced CT scan of the chest. All patients underwent 18F-FDG PET-CT scan for evaluation of mediastinal lymph nodes. Results of PET-CT were compared with histopathology of the lymph nodes and sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were calculated.
STATISTICAL ANALYSIS:
The data were collected prospectively and analyzed using (SPSS Inc., Chicago, IL) 11.5 software.
RESULTS:
Histopathology results in 35 patients revealed tuberculosis in 12, sarcoidosis in 8, and lymphoma in 15. Maximum standardized uptake value (SUVmax) of the benign lymph nodes ranged from 2.3 to 11.8 with a mean±standard deviation (SD) of 5.02±3.26. SUVmax of the malignant lymph nodes ranged from 2.4 to 34 with a mean±SD of 10.8±8.12. There was a statistically significant difference between benign and malignant pathology (P<0.0059). 18F-FDG PET-CT has sensitivity of 93% and specificity of 40% with SUVmax 2.5 as the cutoff. We found the optimal SUVmax cutoff to be 6.2 as determined by the receiver–operator characteristic curve. With 6.2 as cutoff, the sensitivity, specificity, and accuracy were 87%, 70%, and 77%, respectively.
CONCLUSION
In countries where tuberculosis and other granulomatous diseases are endemic, SUVmax cutoff value of 2.5 has low specificity. Increasing the cutoff value can improve the specificity, while maintaining an acceptable sensitivity.
doi:10.4103/1817-1737.74270
PMCID: PMC3023864  PMID: 21264165
FDG PET-CT; lymphoma; mediastinal lymph nodes; tuberculosis; sarcoidosis
22.  Role of fluorine-18-labeled 2-fluoro-2-deoxy-D-glucose positron emission tomography-computed tomography in the evaluation of axillary lymph node involvement in operable breast cancer in comparison with sentinel lymph node biopsy 
Purpose:
Role of (18 [F] fluorine-18-labeled 2-fluoro-2-deoxy-D-glucose [FDG] positron emission tomography-computed tomography [PET-CT]) in the evaluation of axillary lymph node involvement in T1T2N0 breast cancer and compare results with sentinel lymph node biopsy (SLNB).
Methods:
A total of 37 patients of proven T1T2N0 breast cancer were included in the study. Patients with past history of breast surgery, T3T4 disease, uncontrolled diabetes mellitus and pregnant patients were excluded from the study. Pre-operative FDG PET-CT was performed followed by sentinel lymph node (SLN) biopsy with blue dye or combined technique.
Results:
SLN was identified in 32 of 37 patients with an identification rate of 86.48% (32/37). With combined technique SLN identification rate was 100% (6/6) while with blue dye alone; it was 83.8% (26/31). Among 37 patients, 16 had axillary metastases of which 12 had macrometastases and four had micrometastases detected by immunohistochemistry (IHC). Of 12 patients with axillary macrometastases, skip metastases were present in two patients in whom SLN was negative and in two patients SLN was not identified, but axillary dissection showed metastases. PET-CT had shown sensitivity, specificity, negative predictive value and positive predictive value of 56%, 90%, 73%, and 81.8%, respectively. IHC of SLN detected four patients with micrometastases upstaging the disease by 11% (4/37).
Conclusion:
Because FDG PET-CT has a high specificity in the evaluation of axillary lymph node involvement in T1T2N0 breast cancer patients according to the results of this study if FDG PET-CT is positive in axillary lymph nodes, axillary lymph node dissection may be considered instead of SLNB.
doi:10.4103/0972-3919.119542
PMCID: PMC3822412  PMID: 24250021
Breast cancer; fluorine-18-labeled 2-fluoro-2-deoxy-D-glucose positron emission tomography-computed tomography; immunohistochemistry; sentinel lymph node biopsy
23.  Lymph node staging in non-small cell lung cancer: evaluation by [18F]FDG positron emission tomography (PET) 
Thorax  1997;52(5):438-441.
