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Montrazi ET, Sasson K, Agemy L, Scherz A, Frydman L. Molecular imaging of tumor metabolism: Insight from pyruvate- and glucose-based deuterium MRI studies. SCIENCE ADVANCES 2024; 10:eadm8600. [PMID: 38478615 PMCID: PMC10936946 DOI: 10.1126/sciadv.adm8600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 02/07/2024] [Indexed: 03/17/2024]
Abstract
Cancer diagnosis by metabolic MRI proposes to follow the fate of glycolytic precursors such as pyruvate or glucose, and their in vivo conversion into lactate. This study compares the 2H MRI outlooks afforded by these metabolites when targeting a pancreatic cancer model. Exogenously injected [3,3',3″-2H3]-pyruvate was visible only briefly; it generated a deuterated lactate signal throughout the body that faded after ~5 min, showing a minor concentration bias at the rims of the tumors. [6,6'-2H2]-glucose by contrast originated a lactate signal that localized clearly within the tumors, persisting for over an hour. Investigations alternating deuterated and nondeuterated glucose injections revealed correlations between the lactate generation and the glucose available at the tumor, evidencing a continuous and avid glucose consumption generating well-localized lactate signatures as driven by the Warburg effect. This is by contrast to the transient and more promiscuous pyruvate-to-lactate transformation, which seemed subject to transporter and kinetics effects. The consequences of these observations within metabolic MRI are briefly discussed.
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Affiliation(s)
- Elton T Montrazi
- Department of Chemical and Biological Physics, Weizmann Institute of Science, Rehovot, Israel
| | - Keren Sasson
- Department of Plant and Environmental Sciences, Weizmann Institute of Science, Rehovot, Israel
| | - Lilach Agemy
- Department of Plant and Environmental Sciences, Weizmann Institute of Science, Rehovot, Israel
| | - Avigdor Scherz
- Department of Plant and Environmental Sciences, Weizmann Institute of Science, Rehovot, Israel
| | - Lucio Frydman
- Department of Chemical and Biological Physics, Weizmann Institute of Science, Rehovot, Israel
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2
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Bai JW, Qiu SQ, Zhang GJ. Molecular and functional imaging in cancer-targeted therapy: current applications and future directions. Signal Transduct Target Ther 2023; 8:89. [PMID: 36849435 PMCID: PMC9971190 DOI: 10.1038/s41392-023-01366-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 01/19/2023] [Accepted: 02/14/2023] [Indexed: 03/01/2023] Open
Abstract
Targeted anticancer drugs block cancer cell growth by interfering with specific signaling pathways vital to carcinogenesis and tumor growth rather than harming all rapidly dividing cells as in cytotoxic chemotherapy. The Response Evaluation Criteria in Solid Tumor (RECIST) system has been used to assess tumor response to therapy via changes in the size of target lesions as measured by calipers, conventional anatomically based imaging modalities such as computed tomography (CT), and magnetic resonance imaging (MRI), and other imaging methods. However, RECIST is sometimes inaccurate in assessing the efficacy of targeted therapy drugs because of the poor correlation between tumor size and treatment-induced tumor necrosis or shrinkage. This approach might also result in delayed identification of response when the therapy does confer a reduction in tumor size. Innovative molecular imaging techniques have rapidly gained importance in the dawning era of targeted therapy as they can visualize, characterize, and quantify biological processes at the cellular, subcellular, or even molecular level rather than at the anatomical level. This review summarizes different targeted cell signaling pathways, various molecular imaging techniques, and developed probes. Moreover, the application of molecular imaging for evaluating treatment response and related clinical outcome is also systematically outlined. In the future, more attention should be paid to promoting the clinical translation of molecular imaging in evaluating the sensitivity to targeted therapy with biocompatible probes. In particular, multimodal imaging technologies incorporating advanced artificial intelligence should be developed to comprehensively and accurately assess cancer-targeted therapy, in addition to RECIST-based methods.
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Affiliation(s)
- Jing-Wen Bai
- Fujian Key Laboratory of Precision Diagnosis and Treatment in Breast Cancer, Xiang'an Hospital of Xiamen University, School of Medicine, Xiamen University, 361100, Xiamen, China
- Xiamen Key Laboratory of Endocrine-Related Cancer Precision Medicine, Xiang'an Hospital of Xiamen University, School of Medicine, Xiamen University, 361100, Xiamen, China
- Xiamen Research Center of Clinical Medicine in Breast and Thyroid Cancers, Xiang'an Hospital of Xiamen University, School of Medicine, Xiamen University, 361100, Xiamen, China
- Department of Breast-Thyroid-Surgery and Cancer Center, Xiang'an Hospital of Xiamen University, School of Medicine, Xiamen University, 361100, Xiamen, China
- Department of Medical Oncology, Xiang'an Hospital of Xiamen University, School of Medicine, Xiamen University, 361100, Xiamen, China
- Cancer Research Center of Xiamen University, School of Medicine, Xiamen University, 361100, Xiamen, China
| | - Si-Qi Qiu
- Diagnosis and Treatment Center of Breast Diseases, Clinical Research Center, Shantou Central Hospital, 515041, Shantou, China
- Guangdong Provincial Key Laboratory for Breast Cancer Diagnosis and Treatment, Shantou University Medical College, 515041, Shantou, China
| | - Guo-Jun Zhang
- Fujian Key Laboratory of Precision Diagnosis and Treatment in Breast Cancer, Xiang'an Hospital of Xiamen University, School of Medicine, Xiamen University, 361100, Xiamen, China.
- Xiamen Key Laboratory of Endocrine-Related Cancer Precision Medicine, Xiang'an Hospital of Xiamen University, School of Medicine, Xiamen University, 361100, Xiamen, China.
- Xiamen Research Center of Clinical Medicine in Breast and Thyroid Cancers, Xiang'an Hospital of Xiamen University, School of Medicine, Xiamen University, 361100, Xiamen, China.
- Department of Breast-Thyroid-Surgery and Cancer Center, Xiang'an Hospital of Xiamen University, School of Medicine, Xiamen University, 361100, Xiamen, China.
- Cancer Research Center of Xiamen University, School of Medicine, Xiamen University, 361100, Xiamen, China.
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3
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Shi Y, Wang M, Zhang J, Xiang Z, Li C, Zhang J, Ma X. Tailoring the clinical management of colorectal cancer by 18F-FDG PET/CT. Front Oncol 2022; 12:1062704. [PMID: 36620584 PMCID: PMC9814158 DOI: 10.3389/fonc.2022.1062704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 12/12/2022] [Indexed: 12/24/2022] Open
Abstract
Colorectal cancer (CRC) is among the most commonly diagnosed gastrointestinal malignancies worldwide. It is inadequate to handle in terms of staging and restaging only based on morphological imaging modalities and serum surrogate markers. And the correct and timely staging of CRC is imperative to prognosis and management. When compared to established sequential, multimodal conventional diagnostic methods, the molecular and functional imaging 18F-FDG PET/CT shows superiorities for tailoring appropriate treatment maneuvers to each patient. This review aims to summarize the utilities of 18F-FDG PET/CT in CRC, focusing on primary staging, follow-up assessment of tumor responses and diagnostic of recurrence. In addition, we also summarize the technical considerations of PET/CT and the conventional imaging modalities in those patients who are either newly diagnosed with CRC or has already been treated from this cancer.
