The maximum standardized uptake values on positron emission tomography of a non-small cell lung cancer predict stage, recurrence, and survival

A comparison between centralized and asynchronous federated learning approaches for survival outcome prediction using clinical and PET data from non-small cell lung cancer patients

BACKGROUND AND OBJECTIVE

Survival analysis plays an essential role in the medical field for optimal treatment decision-making. Recently, survival analysis based on the deep learning (DL) approach has been proposed and is demonstrating promising results. However, developing an ideal prediction model requires integrating large datasets across multiple institutions, which poses challenges concerning medical data privacy.

METHODS

In this paper, we propose FedSurv, an asynchronous federated learning (FL) framework designed to predict survival time using clinical information and positron emission tomography (PET)-based features. This study used two datasets: a public radiogenic dataset of non-small cell lung cancer (NSCLC) from the Cancer Imaging Archive (RNSCLC), and an in-house dataset from the Chonnam National University Hwasun Hospital (CNUHH) in South Korea, consisting of clinical risk factors and F-18 fluorodeoxyglucose (FDG) PET images in NSCLC patients. Initially, each dataset was divided into multiple clients according to histological attributes, and each client was trained using the proposed DL model to predict individual survival time. The FL framework collected weights and parameters from the clients, which were then incorporated into the global model. Finally, the global model aggregated all weights and parameters and redistributed the updated model weights to each client. We evaluated different frameworks including single-client-based approach, centralized learning and FL.

RESULTS

We evaluated our method on two independent datasets. First, on the RNSCLC dataset, the mean absolute error (MAE) was 490.80±22.95 d and the C-Index was 0.69±0.01. Second, on the CNUHH dataset, the MAE was 494.25±40.16 d and the C-Index was 0.71±0.01. The FL approach achieved centralized method performance in PET-based survival time prediction and outperformed single-client-based approaches.

CONCLUSIONS

Our results demonstrated the feasibility and effectiveness of employing FL for individual survival prediction in NSCLC patients, using clinical information and PET-based features.

Beneficial implications of adjuvant chemotherapy for stage IB lung adenocarcinoma exhibiting elevated SUVmax in FDG-PET/CT: a retrospective study from a single center

Background

Controversy surrounds the efficacy of adjuvant chemotherapy (ACT) in the treatment of stage I lung adenocarcinoma (LUAD). The objective of this study was to examine the impact of the maximum standardized uptake value (SUVmax) as measured by 18F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) on the efficacy of ACT in patients diagnosed with stage I LUAD.

Methods

We scrutinized the medical records of 928 consecutive patients who underwent complete surgical resection for pathological stage I LUAD at our institution. The ideal cut-off value for primary tumor SUVmax in terms of disease-free survival (DFS) and overall survival (OS) was determined using the X-tile software. The Kaplan-Meier method and Cox regression analysis were used for survival analysis.

Results

Based on the SUVmax algorithm, the ideal cutoff values were determined to be 4.9 for DFS and 5.0 for OS. We selected 5.0 as the threshold because OS is the more widely accepted predictive endpoint. In a multivariate Cox regression analysis, SUVmax ≥ 5.0, problematic IB stage, and sublobectomy were identified as independent risk factors for poor DFS and OS. It is noteworthy that patients who were administered ACT had significantly longer DFS and OS than what was observed in the subgroup of patients with pathological stage IB LUAD and SUVmax ≥ 5.0 (p < 0.035 and p ≤ 0.046, respectively). However, there was no observed survival advantage for patients in stages IA or IB who had an SUVmax < 5.0.

Conclusion

The preoperative SUVmax of tumors served as an indicator of the impact of ACT in the context of completely resected pathological stage I LUAD. Notably, patients within the Stage IB category exhibiting elevated SUVmax levels emerged as a subgroup experiencing substantial benefits from postoperative ACT.

Prognostic thresholds of fluorine-18 fluorodeoxyglucose-positron emission tomography mean and maximum standardized uptake values for survival and nodal involvement in lung neuroendocrine neoplasms

OBJECTIVES

The mean standardized uptake value (SUVmean) and maximum standardized uptake value (SUVmax) on fluorine-18 fluorodeoxyglucose-positron emission tomography are prognostic biomarkers for survival and nodal involvement in non-small-cell lung cancer but their prognostic value in lung neuroendocrine neoplasms (NENs) remains unexplored. In this study, we aimed to examine whether they are also prognostic biomarkers for survival and nodal involvement in lung NENs.

METHODS

We retrospectively studied patients with typical carcinoid, atypical carcinoid or large cell neuroendocrine carcinoma who had been radically resected at our institution between 2008 and 2020. We measured SUVmean and SUVmax on all primary tumours and lymph nodes that were clinically and/or pathologically involved. We dichotomized the patients into groups of high or low SUVmean and SUVmax of the primary tumour using time-dependent receiver operating characteristic curves and compared their overall survival using Kaplan-Meier curves and Cox models. Lastly, we predicted the patients' pathological nodal status with SUVmean and SUVmax of the lymph nodes using binomial logistic models.

RESULTS

The study included 245 patients. Patients died earlier if their SUVmean of the primary tumour exceeded 3.9 [hazard ratio 1.97, 95% confidence interval (CI) 1.27-3.04, P = 0.002] or SUVmax exceeded 5.3 (hazard ratio 1.85, 95% CI 1.20-2.87, P = 0.006). Likewise, patients had a higher risk of pathological nodal involvement if their SUVmean of the lymph nodes exceeded 3.3 (odds ratio 10.00, 95% CI 2.59-51.01, P = 0.002) or SUVmax exceeded 4.2 (odds ratio 4.00, 95% CI 1.20-14.65, P = 0.028).

CONCLUSIONS

The fluorine-18 fluorodeoxyglucose-positron emission tomography SUVmean and SUVmax are strong prognostic biomarkers for survival and nodal involvement in lung NENs and could be important guides for making treatment decisions.

Tumor to liver maximum standardized uptake value ratio of FDG-PET/CT parameters predicts tumor treatment response and survival of stage III non-small cell lung cancer

BACKGROUND

To assess the predictive values of primary tumor FDG uptake for patients with inoperable stage III non-small cell lung cancer (NSCLC) after concurrent chemoradiotherapy (CCRT).

METHODS

A total of 107 patients with diagnosis of stage III NSCLC and CCRT were enrolled. The tumor maximum uptake value (SUVmax) was standardized by calculating several ratios between tumor and each background tissues. The receiver operating characteristics curve (ROC) was used to compare the predictive power of prognostic models. The tumor objective response rate (ORR) and overall survival (OS) were compared and analyzed by the Kaplan-Meier method and univariate and multivariate Cox regression models.

RESULTS

The areas under ROC curve (AUCs) ranged from 0.72 to 0.81 among these tumor SUVmax and standardized SUVmax ratios, and the tumor SUVmax and tumor SUVmax-to-liver SUVmean ratio (TLMR) were more predictive of ORR (AUC, 0.81; 95% CI, 0.73-0.88 for tumor SUVmax and AUC, 0.84; 95%CI, 0.76-0.91 for TLMR) than any of other SUVmax ratios. The patients with lower tumor SUVmax, SUVmean and SUVmax ratios had a significantly better OS than those with their corresponding higher ones. Moreover, both univariate and multivariable analyses revealed that TLMR was significantly associated with better ORR and OS after adjustment with other prognostic variables.

CONCLUSIONS

TLMR, a standardized tumor SUVmax, was an independent prognostic predictor for tumor ORR and OS of patients with stage III NSCLC after CCRT.

Additional Value of PET and CT Image-Based Features in the Detection of Occult Lymph Node Metastases in Lung Cancer: A Systematic Review of the Literature

Lung cancer represents the second most common malignancy worldwide and lymph node (LN) involvement serves as a crucial prognostic factor for tailoring treatment approaches. Invasive methods, such as mediastinoscopy and endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), are employed for preoperative LN staging. Among the preoperative non-invasive diagnostic methods, computed tomography (CT) and, recently, positron emission tomography (PET)/CT with fluorine-18-fludeoxyglucose ([¹⁸F]FDG) are routinely recommended by several guidelines; however, they can both miss pathologically proven LN metastases, with an incidence up to 26% for patients staged with [¹⁸F]FDG PET/CT. These undetected metastases, known as occult LN metastases (OLMs), are usually cases of micro-metastasis or small LN metastasis (shortest radius below 10 mm). Hence, it is crucial to find novel approaches to increase their discovery rate. Radiomics is an emerging field that seeks to uncover and quantify the concealed information present in biomedical images by utilising machine or deep learning approaches. The extracted features can be integrated into predictive models, as numerous reports have emphasised their usefulness in the staging of lung cancer. However, there is a paucity of studies examining the detection of OLMs using quantitative features derived from images. Hence, the objective of this review was to investigate the potential application of PET- and/or CT-derived quantitative radiomic features for the identification of OLMs.

Correlation between Imaging Markers Derived from PET/MRI and Invasive Acquired Biomarkers in Newly Diagnosed Breast Cancer

PURPOSE

Evaluate the diagnostic potential of [¹⁸F]FDG-PET/MRI data compared with invasive acquired biomarkers in newly diagnosed early breast cancer (BC).

METHODS

Altogether 169 women with newly diagnosed BC were included. All underwent a breast- and whole-body [¹⁸F]FDG-PET/MRI for initial staging. A tumor-adapted volume of interest was placed in the primaries and defined bone regions on each standard uptake value (SUV)/apparent diffusion coefficient (ADC) dataset. Immunohistochemical markers, molecular subtype, tumor grading, and disseminated tumor cells (DTCs) of each patient were assessed after ultrasound-guided biopsy of the primaries and bone marrow (BM) aspiration. Correlation analysis and group comparisons were assessed.

RESULTS

A significant inverse correlation of estrogen-receptor (ER) expression and progesterone-receptor (PR) expression towards SUV_max was found (ER: r = 0.27, p < 0.01; PR: r = 0.19, p < 0.05). HER2-receptor expression showed no significant correlation towards SUV and ADC values. A significant positive correlation between Ki67 and SUVmax and SUV_mean (r = 0.42 p < 0.01; r = 0.19 p < 0.05) was shown. Tumor grading significantly correlated with SUV_max and SUV_mean (ρ = 0.36 and ρ = 0.39, both p's < 0.01). There were no group differences between SUV/ADC values of DTC-positive/-negative patients.

CONCLUSIONS

[¹⁸F]FDG-PET/MRI may give a first impression of BC-receptor status and BC-tumor biology during initial staging by measuring glucose metabolism but cannot distinguish between DTC-positive/-negative patients and replace biopsy.

