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Incidence of suspicious axillary lymph node involvement in fluorine-18 fluoro-D-glucose positron emission tomography/computed tomography in gynecologic cancers/Jinekolojik kanserlerde flor-18 floro-D-glukoz pozitron emisyon tomografisi-bilgisayarli tomografide supheli aksiller lenf nodu tutulumunun insidansi.

Introduction

Two-deoxy-2-[fluorine-18] fluoro-D-glucose ([.sup.18]F-FDG) positron emission tomography (PET) adds valuable data based on the increased glucose uptake and depicts metabolic abnormalities before morphologic alterations occur. PET has been widely used in staging, pre-operative planning, and follow-up of gynecologic cancers in our department, as well as worldwide. Whole-body acquisition by [.sup.18]F-FDG PET/computed tomography (CT) imaging may demonstrate unusual findings in distant unexpected localizations (1). Patients with a gynecologic malignancy are at greater risk of developing synchronous or metachronous secondary cancers, therefore these unusual [.sup.18]F-FDG PET/CT findings may be important. Besides, skip metastases to the axillary lymph nodes may influence surgical and adjuvant treatment of the patient. We have noticed that in an important part of patients with gynecologic cancer, [.sup.18]F-FDG PET/CT has indicated incidental axillary lymph nodes although axillary lymphadenopathy is rare in gynecologic cancers (1). There is a paucity of information about axillary lymph node involvement in gynecologic cancers in terms of prognostic importance and accurate management. The aim of the present study was to analyze the incidence of suspicious axillary lymph nodes in gynecologic cancers and evaluate the oncologic and [.sup.18]F-FDG PET/CT features.

Materials and Methods

We retrospectively analyzed the [.sup.18]F-FDG PET/CT findings of 251 patients with endometrial, cervical, and ovarian cancer who were referred to our clinic between 2010 and 2017. We included gynecologic oncology patients with suspicious axillary lymph nodes when they had one of the following features in [.sup.18]F-FDG PET/CT imaging: lymph nodes with a diameter equal to or larger than 10 mm, parenchymal thickening and loss of fatty hilum, or increased FDG-uptake value equal to or greater than 1.8. There is no cut-off value documented for axillary metastases from gynecologic tumors; therefore, we adopted the cut-off standardized uptake value (SUV) proclaimed in breast cancer. However, there is also no consensus for SUV values for the detection of axillary metastases in breast cancer. An SUV cut-off value of axillary metastases in breast cancer set at 1.8 or more is reported to have 35.6% sensitivity, 100% specificity, and 100% positive predictive value (2). In other studies, the optimal cut-off level of maximum SUV ([SUV.sub.max]) on PET/CT for malignant isolated axillary lymph nodes was reported as 3.01 (3). Women with an SUV uptake higher than 3 underwent histopathologic evaluation through fine-needle core biopsy, excisional biopsy or complete axillary lymph node dissection according to the surgeon's preference. Demographic and oncologic characteristics of the patients, [.sup.18]F-FDG PET/CT findings, [SUV.sub.max], follow-up of axillary lesions, and biopsy results were recorded. FDG-PET image acquisition and whole-body FDG-PET scans were performed as described using the Philips Gemini TF PET/CT scanner (Philips Medical Systems B.V., Eindhoven, The Netherlands). Patients were prepared with a 6 h fast because serum glucose levels had to be <150 mg/dL prior to glucose tracer administration. At 60 min after the intravenous injection of 3.7 MBq/kg (0.1 mCi/kg) [.sup.18]F-FDG (Monrol, Eczacibasi, Istanbul, Turkey), PET/CT was performed. Subsequently, an emission scan was recorded in the three-dimensional mode following CT for 2 min per position. PET and CT images were examined in the cross-sectional planes view and in the rotating maximum-intensity projection. The study was approved by the Suleyman Demirel University Local Ethics Committee (approval number: 175 dated 04.10.2017).

Statistical Analysis

Statistical analyses were performed using the MedCalc Software (version 17.4.4, Belgium) and IBM SPSS Statistics 24 Software. One-way ANOVA and the chi-square test were used to compare variables. A p value of 0.05 or less was defined as statistical significance.

