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Nuclear Medicine |
1 From the Department of Radiology and Center for Imaging Science (S.S.S., K.S.L., M.J.C.); Departments of Nuclear Medicine (B.T.K., E.J.L., J.Y.C.) and Diagnostic Pathology (J.H.); Division of Pulmonary and Critical Care Medicine, Department of Medicine (O.J.K.); Department of Thoracic Surgery (Y.M.S.); and Biostatistics Unit of the Samsung Biomedical Research Institute (S.K.), Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Ilwon-Dong, Kangnam-Ku, Seoul 135-710, Korea. From the 2004 RSNA Annual Meeting. Received July 28, 2004; revision requested October 5; revision received October 20; accepted January 17, 2005. Address correspondence to K.S.L. (e-mail: kyungs.lee{at}samsung.com).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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MATERIALS AND METHODS: Institutional review board approval and patient informed consent were obtained. From November 2003 to February 2004, 106 patients (78 men, 28 women; mean age, 56 years) with non–small cell lung cancer underwent curative surgical resection (tumor resection and lymph node dissection) after stand-alone CT followed by integrated FDG PET/CT. Tumor stages were determined by using the TNM and American Joint Committee on Cancer staging systems. Histopathologic results served as the reference standard. Statistically significant differences in tumor staging between integrated PET/CT and stand-alone CT were determined with P < .05 obtained by using the McNemar test or with a generalized estimating equation.
RESULTS: The primary tumor was correctly staged in 84 patients (79%) at stand-alone CT and in 91 patients (86%) at integrated FDG PET/CT (P = .25). For the depiction of malignant nodes, the sensitivity, specificity, and accuracy of CT were 70% (23 of 33 nodal groups), 69% (248 of 360), and 69% (271 of 393), respectively, whereas those of PET/CT were 85% (28 of 33), 84% (302 of 360), and 84% (330 of 393) (P = .25, P < .001, and P < .001, respectively). There were 112 false-positive interpretations at CT for 54 hilar, 16 subcarinal, 29 paratracheal, 10 subaortic, and two pulmonary ligament nodal groups and one upper paratracheal group, compared with only 58 false-positive interpretations at PET/CT for 32 hilar, seven subcarinal, 13 lower paratracheal, and six subaortic nodal groups. There were 10 false-negative interpretations at CT for four hilar, two lower paratracheal, and two subcarinal nodal groups, one prevascular and retrotracheal group, and one inferior pulmonary group, but only five false-negative interpretations at PET/CT (one each for paratracheal, subaortic, subcarinal, inferior pulmonary, and hilar nodal groups).
CONCLUSION: Integrated FDG PET/CT is significantly better than stand-alone CT for lung cancer staging and provides enhanced accuracy and specificity in nodal staging.
© RSNA, 2005
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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According to one report about esophageal cancer staging, however, FDG PET is substantially less specific than CT for depicting lymph node metastasis, especially in regions of granulomatous disease (6). This is mainly because PET scans show falsely increased uptake of FDG in inflammatory nodes, a finding that may be accompanied by calcification or by attenuation higher than that in surrounding great vessels on unenhanced CT scans (6–8).
The limited spatial resolution yielded by PET because of a lack of anatomic information can be overcome by combining morphologic CT and functional PET data. Although investigators in several studies, by using only visual correlations between CT scans and FDG PET scans, demonstrated improved results for cancer staging (4,9), positional and motion-induced misregistrations limit confidence in this method. Integrated PET/CT scanners, introduced since those early studies, have produced promising initial results for oncologic imaging (10). Thus, the purpose of our study was to evaluate prospectively the accuracy of integrated FDG PET/CT, compared with that of stand-alone CT, for the preoperative staging of non–small cell lung cancer, with surgical and histologic findings used as the reference standard.
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MATERIALS AND METHODS |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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Integrated PET/CT acquisition and scan analysis.—All patients fasted for at least 6 hours before PET/CT examination, although oral hydration with glucose-free water was allowed. After a normal blood glucose level in peripheral blood was ensured, patients received an intravenous injection of 370 MBq (10 mCi) of FDG and then rested for approximately 45 minutes before undergoing scanning. Scans were acquired with a PET/CT device (Discovery LS; GE Medical Systems, Milwaukee, Wis) that consisted of a PET scanner (Advance NXi; GE Medical Systems) and an eight-section CT scanner (LightSpeed Plus; GE Medical Systems). The axes of both systems were mechanically aligned so that the patient could be moved from the CT scanner to the PET scanner gantry by shifting the examination table 68 cm. The resulting PET and CT scans were coregistered on hardware.
