Usefulness of (18)F-fluorodeoxyglucose positron emission tomography to detect para-aortic lymph nodal metastasis in advanced cervical cancer with negative computed tomography findings

OBJECTIVE: In advanced cervical cancer, it has been reported that progression-free survival is significantly related to para-aortic lymph node metastasis. Computed tomography (CT) has been widely used for clinical staging, but its sensitivity for lymph nodal metastasis is low. Therefore, this prospective study was undertaken to evaluate (18)F-fluorodeoxyglucose positron emission tomography (FDG-PET) in detecting para-aortic lymph nodal metastasis in patients with locally advanced cervical carcinoma when CT findings were negative. METHODS: Fifty women with advanced cervical cancer confined to the pelvis with negative abdominal CT findings were included in this study. After 10 mCi of FDG was administered intravenously, the abdomens were scanned by PET. Para-aortic lymph node metastases were diagnosed as present or absent according to a standardized staging procedure. RESULTS: Retroperitoneal surgical exploration revealed 14 patients with para-aortic lymph nodal metastasis. Two patients had false-negative FDG-PET findings and the other two patients had false-positive FDG-PET findings. CONCLUSION: Overall, FDG-PET imaging had a sensitivity of 85.7%, a specificity of 94.4%, and an accuracy of 92%. When abdominal CT findings are negative, the use of FDG-PET can accurately detect para-aortic lymph nodal metastatis in patients with advanced cervical cancer.     

Can initial serum cyfra 21-1, SCC antigen, and TPA levels in squamous cell cervical cancer predict lymph node metastases or prognosis?

OBJECTIVE: The aim of this study was to determine whether lymph node metastases or prognosis can be predicted by initial serum Cyfra 21-1, tissue polypeptide antigen (TPA), and squamous cell carcinoma antigen (SCC-Ag) levels in squamous cell cervical cancer. METHODS: Pretreatment serum levels of 92 patients were correlated with clinicopathologic parameters and prognostic data. The clinical performance of the tests was evaluated by their receiver operating characteristic curves. The prognostic power of the variables was assessed using Cox regression analysis. RESULTS: Serum levels of each marker were significantly related to tumor stage, size, and depth of infiltration. The clinical performance of each marker in predicting lymph node metastases or parametrial involvement was poor. In the stepwise Cox regression analysis, regarding patients with early stage cervical cancer (stage Ib/IIa, n = 63), tumor size (P = 0.0005) was the only independent prognostic factor for disease-free interval. Lymph node status (P = 0.0014), tumor size (P = 0.004), and parametrial involvement (P = 0.025) were independent risk factors for survival. Considering all patients with stages Ia through IVb disease, tumor size (P = 0.0001) and TPA level (P = 0. 026) were independent risk factors for disease-free interval, whereas tumor size (P = 0.0001) and parametrial involvement (P = 0. 0002) were risk factors for survival. CONCLUSIONS: Pretreatment Cyfra 21-1, TPA, and SCC-Ag levels were strongly related to tumor burden, but insufficiently reliable for identifying patients at risk of the presence of lymph node metastases or parametrial involvement. Serum levels of each marker showed no independent prognostic value in early stage cervical cancer.     

Prognostic significance of progesterone receptor immunohistochemistry for lymph node metastases in endometrial carcinoma

OBJECTIVE: The aim of this study was to determine whether progesterone receptor (PR), estrogen receptor (ER), p53 protein, and proliferating cell nuclear antigen (PCNA) expression constitute independent prognostic factors for lymph node metastases in endometrial carcinoma using immunohistochemical techniques on hysterectomy and biopsy specimens. METHODS: We evaluated the correlation between lymph node metastases and PR/ER immunohistochemistry, p53/PCNA expression, age, tumor grade, myometrial tumor invasion, cervical involvement, and ovarian metastases in a series of 99 cases of primary endometrial carcinoma surgically staged with systemic pelvic lymphadenectomy and para-aortic lymph node biopsy. RESULTS: Lymph node metastases from endometrial carcinoma were statistically correlated with negative PR immunohistochemistry (P = 0.001), intense p53 expression (66% or more of the tumor cells stained, P = 0.003), deep myometrial tumor invasion (greater than one-half, P = 0.001), and cervical involvement (P = 0.001). Tumor grade showed borderline statistical significance for lymph node metastases (P = 0.058). On multivariate analysis, negative PR, intense p53 expression, and cervical involvement were significant prognostic variables for lymph node metastases (P = 0.0001, 0.0023, and 0.002, respectively). Immunohistochemical study indicated that the PR status on preoperative biopsy specimens and hysterectomy specimens was in good agreement, but p53 status was not. Age, ovarian metastases, ER immunohistochemistry, and PCNA expression were not significantly related to lymph node metastases. CONCLUSION: PR immunohistochemistry appeared to be the most powerful prognostic factor associated with lymph node metastases in endometrial carcinoma, independent of other clinicopathological parameters.     

