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Zhu J, Pan F, Cai H, Pan L, Li Y, Li L, Li Y, Wu X, Fan H. Positron emission tomography imaging of lung cancer: An overview of alternative positron emission tomography tracers beyond F18 fluorodeoxyglucose. Front Med (Lausanne) 2022; 9:945602. [PMID: 36275809 PMCID: PMC9581209 DOI: 10.3389/fmed.2022.945602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 08/31/2022] [Indexed: 11/13/2022] Open
Abstract
Lung cancer has been the leading cause of cancer-related mortality in China in recent decades. Positron emission tomography-computer tomography (PET/CT) has been established in the diagnosis of lung cancer. 18F-FDG is the most widely used PET tracer in foci diagnosis, tumor staging, treatment planning, and prognosis assessment by monitoring abnormally exuberant glucose metabolism in tumors. However, with the increasing knowledge on tumor heterogeneity and biological characteristics in lung cancer, a variety of novel radiotracers beyond 18F-FDG for PET imaging have been developed. For example, PET tracers that target cellular proliferation, amino acid metabolism and transportation, tumor hypoxia, angiogenesis, pulmonary NETs and other targets, such as tyrosine kinases and cancer-associated fibroblasts, have been reported, evaluated in animal models or under clinical investigations in recent years and play increasing roles in lung cancer diagnosis. Thus, we perform a comprehensive literature review of the radiopharmaceuticals and recent progress in PET tracers for the study of lung cancer biological characteristics beyond glucose metabolism.
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Affiliation(s)
- Jing Zhu
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China,Respiratory and Critical Care Medicine, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, China,NHC Key Laboratory of Nuclear Technology Medical Transformation, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, China
| | - Fei Pan
- Department of Nuclear Medicine, Laboratory of Clinical Nuclear Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Huawei Cai
- Department of Nuclear Medicine, Laboratory of Clinical Nuclear Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Lili Pan
- Department of Nuclear Medicine, Laboratory of Clinical Nuclear Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Yalun Li
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Lin Li
- Department of Nuclear Medicine, Laboratory of Clinical Nuclear Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - YunChun Li
- Department of Nuclear Medicine, Laboratory of Clinical Nuclear Medicine, West China Hospital, Sichuan University, Chengdu, China,Department of Nuclear Medicine, The Second People’s Hospital of Yibin, Yibin, China
| | - Xiaoai Wu
- Department of Nuclear Medicine, Laboratory of Clinical Nuclear Medicine, West China Hospital, Sichuan University, Chengdu, China,Xiaoai Wu,
| | - Hong Fan
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China,*Correspondence: Hong Fan,
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FLT-PET/CT in Non-Small Cell Lung Cancer treated with stereotactic body radiotherapy- A Pilot study. Adv Radiat Oncol 2022; 7:101037. [DOI: 10.1016/j.adro.2022.101037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 07/19/2022] [Indexed: 11/20/2022] Open
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Krarup MMK, Fischer BM, Christensen TN. New PET Tracers: Current Knowledge and Perspectives in Lung Cancer. Semin Nucl Med 2022; 52:781-796. [PMID: 35752465 DOI: 10.1053/j.semnuclmed.2022.05.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 05/04/2022] [Indexed: 11/11/2022]
Abstract
PET/CT with the tracer 2-[18F]fluoro-2-deoxy-D-glucose ([18F]FDG) has improved diagnostic imaging in cancer and is routinely used for diagnosing, staging and treatment planning in lung cancer patients. However, pitfalls of [18F]FDG-PET/CT limit the use in specific settings. Additionally, lung cancer is still the leading cause of cancer associated death and has high risk of recurrence after curative treatment. These circumstances have led to the continuous search for more sensitive and specific PET tracers to optimize lung cancer diagnosis, staging, treatment planning and evaluation. The objective of this review is to present and discuss current knowledge and perspectives of new PET tracers for use in lung cancer. A literature search was performed on PubMed and clinicaltrials.gov, limited to the past decade, excluding case reports, preclinical studies and studies on established tracers such as [18F]FDG and DOTATE. The most relevant papers from the search were evaluated. Several tracers have been developed targeting specific tumor characteristics and hallmarks of cancer. A small number of tracers have been studied extensively and evaluated head-to-head with [18F]FDG-PET/CT, whereas others need further investigation and validation in larger clinical trials. At this moment, none of the tracers can replace [18F]FDG-PET/CT. However, they might serve as supplementary imaging methods to provide more knowledge about biological tumor characteristics and visualize intra- and inter-tumoral heterogeneity.
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Affiliation(s)
- Marie M K Krarup
- Department of Clinical Physiology and Nuclear Medicine, Rigshospitalet Copehagen University Hospital, Copenhagen, Denmark.
| | - Barbara M Fischer
- Department of Clinical Medicine, Faculty of Health, Univeristy of Copenhagen (UCPH), Copenhagen, Denmark; School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Tine N Christensen
- Department of Clinical Physiology and Nuclear Medicine, Rigshospitalet Copehagen University Hospital, Copenhagen, Denmark
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Alwadani B, Dall'Angelo S, Fleming IN. Clinical value of 3'-deoxy-3'-[ 18F]fluorothymidine-positron emission tomography for diagnosis, staging and assessing therapy response in lung cancer. Insights Imaging 2021; 12:90. [PMID: 34213667 PMCID: PMC8253862 DOI: 10.1186/s13244-021-01026-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 06/02/2021] [Indexed: 12/09/2022] Open
Abstract
Lung cancer has the highest mortality rate of any tumour type. The main driver of lung tumour growth and development is uncontrolled cellular proliferation. Poor patient outcomes are partly the result of the limited range of effective anti-cancer therapies available and partly due to the limited accuracy of biomarkers to report on cell proliferation rates in patients. Accordingly, accurate methods of diagnosing, staging and assessing response to therapy are crucial to improve patient outcomes. One effective way of assessing cell proliferation is to employ non-invasive evaluation using 3'-deoxy-3'-[18F]fluorothymidine ([18F]FLT) positron emission tomography [18F]FLT-PET. [18F]FLT, unlike the most commonly used PET tracer [18F]fluorodeoxyglucose ([18F]FDG), can specifically report on cell proliferation and does not accumulate in inflammatory cells. Therefore, this radiotracer could exhibit higher specificity in diagnosis and staging, along with more accurate monitoring of therapy response at early stages in the treatment cycle. This review summarises and evaluates published studies on the clinical use of [18F]FLT to diagnose, stage and assess response to therapy in lung cancer.
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Affiliation(s)
- Bandar Alwadani
- Diagnostic Radiology Department, College of Applied Medical Sciences, Jazan University, Al Maarefah Rd, POB 114, Jazan, 45142, Saudi Arabia.,Institute of Medical Sciences, University of Aberdeen, Aberdeen, AB25 2ZD, UK
| | - Sergio Dall'Angelo
- Institute of Medical Sciences, University of Aberdeen, Aberdeen, AB25 2ZD, UK
| | - Ian N Fleming
- Institute of Medical Sciences, University of Aberdeen, Aberdeen, AB25 2ZD, UK.
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Christensen TN, Langer SW, Persson G, Larsen KR, Amtoft AG, Keller SH, Kjaer A, Fischer BM. Impact of [ 18F]FDG-PET and [ 18F]FLT-PET-Parameters in Patients with Suspected Relapse of Irradiated Lung Cancer. Diagnostics (Basel) 2021; 11:diagnostics11020279. [PMID: 33670242 PMCID: PMC7916960 DOI: 10.3390/diagnostics11020279] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 01/26/2021] [Accepted: 02/07/2021] [Indexed: 12/25/2022] Open
Abstract
Radiation-induced changes may cause a non-malignant high 2-deoxy-2-[18F]fluoro-d-glucose (FDG)-uptake. The 3′-deoxy-3′-[18F]fluorothymidine (FLT)-PET/CT performs better in the differential diagnosis of inflammatory changes and lung lesions with a higher specificity than FDG-PET/CT. We investigated the association between post-radiotherapy FDG-PET-parameters, FLT-PET-parameters, and outcome. Sixty-one patients suspected for having a relapse after definitive radiotherapy for lung cancer were included. All the patients had FDG-PET/CT and FLT-PET/CT. FDG-PET- and FLT-PET-parameters were collected from within the irradiated high-dose volume (HDV) and from recurrent pulmonary lesions. For associations between PET-parameters and relapse status, respectively, the overall survival was analyzed. Thirty patients had a relapse, of these, 16 patients had a relapse within the HDV. FDG-SUVmax and FLT-SUVmax were higher in relapsed HDVs compared with non-relapsed HDVs (median FDG-SUVmax: 12.8 vs. 4.2; p < 0.001; median FLT-SUVmax 3.9 vs. 2.2; p < 0.001). A relapse within HDV had higher FDG-SUVpeak (median FDG-SUVpeak: 7.1 vs. 3.5; p = 0.014) and was larger (median metabolic tumor volume (MTV50%): 2.5 vs. 0.7; 0.014) than the relapsed lesions outside of HDV. The proliferative tumor volume (PTV50%) was prognostic for the overall survival (hazard ratio: 1.07 pr cm3 [1.01–1.13]; p = 0.014) in the univariate analysis, but not in the multivariate analysis. FDG-SUVmax and FLT-SUVmax may be helpful tools for differentiating the relapse from radiation-induced changes, however, they should not be used definitively for relapse detection.
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Affiliation(s)
- Tine N. Christensen
- Department of Clinical Physiology, Nuclear Medicine & PET, Copenhagen University Hospital, Rigshospitalet, 2100 Copenhagen Ø, Denmark; (A.G.A.); (S.H.K.); (A.K.); (B.M.F.)
