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Zou J, Zeng Y, Wu F. Opportunities and challenges of neoadjuvant targeted therapy in nonsmall cell lung cancer. Curr Opin Oncol 2023; 35:22-30. [PMID: 36475459 DOI: 10.1097/cco.0000000000000914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW The aim of this study is to summarize the completed and ongoing clinical trials of neoadjuvant targeted therapy, discuss tolerability and efficacy, and explain the role of neoadjuvant targeted therapy in patients with resectable nonsmall cell lung cancer (NSCLC). At the same time, the existing challenges are presented, including assessment methods, biomarkers, surrogate endpoints and so on. We also put forward our views on possible ways to make improvements and establish neoadjuvant therapy a standard treatment in resectable NSCLC. RECENT FINDINGS The mortality of lung cancer has decreased in the last 10 years, which can partly be attributed to advancement of targeted therapy. Targeted therapy has become the first-line treatment for patients with advanced mutation gene positive NSCLC, achieving the effect of prolonging overall survival (OS). Compared with chemotherapy, targeted therapy is associated with good tolerability and high response rate. Neoadjuvant targeted therapy has emerged in recent years and attracted attention of researchers. Early findings proved that neoadjuvant targeted therapy alone can improve patients' disease-free survival (DFS) and the efficacy of combining with other forms of neoadjuvant therapy is also being explored by researchers. SUMMARY Neoadjuvant targeted therapy is playing an important role in NSCLC and worth more in-depth research.
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Affiliation(s)
- Ji'an Zou
- Department of Oncology, The Second Xiangya Hospital, Central South University
- Xiangya School of Medicine, Central South University, Changsha, Hunan, China
| | - Yue Zeng
- Department of Oncology, The Second Xiangya Hospital, Central South University
| | - Fang Wu
- Department of Oncology, The Second Xiangya Hospital, Central South University
- Hunan Cancer Mega-Data Intelligent Application and Engineering Research Centre
- Hunan Key Laboratory of Tumor Models and Individualized Medicine
- Hunan Key Laboratory of Early Diagnosis and Precision Therapy in Lung Cancer, The Second Xiangya Hospital
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2
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Chen Z, Fu R, Tan X, Yan L, Tang W, Qiu Z, Qi Y, Li Y, Hou Q, Wu Y, Zhong W, Jiang B. Dynamic 18 F-FDG PET/CT can predict the major pathological response to neoadjuvant immunotherapy in non-small cell lung cancer. Thorac Cancer 2022; 13:2524-2531. [PMID: 35822254 PMCID: PMC9436661 DOI: 10.1111/1759-7714.14562] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 06/12/2022] [Accepted: 06/13/2022] [Indexed: 01/09/2023] Open
Abstract
Major pathological response (MPR) is a potential surrogate for overall survival. We determined whether the dynamic changes in 18 F-labeled fluoro-2-deoxyglucose positron emission tomography/computed tomography (18 F-FDG PET/CT) were associated with MPR in patients receiving neoadjuvant immunotherapy. Forty-four patients with stage II-III non-small cell lung cancer (NSCLC) who received neoadjuvant immunotherapy and radical surgery were enrolled. Moreover, 18 F-FDG PET/CT scans were performed at baseline and within 1 week before surgery to evaluate the disease. All histological sections were reviewed to assess MPR. The detailed clinical features of the patients were analyzed. The reliability of the clinical variables was assessed in differentiating between MPR and non-MPR using logistic regression. Receiver-operating characteristic (ROC) curve analysis identified the SUVmax changes threshold most associated with MPR. Most of the patients were pathologically diagnosed with squamous cell carcinoma and received anti-PD-1 antibodies plus chemotherapy. The immunotherapy regimens included nivolumab, pembrolizumab, and camrelizumab. MPR was observed in more than half of lesions. Tumors with MPR had a higher decrease in the longest dimension on dynamic PET/CT than those without MPR. Furthermore, the decline in SUVmax was significantly different between MPR and non-MPR diseases, and MPR lesions had a prominent mean reduction in SUVmax. SUVmax reduction was independently associated with MPR in the multivariate regression. On ROC analysis, the threshold of SUVmax decrease in 60% was associated with MPR. Dynamic changes in SUVmax were associated with MPR. The tumors with MPR showed a greater PET/CT response than those without MPR. A SUVmax decrease of more than 60% is more likely to result in an MPR after receiving neoadjuvant immunotherapy.
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Affiliation(s)
- Zhi‐Yong Chen
- Guangdong Lung Cancer Institute, Guangdong Provincial People's HospitalGuangdong Academy of Medical SciencesGuangzhouChina
| | - Rui Fu
- School of MedicineSouth China University of TechnologyGuangzhouChina,Guangdong Provincial Key Laboratory of Translational Medicine in Lung CancerGuangdong Provincial People's Hospital, Guangdong Academy of Medical SciencesGuangzhouChina
| | - Xiao‐Yue Tan
- Department of Nuclear Medicine, WeiLun PET/CT CenterGuangdong Provincial People's Hospital, Guangdong Academy of Medical SciencesGuangzhouChina
| | - Li‐Xu Yan
- Department of PathologyGuangdong Provincial People's Hospital, Guangdong Academy of Medical SciencesGuangzhouChina
| | - Wen‐Fang Tang
- Department of Cardiothoracic SurgeryZhongshan City People's Hospital, ZhongshanGuangdongChina
| | - Zhen‐Bin Qiu
- Guangdong Provincial Key Laboratory of Translational Medicine in Lung CancerGuangdong Provincial People's Hospital, Guangdong Academy of Medical SciencesGuangzhouChina
| | - Yi‐Fan Qi
- School of MedicineSouth China University of TechnologyGuangzhouChina,Guangdong Provincial Key Laboratory of Translational Medicine in Lung CancerGuangdong Provincial People's Hospital, Guangdong Academy of Medical SciencesGuangzhouChina
| | - Yu‐Fa Li
- Department of PathologyGuangdong Provincial People's Hospital, Guangdong Academy of Medical SciencesGuangzhouChina
| | - Qing‐Yi Hou
- Department of Nuclear Medicine, WeiLun PET/CT CenterGuangdong Provincial People's Hospital, Guangdong Academy of Medical SciencesGuangzhouChina
| | - Yi‐Long Wu
- Guangdong Lung Cancer Institute, Guangdong Provincial People's HospitalGuangdong Academy of Medical SciencesGuangzhouChina,School of MedicineSouth China University of TechnologyGuangzhouChina,Guangdong Provincial Key Laboratory of Translational Medicine in Lung CancerGuangdong Provincial People's Hospital, Guangdong Academy of Medical SciencesGuangzhouChina
| | - Wen‐Zhao Zhong
- Guangdong Lung Cancer Institute, Guangdong Provincial People's HospitalGuangdong Academy of Medical SciencesGuangzhouChina,School of MedicineSouth China University of TechnologyGuangzhouChina,Guangdong Provincial Key Laboratory of Translational Medicine in Lung CancerGuangdong Provincial People's Hospital, Guangdong Academy of Medical SciencesGuangzhouChina
| | - Ben‐Yuan Jiang
- Guangdong Lung Cancer Institute, Guangdong Provincial People's HospitalGuangdong Academy of Medical SciencesGuangzhouChina
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Saqi A, Leslie KO, Moreira AL, Lantuejoul S, Shu CA, Rizvi NA, Sonett JR, Tajima K, Sun SW, Gitlitz BJ, Colby TV. Assessing Pathologic Response in Resected Lung Cancers: Current Standards, Proposal for a Novel Pathologic Response Calculator Tool, and Challenges in Practice. JTO Clin Res Rep 2022; 3:100310. [PMID: 35498382 PMCID: PMC9044000 DOI: 10.1016/j.jtocrr.2022.100310] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 02/15/2022] [Accepted: 03/06/2022] [Indexed: 11/04/2022] Open
Abstract
The efficacy of neoadjuvant treatment for NSCLC can be pathologically assessed in resected tissue. Major pathologic response (MPR) and pathologic complete response (pCR), defined as less than or equal to 10% and 0% viable tumor cells, respectively, are increasingly being used in NSCLC clinical trials to establish them as surrogate end points for efficacy to shorten time to outcome. Nevertheless, sampling and MPR calculation methods vary between studies. The International Association for the Study of Lung Cancer recently published detailed recommendations for pathologic assessment of NSCLC after neoadjuvant treatment, with methodology being critical. To increase methodological rigor further, we developed a novel MPR calculator tool (MPRCT) for standardized, comprehensive collection of percentages of viable tumor, necrosis, and stroma in the tumor bed. In addition, tumor width and length in the tumor bed are measured and unweighted and weighted MPR averages are calculated, the latter to account for the varying proportions of tumor beds on slides. We propose sampling the entire visible tumor bed for tumors having pCR regardless of size, 100% of tumors less than or equal to 3 cm in diameter, and at least 50% of tumors more than 3 cm. We describe the uses of this tool, including potential formal analyses of MPRCT data to determine the optimum sampling strategy that balances sensitivity against excessive use of resources. Solutions to challenging scenarios in pathologic assessment are proposed. This MPRCT will facilitate standardized, systematic, comprehensive collection of pathologic response data with a standardized methodology to validate studies designed to establish MPR and pCR as surrogate end points of neoadjuvant treatment efficacy.