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Affiliation(s)
- Yang Shi
- Department of Gastroenterology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China,State Key Laboratory for the Prevention and Treatment of Esophageal Cancer, Zhengzhou University, Zhengzhou, China,*Correspondence: Yang Shi, ; ; Jingjing Zhang, ; Xing Ma,
| | - Meiqi Wang
- Academy of Medical Sciences, Zhengzhou University, Zhengzhou, China
| | - Jiyu Zhang
- Department of Gastroenterology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China,State Key Laboratory for the Prevention and Treatment of Esophageal Cancer, Zhengzhou University, Zhengzhou, China
| | - Zheng Xiang
- Department of Pathology, Henan Provincial People’s Hospital, Zhengzhou University People’s Hospital, Henan University People’s Hospital, Zhengzhou, China
| | - Can Li
- Department of Administration, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
| | - Jingjing Zhang
- Department of Nuclear Medicine, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China,*Correspondence: Yang Shi, ; ; Jingjing Zhang, ; Xing Ma,
| | - Xing Ma
- Department of Nuclear Medicine, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China,*Correspondence: Yang Shi, ; ; Jingjing Zhang, ; Xing Ma,
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4
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Behrenbruch C, Prabhakaran S, Udayasiri D D, Michael M, Hollande F, Hayes I, Heriot AG, Knowles B, Thomson BN. Association between imaging response and survival following neoadjuvant chemotherapy in patients with resectable colorectal liver metastases: A cohort study. J Surg Oncol 2021; 123:1263-1273. [PMID: 33524184 DOI: 10.1002/jso.26400] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Revised: 12/12/2020] [Accepted: 01/18/2021] [Indexed: 01/16/2023]
Abstract
BACKGROUND The association between the imaging response (structural or metabolic) to neoadjuvant chemotherapy (neoCT) before colorectal liver metastasis (CRLM) and survival is unclear. METHOD A total of 201 patients underwent their first CRLM resection. A total of 94 (47%) patients were treated with neoCT. A multivariable, Cox proportional hazard regression analysis was performed to compare overall survival (OS) and progression-free survival (PFS) between response groups. RESULTS Multivariable regression analysis of the CT/MRI (n = 94) group showed no difference in survival (OS and PFS) in patients who had stable disease/partial response (SD/PR) or complete response (CR) versus patients who had progressive disease (PD) (OS: HR, 0.36 (95% CI: 0.11-1.19) p = .094, HR, 0.78 (95% CI: 0.13-4.50) p = .780, respectively), (PFS: HR, 0.70 (95% CI: 0.36-1.35) p = .284, HR, 0.51 (0.18-1.45) p = .203, respectively). In the FDG-PET group (n = 60) there was no difference in the hazard of death for patients with SD/PR or CR versus patients with PD for OS or PFS except for the PFS in the small CR subgroup (OS: HR, 0.75 (95% CI: 0.11-4.88) p = .759, HR, 1.21 (95% CI: 0.15-9.43) p = .857), (PFS: HR, 0.34% (95% CI: 0.09-1.22), p = .097, HR, 0.17 (95% CI: 0.04-0.62) p = .008, respectively). CONCLUSION There was no convincing evidence of association between imaging response to neoCT and survival following CRLM resection.
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Affiliation(s)
- C Behrenbruch
- Sir Peter MacCallum Department of Oncology, Victorian Comprehensive Cancer Centre, The University of Melbourne, Melbourne, Australia.,Department of General Surgical Specialties, The Royal Melbourne Hospital, Parkville, Australia.,Department of Clinical Pathology, Victorian Comprehensive Cancer Centre, The University of Melbourne, Melbourne, Australia
| | - S Prabhakaran
- Department of General Surgical Specialties, The Royal Melbourne Hospital, Parkville, Australia
| | - D Udayasiri D
- Department of General Surgical Specialties, The Royal Melbourne Hospital, Parkville, Australia.,Department of Surgery, Royal Melbourne Hospital, The University of Melbourne, Parkville, Australia.,Colorectal Surgery Unit, The Royal Melbourne Hospital, Parkville, Australia
| | - M Michael
- Sir Peter MacCallum Department of Oncology, Victorian Comprehensive Cancer Centre, The University of Melbourne, Melbourne, Australia.,Department of Medical Oncology, Victorian Comprehensive Cancer Centre, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - F Hollande
- Department of Clinical Pathology, Victorian Comprehensive Cancer Centre, The University of Melbourne, Melbourne, Australia.,Centre for Cancer Research, Victorian Comprehensive Cancer Centre, University of Melbourne, Melbourne, Australia
| | - I Hayes
- Department of General Surgical Specialties, The Royal Melbourne Hospital, Parkville, Australia.,Department of Surgery, Royal Melbourne Hospital, The University of Melbourne, Parkville, Australia.,Colorectal Surgery Unit, The Royal Melbourne Hospital, Parkville, Australia
| | - A G Heriot
- Sir Peter MacCallum Department of Oncology, Victorian Comprehensive Cancer Centre, The University of Melbourne, Melbourne, Australia.,Department of Cancer Surgery, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Australia.,Department of Surgery, St Vincent's Hospital, The University of Melbourne, Fitzroy, Australia
| | - B Knowles
- Department of General Surgical Specialties, The Royal Melbourne Hospital, Parkville, Australia
| | - B N Thomson
- Department of General Surgical Specialties, The Royal Melbourne Hospital, Parkville, Australia.,Department of Cancer Surgery, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Australia.,Department of Surgery, Royal Melbourne Hospital, The University of Melbourne, Parkville, Australia
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5
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Bashir U, Weeks A, Goda JS, Siddique M, Goh V, Cook GJ. Measurement of 18F-FDG PET tumor heterogeneity improves early assessment of response to bevacizumab compared with the standard size and uptake metrics in a colorectal cancer model. Nucl Med Commun 2019; 40:611-617. [PMID: 30893213 PMCID: PMC6553522 DOI: 10.1097/mnm.0000000000000992] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 01/24/2019] [Indexed: 12/24/2022]
Abstract
PURPOSE Treatment of metastatic colorectal cancer frequently includes antiangiogenic agents such as bevacizumab. Size measurements are inadequate to assess treatment response to these agents, and newer response assessment criteria are needed. We aimed to evaluate F-FDG PET-derived texture parameters in a preclinical colorectal cancer model as alternative metrics of response to treatment with bevacizumab. MATERIALS AND METHODS Fourteen CD1 athymic mice injected in the flank with 5×106 LS174T cells (human colorectal carcinoma) were either untreated controls (n=7) or bevacizumab treated (n=7). After 2 weeks, mice underwent F-FDG PET/CT. Calliper-measured tumor growth (Δvol) and final tumor volume (Volcal), F-FDG PET metabolically active volume (Volmet), mean metabolism (Metmean), and maximum metabolism (Metmax) were measured. Twenty-four texture features were compared between treated and untreated mice. Immunohistochemical mean tumor vascular density was estimated by anti-CD-34 staining after tumor resection. RESULTS Treated mice had significantly lower tumor vascular density (P=0.032), confirming the antiangiogenic therapeutic effect of bevacizumab. None of the conventional measures were different between the two groups: Δvol (P=0.9), Volcal (P=0.7), Volmet (P=0.28), Metmax (P=0.7), or Metmean (P=0.32). One texture parameter, GLSZM-SZV (visually indicating that the F-FDG PET images of treated mice comprise uniformly sized clusters of different activity) had significantly different means between the two groups of mice (P=0.001). CONCLUSION F-FDG PET derived texture parameters, particularly GLSZM-SZV, may be valid biomarkers of tumor response to treatment with bevacizumab, before change in volume.