- Cluster for Molecular Imaging, University of Copenhagen, 2200 Copenhagen N, Denmark
- Correspondence:
| | - Seppo W. Langer
- Department of Oncology, Copenhagen University Hospital, Rigshospitalet, 2100 Copenhagen Ø, Denmark;
- Department of Clinical Medicine, University of Copenhagen, 2100 Copenhagen Ø, Denmark;
| | - Gitte Persson
- Department of Clinical Medicine, University of Copenhagen, 2100 Copenhagen Ø, Denmark;
- Department of Oncology, Herlev-Gentofte Hospital, University of Copenhagen, 2730 Herlev, Denmark
| | - Klaus Richter Larsen
- Department of Pulmonary Medicine, Bispebjerg University Hospital, 2400 Copenhagen NV, Denmark;
| | - Annemarie G. Amtoft
- Department of Clinical Physiology, Nuclear Medicine & PET, Copenhagen University Hospital, Rigshospitalet, 2100 Copenhagen Ø, Denmark; (A.G.A.); (S.H.K.); (A.K.); (B.M.F.)
| | - Sune H. Keller
- Department of Clinical Physiology, Nuclear Medicine & PET, Copenhagen University Hospital, Rigshospitalet, 2100 Copenhagen Ø, Denmark; (A.G.A.); (S.H.K.); (A.K.); (B.M.F.)
| | - Andreas Kjaer
- Department of Clinical Physiology, Nuclear Medicine & PET, Copenhagen University Hospital, Rigshospitalet, 2100 Copenhagen Ø, Denmark; (A.G.A.); (S.H.K.); (A.K.); (B.M.F.)
- Cluster for Molecular Imaging, University of Copenhagen, 2200 Copenhagen N, Denmark
| | - Barbara Malene Fischer
- Department of Clinical Physiology, Nuclear Medicine & PET, Copenhagen University Hospital, Rigshospitalet, 2100 Copenhagen Ø, Denmark; (A.G.A.); (S.H.K.); (A.K.); (B.M.F.)
- Department of Clinical Medicine, University of Copenhagen, 2100 Copenhagen Ø, Denmark;
- The PET Centre, School of Biomedical Engineering and Imaging Science, King’s College London, London SE1 7EH, UK
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Christensen TN, Langer SW, Villumsen KE, Johannesen HH, Löfgren J, Keller SH, Hansen AE, Kjaer A, Fischer BM. 18F-fluorothymidine (FLT)-PET and diffusion-weighted MRI for early response evaluation in patients with small cell lung cancer: a pilot study. Eur J Hybrid Imaging 2020; 4:2. [PMID: 34191195 PMCID: PMC8218141 DOI: 10.1186/s41824-019-0071-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 12/23/2019] [Indexed: 12/25/2022] Open
Abstract
Background Small cell lung cancer (SCLC) is an aggressive cancer often presenting in an advanced stage and prognosis is poor. Early response evaluation may have impact on the treatment strategy. Aim We evaluated 18F-fluorothymidine-(FLT)-PET/diffusion-weighted-(DW)-MRI early after treatment start to describe biological changes during therapy, the potential of early response evaluation, and the added value of FLT-PET/DW-MRI. Methods Patients with SCLC referred for standard chemotherapy were eligible. FLT-PET/DW-MRI of the chest and brain was acquired within 14 days after treatment start. FLT-PET/DW-MRI was compared with pretreatment FDG-PET/CT. Standardized uptake value (SUV), apparent diffusion coefficient (ADC), and functional tumor volumes were measured. FDG-SUVpeak, FLT-SUVpeak, and ADCmedian; spatial distribution of aggressive areas; and voxel-by-voxel analyses were evaluated to compare the biological information derived from the three functional imaging modalities. FDG-SUVpeak, FLT-SUVpeak, and ADCmedian were also analyzed for ability to predict final treatment response. Results Twelve patients with SCLC completed FLT-PET/MRI 1–9 days after treatment start. In nine patients, pretreatment FDG-PET/CT was available for comparison. A total of 16 T-sites and 12 N-sites were identified. No brain metastases were detected. FDG-SUVpeak was 2.0–22.7 in T-sites and 5.5–17.3 in N-sites. FLT-SUVpeak was 0.6–11.5 in T-sites and 1.2–2.4 in N-sites. ADCmedian was 0.76–1.74 × 10− 3 mm2/s in T-sites and 0.88–2.09 × 10−3 mm2/s in N-sites. FLT-SUVpeak correlated with FDG-SUVpeak, and voxel-by-voxel correlation was positive, though the hottest regions were dissimilarly distributed in FLT-PET compared to FDG-PET. FLT-SUVpeak was not correlated with ADCmedian, and voxel-by-voxel analyses and spatial distribution of aggressive areas varied with no systematic relation. LT-SUVpeak was significantly lower in responding lesions than non-responding lesions (mean FLT-SUVpeak in T-sites: 1.5 vs. 5.7; p = 0.007, mean FLT-SUVpeak in N-sites: 1.6 vs. 2.2; p = 0.013). Conclusions FLT-PET and DW-MRI performed early after treatment start may add biological information in patients with SCLC. Proliferation early after treatment start measured by FLT-PET is a promising predictor for final treatment response that warrants further investigation. Trial registration Clinicaltrials.gov, NCT02995902. Registered 11 December 2014 - Retrospectively registered.
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Affiliation(s)
- Tine Nøhr Christensen
- Department of Clinical Physiology, Nuclear Medicine & PET, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100, Copenhagen Ø, Denmark. .,Cluster for Molecular Imaging, University of Copenhagen, Copenhagen, Denmark.
| | - Seppo W Langer
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Katrine Engholm Villumsen
- Department of Clinical Physiology, Nuclear Medicine & PET, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100, Copenhagen Ø, Denmark
| | - Helle Hjorth Johannesen
- Department of Clinical Physiology, Nuclear Medicine & PET, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100, Copenhagen Ø, Denmark
| | - Johan Löfgren
- Department of Clinical Physiology, Nuclear Medicine & PET, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100, Copenhagen Ø, Denmark
| | - Sune Høgild Keller
- Department of Clinical Physiology, Nuclear Medicine & PET, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100, Copenhagen Ø, Denmark
| | - Adam Espe Hansen
- Department of Clinical Physiology, Nuclear Medicine & PET, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100, Copenhagen Ø, Denmark
| | - Andreas Kjaer
- Department of Clinical Physiology, Nuclear Medicine & PET, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100, Copenhagen Ø, Denmark.,Cluster for Molecular Imaging, University of Copenhagen, Copenhagen, Denmark
| | - Barbara Malene Fischer
- Department of Clinical Physiology, Nuclear Medicine & PET, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100, Copenhagen Ø, Denmark.,PET Centre, School of Biomedical Engineering and Imaging Science, Kings College London, London, UK
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Kairemo K, Santos EB, Macapinlac HA, Subbiah V. Early Response Assessment to Targeted Therapy Using 3'-deoxy-3'[(18)F]-Fluorothymidine ( 18F-FLT) PET/CT in Lung Cancer. Diagnostics (Basel) 2020; 10:diagnostics10010026. [PMID: 31935818 PMCID: PMC7169847 DOI: 10.3390/diagnostics10010026] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 12/25/2019] [Accepted: 01/02/2020] [Indexed: 01/01/2023] Open
Abstract
Although 2-deoxy-2-[18F]-fluoro-D-glucose positron emission tomography/computed tomography (18F-FDG PET/CT) is a sensitive nuclear medicine modality, specificity for characterizing lung cancer is limited. Tumor proliferation and early response to molecularly targeted therapy could be visualized using 3′-deoxy-3′[(18)F]-fluorothymidine (18F-FLT) PET/CT. The superiority of 18F-FLT PET/CT over 18F-FDG PET/CT in early therapeutic monitoring has been well described in patients after chemotherapy, radiotherapy, and/or chemo/radiotherapy. In thispilot study, we explorethe use of 18F-FLT PET/CT as an early response evaluation modality in patients with lung cancerand provide specific case studies of patients with small cell lung cancer and non-small cell lung cancer who received novel targeted therapies. Early response for c-MET inhibitor was observed in four weeks and for MDM2 inhibitor in nine days.
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Affiliation(s)
- Kalevi Kairemo
- Department of Nuclear Medicine, The University of Texas M.D. Anderson Cancer Center, Houston, TX 77030, USA; (K.K.); (H.A.M.)
| | - Elmer B. Santos
- Department of Nuclear Medicine, The University of Texas M.D. Anderson Cancer Center, Houston, TX 77030, USA; (K.K.); (H.A.M.)
