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Original Article
Is there any improvement in clinical staging with 18F-FDG PET/CT compared to surgical staging in cases of lung cancer?
¿Hay alguna mejora en la estadificación clínica con PET/TC con 18F-FDG en comparación con la estadificación quirúrgica en el cáncer de pulmón?
Gonca Kara Gedik
Corresponding author
goncakara@yahoo.com

Corresponding author.
, Farise Yilmaz
Selcuk University, Faculty of Medicine, Department of Nuclear Medicine, Konya, Turkey
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two primary lung cancer staging procedures are available&#58; clinical staging&#44; which is provided by noninvasive imaging procedures&#44; or minimally invasive approaches&#44; such as mediastinoscopy&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">3</span></a> For the pathologic staging&#44; information is obtained from invasive surgery and the pathologic evaluation of the excised tumor&#46; Clinical staging can done with preoperative imaging techniques including computed tomography &#40;CT&#41; and positron emission tomography&#47;computed tomography &#40;PET&#47;CT&#41; performed with <span class="elsevierStyleSup">18</span>Fluorine fluorodeoxyglucose &#40;<span class="elsevierStyleSup">18</span>F-FDG&#41;&#46; With the size based criteria for malignancy&#44; CT has a limited sensitivity and specificity&#44; especially in nodal staging of mediastinum&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">4</span></a> Mediastinoscopy&#44; which is considered to be gold standard for mediastinal lymph node staging&#44; is unreliable in &#60;10&#37; of cases for lymph nodes measuring &#60;1<span class="elsevierStyleHsp" style=""></span>cm&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">5</span></a> Surgical staging&#44; on the other hand&#44; makes available greater certainty about prognosis and is useful in making decisions about adjuvant therapy after surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">6</span></a> A study comparing imaging TNM and pathological TNM in staging lung carcinoma with CT pointed out the low diagnostic accuracy of clinical staging as compared with pathological staging&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">6&#44;7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleSup">18</span>F-FDG PET&#47;CT is increasingly being used for diagnosis&#44; staging and for evaluation of therapy response in various tumors including lung carcinoma&#46; Improvement in staging of patients with lung carcinoma has been shown with integrated <span class="elsevierStyleSup">18</span>F-FDG PET&#47;CT systems compared to PET systems alone&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">8&#44;9</span></a> Besides having the ability of analyzing cell metabolism&#44; <span class="elsevierStyleSup">18</span>F-FDG PET&#47;CT also offers semiquantitative metabolic parameters of the tumor which give information about metastatic potential and risk of recurrence&#46; Although maximum standard uptake value &#40;SUVmax&#41; is the most commonly used one in clinical practice&#44; the role of metabolic tumor burden as measured with metabolic tumor volume &#40;MTV&#41; or total lesion glycolysis &#40;TLG&#41; has been introduced and have been suggested as yielding prognostic information on survival and giving better prognostic measures than SUVmax in patients with nonsmall cell lung cancer&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">2&#44;10&#8211;12</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The aim of this study was to compare clinical staging performed with <span class="elsevierStyleSup">18</span>F-FDG PET&#47;CT and surgical staging in patients with lung carcinoma treated surgically&#46; The role of semiquantitative parameters derived from primary tumor and mediastinal lymph nodes&#44; as predictors of postoperative upstaging and mediastinal involvement&#44; have also been evaluated&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Patients</span><p id="par0025" class="elsevierStylePara elsevierViewall">The files of 691 patients with lung carcinoma&#44; who underwent <span class="elsevierStyleSup">18</span>F-FDG PET&#47;CT between September 2012 and December 2018 in Selcuk University Medical Faculty Department of Nuclear Medicine&#44; were retrospectively reviewed&#46; Patients with histologically proven lung cancer&#44; who had undergone an <span class="elsevierStyleSup">18</span>F-FDG PET&#47;CT scanning for staging and had been surgically treated after imaging&#44; were selected&#46; Patients with small cell carcinoma&#44; patients whose pathological data of the surgical specimen could not be the recovered and cases in whom induction therapy was delivered after <span class="elsevierStyleSup">18</span>F-FDG PET&#47;CT&#44; were excluded from the study&#46; This study was approved by the local ethics committee of our faculty &#40;meeting date&#58; 24&#46;10&#46;2018&#44; decision number&#58; 2018&#47;366&#41; and written informed consent form was obtained in all patients&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080"><span class="elsevierStyleSup">18</span>F-FDG PET&#47;CT scanning</span><p id="par0030" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleSup">18</span>F-FDG PET&#47;CT imaging was carried out with an integrated scanner &#40;Biograph mCT&#44; Siemens&#44; Germany&#41; in 8 or 9 bed positions with an acquisition time of 2<span class="elsevierStyleHsp" style=""></span>min per bed position from skull base to the mid thigh&#46; All patients were asked to fast at least 6<span class="elsevierStyleHsp" style=""></span>h before the examination and blood sugar levels were confirmed to be less than 200<span class="elsevierStyleHsp" style=""></span>mg&#47;dL before the injection of 370<span class="elsevierStyleHsp" style=""></span>MBq of <span class="elsevierStyleSup">18</span>F-FDG&#46; Sixty minutes after the administration of the radiopharmaceutical&#44; a low dose unenhanced CT using the 16 slice CT with acquisition parameters of 190<span class="elsevierStyleHsp" style=""></span>mA&#44; 