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Affiliation(s)
- Usman Bashir
- Department of Radiology, Barts and London NHS Trust
| | - Amanda Weeks
- Department of Cancer Imaging, School of Biomedical Engineering and Imaging Sciences
| | - Jayant S. Goda
- Department of Cancer Imaging, School of Biomedical Engineering and Imaging Sciences
| | - Muhammad Siddique
- Department of Cancer Imaging, School of Biomedical Engineering and Imaging Sciences
| | - Vicky Goh
- Department of Radiology, Barts and London NHS Trust
- Department of Radiology, Guy’s Hospital, London, UK
| | - Gary J. Cook
- Department of Radiology, Barts and London NHS Trust
- PET Imaging Centre and the Division of Imaging Sciences and Biomedical Engineering, King’s College London
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6
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Can the Efficacy of [ 18F]FDG-PET/CT in Clinical Oncology Be Enhanced by Screening Biomolecular Profiles? Pharmaceuticals (Basel) 2019; 12:ph12010016. [PMID: 30678034 PMCID: PMC6469153 DOI: 10.3390/ph12010016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 01/03/2019] [Accepted: 01/14/2019] [Indexed: 12/22/2022] Open
Abstract
Positron Emission Tomography (PET) is a functional imaging modality widely used in clinical oncology. Over the years the sensitivity and specificity of PET has improved with the advent of specific radiotracers, increased technical accuracy of PET scanners and incremental experience of Radiologists. However, significant limitations exist—most notably false positives and false negatives. Additionally, the accuracy of PET varies between cancer types and in some cancers, is no longer considered a standard imaging modality. This review considers the relative influence of macroscopic tumour features such as size and morphology on 2-Deoxy-2-[18F]fluoroglucose ([18F]FDG) uptake by tumours which, though well described in the literature, lacks a comprehensive assessment of biomolecular features which may influence [18F]FDG uptake. The review aims to discuss the potential influence of individual molecular markers of glucose transport, glycolysis, hypoxia and angiogenesis in addition to the relationships between these key cellular processes and their influence on [18F]FDG uptake. Finally, the potential role for biomolecular profiling of individual tumours to predict positivity on PET imaging is discussed to enhance accuracy and clinical utility.
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7
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Chiu KWH, Lam KO, An H, Cheung GTC, Lau JKS, Choy TS, Lee VHF. Long-term outcomes and recurrence pattern of 18F-FDG PET-CT complete metabolic response in the first-line treatment of metastatic colorectal cancer: a lesion-based and patient-based analysis. BMC Cancer 2018; 18:776. [PMID: 30064385 PMCID: PMC6069713 DOI: 10.1186/s12885-018-4687-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 07/22/2018] [Indexed: 12/22/2022] Open
Abstract
Background 18F-FDG PET-CT is commonly used to monitor treatment response in patients with metastatic colorectal cancer (mCRC). With improvement in systemic therapy, complete metabolic response (CMR) is increasingly encountered but its clinical significance is undefined. The study examined the long-term outcomes and recurrence patterns in these patients. Methods Consecutive patients with mCRC who achieved CMR on PET-CT during first-line systemic therapy were retrospectively analysed. Measurable and non-measurable lesions identified on baseline PET-CT were compared with Response Criteria in Solid Tumors (RECIST) on CT on a per-lesion basis. Progression free (PFS) and Overall Survival (OS) were compared with clinical parameters and treatment characteristics on a per-patient basis. Results Between 2008 and 2011, 40 patients with 192 serial PET-CT scans were eligible for analysis involving 44 measurable and 38 non-measurable lesions in 59 metastatic sites. On a per-lesion basis, 46% also achieved Complete Response (CR) on RECIST criteria and sustained CMR was more frequent in these lesions (OR 1.727, p = 0.0031). Progressive metabolic disease (PMD) was seen in 12% of lesions, with liver metastasis the most common. Receiver operating characteristics (ROC) curve analysis revealed the optimal value of SUVmax for predicting PMD of a lesion was 4.4 (AUC 0.734, p = 0.004). On a per-patient basis, 14 patients achieved sustained CMR and their outcomes were better than those with PMD (median OS not reached vs 37.7 months p = 0.0001). No statistical difference was seen in OS between patients who achieved PR or CR (median OS 51.4 vs 44.2 months p = 0.766). Conclusion Our results provided additional information of long-term outcomes and recurrence patterns of patients with mCRC after achieving CMR. They had improved survival and sustained CMR using systemic therapy alone is possible. Discordance between morphological and metabolic response was consistent with reported literature but in the presence of CMR the two groups had comparable outcomes.
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Affiliation(s)
- Keith W H Chiu
- Department of Diagnostic Radiology, LKS Faculty of Medicine, The University of Hong Kong, 102, Pokfulam Raod, Hong Kong, China
| | - Ka-On Lam
- Department of Clinical Oncology, LKS Faculty of Medicine, The University of Hong Kong, 1/F Professorial Block, 102, Pokfulam Raod, Hong Kong, China. .,Clinical Oncology Center, The University of Hong Kong-Shenzhen Hospital, 102, Pokfulam Raod, Hong Kong, China.
| | - H An
- Department of Diagnostic Radiology, LKS Faculty of Medicine, The University of Hong Kong, 102, Pokfulam Raod, Hong Kong, China
| | - Gavin T C Cheung
- Department of Clinical Oncology, Queen Elizabeth Hospital, 30 Gascoigne Raod, Hong Kong, China
| | - Johnny K S Lau
- Department of Clinical Oncology, Queen Mary Hospital, 1/F Professorial Block, 102, Pokfulam Raod, Hong Kong, China
| | - Tim-Shing Choy
- Department of Clinical Oncology, Queen Mary Hospital, 1/F Professorial Block, 102, Pokfulam Raod, Hong Kong, China
| | - Victor H F Lee
- Department of Clinical Oncology, LKS Faculty of Medicine, The University of Hong Kong, 1/F Professorial Block, 102, Pokfulam Raod, Hong Kong, China.,Clinical Oncology Center, The University of Hong Kong-Shenzhen Hospital, 102, Pokfulam Raod, Hong Kong, China
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Sheikhbahaei S, Mena E, Pattanayak P, Taghipour M, Solnes LB, Subramaniam RM. Molecular Imaging and Precision Medicine: PET/Computed Tomography and Therapy Response Assessment in Oncology. PET Clin 2016; 12:105-118. [PMID: 27863562 DOI: 10.1016/j.cpet.2016.08.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
A variety of methods have been developed to assess tumor response to therapy. Standardized qualitative criteria based on 18F-fluoro-deoxyglucose PET/computed tomography have been proposed to evaluate the treatment effectiveness in specific cancers and these allow more accurate therapy response assessment and survival prognostication. Multiple studies have addressed the utility of the volumetric PET biomarkers as prognostic indicators but there is no consensus about the preferred segmentation methodology for these metrics. Heterogeneous intratumoral uptake was proposed as a novel PET metric for therapy response assessment. PET imaging techniques will be used to study the biological behavior of cancers during therapy.
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Affiliation(s)
- Sara Sheikhbahaei
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins School of Medicine, Johns Hopkins University, 601 North Caroline Street, Baltimore, MD 21287, USA
| | - Esther Mena
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins School of Medicine, Johns Hopkins University, 601 North Caroline Street, Baltimore, MD 21287, USA
| | - Puskar Pattanayak
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins School of Medicine, Johns Hopkins University, 601 North Caroline Street, Baltimore, MD 21287, USA
| | - Mehdi Taghipour
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins School of Medicine, Johns Hopkins University, 601 North Caroline Street, Baltimore, MD 21287, USA
| | - Lilja B Solnes
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins School of Medicine, Johns Hopkins University, 601 North Caroline Street, Baltimore, MD 21287, USA
| | - Rathan M Subramaniam
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins School of Medicine, Johns Hopkins University, 601 North Caroline Street, Baltimore, MD 21287, USA; Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA; Department of Clinical Sciences, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA; Department of Biomedical Engineering, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA; Advanced Imaging Research Center, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA.
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9
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Ahn SJ, Kim JH, Park SJ, Han JK. Prediction of the therapeutic response after FOLFOX and FOLFIRI treatment for patients with liver metastasis from colorectal cancer using computerized CT texture analysis. Eur J Radiol 2016; 85:1867-1874. [PMID: 27666629 DOI: 10.1016/j.ejrad.2016.08.014] [Citation(s) in RCA: 92] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 08/18/2016] [Accepted: 08/22/2016] [Indexed: 02/07/2023]
Abstract
PURPOSE To determine whether baseline CT texture analysis of hepatic metastasis from colorectal cancer (CRC) is predictive of therapeutic response after cytotoxic chemotherapy. MATERIALS AND METHODS 235 patients with liver metastasis from CRC who underwent CT and cytotoxic chemotherapy using FOLFOX and FOLFIRI were divided into derivation cohort (n=145) and validation cohort (n=90). The CT texture of the hepatic metastasis was quantified using baseline CT. We analyzed the independent predictor for the response from derivation cohort and validated it using validation cohort. We also compared texture features between included four CT scanners. RESULTS 89 responding and 146 non-responding patients were evaluated. In the derivation cohort, lower skewness (OR, 6.739) in 2D, higher mean attenuation (OR, 2.587), and narrower standard deviation (SD) (OR, 3.163) in 3D were independently associated with response to chemotherapy. However, only lower skewness (P=0.213) on 2D and narrower SD on 3D analysis (P=0.097) did not show a significant difference on either CT scanner. When applied to the validation set, the lower skewness on 2D (AUC=0.797) and narrower SD on 3D (AUC=0.785) showed good performance. CONCLUSION CT texture analysis is useful for prediction of therapeutic response after cytotoxic chemotherapy in patients with liver metastasis from colorectal cancer.
