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Tumor characteristics of lung cancer in predicting axillary lymph node metastases
Características tumorales del cáncer de pulmón para predecir metástasis en los ganglios axilares
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Las metástasis ganglionares se confirmaron histológicamente: (A) MIP; (B) fusión axilar; (C) TC axial (flecha blanca MGA); (D) imagen de fusión coronal; (E) metástasis ganglionares del adenocarcinoma de pulmón (flecha roja: células linfoides normales, flecha azul: adenocarcinoma).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "F. Üstün, B. Tokuc, E. Tastekin, G. Durmuş Altun" "autores" => array:4 [ 0 => array:2 [ "nombre" => "F." "apellidos" => "Üstün" ] 1 => array:2 [ "nombre" => "B." "apellidos" => "Tokuc" ] 2 => array:2 [ "nombre" => "E." "apellidos" => "Tastekin" ] 3 => array:2 [ "nombre" => "G." 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pacientes con sospecha clínica de hiperplasia condilar" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1019 "Ancho" => 950 "Tamanyo" => 90581 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">ROI variable-size, one image: The image showing highest uptake was selected in both condyles. A variable-size ROI was manually outlined, including the total uptake area. Maximum counts, pixel number and average counts were obtained for that area.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Diego F. López Buitrago, Juan M. Muñoz Acosta, Rodrigo A. Cárdenas-Perilla" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Diego F." "apellidos" => "López Buitrago" ] 1 => array:2 [ "nombre" => "Juan M." "apellidos" => "Muñoz Acosta" ] 2 => array:2 [ "nombre" => "Rodrigo A." 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PET/CT at diagnosis showing primary tumor (47<span class="elsevierStyleHsp" style=""></span>mm in diameter and SUVmax 13.7), right axillary lymph nodes (13<span class="elsevierStyleHsp" style=""></span>mm and SUVmax 5.1) and adrenal, liver, ipsilateral lung and bone metastases. Histopthologic lymph node metastases were confirmed. (a) MIP. (b) Coronal PET (white arrow ALM). (c) Coronal fusion. (d) Coronal CT (white arrow ALM). (e) Lymph node metastasis of SCLC (red arrow: necrosis, blue arrow: small cell carcinoma).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Cancer is the leading cause of death in the world, which constitutes 8.2 million deaths in 2012.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">1</span></a> Lung cancer was the most frequently diagnosed cancer, and the leading cause of death among males worldwide, with approximately 1.01 million deaths in 2012.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">1</span></a> Cancer mortality can be reduced if cases are detected and treated early. However, lung carcinomas when detected are most often in a metastatic stage IV. Distant metastasis at the time of diagnosis of non-small-cell lung cancer (NSCLC) is approximately 30–40%.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The anatomical extent of the disease, defined according to the TNM classification, remains the most important prognostic factor for lung cancer. TNM classifications are updated from time to time. 7th TNM has evolved to the 8th TNM classification.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">2</span></a> In the latter, the most significant change was in M without any change in N. In lung cancer metastasis is one of the most important determinants of prognosis. Accurate staging is therefore imperative to select therapeutic strategies. In each case, the involved metastasis status could probably have different influences on patients’ survival.</p><p id="par0015" class="elsevierStylePara elsevierViewall">In the 8th edition of the TNM staging system, M1 category is reclassified as M1a (Separate tumor nodule(s) in a contralateral lobe; tumor with pleural or pericardial nodule(s) or malignant pleural or pericardial effusion), M1b (single metastatic lesion in one organ), and M1c (multiple metastases in either single organ or multiple organs).<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">2</span></a> According to the 7th grading system, supraclavicular lymph node involvement is defined as N3. The axillary lymph node involvement in lung cancer is not included in the N classification, nor is it defined in the distant metastases group in 7th edition grading system.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">3,4</span></a> The incidence of axillary lymph node metastases (ALM) from lung cancer is rare, occurring in <1% patients.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">5,6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">According to the 8th grading system, M1b is the single extra-thoracic metastases present with non-regional lymph node. Therefore, ALM is classified as M1b disease.</p><p id="par0025" class="elsevierStylePara elsevierViewall">In this descriptive cross-sectional single institution study, the presence of ALM in lung cancer and the factors affecting its development in lung cancer patients were assessed.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><p id="par0030" class="elsevierStylePara elsevierViewall">We retrospectively reviewed <span class="elsevierStyleSup">18</span>F-FDG PET/CT images at our institution to identify ALM FDG uptake. From October 2009 to December 2016, there were 20,539 patients with lung cancer diagnosis who underwent PET/CT imaging. This descriptive cross-sectional study was approved by our institutional ethic committee.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The inclusion criteria for the ALM group were: (1) histologically proven lung cancer diagnosed at our hospital, (2) patients with complete medical information and (3) ALM FDG uptake. ALM was defined as pathologic <span class="elsevierStyleSup">18</span>F-FDG avidity on positron emission tomography (PET), and/or biopsy-proven disease. From October 2009 to December 2016, the number of patients with ALM on PET/CT imaging for lung cancer diagnosis was 63 (0.3%). In 8 of these patients axillary lymph node biopsies were done.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The control group patients were randomly selected during the same period. The inclusion criteria for the control group were: (1) histologically proven lung cancers diagnosed at our hospital, (2) patients with complete medical information and (3) no ALM. Patients were excluded from this study if clinical data was not complete. The number of patients included in the control group was 94 (1.5 times the ALM group).