Preoperative Fluorodeoxyglucose Positron Emission Tomography Research Articles

Prognostic prediction using maximum standardized uptake value ratio of lymph node-to-primary tumor in preoperative PET-CT for oral squamous cell carcinoma

This study aimed to calculate the ratio of maximum standardized uptake values of cervical lymph nodes to maximum standardized uptake values of primary tumors measured by preoperative fluorodeoxyglucose positron-emission tomography in oral cancer patients, and to retrospectively examine the prognostic association and evaluate whether it could be a prognostic factor. We retrospectively examined consecutive Japanese patients diagnosed with oral squamous cell carcinoma who underwent oral cancer resection and cervical dissection between January 2014 and December 2018. The study included 52 patients aged 39–89 years (median age 66.5 years), excluding non-cervical dissection surgery and/or non-underwent preoperative positron-emission tomography. The maximum standardized uptake value of the cervical lymph nodes and primary tumor was measured, and the ratio of maximum standardized uptake values of the lymph nodes to that of the primary tumor was calculated. The median follow-up of 52 patients was 1,465 days (198–2,553 days), and overall survival was significantly worse in patients with a high lymph node-to-tumor standardized uptake values ratio (>0.4739) (5 years, 58.8% vs. 88.2%; P<0.05). Pretreatment lymph node-to-tumor standardized uptake values ratio can be easily calculated, and as a predictor of prognosis, it may be of assistance when considering the treatment strategy for oral cancer.

Value of SUVmax for the Prediction of Bone Invasion in Oral Squamous Cell Carcinoma.

In advanced oral squamous cell carcinoma (OSCC), accurate planning of surgical resection and reconstruction are crucial for outcome and postoperative function. For OSCC close to the maxilla or mandible, prediction of bone invasion is necessary. The aim of this study was to examine whether metabolic tumor imaging obtained by fluorodeoxyglucose positron emission tomography (FDG-PET) could enhance preoperative predictability of bone invasion. We performed an analysis of 84 treatment-naïve OSCCs arising from gum (upper and lower), hard palate, floor of mouth, and retromolar trigone treated at the University Hospital Zurich, Switzerland, who underwent wide local excision with free flap reconstruction between 04/2010 and 09/2018 and with available preoperative FDG-PET. Prediction of bone invasion by metabolic tumor imaging such as maximum standardized uptake value (SUVmax) was examined. On definitive histopathology, bone invasion was present in 47 of 84 cases (56%). The probability of bone infiltration increased with a higher pretherapeutic SUVmax in an almost linear manner. A pretherapeutic SUVmax of primary tumor below 9.5 ruled out bone invasion preoperatively with a high specificity (97.6%). The risk of bone invasion was 53.6% and 71.4% for patients with SUVmax between 9.5–14.5 and above 14.5, respectively. Patients with bone invasion had worse distant metastasis-free survival compared to patients without bone invasion (log-rank test, p = 0.032). In conclusion, metabolic tumor imaging using FDG-PET could be used to rule out bone invasion in oral cancer patients and may serve in treatment planning.

Association of the primary tumor's SUVmax with survival after surgery for clinical stage IA esophageal cancer: a single-center retrospective study.

Compared to other esophageal cancers, clinical stage IA esophageal cancer generally has a good prognosis, although a subgroup of patients has a poor prognosis. Unfortunately, clinical diagnoses of invasion depth or lymph node metastasis are not always accurate, which make it difficult to identify patients with a high risk of postoperative recurrence using the tumor-node-metastasis staging system. Fluorodeoxyglucose-positron emission tomography may help guide the identification of malignant tumors and the evaluation of their malignant grade based on glucose metabolism. We aimed to evaluate the association between pre-operative fluorodeoxyglucose-positron emission tomography findings and the postoperative prognosis of patients with clinical stage IA esophageal cancer. This single-center retrospective study evaluated pre-esophagectomy fluorodeoxyglucose-positron emission tomography findings from 38 patients with clinical stage IA esophageal cancer. Receiver operating characteristic curve analysis was performed to evaluate the prognostic significance of the primary tumor having low and high SUVmax values (cut-off: 3.56). Overall survival (log-rank p = 0.034) and progression-free survival (log-rank p = 0.008) were significantly different between the groups with low SUVmax values (n = 18) and high SUVmax values (n = 20). Furthermore, the primary tumor's SUVmax value was related to pathological vascular invasion (p = 0.045) and distant metastasis (p = 0.042). The SUVmax of the primary tumor is a predictor of postoperative survival for clinical stage IA esophageal cancer. Thus, using fluorodeoxyglucose-positron emission tomography to evaluate the primary tumor's glucose metabolism may reflect the tumor's grade and potentially compensate for inaccuracies in tumor-node-metastasis staging.

