PET/CT features discriminate risk of metastasis among single-bone FDG lesions detected in newly diagnosed non-small-cell lung cancer patients

What enlightenment has the development of lung cancer bone metastasis brought in the last 22 years

BACKGROUND

Lung cancer bone metastasis (LCBM) is a disease with a poor prognosis, high risk and large patient population. Although considerable scientific output has accumulated on LCBM, problems have emerged, such as confusing research structures.

AIM

To organize the research frontiers and body of knowledge of the studies on LCBM from the last 22 years according to their basic research and translation, clinical treatment, and clinical diagnosis to provide a reference for the development of new LCBM clinical and basic research.

METHODS

We used tools, including R, VOSviewer and CiteSpace software, to measure and visualize the keywords and other metrics of 1903 articles from the Web of Science Core Collection. We also performed enrichment and protein-protein interaction analyses of gene expression datasets from LCBM cases worldwide.

RESULTS

Research on LCBM has received extensive attention from scholars worldwide over the last 20 years. Targeted therapies and immunotherapies have evolved into the mainstream basic and clinical research directions. The basic aspects of drug resistance mechanisms and parathyroid hormone-related protein may provide new ideas for mechanistic study and improvements in LCBM prognosis. The produced molecular map showed that ribosomes and focal adhesion are possible pathways that promote LCBM occurrence.

CONCLUSION

Novel therapies for LCBM face animal testing and drug resistance issues. Future focus should centre on advancing clinical therapies and researching drug resistance mechanisms and ribosome-related pathways.

Prognostic factors for survival in unresectable stage III EGFR mutation-positive lung adenocarcinoma: impact of pre-CCRT PET-CT

PURPOSE

To assess the survival impact of pre-concurrent chemoradiotherapy (CCRT) staging with positron emission tomography-CT (PET-CT) in patients with unresectable epidermal growth factor receptor (EGFR) mutation-positive adenocarcinoma.

METHODS

Patients with unresectable stage IIIA-IIIC EGFR mutation-positive adenocarcinoma undergoing definitive CCRT were divided into two groups: those who received PET-CT staging prior to CCRT and those with other staging methods. Survival outcomes were compared after propensity score matching.

RESULTS

Analysis of 11 856 patients (5928 in each group) showed that PET-CT staging was associated with improved survival (adjusted HR of all-cause mortality: 0.74, 95% CI 0.71 to 0.79). Other prognostic factors included male sex, age group, clinical stage, adjuvant treatment, smoking status, Charlson Comorbidity Index score and treatment setting.

CONCLUSION

Pre-CCRT staging with PET-CT in patients with unresectable EGFR mutation-positive adenocarcinoma of clinical stage IIIA-IIIC was associated with enhanced survival. Independent prognostic factors were also identified.

Clinical Effects of PET-CT Before Definite Concurrent Chemoradiotherapy in Patients With Unresectable Stage IIIA-IIIB Squamous Cell Carcinoma of the Lungs

PURPOSE

No large-scale, retrospective cohort study with a long-term follow-up time has yet evaluated the effects of preoperative 18 F-FDG PET-CT on survival in patients with unresectable stages IIIA-IIIB squamous cell lung carcinoma (SqCLC) who received definite concurrent chemoradiotherapy (CCRT).

METHODS

We included patients with unresectable stages IIIA-IIIB SqCLC receiving definite CCRT and categorized them into 2 groups. The case group comprised patients who underwent pre-CCRT 18 F-FDG PET-CT, and the comparison group comprised patients who did not receive pre-CCRT 18 F-FDG PET-CT; the groups were matched at a ratio of 1:1.

RESULTS

The matching process yielded a final cohort of 4042 eligible patients (2021 and 2021 in the case and comparison groups, respectively). Multivariable Cox regression analyses revealed a positive correlation between patients with unresectable stages IIIA-IIIB SqCLC receiving definite CCRT and all-cause death in the pre-CCRT 18 F-FDG PET-CT (adjusted hazard ratio, 0.85; 95% confidence interval, 0.80-0.91; P < 0.0001).