- Correspondence: ; Tel.: +1-(713)-792-3008
| | - Homer A. Macapinlac
- Department of Nuclear Medicine, The University of Texas M.D. Anderson Cancer Center, Houston, TX 77030, USA; (K.K.); (H.A.M.)
| | - Vivek Subbiah
- Investigational Cancer Therapeutics, The University of Texas M.D. Anderson Cancer Center, Houston, TX 77030, USA;
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Filice A, Casali M, Ciammella P, Galaverni M, Fioroni F, Iotti C, Versari A. Radiotherapy Planning and Molecular Imaging in Lung Cancer. Curr Radiopharm 2020; 13:204-217. [PMID: 32186275 PMCID: PMC8206193 DOI: 10.2174/1874471013666200318144154] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 03/11/2019] [Accepted: 11/11/2019] [Indexed: 12/24/2022]
Abstract
INTRODUCTION In patients suitable for radical chemoradiotherapy for lung cancer, 18F-FDGPET/ CT is a proposed management to improve the accuracy of high dose radiotherapy. However, there is a high rate of locoregional failure in patients with locally advanced non-small cell lung cancer (NSCLC), probably due to the fact that standard dosing may not be effective in all patients. The aim of the present review was to address some criticisms associated with the radiotherapy image-guided in NSCLC. MATERIALS AND METHODS A systematic literature search was conducted. Only published articles that met the following criteria were included: articles, only original papers, radiopharmaceutical ([18F]FDG and any tracer other than [18F]FDG), target, only specific for lung cancer radiotherapy planning, and experimental design (eventually "in vitro" studies were excluded). Peer-reviewed indexed journals, regardless of publication status (published, ahead of print, in press, etc.) were included. Reviews, case reports, abstracts, editorials, poster presentations, and publications in languages other than English were excluded. The decision to include or exclude an article was made by consensus and any disagreement was resolved through discussion. RESULTS Hundred eligible full-text articles were assessed. Diverse information is now available in the literature about the role of FDG and new alternative radiopharmaceuticals for the planning of radiotherapy in NSCLC. In particular, the role of alternative technologies for the segmentation of FDG uptake is essential, although indeterminate for RT planning. The pros and cons of the available techniques have been extensively reported. CONCLUSION PET/CT has a central place in the planning of radiotherapy for lung cancer and, in particular, for NSCLC assuming a substantial role in the delineation of tumor volume. The development of new radiopharmaceuticals can help overcome the problems related to the disadvantage of FDG to accumulate also in activated inflammatory cells, thus improving tumor characterization and providing new prognostic biomarkers.
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Affiliation(s)
- Angelina Filice
- Address correspondence to this author at the Nuclear Medicine Unit, Azienda Unità Sanitaria Locale, Istituto di Ricovero e Cura a Carattere Scientifico, Reggio Emilia, Italy; E-mail:
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Telo S, Calderoni L, Vichi S, Zagni F, Castellucci P, Fanti S. Alternative and New Radiopharmaceutical Agents for Lung Cancer. Curr Radiopharm 2020; 13:185-194. [PMID: 31868150 PMCID: PMC8206190 DOI: 10.2174/1874471013666191223151402] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 01/27/2019] [Accepted: 11/11/2019] [Indexed: 01/06/2023]
Abstract
BACKGROUND FDG PET/CT imaging has an established role in lung cancer (LC) management. Whilst it is a sensitive technique, FDG PET/CT has a limited specificity in the differentiation between LC and benign conditions and is not capable of defining LC heterogeneity since FDG uptake varies between histotypes. OBJECTIVE To get an overview of new radiopharmaceuticals for the study of cancer biology features beyond glucose metabolism in LC. METHODS A comprehensive literature review of PubMed/Medline was performed using a combination of the following keywords: "positron emission tomography", "lung neoplasms", "non-FDG", "radiopharmaceuticals", "tracers". RESULTS Evidences suggest that proliferation markers, such as 18F-Fluorothymidine and 11CMethionine, improve LC staging and are useful in evaluating treatment response and progression free survival. 68Ga-DOTA-peptides are already routinely used in pulmonary neuroendocrine neoplasms (NENs) management and should be firstly performed in suspected NENs. 18F-Fluoromisonidazole and other radiopharmaceuticals show a promising impact on staging, prognosis assessment and therapy response in LC patients, by visualizing hypoxia and perfusion. Radiolabeled RGD-peptides, targeting angiogenesis, may have a role in LC staging, treatment outcome and therapy. PET radiopharmaceuticals tracing a specific oncogene/signal pathway, such as EGFR or ALK, are gaining interest especially for therapeutic implications. Other PET tracers, like 68Ga-PSMA-peptides or radiolabeled FAPIs, need more development in LC, though, they are promising for therapy purposes. CONCLUSION To date, the employment of most of the described tracers is limited to the experimental field, however, research development may offer innovative opportunities to improve LC staging, characterization, stratification and response assessment in an era of increased personalized therapy.
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Affiliation(s)
- Silvi Telo
- Address correspondence to this author at the Department of Metropolitan Nuclear Medicine, University of Bologna, Bologna, Italy; Tel/Fax: +390512143959; E-mail:
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Tamal M. A hybrid region growing tumour segmentation method for low contrast and high noise Nuclear Medicine (NM) images by combining a novel non-linear diffusion filter and global gradient measure (HNDF-GGM-RG). Heliyon 2019; 5:e02993. [PMID: 31879709 PMCID: PMC6920261 DOI: 10.1016/j.heliyon.2019.e02993] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 09/26/2019] [Accepted: 12/03/2019] [Indexed: 10/27/2022] Open
Abstract
Poor spatial resolution and low signal-to-noise ratio (SNR) along with the finite image sampling constraint make lesion segmentation on Nuclear Medicine (NM) images (e.g., PET-Positron Emission Tomography) a challenging task. Since the size, signal-to-background ratio (SBR) and SNR of lesion vary within and between patients, performance of the conventional segmentation methods are not consistent against statistical fluctuations. To overcome these limitations, a hybrid region growing segmentation method is proposed combining non-linear diffusion filter and global gradient measure (HNDF-GGM-RG). The performance of the algorithm is validated on PET images and compared with the 40%-fixed threshold and a state-of-the-art active contour (AC) methods. Segmented volume, dice similarity coefficient (DSC) and percentage classification error (% CE) were used as the quantitative figures of merit (FOM) using the torso NEMA phantom that contains six different sizes of spheres. A 2:1 SBR was created between the spheres and background and the phantom was scanned with a Siemens TrueV PET-CT scanner. 40T method is SNR dependent and overestimates the volumes ( ≈ 4.5 times ) . AC volumes match with the true volumes only for the largest three spheres. On the other hand, the proposed HNDF-GGM-RG volumes match closely with the true volumes irrespective of the size and SNR. Average DSC of 0.32 and 0.66 and % CE of 700% and 160% were achieved by the 40T and AC methods respectively. Conversely, average DSC and %CE are 0.70 and 60% for HNDF-GGM-RG and less dependent on SNR. Since two-sample t-test indicates that the performance of AC and HNDF-GGM-RG are statistically significant for the smallest three spheres and similar for the rest, HNDF-GGM-RG can be applied where the size, SBR and SNR are subject to change either due to alterations in the radiotracer uptake because of treatment or uptake variability of different radiotracers because of differences in their molecular pathways.
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Affiliation(s)
- Mahbubunnabi Tamal
- Department of Biomedical Engineering, Imam Abdulrahman Bin Faisal University, PO Box 1982, Dammam, 31441, Saudi Arabia
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A phantom study to assess the reproducibility, robustness and accuracy of PET image segmentation methods against statistical fluctuations. PLoS One 2019; 14:e0219127. [PMID: 31283779 PMCID: PMC6613706 DOI: 10.1371/journal.pone.0219127] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 06/17/2019] [Indexed: 01/21/2023] Open
Abstract
Background Automatic and semi-automatic segmentation methods for PET serve as alternatives to manual delineation and eliminate observer variability. The robustness of these segmentation methods against statistical fluctuations arising from variable size, contrast and noise are vital for providing reliable clinical outcomes for diagnosis and treatment response assessment. In this study, the performances of several segmentation methods have been investigated using the torso NEMA phantom against statistical fluctuations. Methods The six hot spheres (0.5-27ml) and the background of the phantom were filled with different activities of 18F to yield 2:1 and 4:1 contrast ratios. The phantom was scanned on a TrueV PET-CT scanner for 120 minutes. The images were reconstructed using OSEM (4iterations-21subsets) for different durations (15, 20, 34 and 67 minutes) to represent different noise levels and smoothed with a 4-mm Gaussian filter. Each sphere with different settings was delineated using a fixed 40% threshold (40T), fuzzy clustering mean (FCM), adaptive threshold and region based variational (C-V) segmentation methods and compared with the gold standard volume, which was estimated from the known diameter and position of each sphere. Results The smallest three spheres at the 2:1 contrast level are not evaluable for the 40T method. For the other spheres, the 40T method grossly overestimates the volumes and the segmented volumes are highly dependent on the statistical variations. These volumes are the least reproducible (80%) with a mean Dice Similarity Coefficient (DSC) of 0.67 and 90% classification error (CE). The other three methods reduce the dependency on noise and contrast in a similar manner by providing low bias (<10%) and CE (<25%) as well as a high DSC (0.88) and reproducibility (30%) for objects >17mm in diameter. However, for the smallest three spheres at a 2:1 contrast level, the performances of all three methods were significantly low, with the adaptive method being superior to the FCM and C-V (mean bias 168% and 350%, mean DSC 0.65 and 0.50, mean CE 227% and 454% for the adaptive and other two methods (approximately similar for FCM and C-V), respectively). Conclusions The segmentation accuracy of the fixed threshold-based method depends on size, contrast and noise. The intensity thresholds determined by the adaptive threshold methods are less sensitive to noise and therefore, the segmented volumes are more reproducible across different acquisition durations. A similar performance can be achieved with the FCM and C-V methods. Though, for small lesions (< 2cm diameter) with low counts and contrast, the adaptive threshold-based method outperforms the FCM and C-V methods, and the performance of neither of these methods is optimal for volumes <2cm in diameter. These three methods can only reliably be used to delineate tumours for diagnostic and monitoring purposes provided that the contrast between the tumour and background is not below a 2:1 ratio and the size of the tumour does not fall not below 2cm in diameter in response to treatment. They can also be used for different radiotracers with variable uptake. However, the FCM and C-V methods have the advantage of not requiring calibrations for different scanners and settings.
