Prognostic value of pre-treatment F-18-FDG PET-CT in patients with hepatocellular carcinoma undergoing radioembolization

Prognostic factors influencing outcomes in hepatocellular carcinoma patients undergoing selective internal radiation therapy

Selective internal radiation therapy (SIRT) has emerged as a viable endovascular treatment strategy for hepatocellular carcinoma (HCC). According to the Barcelona Clinic Liver Cancer (BCLC) classification, SIRT is currently recommended for early- and intermediate-stage HCC that is unsuitable for alternative locoregional therapies. Additionally, SIRT remains a recommended treatment for patients with advanced-stage HCC and portal vein thrombosis (PVT) without extrahepatic metastasis. Several studies have shown that SIRT is a versatile and promising treatment with a wide range of applications. Consequently, given its favourable characteristics in various scenarios, SIRT could be an encouraging treatment option for patients with HCC across different BCLC stages. Over the past decade, an increasing number of studies have focused on better understanding the prognostic factors associated with SIRT to identify patients who derive the most benefit from this treatment or to refine the optimal technical procedures of SIRT. Several variables can influence treatment decisions, with a growing emphasis on a personalised approach. This review, based on the literature, will focus on the prognostic factors associated with the effectiveness of radioembolization and related complications. By comprehensively analysing these factors, we aimed to provide a clearer understanding of how to optimise the use of SIRT in managing HCC patients, thereby enhancing outcomes across various clinical scenarios.

Total Lesion Glycolysis on 18F-FDG PET/CT Is a Better Prognostic Factor Than Tumor Dose on 90Y PET/CT in Patients With Hepatocellular Carcinoma Treated With 90Y Transarterial Radioembolization

PURPOSE

This study aimed to evaluate the prognostic value of metabolic parameters on 18F-FDG PET/CT and tumor dose (TD) on posttreatment 90Y PET/CT in patients with hepatocellular carcinoma (HCC) who underwent 90Y transarterial radioembolization (TARE).

PATIENTS AND METHODS

Forty-seven HCC patients treated with 90Y TARE were retrospectively enrolled between January 2013 and October 2018. 18F-FDG PET/CT was performed before treatment. Maximum tumor SUV-to-mean normal liver SUV ratio (TLR), metabolic tumor volume (MTV), and total lesion glycolysis (TLG) were measured for each patient. Voxel dosimetry was performed on 90Y PET/CT images to measure TD. The prognostic significance of metabolic parameters on 18F-FDG PET/CT, TD on 90Y PET/CT, and clinical factors for overall survival (OS) was evaluated. In addition, TD on 90Y PET/CT was analyzed in relation to the administered dose of 90Y-labeled microspheres and metabolic parameters on 18F-FDG PET/CT.

RESULTS

The median patient age was 57 years, and 37 patients (78.7%) were men. During the follow-up period, 25 patients (53.2%) died. In univariable analysis, Barcelona Clinic Liver Cancer stage C, Child-Pugh score, TD on 90Y PET/CT, TLR, MTV, and TLG were significant prognostic factors affecting OS (P < 0.05). In multivariable analysis, Barcelona Clinic Liver Cancer stage C and high TLG on 18F-FDG PET/CT were independent prognostic factors for OS (P < 0.05). The 1-year OS rates were 72.9% in patients with low TLG and 33.3% in patients with high TLG (P < 0.05). We also found that TD on 90Y PET/CT was not correlated with the administered dose of 90Y-labeled microspheres, but negatively correlated with TLG on pretreatment 18F-FDG PET/CT (P < 0.05).

CONCLUSIONS

TLG, a parameter incorporating both the degree of 18F-FDG uptake and amount of metabolically active tumor volume on pretreatment 18F-FDG PET/CT, is a better prognostic factor than TD on 90Y PET/CT for predicting OS in HCC patients treated with 90Y TARE.

