Platelet increment is not associated with endothelial damage in haematological patients: a prospective observational study.

The aim of this study was to investigate if thrombocytopenic haematology patients show signs of endothelial damage when transfused with platelets and if that damage correlates with platelet increment measured with corrected count increment (CCI). Endothelial damage secondary to radiation or chemotherapy may lead to consumption of transfused platelets but research in this field is scarce. Patients were divided into four groups: Group 1: Acute leukaemia; Group 2: Autologous stem cell transplantation (SCT); Group 3: Allogenic SCT; and Group 4: patients receiving platelets prior to interventions. Blood was sampled before (baseline) and immediately after (0 h) transfusion and then at 1, 4, 8, 16 and 24 h after transfusion. The biomarkers syndecan-1, soluble thrombomodulin (sTM) and vascular endothelial growth factor (VEGF) were analysed. The plasma concentration differences between baseline and later sampling times were referred to as delta (Δ). Fifty-four platelet transfusion events were studied. All biomarkers were within the normal ranges both before and after the transfusions. The Δsyndecan-1 increased at 0 h (p = .02), but there was no significant correlation between Δsyndecan-1 and CCI. There was no change in any of the other biomarkers after transfusion compared to before. There were no differences between the groups and no correlations were found between CCI and C-reactive protein, Δsyndecan-1, ΔsTM or ΔVEGF. There were no signs of endothelial damage before or after platelet transfusions. A transient significant change in syndecan-1 immediately after platelet transfusion did not influence platelet count or platelet CCI.

Proton pump inhibitor medication is associated with colonisation of gut flora in the oropharynx.

BACKGROUND: The normal body exists in mutualistic balance with a large range of microbiota. The primary goal of this study was to establish whether there is an imbalance in the oropharyngeal flora early after hospital or ICU admittance, and whether flora differs between control, ward and critically ill patients. The secondary goal was to explore whether there are patient characteristics that can be associated with a disturbed oropharyngeal flora. METHODS: Oropharyngeal cultures were obtained from three different study groups: (1) controls from the community, (2) ward patients and (3) critically ill patients, the two latter within 24 h after admittance. RESULTS: Cultures were obtained from 487 individuals: 77 controls, 193 ward patients and 217 critically ill patients. Abnormal pharyngeal flora was more frequent in critically ill and ward patients compared with controls (62.2% and 10.4% vs. 1.3%, P < 0.001 and P = 0.010, respectively). Colonisation of gut flora in the oropharynx was more frequent in critically ill patients compared with ward patients or controls (26.3% vs. 4.7% and 1.3%, P < 0.001 and P < 0.001, respectively). Proton pump inhibitor medication was the strongest independent factor associated with the presence of gut flora in the oropharynx in both ward and critically ill patients (P = 0.030 and P = 0.044, respectively). CONCLUSION: This study indicates that abnormal oropharyngeal flora is an early and frequent event in hospitalised patients and more so in the critically ill, compared to controls. Proton pump inhibitor medication is associated with colonisation of gut flora in the oropharynx.

Comparison of citrated and fresh whole blood for viscoelastic coagulation testing during elective neurosurgery.

BACKGROUND: Previous viscoelastic haemostatic tests studies have often indicated a hypercoagulative test signal with citrated blood, which could influence clinical decision makings. PURPOSE: The aim of this study was to compare fresh and citrated whole blood using two non-automated viscoelastic ROTEM and Sonoclot tests. Our hypothesis was that citrated blood would demonstrate a hypercoagulative response in this setting, not tested before. METHODS: Perioperative viscoelastic coagulation changes were evaluated with a ROTEM and Sonoclot in 38 patients undergoing elective brain tumor surgery. The citrated samples were recalcified with CaCl2. Wilcoxon nonparametric-paired tests and Bland-Altman plots were performed to compare the fresh and citrated blood analyses. RESULTS: The citrated blood showed a hypercoagulative response in ROTEM NATEM-clot formation time and α-angle, Sonoclot-clot rate and platelet function, as compared to fresh blood (p<0.0001). CONCLUSIONS: Fresh whole blood may theoretically reflect in vivo haemostasis more closely than citrated analyses, which indicated a hypercoagulative response as compared to the fresh whole blood analyses Bland-Altman plots also indicated that ROTEM reference ranges in patients undergoing brain surgery should be redefined. Future studies must establish the correlation between viscoelastic test results using fresh or citrate anticoagulated blood and clinical outcomes, such as bleeding, transfusion or reoperation for postoperative haematoma.