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12
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Hiniker SM, Sodji Q, Quon A, Gutkin PM, Arksey N, Graves EE, Chin FT, Maxim PG, Diehn M, Loo BW. FLT-PET-CT for the Detection of Disease Recurrence After Stereotactic Ablative Radiotherapy or Hyperfractionation for Thoracic Malignancy: A Prospective Pilot Study. Front Oncol 2019; 9:467. [PMID: 31214507 PMCID: PMC6555304 DOI: 10.3389/fonc.2019.00467] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 05/15/2019] [Indexed: 02/01/2023] Open
Abstract
Differentiating local recurrence from post-treatment changes on PET scans following stereotactic ablative radiotherapy (SABR) or hyperfractionation for lung tumors is challenging. We performed a prospective pilot study of 3-deoxy-3-[18F]-fluorothymidine (FLT)-PET-CT in patients with equivocal post-radiation FDG-PET-CT to assess disease recurrence. Methods: We prospectively enrolled 10 patients, 9 treated with SABR and 1 with hyperfractionated external beam radiotherapy for thoracic malignancy with subsequent equivocal follow-up FDG-PET-CT, to undergo FLT-PET-CT prior to biopsy or serial imaging. FLT-PET scans were interpreted by a radiologist with experience in reading FLT-PET-CT and blinded to the results of any subsequent biopsy or imaging. Results: Of the 10 patients enrolled, 8 were evaluable after FLT-PET-CT. Based on the FLT-PET-CT, a blinded radiologist accurately predicted disease recurrence vs. inflammatory changes in 7 patients (87.5%). The combination of higher lesion SUVmax and higher ratio of lesion SUVmax to SUVmax of mediastinal blood pool was indicative of recurrence. Qualitative assessment of increased degree of focality of the lesion also appears to be indicative of disease recurrence. Conclusion: Adjunctive FLT-PET-CT imaging can complement FDG-PET-CT scan in distinguishing post-treatment radiation changes from disease recurrence in thoracic malignancies. These findings support the investigation of FLT-PET-CT in a larger prospective study.
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Affiliation(s)
- Susan M Hiniker
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, United States.,Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA, United States
| | - Quaovi Sodji
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, United States.,Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA, United States
| | - Andrew Quon
- Department of Nuclear Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | - Paulina M Gutkin
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, United States
| | - Natasha Arksey
- Department of Nuclear Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | - Edward E Graves
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, United States
| | - Frederick T Chin
- Department of Nuclear Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | - Peter G Maxim
- Department of Radiation Oncology, Indiana University, Indianapolis, IN, United States
| | - Maximilian Diehn
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, United States.,Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA, United States
| | - Billy W Loo
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, United States.,Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA, United States
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13
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Press RH, Shu HKG, Shim H, Mountz JM, Kurland BF, Wahl RL, Jones EF, Hylton NM, Gerstner ER, Nordstrom RJ, Henderson L, Kurdziel KA, Vikram B, Jacobs MA, Holdhoff M, Taylor E, Jaffray DA, Schwartz LH, Mankoff DA, Kinahan PE, Linden HM, Lambin P, Dilling TJ, Rubin DL, Hadjiiski L, Buatti JM. The Use of Quantitative Imaging in Radiation Oncology: A Quantitative Imaging Network (QIN) Perspective. Int J Radiat Oncol Biol Phys 2018; 102:1219-1235. [PMID: 29966725 PMCID: PMC6348006 DOI: 10.1016/j.ijrobp.2018.06.023] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Revised: 05/25/2018] [Accepted: 06/14/2018] [Indexed: 02/07/2023]
Abstract
Modern radiation therapy is delivered with great precision, in part by relying on high-resolution multidimensional anatomic imaging to define targets in space and time. The development of quantitative imaging (QI) modalities capable of monitoring biologic parameters could provide deeper insight into tumor biology and facilitate more personalized clinical decision-making. The Quantitative Imaging Network (QIN) was established by the National Cancer Institute to advance and validate these QI modalities in the context of oncology clinical trials. In particular, the QIN has significant interest in the application of QI to widen the therapeutic window of radiation therapy. QI modalities have great promise in radiation oncology and will help address significant clinical needs, including finer prognostication, more specific target delineation, reduction of normal tissue toxicity, identification of radioresistant disease, and clearer interpretation of treatment response. Patient-specific QI is being incorporated into radiation treatment design in ways such as dose escalation and adaptive replanning, with the intent of improving outcomes while lessening treatment morbidities. This review discusses the current vision of the QIN, current areas of investigation, and how the QIN hopes to enhance the integration of QI into the practice of radiation oncology.
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Affiliation(s)
- Robert H. Press
- Dept. of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - Hui-Kuo G. Shu
- Dept. of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - Hyunsuk Shim
- Dept. of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - James M. Mountz
- Dept. of Radiology, University of Pittsburgh, Pittsburgh, PA
| | | | | | - Ella F. Jones
- Dept. of Radiology, University of California, San Francisco, San Francisco, CA
| | - Nola M. Hylton
- Dept. of Radiology, University of California, San Francisco, San Francisco, CA
| | - Elizabeth R. Gerstner
- Dept. of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | | | - Lori Henderson
- Cancer Imaging Program, National Cancer Institute, Bethesda, MD
| | | | - Bhadrasain Vikram
- Radiation Research Program/Division of Cancer Treatment & Diagnosis, National Cancer Institute, Bethesda, MD
| | - Michael A. Jacobs
- Dept. of Radiology and Radiological Science, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore MD
| | - Matthias Holdhoff
- Brain Cancer Program, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore MD
| | - Edward Taylor
- Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - David A. Jaffray
- Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | | | - David A. Mankoff
- Dept. of Radiology, University of Pennsylvania, Philadelphia, PA
| | | | | | - Philippe Lambin
- Dept. of Radiation Oncology (MAASTRO), GROW-School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Thomas J. Dilling
- Dept. of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | | | | | - John M. Buatti
- Dept. of Radiation Oncology, University of Iowa, Iowa City, IA
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14
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Grootjans W, de Geus-Oei LF, Bussink J. Image-guided adaptive radiotherapy in patients with locally advanced non-small cell lung cancer: the art of PET. THE QUARTERLY JOURNAL OF NUCLEAR MEDICINE AND MOLECULAR IMAGING : OFFICIAL PUBLICATION OF THE ITALIAN ASSOCIATION OF NUCLEAR MEDICINE (AIMN) [AND] THE INTERNATIONAL ASSOCIATION OF RADIOPHARMACOLOGY (IAR), [AND] SECTION OF THE SOCIETY OF RADIOPHARMACEUTICAL CHEMISTRY AND BIOLOGY 2018; 62:369-384. [PMID: 29869486 DOI: 10.23736/s1824-4785.18.03084-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
With a worldwide annual incidence of 1.8 million cases, lung cancer is the most diagnosed form of cancer in men and the third most diagnosed form of cancer in women. Histologically, 80-85% of all lung cancers can be categorized as non-small cell lung cancer (NSCLC). For patients with locally advanced NSCLC, standard of care is fractionated radiotherapy combined with chemotherapy. With the aim of improving clinical outcome of patients with locally advanced NSCLC, combined and intensified treatment approaches are increasingly being used. However, given the heterogeneity of this patient group with respect to tumor biology and subsequent treatment response, a personalized treatment approach is required to optimize therapeutic effect and minimize treatment induced toxicity. Medical imaging, in particular positron emission tomography (PET), before and during the course radiotherapy is increasingly being used to personalize radiotherapy. In this setting, PET imaging can be used to improve delineation of target volumes, employ molecularly-guided dose painting strategies, early response monitoring, prediction and monitoring of treatment-related toxicity. The concept of PET image-guided adaptive radiotherapy (IGART) is an interesting approach to personalize radiotherapy for patients with locally advanced NSCLC, which might ultimately contribute to improved clinical outcomes and reductions in frequency of treatment-related adverse events in this patient group. In this review, we provide a comprehensive overview of available clinical data supporting the use of PET imaging for IGART in patients with locally advanced NSCLC.
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Affiliation(s)
- Willem Grootjans
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands -
| | - Lioe-Fee de Geus-Oei
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Johan Bussink
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
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15
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Kramer GM, Liu Y, de Langen AJ, Jansma EP, Trigonis I, Asselin MC, Jackson A, Kenny L, Aboagye EO, Hoekstra OS, Boellaard R. Repeatability of quantitative 18F-FLT uptake measurements in solid tumors: an individual patient data multi-center meta-analysis. Eur J Nucl Med Mol Imaging 2018; 45:951-961. [PMID: 29362858 PMCID: PMC5915500 DOI: 10.1007/s00259-017-3923-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Accepted: 12/26/2017] [Indexed: 12/26/2022]
Abstract
INTRODUCTION 3'-deoxy-3'-[18F]fluorothymidine (18F-FLT) positron emission tomography (PET) provides a non-invasive method to assess cellular proliferation and response to antitumor therapy. Quantitative 18F-FLT uptake metrics are being used for evaluation of proliferative response in investigational setting, however multi-center repeatability needs to be established. The aim of this study was to determine the repeatability of 18F-FLT tumor uptake metrics by re-analyzing individual patient data from previously published reports using the same tumor segmentation method and repeatability metrics across cohorts. METHODS A systematic search in PubMed, EMBASE.com and the Cochrane Library from inception-October 2016 yielded five 18F-FLT repeatability cohorts in solid tumors. 18F-FLT avid lesions were delineated using a 50% isocontour adapted for local background on test and retest scans. SUVmax, SUVmean, SUVpeak, proliferative volume and total lesion uptake (TLU) were calculated. Repeatability was assessed using the repeatability coefficient (RC = 1.96 × SD of test-retest differences), linear regression analysis, and the intra-class correlation coefficient (ICC). The impact of different lesion selection criteria was also evaluated. RESULTS Images from four cohorts containing 30 patients with 52 lesions were obtained and analyzed (ten in breast cancer, nine in head and neck squamous cell carcinoma, and 33 in non-small cell lung cancer patients). A good correlation was found between test-retest data for all 18F-FLT uptake metrics (R2 ≥ 0.93; ICC ≥ 0.96). Best repeatability was found for SUVpeak (RC: 23.1%), without significant differences in RC between different SUV metrics. Repeatability of proliferative volume (RC: 36.0%) and TLU (RC: 36.4%) was worse than SUV. Lesion selection methods based on SUVmax ≥ 4.0 improved the repeatability of volumetric metrics (RC: 26-28%), but did not affect the repeatability of SUV metrics. CONCLUSIONS In multi-center studies, differences ≥ 25% in 18F-FLT SUV metrics likely represent a true change in tumor uptake. Larger differences are required for FLT metrics comprising volume estimates when no lesion selection criteria are applied.