Influence of Body Mass Index on the Prognostic Value of Tumor ¹⁸F-FDG Uptake in Stage I Non-Small Cell Lung Cancer.

BackgroundThe impact of host energy balance status on outcome of lung cancer has not been fully explored. It is also unknown if there is a potential modifying effect of body mass index (BMI) on tumor cell behavior in patients with early-stage non-small cell lung cancer (NSCLC). We therefore investigated the interactive effects of tumor [18F]-fluorodeoxyglucose (FDG) avidity and BMI.MethodsWe investigated 1,197 patients with stage I NSCLC who underwent preoperative FDG positron emission tomography followed by curative resection. The primary outcome measure was disease-free survival (DFS). A multivariable Cox proportional hazards model was used to assess the potential independent effects of the prognostic variables. A stratified Cox regression analysis was also performed to assess the potential modifying effects of BMI on the relationship between tumor FDG uptake and patient survival.ResultsThere were 145 tumor recurrences and 19 deaths during a median follow-up of 30 months. Tumor-related variables, including tumor size, maximum standardized uptake value (SUVmax), histologic cell type, differentiation, lymphovascular invasion, and visceral pleural invasion, did not differ significantly according to BMI status. In multivariable Cox regression analysis, overweight or obesity [hazard ratio (HR), 0.59; 95% CI, 0.43–0.81; P = 0.001] and tumor SUVmax (HR, 1.72; 95% CI, 1.43–2.07; P < 0.001) were significantly associated with DFS. There was a significant modifying effect of BMI (P for interaction < 0.001 in multivariable analysis). High tumor SUVmax was more strongly associated with worse DFS in normal weight patients (HR, 4.72; 95% CI, 2.77–8.06; P < 0.001) than in overweight or obese patients (HR, 2.61; 95% CI, 1.58–4.31; P < 0.001).ConclusionsTumor FDG avidity is an independent predictor of DFS in patients with early-stage NSCLC and this prognostic value was strengthened in normal weight patients than in overweight or obese patients. These results suggest that the host-tumor interaction between host energy balance status and tumor glucose metabolism plays an important role in the outcome of early-stage NSCLC.

False-positive fluorodeoxyglucose positron emission tomography results after chemotherapy in patients with metastatic seminoma

IntroductionThe treatment of residual masses after chemotherapy in seminomas remains a controversial topic. Postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) in all patients would lead to severe overtreatment with a high rate of complications and additional procedures. For this reason, fluorodeoxyglucose positron emission tomography (FDG-PET) was introduced. FDG-PET has an accuracy of 88%. In 15% of cases, FDG-PET findings are false positive (FP) with unclear consequences. Therefore, we retrospectively investigated the rate of unnecessary procedures due to FP results on FDG-PET. Materials and methodsBetween July 2003 and September 2013 we performed 305 PC-RPLNDs in 277 patients, 22 because of metastatic seminoma. Of them, 11 patients had a preoperative FDG-PET at least 6 weeks after chemotherapy. Indication for surgery was a marker-negative progression of the lesion in 7 patients who did not undergo FDG-PET, a marker-negative progression with a negative result on FDG-PET in 2 patients, and a positive result on FDG-PET with normal markers in 9 patients. Furthermore, PC-RPLND was indicated in 3 patients because of ureteral compression/infiltration with ureteral stents or nephrostomies. In 1 patient, there was uncertainty whether the initial retroperitoneal tumor contained choriocarcinoma elements. Standardized uptake values (SUVs) were recorded for all patients undergoing FDG-PET. ResultsThe FDG-PET findings were FP in 7 of 11 (64%) patients. The median age of the patients was 45.4 years (39–49). The median SUV in the patients was 6.6 (3.1–11.6), and the median diameter of the residual mass was 6.8cm (2.9–11). In 4 of 7 patients, intraoperative or postoperative complications occurred (polar artery ligation with functional loss, bilateral non–nerve-sparing technique with retrograde ejaculation, ureteral replacement with an ileal segment, and pulmonary embolism). ConclusionIn patients with metastatic seminoma who received chemotherapy, FDG-PET is a valuable tool to evaluate whether the residual mass contains viable tumor tissue or only necrosis. Nevertheless, because of FP results, a subgroup is overtreated with consecutive mortality or morbidity. We suggest an alternative therapy algorithm. In case of a positive result on FDG-PET studies, at least 8 weeks after the end of the chemotherapy, only a minority require surgery (e.g., patients with ureteral compression, patients with high risk of recurrence, or patients with unclear initial histology). In all other cases, we suggest a repeat FDG-PET study at least 6 weeks after the initial PET scan. Only in cases of increased SUVs or progressive disease histology should be obtained, all others can be on active surveillance.

