Significance of 18F-FDG PET Parameters According to Histologic Subtype in the Treatment Outcome of Stage III Non–small-cell Lung Cancer Undergoing Definitive Concurrent Chemoradiotherapy

Early radiologic and metabolic tumour response assessment during combined chemo-radiotherapy for locally advanced NSCLC

Background

The role of early treatment response for patients with locally advanced non-small cell lung cancer (LA-NSCLC) treated with concurrent chemo-radiotherapy (cCRT) is unclear. The study aims to investigate the predictive value of response to induction chemotherapy (iCX) and the correlation with pattern of failure (PoF).

Materials and methods

Patients with LA-NSCLC treated with cCRT were included for analyses (n = 276). Target delineations were registered from radiotherapy planning PET/CT to diagnostic PET/CT, in between which patients received iCX. Volume, sphericity, and SUVpeak were extracted from each scan. First site of failure was categorised as loco-regional (LR), distant (DM), or simultaneous LR+M (LR+M). Fine and Gray models for PoF were performed: a baseline model (including performance status (PS), stage, and histology), an image model for squamous cell carcinoma (SCC), and an image model for non-SCC. Parameters included PS, volume (VOL) of tumour, VOL of lymph nodes, ΔVOL, sphericity, SUVpeak, ΔSUVpeak, and oligometastatic disease.

Results

Median follow-up was 7.6 years. SCC had higher sub-distribution hazard ratio (sHR) for LRF (sHR = 2.771 [1.577:4.87], p < 0.01) and decreased sHR for DM (sHR = 0.247 [0.125:0.485], p  <  0.01). For both image models, high diagnostic SUVpeak increased risk of LRF (sHR = 1.059 [1.05:1.106], p < 0.01 for SCC, sHR = 1.12 [1.03:1.21], p < 0.01 for non-SCC). Patients with SCC and less decrease in VOL had higher sHR for DM (sHR = 1.025[1.001:1.048] pr. % increase, p = 0.038).

Conclusion

Poor response in disease volume was correlated with higher sHR of DM for SCC, no other clear correlation of response and PoF was observed. Histology significantly correlated with PoF with SCC prone to LRF and non-SCC prone to DM as first site of failure. High SUVpeak at diagnosis increased the risk of LRF for both histologies.

Solute carrier family 2 members 1 and 2 as prognostic biomarkers in hepatocellular carcinoma associated with immune infiltration

BACKGROUND

Metabolic reprogramming has been identified as a core hallmark of cancer. Solute carrier family 2 is a major glucose carrier family. It consists of 14 members, and we mainly study solute carrier family 2 member 1 (SLC2A1) and solute carrier family 2 member 2 (SLC2A2) here. SLC2A1, mainly existing in human erythrocytes, brain endothelial cells, and normal placenta, was found to be increased in hepatocellular carcinoma (HCC), while SLC2A2, the major transporter of the normal liver, was decreased in HCC.

AIM

To identify if SLC2A1 and SLC2A2 were associated with immune infiltration in addition to participating in the metabolic reprogramming in HCC.

METHODS

The expression levels of SLC2A1 and SLC2A2 were tested in HepG2 cells, HepG215 cells, and multiple databases. The clinical characteristics and survival data of SLC2A1 and SLC2A2 were examined by multiple databases. The correlation between SLC2A1 and SLC2A2 was analyzed by multiple databases. The functions and pathways in which SLC2A1, SLC2A2, and frequently altered neighbor genes were involved were discussed in String. Immune infiltration levels and immune marker genes associated with SLC2A1 and SLC2A2 were discussed from multiple databases.

RESULTS

The expression level of SLC2A1 was up-regulated, but the expression level of SLC2A2 was down-regulated in HepG2 cells, HepG215 cells, and liver cancer patients. The expression levels of SLC2A1 and SLC2A2 were related to tumor volume, grade, and stage in HCC. Interestingly, the expression levels of SLC2A1 and SLC2A2 were negatively correlated. Further, high SLC2A1 expression and low SLC2A2 expression were linked to poor overall survival and relapse-free survival. SLC2A1, SLC2A2, and frequently altered neighbor genes played a major role in the occurrence and development of tumors. Notably, SLC2A1 was positively correlated with tumor immune infiltration, while SLC2A2 was negatively correlated with tumor immune infiltration. Particularly, SLC2A2 methylation was positively correlated with lymphocytes.

CONCLUSION

SLC2A1 and SLC2A2 are independent therapeutic targets for HCC, and they are quintessential marker molecules for predicting and regulating the number and status of immune cells in HCC.

