Prognostic value of tumoral heterogeneity and volumetric parameters as measured by F18-FDG PET/CT in sinonasal cancer

The value of a nomogram based on 18F-FDG PET/CT metabolic parameters and metabolic heterogeneity in predicting distant metastasis in gastric cancer

OBJECTIVE

To investigate the value of metabolic parameters and metabolic heterogeneity from pretreatment deoxy-2-[fluorine-18]-fluoro-D-glucose positron emission tomography/computed tomography (18F-FDG PET/CT) in predicting distant metastasis in gastric cancer.

METHODS

Eighty-six patients with pathologically confirmed gastric adenocarcinoma were included in this study. All patients underwent a whole-body 18F-FDG PET/CT scan before treatment. Clinicopathologic and imaging data were collected, including metabolic parameters such as maximum standardized uptake value (SUVmax), mean standardized uptake value (SUVmean), metabolic tumor volume (MTV), and total lesion glycolysis (TLG) of the primary gastric cancer lesions. Heterogeneity index (HI)-1 was expressed as the absolute value of the linear regression slopes between the MTVs at different SUVmax thresholds (40% × SUVmax, 80% × SUVmax), while HI-2 was expressed as the difference between SUVmax and SUVmean. Patients were randomly divided into training and validation cohorts at a 7:3 ratio. The correlation between the above parameters and distant metastasis in gastric cancer was analyzed using the training cohort. A nomogram prediction model was then established and later verified with the validation cohort. Finally, decision curve analysis was used to evaluate the clinical utility of the model.

RESULTS

This study included 86 patients with gastric cancer, with 60 (69.8%) in the training cohort and 26 (30.2%) in the validation cohort. There was no significant difference in the balanced comparison between both cohorts (all P > .05). Among all patients, 31 (36.0%) developed distant metastasis, while 55 (64.0%) did not. In patients who developed distant tumor metastasis, carcinoembryonic antigen, carbohydrate antigen (CA)12-5, CA19-9, CA72-4, MTV, TLG, and HI-1 were significantly higher than in patients without distant metastasis (all P < .05). Multivariate logistic regression analysis identified CA72-4 (OR: 1.151, 95% CI: 1.020-1.300, P = .023) and HI-1 (OR: 1.647, 95% CI: 1.063-2.553, P = .026) as independent risk factors for predicting distant metastasis in gastric cancer. The nomogram constructed from this analysis exhibited high predictive efficacy in the training (AUC: 0.874, 95% CI: 0.766-0.983) and validation (AUC: 0.915, 95% CI: 0.790-1.000) cohorts, providing a net clinical benefit for patients.

CONCLUSION

HI-1 is an independent risk factor for predicting distant metastasis in gastric cancer. A comprehensive prediction model combining HI-1 with the tumor marker CA72-4 can increase the net clinical benefit for patients.

When to Consider Invasive Lymph Node Staging in Non-Small-Cell Lung Cancer? A Novel Scoring System Utilising Metabolic Parameters in 18F-FDG PET/CT

OBJECTIVE

The maximum standardised uptake value (SUVmax) is a widely utilised metric in positron emission tomography/computed tomography for clinically staging non-small-cell lung cancer (NSCLC), yet the reliability of SUVmax remains controversial. We herein aimed to assess the effectiveness of semi-quantitative parameters, encompassing size, SUVmax, metabolic tumour volume (MTV), total lesion glycolysis (TLG) and heterogeneity factor (HF), in evaluating both primary tumours and lymph nodes (LNs) on positron emission tomography/computed tomography. A novel scoring system was devised to appraise the role of semi-quantitative parameters and visually evaluate LNs for nodal staging.

MATERIALS AND METHODS

Patients with pathological NSCLC, diagnosed between 2014 and 2019 and clinically staged I-III, were enrolled in the study. Patient demographics, including age, sex, tumour location, diameter, tumour-node-metastasis stage, as well as SUVmax, MTV, TLG and HF parameters of primary tumours and LNs, were documented.