CONCLUSION

Pre-CCRT 18 F-FDG PET-CT was associated with more favorable survival in both patients with unresectable clinical stage IIIA and those with stage IIIB receiving definite CCRT.

Use of Preoperative FDG PET/CT and Survival of Patients with Resectable Non-Small Cell Lung Cancer

Background The added value of preoperative PET/CT for the overall survival of patients with resectable non-small cell lung cancer (NSCLC) is unknown. Purpose To investigate the association of the use of preoperative PET/CT on survival of patients with resectable stage I-IIIB NSCLC. Materials and Methods In this retrospective study, patients with resectable stage I-IIIB NSCLC who underwent thoracic surgery from January 1, 2009, to December 31, 2018, from the Taiwan Cancer Registry were included. The last follow-up date was December 31, 2019. Patients were categorized into two groups according to whether they underwent preoperative metabolic imaging with fluorine 18 fluorodeoxyglucose PET/CT. Patients who did not undergo preoperative imaging were used as the control group. The primary outcome of interest was all-cause mortality. Patients in both groups were propensity score matched at a ratio of 1:1. Matching variables used were sex, age, histologic findings, American Joint Committee on Cancer clinical stage, cT stage, cN stage, current and past smoker history, adjuvant chemotherapy, adjuvant chemoradiation, Charlson comorbidity index, and hospital type. Survival curves were generated using the Kaplan-Meier method and compared using the log-rank test. Results In the matched cohort, 6754 patients (3349 men, mean age ± SD: 64 years ± 11) underwent PET/CT and 6754 did not (3362 men, mean age: 64 years ± 11). In adjusted analysis, patients with stage IIIA or IIIB NSCLC and preoperative PET/CT had a lower risk of death versus those without PET/CT (for stage IIIA: hazard ratio [HR] = 0.90 [95% CI: 0.79, 0.94], P = .02; for stage IIIB: HR = 0.80 [95% CI: 0.71, 0.90], P < .01). There was no improvement in a lower risk of death for patients with stage I-II NSCLC (after multivariable adjustment, the HR was 1.19 [95% CI: 0.89, 1.30], P = .65). Conclusion Use of preoperative PET/CT was associated with lower risk of death in patients with stage IIIA-IIIB non-small cell lung cancer compared with those without preoperative PET/CT. © RSNA, 2022 Online supplemental material is available for this article.

Efficacy Evaluation of Zoledronic Acid Combined with Chemotherapy in the Treatment of Lung Cancer Spinal Metastases on Computed Tomography Images on Intelligent Algorithms

To analyze the effectiveness and safety of zoledronic acid combined with chemotherapy for lung cancer spinal metastases, 96 patients with lung cancer spinal metastases were averagely classified into the experimental group (gemcitabine, cisplatin, and zoledronic acid) and the control group (gemcitabine and cisplatin). An optimized noise variance estimation algorithm (OMAPB) was proposed based on the maximum a posteriori Bayesian method (MAPB), and the algorithm was applied to the patient's computed tomography (CT) scan. The results indicated that in terms of curative effect, the number of complete remission (CR), partial remission (PR) cases, effective rate, and clinical benefit rate of the test group was significantly higher than those of the control group. The number of progress disease (PD) cases was significantly lower than that of the control group (P < 0.05). The disease progression time of the test group patients was 6.2 months, and the disease progression time of the control group patients was 3.7 months (P < 0.05). The test group patients had 8 cases of bone marrow suppression and gastrointestinal reactions after treatment. In the test group, there were 8 cases of bone marrow suppression, 9 cases of gastrointestinal reaction, 3 cases of fever, 4 cases of pain, and 2 cases of hair loss. The patients in the control group were complicated with bone marrow suppression in 14 cases, gastrointestinal reaction in 17 cases, fever in 5 cases, pain in 4 cases, and hair loss in 6 cases. The difference was statistically significant (P < 0.05). It showed that zoledronic acid combined with chemotherapy could effectively improve the treatment efficiency and clinical benefit rate of patients with lung cancer spinal metastases, prolong the progression of the disease, reduce the degree of bone tissue damage, and would not increase chemotherapy adverse events.

