A case of EBV-associated adrenal leiomyoma.

Adrenal leiomyomas are rare and often reported as Epstein-Barr virus (EBV)-associated smooth muscle tumor (SMT) in association with EBV infection in immunocompromised patients. We experienced a case of right adrenal leiomyoma that was incidentally found in a man in his 70s. Computed Tomography (CT) showed a well-circumscribed mass of 3.1 cm in diameter in the right adrenal gland, which increased to 4.9 cm in diameter over 1 year. Preoperative diagnosis was difficult due to the lack of specific imaging findings. He had a history of diffuse large B-cell lymphoma (DLBCL) 8 years ago, and EBV had been detected in his blood. EBV-encoded small RNA(EBER) in situ hybridization (EBER-ISH) of the right adrenal leiomyoma was positive, and the final diagnosis was EBV-associated leiomyoma.

Multiple benign notochordal cell tumors in lung with cystic change.

Benign notochordal cell tumor (BNCT) is a benign lesion derived from notochordal cells. Although it is relatively common in intraosseous lesion, pulmonary BNCT is extremely rare. We present a case of 54-year-old male with multiple pulmonary nodules, in which were considered to be metastatic chordomas initially. For 20 months follow-up without any therapy, most of the nodules had no remarkable change but some nodules showed cystic change. We consulted with pathologists specializing in chordoma and the final diagnosis of the nodules was considered as BNCT rather than chordoma. We herein report the case of multiple pulmonary BNCTs with cystic change, comparing with previous reports.

Impact of palliative radiotherapy with or without lung irradiation in patients with interstitial lung disease.

BACKGROUND AND PURPOSE: Acute exacerbations or acute lung injury, including radiation pneumonitis (AE-ALI/RP) of interstitial lung disease (ILD), has a fatal prognosis. We evaluated the risk of palliative-intent radiotherapy (RT), with or without lung irradiation, for AE-ALI/RP of ILD. MATERIALS AND METHODS: The data of patients with ILD who received palliative-intent RT between January 2011 and January 2022 were retrospectively reviewed. Factors associated with AE-ALI/RP grade ≥ 3 were assessed using univariate and multivariate analyses. RESULTS: One hundred and three patients were examined, with median imaging and survival follow-up times of 88 (2-1440) and 144 (8-1441) days. The median time to onset of AE-ALI/RP grade ≥ 3 was 72 (5-206) days. In multivariate analysis, a higher pulmonary fibrosis score (PFS ≥ 3) (hazard ratio, HR: 2.16; 95% confidence interval, CI: 1.36-3.43; p < 0.01) and lung irradiation (lung-RT) (HR: 3.82; 95% CI: 1.01-15.73; p = 0.04) were significant factors for AE-ALI/RP grade ≥ 3. In patients who received lung-RT, the 100-day survival rate and cumulative incidence of AE-ALI/RP grade ≥ 3 were 56.8% and 13.7%, respectively. In patients with PFS ≥ 3 and who underwent lung-RT, the 100-day cumulative incidence of AE-ALI/RP grade ≥ 3 was 37.5%; all patients with AE-ALI/RP grade ≥ 3 had grade 5. In patients with PFS ≥ 3 without lung-RT, the 100-day cumulative incidence of AE-ALI/RP grade ≥ 3 was 4.8%. CONCLUSION: High PFS and lung-RT are significant risk factors for AE-ALI/RP grade ≥ 3. Even with relatively low doses, palliative-intent lung-RT carries an extremely high risk of AE-ALI/RP when PFS is high.

Radiation-induced enterocolitis after combination therapy with palliative radiotherapy and immune checkpoint inhibitors in patients with metastatic lung cancer.