5<span class="elsevierStyleHsp" style=""></span>mm slice thickness and 140<span class="elsevierStyleHsp" style=""></span>kV was performed for attenuation correction&#44; which was followed by the PET acquisition&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Image interpretation and semiquantification</span><p id="par0035" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleSup">18</span>F-FDG PET&#47;CT images were interpreted and semiquantitative analysis of <span class="elsevierStyleSup">18</span>F-FDG uptake was calculated on a Siemens Syngo&#46;via PET&#47;CT workstation&#46; In each patient&#44; a 1&#46;0<span class="elsevierStyleHsp" style=""></span>cm diameter region of interest &#40;ROI&#41; was manually placed over the primary lung lesion and suspicious lymph node stations on the attenuation corrected <span class="elsevierStyleSup">18</span>F-FDG PET images on the slice with the highest <span class="elsevierStyleSup">18</span>F-FDG uptake&#46; The activity concentration within the ROI was determined and expressed as SUV which was calculated using the formula below&#58; activity in the region of interest &#40;MBq&#47;mL&#41;&#47;&#40;injected activity&#47;body size&#41;&#46; From these ROIs&#44; SUVmax and peak standardized uptake value &#40;SUVpeak&#41; were calculated&#44; both of which were normalized to body weight&#46; For determining mediastinal and hilar lymph node status&#44; we randomly selected 50 patients&#44; drew a 1&#46;0<span class="elsevierStyleHsp" style=""></span>cm diameter ROI in the center of superior vena cava and calculated the mean of their SUVmax to represent blood pool SUV&#44; which was calculated as 3&#46;30&#46; For MTV and TLG calculation&#44; 40&#37; of the SUVmax was adopted as the threshold to delineate the tumor&#59; MTV and TLG of the primary tumor and mediastinal lymph node were automatically measured by the software&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Data analysis</span><p id="par0040" class="elsevierStylePara elsevierViewall">In each patient size of the primary tumor&#44; presence of mediastinal and&#47;or hilar lymph nodes and distant metastases were evaluated and patients were clinically staged &#40;cTNM&#41; according to the eighth edition of TNM classification for lung cancer&#44; taking the findings of the <span class="elsevierStyleSup">18</span>F-FDG PET&#47;CT examination into consideration&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">1</span></a> Patients in whom no lymph nodes in the mediastinal region were observed or the ones with nodal uptake of SUVmax below 3&#46; 30&#59; were staged as N0&#46; Any nodal uptake over the value of 3&#46;30 was recorded and considered as positive for tumoral involvement of mediastinal and&#47;or hilar lymph nodes&#46; In cases of multiple lymph nodes having <span class="elsevierStyleSup">18</span>F-FDG uptake above our threshold in N2 stations&#44; the result of the highest <span class="elsevierStyleSup">18</span>F-FDG uptake was used in analysis&#46; Semiquantitative measurements of lung lesions and nodal uptakes were noted&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Pathologic and surgical data for all patients were obtained from the electronic medical record system of our hospital&#46; For surgical staging &#40;sTNM&#41;&#44; the same classification system was used&#46; Comparison of cTNM and sTNM was performed regarding sTNM as the gold standard&#46; After comparing the cTNM and sTNM&#44; subjects were divided into 2 groups&#58; cTNM changed and cTNM unchanged postoperatively&#46; Patients of cTNM changed postoperatively group&#44; were further classified into 2 groups as upstaged &#40;US&#41; and downstaged &#40;DS&#41;&#46; Besides changes between different stages&#44; changes within the same stage &#40;e&#46;g&#46;&#58; change from stage IA3 to IA2 or from stage IIA to IIB&#41; was also taken into account and regarded as downstaged or upstaged&#44; respectively&#46; In order to evaluate the predictive role of semiquantitative parameteres for postsurgical upstaging&#59; results of patients in US group was compared with the results of the remaining patients consisting of cTNM unchanged and DS&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Statistical analysis</span><p id="par0050" class="elsevierStylePara elsevierViewall">The software package SPSS v16&#46;0 was used to carry out the statistical analysis&#46; Results of SUVmax&#44; SUVpeak&#44; MTV and TLG were expressed as mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD or median&#46; Mann&#8211;Whitney <span class="elsevierStyleItalic">U</span> test was used to compare the results of semiquantitative analysis of the primary tumor in different histological types and also to compare the results of patients in US and the results of the group of patients containing cTNM unchanged and DS&#46; Results of US and DS patients were also compared by Mann&#8211;Whitney <span class="elsevierStyleItalic">U</span> test&#46; From semiquantitative measures obtained from mediastinal lymph nodes&#44; cut-off values were calculated for their ability to predict nodal malignancy&#44; by ROC curve analysis&#46; The <span class="elsevierStyleItalic">p</span>-values were considered statistically significant if &#60;0&#46;05&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Results</span><p id="par0055" class="elsevierStylePara elsevierViewall">Our retrospective study included 99 patients &#40;83 male&#44; 16 female&#44; age range&#58; 40&#8211;82 years&#44; mean age&#58; 64&#46;78<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&#46;70&#41;&#46; All patients were treated surgically&#46; Systematic lymph node dissection was carried out in stations 2&#44; 4&#44; 7&#44; 8&#44; 9&#44; 10 in right sided tumors and in 5&#44; 6&#44; 7&#44; 8&#44; 9&#44; 10 for left sided tumors&#46; Remaining N1 nodes were resected as part of the surgical specimen&#46; Histological analysis of the primary tumor revealed adenocarcinoma in 44 patients&#44; squamous cell carcinoma &#40;SCC&#41; in 46&#44; large cell neuroendocrine