Prediction of Distant Metastases After Stereotactic Body Radiation Therapy for Early Stage NSCLC: Development and External Validation of a Multi-Institutional Model

INTRODUCTION

Distant metastases (DMs) are the primary driver of mortality for patients with early stage NSCLC receiving stereotactic body radiation therapy (SBRT), yet patient-level risk is difficult to predict. We developed and validated a model to predict individualized risk of DM in this population.

METHODS

We used a multi-institutional database of 1280 patients with cT1-3N0M0 NSCLC treated with SBRT from 2006 to 2015 for model development and internal validation. A Fine and Gray (FG) regression model was built to predict 1-year DM risk and compared with a random survival forests model. The higher performing model was evaluated on an external data set of 130 patients from a separate institution. Discriminatory performance was evaluated using the time-dependent area under the curve (AUC). Calibration was assessed graphically and with Brier scores.

RESULTS

The FG model yielded an AUC of 0.71 (95% confidence interval [CI]: 0.57-0.86) compared with the AUC of random survival forest at 0.69 (95% CI: 0.63-0.85) in the internal test set and was selected for further testing. On external validation, the FG model yielded an AUC of 0.70 (95% CI: 0.57-0.83) with good calibration (Brier score: 0.08). The model identified a high-risk patient subgroup with greater 1-year DM rates in the internal test (20.0% [3 of 15] versus 2.9% [7 of 241], p = 0.001) and external validation (21.4% [3 of 15] versus 7.8% [9 of 116], p = 0.095). A model nomogram and online application was made available.

CONCLUSIONS

We developed and externally validated a practical model that predicts DM risk in patients with NSCLC receiving SBRT which may help select patients for systemic therapy.

GLUT1 and PKM2 may be useful prognostic predictors in patients with non‑small cell lung cancer following curative R0 resection

Lung cancer has a poor prognosis despite recent progresses being made regarding its treatment. In addition, there is a paucity of reliable and independent prognostic predictors for non-small cell lung cancer (NSCLC) following curative resection. Glycolysis is associated with the malignancy and proliferation of cancer cells. Glucose transporter 1 (GLUT1) promotes glucose uptake, whereas pyruvate kinase M2 (PKM2) promotes anaerobic glycolysis. The present study aimed to evaluate the relationship between the expression of GLUT1 and PKM2 and the clinicopathological features of patients with NSCLC, and to identify a reliable prognostic factor for NSCLC following curative resection. Patients with NSCLC who underwent curative surgery were retrospectively enrolled to the present study. GLUT1 and PKM2 expression was assessed using immunohistochemistry. Subsequently, the association between the clinicopathological features of patients with NSCLC and the expression of GLUT1 and PKM2 was assessed. Of the 445 patients with NSCLC included in the present study, 65 (15%) were positive for both GLUT1 and PKM2 expression (G+/P+ group). GLUT1 and PKM2 positivity was significantly associated with sex, absence of adenocarcinoma, lymphatic invasion and pleural invasion. Furthermore, patients with NSCLC in the G+/P+ group presented significantly poorer survival rates than those expressing other markers. G+/P+ expression was significantly associated with poor disease-free survival. In conclusion, the findings of the present study indicated that the combination of GLUT1 and PKM2 may be considered a reliable prognostic factor for patients with NSCLC following curative resection, especially in patients with stage I NSCLC.

Preoperative PET-SUVmax and volume based PET parameters of the primary tumor fail to predict nodal upstaging in early-stage lung cancer

OBJECTIVES

Accurate nodal staging is of utmost importance in patients with lung cancer. FDG-PET/CT imaging is now part of the routine staging. Despite thorough preoperative staging nodal upstaging still occurs in early-stage lung cancer. However, the predictive value of preoperative PET metrics of the primary tumor on nodal upstaging remains to be unexplored. Our aim was to assess the association of these preoperative PET-parameters with nodal upstaging in histologically confirmed lung adenocarcinoma and squamous cell carcinoma.

METHODS

From January 2016 to November 2018, 500 patients with pT1-T2/cN0 lung cancer received an anatomical resection with curative intent. 171 patients with adenocarcinoma and squamous cell carcinoma and available PET-CTs were retrospectively included. We analyzed the the association of nodal upstaging with preoperative PET-SUVmax and metabolic PET metrics including total lesion glycolysis (TLG) and metabolic tumor volume (MTV) with different defined thresholds.

RESULTS

High values of preoperative PET-SUVmax of the primary tumor were associated with squamous cell carcinoma (p < 0.0001) and with larger tumors (p < 0.0001). Increased preoperative C-reactive protein levels (<1mg/dL) correlated significantly with high preoperative PET-SUVmax values (p < 0.0001). No significant relationship between PET-SUVmax and lactate dehydrogenase activity (p = 0.6818), white blood cell count (p = 0.7681), gender (p = 0.1115) or age (p = 0.9284) was observed. Nodal upstaging rate was 14.0 % with 8.8 % N1 and 5.3 % N2 upstaging. Tumor size (p = 0.0468) and number of removed lymph nodes (p = 0.0461) were significant predictors of nodal upstaging but no significant association was found with histology or PET parameters. Of note, increased MTV - regardless of the threshold - tended to associate with nodal upstaging.

CONCLUSION

Early-stage lung cancer patients with squamous histology and T2 tumors presented increased preoperative PET-SUVmax values. Nevertheless, beyond tumor size and number of removed lymph nodes neither SUVmax nor metabolic PET parameters MTV and TLG were significant predictors of nodal upstaging.

Higher SUVmax on FDG-PET is associated with shorter survival in adrenocortical carcinoma

BACKGROUND

Adrenocortical carcinoma (ACC) is an aggressive, rare malignancy. 2-deoxy-2-[18F]-fluoro-d-glucose positron emission tomography (FDG-PET) assesses tumor metabolism and glucose utilization. We hypothesized that higher maximum standard uptake value (SUV_max) is associated with decreased survival.

METHODS

We performed a retrospective analysis of patients with ACC. Included patients (n = 26) had an FDG-PET scan available with a documentable SUV_max. Patients were dichotomized into "High" (≥8.4, n = 12) and "Low" (<8.4, n = 14) SUV_max. Univariate analysis and survival analysis were performed to compare groups.

RESULTS

Demographics between groups were equivalent. The high SUV_max cohort demonstrated lower survival (median 479 days or 15.7 months) compared to the low group (median 1490 days or 48.6 months, p = .01). Log-Rank curve confirmed differences in survival (p = .007).

CONCLUSIONS

Higher SUV_max was associated with significantly worse survival in ACC and may reflect a more aggressive phenotype. FDG-PET may provide clinically useful information to determine prognosis and treatment. Further studies should prospectively evaluate using FDG-PET/CT in ACC.

Do fine needle aspirate cytomorphological features correlate with positron emission tomography findings of metastatic non-small cell lung carcinoma in lymph nodes?

BACKGROUND

Our objective was to correlate cytomorphological features of metastatic non-small cell lung carcinoma (mNSCLC) with maximal standardized uptake value (mSUV) of positron emission tomography (PET) in Lymph nodes (LNs).

METHODS

Positive cytology slides of 114 LNs were reviewed from 100 patients with mNSCLC who had undergone PET study. Student's t-test was used for statistical comparisons.

RESULTS

Mean patients' age: 68.5, 54% male. LNs locations were: mediastinum: 99, lung hilum: 13, peribronchial: 1, axilla: 1. Final diagnoses were: Adenocarcinoma: 86, squamous cell carcinoma: 28 LNs. Within the adenocarcinoma subgroup, histological patterns correlate with mSUV. Acinar and papillary patterns were associated with significantly lower mSUVs (mean ± standard error (SE): 7.9 ± 0.9 and 9.2 ± 0.8, respectively) than solid pattern (13.0 ± 1.2; p values: 0.001 and 0.009, respectively). Similar difference exists between patterns associated with low- and high-grade adenocarcinoma (Mean ± SE: 9.2 ± 0.8 and 12.0 ± 1.0, respectively. p value: 0.02). Interestingly, micropapillary pattern was associated with the lowest mSUV amongst all patterns (Mean ± SE: 5.4 ± 1.1). Other features that correlated with higher mSUV were necrosis, moderate/severe nuclear atypia, lower lymphoid tissue yield, and contralateral LN involvement.

CONCLUSIONS

In LNs with mNSCLC, certain cytomorphological features are associated with higher mSUV. Micropapillary, a pattern considered as high-grade, is associated with lower SUV values; hence, a lower SUV threshold may raise concern for metastasis. Although high SUV is associated with LN metastasis, lower SUV levels in certain adenocarcinomas suggest correlation with clinical and morphological characteristics could be valuable in tailoring therapeutic management.

Prognostic value of 18F-FDG PET/CT in patients with advanced or metastatic non-small-cell lung cancer treated with immune checkpoint inhibitors: A systematic review and meta-analysis

PURPOSE

This study aimed to investigate the value of 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) in predicting early immunotherapy response of immune checkpoint inhibitors (ICIs) in patients with advanced or metastatic non-small-cell lung cancer (NSCLC).

METHODS

A comprehensive search of PubMed, Web of science, Embase and the Cochrane library was performed to examine the prognostic value of 18F-FDG PET/CT in predicting early immunotherapy response of ICIs in patients with NSCLC. The main outcomes for evaluation were overall survival (OS) and progression-free survival (PFS). Detailed data from each study were extracted and analyzed using STATA 14.0 software.

RESULTS

13 eligible articles were included in this systematic review. Compared to baseline 18F-FDG PET/CT imaging, the pooled hazard ratios (HR) of maximum and mean standardized uptake values SUVmax, SUVmean, MTV and TLG for OS were 0.88 (95% CI: 0.69-1.12), 0.79 (95% CI: 0.50-1.27), 2.10 (95% CI: 1.57-2.82) and 1.58 (95% CI: 1.03-2.44), respectively. The pooled HR of SUVmax, SUVmean, MTV and TLG for PFS were 1.06 (95% CI: 0.68-1.65), 0.66 (95% CI: 0.48-0.90), 1.50 (95% CI: 1.26-1.79), 1.27 (95% CI: 0.92-1.77), respectively. Subgroup analysis showed that high MTV group had shorter OS than low MTV group in both first line group (HR: 1.97, 95% CI: 1.39-2.79) and undefined line group (HR: 2.11, 95% CI: 1.61-2.77). High MTV group also showed a shorter PFS in first line group (HR: 1.85, 95% CI: 1.28-2.68), and low TLG group had a longer OS in undefined group (HR: 1.37, 95% CI: 1.00-1.86). No significant differences were in other subgroup analysis.