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Affiliation(s)
- Anjali Saqi
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York
| | - Kevin O. Leslie
- Department of Laboratory Medicine and Pathology, Mayo Clinic Arizona, Scottsdale, Arizona
| | - Andre L. Moreira
- Department of Pathology, NYU Grossman School of Medicine, New York, New York
| | - Sylvie Lantuejoul
- Department of BioPathology, Léon Bérard Center, Lyon, France
- Department of Pathology, Grenoble Alpes University, Grenoble, France
| | - Catherine Ann Shu
- Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Naiyer A. Rizvi
- Herbert Irving Comprehensive Cancer Center, Columbia University, New York, New York
| | - Joshua R. Sonett
- Department of Thoracic Surgery, NewYork-Presbyterian Columbia University Irving Medical Center, New York, New York
| | - Kosei Tajima
- Biometrics Department, Chugai Pharmaceutical Co., Ltd., Tokyo, Japan
| | - Shawn W. Sun
- Product Development Clinical Oncology, Genentech Inc., South San Francisco, California
- Gilead Sciences, Inc., Foster City, California
| | - Barbara J. Gitlitz
- Product Development Clinical Oncology, Genentech Inc., South San Francisco, California
| | - Thomas V. Colby
- Department of Laboratory Medicine and Pathology, Mayo Clinic Arizona, Scottsdale, Arizona
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Stefani D, Plönes T, Viehof J, Darwiche K, Stuschke M, Schuler M, Aigner C. Lung Cancer Surgery after Neoadjuvant Immunotherapy. Cancers (Basel) 2021; 13:4033. [PMID: 34439187 PMCID: PMC8393473 DOI: 10.3390/cancers13164033] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 08/06/2021] [Accepted: 08/09/2021] [Indexed: 12/25/2022] Open
Abstract
In early-stage lung cancer, recurrences are observed even after curative resection. Neoadjuvant immunotherapy might be a promising approach to eliminate micrometastasis and to potentially reduce recurrence rates and improve survival. Early trials have shown encouraging rates of pathologic response to neoadjuvant therapy and have demonstrated that surgery can be safely performed after neoadjuvant immunotherapy with various agents and in combination with chemo-(radio)therapy. However, whether these response rates translate into improved disease-free survival rates and overall survival rates remains to be determined by ongoing phase III studies.
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Affiliation(s)
- Dirk Stefani
- Department of Thoracic Surgery, University Medicine Essen–Ruhrlandklinik, Tueschener Weg 40, 45239 Essen, Germany; (D.S.); (T.P.); (J.V.)
| | - Till Plönes
- Department of Thoracic Surgery, University Medicine Essen–Ruhrlandklinik, Tueschener Weg 40, 45239 Essen, Germany; (D.S.); (T.P.); (J.V.)
| | - Jan Viehof
- Department of Thoracic Surgery, University Medicine Essen–Ruhrlandklinik, Tueschener Weg 40, 45239 Essen, Germany; (D.S.); (T.P.); (J.V.)
| | - Kaid Darwiche
- Department of Pneumology, University Medicine Essen–Ruhrlandklinik, Tueschener Weg 40, 45239 Essen, Germany;
| | - Martin Stuschke
- Department of Radiation Oncology, University Medicine Essen, Hufelandstrasse 55, 45147 Essen, Germany;
| | - Martin Schuler
- Department of Medical Oncology, University Medicine Essen, Hufelandstrasse 55, 45147 Essen, Germany;
| | - Clemens Aigner
- Department of Thoracic Surgery, University Medicine Essen–Ruhrlandklinik, Tueschener Weg 40, 45239 Essen, Germany; (D.S.); (T.P.); (J.V.)
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5
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Pataer A, Weissferdt A, Vaporciyan AA, Correa AM, Sepesi B, Wistuba II, Heymach JV, Cascone T, Swisher SG. Evaluation of Pathologic Response in Lymph Nodes of Patients With Lung Cancer Receiving Neoadjuvant Chemotherapy. J Thorac Oncol 2021; 16:1289-1297. [PMID: 33857666 DOI: 10.1016/j.jtho.2021.03.029] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 03/23/2021] [Accepted: 03/27/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Major pathologic response (MPR), defined as residual viable tumor of less than or equal to 10%, currently serves as a surrogate end point for survival for patients with resectable NSCLC after neoadjuvant chemotherapy. However, the significance of pathologic response in lymph nodes harboring metastatic tumors in such patients remains uncertain. Therefore, we studied the effect of neoadjuvant chemotherapy on resected positive lymph nodes and determined if the degree of pathologic response in the lymph nodes alone (LN-MPR) or in combination with that of the primary tumor (PT-MPR) was able to predict the outcome. METHODS A total of 75 patients with NSCLC who underwent neoadjuvant chemotherapy and completed surgical resection were included in this study. Tissue specimens were retrospectively evaluated by two pathologists blinded to the patients' treatments and outcomes. Specimens were reviewed for the degree of pathologic response in the primary tumor and in any involved lymph nodes. The prognostic performance of LN-MPR alone or in combination with PT-MPR with respect to overall survival (OS) was evaluated using the Kaplan-Meier method and Cox regression model. RESULTS LN-MPR was significantly predictive of long-term OS after neoadjuvant chemotherapy. A combination of PT-MPR with LN-MPR was significantly associated with outcome and allowed stratification of patients into three prognostic groups (p = 0.001). CONCLUSIONS LN-MPR in isolation is a reliable predictor of OS in patients with NSCLC receiving neoadjuvant chemotherapy. A combination of LN-MPR with PT-MPR seems to correlate well with the outcome and can be used to predict prognosis in this patient population.
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Affiliation(s)
- Apar Pataer
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas.
| | - Annikka Weissferdt
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas; Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ara A Vaporciyan
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Arlene M Correa
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Boris Sepesi
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ignacio I Wistuba
- Department of Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - John V Heymach
- Department of Thoracic/Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Tina Cascone
- Department of Thoracic/Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Stephen G Swisher
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
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6
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Calvo V, Aliaga C, Carracedo C, Provencio M. Prognostic factors in potentially resectable stage III non-small cell lung cancer receiving neoadjuvant treatment-a narrative review. Transl Lung Cancer Res 2021; 10:581-589. [PMID: 33569338 PMCID: PMC7867763 DOI: 10.21037/tlcr-20-515] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Lung cancer is the leading cause of cancer-related death in worldwide. The most important treatment for patients with stage I and II non-small cell lung cancer (NSCLC) is surgery. Resected stage II and III NSCLC patients should be offered adjuvant chemotherapy and in patients with resected stage IB disease and with a primary tumor >4 cm this treatment could be considered. The treatment of resectable locally advanced NSCLC should be evaluated within an experienced multidisciplinary team. Neoadjuvant chemotherapy can be considered in patients with resectable disease and clear candidates for complementary chemotherapy. Neoadjuvant chemotherapy has similar impact on overall survival (OS) than adjuvant chemotherapy, however postoperative chemotherapy has more evidence-based support. Immunotherapy is being studied in early and locally advanced NSCLC as a neoadjuvant or adjuvant treatment. Different prognostic factors have been described in patients with stage III who have received neoadjuvant treatment, which we intend to review in this article.