Prospective evaluation of FDG-PET for detecting pelvic and para-aortic lymph node metastasis in uterine corpus cancer

OBJECTIVES: To estimate the sensitivity and specificity of positron emission tomography (PET) with 2-[(18)F]fluoro-2-deoxy-d-glucose (FDG) for detecting pelvic and para-aortic lymph node metastasis in patients with uterine corpus carcinoma before surgical staging. METHODS: Patients with newly diagnosed FIGO grade 2 or 3 endometrioid, papillary serous, or clear cell adenocarcinoma or uterine corpus sarcoma scheduled for surgical staging, including bilateral pelvic and para-aortic lymphadenectomy, were eligible. PET was performed within 30 days of surgery and interpreted independently by two nuclear medicine physicians. The imaging, operative, and pathologic findings for each patient and each nodal site were compared, and the sensitivity and specificity of FDG-PET in predicting nodal metastasis were determined. RESULTS: Twenty patients underwent FDG-PET before surgical staging. One patient found to have ovarian carcinoma on final pathology was excluded. Of the 19 primary intrauterine tumors, 16 (84%) exhibited increased FDG uptake. One patient did not undergo lymphadenectomy; her chest CT was suspicious for metastatic disease and FDG-PET showed uptake in multiple nodal and pulmonary foci. Metastatic disease was confirmed by percutaneous nodal biopsy. A total of three pathologically positive nodes were found in 2 of the 18 patients (11%). FDG-PET predicted that 3 patients would have positive lymph nodes (2 true positive and 1 false positive). Analyzed by lymph node regions, FDG-PET had 60% sensitivity and 98% specificity. The sensitivity and specificity by individual patient were 67% and 94%, respectively. CONCLUSIONS: FDG-PET is only moderately sensitive in predicting lymph node metastasis pre-operatively in patients with endometrial cancer. This imaging modality should not replace lymphadenectomy, but may be helpful for patients in whom lymphadenectomy cannot be, or was not, performed.     

Biological markers in pT1 and pT2 ovarian cancer with lymph node metastases

OBJECTIVE: A relatively high incidence of pelvic and paraaortic lymph node metastases is found in patients with pT1 and pT2 ovarian cancer. This paper investigates the clinicomorphological parameters and the expression of various biological markers in these tumors in order to define possible risk factors for lymphatic dissemination. METHODS: In a retrospective study we identified 51 patients with pT1 and pT2 ovarian cancer. All patients underwent total hysterectomy, bilateral salpingo-oophorectomy, omentectomy, and systemic pelvic +/- paraaortal lymphadenectomy. The incidence of lymph node metastases in these patients and the clinicomorphological parameters of their tumors were examined. Immunohistochemistry was used to determine the expression levels of the cell proliferation marker Ki-67, the cell adhesion molecules CD44s and CD44v6, and the oncoprotein HER2/neu of the tumors and their respective lymph node metastases. RESULTS: Lymph node involvement was found in 5 of 26 patients with pT1 ovarian cancer and in 6 of 25 patients with pT2 ovarian cancer. Serous adenocarcinoma was associated with a significantly higher incidence of lymph node metastases than other histological types (chi(2) = 4.7, P = 0.03). No correlation was found between tumor grade and the lymph node status. High Ki-67 expression was significantly correlated with spread to the lymph nodes (chi(2) = 4.2, P = 0.04), whereas expression of CD44s, CD44v6, and HER2/neu was not related to the lymph node status. Survival analyses showed no difference in disease-free and overall survival in patients with lymph node metastases compared to those without lymph node metastases. No association was seen among histological type, tumor grade, and immunohistochemically detected Ki-67, CD44s, CD44v6, and HER2/neu expression on the one hand and disease-free and overall survival on the other hand. CONCLUSIONS: Our data suggest that in early stage ovarian cancer the serous histological type and tumors showing a high Ki-67 expression carry a high risk of lymph node metastases. With respect to prognosis our data showed a minor role for Ki-67, CD44s, CD44v6, and HER2/neu expression and the occurrence of lymph node metastases in pT1 and pT2 ovarian cancer.     

