The Prognostic Value of 18F-Fluorodeoxyglucose Uptake by Using Serial Positron Emission Tomography and Computed Tomography in Patients With Stage III Nonsmall Cell Lung Cancer

Clinical Effects of PET-CT Before Definite Concurrent Chemoradiotherapy in Patients With Unresectable Stage IIIA-IIIB Squamous Cell Carcinoma of the Lungs

PURPOSE

No large-scale, retrospective cohort study with a long-term follow-up time has yet evaluated the effects of preoperative 18 F-FDG PET-CT on survival in patients with unresectable stages IIIA-IIIB squamous cell lung carcinoma (SqCLC) who received definite concurrent chemoradiotherapy (CCRT).

METHODS

We included patients with unresectable stages IIIA-IIIB SqCLC receiving definite CCRT and categorized them into 2 groups. The case group comprised patients who underwent pre-CCRT 18 F-FDG PET-CT, and the comparison group comprised patients who did not receive pre-CCRT 18 F-FDG PET-CT; the groups were matched at a ratio of 1:1.

RESULTS

The matching process yielded a final cohort of 4042 eligible patients (2021 and 2021 in the case and comparison groups, respectively). Multivariable Cox regression analyses revealed a positive correlation between patients with unresectable stages IIIA-IIIB SqCLC receiving definite CCRT and all-cause death in the pre-CCRT 18 F-FDG PET-CT (adjusted hazard ratio, 0.85; 95% confidence interval, 0.80-0.91; P < 0.0001).

CONCLUSION

Pre-CCRT 18 F-FDG PET-CT was associated with more favorable survival in both patients with unresectable clinical stage IIIA and those with stage IIIB receiving definite CCRT.

Use of 18F-FDG PET/CT to predict short-term outcomes early in the course of chemoradiotherapy in stage III adenocarcinoma of the lung

The purpose of the present prospective study was to evaluate the use of ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography (¹⁸F-FDG PET/CT) in the assessment of therapy response and the prediction of short-term outcomes by maximum and mean standardized uptake values (SUVmax and SUVmean, respectively), metabolic tumor volume (MTV) and total lesion glycolysis (TLG) following chemoradiotherapy (CRT) in patients with stage III adenocarcinoma of the lung. The study included a total of 15 patients, all of whom underwent two serial ¹⁸F-FDG PET/CT scans prior to and following 60-Gy radiotherapy with a concurrent cisplatin/pemetrexed combined chemotherapy regimen. SUVmax, SUVmean, MTV and TLG were determined. Short-term outcomes were assessed according to the Response Evaluation Criteria in Solid Tumors (RECIST) and the PET Response Criteria in Solid Tumors (PERCIST). Post-CRT SUVmax, ΔSUVmax, ΔMTV and ΔTLG varied significantly between responders and non-responders (P=0.009, P=0.015, P=0.006 and P=0.004, respectively). The differences in SUVmax, SUVmean, carcinoembryonic antigen, MTV and TLG between the responders and the non-responders at the initial ¹⁸F-FDG PET/CT scans were not statistically significant (P>0.05). The overall response rate was significantly higher (P=0.01) when evaluated using PERCIST compared with evaluation using RECIST. It was concluded that post-CRT SUVmax, ΔSUVmax, ΔMTV and ΔTLG may be used to differentiate the responders from the non-responders following CRT for stage III adenocarcinoma of the lung. This would aid in deciding whether or not to increase dosages or to incorporate a boost treatment without the requirement to suspend therapy.

Prognostic value of pre-treatment 18F-FDG PET uptake for nasopharyngeal carcinoma

PURPOSE

To evaluate the prognostic value of maximal standardized uptake values (SUVmax) from serial fluor-18-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) in patients with nasopharyngeal carcinoma (NPC).

MATERIALS AND METHODS

Fifty-two patients with NPC who underwent 18F-FDG PET/CT scan before radiotherapy with/without chemotherapy were reviewed retrospectively. Twenty-seven patients (52%) were applied 3-D conformal radiotherapy and 25 patients (48%) applied intensity-modulated radiotherapy (IMRT). Fourteen (27%) patients were given neoadjuvant chemotherapy and forty-four (84.6%) patients were given concomitant and adjuvant chemotherapy.