tumor in 6&#44; carcinoid tumor in 2 and large cell carcinoma in 1 patient&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">In all patients&#44; SUVmax of the primary tumor was determined&#46; In 12 patients&#44; in which the <span class="elsevierStyleSup">18</span>F-FDG PET&#47;CT studies were not available&#44; the values of SUVmax of primary tumors and mediastinal lymph nodes were recorded from the reports of the patients&#59; these results were included in the review&#46; However&#44; SUVpeak&#44; TLG and MTV of the primary tumor and mediastinal lymph nodes could not be calculated&#46; The mean and median SUVmax values were higher in patients with SCC than in the ones with adenocarcinoma&#44; which were calculated as 16&#46;43<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&#46;54 and 14&#46;62 and 10&#46;19<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&#46;4 and 8&#46;43&#44; respectively &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41;&#46; Among the 87 patients in whom all semiquantitative parameters could be calculated &#40;39 patients with adenocarcinoma&#44; 39 with SCC&#44; 9 with other histological types&#41;&#44; mean and median SUVpeak&#44; TLG and MTV values were all higher in patients with SCC than in patients with adenocarcinoma and the differences were statistically significant &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; The results of semiquantitative measurements of primary tumors of different histopathologic types are depicted in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Out of 99 patients&#44; cTNM revealed that 1 patient was in stage IA1&#44; 10 were in IA2&#44; 20 were in IA3&#46; There were 20 patients in cIB&#44; 7 in cIIA&#44; 19 in cIIB and finally 15 in cIIIA&#44; 7 in cIIIB&#46; None of the patients were noted to have distant metastases&#46; cTNM changed postoperatively in 56 patients &#40;57&#37;&#41; and unchanged in the remaining 43 &#40;43&#37;&#44; <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; sTNM demonstrated that&#44; 7 patients were in stage IA1&#44; 13 in stage in IA2 and 16 were in sIA3&#46; There were 20 patients in sIB group&#44; 8 in sIIA and 19 in sIIB category&#46; Surgical IIIA and IIIB classes included 13 and 3 patients&#44; respectively&#46; Change in substage occurred in 19 of 56 patients &#40;34&#37;&#41;&#44; whereas in 37 patients &#40;66&#37;&#41; a change of cTNM was observed between stages&#46; Comparison of cTNM and sTNM is summarized in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">Diagnostic accuracy in cT staging was higher than of cN staging which were calculated as 72&#37; and 62&#37;&#44; respectively&#46; Concurrence of cTNM and sTNM was more pronounced in T1 and N0 subsets which were 84&#37; and 74&#37;&#44; respectively&#46; The lowest concurrence was observed in N1 classification followed by T4 and N2 &#40;1&#37;&#44; 50&#37; and 58&#37;&#44; respectively&#41;&#46; Change in T staging occurred in 20 of 56 &#40;36&#37;&#41;&#44; in N staging 22 of 56 &#40;39&#37;&#41; and change in T and N in 14 of them &#40;25&#37;&#41;&#46; Among 56 patients whose cTNM were changed&#44; upstaging was observed in 24 of 56 &#40;43&#37;&#44; <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41; and downstaging in 32 &#40;57&#37;&#44; <a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; In patients of US group&#44; T upstaging was observed in 10 of 24 &#40;42&#37;&#41;&#44; N upstaging in 10 of 24 &#40;42&#37;&#41; and T and N upstaging in 4 of them &#40;16&#37;&#41;&#46; In patients of DS group&#44; downstage in T stage was present in 10 of 32 &#40;31&#37;&#41;&#44; downstaging in N stage occured in 12 of 32 &#40;38&#37;&#41; and T and N downstaging was observed in 10 of 32 patients &#40;31&#37;&#41;&#46; Comparisons of cTNM and sTNM in T and N categories are outlined in <a class="elsevierStyleCrossRefs" href="#tbl0015">Tables 3 and 4</a>&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">The analyses which were carried out to investigate the role of semiquantitative measures in predicting post surgical upstaging revealed that all parameteres were significantly higher in US patients than the results of the group consisting of DS and cTNM unchanged patients &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; The mean and median values of SUVmax of the primary tumor in US and DS groups were calculated as 14&#46;52<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#46;02 and 13&#46;91 in the US group compared to 13&#46;05<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#46;92 and 9&#46;47 in the DS group&#44; respectively and the difference between them was not statistically significant &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;061&#41;&#46; In the cTNM changed group&#59; SUV peak&#44; TLG and MTV could be calculated in 47 patients&#44; 22 were US and 25 were DS&#46; Mean and median values of SUVpeak were 11&#46;49<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#46;32 and 10&#46;51 in US group and 10&#46;13<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&#46;56 and 7&#46;05 in DS group&#44; respectively&#46; Like SUVmax&#44; the difference of median values between US and DS groups was not found as statistically significant &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;105&#41;&#46; However&#44; when we looked at the TLG and MTV values of primary tumors in US and DS groups&#44; median TLG was calculated as 94&#46;44 in US group and 22&#46;05 in DS group&#46; Median value of MTV in US group was again higher than the value in DS group &#40;10&#46;67 vs&#46; 4&#46;08&#41;&#44; and the statistical analysis showed significant difference for both parameters &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;013 and <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;006&#44; respectively&#41;&#46; The results of semiquantitative parameters of the primary tumors for US and DS patients are shown in <a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">To predict mediastinal lymph node metastases&#44; a cut-off value of 5&#46;05 was