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Affiliation(s)
- G M Kramer
- Department of Radiology and Nuclear Medicine, VU University Medical Center, PO Box 7057, 1007 MB, Amsterdam, Netherlands.
| | - Y Liu
- European Organisation for Research and Treatment for Cancer (EORTC), Headquarters, Brussels, Belgium
| | - A J de Langen
- Department of Pulmonology, VU University Medical Center, PO Box 7057, 1007 MB, Amsterdam, Netherlands
| | - E P Jansma
- Medical Library, VU University Medical Center, PO Box 7057, 1007 MB, Amsterdam, The Netherlands
| | - I Trigonis
- Division of Informatics, Imaging and Data Sciences Institute of Population Health, Wolfson Molecular Imaging Centre, Manchester Academic Health Sciences Centre, The University of Manchester, Manchester, UK
| | - M-C Asselin
- Division of Informatics, Imaging and Data Sciences Institute of Population Health, Wolfson Molecular Imaging Centre, Manchester Academic Health Sciences Centre, The University of Manchester, Manchester, UK
| | - A Jackson
- Division of Informatics, Imaging and Data Sciences Institute of Population Health, Wolfson Molecular Imaging Centre, Manchester Academic Health Sciences Centre, The University of Manchester, Manchester, UK
| | - L Kenny
- Department of Surgery and Cancer, Imperial College London, Hammersmith Campus, London, UK
| | - E O Aboagye
- Department of Surgery and Cancer, Imperial College London, Hammersmith Campus, London, UK
| | - O S Hoekstra
- Department of Radiology and Nuclear Medicine, VU University Medical Center, PO Box 7057, 1007 MB, Amsterdam, Netherlands
| | - R Boellaard
- Department of Radiology and Nuclear Medicine, VU University Medical Center, PO Box 7057, 1007 MB, Amsterdam, Netherlands
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16
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Salem A, Mistry H, Backen A, Hodgson C, Koh P, Dean E, Priest L, Haslett K, Trigonis I, Jackson A, Asselin MC, Dive C, Renehan A, Faivre-Finn C, Blackhall F. Cell Death, Inflammation, Tumor Burden, and Proliferation Blood Biomarkers Predict Lung Cancer Radiotherapy Response and Correlate With Tumor Volume and Proliferation Imaging. Clin Lung Cancer 2018; 19:239-248.e7. [PMID: 29398577 PMCID: PMC5927801 DOI: 10.1016/j.cllc.2017.12.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 11/21/2017] [Accepted: 12/01/2017] [Indexed: 12/25/2022]
Abstract
INTRODUCTION There is an unmet need to develop noninvasive biomarkers to stratify patients in drug-radiotherapy trials. In this pilot study we investigated lung cancer radiotherapy response and toxicity blood biomarkers and correlated findings with tumor volume and proliferation imaging. PATIENTS AND METHODS Blood samples were collected before and during (day 21) radiotherapy. Twenty-six cell-death, hypoxia, angiogenesis, inflammation, proliferation, invasion, and tumor-burden biomarkers were evaluated. Clinical and laboratory data were collected. Univariate analysis was performed on small-cell and non-small-cell lung cancer (NSCLC) whereas multivariate analysis focused on NSCLC. RESULTS Blood samples from 78 patients were analyzed. Sixty-one (78.2%) harbored NSCLC, 48 (61.5%) received sequential chemoradiotherapy. Of tested baseline biomarkers, undetectable interleukin (IL)-1b (hazard ratio [HR], 4.02; 95% confidence interval [CI], 2.04-7.93; P < .001) was the only significant survival covariate. Of routinely collected laboratory tests, high baseline neutrophil count was a significant survival covariate (HR, 1.07; 95% CI, 1.02-1.11; P = .017). Baseline IL-1b and neutrophil count were prognostic for survival in a multivariate model. The addition of day-21 cytokeratin-19 antigen modestly improved this model's survival prediction (concordance probability, 0.75-0.78). Chemotherapy (P < .001) and baseline keratinocyte growth factor (P = .019) predicted acute esophagitis, but only chemotherapy remained significant after Bonferroni correction. Baseline angioprotein-1 and hepatocyte growth factor showed a direct correlation with tumor volume whereas changes in vascular cell adhesion molecule 1 showed significant correlations with 18F-fluorothymidine (FLT) positron emission tomography (PET). CONCLUSION Select biomarkers are prognostic after radiotherapy in this lung cancer series. The correlation between circulating biomarkers and 18F-FLT PET is shown, to our knowledge for the first time, highlighting their potential role as imaging surrogates.
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Affiliation(s)
- Ahmed Salem
- Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom.
| | - Hitesh Mistry
- Division of Pharmacy, University of Manchester, Manchester, United Kingdom
| | - Alison Backen
- Institute of Cancer Sciences, University of Manchester, Manchester, United Kingdom
| | - Clare Hodgson
- Clinical and Experimental Pharmacology Group, Cancer Research UK Manchester Institute, Manchester, United Kingdom
| | - Pek Koh
- Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
| | - Emma Dean
- Early Phase Oncology, AstraZeneca, Cambridge, United Kingdom
| | - Lynsey Priest
- Clinical and Experimental Pharmacology Group, Cancer Research UK Manchester Institute, Manchester, United Kingdom
| | - Kate Haslett
- Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
| | - Ioannis Trigonis
- Division of Informatics, Imaging and Data Sciences, University of Manchester, Manchester, United Kingdom
| | - Alan Jackson
- Division of Informatics, Imaging and Data Sciences, University of Manchester, Manchester, United Kingdom
| | - Marie-Claude Asselin
- Division of Informatics, Imaging and Data Sciences, University of Manchester, Manchester, United Kingdom
| | - Caroline Dive
- Clinical and Experimental Pharmacology Group, Cancer Research UK Manchester Institute, Manchester, United Kingdom
| | - Andrew Renehan
- Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
| | - Corinne Faivre-Finn
- Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
| | - Fiona Blackhall
- Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
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17
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Scarpelli M, Eickhoff J, Cuna E, Perlman S, Jeraj R. Optimal transformations leading to normal distributions of positron emission tomography standardized uptake values. Phys Med Biol 2018; 63:035021. [PMID: 29235988 DOI: 10.1088/1361-6560/aaa175] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The statistical analysis of positron emission tomography (PET) standardized uptake value (SUV) measurements is challenging due to the skewed nature of SUV distributions. This limits utilization of powerful parametric statistical models for analyzing SUV measurements. An ad-hoc approach, which is frequently used in practice, is to blindly use a log transformation, which may or may not result in normal SUV distributions. This study sought to identify optimal transformations leading to normally distributed PET SUVs extracted from tumors and assess the effects of therapy on the optimal transformations. METHODS The optimal transformation for producing normal distributions of tumor SUVs was identified by iterating the Box-Cox transformation parameter (λ) and selecting the parameter that maximized the Shapiro-Wilk P-value. Optimal transformations were identified for tumor SUVmax distributions at both pre and post treatment. This study included 57 patients that underwent 18F-fluorodeoxyglucose (18F-FDG) PET scans (publically available dataset). In addition, to test the generality of our transformation methodology, we included analysis of 27 patients that underwent 18F-Fluorothymidine (18F-FLT) PET scans at our institution. RESULTS After applying the optimal Box-Cox transformations, neither the pre nor the post treatment 18F-FDG SUV distributions deviated significantly from normality (P > 0.10). Similar results were found for 18F-FLT PET SUV distributions (P > 0.10). For both 18F-FDG and 18F-FLT SUV distributions, the skewness and kurtosis increased from pre to post treatment, leading to a decrease in the optimal Box-Cox transformation parameter from pre to post treatment. There were types of distributions encountered for both 18F-FDG and 18F-FLT where a log transformation was not optimal for providing normal SUV distributions. CONCLUSION Optimization of the Box-Cox transformation, offers a solution for identifying normal SUV transformations for when the log transformation is insufficient. The log transformation is not always the appropriate transformation for producing normally distributed PET SUVs.
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Affiliation(s)
- Matthew Scarpelli
- Department of Medical Physics, University of Wisconsin, 1111 Highland Ave, Room 1005, Madison, WI 53792, United States of America
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18
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Abstract
F18 Flurodeoxyglucose (FDG) is a nonspecific PET tracer representing tumor energy metabolism, with common false-positive and false-negative findings in clinical practice. Non-small cell lung cancer is highly heterogeneous histologically, biologically, and molecularly. Novel PET tracers designed to characterize a specific aspect of tumor biology or a pathway-specific molecular target have the potential to provide noninvasive key information in tumor heterogeneity for patient stratification and in the assessment of treatment response. Non-FDG PET tracers, including 68Ga-somatostatin analogs, and some PET tracers targeting tumor proliferation, hypoxia, angiogenesis, and pathway-specific targets are briefly reviewed in this article.
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Affiliation(s)
- Gang Cheng
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA.