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Affiliation(s)
- Virginia Calvo
- Medical Oncology Department, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
| | - Carlos Aliaga
- Medical Oncology Department, Aliada Contra el Cáncer, Lima, Perú
| | - Carlos Carracedo
- Medical Oncology Department, Aliada Contra el Cáncer, Lima, Perú
| | - Mariano Provencio
- Medical Oncology Department, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
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7
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Kidane B, Spicer J, Kim JO, Fiset PO, Abdulkarim B, Malthaner R, Palma D. SABR-BRIDGE: Stereotactic ABlative Radiotherapy Before Resection to Avo Id Delay for Early-Stage Lun G Cancer or Oligom Ets During the COVID-19 Pandemic. Front Oncol 2020; 10:580189. [PMID: 33072612 PMCID: PMC7544973 DOI: 10.3389/fonc.2020.580189] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 08/20/2020] [Indexed: 12/11/2022] Open
Abstract
Surgical resection is the standard-of-care approach for early-stage non-small cell lung cancer (NSCLC). Surgery is also considered an acceptable standard infit patients with oligometastatic lesions in the lungs. The COVID-19 pandemic has led to worldwide issues with access to operating room time, with patients and physicians facing uncertainty as to when surgical resection will be available, with likely delays of months. Further compounding this are concerns about increased risks of respiratory complications with lung cancer surgery during active phases of the pandemic. In this setting, many thoracic oncology teams are embracing a paradigm where stereotactic ablative radiotherapy (SABR) is used as a bridge, to provide radical-intent treatment based on a combination of immediate SABR followed by planned surgery in 3–6 months. This pragmatic approach to treatment has been named SABR-BRIDGE (Stereotactic ABlative Radiotherapy Before Resection to avoId Delay for early-stage lunG cancer or oligomEts). This term has also been applied to the pragmatic study of the outcomes of this approach. In this paper, we discuss the standards of care in treatment of early-stage (NSCLC) and pulmonary oligometastases, the impetus for the SABR-BRIDGE approach, and the controversies surrounding assessment of pathological response to neo-adjuvant radiation therapy.
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Affiliation(s)
- Biniam Kidane
- Section of Thoracic Surgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.,Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada.,Research Institute in Oncology and Hematology, Cancer Care Manitoba, University of Manitoba, Winnipeg, MB, Canada
| | - Jonathan Spicer
- Division of Thoracic Surgery, Department of Surgery, McGill University, Montreal, QC, Canada.,Research Institute of the McGill University Health Center, Montreal, QC, Canada
| | - Julian O Kim
- Research Institute in Oncology and Hematology, Cancer Care Manitoba, University of Manitoba, Winnipeg, MB, Canada.,Department of Radiation Oncology, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | | | - Bassam Abdulkarim
- Division of Radiation Oncology, Department of Oncology, McGill University and Cedars Cancer Center, Montreal, QC, Canada
| | - Richard Malthaner
- Division of Thoracic Surgery, Department of Surgery, Western University, London, ON, Canada.,Lawson Health Research Institute, London, ON, Canada
| | - David Palma
- Lawson Health Research Institute, London, ON, Canada.,Division of Radiation Oncology, Western University, London, ON, Canada
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Travis WD, Dacic S, Wistuba I, Sholl L, Adusumilli P, Bubendorf L, Bunn P, Cascone T, Chaft J, Chen G, Chou TY, Cooper W, Erasmus JJ, Ferreira CG, Goo JM, Heymach J, Hirsch FR, Horinouchi H, Kerr K, Kris M, Jain D, Kim YT, Lopez-Rios F, Lu S, Mitsudomi T, Moreira A, Motoi N, Nicholson AG, Oliveira R, Papotti M, Pastorino U, Paz-Ares L, Pelosi G, Poleri C, Provencio M, Roden AC, Scagliotti G, Swisher SG, Thunnissen E, Tsao MS, Vansteenkiste J, Weder W, Yatabe Y. IASLC Multidisciplinary Recommendations for Pathologic Assessment of Lung Cancer Resection Specimens After Neoadjuvant Therapy. J Thorac Oncol 2020; 15:709-740. [PMID: 32004713 DOI: 10.1016/j.jtho.2020.01.005] [Citation(s) in RCA: 196] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 12/25/2019] [Accepted: 01/04/2020] [Indexed: 12/14/2022]
Abstract
Currently, there is no established guidance on how to process and evaluate resected lung cancer specimens after neoadjuvant therapy in the setting of clinical trials and clinical practice. There is also a lack of precise definitions on the degree of pathologic response, including major pathologic response or complete pathologic response. For other cancers such as osteosarcoma and colorectal, breast, and esophageal carcinomas, there have been multiple studies investigating pathologic assessment of the effects of neoadjuvant therapy, including some detailed recommendations on how to handle these specimens. A comprehensive mapping approach to gross and histologic processing of osteosarcomas after induction therapy has been used for over 40 years. The purpose of this article is to outline detailed recommendations on how to process lung cancer resection specimens and to define pathologic response, including major pathologic response or complete pathologic response after neoadjuvant therapy. A standardized approach is recommended to assess the percentages of (1) viable tumor, (2) necrosis, and (3) stroma (including inflammation and fibrosis) with a total adding up to 100%. This is recommended for all systemic therapies, including chemotherapy, chemoradiation, molecular-targeted therapy, immunotherapy, or any future novel therapies yet to be discovered, whether administered alone or in combination. Specific issues may differ for certain therapies such as immunotherapy, but the grossing process should be similar, and the histologic evaluation should contain these basic elements. Standard pathologic response assessment should allow for comparisons between different therapies and correlations with disease-free survival and overall survival in ongoing and future trials. The International Association for the Study of Lung Cancer has an effort to collect such data from existing and future clinical trials. These recommendations are intended as guidance for clinical trials, although it is hoped they can be viewed as suggestion for good clinical practice outside of clinical trials, to improve consistency of pathologic assessment of treatment response.
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Affiliation(s)
- William D Travis
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York.