Progress and future prospective of FDG-PET/CT imaging combined with optimized procedures in lung cancer: toward precision medicine

With a 5-year overall survival of approximately 20%, lung cancer has always been the number one cancer-specific killer all over the world. As a fusion of positron emission computed tomography (PET) and computed tomography (CT), PET/CT has revolutionized cancer imaging over the past 20 years. In this review, we focused on the optimization of the function of ¹⁸F-flurodeoxyglucose (FDG)-PET/CT in diagnosis, prognostic prediction and therapy management of lung cancers by computer programs. FDG-PET/CT has demonstrated a surprising role in development of therapeutic biomarkers, prediction of therapeutic responses and long-term survival, which could be conducive to solving existing dilemmas. Meanwhile, novel tracers and optimized procedures are also developed to control the quality and improve the effect of PET/CT. With the continuous development of some new imaging agents and their clinical applications, application value of PET/CT has broad prospects in this area.

New developments in locally advanced nonsmall cell lung cancer

Locally advanced nonsmall cell lung cancer, due to its varying prognosis, is grouped according to TNM stage IIIA, IIIB and IIIC. Developments over the last 3 years have been focused on the integration of immunotherapy into the combination treatment of a locally definitive therapy (surgery or radiotherapy) and chemotherapy. For concurrent chemoradiotherapy, consolidation therapy with durvalumab was established. Adjuvant targeted therapy has again gained increasing interest. In order to adapt treatment to the specific stage subgroup and its prognosis, fluorodeoxyglucose positron emission tomography/computed tomography and pathological evaluation of the mediastinum are important. Tumours should be investigated for immunological features and driver mutations. Regarding toxicity, evaluation of pulmonary and cardiac function, as well as symptoms and quality of life, is of increasing importance. To improve the management and prognosis of this heterogeneous entity, clinical trials and registries should take these factors into account.

Stage-Specific PET Radiomic Prediction Model for the Histological Subtype Classification of Non-Small-Cell Lung Cancer

Purpose

To investigate the impact of staging on differences in glucose metabolic heterogeneity between lung adenocarcinoma (ADC) and squamous cell carcinoma (SCC) by ¹⁸F-fluorodeoxyglucose positron emission tomography (¹⁸F-FDG PET) textural analysis and to develop a stage-specific PET radiomic prediction model to distinguish lung ADC from SCC.

Patients and Methods

Patients who were histologically diagnosed with lung ADC or SCC and underwent pretreatment ¹⁸F-FDG PET/CT scans were retrospectively identified. Radiomic features were extracted from a semiautomatically outlined tumor region in the Chang-Gung Image Texture Analysis (CGITA) software package. The differences in radiomic parameters between lung ADC and SCC were compared stage-by-stage in 253 consecutive NSCLC patients with stages I to III disease. The least absolute shrinkage and selection operator (LASSO) algorithm was used for feature selection. A radiomic signature for each stage was subsequently constructed and evaluated. Then, an individual nomogram incorporating the radiomic signature and clinical risk factors was established and evaluated. The performance of the constructed models was assessed by receiver operating characteristic (ROC) curve analysis, and the nomogram was further validated by calibration curve analysis.

Results

The performance of the radiomic signature for distinguishing lung ADC and SCC in both the training and validation cohorts was good, with AUCs of 0.883, 0.854, and 0.895 in the training cohort and 0.932, 0.944, and 0.886 in the validation cohort for stages I, II, and III NSCLC, respectively. The radiomic-clinical nomogram integrating radiomic features with independent clinical predictors exhibited more favorable discriminative performance, with AUCs of 0.982, 0.963, and 0.979 in the training cohort and 0.989, 0.984, and 0.978 in the validation cohort for stages I, II, and III, respectively.

Conclusion

Differences in PET radiomic features between lung ADC and SCC varied in different stages. Stage-specific PET radiomic prediction models provided more favorable performance for discriminating the histological subtype of NSCLC.

Prognostic factors for overall survival of stage III non-small cell lung cancer patients on computed tomography: A systematic review and meta-analysis

INTRODUCTION

Prognosis prediction is central in treatment decision making and quality of life for non-small cell lung cancer (NSCLC) patients. However, conventional computed tomography (CT) related prognostic factors may not apply to the challenging stage III NSCLC group. The aim of this systematic review was therefore to identify and evaluate CT-related prognostic factors for overall survival (OS) of stage III NSCLC.

METHODS

The Medline, Embase, and Cochrane electronic databases were searched. After study selection, risk of bias was estimated for the included studies. Meta-analysis of univariate results was performed when sufficient data were available.