calculated with the sensitivity and specificity of 60&#37; and 64&#37;&#44; respectively for SUVmax&#46; For SUV peak&#44; cut-off value was found as 3&#46;84 with 67&#37; sensitivity and 75&#37; specificity&#46; Areas under curves were 0&#46;632 for SUVmax and 0&#46;731 for SUVpeak&#46; On the other hand&#44; for volumetric tumor parameters the cut-off value was 4&#46;23 with a sensitivity of 67&#37; and specificity of 90&#37; for MTV and 12&#46;97 for TLG with sensitivity and specificity of 78&#37; and 75&#37;&#44; respectively&#46; Areas under the curves were found as 0&#46;786 for MTV and 0&#46;772 for TLG&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Discussion</span><p id="par0085" class="elsevierStylePara elsevierViewall">Studies comparing clinical and pathologic staging in lung carcinoma underline the inaccuracy of clinical staging and&#44; furthermore pooled results support that the true extent of intra thoracic disease is under or overestimated in spite of the technologic advances in imaging modalities&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">4&#44;6&#44;7&#44;13</span></a> Gdeedo et al&#46; reported that&#44; imaging TNM provides no accurate information&#44; CT is inadequate for mediastinal lymph node staging and T3 and T4 determinations of CT are unreliable in lung cancer&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">7</span></a> The limited role of CT in demonstrating mediastinal involvement and in T4 definition in patients with non-small carcinoma were also emphasized in another study by &#199;etinkaya et al&#46;&#44; later&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">4</span></a> Another study by Lopez-Encuentra et al&#46;&#44; compared clinical against pathological staging in 2994 cases of lung cancer&#44; found low diagnostic accuracy of clinical staging and finalized their report with the hopes of integrated PET systems to improve clinical TN staging&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">6</span></a> Verma et al&#46;&#44; looked for an answer for this question recently&#59; reported 42&#37; TNM upstaged patients postoperatively and found out that high primary tumor SUVmax of adenocarcinoma might predict postsurgical upstaging&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">14</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">We found a clinical and surgical concurrence of 43&#37; and postoperative stage changing was observed in more than half of the patients in whom downstaging was more prominent&#46; In the conducted studies comparing clinical staging with surgical staging in lung carcinoma beginning from the early1990s&#59; 56&#37;&#44;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">15</span></a> 35&#37;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">7</span></a> and 47&#37;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">4&#44;6&#44;13</span></a> agreement levels were reported in patients majority of whom underwent CT&#46; Although different clinical staging modality and a TNM staging system consisting of more sub stages was used&#44; our result was similar with the level of 47&#37; which was reported by most of the experiences&#46; We observed higher accuracy in the determination of T status than N stations &#40;72&#37; and 62&#37;&#44; respectively&#59; <a class="elsevierStyleCrossRefs" href="#tbl0015">Tables 3 and 4</a>&#41; which was also a similar result with the other studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">4&#44;7&#44;11&#44;13&#44;15</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Overestimation or underestimation of the staging varies among studies and this is mostly caused by false negative or positive interpretations of mediastinal nodal assessments&#46; With the clinical introduction of of integrated FDG PET&#47;CT clinically&#44; improvement in its diagnostic power and accuracy of staging in non small cell carcinoma compared to PET systems alone has been well established&#46; The effectiveness of FDG PET&#47;CT systems in decreasing the number of futile thoracotomies and also showing unexpected metastatic disease is demonstrated as well&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">16&#44;17</span></a> Integrated FDG PET&#47;CT is also useful for predicting negativity of the mediastinal lymph node status&#44; however false positive results caused by inflammatory process has been reported in mediastinal stations which was also observed by us&#46; Eleven of the 17 patients &#40;65&#37;&#41; who were classified as cN2 and 7 of 10 patients &#40;70&#37;&#41; of cN1 were finally staged as sN0 in our study &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46; There is not any consensus in the literature for cut-off values of SUVmax in mediastinal lymph nodes in order to clarify the ones containing tumor cells and recommended values range from 2&#46;5&#8211;5&#46;3&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">18</span></a> Because of this wide spectrum of cut-off values&#44; we calculated the mean of the SUVmax of blood pool from randomly selected patients as suggested in the literature&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">18</span></a> However our efforts of calculating a mean value instead of regarding an arbitrary cut-off could not help us and the unreliability of mediastinal nodal assessment still existed in our study&#46; False-positive lymph nodes exceeding our threshold value of 3&#46;30 were related to inflammatory reaction including all of 3 patients who were classified as cN3 who first gone through mediastinoscopy and later toracotomy when metastatic involvement was ruled out &#40;<a class="elsevierStyleCrossRefs" href="#fig0015">Figs&#46; 3 and 4</a>&#41;&#46; On the other side of the coin&#44; 13 of 18 patients &#40;72&#37;&#41; of sN1 category&#44; were false negatively staged as cN0 and only 2 of them &#40;1&#37;&#41; could be correctly classified &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46; This inaccuracy of predicting hilar lymph node involvement was also observed by &#199;etinkaya et al&#46; and