</p><p id="par0045" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleSup">18</span>F-FDG PET/CT was performed using a PET/CT scanner (Discovery LS; GE Healthcare). In addition, patients received oral contrast to improve delineation of abdominal structures on CT. Serum levels of glucose were monitored immediately before the <span class="elsevierStyleSup">18</span>F-FDG injection. Blood glucose levels were <200<span class="elsevierStyleHsp" style=""></span>mg/dL in all patients. After fasting for at least 6<span class="elsevierStyleHsp" style=""></span>h, they were injected with 370–550<span class="elsevierStyleHsp" style=""></span>MBq of <span class="elsevierStyleSup">18</span>F-FDG intravenously. PET emission images were acquired from the proximal thigh to the top of cranium, typically requiring 6–7 bed positions with a 3-min acquisition at each.</p><p id="par0050" class="elsevierStylePara elsevierViewall">All PET images were interpreted by experienced nuclear medicine physicians. <span class="elsevierStyleSup">18</span>F-FDG accumulation was analyzed semi-quantitatively by calculating the maximum standardized uptake value (SUVmax) in the regions of interest placed over the suspected lesions.</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Statistical analysis</span><p id="par0055" class="elsevierStylePara elsevierViewall">Data analysis was conducted with the IBM SPSS Statistics 22 software. Descriptive analysis was carried out to assess the patients’ demographic and clinical characteristics. Continuous variables were expressed as the mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>standard deviation (SD), and analyzed by student t test. Categorical data were tested by the chi-square test. Logistic regression analysis was performed for determining ALM predictors. All <span class="elsevierStyleItalic">p</span> values were two-tailed and <span class="elsevierStyleItalic">p</span> values <0.05 were considered statistically significant.</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Results</span><p id="par0060" class="elsevierStylePara elsevierViewall">Between 2009 and 2016, there were 157 patients included in this analysis [ALM group (63 patients) and control group (94 patients)]. The clinical and pathologic characteristics of the ALM and the control groups are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. Median age at diagnosis was 61 years (range, 32–85 years) in the ALM group and 66 years (range, 27–89 years) in the control group.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Histopathologically, 39 patients (61.9%) had adenocarcinoma (AC), 11 had squamous cell carcinoma (SQC), 11 had small cell lung cancer (SCLC), and 2 had large cell carcinoma (LC) in the ALM group. Pathologic diagnosis of the patients in the control group was significantly different from the ALM group (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.005), and the majority of the patients in this group were SQC (47.9%) and AC (38.3%).</p><p id="par0070" class="elsevierStylePara elsevierViewall">Mean tumor size was 48.25<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>36.96<span class="elsevierStyleHsp" style=""></span>mm in the ALM group, and 46.68<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>23.02 in the control group. The difference between groups was not significant. Primary tumor SUVmax was 12.04<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>6.07 for the ALM group, and 11.54<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>5.65 for the control group. However, SUVmax values did not significantly differ according to the type of primary tumor.</p><p id="par0075" class="elsevierStylePara elsevierViewall">The presence of mediastinal lymph nodes in 93.7% of the patients was significantly higher in the ALM group (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.005) versus 62.8% in the control group. In the ALM group, 81% of these patients were N3. In addition, lymph node diameter and SUVmax values were also significantly higher in the ALM group (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.005).</p><p id="par0080" class="elsevierStylePara elsevierViewall">Chest wall invasion and pleural invasion were also significantly different between ALM and control groups (41.3% versus 11.7%, and 42.9% versus 11.7%, respectively) (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.005).</p><p id="par0085" class="elsevierStylePara elsevierViewall">Head and neck lymph node presence was observed more frequently in the the ALM group (65.1%) versus the control group (17%) and SUVmax values were significantly higher in the ALM group (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.005).</p><p id="par0090" class="elsevierStylePara elsevierViewall">The presence of abdominal lymph node was significantly higher in the ALM group (28.6%) versus the control group (3.2%) (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.005) and SUVmax values of abdominal lymph node were significantly higher in the ALM group (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.005).</p><p id="par0095" class="elsevierStylePara elsevierViewall">The presence of lung parenchyma metastases and SUVmax values were not different between the groups (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>0.05). However, the presence of contralateral lung metastases was significantly higher in the ALM group (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05). SUVmax values were not statistically different between groups.</p><p id="par0100" class="elsevierStylePara elsevierViewall">Adrenal metastases were observed in 39.8% of cases in the ALM and in 7.4% of cases in the control group. Bone metastases were present in 56.5% in the ALM group and 20.2% in the control group. The presence of adrenal metastases and SUVmax values (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.005); bone metastases and SUVmax values (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.005); and soft tissue metastases (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05) and SUVmax values (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05) were significantly higher in the ALM group compared to the control group.</p><p id="par0105" class="elsevierStylePara elsevierViewall">The presence of liver metastases was higher in the ALM group (15.9% vs 8.5%) but it was not statistically significant. However, the liver metastases SUVmax value for the ALM group was significantly higher than for the control group (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05).