CT was performed from the head to the pelvic floor according to a standardized protocol with the following settings: 140 kV; 80 mA; tube rotation time, 0.5 second per rotation; pitch, 6; and section thickness, 5 mm (to match the PET section thickness). Patients maintained normal shallow respiration during the acquisition of CT scans. No iodinated contrast material was administered. Immediately after unenhanced CT, PET was performed in the identical transverse field of view. The acquisition time for PET was 5 minutes per table position. The CT data were resized from a 512 x 512 matrix to a 128 x 128 matrix to match the PET data so that the scans could be fused and CT-based transmission maps could be generated. PET data sets were reconstructed iteratively with an ordered subsets expectation maximization algorithm and segmented attenuation correction (two iterations, 28 subsets) and the CT data. Coregistered scans were displayed by using software (eNTEGRA; GE Medical Systems).
One nuclear medicine physician (B.T.K., 11 years of experience [1 year of experience in integrated PET/CT analysis]), who was blinded to all findings at stand-alone contrast-enhanced CT performed before integrated FDG PET/CT, as well as to all clinical and pathologic results, evaluated the integrated PET/CT data sets. Hilar or mediastinal nodes with increased glucose uptake (higher than that of the surrounding tissue as determined by qualitative analysis, and with a maximum standardized uptake value [SUV], adjusted for the patient's body weight, of more than 3.5 as determined by quantitative analysis) and with a distinct margin were considered positive. Using receiver operating characteristic analysis with different SUV threshold cutoffs, we reached a decision that an SUV of 3.5 is optimal for differentiating between benign and malignant tissues with our imaging systems (11). Hilar and mediastinal nodes were classified by the nuclear medicine physician, according to the integrated PET/CT results, in the following four categories: positive uptake with neither calcification nor high attenuation, positive uptake with calcification or high attenuation, negative uptake with calcification or high attenuation, and negative uptake with neither calcification nor high attenuation. Calcification was considered present when it was nodular or laminated and attenuation was higher than 200 HU. High-attenuation nodes were defined as those that appeared to have attenuation higher than that of mediastinal vascular structures or higher than 70 HU according to region-of-interest–based measurement.
Integrated PET/CT–histopathologic comparison.—The lymph nodes classified in the categories of positive uptake with or without calcification and high attenuation at integrated PET/CT were compared with the surgically sampled nodes at histopathologic examination. An experienced lung pathologist (J.H., 13 years of experience) evaluated all lymph node samples. Briefly, dissected lymph nodes were fixed overnight in 10% neutral buffered formalin, sectioned, stained with a standard hematoxylin-eosin technique, and examined under an optical light microscope. One hundred thirteen nodal groups (hilar and mediastinal) from 50 patients were dissected during lung cancer surgery, and findings were compared with integrated PET/CT results.
Prospective Study
Patient population.—One hundred ten patients with histopathologically proved non–small cell lung cancer were enrolled. All consecutive patients referred for surgery between November 2003 and February 2004 were included. All patients underwent conventional preoperative lung cancer staging based on clinical information and results of stand-alone contrast material–enhanced CT of the chest and integrated whole-body FDG PET/CT studies. Four patients were excluded from further study because they had received chemotherapy (n = 1) or chemo- and radiation therapy (n = 3). Thus, 106 patients were included (78 men and 28 women; mean age, 56 years; range, 47–78 years). Of these 106 patients, 35 (33%) had a medical history of pulmonary tuberculosis evidenced at either clinical or imaging evaluation.
Contrast-enhanced CT acquisitions and scan analysis.—CT scans were acquired by means of a helical technique (HiLight or LightSpeed Ultra 16; GE Medical Systems). For centrally located tumors, scans were obtained at 120 kVp, 170 mA, 2.5-mm collimation, and a total active detector length pitch of 1.3–1.5, from the supraclavicular region to the middle of the kidneys, and they were reconstructed (2.5-mm section thickness) in transverse and coronal planes. For peripheral tumors depicted at thin-section CT (targeted thin-section CT; 2.5-mm collimation with a helical technique, 0.8-second gantry rotation time, 120 kVp, and 70 mA), scans for staging were obtained at 120 kVp, 170 mA, 5.0-mm collimation, and a total active detector length pitch of 1.3–1.5. These scans were reconstructed (5.0-mm section thickness) in the transverse plane only.