Is there utility for fluorine-18-fluorodeoxyglucose positron-emission tomography scan before surgery in breast cancer? A 15-year overall survival analysis

BACKGROUND

The prognostic value of preoperative fluorine-18-fluorodeoxyglucose positron-emission tomography (¹⁸F-FDG PET) scan for determining overall survival (OS) in breast cancer (BC) patients is controversial.

AIM

To evaluate the OS predictive value of preoperative PET positivity after 15 years.

METHODS

We performed a retrospective search of the Universitair Ziekenhuis Brussel patient database for nonmetastatic patients who underwent preoperative PET between 2002-2008. PET positivity was determined by anatomical region of interest (AROI) findings for breast and axillary, sternal, and distant sites. The prognostic role of PET was examined as a qualitative binary factor (positive vs negative status) and as a continuous variable [maximum standard uptake value (SUVmax)] in multivariate survival analyses using Cox proportional hazards models. Among the 104 identified patients who received PET, 36 were further analyzed for the SUVmax in the AROI.

RESULTS

Poor OS within the 15-year study period was predicted by PET-positive status for axillary (P = 0.033), sternal (P = 0.033), and combined PET-axillary/sternal (P = 0.008) nodes. Poor disease-free survival was associated with PET-positive axillary status (P = 0.040) and combined axillary/sternal status (P = 0.023). Cox models confirmed the long-term prognostic value of combined PET-axillary/sternal status [hazard ratio (HR): 3.08, 95% confidence interval: 1.42-6.69]. SUVmax of ipsilateral breast and axilla as continuous covariates were significant predictors of long-term OS with HRs of 1.25 (P = 0.048) and 1.54 (P = 0.029), corresponding to relative increase in the risk of death of 25% and 54% per SUVmax unit, respectively. In addition, the ratio of the ipsilateral axillary SUVmax over the contralateral axillary SUVmax was the most significant OS predictor (P = 0.027), with 1.94 HR, indicating a two-fold relative increase of mortality risk.

CONCLUSION

Preoperative PET is valuable for prediction of long-term survival. Ipsilateral axillary SUVmax ratio over the uninvolved side represents a new prognostic finding that warrants further investigation.

Optimization of the Clinical Effectiveness of Radioembolization in Hepatocellular Carcinoma with Dosimetry and Patient-Selection Criteria

Selective internal radiation therapy (SIRT) is part of the treatment strategy for hepatocellular carcinoma (HCC). Strong clinical data demonstrated the effectiveness of this therapy in HCC with a significant improvement in patient outcomes. Recent studies demonstrated a strong correlation between the tumor response and the patient outcome when the tumor-absorbed dose was assessed by nuclear medicine imaging. Dosimetry plays a key role in predicting the clinical response and can be optimized using a personalized method of activity planning (multi-compartmental dosimetry). This paper reviews the main clinical results of SIRT in HCC and emphasizes the central role of dosimetry for improving it effectiveness. Moreover, some patient and tumor characteristics predict a worse outcome, and toxicity related to SIRT treatment of advanced HCC patient selection based on the performance status, liver function, tumor characteristics, and tumor targeting using technetium-99m macro-aggregated albumin scintigraphy can significantly improve the clinical performance of SIRT.

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

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

Biomarkers in Hepatobiliary Cancers: What is Useful in Clinical Practice?

Hepatocellular carcinoma (HCC) and biliary tract cancers (BTC) exhibit a poor prognosis with 5-year overall survival rates around 15%, all stages combined. Most of these primary liver malignancies are metastatic at diagnostic, with only limited therapeutic options, relying mainly on systemic therapies. Treatment modalities are different yet partially overlapping between HCC and BTC. The complex molecular profile of BTC yields to several actionable therapeutic targets, contrary to HCC that remains the field of antiangiogenic drugs in non-molecularly selected patients. Immunotherapy is now validated in the first line in HCC in combination with bevacizumab, while clinical activity of single agent immunotherapy appears limited to a subset of patients in BTC, still poorly characterized, and combinations are currently under investigation. In this review, we provide a critical evaluation and grading of clinical relevance on (i) the main prognostic biomarkers in HCC and BTC, (ii) the main theragnostic biomarkers in both tumors, and lastly (iii) what is recommended in clinical practice.

