{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,2,19]],"date-time":"2026-02-19T14:45:04Z","timestamp":1771512304354,"version":"3.50.1"},"reference-count":34,"publisher":"MDPI AG","issue":"7","license":[{"start":{"date-parts":[[2023,3,23]],"date-time":"2023-03-23T00:00:00Z","timestamp":1679529600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Embassy of the State of Kuwait"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Diagnostics"],"abstract":"<jats:p>18F-FDG positron emission tomography with computed tomography (PET\/CT) is a standard imaging modality for the nodal staging of non-small cell lung cancer (NSCLC). To improve the accuracy of pre-operative staging, we compare the staging accuracy of mediastinal lymph node (LN) standard uptake values (SUV) with four derived SUV ratios based on the SUV values of primary tumours (TR), the mediastinal blood pool (MR), liver (LR), and nodal size (SR). In 2015\u20132017, 53 patients (29 women and 24 men, mean age 67.4 years, range 53\u201387) receiving surgical resection have pre-operative evidence of mediastinal nodal involvement (cN2). Among these, 114 mediastinal nodes are resected and available for correlative PET\/CT analysis. cN2 status accuracy is low, with only 32.5% of the cN2 cases confirmed pathologically. Using receiver operating characteristic (ROC) curve analyses, a SUVmax of N2 LN performs well in predicting the presence of N2 disease (AUC, 0.822). Based on the respective selected thresholds for each ROC curve, normalisation of LN SUVmax to that for mediastinum, liver and tumour improved sensitivities of LN SUVmax from 68% to 81.1\u201389.2% while maintaining acceptable specificity (68\u201370.1%). In conclusion, normalised SUV ratios (particularly LR) improve current pre-operative staging performance in detecting mediastinal nodal involvement.<\/jats:p>","DOI":"10.3390\/diagnostics13071209","type":"journal-article","created":{"date-parts":[[2023,3,23]],"date-time":"2023-03-23T02:35:26Z","timestamp":1679538926000},"page":"1209","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":5,"title":["A Comparative Evaluation of Mediastinal Nodal SUVmax and Derived Ratios from 18F-FDG PET\/CT Imaging to Predict Nodal Metastases in Non-Small Cell Lung Cancer"],"prefix":"10.3390","volume":"13","author":[{"given":"Maha","family":"AlRasheedi","sequence":"first","affiliation":[{"name":"School of Cancer Sciences, University of Glasgow, Glasgow G61 1QH, UK"},{"name":"West of Scotland PET Centre, Gartnavel General Hospital, NHS Greater Glasgow and Clyde, Glasgow G12 0YN, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Sai","family":"Han","sequence":"additional","affiliation":[{"name":"West of Scotland PET Centre, Gartnavel General Hospital, NHS Greater Glasgow and Clyde, Glasgow G12 0YN, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Helene","family":"Thygesen","sequence":"additional","affiliation":[{"name":"School of Cancer Sciences, University of Glasgow, Glasgow G61 1QH, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Matt","family":"Neilson","sequence":"additional","affiliation":[{"name":"Cancer Research UK Beatson Institute, Garscube Estate, Switchback Road, Glasgow G61 1BD, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Fraser","family":"Hendry","sequence":"additional","affiliation":[{"name":"West of Scotland PET Centre, Gartnavel General Hospital, NHS Greater Glasgow and Clyde, Glasgow G12 0YN, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5947-1040","authenticated-orcid":false,"given":"Ahmed","family":"Alkarn","sequence":"additional","affiliation":[{"name":"Department of Respiratory Medicine, Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, Glasgow G4 0SF, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"John D.","family":"Maclay","sequence":"additional","affiliation":[{"name":"Department of Respiratory Medicine, Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, Glasgow G4 0SF, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3933-3975","authenticated-orcid":false,"given":"Hing Y.","family":"Leung","sequence":"additional","affiliation":[{"name":"School of Cancer Sciences, University of Glasgow, Glasgow G61 1QH, UK"},{"name":"Cancer Research UK Beatson Institute, Garscube Estate, Switchback Road, Glasgow G61 1BD, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2023,3,23]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"7","DOI":"10.3322\/caac.21654","article-title":"Cancer statistics, 2021","volume":"71","author":"Siegel","year":"2021","journal-title":"CA A Cancer J. Clin."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"76","DOI":"10.4103\/atm.ATM_243_17","article-title":"Causes of death in long-term survivors of non-small cell lung cancer: A regional surveillance, epidemiology, and end results study","volume":"13","author":"Kanitkar","year":"2018","journal-title":"Ann. Thorac. Med."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"625","DOI":"10.1038\/s41571-021-00520-1","article-title":"Selecting the optimal immunotherapy regimen in driver-negative metastatic NSCLC","volume":"18","author":"Grant","year":"2021","journal-title":"Nat. Rev. Clin. Oncol."