Baseline 18F-FDG PET/CT as predictor of the pathological response to neoadjuvant therapy in esophageal cancer: A retrospective study

18F-Fluorodeoxyglucose Positron Emission Tomography Parameters can Predict Long-Term Outcome Following Trimodality Treatment for Oesophageal Cancer

AIMS

¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography (¹⁸FDG-PET/CT) is routinely used for the pre-treatment staging of oesophageal or gastro-oesophageal junction cancers (EGEJC). The aim of this study was to identify objective ¹⁸FDG-PET/CT-derived parameters that can aid in predicting the patterns of recurrence and prognostication in patients with EGEJC.

PATIENTS AND METHODS

EGEJC patients referred for consideration of preoperative chemoradiation therapy were identified and clinicopathological data were collected. ¹⁸FDG-PET/CT imaging data were reviewed and correlated with treatment outcomes. Maximum standardised uptake value (SUV_max), metabolic tumour volume (MTV) and total lesion glycolysis were assessed and association with recurrence-free survival (RFS), locoregional recurrence-free survival (LR-RFS), oesophageal cancer-specific survival (ECSS) and overall survival were evaluated using receiver operating characteristic curves, as well as Cox regression and Kaplan-Meier models.

RESULTS

In total, 191 EGEJC patients completed trimodality treatment and 164 with ¹⁸FDG-PET/CT data were included in this analysis. At the time of analysis, 15 (9.1%), 70 (42.7%) and two (1.2%) patients were noted to have locoregional, distant and both locoregional and distant metastases, respectively. The median RFS was 30 months (9.6-50.4) and the 5-year RFS was 31.1%. The 5-year overall survival and ECSS were both noted to be 34.8%. Pre-treatment MTV₂₅ > 28.5 cm³ (P = 0.029), MTV₄₀ > 12.4 cm³ (P = 0.018) and MTV₅₀ > 10.2 cm³ (P = 0.005) predicted for worse LR-RFS, ECSS and overall survival for MTV definition of voxels ≥25%, 40% and 50% of SUV_max.

CONCLUSION

¹⁸FDG-PET/CT parameters MTV and total lesion glycolysis are useful prognostic tools to predict for LR-RFS, ECSS and overall survival in EGEJC. MTV had the highest accuracy in predicting clinical outcomes. The volume cut-off points we identified for different MTV thresholds predicted outcomes with significant accuracy and may potentially be used for decision making in clinical practice.

Early prediction of residual disease after neoadjuvant chemoradiotherapy and cetuximab for locally advanced esophageal cancer using 18F-FDG PET-CT imaging: a prospective cohort study

Background

Previous studies in locally advanced esophageal cancer (LAEC) suggested that a change in the tumor's metabolic response, i.e., decrease of its interim ¹⁸F-FDG uptake compared with baseline, may predict histopathological response. We evaluated the possible predictive correlation between various PET-CT and histopathological parameters following a neoadjuvant biological-containing chemoradiotherapy (CRT) regimen.

Methods

Patients with resectable LAEC received neoadjuvant cisplatin/5-fluorouracil-based CRT and cetuximab following one cycle of induction chemotherapy and cetuximab. Changes in maximum and mean standardized uptake values (ΔSUV-max and ΔSUV-mean, respectively) and metabolic tumor volume (ΔMTV), measured by PET-CT at baseline and 2 weeks after the onset of treatment, were compared with histopathological findings at surgery. Histopathological response was defined by tumor regression grade (TRG), pathological complete response (pCR) and microscopic or macroscopic residual disease (RD).

Results

Of 18 patients, 13 (72%) with adenocarcinoma (AC) and 5 (28%) with squamous cell carcinoma (SCC), were included. None of the changes in the parameters of PET was associated with pCR; only ΔSUV-mean was associated with TRG in the AC cohort. In contrast, both ΔSUV-mean% and ΔSUV-max% were significantly associated with RD, both in the whole cohort and in the AC cohort. Changes in FDG-uptake predicted RD2 at surgery: only patients with less than 13% decrease in SUV-mean% or less than 29% decrease in SUV-max% had RD2, while all patients with RD0 or RD1 had greater reductions [100% specificity and 100% positive predictive value (PPV)].

Conclusions

Changes in ΔSUV-max and ΔSUV-mean after two weeks of onset of cetuximab-based neoadjuvant chemotherapy for LAEC may predict macroscopic RD but not TRG or pCR at surgery.

Volumetric Evaluation of Staging 18F-FDG PET/CT Images in Patients with Esophageal Cancer

Objectives

The aim of this study was to evaluate the metastatic potential of primary tumor and survival in esophageal cancer (EC) patients by using metabolic tumor volume (MTV) and total lesion glycolysis (TLG) from the staging 18F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) images. Another aim is to determine a tumor volume-based cut-off value to predict long-term survival.