Lin et al&#46;&#44;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">4&#44;18</span></a> Al-Sarraf et al&#46;&#44; showed that the distinction between primary tumor and adjacent lymph node invasion can be difficult in cases of hilar tumors&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">19</span></a> In our study&#44; 7 of 13 &#40;54&#37;&#41; patients had hilus located tumoral lesions which supports this hypothesis&#59; however in 6&#44; the locations of tumors were outside the hilum&#44; but we were still unable to discriminate peribronchial and intrapulmonary lymph node involvement&#44; the resolution of current FDG PET&#47;CT systems&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">In terms of cT staging&#44; the highest diagnostic accuracy was observed in T1 assessments &#40;84&#37;&#41; and the lowest in T4 &#40;50&#37;&#41;&#46; When we looked at the sub stages of T1 category&#59; FDG PET&#47;CT was able to discriminate T1c tumors better than other categories and was worst at definition of T1a &#40;65&#37; and 44&#37; clinical and surgical concordance&#44; respectively&#41;&#46; In the 8th edition TNM staging system&#44; 7 categories per size as compared with 6 the categories exist with 1 more sub division in T1 category which makes difficult to resolve the tumors of smaller than 1<span class="elsevierStyleHsp" style=""></span>cm standing inT1a category which was also mentioned by Kandathil et al&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">20</span></a> Although the spatial resolution has improved from 25<span class="elsevierStyleHsp" style=""></span>mm to 5<span class="elsevierStyleHsp" style=""></span>mm with improvement in scanner design and performance&#44;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">21</span></a> inaccuracies exist in microscopic determination of tumor margins which was also emphasized by Verma et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">14</span></a> In our study&#44; agreement in T3 determination was higher than in T4 &#40;62&#37; vs&#46; 50&#37;&#44; respectively&#41; but was still lower than T1 and T2 stages&#46; Among sT4 patients&#44; 1 of them was falsely classified as cT3 because of a separate lesion in different lobe of the same lung was noted in the excised pathology specimen and this was not observed by PET scan&#46; In the remaining 2 of sT4 and 5 of 13 of sT3 patients who were falsely classified as cT3 and cT2 respectively&#44; the longest dimension of the tumor was measured smaller than the actual size which may be secondary to consolidative changes around the tumor which were not regarded as part of malignancy&#46; Our result of observing the success of cTNM in T1 and T2 staging and unreliability in determination of T3 and T4 status is concordant with the results of other studies reported in the literature&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">6&#44;7</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Although the highest diagnostic accuracy of 67&#37; seems to be observed in cIIIB stage in our study which is discordant with the other results reported before&#44; we thought that this finding evolved secondary to the low number patients in sIIIB group which consisted only 3 patients &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; Followed by clinical IIIB stage&#44; cIA3 took the second highest clinical and surgical concurrence ratio of 56&#37; which was concordant with the high agreement level in stage I observed by Lopez-Encuentra et al&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">6</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">One of the main advantages of PET imaging is its ability of quantifying the metabolic activity of the tumor which is unique for this modality&#46; Besides using for differentiate between benign and malignant lesions&#44; semiquantitative measurements are also valuable for evaluation prognosis and assessing the response to treatment in oncology armamentarium&#46; Among these&#44; SUVmax&#44; which represents the highest voxel value within the ROI&#44; is the most commonly used one because of its observer-independent nature and being available in commercial workstations&#46; However&#44; SUVmax can be substantially affected by image noise&#44; this can be eliminated by calculating SUVpeak&#44; which was suggested a more robust alternative than SUVmax&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">22</span></a> Duan XY et al&#46; reported that the histopathologic type and grade of tumor were related to SUVmax in patients with lung cancer&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">23</span></a> Verma et al&#46; reported that SUVmax of the primary tumor was found as a predictor for upstaging in patients with adenocarcinoma of lung cancer which may serve as a surrogate for preoperative nodal sampling of lymph nodes with equivocal FDG uptake&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">14</span></a> In our study&#44; all of the semiquantitative parameters calculated from the primary tumor were significantly higher in squamous cell carcinoma than adenocarcinoma which demonstrates the difference in metabolism according to histologic subtypes which was also reported by Kim et al&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">24</span></a> Concordant with the results of Verma et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">14</span></a> results of SUVmax and as well as other semiquantitative parameters&#44; were all significantly higher in US patients compared to other patients&#46; However&#44; on the contrary to studies supporting SUV as a respresentative parameter of tumor aggressiveness&#44; SUVmax and SUVpeak values calculated from the primary tumor were not significantly different in patients between US and DS in our study&#46; This may be because SUVmax showing the highest intensity of FDG uptake within the region of interest cannot represent total tumor uptake for the entire tumor mass&#46; Results of MTV and TLG derived from primary tumor on the other hand&#44; were significantly higher in US