The impact of immune checkpoint inhibitors (ICIs) on radiation-induced enterocolitis (RIE) after palliative radiotherapy (PRT) to the bowel has remained to be fully investigated. The aim of the present study was to investigate whether ICIs affect RIE after PRT. For this purpose, 32 lesions (vertebral bone, 13; pelvic bone, 12; adrenal gland, 3; lymph node, 3; liver, 1) in 28 patients with metastatic lung cancer who were treated with both PRT involving the bowel (8-48 Gy; typically 30 Gy in 10 fractions or 20 Gy in 5 fractions) and ICIs between December 2015 and June 2021 were retrospectively reviewed. A total of 12 lesions were treated with ICIs only prior to PRT, 16 received ICIs only after PRT and the remaining 4 received ICIs both prior to and after PRT. The 1-year overall survival rate was 53%. The median PRT dose was 30 Gy (range, 8-48 Gy) in 10 fractions (range, 1-24 fractions). The median interval between PRT and the closest administration of ICIs was 20.5 days (range, 1-212 days). Combination therapy with PRT and ICIs was well tolerated by the majority of patients. However, grade 2 or higher RIE occurred in 6.3% of the patients. In these patients, ICIs were administered within 7 days after completing PRT with 3.6 Gy or a higher-fraction dose (evaluated at the isocenter). There were significant differences in the incidence of RIE between administration of ICIs <7 days after PRT completion and ≥7 days (P=0.05), between <3.6 Gy per fraction and ≥3.6 Gy (P=0.04), and between maximum dose to 2 cc (D2cc) of large bowel <3.3 Gy and D2cc of large bowel ≥3.3 Gy (P=0.02). There was no clear association between the incidence of RIE and any other factors. These results suggest that the administration of ICIs soon after PRT completion and a comparatively high fraction dose may potentially increase the risk of grade 2 or higher RIE.

The prognostic significance of whole-body and spleen MTV (metabolic tumor volume) scanning for patients with diffuse large B cell lymphoma.

BACKGROUND: Positron Emission Tomography-Computed Tomography (PET-CT) has been changing diagnostic and therapeutic strategies for patients with cancers, and several PET-CT-related prognostic factors have been reported. We have focused on metabolic tumor volumes (MTVs) over the whole body and in specific organs using 18F-PET-CT imaging, and have compared clinical data to know the prognosis of patients with diffuse large B cell lymphoma (DLBCL). PATIENTS AND METHODS: From January 2006 to December 2016, patients who were newly diagnosed for de novo DLBCL and who received 18F-FDG PET-CT scans for disease staging at Ehime University Hospital were reviewed. RESULTS: A total of forty out of 108 patients with DLBCL were analyzed. The median and the average follow-up were 3.9 years and 3.6 years. Both MTV50 and MTV60 whole-body searching indicated effective prognostic values for patients with DLBCL statistically (P = 0.027). However, analysis of MTVs in the spleen and in bone marrow did not provide any prognostic value. Receiver operating characteristic (ROC) analysis indicated that the cutoff level 25.8 in MTV60 is the most effective prognostic value (P = 0.022) which predicts patient survival after treatment with R-CHOP chemotherapy. CONCLUSION: MTV60 using whole-body scanning appears to be an effective indicator in DLBCL and indicates the patient prognosis.

Early response of bone metastases can predict tumor response in patients with non-small-cell lung cancer with bone metastases in the treatment with nivolumab.

The effect of nivolumab and the relation between bone response and tumor control in patients with non-small-cell lung cancer (NSCLC) with bone metastases are not clear. The outcome of nivolumab monotherapy was investigated, and whether the response of bone metastases is useful as an early predictor of tumor control in patients with NSCLC with bone metastases was examined. The participants included 15 patients who received nivolumab monotherapy for NSCLC with bone metastases in our institution between 2015 and 2017. Tumor control was defined using Response Evaluation Criteria in Solid Tumors, version 1.1 (RECIST1.1). Response of bone metastases was assessed by the MD Anderson response criteria (MDA criteria). Responses according to RECIST1.1 and the MDA criteria were classified as responder (complete response or partial response) and non-responder [progressive disease (PD) or stable disease]. Progression-free survival (PFS) was investigated using the Kaplan-Meier method. With RECIST1.1, the overall response rate was 20%. Multivariate analysis showed that the MDA criteria were the only risk factor for patients with PD (RECIST1.1). Median PFS was 1.9 months, with PFS of 20% at 6 months. Univariate analysis showed that being a non-responder according to the MDA criteria was the only risk factor for PFS. In patients who were responders (MDA criteria) within 3 months, PFS was 83 and 50% at 3 and 6 months, respectively, though all non-responder (MDA criteria) patients converted to PD (RECIST1.1) within 3 months. Response according to RECIST1.1 was significantly correlated with response according to the MDA criteria (P<0.05). In patients who were both responders according to RECIST1.1 and the MDA criteria, time to response with the MDA criteria (1.4-2.0 months) was earlier than with RECIST1.1 (2.8-3.0 months) in all patients. In conclusion, application of the MDA criteria within 2 months of nivolumab monotherapy is useful for early prediction of response and prognosis in patients with NSCLC with bone metastases.