In all patients, a power injector (MCT Plus; Medrad, Pittsburgh, Pa) was used to inject 100 mL of contrast medium (iopamidol, Iopamiron 300; Bracco, Milan, Italy) intravenously at a rate of 2 mL/sec prior to scanning. Scan data were directly interfaced and forwarded to a picture archiving and communication system (Centricity 1.0; GE Medical Systems Integrated Imaging Solutions, Mt Prospect, Ill). Scans were viewed with both mediastinal (window width, 400 HU; window level, 20 HU) and lung (window width, 1500 HU; window level, –700 HU) window settings.
An experienced thoracic radiologist (K.S.L., 14 years of experience), who was unaware of integrated PET/CT, surgical, or pathologic findings and of any clinical information except that the patients had lung cancer, prospectively read all CT scans. Tumor staging with CT and PET/CT was based on the revised International System for Staging Lung Cancer as adopted by the American Joint Committee on Cancer and on the Union Internationale Contre le Cancer system for the classification of lung cancer (12).
Tumor staging was performed in consideration of the lesion size, involvement of surrounding organ or chest wall, and distance of the primary tumor from the carina. Nodal stations were evaluated and allocated to 10 groups, according to the lymph node map definition for lung cancer staging proposed by Mountain and Dresler (13): group 1, highest mediastinal (1R, right; 1L, left); group 2, upper paratracheal (2R, right; 2L, left); group 3, prevascular and retrotracheal; group 4, lower paratracheal (4R, right; 4L, left); group 5, subaortic (aortopulmonary window); group 6, paraaortic (ascending aorta or phrenic); group 7, subcarinal; group 8, paraesophageal; group 9, pulmonary ligament (9R, right; 9L, left); and group 10, hilar (10R, right; 10L, left). In the present study, nodes distal to the hilar region were classified as group 10 (N1 nodal station). Lymph node assessment was based on size; nodes with a short-axis diameter of more than 10 mm were defined as abnormal. The presence of necrosis within a lymph node was considered a sign of malignancy, regardless of nodal size. Hilar lymph nodes were considered positive for malignancy when their greatest diameter exceeded 10 mm (14). If mediastinal or hilar nodes contained nodular or laminated calcification, they were regarded as benign, irrespective of their size.
Integrated FDG PET/CT acquisitions and scan analysis.—All 106 patients underwent integrated PET/CT performed according to the same method used in the retrospective study. Integrated PET/CT data sets were evaluated by one of two nuclear medicine physicians (B.T.K. and J.Y.C., 11 years and 5 years of experience, respectively). They were trained for 2 months (during the retrospective analysis of integrated PET/CT and pathologic correlation) by an experience chest radiologist (K.S.L.) in the CT anatomy of the lung and hilar and mediastinal nodal groups. Tumor staging was performed as at CT. Nodal stations were evaluated with the same lymph node map definition as was used in CT scan interpretation (13). Lesions with high uptake (higher than that of the surrounding normal mediastinal structure) and with a distinct margin and a round shape were considered malignant. Lesions with equivocally increased glucose uptake (to a level similar to that of the surrounding normal mediastinal structures) and with a morphologic appearance of lobar or bronchopneumonia at CT were interpreted as benign. Even if glucose uptake was high at integrated PET/CT (ie, higher than background activity, or with an SUV of more than 3.5), calcified lymph nodes or lymph nodes with attenuation higher than that in surrounding great vessels on CT scans were regarded as benign.
Surgical and Histopathologic Analysis
Tumor resection and extensive mediastinal lymph node dissection were performed by one of two experienced thoracic surgeons (Y.M.S. and another surgeon, with 17 and 12 years of experience, respectively) after they had considered the results of preoperative CT and PET/CT. According to our surgical protocol, the surgeons sampled all visible and palpable lymph nodes that were accessible in the hilum and mediastinum. All encountered lymph nodes were removed from American Thoracic Society lymph node map areas of 10R, 9, 8, 7, 4R, 3, and 2R in tumors of the right lung and from areas 10L, 9, 8, 7, 6, 5, and 4L of the left lung.