| | - Sanja Dacic
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ignacio Wistuba
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Lynette Sholl
- Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Prasad Adusumilli
- Thoracic Surgery Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Lukas Bubendorf
- Department of Pathology, University of Basel, Basel, Switzerland
| | - Paul Bunn
- Medical Oncology, Colorado University School of Medicine, Aurora, Colorado
| | - Tina Cascone
- Department of Thoracic Head and Neck Medical Oncology, MD Anderson Cancer Center, Houston, Texas
| | - Jamie Chaft
- Thoracic Oncology Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Gang Chen
- Department of Pathology, Zhongshan Hospital Fudan University, Shanghai, China
| | | | - Wendy Cooper
- Department of Pathology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Jeremy J Erasmus
- Department of Radiology, MD Anderson Cancer Center, Houston, Texas
| | | | - Jin-Mo Goo
- Department of Radiology, Seoul National University College of Medicine, Seoul, South Korea
| | - John Heymach
- Department of Thoracic Head and Neck Medical Oncology, MD Anderson Cancer Center, Houston, Texas
| | - Fred R Hirsch
- Center for Thoracic Oncology, Tisch Cancer Institute at Mount Sinai, New York, New York
| | - Hidehito Horinouchi
- Department of Thoracic Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Keith Kerr
- Department of Pathology, Aberdeen University Medical School, Aberdeen, Scotland
| | - Mark Kris
- Thoracic Oncology Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Deepali Jain
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Young T Kim
- Thoracic and Cardiovascular Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Fernando Lopez-Rios
- Laboratorio de Dianas Terapeuticas, Hospital Universitario Madrid Sanchinarro, Madrid, Spain
| | - Shun Lu
- Shanghai Lung Cancer Center, Shanghai Chest Hospital, Shanghai, China
| | - Tetsuya Mitsudomi
- Thoracic Surgery, Kinki University Faculty of Medicine, Osaka-Sayama, Japan
| | - Andre Moreira
- Department of Pathology, New York University School of Medicine, New York, New York
| | - Noriko Motoi
- Department of Pathology, Mational Cancer Center, Tokyo, Japan
| | - Andrew G Nicholson
- Department of Pathology, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
| | | | - Mauro Papotti
- Department of Pathology, University of Turin, Torino, Italy
| | - Ugo Pastorino
- Thoracic Surgery Division, Istituto Nazionale Tumor, Milan, Italy
| | - Luis Paz-Ares
- Medical Oncology, National Oncology Research Center, Madrid, Spain
| | | | - Claudia Poleri
- Office of Pathology Consultants, Buenos Aries, Argentina
| | - Mariano Provencio
- Oncology Department, Hospital Universitario Puerta de Hierro, Madrid, Spain
| | - Anja C Roden
- Department of Pathology, Mayo Clinic, Rochester, Minnesota
| | | | | | - Erik Thunnissen
- Department of Pathology, VU University Medical Center, Amsterdam, The Netherlands
| | - Ming S Tsao
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada
| | | | - Walter Weder
- Division of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Yasushi Yatabe
- Department of Pathology, Mational Cancer Center, Tokyo, Japan
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Pfannschmidt J, Kollmeier J. Ergebnisse der N1- und N2-Chirurgie beim nichtkleinzelligen Lungenkarzinom. Chirurg 2019; 90:974-981. [DOI: 10.1007/s00104-019-01029-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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10
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Prognostic value of total lesion glycolysis in stage IIIB/IV non–small cell lung cancer. JOURNAL OF ONCOLOGICAL SCIENCES 2017. [DOI: 10.1016/j.jons.2017.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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11
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Arnett AL, Packard AT, Mara K, Mansfield AS, Wigle DA, Haddock MG, Park SS, Olivier KR, Garces YI, Merrell KW. FDG-PET parameters as predictors of pathologic response and nodal clearance in patients with stage III non-small cell lung cancer receiving neoadjuvant chemoradiation and surgery. Pract Radiat Oncol 2017; 7:e531-e541. [DOI: 10.1016/j.prro.2017.04.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 04/13/2017] [Accepted: 04/17/2017] [Indexed: 01/21/2023]
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12
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Eight cases of salvage pulmonary resection for residual disease or isolated local recurrence detected after definitive chemoradiotherapy for N2 Stage-IIIA lung cancer. Asian J Surg 2017; 40:95-99. [DOI: 10.1016/j.asjsur.2015.05.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Revised: 04/21/2015] [Accepted: 05/28/2015] [Indexed: 11/20/2022] Open
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Coroller TP, Agrawal V, Narayan V, Hou Y, Grossmann P, Lee SW, Mak RH, Aerts HJWL. Radiomic phenotype features predict pathological response in non-small cell lung cancer. Radiother Oncol 2016; 119:480-6. [PMID: 27085484 DOI: 10.1016/j.radonc.2016.04.004] [Citation(s) in RCA: 223] [Impact Index Per Article: 27.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Revised: 03/03/2016] [Accepted: 04/03/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND PURPOSE Radiomics can quantify tumor phenotype characteristics non-invasively by applying advanced imaging feature algorithms. In this study we assessed if pre-treatment radiomics data are able to predict pathological response after neoadjuvant chemoradiation in patients with locally advanced non-small cell lung cancer (NSCLC). MATERIALS AND METHODS 127 NSCLC patients were included in this study. Fifteen radiomic features selected based on stability and variance were evaluated for its power to predict pathological response. Predictive power was evaluated using area under the curve (AUC). Conventional imaging features (tumor volume and diameter) were used for comparison. RESULTS Seven features were predictive for pathologic gross residual disease (AUC>0.6, p-value<0.05), and one for pathologic complete response (AUC=0.63, p-value=0.01). No conventional imaging features were predictive (range AUC=0.51-0.59, p-value>0.05). Tumors that did not respond well to neoadjuvant chemoradiation were more likely to present a rounder shape (spherical disproportionality, AUC=0.63, p-value=0.009) and heterogeneous texture (LoG 5mm 3D - GLCM entropy, AUC=0.61, p-value=0.03). CONCLUSION We identified predictive radiomic features for pathological response, although no conventional features were significantly predictive. This study demonstrates that radiomics can provide valuable clinical information, and performed better than conventional imaging features.
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Affiliation(s)
- Thibaud P Coroller
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Harvard Medical School, Boston, USA.
| | - Vishesh Agrawal
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Vivek Narayan
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Ying Hou
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Patrick Grossmann
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Stephanie W Lee
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Raymond H Mak
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Hugo J W L Aerts
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Harvard Medical School, Boston, USA; Department of Radiology, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
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Weller A, O'Brien MER, Ahmed M, Popat S, Bhosle J, McDonald F, Yap TA, Du Y, Vlahos I, deSouza NM. Mechanism and non-mechanism based imaging biomarkers for assessing biological response to treatment in non-small cell lung cancer. Eur J Cancer 2016; 59:65-78. [PMID: 27016624 DOI: 10.1016/j.ejca.2016.02.017] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 02/18/2016] [Indexed: 12/18/2022]
Abstract
Therapeutic options in locally advanced non-small cell lung cancer (NSCLC) have expanded in the past decade to include a palate of targeted interventions such as high dose targeted thermal ablations, radiotherapy and growing platform of antibody and small molecule therapies and immunotherapies. Although these therapies have varied mechanisms of action, they often induce changes in tumour architecture and microenvironment such that response is not always accompanied by early reduction in tumour mass, and evaluation by criteria other than size is needed to report more effectively on response. Functional imaging techniques, which probe the tumour and its microenvironment through novel positron emission tomography and magnetic resonance imaging techniques, offer more detailed insights into and quantitation of tumour response than is available on anatomical imaging alone. Use of these biomarkers, or other rational combinations as readouts of pathological response in NSCLC have potential to provide more accurate predictors of treatment outcomes. In this article, the robustness of the more commonly available positron emission tomography and magnetic resonance imaging biomarker indices is examined and the evidence for their application in NSCLC is reviewed.
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Affiliation(s)
- A Weller
- CRUK Cancer Imaging Centre, Institute of Cancer Research and Royal Marsden NHS Foundation Trust, UK.