Clinical Value of Surveillance 18F-fluorodeoxyglucose PET/CT for Detecting Unsuspected Recurrence or Second Primary Cancer in Non-Small Cell Lung Cancer after Curative Therapy

Simple Summary

Non-small cell lung cancer (NSCLC) patients are at considerable risk of recurrence or second primary cancer (SPC) after curative therapy. The utility of ¹⁸F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) surveillance to detect recurrent lesions in NSCLC patients without suspicion of recurrence has not been established. The aim of our retrospective study was to evaluate the diagnostic value of surveillance FDG PET/CT for detecting clinically unsuspected recurrence or SPC in patients with NSCLC after curative therapy. In a cohort of 2684 NSCLC patients after curative therapy, surveillance FDG PET/CT showed good diagnostic efficacy for detecting clinically unexpected recurrence or SPC. Furthermore, the diagnostic performance was improved in subgroups of patients with advanced stage prior to curative therapy, PET/CT scans performed within 3 years after curative-intent therapy, and curative surgery. Surveillance PET/CT can be more useful when performed soon after therapy in curative surgery recipients and those with an advanced disease stage considering its diagnostic efficacy and yield.

Abstract

We evaluated the diagnostic value of ¹⁸F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT surveillance for detecting clinically unsuspected recurrence or second primary cancer (SPC) in patients with non-small cell lung cancer (NSCLC) after curative therapy. A total of 4478 surveillance FDG PET/CT scans from 2864 NSCLC patients without suspicion of recurrence after curative therapy were reviewed retrospectively. In 274 of 2864 (9.6%) patients, recurrent NSCLC or SPC was found by surveillance PET/CT during clinical follow-up. Surveillance PET/CT scans showed sensitivity of 98.9% (274/277), specificity of 98.1% (4122/4201), accuracy of 98.2% (4396/4478), positive predictive value (PPV) of 77.6% (274/353), and negative predictive value of 99.9% (4122/4125). The specificity and accuracy in the curative surgery group were significantly higher than those in the curative radiotherapy group. PPV was significantly improved in subgroups of patients with advanced stage prior to curative therapy, PET/CT scans performed within 3 years after curative-intent therapy, and curative surgery. FDG PET/CT surveillance showed good diagnostic efficacy for detecting clinically unexpected recurrence or SPC in NSCLC patients after curative therapy. It can be more useful when performed soon after therapy in curative surgery recipients and those with an advanced disease stage considering its diagnostic efficacy and yield.

Predictive factors, preventive implications, and personalized surgical strategies for bone metastasis from lung cancer: population-based approach with a comprehensive cancer center-based study

Background

Bone metastasis (BM) and skeletal-related events (SREs) happen to advanced lung cancer (LC) patients without warning. LC-BM patients are often passive to BM diagnosis and surgical treatment. It is necessary to guide the diagnosis and treatment paradigm for LC-BM patients from reactive medicine toward predictive, preventive, and personalized medicine (PPPM) step by step.

Methods

Two independent study cohorts including LC-BM patients were analyzed, including the Surveillance, Epidemiology, and End Results (SEER) cohort (n = 203942) and the prospective Fudan University Shanghai Cancer Center (FUSCC) cohort (n = 59). The epidemiological trends of BM in LC patients were depicted. Risk factors for BM were identified using a multivariable logistic regression model. An individualized nomogram was developed for BM risk stratification. Personalized surgical strategies and perioperative care were described for FUSCC cohort.