Results

A total of 251 patient records were available for analyses. Forty (15.9%) patients with suspicious axillary lymph node metastases were included in the study. The mean age of patients was 60.4[+ or -]9.1 years. Axillary lymph node involvement was most commonly observed in patients with endometrium cancer. There were 93 patients with endometrium cancer and a suspicious lymph node was found in 21.5% (n=20). There were 99 patients with ovarian cancer and 14.1% (n=14) had a suspicious axillary lymph node in [.sup.18]F-FDG PET/CT imaging. Ten percent (n=6/59) of patients with cervical cancer had suspicious axillary lymph nodes (Table 1). In 17 patients (out of 40), suspicious axillary findings were evident in pre-operative/treatment PET/CT. Twenty-three patients (out of 40) had no suspicious axillary lymph nodes in preoperative/treatment PET/CT; suspicious axillary lymph nodes were found as a new findings in the follow-up of these patients (Table 2). In follow-up of the 40 patients with suspicious axillary lymph nodes, 28 (70%) patients had regression, 3 (7.5%) progressed, and 9 (22.5%) patients remained stable. Of the three progressive cases, one patient with endometrial cancer did not accept any surgical or medical treatment for endometrial cancer and died 23 months after [.sup.18]F-FDG PET/CT imaging. The second patient had stage IIIB ovarian cancer and received 6 courses of carboplatin-paclitaxel chemotherapy (3 neoadjuvant and 3 adjuvant); the suspicious lymph node regressed after chemotherapy. The third patient with progressive suspicious axillary lymph node had stage IIIC ovarian cancer, she received 3 courses of carboplatin + paclitaxel chemotherapy before surgery, and was followed up with 36 courses of chemotherapy after surgery, (6 courses of carboplatin + paclitaxel, 6 courses of bevacizumab, 6 courses of carboplatin + paclitaxel, 6 courses of gemcitabine, 6 courses of topotecan, 6 courses of doxorubicin); however, despite this intense chemotherapy, the disease progressed and she died after 42 months' survival. The treatment and follow-up of 40 patients with the suspicious axillary lymph node in PET-CT is shown in Tables 3 to 5. In our last follow-up, 18 patients out of the 40 had died, 16 of which of their cancer, and 2 of other causes (Table 4). Eighteen of the remaining 22 patients were in remission, 3 patients had progression, and 1 patient was lost to follow-up. Twenty-one of the 40 patients had no FDG uptake but had obviously enlarged axillary lymphadenopathy in [.sup.18]F-FDG PET/CT imaging, and 19 patients had FDG uptake in the axilla (Table 1, Figure 1, 2). The mean [SUV.sub.max] in axillary lymph nodes with FDG uptake ([SUV.sub.max]) was 2.4[+ or -]2.3. Forty-two percent of patients had an [SUV.sub.max] higher than the cut-off value of 1.8 (Table 2). Patients with an [SUV.sub.max] uptake higher than 3 underwent axillary lymph node biopsy. There were 6 patients with an [SUV.sub.max] >3. All but one gave informed consent for an intervention for histopathologic verification. None of the patients was found to have axillary metastases in the pathologic evaluation. In one patient with endometrial cancer, an obscure breast ductal carcinoma was diagnosed, the patient had stage IIIC breast cancer with axillary metastasis. She underwent surgical treatment for breast cancer along with surgical treatment for endometrial cancer. She received adjuvant chemo-radiotherapy for breast cancer and was disease-free in her last follow-up. The second patient was found to have follicular lymphoma and sent to hematology after surgical treatment of endometrial cancer. The third patient with endometrial cancer had no malignancy in her axillary lymph node biopsy, but had Hurthle cell neoplasia in a thyroid biopsy; she refused surgical or medical treatment for endometrial cancer and died 23 months later. The other patients who underwent axillary lymph node biopsy had no malignancy at the pathologic evaluation. In the sixth patient with cervical cancer; initially, there was a suspicious lymph node with an [SUV.sub.max] equal 3.64, which was interpreted as reactive, but it could not be observed in the second [.sup.18]F-FDG PET/CT imaging after the first-line chemo-radiotherapy before the biopsy. In the last follow-up, she was in remission. The features of patients who underwent axillary biopsy are shown in Table 5.