Lymph node metastasis in stage I epithelial ovarian cancer

OBJECTIVES: A relatively high incidence of para-aortic and pelvic lymph node metastasis is found in epithelial ovarian cancer. This paper investigates the clinicomorphological features of intra-abdominal stage I epithelial ovarian cancer that may predict the occurrence of lymph node metastasis and the prognosis of patients in whom lymph node metastases are identified. METHODS: From November 1988 to December 1997 we performed systematic para-aortic and pelvic lymphadenectomy as primary surgery in 47 patients with intra-abdominal stage I epithelial ovarian cancer. The incidence of lymph node metastasis in these patients and the clinicomorphological features of the patients with lymph node involvement were examined. RESULTS: Five patients (10.6%) were metastasis positive (IC: four; IA: one), of whom four had serous adenocarcinoma. Serous adenocarcinoma was associated with a significantly higher incidence of metastases than other histological types (P < 0.05). The number of positive lymph nodes was one in four patients and two in one patient, and the metastatic sites ranged from the para-aortic to the suprainguinal lymph nodes. All five metastasis-positive patients were alive and disease free at the time of this report (survival 28-85 months: median 59 months). CONCLUSION: This clinical study suggests that serous adenocarcinoma carries a high risk of lymph node metastasis, requiring systematic lymphadenectomy for accurate staging in intra-abdominal stage I epithelial ovarian cancer.     

Occult supraclavicular lymph node metastasis identified by FDG-PET in patients with carcinoma of the uterine cervix

PURPOSE: The objective was to evaluate the frequency and prognostic significance of occult supraclavicular lymph node metastases identified by 2-[(18)F]fluoro-2-deoxy-D-glucose-positron emission tomography (FDG-PET) in patients with cervical carcinoma. PATIENTS AND METHODS: Between March 1998 and January 2002, 186 patients with a new diagnosis of cervical cancer underwent whole-body FDG-PET before therapy. Fourteen patients had abnormal FDG uptake in left supraclavicular lymph nodes without palpable disease. All 14 patients underwent sonographically guided fine-needle aspiration of the left supraclavicular lymph nodes. One patient refused therapy, 6 were treated with palliative intent, and 7 received definitive irradiation and concurrent chemotherapy. Survival was calculated by the Kaplan-Meier method. RESULTS: The overall frequency of FDG-positive left supraclavicular lymph nodes was 8% (14/186). Metastasis was pathologically confirmed in all 14 patients. Therefore, the positive predictive value of abnormal FDG uptake in left supraclavicular lymph nodes was 100%. Nineteen percent of all patients (35/186) had abnormal FDG uptake in para-aortic lymph nodes. The frequency of positive FDG uptake in the left supraclavicular lymph nodes was 40% (14/35) in those with para-aortic lymph node uptake and 15% in those with stage IIIb disease. The median overall survival was 7.5 months. At last follow-up, 11 patients were dead and 3 were alive with disease. All patients developed metastatic disease, most commonly to bone and lung. CONCLUSION: The positive predictive value of abnormal FDG uptake in left supraclavicular lymph nodes was 100%. Prognosis for these patients was dismal despite aggressive therapy.     

Should the presence of lymphvascular space involvement be used to assign patients to adjuvant therapy following hysterectomy for unstaged endometrial cancer?