CONCLUSION

Baseline MTV and TLG may have predictive value and should be prospectively studied in clinical trials. Baseline SUVmax and SUVmean may not be appropriate prognostic markers in advanced or metastatic NSCLC patients treated with ICIs.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=323906, identifier CRD42022323906.

Consistency and prognostic value of preoperative staging and postoperative pathological staging using 18F-FDG PET/MRI in patients with non-small cell lung cancer

OBJECTIVE

In recent years, positron emission tomography/magnetic resonance imaging (PET/MRI) has been clinically used as a method to diagnose non-small cell lung cancer (NSCLC). This study aimed to evaluate the concordance of staging and prognostic ability of NSCLC patients using thin-slice computed tomography (CT) and ¹⁸F-fluorodeoxyglucose (FDG) PET/MRI.

METHODS

This retrospective study was performed on consecutive NSCLC patients who underwent both diagnostic CT and ¹⁸F-FDG PET/MRI before surgery between November 2015 and May 2019. The cTNM staging yielded from PET/MRI was compared with CT and pathological staging, and concordance was investigated, defining pathological findings as reference. To assess the prognostic value of disease-free survival (DFS) and overall survival (OS), we dichotomized the typical prognostic factors and TNM classification staging (Stage I vs. Stage II or higher). Kaplan-Meier curves derived by the log-rank test were generated, and univariate and multivariate analyses were performed to identify the factors associated with DFS and OS.

RESULTS

A total of 82 subjects were included; PET/MRI staging was more consistent (59 of 82) with pathological staging than with CT staging. There was a total of 21 cases of CT and 11 cases of PET/MRI that were judged as cStage I, but were actually pStage II or pStage III. CT tended to judge pN1 or pN2 as cN0 compared to PET/MRI. There was a significant difference between NSCLC patients with Stage I and Stage II or higher by PET/MRI staging as well as prognosis prediction of DFS by pathological staging (P < 0.001). In univariate analysis, PET/MRI, CT, and pathological staging (Stage I or lower vs. Stage II or higher) all showed significant differences as prognostic factors of recurrence or metastases. In multivariate analysis, pathological staging was the only independent factor for recurrence (P = 0.009), and preoperative PET/MRI staging was a predictor of patient survival (P = 0.013).

CONCLUSIONS

In NSCLC, pathologic staging was better at predicting recurrence, and preoperative PET/MRI staging was better at predicting survival. Preoperative staging by PET/MRI was superior to CT in diagnosing hilar and mediastinal lymph-node metastases, which contributed to the high concordance with pathologic staging.

Application of Dynamic 18F-FDG PET/CT for Distinguishing Intrapulmonary Metastases from Synchronous Multiple Primary Lung Cancer

It has been a big challenge to distinguish synchronous multiple primary lung cancer (sMPLC) from primary lung cancer with intrapulmonary metastases (IPM). We aimed to assess the clinical application of dynamic ¹⁸F-FDG PET/CT in patients with multiple lung cancer nodules. We enrolled patients with multiple pulmonary nodules who had undergone dynamic ¹⁸F-FDG PET/CT and divided them into sMPLC and IPM groups based on comprehensive features. The SUV_max, fitted K_i value based on dynamic scanning, and corresponding maximum diameter (D_max) from the two largest tumors were determined in each patient. We determined the absolute between-tumor difference of SUV_max/D_max and K_i/D_max (ΔSUV_max/D_max; ΔK_i/D_max) and assessed the between-group differences. Further, the diagnostic accuracy was evaluated by ROC analysis and the correlation between ΔSUV_max/D_max and ΔK_i/D_max from all groups was determined. There was no significant difference for ΔSUV_max/D_max between the IPM and sMPLC groups, while the IPM group had a significantly higher ΔK_i/D_max than the sMPLC group. The AUC of ΔK_i/D_max for differentiating sMPLC from IPM was 0.80 (cut-off value of K_i = 0.0059, sensitivity 79%, specificity 75%, p < 0.001). There was a good correlation (Pearson r = 0.91, 95% CI: 0.79-0.96, p < 0.0001) between ΔSUV_max/D_max and ΔK_i/D_max in the IPM group but not in the sMPLC group (Pearson r = 0.45, p > 0.05). Dynamic ¹⁸F-FDG PET/CT could be a useful tool for distinguishing sMPLC from IPM. K_i calculation based on Patlak graphic analysis could be more sensitive than SUV_max in discriminating IPM from sMPLC in patients with multiple lung cancer nodules.

Toward Improved Outcomes for Patients With Lung Cancer Globally: The Essential Role of Radiology and Nuclear Medicine

PURPOSE

Key to achieving better population-based outcomes for patients with lung cancer is the improvement of medical imaging and nuclear medicine infrastructure globally. This paper aims to outline why and spark relevant health systems strengthening.

METHODS

The paper synthesizes the global lung cancer landscape, imaging referral guidelines (including resource-stratified ones), the reliance of TNM staging upon imaging, relevant multinational health technology assessments, and precisely how treatment selection and in turn patient outcomes hinge upon imaging findings. The final discussion presents data on current global gaps in both diagnostics (including imaging) and therapies and how, informed by such data, improved population-based outcomes are tangible through strategic planning.

RESULTS

Imaging findings are central to appropriate lung cancer patient management and can variably lead to life-prolonging interventions and/or to life-enhancing palliative measures. Early-stage lung cancer can be treated with curative intent but, unfortunately, most patients with lung cancer still present at advanced stages and many patients lack access to both diagnostics and therapies. Furthermore, half of lung cancer cases occur in low- and middle-income countries. The role of medical imaging and nuclear medicine in lung cancer management, as outlined herein, may help inform strategic planning.

CONCLUSION

Lung cancer is the number one cancer killer worldwide. The essential role that medical imaging and nuclear medicine play in early diagnosis and disease staging cannot be overstated, pivotal in selecting the many patients for whom measurably improved outcomes are attainable. Prevention synergized with patient-centered, compassionate, high-quality lung cancer management provision mandate that strategic population-based planning, including universal health coverage strategies, should extend well beyond the scope of disease prevention to include both curative and noncurative treatment options for the millions afflicted with lung cancer.

Value of 18F FDG-PET/CT parameters on long term follow-up for patients with non-small cell lung cancer

Objectives

The purpose of this study was to investigate the value of PET/CT in the preoperative staging of non-small cell lung cancer in predicting long-term survival and diagnostic performance, validated by histopathology following surgical resection.

Methods

Between 02/2009 and 08/2011, 255 patients with non-small cell lung cancer were included in this single-center prospective study. All underwent 18F FDG-PET/CT for pre-operative staging, and in 243 patients complete surgical resection was possible. Regarding lymph node involvement and extrathoracic metastases, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated using the histopathological staging as reference. Median follow-up for censored patients was 9.1 years.

Results

Overall 5-year survival rate of all patients was 55.6%, and of patients who had complete surgical resection it was 58.2%. In multivariate analysis of all surgically resected patients lymph node involvement (p=0.029) and age >61 years (p=<0.001) were significant independent prognostic factors. SUVmax and SUVmean cut-offs between SUV 2 and 11, however, were not associated with better or ;worse survival. The PET-CT sensitivity, specificity, positive predictive value and negative predictive value for predicting lymph node involvement were 57, 95, 88, and 76%, respectively. Furthermore, sensitivity, specificity, positive predictive value, and negative predictive value for detecting extrathoracic metastases were 100, 58, 98, and 100%, respectively.

Conclusions

In this study, tumor 18F FDG-uptake values did not provide additional prognostic information. Age>61 years and lymph node metastasis were associated with worse long-term survival in surgically resected patients. 18F FDG-PET/CT scans allow for improved patient selection. However, in staging mediastinal lymph nodes, there is a high rate of false positives and false negatives, suggesting that tissue biopsy is still indicated in many cases.

Relationships between SUVmax of lung adenocarcinoma and different T stages, histological grades and pathological subtypes: a retrospective cohort study in China

OBJECTIVES

Cancer cell has aberrant metabolism. The purpose of this study aimed to investigate relationships between maximum standard uptake value (SUVmax）of ¹⁸fluoro-2-deoxy-d-glucose and T stages, histological grades and pathological subtypes of lung adenocarcinoma.

DESIGN

Retrospective cohort study, employing the Kruskal-Wallis, Bonferroni-Dunn and Mann-Whitney tests to compare SUVmax of different T stages, histological grades and pathological subtypes of lung adenocarcinoma.

SETTING

The outpatients who had aberrant positron emission tomography/CT (PET/CT) images in chest were enrolled this study from August 2016 to November 2018 in Shanghai, China.

PARTICIPANT

Initial 11 270 patients with suspected lung cancer who underwent PET/CT examinations were surveyed. A total of 1454 patients who were diagnosed as lung adenocarcinoma by pathologist were included in this project.

PRIMARY OUTCOME MEASURES

SUVmax value at different tumour-node-metastasis stages of lung adenocarcinoma before surgery.

RESULTS

The mean SUVmax of patients with lung adenocarcinoma was significantly elevated with the increase in T stages. There were significant evident differences in SUVmax among T1a-T1c (p<0.05). However, after the staging of patients was more than T1 stage, SUVmax of T2a, T2b, T2 visceral pleural invasion, T3 and T4 had not dramatic changes. SUVmax value of lung adenocarcinoma in the same T stage group was the highest in patients with the high grade of malignancy and solid-predominant invasive adenocarcinoma.

CONCLUSIONS

SUVmax value was significantly associated with T stages, grades of malignancy and pathological subtypes of lung adenocarcinoma.

Correlation of preoperative PET/computer tomography 18F-fluorodeoxyglucose uptake (maximum standardized uptake value) with prognosis in patients with operated lung cancer

PURPOSE

The aim of this study was to investigate the correlation of preoperative 18F-fluorodeoxyglucose PET/computed tomography maximum standardized uptake value (SUVmax) in operated non-small cell lung cancer (NSCLC) cases with other prognostic parameters and survival.

PATIENTS AND METHODS

NSCLC patients treated by surgical resection were imaged with PET within 60 days before surgery.

RESULTS

Overall, 525 cases consecutive patients were retrospectively reviewed. The median value of SUVmax in a total of 525 cases was 12.1, and the mean was 13.3 ± 7.13. Logistic regression analysis performed to identify the variables that have an impact on SUVmax revealed that histology [hazard ratio (HR: 1.893; 95% CI; P = 0.001) and T status (HR: 8.991; 95% CI; P = 0.000) are correlated with SUVmax. Kaplan-Meier analysis revealed a mean survival of 73.7 ± 1.95 months and a median survival of 85.6 ± 6.03 months. In the group with an SUVmax value of less than 10, the mean survival was 81.9 ± 3.02 months (76.0-87.8), and in the group with SUVmax greater than 10.1, the mean survival was 68.6 ± 2.4 months (63.9-73.3) (P = 0.000). In the multivariate analysis, SUVmax, age, tumor histology, lymph node metastasis, comorbid diseases and complete/incomplete status of the resection were identified as the factors predictive of prognosis.