patients than DS patients which may support the hypothesis of their being better prognostic measures for disease progression than SUVmax reported for surgical and nonsurgical patients with non-small cell carcinoma before&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">2</span></a> For predicting malignancy in mediastinal lymph nodes&#44; the area under curve in ROC analysis was the largest for MTV and calculated cut-off level for this parameter was found as the most specific one for predicting lymph node metastases with an acceptable sensitivity in our study&#46; But the problem of whether the semiquantitative data of one report can be translatable from one center to another is still unanswered and adopting standardized techniques for measurements of the primary tumor and as well of the lymph nodes have been recommended by Bryant et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">25</span></a> We think that&#44; determining center specific cut-off values for semiquantitative parameters may help determining postsurgical upstaging and clarify lymph nodes harboring tumoral involvement&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">The limitations of our study are its retrospective origin and relatively low number of patients in subgroups&#46; Further studies with larger number of patients are needed to validate the role of MTV in predicting medistinal lymph node metastases&#46; Excluding patients with metastases because of study design also limited evaluating the role of FDG PET&#47;CT in identifying unexpected metastatic disease&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">In conclusion&#44; clinical staging of T status is more accurate than nodal staging with FDG PET&#47;CT in patients with non-small cell carcinoma&#46; The quantitative nature of FDG uptake of the primary tumor play role in postsurgical upstaging&#46; Volume dependent PET parameters may be more valuable than SUVmax in predicting nodal involvement&#46; Adopting center specific cut-off values for MTV for interpretation of FDG uptakes in mediastinal lymph nodes may improve the diagnostic accuracy of FDG PET&#47;CT in nodal assessments which enables correct clinical staging&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflict of interest</span><p id="par0125" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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          "identificador" => "xres1269185"
          "titulo" => "Abstract"
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            0 => array:2 [
              "identificador" => "abst0005"
              "titulo" => "Objective"
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            1 => array:2 [
              "identificador" => "abst0010"
              "titulo" => "Materials and methods"
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              "identificador" => "abst0015"
              "titulo" => "Results"
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        1 => array:2 [
          "identificador" => "xpalclavsec1174748"
          "titulo" => "Keywords"
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          "titulo" => "Resumen"
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              "titulo" => "Material y m&#233;todos"
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              "titulo" => "Resultados"
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          "titulo" => "Palabras clave"
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          "identificador" => "sec0005"
          "titulo" => "Introduction"
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          "identificador" => "sec0010"
          "titulo" => "Materials and methods"
          "secciones" => array:5 [
            0 => array:2 [
              "identificador" => "sec0015"
              "titulo" => "Patients"
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            1 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "F-FDG PET&#47;CT scanning"
            ]
            2 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Image interpretation and semiquantification"
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              "titulo" => "Data analysis"
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              "titulo" => "Statistical analysis"
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          "titulo" => "Results"
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    "fechaRecibido" => "2019-01-15"
    "fechaAceptado" => "2019-05-13"
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
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          "palabras" => array:5 [
            0 => "Clinical"
            1 => "FDG PET&#47;CT"
            2 => "Lung carcinoma"
            3 => "Quantification"
            4 => "Staging"
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          "clase" => "keyword"
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          "palabras" => array:5 [
            0 => "Cl&#237;nico"
            1 => "FDG PET&#47;TC"
            2 => "Carcinoma de pulm&#243;n"
            3 => "Cuantificaci&#243;n"
            4 => "Estadificaci&#243;n"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleSup">18</span>F-Fluorine fluorodeoxyglucose positron emission tomography&#47;computed tomography &#40;<span class="elsevierStyleSup">18</span>F-FDG PET&#47;CT&#41; imaging is considered the standard imaging modality for patients with non-small cell lung carcinoma&#46; The aim of this study was to compare clinical staging &#40;cTNM&#41; performed with <span class="elsevierStyleSup">18</span>F-FDG PET&#47;CT and surgical staging &#40;sTNM&#41; in patients with non-small cell carcinoma treated with surgery&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Materials and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We performed a retrospective analysis of 99 surgical patients with non-small cell carcinoma who underwent <span class="elsevierStyleSup">18</span>F-FDG PET&#47;CT examination&#46; Semiquantitative measures were