Multidisciplinary treatment system for bone metastases for early diagnosis, treatment and prevention of malignant spinal cord compression.

Malignant spinal cord compression (MSCC) is a serious complication of cancers. The present study aimed to establish a multidisciplinary treatment system for urgent magnetic resonance imaging (MRI) and referral to orthopedists in order to prevent neurological deficits caused by MSCC. In the present study, the extent to which this system achieved early diagnosis and treatment and prevented MSCC-caused neurological deficits was examined. The records from patients with neurological deficits caused by MSCC before (between April 2007 and March 2012; group A) and after (between April 2012 and March 2017; group B) the establishment of the multidisciplinary system at the Shikoku Cancer Center (Ehime, Japan) were retrospectively evaluated. The numbers of patients with neurological deficits were 38 and 7 in groups A and B, respectively. All patients received radiotherapy. The incidence of neurological deficits was 13.2 and 3.4% in groups A and B, respectively (P<0.001). The proportion of patients with improvement in the severity of neurological deficits was 5.3 and 28.6% in groups A and B, respectively (P<0.001). The interval between physicians' recognition of a neurological deficit and MRI and the start of treatment, the number of cases, and the severity of neurological deficits were evaluated in groups A and B. The median interval between recognition of a neurological deficit by physicians and MRI was 3 and 0 days in groups A and B, respectively (P<0.001). The median interval between physicians' recognition of a neurological deficit and the start of treatment was 3 and 0 days in groups A and B, respectively (P<0.001). By using a multidisciplinary treatment system, the incidence and severity of neurological deficits following treatment were significantly improved. Therefore, the multidisciplinary treatment system used in the present study may be useful for early diagnosis, treatment and prevention of MSCC in patients with bone metastases.

Uterine leiomyosarcoma well-controlled with eribulin mesylate.

Uterine leiomyosarcoma is a rare type of malignant gynecological tumor and has a poor prognosis; therefore, this tumor is often difficult to treat. Some new drugs have been approved during the past several years in Japan and are expected to be efficacious. Eribulin, one of these drugs, is a natural product of halichondrin B, which is isolated from a marine sponge. A recent clinical trial comparing eribulin with dacarbazine to target liposarcoma and leiomyosarcoma indicated that overall survival (OS) was prolonged by treatment with eribulin. We report a case of uterine progressive leiomyosarcoma that responded to eribulin. A 57-year-old woman was suspected of having leiomyosarcoma based on an endometrial biopsy and imaging examinations. Although the tumor grew toward the uterine artery on the right side of the uterine cervix, we performed a total abdominal hysterectomy and bilateral salpingo-oophorectomy to obtain an outcome of no gross residual disease. However, the margin of the right side of the uterine cervix was histologically positive, so leiomyosarcoma stage IIB (pT2bcN0cM0, FIGO2008) was diagnosed. Gemcitabine and docetaxel therapy was administered postoperatively. However, after three cycles, the residual tumor progressed. Other anticancer drugs were administered but were ineffective. We administered eribulin (1.4 mg/m2) as a fourth-line regimen, and the mass decreased by 32% after four cycles. However, the residual tumor continued to grow after eight cycles. The only adverse event associated with eribulin treatment was mild, grade 2 neutropenia. For our patient, eribulin was effective for her recurrent leiomyosarcoma. In selecting chemotherapy, there are currently no fixed guidelines; we should consider the characteristics and adverse events associated with each drug and patient performance status and comorbidities. In this patient, eribulin was associated with few adverse events, an easy route of administration and a good quality of life. Therefore, eribulin is expected to be efficacious for the treatment of gynecologic sarcoma.