Lung resection, including lobectomy and pneumonectomy with mediastinal lymph node dissection, was performed in 106 patients, along with complete TNM staging. Patients in whom the primary tumor was limited to a lobe (n = 88) underwent lobectomy, and those with a tumor extending to another lobe or to the bronchi underwent bilobectomy (n = 9) or pneumonectomy (n = 9). In two patients who underwent lobectomy, additional wedge resection was also performed, for a metastatic nodule in one patient and for a coexisting hamartoma in the other. In addition to lung resection surgery, surgeons dissected all visible and palpable lymph nodes in the surgical field, irrespective of the size of the node.
A lung pathologist (J.H.) with 10 years of experience described the tumors (ie, histopathologic class, size, involvement of surrounding organ, necrosis, distance from the resection margin) and lymph nodes (location and number). Surgeons labeled dissected lymph nodes by numbering the nodes (identifying nodal station) according to the lymph node map definition for lung cancer staging proposed by Mountain and Dresler (13). The pathologist then evaluated the nodes as numbered in the surgical field. Specimens were stained with hematoxylin-eosin and examined with optical light microscopy. The pathologic stage was recorded for each patient, and 393 nodal groups from 106 patients were dissected.
Statistical Analysis
We regarded each case in which there was agreement between pathologic results and tumor staging or nodal staging as positive and each case in which there was disagreement as negative at CT and PET/CT for dichotomous analysis. The accuracy of CT and PET/CT for staging of primary tumors was determined, and the two values were compared. In this test, the degrees of agreement between CT, PET/CT, and pathologic results were indicated by means of weighted 
statistics, and differences between CT and PET/CT were evaluated with the McNemar test.
In addition, the accuracy, sensitivity, and specificity values of both methods for malignant lymph node detection in 10 nodal groups were assessed and compared by means of a generalized estimating equation. When we compared differences in the diagnostic accuracies of the two modalities in terms of the detection of metastasis in individual nodal groups, we took into account intrapatient and intranodal correlations, because multiple nodes with metastasis were observed in some patients during scanning or surgery; this multiplicity could have affected scan interpretation and increased the likelihood of a particular diagnosis. CT and PET/CT accuracy values for overall tumor staging were compared by means of a McNemar test. P values less than .05 were considered to indicate statistical significance.
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RESULTS |
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Tumor Staging
The distribution of tumor stages determined at pathologic analysis in 106 patients included T1 in 44 patients, T2 in 52, T3 in six, and T4 in four. The primary tumor was correctly staged in 84 patients (79%) at CT and in 91 patients (86%) at PET/CT (Fig 3). The difference in accuracies between integrated PET/CT and CT was not significant (P = .25; McNemar test).
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Twenty-three (70%) of 33 malignant nodal groups were detected at CT, and 28 (85%) at PET/CT (P = .249; generalized estimating equation) (Table 3). The weighted values for degrees of agreement showed no agreement between CT and pathologic results but did show agreement between PET/CT and pathologic results ( = 0.1871 and 0.3728, respectively). There were 10 false-negative interpretations at CT for the following nodal groups: four hilar, two paratracheal, two subcarinal, one prevascular and retrotracheal (group 3), and one inferior pulmonary (group 9). There were five false-negative interpretations at PET/CT for one each of the paratracheal, subaortic, subcarinal, inferior pulmonary, and hilar nodal groups (Fig 4).
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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Where available, FDG PET is increasingly incorporated into the routine work-up. Studies published to date demonstrate that FDG PET is consistently more accurate than CT for detecting or excluding nodal disease (21–25). According to a report by Gupta et al (5), the sensitivity and specificity of CT for metastatic mediastinal lymph nodes were 68% and 61%, respectively, compared with 87% and 91% for FDG PET. Gupta et al also described correct mediastinal lymph node staging based on FDG PET scans in 15 of 17 lymph nodes, which showed metastases that previously had not been detected at CT. These findings indicated that FDG PET was more sensitive for the detection also of early metastasis, because of its ability to demonstrate increased (tumorlike) metabolic activity in normal-sized lymph nodes. Other studies that were focused on mediastinal staging with FDG PET showed only a slight sensitivity advantage over CT. Weng et al (26) reported a sensitivity and specificity of 73% and 77%, respectively, for CT, compared with 73% and 94% for FDG PET.