Objective. Thegoal of this study was to determine the influence of LVSI (lymphvascular space involvement) on the risk of lymph node metastases from endometrial cancer.Methods. All patients with surgically staged endometrial cancer from 1998 to 2000 were identified from divisional databases. The influence of LVSI on the risk for nodal metastases was determined after controlling for tumor grade and depth of invasion, and comparisons were made with the chi(2) or Fisher's exact tests. Multivariable analysis was performed using a logistic regression model.Results. We identified 366 patients who fit the study criteria. Pathologically, 92/366 (25%) tumors had LVSI, and 46 patients (13%) had evidence of pelvic lymph node metastases. Cancers with LVSI were significantly more likely to have nodal disease (35/92 versus 11/274, P < 0.001). When controlled for tumor grade, the presence of LVSI led to an increased incidence of pelvic node metastases (P < 0.001 for all grades). When stratified by depth of invasion in thirds, the presence of LVSI led to a significantly increased chance of pelvic lymph node metastases (P < 0.05 for each strata). When tumor grade and depth of invasion were evaluated together, LVSI led to a significantly increased risk of pelvic node metastases in patients with deeply invasive tumors. In a multivariable analysis, LVSI led to a significantly increased risk for pelvic lymph node metastases (P < 0.05).Conclusion. LVSI leads to an independent and significantly increased risk for pelvic lymph node metastases. As such, the presence of LVSI may indicate the need for lymphadenectomy or adjuvant therapy for potential regional lymph node metastases in patients with unstaged endometrial cancer.     

Mesenteric and mesocolic lymph node metastases from ovarian carcinoma: A clinicopathological analysis

Lax SF, Petru E, Holzer E, Pertl AM, Ralph G, Greenspan DL, Berger A, Jatzko G. Mesenteric and mesocolic lymph node metastases from ovarian carcinoma: a clinicopathological analysis. Int J Gynecol Cancer 1998; 8 :119–123.
The aim of this study was to analyze the clinicopathological features of ovarian carcinomas with metastases to mesenteric or mesocolic lymph nodes. Thirty patients with primary ovarian carcinomas metastatic to the bowel were analyzed for the extent of bowel infiltration, lymph node involvement, lymphatic channel involvement, and the number of examined lymph nodes. Metastases to mesenteric or mesocolic lymph nodes were found in 20 of the 30 patients. Metastases to mesenteric/mesocolic lymph nodes were more frequently associated with lymph vascular invasion at the site of the bowel implants and metastatic involvement of multiple bowel segments compared to mesenteric/mesocolic node-negative cases ( P < 0.04). There was no significant difference between the mesenteric/mesocolic node-positive and node-negative patients with regard to FIGO stage, histologic type, tumor grade, residual tumor after surgery, gross pattern of bowel metastases, and involvement of retroperitoneal lymph nodes. While the presence of mesenteric/mesocolic lymph node metastases tended to be associated with shorter survival, this was not statistically significant. The prognostic and putative therapeutic importance of positive mesenteric/mesocolic lymph nodes in ovarian carcinoma awaits further evaluation in a larger number of cases.     

Pattern of lymph node metastasis and the optimal extent of pelvic lymphadenectomy in FIGO stage IB cervical cancer

AIM: To evaluate the distribution pattern of lymph node metastasis and to determine the optimal extent of pelvic lymphadenectomy (LA) in FIGO stage IB cervical cancer. METHODS: The medical records of 187 patients with FIGO stage IB cervical cancer from March 1996 to December 2002 were reviewed retrospectively. The distribution pattern and risk factors of lymph node metastases were analyzed in 31 patients with lymph node metastases confirmed surgically. One hundred patients, who underwent type III hysterectomy with pelvic LA but did not receive any adjuvant treatment, were analyzed to evaluate whether the extent of LA affected the prognosis of FIGO stage IB cervical cancer. Type I LA included the external iliac nodes, hypogastric nodes, obturator nodes, and parametrial nodes. Type II LA included the pelvic nodes described in type I LA, the common iliac nodes, gluteal nodes, deep inguinal nodes and sometimes the presacral nodes. RESULTS: Solitary lymph node metastasis confined to one node group was seen in the obturator, external iliac or hypogastric lymph nodes. All patients with lymph node metastases at multiple sites had metastasis in at least one of these lymph-node groups. There was no significant difference in disease-free survival and overall survival in patients without pathologic high-risk factors according to the type of pelvic LA. CONCLUSION: The extent of LA should be adjusted to reduce complications and not to affect adversely the prognosis of FIGO stage IB cervical cancer patients without pathologic high-risk factors.     