Effects of different colloid infusions on ROTEM and Multiplate during elective brain tumour neurosurgery.

BACKGROUND: The European Medicines Agency does not recommend the use of hydroxyethyl starch-based volume replacement solutions in critically ill patients due to an increased risk of renal failure. However, this recommendation is questionable for its perioperative use. Several recent randomised controlled studies do not indicate a risk for renal failure-not even after high-risk surgery. Human albumin is used in our neurointensive care unit as a part of the "Lund concept" of brain injury resuscitation, and albumin has been introduced in elective neurosurgery instead of starch. The aim of our prospective unblinded observational cohort study was to compare the degree of dilutive coagulopathy after albumin and starch intra-operative fluid therapy. METHODS: Thirty-nine patients undergoing elective brain tumour surgery with craniotomy received either 130/0.42 hydroxyethyl starch or 5 % albumin infusions. The first 18 patients received starch, whereas the rest received albumin. Rotational thromboelastometry with ROTEM and platelet aggregometry with Multiplate were performed before surgery, after the first and second consecutive colloid infusions (250/500 ml albumin or 500/1000 ml starch) and at the end of surgery. RESULTS: Both intra- and inter-group comparisons showed more deranged ROTEM parameters after the higher doses of starch. Multiplate detected changes only in the albumin group after 500-ml infusion. Blood los did not differ between groups, nor did haemoglobin preoperatively or at end of surgery. Lower volumes of albumin were required to maintain stable intra-operative haemodynamic parameters; 250/500 ml albumin corresponded to 500/1000 ml starch. CONCLUSIONS: Hydroxyethyl starch affected coagulation at lower volumes, with a more prominent effect on clot structure at the end of surgery, corroborating previous research. Only albumin decreased platelet aggregation, and 5 % albumin had a more potential volume effect than 130/0.42 hydroxyethyl starch.

Comparison of point-of-care hemostatic assays, routine coagulation tests, and outcome scores in critically ill patients.

PURPOSE: The purposes of the study are to compare point-of-care (POC) hemostatic devices in critically ill patients with routine laboratory tests and intensive care unit (ICU) outcome scoring assessments and to describe the time course of these variables in relation to mortality rate. MATERIALS AND METHODS: Patients admitted to the ICU with a prognosis of more than 3 days of stay were included. The POC devices, Multiplate platelet aggregometry, rotational thromboelastometry, and ReoRox viscoelastic tests, were used. All variables were compared between survivors and nonsurvivors. Point-of-care results were compared to prothrombin time, activated partial thromboplastin time, platelet count, fibrinogen concentration, and Sequential Organ Failure Assessment score and Simplified Acute Physiology Score 3. RESULTS: Blood was sampled on days 0 to 1, 2 to 3, and 4 to 10 from 114 patients with mixed diagnoses during 237 sampling events. Nonsurvivors showed POC and laboratory signs of hypocoagulation and decreased fibrinolysis over time compared to survivors. ReoRox detected differences between survivors and nonsurvivors better than ROTEM and Multiplate. CONCLUSIONS: All POC and routine laboratory tests showed a hypocoagulative response in nonsurvivors compared to survivors. ReoRox was better than ROTEM and Multiplate at detecting differences between surviving and nonsurviving ICU patients. However, Simplified Acute Physiology Score 3 showed the best association to mortality outcome.

Bleeding complications after central line insertions: relevance of pre-procedure coagulation tests and institutional transfusion policy.

BACKGROUND: The aim of this study was to map pre-procedural variables for insertion of a central venous catheter, prophylactic blood component use and to investigate whether any independent variable could be identified as an independent risk factor for associated bleeding complications in patients outside the intensive care unit. METHODS: In this retrospective study, we investigated 1737 consecutive insertions of central venous catheters in 1444 patients in a large university hospital during 2009-2010. Pre-procedural coagulation status, blood component use, type of catheter, insertion site and complications during insertion were recorded and compared with bleeding complications documented on electronic charts. RESULTS: No serious bleeding complications were recorded in connection with the insertion of central venous catheters. Sixteen of 1769 (0.9%) insertions caused grade 2 bleeding, defined as bleeding requiring prolonged compression at the insertion site. Insertion of a large bore central dialysis catheter was found to be an independent risk factor for bleeding complications. Neither conventional coagulation tests nor accidental arterial puncture or the number of needle passes could predict bleeding complications in this study. CONCLUSION: This retrospective study, in non-ICU patients, shows that serious bleeding complications in association with central line insertions are uncommon and that insertion of a large bore catheter is likely to be an independent risk factor for mild-bleeding complications in this population.