Methods

Medical records of EC patients were retrospectively evaluated. Sixty-two patients with staging 18F-FDG PET/CT and at least five years of follow-up were included in the study. The region of interest to the primary tumor and all metastatic sites was created and MTV and TLG values of the primary tumor (MTVp, TLGp) and total tumor volume (MTVt and TLGt) values were obtained. The relationship between the obtained MTV and TLG values and short-time (one-year) and long time (five-year) survival was investigated.

Results

Significant factors on survival were determined as lymph node or distant metastasis (p=0.024, 0.008, respectively) at the staging PET/CT. A significant relationship between volumetric parameters of the primary tumor and total tumor burden (MTVp, TLGp, MTVwb and TLGwb) between survivors and non-survivors for one-year and five-year was detected. In receiver operating characteristics analysis, the most significant volumetric parameter was MTVwb, with area under curve 0.771 in estimated five-year survival. The best cut-off value was detected as 36.1 mL with 78% sensitivity and 75% specificity for MTVwb in determining long-term survivors.

Conclusion

Tumor burden in 18F-FDG PET/CT images at the time of staging of patients with EC will contribute to the prediction of long-term survivors.

Predictive value of clinical and 18F-FDG-PET/CT derived imaging parameters in patients undergoing neoadjuvant chemoradiation for esophageal squamous cell carcinoma

Aim of this study was to validate the prognostic impact of clinical parameters and baseline ¹⁸F-FDG-PET/CT derived textural features to predict histopathologic response and survival in patients with esophageal squamous cell carcinoma undergoing neoadjuvant chemoradiation (nCRT) and surgery. Between 2005 and 2014, 38 ESCC were treated with nCRT and surgery. For all patients, the ¹⁸F-FDG-PET-derived parameters metabolic tumor volume (MTV), SUVmax, contrast and busyness were calculated for the primary tumor using a SUV-threshold of 3. The parameter uniformity was calculated using contrast-enhanced computed tomography. Based on histopathological response to nCRT, patients were classified as good responders (< 10% residual tumor) (R) or non-responders (≥ 10% residual tumor) (NR). Regression analyses were used to analyse the association of clinical parameters and imaging parameters with treatment response and overall survival (OS). Good response to nCRT was seen in 27 patients (71.1%) and non-response was seen in 11 patients (28.9%). Grading was the only parameter predicting response to nCRT (Odds Ratio (OR) = 0.188, 95% CI: 0.040–0.883; p = 0.034). No association with histopathologic treatment response was seen for any of the evaluated imaging parameters including SUVmax, MTV, busyness, contrast and uniformity. Using multivariate Cox-regression analysis, the heterogeneity parameters busyness (Hazard Ratio (HR) = 1.424, 95% CI: 1.044–1.943; p = 0.026) and contrast (HR = 6.678, 95% CI: 1.969–22.643;p = 0.002) were independently associated with OS, while no independent association with OS was seen for SUVmax and MTV. In patients with ESCC undergoing nCRT and surgery, baseline ¹⁸F-FDG-PET/CT derived parameters could not predict histopathologic response to nCRT. However, the PET/CT derived features busyness and contrast were independently associated with OS and should be further investigated.

Baseline 18F-FDG PET/CT quantitative parameters as prognostic factors in esophageal squamous cell cancer

AIM

To determine the utility of [¹⁸F]FDG PET/CT quantitative parameters as prognostic factors for the response to neoadjuvant treatment, progression-free survival (PFS) and cancer-specific survival (CSS) in patients with esophageal squamous cell carcinoma (SCC).

MATERIAL AND METHODS

Thirty patients (29 men) diagnosed with SCC were retrospectively evaluated over a 6-year interval. Metabolic parameters were determined: maximum SUV (SUVmax), mean SUV (SUVmed), metabolic tumor volume (MTV) and total lesion glycolysis (TLG) from baseline PET/CT study. After treatment with chemotherapy and/or radiotherapy, response to treatment and patient survival were assessed. The comparison of parameters between groups of responders and non-responders was carried out using a Mann-Whitney U test ROC curves and the Kaplan-Meier method were used for analysis of prognostic factors and survival curves.

RESULTS

The average follow-up was 22.4 months, with 22 recurrence-progressions and 25 deaths. Significant differences were demonstrated between responders and non-responders with respect to tumor size, MTV and TLG. Survival analysis found significant differences for SCE and CSS depending on these three parameters.

CONCLUSION

Metabolic parameters MTV and TLG, and tumor size were prognostic factors for neoadjuvant treatment response, PFS, and CSS in patients diagnosed with SCC. Neither SUVmax nor SUVmed were predictive for any of the evaluation criteria. Results could help to personalize patient treatment.

18F-FDG-PET/CT Imaging for Gastrointestinal Malignancies

Gastrointestinal malignancies encompass a variety of primary tumor sites, each with different staging criteria and treatment approaches. In this review we discuss technical aspects of 18F-FDG-PET/CT scanning to optimize information from both the PET and computed tomography components. Specific applications for 18F-FDG-PET/CT are summarized for initial staging and follow-up of the major disease sites, including esophagus, stomach, hepatobiliary system, pancreas, colon, rectum, and anus.