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Affiliation(s)
- Su Joa Ahn
- Department of Radiology, Seoul National University Hospital, Seoul, South Korea.
| | - Jung Hoon Kim
- Department of Radiology, Seoul National University Hospital, Seoul, South Korea; Institute of Radiation Medicine, Seoul National University College of Medicine, Seoul, South Korea.
| | - Sang Joon Park
- Department of Radiology, Seoul National University Hospital, Seoul, South Korea; Cancer Research Institute, Seoul National University, Seoul, South Korea.
| | - Joon Koo Han
- Department of Radiology, Seoul National University Hospital, Seoul, South Korea; Institute of Radiation Medicine, Seoul National University College of Medicine, Seoul, South Korea.
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10
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Lau LF, Murone C, Williams DS, Standish R, Lee ST, Christophi C, Scott AM, Muralidharan V. Metabolic response evaluation for colorectal liver metastases and correlation to pathologic response and tumour markers. ANZ J Surg 2016; 88:E108-E113. [PMID: 27452367 DOI: 10.1111/ans.13680] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Revised: 05/30/2016] [Accepted: 05/31/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Tumour metabolic response to chemotherapy is increasingly recognized as a prognostic indicator for colorectal cancer liver metastases (CRCLM). However, its clinical role and the underlying biological mechanism of its prognostic ability are unclear. This study compares metabolic to pathologic response for CRCLM, and correlates metabolic response to tumour expression of six key biomarkers. METHODS Thirty-seven patients who had positron emission tomography imaging before and after pre-operative chemotherapy prior to liver resection for CRCLM were included. Metabolic response was assessed according to the positron emission tomography response criteria in solid tumours (PERCIST) and correlated to recurrence-free and overall survival. PERCIST was compared to tumour regression grading, computed tomography (CT) response, tumour necrosis and mucin and immunohistochemical expression of Ki-67, hypoxia inducible factor 1α, vascular endothelial growth factor, p53, p16 and vimentin. Area under the receiver operating characteristic curve (AUC), Kaplan-Meier survival, Spearman's correlation (rs ) and multivariate Cox regression analyses were used. RESULTS PERCIST correlated significantly to 2-year mortality (AUC = 0.162, P < 0.01) and 2-year recurrence (AUC = 0.284, P = 0.03). Metabolically responsive tumours conferred a better overall survival (P = 0.01) and recurrence-free survival (P = 0.03). Tumour regression grading did not stratify for outcome. Metabolic response was significantly correlated to Ki-67 and p16 expression (rs = 0.559 and rs = -0.549, respectively). Multivariate analysis revealed only PERCIST to be correlated to death and recurrence. CONCLUSION Pre-operative PERCIST assessment of CRCLM was more prognostic than pathologic and CT response assessment. Metabolic non-response correlated with tumour proliferation and loss of tumour suppression.
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Affiliation(s)
- Lawrence F Lau
- Department of Surgery, Austin Hospital, The University of Melbourne, Heidelberg, Victoria, Australia
| | - Carmel Murone
- Department of Pathology, Austin Hospital, The University of Melbourne, Heidelberg, Victoria, Australia.,Olivia Newton-John Cancer Research Institute, Heidelberg, Victoria, Australia
| | - David S Williams
- Department of Pathology, Austin Hospital, The University of Melbourne, Heidelberg, Victoria, Australia.,Olivia Newton-John Cancer Research Institute, Heidelberg, Victoria, Australia
| | - Richard Standish
- Department of Pathology, Austin Hospital, The University of Melbourne, Heidelberg, Victoria, Australia
| | - Sze Ting Lee
- Olivia Newton-John Cancer Research Institute, Heidelberg, Victoria, Australia.,Department of Molecular Imaging and Therapy, Austin Hospital, Heidelberg, Victoria, Australia
| | - Christopher Christophi
- Department of Surgery, Austin Hospital, The University of Melbourne, Heidelberg, Victoria, Australia
| | - Andrew M Scott
- Olivia Newton-John Cancer Research Institute, Heidelberg, Victoria, Australia.,Department of Molecular Imaging and Therapy, Austin Hospital, Heidelberg, Victoria, Australia
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Heijmen L, Ter Voert EGW, Punt CJA, Heerschap A, Oyen WJG, Bussink J, Sweep CGJ, Laverman P, Span PN, de Geus-Oei LF, Boerman OC, van Laarhoven HWM. Monitoring hypoxia and vasculature during bevacizumab treatment in a murine colorectal cancer model. CONTRAST MEDIA & MOLECULAR IMAGING 2015; 9:237-45. [PMID: 24700751 DOI: 10.1002/cmmi.1564] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Revised: 07/24/2013] [Accepted: 08/01/2013] [Indexed: 01/17/2023]
Abstract
The purpose of this study was to assess the effect of bevacizumab on vasculature and hypoxia in a colorectal tumor model. Nude mice with subcutaneous LS174T tumors were treated with bevacizumab or saline. To assess tumor properties, separate groups of mice were imaged using (18) F-Fluoromisonidazole (FMISO) and (18) F-Fluorodeoxyglucose (FDG) positron emission tomography or magnetic resonance imaging before and 2, 6 and 10 days after the start of treatment. Tumors were harvested after imaging to determine hypoxia and vascular density immunohistochemically. The T2 * time increased significantly less in the bevacizumab group. FMISO uptake increased more over time in the control group. Vessel density significantly decreased in the bevacizumab-treated group. The Carbonic anhydrase 9 (CAIX) and glucose uptake transporter 1 (GLUT1) fractions were higher in bevacizumab-treated tumors. However, the hypoxic fraction showed no significant difference. Bevacizumab led to shorter T2 * times and higher GLUT1 and CAIX expression, suggesting an increase in hypoxia and a higher glycolytic rate. This could be a mechanism of resistance to bevacizumab. The increase in hypoxia, however, could not be demonstrated by pimonidazole/FMISO, possibly because distribution of these tracers is hampered by bevacizumab-induced effects on vascular permeability and perfusion.
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Affiliation(s)
- L Heijmen
- Department of Medical Oncology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
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12
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Performance of tumor growth kinetics as an imaging biomarker for response assessment in colorectal liver metastases: correlation with FDG PET. ACTA ACUST UNITED AC 2015; 40:3043-51. [DOI: 10.1007/s00261-015-0546-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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13
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Bernardin L, O'Flynn EAM, Desouza NM. Functional imaging biomarkers for assessing response to treatment in liver and lung metastases. Cancer Imaging 2013; 13:482-94. [PMID: 24334562 PMCID: PMC3864224 DOI: 10.1102/1470-7330.2013.0047] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2013] [Indexed: 01/15/2023] Open
Abstract
Management of patients with metastatic cancer and development of new treatments rely on imaging to provide non-invasive biomarkers of tumour response and progression. The widely used size-based criteria have increasingly become inadequate where early measures of response are required to avoid toxicity of ineffective treatments, as biological, physiologic, and molecular modifications in tumours occur before changes in gross tumour size. A multiparametric approach with the current range of imaging techniques allows functional aspects of tumours to be simultaneously interrogated. Appropriate use of these imaging techniques and their timing in relation to the treatment schedule, particularly in the context of clinical trials, is fundamental. There is a lack of consensus regarding which imaging parameters are most informative for a particular disease site and the best time to image so that, despite an increasing body of literature, open questions on these aspects remain. In addition, standardization of these new parameters is required. This review summarizes the published literature over the last decade on functional and molecular imaging techniques in assessing treatment response in liver and lung metastases.