Complement activation products in liquid stored plasma and C3a kinetics after transfusion of autologous plasma.

BACKGROUND AND OBJECTIVES: Keeping a small stock of liquid plasma readily available for transfusion is common practise in Sweden. We report data on complement activation markers in plasma components during storage in the liquid state and the kinetics of C3a-(desArg) after transfusion of autologous plasma with high content of C3a-(desArg). MATERIAL AND METHODS: Plasma components were prepared by apheresis or from whole blood. C3 fragments (C3a-(desArg), C3d,g, iC3), and soluble terminal complement complex (sC5b-9) were investigated. C3a-(desArg) kinetics was investigated in regular apheresis donors. RESULTS: Apheresis plasma prepared by membrane centrifugation had significantly higher level of C3a-(desArg), C3d,g and sC5b-9 from day 0 and low iC3, than plasma prepared by other methods. By storage day 7, C3a-(desArg)-levels were above the reference value in 88% of all components. After re-infusion of autologous plasma with high C3a-(desArg) content, there were rapid a(1) and a(2)-distribution followed by a slower b-elimination phase. CONCLUSION: Plasma components prepared by different methods and stored in the liquid phase differ significantly in the amount and timing of complement activation. C3a-(desArg) present in plasma is rapidly eliminated after transfusion. Autologous plasma could be used to study complement kinetics in different clinical situations.

An evaluation of monitoring possibilities of argatroban using rotational thromboelastometry and activated partial thromboplastin time.

BACKGROUND: Rotational thrombelastometry/thrombelastography with ROTEM and TEG is becoming available bedside in an increasing number of intensive care units, where many patients with heparin-induced thrombocytopenia (HIT) are treated. The study has been performed in an effort to find out whether ROTEM could be an alternative to activated partial thromboplastin time (aPTT) when argatroban is used for anticoagulation. METHODS: Argatroban was added in vitro to a series of citrated whole-blood samples from 10 healthy volunteers to obtain whole-blood concentrations of 0, 0.125, 0.25, 0.5, 1.0, 2.0, 4.0 and 8.0 mg/l. ROTEM and whole-blood aPTT analyses were performed at each argatroban concentration. Correlation analyses were performed using the Spearman correlation analysis. RESULTS: There was a significant and strong correlation between argatroban concentrations and clotting time (CT in ROTEM analysis with INTEM) (P<0.0001 and r=0.98). Also, the ROTEM time to maximum clot formation velocity (MAXV-t) appeared to have a very strong and highly significant correlation to argatroban concentrations (P<0.0001 and r=0.95). When we studied the correlation between aPTT and CT, we found a highly significant and strong correlation between these two analyses (P<0.0001 and r=0.97), especially so in the clinically relevant therapeutic range up to 100 s aPTT prolongation for HIT patients. CONCLUSION: A significant and strong correlation was found between argatroban concentrations and several ROTEM parameters. Rotational thrombelastometry/thrombelastography has a potential role in increasing the safety of argatroban anticoagulation in critically ill patients.

Value of positron emission tomography for lung cancer staging.