calculated from the primary lesions and mediastinal lymph nodes&#46; Findings of cTNM were compared with final surgical&#8211;pathological evaluation&#46; Subjects were divided into two groups as postsurgical cTNM changed and cTNM unchanged&#46; Patients in the cTNM changed group were further classified as postsurgical upstaged &#40;US&#41; and downstaged &#40;DS&#41;&#46; Results of the US patients were compared with the results of the remaining patients consisting of cTNM unchanged and DS to evaluate the predictable roles of semiquantitative parameters for postsurgical upstaging&#46; To determine mediastinal tumoral involvement&#44; cut-off values were obtained from calculated semiquantitative results of FDG uptakes in lymph nodes&#46; A <span class="elsevierStyleItalic">p</span> value &#60;&#46;05 was considered statistically significant&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Subjects were aged 40&#8211;82 years with a mean age of 64&#46;78<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&#46;70 years&#46; Classification agreement was observed in 43 patients &#40;43&#37;&#41; and in 57&#37;&#44; postsurgical stage migration was seen&#46; Concurrence of cTNM and sTNM was more pronounced in the T1 and N0 subsets which were 84&#37; and 74&#37;&#44; respectively&#46; The lowest concurrence was observed in N1 classification followed by T4 and N2 &#40;1&#37;&#44; 50&#37; and 58&#37;&#44; respectively&#41;&#46; Change in T staging occurred in 20 of 56 &#40;36&#37;&#41;&#44; in N staging 22 of 56 &#40;39&#37;&#41; and change in T and N in 14 patients &#40;25&#37;&#41;&#46; Distribution of US and DS patients in the cTNM changed group was&#44; 43&#37; &#40;24 of 56&#41; and 57&#37; &#40;32 of 56&#41;&#44; respectively&#46; Results of semiquantitative measures were significantly higher in US patients than the results of the group consisting of DS patients and cTNM unchanged patients&#44; for all parameters&#46; Cut-off value calculated from mediastinal uptakes was most specific for metastases in MTV &#40;metabolic tumor volume&#41; with an acceptable sensitivity &#40;90&#37; and 67&#37;&#44; respectively&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The concordance between cTNM and sTNM was better in staging T category compared to N stations&#46; Semiquantitative measures of primary tumor may play a role in predicting postsurgical upstaging&#46; Taking MTV into consideration in the mediastinal region may be more valuable than other parameters in the assessment of nodal involvement&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objective"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Materials and methods"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
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          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusions"
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      "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">La imagen de tomograf&#237;a por emisi&#243;n de positrones&#47;tomograf&#237;a computarizada con <span class="elsevierStyleSup">18</span>F-fluordesoxiglucosa &#40;<span class="elsevierStyleSup">18</span>F-FDG PET&#47;TC&#41; se considera una modalidad de imagen est&#225;ndar en pacientes con carcinoma de pulm&#243;n de c&#233;lulas no peque&#241;as&#46; El objetivo de este estudio fue comparar la estadificaci&#243;n cl&#237;nica &#40;cTNM&#41; realizada con <span class="elsevierStyleSup">18</span>F-FDG PET&#47;TC y la estadificaci&#243;n quir&#250;rgica &#40;qTNM&#41; en pacientes con carcinoma de c&#233;lulas no peque&#241;as tratados con cirug&#237;a&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Realizamos un an&#225;lisis retrospectivo de 99 pacientes con carcinoma de c&#233;lulas no peque&#241;as intervenidos quir&#250;rgicamente a los que se realiz&#243; un estudio <span class="elsevierStyleSup">18</span>F-FDG PET&#47;TC&#46; Se realizaron medidas semicuantitativas en las lesiones primarias y los ganglios linf&#225;ticos mediast&#237;nicos&#46; Los hallazgos de cTNM se compararon con la evaluaci&#243;n quir&#250;rgica-patol&#243;gica final&#46; Los pacientes se dividieron en dos grupos&#44; qTNM posquir&#250;rgico modificado y qTNM no modificado&#46; Los pacientes en el grupo con cambio de qTNM se clasificaron adicionalmente como upstaged &#40;US&#41; y downstaged &#40;DS&#41; postquir&#250;rgicos&#46; Los resultados de los pacientes US se compararon con los resultados de los pacientes restantes&#44; que consist&#237;an en qTNM sin cambios y DS&#44; para evaluar el posible papel predictivo de los par&#225;metros semicuantitativos en la estadificaci&#243;n postoperatoria&#46; Para determinar la afectaci&#243;n mediast&#237;nica tumoral&#44; se obtuvieron valores de corte de los resultados semicuantitativos de captaci&#243;n de FDG en los ganglios linf&#225;ticos&#46; Un valor p &#60;0&#44;05 fue considerado estad&#237;sticamente significativo&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Los pacientes ten&#237;an entre 40 y 82 a&#241;os&#44; con una edad media de 64&#44;78 &#177; 8&#44;7 a&#241;os&#46; Se observ&#243; un acuerdo de clasificaci&#243;n en 43 pacientes &#40;43&#37;&#41;&#44; y en 57&#37; se observ&#243; modificaci&#243;n en la estadificaci&#243;n posquir&#250;rgica&#46; La concurrencia de cTNM y qTNM fue m&#225;s destacada en la clasificaci&#243;n T1 y N0&#44; con valores de 84&#37; y 74&#37;&#44; respectivamente&#46; La concurrencia m&#225;s baja se observ&#243; en la clasificaci&#243;n N1 seguida de T4 y N2 &#40;1&#37;&#44; 50&#37; y 58&#37;&#44; respectivamente&#41;&#46; El cambio en la estadificaci&#243;n T ocurri&#243; en 20 de 56 pacientes &#40;36&#37;&#41;&#59; el cambio en la estadificaci&#243;n N&#44; en 22 de 56 &#40;39&#37;&#41;&#59; y el cambio en T y N&#44; en 14 pacientes &#40;25&#37;&#41;&#46; La distribuci&#243;n de pacientes de US y DS en el grupo con cambio de cTNM fue de 43&#37; &#40;24 de 56&#41; y 57&#37; &#40;32 de 56&#41;&#44; respectivamente&#46; Los resultados de las medidas semicuantitativas fueron significativamente m&#225;s altos en los pacientes de US que los resultados del grupo compuesto por pacientes con DS y qTNM sin cambios&#44; para todos los par&#225;metros&#46; El valor de corte calculado a partir de las captaciones mediast&#237;nicas fue m&#225;s espec&#237;fico para met&#225;stasis en el MTV &#40;volumen metab&#243;lico tumoral&#41; con una sensibilidad aceptable &#40;90&#37; y 67&#37;&#44; respectivamente&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La concordancia entre TNM y qTNM es mejor en la clasificaci&#243;n de la categor&#237;a T en comparaci&#243;n con la categor&#237;a N&#46; Las medidas semicuantitativas en los tumores primarios pueden jugar un papel en la predicci&#243;n del US posquir&#250;rgico&#46; El MTV en la regi&#243;n mediast&#237;nica puede tener un mayor valor que otros par&#225;metros en la evaluaci&#243;n de la afectaci&#243;n ganglionar&#46;</p></span>"