Results

The BM incidence rate in LC patients grew (from 17.53% in 2010 to 19.05% in 2016). Liver metastasis was a significant risk factor for BM (OR = 4.53, 95% CI = 4.38-4.69) and poor prognosis (HR = 1.29, 95% CI = 1.25-1.32). The individualized nomogram exhibited good predictive performance for BM risk stratification (AUC = 0.784, 95%CI = 0.781-0.786). Younger patients, males, patients with high invasive LC, and patients with other distant site metastases should be prioritized for BM prevention. Spine is the most common site of BM, causing back pain (91.5%), pathological vertebral fracture (27.1%), and difficult walking (25.4%). Spinal surgery with personalized spinal reconstruction significantly relieved pain and improved daily activities. Perioperative inflammation, immune, and nutrition abnormities warrant personalized managements. Radiotherapy needs to be recommended for specific postoperative individuals.

Conclusions

The presence of liver metastasis is a strong predictor of LC-BM. It is recommended to take proactive measures to prevent BM and its SREs, particularly in young patients, males, high invasive LC, and LC with liver metastasis. BM surgery and perioperative management are personalized and required. In addition, adjuvant radiation following separation surgery must also be included in PPPM-guided management.

Graphical abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s13167-022-00270-9.

Development and validation of tumor-to-blood based nomograms for preoperative prediction of lymph node metastasis in lung cancer

Background

To develop and validate tumor‐to‐blood based nomograms for preoperative prediction of lymph node (LN) metastasis in patients with lung cancer (LC).

Methods

A prediction model was developed in a primary cohort comprising 330 LN stations from patients with pathologically confirmed LC, these data having been gathered from January 2016 to June 2019. Tumor‐to‐blood variables of LNs were calculated from positron emission tomography‐computed tomography (PET‐CT) images of LC and the short axis diameters of LNs were measured on CT images. Tumor‐to‐blood variables, number of stations suspected of harboring LN metastasis according to PET, and independent clinicopathological risk factors were included in the final nomograms. After being internally validated, the nomograms were used to assess an independent validation cohort containing 101 consecutive LN stations accumulated from July 2019 to March 2020.

Results

Four tumor‐to‐blood variables (left atrium, inferior vena cava, liver, and aortic arch) and the maximum standardized uptake value (SUVmax) for LNs were found to be significantly associated with LN status (p < 0.001 for both primary and validation cohorts). Five predictive nomograms were built. Of these, one with LN SUVmax/left atrium SUVmax was found to be optimal for predicting LN status with AUC 0.830 (95% confidence interval [CI]: 0.774–0.886) in the primary cohort and AUC 0.865 (95% CI: 0.782–0.948) in the validation cohort. All models showed good discrimination, with a modest C‐index, and good calibration in both primary and validation cohorts.

Conclusions

We have developed tumor‐to‐blood based nomograms that incorporate identified clinicopathological risk factors and facilitate preoperative prediction of LN metastasis in LC patients.

Clinical value of dual-phase F-18 sodium fluoride PET/CT for diagnosing bone metastasis in cancer patients with solitary bone lesion

Background

The present study aimed to investigate whether dual-phase F-18 sodium-fluoride (NaF) positron emission tomography/computed tomography (PET/CT) could improve the diagnostic accuracy of detecting bone metastasis in cancer patients with a solitary bone lesion compared to conventional F-18 NaF PET/CT.

Methods

We retrospectively enrolled 113 cancer patients who underwent dual-phase F-18 NaF PET/CT for the differential diagnosis of a solitary bone lesion seen on bone scintigraphy. According to the dual-phase PET/CT protocol, an early-phase scan was acquired immediately after radiotracer injection and a conventional F-18 NaF PET/CT scan was performed. The diagnostic abilities of the visual analysis of conventional and dual-phase PET/CT scans and two quantitative parameters (lesion-to-blood pool uptake ratio on early-phase scan and lesion-to-bone uptake ratio on conventional scan) for detecting bone metastasis were compared. The final diagnosis of bone metastasis was made by histopathological confirmation or follow-up imaging studies.