RESULTS

1595 of the 11,996 retrieved records were selected for full text review, leading to inclusion of 65 studies that reported data of 144,513 stage III NSCLC patients andcompromising 26 unique CT-related prognostic factors. Relevance and validity varied substantially, few studies had low relevance and validity. Only four studies evaluated the added value of new prognostic factors compared with recognized clinical factors. Included studies suggested gross tumor volume (meta-analysis: HR = 1.22, 95%CI: 1.05-1.42), tumor diameter, nodal volume, and pleural effusion, are prognostic in patients treated with chemoradiation. Clinical T-stage and location (right/left) were likely not prognostic within stage III NSCLC. Inconclusive are several radiomic features, tumor volume, atelectasis, location (pulmonary lobes, central/peripheral), interstitial lung abnormalities, great vessel invasion, pit-fall sign, and cavitation.

CONCLUSIONS

Tumor-size and nodal size-related factors are prognostic for OS in stage III NSCLC. Future studies should carefully report study characteristics and contrast factors with guideline recognized factors to improve evidence evaluation and validation.

Maximum standardized uptake value of primary tumor (SUVmax_PT) and horizontal range between two most distant PET-positive lymph nodes predict patient outcome in inoperable stage III NSCLC patients after chemoradiotherapy

Background

18F-FDG-positron emission tomography (PET)/computed tomography (CT) is a standard for initial staging in patients with locally advanced stage III non-small cell lung cancer (NSCLC). We evaluated a PET/CT staging score to characterize disease extension and patient outcome in this disease.

Methods

Ninety-nine consecutive patients with NSCLC stage IIIA–B (UICC 7th edition), who underwent 18F-FDG-PET/CT before the start of chemoradiotherapy (CRT) were analyzed. Maximum standardized uptake value of primary tumor (SUVmax_PT) and range between two most distant PET-positive (SUV ≥2.5) lymph nodes in two directions were analyzed for their correlation with patient outcome. The vertical distance was defined as A- and the horizontal as a B-line.

Results

According to the results of univariate analysis, score included the SUVmax_PT and horizontal B-line, patients were divided into three risk subgroups: low, intermediate and high-risk subgroups. Subgroups were defined as SUVmax_PT <8 and B-line <3.7 cm, SUVmax_PT >8 or B-line >3.7 cm and SUVmax_PT >8 plus B-line >3.7 cm, respectively. Twenty-eight (28%), 45 (46%) and 26 (26%) patients were assigned to the low, intermediate and high-risk subgroup, respectively. Median event-free survival (EFS) in low, intermediate and high-risk subgroups was 16 (95% CI: 7–25), 13 (95% CI: 12–15) and 10 (95% CI: 7–13) months (P=0.002, log-rank test). Median OS in the low, intermediate and high-risk subgroups was 40 (95% CI: 11–69), 23 (95% CI: 15–31) and 14 (95% CI: 13–14) months (P=0.0001, log-rank test). In the multivariate analysis, SUV, B-line and PET/CT score were significantly associated with EFS [harard ratio (HR) 2.12 (95% CI: 1.27–3.55) and intermediate risk HR 2.01 (95% CI: 1.13–3.59), P=0.003] and OS [high-risk HR 2.79 (95% CI: 1.16–4.55) and intermediate risk HR 2.30 (95% CI: 1.58–4.94), P=0.001].

Conclusions

A PET/CT score was developed for inoperable stage III NSCLC patients treated with CRT and was an independent predictor of patient outcome in the single-center cohort.

An investigative expansion of a competing risk model for first failure site in locally advanced non-small cell lung cancer

Introduction: We hypothesized that gross tumor volume (GTV) of primary tumor (GTV_T) and nodal volumes (GTV_N) were predictors of first failure site in non-small cell lung cancer (NSCLC). We aimed at also comparing the prognostic model's complexity to its ability to generate absolute risk predictions with emphasis on variables available at the time of diagnosis. Materials and methods: Three hundred and forty-two patients treated with definitive chemoradiotherapy (CRT) for adenocarcinoma (AC) or squamous cell carcinoma (SCC) in 2009-2017 were analyzed. Clinical data, standardized uptake values on FDG-PET/CT, GTV_T and GTV_N were analyzed using multivariate competing risk models. Results: One hundred and thirty-seven patients had SCC. As first site of failure 49 had locoregional failure (LRF), 40 had distant metastasis (DM) and 24 died with no evidence of disease (NED). In 205 patients with AC, 34 had LRF, 118 had DM as first failure site and 17 died with NED. Performance status predicted LRF (p = .02) and UICC stage risk of DM (p = .05 for stage 3, p < .001 for stage 4). Adding histopathology changed predictions with much reduced risk of LRF in AC compared to SCC (HR = 0.5, 95% CI: (0.3-0.75), p = .001). Conversely, AC had a higher rate of DM than SCC (HR = 2.1, 95% CI: (1.5-3.0], p < .001). Addition of FDG metrics and tumor/nodal volume data predicted DM risk (p = .001), but with smaller impact on absolute risk compared to histopathology. Separation of GTV in nodal and tumor lesions did not improve risk predictions. Conclusions: We quantified the effect of adding volumetric and quantitative imaging to competing risk models of first failure site, but did not find tumor volume components to be important. Histopathology remains the simplest and most important factor in prognosticating failure patterns in NSCLC.