CONCLUSION

It is seen that preoperative SUVmax is a parameter with prognostic significance at least as much as histopathology, age, complete/incomplete status of resection and lymph node involvement.

Pre-treatment total metabolic tumour volumes in lymphoma: Does quantity matter?

Positron emission tomography/computed tomography (PET/CT) is used for the staging of lymphomas. Clinical information, such as Ann Arbor stage and number of involved sites, is derived from baseline staging and correlates with tumour volume. With modern imaging software, exact measures of total metabolic tumour volumes (tMTV) can be determined, in a semi- or fully-automated manner. Several technical factors, such as tumour segmentation and PET/CT technology influence tMTV and there is no consensus on a standardized uptake value (SUV) thresholding method, or how to include the volumes in the bone marrow and spleen. In diffuse large B-cell lymphoma, follicular lymphoma, peripheral T-cell lymphoma, and Hodgkin lymphoma, tMTV has been shown to predict progression-free survival and/or overall survival, after adjustments for clinical risk scores. However, most studies have used receiver operating curves to determine the optimal cut-off for tMTV and many studies did not include a training-validation approach, which led to the risk of overestimation of the independent prognostic value of tMTV. The identified cut-off values are heterogeneous, even when the same SUV thresholding method is used. Future studies should focus on testing tMTV in homogeneously-treated cohorts and seek to validate identified cut-off values externally so that a prognostic value can be documented, over and above currently used clinical surrogates for tumour volume.

Predictive value of metabolic activity detected by pre-operative 18F FDG PET/CT in ampullary adenocarcinoma

In ampullary adenocarcinoma cases, the clinical effects of 18F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) have not yet been well-studied, unlike other prognostic factors that have been reported till date. This study aimed to investigate the clinical impact of maximum standardized uptake value (SUVmax) in predicting the prognosis of ampullary adenocarcinoma.Thirty-eight patients who underwent pre-operative 18F-FDG PET/CT and curative-intent resection of ampullary adenocarcinoma at Pusan National University Hospital (Pusan, South Korea) between 2008 and 2017 were retrospectively analyzed in this study. We evaluated the clinicopathologic outcomes according to the SUVmax using univariate and multivariate Cox proportional hazard regression analyses and receiver operating characteristic analysis to arrive at a cutoff value.Lymph node metastasis was detected in 9 patients, and 15 patients experienced a recurrence during the follow-up period. Among 38 patients, 33 showed an increased FDG uptake by the main tumor. SUVmax of 4.55 was selected as a significant independent predictive factor for patient survival along with poor tumor differentiation and high neutrophil-to-lymphocyte ratio in multivariate analysis (P = .016, hazard ratio = 5.040). Patients with SUVmax under 4.55 exhibited significantly longer overall survival than the rest (<4.55 vs ≥4.55), and the 5-year overall survival was 82.8% versus 57.4% (P = .049).SUVmax of 4.55 on 18F-FDG PET/CT could be a predictive factor for tumor biology and long-term survival in patients with ampullary adenocarcinoma. Nevertheless, considering the cost aspect and its limited prognostic effect, this study seems to require more patient and multicenter studies.

Is It Possible to Establish a Reliable Correlation between Maximum Standardized Uptake Value of 18-Fluorine Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography and Histological Types of Non-Small Cell Lung Cancer? Analysis of the Italian VATS Group Database

BACKGROUND

Although positron emission tomography/computed tomography, often integrated with 2-deoxy-2-[fluorine-18] fluorine-D-glucose (18F-FDG-PET/CT), is fundamental in the assessment of lung cancer, the relationship between metabolic avidity of different histotypes and maximum standardized uptake value (SUVmax) has not yet been thoroughly investigated. The aim of the study is to establish a reliable correlation between Suvmax and histology in non-small cell lung cancer (NSCLC), in order to facilitate patient management.

METHODS

We retrospectively assessed the data about lung cancer patients entered in the Italian Registry of VATS Group from January 2014 to October 2019, after establishing the eligibility criteria of the study. In total, 8139 patients undergoing VATS lobectomy were enrolled: 3260 females and 4879 males. The relationship between SUVmax and tumor size was also analyzed.

RESULTS

The mean values of SUVmax in the most frequent types of lung cancer were as follows: (a) 4.88 ± 3.82 for preinvasive adenocarcinoma; (b) 5.49 ± 4.10 for minimally invasive adenocarcinoma; (c) 5.87 ± 4.18 for invasive adenocarcinoma; and (d) 8.85 ± 6.70 for squamous cell carcinoma. Processing these data, we displayed a statistically difference (p < 0.000001) of FDG avidity between adenocarcinoma and squamous cell carcinoma. Moreover, by classifying patients into five groups based on tumor diameter and after evaluating the SUVmax value for each group, we noted a statistical correlation (p < 0.000001) between size and FDG uptake, also confirmed by the post hoc analysis.

CONCLUSIONS

There is a correlation between SUVmax, histopathology outcomes and tumor size in NSCLC. Further clinical trials should be performed in order to confirm our data.

Pre-surgical assessment of mediastinal lymph node metastases in patients having ≥ 30 mm non-small-cell lung cancers

INTRODUCTION

Computed tomography (CT) and fluorodeoxyglucose-positron-emission-tomography (FDG-PET) measurements of mediastinal lymph nodes (MLNs) of patients with non-small-cell-lung-cancers (NSCLCs) ≤ 30 mm in maximum diameter are recommended for pre-surgical prediction of MLN metastases.

METHODS

We reviewed all patients at Mount Sinai Health System enrolled in the Initiative for Early Lung Cancer Research on Treatment (IELCART), prospective cohort between 2016 and 2020, who had pre-surgical FDG-PET and underwent surgery with MLN resection and/or pre-operative endobronchial ultrasound (EBUS) for a first primary NSCLC ≤ 30 mm in maximum diameter on pre-surgical CT.

RESULTS

Among 470 patients, none with part-solid (n = 63) or nonsolid (n = 23) NSCLCs had MLN metastases. Solid NSCLCs were identified in 384 patients, none in typical carcinoid (n = 48) or NSCLC ≤ 10 mm in maximum diameter (n = 47, including 8 typical carcinoids) had MLN metastases. Among the remaining 297 patients with solid NSCLCs 10.1-30.0 mm, 7 (2.4%) had MLN metastases. Area-under-the-curve (AUC) for predicting MLN metastases in solid NSCLCs 10.1-30.0 mm, using the CT maximum short-axis MLN diameter was 0.62 (95% CI:0.44-0.81, p = 0.18) and using the highest SUVmax of any MLN, AUC was 0.58 (95% CI:0.39-0.78,p = 0.41). Neither AUCs were significantly different from chance alone. Optimal cutoff for prediction of MLN metastases was ≥ 18.9 mm for CT maximum short-axis diameter [sensitivity 14.3% (95%CI:0.0%-57.9%); specificity 100.0% (95%CI:98.9%-100.0%)] and for highest SUVmax was ≥ 11.7 [sensitivity 14.3% (95%CI:0.0%-57.9%) and specificity 99.7% (95%CI:98.3%-100.0%)].

CONCLUSIONS

CT and SUVmax had low sensitivity but high specificity for predicting MLN metastases in solid NSCLCs 10.1-30.0 mm. Clinical Stage IA NSCLCs ≤ 30 mm should be based on CT maximum tumor diameter and MLN maximum short-axis diameter ≤ 20 mm.

Positron emission tomography/computed tomography findings of lung invasive adenocarcinoma subgroups and comparison of their short-term survivals

Background

The aim of this study was to compare the maximum standardized uptake values on positron emission tomography/ computed tomography and survival of lung invasive adenocarcinoma subgroups.

Methods

Between January 2010 and January 2016, a total of 152 patients (112 males, 40 females; mean age: 64.2±8.6 years; range, 41 to 88 years) who underwent lung resection for an invasive adenocarcinoma were retrospectively analyzed. The patients were divided into subgroups as follows: acinar, lepidic, micropapillary, papillary, and solid. The maximum standardized uptake values in the imaging study and their relationship with survival were examined.

Results

There were 84 acinar (55%), 31 solid (20%), 23 lepidic (15%), nine papillary (5%), and five micropapillary (3%) cases. The positron emission tomography/computed tomography enhancement showed a statistically significant difference among the subgroups (p=0.004). The solid subgroup was the most involved (9.76), followed by micropapillary (8.98), acinar (8.06), papillary (5.82), and lepidic (4.23) subgroups, respectively. According to Tumor, Node, Metastasis staging, Stage I was present in 48.68% (n=74) of the cases, Stage II in 25.0% (n=38), Stage III in 25.0% (n=38), and Stage IV in 1.31% (n=2). The one-year, three-year, and five-year survival rates were significantly different among the disease stages (p=0.01). The longest survival duration was in the lepidic subgroup, although it did not reach statistical significance among the subgroups (p=0.587).

Conclusion

The evaluation of invasive adenocarcinomas based on maximum standardized uptake values provides valuable information and may guide neoadjuvant and adjuvant therapies in the future.

Metabolic active tumour volume quantified on [18F]FDG PET/CT further stratifies TNM stage IV non-small cell lung cancer patients

PURPOSE

This study aimed to assess whether the whole body metabolic active tumour volume (MTV_WB), quantified on staging [¹⁸F]FDG PET/CT, could further stratify stage IV non-small cell lung cancer (NSCLC) patients.

METHODS

A group of 160 stage IV NSCLC patients, submitted to staging [¹⁸F]FDG PET/CT between July 2010 and May 2020, were retrospectively evaluated. MTV_WB was quantified. Univariate and multivariate Cox regressions were carried out to assess correlation with overall survival (OS). C-statistic was used to test predictive power. Kaplan-Meier survival curves with Log-Rank tests were performed to compute statistical differences between strata from dichotomized variables and to calculate the estimated mean survival times (EMST). Survival rates at 1 and 5 years were calculated.

RESULTS

MTV_WB was a statistically significant predictor of OS on univariate (p < 0.0001) and multivariate analyses (p < 0.0001). The multivariate model with MTV_WB (Cindex ± SE = 0.657 ± 0.024) worked significantly better as an OS predictor than the cTNM model (Cindex ± SE = 0.544 ± 0.028) (p = 0.003). An EMST of 29.207 ± 3.627(95% CI 22.099-36.316) months and an EMST of 10.904 ± 1.171(95% CI 8.609-13.199) months (Log-Rank p < 0.0001) were determined for patients with MTV_WB < 104.3 and MTV_WB ≥ 104.3, respectively. In subsamples of stage IVA (cut-off point = 114.5) and IVB patients (cut-off point = 191.1), statistically significant differences between EMST were also reported, with p-values of 0.0001 and 0.0002, respectively. In both substages and in the entire cohort, patients with MTV_WB ≥ cut-off points had lower EMST and survival rates.