Discussion

We found that an important proportion of gynecologic oncology patients had suspicious lymphadenopathy in [.sup.18]F-FDG PET/CT imaging, in particular, a significant proportion of patients with endometrium and ovarian cancer (21.5% and 14.1%, respectively). In our study, 52.5% of these patients had enlarged axillary lymph nodes without FDG uptake and 47.5% of these patients had enlarged axillary lymph nodes with high SUV uptake. The mean axillary [SUV.sub.max] was 2.4[+ or -]2.3. PET-CT is reported to have low sensitivity but high specificity in breast cancer, which indicates that it is more useful when metastasis is suspected. There is currently no consensus regarding the differentiation of benign from malignant lymph nodes and there is also no agreement on the cut-off for [SUV.sub.max] values (4). Axillary lymph node metastases are usually expected in primary tumors of the breast, lung, thyroid, stomach, skin, and ovary (5). The most common source of axillary lymph node metastasis is breast cancer, metastasis from non-mammary primary cancer to the axillary lymph nodes is less than 3% (6). Metastases from a gynecologic malignancy are considered extraordinary. Axillary lymph node metastases in endometrium cancer are reported as 0.03% by Aalders et al. (7). Axillary involvement in ovarian cancer has been reported as case series and is usually associated with breast metastases (8). Serous histology in ovarian cancer was the most important risk factor for axillary metastasis. Euscher et al. (9) studied 35 patients with ovarian, fallopian tube or peritoneal serous carcinoma that presented as lymphadenopathy. In their study, there were only 2 axillary lymphadenopathies with peritoneum primary sites (9). Sangle et al. (10) reported a 63-year-old patient who had serous carcinoma of the fallopian tube with axillary lymph node involvement. Isolated axillary lymph node metastasis from serous ovarian cancer has also been published as case reports in the literature (11,12). Skagias et al. (8) reported a patient with ovarian carcinoma that presented with axillary lymph node metastasis. Sanuki et al. (5) reported a 57-year-old woman with endometrium cancer with axillary lymph node involvement in Japan in 2007. As a determination of their study to evaluate a cut-off value regarding the differentiation of benign from malignant lymph nodes, Kyoung (3) reported that axillary lymph nodes with isolated FDG uptakes in whole-body PET/CT showed a low risk of malignancy (25%), and axillary lymph nodes with an SUV greater than 3.01 were malignant. Therefore, in our protocol, we suggested histopathologic evaluation of axillary lymph nodes in patients with an [SUV.sub.max] >3. In our study, 6 patients had an [SUV.sub.max] higher than 3. All but one gave informed consent for an intervention for histopathological verification. However, management and follow-up for axillary lymph nodes with abnormal visual and functional findings in PET/CT in patients with endometrial or ovarian cancer are not consistently established. It is uncommon to detect a synchronous or metachronous secondary cancer in reproductive system malignancies. The incidence of occult breast cancer is reported as 0.3-1% of all patients with breast cancer. Occult breast cancer is the most likely diagnosis associated with axillary metastasis (13). Sughayer et al. (14) reported a 63-year-old woman with collision axillary metastasis from breast cancer and ovarian cancer. Atallah et al. (6) reported a case of ipsilateral breast cancer and occult tubal serous carcinoma. In our study, there were 3 (7.5%) metachronous cancers out of 40 gynecologic cancers with suspicious axillary lymph nodes in PET/CT imaging, which is reported as uncommon in previous literature. The first patient with endometrial cancer, an obscure breast ductal carcinoma, was diagnosed through axillary lymph node biopsy, she had stage IIIC breast cancer with axillary metastasis. The second patient was found to have follicular lymphoma via axillary lymph node biopsy and was sent to hematology after surgical treatment for endometrial cancer. The third patient, who had stage IB endometrial cancer, was not histopathologically evaluated because of having an axillary [SUV.sub.max] <3, had rectosigmoid cancer and glioblastoma metachronously. This patient died of glioblastoma. This high metachronous cancer ratio warrants detailed evaluation of patients with gynecologic cancer with axillary lymph node abnormalities in [.sup.18]F-FDG PET/CT for secondary primary cancer.

Conclusion

Our study shows that an important ratio (14-21%) of patients with gynecologic cancer has suspicious axillary lymph nodes. Increased [SUV.sub.max], particularly higher than 3, might be used as an indication for axillary lymph node biopsy and may help to identify secondary metastatic cancer. Axillary metastases in gynecologic cancers may up-stage the patient to stage IV and may preclude aggressive cytoreductive surgery or may ensure adjuvant chemotherapy. Patients with increased SUV uptake higher than 3 in [.sup.18]F-FDG PET/CT imaging need to be evaluated, and further investigations should be performed to exclude other causes of lymphadenopathy.