| | - M E R O'Brien
- Department of Medicine, Royal Marsden NHS Foundation Trust, Downs Road, Surrey, SM2 5PT, UK
| | - M Ahmed
- Department of Radiotherapy, Royal Marsden NHS Foundation Trust, Downs Road, Surrey, SM2 5PT, UK
| | - S Popat
- Department of Medicine, Royal Marsden NHS Foundation Trust, Downs Road, Surrey, SM2 5PT, UK
| | - J Bhosle
- Department of Medicine, Royal Marsden NHS Foundation Trust, Downs Road, Surrey, SM2 5PT, UK
| | - F McDonald
- Department of Radiotherapy, Royal Marsden NHS Foundation Trust, Downs Road, Surrey, SM2 5PT, UK
| | - T A Yap
- Department of Medicine, Royal Marsden NHS Foundation Trust, Downs Road, Surrey, SM2 5PT, UK
| | - Y Du
- Department of Nuclear Medicine, Royal Marsden NHS Foundation Trust, Downs Road, Surrey, SM2 5PT, UK
| | - I Vlahos
- Radiology Department, St George's Hospital NHS Trust, London, SW17 0QT, UK
| | - N M deSouza
- CRUK Cancer Imaging Centre, Institute of Cancer Research and Royal Marsden NHS Foundation Trust, UK
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Burger IA, Casanova R, Steiger S, Husmann L, Stolzmann P, Huellner MW, Curioni A, Hillinger S, Schmidtlein CR, Soltermann A. 18F-FDG PET/CT of Non-Small Cell Lung Carcinoma Under Neoadjuvant Chemotherapy: Background-Based Adaptive-Volume Metrics Outperform TLG and MTV in Predicting Histopathologic Response. J Nucl Med 2016; 57:849-54. [PMID: 26823566 DOI: 10.2967/jnumed.115.167684] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Accepted: 12/22/2015] [Indexed: 01/08/2023] Open
Abstract
UNLABELLED Assessment of tumor response after chemotherapy using (18)F-FDG PET metrics is gaining acceptance. Several studies have suggested that the parameters metabolically active tumor volume (MTV) and total lesion glycolysis (TLG) are superior to SUVmax for measuring tumor burden. However, the measurement of MTV and TLG is still controversial; the most common method uses an absolute threshold of 42% of SUVmax Recently, we implemented a background-adaptive method to determine the background-subtracted lesion activity (BSL) and the background-subtracted volume (BSV). In this study, we investigated the correlation between such PET metrics and histopathologic response in non-small cell lung carcinoma (NSCLC). METHODS Forty-four NSCLC patients were retrospectively identified. Their PET/CT data on both types of scan before and after neoadjuvant chemotherapy were analyzed regarding SUVmax, MTV, TLG, BSL, and BSV, as well as the relative changes in these parameters. The tumor regression score as an indicator of histopathologic response was scored on hematoxylin- and eosin-stained sections of the surgical specimens using a 4-tiered scale (scores 1-4). The correlation between score and the absolute and relative PET metrics after chemotherapy was analyzed using Spearman rank correlation tests. RESULTS Tumors that demonstrated a good response after neoadjuvant chemotherapy had significantly lower (18)F-FDG activity than nonresponding tumors (scores 3 and 4: SUVmax, 4.2 [range, 1.8-7.9] vs. scores 1 and 2: SUVmax, 8.1 [range, 1.4-40.4]; P = 0.001). The same was found for change in SUVmax and score (P = 0.001). PET volume metrics based on a 42% fixed threshold for SUVmax did not correlate with score (TLG, P = 0.505; MTV, P = 0.386). However, both of the background activity-based PET volume metrics-BSL and BSV-significantly correlated with score (P < 0.001 each). CONCLUSION PET volume metrics based on background-adaptive methods correlate better with histopathologic tumor regression score in NSCLC patients under neoadjuvant chemotherapy than algorithms and methods using a fixed threshold (42% SUVmax).
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Affiliation(s)
- Irene A Burger
- Department of Nuclear Medicine, University Hospital Zurich, Zurich, Switzerland Department of Radiology, University Hospital Zurich, Zurich, Switzerland
| | - Ruben Casanova
- Department of Surgical Pathology, University Hospital Zurich, Zurich, Switzerland
| | - Seraina Steiger
- Department of Radiology, University Hospital Zurich, Zurich, Switzerland
| | - Lars Husmann
- Department of Nuclear Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Paul Stolzmann
- Department of Nuclear Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Martin W Huellner
- Department of Nuclear Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Alessandra Curioni
- Department of Medical Oncology, University Hospital Zurich, Zurich, Switzerland
| | - Sven Hillinger
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland; and
| | - C Ross Schmidtlein
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Alex Soltermann
- Department of Surgical Pathology, University Hospital Zurich, Zurich, Switzerland
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FDG PET/CT for assessing the resectability of NSCLC patients with N2 disease after neoadjuvant therapy. Ann Nucl Med 2015; 30:114-21. [DOI: 10.1007/s12149-015-1038-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 11/01/2015] [Indexed: 01/02/2023]
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Lim HJ, Lee HY, Lee KS, Han J, Kwon OJ, Park K, Ahn YC, Kim BT, Shim YM. Predictive factors for survival in stage IIIA N2 NSCLC patients treated with neoadjuvant CCRT followed by surgery. Cancer Chemother Pharmacol 2014; 75:77-85. [PMID: 25374409 DOI: 10.1007/s00280-014-2619-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Accepted: 10/26/2014] [Indexed: 11/28/2022]
Abstract
PURPOSE To assess the impact of imaging, surgical, histopathologic and patient-related factors on the risks of recurrence and overall survival (OS) in stage IIIA-N2 non-small cell lung cancer (NSCLC) patients undergoing definitive resection after neoadjuvant concurrent chemoradiotherapy (CCRT). METHODS We retrospectively examined 104 consecutive patients with stage IIIA-N2 NSCLC who received neoadjuvant CCRT followed by surgery between 2008 and 2011. While reviewing the clinical and surgical data, we also assessed histopathologic and imaging (CT and PET/CT) factors. Disease-free survival (DFS) and OS were estimated with predictors for recurrence and survival. RESULTS The 3-year OS for patients with and without recurrence was 37.1 and 63.3 %, respectively (p < 0.001). Size decrease of target lesion(s) ≥36 % on post-neoadjuvant CCRT CT (p = 0.048) and viable tumor size on surgical specimen <9.4 mm (p = 0.035) were related to longer OS. Regarding shorter DFS, tumor size on post-neoadjuvant CCRT CT (p = 0.046), SUV(max) of the primary tumor (p = 0.011), male gender (p = 0.023), total tumor size on surgical specimen (p = 0.041) and viable tumor size on surgical specimen (p = 0.043) were the significant predictors. CONCLUSIONS OS is prolonged with greater extent of size decrease of target lesion(s) on post-neoadjuvant CCRT CT and smaller viable tumor size on surgical specimen. Larger tumor size on post-neoadjuvant CCRT CT, higher SUV(max), male gender, larger total tumor size and larger viable tumor size on surgical specimen may herald the higher probability of recurrence and the necessity of more attention.
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Affiliation(s)
- Hyun-ju Lim
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50, Ilwon-Dong, Kangnam-Ku, Seoul, 135-710, Korea
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Bahce I, Vos C, Dickhoff C, Hartemink K, Dahele M, Smit E, Boellaard R, Hoekstra O, Thunnissen E. Metabolic activity measured by FDG PET predicts pathological response in locally advanced superior sulcus NSCLC. Lung Cancer 2014; 85:205-12. [DOI: 10.1016/j.lungcan.2014.04.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Revised: 04/11/2014] [Accepted: 04/15/2014] [Indexed: 10/25/2022]
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Soussan M, Cyrta J, Pouliquen C, Chouahnia K, Orlhac F, Martinod E, Eder V, Morère JF, Buvat I. Fluorine 18 fluorodeoxyglucose PET/CT volume-based indices in locally advanced non-small cell lung cancer: prediction of residual viable tumor after induction chemotherapy. Radiology 2014; 272:875-84. [PMID: 24761836 DOI: 10.1148/radiol.14132191] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
PURPOSE To study whether volume-based indices of fluorine 18 fluorodeoxyglucose positron emission tomographic (PET)/computed tomographic (CT) imaging is an accurate tool to predict the amount of residual viable tumor after induction chemotherapy in patients with locally advanced non-small cell lung cancer (NSCLC). MATERIALS AND METHODS This study was approved by institutional review board with waivers of informed consent. Twenty-two patients with locally advanced NSCLC underwent surgery after induction chemotherapy. All had pre- and posttreatment FDG PET/CT scans. CT largest diameter, CT volume, maximum standardized uptake value (SUVmax), mean SUV (SUVmean), metabolic tumor volume (TV), and total lesion glycolysis of primary tumor were calculated. Changes in tumor measurements were determined by dividing follow-up by baseline measurement (ratio index). Amounts of residual viable tumor, necrosis, fibrous tissue, inflammatory infiltrate, and Ki-67 proliferative index were estimated on resected tumor. Correlations between imaging indices and histologic parameters were estimated by using Spearman correlation coefficients or Mann-Whitney tests. RESULTS No baseline or posttreatment indices correlated with percentage of residual viable tumor. TV ratio was the only index that correlated with percentage of residual viable tumor (r = 0.61 [95% confidence interval: 0.24, 0.81]; P = .003). Conversely, SUVmax and SUVmean ratios were only indices correlated with Ki-67 (r = 0.62 [95% confidence interval: 0.24, 0.82]; P = .003; and r = 0.60 [95% confidence interval: 0.21, 0.81]; P = .004, respectively). Total lesion glycolysis ratio was moderately correlated with residual viable tumor (r = 0.53 [95% confidence interval: 0.13, 0.78]; P = .01) and with Ki-67 (r = 0.57 [95% confidence interval: 0.18, 0.80]; P = .006). No ratios were correlated with presence of inflammatory infiltrate or foamy macrophages. CONCLUSION TV and total lesion glycolysis ratios were the only indices correlated with residual viable tumor after induction chemotherapy in locally advanced NSCLC.