        "secciones" => array:4 [
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            "identificador" => "abst0025"
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          1 => array:2 [
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Please cite this article as&#58; Gedik GK&#44; Yilmaz F&#46; &#191;Hay alguna mejora en la estadificaci&#243;n cl&#237;nica con PET&#47;TC con 18F-FDG en comparaci&#243;n con la estadificaci&#243;n quir&#250;rgica en el c&#225;ncer de pulm&#243;n&#63; Rev Esp Med Nucl Imagen Mol&#46; 2019&#59;38&#58;348&#8211;354&#46;</p>"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Transaxial PET &#40;a&#41;&#44; CT &#40;b&#41;&#44; and fused &#40;c&#41; images of 68 year old male patient showed a primary tumor in the lower lobe of the right lung with a longest diameter of 61<span class="elsevierStyleHsp" style=""></span>mm&#44; which was diagnosed as squamous cell carcinoma &#40;arrow&#44; c&#41; In the transaxial PET &#40;d&#41;&#44; CT &#40;e&#41;&#44; and fused &#40;f&#41; images of the same patient&#44; subcarinal lymph nodes with a SUVmax of 16&#46;47 were observed&#44; which were finally confirmed as metastatic &#40;arrow&#44; f&#41;&#46; Calculated semiquantitative values for lymph nodes were all above the cut-of levels determined for them&#44; including MTV&#46; This patient was clinically and surgically staged as T3N2&#46;</p>"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">In transaxial PET &#40;a&#41;&#44; CT &#40;b&#41;&#44; and fused &#40;c&#41; images of a 68 year male patient who was clinically staged as T2aN0&#44; a primary tumor located in the upper lobe of left the lung was observed &#40;arrow&#44; c&#41;&#46; In the histopathological analysis&#44; besides main tumor&#44; a satellite nodule in the same lobe consistent with adenocarcinoma was also reported&#46; The patient was finally staged as sT3N0&#46;</p>"
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Transaxial PET &#40;a&#41;&#44; CT &#40;b&#41;&#44; and fused &#40;c&#41; images of a 68 year old female patient depicted the primary tumor in the upper lobe of the right lung &#40;arrow&#44; c&#41;&#46; Mediastinal window of transaxial PET &#40;d&#41;&#44; CT &#40;e&#41;&#44; and fused &#40;f&#41; images of the same patient showed lymph node with elevated FDG uptake in the right paratracheal region &#40;arrow&#44; f&#41;&#46; SUVmax of the lymph node was calculated as 9&#46;51&#44; the patient was clinically staged as cIIIA&#46; Histopathologic evaluation revealed inflammatory reaction in the lymph node and confirmed adenocarcinoma in the primary tumor so the final stage of the patient was sIA2&#46; The calculated MTV level from this lymph node was found as 3&#46;98&#46;</p>"
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">In transaxial PET &#40;a&#41;&#44; CT &#40;b&#41;&#44; and fused &#40;c&#41; images of a 70 year old male patient&#44; the primary tumor located in the left hilium &#40;arrow&#44; c&#41; which then proved as adenocarcinoma&#44; was seen&#46; Transaxial PET &#40;d&#41;&#44; CT &#40;e&#41;&#44; and fused &#40;f&#41; images of same patient showed increased FDG uptake with calculated results of 7&#46;70 and 3&#46;88 for SUVmax and MTV respectively in right hilar lymph nodes &#40;arrow&#44; f&#41;&#46; Being clinically staged as cIIIB&#44; the final stage turned out to sIIB with inflammatory reaction in the right hilar lymph nodes which were removed by mediastinoscopy&#44; however&#44; metastatic involvement in the left ones in the final pathologic evaluation of the surgical specimen&#46;</p>"
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                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2170917.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Comparison of clinical and surgical staging in whole patients&#46;</p>"
        ]
      ]
      6 => 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:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
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                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">sT3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">sT4&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">T1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">T2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t">&#8211;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">&#8211;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Agreement &#40;c&#47;p&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">72&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2170921.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Comparison of clinical and surgical tumor staging&#46;</p>"
        ]
      ]
      7 => array:8 [
        "identificador" => "tbl0020"
        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at4"
            "detalle" => "Table "
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          ]
        ]
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
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Article information
ISSN: 22538089
Original language: English
DOI:10.1016/j.remnie.2019.05.007
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