Noninvasive detection of inguinofemoral lymph node metastases in squamous cell cancer of the vulva by L-[1–11C]-tyrosine positron emission tomography

In the majority of patients with early stage squamous cell cancer (SCC) of the vulva, an inguinofemoral lymphadenectomy is performed (in retrospect) for diagnostic reasons: exclusion of inguinofemoral lymph node metastases. The morbidity of this procedure, however, is significant. The aim of the present study was to evaluate noninvasive detection of inguinofemoral lymph node metastases by positron emission tomography (PET) using L-[1–¹¹C]-tyrosine (TYR) as tracer.
In patients with SCC of the vulva, scheduled for resection of the primary tumor and uni- or bilateral inguinofemoral lymphadenectomy, results of preoperative palpation of the groins and TYR-PET imaging were compared with histopathology. PET imaging was performed using two different methods. In a first group ( n = 16), nonattenuation corrected 'whole body' scans were performed, and in a second group ( n = 9), attenuation corrected static emission scans.
Sensitivity, specificity, accuracy, and positive and negative predictive value for palpation were 62%, 89%, 82%, 67%, and 87% per groin. Sensitivity, specificity, accuracy, and positive and negative predictive value for TYR-PET were calculated for the two methodologies separately and overall. There were no significant differences. Overall values were 53%, 95%, 94%, 33%, and 98% per lymph node and 75%, 62%, 65%, 41% and 88% per groin.
Detection of inguinofemoral lymph node metastases by TYR-PET is not superior to palpation. Neither palpation nor TYR-PET is able to adequately predict or exclude presence of inguinofemoral lymph node metastases in patients with SCC of the vulva.     

Squamous cell carcinoma antigen: pretreatment levels as an indicator of advanced or metastatic disease

Pretreatment values of squamous cell carcinoma antigen (SCC) were obtained in 100 consecutive patients with squamous cell carcinoma of the cervix presenting to the Regional Gynaecological Oncology Centre in Gateshead, UK. Nine patients deemed to have locally advanced disease not suitable for primary surgery had elevated levels. Ninety-one patients were suitable for primary surgery. Sixty-seven had normal SCC levels, two of which had lymph node metastases. Twenty-four had elevated SCC levels, 14 of which had lymph node metastases. Two early recurrences have been detected in the raised SCC group where no lymph node metastases were present. Elevated levels of SCC in the pretreatment assessment indicate a high risk of lymph node metastases and of developing recurrent disease after primary surgery.     

Extrapelvic lymph node metastases in cervical carcinoma.

One hundred and fifty patients with invasive cervical carcinoma underwent preradiation therapy celiotomy and para-aortic node excision. The incidence of histologically documented metastases in these nodes was 33% (34/102) in Stage IIIB. The last 23 patients with positive para-aortic nodes had left sclanene node excision; nodes were positive in eight patients (34.8%). Sixteen patients had visceral metastases including 11 with small and large bowel metastases, two with liver metastases, and one with metastases to the liver and intestine. Pretreatment celiotomy with para-aortic lymph node excision and, where positive, followed by scalene lymph node excision is valuable in treatment planning in advanced cervical carcinoma limited to the pelvis.     

The influence of pretreatment celiotomy and para-aortic lymphadenectomy on the management of advanced stage squamous cell carcinoma of the cervix

Thirty patients with advanced stage squamous cell carcinoma of the cervix underwent exploratory celiotomy and para-aortic lymphadenectomy prior to beginning radiation therapy. Para-aortic lymph node metastases were found in 9 patients (30%), and visceral metastases in 2 patients (7%). Findings at celiotomy prior to initiation of therapy allowed patients to be divided into 3 groups: Patients with 1) visceral metastases, 2) para-aortic lymph node metastases but without visceral or scalene lymph node metastases, and 3) patients with disease confined to the pelvis. Therapy was then based on the extent of disease present in each patient. As a result of the surgical findings, 10 of 30 patients (33%) received therapy other than standard pelvic radiation therapy. The surgical technique, operative morbidity, and prognostic significance of the surgical findings are discussed.     