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Affiliation(s)
- Michael Soussan
- From the Departments of Nuclear Medicine (M.S., V.E.), Pathology (J.C., C.P.), Oncology (K.C., J.F.M.), and Thoracic Surgery (E.M.), AP-HP, Avicenne Hospital, 125 rue de Stalingrad, 93000 Bobigny, France; and IMNC-UMR 8165 CNRS-Universités Paris 7 and 11, Orsay, France (M.S., F.O.); and CEA-SHFJ, Orsay, France (I.B.)
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Langer NH, Christensen TN, Langer SW, Kjaer A, Fischer BM. PET/CT in therapy evaluation of patients with lung cancer. Expert Rev Anticancer Ther 2014; 14:595-620. [PMID: 24702537 DOI: 10.1586/14737140.2014.883280] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
FDG-PET/CT is a well documented and widespread used imaging modality for the diagnosis and staging of patient with lung cancer. FDG-PET/CT is increasingly used for the assessment of treatment effects during and after chemotherapy. However, PET is not an accepted surrogate end-point for assessment of response rate in clinical trials. The aim of this review is to present current evidence on the use of PET in response evaluation of patients with lung cancer and to introduce the pearls and pitfalls of the PET-technology relating to response assessment. Based on this and relating to validation criteria, including stable technology, standardization, reproducibility and broad availability, the review discusses why, despite numerous studies on response assessment indicating a possible role for FDG-PET/CT, PET still has no place in guidelines relating to response evaluation in lung cancer.
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Affiliation(s)
- Natasha Hemicke Langer
- Department of Clinical Physiology, Nuclear Medicine and PET, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
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Computed tomography RECIST assessment of histopathologic response and prediction of survival in patients with resectable non-small-cell lung cancer after neoadjuvant chemotherapy. J Thorac Oncol 2013; 8:222-8. [PMID: 23287849 DOI: 10.1097/jto.0b013e3182774108] [Citation(s) in RCA: 95] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
INTRODUCTION This study's objectives were to determine whether tumor response measured by computed tomography (CT) and evaluated using Response Evaluation Criteria in Solid Tumors (RECIST) correlated with overall survival (OS) in patients with non-small-cell lung cancer (NSCLC) after neoadjuvant chemotherapy and surgical resection. METHODS We measured primary tumor size on CT before and after neoadjuvant chemotherapy in 160 NSCLC patients who underwent surgical resection. The relationship between CT-measured response (RECIST) and histopathologic response (≤ 10% viable tumor) and OS were assessed by Kaplan-Meier survival, univariable, and multivariable Cox proportional hazards regression. RESULTS There was a statistically significant association between CT-measured response (RECIST) and OS (p = 0.03). However, histopathologic response was a stronger predictor of OS (p = 0.002), with a more pronounced separation of the survival curves when compared with CT-measured response. In multivariable Cox regression analysis, only pathologic stage and histopathologic response were significant predictors of OS. A 41% overall discordance rate was noted between CT RECIST response and histopathologic response. CT RECIST classified as nonresponders a subset of patients with histopathologic response (8 out of 30 points, 27%) who demonstrated prolonged survival after neoadjuvant chemotherapy. CONCLUSION We were unable to show that CT RECIST is a reliable predictor of OS in patients with NSCLC undergoing surgical resection after neoadjuvant chemotherapy. The failure of CT RECIST to predict long-term outcome may be because of the inability of CT imaging to consistently identify patients with histopathologic response. CT RECIST may have only a limited role as an efficacy endpoint after neoadjuvant chemotherapy in patients with resectable NSCLC.
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Nakajima EC, Van Houten B. Metabolic symbiosis in cancer: refocusing the Warburg lens. Mol Carcinog 2013; 52:329-37. [PMID: 22228080 PMCID: PMC9972501 DOI: 10.1002/mc.21863] [Citation(s) in RCA: 123] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2011] [Revised: 11/22/2011] [Accepted: 11/30/2011] [Indexed: 01/21/2023]
Abstract
Using relatively primitive tools in the 1920s, Otto Warburg demonstrated that tumor cells show an increased dependence on glycolysis to meet their energy needs, regardless of whether they were well-oxygenated or not. High rates of glucose uptake, fueling glycolysis, are now used clinically to identify cancer cells. However, the Warburg effect does not account for the metabolic diversity that has been observed amongst cancer cells nor the influences that might direct such diversity. Modern tools have shown that the oncogenes, variable hypoxia levels, and the utilization of different carbon sources affect tumor evolution. These influences may produce metabolic symbiosis, in which lactate from a hypoxic, glycolytic tumor cell population fuels ATP production in the oxygenated region of a tumor. Lactate, once considered a waste product of glycolysis, is an important metabolite for oxidative phosphorylation in many tissues. While much is known about how muscle and the brain use lactate in oxidative phosphorylation, the contribution of lactate in tumor bioenergetics is less defined. A refocused perspective of cancer metabolism that recognizes metabolic diversity within a tumor offers novel therapeutic targets by which cancer cells may be starved from their fuel sources, and thereby become more sensitive to traditional cancer treatments.
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Affiliation(s)
- Erica C. Nakajima
- University of Pittsburgh School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Bennett Van Houten
- University of Pittsburgh School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania,Department of Pharmacology and Chemical Biology, Hillman Cancer Center, University of Pittsburgh Cancer Institute, University of Pittsburgh, Pittsburgh, Pennsylvania,Correspondence to: Hillman Cancer Center, 5117 Centre Avenue, Research Pavilion, Suite 2.6, Pittsburgh, PA 15213-1863
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Phase I trial of induction histone deacetylase and proteasome inhibition followed by surgery in non-small-cell lung cancer. J Thorac Oncol 2013; 7:1683-90. [PMID: 23059775 DOI: 10.1097/jto.0b013e318267928d] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Despite complete surgical resection survival in early-stage non-small-cell lung cancer (NSCLC) remains poor. On the basis of prior preclinical evaluations, we hypothesized that combined induction proteasome and histone deacetylase inhibitor therapy, followed by tumor resection, is feasible. METHODS A phase I clinical trial using a two-staged multiple-agent design of bortezomib and vorinostat as induction therapy followed by consolidative surgery in patients with NSCLC was performed. Standard toxicity and maximum tolerated dose were examined. Pre- and post-treatment tumor gene-expression arrays were performed and analyzed. Pre- and post-treatment fluorodeoxyglucose-positron emission tomography imaging was used to assess tumor metabolism. Finally, serum 20S proteasome levels were analyzed with enzyme-linked immunosorbent assay, and selected intratumoral proteins were assessed by immunohistochemistry. RESULTS Of the 34-four patients providing written consent to participate in the trial, 21 were enrolled. One patient withdrew early because of disease progression. The maximum tolerated dose was bortezomib 1.3 mg/m and vorinostat 300 mg twice daily. There were grade III dose-limiting toxicities of fatigue and hypophosphatemia, which were self-limited. There was no mortality. Thirty percent of patients (6 of 20) had more than 60% histologic necrosis of their tumor after treatment, with two having 90% or more tumor necrosis. Tumor metabolism, 20S proteasome activity, and specific protein expression did not demonstrate consistent results. Gene-expression arrays comparing pre- and post-therapy NSCLC specimens revealed robust intratumoral changes in specific genes. CONCLUSIONS Induction bortezomib and vorinostat therapy followed by surgery in patients with operable NSCLC is feasible. Correlative gene-expression studies suggest new targets and cell-signaling pathways that may be important in modulating this combined therapy.