A survival benefit of major hepatectomy for hepatocellular carcinoma identified by preoperative [18F] fluorodeoxyglucose positron emission tomography in patients with well-preserved hepatic function

Hepatic resection can cure hepatocellular carcinoma (HCC). However, the optimal extent of resection remains controversial. Major hepatectomy could minimize a tumor recurrence, but it is harmful due to decreased hepatic functional reserve. [18F] fluorodeoxyglucose positron emission tomography (FDG-PET) scans are known as their reflection tumor differentiation and biological activity in HCC. To evaluate a benefit of major hepatectomy for HCC, we performed this retrospective analysis in patients with well-preserved hepatic function, and further analyzed in the subset identified by preoperative FDG-PET. We reviewed the medical records of 189 patients with HCC who underwent curative resection between August 2004 and December 2010 at two institutes. All patients underwent anatomical resection, either by major or minor hepatectomy. Median overall survival did not differ significantly between the major and minor hepatectomy groups (29.4 versus 26.3 months, p = 0.269). However, the major hepatectomy group had a better recurrence-free survival (24.5 versus 19.9 months, p = 0.004). On multivariate analysis, the presence of intrahepatic metastasis independently predicted overall survival (p = 0.009), but other examined variables did not. Overall survival and recurrence-free survival were significantly better following major hepatectomy rather than minor hepatectomy in patients whose preoperative FDG-PET indicated that the maximum standardized uptake value of the tumor (SUVtumor) was ≥4 and the tumor-to-nontumor SUV ratio (TNR) was ≥1.5. Our findings suggest that preoperative FDG-PET may be useful in identifying patients with favorable hepatic reserve who are most likely to benefit from major rather than minor hepatectomy.

Abstract LB-296: FDG-PET avidity negatively impacts survival in pStage I NSCLC in the ACOSOG Z4031 trial.