</p><p id="par0110" class="elsevierStylePara elsevierViewall">Brain metastases did not differ significantly between the groups (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>0.05).</p><p id="par0115" class="elsevierStylePara elsevierViewall">When the 7th staging system is considered, 8 patients were M0, 5 were M1a, and 50 were M1b. However, when the new 8th staging system is considered, no patients were M0. Five patients with M1a remained in this group while 8 patients with M0 were categorized into the M1b group.</p><p id="par0120" class="elsevierStylePara elsevierViewall">The percentage of localized tumors in the upper lobe in the ALM group was 33.3% (right lobe), 27% (left lobe) and 7.9% (central), while in the control group it was 29.8%, 16% and 1.1% respectively. ALM involvement according to the primary site as the upper lobe, lower lobe and central is shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>. The presence of ALM was related to location of the tumor; in the ALM group the primary tumor was mostly located in the upper lobe (60.3%) (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.005).</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall">In 66.7% patients, ALM was detected at the time of initial diagnosis. The localization of the axillary lymph node was 54% right, 33.3% left, and 12.7% bilateral. The SUVmax value of the axillary lymph nodes was 1.7–32.2 (7.68<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>5.64), while the maximum lymph node size was 8–101 (20.2<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>13.81) mm.</p><p id="par0130" class="elsevierStylePara elsevierViewall">In 8 patients of the ALM group, axillary lymph node biopsies were done, and 7 patients’ metastases were confirmed histopathologically. The 18F-FDG PET/CT images of 2 patients are presented in <a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>. One patient's biopsy result was reported as benign; images and follow-up PET/CT images showed that the metabolic activity of the lymph node, which was evaluated as axillary metastasis, persisted. As a result, this patient was left in the ALM group with no histopathologic confirmation due to inadequate sampling.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0135" class="elsevierStylePara elsevierViewall">Logistic regression analysis was performed for determining the predictors of axillary metastasis (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>). In this model, only 2 factors remained independent predictors for developing axillary metastasis, pathologic subgroup and the localization of the primary tumor. The SUVmax value of the primary tumor was not a predictor of ALM. According to the primary pathologic diagnosis, SCLC was found to cause ALM development 3.4 times as much as SQC (OR: 3.40 (95% CI 1.3–10.20), <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05) and AC was found to cause ALM development 4 times as much as SQC (OR: 4.02 (95% CI 1.73–9.34), <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.005). The second important factor was the localization of the primary tumor. Both lungs were divided into upper, middle and lower lungs. The likelihood of developing ALM was significantly higher in tumors located in the central and upper lobe versus the lower lobe.</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0140" class="elsevierStylePara elsevierViewall">In the light of this data, we prepared a figure for the differential diagnosis of lesions in the presence of ALM in PET/CT in patients with lung cancer (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). The need of histopathologic confirmation is determined according to the results of primary tumor localization, primary tumor histopathology, localization of ALM according to primary tumor, and M stage and N stage on PET/CT imaging.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Discussion</span><p id="par0145" class="elsevierStylePara elsevierViewall">In our study, we reached three main conclusions: (i) patient's primary tumor with upper lobe and central localization is more likely to develop ALM. Therefore, these patients are easily reclassified to the advanced stage. (ii) AC and SCLC are aggressive forms and also metastasizes to axillary nodes. (iii) ALM is an advanced disease.</p><p id="par0150" class="elsevierStylePara elsevierViewall">The international TNM staging system (primary tumor spread-regional lymph node involvement-intrathoracic or distant metastases) is used in the lung cancer stage. TNM staging was the strongest known predictive factor for regional and distant disease recurrence in lung cancer. The 5-year survival rate for lung cancer is only 18.1%; the 5-year survival rate for those with stage IV (metastatic) disease at diagnosis is much lower (approximately 4.5%).<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">7</span></a> In the 8th edition of the TNM staging system, M1 category is reclassified as M1a, M1b, and M1c.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">2</span></a> According to the 8th grading system, M1b corresponds to single extrathoracic metastases with nonregional lymph node. Therefore, ALM entity is classified as M1b disease. Old age, male gender, large tumor size, and presence of pleural invasion, lymphatic permeation, lymph node and distant metastases are all indicative of an unfavorable prognosis.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">2,8,9</span></a> Patients with extra-thoracic metastases had a collective median survival of only 6 months. The survival of those with metastases to multiple extra-thoracic sites (median survival, 5 months) was slightly worse than that of patients with single-site extra-thoracic metastases (median survival, 6 months). Since ALM usually occurs in patients with advanced stage and multiple metastases, these patients will have a poor prognosis. So, the presence of ALM should be carefully monitored. At this stage, the treatment strategy is important. Therefore, a greater understanding of the clinical features of patients with lung cancer associated with ALM would be valuable. For these reasons, a clear indication for regular screening especially using PET/CT for early lesion detection of metastatic lung cancer patients with the highest risk of developing ALM should be considered.</p><p id="par0155" class="elsevierStylePara elsevierViewall">This study describes the association of histological and demographic data with the incidence of ALM in lung cancer. Not surprisingly, ALM prevalence is higher in patients with more advanced disease stages. Knowledge of ALM-related characteristics in patients with lung cancer may provide important advantages, including early diagnosis and more effective treatment and improved detection strategies.