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19
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Early assessment of response to induction therapy in acute myeloid leukemia using 18F-FLT PET/CT. EJNMMI Res 2017; 7:75. [PMID: 28916904 PMCID: PMC5602811 DOI: 10.1186/s13550-017-0326-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 09/07/2017] [Indexed: 12/24/2022] Open
Abstract
Background We evaluated the suitability of 18F-fluorodeoxythymidine (18F-FLT) positron emission tomography (PET)/computed tomography (CT) for assessment of the early response to induction therapy and its value for predicting clinical outcome in patients with acute myeloid leukemia (AML). Adult patients who had histologically confirmed AML and received induction therapy were enrolled. All patients underwent 18F-FLT PET/CT after completion of induction. PET/CT images were visually and quantitatively assessed. Cases with intensely increased bone marrow uptake in more than one third of the long bones and throughout the central skeleton were interpreted as PET-positive for resistant disease (RD). PET results were compared to the clinical response and outcome. Results In visual PET analysis of 10 eligible patients (7 male, 3 female; median age 58 years), 5 patients were interpreted as being PET-positive and 5 as PET-negative. Standardized uptake values were significantly different between PET-positive and PET-negative groups. Eight of 10 patients achieved clinical complete remission (CR)/CR with incomplete blood count recovery (CRi). Five CR/CRi patients had PET-negative findings, but 3 CR patients had PET-positive findings. Both of the RD patients had PET-positive findings. During follow-up, 2 CR patients with PET-positive findings relapsed, or were strongly suspected of relapse, 4 months after consolidation. Conclusion 18F-FLT PET/CT after induction therapy showed good sensitivity and negative-predictive value for evaluating RD in patients with AML. This preliminary study suggests that 18F-FLT PET/CT may be valuable as a noninvasive tool for early assessment of the response to treatment and may provide prognostic value for survival in patients with AML.
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Everitt S, Ball D, Hicks RJ, Callahan J, Plumridge N, Trinh J, Herschtal A, Kron T, Mac Manus M. Prospective Study of Serial Imaging Comparing Fluorodeoxyglucose Positron Emission Tomography (PET) and Fluorothymidine PET During Radical Chemoradiation for Non-Small Cell Lung Cancer: Reduction of Detectable Proliferation Associated With Worse Survival. Int J Radiat Oncol Biol Phys 2017; 99:947-955. [PMID: 29063854 DOI: 10.1016/j.ijrobp.2017.07.035] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Revised: 07/19/2017] [Accepted: 07/24/2017] [Indexed: 12/25/2022]
Abstract
PURPOSE To investigate the associations between interim tumor responses on 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography (PET) and 18F-fluorothymidine (18F-FLT) PET and patient outcomes, especially progression-free survival (PFS) and overall survival (OS), in non-small cell lung cancer (NSCLC) patients. METHODS AND MATERIALS Patients with FDG-PET/computed tomography stage I-III NSCLC were prescribed concurrent chemotherapy and radiation therapy (60 Gy in 30 fractions). Scans were acquired at baseline (FDG-PET/computed tomography [FDGBL] for radiation therapy planning and FLT-PET [FLTBL]), week 2 (FDGwk2 and FLTwk2), and week 4 (FDGwk4 and FLTwk4) of chemoradiation therapy. Tumor responses were categorized as complete or partial responses or stable or progressive disease (SD, PD) using European Organization for Research and Treatment of Cancer criteria. Associations between response, OS, and PFS were analyzed with univariate Cox regressions and plotted using Kaplan-Meier curves. RESULTS Between 2009 and 2013, 60 patients were recruited. Thirty-seven (62%) were male, and the median age was 66 years (range, 31-86 years). Two-year OS and PFS were 0.51 and 0.26, respectively. Unexpectedly, SD on FLTwk2 compared with complete response/partial response was associated with longer OS (hazard ratio [95% confidence interval] 2.01 [0.87-4.65], P=.082) and PFS (2.01 [0.92-4.36], P=.061). Weeks 2 and 4 FDG PET/CT were not significantly associated with survival. Study scans provided additional information to FDGBL in 21 patients (35%). Distant metastases detected in 3 patients on FLTBL and in 2 patients on FDG/FLTwk2 changed treatment intent from curative to palliative. Locoregional progression during radiation therapy was observed in 5 (8%) patients, prompting larger radiation therapy fields. CONCLUSIONS Stable uptake of 18F-FLT at week 2 was paradoxically associated with longer OS and PFS. This suggests that suppression of tumor cell proliferation may protect against radiation-induced tumor cell killing. Baseline FLT, FLTwk2, and FDGwk2 detected rapid distant and locoregional progression in 10 patients (17%), prompting changes in management.
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Affiliation(s)
- Sarah Everitt
- Radiation Therapy Services, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, Australia; Department of Medical Imaging and Radiation Sciences, Faculty of Medicine, Nursing & Health Sciences, Monash University, Clayton, Victoria, Australia.
| | - David Ball
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, Australia; Division of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Rodney J Hicks
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, Australia; Centre for Cancer Imaging, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Jason Callahan
- Department of Medical Imaging and Radiation Sciences, Faculty of Medicine, Nursing & Health Sciences, Monash University, Clayton, Victoria, Australia; Centre for Cancer Imaging, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Nikki Plumridge
- Division of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Jenny Trinh
- Division of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Alan Herschtal
- Centre for Biostatistics and Clinical Trials, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Tomas Kron
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, Australia; Department of Medical Imaging and Radiation Sciences, Faculty of Medicine, Nursing & Health Sciences, Monash University, Clayton, Victoria, Australia; Department of Physical Sciences, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Michael Mac Manus
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, Australia; Division of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
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Qi S, Zhongyi Y, Yingjian Z, Chaosu H. 18F-FLT and 18F-FDG PET/CT in Predicting Response to Chemoradiotherapy in Nasopharyngeal Carcinoma: Preliminary Results. Sci Rep 2017; 7:40552. [PMID: 28091565 PMCID: PMC5238364 DOI: 10.1038/srep40552] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 12/07/2016] [Indexed: 12/25/2022] Open
Abstract
The purpose of this study was to explore the feasibility of 18F-Fluorothymidine (18F-FLT) and 18F-Fluorodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) in predicting treatment response of nasopharyngeal carcinoma (NPC). Patients with NPC of Stage II-IVB were prospectively enrolled, receiving 2 cycles of neoadjuvant chemotherapy (NACT), followed by concurrent chemoradiotherapy. Each patient underwent pretreatment and post-NACT FLT PET/CT and FDG PET/CT. Standard uptake values (SUV) and tumor volume were measured. Tumor response to NACT was evaluated before radiotherapy by MRI (magnetic resonance imaging), and tumor regression at the end of radiotherapy was evaluated at 55 Gy, according to RECIST 1.1 Criteria. Finally, 20 patients were consecutively enrolled. At the end of radiotherapy, 7 patients reached complete regression while others were partial regression. After 2 cycles of NACT both FLT and FDG parameters declined remarkably. Parameters of FDG PET were more strongly correlated to tumor regression than those of FLT PET.70% SUVmax was the best threshold to define contouring margin around the target. Some residual lesions after NACT showed by MRI were negative in PET/CT. Preliminary results showed both 18F-FDG and 18F-FLT PET have the potential to monitor and predict tumor regression.
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Affiliation(s)
- Shi Qi
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
| | - Yang Zhongyi
- Department of Nuclear Medicine, Fudan University Shanghai Cancer Center; Department of Oncology, Shanghai Medical College, Fudan University; Center for Biomedical Imaging, Fudan University; Shanghai Engineering Research Center for Molecular Imaging Probes, Shanghai 200032, China
| | - Zhang Yingjian
- Department of Nuclear Medicine, Fudan University Shanghai Cancer Center; Department of Oncology, Shanghai Medical College, Fudan University; Center for Biomedical Imaging, Fudan University; Shanghai Engineering Research Center for Molecular Imaging Probes, Shanghai 200032, China
| | - Hu Chaosu
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
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Lai YL, Wu CY, Chao KSC. Biological imaging in clinical oncology: radiation therapy based on functional imaging. Int J Clin Oncol 2016; 21:626-632. [PMID: 27384183 DOI: 10.1007/s10147-016-1000-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Accepted: 05/29/2016] [Indexed: 12/25/2022]
Abstract
Radiation therapy is one of the most effective tools for cancer treatment. In recent years, intensity-modulated radiation therapy has become increasingly popular in that target dose-escalation can be done while sparing adjacent normal tissues. For this reason, the development of measures to pave the way for accurate target delineation is of great interest. With the integration of functional information obtained by biological imaging with radiotherapy, strategies using advanced biological imaging to visualize metabolic pathways and to improve therapeutic index and predict treatment response are discussed in this article.
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Affiliation(s)
- Yo-Liang Lai
- Department of Radiation Oncology, China Medical University Hospital, China Medical University, Taichung, Taiwan
| | - Chun-Yi Wu
- Department of Biomedical Imaging and Radiological Science, China Medical University, Taichung, Taiwan
| | - K S Clifford Chao
- China Medical University, 91 Hsueh-Shih Road, Taichung, 40402, Taiwan.
