Standard Uptake Value Predicts Survival in Non–Small Cell Lung Cancer

Prognostic Significance of Volumetric Parameters Based on FDG PET/CT in Patients with Lung Adenocarcinoma Undergoing Curative Surgery

INTRODUCTION

FDG PET/CT is a robust imaging modality to diagnose and stratify prognoses for non-small cell lung carcinoma. However, the role of FDG PET/CT in operable lung adenocarcinoma patients has not been previously investigated in a large cohort with varying pathological stages. The prognostic value of volumetric parameters based on FDG PET/CT was investigated in patients with stage I-III lung adenocarcinoma receiving curative surgery.

METHODS

This retrospective study included 432 patients with lung adenocarcinoma undergoing preoperative FDG PET/CT between January 2016 and December 2017. Clinicopathologic variables, conventional image parameters, such as the maximum standardized uptake value (SUVmax) and mean SUV (SUVmean) of the primary tumor, and volumetric parameters, such as metabolic tumor volume (MTV) and total lesion glycolysis (TLG), were included in Cox regression analysis. Subgroup analysis was conducted to compare hazard ratios (HRs) based on MTV in each pathological stage. A new staging system including volumetric parameters was suggested.

RESULTS

A total of 432 patients (median age: 62 years; interquartile range: 56-70 years; 225 males) were evaluated. Sex, age, presence of EGFR mutation, pathological stage, MTV, and TLG of the primary tumor were selected as statistically significant prognostic factors for overall survival irrespective of other variables (OS; p < 0.05 for all). Pathological stage, MTV, and TLG of the primary tumor were selected as statistically significant prognostic factors for disease-free survival irrespective of other variables (p < 0.05 for all). The suggested new staging system including MTV as an additional criterion showed better discrimination and prediction for OS than the conventional pathological staging system despite statistical insignificance (concordance index: 0.698 vs. 0.673).

CONCLUSIONS

The volumetric parameters of the primary tumor based on preoperative FDG PET/CT were independent prognostic factors in addition to pathological stage in patients with operable lung adenocarcinoma. The suggested new staging system considering MTV predicted the prognoses better than the conventional pathological staging system.

The location of metastatic lymph nodes and the evaluation of lymphadenectomy by near-infrared photoacoustic imaging with iridium complex nanoparticles

Histopathology evaluation and lymphadenectomy of node-positive patients is the usual procedure in clinical therapy. However, it requires days for the histopathology result analysis, which impedes intraoperative decision-making and immediate treatment. Noninvasive real-time imaging of metastatic lymph nodes can overcome these defects and help medical workers evaluate lymph nodes and make the operation decision more efficiently. Herein we developed iridium(III)-cyanine complex/bovine serum albumin (BSA)-based nanoparticles which are conjugated with folic acid (FA) (IrCy-FA NPs). The synthesized IrCy-FA NPs exhibit good biocompatibility, strong near-infrared absorption, and impressive lymph node accumulation and can serve as a photoacoustic (PA) imaging probe for lymph node imaging. Besides, the lymph nodes enriched with IrCy-FA NPs showing green color are easily visible to the naked eye, suggesting their potential as an intraoperative indicator. The real-time PA imaging with excellent contrast and high spatial resolution can promote efficient and reliable quantitative analysis of lymph nodes in vivo. By employing IrCy-FA NPs as the PA agent for lymph node imaging, we achieve effective pre-operative and post-operative evaluations of metastatic lymph nodes in lymphadenectomy. This study may provide helpful information for PA imaging guided colocalization and evaluation of lymph nodes and facilitate this method towards clinical trials.

PET standardized uptake values of primary lung cancer for comparison with tumor volume doubling times

OBJECTIVE

To determine the relationship between two documented indicators of tumor aggressiveness, SUV and volume doubling time (VDT) for stage I non-small cell lung cancer (NSCLC).

METHODS

116 pathology proven solid NSCLC patients with 2 pretreatment CT and 1 PET/CT scan were retrospectively identified. The 2 CT scans were at least 85 days apart. SUV values were collected from PET/CT reports and CT derived VDT's were calculated assuming an exponential growth rate. Corrected SUV values were also obtained for all cases. Median VDT, SUV and corrected SUV values were reported according to cancer histology. Relationships between VDT, SUV and corrected SUV were examined.

RESULTS

91 Adenocarcinomas and 25 squamous-cell carcinomas had median VDT values of 150.6 and 110.0 days respectively. Median SUV values were 5.1 and 12.3 for adenocarcinoma and squamous-cell carcinoma, respectively (p = 0.0003); median corrected SUV values were 16.8 and 31.7 respectively (p = 0.003). A statistically significant monotonic relationship was observed between increased SUV uptake and faster VDT (p = 0.05) and corrected SUV and VDT (P = 0.0002). When stratified by cancer histology, the relationship between VDT and either SUV or corrected SUV was statistically significant for adenocarcinomas (p = 0.02 and p = 0.0001, respectively), but not for squamous-cell carcinoma (p = 0.85 and p = 0.37, respectively).

CONCLUSION

We demonstrated an overall significant relationship between VDT, SUV and corrected SUV. The relationship, however, was stronger for adenocarcinomas than for squamous-cell carcinomas. This implies that the primary determinant for these relationships is histology and within each cell type, there are other factors that have strong influences.