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"422","DOI":"10.1097\/COC.0000000000000059","article-title":"Emerging immunotherapies in the treatment of non\u2013small cell lung cancer (NSCLC): The role of immune checkpoint inhibitors","volume":"38","author":"Langer","year":"2015","journal-title":"Am. J. Clin. Oncol."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"4561","DOI":"10.21037\/jtd.2017.10.129","article-title":"Long-term outcomes of stage I NSCLC (\u22643 cm) patients following segmentectomy are equivalent to lobectomy under analogous extent of lymph node removal: A PSM based analysis","volume":"9","author":"Qu","year":"2017","journal-title":"J. Thorac. Dis."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"1843","DOI":"10.1016\/j.jtcvs.2017.10.151","article-title":"The impact of enhanced recovery after surgery (ERAS) protocol compliance on morbidity from resection for primary lung cancer","volume":"155","author":"Rogers","year":"2018","journal-title":"J. Thorac. Cardiovasc. Surg."},{"key":"ref_7","first-page":"242","article-title":"Recurrence after surgery in patients with NSCLC","volume":"3","author":"Uramoto","year":"2014","journal-title":"Transl. Lung Cancer Res."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"15009","DOI":"10.1038\/nrdp.2015.9","article-title":"Non-small-cell lung cancer","volume":"1","author":"Gridelli","year":"2015","journal-title":"Nat. Rev. Dis. Prim."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"109619","DOI":"10.1016\/j.ejrad.2021.109619","article-title":"Diagnostic performance of preoperative CT in differentiating between benign and malignant origin of suspicious gallbladder lesions","volume":"138","author":"Kuipers","year":"2021","journal-title":"Eur. J. Radiol."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"109878","DOI":"10.1016\/j.ejrad.2021.109878","article-title":"Distinguishing benign and malignant lesions on contrast-enhanced breast cone-beam CT with deep learning neural architecture search","volume":"142","author":"Ma","year":"2021","journal-title":"Eur. J. Radiol."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"114","DOI":"10.1016\/j.ejrad.2017.05.001","article-title":"Differentiation and diagnosis of benign and malignant testicular lesions using 18F-FDG PET\/CT","volume":"93","author":"Shao","year":"2017","journal-title":"Eur. J. Radiol."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"701","DOI":"10.2967\/jnumed.111.095299","article-title":"Repeatability of 18F-FDG uptake measurements in tumors: A metaanalysis","volume":"53","author":"Vincent","year":"2012","journal-title":"J. Nucl. Med."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"e253","DOI":"10.1016\/j.cllc.2015.06.001","article-title":"Ratio of lymph node to primary tumor SUV on PET\/CT accurately predicts nodal malignancy in non\u2013small-cell lung cancer","volume":"16","author":"Mattes","year":"2015","journal-title":"Clin. Lung Cancer"},{"key":"ref_14","first-page":"784","article-title":"Within-patient variability of 18F-FDG: Standardized uptake values in normal tissues","volume":"45","author":"Paquet","year":"2004","journal-title":"J. Nucl. Med."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"328","DOI":"10.1007\/s00259-014-2961-x","article-title":"FDG PET\/CT: EANM procedure guidelines for tumour imaging: Version 2.0","volume":"42","author":"Boellaard","year":"2015","journal-title":"Eur. J. Nucl. Med. Mol. Imaging"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"21","DOI":"10.1186\/s13550-016-0177-8","article-title":"For avid glucose tumors, the SUV peak is the most reliable parameter for [18 F] FDG-PET\/CT quantification, regardless of acquisition time","volume":"6","author":"Sher","year":"2016","journal-title":"EJNMMI Res."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1186\/1471-2105-12-77","article-title":"pROC: An open-source package for R and S+ to analyze and compare ROC curves","volume":"12","author":"Robin","year":"2011","journal-title":"BMC Bioinform."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"901","DOI":"10.1080\/03610919708813417","article-title":"A comparison between bootstrap methods and generalized estimating equations for correlated outcomes in generalized linear models","volume":"26","author":"Sherman","year":"1997","journal-title":"Commun. Stat.-Simul. Comput."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"1622","DOI":"10.1016\/j.athoracsur.2016.06.071","article-title":"The quality of staging non-small cell lung cancer in the Netherlands: Data from the Dutch Lung Surgery Audit","volume":"102","author":"Heineman","year":"2016","journal-title":"Ann. Thorac. Surg."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"23","DOI":"10.1007\/s00330-006-0284-4","article-title":"Additional value of PET-CT in the staging of lung cancer: Comparison with CT alone, PET alone and visual correlation of PET and CT","volume":"17","author":"Ceyssens","year":"2007","journal-title":"Eur. Radiol."