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ABSTRACT: The recent proposal for histological subtyping of pulmonary adenocarcinoma by predominant pattern and introduction of the terms adenocarcinoma in situ and minimally invasive adenocarcinoma to replace the term bronchioloalveolar carcinoma by the International Association for the Study of Lung Cancer/American Thoracic Society/European Respiratory Society has led us to conduct a study of 104 patients with early-stage primary pulmonary adenocarcinoma (T1N0M0), with a view to histological subtype as defined by the new proposal and clinical outcome. None of the clinical parameters of our patient population (type of surgery, age, gender, tumor size, and comorbidities) showed any statistically significant correlation with outcome, except for associated malignancies, which not surprisingly appeared to have a negative impact on survival. In addition, statistical analyses of the histological characteristics to include tumor differentiation and the percentage of a lepidic or bronchioloalveolar component did not show any statistically significant values in terms of survival. Our results failed to show any statistically significant difference of survival between those T1N0M0 adenocarcinomas with a lepidic component and those without, thus questioning the use of terms such as in situ or minimally invasive adenocarcinoma. On the basis of our results, we consider that the outcome for patients with T1N0M0 disease is still best determined by appropriate staging rather than by changes in the pathology nomenclature of adenocarcinoma.Modern Pathology advance online publication, 29 March 2013; doi:10.1038/modpathol.2013.33.
Modern Pathology 03/2013; · 4.79 Impact Factor
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ABSTRACT: INTRODUCTION:: Advanced thymoma (stage III and IV) is difficult to detect by computed tomography (CT), yet it is important to distinguish between early (stage I and II) and advanced disease before surgery, as patients with locally advanced tumors require neoadjuvant chemotherapy to enable effective resection. This study assessed whether the amount of fluorodeoxyglucose (FDG) uptake can predict advanced thymoma and whether it can separate thymoma from thymic cancer. METHODS:: We retrospectively reviewed FDG positron emission tomography (PET)-CT scans of 51 consecutive newly diagnosed patients with thymic epithelial malignancy. PET-CT findings documented focal FDG activity: SUVmax, SUVmean, SUVpeak, and total body volumetric standardized uptake value (SUV) measurements. These were correlated with Masaoka-Koga staging and World Health Organization classification. Wilcoxon ranked sum tests were used to assess association between SUV and pathological stage, cancer type, and classification. RESULTS:: Among the study patients, 37 had thymoma, 12 thymic carcinoma, and 2 thymic carcinoid. Higher focal FDG uptake was seen in patients with type B3 thymoma than in those with type A, AB, B1, or B2 thymoma (p < 0.006). FDG uptake was higher in patients with thymic carcinoma or carcinoid than in patients with thymoma (p < 0.0003), with more variable associations with volumetric SUV measurements. There was no significant association observed between higher focal FDG uptake and advanced-stage disease in thymoma patients (p > 0.09), although greater FDG-avid tumor volume was significantly associated with advanced disease (p < 0.03). CONCLUSIONS:: Focal FDG uptake cannot predict advanced thymoma but is helpful in distinguishing thymoma from thymic carcinoma, or the more aggressive thymoma, type B3.
Journal of thoracic oncology: official publication of the International Association for the Study of Lung Cancer 02/2013; · 4.55 Impact Factor
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ABSTRACT: ObjectiveTo determine if the location of the point of maximum standardized uptake value (SUVmax) being included in or not included
in the histopathologic slab section corresponded to tumor necrosis or survival.
Materials and methodsTwenty-nine osteosarcoma patients underwent post-chemotherapy [fluorine-18]-fluoro-2-deoxy-D-glucose (FDG) positron-emission tomography–computed tomography (PET/CT) prior to resection. PET/CT images were correlated
with slab-section location as determined by photographs or knowledge of specimen processing. The location of the point of
SUVmax was then assigned as being ‘in’ or ‘out’ of the slab section. Cox’s proportional hazard regression was used to evaluate
relationships between the location and value of SUVmax and survival. Logistic regression was employed to evaluate tumor necrosis.
ResultsNo correlation was found between the SUVmax location and survival or tumor necrosis. High SUVmax correlated to poor survival.