Differential effect of GLUT1 overexpression on survival and tumor immune microenvironment of human papilloma virus type 16-positive and -negative cervical cancer

Glucose transporter-1 (GLUT1) has been proposed as a prognosticator in various cancers associated with therapeutic resistance and immune evasion; however little data is available on the role of GLUT1 in cervical cancer. Most cervical cancers are caused by human papilloma virus (HPV), but studies on the treatment response and prognosis depending on the HPV subtype, are conflicting. This hypothesis-generating study aims to investigate the prognostic impact of GLUT1 in cervical cancer, in conjunction with HPV subtype. Clinicopathologic factors, along with mRNA expression data were obtained using The Cancer Genome Atlas database. Tumor HPV status and immune cell scores were extracted from previous publications. In total, 298 patients were analyzed. High GLUT1 expression was associated with old age, squamous cell carcinoma, high tumor stage, pelvic lymph node metastases, and low hysterectomy rate. Multivariate survival analysis revealed that high GLUT1 expression (Hazard ratio (HR) 2.57, p = 0.002) and HPV16 subtype (HR 0.56, p = 0.033) were independent prognostic factors for overall survival. In the subgroup analysis, poor prognostic impact of high GLUT1 expression was maintained in HPV16-positive group (p < 0.001), but not in HPV16-negative group (p = 0.495). Decreased immune cell scores of CD8⁺ T cells, B cells, and Th1 cells by high GLUT1 expression were observed only in HPV16-positive group. In conclusion, these results suggested that GLUT1 expression and HPV16 subtype might have an independent prognostic value in cervical cancer. GLUT1-mediated immunomodulation might be an important cause of treatment failure, especially in HPV16-positive group.

Is there any improvement in clinical staging with 18F-FDG PET/CT compared to surgical staging in cases of lung cancer?

OBJECTIVE

¹⁸F-Fluorine fluorodeoxyglucose positron emission tomography/computed tomography (¹⁸F-FDG PET/CT) imaging is considered the standard imaging modality for patients with non-small cell lung carcinoma. The aim of this study was to compare clinical staging (cTNM) performed with ¹⁸F-FDG PET/CT and surgical staging (sTNM) in patients with non-small cell carcinoma treated with surgery.

MATERIAL AND METHODS

We performed a retrospective analysis of 99 surgical patients with non-small cell carcinoma who underwent ¹⁸F-FDG PET/CT examination. Semiquantitative measures were calculated from the primary lesions and mediastinal lymph nodes. Findings of cTNM were compared with final surgical-pathological evaluation. Subjects were divided into two groups as postsurgical cTNM changed and cTNM unchanged. Patients in the cTNM changed group were further classified as postsurgical upstaged (US) and downstaged (DS). Results of the US patients were compared with the results of the remaining patients consisting of cTNM unchanged and DS to evaluate the predictable roles of semiquantitative parameters for postsurgical upstaging. To determine mediastinal tumoral involvement, cut-off values were obtained from calculated semiquantitative results of FDG uptakes in lymph nodes. A p value<0.05 was considered statistically significant.

RESULTS

Subjects were aged 40-82 years with a mean age of 64.78±8.70 years. Classification agreement was observed in 43 patients (43%) and in 57%, postsurgical stage migration was seen. Concurrence of cTNM and sTNM was more pronounced in the T1 and N0 subsets which were 84% and 74%, respectively. The lowest concurrence was observed in N1 classification followed by T4 and N2 (1%, 50% and 58%, respectively). Change in T staging occurred in 20 of 56 (36%), in N staging 22 of 56 (39%) and change in T and N in 14 patients (25%). Distribution of US and DS patients in the cTNM changed group was 43% (24 of 56) and 57% (32 of 56), respectively. Results of semiquantitative measures were significantly higher in US patients than the results of the group consisting of DS patients and cTNM unchanged patients, for all parameters. Cut-off value calculated from mediastinal uptakes was most specific for metastases in MTV (metabolic tumor volume) with an acceptable sensitivity (90% and 67%, respectively).

CONCLUSIONS

The concordance between cTNM and sTNM was better in staging T category compared to N stations. Semiquantitative measures of primary tumor may play a role in predicting postsurgical upstaging. Taking MTV into consideration in the mediastinal region may be more valuable than other parameters in the assessment of nodal involvement.