Surgical outcomes in 13 patients with bronchopulmonary carcinoid tumors including one recurrent oncocytic carcinoid tumor.

INTRODUCTION: Bronchopulmonary carcinoids are low-grade tumors for which the standard treatment is surgical resection. We retrospectively evaluated the surgical outcomes. METHODS: Thirteen patients underwent surgical resection for them at our institution between January 2005 and December 2016. We collected their clinicopathologic data to evaluate surgical outcomes. RESULTS: The 13 patients comprised seven men and six women. Complete resection was performed in all cases. All the tumors were typical carcinoids, including one oncocytic carcinoid which showed highest fluorodeoxyglucose (FDG) uptake (SUVmax 45.7). The 5-year overall survival rates were 100%. The only patient with oncocytic carcinoid developed recurrence of liver metastasis 49 months after the primary lung resection. The metastasis showed low FDG uptake (SUVmax 2.8) and its histology was typical carcinoid and not oncocytic carcinoid. CONCLUSION: Surgical outcomes in our patients were favorable. In oncocytic carcinoid, metastatic site may have a radiologic and histologic appearance different from the primary tumor.

Parotid Oncocytoma as a Manifestation of Birt-Hogg-Dubé Syndrome.

Birt-Hogg-Dubé syndrome (BHD) is a rare autosomal dominant disease characterized by skin fibrofolliculomas, pulmonary cysts, spontaneous pneumothoraces, and renal cancers. Oncocytomas are benign epithelial tumors that are also rare. Recently, there have been a few case reports of BHD with a parotid oncocytoma that appears to have a BHD phenotype. Here we document the eighth known case and describe the magnetic resonance imaging features of the parotid oncocytoma, which mimicked Warthin's tumor. Radiologists should be aware of the association between these rare disorders.

Usefulness of positron emission tomography (PET)/contrast-enhanced computed tomography (CE-CT) in discriminating between malignant and benign intraductal papillary mucinous neoplasms (IPMNs).

BACKGROUND/OBJECTIVES: We evaluated the usefulness of positron emission tomography (PET)/contrast-enhanced computed tomography (CE-CT) in discriminating between malignant and benign intraductal papillary mucinous neoplasms (IPMNs). METHODS: PET/CE-CT imaging was conducted on 29 IPMN lesions, which subsequently underwent surgery. Preoperative findings on PET/CE-CT imaging were compared with the histological findings of the resected specimens to determine the diagnostic accuracy of PET/CE-CT imaging for evaluation of the differential diagnosis between benign and malignant IPMNs. RESULTS: The final diagnoses of the 29 IPMN lesions were 9 benign and 20 malignant. Overall, 18 of the 20 malignant cases were positive for FDG uptake, while 7 of 9 benign cases were negative. The sensitivity, specificity, and diagnostic accuracy for benign/malignant differentiation using FDG uptake as a marker were 90.0%, 77.8%, and 86.2%, respectively. When guideline-based high-risk findings were used as markers, sensitivity, specificity, and diagnostic accuracy for mural nodules were 50.0%, 66.7%, and 55.2%, while they were 40.0%, 56%, and 48.3% for main duct dilatation, respectively. CONCLUSIONS: FDG uptake on PET is a useful new marker for malignancy in benign/malignant differentiation. Because PET/CE-CT imaging is a noninvasive imaging modality that can evaluate FDG uptake in addition to the conventional high-risk findings, we believe it should be the first-line method for determining therapeutic approaches to IPMN.

Predictive Ability of 18F-fluorodeoxyglucose Positron Emission Tomography/computed Tomography for Pathological Complete Response and Prognosis after Neoadjuvant Chemotherapy in Triple-negative Breast Cancer Patients.