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Affiliation(s)
- Livia Bernardin
- Clinical Magnetic Resonance Group, Institute of Cancer Research, Royal Marsden NHS Foundation Trust, Downs Road, Sutton, Surrey, UK
| | - Elizabeth A M O'Flynn
- Clinical Magnetic Resonance Group, Institute of Cancer Research, Royal Marsden NHS Foundation Trust, Downs Road, Sutton, Surrey, UK
| | - Nandita M Desouza
- Clinical Magnetic Resonance Group, Institute of Cancer Research, Royal Marsden NHS Foundation Trust, Downs Road, Sutton, Surrey, UK
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A radiologist's guide to treatment response criteria in oncologic imaging: functional, molecular, and disease-specific imaging biomarkers. AJR Am J Roentgenol 2013; 201:246-56. [PMID: 23883206 DOI: 10.2214/ajr.12.9878] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE This article reviews the functional, molecular, and disease-specific imaging biomarkers of treatment response. CONCLUSION Substantial progress has been made in the evolution of drugs directed at specific targets of the tumor lifecycle. These novel agents are predominantly cytostatic, and their efficacy may be optimally evaluated by functional, molecular, and disease-specific imaging biomarkers.
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15
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Mudd SR, Holich KD, Voorbach MJ, Cole TB, Reuter DR, Tapang P, Bukofzer G, Chakravartty A, Donawho CK, Palma JP, Fox GB, Day M, Luo Y. Pharmacodynamic evaluation of irinotecan therapy by FDG and FLT PET/CT imaging in a colorectal cancer xenograft model. Mol Imaging Biol 2013; 14:617-24. [PMID: 22167582 DOI: 10.1007/s11307-011-0529-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
PURPOSE Longitudinal changes of 3'-[(18) F]fluoro-3'-deoxythymidine (FLT) and 2-deoxy-2-[(18) F]fluoro-D-glucose (FDG) in response to irinotecan therapy in an animal model of colorectal cancer were compared. PROCEDURES SCID/CB-17 mice with HCT116 tumors were treated with 50 mg/kg irinotecan by intraperitoneal injection weekly for 3 weeks. FLT and FDG-positron emission tomography (PET) were performed at baseline, the day after each treatment, and 5 days after the first treatment. Proliferation and apoptosis were evaluated by immunohistochemistry (IHC) after day 15 of imaging. RESULTS Irinotecan treatment resulted in a suppression of tumor growth. Tumor FLT uptake was decreased the day after each treatment but to a lesser extent 5 days after the first treatment. FDG uptake increased the day after each treatment with a continuous increase throughout the experiment. IHC analysis of phospho-H3 and Ki67 confirmed FLT-PET results, indicating a decrease in proliferation the day after the final irinotecan treatment. Increased apoptosis monitored by caspase-3 was observed after day 15 with irinotecan treatment. CONCLUSIONS FLT-PET may be a better method than FDG-PET for assessing treatment response to irinotecan. Changes in imaging occur before changes in tumor volume.
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Affiliation(s)
- Sarah R Mudd
- Translational Imaging and Biochemical Biomarkers, Advanced Technology, Global Pharmaceutical Research and Development, Abbott Laboratories, Abbott Park, IL, USA.
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16
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Blackham AU, Swett K, Levine EA, Shen P. Surgical management of colorectal cancer metastases to the liver: multimodality approach and a single institutional experience. COLORECTAL CANCER 2013; 2:73-88. [PMID: 25110522 DOI: 10.2217/crc.12.80] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Over the past 30 years, the treatment of metastatic colorectal cancer to the liver has undergone major changes. Once considered terminal and incurable, the prognosis of patients with colorectal hepatic metastases has seen dramatic improvements using modern multimodality therapy and now long-term survival and even cure are possible in some patients. Despite the advances seen in systemic therapy, hepatic resection offers the longest survival potential and remains the only curative option. Based on long-term outcomes and the improved safety of hepatic resection using modern operative techniques and critical care support, an aggressive locoregional approach to colorectal hepatic metastasis has become the standard of care. This article focuses on the management of colorectal hepatic metastases and highlights the importance of multimodality therapy. We also report our 18-year experience treating patients with hepatic resection for colorectal metastases.
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Affiliation(s)
- Aaron U Blackham
- Department of General Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Katrina Swett
- Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Edward A Levine
- Department of General Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Perry Shen
- Department of General Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
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17
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Li XF, Li MD, Shen H, Fang XF, Huang PT, Yuan Y. Evaluation of therapeutic effect of tumor-targeted therapy. Onco Targets Ther 2012; 5:191-8. [PMID: 23049263 PMCID: PMC3459839 DOI: 10.2147/ott.s36307] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The response evaluation criteria in solid tumors, which are based on tumor size alone, are the most frequently used and effective criteria by which to evaluate the tumor response to chemotherapy. However, the mechanism of tumor-targeted drugs is different from traditional cytotoxic drugs. Tumor-targeted drugs are designed to interfere with specific aberrant biological pathways involved in tumorigenesis. For this reason, the response evaluation in solid tumors is not adequate for the evaluation of targeted therapy. Molecular and functional imaging techniques such as dynamic contrast-enhanced perfusion computed tomography, dynamic contrast-enhanced magnetic resonance imaging, dynamic contrast-enhanced ultrasound, and fluorodeoxyglucose-positron emission tomography can reflect tumor blood flow and cellular metabolic changes directly, and are being used more frequently for the evaluation of targeted therapies. This article gives an overview of some of the new computed tomography criteria and the commonly used methods of targeted therapy evaluation.
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Affiliation(s)
- Xiao-Fen Li
- Department of Medical Oncology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
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18
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Masi G, Fornaro L, Caparello C, Falcone A. Liver metastases from colorectal cancer: how to best complement medical treatment with surgical approaches. Future Oncol 2011; 7:1299-323. [DOI: 10.2217/fon.11.108] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Colorectal liver metastases (CLM) represent a major challenge for oncologists and surgeons. In fact, in this setting, the optimal treatment of patients can achieve a long-term survival and sometimes a definitive cure of disease. In recent years, improvements in both medical therapies and surgical approaches have led to an increased rate of patients considered amenable for surgery on CLM. New perspectives in the management of CLM underline the need for a comprehensive assessment of patient and tumor characteristics, to integrate technical and prognostic issues into an individualized therapeutic strategy in different patient subgroups. The multidisciplinary evaluation from the onset and during treatment remains the key element to maximizing the benefit of more intensive treatment modalities.
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Affiliation(s)
| | - Lorenzo Fornaro
- U.O. Oncologia Medica Universitaria, Azienda Ospedaliero-Universitaria Pisana, Via Roma 67, 56126 Pisa, Italy
| | - Chiara Caparello
- U.O. Oncologia Medica Universitaria, Azienda Ospedaliero-Universitaria Pisana, Via Roma 67, 56126 Pisa, Italy
| | - Alfredo Falcone
- U.O. Oncologia Medica Universitaria, Azienda Ospedaliero-Universitaria Pisana, Via Roma 67, 56126 Pisa, Italy
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19
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Lin M, Wong K, Ng WL, Shon IH, Morgan M. Positron emission tomography and colorectal cancer. Crit Rev Oncol Hematol 2011; 77:30-47. [PMID: 20619671 DOI: 10.1016/j.critrevonc.2010.04.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2009] [Revised: 04/30/2010] [Accepted: 04/30/2010] [Indexed: 12/16/2022] Open
Abstract
Colorectal cancer (CRC) is a major cause of cancer-related morbidity and mortality. Molecular imaging using positron emission tomography (PET) is now an integral part of multidisciplinary cancer care. In this review, we discuss the role of PET in CRC including well established indications in the assessment of recurrent disease and emerging applications such as initial staging, monitoring therapy efficacy and using PET for radiotherapy planning. With rapid advancement in imaging technology, we also discuss the future potential of combining PET and magnetic resonance imaging and the use of novel radiotracers.