Ethics

Ethics Committee Approval: The study was approved by the Suleyman Demirel University Local Ethics Committee (approval number: 175 dated 04.10.2017).

Informed Consent: Consent form was filled out by all participants.

Peer-review: External and internal peer-reviewed.

Authorship Contributions

Surgical and Medical Practices: E.E., Concept: J.R., S.C.I., E.E., Design: J.R., S.C.I., E.E., E.E., Data Collection or Processing: J.R., E.E.O., C.H., Analysis or Interpretation: J.R., E.E.O., C.H., S.S.C., E.E., Literature Search: J.R., E.E.O., C.H., E.E., E.E., Writing: J.R., E.E.O., C.H., E.E.

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study received no financial support.

References

(1.) Liu Y, Ghesani N V, Zuckier LS. Physiology and pathophysiology of incidental findings detected on FDG-PET scintigraphy. Semin Nucl Med 2010;40:294-315.

(2.) Ueda S, Tsuda H, Asakawa H, Omata J, Fukatsu K, Kondo T, et al. Utility of 18F-fluoro-deoxyglucose emission tomography/computed tomography fusion imaging (18F-FDG PET/CT) in combination with ultrasonography for axillary staging in primary breast cancer. BMC Cancer 2008;8:165.

(3.) Kyoung, JH. Isolated FDG uptakes of axillary lymph nodes identified on PET/CT: Clinical significance and sonographic correlation. J Nucl Med 2012;53(Suppl 1):2148.

(4.) Sun WY, Choi YJ, Song YJ. Prediction of Axillary Nodal Status according to the Axillary Lymph Node to Primary Breast Tumor Maximum Standardized Uptake Value Ratio on 18F-fluorodeoxyglucose Positron Emission Tomography/Computed Tomography. Journal of Breast Disease 2016;4:92-9.

(5.) Sanuki J, Uchida Y, Uematsu T, Yamada Y, Kasami M. Axillary mass suspected to be occult breast carcinoma: a case study of skipped axillary lymph node metastasis from endometrial carcinoma in which core-needle biopsy was useful for diagnosis. Breast Cancer 2009;16:72-6.

(6.) Atallah C, Altinel G, Fu L, Arseneau J, Omeroglu A. Axillary Metastasis from an Occult Tubal Serous Carcinoma in a Patient with Ipsilateral Breast Carcinoma: a Potential Diagnostic Pitfall. Case Rep Pathol 2014;2014:534034.

(7.) Aalders JG, Abeler V, Kolstad P. Stage IV endometrial carcinoma: a clinical and histopathological study of 83 patients. Gynecol Oncol 1984;17:75-84.

(8.) Skagias L, Ntinis A, Vasou O, Kondi-Pafiti A, Politi E. Ovarian carcinoma presenting with axillary lymph node metastasis: a case diagnosed by fine-needle aspiration and brief review of the literature. Diagn Cytopathol 2008;36:891-3.

(9.) Euscher ED, Silva EG, Deavers MT, Elishaev E, Gershenson DM, Malpica A. Serous carcinoma of the ovary, fallopian tube, or peritoneum presenting as lymphadenopathy. Am J Surg Pathol 2004;28:1217-23.

(10.) Sangle N, Webb J, Jarboe EA. Serous Carcinoma of the Fallopian Tube Presenting as Axillary Lymphadenopathy. Int J Gynecol Pathol 2011;30:53-7.

(11.) Aydin C, Unalp HR, Baloglu A, Inci AG, Yigit S, Yavuzcan A. Axillary lymph node metastasis from serous ovarian cancer: a case report and review of the literature. Arch Gynecol Obstet 2009;279:203-7.

(12.) Goyal H, Mattoo VK, Singla U. Isolated Axillary Lymph Node Metastasis from Serous Ovarian Cancer. Case Rep Oncol Med 2012;2012:307567.

(13.) Hess KR, Varadhachary GR, Taylor SH, Wei W, Raber MN, Lenzi R, et al. Metastatic patterns in adenocarcinoma. Cancer 2006;106:1624-33.

(14.) Sughayer MA, Zakarneh L, Abu-Shakra R. Collision Metastasis of Breast and Ovarian Adenocarcinoma in Axillary Lymph Nodes: A Case Report and Review of the Literature. Pathol Oncol Res 2009;15:423-7.