Zinc Finger Protein St18 Protects against Septic Death by Inhibiting VEGF-A from Macrophages

Zinc finger protein St18 was initially reported as candidate tumor suppressor gene, and also suggested that fibroblast St18 positively regulates NF-κB activation. Despite the pleiotropic functions of St18, little is known about its roles in macrophages. Here, we report that myeloid St18 is a potent inhibitor of VEGF-A. Mice lacking St18 in myeloid lineages exhibit increased retinal vasculature with enhanced serum VEGF-A concentrations. Despite the normal activation of NF-κB target genes, these mice are highly susceptible to LPS-induced shock, polymicrobial sepsis, and experimental colitis, accompanied by enhanced vascular and intestinal leakage. Pharmacological inhibition of VEGF signaling rescued the high mortality rate of myeloid-specific St18-deficient mice in response to inflammation. Mechanistically, St18 directly binds to Sp1 and attenuates its activity, leading to the suppression of Sp1 target gene VEGF-A. Using mouse genetic and pharmacological models, we reveal myeloid St18 as a critical septic death protector.

Role of PET/CT in patients with unexplained rising alpha fetoprotein post HCC interventional management

Background

Positron emission tomography–computed tomography (PET/CT) is considered a powerful modality in the follow-up of hepatocellular carcinoma (HCC) patients. In this study, PET/CT was done in an evaluation of patients with unexplained rising alpha fetoprotein (AFP) post hepatocellular carcinoma (HCC) interventional management in 40 patients (16 females and 24 males); their age ranged from 25 to 82 years, had undergone interventional management for HCC and underwent PET/CT follow-up within an 8-month duration from their intervention. Whole-body PET/CT was performed after injection of (18)-FDG, and the results were read in a masked manner by two specialists, and diagnostic performance was assessed from the results of consensus masked reading. All the results were evaluated with the Barcelona criteria and biopsy correlation.

Results

During the follow-up PET/CT, 24 patients had complete response and 8 patients showed focal residual while the rest 8 patients showed newly developed lesions.

Conclusion

PET/CT is an excellent method for the evaluation of HCC patients with equivocal results after interventional management.

Emerging role of 18F-fluorodeoxyglucose positron emission tomography for guiding management of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is one of major causes of cancer mortality worldwide. For decades, ¹⁸F-fluorodeoxyglucose (FDG) positron emission tomography (PET) has been widely used for staging, predicting prognosis, and detecting cancer recurrence in various types of malignant diseases. Due to low sensitivity of FDG PET for detecting intrahepatic HCC lesions, the clinical value of FDG PET in HCC patients has been limited. However, recent studies with diverse analytic methods have shown that FDG PET has promising role in aiding management of HCC patients. In this review, we will discuss the clinical role of FDG PET for staging, predicting prognosis, and evaluating treatment response in HCC. Further, we will focus on recent clinical studies regarding implication of volumetric FDG PET parameters, the significance of FDG uptake in HCC for selecting treatment and predicting treatment response, and the use of radiomics of FDG PET in HCC.

Using the Albumin-Bilirubin (ALBI) grade as a prognostic marker for radioembolization of hepatocellular carcinoma

Background

The Child-Pugh (CP) class is a commonly used scoring system to measure liver function in patients with hepatocellular carcinoma (HCC). We correlate the Albumin-Bilirubin (ALBI) grading system and CP to overall survival in our HCC patients receiving radioembolization.

Methods

We retrospectively evaluated patients who received radioembolization for HCC between the years 2009-2014. We evaluated the albumin and bilirubin levels in our patients prior to receiving their first (n=124) radioembolization. The ALBI grades were calculated from these data with the formula (log₁₀ bilirubin ×0.66) + (albumin × -0.085) and correlated to outcomes using Mantel-Cox Log analysis. These statistical comparisons were duplicated with CP classes.