Lymph node involvement in primary carcinoma of the fallopian tube

Although the bad prognosis of primary fallopian tube carcinoma has been mostly ascribed to early lymphogenous dissemination, precise information regarding the characteristics of retroperitoneal spread are still missing. Our study was designed to evaluate the incidence and clinical significance of lymph node metastases in 33 patients with primary carcinoma of the fallopian tube. During primary surgery nine patients (27%) were submitted to systematic pelvic and para-aortic lymphadenectomy, whereas 24 received lymph node sampling. The clinicopathologic characteristics of the patients (intraperitoneal spread, grading, peritoneal cytology, depth of tubal infiltration and residual disease after primary surgery) were compared with lymphnodal status.
Overall 15 patients (45%) had positive nodes, that is, invaded by tumor; whereas 18 (55%) showed no lymphatic spread. Six patients (40%) had exclusively positive para-aortic lymph nodes; five (33%) had only tumor metastases in pelvic lymph nodes, three (20%) manifested simultaneously pelvic and para-aortic spread, and one patient with pure primary squamous cell carcinoma had a massive groin node metastasis as presenting sign of the tumor. The rate of lymphogenous metastases was not significantly related to progressive intra-abdominal dissemination, histologic grade or depth of tubal infiltration. On the other hand, the presence of residual disease after primary surgery and positive peritoneal cytology significantly increased the risk of nodal metastases. Patients with lymph node metastasis had a significantly ( P = 0.02) worse prognosis compared with patients without nodal involvement (median survival 39 vs 58 months).
Considering the high incidence of lymph node metastasis, correct staging of tubal carcinoma should include a thorough surgical evaluation of both pelvic and para-aortic lymph nodes. The role of systematic lymph node dissection in the treatment of tubal carcinoma remains controversial.     

Pretreatment levels of serum squamous cell carcinoma antigen and urine polyamines in women with squamous cell carcinoma of the cervix.

OBJECTIVES: To investigate whether pretreatment levels of serum squamous cell carcinoma antigen (SCCA) and urine polyamines can predict lymph node metastases in patients with early stage cervical carcinoma. METHODS: Pretreatment measurement of serum SCCA and urine polyamine levels was carried out for 419 women. Of those women, 104 with stage IB and IIA cancer received radical surgery and had tumor size reassessed postoperatively. RESULTS: The women had increased levels of serum SCCA (>2.0 ng/mL) and elevated urine polyamines (>45 micromol/g of creatinine) with advanced cancer stage (P<0.01). The median SCCA level was significantly higher in women with metastatic disease than that in those without lymph node involvement (3.9 vs. 1.1; P<0.01). Women with nodal involvement also had significantly higher median levels of urine polyamines than those without nodal disease. CONCLUSIONS: Pretreatment measurement of SCCA and urine polyamine levels may help in predicting lymph node metastases in women with early stage cervical carcinoma.     

Predictability of retroperitoneal lymph node metastasis by using clinicopathologic variables in surgically staged endometrial cancer

The purpose of this study was to predict lymphatic involvement in endometrial cancer using clinicopathologic variables of patients treated with surgical staging. Overall, 461 patients treated with an initial surgical staging procedure including complete pelvic-para-aortic lymphadenectomy were included. The mean number of resected lymph nodes was 27 (median 26; range 15-83), and 54 patients (12%) had lymphatic involvement. Of these patients, 32 had only pelvic, 15 had both pelvic and para-aortic, and 7 had isolated para-aortic metastases. In the multivariate analysis, deep myometrial invasion (P= 0.02), lymphvascular space invasion (P= 0.001), positive peritoneal cytology (P= 0.002), and cervical involvement (P= 0.003) predicted retroperitoneal lymph node metastasis (RLN) significantly. Two hundred seventy-four patients (59.4%) had at least one of these poor prognostic factors identified by multivariate analysis. In this patient population, 53 (19.3%) had lymphatic involvement compared to 1 patient in the group of 187 patients with low-risk criteria. Ninety-eight percent of patients with RLN were predicted by this model, and with the advent of accurate diagnostic techniques, 40% of patients could be saved from undergoing lymphadenectomy.     

FDG-PET in the detection of recurrence of uterine cervical carcinoma following radiation therapy--tumor volume and FDG uptake value