Results

A metastatic bone lesion was diagnosed in 28 patients (24.8%). The sensitivity, specificity, and accuracy were 100.0%, 70.6%, and 77.9%, respectively, for visual analysis of conventional F-18 NaF PET/CT, 92.9%, 42.4%, 54.9%, respectively, for lesion-to-bone uptake ratio, 96.4%, 88.2%, and 90.3%, respectively, for visual analysis of dual-phase PET/CT, and 92.9%, 81.2%, and 83.2%, respectively, for lesion-to-blood pool uptake ratio. Visual analysis of dual-phase PET/CT was shown to have the highest area under the receiver operating characteristic curve value (0.923; 95% CI, 0.858-0.965) among all parameters.

Conclusions

Dual-phase F-18 NaF PET/CT showed a high diagnostic ability for detecting bone metastasis with improved specificity and accuracy compared to conventional F-18 NaF PET/CT in cancer patients. Dual-phase F-18 NaF PET/CT might help diagnose bone metastasis in patients with malignancies who were shown to have a solitary bone lesion on bone scintigraphy.

18F-fluorodeoxyglucose positron emission tomography/computed tomography in the evaluation of spinal giant cell tumors

OBJECTIVE

To investigate the value of ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) positron emission tomography/computed tomography (PET/CT) in the evaluation of spinal giant cell tumors (GCTs).

MATERIALS AND METHODS

The PET/CT and clinical data of 16 patients with spinal GCTs were reviewed. The maximal standardized uptake value (SUVmax), longest diameter, and CT features of spinal GCTs were analyzed. The value of PET/CT and MRI in displaying the recurrent lesions was compared. PET Response Criteria in Solid Tumors were adopted to evaluate the response to radiotherapy.

RESULTS

Data from 7 males and 9 females (median age 32.5 years) were analyzed. Eight patients had primary GCTs with a median SUVmax of 11.91 and a median length of 4.42 cm. Eight patients had relapsed GCTs with a median SUVmax of 10.34 and a median length of 6.23 cm. There was no statistical difference between the SUVmax of primary and relapsed GCTs. The SUVmax did not correlate with length. In 8 relapsed patients, 4 lesions invaded the vertebral canal, but 2 of which were not displayed on MRI. Metal prostheses showed extremely low signal intensity on MRI, even in the 3 cases with increased intra-prosthetic ¹⁸F-FDG concentration. Five relapsed patients with subsequent radiotherapy had a repeat PET/CT. A complete, partial, and stable metabolic response was observed in 1, 3, and 1 patient, respectively.

CONCLUSIONS

Both the primary and recurrent spinal GCTs avidly accumulate ¹⁸F-FDG. For recurrent GCTs, PET/CT may provide incremental value in the assessment of the vertebral canal and intra-prosthetic involvement and the response to radiotherapy.

A Retrospective Study of predicting risk of Metastasis among FDG-avid Bone Lesions in 18F-FDG PET/CT

Purpose: We evaluated the imaging and clinical features for discriminating the possibility of metastasis among FDG-avid bone lesions in 18F-FDG PET/CT in patients who have received bone biopsy.

Methods: The retrospective study included patients who underwent both ¹⁸F-FDG PET/CT and bone biopsy for FDG-avid bone lesions. Bone lesions maximum standardized uptake value (SUVmax), CT findings, alongside with common clinical features were analyzed.

Results: From the 338 patients enrolled in the final study, all of them were received bone biopsy. Biopsies confirm metastasis in 256 cases (75.74%) and benign tissue in 82 cases (24.26%). Metastasis group had higher bone SUVmax than benign group (median 7.9 vs 4.5, p <0.001). A cutoff bone SUVmax of 5 achieved an AUC of 0.748 in all patients. Lytic CT feature and higher age were more likely frequent in metastasis group. Moreover, in patients without obvious CT abnormality (45, 13.31%), the AUC was 0.743 by a SUVmax cutoff of 5.38, whilst in patients with a solitary bone lesion (74, 21.89%), the AUC was 0.803 by a SUVmax cutoff of 4.3.

Conclusions: SUVmax is a promising and valuable metabolic indicator for predicting risk of metastasis among FDG-avid bone lesions in 18F-FDG PET/CT, ancillary clinical and imaging features may increase the probability of a metastatic bone lesion.