ConclusionHigh SUVmax value correlated to poor survival. Minimal viable tumor (> 10%) following chemotherapy is a known indicator of
poor survival. No correlation was found between the location of SUVmax and survival or tumor necrosis. Therefore, the SUVmax
value either does not correspond to a sufficient number of tumor cells to influence tumor necrosis measurement or it was included
in the out-of-slab samples that were directed to viable-appearing areas of the gross specimen. Since high SUVmax has been
previously found to correspond to poor tumor necrosis, and tumor necrosis is simply an estimate of the amount of viable tumor,
SUVmax likely represents many viable tumor cells. Therefore, when not in the slab section, SUVmax was likely included in the
tumor necrosis measurement through directed sampling, validating our current method of osteosarcoma specimen analysis.
Skeletal Radiology 04/2012; 39(2):131-140. · 1.54 Impact Factor
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John A Harvin,
Guy Lahat,
Arlene M Correa,
Jared Lee,
Dipen Maru,
Jaffer Ajani, Edith M Marom,
James Welsh,
Manoop S Bhutani,
Garret Walsh,
Jack Roth,
Reza Mehran,
Ara Vaporciyan,
David Rice,
Stephen Swisher,
Wayne Hofstetter
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ABSTRACT: The incidence and consequence of an isolated involved circumferential radial margin (CRM) after resection for esophageal adenocarcinoma in the setting of neoadjuvant chemoradiotherapy (CRT) has not been reported. We aimed to determine the frequency and significance of a close (<1 mm) or involved CRM in patients undergoing esophagectomy after CRT.
We retrospectively analyzed the data from patients undergoing resection from 1997 to 2008 for esophageal adenocarcinoma after neoadjuvant CRT. A positive CRM was defined as microscopic tumor at or less than 1 mm of the radial margin. An R1 resection was tumor at the radial margin. Only patients with ypT3 or greater tumors were included. R2 resections were excluded. Statistical comparisons were performed using Cox regression and Kaplan-Meier analyses.
A total of 160 patients met the inclusion criteria, 42 (26%) had a positive CRM. The median survival did not significantly differ between the CRM-negative and -positive groups (28 vs 50 months, P = .84). A propensity score matching analysis also failed to find a significant difference in outcomes. When analyzed by tumor present at the margin (R1), R0 patients had a longer median survival compared with R1 patients (28 vs 8 months, P = .01). This difference, however, was not seen on propensity score matching.
Resections of locally advanced esophageal adenocarcinoma with residual transmural viable tumor after CRT frequently showed involvement of the radial margin with tumor either close to or at the margin. Tumor close (<1 mm) to the radial margin did not result in a significant decrease in overall or disease-free survival or increase in local recurrence.
The Journal of thoracic and cardiovascular surgery 12/2011; 143(2):412-20. · 3.41 Impact Factor
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Journal of thoracic oncology: official publication of the International Association for the Study of Lung Cancer 12/2011; 6(12):2144-2145. · 4.55 Impact Factor
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Radiographics 11/2011; 31(7):1863. · 2.85 Impact Factor
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ABSTRACT: Thymoma is a rare mediastinal neoplasm but is the most common primary neoplasm of the anterior mediastinum. There have been only a few published reports assessing this disease. Furthermore, many of these reports are from a single institution and span several decades, which may lead to potentially misleading conclusions related to diagnosis, staging, and treatment. Computed tomography is the imaging modality of choice for evaluating thymoma and can help distinguish thymoma from other anterior mediastinal abnormalities. Tumor stage and extent of resection are the most important prognostic factors. Tumors that are encapsulated and are amenable to complete resection have a good prognosis, whereas invasive and unresectable tumors have a poor prognosis regardless of their histologic characteristics. Radiologists must be aware of the full spectrum of imaging findings of thymoma, the standard guidelines for diagnostic evaluation, and how imaging findings affect therapeutic decisions.
Radiographics 11/2011; 31(7):1847-61; discussion 1861-3. · 2.85 Impact Factor
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Jae Y Kim,
Arlene M Correa,
Ara A Vaporciyan,
Jack A Roth,
Reza J Mehran,
Garrett L Walsh,
David C Rice,
Jaffer A Ajani,
Dipen M Maru,
Manoop S Bhutani,
James Welsh, Edith M Marom,
Stephen G Swisher,
Wayne L Hofstetter
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ABSTRACT: After neoadjuvant chemoradiation (CXRT) for esophageal cancer, surgery has traditionally been recommended to be performed within 8 weeks. However, surgery is often delayed for various reasons. Data from other cancers suggest that delaying surgery may increase the pathologic complete response rate. However, there are theoretical concerns that waiting longer after radiation may lead to a more difficult operation and more complications. The optimal timing of esophagectomy after CXRT is unknown.