CONCLUSION

Baseline MTV_WB, measured on staging [¹⁸F]FDG PET/CT, further stratifies stage IV NSCLC patients. This parameter is an independent predictor of OS and provides valuable prognostic information over the 8th edition of cTNM staging.

18F-FDG PET/CT metabolic parameters correlate with EIF2S2 expression status in colorectal cancer

Background: We sought to investigate whether the expression of the gene EIF2S2 is related to ¹⁸F-FDG PET/CT metabolic parameters in patients with colorectal cancer (CRC).

Materials and methods: The expression of EIF2S2 in CRC and its relationship with clinicopathological features were obtained through the ONCOMINE, UALCAN and GEPIA databases. EIF2S2 and GLUT1 expression were examined by immunohistochemistry in 42 CRC patients undergoing preoperative PET-CT examination. Spearman correlation analysis was used to assess the relationship between EIF2S2 and GLUT1 levels and clinical parameters. Correlation analysis between EIF2S2 and Reactome-Glycolysis signatures was performed using GEPIA2. We describe the effect of EIF2S2 knockdown on lactate production and the mRNA levels of glycolysis-related genes in human colon cancer SW480 cells.

Results: Immunohistochemistry revealed an upregulation of EIF2S2 protein expression in tumor tissues of colorectal cancer patients, which is consistent with the significant upregulation of EIF2S2 transcript levels in the database. These colorectal cancer patients included 24 cases of colon cancer and 18 cases of rectal cancer, ranging in age from 31 to 78 years. The transcription was significantly related to histological subtypes and TP53 mutations (P <0.05). The value of SUVmax in CRC significantly correlated with the expression of EIF2S2 (rho = 0.462, P <0.01). Although SUVmax and SUVmean was not correlate with the expression of GLUT1 (P <0.05), a significant correlation was observed between the expression of GLUT1 and the volumetric PET parameters, such as MTV and TLG (P < 0.01). GLUT1 expression in CRC was positively correlated with EIF2S2 status (rho = 0.470, P <0.01). In SW480 cells, RNAi-mediated depletion of EIF2S2 inhibited lactic acid production (P <0.05) and SLC2A1, SLC2A3, SLC2A10, HK2, PKM2, LDHA mRNA level (P <0.01).

Conclusions: Primary CRC FDG uptake is strongly associated with the overexpression of EIF2S2, and EIF2S2 may promote glycolysis in CRC by mediating GLUT1.

Update on Molecular Imaging and Precision Medicine in Lung Cancer

Precision medicine integrates molecular pathobiology, genetic make-up, and clinical manifestations of disease in order to classify patients into subgroups for the purposes of predicting treatment response and suggesting outcome. By identifying those patients who are most likely to benefit from a given therapy, interventions can be tailored to avoid the expense and toxicity of futile treatment. Ultimately, the goal is to offer the right treatment, to the right patient, at the right time. Lung cancer is a heterogeneous disease both functionally and morphologically. Further, over time, clonal proliferations of cells may evolve, becoming resistant to specific therapies. PET is a sensitive imaging technique with an important role in the precision medicine algorithm of lung cancer patients. It provides anatomo-functional insight during diagnosis, staging, and restaging of the disease. It is a prognostic biomarker in lung cancer patients that characterizes tumoral heterogeneity, helps predict early response to therapy, and may direct the selection of appropriate treatment.

Benefit of three-dimensional image simulation in surgical resection of early stage lung cancer

BACKGROUND

The present study investigated the oncological outcomes of clinical stage IA2 non-small cell lung cancer that was treated using preoperative simulation and surgical resection.

METHODS

The data of patients who underwent surgical resection for clinical stage IA2 non-small cell lung cancer between January 2002 and June 2018 were reviewed. Preoperative simulations were indicated for patients with centrally located tumors who can undergo anatomic resection. The clinical features, imaging characteristics of the tumors, surgical approaches and outcomes were analyzed.

RESULTS

Of the 1086 identified patients, 281 patients with clinical stage IA2 non-small cell lung were enrolled and categorized into 2 groups, with and without preoperative simulation. The tumor location, maximum standard uptake value, histological grade, disease-free survival and disease recurrence were significantly different between the 2 groups. For the group with preoperative simulations, 70.7% of the patients underwent anatomic resection, and 79.7% of the patients without preoperative simulations underwent anatomic resection (P <0.001). Patients with preoperative simulations had fewer relapses (2%) than patients without preoperative simulations (11.5%, P < 0.01).

CONCLUSIONS

Preoperative simulation confirmed the relationship between the tumor and surrounding blood vessels and bronchus and ensured an oncological safety margin. 3D simulations are a useful and feasible tool for planar operative procedures, satisfy the requirements for early-stage NSCLC. These results are promising but preliminary and more extended follow-up is needed.

Maximum Standardized Uptake Value on Positron Emission Tomography is Associated With More Advanced Disease and High-risk Features in Lung Adenocarcinoma

¹⁸F-fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography (FDG-PET/CT) has been widely used for preoperative staging of lung adenocarcinomas. The aim of this study was to determine whether a high maximum standardized uptake value (SUVmax) could correlate with pathological characteristics in those patients. We retrospectively reviewed patients with clinical stage 0-IA lung adenocarcinoma who underwent preoperative ¹⁸F-fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography followed by curative anatomical resection. To identify more advanced disease and high-risk features, representing visceral pleural involvement, pulmonary metastasis, lymph node involvement, and lymphovascular involvement in resected surgical specimens, univariate and multivariate logistic regression analyses were performed. The optimal cutoff point for the SUVmax was determined by receiver operating characteristic analysis. In 2 groups divided according to the cutoff point, the disease-free survivals were calculated and compared using the Kaplan-Meier method and the log-rank test. More advanced disease and high-risk features were identified in 55 (18.9%) of the 291 patients. SUVmax was significantly correlated with more advanced disease and high-risk features, as did the consolidation/tumor ratio on computed tomography. Only 2 (1.2%) of the 169 patients with a SUVmax <3.20 showed more advanced disease and high-risk features, compared with 43.4% of patients with a SUVmax ≥3.20. The disease-free survival was significantly higher in patients with a SUVmax <3.20 than in those with a SUVmax ≥3.20 (P = 0.002). A high SUVmax correlates with more advanced disease and high-risk features in patients with clinical stage 0-IA lung adenocarcinoma. The SUVmax should be considered when deciding treatment strategy in early-stage lung adenocarcinoma.

Prognosis of segmentectomy and lobectomy for radiologically aggressive small-sized lung cancer

OBJECTIVES

The purpose of this study was to determine the radiological characteristics of aggressive small-sized lung cancer and to compare the outcomes between segmentectomy and lobectomy in patients with these lung cancers.

METHODS

A series of 1046 patients with clinical stage IA1-IA2 lung cancer who underwent lobectomy or segmentectomy at 3 institutions was retrospectively evaluated to identify radiologically aggressive small-sized (solid tumour size ≤ 2 cm) lung cancers. Prognosis of segmentectomy was compared with that of lobectomy in 522 patients with radiologically aggressive small-sized lung cancer using propensity score matching.

RESULTS

Multivariable analysis showed that increasing consolidation-to-tumour ratio on preoperative high-resolution computed tomography (CT) (P = 0.037) and maximum standardized uptake on 18 fluoro-2-deoxyglucose positron emission tomography/CT (P = 0.029) was independently associated with worse recurrence-free survival. Based on analysis of the receiver operating characteristic curve, radiologically aggressive lung cancer was defined as a radiologically solid (consolidation-to-tumour ratio ≥ 0.8) or highly metabolic (maximum standardized uptake ≥ 2.5) tumour. Among patients with radiologically aggressive lung cancer, no significant statistical differences in 5-year recurrence-free (81% vs 90%; P = 0.33) and overall (88% vs 93%; P = 0.76) survival comparing lobectomy (n = 392) to segmentectomy (n = 130) were observed. Among 115 propensity-matched pairs, 5-year recurrence-free survival and overall survival were similar between patients who underwent lobectomy and those who underwent segmentectomy (83.3% and 88.3% vs 90.9% and 94.5%, respectively).

CONCLUSIONS

Difference in survival was not identified with segmentectomy and lobectomy in patients with radiologically aggressive small-sized lung cancer with high risk of recurrence.

Application of Artificial Neural Network to Preoperative 18F-FDG PET/CT for Predicting Pathological Nodal Involvement in Non-small-cell Lung Cancer Patients

Purpose: To evaluate the performance of artificial neural networks (aNN) applied to preoperative ¹⁸F-FDG PET/CT for predicting nodal involvement in non-small-cell lung cancer (NSCLC) patients.

Methods: We retrospectively analyzed data from 540 clinically resectable NSCLC patients (333 M; 67.4 ± 9 years) undergone preoperative ¹⁸F-FDG PET/CT and pulmonary resection with hilo-mediastinal lymphadenectomy. A 3-layers NN model was applied (dataset randomly splitted into 2/3 training and 1/3 testing). Using histopathological reference standard, NN performance for nodal involvement (N0/N+ patient) was calculated by ROC analysis in terms of: area under the curve (AUC), accuracy (ACC), sensitivity (SE), specificity (SP), positive and negative predictive values (PPV, NPV). Diagnostic performance of PET visual analysis (N+ patient: at least one node with uptake ≥ mediastinal blood-pool) and of logistic regression (LR) was evaluated.

Results: Histology proved 108/540 (20%) nodal-metastatic patients. Among all collected data, relevant features selected as input parameters were: patients' age, tumor parameters (size, PET visual and semiquantitative features, histotype, grading), PET visual nodal result (patient-based, as N0/N+ and N0/N1/N2). Training and testing NN performance (AUC = 0.849, 0.769): ACC = 80 and 77%; SE = 72 and 58%; SP = 81 and 81%; PPV = 50 and 44%; NPV = 92 and 89%, respectively. Visual PET performance: ACC = 82%, SE = 32%, SP = 94%; PPV = 57%, NPV = 85%. Training and testing LR performance (AUC = 0.795, 0.763): ACC = 75 and 77%; SE = 68 and 55%; SP = 77 and 82%; PPV = 43 and 43%; NPV = 90 and 88%, respectively.