Results

Median survival differences between CP class A and B and between ALBI grade 1 and 2 were 4.7 and 9.9 months, respectively. A subset of ALBI grades 1 and 2 were identified within our CP class A patients with a median survival difference of 9.9 months.

Conclusions

ALBI is a more sensitive marker of liver function than CP in the setting of mild dysfunction. Using ALBI, we identified a subset of patients that have significantly better outcomes from Y-90 radioembolization than previously identified with CP.

Efficacy of contrast-enhanced FDG PET/CT in patients awaiting liver transplantation with rising alpha-fetoprotein after bridge therapy of hepatocellular carcinoma

OBJECTIVE

To assess the diagnostic accuracy and illustrate positive findings of contrast-enhanced fluorine-18 fluoro-D-glucose positron emission tomography/computed tomography (¹⁸F-FDG PET/CT) image in patients awaiting liver transplantation (LT) with rising alpha-fetoprotein (AFP) after bridge therapy of hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

This prospective study included 100 patients who were waiting for LT and who previously underwent locoregional therapy (LRT) of HCC. These patients had rising AFP levels on a routine follow-up examination awaiting LT. All patients underwent a contrast-enhanced ¹⁸F-FDG PET/CT examination. We calculated for each patient the maximum standardised uptake value (SUVmax) of the tumour and the ratio of the tumoral SUVmax to the normal-liver SUVmax. The diagnostic accuracy and positive contrast-enhanced findings of ¹⁸F-FDG PET/CT were established by histopathology and clinical and imaging follow-up as the reference standards.

RESULTS

Contrast-enhanced ¹⁸F-FDG PET/CT detected tumour relapse in 78 patients (13 patients had intrahepatic lesions, 10 patients had extrahepatic metastases and 55 patients with combined lesions). The sensitivity, specificity and accuracy values of contrast-enhanced ¹⁸F-FDG PET/CT examination in the detection of HCC recurrence were 92.8%, 94.1% and 93%, respectively. A significant correlation was found between the AFP level and SUVmax ratio (r = 0.2283; p = 0.0224). The best threshold for ¹⁸F-FDG PET positivity was >1.21.

CONCLUSION

Contrast-enhanced ¹⁸F-FDG PET/CT is a valuable tool for the detection of intrahepatic HCC recurrence or extrahepatic metastasis following rising AFP levels after LRT of HCC, and should be incorporated during routine workup awaiting LT.

KEY POINTS

• ¹⁸F-FDG PET/CT is a valuable tool for the detection of HCC recurrence • ¹⁸ F-FDG PET/CT should be incorporated during routine workup awaiting liver transplantation • Significant correlation was found between AFP level and SUVmax ratio • The best threshold for ¹⁸ F-FDG PET positivity was >1.21 • The ideal cut-off value for AFP was >202.

Signature of survival: a 18F-FDG PET based whole-liver radiomic analysis predicts survival after 90Y-TARE for hepatocellular carcinoma

Purpose

To generate a predictive whole-liver radiomics scoring system for progression-free survival (PFS) and overall survival (OS) in patients undergoing transarterial radioembolization using Yttrium-90 (⁹⁰Y-TARE) for unresectable hepatocellular carcinoma (uHCC).

Results

The generated pPET-RadScores were significantly correlated with survival for PFS (median of 11.4 mo [95% confidence interval CI: 6.3–16.5 mo] in low-risk group [PFS-pPET-RadScore < 0.09] vs. 4.0 mo [95% CI: 2.3–5.7 mo] in high-risk group [PFS-pPET-RadScore > 0.09]; P = 0.0004) and OS (median of 20.3 mo [95% CI: 5.7–35 mo] in low-risk group [OS-pPET-RadScore < 0.11] vs. 7.7 mo [95% CI: 6.0–9.5 mo] in high-risk group [OS-pPET-RadScore > 0.11]; P = 0.007). The multivariate analysis confirmed PFS-pPET-RadScore (P = 0.006) and OS-pPET-RadScore (P = 0.001) as independent negative predictors.