OBJECTIVE: The therapeutic strategy in non-small-cell lung cancer (NSCLC) requires exact staging of tumour invasion (T) as well as differentiation between ipsi- and contralateral lymph node invasion (N1/2 vs N3). [18F]FDG-positron emission tomography (FDG-PET) has been shown to detect invaded N with high accuracy while correct determination of T appears to be unclear. The purpose of this prospective study was to evaluate benefit and necessity of 18FDG-PET as an additive to conventional staging modalities. METHODS: Forty patients with suspected non-small-cell lung cancer (NSCLC) were staged by means of computed tomography (CT), bronchoscopy, mediastinoscopy and bone scintigraphy. Additionally, attenuation corrected FDG-PET of the thorax was performed pre-operatively for analysis of T and N topography. After surgical resection with radical lymphadenectomy T and N staging results of CT and PET were compared with the pathological diagnoses. Specificity, sensitivity, positive predictive value and accuracy of CT and PET were calculated. RESULTS: Twenty three squamous cell carcinomas, 14 adenocarcinomas, and three non-malignant tumours were found. Accuracy of CT-T was 0.75 and of PET-T 0.78; accuracy of CT-N was 0.78 and of PET-N 0.80. By combination of CT-T and PET-T accuracy was 0.88. Combination of CT-N and PET-N yielded an accuracy of 0.90. In two out of three cases, PET correctly determined T0. In two cases non-malignant inflammatory lymph nodes were falsely staged as malignant by PET. CONCLUSIONS: Adequate pre-operative T- and N-staging is possible with both CT and FDG-PET. Accuracy can be improved by combination of CT and FDG-PET. FDG-PET is superior to CT in order to differentiate between malignant and benign tumours. However, acute inflammation can mimic malignant lymph node invasion. FDG-PET is justified as a supporting staging measure in cases presenting unclear differentiation between N2 and N3 after conventional staging and is helpful in cases with unclear cell type of the primary tumour.

The effects of platelet apheresis in total hip replacement surgery on platelet activation.

BACKGROUND: Autologous platelet rich plasma (PRP) harvest with autotransfusion devices has been used for 10 years in cardiac surgery and recently in orthopedics as a blood saving method. The quality of the harvested platelets has not been adequately examined, in part because of methodological difficulties in studying platelet function during surgery. METHODS: Twenty patients undergoing primary total hip replacement (THR) were studied. Ten patients underwent an immediate preoperative platelet apheresis to obtain concentrated platelet rich plasma (c-PRP). The other 10 patients not undergoing apheresis were allocated to a control group. Platelet activation was evaluated as the population expressing P-selectin on the surface of platelets in the c-PRP and in blood samples collected pre-, per- and postoperatively. The method used was flow cytometry. RESULTS AND CONCLUSIONS: A minor population of activated platelets was found to be circulating in the patients' blood, with a highly significant difference between patients (P = 0.005), and with a range of 1-23% in peroperative activation. PRP harvest did not significantly alter platelet activity. The platelet apheresis procedure did not inhibit platelet function in the c-PRP, as judged by a high proportion of platelets that could be activated in ADP stimulation experiments (mean value +/- SD 86% +/- 7.5%).

[Technique and results of CT-guided percutaneous bone biopsy]. / Technik und Ergebnisse der CT-gesteuerten perkutanen Knochenbiopsie.

PURPOSE: The aim of the study was to evaluate the feasibility and results of CT-guided percutaneous bone biopsy (PBB) of unknown bone lesions in a representative number of patients. METHODS: In 92 patients (100 biopsies) with different bone lesions CT-guided PBB was performed. RESULTS: The rate of technical success, defined as a successful retrieval of a sufficient tissue sample which then was sent for histological evaluation, was 89% (89/100 biopsies). The diagnostic accuracy was defined as a clinically useful histological result and was obtained in 80% (80/100 biopsies). Minor complications (minimal bleedings) occurred in 3% of all biopsies, no special therapy was necessary. Osteolytic lesions (92%) were classified more accurately by PBB than osteoplastic (80%) or mixed lesions (67%). Considering the anticipated dignity of the lesions prior to PBB, the suspected malignant bone lesions had a better diagnostic accuracy of 82% than the suspected benign bone lesions with an accuracy of 50%. CONCLUSION: Due to its universal availability combined with a low risk and a high diagnostic value the PBB of unknown bone lesions can be regarded as a valuable diagnostic tool. However, leave-me-alone lesions should be excluded.

MR-guided biopsy of musculoskeletal lesions in a low-field system.

Thirty magnetic resonance (MR)-guided biopsies were obtained from 20 skeletal and 10 soft-tissue lesions in 31 patients using an open 0.2 T MR system equipped with interventional accessories. The results from aspiration (N = 3), core biopsy (N = 15), and transcortical trephine biopsy (N = 12) were evaluated for accuracy and clinical efficacy. Specimens were successfully obtained from 29 patients. Results were clinically effective in 23 patients, rated definitive in 16, nonconclusive in 9, and unspecific in 2 patients. A false diagnosis due to sampling error occurred in 2 patients, and biopsy sampling was impossible in one case. The best diagnostic yield was achieved from nontranscortical biopsies of osteolytic or soft-tissue masses. Results from transcortical biopsies were less specific due to the predominance of benign lesions. MR fluoroscopy for needle guidance was applied in 13 patients. Complete needle placement inside the magnet could be performed in 16 patients. MR-guided biopsy using an open low-field MR imager is feasible and clinically effective and will become a valuable tool in the management of musculoskeletal lesions. J. Magn. Reson. Imaging 2001;13:761-768.