Determination of prognostic factors of surgically treated pathological Stage IIIA non-small cell lung cancer

Background

This study aims to identify the prognostic factors in Stage IIIA non-small cell lung cancer and to investigate whether there was a significant difference in terms of overall survival and diseasefree survival among the subgroups belonging to this disease stage.

Methods

Between January 2010 and December 2018, a total of 144 patients (125 males, 19 females; median age 60 years; range, 41 to 80 years) who were operated for non-small cell lung cancer in our clinic and whose pathological stage was reported as IIIA were retrospectively analyzed. Data including demographic and clinical characteristics of the patients, histopathological diagnosis, the standardized uptake value of the mass on positron emission tomography-computed tomography, tumor diameter, type of surgery, lymph node metastasis status, visceral pleural invasion, and overall and disease-free survival rates were recorded.

Results

The median survival was 39 (range, 27.8 to 46.1) months and the five-year overall survival rate was 28%. The mean tumor diameter was 4.3±2.7 cm. The median disease-free survival was 37 (range, 28.1 to 48.6) months and the five-year disease-free survival rate was 26.9%. In the multivariate analysis, overall survival and disease-free survival in T2N2M0 subgroup were significantly worse than the other subgroups. The other poor prognostic factors of survival were the standardized uptake value of the tumor, pneumonectomy, and histopathological subtypes other than squamous cell carcinoma and adenocarcinoma. Parietal pleural invasion was significantly associated with worse disease-free survival rates.

Conclusion

Our results showed that there may be significant survival differences between subgroups created by tumor histopathology, lymph node invasion and the type of surgery in a heterogeneous lung cancer stage.

Prognostic effect of incongruous lymph node status in early-stage non-small cell lung cancer

INTRODUCTION

Tumor recurrence is an important issue for patients with stage I non-small cell lung cancer (NSCLC) and adjuvant therapy is considered of no benefit to a tumor less than 4 cm. The purpose of this study was to evaluate the impact of positron emission tomography/computed tomography (PET/CT) on tumor recurrence in patients with a completely resected pN0 NSCLC less than 4 cm.

METHODS

Between January 2011 and December 2016, 211 consecutive patients with diagnoses of stage I NSCLC less than 4 cm after complete resection were included. The maximum of standard uptake value (SUVmax) of primary tumor and the presence of positive lymph nodes on PET/CT scans were documented. Disease-free survival was evaluated by the Kaplan-Meier method and recurrence risk factors were identified by univariable and multivariable analyses.

RESULTS

Patients with positive lymph nodes on PET/CT had a lower 5-year disease-free survival (37.6% vs 72.7%, p < 0.001). Multivariable analysis demonstrated that the tumor SUVmax >2.93, the presence of positive lymph nodes on PET/CT, and poor differentiation were significant factors for tumor recurrence. Patients with the tumor SUVmax >2.93 and positive lymph nodes on PET/CT simultaneously had 5.33-fold increase in the risk of recurrence (p < 0.001).

CONCLUSION

The presence of positive lymph nodes on PET/CT scans can be a good indicator in predicting patients with high risk of developing recurrence in pN0 NSCLC less than 4 cm. This result helps identify patients likely to benefit from adjuvant therapy.

Liquid biopsy-based single-cell metabolic phenotyping of lung cancer patients for informative diagnostics

Accurate prediction of chemo- or targeted therapy responses for patients with similar driver oncogenes through a simple and least-invasive assay represents an unmet need in the clinical diagnosis of non-small cell lung cancer. Using a single-cell on-chip metabolic cytometry and fluorescent metabolic probes, we show metabolic phenotyping on the rare disseminated tumor cells in pleural effusions across a panel of 32 lung adenocarcinoma patients. Our results reveal extensive metabolic heterogeneity of tumor cells that differentially engage in glycolysis and mitochondrial oxidation. The cell number ratio of the two metabolic phenotypes is found to be predictive for patient therapy response, physiological performance, and survival. Transcriptome analysis reveals that the glycolytic phenotype is associated with mesenchymal-like cell state with elevated expression of the resistant-leading receptor tyrosine kinase AXL and immune checkpoint ligands. Drug targeting AXL induces a significant cell killing in the glycolytic cells without affecting the cells with active mitochondrial oxidation.

Non-invasive methods to predict treatment response are urgently needed. Here in lung cancer, the authors develop a single-cell on-chip cytometry method to metabolically phenotype disseminated tumor cells, revealing metabolic heterogeneity and predictors of therapy response and survival.

Involvement of increased p53 expression in the decrease of mitochondrial DNA copy number and increase of SUVmax of FDG-PET scan in esophageal squamous cell carcinoma

We appraised Warburg effect through analysis of mitochondrial DNA (mtDNA) copy number and maximum standard uptake value (SUV_max) of ¹⁸F-fluorodeoxyglucose positron emission tomography (FDG-PET) scan and their alterations in esophageal squamous cell carcinoma (ESCC). Later T-status and longer longitudinal tumor length were associated with lower mtDNA^ESCC copy number (p < .05) but higher SUV_max-ESCC (p < .05), respectively. Lower mtDNA^ESCC copy number correlated with higher SUV_max-ESCC, reciprocally (p < .05). ESCCs expressing mutant p53 protein had lower mtDNA^ESCC copy number (p = .056) but higher SUV_max-ESCC (p = .046). We conclude that mutant p53 protein may be involved in the Warburg effect of ESCC.