Conclusion

Pretreatment ¹⁸F-FDG PET whole-liver radiomics signature appears as an independent negative predictor for PFS and OS in patients undergoing ⁹⁰Y-TARE for uHCC.

Methods

Pretreatment ¹⁸F-FDG PET of 47 consecutive patients undergoing ⁹⁰Y-TARE for uHCC (31 resin spheres, 16 glass spheres) were retrospectively analyzed. For each patient, based on PET radiomics signature from whole-liver semi-automatic segmentation, PFS and OS predictive PET-radiomics scores (pPET-RadScores) were obtained using LASSO Cox regression. Using X-tile software, the optimal score to predict PFS (PFS-pPET-RadScore) and OS (OS-pPET-RadScore) served as cutoff to separate high and low-risk patients. Survival curves were estimated using the Kaplan-Meier method. The prognostic value of PFS and OS-pPET-RadScore, Barcelona-Clinic Liver Cancer staging system and serum alpha-fetoprotein level was analyzed to predict PFS and OS in multivariate analysis.

Clinical usefulness of FDG-PET in patients with hepatocellular carcinoma undergoing surgical resection

Backgrounds/Aims

Diagnosis and staging of hepatocellular carcinoma (HCC) is critical because of the variety of treatment methods and prognosis. [¹⁸F]fludeoxyglucose-positron emission tomography/computed tomography ([¹⁸F]FDG-PET/CT) has been suggested as a diagnostic modality in HCC. The purpose of this study is to evaluate the accuracy of FDG-PET for staging of HCC after surgical resection and histological confirmation.

Methods

We retrospectively collected data of 56 patients that underwent FDG-PET before surgical resection for HCC March 2011–May 2017, all of whom were suitable for resection by conventional HCC staging. Results of the maximal standardized uptake value (SUVmax) were compared with histological confirmation.

Results

A larger tumor size was related with higher SUVmax (≥4.9). The serum alpha-feto protein was associated with SUVmax. Recurrence rate was higher in patients with higher SUVmax and patients with lower SUVmax had a better survival rate.

Conclusions

The SUVmax correlates well with tumor size and factors associated with biological behavior of HCC such as alpha-feto protein, and it could be a beneficial modality in providing prognostic information for HCC.

Preoperative [18]fluorodeoxyglucose-positron emission tomography/computed tomography in early stage breast cancer: Rates of distant metastases

AIM

To investigate rates of distant metastases (DM) detected with [18]fluorodeoxyglucose-positron emission tomography/computed tomography (18FDG-PET/CT) in early stage invasive breast cancer.

METHODS

We searched the English language literature databases of PubMed, EMBASE, ISI Web of Knowledge, Web of Science and Google Scholar, for publications on DM detected in patients who had 18FDG-PET/CT scans as part of the staging for early stages of breast cancer (stage I and II), prior to or immediately following surgery. Reports published between 2011 and 2017 were considered. The systematic review was conducted according to the PRISMA guidelines.

RESULTS

Among the 18 total studies included in the analysis, the risk of DM ranged from 0% to 8.3% and 0% to 12.9% for stage I and II invasive breast cancer, respectively. Among the patients with clinical stage II, the rate of occult metastases diagnosed by 18FDG-PET/CT was 7.2% (range, 0%-19.6%) for stage IIA and 15.8% (range, 0%-40.8%) for stage IIB. In young patients (< 40-year-old), 18FDG-PET/CT demonstrated a higher prevalence of DM at the time of diagnosis for those with aggressive histology (i.e., triple-negative receptors and poorly differentiated grade).

CONCLUSION

Young patients with poorly differentiated tumors and stage IIB triple-negative breast cancer may benefit from 18FDG-PET/CT at initial staging to detect occult DM prior to surgery.