From a prospective database, we analyzed 266 patients with resected esophageal cancer who were treated with neoadjuvant CXRT from 2002 to 2008. Salvage resections were excluded from this analysis. We compared patients who had surgery within 8 weeks of CXRT and those who had surgery after 8 weeks. We used multivariable analysis to determine whether increased interval between chemoradiation and surgery was independently associated with perioperative complication, pathologic response, or overall survival.
One hundred fifty patients were resected within 8 weeks and 116 were resected greater than 8 weeks after completing CXRT. Mean length of operation, intraoperative blood loss, anastomotic leak rate, and perioperative complication rate were similar for the two groups. Pathologic complete response rate and overall survival were also similar for the two groups (p=not significant). In multivariable analysis, timing of surgery was not an independent predictor of perioperative complication, pathologic complete response, or overall survival.
The timing of esophagectomy after neoadjuvant CXRT is not associated with perioperative complication, pathologic response, or overall survival. It may be reasonable to delay esophagectomy beyond 8 weeks for patients who have not yet recovered from chemoradiation.
The Annals of thoracic surgery 09/2011; 93(1):207-12; discussion 212-3. · 3.74 Impact Factor
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Anne S Tsao,
Suyu Liu,
Junya Fujimoto,
Ignacio I Wistuba,
J Jack Lee, Edith M Marom,
Chusilp Charnsangavej,
Frank V Fossella,
Hai T Tran,
George R Blumenschein,
Vassiliki Papadimitrakopoulou,
Merrill S Kies,
Waun K Hong,
David J Stewart
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ABSTRACT: Two phase II clinical trials in the aerodigestive tumors were undertaken to evaluate the efficacy of imatinib mesylate-docetaxel. We hypothesized that imatinib mesylate would inhibit platelet-derived growth factor receptor (PDGFR) on pericytes and increase docetaxel uptake into tumor cells for an additive antitumor effect. Baseline tumor specimens, serum, and perfusion computed tomography (CT) scans were obtained for supportive evaluation.
Eligible patients with metastatic non-small cell lung cancer (NSCLC) treated with 1 prior therapy and chemonaive patients with head and neck squamous cell carcinoma (HNSCC) were enrolled in separate trials, which administered both docetaxel (60 mg/m every 3 weeks) and oral imatinib mesylate (400 mg daily). Both trials used interim analyses for efficacy and safety.
Twenty-two patients with NSCLC and seven patients with HNSCC were enrolled. Both trials were closed early due to lack of efficacy, significant toxicity, and a potential antagonistic effect. In the NSCLC study, the response rate was 4.5%, median progression-free survival (PFS) 7.9 weeks, and overall survival 35.6 weeks. The HNSCC trial yielded a response rate 0%, PFS 8.8 weeks, and overall survival 34.7 weeks. Baseline NSCLC tumor immunohistochemical biomarker analyses indicated that lower expression of stromal PDGFRβ correlated with a better PFS, whereas stromal PDGFRα and tumor cell PDGFRβ were associated with a worse clinical outcome when treated with imatinib mesylate-docetaxel.
We do not recommend further investigation of this regimen in the aerodigestive tumors. Future investigations in PDGFR tyrosine kinase inhibitors should be used with caution in combination with taxanes and validation of the potential predictive or prognostic biomarkers stromal PDGFRα/β, and tumor cell PDGFRβ are needed.
Journal of thoracic oncology: official publication of the International Association for the Study of Lung Cancer 09/2011; 6(12):2104-11. · 4.55 Impact Factor
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ABSTRACT: OBJECTIVE: The purpose of this article is to present the spectrum of inflammatory bowel disease manifestations in the chest, including the airways, lung parenchyma, pulmonary vasculature, and serosal surfaces. CONCLUSION: The spectrum of inflammatory bowel disease manifestations in the chest is broad, and the manifestations may mimic other diseases. Knowledge of these manifestations in conjunction with pertinent clinical data is essential for establishing the correct diagnosis and treatment.
American Journal of Roentgenology 09/2011; 197(3):W452-6. · 2.78 Impact Factor
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Journal of thoracic oncology: official publication of the International Association for the Study of Lung Cancer 07/2011; 6(7 Suppl 3):S1717-23. · 4.55 Impact Factor
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ABSTRACT: The aim is to review imaging advances in invasive fungal pneumonia in cancer and transplant recipients and how their use can help guide treatment.