Comparison of prognostic values of primary tumor and nodal 18F-fluorodeoxyglucose uptake in non-small cell lung cancer with N1 disease

INTRODUCTION

We hypothesized that, in non-small cell lung cancer (NSCLC) with N1 metastasis, N1 nodal ¹⁸F-fluorodeoxyglucose (FDG) status offers independent and incremental prognostic value.

METHODS

We enrolled 106 NSCLC patients with pathology-confirmed N1 metastasis. N1 node FDG positivity, primary tumor maximum standard uptake value (SUV_max), metabolic tumor volume (MTV), and total lesion glycolysis (TLG) were measured. Kaplan-Meier method and Cox regression analyses were performed for cancer-specific survival (CSS) and disease-free survival (DFS).

RESULTS

Subjects were 67 males and 39 females (61.9 ± 9.4 years). Eighty-one (76.4%) and 25 (23.6%) had pathologic stage IIB and IIIA NSCLC, respectively. All underwent complete tumor resection. FDG-positive N1 nodes were larger and had higher primary tumor SUV_max. During a follow-up of 42 months, there were 56 recurrences and 31 cancer deaths. Significant univariate predictors were stage, no adjuvant therapy, and FDG-positive nodes for DFS, and stage, no adjuvant therapy, node size, tumor MTV, TLG, and SUV_max, and FDG-positive nodes for CSS. Independent predictors on multivariate analyses were FDG-positive nodes (HR = 3.071, p = 0.003), greater tumor TLG (HR = 3.224, p = 0.002), and no adjuvant therapy (HR = 3.631, p < 0.001) for poor CSS, and FDG-positive nodes (HR = 1.771, p = 0.040) and no adjuvant therapy (HR = 2.666, p = 0.002) for poor DFS. Harrell's concordance and net reclassification improvement tests showed that CSS prediction was significantly improved by the addition of N1 FDG status to a model containing tumor TLG.

CONCLUSION

N1 node FDG status can be useful for predicting the outcome of NSCLC patients with N1 metastasis beyond that provided by other prognostic variables.

KEY POINTS

• In NSCLC with N1 disease, N1 node FDG status is useful as a prognostic predictor. • FDG-positive N1 nodes provide additional prognostic value beyond TLG of primary tumor. • Combining TLG of primary tumor and N1 node uptake can stratify the survival of patients.

Effect of PET/CT standardized uptake values on complete response to treatment before definitive chemoradiotherapy in stage III non-small cell lung cancer

PURPOSE

The standard treatment for patients with stage III non-small cell lung cancer (NSCLC), unsuitable for resection and with good performance, is definitive radiotherapy with cisplatin-based chemotherapy. Our aim is to evaluate the effect of the maximum value of standardized uptake values (SUVmax) of the primary tumor in positron emission tomography-computed tomography (PET/CT) before treatment on complete response (CR) and overall survival.

METHODS

The data of 73 stage III NSCLC patients treated with concurrent definitive chemoradiotherapy (CRT) between 2008 and 2017 and had PET/CT staging in the pretreatment period were evaluated. ROC curve analysis was performed to determine the ideal cut-off value of pretreatment SUVmax to predict CR.

RESULTS

Median age was 58 years (range 27-83 years) and 66 patients were male (90.4%). Median follow-up time was 18 months (range 3-98 months); median survival was 23 months. 1-year overall survival (OS) rate and 5-year OS rate were 72 and 19%, respectively. Median progression-free survival (PFS) was 9 months; 1-year PFS rate and 5-year PFS rate were 38 and 19%, respectively. The ideal cut-off value of pretreatment SUVmax that predicted the complete response of CRT was 12 in the ROC analysis [AUC 0.699 (0.550-0.833)/P < 0.01] with a sensitivity of 83%, and specificity of 55%. In patients with SUVmax < 12, CR rate was 60%, while, in patients with SUV ≥ 12, it was only 19% (P = 0.002). Median OS was 26 months in patients with pretreatment SUVmax < 12, and 21 months in patients with SUVmax ≥ 12 (HR = 2.93; 95% CI 17.24-28.75; P = 0.087). CR rate of the whole patient population was 26%, and it was the only factor that showed a significant benefit on survival in both univariate and multivariate analyses.

CONCLUSION

Pretreatment SUVmax of the primary tumor in PET/CT may predict CR in stage III NSCLC patients who were treated with definitive CRT. Having clinical CR is the only positive predictive factor for prolonged survival.

Clinical impact of fluorine-18-fluorodeoxyglucose positron emission tomography/computed tomography in patients with resectable pancreatic cancer: diagnosing lymph node metastasis and predicting survival

PURPOSE

To evaluate the diagnostic accuracy of fluorine-18-fluorodeoxyglucose PET/computed tomography (F-FDG PET/CT) for lymph node (LN) metastasis and the prognostic significance of F-FDG PET/CT LN parameters in patients with resectable pancreatic cancer.

PATIENTS AND METHODS

Patients with resectable pancreatic cancer who underwent staging F-FDG PET/CT between May 2007 and September 2016 were retrospectively enrolled and analyzed through medical record and image re-evaluation. The diagnostic accuracy of F-FDG PET/CT in predicting LN metastasis was evaluated and compared with that of contrast-enhanced abdominal computed tomography (CECT). Prognostic variables, including LN parameters assessed by F-FDG PET/CT [standardized uptake value (SUV)LN and LN/tumor SUV ratio], that affect disease-free survival (DFS) and overall survival (OS) were evaluated by regression analysis.