Conclusions: aNN application to preoperative ¹⁸F-FDG PET/CT provides overall good performance for predicting nodal involvement in NSCLC patients candidate to surgery, especially for ruling out nodal metastases, being NPV the best diagnostic result; a high NPV was also reached by PET qualitative assessment. Moreover, in such population with low a priori nodal involvement probability, aNN better identify the relatively few and unexpected nodal-metastatic patients than PET analysis, so supporting the additional aNN use in case of PET-negative images.

Prospective Correlation of Prognostic Immunohistochemical Markers With SUV and ADC Derived From Dedicated Hybrid Breast 18F-FDG PET/MRI in Women With Newly Diagnosed Breast Cancer

PURPOSE

The aim of this study was to correlate prognostically relevant immunohistochemical parameters of breast cancer with simultaneously acquired SUVs and apparent diffusion coefficient (ADC) values derived from hybrid breast PET/MRI.

PATIENTS AND METHODS

Fifty-six women with newly diagnosed, therapy-naive, histologically proven breast cancer (mean age, 54.1 ± 12.0 years) underwent dedicated prone 18F-FDG breast PET/MRI. Diffusion-weighted imaging (b-values: 0, 500, 1000 s/mm2) was performed simultaneously with the PET acquisition. A region of interest encompassing the entire primary tumor on each patient's PET/MRI scan was used to determine the glucose metabolism represented by maximum and mean SUV as well as into corresponding ADC maps to assess tumor cellularity represented by mean and minimum ADC values. Histopathological tumor grading and prognostically relevant immunohistochemical markers, that is, Ki67, progesterone receptor, estrogen receptor, and human epidermal growth factor receptor 2 (HER2), were assessed. Pearson correlation coefficients were calculated to compare SUV and ADC values as well as the immunohistochemically markers and molecular subtype. For the comparison with the tumor grading, a Wilcoxon test was used.

RESULTS

A significant inverse correlation between SUV and ADC values derived from breast PET/MRI (r = -0.49 for SUVmean vs ADCmean; r = -0.43 for SUVmax vs ADCmin; both P's < 0.001) was found. Tumor grading and Ki67 both showed a positive correlation with SUVmean from breast PET/MRI (r = 0.37 and r = 0.32, P < 0.01). For immunohistochemical markers, HER2 showed an inverse correlation with ADC values from breast PET/MRI (r = -0.35, P < 0.01). Molecular subtypes significantly correlate with SUVmax and SUVmean (r = 0.52 and r = 0.42, both P's < 0.05). In addition, estrogen receptor expression showed an inverse correlation with SUVmax and SUVmean from breast PET/MRI (r = -0.45 and r = -0.42, P < 0.001).

CONCLUSIONS

The present data show a correlation between increased glucose metabolism, cellularity, tumor grading, estrogen and HER2 expression, as well as molecular subtype of breast cancer primaries. Hence, simultaneous 18F-FDG PET and diffusion-weighted imaging from hybrid breast PET/MRI may serve as a predictive tool for identifying high-risk breast cancer patients in initial staging and guide-targeted therapy.

Clinical impact and utility of positron emission tomography on occult lymph node metastasis and survival: radical surgery for stage I lung cancer

OBJECTIVE

The surgical result of early-staged lung cancer is not satisfactory due to unexpected postoperative lymph node metastasis and recurrence. This study aimed to investigate which preoperative factors-including the standard uptake value max (SUV_max) of positron emission tomography-could predict occult lymph node metastasis and survival.

METHODS

We retrospectively analyzed data from 598 patients with clinical stage I lung cancer who underwent surgery, and examined their preoperative clinical characteristics.

RESULTS

A total of 1586 patients had surgery for primary lung cancer between 2006 and 2019; 598 patients with clinical stage I lung cancer were the study inclusion; occult lymph node metastasis was detected in 102 (17.1%). Univariable and multivariable analyses showed that SUV_max ≥ 3 (P < 0.001), clinical invasive tumor size ≥ 2 cm (P = 0.009), and carcinoembryonic antigen > 5 (P = 0.03) were associated with significant risk factors rated (%) for occult lymph node metastasis, as follows: high-risk group (three factors), moderate-risk group (two factors) and low-risk group (one factor or none) corresponding to 32.2 (28/87), 22.8 (41/180) and 7.3 (19/262), respectively (P < 0.001). The 5-year overall survival rates (%) of patients without lymph node metastasis holding SUV_max 6 or over were as poor as those of patients with lymph node metastasis (72.0% vs 64.1%; P = 0.56).

CONCLUSIONS

We might consider wedge resection or segmentectomy, omitting lymphadenectomy, for the low-risk group; adjuvant therapy is indicated for patients without lymph node metastasis having SUV_max 6 or over.

Positron Emission Tomography in Segmentectomy for cT1N0M0 Nonsmall Cell Lung Cancer

BACKGROUND

This study was aimed to examine the significance of fluorodeoxyglucose positron emission tomography in predicting prognosis after segmentectomy in lung cancer.

METHODS

This was a retrospective cohort study, including 227 patients with cT1N0M0 nonsmall cell lung cancer who underwent positron emission tomography followed by segmentectomy between 2012 and 2019. Significance of tumor histology, T-stage, tumor size, and standardized uptake value on positron emission tomography in relation to recurrence-free survival were examined using Cox's proportional hazard analysis. Median follow-up period was 56 months (range: 1-95 months).

RESULTS

Tumor stages were Tis in 25 patients, T1mi/T1a in 51, T1b in 98, and T1c in 53. Twenty-six patients (11%) experienced recurrences, including local (n = 8) and distant (n = 18). Multivariate analysis showed that the significant variables for recurrence-free survival were T-stage and standardized uptake value (p = 0.002 and 0.015, respectively), whereas tumor histology and tumor size were not significant (p = 0.28 and 0.44, respectively). When tumor size was divided into ≤2 cm and >2 cm for analysis, it was not significant again (p = 0.49), whereas standardized uptake value remained significant (p = 0.008). While standardized uptake value of tumors with recurrences was significantly higher than those without (4.9-2.8 and 2.6-2.5, respectively, p < 0.001), there was no significant difference between local and distant recurrences (p = 0.32). Cut-off value of standardized uptake value for recurrences was 3.2. Five-year recurrence-free survival rates in tumors with standardized uptake value <3.2 and ≥3.2 were 86 and 65%, respectively (p < 0.001).

CONCLUSION

Positron emission tomography could predict the prognosis after segmentectomy better than tumor size.

PET-Based Volumetric Biomarkers for Risk Stratification of Non-Small Cell Lung Cancer Patients

Despite the recent advances in lung cancer biology, molecular pathology, and treatment, this malignancy remains the leading cause of cancer-related death worldwide and non-small cell lung cancer (NSCLC) is the most common form found at diagnosis. Accurate staging of the disease is a fundamental prognostic factor that correctly predicts progression-free (PFS) and overall survival (OS) of NSCLC patients. However, outcome of patients within each TNM staging group can change widely highlighting the need to identify additional prognostic biomarkers to better stratify patients on the basis of risk. 18F-FDG PET/CT plays an essential role in staging, evaluation of treatment response, and tumoral target delineation in NSCLC patients. Moreover, a number of studies showed the prognostic role of imaging parameters derived from PET images, such as metabolic tumor volume (MTV) and total lesion glycolysis (TLG). These parameters represent three-dimensional PET-based measurements providing information on both tumor volume and metabolic activity and previous studies reported their ability to predict OS and PFS of NSCLC patients. This review will primarily focus on the studies that showed the prognostic and predictive role of MTV and TLG in NSCLC patients, addressing also their potential utility in the new era of immunotherapy of NSCLC.

Prognostic impact of maximum standardized uptake value on 18 F-FDG PET/CT imaging of the primary lung lesion on survival in advanced non-small cell lung cancer: A retrospective study

Background

Positron emission tomography/computed tomography (PET/CT) has been recognized for diagnosing and staging lung cancer, but the prognostic value of standardized uptake value (SUV) on ¹⁸F‐FDG PET/CT imaging in patients with advanced non‐small cell lung cancer (NSCLC) remains controversial.

Methods

We performed a retrospective analysis of patients with advanced NSCLC who had undergone ¹⁸F‐FDG PET/CT before systemic treatment between June 2012 and June 2016. The relationship between the maximum SUV (SUVmax) of the pulmonary lesion and lesion size was evaluated via Spearman's correlation analysis. We collected patients' clinical and pathological data. Univariate and multivariate analyses were performed to analyze the factors influencing survival.

Results

We included 157 patients with advanced NSCLC. Among these, 135 died, 13 survived, and nine were lost to follow‐up (median follow‐up period, 69 months). SUVmax was correlated with lesion size and was significantly greater for tumors ≥3 cm than for tumors <3 cm (10.2 ± 5.4 vs. 5.6 ± 3.3, t = −6.709, p = 0.000). Univariate analysis showed that survival was associated with gender, tumor size, epidermal growth factor receptor gene mutation or anaplastic lymphoma kinase rearrangement, SUVmax of the primary lung lesion, and treatment lines. Multivariate analysis showed a significant correlation between SUVmax of the primary lung lesion and survival. The mortality risk of patients with SUVmax ≤6 was 35% lower than that of patients with SUVmax >6 (HR = 0.651, 95% confidence interval, 0.436–0.972; Wald value, 4.400; p = 0.036).

Conclusions

The SUVmax of the primary lung lesion on PET/CT is significantly correlated with survival in treatment‐naive patients with advanced NSCLC.

Combined prognostic value of the SUVmax derived from FDG-PET and the lymphocyte-monocyte ratio in patients with stage IIIB-IV non-small cell lung cancer receiving chemotherapy

Background

We evaluated the prognostic potential of tumor ¹⁸F-fluorodeoxyglucose (FDG) uptake derived from positron emission tomography (PET) and known inflammatory hematological markers, both individually and in combination, for chemosensitivity and survival in patients with stage IIIB-IV non-small cell lung cancer (NSCLC) receiving first-line chemotherapy.

Methods

A total of 149 patients with stage IIIB and IV NSCLC (based on TNM 7th edition) were retrospectively reviewed. Maximum standardized uptake value (SUVmax) were used to quantitatively assess FDG uptake. The lymphocyte-monocyte ratio (LMR), neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) were selected as hematological markers. Receiver operating characteristic (ROC) curves were constructed for the determination of optimal cut-off values to predict chemotherapeutic response.