BACKGROUND: A study was undertaken to investigate the accuracy of positron emission tomography (PET) with 2-[18F]-fluoro-2-deoxy-D- glucose (FDG) in the thoracic lymph node staging of non-small cell lung cancer (NSCLC). METHODS: Forty six patients with focal pulmonary tumours who underwent preoperative computed tomographic (CT) and FDG- PET scanning were evaluated retrospectively. Thirty two patients had NSCLC and 14 patients had a benign process. The final diagnosis was established by means of histopathological examination at thoracotomy, and the nodal classification in patients with lung cancer was performed by thorough dissection of the mediastinal nodes at surgery. RESULTS: FDG-PET was 80% sensitive, 100% specific, and 87.5% accurate in staging thoracic lymph nodes in patients with NSCLC, whereas CT scanning was 50% sensitive, 75% specific, and 59.4% accurate. The absence of lymph node tumour involvement was identified by FDG-PET in all 12 patients with NO disease compared with nine by CT scanning. Lymph node metastases were correctly detected by FDG-PET in three of five patients with N1 disease compared with two by CT scanning, in nine of 11 with N2 disease compared with six by CT scanning, an in all four with N3 nodes compared with two by CT scanning. CONCLUSIONS: FDG-PET provides a new and effective method for staging thoracic lymph nodes in patients with lung cancer and is superior to CT scanning in the assessment of hilar and mediastinal nodal metastases. With regard to resectability, FDG-PET could differentiate reliably between patients with N1/N2 disease and those with unresectable N3 disease. 



PMCID: PMC1758560  PMID: 9176535
24.  Diffusion-weighted imaging and FDG PET/CT: predicting the prognoses with apparent diffusion coefficient values and maximum standardized uptake values in patients with invasive ductal carcinoma 
Background
FDG PET/CT and DWI are both functional modalities that indirectly represent the biological characteristics of cancer, but there are few studies exploring the association between the two modalities and prognostic factors. Our study attempted to evaluate the mutual association by comparing the prognostic factors, SUVmax value of PET/CT, and ADC values associated with diffusion imaging in invasive ductal carcinoma (IDC) patients.
Methods
Patients with pathologically confirmed IDC were recruited. There were 118 patients who underwent MRI, including DWI, FDG PET/CT, and immunohistochemical staining of the surgical specimen. Histologic analysis was done on tumor size, lymph node metastasis, expression of estrogen receptors (ER), progesterone receptors (PR), human epidermal growth factor receptor 2 (HER2), Ki-67, and epidermal growth factor receptors (EGFR). The relationship among ADC values, SUVmax and prognostic factors were evaluated.
Results
There was significant association between the ADC value and ER-positive and HER2-negative expression. Significant associations were noted between SUVmax and tumor size, lymph node metastasis, histologic grade, ER and PR expression, EGFR and Ki-67. However, there was no significant correlation between the ADC value and SUVmax.
Conclusions
Even though there was no correlation between ADC and SUVmax, both indexes are useful for predicting the prognosis of IDC.
doi:10.1186/1477-7819-10-126
PMCID: PMC3443424  PMID: 22741544
Invasive ductal carcinoma; breast; magnetic resonance imaging; diffusion magnetic resonance imaging; positron emission tomography
25.  The incremental value of dual modality PET/CT imaging over PET imaging alone in advanced colorectal cancer 
The Indian Journal of Surgery  2009;71(2):63-68.
Background
18Fluoro-2-Deoxy Glucose (18 FDG) positron emission tomography (PET) impacts upon the management of recurrent colorectal cancer (CRC) but is limited by anatomical localisation. The development of integrated positron emission and computerised tomography (PET/CT) yields high anatomical resolution combined with the PET data. We evaluate the added value of PET/CT over PET alone.
Method
Thirty-one consecutive patients had PET/CT for suspected recurrent CRC. Two blinded observers (A and B) reported images from PET alone and from integrated PET/CT. Lesion detection, lesion localisation, diagnostic certainty and impact on surgical management was assessed for each data set and then compared. The minimum clinical follow up was for 8 months (median 9.6 months) and 7 patients had histological confirmation of diagnosis.
Results
Compared to PET alone, PET/CT the percentage of lesions accurately localised increased from 96% to 99% for observer A and 86% to 99% for Observer B. PET/CT increased the number of lesions reported as definitely abnormal or normal from 78% to 95% for Observer A and from 72% to 94% for Observer B. Surgical management was changed in 6 patients (19%). Inter-observer variability was reduced with PET/CT.
Conclusion
PET/CT improves the accuracy of reporting in recurrent colorectal cancer and influences surgical management in a significant proportion of patients when compared to PET only imaging.
doi:10.1007/s12262-009-0018-3
PMCID: PMC3452604  PMID: 23133117
PETCT; Advanced colorectal cancer; Surgical management

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