RESULTS

When predicting LN metastasis, F-FDG PET/CT showed greater sensitivity, positive predictive value, negative predictive value, and accuracy than CECT. Among prognostic factors affecting DFS, PET-positive LN (P=0.008), and LN/tumor SUV ratio (P=0.003) were found to be significant by regression analysis. Among the variables affecting OS, lymphovascular invasion (P=0.018) and the LN/tumor SUV ratio (P=0.046) were found to be significant.

CONCLUSION

F-FDG PET/CT showed higher diagnostic accuracy in predicting LN metastasis than CECT in patients with resectable pancreatic cancer. Only the LN/tumor SUV ratio of F-FDG PET/CT was an independent prognostic variable in both DFS and OS.

PET Scan Contribution in Chest Tumor Management: A Systematic Review for Thoracic Surgeons

Aims and background

In the 90s, the introduction of positron emission tomography (PET) represented a milestone in the staging of thoracic tumors. In the last 10 years, PET scan has been widely adopted in thoracic oncology, showing high accuracy in diagnosis and staging and with promising issues in defining prognosis. The aim of this systematic review was to focus on the results and pitfalls of PET scan use in the modern management of chest tumors.

Methods and study design.

The literature search was performed on May 2010 in PubMed, Embase, and Cochrane according to PRISMA protocol. The search was restricted to publications in English, using in the same string the word “PET” with 9 different chest tumors; results were then filtered by eliminating technical articles, focusing only on papers in which surgery was considered as a potential diagnostic or therapeutic tool. From 6600 papers initially selected, 99 manuscripts were fully analyzed.

Results

Glucose uptake is a metabolic marker useful in the diagnosis and staging of chest tumors. In lung cancer screening, standard uptake value is helpful in defining the risk of malignancy of isolated pulmonary nodules. The addition of PET scan to conventional staging increases detection of nodal and distant metastases in lung cancer, esophageal cancer and malignant mesothelioma. In thymoma, a close relationship between standard uptake value, histology, and Masaoka stage has been advocated. This link between glucose uptake and prognosis suggests that PET translates biological tumor behavior into clinically detectable findings.

Conclusions

PET scan has a crucial role in thoracic oncology due to its impact on diagnosis, staging and prognosis. PET scan expresses the biological behavior of tumors, opening interesting perspectives in chest tumor management and improving detection and stage grouping in lung cancer. It anticipates the diagnosis in long-incubating diseases such as mesothelioma and increases biological knowledge of rare diseases, such as thymoma and other mediastinal tumors.

Application of novel quantitative techniques for fluorodeoxyglucose positron emission tomography/computed tomography in patients with non-small-cell lung cancer

AIM

Flurodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) is routinely used in non-small-cell lung cancer. This study aims to assess the prognostic value of quantitative FDG-PET/CT parameters including standard uptake value (SUV), metabolic tumor volume (MTV) and total lesional glycolysis (TLG) in non-small-cell lung cancer.

METHODS

A retrospective review of 92 nonsurgical patients with pathologically confirmed stage I-III non-small-cell lung cancers treated with radical dose radiotherapy (≥50 Gy) was conducted. Metabolically active tumor regions on FDG-PET/CT scans were contoured manually. SUV, MTV and TLG were calculated for primary, nodal and whole-body disease. Univariate and multivariate (adjusting for age, sex, disease stage and primary tumor size in centimeters) Cox regression modeling were performed to assess the association between these parameters and both overall and progression-free survival (PFS).

RESULTS

On univariate analysis, overall survival (OS) was significantly associated with primary MTV (P = 0.03), whole-body MTV (P = 0.02), whole-body maximum SUV (P = 0.05) and whole-body TLG (P = 0.03). PFS was significantly associated with primary MTV (P = 0.01), primary TLG (P = 0.04), whole-body MTV (P < 0.01) and whole-body TLG (P = 0.01). On multivariate analysis, OS was significantly associated with whole-body MTV (P = 0.05). PFS was significantly associated with whole-body MTV (P = 0.02) and whole-body TLG (P = 0.05).

CONCLUSIONS

Whole-body MTV was significantly associated with overall and PFS, and whole-body TLG was significantly associated with PFS on multivariate analysis. These two parameters may be significant prognostic factors independent of other factors such as stage. SUV was not significantly associated with survival on multivariate analysis.

Primary Adenoid Cystic Carcinoma of the Peripheral Lungs

We herein report a very rare case of adenoid cystic carcinoma of the peripheral lungs. A 77-year-old female visited a family physician for aortitis syndrome, diabetes mellitus and hyperlipidemia. A follow-up chest computed tomography scan for aortitis syndrome revealed a nodule in the middle lobe of the right lung. Although a transbronchial lung biopsy was attempted, a definitive diagnosis could not be made. Because the possibility of lung malignancy could not be ruled out, thoracoscopic wedge resection of the middle lobe was performed. The intraoperative pathological diagnosis revealed carcinoma of the lungs and we performed middle lobectomy under complete video-assisted thoracoscopic surgery. A histopathological examination demonstrated an adenoid cystic carcinoma with a characteristic cribriform structure.