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Szyszko TA, Yip C, Szlosarek P, Goh V, Cook GJR. The role of new PET tracers for lung cancer. Lung Cancer 2016; 94:7-14. [PMID: 26973200 DOI: 10.1016/j.lungcan.2016.01.010] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 01/17/2016] [Indexed: 01/04/2023]
Abstract
18F-fluorodeoxyglucose (18F-FDG) positron emission tomography-computed tomography (PET/CT) is established for characterising indeterminate pulmonary nodules and staging lung cancer where there is curative intent. Whilst a sensitive technique, specificity for characterising lung cancer is limited. There is recognition that evaluation of other aspects of abnormal cancer biology in addition to glucose metabolism may be more helpful in characterising tumours and predicting response to novel targeted cancer therapeutics. Therefore, efforts have been made to develop and evaluate new radiopharmaceuticals in order to improve the sensitivity and specificity of PET imaging in lung cancer with regards to characterisation, treatment stratification and therapeutic monitoring. 18F-fluorothymidine (18F-FLT) is a marker of cellular proliferation. It shows a lower accumulation in tumours than 18F-FDG as it only accumulates in the cells that are in the S phase of growth and demonstrates a low sensitivity for nodal staging. Its main role is in evaluating treatment response. Methionine is an essential amino acid. 11C-methionine is more specific and sensitive than 18F-FDG in differentiating benign and malignant thoracic nodules. 18Ffluoromisonidazole (18F-FMISO) is used for imaging tumour hypoxia. Tumour response to treatment is significantly related to the level of tumour oxygenation. Angiogenesis is the process by which new blood vessels are formed in tumours and is involved in tumour growth and metastatic tumour spread and is a therapeutic target. Most clinical studies have focused on targeted integrin PET imaging of which αvβ3 integrin is the most extensively investigated. It is upregulated on activated endothelial cells in association with tumour angiogenesis. Neuroendocrine tumour tracers, particularly 68Ga-DOTA-peptides, have an established role in imaging of carcinoid tumours. Whilst most of these tracers have predominantly been used in the research environment, they offer exciting opportunities for improving staging, characterisation, stratification and response assessment in an era of increased personalised therapy in lung cancer.
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Affiliation(s)
- Teresa A Szyszko
- King's College London and Guy's & St. Thomas' PET Centre, Division of Imaging Sciences and Biomedical Engineering, King's College London, London SE1 7EH, UK; Department of Cancer Imaging, Division of Imaging Sciences and Biomedical Engineering, King's College London, London, UK
| | - Connie Yip
- King's College London and Guy's & St. Thomas' PET Centre, Division of Imaging Sciences and Biomedical Engineering, King's College London, London SE1 7EH, UK; Department of Cancer Imaging, Division of Imaging Sciences and Biomedical Engineering, King's College London, London, UK; Department of Radiation Oncology, National Cancer Centre Singapore 169610, Singapore
| | - Peter Szlosarek
- Lung and Mesothelioma Unit, Department of Medical Oncology, KGV Basement, St. Bartholomew's Hospital, West Smithfield, London EC1A 7BE, UK
| | - Vicky Goh
- Department of Cancer Imaging, Division of Imaging Sciences and Biomedical Engineering, King's College London, London, UK; Radiology Department, Guys & St. Thomas' NHS Trust, London SE1 7EH, UK
| | - Gary J R Cook
- King's College London and Guy's & St. Thomas' PET Centre, Division of Imaging Sciences and Biomedical Engineering, King's College London, London SE1 7EH, UK; Department of Cancer Imaging, Division of Imaging Sciences and Biomedical Engineering, King's College London, London, UK.
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A systematic review on [(18)F]FLT-PET uptake as a measure of treatment response in cancer patients. Eur J Cancer 2016; 55:81-97. [PMID: 26820682 DOI: 10.1016/j.ejca.2015.11.018] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Accepted: 11/15/2015] [Indexed: 12/19/2022]
Abstract
Imaging biomarkers have a potential to depict the hallmarks of cancers that characterise cancer cells as compared to normal cells. One pertinent example is 3'-deoxy-3'-(18)F-fluorothymidine positron emission tomography ([(18)F]FLT-PET), which allows non-invasive in vivo assessment of tumour proliferation. Most importantly, [(18)F]FLT does not seem to be accumulating in inflammatory processes, as seen in [(18)F]-fludeoxyglucose, the most commonly used PET tracer for assessment of cell metabolism. [(18)F]FLT could therefore provide additional information about the tumour biology before, during and after treatment. This systematic review focuses on the use of [(18)F]FLT-PET tumour uptake values as a measure of tumour response to therapeutic interventions. The clinical studies which evaluated the role of [(18)F]FLT-PET as a measure of tumour response to treatment are summarised and the evidence linking [(18)F]FLT-PET tumour uptake values with clinical outcome is evaluated.
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(18)F-FDG PET/CT mean SUV and metabolic tumor volume for mean survival time in non-small cell lung cancer. Clin Nucl Med 2015; 40:459-63. [PMID: 25742234 DOI: 10.1097/rlu.0000000000000740] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE The study was designed to determine the relationship between survival time of standardized uptake value (SUVmax and SUVmean) and metabolic tumor volume (MTV) in patients with non-small cell lung cancer (NSCLC), and examine the impact of demographic, clinical, and radiological data of these patients on survival. MATERIALS AND METHODS We performed a retrospective analysis of the records of 79 patients with NSCLC who presented to our hospital between May 2010 and March 2013, received a final diagnosis, and underwent F-FDG PET/CT for staging. Clinical, radiological, and F-FDG PET/CT parameters with an impact on prognosis such as the SUVmax of the primary tumor as calculated by the volumetric region of interest in the F-FDG PET/CT scans during initial diagnosis, mean SUV of the tumor, and MTV obtained with a threshold of SUVmax greater than 2.5 were recorded and statistically analyzed. A statistical analysis was carried out based on the clinical, radiological, and PET/CT findings of the patients who were divided into 2 groups: survivors and nonsurvivors. RESULTS Seventy patients (88.6%) were men, and 9 (11.4%) were women. The mean age was 63.65 ± 11.51 years in the nonsurvivor group (n = 40) versus 62.74 ± 10.60 years in the survivor group (n = 39) (Table 1). The mean survival time from diagnosis was 7.9 ± 6.52 months in the nonsurvivor group versus 14.09 ± 7.41 months in the survivor group. The mean survival time was 12.9 ± 7.9 months for those aged 60 or younger, whereas it was 9.9 ± 7.2 years for those aged 60 or older. According to the Cox regression analysis, higher MTV [relative risk (RR), 1.006; P = 0.03] and mean SUVmax (mSUV) (RR, 1.302; P = 0.03) had a significant impact on shortening of the mean survival time. However, no statistical significance was reached for SUVmax measurements (RR, 0.970; P = 0.39). Furthermore, there was a significant relationship between increased tumor size (<2 cm, 2-4 cm, and ≥4 cm) and shortened mean survival time (P = 0.03). CONCLUSION The present study showed that MTV and mSUV of FDG PET/CT scans of the tumor, but not SUVmax, had a significant impact on survival time of patients with NSCLC. Based on this result, we believe that we might have more accurate information about the survival time of our patients if we also evaluate mSUV and MTV in combination with mSUV, which is frequently used for diagnosis and monitoring of patients with NSCLC during our daily practice.
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Jeraj R, Bradshaw T, Simončič U. Molecular Imaging to Plan Radiotherapy and Evaluate Its Efficacy. J Nucl Med 2015; 56:1752-65. [PMID: 26383148 DOI: 10.2967/jnumed.114.141424] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2015] [Accepted: 09/08/2015] [Indexed: 12/25/2022] Open
Abstract
Molecular imaging plays a central role in the management of radiation oncology patients. Specific uses of imaging, particularly to plan radiotherapy and assess its efficacy, require an additional level of reproducibility and image quality beyond what is required for diagnostic imaging. Specific requirements include proper patient preparation, adequate technologist training, careful imaging protocol design, reliable scanner technology, reproducible software algorithms, and reliable data analysis methods. As uncertainty in target definition is arguably the greatest challenge facing radiation oncology, the greatest impact that molecular imaging can have may be in the reduction of interobserver variability in target volume delineation and in providing greater conformity between target volume boundaries and true tumor boundaries. Several automatic and semiautomatic contouring methods based on molecular imaging are available but still need sufficient validation to be widely adopted. Biologically conformal radiotherapy (dose painting) based on molecular imaging-assessed tumor heterogeneity is being investigated, but many challenges remain to fully exploring its potential. Molecular imaging also plays increasingly important roles in both early (during treatment) and late (after treatment) response assessment as both a predictive and a prognostic tool. Because of potentially confounding effects of radiation-induced inflammation, treatment response assessment requires careful interpretation. Although molecular imaging is already strongly embedded in radiotherapy, the path to widespread and all-inclusive use is still long. The lack of solid clinical evidence is the main impediment to broader use. Recommendations for practicing physicians are still rather scarce. (18)F-FDG PET/CT remains the main molecular imaging modality in radiation oncology applications. Although other molecular imaging options (e.g., proliferation imaging) are becoming more common, their widespread use is limited by lack of tracer availability and inadequate reimbursement models. With the increasing presence of molecular imaging in radiation oncology, special emphasis should be placed on adequate training of radiation oncology personnel to understand the potential, and particularly the limitations, of quantitative molecular imaging applications. Similarly, radiologists and nuclear medicine specialists should be sensitized to the special need of the radiation oncologist in terms of quantification and reproducibility. Furthermore, strong collaboration between radiation oncology, nuclear medicine/radiology, and medical physics teams is necessary, as optimal and safe use of molecular imaging can be ensured only within appropriate interdisciplinary teams.
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Affiliation(s)
- Robert Jeraj
- School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin; and Faculty of Mathematics and Physics, University of Ljubljana, Ljubljana, Slovenia
| | - Tyler Bradshaw
- School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin; and
| | - Urban Simončič
- Faculty of Mathematics and Physics, University of Ljubljana, Ljubljana, Slovenia
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Alam IS, Arshad MA, Nguyen QD, Aboagye EO. Radiopharmaceuticals as probes to characterize tumour tissue. Eur J Nucl Med Mol Imaging 2015; 42:537-61. [PMID: 25647074 DOI: 10.1007/s00259-014-2984-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Accepted: 12/18/2014] [Indexed: 01/06/2023]
Abstract
Tumour cells exhibit several properties that allow them to grow and divide. A number of these properties are detectable by nuclear imaging methods. We discuss crucial tumour properties that can be described by current radioprobe technologies, further discuss areas of emerging radioprobe development, and finally articulate need areas that our field should aspire to develop. The review focuses largely on positron emission tomography and draws upon the seminal 'Hallmarks of Cancer' review article by Hanahan and Weinberg in 2011 placing into context the present and future roles of radiotracer imaging in characterizing tumours.