Inherent limitations of PET include its failure to depict anatomic landmarks and its limited spatial resolution, which restrict its use for assessing tumor size and potential infiltration of the thoracic wall, mediastinum, or other adjacent structures. SUV measurement is widely used, either for categorizing lesions as malignant or benign or for staging and monitoring cancer. However, many well-known factors can affect the accuracy of SUV measurement; these include patient weight, blood glucose level, uptake period, partial-volume averaging effect, recovery coefficient, and the type of region of interest (27). Moreover, increased glucose uptake in a benign node can be caused by either reactive hyperplasia or granulomatous inflammation, which may be indistinguishable from malignancy. Therefore, it is difficult to differentiate between benign lymph nodes and malignant lymph nodes with CT or FDG PET alone.
Developed in an effort to improve the accuracy of FDG PET scanning, an alternative software-based approach to postprocessing alignment of scan data involves the fusion of techniques in one scanner that can acquire both anatomic and functional scans during a single scanning session. This and other similar efforts have been directed at improving the individual performance of CT and PET components rather than at integrating the component outputs. Magnani et al (9) reported that integrated PET/CT results in improved sensitivity, specificity, and overall accuracy (78%, 95%, and 89%, respectively) for the detection of malignant lymph nodes, compared with visually correlated PET and CT (67%, 95%, and 86%, respectively). More recently, the greater accuracy and sensitivity of integrated PET/CT have been corroborated by the results of several studies (28,29). In the current study, we used integrated PET/CT to improve the diagnostic accuracy of tumor and nodal staging compared with that at stand-alone CT and found significant differences between the modalities.
In the current study, the sensitivity and accuracy (84%–86%) of integrated PET/CT for tumor and nodal lung cancer staging were slightly lower than those in publications based on previous studies (about 90%) (28,29). One possible reason for these relatively lower values is the different inclusion criteria used. In the present study, only patients who underwent surgical treatment with lymph node dissection were included. Patients who received palliative treatment, preoperative chemotherapy, or radiation therapy were excluded. More cases of early-stage disease, and, therefore, more patients with microscopic metastatic foci, were probably included.
The present study shows that the sensitivity of integrated PET/CT is superior to that of CT for the detection of mediastinal nodal metastasis; 23 (70%) of 33 metastases were detected at CT versus 28 (85%) at integrated PET/CT (difference not significant). This improved sensitivity resulted from the detection of small metastatic lymph nodes (
10 mm in short-axis diameter) with integrated PET/CT. These limitations of size-based nodal characterization systems are well documented; up to 21% of nodes 10 mm or smaller are malignant and up to 40% of those larger than 10 mm are benign (30,31). One hundred twelve benign nodal groups (of 360 [31%]; 54 hilar, 16 subcarinal, 29 paratracheal, 10 subaortic, two pulmonary ligament, and one upper paratracheal) were falsely characterized as malignant at CT. A high frequency of hilar, paratracheal, and subcarinal lymph node hyperplasia may have led to these false-positive results. In contrast, 58 nodal groups (of 360 [16%]) were falsely interpreted as malignant at integrated PET/CT, more than half (32 nodal groups in 18 patients) of which were hilar lymph node groups. These false-positive results may have been caused by reactive hyperplasia or active inflammation due to granulomatous diseases such as tuberculosis.
In the present study, nodes that showed positive uptake with calcification or with higher attenuation than that in the surrounding great vessels proved to be benign. These nodes showed follicular hyperplasia in the cortex and anthracotic pigmentation and macrophage infiltration with or without fibrotic micronodule formation in the medulla. These inflammatory changes of follicular hyperplasia and macrophage infiltration may have contributed to increased glucose uptake in the corresponding nodes. Therefore, nodes containing calcification or with higher attenuation than the surrounding great vessels, although they show positive uptake at PET, should be regarded as benign, especially where chronic granulomatous disease is endemic.