RESULTS

Median follow-up time was 34 months (range 5.6-66.4 months). Forty-four (84.6%) patients were alive at last follow-up and eight (15.4%) had died. The best cut-off value of the SUVmax for the primary tumor site (SUVmax-PT) was 13 and 9 for the lymph nodes (SUVmax-LN). Patients with SUVmax-PT ≥ 13.0 and SUVmax-LN ≥ 9 had a significantly higher risk for the development of the distant metastases (p = 0.044 and p = 0.038). DFS was affected in patients with SUVmax-PT ≥ 13 (log rank χ 2 = 2.54, p = 0.017) and was significantly lower in patients with SUVmax-LN ≥ 9 for the lymph nodes (log rank χ 2 = 5.81, p = 0.013). OS was not affected by SUV levels. A multivariate Cox proportional hazard model of DFS included age (≥ 40), SUVmax-LN (< 9), T stage (T1-2) and neoadjuvant chemotherapy are significantly better prognosis for the DFS.

CONCLUSION

18F-FDG PET/CT uptake before treatment, as determined by SUVmax, may be a valuable tool to evaluate prognosis in NPC patients.

Watch the weathercock: changes in re-staging 18F-FDG PET/CT scan predict the probability of relapse in locally advanced non-small cell lung cancer

INTRODUCTION

Induction treatment is be coming the gold standard for locally advanced non-small cell lung cancers (LA-NSCLC). In contrast to baseline positron emission/computed tomography scan (PET/CT scan), re-staging PET/CT scan has been poorly studied in LA-NSCLC.

MATERIALS AND METHODS

We retrospectively explored the efficacy of re-staging PET/CT scan to diagnose response and to predict disease-free survival (DFS) in 55 induction-treated LA-NSCLC further treated with curative surgery or radiation but not with adjuvant therapy.

RESULTS

Re-staging N status by PET/CT scan significantly correlated with pathological N status. Radiological or metabolic response in the re-staging PET/CT scan was associated with a significantly better DFS, which decreased from 25.8 to 19.3, to 11.2, and to 9.4 months in cN0, cN1, cN2, and cN3 patients, respectively.

CONCLUSION

Re-staging PET/CT scan helps to define response and consolidation treatment in induction-treated LA-NSCLC and predicts DFS. Further extended studies should confirm our results.

Metabolic response assessment with 18F-FDG PET/CT: inter-method comparison and prognostic significance for patients with non-small cell lung cancer

OBJECTIVE

This study aimed to (1) compare the agreement of two evaluation methods of metabolic response in patients with non-small cell lung cancer (NSCLC) and determine their prognostic value and (2) explore an optimal cutoff of metabolic reduction to distinguish a more favorable subset of responders.

METHODS

This is a secondary analysis of prospective studies. Enrolled patients underwent 18F-PET/CT within 2 weeks before, during, and months after radiotherapy (post-RT). Metabolic response was assessed using both Peter MacCallum (PM) method of qualitative visual assessment and University of Michigan (UM) method of semiquantitative measurement. The agreement between two methods determined response, and their prediction of outcome was analyzed.

RESULTS

Forty-four patients with median follow-up of 25.2 months were analyzed. A moderate agreement was observed between PM- and UM-based response assessment (Kappa coefficient = 0.434), unveiling a significant difference in CMR rate (p = 0.001). Categorical responses derived from either method were significantly predictive of overall survival (OS) and progression-free survival (PFS) (p < 0.0001). Numerical percentage decrease of FDG uptake also showed significant correlations with survival, presenting a hazard ratio of 0.97 for both OS and PFS. A 75 % of SUV decrease was found to be the optimal cutoff to predict OS and 2-year progression.

CONCLUSIONS

There was a modest discrepancy in metabolic response rates between PM and UM criteria, though both could offer predictive classification for survival. The percentage decrease provides an ordinal value that correlates with prolonged survival, recommending 75 % as the optimal threshold at identifying better responders.

The use and misuse of positron emission tomography in lung cancer evaluation

This article discusses the potential benefits and limitations of positron emission tomography (PET) for characterizing lung nodules, staging the mediastinum, identifying occult distant metastasis, determining prognosis and treatment response, guiding plans for radiation therapy, restaging during and after treatment, and selecting targets for tissue sampling. The key findings from the medical literature are presented regarding the capabilities and fallibilities of PET in lung cancer evaluation, including characterization of pulmonary nodules and staging in patients with known or suspected non-small-cell lung cancer. The discussion is limited to PET imaging with fluorodeoxyglucose.