OBJECTIVES: The mortality of patients with locally advanced triple-negative breast cancer (TNBC) is high, and pathological complete response (pCR) to neoadjuvant chemotherapy (NAC) is associated with improved prognosis. This retrospective study was designed and powered to investigate the ability of 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG-PET/CT) to predict pathological response to NAC and prognosis after NAC. METHODS: The data of 32 consecutive women with clinical stage II or III TNBC from January 2006 to December 2013 in our institution who underwent FDG-PET/CT at baseline and after NAC were retrospectively analyzed. The maximum standardized uptake value (SUVmax) in the primary tumor at each examination and the change in SUVmax (ΔSUVmax) between the two scans were measured. Correlations between PET parameters and pathological response, and correlations between PET parameters and disease-free survival (DFS) were examined. RESULTS: At the completion of NAC, surgery showed pCR in 7 patients, while 25 had residual tumor, so-called non-pCR. Median follow-up was 39.0 months. Of the non-pCR patients, 9 relapsed at 3 years. Of all assessed clinical, biological, and PET parameters, N-stage, clinical stage, and ΔSUVmax were predictors of pathological response (p value of 0.0288, 0.0068, 0.0068 respectively; Fischer's exact test). The cut-off value of ΔSUVmax to differentiate pCR evaluated by the receiver operating characteristic (ROC) curve analysis was 81.3%. Three-year disease-free survival (DFS) was lower in patients with non-pCR than in patients with pCR (p=0.328, log-rank test). The cut-off value of ΔSUVmax to differentiate 3-year DFS evaluated by the ROC analysis was 15.9%. In all cases, 3-year DFS was lower in patients with ΔSUVmax <15.9% than in patients with ΔSUVmax ≥15.9% (P=0.0078, log-rank test). In non-pCR patients, 3-year DFS was lower in patients with ΔSUVmax <15.9% than in patients with ΔSUVmax ≥15.9% (P=0.0238, log-rank test). CONCLUSION: FDG-PET/CT at baseline and after NAC could predict pathological response to NAC before surgery and the clinical outcome after surgery in locally advanced TNBC patients.

Pulmonary metastasectomy from renal cell carcinoma including 3 cases with sarcomatoid component.

INTRODUCTION: Usefulness of complete metastasectomy against pulmonary metastases from renal cell carcinoma (RCC) is well known. We examined the efficacy of surgical resection of pulmonary metastases from RCC performed in Shikoku Cancer Center. METHOD: Between January 2004 and December 2014, 11 patients with pulmonary metastases from RCC underwent thoracic resection in our institution. We examined disease-free interval (DFI) and overall survival of these patients after pulmonary metastasectomy. RESULTS: Patients included 9 men and 2 women with a mean age of 63.2 years. The median number of metastases was 1 (range 1-6). Overall, 5 patients had a single metastasis (45.5%), 8 patients had unilateral metastases (72.7%), and 3 patients received immunotherapy or chemotherapy in the interval between radical nephrectomy and pulmonary metastasectomy. We performed complete pulmonary metastasectomy in these patients. The median observation period was 43 months (range 5-82), median DFI was 5 months (range 2-17), and 3-year overall survival rate was 86%. In the 3 patients who had primary or metastatic tumors with sarcomatoid (SA) component, their median DFI tended to be shorter than that of 8 patients without it (2 vs. 8 months, p = 0.07). CONCLUSION: The pulmonary metastasectomy for RCC is a treatment option, while the indication for RCC with SA component should be carefully considered.

A case of uterine corpus large cell neuroendocrine carcinoma showing prominent myometrial invasion without any macroscopically clear tumor formation.

Large cell neuroendocrine carcinoma (LCNEC) arising in the uterine corpus is a very rare. Here, we report our experience with a primary LCNEC in the uterine corpus that showed prominent myometrial invasion without exhibiting any macroscopically distinct tumor formation in the uterine cavity. The patient was a 54-year-old woman. She had a past medical history of right breast cancer and was referred to our department with irregular genital bleeding, elevated serum carcinoembryonic antigen in periodic medical examinations and computed tomography (CT) findings of uterine cavity dilation. Endometrial biopsy suggested a poorly differentiated tumor. Although magnetic resonance imaging (MRI) showed hematometra-like findings in the uterine cavity, it did not indicate any clear endometrial lesion. The myometrium was unequally thickened, and the entire muscle layer showed a high signal intensity on diffusion-weighted images. Fluorine-18-deoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) showed strong FDG accumulation in the whole uterus, and on the bottom of the uterus, there was a ring-shaped accumulation mainly in the muscle layer. The postoperative resected specimen did not show any tumor formation in the uterine cavity, whereas the myometrium was hard and thickened, and colored white overall. Histopathological examination revealed prominent myometrial invasion in most layers, cervical stromal invasion and pelvic lymph node metastasis. The diagnosis was a LCNEC of the uterine corpus, at FIGO stage IIIC1 and pT2N1M0. With these patients, we found that functional metabolic images, such as MRI diffusion-weighted images and FDG-PET/CT, were useful in identifying the lesion. Preoperatively, when a poorly differentiated tumor is estimated and characteristic myometrial invasion is suspected, the possibility of LCNEC should be considered.