Preoperative platelet-rich plasmapheresis and hemodilution with an autotransfusion device in total hip replacement surgery.

The effectiveness of both preoperative autologous donation (PAD) and intraoperative autotransfusion (IAT) with an autotransfusion device has recently been questioned. Preoperative apheresis, with separation of concentrated platelet rich-plasma (c-PRP) and erythrocyte concentrate (ERC), represents an aggressive use of the autotransfusion device. Can such a procedure replace PAD in total hip replacement surgery (THR)? Eighty patients undergoing THR were investigated in a prospective and randomized study. Forty patients underwent PAD, and 2 units of ERC + plasma were retrieved within 4 weeks preoperatively. Another 40 patients underwent an immediately preoperative apheresis with a concomitant hemodilution with 4% albumin, retrieving c-PRP (30% of the platelet pool) and 2 units of ERC. Both groups used IAT up to 2 hours postoperatively, with 3% dextran-60 as a plasma substitute according to our standard of care. There were no differences in blood loss, B-hemoglobin or allogeneic transfusions between the groups: 85% of the patients did not receive allogeneic blood. Both apheresis and reinfusion of c-PRP had minor impact on the coagulation parameters. Platelet count increased slightly but significantly (P<0.05) from 154 to 179 x 10(9)/L after the c-PRP at wound closure. Preoperative apheresis with an autotransfusion device, separating platelet-rich plasma and erythrocyte concentrate, is a useful alternative for patients who are unable to utilize the PAD technique for either religious or practical reasons.

Tranexamic acid reduces blood loss in total hip replacement surgery.

UNLABELLED: Intraoperatively administered, tranexamic acid (TA) does not reduce bleeding in total hip replacement (THR). Therefore, its prophylactic use was attempted in the present study because this has been shown to be more effective in cardiac surgery. We investigated 40 patients undergoing THR in a prospective, randomized, double-blinded study. Twenty patients received TA given in two bolus doses of 10 mg/kg each, the first just before surgical incision and the second 3 h later. In addition, a continuous infusion of TA, 1.0 mg. kg(-1). h(-1) for 10 h, was given after the first bolus dose. The remaining 20 patients formed a control group. Both groups used preoperative autologous blood donation and intraoperative autotransfusion. Intraoperative bleeding was significantly less (P: = 0.001) in the TA group compared with the control group (630 +/- 220 mL vs 850 +/- 260 mL). Postoperative drainage bleeding was correspondingly less (P: = 0.001) (520 +/- 280 vs 920 +/- 410 mL). Up to 10 h postoperatively, plasma D-dimer concentration was halved in the TA group compared with the control group. One patient in each group had an ultrasound-verified late deep vein thrombosis. In conclusion, we found TA, administrated before surgical incision, to be efficient in reducing bleeding during THR. IMPLICATIONS: In a prospective, double-blinded study of 40 patients undergoing total hip replacement, the preoperative administration of tranexamic acid reduced bleeding by 35%, probably by decreasing induced fibrinolysis. Whether tranexamic acid therapy can replace predonation of autologous blood or intraoperative autotransfusion requires further study.

Sonoclot coagulation analysis: a study of test variability.

OBJECTIVE: To test the reproducibility of Sonoclot coagulation analysis (SCA; Sienco Inc, Morrison, CO). The authors wished to determine if the mix/release of the preloaded celite activator in standard Sono-cuvettes could be responsible for the high variation coefficients for SCA parameters with citrated whole blood and if citrated whole blood is optimal for SCA. DESIGN: A prospective trial. SETTING: A large academic teaching medical center. PARTICIPANTS: Eight healthy volunteers. INTERVENTIONS: Repeated blood sampling was performed through indwelling radial artery catheters. Seven different Sonoclot analyzers were used to test seven different types of analysis procedures in the volunteers, involving activators of different types and amounts and in different forms, and the use of citrated or native whole blood. MEASUREMENTS AND MAIN RESULTS: Two-way and one-way ANOVA, variance, variance analysis, and Tukey's test were used to evaluate differences in SCA methods and volunteer influence. A high variance, with SDs up to 200% of the median values of the SCA parameters with recalcified citrated blood and the standard Sono-cuvette, was confirmed. SCA with native blood and/or the use of other types of preloaded activators, ie, kaolin, significantly (p < 0.05) reduced this variance. Repeated SCAs further reduced the variance to 10% to 35% of the variance for a single analysis (standard cuvette and native blood). CONCLUSION: Improvement of the activator in the Sonocuvette, use of native whole blood, and repeated Sonoclot analyses reduced the previously reported high variability of this instrument.