Results

Patients with SUVmax > 11.6 or LMR ≤3.73 exhibited a significantly lower objective response rate (ORR) to chemotherapy (p < 0.001 and p < 0.001). Through multivariable logistic regression analysis, both the SUVmax and LMR were identified as independent predictive factors for chemotherapeutic response (p = 0.001 and p < 0.001). Furthermore, a multivariable Cox proportional hazard model identified a high SUVmax (> 11.6) and low LMR (≤3.73) as independent predictors of poor PFS (p < 0.001 and p = 0.025) and OS (p < 0.001 and p = 0.032). A novel score system was constructed based on the SUVmax and LMR (SUV_LMR score), and patients were stratified into three subgroups. The patients with a score of 0 had a significantly higher ORR (88.9%) than did those with a score of 1 (59.6%) and score of 2 (25.0%) (p < 0.001). Moreover, multivariable Cox analysis further identified the SUV_LMR score as an independent prognostic factor for PFS (p < 0.001) and OS (p < 0.001).

Conclusions

Pre-treatment SUVmax and LMR were not only predictive factors for chemotherapeutic response but also independent prognostic factors of survival in stage IIIB-IV NSCLC. Moreover, the SUV_LMR score, which is based on primary tumor metabolic activity and the systemic inflammatory response, might provide a promising tool to predict chemosensitivity, recurrence and survival of advanced NSCLC.

SUVmax of 18FDG PET/CT Predicts Histological Grade of Lung Adenocarcinoma

OBJECTIVES

The relationship between the ¹⁸FDG PET-CT maximum standard uptake value (SUVmax) and the type of lung adenocarcinoma is still not established. The aim of this study was to investigate the relationship between SUVmax value and histological grade and pathological subtype of lung adenocarcinoma, and to determine the optimum SUVmax cutoffs for distinguishing different histological grades.

MATERIALS AND METHODS

The data of 618 lung adenocarcinoma patients were retrospectively analyzed. The relationship between SUVmax measured on preoperative ¹⁸FDG-PET-CT and the histological grade and pathological subtype was examined. The Kruskal-Wallis test was used to compare differences among groups, and the Bonferroni-Dunn test for pairwise comparison among groups. ROC analysis was applied to determine the optimal cut-off values for distinguishing different groups. In addition, the cut-off value was verified in an independent cohort of 85 consecutive lung adenocarcinoma cases.

RESULTS

The SUVmax was significantly different between the low, intermediate, and high-grade groups(p < .001). SUVmax value increased with increase in the degree of malignancy. The optimal cut-off value for identifying low-grade tumors was 2.01 (sensitivity 90.4%, specificity 86.9%, area under the curve [AUC] = 0.928, 95% confidence interval: 0.91-0.95; p < .001). The optimal cutoff SUVmax value for identifying high-grade tumors was 7.41 (sensitivity 79.8%, specificity 73.5%, AUC = 0.830, 95% confidence interval: 0.79-0.87; p < .001). The validation experiment showed that the coincidence rate was 88.89% in the low-level group, 64.15% in the middle-level group, and 78.57% in the high-level group.

CONCLUSION

SUVmax can be used to predict pathological subtype and histological grade of lung adenocarcinoma. Thus, ¹⁸FDG PET-CT can serve as a noninvasive tool for precise diagnosis and help in the preoperative formulation of patient-specific treatment strategies.

Multiple Testing, Cut-Point Optimization, and Signs of Publication Bias in Prognostic FDG-PET Imaging Studies of Head and Neck and Lung Cancer: A Review and Meta-Analysis

Positron emission tomography (PET) imaging with 2-deoxy-2-[¹⁸F]-fluorodeoxyglucose (FDG) was proposed as prognostic marker in radiotherapy. Various uptake metrics and cut points were used, potentially leading to inflated effect estimates. Here, we performed a meta-analysis and systematic review of the prognostic value of pretreatment FDG–PET in head and neck squamous cell carcinoma (HNSCC) and non-small cell lung cancer (NSCLC), with tests for publication bias. Hazard ratio (HR) for overall survival (OS), disease free survival (DFS), and local control was extracted or derived from the 57 studies included. Test for publication bias was performed, and the number of statistical tests and cut-point optimizations were registered. Eggers regression related to correlation of SUVmax with OS/DFS yielded p = 0.08/p = 0.02 for HNSCC and p < 0.001/p = 0.014 for NSCLC. No outcomes showed significant correlation with SUVmax, when adjusting for publication bias effect, whereas all four showed a correlation in the conventional meta-analysis. The number of statistical tests and cut points were high with no indication of improvement over time. Our analysis showed significant evidence of publication bias leading to inflated estimates of the prognostic value of SUVmax. We suggest that improved management of these complexities, including predefined statistical analysis plans, are critical for a reliable assessment of FDG–PET.

Prognostic impact of preoperative FDG-PET positive lymph nodes in lung cancer

BACKGROUND

2-[¹⁸F] Fluoro-D-deoxyglucose positron emission tomography (FDG-PET) is an appropriate diagnostic procedure for staging lung cancer. However, accurate evaluation of lymph node (LN) metastases by PET is controversial owing to false-positive/-negative FDG uptake results. The prognostic significance of both false-negative and false-positive LNs on FDG-PET remains to be determined.

METHODS

A total of 235 patients with lung cancer were retrospectively analyzed. Maximum standardized uptake values (SUVmax) of the lymph nodes were compared with pathological LN metastases to correlate PET findings with clinicopathological variables and patients' outcomes.

RESULTS

When SUVmax ≥ 4 was defined as PET-positive for LN metastasis, sensitivity, specificity, and accuracy were 46.0%, 79.5%, and 72.3%, respectively. False-negative cases and pathological n0 cases were significantly younger, had primary tumors that were smaller or lower SUVmax, and adenocarcinomas compared with false-positive and pathological n⁺ cases. The difference in survival time between patients with abnormal FDG uptake in the LN and those without was larger than that between pathological LN metastases and no pathological metastases in patients with adenocarcinoma. Multivariate analysis by the Cox proportional hazard model identified smoker, EGFR/ALK negative and LN positive on PET as significant adverse prognostic factors, rather than pathological n-stage.

CONCLUSIONS

Abnormal FDG uptake in the LN is an important prognostic factor. Increased glucose metabolism on FDG-PET appears to be a more efficient postoperative prognostic marker than pathological n-stage in patients with lung cancer.

Is there a connection between immunohistochemical markers and grading of lung cancer with apparent diffusion coefficient (ADC) and standardised uptake values (SUV) of hybrid 18F-FDG-PET/MRI?

INTRODUCTION

To correlate tumour grading and prognostic immunohistochemical markers of lung cancer with simultaneously acquired standardised uptake values (SUV) and apparent diffusion coefficient (ADC) derived from hybrid PET/MRI.

METHODS

In this retrospective study, 55 consecutive patients (mean age 62.5 ± 9.2 years) with therapy-naïve, histologically proven lung cancer were included. All patients underwent whole-body PET/MRI using 18F-flourdeoxyglucose (18F-FDG) as a radiotracer. Diffusion-weighted imaging of the chest (DWI, b-values: 0, 500, 1000 s/mm² ) was performed simultaneously with PET acquisition. Histopathological tumour grading was available in 43/55 patients. In 15/55 patients, immunohistochemical markers, that is, phospho-AKT Ser473 (pAKTS473), phosphorylated extracellular signal-regulated kinase (pERK), phosphatase and tensin homolog (PTEN), and human epidermal growth factor receptor 2 (erbB2) were available.

RESULTS

The average SUVmax, SUVmean, ADCmin and ADCmean in lung cancer primaries were 12.6 ± 5.9, 7.7 ± 4.6, 569.9 ± 96.1 s/mm² and 825.8 ± 93.2 s/mm² , respectively. We found a significant inverse correlation between the ADCmin and SUVmax (r = -0.58, P < 0.001) as well as between the ADCmin and SUVmean (r = -0.44, P < 0.001). Tumour grading showed a significant positive correlation with SUVmax and SUVmean (R = 0.34 and R = 0.31, both P < 0.05) and a significant inverse correlation with ADCmin and ADCmean (r = -0.30 and r = -0.40, both P < 0.05). In addition, erbB2 showed a significant inverse correlation with SUVmax and SUVmean (r = -0.50 and r = -0.49, both P < 0.05). The other immunohistochemical markers did not show any significant correlation.

CONCLUSION

18F-FDG-PET/MRI showed weak to moderate correlations between SUV, ADC, tumour grading and erbB2-expression of lung cancer. Hence, 18F-FDG-PET/MRI may, to some extent, offer complementary information to the histopathology of lung cancer, for the evaluation of tumour aggressiveness and treatment response.

Surgical outcomes of second primary lung cancer after the extrapulmonary malignancy

OBJECTIVE

To study the surgical outcomes of patients with a second primary lung cancer after the extrapulmonary malignancy.

MATERIALS AND METHODS

Patients who underwent surgical resection for lung cancers between January 2005 and December 2014 were reviewed. Clinical data, imaging characteristics of tumors, surgical approaches, and outcomes were analyzed with a mean follow-up of 97 months.

RESULTS

Of 1075 patients, 166 (15.4%) had a second primary lung cancer after extrapulmonary malignancy. There were no differences in overall 5-year survival rates (81.8% for the group of lung cancer vs. 72.9% for the second primary lung cancer group, p = 0.069) and 5-year disease-free survival (70.1% for the lung cancer group vs. 70.3% for the second primary lung cancer group, p = 0.863) between the two groups. Gender, performance status, tumor size, and maximum standard uptake value (SUVmax) were significantly different between the two groups. After propensity-score matching analysis, patients in the group with lung cancers had better 5-year overall survival (88.1% vs. 72.1% for the group with second primary lung cancers, p = 0.016) and 5-year disease-free survival (80.6% vs. 70.3% for the group with second primary lung cancers; p = 0.054). In the second primary lung cancer group, the patients with preceding breast or thyroid cancers had better prognoses than did those with other extrapulmonary malignancy.

CONCLUSIONS

Second primary lung cancers following extrapulmonary malignancies were not uncommon. Surgical resection is considered for early stage secondary primary lung cancer after meticulous work up and result in fair outcome.

Enhanced prognostic stratification of neoadjuvant treated lung squamous cell carcinoma by computationally-guided tumor regression scoring

INTRODUCTION

The amount of residual tumor burden after neoadjuvant chemotherapy is an important prognosticator, but for non-small cell lung carcinoma (NSCLC), no official regression scoring system is yet established. Computationally derived histological regression scores could provide unbiased and quantitative readouts to complement the clinical assessment of treatment response.