</p><p id="par0160" class="elsevierStylePara elsevierViewall">We found two independent factors associated with the risk of ALM in our study group: upper lobe and central area tumor for tumor localization and AC and SCLC for histopathologic diagnosis.</p><p id="par0165" class="elsevierStylePara elsevierViewall">There is a close relationship between the basic anatomic lymph node drainage patterns of the lungs and metastases to the lymph nodes. Thoracic lymph node drainage patterns are divided into intraparenchymal (pulmonary) drainage and mediastinal (drainage). Mediastinal drainage to specific lymph node stations is considered to be lobe-dependent.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">10</span></a> It is a known fact that upper lobe tumors of the right lung frequently metastasize to the right paratracheal lymph node and middle and lower lobe tumors metastasize to the inferior mediastinum and subcarinal lymph nodes. Left upper lobe malignancies tend to drain toward the aorto-pulmonary window and periaortic lymph nodes. Similar to the right lower lobe, left lower lobe tumors drain to the subcarinal lymph nodes most frequently. However, skip metastases represent an abnormal drainage pattern bypassing the intrapulmonary lymph nodes into the mediastinal lymph nodes. In a study on autopsy specimens, Onuigbo<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">11</span></a> documented that a cancer originating from any lobe of the lung could spread to the contralateral cervical lymph nodes. Generally, ipsilateral metastases are more common than contralateral metastases. As seen in our study, ipsilateral ALM is frequently observed and contralateral can develop. Skip metastases have been found to be more frequent among AC than SQC.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">10</span></a> This finding might partly explain why AC is more frequently caused by ALM in our study. For this reason, ALM was affected not only by the lymphatic drainage pattern as other mechanisms also influence the development of ALM.</p><p id="par0170" class="elsevierStylePara elsevierViewall">Another possible reason for the development of ALM has been described in previous studies.<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">6,12</span></a> It is assumed that the ipsilateral axillary lymph nodes are affected by retrograde propagation through the chest wall or from the supraclavicular lymph nodes; and contralateral axillary lymph nodes are affected by the retrograde spreading of the contralateral mediastinal and supraclavicular lymph nodes. Retrograde involvement may occur when the valvular competence of the lymphatic vessels are lost.<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">6,12</span></a> Tumor spread may occur through newly evolving lymphatic ducts that appear in pleural adhesions.<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">6,12</span></a> In the absence of a supraclavicular metastatic disease, axillary lymph nodes and chest wall lymphatics may be another way of spreading through intercostal lymphatics by mediastinal lymphatic channels. In our study, pleural invasion was more frequent in the ALM group versus the control group.</p><p id="par0175" class="elsevierStylePara elsevierViewall">According to Riquet et al.,<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">6</span></a> axillary lymph nodes behave differently than intra-abdominal and supraclavicular lesions normally present in the lung lymph pathways. For this reason ALM must be systemic in origin. The carcinoma cells entering the bloodstream cause early onset of distant metastases and thus shortens the overall survival time of the patient. Lung cancer cells escape from the circulation due to the stimulating effect of adhesion molecules. Lung carcinomas have preferred organs for metastases, such as brain, bone and adrenal glands. Among the different types of lung cancer, the preferred metastatic sites are lung and brain in SCLC and AC, and pleura in AC.<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">13,14</span></a> The process of selecting the final destination of tumor cells is still uncertain.</p><p id="par0180" class="elsevierStylePara elsevierViewall">Hypermetabolic appearance of the left axillary nodal metastatic disease was observed in PET/CT with bilateral silicone breast implants and right lung mass in a 49-year-old transgender individual (biopsy, NSCLC).<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">15</span></a> Histological examination revealed lymph node silicone implant leakage and silicone adenitis. Therefore, care must be taken in this assessment as it can change from M0 to M1b, especially in the presence of contralateral ALM and in the absence of metastases in other areas of the body. It is absolutely necessary to consider that ALM on the same side of the tumor is likely to be a metastasis, however further research is recommended when it is the opposite side.</p><p id="par0185" class="elsevierStylePara elsevierViewall">According to Mc Evoy et al.,<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">16</span></a> the risk of developing ALN metastases was significantly higher in patients with BRAF mutated lung cancer (15%) than in patients with non-BRAF mutated lung cancer. The BRAF mutation was not studied because our study was retrospective. This issue should be studied prospectively in a larger group of patients.</p><p id="par0190" class="elsevierStylePara elsevierViewall">When these studies involving a limited number of patients are evaluated together in the light of our study, it is thought that ALM develops as a result of a combination of these defined factors rather than a single factor. ALM development is a multi-factor process.</p><p id="par0195" class="elsevierStylePara elsevierViewall">Considering previous studies, ALM are rare in patients with lung cancer as 0.61–0.75%.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">5,6</span></a> In our study, ALM rate was 0.3%. Satoh et al.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">5</span></a> concluded that the probability of developing ALM was so low that no imaging procedures are specifically required in the absence of clinical evidence of ALN metastases. However, nowadays many cases are encountered with the widespread use of PET/CT. This information is important for patient follow-up strategy. Therefore, in the group of patients predicting the likelihood of ALM, axillary examination should be performed and imaging methods should be performed at clinical necessity.