Axillary Lymph Node-to-Primary Tumor Standard Uptake Value Ratio on Preoperative (18)F-FDG PET/CT: A Prognostic Factor for Invasive Ductal Breast Cancer

Purpose

This study assessed the axillary lymph node (ALN)-to-primary tumor maximum standard uptake value (SUV_max) ratio (ALN/T SUV ratio) in invasive ductal breast cancer (IDC) on preoperative ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) to determine the effectiveness in predicting recurrence-free survival (RFS).

Methods

One hundred nineteen IDC patients (mean age, 50.5±10.5 years) with pathologically proven ALN involvement without distant metastasis and preoperative FDG PET/CT were enrolled in the study. SUV_max values of the ALN and primary tumor were obtained on FDG PET/CT, and ALN/T SUV ratio was calculated. Several factors were evaluated for their effectiveness in predicting RFS. These included several parameters on FDG PET/CT as well as several clinicopathological parameters: pathologic tumor/node stage; nuclear and histological grade; hormonal state; status with respect to human epidermal growth factor receptor 2, mindbomb E3 ubiquitin protein ligase 1 (MIB-1), and p53; primary tumor size; and ALN size.

Results

Among 119 patients with breast cancer, 17 patients (14.3%) experienced relapse during follow-up (mean follow-up, 28.4 months). The ALN/T SUV ratio of the group with disease recurrence was higher than that of the group without recurrence (0.97±1.60 and 0.45±0.40, respectively, p=0.005). Univariate analysis showed that the primary tumor SUV_max, ALN SUV_max, ALN/T SUV ratio, ALN status, nuclear and histological grade, estrogen receptor (ER) status, and MIB-1 status were predictors for RFS. Among these variables, ALN/T SUV ratio with hazard ratio of 4.20 (95% confidence interval [CI], 1.74-10.13) and ER status with hazard ratio of 4.33 (95% CI, 1.06-17.71) were predictors for RFS according to multivariate analysis (p=0.002 and p=0.042, respectively).

Conclusion

Our study demonstrated that ALN/T SUV ratio together with ER status was an independent factor for predicting relapse in IDC with metastatic ALN. ALN/T SUV ratio on preoperative FDG PET/CT may be a useful marker for selecting IDC patients that need adjunct treatment to prevent recurrence.

Feasibility of cetuximab and chemoradiotherapy combination in Chinese patients with unresectable stage III non-small cell lung cancer: a preliminary report

OBJECTIVE

In recent years, the combination of cetuximab and chemoradiotherapy (CRT) has been used to treat stage III non-small cell lung cancer (NSCLC); however, limited data are available for Chinese patients. Herein, we report preliminary data from a phase I/II study testing the combination of cetuximab with inductive chemotherapy, followed by concurrent CRT (CCRT) in Chinese patients with stage III NSCLC.

METHODS

Eligibility criteria were Zubrod performance status (PS) 0-1, forced expiratory volume in 1 second (FEV1) ≥1.2 L and adequate organ function. Enrolled patients received weekly cetuximab (initial dose of 400 mg/m(2) on day 1 of week 1 and a maintenance dose of 250 mg/m(2) on week 2 to the end of CCRT) with cisplatin/vinorelbine (NP) chemotherapy (every 3 weeks for 2 cycles from week 2, followed by two cycles of concomitant NP chemotherapy and intensity-modulated thoracic radiotherapy (TRT) (60-66 Gy/2 Gy). The primary endpoints were toxicity and feasibility. All patients received positron emission tomography-computerized tomography (PET-CT) scans within the 2 weeks prior to enrollment. Univariate analyses were used to assess the correlation between SUV-T, SUV-N, SUV-TOTAL, gender, age, histology, tumor-node-metastasis (TNM) stage, PS and smoking status and survival. Survival curves were generated for different populations using the Kaplan-Meier method and compared using a log-rank test.

RESULTS

Seventeen patients were enrolled and 16 completed the full regime. The overall response rate (ORR) was 58.8% and 82.3% after the induction and CCRT phases, respectively. With a median follow-up duration of 27.6 months, the median survival was 27.6 months [95% confidence interval (CI): 11.3-43.9 months] with 1- and 2-year survival rates of 88.2% (95% CI, 60.6-96.9%) and 58.8% (95% CI, 60.6-77.8%), respectively. Three patients remain progression-free to date, and the median progression-free survival (PFS) was 13.5 months (95% CI, 6.8-20.2 months). No treatment-related death occurred; however, 76% of the patients experienced grade 3+ adverse events (AEs), including nausea/vomiting, intestinal obstruction, and esophagitis (<6%), while other AEs were mostly of hematological nature (71%). The cut-off values for SUV-T and SUV-TOTAL were 11 and 20, respectively. Univariate analyses revealed SUV-TOTAL (P=0.027), SUV-T (P=0.025), and PS (P=0.006) as potential survival predictors, with a hazard ratio (HR) of 3.4, 3.7, and 9.9, respectively.

CONCLUSIONS

The combination of cetuximab with induction chemotherapy followed by CCRT appears feasible and promising. Local and locoregional maximal SUVs, defined by (18)F-FDG PET-CT scanning, may represent a prognostic indicator for long-term survival for these patients, which warrants further study.

