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Sivakumaran T, Cardin A, Callahan J, Wong HL, Tothill RW, Hicks RJ, Mileshkin LR. Evaluating the Utility of 18F-FDG PET/CT in Cancer of Unknown Primary. J Nucl Med 2024:jnumed.123.267274. [PMID: 39237349 DOI: 10.2967/jnumed.123.267274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 08/13/2024] [Indexed: 09/07/2024] Open
Abstract
Cancer of unknown primary (CUP) represents a heterogeneous group of metastatic tumors for which standardized diagnostic work-up fails to identify the primary site. We aimed to describe the Peter MacCallum Cancer Centre experience with 18F-FDG PET/CT in extracervical CUP with respect to detection of a primary site and its impact on management. A secondary aim was to compare overall survival (OS) in patients with and without a detected primary site. Methods: CUP patients treated between 2014 and 2020 were identified from medical oncology clinics and 18F-FDG PET/CT records. Information collated from electronic medical records included the suspected primary site and treatment details before and after 18F-FDG PET/CT. Clinicopathologic details and genomic analysis were used to determine the clinically suspected primary site and compared against 2 independent masked reads of 18F-FDG PET/CT images by nuclear medicine specialists to determine sensitivity, specificity, accuracy, and the rate of detection of the primary site. Results: We identified 147 patients, 65% of whom had undergone molecular profiling. The median age at diagnosis was 61 y (range, 20-84 y), and the median follow-up time was 74 mo (range, 26-83 mo). Eighty-two percent were classified as having an unfavorable CUP subtype as per international guidelines.18F-FDG PET/CT demonstrated a primary site detection rate of 41%, resulted in a change in management in 22%, and identified previously occult disease sites in 37%. Median OS was 16.8 mo for all patients and 104.7 and 12.1 mo for favorable and unfavorable CUP subtypes, respectively (P < 0.0001). Median OS in CUP patients when using 18F-FDG PET/CT, clinicopathologic, and genomic information was 19.8 and 8.5 mo when a primary site was detected and not detected, respectively (P = 0.016). Multivariable analysis of survival adjusted for age and sex remained significant for identification of a potential primary site (P < 0.001), a favorable CUP (P < 0.001), and an Eastern Cooperative Oncology Group status of 1 or less (P < 0.001). Conclusion: 18F-FDG PET/CT plays a complementary role in CUP diagnostic work-up and was able to determine the likely primary site in 41% of cases. OS is improved with primary site identification, demonstrating the value of access to diagnostic 18F-FDG PET/CT for CUP patients.
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Affiliation(s)
- Tharani Sivakumaran
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia;
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
| | - Anthony Cardin
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
- Cancer Imaging, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Jason Callahan
- Melbourne Theranostic Innovation Centre, Melbourne, Victoria, Australia
| | - Hui-Li Wong
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
| | - Richard W Tothill
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
- Department of Clinical Pathology and University of Melbourne Centre for Cancer Research, University of Melbourne, Melbourne, Victoria, Australia; and
| | - Rodney J Hicks
- Melbourne Theranostic Innovation Centre, Melbourne, Victoria, Australia
- University of Melbourne Department of Medicine, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Linda R Mileshkin
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
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Willemse JRJ, Lambregts DMJ, Balduzzi S, Schats W, Snaebjornsson P, Marchetti S, Vollebergh MA, van Golen LW, Cheung Z, Vogel WV, Bodalal Z, Rostami S, Gerke O, Sivakumaran T, Beets-Tan RGH, Lahaye MJ. Identifying the primary tumour in patients with cancer of unknown primary (CUP) using [ 18F]FDG PET/CT: a systematic review and individual patient data meta-analysis. Eur J Nucl Med Mol Imaging 2024:10.1007/s00259-024-06860-1. [PMID: 39141069 DOI: 10.1007/s00259-024-06860-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Accepted: 07/26/2024] [Indexed: 08/15/2024]
Abstract
PURPOSE In this systematic review and individual patient data (IPD) meta-analysis, we analysed the diagnostic performance of [18F]FDG PET/CT in detecting primary tumours in patients with CUP and evaluated whether the location of the predominant metastatic site influences the diagnostic performance. METHODS A systematic literature search from January 2005 to February 2024 was performed to identify articles describing the diagnostic performance of [18F]FDG PET/CT for primary tumour detection in CUP. Individual patient data retrieved from original articles or obtained from corresponding authors were grouped by the predominant metastatic site. The diagnostic performance of [18F]FDG PET/CT in detecting the underlying primary tumour was compared between predominant metastatic sites. RESULTS A total of 1865 patients from 32 studies were included. The largest subgroup included patients with predominant bone metastases (n = 622), followed by liver (n = 369), lymph node (n = 358), brain (n = 316), peritoneal (n = 70), lung (n = 67), and soft tissue (n = 23) metastases, leaving a small group of other/undefined metastases (n = 40). [18F]FDG PET/CT resulted in pooled detection rates to identify the primary tumour of 0.74 (for patients with predominant brain metastases), 0.54 (liver-predominant), 0.49 (bone-predominant), 0.46 (lung-predominant), 0.38 (peritoneal-predominant), 0.37 (lymph node-predominant), and 0.35 (soft-tissue-predominant). CONCLUSION This individual patient data meta-analysis suggests that the ability of [18F]FDG PET/CT to identify the primary tumour in CUP depends on the distribution of metastatic sites. This finding emphasises the need for more tailored diagnostic approaches in different patient populations. In addition, alternative diagnostic tools, such as new PET tracers or whole-body (PET/)MRI, should be investigated.