Novel Criterion Using Esophageal Major and Minor Axes is Useful to Evaluate the Therapeutic Effect and Prognosis After Neoadjuvant Chemotherapy Followed by Surgery in Locally Advanced Esophageal Cancer

BACKGROUND

An appropriate strategy is needed to determine the therapeutic effect of chemotherapy on primary lesions in esophageal cancer. This multicenter cohort study aimed to examine the usefulness of a novel criterion obtained by multiplying the lengths of the major and minor esophageal axes from helical computed tomography as a tool to evaluate the therapeutic effect of neoadjuvant chemotherapy and to predict prognosis after surgery in locally advanced esophageal cancer.

MATERIALS AND METHODS

A first investigation evaluated the reproducibility of the new criterion between two independent examiners. In a second investigation, we examined the association of the novel criterion with pathological tumor regression grade and long-term outcomes. Pretreatment primary lesions less than 20 mm on computed tomography were excluded.

RESULTS

In an initial cohort of 81 patients, the intraclass correlation coefficient for the novel criterion was higher than that for the tumor major axis both before and after neoadjuvant chemotherapy. In the second cohort of 255 patients, the novel criterion significantly correlated with tumor regression grade (p = 0.0003), overall survival (p < 0.0001), and disease-free survival (p < 0.0001). It was also an independent predictor for overall survival (p = 0.0023), along with age, tumor regression grade, and pathological stage.

CONCLUSIONS

The measurement derived by multiplying the esophageal major and minor axes on computed tomography is easy to obtain and has better objectivity and reproducibility for tumors of any shape. This novel criterion may be clinically useful because it can estimate therapeutic effect, tumor regression grade, and prognosis after neoadjuvant chemotherapy followed by surgery for esophageal cancer.

Baseline 18F-FDG PET/CT quantitative parameters as prognostic factors in esophageal squamous cell cancer

AIM

To determine the utility of 18F-FDG PET/CT quantitative parameters as prognostic factors for the response to neoadjuvant treatment, progression-free survival (PFS) and cancer-specific survival (CSS) in patients with esophageal squamous cell carcinoma (SCC).

MATERIAL AND METHODS

Thirty patients (29 men) diagnosed with SCC were retrospectively evaluated over a 6-year interval. Metabolic parameters were determined: maximum SUV (SUVmax), mean SUV (SUVmed), metabolic tumor volume (MTV) and total lesion glycolysis (TLG) from baseline PET/CT study. After treatment with chemotherapy and/or radiotherapy, response to treatment and patient survival were assessed. The comparison of parameters between groups of responders and non-responders was carried out using a Mann-Whitney U test. ROC curves and the Kaplan-Meier method were used for analysis of prognostic factors and survival curves.

RESULTS

The average follow-up was 22.4months, with 22 recurrence-progressions and 25 deads. Significant differences were demonstrated between responders and non-responders with respect to tumor size, MTV and TLG. Survival analysis found significant differences for SCE and CSS depending on these three parameters.

CONCLUSION

Metabolic parameters MTV and TLG, and tumor size were prognostic factors for neoadjuvant treatment response, PFS, and CSS in patients diagnosed with SCC. Neither SUVmax nor SUVmed were predictive for any of the evaluation criteria. Results could help to personalize patient treatment.

Prediction of lymph node metastasis by PET/CT metabolic parameters in patients with esophageal squamous cell carcinoma

OBJECTIVE

The aim of this study was to investigate the capability of F-FDG PET/computed tomography (CT)-related metabolic parameters to predict lymph node metastasis (LNM) and occult lymph node metastasis (OLNM) in patients with esophageal squamous cell carcinoma (ESCC).

METHODS

Totally 84 patients undergoing curative esophagectomy with lymph node dissection were enrolled in this study. Metabolic tumor volume (MTV) was measured using threshold-based methods with a threshold of 40% maximum standardized uptake value (SUVmax). The derivative of the volume (V)-threshold (T) function (volume difference/threshold difference) was defined as the heterogeneity factor (HF). In addition, SUVmax, SUVmean, total lesion glycolysis (TLG), maximum tumor-to-blood SUV ratio (SURmax), SURmean and several clinicopathologic parameters were analyzed to identify risk factors of LNM and OLNM.

RESULTS

SUVmax, SUVmean, MTV, TLG, SURmax, SURmean and HF were significantly different between LNM (+) and LNM (-). The optimal cut-off values of those parameters were 12.5, 8.34, 15.01, 117.185, 7.885, 4.855 and 0.300, respectively. Logistic regression analysis showed that MTV (OR = 1.127, P = 0.04) and SURmax (OR = 1.446, P = 0.004) were independent predictors of LNM, with sensitivity and specificity were 51.2%, 83.7% vs. 53.7%, 79.1%. In univariate and multivariate analysis, MTV was the sole parameter associated with OLMN (P = 0.024).

CONCLUSION

MTV and SURmax were statistically significant predictors of LNM in patients with ESCC, while MTV was a predictor of OLNM. High SURmax and MTV may indicate that the treatment planning should be tailored, which may improve patient prognosis.