RESULTS

The analysis comprised 319 patients and 963 LNs. Patients had a mean age of 61.62 years, with 91.5% being male. Adenocarcinoma exhibited a histological association with LN metastasis (P=0.043). The study findings revealed that tumour size, SUVmax, MTV, TLG and HF did not significantly affect the detection of LN metastasis. Conversely, non-squamous cell carcinoma, LNs exhibiting higher FDG levels than the liver, LN size, SUVmax, MTV and TLG were identified as risk factors (P<0.0001). The identified cut-off values were 1.05cm for LN size, 4.055 for SUVmax, 1.805cm3 for MTV and 5.485 for TLG. The scoring system incorporated these parameters, and visual assessment indicated that a score of ≥3 increased the risk of metastasis by 14.33 times.

CONCLUSION

We devised a novel scoring system and demonstrated that LNs with a score of ≥3 in patients with NSCLC have a high likelihood of metastasis. This innovative scoring system can serve as a valuable tool to mitigate excessive and extreme measures in the assessment of invasive pathological staging.

Predictive value of 18F-FDG PET/CT multi-metabolic parameters and tumor metabolic heterogeneity in the prognosis of gastric cancer

OBJECTIVE

We aimed to investigate the predictive value of pre-treatment 18F-FDG PET/CT multi-metabolic parameters and tumor metabolic heterogeneity for gastric cancer prognosis.

METHODS

Seventy-one patients with gastric cancer were included. All patients underwent 18F-FDG PET/CT whole-body scans prior to treatment and had pathologically confirmed gastric adenocarcinomas. Each metabolic parameter, including SUVmax, SUVmean, MTV, and TLG, was collected from the primary lesions of gastric cancer in all patients, and the slope of the linear regression between the MTV corresponding to different SUVmax thresholds (40% × SUVmax, 80% × SUVmax) of the primary lesions was calculated. The absolute value of the slope was regarded as the metabolic heterogeneity of the primary lesions, expressed as the heterogeneity index HI-1, and the coefficient of variance of the SUVmean of the primary lesions was regarded as HI-2. Patient prognosis was assessed by PFS and OS, and a nomogram of the prognostic prediction model was constructed, after which the clinical utility of the model was assessed using DCA.

RESULTS

A total of 71 patients with gastric cancer, including 57 (80.3%) males and 14 (19.7%) females, had a mean age of 61 ± 10 years; disease progression occurred in 27 (38.0%) patients and death occurred in 24 (33.8%) patients. Multivariate Cox regression analysis showed that HI-1 alone was a common independent risk factor for PFS (HR: 1.183; 95% CI: 1.010-1.387, P < 0.05) and OS (HR: 1.214; 95% CI: 1.016-1.450, P < 0.05) in patients with gastric cancer. A nomogram created based on the results of Cox regression analysis increased the net clinical benefit for patients. Considering disease progression as a positive event, patients were divided into low-, intermediate-, and high-risk groups, and Kaplan-Meier survival analysis showed that there were significant differences in PFS among the three groups. When death was considered a positive event and patients were included in the low- and high-risk groups, there were significant differences in OS between the two groups.

CONCLUSION

The heterogeneity index HI-1 of primary gastric cancer lesions is an independent risk factor for patient prognosis. A nomogram of prognostic prediction models constructed for each independent factor can increase the net clinical benefit and stratify the risk level of patients, providing a reference for guiding individualized patient treatment.

The Role of Positron Emission Tomography for the Management of Sinonasal Malignancies: A Systematic Review

BACKGROUND

Positron emission tomography (PET) scan is a valuable imaging modality widely used in the management of cancers. Its usage is well defined for most head and neck malignancies. However, there is a lack of consensus regarding the utility of PET scan for sinonasal malignancies. This is highlighted by the latest international consensus statement on endoscopic skull base surgery.