Spontaneous regression of non-small cell lung cancer that progressed after multiple chemotherapies: A case report

Spontaneous regression (SR) of cancer is defined as a complete or partial, temporary or permanent disappearance of all or at least some relevant parameters of malignant disease with inadequate or no treatment. SR of cancer is an extremely rare phenomenon. We report a case of a 67-year-old man who experienced SR of non-small-cell lung cancer (NSCLC), which progressed after fifth-line chemotherapy and regressed after chemotherapy ceased. Surprisingly, the primary tumor size continued to decrease for more than 13 months and his general condition markedly improved after discontinuation of the chemotherapy. To our knowledge, this is the first report of SR in a patient with NSCLC that was not responsive to a fifth round of chemotherapy.

Inferior glucose metabolism and chemosensitivity of post-radiotherapy local recurrence in comparison with distant metastases as assessed by sequential (18)F-FDG PET/CT imaging

PURPOSE

To compare glucose metabolism and chemosensitivity between recurrence within the irradiation field and metastases outside the irradiation field in the same patient using (18)F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography images (PET/CT).

METHODS

The (18)F-FDG PET/CT images of 43 cancer patients with both local recurrence (in-field) and distal metastases (out-field) after initial treatments were reviewed. 23 patients after definitive radiotherapy/chemoradiotherapy and 20 patients after radical surgery were assigned to a radiation group and surgery group, respectively. The tumor maximal diameter on CT and PET images (D CT and D PET), maximal SUV (SUVmax), and mean SUV (SUVmean) were measured. All the patients were administered chemotherapy, and 17 patients from the radiation group and 10 patients from the surgery group underwent PET/CT scanning within 1-2 months after the treatment. The changes in D CT, D PET, SUVmax and SUVmean for each lesion were calculated and compared between in-field and out-field tumors for both groups.

RESULTS

In the surgery group, no significant difference was found in tumor size or FDG uptake between the local recurrence and metastases. In the radiation group, both SUVmax (7.03 ± 3.48) and SUVmean (4.33 ± 1.67) of the in-field tumors were lower than those (8.45 ± 4.34 and 5.36 ± 2.51, respectively, P < 0.05) of out-field tumors. Moreover, the response extent of in-field tumors was lower than that of out-field tumors in the radiation group (P < 0.05). However, in the surgery group, there was no difference in the response extent (tumor size and SUVs) between the local recurrence and metastases (P > 0.05).

CONCLUSION

The recurrence within the irradiation field and metastases outside the irradiation field in the same patient do not share the same biological characteristics or treatment response, with inferior glucose metabolism and chemosensitivity seen in locally recurrent tumors.

Correlation between 18F-fluorodeoxyglucose positron emission tomography and pathologic differentiation in pancreatic cancer

OBJECT

The histopathological grade of differentiation is one of the significant prognostic factors in pancreatic adenocarcinoma. Especially in the patients with unresectable pancreatic cancer, it is important to obtain the prognostic information non-invasively to avoid unnecessary invasive procedure. The aim of the study was to correlate (18)F-fluorodeoxyglucose (FDG) uptake with pathologic grade of pancreatic cancer, furthermore, to evaluate prognostic value of standardized uptake value (SUV).

METHODS

FDG-PET scans of 102 patients with histologically proven pancreas adenocarcinoma were retrospectively reviewed. SUV of the primary tumor was calculated for quantification analysis. Pathological differentiation was graded into well-, moderately, and poorly differentiated groups. One-way analysis of variance is performed to test the correlation of the SUV and histopathologic grades. Patients were assigned into 3 categorical groups, using SUV cut-offs of 4 and 7, respectively. Survival functions of different histologic grade and assigned groups according to SUV were estimated by Kaplan-Meier estimator and compared by log-rank test. Multivariate analysis was performed using the Cox proportional hazard regression model.

RESULTS

There was a significant correlation of SUVs and pathologic grades (F=4.97, p<0.01). The mean SUV of well-, moderately and poorly differentiated groups was 4.93, 6.47 and 7.29, respectively. Tumor size, AJCC stage and treatment method were significantly related to the degree of FDG uptakes. SUV also shows a significant correlation with survival (p<0.01), with better prognosis in lower SUV group. In multivariate analysis, the treatment method was the most strongly independent predictor (p<0.01), followed by age (p=0.04) and tumor size (p=0.06). In moderately differentiated group, higher SUV showed significantly worse survival (p=0.02).

CONCLUSION

SUV is related with histologic grade and might be competitive predictor for patients' survival. Specifically, the prognosis of the patients with moderately differentiated pancreas adenocarcinoma could be stratified according to SUV.

Significance of tumour vessel invasion in determining the morphology of isolated tumour cells in the pulmonary vein in non-small-cell lung cancer

OBJECTIVES

The existence of clustered isolated tumour cells (ITCs) in the pulmonary vein (PV) of the lungs of patients with lung cancer has been reported to be a prognostic factor. However, the clinical-pathological characteristics related to their presence in the PV remain unclear.

METHODS

We analysed the surgical results and clinical-pathological findings of 130 patients who underwent surgery for non-small-cell lung cancer in regard to blood vessel invasion (BVI), serum carcinoembryonic antigen (CEA) level, maximum standardized uptake value (SUV-max), size of the solid region in computed tomography findings and pathological stage according to an ITC type, i.e. no tumour (N), singular tumour cells (S) and clustered tumour cells (C).