Utility of (18)F FDG-PET/CT for predicting prognosis of luminal-type breast cancer.

Postoperative prognosis is better for hormonal receptor-positive breast cancer than for other phenotypes; however, there are no definitive predictive factors for relapse or survival. This study aimed to evaluate the maximum standardized uptake value (SUVmax) on (18)F-fluoro-2-deoxy-glucose positron emission tomography/computed tomography (FDG-PET/CT) and clinicopathological characteristics as possible predictors of postoperative relapse-free survival (RFS) and overall survival (OS) in hormonal receptor-positive breast cancer patients. We evaluated 262 patients with Stage I-III breast cancer diagnosed as luminal type (luminal A, 166; luminal B, 96 patients) who underwent preoperative FDG-PET/CT between January 2006 and December 2011 at two institutions. The relationships among SUVmax and clinicopathological factors (age, clinical T/N stage, nuclear grade, lymph node metastasis and vascular invasion) were evaluated. A phantom study was performed to correct differences in PET/CT analysis between two institutions. The patients were divided according to the SUVmax cutoff on receiver operating characteristic (ROC) analysis for OS (≤6.0 group vs. >6.0 group, AUC = 0.742). Clinical T-factor and nuclear grade were significantly correlated with SUVmax (p < 0.0001 and p = 0.0092, respectively). In the uni- and multivariate analyses using the Cox model for relapse, SUVmax was significant (p = 0.013 and p = 0.055, respectively) among characteristics. RFS curves showed that prognosis was significantly better for the SUVmax ≤ 6.0 group than for the SUVmax > 6.0 group (p = 0.004). Similarly, SUVmax was significant for OS (p = 0.007 and p = 0.008). OS was significantly different between the SUVmax ≤ 6.0 and >6.0 groups (p < 0.001). SUVmax was useful for predicting outcomes in patients with luminal-type breast cancer.

A multicenter, randomized, controlled, single-blind comparison phase III study to determine the efficacy and safety of gadobutrol 1.0 M versus gadopentetate dimeglumine following single injection in patients referred for contrast-enhanced MRI of the body regions or extremities.

PURPOSE: To demonstrate the noninferiority of gadobutrol-enhanced magnetic resonance imaging (MRI) compared with gadopentetate dimeglumine-enhanced MRI in Asian patients referred for contrast-enhanced imaging of the body or extremities. MATERIALS AND METHODS: A multicenter, parallel-group comparison study of Asian adults referred for contrast-enhanced MRI were randomized (1:1) to either gadobutrol or gadopentetate dimeglumine. Lesions were assessed for three primary visualization variables: degree of contrast enhancement, border delineation, and internal morphology. Secondary efficacy variables included number of lesions detected, match of MRI diagnosis with final clinical diagnosis, and sensitivity and specificity for malignant lesion detection. Safety was monitored for 24 ± 4 hours after contrast agent administration. RESULTS: A total of 363 patients received either gadobutrol (n = 168) or gadopentetate dimeglumine (n = 178). Mean total scores for three primary visualization variables were 9.39 and 9.34 for gadobutrol and gadopentetate dimeglumine, respectively. The proportion of patients with matched MRI and final diagnosis and sensitivity for malignant lesion detection was greater for unenhanced versus combined images (gadobutrol: 72.2% vs. 81.7%; gadopentetate dimeglumine: 76.2% vs. 82.2%, respectively). Both contrast agents were well tolerated. CONCLUSION: Gadobutrol (0.1 mmol/kg BW) was well tolerated and effective in Asian patients referred for contrast-enhanced MRI of the body or extremities.