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Affiliation(s)
- Jeroen R J Willemse
- Department of Radiology, the Netherlands Cancer Institute, Plesmanlaan 121, Amsterdam, 1066CX, The Netherlands
- GROW Research Institute for Oncology and Reproduction - Maastricht University, Maastricht, Netherlands
| | - Doenja M J Lambregts
- Department of Radiology, the Netherlands Cancer Institute, Plesmanlaan 121, Amsterdam, 1066CX, The Netherlands
- GROW Research Institute for Oncology and Reproduction - Maastricht University, Maastricht, Netherlands
| | - Sara Balduzzi
- Department of Biometrics, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Winnie Schats
- Department of Scientific Information Service, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Petur Snaebjornsson
- Department of Pathology, Netherlands Cancer Institute, Amsterdam, Netherlands
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Serena Marchetti
- Department of Medical Oncology and Clinical Pharmacology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Marieke A Vollebergh
- Department of Gastrointestinal Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Larissa W van Golen
- Department of Nuclear Medicine, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Zing Cheung
- Department of Nuclear Medicine, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Wouter V Vogel
- Department of Nuclear Medicine, Netherlands Cancer Institute, Amsterdam, Netherlands
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Zuhir Bodalal
- Department of Radiology, the Netherlands Cancer Institute, Plesmanlaan 121, Amsterdam, 1066CX, The Netherlands
- GROW Research Institute for Oncology and Reproduction - Maastricht University, Maastricht, Netherlands
| | - Sajjad Rostami
- Department of Radiology, the Netherlands Cancer Institute, Plesmanlaan 121, Amsterdam, 1066CX, The Netherlands
- GROW Research Institute for Oncology and Reproduction - Maastricht University, Maastricht, Netherlands
| | - Oke Gerke
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Nuclear Medicine, Odense University Hospital, Odense, Denmark
| | - Tharani Sivakumaran
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne VIC, Melbourne, VIC, Australia
| | - Regina G H Beets-Tan
- Department of Radiology, the Netherlands Cancer Institute, Plesmanlaan 121, Amsterdam, 1066CX, The Netherlands
- GROW Research Institute for Oncology and Reproduction - Maastricht University, Maastricht, Netherlands
- Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Max J Lahaye
- Department of Radiology, the Netherlands Cancer Institute, Plesmanlaan 121, Amsterdam, 1066CX, The Netherlands.
- GROW Research Institute for Oncology and Reproduction - Maastricht University, Maastricht, Netherlands.
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Zhi Y, Zhang Y, Zhang B. Transoral robotic surgery in the diagnosis and treatment of primary unknown head and neck squamous cell carcinoma: A preliminary single centre experience. Int J Med Robot 2024; 20:e2652. [PMID: 39031752 DOI: 10.1002/rcs.2652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 06/01/2024] [Accepted: 06/06/2024] [Indexed: 07/22/2024]
Abstract
BACKGROUND Squamous cell carcinoma of unknown primary (CUP) in the head and neck is difficult to diagnose and treat. This report outlines 11 cases of CUP treated with transoral robotic surgery (TORS), aimed at investigating the diagnostic efficiency of primary tumour and radical resection effectiveness of TORS. METHODS 11 cases of CUP among 68 oropharyngeal cancer patients treated by TORS were analysed retrospectively. RESULTS All the 11 cases received TORS with cervical lymph node dissection. Primary tumours were found in 8 cases (72.7%), 4 cases in the palatine tonsil and 4 cases in the base of the tongue. The average diameter of the primary tumour was 1.65 cm. All patients resumed eating by mouth within 24 h, no tracheotomy, no pharyngeal fistula and no postoperative death. The 3-year disease-free survival rate was 91%. CONCLUSIONS TORS can improve the diagnostic efficiency of primary tumour of CUP and achieve good oncology and functional results.