[iD] Jalal Raoufi (1), [iD] Serhan Can Iscan (1), [iD] Candost Hanedan (1), [iD] Emine Elif Ozkan (2), [iD] Sevim Sureyya Cerci (3), [iD] Ebru Erdemoglu (4), [iD] Evrim Erdemoglu (1)

(1) Suleyman Demirel University Faculty of Medicine, Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Isparta, Turkey

(2) Suleyman Demirel University Faculty of Medicine, Department of Radiation Oncology, Isparta, Turkey

(3) Suleyman Demirel University Faculty of Medicine, Department of Nuclear Medicine, Isparta, Turkey

(4) Isparta Maternity and Children's Diseases Hospital, Clinic of Obstetrics and Gynecology, Isparta, Turkey

Address for Correspondence/Yazisma Adresi: Evrim Erdemoglu, MD,

Suleyman Demirel University Faculty of Medicine, Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Isparta, Turkey

Phone: +90 505 272 43 44 E-mail: evrimmd@yahoo.com ORCID ID: orcid.org/0000-0003-0826-7618

Received/Gelis Tarihi: 28.11.2017 Accepted/Kabul Tarihi: 26.04.2018

[c]Copyright 2018 by Turkish Society of Obstetrics and Gynecology

Turkish Journal of Obstetrics and Gynecology published by Galenos Publishing House.

DOI: 10.4274/tjod.12144
Table 1. Characteristic of gynecologic oncology patients with
suspicious axillary imaging in positron emission tomography/computed
tomography

              Endometrium      Ovarian           Cervical         p
              cancer           cancer            cancer
              n=93             n=99              n=59

Age           61.3[+ or -]7.8  57.2[+ or -]10.6  64.6[+ or -]8.8  >0.05
Suspicious    20 (21.5%)       14                6 (10.1%)        >0.05
axillary                       (14.1%)
lymph node
(n)
FDG uptake    9/20             7/14              3/6              >0.05
Parenchymal   11/20            7/14              3/6              >0.05
thickening
and loss of
fatty hilum
in lymph
nodes with a
diameter =10
mm, no FDG
uptake

FDG: Fluoro-D-glucose

Table 2. Positron emission tomography/computed tomography features,
maximum standardized uptake value values, and results of a suspicious
axillary lymph node imaging

Diagnosis of suspicious axillary lymph node in
Pre-treatment first PET/CT                      17/40 (42.5%)
Follow up PET/CT as a new finding               23/40 (57.5%)
Mean [SUV.sub.max]                               2.4[+ or -]2.3
[SUV.sub.max] cut-off
No FDG uptake                                   21 (52.5%)
<1.8                                             2 (5%)
>1.8                                            17 (42.5%)
Follow-up of suspicious axillary lymph nodes
Regression                                      28 (70%)
Progression                                      3 (7.5%)
Stable disease                                   9 (22.5%)

[SUV.sub.max]: Maximum standardized uptake value, PET/CT: Positron
emission tomography/computed tomography, FDG: Fluoro-D-glucose

Table 3. The treatment and follow-up of 40 patients with suspicious
axillary lymph node in positron emission tomography/computed tomography

             Stage       n  Treatment

             IA          7  Follow-up
             IB          3  Radiotherapy: 2 patients
                            Follow-up: 1 patient
             II          5  Radiotherapy: 4 patients
                            Radiotherapy and
                            chemotherapy: 1 patient
Endometrial  IIIC1       1  Chemotherapy
cancer       IIIC2       1  Radiotherapy and chemotherapy
             IVB         2  Chemotherapy: 1 patient
                            Refused surgical or medical
                            treatment for endometrial
                            cancer: 1 patient
             ?           1  After diagnosis with endometrial
                            biopsy she has had no follow-
                            up and treatment in our center
             IIC         2  Chemotherapy
             IIIA        1  Chemotherapy
             IIIB        4  Chemotherapy: 1 patient
Ovarian                     Radiotherapy and
                            chemotherapy: 3 patients
cancer       IIIC        5  Chemotherapy
             IV          1  Chemotherapy
             Serous      1  Follow-up
             borderline
             IA2         1  Follow-up
Cervical     IB1         1  Radiotherapy and chemotherapy
cancer       IVA         2  Radiotherapy and chemotherapy
             IVB         2  Radiotherapy and chemotherapy