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Affiliation(s)
- Michael Lin
- Department of Nuclear Medicine and PET, Liverpool Hospital, Sydney, Australia; University of New South Wales, Sydney, Australia.
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20
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Strasberg SM, Dehdashti F. Role of FDG-PET staging in selecting the optimum patient for hepatic resection of metastatic colorectal cancer. J Surg Oncol 2011; 102:955-9. [PMID: 21165998 DOI: 10.1002/jso.21729] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Staging by FDG-PET of patients who are candidates for surgical treatment of colorectal metastases is an essential part of management of this problem. FDG-PET is highly sensitive and specific for intrahepatic colorectal tumors and the most sensitive test for extrahepatic tumors. FDG-PET alters management in 25% of patients, reducing futile laparotomies and hepatectomies.
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Affiliation(s)
- Steven M Strasberg
- Section of Hepato-Pancreato-Biliary Surgery, Department of Surgery, Washington University in St. Louis, St. Louis, MO, USA.
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21
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Power DG, Kemeny NE. Chemotherapy for the conversion of unresectable colorectal cancer liver metastases to resection. Crit Rev Oncol Hematol 2010; 79:251-64. [PMID: 20970353 DOI: 10.1016/j.critrevonc.2010.08.001] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2010] [Revised: 08/01/2010] [Accepted: 08/19/2010] [Indexed: 02/06/2023] Open
Abstract
Resection of colorectal liver metastases (CLM) is the ultimate aim of treatment strategies in most patients with liver-confined metastatic colorectal cancer. Long-term survival is possible in selected patients with initially resectable or unresectable CLM. As a majority of patients have unresectable liver disease at the outset, there is a clear role for chemotherapy to downstage liver disease making resection possible. Studies of systemic chemotherapy with or without biologic therapy in patients with unresectable CLM have resulted in increased response rates, liver resection rates and survival. A sound physiologic rationale exists for the use of hepatic arterial infusion (HAI) therapy. Studies have shown that HAI with floxuridine combined with systemic chemotherapy increases response rates and liver resection rates in those patients with initially unresectable CLM. Toxicity from preoperative chemotherapy, biologic therapy and HAI therapy may adversely affect hepatic resection but can be kept minimal with appropriate monitoring. All conversion strategies should be decided by a multidisciplinary team.
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Affiliation(s)
- Derek G Power
- Department of Medicine, Gastrointestinal Oncology Division, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA.
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22
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Assessment of liver metastases from colorectal adenocarcinoma following chemotherapy: SPIO-MRI versus FDG-PET/CT. Radiol Med 2010; 115:1087-100. [PMID: 20574703 DOI: 10.1007/s11547-010-0560-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2009] [Accepted: 11/27/2009] [Indexed: 01/06/2023]
Abstract
PURPOSE This study compared superparamagnetic iron-oxide-enhanced magnetic resonance imaging (SPIO-MRI) and combined fluorodeoxyglucose positron emission tomography and computed tomography (FDG-PET/CT) in evaluating liver metastases from colorectal adenocarcinoma following chemotherapy. MATERIALS AND METHODS Nineteen patients were included in this retrospective study. SPIO-MRI and PET/CT results were compared with surgery, intraoperative ultrasound and pathology results in 11 patients and with the follow-up in eight patients. RESULTS SPIO-MRI and PET/CT identified 125 and 71 metastases, respectively. False negative lesions were 11 for SPIO-MRI and 65 for PET/CT. In the whole study population, the per-lesion analysis of SPIO-MRI and PET/CT showed a sensitivity of 92% and 52% (p<0.001) and the per-segment analysis a sensitivity of 99% and 79% (p<0.001), respectively. In patients who underwent surgery, the per-lesion analysis of SPIO-MRI and PET/CT showed a sensitivity of 85% and 58% (p<0.05) and the per-segment analysis a sensitivity of 97% and 63% (p<0.05), respectively. In patients who underwent follow-up, the per-lesion analysis of SPIO-MRI and PET/CT showed a sensitivity of 97% and 47% (p<0.001) and the per-segment analysis a sensitivity of 100% and 63% (p<0.007), respectively. For lesions ≥15 and <30 mm and for lesions <15 mm, SPIO-MRI demonstrated a higher sensitivity than PET/CT (p<0.001). CONCLUSIONS SPIO-MRI appears superior to PET/CT in evaluating liver metastases from colorectal adenocarcinoma following chemotherapy.
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23
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Tan CH, Iyer R. Use of computed tomography in the management of colorectal cancer. World J Radiol 2010; 2:151-8. [PMID: 21161029 PMCID: PMC2999018 DOI: 10.4329/wjr.v2.i5.151] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2010] [Revised: 04/21/2010] [Accepted: 04/28/2010] [Indexed: 02/06/2023] Open
Abstract
Computed tomography (CT) plays an important role in the management of colorectal cancer (CRC). The use of CT (colonography) as a screening tool for CRC has been validated and is expected to rise over time. The results of prior studies suggest that CT is suboptimal for assessment of local T stage and moderate for N stage disease. Recent advances in CT technology are expected to lead to some improvement in staging accuracy. At present, the main role of CT in pre-treatment imaging assessment lies in its use for the detection of distant metastases, especially in the liver. In a select group of patients, routine post-treatment surveillance with CT confers survival benefits. The role of CT for post-treatment assessment has been radically altered and improved with the advent of fusion positron emission tomography/CT. Perfusion CT shows promise as another functional imaging modality but further experience with this technique is necessary before it can be applied to routine clinical practice.
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24
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Current perspective: Bevacizumab in colorectal cancer – A time for reappraisal? Eur J Cancer 2009; 45:2452-61. [DOI: 10.1016/j.ejca.2009.06.028] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2009] [Accepted: 06/26/2009] [Indexed: 01/03/2023]
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25
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de Geus-Oei LF, Vriens D, van Laarhoven HWM, van der Graaf WTA, Oyen WJG. Monitoring and predicting response to therapy with 18F-FDG PET in colorectal cancer: a systematic review. J Nucl Med 2009; 50 Suppl 1:43S-54S. [PMID: 19403879 DOI: 10.2967/jnumed.108.057224] [Citation(s) in RCA: 178] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Molecular imaging with (18)F-FDG PET has been proven useful in the management of colorectal cancer. (18)F-FDG PET plays a pivotal role in staging before surgical resection of recurrent colorectal cancer and metastases, in the localization of recurrence in patients with an unexplained rise in serum carcinoembryonic antigen levels, and in the assessment of residual masses after treatment. Currently, there is increasing interest in the role of (18)F-FDG PET beyond staging. The technique appears to have significant potential for the characterization of tumors and for the prediction of prognosis in the context of treatment stratification and early assessment of tumor response to therapy. This systematic review provides an overview of the literature on the value of (18)F-FDG PET for monitoring and predicting the response to therapy in colorectal cancer. The review covers chemotherapy response monitoring in advanced colorectal cancer, monitoring of the effects of local ablative therapies, and preoperative radiotherapy and multimodality treatment response evaluation in primary rectal cancer. Given the added value of (18)F-FDG PET for these indications, implementation in clinical practice and systematic inclusion in therapeutic trials to exploit the potential of (18)F-FDG PET are warranted.
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Affiliation(s)
- Lioe-Fee de Geus-Oei
- Department of Nuclear Medicine, Radboud University, Nijmegen Medical Centre, Nijmegen, The Netherlands.