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Affiliation(s)
- Yinghui Zhi
- Department of General Surgery, Beijing United Family Hospital and Clinics, Beijing, China
| | - Yabing Zhang
- Department of Head and Neck Surgery, Peking University Cancer Hospital and Institute, Beijing, China
| | - Bin Zhang
- Department of Head and Neck Surgery, Peking University Cancer Hospital and Institute, Beijing, China
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Huang R, Hu Y, Zhang Y. Utility of 18F-FDG PET/CT in Treatment Strategies for Patients With Cancer of Unknown Primary: A Single-Center, Retrospective Change-in-Management Study. Clin Med Insights Oncol 2024; 18:11795549241245691. [PMID: 38655397 PMCID: PMC11036913 DOI: 10.1177/11795549241245691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 03/20/2024] [Indexed: 04/26/2024] Open
Abstract
Background Cancer of unknown primary (CUP) is difficult to diagnose and classify clinically, and the disease develops rapidly. Therefore, the primary tumor detected in patients with CUP plays a profound role in the diagnosis and treatment of patients. The search for the primary tumor of CUP is also one of the indications for 18F-fluoro-2-deoxyglucose-positron emission tomography and computed tomography (FDG-PET/CT). Our objective was to evaluate the role of 18F-FDG PET/CT imaging in primary tumor detection and treatment formulation in patients with CUP. Methods Sixty-two patients with CUP were selected from a database consisting of 18 802 cases in the Jiangsu Cancer Hospital PET/CT center from May 18, 2016 to November 18, 2022. Clinical data and changes in treatment strategies before and after PET/CT were collected. Results A total of 42 primary tumors (42/62, 67.7%) were identified by PET/CT examination. The tumor staging of patients before conventional PET/CT imaging (such as CT/magnetic resonance imaging [MRI]/US) and after PET/CT did not change in 28 patients (28/62, 45.2%), whereas for 34 patients (34/62, 54.8%), tumor staging changed. Forty-five patients (45/62, 72.6%) had not developed treatment plans before PET/CT examination, but treatment plans were clarified after PET/CT examination. Thirteen patients (13/62, 21.0%) underwent changes in treatments before and after PET/CT examination. Among the 20 patients (20/62, 32.3%) whose primary tumors were not detected, 16 patients (16/20, 80.0%) had no treatment plans before PET/CT and the treatment plans were defined after PET/CT, 3 patients (3/20, 15.0%) changed the treatment plans before and after PET/CT, and 1 patient (1/20, 5.0%) did not change the treatment plan. Conclusions The 18F-FDG PET/CT plays an important role in the detection and staging of primary tumors in patients with CUP. The PET/CT findings can not only help clinicians develop appropriate treatment plans for patients with CUP but also serve as an effective approach to improve real-life treatment strategies for these patients.
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Affiliation(s)
- Rong Huang
- Department of PET/CT Center, Jiangsu Cancer Hospital and Jiangsu Institute of Cancer Research and The Affiliated Cancer Hospital of Nanjing Medical University, Nanjing, China
| | - Yuxiao Hu
- Department of PET/CT Center, Jiangsu Cancer Hospital and Jiangsu Institute of Cancer Research and The Affiliated Cancer Hospital of Nanjing Medical University, Nanjing, China
| | - Yun Zhang
- Department of PET/CT Center, Jiangsu Cancer Hospital and Jiangsu Institute of Cancer Research and The Affiliated Cancer Hospital of Nanjing Medical University, Nanjing, China
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Rimer H, Jensen MS, Dahlsgaard-Wallenius SE, Eckhoff L, Thye-Rønn P, Kristiansen C, Hildebrandt MG, Gerke O. 2-[18F]FDG-PET/CT in Cancer of Unknown Primary Tumor-A Retrospective Register-Based Cohort Study. J Imaging 2023; 9:178. [PMID: 37754942 PMCID: PMC10532746 DOI: 10.3390/jimaging9090178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 08/17/2023] [Accepted: 08/25/2023] [Indexed: 09/28/2023] Open
Abstract
