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The diagnostic ability of 18F-FDG PET/CT for mediastinal lymph node staging using 18F-FDG uptake and volumetric CT histogram analysis in non-small cell lung cancer



To evaluate the clinical implications of lymph node (LN) density on 18F-FDG PET/CT for mediastinal LN characterization in non-small cell lung cancer (NSCLC).


One hundred and fifty-two patients with 271 mediastinal LNs who underwent PET/CT and endobronchial ultrasound-guided transbronchial needle aspiration for staging were enrolled. Maximum standardized uptake value (SUVmax), short axis diameter, LN-to-primary cancer ratio of SUVmax, and median Hounsfield unit (HU) based on CT histogram were correlated to histopathology.


Of 271 nodes, 162 (59.8 %) were malignant. SUVmax, short axis diameter, and LPR of malignant LNs were higher than those of benign nodes. Among malignant LNs, 71.0 % had median HU between 25 and 45, while 78.9 % of benign LNs had values <25 HU or >45 HU. Using a cutoff value of 4.0, SUVmax showed the highest diagnostic ability for detecting malignant LNs with a specificity of 94.5 %, but showing a sensitivity of 70.4 %. Using additional density criteria (median HU 25-45) in LNs with 2.0< SUVmax ≤4.0, the sensitivity increased to 88.3 % with the specificity of 82.6 %.


LN density is useful for the characterization of LNs with mild 18F-FDG uptake. The risk of mediastinal LN metastasis in NSCLC patients could be further stratified using both 18F-FDG uptake and LN density.

Key Points

• SUVmax showed the highest diagnostic ability for detecting malignant LNs.

• LN density was useful in characterization of LNs with mild FDG uptake.

• SUVmax and LN density together could stratify the risk of LN metastasis.

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Receiver operating characteristics


Area under the curve


Concurrent chemoradiotherapy


Computational Environment for Radiotherapy Research


Endobronchial ultrasound-guided transbronchial needle aspiration


Lymph node


Lymph node-to-primary cancer ratio of SUVmax


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The authors are grateful to Jung Hwa Hong (Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Korea) for her statistical comments and analysis. The scientific guarantor of this publication is Jae-Hoon Lee, MD. The authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article. The authors state that this work has not received any funding. No complex statistical methods were necessary for this paper. Institutional Review Board approval was obtained. Written informed consent was waived by the Institutional Review Board. Methodology: Retrospective diagnostic study performed at one institution

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Correspondence to Jae-Hoon Lee.

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Lee, J.W., Kim, E.Y., Kim, D.J. et al. The diagnostic ability of 18F-FDG PET/CT for mediastinal lymph node staging using 18F-FDG uptake and volumetric CT histogram analysis in non-small cell lung cancer. Eur Radiol 26, 4515–4523 (2016).

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  • Lung cancer
  • 18F-FDG
  • Positron-Emission Tomography
  • Cancer staging
  • Lymph node