Abstract Background: Fluoro-deoxyglucose positron emission tomography (FDG-PET) scans are used for diagnosis and staging of known or suspected non-small cell lung cancer (NSCLC). Single institution studies examining the impact of avidity on survival have reported mixed results. The purpose of this study is to evaluate the association between FDG-PET avidity and survival in the national prospective ACOSOG Z4031 trial in patients with pathological Stage I NSCLC. Methods: Between 2004 and 2006, 1074 patients with known or suspected clinical stage I (cT1-2N0M0) NSCLC were enrolled in the ACOSOG Z4031 trial and underwent surgical resection. FDG-PET results were abstracted from radiology interpretations included in the case report forms. FDG-PET avidity was categorized based on either radiologist description or reported maximum standard uptake value (SUV). The four categories were: 1) not avid and not cancerous (SUV=0), 2) low avidity and likely not cancerous (SUV&amp;gt;0 and &amp;lt;2.5), 3) avid and probably cancerous (SUV≥2.5 and &amp;lt;5) and 4) highly avid and likely cancerous (SUV≥5). The lesion was classified as avid if in categories 3 or 4. The final diagnosis was determined by pathological examination and all cause mortality was reported. Cox proportional hazard regression was used to assess the impact of FDG-PET avidity on survival. The covariates used in the model included pStage, gender, age, race, and preoperative lesion size. Kaplan-Meier survival curves were calculated and the log-rank test was used to determine differences in survival based on FDG-PET avidity. Results: There were 51 enrolling sites in 39 cities with 969 eligible participants. Preoperative FDG-PET results were available for 540 participants with NSCLC and 81% had FDG-PET avid or highly avid lesions. 400 patients had pStage I NSCLC and the 5 year survival was 70% with 95%CI (65%, 75%). FDG-PET avidity, male gender, age, and lesion size negatively impacted survival. FDG-PET avidity in pStage I disease still negatively impacted survival (p=0.03) when controlling for lesion size. The 5 year survival for Stage I disease was 80% with 95%CI (68%, 88%) in FDG-PET negative patients and 67% with 95% CI (61%, 72%) in FDG-PET positive patients (p=0.02). Conclusions: In a national surgical population with pathological stage I NSCLC, FDG-PET avidity negatively impacted five year survival, independently of lesion size. Further work should be done to determine if chemotherapy would be beneficial in patients with PET avid lesions and pStage I NSCLC. Citation Format: Eric L. Grogan, Stephen A. Deppen, Heidi Chen, Karla V. Ballman, Francys C. Verdial, Melinda C. Aldrich, Paul A. Decker, David H. Harpole, Robert J. Cerfolio, Robert J. Keenan, David R. Jones, Thomas A. D'Amico, Joseph B. Shrager, Bryan F. Meyers, Joe B. Putnam. FDG-PET avidity negatively impacts survival in pStage I NSCLC in the ACOSOG Z4031 trial. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr LB-296. doi:10.1158/1538-7445.AM2013-LB-296

The maximum standardized uptake value of fluorodeoxyglucose positron emission tomography of the primary tumour is a good predictor of pathological nodal involvement in clinical N0 non-small-cell lung cancer

Fluorodeoxyglucose positron emission tomography (FDG-PET) plays an important role in the evaluation of resectable non-small-cell lung cancer (NSCLC). However, this modality cannot be used to detect histological nodal involvement, which can result in stage-migration for resectable lung cancer. In this study, we tried to evaluate the possibility of predicting histological nodal involvement in patients with NSCLC using the maximum standardized uptake value (SUVmax) of FDG-PET of the primary tumour instead of that of the lymph nodes. Between February 2008 and September 2011, 898 patients underwent lung cancer surgery at our institute. Among them, we retrospectively analysed 265 patients with clinical N0 NSCLC, who underwent preoperative FDG-PET. The relationships between clinicopathological features, including the findings of FDG-PET and pathological nodal involvement, were investigated. The factors investigated were age, gender, preoperative carcinoembryonic antigen titre, maximum tumour dimension, consolidation/tumour dimension ratio (C/T ratio), SUVmax in the primary tumour and smoking history. Of the 265 clinical N0 NSCLC patients, 214 (80.8%) had pathological N0 status and 27 (10.2%) and 24 (9.0%) had pathological N1 and N2 disease. In a multivariate analysis, the C/T ratio (P = 0.046) and SUVmax of the primary tumour (P = 0.016) were significant predictors of pathological nodal involvement. With regard to pathological N1-2 disease, the sensitivity, specificity, accuracy and positive and negative predictive values of mediastinal node involvement in patients with NSCLC with an SUVmax for FDG-PET of 10 or more were 49.0, 83.2, 76.6, 41.0 and 87.3%, respectively. Of the 61 patients with NSCLC with an SUVmax for FDG-PET of 10 or more, 25 (41.0%) had pathological N1-2 disease, while only 26 (12.7%) of the remaining 204 patients with an SUVmax for FDG-PET of <10 had nodal disease (P < 0.0001). Postoperative nodal status was significantly predicted by the SUVmax of FDG-PET of the primary tumour instead of the lymph nodes themselves. The patients with NSCLC in particular who show strong uptake values of SUVmax in the primary tumour could have occult nodal metastases, and may be indicated for a further preoperative modality for an accurate staging.