RESULTS

ITCs were detected in 96 (74%) of the patients, with C observed in 43, S in 53 and N in 34. Recurrence was seen in 33 (26%) cases, 21 of which were classified as C, 9 as S and 3 as N. The disease-free survival rate was significantly worse in C cases when compared with the others (P < 0.01). The rate of C was high in cases with high serum CEA, advanced p-staging and positive BVI ratio. Furthermore, BVI positive and ITC morphology were strongly related (BVI positive; 79 in C, 40 in S, 9% in N; P < 0.01).

CONCLUSIONS

Clustered ITCs were shown to be a prognostic indicator and strongly related to BVI. Our results suggest that determination of BVI has prognostic value, as clustered ITCs with metastatic potential are disseminated from the invaded vein.

Multifunctional profiling of non-small cell lung cancer using 18F-FDG PET/CT and volume perfusion CT

The aim of this study was to investigate correlations between glucose metabolism registered by (18)F-FDG PET/CT and tumor perfusion quantified by volume perfusion CT and immunohistochemical markers Ki67 and microvessel density (MVD) in patients with non-small cell lung cancer (NSCLC).

METHODS

Between February 2010 and April 2011, 24 consecutive patients (21 women, 3 men; mean age ± SD, 67.6 ± 6.8 y; age range, 55.6-81.3 y) with histologically proven NSCLC (14 adenocarcinoma, 9 squamous cell lung carcinoma [SCC], and 1 mixed adenocarcinoma and SCC) underwent (18)F-FDG PET/CT and additional volume perfusion CT. Maximum standardized uptake value (SUV(max)), mean SUV, and the metabolic tumor volume were used for (18)F-FDG uptake quantification. Blood flow (BF), blood volume (BV), flow extraction product (K(trans)), and standardized perfusion value (SPV) were determined as CT perfusion parameters. Both perfusion parameters and (18)F-FDG uptake values were subsequently related to the histologic subtypes, proliferation marker Ki67, MVD according to CD34 staining, and total tumor volume.

RESULTS

Mean SUV, SUV(max), and the metabolic tumor volume (mL) were 5.8, 8.7, and 32.3, respectively, in adenocarcinoma and 8.5, 12.9, and 16.8, respectively, in SCC. Mean BF (mL/100 mL/min), mean BV (mL/100 mL), and K(trans) (mL/100 mL/min) were 35.4, 7.3, and 27.8, respectively, in adenocarcinoma and 35.5, 10.0, and 27.8, respectively, in SCC. Moderate correlations were found between the (18)F-FDG PET/CT parameters and Ki67 as well as between CT perfusion parameters and MVD but not vice versa. For all tumors, the following correlations were found: between SUV(max) and Ki67, r = 0.762 (P = 0.017); between SUV(max) and MVD, r = -0.237 (P = 0.359); between mean BF and Ki67, r = -0.127 (P = 0.626); and between mean BF and MVD, r = 0.467 (P = 0.059). Interestingly, correlations between the BF-metabolic relationship and total tumor volume were higher in SCC (r = 0.762, P = 0.017) than in adenocarcinoma (r = -0.0791, P = 0.788).

CONCLUSION

(18)F-FDG uptake correlates with Ki67, whereas BF, BV, and K(trans) correlate with MVD. Therefore, (18)F-FDG uptake and perfusion parameters provide complementary functional information. An improved tumor profiling will be beneficial for both prognosis and therapy response evaluation in these tumors.

Value of dual time point F-18 FDG-PET/CT imaging for the evaluation of prognosis and risk factors for recurrence in patients with stage I non-small cell lung cancer treated with stereotactic body radiation therapy

PURPOSE

To investigate prognostic and risk factors for recurrence after stereotactic body radiation therapy (SBRT) in patients with stage I non-small cell lung carcinoma (NSCLC), focusing on dual time point [18]F-fluorodeoxyglucose positron emission tomography (FDG PET).

MATERIALS AND METHODS

We prospectively evaluated 57 patients with stage I NSCLC (45 T1N0M0 and 12 T2N0M0) who had undergone pretreatment FDG-PET/CT and were subsequently treated with SBRT. All patients received a whole-body PET/CT scan at 60 min and a whole-lung at 120 min after the injection. The maximum standardized uptake value (SUV) and retention index (RI) of the lesions were calculated. Local recurrence, regional lymph node metastasis, distant metastasis, and the recurrence pattern were evaluated. Cox proportional hazard regression analyses were performed to evaluate prognostic factors or risk factors of recurrence.

RESULTS

During the median follow-up period of 27 months, local recurrence, regional lymph node metastasis, and distant metastasis were seen in 17 (30%), 12 (21%), and 17 (30%) of the 57 patients, respectively. The 3-year overall survival rate was 63.4%. SUVmax did not affect any recurrence, DFS, OS, or CSS. RI significantly predicted higher distant metastasis (HR 47.546, p=0.026). In contrast, RI tended to predict lower local recurrence (HR 0.175, p=0.246) and regional lymph node metastasis (HR 0.109, p=0.115).

CONCLUSIONS

SUVmax at staging FDG-PET does not predict any recurrence, DFS, OS or CSS. In contrast, higher RI predicts higher distant metastasis and tended to predict lower local or regional lymph node metastasis.