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Affiliation(s)
- Israt S Alam
- Comprehensive Cancer Imaging Centre, Imperial College London, London, W12 0NN, UK
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29
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Thorwarth D. Functional imaging for radiotherapy treatment planning: current status and future directions-a review. Br J Radiol 2015; 88:20150056. [PMID: 25827209 PMCID: PMC4628531 DOI: 10.1259/bjr.20150056] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
In recent years, radiotherapy (RT) has been subject to a number of technological innovations. Today, RT is extremely flexible, allowing irradiation of tumours with high doses, whilst also sparing normal tissues from doses. To make use of these additional degrees of freedom, integration of functional image information may play a key role (i) for better staging and tumour detection, (ii) for more accurate RT target volume delineation, (iii) to assess functional information about biological characteristics and individual radiation resistance and (iv) to apply personalized dose prescriptions. In this article, we discuss the current status and future directions of different clinically available functional imaging modalities; CT, MRI, positron emission tomography (PET) as well as the hybrid imaging techniques PET/CT and PET/MRI and their potential for individualized RT.
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Affiliation(s)
- D Thorwarth
- Section for Biomedical Physics, Department of Radiation Oncology, Eberhard Karls University Tübingen, Tübingen, Germany
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30
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Gilardi L, de Marinis F, Grana CM. PET/CT characterization of non-small-cell lung cancer heterogeneity. Nucl Med Commun 2015; 36:411-3. [PMID: 25816217 DOI: 10.1097/mnm.0000000000000270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Laura Gilardi
- aDivision of Nuclear Medicine bThoracic Oncology Division, European Institute of Oncology, Milan, Italy
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31
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Bradshaw TJ, Bowen SR, Deveau MA, Kubicek L, White P, Bentzen SM, Chappell RJ, Forrest LJ, Jeraj R. Molecular imaging biomarkers of resistance to radiation therapy for spontaneous nasal tumors in canines. Int J Radiat Oncol Biol Phys 2015; 91:787-95. [PMID: 25752393 PMCID: PMC4355478 DOI: 10.1016/j.ijrobp.2014.12.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Revised: 11/26/2014] [Accepted: 12/04/2014] [Indexed: 12/12/2022]
Abstract
PURPOSE Imaging biomarkers of resistance to radiation therapy can inform and guide treatment management. Most studies have so far focused on assessing a single imaging biomarker. The goal of this study was to explore a number of different molecular imaging biomarkers as surrogates of resistance to radiation therapy. METHODS AND MATERIALS Twenty-two canine patients with spontaneous sinonasal tumors were treated with accelerated hypofractionated radiation therapy, receiving either 10 fractions of 4.2 Gy each or 10 fractions of 5.0 Gy each to the gross tumor volume. Patients underwent fluorodeoxyglucose (FDG)-, fluorothymidine (FLT)-, and Cu(II)-diacetyl-bis(N4-methylthiosemicarbazone) (Cu-ATSM)-labeled positron emission tomography/computed tomography (PET/CT) imaging before therapy and FLT and Cu-ATSM PET/CT imaging during therapy. In addition to conventional maximum and mean standardized uptake values (SUV(max); SUV(mean)) measurements, imaging metrics providing response and spatiotemporal information were extracted for each patient. Progression-free survival was assessed according to response evaluation criteria in solid tumor. The prognostic value of each imaging biomarker was evaluated using univariable Cox proportional hazards regression. Multivariable analysis was also performed but was restricted to 2 predictor variables due to the limited number of patients. The best bivariable model was selected according to pseudo-R(2). RESULTS The following variables were significantly associated with poor clinical outcome following radiation therapy according to univariable analysis: tumor volume (P=.011), midtreatment FLT SUV(mean) (P=.018), and midtreatment FLT SUV(max) (P=.006). Large decreases in FLT SUV(mean) from pretreatment to midtreatment were associated with worse clinical outcome (P=.013). In the bivariable model, the best 2-variable combination for predicting poor outcome was high midtreatment FLT SUV(max) (P=.022) in combination with large FLT response from pretreatment to midtreatment (P=.041). CONCLUSIONS In addition to tumor volume, pronounced tumor proliferative response quantified using FLT PET, especially when associated with high residual FLT PET at midtreatment, is a negative prognostic biomarker of outcome in canine tumors following radiation therapy. Neither FDG PET nor Cu-ATSM PET were predictive of outcome.
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Affiliation(s)
- Tyler J Bradshaw
- Department of Medical Physics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
| | - Stephen R Bowen
- Departments of Radiation Oncology and Radiology, University of Washington, Seattle, Washington
| | - Michael A Deveau
- Department of Small Animal Clinical Sciences, Texas A&M University, College Station, Texas
| | | | - Pamela White
- Department of Surgical Sciences, School of Veterinary Medicine, University of Wisconsin-Madison, Madison, Wisconsin
| | - Søren M Bentzen
- Division of Biostatistics and Bioinformatics, University of Maryland Greenebaum Cancer Center, and Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
| | - Richard J Chappell
- Department of Biostatistics and Medical Informatics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
| | - Lisa J Forrest
- Department of Surgical Sciences, School of Veterinary Medicine, University of Wisconsin-Madison, Madison, Wisconsin
| | - Robert Jeraj
- Department of Medical Physics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin; Department of Human Oncology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin.
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Lin C, Kume K, Mori T, Martinez ME, Okazawa H, Kiyono Y. Predictive Value of Early-Stage Uptake of 3'-Deoxy-3'-18F-Fluorothymidine in Cancer Cells Treated with Charged Particle Irradiation. J Nucl Med 2015; 56:945-50. [PMID: 25766892 DOI: 10.2967/jnumed.114.152983] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Accepted: 02/03/2015] [Indexed: 12/13/2022] Open
Abstract
UNLABELLED The aim of this study was to investigate whether 3'-deoxy-3'-(18)F-fluorothymidine ((18)F-FLT) can monitor the early response of tumor cell proliferation to charged particle irradiation in vitro and in vivo. METHODS In vitro, after 0.1, 0.5, 1, 5, and 10 Gy of proton or carbon ion irradiation, (18)F-FLT cell uptake was examined at 24 h and cell proliferation ability was measured from days 1 to 4. In vivo, after 0.5, 1, and 5 Gy of proton or carbon ion irradiation, (18)F-FLT PET imaging was performed on tumor-bearing BALB/c nu/nu mice at 24 h and tumor growth was measured from days 1 to 7. Tumor-to-background ratios of standardized uptake values were calculated to assess the (18)F-FLT accumulation in tumors. Both cells and mice also received x-irradiation as a control. RESULTS In vitro, (18)F-FLT cell uptake was significantly lower after 1 Gy of proton irradiation (P < 0.05) and carbon ion irradiation (P < 0.05) and after 5 Gy of x-irradiation (P < 0.01), but cell proliferation ability at these doses did not show significant differences until day 3. In vivo, (18)F-FLT tumor uptake was significantly lower after 1 Gy of proton (P < 0.001) and carbon ion irradiation (P < 0.01) and after 5 Gy of x-irradiation (P < 0.001), but tumor growth did not significantly differ at these doses until day 4 after proton irradiation, day 3 after carbon ion irradiation, and day 5 after x-irradiation. CONCLUSION The reduction in (18)F-FLT uptake after charged particle irradiation was more rapid than the change in tumor growth in vivo or the change in cell proliferation ability in vitro. Therefore, (18)F-FLT is a promising tracer for monitoring the early response of cancer to charged particle irradiation.
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Affiliation(s)
- Chao Lin
- Biomedical Imaging Research Center, University of Fukui, Fukui, Japan
| | - Kyo Kume
- Research and Development Division, Wakasa Wan Energy Research Center, Fukui, Japan; and
| | - Tetsuya Mori
- Biomedical Imaging Research Center, University of Fukui, Fukui, Japan
| | - Miguel E Martinez
- Biomedical Imaging Research Center, University of Fukui, Fukui, Japan
| | - Hidehiko Okazawa
- Biomedical Imaging Research Center, University of Fukui, Fukui, Japan
| | - Yasushi Kiyono
- Biomedical Imaging Research Center, University of Fukui, Fukui, Japan Research and Education Program for Life Science, University of Fukui, Fukui, Japan
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33
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Image-derived biomarkers and multimodal imaging strategies for lung cancer management. Eur J Nucl Med Mol Imaging 2015; 42:634-43. [DOI: 10.1007/s00259-014-2974-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Accepted: 12/08/2014] [Indexed: 12/14/2022]
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Herrmann K, Buck AK. Proliferation imaging with ¹⁸F-fluorothymidine PET/computed tomography: physiologic uptake, variants, and pitfalls. PET Clin 2014; 9:331-8. [PMID: 25030396 DOI: 10.1016/j.cpet.2014.03.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
For noninvasive in vivo imaging of proliferation, 18F-FLT PET/CT remains a promising tool, owing to its correlation with proliferation indexes in many tumor entities. Future clinical applications will focus on monitoring response to cancer therapy, whereas tumor detection will be limited to organs with high physiologic 18F-FDG uptake. Use and interpretation of 18F-FLT requires knowledge of the physiologic tracer distribution and how it will be affected by anticancer treatment. Further studies are needed to determine the optimal timing of 18F-FLT PET/CT imaging in the course of cancer therapies or at the conclusion of therapy.
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Affiliation(s)
- Ken Herrmann
- Department of Nuclear Medicine, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, Würzburg 97080, Germany.
| | - Andreas K Buck
- Department of Nuclear Medicine, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, Würzburg 97080, Germany
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