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Soussan M, Chouahnia K, Maisonobe JA, Boubaya M, Eder V, Morère JF, Buvat I. Prognostic implications of volume-based measurements on FDG PET/CT in stage III non-small-cell lung cancer after induction chemotherapy. Eur J Nucl Med Mol Imaging 2013; 40:668-76. [PMID: 23306807 DOI: 10.1007/s00259-012-2321-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Accepted: 12/10/2012] [Indexed: 12/25/2022]
Abstract
PURPOSE We sought to determine whether metabolic volume-based measurements on FDG PET/CT scans could provide additional information for predicting outcome in patients with stage III non-small-cell lung cancer (NSCLC) treated with induction chemotherapy. METHODS Included in the study were 32 patients with stage III NSCLC who were treated with induction platinum-based chemotherapy followed in 21 by surgery. All patients had an FDG PET/CT scan before and after the induction chemotherapy. Tumours were delineated using adaptive threshold methods. The SUVmax, SUVpeak, SUVmean, tumour volume (TV), total lesion glycolysis (TLG), and volume and largest diameter on the CT images (CTV and CTD, respectively) were calculated. Index ratios of the primary tumour were calculated by dividing the follow-up measurements by the baseline measurements. The prognostic value of each parameter for event-free survival (EFS) was determined using Cox regression models. RESULTS The median follow-up time was 19 months (range 6-43 months). Baseline PET and CT parameters were not significant prognostic factors. After induction therapy, only SUVmax, SUVpeak, SUVmean, TV, TLG and CTV were prognostic factors for EFS, in contrast to CTD. Of the index ratios, only TV and TLG ratios were prognostic factors for EFS. Patients with a TLG ratio <0.48 had a longer EFS than those with a TLG ratio >0.48 (13.9 vs. 9.2 months, p = 0.04). After adjustment for the effect of surgical treatment, all the parameters significantly correlated with EFS remained significant. CONCLUSION SUV, metabolic volume-based indices, and CTV after induction chemotherapy give independent prognostic information in stage III NSCLC. However, changes in metabolic TV and TLG under induction treatment provide more accurate prognostic information than SUV alone, and CTD and CTV.
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Histopathologic response criteria predict survival of patients with resected lung cancer after neoadjuvant chemotherapy. J Thorac Oncol 2012; 7:825-32. [PMID: 22481232 DOI: 10.1097/jto.0b013e318247504a] [Citation(s) in RCA: 267] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
INTRODUCTION We evaluated the ability of histopathologic response criteria to predict overall survival (OS) and disease-free survival (DFS) in patients with surgically resected non-small cell lung cancer (NSCLC) treated with or without neoadjuvant chemotherapy. METHODS Tissue specimens from 358 patients with NSCLC were evaluated by pathologists blinded to the patient treatment and outcome. The surgical specimens were reviewed for various histopathologic features in the tumor including percentage of residual viable tumor cells, necrosis, and fibrosis. The relationship between the histopathologic findings and OS was assessed. RESULTS The percentage of residual viable tumor cells and surgical pathologic stage were associated with OS and DFS in 192 patients with NSCLC receiving neoadjuvant chemotherapy in multivariate analysis (p = 0.005 and p = 0.01, respectively). There was no association of OS or DFS with percentage of viable tumor cells in 166 patients with NSCLC who did not receive neoadjuvant chemotherapy (p = 0.31 and p = 0.45, respectively). Long-term OS and DFS were significantly prolonged in patients who had ≤10% viable tumor compared with patients with >10% viable tumor cells (5 years OS, 85% versus 40%, p < 0.0001 and 5 years DFS, 78% versus 35%, p < 0.001). CONCLUSION The percentages of residual viable tumor cells predict OS and DFS in patients with resected NSCLC after neoadjuvant chemotherapy even when controlled for pathologic stage. Histopathologic assessment of resected specimens after neoadjuvant chemotherapy could potentially have a role in addition to pathologic stage in assessing prognosis, chemotherapy response, and the need for additional adjuvant therapies.
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Novello S, Giaj Levra M, Vavalà T. Functional imaging in predicting response to antineoplastic agents and molecular targeted therapies in lung cancer: a review of existing evidence. Crit Rev Oncol Hematol 2011; 83:208-15. [PMID: 22062925 DOI: 10.1016/j.critrevonc.2011.09.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2010] [Revised: 02/18/2011] [Accepted: 09/28/2011] [Indexed: 11/17/2022] Open
Abstract
The increasing use of FDG-PET ((18)F-2-fluoro-2-deoxy-d-glucose positron emission tomography) imaging in the staging of non-small-cell lung cancer (NSCLC) may result in a significant shift in stage distribution, with an increased percentage of patients staged as having metastatic disease and consequently a higher percentage of patients treated with systemic therapy. The amount of FDG-PET uptake in primary lung lesions has been shown to be correlated with tumour growth rate. Data suggest that tumours with increased glucose uptake are presumably more metabolically active and more biologically aggressive, and standardized uptake value (SUV) at PET may be regarded as a prognostic factor. Growing evidence suggests that PET may be used as a predictive marker to assess the activity of antineoplastic agents, allowing close monitoring of the efficacy of the treatment in order to be able to switch earlier to alternative therapies according to the individual chemosensitivity of the tumour. Currently the value of FDG-PET for monitoring response is complicated by the heterogeneity of the published data on the methods used for FDG quantification and the selection of the primary targets and clinical endpoints. As a result, objective validation of proposed thresholds of responsiveness is lacking. This article discusses the assessment of treatment response in NSCLC patients using functional imaging, and emphasizes advantages and limitations in clinical management.
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Affiliation(s)
- S Novello
- Thoracic Oncology Unit, Department of Clinical & Biological Sciences, University of Turin, AOU San Luigi Orbassano, Italy.
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Integrated imaging of non-small cell lung cancer recurrence: CT and PET-CT findings, possible pitfalls and risk of recurrence criteria. Eur Radiol 2011; 22:588-606. [DOI: 10.1007/s00330-011-2299-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2011] [Revised: 09/06/2011] [Accepted: 09/12/2011] [Indexed: 12/18/2022]
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Wahl RL, Herman JM, Ford E. The promise and pitfalls of positron emission tomography and single-photon emission computed tomography molecular imaging-guided radiation therapy. Semin Radiat Oncol 2011; 21:88-100. [PMID: 21356477 PMCID: PMC4337868 DOI: 10.1016/j.semradonc.2010.11.004] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
External beam radiation therapy procedures have, until recently, been planned almost exclusively using anatomic imaging methods. Molecular imaging using hybrid positron emission tomography (PET)/computed tomography scanning or single-photon emission computed tomography (SPECT) imaging has provided new insights into the precise location of tumors (staging) and the extent and character of the biologically active tumor volume (BTV) and has provided differential response information during and after therapy. In addition to the commonly used radiotracer (18)F-fluoro- 2-deoxyD-glucose (FDG), additional radiopharmaceuticals are being explored to image major physiological processes as well as tumor biological properties, such as hypoxia, proliferation, amino acid accumulation, apoptosis, and receptor expression, providing the potential to target or boost the radiation dose to a biologically relevant region within a tumor, such as the most hypoxic or most proliferative area. Imaging using SPECT agents has furthered the possibility of limiting dose to functional normal tissues. PET can also portray the distribution of particle therapy by displaying activated species in situ. With both PET and SPECT imaging, fundamental physical issues of limited spatial resolution relative to the biological process, partial volume effects for quantification of small volumes, image misregistration, motion, and edge delineation must be carefully considered and can differ by agent or the method applied. Molecular imaging-guided radiation therapy (MIGRT) is a rapidly evolving and promising area of investigation and clinical translation. As MIGRT evolves, evidence must continue to be gathered to support improved clinical outcomes using MIGRT versus purely anatomic approaches.