We investigated the impact of 2-[18F]FDG-PET/CT on detection rate (DR) of the primary tumor and survival in patients with suspected cancer of unknown primary tumor (CUP), comparing it to the conventional diagnostic imaging method, CT. Patients who received a tentative CUP diagnosis at Odense University Hospital from 2014-2017 were included. Patients receiving a 2-[18F]FDG-PET/CT were assigned to the 2-[18F]FDG-PET/CT group and patients receiving a CT only to the CT group. DR was calculated as the proportion of true positive findings of 2-[18F]FDG-PET/CT and CT scans, separately, using biopsy of the primary tumor, autopsy, or clinical decision as reference standard. Survival analyses included Kaplan-Meier estimates and Cox proportional hazards regression adjusted for age, sex, treatment, and propensity score. We included 193 patients. Of these, 159 were in the 2-[18F]FDG-PET/CT group and 34 were in the CT group. DR was 36.5% in the 2-[18F]FDG-PET/CT group and 17.6% in the CT group, respectively (p = 0.012). Median survival was 7.4 (95% CI 0.4-98.7) months in the 2-[18F]FDG-PET/CT group and 3.8 (95% CI 0.2-98.1) in the CT group. Survival analysis showed a crude hazard ratio of 0.63 (p = 0.024) and an adjusted hazard ratio of 0.68 (p = 0.087) for the 2-[18F]FDG-PET/CT group compared with CT. This study found a significantly higher DR of the primary tumor in suspected CUP patients using 2-[18F]FDG-PET/CT compared with patients receiving only CT, with possible immense clinical importance. No significant difference in survival was found, although a possible tendency towards longer survival in the 2-[18F]FDG-PET/CT group was observed.
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Affiliation(s)
- Heidi Rimer
- Department of Clinical Research, University of Southern Denmark, 5000 Odense, Denmark
| | - Melina Sofie Jensen
- Department of Clinical Research, University of Southern Denmark, 5000 Odense, Denmark
| | | | - Lise Eckhoff
- Department of Oncology, Odense University Hospital, 5000 Odense, Denmark
| | - Peter Thye-Rønn
- Department of Medicine, Center of Diagnostics, Odense University Hospital, Svendborg Hospital, 5700 Svendborg, Denmark
| | - Charlotte Kristiansen
- Department of Oncology, University Hospital of Southern Denmark, Lillebælt Hospital, 7100 Vejle, Denmark
| | - Malene Grubbe Hildebrandt
- Department of Clinical Research, University of Southern Denmark, 5000 Odense, Denmark
- Department of Nuclear Medicine, Odense University Hospital, 5000 Odense, Denmark
- Centre for Innovative Medical Technology, Odense University Hospital, 5000 Odense, Denmark
| | - Oke Gerke
- Department of Clinical Research, University of Southern Denmark, 5000 Odense, Denmark
- Department of Nuclear Medicine, Odense University Hospital, 5000 Odense, Denmark
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Röhrich M. [Positron emission tomography in CUP syndrome]. RADIOLOGIE (HEIDELBERG, GERMANY) 2023; 63:354-357. [PMID: 37079059 DOI: 10.1007/s00117-023-01144-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Accepted: 03/22/2023] [Indexed: 04/21/2023]
Abstract
CLINICAL/METHODOLOGICAL ISSUE In approximately 2% of all cancers, no primary tumor can be detected and cancer of unknown primary (CUP) syndrome, a diagnosis of exclusion, is made. STANDARD RADIOLOGICAL METHODS In CUP syndrome, computed tomography (CT) and/or magnetic resonance imaging (MRI) do not lead to the detection of primary tumors. METHODOLOGICAL INNOVATIONS In the advanced diagnostic workup of CUP syndrome, 18F‑fluordeoxyglucose positron emission tomography/computed tomography (18F‑FDG PET/CT) can be used. In addition, 68Ga-fibroblast activation protein inhibitor (FAPI) PET/CT as a novel, experimental imaging technique may be considered. PERFORMANCE 18F‑FDG PET/CT is clinically established for the detection of primary tumors of cervical CUP syndrome. High detection rates have also been reported for 18F‑FDG-PET/CT in extracervical CUP syndrome. 68Ga-FAPI PET/CT has not yet been clinically established, but remarkably high detection rates have been shown for 18F‑FDG-negative cervical CUP syndrome due to its low background activity. ACHIEVEMENTS The benefit of 18F‑FDG PET in CUP syndrome has been documented in several meta-analyses. To date, the evidence for the use of 68Ga-FAPI PET/CT in CUP syndrome is still rudimentary. PRACTICAL RECOMMENDATIONS 18F‑FDG PET should be applied regularly in cervical CUP syndrome and can be individually considered in extracervical CUP syndrome.
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Affiliation(s)
- Manuel Röhrich
- , Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland.
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