Early chest computed tomographic (CT) imaging of immunocompromised patients with neutropenic fever leads to improved survival. Some of the typical CT findings of invasive fungal pneumonia are transitory and are most common during the first week of symptoms. The reversed halo sign, an early sign of disease, is more common in mucormycosis. During the first 10 days of infection, invasive fungal pneumonia nodules may grow on follow-up CT scans, but this does not necessarily equate to worsening disease. Because of the excessive radiation of chest CT and because pulmonary nodule size typically expands during the first few weeks of treatment, follow-up CT scans should be ordered only when therapy changes are dependent on imaging findings.
Early chest CT imaging in immunocompromised patients suspected of having invasive fungal pneumonia can help identify disease early, leading to improved outcome.
Current Opinion in Infectious Diseases 06/2011; 24(4):309-14. · 4.93 Impact Factor
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Edith M Marom,
Miguel A Milito,
Cesar A Moran,
Ping Liu,
Arlene M Correa,
Edward S Kim,
Ritsuko Komaki,
Jeremy J Erasmus,
Wayne L Hofstetter,
David C Rice,
Stephen G Swisher
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ABSTRACT: To identify preoperative computed tomography (CT) findings associated with thymoma invasiveness before surgical resection and with clinical outcome.
We retrospectively reviewed CT scans of 99 patients with thymoma surgically treated at our institution between September 1999 and April 2010. Chest CT findings documented were size, volume, and heterogeneity of primary tumor; abutment of mediastinal vessels; and presence of calcifications, lobulation, infiltration of fat surrounding tumor, adjacent pulmonary changes, adenopathy, and pleural nodularity.
Our study group consisted of 53 (54%) men and 46 (46%) women, age 18-79 years (mean: 53.2 years). Masaoka pathologic stages were stage I for 10 (10%), stage II for 48 (48%), stage III for 21 (21%), and stage IV for 20 (20%). The median radiologic tumor size was 7 cm (range: 2.5-21 cm). A multivariable logistic regression model showed that primary tumors with prechemotherapy radiologic tumor size ≥ 7 cm (odds ratio [OR]: 3.18, 95% confidence interval [CI]: 1.16-8.67, p = 0.02), a lobulated tumor contour (OR: 8.20, 95% CI: 1.63-41.35, p = 0.01), and infiltration of surrounding fat (OR: 3.76, 95% CI: 1.45-9.78, p = 0.007) were more likely to have stage III or IV disease. Cox's proportional hazard model showed that the presence of pulmonary nodules on staging CT was the only imaging parameter associated with shorter progression-free survival (hazard ratio: 4.93, 95% CI: 1.60-15.17, p = 0.005) and overall survival (p = 0.03).
The primary tumor CT imaging features can differentiate between stage I/II and stage III/IV disease and, thus, help identify patients more likely to benefit from neoadjuvant therapy.
Journal of thoracic oncology: official publication of the International Association for the Study of Lung Cancer 05/2011; 6(7):1274-81. · 4.55 Impact Factor
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ABSTRACT: The halo sign is a CT finding of ground-glass opacity surrounding a pulmonary nodule or mass. The reversed halo sign is a focal rounded area of ground-glass opacity surrounded by a crescent or complete ring of consolidation. In severely immunocompromised patients, these signs are highly suggestive of early infection by an angioinvasive fungus. The halo sign and reversed halo sign are most commonly associated with invasive pulmonary aspergillosis and pulmonary mucormycosis, respectively. Many other infections and noninfectious conditions, such as neoplastic and inflammatory processes, may also manifest with pulmonary nodules associated with either sign. Although nonspecific, both signs can be useful for preemptive initiation of antifungal therapy in the appropriate clinical setting. This review aims to evaluate the diagnostic value of the halo sign and reversed halo sign in immunocompromised hosts and describes the wide spectrum of diseases associated with them.
Clinical Infectious Diseases 05/2011; 52(9):1144-55. · 9.15 Impact Factor
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Thorax 03/2011; 66(6):544. · 6.84 Impact Factor
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ABSTRACT: Malignant pleural mesothelioma (MPM) is difficult to measure radiographically due to the nonradial and variable pattern of growth and response to therapy. Inaccurate and inconsistent tumor measurements often compromise results from clinical trials that are dependent on identifying response rate and progression-free survival. In this article, we sought to provide a practical guide through the Southwest Oncology Group on how to measure MPM by the updated RECIST version 1.1 and by modified RECIST. We hope that these steps will provide a simple means by which computed tomography measurements can be consistently performed, minimizing intra- and interobserver variability. With this consistency, we may be able to better estimate the prognosis and response to therapy. With greater utilization, we will be able to better understand the biology of MPM.