The prognostic significance of maximum standardized uptake value of primary tumor in surgically treated non-small-cell lung cancer patients: analysis of 413 cases

BACKGROUND

Integrated PET/CT is widely used in the preoperative staging and prognostic assessment of non-small-cell lung cancer (NSCLC) patients. The aims of this study were to evaluate the prognostic significance of SUVmax of primary tumor in patients undergoing surgical treatment and, in order to minimize technical interferences, to verify whether SUVmax standardized by SUVmax liver or SUVmax blood pool provided additional prognostic information.

PATIENTS AND METHODS

A retrospective study of 413 consecutive NSCLC patients undergoing potentially curative surgical resection after PET/CT obtained in the same PET center over a 6-year period. The SUVmax was calculated drawing region of interest around the primitive tumor, the liver, and the aortic arch in PET images. The same procedure was performed for 2 adjacent planes and the average of these measures was considered.

RESULTS

Nine patients were considered 30-day postoperative deaths and were excluded from the analysis. At the end of the study, 312 (77.2%) of the 404 patients were alive (median follow-up, 26 months) and 92 had died (median survival, 17 months). At multivariate analysis tumor-node-metastasis stage, primary tumor grading and primary tumor SUVmax (T-SUVmax) were found to be independent prognostic factors, while T-SUVmax/SUVmax blood pool ratio, and T-SUVmax/SUVmax liver ratio were not.

CONCLUSIONS

T-SUVmax is an independent predictor for survival in NSCLC patients undergoing surgery and might be helpful in guiding adjuvant treatment strategies. SUVmax of primary tumor normalized by SUV blood pool or SUV liver does not provide additional prognostic information.

Prediction of the outcome of definitive chemoradiation by decrease in F-18 FDG uptake in nonsurgical esophageal squamous cell cancer

PURPOSE

To analyze the predictive value of fluorine-18 fluorodeoxyglucose (F-18 FDG) uptake using positron emission tomography and computed tomography to assess the outcome of definitive chemoradiation in nonsurgical esophageal squamous cell carcinoma.

MATERIALS AND METHODS

A retrospective review of 61 patients with clinical stage T1-4, N0/1, and M0 was performed. Chemoradiation included chemotherapy with fluorouracil plus cisplatin and irradiation with a total dose of 5600 to 6400 centigray (cGy). Positron emission tomography combined with computed tomography scans were acquired before and during the therapy. The correlation between a decrease in FDG uptake and 5-year progression-free survival (PFS) was analyzed by a receiver operating characteristic curve method to determine a cutoff value. A 5-year overall survival (OS), PFS, and cancer-specific survival (CSS) were evaluated by Kaplan-Meier method.

RESULTS

The mean of standardized uptake value decreased significantly during chemoradiation (P = 0.001). Using 51% reduction of FDG uptake as a cutoff value provided a sensitivity of 76.9% and a specificity of 79.2% in predicting PFS (P = 0.000). The positive predictive value and negative predictive value were 50% and 95%, respectively. PFS, CSS, and OS were significantly different when grouped by this cutoff value (P < 0.05), and when dichotomized by stage T1-2 and T3-4 (P < 0.05), simultaneously with a decrease of 51% or more in FDG uptake.

CONCLUSIONS

This study showed that a 51% decrease in FDG uptake during chemoradiation was a sensitive and accurate cut-point for predicting PFS. Stage T and decrease in FDG uptake were 2 independent predictive factors for 5-year PFS, CSS, and OS.

The expression of epidermal growth factor receptor and Ki67 in primary and relapse nasopharyngeal cancer: a micro-evidence for anti-EGFR targeted maintenance therapy

Epidermal growth factor receptor (EGFR) was expressed widely in NPC. The aim of this study was to investigate the difference of expression of EGFR and Ki67 in primary and recurrence of NPC to supply a micro-evidence of anti-EGFR targeted maintenance therapy for NPC. A retrospective review of 40 patients with clinical stages I-IV b was performed. Chemoradiation was included chemotherapy with fluorouracil plus cisplatin and irradiation for primary and lymph draining regions. All patients were verified tumor locoregional relapse with/or without distant metastasis by CT or MRI after combined CRT by primary and recurrence biopsies. The correlation between EGFR and Ki67 expression inspected by immunohistochemistry was analyzed. The difference of time to recurrence grouped by different expressions of EGFR and Ki67 was compared by log-rank test. The median follow-up time was 20.0 months ± 2.70 (range 23-71). EGFR and Ki67 expression in primary was not significantly different with recurrent focus. A strong significant correlation between EGFR and Ki67 molecules expression was obtained in primary (r = 0.573; P = 0.001) and in recurrent focus (r = 0.698; P = 0.000). A significantly shorter time to locoregional relapse in patients with positive expression of EGFR than patients with negative EGFR expression in primary (P = 0.010) and in relapse (P = 0.022). There was no significant difference of EGFR and Ki67 expression in primary and recurrence tumor expression. The time to relapse was significantly shorter in high expression of EGFR, which might supply micro-evidence to anti-EGFR targeted maintenance therapy for those patients with EGFR overexpression in primary tumor.