Voxel-based comparison of preoperative FDG-PET between mesial temporal lobe epilepsy patients with and without postoperative seizure-free outcomes

This study aims to elucidate differences in preoperative cerebral glucose metabolism between patients who did and did not become seizure free after unilateral mesial temporal lobe epilepsy (mTLE) surgery. We hypothesized that regional glucose metabolism on preoperative fluorodeoxyglucose positron emission tomography (FDG-PET) in patients with seizure-free outcomes differed from that in patients who were not seizure free after appropriate epilepsy surgery for unilateral mTLE. In this study, we compared preoperative FDG-PET findings between these two patient groups by applying a statistical analysis approach, with a voxel-based Asymmetry index (AI), to improve sensitivity for the detection of hypometabolism. FDG-PET scans of 28 patients with medically refractory mTLE, of whom 17 achieved a seizure-free outcome (Engel class 1 a-b) during a postoperative follow-up period of at least 2 years, were analyzed retrospectively. Voxel values were adjusted by the AI method as well as the global normalization (GN) method. Two types of statistical analysis were performed. One was a voxel severity analysis with comparison of voxel values at the same coordinate, and the other was extent analysis with comparison of the number of significant voxels in the anatomical areas predefined with Talairach's atlas. In the voxel severity analysis, significant hypometabolism restricted to the ipsilateral temporal tip and hippocampal area was detected in the postoperative seizure-free outcome group as compared to controls. No significant area was detected in the non-seizure-free group as compared to controls (family-wise error corrected, p < 0.05). With extent analysis using a low threshold, the extents of hypometabolism in the ipsilateral hippocampal, frontal and thalamic areas were larger in the seizure-free than in the non-seizure-free group (p = 0.01, 0.03 and 0.01, respectively.) On the other hand, in the contralateral frontal and thalamic areas, extents of hypometabolism were smaller in the seizure-free than in the non-seizure-free group (p = 0.01 and 0.01). We found the preoperative distribution of hypometabolism to differ between the two patient groups. Severe hypometabolism restricted to the unilateral temporal lobe, with ipsilateral dominant hypometabolism including mild decreases, may support the existence of an epileptogenic focus in the unilateral temporal lobe and a favorable seizure outcome after mTLE surgery.

Accuracy of FDG-PET to diagnose lung cancer in the ACOSOG Z4031 trial.

7008 Background: Fluoro-deoxyglucose positron emission tomography (FDG-PET) is recommended for diagnosis and staging of known or suspected NSCLC. Meta-analyses examining the accuracy of FDG-PET to diagnose lung cancer demonstrated high sensitivity 94% and specificity 83% but were performed in select centers. The purpose of this study is to evaluate the accuracy of FDG-PET to diagnose NSCLC and examine enrolling site differences in the national prospective ACOSOG Z4031 trial. Methods: 1,074 patients with clinical stage I (cT1-2N0M0) known or suspected NSCLC were enrolled between 2004 and 2006 in the Z4031 study and underwent surgical resection. The final diagnosis was determined by pathological examination. FDG-PET results were abstracted from radiology interpretations included in the case report forms. FDG-PET avidity was categorized based on either radiologist description or reported maximum standard uptake value (SUV). The four categories were: not avid and not cancerous (SUV=0), low avidity and likely not cancerous (SUV&gt;0 and &lt;2.5), avid and probably cancerous (SUV&gt;2.5 and &lt;5) and highly avid and likely cancerous (SUV&gt;5). Sensitivity analysis of FDG-PET diagnostic accuracy was performed for varying levels of avidity and by preoperative lesion size. Differences in accuracy by enrolling site were examined. Results: There were 51 enrolling sites in 39 cities with 969 eligible participants. Preoperative FDG-PET results were available for 682 participants. Lung cancer prevalence was 83%. FDG-PET sensitivity was 82% (95% CI: 79-85), and specificity was 31% (95% CI: 23-40). Positive and negative predictive values were 85% and 26%, respectively and accuracy improved with lesion size. There were 80 false positive scans and 69% were granulomas. False negative scans occurred in 101 patients (11were ≤10mm) with adenocarcinoma, squamous, bronchoalveolar cell and neuroendocrine tumors responsible for 64%, 12%, 10% and 8% of false negative results, respectively. Specificity did not differ between the 8 sites with &gt;25 patients (p=0.74). Conclusions: In a national surgical population with clinical stage I NSCLC, FDG-PET to diagnose lung cancer performed poorly compared to published studies. Reasons for poor test performance should be explored.