[The wound care center in surgery: an interdisciplinary concept for diagnostic and treatment of chronic wounds]. / Die chirurgische Wundsprechstunde. Ein interdisziplinäres, diagnostisches und therapeutisches Konzept für chronische Wunden.

In Germany there is no standardized wound care for patients with chronic wounds in specialized centers. We have established a wound care unit for the past 6 years. The principal concept of therapy was characterized by standardized local surgery, moist wound dressings and concomitant treatment of the underlying disease. We performed local therapy, coordinated the interdisciplinary treatment and developed a new wound documentation system for quality control. We established a close network, integrating general practitioners and home care organizations to realize a mainly outpatient treatment supported by short hospital therapy. Exclusive outpatient treatment was performed in 42% of all patients. According to our prospective data, we achieved an improvement in wound care: 69% of the wounds resistant to therapy for a mean of 30 months healed within 12 months after therapy according to our protocol. Our data strongly supported the importance of local surgery: neither wound depth nor wound infection had any influence on the healing rate, presumably due to radical excisional debridement of necrotic tissue. The presented data justify on medical and economic grounds the establishment of such wound care centers in Germany.

Platelet glycoprotein IIb/IIIa receptor antagonist used in conjunction with thrombolysis for peripheral arterial thrombosis.

OBJECTIVE: This feasibility study was designed to evaluate the therapeutic potential of intraarterial urokinase combined with abciximab, an IV platelet glycoprotein IIb/IIIa receptor antagonist, in peripheral arterial thrombosis. CONCLUSION: The administration of a highly potent glycoprotein IIb/IIIa inhibitor in conjunction with intraarterial fibrinolysis was safe in 14 patients. One distal embolization and no major bleeding occurred. The primary success rate was 100%. Treatment times ranged from 50 min to 8 hr. We found a reocclusion rate of 7% (1/14) at intermediate follow-up.

Improvement of non-small-cell lung cancer staging by means of positron emission tomography.

BACKGROUND: Exact staging of ipsi- and contralateral mediastinal lymph-node metastases (N 1/2 vs. N3) is essential for the therapeutic strategy in non-small-cell lung cancer (NSCLC). CT and mediastinoscopy are the standards of reference for N staging. However, even with these combined measures the extent of invasion of mediastinal lymph nodes can remain vague. 18FDG Positron Emission Tomography (18FDG-PET) has recently been shown to detect invaded nodes with high accuracy. The purpose of this study was to evaluate 18FDG-PET as an aid in N staging. METHODS: 27 patients with suspected NSCLC were clinically staged by means of CT, bronchoscopy, mediastinoscopy, and bone scintigraphy. Additionally, 18FDG-PET was performed preoperatively for analysis of topography of invaded lymph nodes. CT and 18FDG-PET were evaluated in a blinded fashion. Surgical therapy was performed with radical lymphadenectomy. CT N staging as well as PET N staging results were compared with the pathological diagnoses (pTN). Specificity, sensitivity, and accuracy of CT and PET in N staging were calculated. RESULTS: 14 squamous-cell carcinomas, 10 adenocarcinomas, and 3 non-malignant tumors were found. In 8 patients no invasion was found (N0), in 13 patients an ipsilateral invasion (N1/2), and in 3 patients a contralateral invasion (N3). In the correct detection of N1/2 the sensitivity of CT and of PET was 0.77, the specificity of CT and of PET was 0.79. The accuracy of CT was 0.74 and of PET 0.78. By combining CT and PET accuracy was 0.85. CONCLUSIONS: Adequate preoperative LN staging is possible with both CT and 18FDG-PET. The accuracy, however, can be improved by a combination of CT and 18FDG-PET.