Maximum standardized uptake value of fluorodeoxyglucose positron emission tomography/computed tomography is a prognostic factor in ovarian clear cell adenocarcinoma.

BACKGROUND: Fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) is useful for diagnosing malignant tumors. Intracellular FDG uptake is measured as the standardized uptake value (SUV), which differs depending on tumor characteristics. This study investigated differences in maximum SUV (SUVmax) according to histologic type in ovarian epithelial cancer and the relationship of SUVmax with prognosis. METHODS: This study included 80 patients with ovarian epithelial cancer based on histopathologic findings at surgery and who had undergone PET/CT before treatment. Maximum SUV on PET/CT of primary lesions and histopathology were compared based on histologic type, and the prognosis associated with different SUVmax was evaluated. RESULTS: Clinical tumor stage was I in 35 patients, II in 8, III in 25, and IV in 12. Histologic type was serous adenocarcinoma (AC) in 33 patients, clear cell AC in 27, endometrioid AC in 15, and mucinous AC in 5. Median SUVmax was lower in mucinous AC (2.76) and clear cell AC (4.9) than in serous AC (11.4) or endometrioid AC (11.4). Overall, median SUVmax was lower in clinical stage I (5.37) than in clinical stage ≥II (10.3). However, in both clear cell AC and endometrioid AC, when histologic evaluation was possible, no difference was seen between stage I and stage ≥II. Moreover, in clear cell AC, the 5-year survival rate was significantly higher in the low-SUVmax group (100%) than in the high-SUVmax group (43.0%, P = 0.009). CONCLUSIONS: Maximum SUV on preoperative FDG-PET/CT in ovarian epithelial cancer differs according to histologic type. In clear cell AC, SUVmax may represent a prognostic factor.

Enhanced diagnostic accuracy for quantitative bone scan using an artificial neural network system: a Japanese multi-center database project.

BACKGROUND: Artificial neural network (ANN)-based bone scan index (BSI), a marker of the amount of bone metastasis, has been shown to enhance diagnostic accuracy and reproducibility but is potentially affected by training databases. The aims of this study were to revise the software using a large number of Japanese databases and to validate its diagnostic accuracy compared with the original Swedish training database. METHODS: The BSI was calculated with EXINIbone (EB; EXINI Diagnostics) using the Swedish training database (n = 789). The software using Japanese training databases from a single institution (BONENAVI version 1, BN1, n = 904) and the revised version from nine institutions (version 2, BN2, n = 1,532) were compared. The diagnostic accuracy was validated with another 503 multi-center bone scans including patients with prostate (n = 207), breast (n = 166), and other cancer types. The ANN value (probability of abnormality) and BSI were calculated. Receiver operating characteristic (ROC) and net reclassification improvement (NRI) analyses were performed. RESULTS: The ROC analysis based on the ANN value showed significant improvement from EB to BN1 and BN2. In men (n = 296), the area under the curve (AUC) was 0.877 for EB, 0.912 for BN1 (p = not significant (ns) vs. EB) and 0.934 for BN2 (p = 0.007 vs. EB). In women (n = 207), the AUC was 0.831 for EB, 0.910 for BN1 (p = 0.016 vs. EB), and 0.932 for BN2 (p < 0.0001 vs. EB). The optimum sensitivity and specificity based on BN2 was 90% and 84% for men and 93% and 85% for women. In patients with prostate cancer, the AUC was equally high with EB, BN1, and BN2 (0.939, 0.949, and 0.957, p = ns). In patients with breast cancer, the AUC was improved from EB (0.847) to BN1 (0.910, p = ns) and BN2 (0.924, p = 0.039). The NRI using ANN between EB and BN1 was 17.7% (p = 0.0042), and that between EB and BN2 was 29.6% (p < 0.0001). With respect to BSI, the NRI analysis showed downward reclassification with total NRI of 31.9% ( p < 0.0001). CONCLUSION: In the software for calculating BSI, the multi-institutional database significantly improved identification of bone metastasis compared with the original database, indicating the importance of a sufficient number of training databases including various types of cancers.