?: After diagnosis with endometrial biopsy she hasn't had any follow up
and treatment in our center

Table 4. Deceased patients according to diagnostic subtype

Disease          n


                  6  [SUV.sub.max]  No FDG uptake (n=4)
Endometrial
cancer                              <1.8 (n=0)
                                    >1.8 (n=2)
                 10  [SUV.sub.max]  No FDG uptake (n=5)
Ovarian cancer                      <1.8 (n=0)
                                    >1.8 (n=5)
                  2  [SUV.sub.max]  No FDG uptake (n=2)
Cervical cancer                     <1.8 (n=0)
                                    >1.8 (n=0)

Disease          Average survival     p value
                 (months)

                 43.7 ([+ or -]21.0)
Endometrial
cancer            0
                 20 ([+ or -]4.2)     >0.05
                 43.8 ([+ or -]23.4)
Ovarian cancer    0
                 42.8 ([+ or -]11.9)  >0.05
                 35.5 ([+ or -]26.1)
Cervical cancer   0                   -
                  0

Disease          Description


                 Three died of their cancer and 1 of other reasons
Endometrial
cancer
                 One died of her cancer and 1 of other reasons
                 Died of cancer
Ovarian cancer
                 Died of cancer
                 Died of cancer
Cervical cancer

[SUV.sub.max]: Maximum standardized uptake value, FDG: Fluoro-D-glucose

Table 5. Patients who had axillary lymph node standardized uptake value
uptake >3 had intervention for histopathologic evaluation. Features of
patients who had an axillary needle core biopsy. No patient was found
to have axillary metastases in the pathologic evaluation

Patient  Primary disease   Age  Management of      [SUV.sub.max] of
                                primary tumor      axillary
                                                   lesion

1        Endometrium       61   Hysterectomy       10.46
         cancer,                +salpingo-
         mix                    oophorectomy
         endometrioid-          +pelvic and para-
         mucinous               aortic lymph node
         histology,             dissection
         grade 1 stage IA
2        Endometrium       75   Hysterectomy       6.16
         cancer,                +salpingo-
         endometrioid           oophorectomy
         histology,             +pelvic lymph
         grade 1                node dissection
         stage IA
3        Endometrium       67   Hysterectomy       5.49
         cancer,                +salpingo-
         mix                    oophorectomy
         endometrioid-          +pelvic and para-
         mucinous               aortic lymph node
         histology,             dissection
         grade 1,
         stage IA
4        Endometrium       74   Refused surgical   4.72
         cancer                 or medical
                                treatment for
                                endometrial
                                cancer
5        Cervical cancer,  68   Hysterectomy       4.29
         squamous cell,         +salpingo-
         stage IB2              oophorectomy

Patient  Other positive findings   Biopsy method      Biopsy result
         in PET/CT


1        Supraclavicular           Excisional biopsy  Follicular
         lymphadenopathy,          and axillary       lymphoma
         splenic hilar             dissection
         lymphadenopathy,
         splenic hypermetabolic
         lesion,
         gastric lesion
2        Suspicious mass in right  Fine needle        Breast ductal
         breast with SUV uptake    core biopsy        carcinoma
         4.09                      followed by right  metastasis
                                   quadrenectomy
                                   and axillary
                                   dissection
3        6 mm nodulary lesion in   Fine needle core   No tumor
         right lung                biopsy
         hypermetabolic
         mediastinal lymph
         nodes

4        Hypermetabolic            Fine needle core   No tumor
         nodulary lesion in        biopsy of axilla   in axilla and
         thyroid gland (SUV        and thyroid        Hurthle cell
         7.7)                                         neoplasia in
                                                      thyroid
5        Interlobar                Axillary           No tumor
         hypermetabolic            dissection
         lymphnodes in both
         lungs

Patient  Alive/dead

1        Alive

2        Alive

3        Alive

4        Died 23
         months
         after PET/
         CT imaging

5        Alive

[SUV.sub.max]: Maximum standardized uptake value, PET/CT: Positron
emission tomography/computed tomography
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Title Annotation:Clinical Investigation / Arastirma
Author:Raoufi, Jalal; Iscan, Serhan Can; Hanedan, Candost; Ozkan, Emine Elif; Cerci, Sevim Sureyya; Erdemog
Publication:Turkish Journal of Obstetrics and Gynecology
Article Type:Report
Date:Jun 1, 2018
Words:3694
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