Although integrated PET/CT had improved accuracy for mediastinal lymph node staging, the spatial resolution of PET scans is insufficient for detection of microscopic metastases to lymph nodes (32). If radionuclide uptake is not increased at PET, then integrated PET/CT cannot provide further information. In our study, five microscopic metastases were missed in five patients. These results confirm that integrated PET/CT does not obviate mediastinoscopy for mediastinal lymph node staging.
Several drawbacks limited our study. First, because patients with advanced lung cancer stages were excluded, both the sensitivity and accuracy of the modalities examined may have been underestimated with respect to the detection of metastases to lymph nodes. Second, CT scans were interpreted by only one radiologist; integrated PET/CT scans, by only one of two nuclear medicine physicians. Consensus reading results of integrated PET/CT by both a radiologist and a nuclear physician may have increased diagnostic accuracy. Third, surgeons were guided by preoperative CT or integrated PET/CT findings, which may have added verification bias. Fourth, calcified lymph nodes and nodes with higher attenuation than that in surrounding great vessels with high uptake at PET/CT may have contained focal areas of true malignancy. These nodes, however, were regarded as benign in the interpretation of PET/CT findings, a definition that presumably decreased the sensitivity of PET/CT for detection of malignancy. In the presence of granulomatous disease, however, we believe that this kind of interpretation is the best way to enhance the accuracy of lung cancer staging by reducing false-positive interpretations.
In summary, benign hilar and mediastinal lymph nodes, with histopathologic findings of follicular hyperplasia in the cortex and anthracotic pigmentation and macrophage infiltration with or without the formation of microscopic fibrotic nodules in the medulla, falsely showed high uptake at PET. These nodes can be recognized as benign in the presence of calcification or of attenuation higher than that in the surrounding great vessels at CT. By providing both morphologic and functional information and thus enhancing the accuracy and specificity of nodal staging, integrated PET/CT is significantly better than stand-alone CT for lung cancer staging.
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FOOTNOTES |
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Abbreviations: FDG = fluorodeoxyglucose • SUV = standardized uptake value
Authors stated no financial relationship to disclose.
Author contributions: Guarantor of integrity of entire study, K.S.L.; study concepts/study design or data acquisition or data analysis/interpretation, all authors; manuscript drafting or manuscript revision for important intellectual content, all authors; manuscript final version approval, all authors; literature research, S.S.S., K.S.L., B.T.K., M.J.C., E.J.L., J.Y.C.; clinical studies, K.S.L., B.T.K., M.J.C., E.J.L., J.Y.C., O.J.K., Y.M.S.; statistical analysis, K.S.L., E.J.L., O.J.K.; manuscript editing, S.S.S., K.S.L., B.T.K.
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 P Veit-Haibach, G Antoch, T Beyer, H Stergar, R Schleucher, E A M Hauth, and A Bockisch FDG-PET/CT in restaging of patients with recurrent breast cancer: possible impact on staging and therapy Br. J. Radiol., July 1, 2007; 80(955): 508 - 515. [Abstract] [Full Text] [PDF]
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P. Maga, J. Kuzdzal, R. Nizankowski, A. Szczeklik, and K. Sladek Long-term effects of thoracic sympathectomy on microcirculation in the hands of patients with primary Raynaud disease J. Thorac. Cardiovasc. Surg., June 1, 2007; 133(6): 1428 - 1433. [Abstract] [Full Text] [PDF]
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S. Chong, K. S. Lee, B.-T. Kim, J. Y. Choi, C. A Yi, M. J. Chung, D.-K. Oh, and J.-Y. Lee Integrated PET/CT of Pulmonary Neuroendocrine Tumors: Diagnostic and Prognostic Implications Am. J. Roentgenol., May 1, 2007; 188(5): 1223 - 1231. [Abstract] [Full Text] [PDF]