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"e211S","DOI":"10.1378\/chest.12-2355","article-title":"Methods for staging non-small cell lung cancer: Diagnosis and management of lung cancer: American College of Chest Physicians evidence-based clinical practice guidelines","volume":"143","author":"Silvestri","year":"2013","journal-title":"Chest"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"1919","DOI":"10.1056\/NEJMoa1709937","article-title":"Durvalumab after chemoradiotherapy in stage III non\u2013small-cell lung cancer","volume":"377","author":"Antonia","year":"2017","journal-title":"N. Engl. J. Med."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"1973","DOI":"10.1056\/NEJMoa2202170","article-title":"CheckMate 816 Investigators. Neoadjuvant nivolumab plus chemotherapy in resectable lung cancer","volume":"386","author":"Forde","year":"2022","journal-title":"N. Engl. J. Med."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"1711","DOI":"10.1056\/NEJMoa2027071","article-title":"Osimertinib in resected EGFR-mutated non\u2013small-cell lung cancer","volume":"383","author":"Wu","year":"2020","journal-title":"N. Engl. J. Med."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"63","DOI":"10.1186\/1749-8090-8-63","article-title":"The correlation of SUVmax with pathological characteristics of primary tumor and the value of Tumor\/Lymph node SUVmax ratio for predicting metastasis to lymph nodes in resected NSCLC patients","volume":"8","author":"Koksal","year":"2013","journal-title":"J. Cardiothorac. Surg."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"503","DOI":"10.21037\/jtd.2017.11.137","article-title":"Current role of standardized uptake valuemax-derived ratios in N2 fluorine-18 fluorodeoxyglucose positron-emission tomography non-small cell lung cancer","volume":"10","author":"Divisi","year":"2018","journal-title":"J. Thorac. Dis."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"51","DOI":"10.1016\/j.lungcan.2020.02.008","article-title":"Adherence to the mediastinal staging guideline and unforeseen N2 disease in patients with resectable non-small cell lung cancer: Nationwide results from the Dutch Lung Cancer Audit-Surgery","volume":"142","author":"Bousema","year":"2020","journal-title":"Lung Cancer"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"140","DOI":"10.1007\/s13139-016-0447-4","article-title":"Ratio of mediastinal lymph node SUV to primary tumor SUV in 18 F-FDG PET\/CT for nodal staging in non-small-cell lung cancer","volume":"51","author":"Cho","year":"2017","journal-title":"Nucl. Med. Mol. Imaging"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"41","DOI":"10.1007\/s13139-013-0244-2","article-title":"Characteristics of metastatic mediastinal lymph nodes of non-small cell lung cancer on preoperative F-18 FDG PET\/CT","volume":"48","author":"Lee","year":"2014","journal-title":"Nucl. Med. Mol. Imaging"},{"key":"ref_30","doi-asserted-by":"crossref","unstructured":"Namura, K., Minamimoto, R., Yao, M., Makiyama, K., Murakami, T., Sano, F., Hayashi, N., Tateishi, U., Ishigaki, H., and Kishida, T. (2010). Impact of maximum standardized uptake value (SUVmax) evaluated by 18-Fluoro-2-deoxy-D-glucose positron emission tomography\/computed tomography (18 F-FDG-PET\/CT) on survival for patients with advanced renal cell carcinoma: A preliminary report. BMC Cancer, 10.","DOI":"10.1186\/1471-2407-10-667"},{"key":"ref_31","first-page":"122S","article-title":"From RECIST to PERCIST: Evolving considerations for PET response criteria in solid tumors","volume":"50","author":"Wahl","year":"2009","journal-title":"J. Nucl. Med. Off. Publ. Soc. Nucl. Med."},{"key":"ref_32","first-page":"18","article-title":"Ratio of maximum standardized uptake value to primary tumor size is a prognostic factor in patients with advanced non-small cell lung cancer","volume":"4","author":"Chen","year":"2015","journal-title":"Transl. Lung Cancer Res."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"19","DOI":"10.1186\/s13550-016-0174-y","article-title":"An investigation of the relation between tumor-to-liver ratio (TLR) and tumor-to-blood standard uptake ratio (SUR) in oncological FDG PET","volume":"6","author":"Hofheinz","year":"2016","journal-title":"EJNMMI Res."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"4420","DOI":"10.3892\/ol.2017.5952","article-title":"Maximum standardized uptake value on FDG-PET predicts survival in stage I non-small cell lung cancer following carbon ion radiotherapy","volume":"13","author":"Shirai","year":"2017","journal-title":"Oncol. Lett."}],"container-title":["Diagnostics"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2075-4418\/13\/7\/1209\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T19:01:00Z","timestamp":1760122860000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2075-4418\/13\/7\/1209"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2023,3,23]]},"references-count":34,"journal-issue":{"issue":"7","published-online":{"date-parts":[[2023,4]]}},"alternative-id":["diagnostics13071209"],"URL":"https:\/\/doi.org\/10.3390\/diagnostics13071209","relation":{},"ISSN":["2075-4418"],"issn-type":[{"value":"2075-4418","type":"electronic"}],"subject":[],"published":{"date-parts":[[2023,3,23]]}}}