</p><p id="par0200" class="elsevierStylePara elsevierViewall">Our study has several limitations. The main problem is that it is based on a general database, for this reason the results may be biased. Other potential pitfalls can also occur due to the retrospective nature of our work. We tried to overcome these problems with the descriptive nature of the study. Despite these limitations, this study is valuable in light of the new knowledge about the predictive factors and possible developmental mechanism of ALM in lung cancer.</p><p id="par0205" class="elsevierStylePara elsevierViewall">Not all patients taken in the study group were confirmed histopathologically. This may have led to a sampling error due to the possibility of false positive results. However, histopathologic confirmation is not required in the patient group that will not affect staging.</p><p id="par0210" class="elsevierStylePara elsevierViewall">Our hospital is a district hospital facility, serving a wide area. For this reason, not all patients were reached out for the survey analysis.</p><p id="par0215" class="elsevierStylePara elsevierViewall">In our study, patients were diagnosed with histopathology at bronchoscopy; sub-typing of tumor is not possible, especially for AC. For this reason, it may not be possible to predict the invasive distribution of the tumor.</p><p id="par0220" class="elsevierStylePara elsevierViewall">Because of the possibility of genetic factors in predicting ALM, a prospective study should be performed in a larger group of patients.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conclusion</span><p id="par0225" class="elsevierStylePara elsevierViewall">To our knowledge, the current report is the largest to describe lung cancer ALM. Tumor localization (upper lobe and central to lower lobe) and pathology (AC and SCLC to other forms) are proposed as criteria for axillary metastases. Because of the prevalence of axillary metastases on disease progression, the results of our study support the notion that doctors should pay attention to axillary metastases in patients with upper lobe and central area and AC and SCLC in theory.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflict of interest</span><p id="par0230" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres1157595" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Aim" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1084750" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1157596" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1084749" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Methods" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Statistical analysis" ] ] ] 6 => array:2 [ "identificador" => "sec0020" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0025" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0030" "titulo" => "Conclusion" ] 9 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflict of interest" ] 10 => array:2 [ "identificador" => "xack394970" "titulo" => "Acknowledgment" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-03-20" "fechaAceptado" => "2018-09-08" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1084750" "palabras" => array:4 [ 0 => "Axillary lymph node metastasis" 1 => "<span class="elsevierStyleSup">18</span>F-FDG" 2 => "Lung cancer" 3 => "PET/CT" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1084749" "palabras" => array:4 [ 0 => "Metástasis en los ganglios axilares" 1 => "<span class="elsevierStyleSup">18</span>F-FDG" 2 => "Cáncer de pulmón" 3 => "PET/TC" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Aim</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">In lung cancer, axillary lymph node metastases (ALM) are rare, and according to the 8th grading system, it is classified as M1b disease. The aim of this study is to evaluate (i) the presence of ALM, and (ii) the effect of the primary tumors characteristics on the development of ALM.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We performed a descriptive cross-sectional study, with retrospective revision, to identify ALM.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">There were 157 patients included in this analysis: ALM (63 patients) and control group (94 patients). The presence of extrathoracic lymph node, contralateral pulmonary parenchymal and distant metastasis and all SUVmax values were significantly higher in the study group versus the control group (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05). The SUVmax value of the primary tumor was not a predictor of ALM. According to the primary histopathologic diagnosis, small cell lung cancer was found to cause ALM development 3.4 times as much as squamous cancer (SQC) (OR: 3.40 (95% CI 1.3–10.20), <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.029) and adenocarcinoma group was found to cause ALM development 4 times as much as SQC (OR: 4.02 (95% CI 1.73–9.34), <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.001). The likelihood of developing ALM was significantly higher in tumor located in the central and upper lobe versus the lower lobe.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The finding of ALM on PET/CT images, the necessity of histopathologic confirmation is determined according to the results of primary tumor localization, primary tumor histopathology, M stage on PET/CT imaging, localization of ALM according to primary tumor, and N stage on PET/CT imaging.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Aim" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">En el cáncer de pulmón, las metástasis en los ganglios axilares (ALM) son infrecuentes y, con arreglo a la 8ª edición sistema de estadificación, se clasifican como enfermedad metastásica M1b. El objetivo de este estudio es evaluar (i) la presencia de ALM, y (ii) el efecto de las características de los tumores primarios en el desarrollo de ALM.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Realizamos un estudio transversal descriptivo, con revisión retrospectiva, para identificar las ALM.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Incluimos en este análisis a 157 pacientes: ALM (63 pacientes) y grupo control (94 pacientes). La presencia de ganglios extratorácicos, metástasis contralaterales pulmonares parenquimatosas y distantes, y todos los valores SUVmax fueron significativamente más elevados en el grupo de estudio, en comparación con el grupo control (p<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0,05). El valor SUVmax del tumor primario no fue un factor predictivo de ALM. Con arreglo al diagnóstico histopatológico primario, detectamos que el cáncer de pulmón de células pequeñas causaba el desarrollo de ALM en una proporción 3,4 mayor que el cáncer de células escamosas (CCE) (OR: 3,4 (95% IC 1,3–10,2), p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,029), y que el grupo de adenocarcinoma causaba el desarrollo de ALM en proporción 4 veces superior que el CCE (OR: 4,02 (95% IC 1,73–9,34), p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,001). La probabilidad de desarrollar ALM fue considerablemente superior en los tumores localizados en el lóbulo superior que en el lóbulo inferior.