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 W A H Wallace, H M Monaghan, D M Salter, M A Gibbons, and K M Skwarski Endobronchial ultrasound-guided fine-needle aspiration and liquid-based thin-layer cytology J. Clin. Pathol., April 1, 2007; 60(4): 388 - 391. [Abstract] [Full Text] [PDF]
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B. E. Lee, D. von Haag, T. Lown, D. Lau, R. Calhoun, and D. Follette Advances in positron emission tomography technology have increased the need for surgical staging in non-small cell lung cancer J. Thorac. Cardiovasc. Surg., March 1, 2007; 133(3): 746 - 752. [Abstract] [Full Text] [PDF]
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C. A Yi, K. S. Lee, B.-T. Kim, S. S. Shim, M. J. Chung, Y. M. Sung, and S. Y. Jeong Efficacy of Helical Dynamic CT Versus Integrated PET/CT for Detection of Mediastinal Nodal Metastasis in Non-Small Cell Lung Cancer Am. J. Roentgenol., February 1, 2007; 188(2): 318 - 325. [Abstract] [Full Text] [PDF]
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Y. J. Jeong, C. A. Yi, and K. S. Lee Solitary Pulmonary Nodules: Detection, Characterization, and Guidance for Further Diagnostic Workup and Treatment Am. J. Roentgenol., January 1, 2007; 188(1): 57 - 68. [Abstract] [Full Text] [PDF]
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V. Gregoire, K. Haustermans, X. Geets, S. Roels, and M. Lonneux PET-Based Treatment Planning in Radiotherapy: A New Standard? J. Nucl. Med., January 1, 2007; 48(1_suppl): 68S - 77S. [Abstract] [Full Text] [PDF]
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J. Czernin, M. Allen-Auerbach, and H. R. Schelbert Improvements in Cancer Staging with PET/CT: Literature-Based Evidence as of September 2006 J. Nucl. Med., January 1, 2007; 48(1_suppl): 78S - 88S. [Abstract] [Full Text] [PDF]
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S. H. Choi, W. K. Moon, J. H. Hong, K. R. Son, N. Cho, B. J. Kwon, J. J. Lee, J.-K. Chung, H. S. Min, and S. H. Park Lymph Node Metastasis: Ultrasmall Superparamagnetic Iron Oxide-enhanced MR Imaging versus PET/CT in a Rabbit Model Radiology, December 1, 2006; 242(1): 137 - 143. [Abstract] [Full Text] [PDF]
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B.-T. Kim, K. S. Lee, S. S. Shim, J. Y. Choi, O J. Kwon, H. Kim, Y. M. Shim, J. Kim, and S. Kim Stage T1 Non-Small Cell Lung Cancer: Preoperative Mediastinal Nodal Staging with Integrated FDG PET/CT--A Prospective Study Radiology, November 1, 2006; 241(2): 501 - 509. [Abstract] [Full Text] [PDF]
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A. Quon, S. Napel, C. F. Beaulieu, and S. S. Gambhir "Flying Through" and "Flying Around" a PET/CT Scan: Pilot Study and Development of 3D Integrated 18F-FDG PET/CT for Virtual Bronchoscopy and Colonoscopy J. Nucl. Med., July 1, 2006; 47(7): 1081 - 1087. [Abstract] [Full Text] [PDF]
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 M. B. Lobrano Partnerships in Oncology and Radiology: The Role of Radiology in the Detection, Staging, and Follow-up of Lung Cancer Oncologist, July 1, 2006; 11(7): 774 - 779. [Abstract] [Full Text] [PDF]
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 D. Lardinois New Horizons in Staging for Non-Small-Cell Lung Cancer J. Clin. Oncol., April 20, 2006; 24(12): 1785 - 1787. [Full Text] [PDF]
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S. S. Shim, K. S. Lee, M. J. Chung, H. Kim, O J. Kwon, and S. Kim Do hemodynamic studies of stage t1 lung cancer enable the prediction of hilar or mediastinal nodal metastasis? Am. J. Roentgenol., April 1, 2006; 186(4): 981 - 988. [Abstract] [Full Text] [PDF]
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 M. McCulloch, T. Jezierski, M. Broffman, A. Hubbard, K. Turner, and T. Janecki Diagnostic Accuracy of Canine Scent Detection in Early- and Late-Stage Lung and Breast Cancers Integr Cancer Ther, March 1, 2006; 5(1): 30 - 39. [Abstract] [PDF]
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C. A Yi, K. S. Lee, B.-T. Kim, J. Y. Choi, O. J. Kwon, H. Kim, Y. M. Shim, and M. J. Chung Tissue Characterization of Solitary Pulmonary Nodule: Comparative Study Between Helical Dynamic CT and Integrated PET/CT J. Nucl. Med., March 1, 2006; 47(3): 443 - 450. [Abstract] [Full Text] [PDF]
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