Volume-based parameters of 18F-fluorodeoxyglucose positron emission tomography/computed tomography improve disease recurrence prediction in postmastectomy breast cancer patients with 1 to 3 positive axillary lymph nodes.

PURPOSE: To determine whether volume-based parameters on pretreatment (18)F-fluorodeoxyglucose positron emission tomography/computed tomography in breast cancer patients treated with mastectomy without adjuvant radiation therapy are predictive of recurrence. METHODS AND MATERIALS: We retrospectively analyzed 93 patients with 1 to 3 positive axillary nodes after surgery, who were studied with (18)F-fluorodeoxyglucose positron emission tomography/computed tomography for initial staging. We evaluated the relationship between positron emission tomography parameters, including the maximum standardized uptake value, metabolic tumor volume (MTV), and total lesion glycolysis (TLG), and clinical outcomes. RESULTS: The median follow-up duration was 45 months. Recurrence was observed in 11 patients. Metabolic tumor volume and TLG were significantly related to tumor size, number of involved nodes, nodal ratio, nuclear grade, estrogen receptor (ER) status, and triple negativity (TN) (all P values were <.05). In receiver operating characteristic curve analysis, MTV and TLG showed better predictive performance than tumor size, ER status, or TN (area under the curve: 0.85, 0.86, 0.79, 0.74, and 0.74, respectively). On multivariate analysis, MTV was an independent prognostic factor of locoregional recurrence-free survival (hazard ratio 34.42, 95% confidence interval 3.94-882.71, P=.0008) and disease-free survival (DFS) (hazard ratio 13.92, 95% confidence interval 2.65-103.78, P=.0018). The 3-year DFS rate was 93.8% for the lower MTV group (<53.1; n=85) and 25.0% for the higher MTV group (≥53.1; n=8; P<.0001, log-rank test). The 3-year DFS rate for patients with both ER-positive status and MTV<53.1 was 98.2%; and for those with ER-negative status and MTV≥53.1 it was 25.0% (P<.0001). CONCLUSIONS: Volume-based parameters improve recurrence prediction in postmastectomy breast cancer patients with 1 to 3 positive nodes. The addition of MTV to ER status or TN has potential benefits to identify a subgroup at higher risk for recurrence.

Role of maximum standardized uptake value in fluorodeoxyglucose positron emission tomography/computed tomography predicts malignancy grade and prognosis of operable breast cancer: a multi-institute study.

The malignant biological behavior of breast cancer remains obscure on diagnostic images, although understanding the grade of such malignancy is important for selecting appropriate treatment. Therefore, malignancy grades in operable breast cancer were evaluated using positron emission tomography/computed tomography (PET/CT) in a multicenter setting. We prospectively examined the features and prognosis of 344 patients (mean age ± SD: 58.0 ± 12.5 years) with clinical stages I-III breast cancer, who underwent surgical intervention without induction therapy between January 2006 and December 2011. Maximum standardized uptake values (maxSUV) obtained from whole-body fluorodeoxyglucose-PET/CT immediately before surgery were assessed to predict the malignant aggressiveness of tumors including the recurrence-free survival of the patients. Variations in maxSUV among institutions, which are limitations of PET assessments in multicenter studies, were adjusted using a phantom study. The median follow up period was 52 months. The patients were divided into groups according to cut-off maxSUV (≤3.0 vs. >3.0) values established from receiver operating characteristic analysis of recurrence (area under the curve = 0.713). A higher maxSUV was significantly associated with a higher T-factor (p < 0.0001), N-factor (p = 0.0049), nuclear grade (p < 0.0001), negative for estrogen (p = 0.0309), and progesterone receptors (p = 0.0063), positive for human epidermal growth factor receptor 2 (p = 0.0012), lymph node metastasis (p = 0.0128), and vascular invasion (p = 0.0110). Multivariate analysis using Cox proportional hazard regression model revealed high maxSUV and negative estrogen receptor status as significantly prognostic factors (p = 0.033 and p = 0.004, respectively). This study demonstrated that maxSUV on PET/CT as well as estrogen receptor status is useful to predict malignancy grades and the prognosis of patients with breast cancer.