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusión</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Tras el hallazgo de ALM en las imágenes PET/TC, la necesidad de confirmación histopatológica viene determinada con arreglo a los resultados de la localización del tumor primario, la histopatología de éste, el estadio M en PET/TC, la localización de ALM con arreglo al tumor primario, y el estadio N en PET/TC.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Üstün F, Tokuc B, Tastekin E, Durmuş Altun G. Características tumorales del cáncer de pulmón para predecir metástasis en los ganglios axilares. Rev Esp Med Nucl Imagen Mol. 2019;38:80–86.</p>" ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">This work was presented in part at the 28th Annual Congress of the European Association of Nuclear Medicine – EANM, 10–14 October, 2015 Hamburg, Germany.</p>" ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2872 "Ancho" => 2500 "Tamanyo" => 830821 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">57 years old male patient, histopathologic adenocarcinoma, follow-up PET/CT showing primary tumor uptake (67<span class="elsevierStyleHsp" style=""></span>mm in max diameter and SUVmax 7.8), left axillary lymph node (27<span class="elsevierStyleHsp" style=""></span>mm in diameter and SUVmax 6.4), mediastinal, head and neck, and multiple abdominal lymph nodes, ipsilateral lung metastasis, and pleural effusion. Histopathologically lymph node metastases were confirmed. (a) MIP. (b) Axillary fusion. (c) Axial CT (white arrow ALM). (d) Coronal fusion image. (e) Lymph node metastasis of lung adenocarcinoma (red arrow: normal lymphoid cells, blue arrow: adenocarcinoma).</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 3537 "Ancho" => 2500 "Tamanyo" => 766846 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">67 years old male patient, histopathologic SCLC. PET/CT at diagnosis showing primary tumor (47<span class="elsevierStyleHsp" style=""></span>mm in diameter and SUVmax 13.7), right axillary lymph nodes (13<span class="elsevierStyleHsp" style=""></span>mm and SUVmax 5.1) and adrenal, liver, ipsilateral lung and bone metastases. Histopthologic lymph node metastases were confirmed. (a) MIP. (b) Coronal PET (white arrow ALM). (c) Coronal fusion. (d) Coronal CT (white arrow ALM). (e) Lymph node metastasis of SCLC (red arrow: necrosis, blue arrow: small cell carcinoma).</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1379 "Ancho" => 2917 "Tamanyo" => 162286 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Based on this study, the differential diagnosis of lesions in the presence of ALM in PET/CT in patients with lung cancer.</p>" ] ] 3 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">ns: <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>0.05.</p><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">AC: adenocarcinoma, SQC: squamous cell cancer, SCLC: small cell lung cancer, LC: large cell cancer.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Axillary metastases group</th><th class="td" title="table-head " colspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Control group</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">N</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " colspan="2" align="left" valign="top">63</td><td class="td" title="table-entry " colspan="2" align="left" valign="top">94</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Age</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " colspan="2" align="left" valign="top">32–85 (medium 60.98)</td><td class="td" title="table-entry " colspan="2" align="left" valign="top">27–89 (medium 65.83)</td><td class="td" title="table-entry " align="left" valign="top">0.005 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Gender</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Male/Female \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " colspan="2" align="left" valign="top">55/8</td><td class="td" title="table-entry " colspan="2" align="left" valign="top">85/9</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Pathologic diagnosis</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><0.005 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>AC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">39 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">61.9% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">36 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">38.3% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>SQC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">17.5% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">45 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">47.9% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>SCLC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">17.5% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12.8% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>LC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3.1% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Primary tumor diameter (mm)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " colspan="2" align="left" valign="top">48.25<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>36.96</td><td class="td" title="table-entry " colspan="2" align="left" valign="top">46.68<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>23.02</td><td class="td" title="table-entry " align="left" valign="top">ns \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Primary tumor SUVmax</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " colspan="2" align="left" valign="top">12.04<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>6.07</td><td class="td" title="table-entry " colspan="2" align="left" valign="top">11.54<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>5.65</td><td class="td" title="table-entry " align="left" valign="top">ns \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Mediastinal lymph node</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">59 (93.7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">59 (62.8%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><0.005 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>N0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6.3% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">31 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">33% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>N1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3.2% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11.7% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>N2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9.5% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">22.3% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>N3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">51 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">81% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">31 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">33% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Mediastinal lymph node diameter (mm)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " colspan="2" align="left" valign="top">25.61<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>16.05</td><td class="td" title="table-entry " colspan="2" align="left" valign="top">6.04<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>15.04</td><td class="td" title="table-entry " align="left" valign="top"><0.005 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Mediastinal lymph node SUVmax</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " colspan="2" align="left" valign="top">9.4<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>6.1</td><td class="td" title="table-entry " colspan="2" align="left" valign="top">5.27<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>5.93</td><td class="td" title="table-entry " align="left" valign="top"><0.005 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Chest wall invasion</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">26 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">41.3% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11.7% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><0.005 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Pleural invasion</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">27 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">42.9% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11.7% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><0.005 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Pleural SUVmax</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " colspan="2" align="left" valign="top">3.45<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>5.51</td><td class="td" title="table-entry " colspan="2" align="left" valign="top">1.11<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>4.69</td><td class="td" title="table-entry " align="left" valign="top">0.005 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Pleural effusion</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">20.6% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12.8% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ns \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Ipsilateral lobe lung parenchymal metastases</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">25.4% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">18.1% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ns \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Ipsilateral lobe lung parenchymal metastases SUVmax</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " colspan="2" align="left" valign="top">1.56<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>3.12</td><td class="td" title="table-entry " colspan="2" align="left" valign="top">1.08<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>2.54</td><td class="td" title="table-entry " align="left" valign="top">ns \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Counter lateral lobe lung parenchymal metastases</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">27.4% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12.8% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><0.05 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Counter lateral lobe lung parenchymal metastases SUVmax</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " colspan="2" align="left" valign="top">1.35<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>2.97</td><td class="td" title="table-entry " colspan="2" align="left" valign="top">0.68<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>2.32</td><td class="td" title="table-entry " align="left" valign="top">ns \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Head and neck lymph node</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">41 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">65.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><0.005 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Head and neck lymph node SUVmax</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " colspan="2" align="left" valign="top">5.67<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>5.96</td><td class="td" title="table-entry " colspan="2" align="left" valign="top">1.11<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>2.71</td><td class="td" title="table-entry " align="left" valign="top"><0.005 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Abdominal lymph node metastasis</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">28.6% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3.2% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><0.005 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Abdominal lymph node metastases SUVmax</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " colspan="2" align="left" valign="top">2.33<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>5.04</td><td class="td" title="table-entry " colspan="2" align="left" valign="top">0.30<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1.85</td><td class="td" title="table-entry " align="left" valign="top"><0.005 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Liver metastases</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15.9% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8.5% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ns \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Liver metastases SUVmax</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " colspan="2" align="left" valign="top">1.57<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>3.96</td><td class="td" title="table-entry " colspan="2" align="left" valign="top">0.54<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1.99</td><td class="td" title="table-entry " align="left" valign="top"><0.05 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Adrenal metastases</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">39.68% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.4% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><0.005 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Adrenal metastases SUVmax</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " colspan="2" align="left" valign="top">3.49<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>5.48</td><td class="td" title="table-entry " colspan="2" align="left" valign="top">0.50<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>2.06</td><td class="td" title="table-entry " align="left" valign="top"><0.005 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Bone metastases</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">56.5% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">20.2% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><0.005 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Bone metastases SUVmax</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " colspan="2" align="left" valign="top">5.65<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>7.07</td><td class="td" title="table-entry " colspan="2" align="left" valign="top">1.52<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>3.57</td><td class="td" title="table-entry " align="left" valign="top"><0.005 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Soft tissue metastases</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">14.3% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4.3% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><0.05 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Soft tissue metastases SUVmax</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " colspan="2" align="left" valign="top">1.31<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>3.54</td><td class="td" title="table-entry " colspan="2" align="left" valign="top">0.36<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1.86</td><td class="td" title="table-entry " align="left" valign="top"><0.05 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Brain metastases</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16.1% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8.5% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ns \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1976524.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Clinical and pathological features of 157 patients with and without axillary lymph node metastasis (ALM and control group).</p>" ] ] 4 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="6" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Primary tumor site's</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="left" valign="top" scope="col">Upper lobe</th><th class="td" title="table-head " colspan="2" align="left" valign="top" scope="col">Lower lobe</th><th class="td" title="table-head " align="left" valign="top" scope="col">Central \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col"><span class="elsevierStyleItalic">x</span> \t\t\t\t\t\t\n \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">38 (60.3%)</th><th class="td" title="table-head " colspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">6 (9.5%)</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">15 (23.8%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">4 (6.4%) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">R \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">R \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Axillary localization \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">R \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bilateral \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1976523.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Localization of axillary lymph node metastases according to primary lung cancer site.</p>" ] ] 5 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">OR: Odds ratio, CI: confidence interval, SCLC: small cell lung cancer, AC: adenocarcinoma, SQC: squamous cell carcinoma.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variables \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">OR \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">95%CI \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " rowspan="3" align="left" valign="top">Pathologic types</td><td class="td" title="table-entry " align="left" valign="top">SQC (reference) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.005 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SCLC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3.40 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.13–10.20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.05 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">AC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4.02 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.73–9.34 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.005 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="3" align="left" valign="top">Primary tumor localization</td><td class="td" title="table-entry " align="left" valign="top">Lower (reference) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.05 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Central \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3.94 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.23–12.56 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.05 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Upper \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3.99 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.45–10.97 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.05 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Constant \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " colspan="3" align="left" valign="top">0.082</td><td class="td" title="table-entry " align="char" valign="top"><0.005 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1976525.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Logistic regression analysis of clinical and pathologic factors with ALM.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:16 [ 0 => array:3 [ "identificador" => "bib0085" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Global cancer statistics, 2012" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "L.A. 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