PURPOSE: We evaluated the use of positron emission tomography (PET) with fluorine-18-labeled fluoro-2-deoxy-d-glucose (FDG) in follow-up study after radiation therapy in patients with uterine cervical carcinoma. MATERIALS AND METHODS: Thirty-two studies in 25 patients were reviewed. Twenty patients were treated with external beam irradiation and intracavitary brachytherapy, and five with irradiation following initial surgery. Time from initial treatment to FDG-PET was 23.3 (5.2-88.0) months. Rationale for FDG-PET was the presence of symptoms in 6 patients, abnormal serum tumor marker values in 13, abnormal lesions on other diagnostic imaging modalities in 19, and patient request in 2. On visualization of a lesion, the maximum standardized uptake value (maxSUV) of the lesion was calculated, and values over 2.0 were classified as FDG-positive. Maximum tumor diameter and tumor volume in the corresponding disease were estimated by computed tomography (CT) or magnetic resonance imaging (MRI). RESULTS: Sensitivity and specificity of FDG-PET in the detection of recurrent disease were 91.5% (43/47) and 57.1% (4/7), respectively. Four false-negative findings were seen for small lung metastases having a volume less than 1 cm3. Three false-positive cases were a localized pneumonitis, a benign pubic bone fracture, and a fibrosis after interstitial brachytherapy. Sensitivity for extrapelvic lymph node metastases was extremely high (100%); in contrast, sensitivity and specificity for lung and bone lesions were 75.0% (12/16) and 33.3% (1/3), respectively. Regarding tumor volume measurement, good correlation between maxSUV on FDG-PET and tumor volume was obtained (lung metastases, P = 0.03; extrapelvic nodes, P < 0.0001). Within this study, all corresponding lesions over 1 cm3 showed a maxSUV value greater than 2.0. CONCLUSION: FDG-PET is a useful tool for the detection of extrapelvic lesions during the follow-up period after radiation therapy for cervical cancer. This study suggests that FDG uptake is associated with tumor volume, and FDG-PET has limitations in the detection of lesions less than 1 cm3 or microscopic disease. Careful diagnostic agreement between PET and CT/MRI for positive but benign lesions, such as inflammation and bone fracture, remains important.     

The role of preoperative ultrasound evaluation of inguinal lymph nodes in patients with vulvar malignancy

Objectives

Inguinal lymphadenectomy in vulvar malignancies is associated with significant morbidity, especially in patients over 70 years old. Under certain conditions, surgical guidelines recommend biopsy and evaluation of the sentinel node in early vulvar cancer. The purpose of our study is to evaluate ultrasonography as a predictor of inguinal lymph node involvement.

Methods

A retrospective study was performed with 60 patients who had vulvar malignancies (92% of which were squamous cell carcinomas) and who were treated at our hospital between 2002 and 2012. The patients ranged in age from 35 to 89 years, with a median age of 76 years. In total, 118 groin scans were retrospectively evaluated for sonographic evidence of lymph node involvement (i.e., absence of fatty hilum, irregular shape, cortical region diameter and vascularization pattern). The results were then compared with histopathologically confirmed lymph node status.

Results

Histopathologically confirmed lymph node status was available for 107 of the inguinal nodes examined by ultrasound, and lymph node metastases were found in 38 (35.5%) cases. The presence or absence of inguinal lymph node metastases was correctly identified by sonography in 92 (86.0%) of the scanned areas. Sensitivity was 76.3%, specificity was 91.3%, and positive and negative predictive values were 82.9% and 87.5%, respectively.

Conclusions

Ultrasonography of the inguinal lymph nodes showed a relatively high sensitivity and specificity for predicting inguinal tumor metastases. However, our results indicate that surgical lymph node staging is still needed to precisely determine inguinal lymph node status in vulvar cancer, especially because a missed lymph node-metastasis is often fatal.     

Nm23 expression in node-positive and node-negative endometrial cancer.

OBJECTIVE: To examine the relationships between the expression of protein Nm23 and surgical stage, histologic grade, histopathologic findings, and survival in women with endometrial carcinoma. METHODS: 19 patients with lymph node involvement were matched with 24 patients without lymph node involvement and the best paraffin-embedded blocks were selected for Nm23 immunohistochemical staining. The slides were evaluated semiquantitatively according to their degree of cytoplasmic staining. Statistical analysis was performed to determine whether there was a relationship between Nm23 expression and surgical stage, histologic grade, depth of myometrial invasion, lymph node metastasis, and/or lymphovascular space involvement. Survival analysis was also performed. RESULTS: Slides from 15 patients (79%) with lymph node involvement and 22 patients (88%) without lymph node involvement were found to be positive for Nm23 (P=0.01). No significant relations were observed between Nm23 expression and surgical stage, histologic grade, depth of myometrial invasion, or lymphovascular space involvement. Nm23 expression was found to be significantly related to lower rates of lymph node metastasis and longer survival (P=0.02). CONCLUSION: Elevated Nm23 expression is related to lower rates of lymph node metastasis and longer survival.