Journal of thoracic oncology: official publication of the International Association for the Study of Lung Cancer 03/2011; 6(3):598-601. · 4.55 Impact Factor
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The Annals of thoracic surgery 02/2011; 91(2):e29. · 3.74 Impact Factor
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Edith M Marom
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ABSTRACT: Thymoma is a rare tumor, although it is the most common primary neoplasm of the anterior mediastinum. In the majority of thymoma patients, imaging is requested for investigation of symptoms related to their tumor, although an increasing number of asymptomatic patients are discovered incidentally due to the increased utilization of computed tomography for screening or for imaging of other unrelated diseases. This review will focus on the goals of imaging thymoma, the imaging features of thymoma, as well as the advantages and limitations of each imaging modality in establishing the diagnosis, staging, and prognosis of thymoma.
Journal of thoracic oncology: official publication of the International Association for the Study of Lung Cancer 10/2010; 5(10 Suppl 4):S296-303. · 4.55 Impact Factor
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ABSTRACT: To assess whether the type of immune suppression in patients with hematologic malignancies affects the appearance of invasive pulmonary aspergillosis (IPA) on computed tomography (CT), we retrospectively reviewed the CT findings of 66 consecutive patients who were diagnosed with hematologic malignancies and IPA and correlated the findings to patients' IPA risk factors. In our study these risk factors included neutropenia (n = 34, 52%), stem cell transplantation (SCT; n = 30, 45%), graft versus host disease (GVHD; n = 22, 33%), and steroid use (n = 29, 44%). Nodular lesions were the most common finding on CT (n = 54, 82% of the entire patient population). These were seen in 74% of neutropenic patients (n = 25, P > 0.07), 87% of patients following SCT (n = 26, P > 0.35), 95% of patients with GVHD (n = 21, P = 0.04)), and 83% of those receiving steroids (n = 24, P > 0.45). The hypodense sign was often seen in patients without GVHD (n = 17, 39%; P = 0.003). Tree-in-bud opacities were often observed in patients who underwent SCT (n = 10, 33%; P = 0.03). Thus, peripheral nodular lesions are the most common initial finding of IPA in patients with hematologic malignancies, regardless of the mechanism of immunosuppression.
Medical mycology: official publication of the International Society for Human and Animal Mycology 09/2010; 48(6):817-23. · 2.13 Impact Factor
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Min P Kim,
Arlene M Correa,
Jared Lee,
David C Rice,
Jack A Roth,
Reza J Mehran,
Garrett L Walsh,
Jaffer A Ajani,
Dipen M Maru,
Joe Y Chang, Edith M Marom,
Homer A Macapinlac,
Jeff H Lee,
Ara A Vaporciyan,
Thomas Rice,
Stephen G Swisher,
Wayne L Hofstetter
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ABSTRACT: Patients with esophageal carcinoma who appear to have a complete response at the primary tumor site after undergoing neoadjuvant chemoradiotherapy may still have residual disease in regional lymph nodes despite clinically negative restaging (ypT0N1). We hypothesized that these patients would have similar survival to patients with incomplete response to therapy.
We reviewed 336 esophageal cancer patients who received neoadjuvant chemoradiotherapy followed by complete resection. We identified 20 patients who obtained complete pathologic response at the primary tumor with persistent metastatic disease to regional lymph nodes (ypT0N1). These patients were compared to 123 patients with pathologic complete response and 193 with partial response for overall survival.
Demographics among the three groups of patients were similar except that this cohort of patients with ypT0N1 had higher initial clinical stage (p = 0.013) and had more squamous cell carcinoma pathology (p = 0.005). Eighty-six percent of the ypT0N1 patients who had modern preoperative staging were felt to have clinical complete response. Five-year survival of ypT0N1 patients was intermediate, similar to pathologic partial response stage II patients in both the sixth and seventh editions of the American Joint Committee on Cancer staging criteria.
Clinical staging of complete response to chemoradiotherapy may not translate to pathologic complete response. Patients with ypT0N1 disease at resection have intermediate but reasonable survival, justifying an aggressive approach to curative therapy. Future revisions of the staging system should place this group of patients with patients who have metastatic regional lymph nodes, stratified by number of nodes involved.
The Annals of thoracic surgery 09/2010; 90(3):884-90; discussion 890-1. · 3.74 Impact Factor