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Affiliation(s)
- Richard L Wahl
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Cappabianca S, Porto A, Petrillo M, Greco B, Reginelli A, Ronza F, Setola F, Rossi G, Di Matteo A, Muto R, De Rimini ML, Piccolo S, Catalano M, Muto P, De Rosa N, Barra E, De Rosa I, Antinolfi F, Antinolfi G, Caputi M, Brunese L, Grassi R, Rotondo A. Preliminary study on the correlation between grading and histology of solitary pulmonary nodules and contrast enhancement and [18F]fluorodeoxyglucose standardised uptake value after evaluation by dynamic multiphase CT and PET/CT. J Clin Pathol 2010; 64:114-9. [PMID: 21169276 PMCID: PMC3030774 DOI: 10.1136/jcp.2010.076562] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Aim To evaluate whether the histology and grading of solitary pulmonary nodules (SPNs) correlated with the results of dynamic multiphase multidetector CT (MDCT) and the [18F]fluorodeoxyglucose standardised uptake value (SUV) in 30 patients. Methods Chest x-rays of 270 patients with incidentally detected SPNs were retrospectively evaluated. Thirty patients with histologically proven SPNs were enrolled. On MDCT and positron emission tomography (PET)/CT images, two experts measured the density of nodules in all perfusion phases and the SUV. Net enhancement (NE) was calculated by subtracting peak pre-contrast density from peak post-contrast density. The Pearson test was used to correlate nodule NE, SUV, grading, histology and diameter. Results Of the 30 malignant SPNs, six were classified as G1 (median NE, 31.5 Hounsfield units (HU); median SUV, 4.8 units), 15 were classified as G2 (median NE, 49 HU; median SUV, 6 units), and nine were classified as G3 (median NE, 32 HU; median SUV, 4.5 units). A highly negative correlation was found in G3 SPNs between NE and the corresponding diameters (r=−0.834; p=0.00524). NE increased with the increase in diameter (r=0.982; p=0.284). SUV increased as the SPN diameter increased (r=0.789; p=0.421). NE and SUV were higher in G2 than G1 SPNs, and lower in G2 than G3 SPNs (r=0.97; p=0.137). Conclusions The significant correlation in dedifferentiated (G3) SPNs between NE and diameter (r=−0.834; p=0.00524) supports the theory that stroma and neoangiogenesis are fundamental in SPN growth. The highly negative correlation between NE and diameter demonstrates a net decrease in perfusion despite an increase in dimension. The multidisciplinary approach used herein may result in a more precise prognosis and consequently a better therapeutic outcome, particularly in patients with undifferentiated lung cancer.
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Affiliation(s)
- Salvatore Cappabianca
- Department of Clinical Internal Medicine F Magrassi-L Lanzara, Science Section of Radiology, Second University of Studies of Naples, Naples, Italy.
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Rebollo-Aguirre AC, Ramos-Font C, Villegas Portero R, Cook GJR, Llamas Elvira JM, Romero Tabares A. Is FDG-PET suitable for evaluating neoadjuvant therapy in non-small cell lung cancer? Evidence with systematic review of the literature. J Surg Oncol 2010; 101:486-94. [PMID: 20213693 DOI: 10.1002/jso.21525] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Neoadjuvant therapy response assessment is crucial in patients with non-small cell lung cancer (NSCLC). FDG-PET has emerged as a valuable tool for defining therapy response assessment in other tumours. AIM To systematically review publications appearing in the literature describing induction therapy response assessment with FDG-PET in NSCLC. METHODS We performed a bibliographic search and selected only prospective studies in order to include the highest levels of evidence. RESULTS Nine of 497 potentially relevant publications were selected. The ranges of sensitivity, specificity, positive predictive value and negative predictive value for primary tumour response assessment were 80-100%, 0-100%, 42.9-100%, and 66.7-100%, respectively. Pooling data for N2 restaging after neoadjuvant response the overall sensitivity was 63.8% (95% CI, 53.3-73.7%) and overall specificity was 85.3% (95% CI, 80.4-89.4%). CONCLUSION The results of the analysis do not support the use of FDG-PET as the only re-assessment tool for mediastinal lymph node evaluation for routine clinical use. FDG-PET seems to predict primary tumour response to induction therapy but it could not be shown by pooling analysis.
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Value of Combined Interpretation of Computed Tomography Response and Positron Emission Tomography Response for Prediction of Prognosis After Neoadjuvant Chemotherapy in Non-small Cell Lung Cancer. J Thorac Oncol 2010; 5:497-503. [DOI: 10.1097/jto.0b013e3181d2efe7] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Metabolic control probability in tumour subvolumes or how to guide tumour dose redistribution in non-small cell lung cancer (NSCLC): An exploratory clinical study. Radiother Oncol 2009; 91:393-8. [DOI: 10.1016/j.radonc.2009.02.020] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2008] [Revised: 02/19/2009] [Accepted: 02/27/2009] [Indexed: 11/22/2022]
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Herrmann K, Walch A, Balluff B, Tänzer M, Höfler H, Krause BJ, Schwaiger M, Friess H, Schmid RM, Ebert MPA. Proteomic and metabolic prediction of response to therapy in gastrointestinal cancers. Nat Rev Gastroenterol Hepatol 2009; 6:170-83. [PMID: 19259108 DOI: 10.1038/ncpgasthep1366] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2008] [Accepted: 12/09/2008] [Indexed: 12/17/2022]
Abstract
Despite substantial improvements in the diagnosis and treatment of many gastrointestinal cancers, particularly colorectal cancer, numerous patients are only diagnosed in advanced stages of disease, which can preclude curative treatment. Screening and early diagnosis of high-risk individuals might be the most promising approach to improve prognosis; however, molecular biomarkers for early diagnosis of most gastrointestinal cancers are not yet available. The prognosis of patients with advanced gastrointestinal cancers has improved through the development of multimodal treatments and the introduction of targeted therapies. Nonetheless, not all patients benefit equally from these treatment approaches, and toxicity can be substantial. The ability to predict whether a patient will respond to therapy early in their treatment for gastrointestinal cancer may be of particular value to stratify and individualize patient treatment strategies. Despite improvement in the understanding of cancer pathogenesis and progression at the molecular level, the molecular changes that underlie treatment response and/or drug resistance are still largely unknown. PET is the first technique to show promise in prediction of response to therapy, and has resulted in promising advancements, particularly in esophageal and gastric cancers. Tissue-based and blood-based molecular biomarkers are still subject to validation. Prediction of response to treatment could ultimately lead to an overall improvement in prognosis.
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Affiliation(s)
- Ken Herrmann
- Department of Nuclear Medicine, Klinikum rechts der Isar, Technische Universität München, München, Germany
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Dirisamer A, Halpern BS, Flöry D, Wolf F, Beheshti M, Mayerhoefer ME, Langsteger W. Integrated contrast-enhanced diagnostic whole-body PET/CT as a first-line restaging modality in patients with suspected metastatic recurrence of breast cancer. Eur J Radiol 2009; 73:294-9. [PMID: 19181468 DOI: 10.1016/j.ejrad.2008.10.031] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2008] [Revised: 10/23/2008] [Accepted: 10/27/2008] [Indexed: 10/21/2022]
Abstract
OBJECTIVE(S) Only few information exist about the diagnostic accuracy of PET/CT for restaging patients with metastatic recurrence of breast carcinoma. Therefore, our study hypothesis was to perform diagnostic contrast enhanced CT (ce-CT) and FDG-PET in a one-step investigation, to prove sensitivity of each modality and to determine whether diagnostic PET/CT adds information over PET or contrast enhanced CT alone for restaging of patients with suspected recurrence of breast cancer. METHODS Fifty-two patients with suspected recurrence of breast cancer were included in our study. All of them were free of metastasis after the first line therapy. Indications for restaging were: Elevated tumor markers n=32, clinical deterioration n=16 and/or suspicious findings on other imaging studies n=48. Integrated PET/CT was performed using contrast-enhanced diagnostic CT for attenuation correction. RESULTS PET was correct in 44/52 patients (85%), ce-CT in 38/52 patients (73%) and PET/CT in 50/52 patients (96%). Sensitivity and specificity of lesion detection of PET, CT and PET/CT were 84%, 66% and 93%, and 100%, 92%, and 100%, respectively. DISCUSSION PET/CT can improve staging and alter therapeutic options in patients suspected to have breast cancer recurrence and distant metastatic disease, primarily by demonstrating local or distant nodal involvement occult at other imaging studies. The added value of FDG-PET/CT over other diagnostic modalities is mainly expressed by the fact that a noninvasive whole-body evaluation is possible in a single examination.
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Affiliation(s)
- Albert Dirisamer
- Department of Nuclear Medicine, St. Vincent's Hospital, Seilerstaette 4, 4010 Linz, Austria.
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