The variation of prognostic significance of Maximum Standardized Uptake Value of [18F]-fluoro-2-deoxy-glucose positron emission tomography in different histological subtypes and pathological stages of surgically resected Non-Small Cell Lung Carcinoma

Even if the prognostic role of SUVmax of 18-FDG-PET has been largely investigated, many issues regarding its relationship with pathologic staging and histological subtypes still remain controversial. This retrospective study investigated the prognostic significance of SUVmax in 119 completely resected, pathologically proven NSCLC. The SUVmax values resulted significantly related to histological subtypes (p<0.001), histological grading (p<0.001), and pathologic stage (p<0.001). The optimal cut-off value of SUVmax to predict prognosis in the whole series was 6.7 (p=0.029). 2-Year disease-specific survival (DSS) was 91% for SUVmax < or =6.7 and 55% for SUVmax >6.7 (p<0.001). SUVmax still remain a significant predictor of survival in Stage IB (2-year DSS of 100% for SUVmax < or =6.7; 51% for SUVmax >6.7, p=0.016). The optimal cut-off values of SUVmax to predict prognosis were 5 for adenocarcinoma (p=0.027) and 10.7 for other non-adenocarcinoma NSCLC subtypes (p=0.010). These histologic-specific cut-offs resulted significantly related to survival when stratified for stage: 2-year DSS for Stage IB adenocarcinoma were 100% for SUV< or =5 and 40% for SUVmax >5 (p=0.051); 2-year DSS for Stage IB non-adenocarcinoma were 83% for SUVmax < or =10.7 and 26% for SUVmax >10.7 (p=0.018). Adenocarcinomas showed significantly lower survival results respect to other NSCLC for intermediate SUVmax level (range 5.5-11.3) (p=0.021). High SUVmax resulted an independent negative prognostic factor at multivariate analysis (HR of 15.7, 95% CI of 2.50-98.44, p=0.003). In conclusion, SUVmax represents a significant prognostic factor in surgically resected NSCLC but a great variability between different histological subtypes, even when adjusted for stage, is present and could be considered when planning future trials on prognostic role of FDG uptake.

Prognostic value of serial [18F]fluorodeoxyglucose PET-CT uptake in stage III patients with non-small cell lung cancer treated by concurrent chemoradiotherapy

OBJECTIVE

To evaluate (18)FDG PET-CT for the assessment of therapy response and prediction of patient outcome after concurrent chemoradiotherapy (CCRT) for non-small cell lung cancer (NSCLC).

METHODS

Forty-six patients with pathologically proven stage III NSCLC had 2 serial FDG PET-CT scans, before and during CCRT. The maximum standardized uptake value (SUV(max)) of the primary lung lesion was calculated. The value changes of SUV(max) before and during treatment were calculated according to the following equation: SUV=(SUV(before)-SUV(during))100%/SUV(before). The relationship between changes of the SUV(max) and the therapy response as well as long-term survival was studied in the responsive and non-responsive groups after CCRT.

RESULTS

Of the 46 enrolled patients, after a medicine follow-up of 2 years, the initial SUV(max) in the responsive and non-responsive groups was 7.59±3.14 and 14.72±4.67, respectively. The SUV(max) during treatment in the two groups was 2.89±1.39 and 9.82±3.31, respectively. Significant difference (P=0.001; P=0.001) in SUV(max) was observed either before or during treatment. Furthermore, the percent change of SUV(max) before and during treatment was 61.91±86.69 and 33.56±90.37, respectively. There was significant difference between these two groups (P=0.007). In addition, the 1-year survival rate in the responsive and non-responsive group was 73% and 69%, respectively. The 2-year survival rate in the two groups was 40% and 37%, respectively. There was significant difference between these two groups (P=0.001).

CONCLUSIONS

(18)FDG PET-CT is an effective method in the prediction of therapy response in patients with stage III NSCLC. The analysis of percent change of SUV(max) provides additional value in early prediction of therapy response and patient outcome.