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26
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Adie S, Yip C, Chu F, Morris DL. Resection of liver metastases from colorectal cancer: does preoperative chemotherapy affect the accuracy of PET in preoperative planning? ANZ J Surg 2009; 79:358-61. [DOI: 10.1111/j.1445-2197.2009.04889.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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27
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Contractor KB, Aboagye EO. Monitoring Predominantly Cytostatic Treatment Response with 18F-FDG PET. J Nucl Med 2009; 50 Suppl 1:97S-105S. [DOI: 10.2967/jnumed.108.057273] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
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28
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Oldhafer KJ, Stavrou GA, Prause G, Peitgen HO, Lueth TC, Weber S. How to operate a liver tumor you cannot see. Langenbecks Arch Surg 2009; 394:489-94. [DOI: 10.1007/s00423-009-0469-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2009] [Accepted: 01/29/2009] [Indexed: 10/21/2022]
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Abstract
BACKGROUND Surgery has become heavily dependent on accurate imaging in the assessment and treatment of suspected or confirmed intra-abdominal malignancy. Positron emission tomography-computed tomography (PET-CT) fuses uptake of a radiotracer combined with CT images to assess both functional tissue activity and anatomical detail. Since its introduction it has offered new ways of treating gastrointestinal cancers. METHODS The review analyses the present literature regarding the use of PET-CT in the assessment, diagnosis, staging and treatment of hepatobiliary malignancies. RESULTS PET-CT is widely used in pre-operative tumours staging for colorectal liver metastases. There is convincing data that it may also be applicable for neuroendocrine tumours, assessment of indeterminate pancreas lesions and clinical drug trials. PET-CT is of limited value in hepatocellular cancers, although new techniques in dual-tracer PET-CT may change this. CONCLUSION Knowledge of the strengths and limitations of PET-CT is important for all surgeons managing cancer of the hepatobiliary system. More clinical data are required on PET-CT, particularly its effect on long-term survival in PET-CT-staged patients undergoing resection.
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Affiliation(s)
- Ginseppe Garcea
- Department of Hepatobiliary and Upper Gastrointestinal Surgery, The Queen Elizabeth HospitalAdelaide, SA, Australia
| | - Seok Ling Ong
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General HospitalLeicester, UK
| | - Guy J Maddern
- Department of Hepatobiliary and Upper Gastrointestinal Surgery, The Queen Elizabeth HospitalAdelaide, SA, Australia
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31
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Desar IME, van Herpen CML, van Laarhoven HWM, Barentsz JO, Oyen WJG, van der Graaf WTA. Beyond RECIST: molecular and functional imaging techniques for evaluation of response to targeted therapy. Cancer Treat Rev 2009; 35:309-21. [PMID: 19136215 DOI: 10.1016/j.ctrv.2008.12.001] [Citation(s) in RCA: 136] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2008] [Revised: 11/21/2008] [Accepted: 12/03/2008] [Indexed: 12/22/2022]
Abstract
The development of targeted therapies is a major breakthrough in the treatment of cancer. By evoking necrosis and cavitation, evaluation based on tumour size alone, as is done in the RECIST criteria, is no longer an adequate method. New molecular and functional imaging techniques are developed. This review focuses on the use of new imaging modalities for the evaluation of treatment response of pathway based targeted therapies. First, the basic principles of functional and molecular imaging modalities are briefly discussed. Thereafter, their clinical application in targeted therapies is correlated to the underlying biological mechanism. In this way, the best method for response evaluation for a new agent can be identified.
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Affiliation(s)
- I M E Desar
- Department of Medical Oncology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
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32
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Serial PET Scans Demonstrate the Success and Limitations of Antiangiogenic Treatment in a Case of Lung Adenocarcinoma. Clin Nucl Med 2008; 33:635-7. [DOI: 10.1097/rlu.0b013e3181813116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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33
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Gruenberger T, Gruenberger B. In Reply. J Clin Oncol 2008. [DOI: 10.1200/jco.2008.17.8624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Thomas Gruenberger
- Department of General Surgery, Medical University of Vienna, Vienna, Austria
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34
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Nasti G, Ottaiano A, Rosario Iaffaioli V, Berretta M, Delrio P. Trials on preoperative chemotherapy in resectable colorectal liver metastases need prospective evaluation of predictive factors of response. J Clin Oncol 2008; 26:3812-3; author reply 3813. [PMID: 18669474 DOI: 10.1200/jco.2008.17.8301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Sharma RI, Smith TA. Colorectal Tumor Cells Treated with 5-FU, Oxaliplatin, Irinotecan, and Cetuximab Exhibit Changes in 18F-FDG Incorporation Corresponding to Hexokinase Activity and Glucose Transport. J Nucl Med 2008; 49:1386-94. [DOI: 10.2967/jnumed.107.047886] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
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36
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Rankin SC. The role of positron emission tomography in staging of non-small cell lung cancer. Target Oncol 2008. [DOI: 10.1007/s11523-008-0085-6] [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]
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Pocard M. [Anti-angiogenic agents for digestive oncology: a real revolution?]. GASTROENTEROLOGIE CLINIQUE ET BIOLOGIQUE 2008; 32:502-503. [PMID: 18456446 DOI: 10.1016/j.gcb.2008.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
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38
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Boss DS, Olmos RV, Sinaasappel M, Beijnen JH, Schellens JHM. Application of PET/CT in the development of novel anticancer drugs. Oncologist 2008; 13:25-38. [PMID: 18245010 DOI: 10.1634/theoncologist.2007-0097] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Combined positron emission tomography/computed tomography (PET/CT) is a relatively new imaging modality, combining the functional images of PET with the anatomical information of CT. Since its commercial introduction about 5 years ago, PET/CT has become an important tool in oncology. Currently, the technique is used for primary staging and restaging of cancer patients, as well as for surgery and radiation therapy planning. The abilities of PET/CT to measure early treatment response as well as drug distribution within the body make this technique very useful in the development of novel anticancer drugs. In this paper, the recent literature on the current role of PET/CT in drug development is reviewed.
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Affiliation(s)
- David S Boss
- Division of Clinical Pharmacology, Department of Medical Oncology,The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
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39
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MRI and hybrid PET/CT for monitoring tumour metastasis in a metastatic breast cancer model in rabbit. Nucl Med Commun 2008; 29:137-43. [PMID: 18094635 DOI: 10.1097/mnm.0b013e3282f258c1] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To study tumour growth and metastasis in a rabbit metastatic breast cancer (MBC) model and find the most sensitive screening modality in monitoring tumour metastasis. METHODS The MBC model was established by injecting a VX2 tumour mass suspension into the mammary glands of 23 rabbits and was monitored by using physical examination, X-ray, MRI and hybrid PET/CT. RESULTS Of all 23 rabbits, axillary lymph node metastasis was detected in 21 (91%) at day 33 after tumour inoculation, mediastinal node metastasis in five (22%) at day 42, abdominal node metastasis in two (9%) at day 48, lung metastasis in six (26%) at day 39, liver metastasis in three (13%) at day 48, and lumbar spine metastasis in one (4%) at day 51. Tumour invasion of pleura was found in one, stomach wall in one, and pleura and stomach concurrently in one rabbit. Sensitivity for detection of lymph node metastases was 78.6% (22/28) and 67.9% (19/28) with MRI and PET/CT, respectively; and sensitivity for detection of metastases in distant organs was 85.7% (12/14) and 71.4% (10/14), respectively. CONCLUSIONS The MBC model used here exhibits fast tumour growth and extensive metastasis in a relatively short period. Its metastatic pattern is quite similar to that of human MBC and hence could be potentially used as a model for testing imaging modalities and translational research, e.g., MBC management. MRI is superior to PET/CT in monitoring tumour metastasis.