METHODS

Histopathologic tumor regression was microscopically assessed on whole cases in a neoadjuvant chemotherapy-treated cohort (NAC, n = 55 patients) of lung squamous cell carcinomas (LSCC). For each patient, the slide showing the least pathologic regression was selected for subsequent computational analysis and histological features were quantified: percentage of vital tumor cells (cTu.Percentage), total surface covered by vital tumor cells (cTu.Area), area of the largest vital tumor fragment (cTu.Size.max), and total number of vital tumor fragments (cTu.Fragments). A chemo-naïve LSCC cohort (CN, n = 104) was used for reference. For 23 of the 55 patients [¹⁸F]-Fluorodeoxyglucose (FDG) PET/CT measurements of maximum standard uptake value (SUV_max), background subtracted lesion activity (BSL) and background subtracted volume (BSV) were correlated with pathologic regression. Survival analysis was carried out using Cox regression and receiver operating characteristic (ROC) curve analysis using a 3-years cutoff.

RESULTS

All computational regression parameters significantly correlated with relative changes of BSV FDG PET/CT values after neoadjuvant chemotherapy. ROC curve analysis of histological parameters of NAC patients showed that cTu.Percentage was the most accurate prognosticator of overall survival (ROC curve AUC = 0.77, p-value = 0.001, Cox regression HR = 3.6, p = 0.001, variable cutoff < = 30 %).

CONCLUSIONS

This study demonstrates the prognostic relevance of computer-derived histopathologic scores. Additionally, the analysis carried out on slides displaying the least pathologic regression correlated with overall pathologic response and PET/CT values. This might improve the objective histopathologic assessment of tumor response in neoadjuvant setting.

Pre-surgical assessment of mediastinal lymph node metastases in Stage IA non-small-cell lung cancers

OBJECTIVE

Evaluation of sensitivity and specificity of CT and fluorodeoxyglucose-positron emission tomography for pre-surgical staging of mediastinal lymph node metastases (N2/N3) of non-small-cell-lung-cancers ≤30 mm.

METHODS

We reviewed a total of 263 patients from a prospective cohort study, who underwent resection including mediastinal lymph nodes, for first primary non-small-cell-lung-cancer ≤30 mm in maximum diameter on pre-surgical CT. Cutoff criteria for short-axis diameter on CT of the largest N2/N3 node of 10, 15, and 20 mm and positron emission uptake of 2.5, 3.0, and 4.0 were evaluated using Area-Under-the-Curve (AUC) assessment. Accuracy criterion was used to determine the optimal cutoffs.

RESULTS

Of 263 patients, 9 had nonsolid, 42 part-solid, and 212 solid non-small-cell-lung-cancers. Post-surgically, none of the 51 patients with nonsolid or part-solid cancers had mediastinal lymph node metastases. Among the 212 patients with solid cancers, 23 had N2 node metastases. For the 212 patients with solid cancers, the AUC for CT lymph node measurements was 0.67 (95% CI: 0.57-0.77), significantly higher (p = 0.001) than chance alone, while the AUC for SUVmax measurements, 0.56 (95% CI: 0.48-0.65), was not (p = 0.13). Optimal CT cutoff was >20 mm had low sensitivity of 30.4% (95% CI: 11.6%-49.2%) but high specificity of 99.5% (95% CI: 98.4%-100.0%).

CONCLUSION

Based on these results, clinical Stage IA for non-small-cell-lung-cancers with nonsolid, part-solid, or solid consistency should be based on pre-surgical CT maximum tumor diameter and lymph node short-axis measurements on CT ≤20 mm. Further prospective evaluation of these clinical Stage IA staging criteria is needed.

Clinicopathologic Significance of False-Positive Lymph Node Status on FDG-PET in Lung Cancer

INTRODUCTION

2-[¹⁸F] Fluoro-d-deoxyglucose (FDG) positron emission tomography (PET) is a relevant diagnostic procedure for staging lung cancer. However, accurate evaluation of lymph node metastases by PET is controversial because of false-positive FDG uptake.

PATIENTS AND METHODS

A total of 245 patients with lung cancer were retrospectively analyzed. Standardized maximum uptake values (SUV_max) of the primary tumor and lymph nodes were compared to pathologic lymph node metastases to correlate PET findings with clinicopathologic variables and patient outcomes.

RESULTS

The SUV_max values of metastatic lymph nodes were significantly higher than those of lymph nodes without metastases (P = .0036). When SUV_max ≥ 4 was defined as PET positive for metastasis, the sensitivity, specificity, and accuracy were 48.1%, 79.8%, and 73.1%, respectively. Multivariate logistic regression analysis showed that age > 75 years, bilateral hilar FDG uptake, and no lymph node swelling were significant factors related to false-positive lymph node metastases. Smoking status, FDG uptake in the primary tumor, and concurrent lung diseases were not significant factors.

CONCLUSION

Metastatic lymph nodes show higher FDG uptake than false-positive lymph nodes, and older patient age, bilateral hilar FDG uptake, and no swollen nodes are associated with no metastases. Patients with lymph node metastases have worse survival than those with false-positive FDG-PET findings. However, abnormal FDG uptake in the lymph node is an important prognostic factor.

SUVmax Ratio on PET/CT May Differentiate Between Lung Metastases and Synchronous Multiple Primary Lung Cancer

PURPOSE

To investigate the features of ¹⁸F-Fluoro-D-glucose positron emission tomography/computed tomography (¹⁸F-FDG PET/CT) in differentiating synchronous multiple primary lung cancers (sMPLC) from intropulmonary metastasis (IM).

MATERIAL AND METHODS

Fifty-nine patients with two synchronous primary lung cancers were selected and 23 lung cancer patients with an additional solitary IM cancer were chosen as the control group between January 2009 and January 2019. Maximum standardized uptake values (SUVmax) on PET/CT was determined for each tumor. The SUVmax ratio between the two tumors was determined and receiver operating characteristic curve analysis was used to evaluate the diagnostic performance.

RESULTS

The difference of SUVmax ratio between sMPLC (2.3 ± 1.6) and IM (1.5 ± 0.4) was significant, p < 0.01; the area under the curve of the SUVmax ratio was 0.78 with the optimal cutoff value 1.7 (sensitivity 62.7% and specificity 82.6%, p < 0.001).

CONCLUSION

The SUVmax ratio between two tumors may be helpful in differentiating sMPLC from IM, independent studies with bigger size were needed to further confirm the findings.

Genomic Signature of the Standardized Uptake Value in 18F-Fluorodeoxyglucose Positron Emission Tomography in Breast Cancer

The standardized uptake value (SUV), an indicator of the degree of glucose uptake in ¹⁸F-fluorodeoxyglucose positron emission tomography (FDG-PET), has been used for predicting the clinical behavior of malignant tumors. However, its characteristics have been insufficiently explored at the genomics level. Here, we aim to identify genomic signatures reflecting prognostic SUV characteristics in breast cancer (BRC). Through integrative genomic profiling of 3710 BRC patients, including 254 patients who underwent preoperative FDG-PET, we identified an SUV signature, which showed independent clinical utility for predicting BRC prognosis (hazard ratio [HR] 1.27, 95% confidence interval [CI] = 1.12 to 1.45, p = 2.23 × 10⁻⁴). The risk subgroups classified by the signature exhibited mutually exclusive mutation patterns of TP53 and PIK3CA and showed significantly different responsiveness to immunotherapy. Experimental assays revealed that a signaling axis defined by TP53–FOXM1 and its downstream effectors in glycolysis–gluconeogenesis, including LDHA, might be important mediators in the FDG-PET process. Our molecular characterizations support an understanding of glucose metabolism and poor prognosis in BRC with a high SUV, utilizable in clinical practice to assist other diagnostic tools.

Prognostic factors of EGFR-mutated metastatic adenocarcinoma of lung

PURPOSE

The first-line treatment of metastatic lung adenocarcinoma with epidermal growth factor receptor (EGFR) mutation is tyrosine kinase inhibitor (TKI). This study aimed to evaluate potential factors affecting the progression-free survival under TKI treatment.

METHODS

Forty one patients with EGFR-mutated metastatic lung adenocarcinoma under first-line TKI treatment were retrospectively evaluated. Ten factors potentially influencing the progression-free survival were studied: patients' age, gender, smoking history, number of comorbidities, performance status, tumor mutation site, maximum of standardized uptake value (SUV_max) of primary tumor in FDG PET/CT, serum CEA level, number of metastatic organs and presence of pleural/pericardial effusion. Mantel-Cox tests and waterfall plots were performed for statistical analyses.

RESULTS

Statistical evaluation demonstrated that primary SUV_max, serum CEA level, gender and smoking history were important prognostic factors, with corresponding p values of 0.001, 0.023, 0.034 and 0.041 respectively in Mantel-Cox analyses.

CONCLUSION

Low primary SUV_max, low serum CEA level, female and never smoker were four prognostic factors suggestive of good response to TKI in mutated EGFR metastatic lung adenocarcinoma. SUV_max is probably the most important among the four factors.

Incorporation of the SUVmax Measured From FDG PET and Neutrophil-to-lymphocyte Ratio Improves Prediction of Clinical Outcomes in Patients With Locally Advanced Non-small-cell Lung Cancer

INTRODUCTION

The aim of the present study was to investigate the value of incorporation 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) maximum standardized uptake value (SUVmax) and neutrophil-to-lymphocyte ratio (NLR) for improving prediction of clinical outcomes of patients with locally advanced non-small-cell lung cancer (LA NSCLC).

MATERIALS AND METHODS

We retrospectively enrolled 138 patients with unresectable LA NSCLC at our institution from July 2010 to August 2017. Spearman correlation analyses were used to estimate the correlations between SUVmax and NLR level. The univariate and multivariate Cox survival analyses were used to evaluate the prognostic indicators, including the incorporation of SUVmax and NLR. We defined the SUVmax and NLR grade (SNG = 0, 1, or 2) score as the number of risk factors among (1) SUVmax > 11.95 and (2) NLR > 3.82. The SNG score prognostic value was evaluated for overall survival (OS) and progression-free survival (PFS).

RESULTS

Univariate analysis showed that tumor stage, SUVmax, SUVmean, NLR, and SNG score were significantly associated with OS and PFS in patients with LA NSCLC. Kaplan-Meier analysis and log-rank test demonstrated significant differences in both OS and PFS among patients in SNG score (OS, P < .001; PFS, P < .001). Spearman correlation analyses showed that SUVmax had a correlation with the NLR (r = 0.237; P = .005). In subgroup analyses for patients with tumor pathologic stage IIIA/IIIB, we found that the SNG score was significantly associated with OS and PFS in each subgroup (P < .001, P < .001 for OS and P = .027, P < .001 for PFS, respectively). Multivariate analysis showed that the SNG score was a significantly independent prognostic factor for OS (hazard ratio, 1.612; 95% confidence interval, 1.157-2.246; P = .005) and PFS (hazard ratio, 2.241; 95% confidence interval, 1.486-3.379; P < .001).

CONCLUSION

Incorporation of the SUVmax and NLR improves prediction of clinical outcomes in patients with LA NSCLC.