Influence of ROI definition, partial volume correction and SUV normalization on SUV–survival correlation in oesophageal cancer

An explanation for the discrepancies in the reported correlations between standardized uptake value (SUV) and survival might be the application of different SUV methodologies. The primary aim of this study was to examine the influence of using different methodologies on SUV-survival correlation. Data were used from a prospective cohort study consisting of oesophageal cancer patients in whom preoperative fluorodeoxyglucose positron emission tomography was performed. Various methodologies of SUV calculation/correction were correlated with the default (SUV A41% corrected for body surface area): different volume of interest definitions, different SUV normalization, with and without serum glucose correction, and with (PVC+ ) and without partial volume correction (PVC- ). Receiver operating characteristic (ROC) curves using any type of SUV for the identification of potential correlation with disease-free survival were also compared. Fifty-two patients were included for this study. Significant correlations were found between SUV A41% and all the other described SUVs: SUV 50% (r2=0.99; P< 0.001), SUV A50% (r2= 0.98; P< 0.001), SUVmax (r2= 0.98; P < 0.001), SUV A41% PVC+ (r2= 0.97; P < 0.001) and SUV A41% glucose (r2= 0.93; P <0.001). No correlation was found between volume of interest 41% and SUV A41%, with or without, PVC (P = 0.85 and P = 0.41). Significant correlations were found between SUVmax corrected for body surface area, SUVmax corrected for body weight (r2=0.96; P < 0.001) and SUV corrected for lean body mass (r2= 0.98; P < 0.001). ROC curves for various SUV methodologies showed an almost identical area under the curve for any type of SUV. A strong correlation was found between all the investigated SUV methodologies. Moreover, when looking for correlations between SUV and disease-free survival, the areas under the ROC curves were almost identical for any type of SUV methodology.

Different Degree of FDG Uptake of Non-Small Cell Lung Cancer in PET-CT: What Dose It Imply?

Purpose: To examine the degree of fluorodeoxyglucose (FDG) uptake in non small cell lung cancers (NSCLCs) and its implications according to the cell type, tumor differentiation, size and stage. Materials and Methods: From February 2004 to February 2008, 161 patients (117 males, 44 Females) with surgically proven NSCLCs who underwent preoperative FDG positron emission tomography (PET) and curative surgery (stage I-IIIA) were enrolled in this study. The degree of FDG uptake of NSCLCs was evaluated retrospectively by measuring the maximum standard uptake values (max SUVs) in PET-CT according to the cell type, tumor differentiation, size and stage. Results: Squamous cell carcinomas (SCCs, n=75) had higher max SUVs than the adenocarcinomas (ADCs, n=86) (p

Preoperative FDG-PET imaging to assess the malignant potential of follicular neoplasms of the thyroid

When a fine needle aspiration biopsy of a thyroid nodule suggests follicular neoplasm, surgery is required for diagnosis. Establishing the diagnosis preoperatively would allow the patient to undergo the appropriate initial thyroidectomy. Preoperative [(18)F]-fluorodeoxyglucose positron emission tomography (FDG-PET) imaging may be able to determine malignancy in follicular neoplasms. Prospective cases series. Twenty-three patients with a diagnosis of follicular neoplasm underwent presurgical FDG-PET at 60, 90, and 120 minutes after injection of fluorodeoxyglucose (F18). Thyroidectomy was performed with comparison of the histopathologic results with the FDG-PET results. There were 5 malignant conditions and 18 benign conditions identified with the standard uptake valve (SUV) ranging from 0.9 to 44.8. The follicular thyroid cancers that exhibited only capsular invasion had an average SUV of 3.1, whereas those with vascular invasion had an average SUV of 39.9. The SUV increased in 80% of the malignant cases but in only 50% of the benign cases. Despite certain patterns being suggestive of malignancy, FDG-PET can not consistently predict the malignant potential of a follicular neoplasm.