False-positivity of mediastinal lymph nodes has negative effect on survival in potentially resectable non-small cell lung cancer

OBJECTIVES

It has been shown that increased metabolic activity of primary tumour has a negative effect on survival in non-small cell lung cancer (NSCLC) staged with positron emission tomography integrated computed tomography (PET/CT). We hypothesized that an increased metabolic activity of mediastinal lymph nodes would have worse survival even if it is false.

METHODS

Three hundred and twenty-eight consecutive patients with NSCLC histology were imaged with PET/CT within 90 days of surgery between September 2005 and March 2009. Patients who had neoadjuvant chemotherapy (n = 22), patients with prior history of NSCLC (n = 9) or other malignancies within 5 years (n = 11) were excluded from the study. Patients with negative mediastinoscopy underwent resection. Pathological results were revised according to the seventh tumor-node-metastasis staging system. Kaplan-Meier test was used for survival. Log-rank and Cox analyses were used for comparisons.

RESULTS

A total of 286 patients (262 male; mean age: 58.5 years) were evaluated. There were 22 (6.7%) operative deaths and none of the patients were lost to follow-up. The median follow-up in the remaining 264 patients was 26 months (range, 2-61 months). Tumour size, nodal spread and stage were all strongly associated with survival from NSCLC (P < 0.001). There were 63 true-positive, 65 false-positive (FP), 152 true-negative (TN) and six false-negative findings on mediastinal staging after PET/CT. The maximum standardized uptake value of primary tumour was significantly higher in FP patients than in TN patients (P = 0.012). After excluding pN2-positive patients, TN patients had better survival than FP patients (P = 0.006). Multivariate analysis showed that false-positivity of mediastinal lymph nodes was independently associated with worse survival (hazard ratio = 0.63; P = 0.02). There were 146 patients with pT1-4, pN0 treated with R0 surgical resection. Disease-free survival and overall survival were also significantly better for TN patients in completely resected group (P = 0.009 versus 0.016).

CONCLUSIONS

We have shown that false-positivity of mediastinal lymph nodes had yielded worse survival in surgically staged or resected NSCLC patients staged with PET/CT. This result may help to allocate patients with potentially poor prognosis for considered additional therapy.

Ratio of standardized uptake value on PET helps predict response and outcome after chemotherapy in advanced non-small cell lung cancer

BACKGROUND

The maximum standardized uptake value (SUV(max)) on (18)F-fluorodeoxyglucose-positron emission tomography ((18)F-FDG PET) within the primary tumor may predict outcome in patients with surgically resected non-small cell lung cancer (NSCLC). However, it remains uncertain whether the SUV(max) of the primary tumor predicts outcome after chemotherapy in advanced NSCLC. Thus, we evaluated the ratio of SUV(max) of the metastatic tumor to the primary tumor (M/P ratio) to determine whether it could be a useful marker in predicting response and outcome after chemotherapy in advanced NSCLC.

METHODS

Chemo-naïve patients with advanced NSCLC who had locoregional lymph nodes and/or distant metastases other than brain, were eligible for inclusion in this study. Response and survival were analyzed according to the SUV(max) of primary tumor, the ratio of the SUV(max) of the tumor to the mean SUV of the mediastinum (T/M ratio) and M/P ratio.

RESULTS

One hundred and four consecutive patients were included in the retrospective study. Patients with high M/P ratio exhibited significantly lower response rates. The value of SUV(max) and T/M ratio were not associated with the response to initial chemotherapy. In the univariate analysis, T/M ratio and SUV(max) were significantly associated with poor outcome. However, the outcome of non-adenocarcinoma was unaffected by T/M ratio and SUV(max). Multivariate analysis confirmed that high M/P ratio was a significant independent factor predicting a poor outcome.

CONCLUSION

High M/P ratio was associated with a poor response to initial chemotherapy and was a significant independent factor in predicting poor outcome in advanced NSCLC patients with metastatic tumors other than in brain.

Imaging and 'omic' methods for the molecular diagnosis of cancer

Molecular imaging methods can noninvasively detect specific biological processes that are aberrant in cancer, including upregulated glycolytic metabolism, increased cellular proliferation and altered receptor expression. PET using the glucose analogue 18F-fluoro-2-deoxyglucose, which detects the increased glucose uptake that is a characteristic of tumor cells, has been widely used in the clinic to detect tumors and their responses to treatment; however, there are many new PET tracers being developed for a wide range of biological targets. Magnetic resonance spectroscopy (MRS), which can be used to detect cellular metabolites, can also provide prognostic information, particularly in brain, breast and prostate cancers. An emerging technique, which by hyperpolarizing 13C-labeled cell substrates dramatically enhances their sensitivity to detection, could further extend the use of MRS in molecular imaging in the clinic. Molecular diagnostics applied to serum samples or tumor samples obtained by biopsy, can measure changes at the individual cell level and the underlying changes in gene or protein expression. DNA microarrays enable high-throughput gene-expression profiling, while mass spectrometry can detect thousands of proteins that may be used in the future as biomarkers of cancer. Probing molecular changes will aid not only cancer diagnosis, but also provide tumor grading, based on gene-expression analysis and imaging measurements of cell proliferation and changes in metabolism; staging, based on imaging of metastatic spread and elevation of protein biomarkers; and the detection of therapeutic response, using serial molecular imaging measurements or monitoring of serum markers. The present article provides a summary of the molecular diagnostic methods that are currently being trialed in the clinic.