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Pantaleo MA, Nannini M, Maleddu A, Fanti S, Ambrosini V, Nanni C, Boschi S, Biasco G. Conventional and novel PET tracers for imaging in oncology in the era of molecular therapy. Cancer Treat Rev 2007; 34:103-21. [PMID: 18055120 DOI: 10.1016/j.ctrv.2007.10.001] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2007] [Revised: 10/03/2007] [Accepted: 10/06/2007] [Indexed: 01/18/2023]
Abstract
In the last ten years, the development of several novel targeted drugs and the refinement of state of the art technologies such as the genomics and proteomics and their introduction to clinical practice have revolutionized the management of patients affected by cancer. However, everyday practice points out several clinical questions: the difficulty of response assessment to new drugs especially using standard RECIST criteria that do not provide information on biological, vascular or metabolic variations; the inadequate selection of patients who are likely to benefit from a targeted therapy excluding those with breast cancer and gastrointestinal stromal tumours; the need to know the global biological background of diseases especially in metastatic setting using repeatable non-invasive procedures. Molecular imaging could provide information on in vivo distribution of biological markers in response to targeted therapy and could improve the selection of patients before therapies. The aim of this review is to analyze the current role of conventional and innovative positron emission tomography (PET) radiotracers in clinical practice and to explore the promising perspectives of molecular imaging in cancer research.
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Affiliation(s)
- M A Pantaleo
- Institute of Hematology and Medical Oncology L. & A. Seragnoli, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy.
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41
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Bandrés E, Zárate R, Ramirez N, Abajo A, Bitarte N, García-Foncillas J. Pharmacogenomics in colorectal cancer: The first step for individualized-therapy. World J Gastroenterol 2007; 13:5888-901. [PMID: 17990354 PMCID: PMC4205435 DOI: 10.3748/wjg.v13.i44.5888] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Interindividual differences in the toxicity and response to anticancer therapies are currently observed in practically all available treatment regimens. A goal of cancer therapy is to predict patient response and toxicity to drugs in order to facilitate the individualization of patient treatment. Identification of subgroups of patients that differ in their prognosis and response to treatment could help to identify the best available drug therapy according the genetic profile. Several mechanisms have been suggested to contribute to chemo-therapeutic drug resistance: amplification or overexpression of membrane transporters, changes in cellular proteins involved in detoxification or in DNA repair, apoptosis and activation of oncogenes or tumor suppressor genes. Colorectal cancer (CRC) is regarded as intrinsically resistant to chemotherapy. Several molecular markers predictive of CRC therapy have been included during the last decade but their results in different studies complicate their application in practical clinical. The simultaneous testing of multiple markers predictive of response could help to identify more accurately the true role of these polymorphisms in CRC therapy. This review analyzes the role of genetic variants in genes involved in the action mechanisms of the drugs used at present in colorectal cancer.
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Herbertson RA, Lee ST, Tebbutt N, Scott AM. The expanding role of PET technology in the management of patients with colorectal cancer. Ann Oncol 2007; 18:1774-81. [PMID: 17434894 DOI: 10.1093/annonc/mdm108] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
The therapeutic options and subsequent survival of colorectal cancer (CRC) patients has increased substantially over recent years. While surgical excision of the primary cancer results in cure of approximately 50% of patients, recurrence and metastatic disease still remains a significant cause of death. Although resection of liver or lung metastases can result in cure, relapse rates remain high, indicating that patient selection needs improvement. Positron emission tomography (PET) technology has a great deal to offer with respect to CRC management, particularly in the setting of patient selection for metastasectomy and in the evaluation of possible recurrent disease, however it has not yet become a routine part of the management of all CRC patients. This review article aims to discuss the current and future implications of PET technology in the optimal management of CRC patients throughout their care pathway.
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Affiliation(s)
- R A Herbertson
- Ludwig Institute for Cancer Research, Melbourne Centre for Clinical Sciences, Harold Stokes Building, Austin Hospital, Heidelberg, Victoria, Australia.
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Tan MCB, Linehan DC, Hawkins WG, Siegel BA, Strasberg SM. Chemotherapy-induced normalization of FDG uptake by colorectal liver metastases does not usually indicate complete pathologic response. J Gastrointest Surg 2007; 11:1112-9. [PMID: 17623263 DOI: 10.1007/s11605-007-0218-8] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2007] [Accepted: 06/13/2007] [Indexed: 01/31/2023]
Abstract
Dramatic responses are being observed in colorectal cancer liver metastases treated with newer chemotherapeutic regimens. These have been associated with normalization of [(18)F]fluoro-2-deoxy-D-glucose (FDG) uptake (complete metabolic response) on follow-up Positron Emission Tomography with [(18)F]fluoro-2-deoxy-D-glucose (FDG-PET) scans in some patients. It is unclear how often complete metabolic response is indicative of complete tumor destruction. We analyzed a subset of patients who had neoadjuvant chemotherapy for hepatic metastases from colorectal adenocarcinoma. Inclusion criteria were: (1) FDG-avid hepatic lesions before initiation of chemotherapy; (2) complete metabolic response of the same lesions after chemotherapy; and (3) histopathologic examination of hepatic lesions. Complete pathologic response was defined as no histologically identifiable viable tumor. Fourteen patients fit the inclusion criteria. All had synchronous, hepatic-only colorectal metastases. On microscopic examination, complete pathologic response to the neoadjuvant regimen was found in only 5 of 34 lesions (15%) and in only 3 of the 14 patients (21%). Seven lesions had complete metabolic response and disappeared on computed tomography (CT); of these, six still contained viable tumor. We conclude that complete metabolic response on FDG-PET after neoadjuvant chemotherapy is an unreliable indicator of complete pathologic response. Therefore, currently, curative resection of liver metastases in these patients should not be deferred on the basis of FDG-PET findings.
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Affiliation(s)
- Marcus C B Tan
- Section of Hepato-Pancreato-Biliary and GI Surgery, Department of Surgery, Washington University School of Medicine, St Louis, MO 63110, USA
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Koh DM, Scurr E, Collins D, Kanber B, Norman A, Leach MO, Husband JE. Predicting response of colorectal hepatic metastasis: value of pretreatment apparent diffusion coefficients. AJR Am J Roentgenol 2007; 188:1001-8. [PMID: 17377036 DOI: 10.2214/ajr.06.0601] [Citation(s) in RCA: 299] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The purposes of this study were to determine whether the pretreatment apparent diffusion coefficients (ADCs) of hepatic metastatic lesions from colorectal cancer are predictive of response to chemotherapy and to compare the ADCs of metastatic lesions before and after chemotherapy. SUBJECTS AND METHODS Twenty patients with potentially operable hepatic lesions larger than 1 cm in diameter metastatic from colorectal carcinoma were prospectively evaluated with diffusion-weighted imaging at three b values before and after chemotherapy. Quantitative ADC maps were calculated with images with b values of 0, 150, and 500 s/mm2 (ADC0-500) and with images with b values of 150 and 500 s/mm2 (ADC150-500). Regions of interest were drawn around metastatic lesions and randomly over liver. The mean ADC0-500 and mean ADC150-500 of metastatic lesions before and after chemotherapy were compared according to response defined by Response Evaluation Criteria in Solid Tumors criteria. RESULTS Twenty-five responding and 15 nonresponding metastatic lesions were evaluated. Nonresponding lesions had a significantly higher pretreatment mean ADC0-500 and mean ADC150-500 than did responding lesions (Mann-Whitney U test, p < 0.002). There was a linear regression relation (r2 = 0.34, p = 0.02) between percentage size reduction of metastatic lesions and pretreatment mean ADC150-500. After chemotherapy, responding lesions had a significant increase in mean ADC0-500 and ADC150-500 (Wilcoxon's signed rank, p = 0.025). No significant change was observed in nonresponding metastatic lesions (Wilcoxon's signed rank, p > 0.5) or in normal liver parenchyma (Wilcoxon's signed rank, p > 0.4). CONCLUSION High pretreatment mean ADC0-500 and mean ADC150-500 of colorectal hepatic metastatic lesions were predictive of poor response to chemotherapy. A significant increase in mean ADC0-500 and ADC150-500 was observed in metastatic lesions that responded to chemotherapy. These findings may have implications for development of individualized therapy.
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Affiliation(s)
- Dow-Mu Koh
- Academic Department of Radiology, Royal Marsden Hospital, Downs Rd., Sutton, Surrey, United Kingdom, SM2 5PT
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