OBJECTIVE

This systematic review aims to clarify the role of PET scan in the management of sinonasal malignancies.

METHODS

We conducted a comprehensive literature search using PubMed, MEDLINE, EMBASE, Web of Science, CINAHL, and Cochrane databases for research studies of interest. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) updated statement was used to guide the review.

RESULTS

In total, 1807 articles were assessed for eligibility. Thirty-nine original papers, published between 2004 and 2021, met inclusion criteria. Seven articles focused on the role of PET scan for inverted papilloma, 23 for sinonasal carcinoma, 4 for melanoma, and 3 for lymphoma, and finally, 3 articles focused on the use of specific PET scan tracers for sinonasal malignancies. Qualitative summaries for each potential role of PET scans were provided. In general, included studies were retrospective in nature with low level of evidence.

CONCLUSIONS

In general, and across all types of sinonasal malignancies, PET scan yielded positive results regarding detection and initial staging. It was also considered as the modality of choice for detection of distant metastases, except in the case of sinonasal lymphoma. PET scan's main limit resides in its inability to detect lesions in or close to the metabolic activity of the brain.

Prognostic role of baseline 18 F-FDG pet/CT in squamous cell carcinoma of the paranasal sinuses

BACKGROUND

To retrospectively investigate the prognostic role of baseline ¹⁸ F-FDG PET/CT in squamous cell carcinoma (SCC) of the paranasal sinuses.

METHODS

Clinical features and PET/CT semiquantitative parameters of 49 patients were collected. Anova and Kruskall-Wallis tests were used to assess the relationship between these parameters. Kaplan-Meier, univariate, and multivariate analysis were performed to search for independent prognostic factors for progression free (PFS) and overall survival (OS).

RESULTS

Mean PFS was 29.95 months (SD 29.36) with relapse/progression of disease occurring in 18 patients; mean OS was 33.40 (SD 27.78) months with death occurring in 15 patients. Presence of nodal metastasis (14 subjects) was correlated with standardize uptake value (SUV) max, SUVmean, SUV/blood-pool ratio, SUV/liver ratio, metabolic tumor volume, and total lesion glycolysis. SUVmax, SUVmean, and presence of nodal metastasis resulted as independent prognostic factors for OS.

CONCLUSION

¹⁸ F-FDG PET/CT semiquantitative parameters confirmed their prognostic role for SCC of paranasal sinuses.

Metabolic Tumour Volume as a Predictor of Survival for Sinonasal Tract Squamous Cell Carcinoma

Background: High uptake of F18-fluorodeoxyglucose parameters for glucose metabolism is related to shorter survival in sinonasal tract cancer with various histological classifications. We investigated whether F18-fluorodeoxyglucose uptake parameters are associated with survival outcomes for patients with only squamous cell carcinoma (SCC) in the sinonasal tract that are treated either with surgery or nonsurgery. Methods: We retrospectively observed F18-fluorodeoxyglucose uptake parameters on positron emission tomography with computed tomography for the primary tumour of SCC in 39 patients. Log-rank test or a Cox regression model with 95% confidence interval (95%CI) and hazard ratio (HR) were used for monovariable or multivariable analysis, respectively. We determined cut-off values of the F18-fluorodeoxyglucose uptake parameters using the lowest p value for monovariable sinonasal tract cancer-specific survival analysis. Results: Monovariable analysis showed that patients with metabolic tumour volume (MTV) ≥ 21.8 had a shorter cancer-specific, disease-free and local recurrence-free survival than those with MTV < 21.8. After adjusting for age, gender, clinical stage and treatment group in the multivariable analysis, MTV (≥21.8/<21.8) was related to shorter cancer-specific (HR: 3.69, 95%CI: 1.17–12.0), disease-free (HR: 3.38, 95%CI: 1.19–9.71) and local recurrence-free (HR: 5.42, 95%CI: 1.59–20.3) survivals. Conclusions: MTV as advances in diagnostics of sinonasal tract SCC is a predictor.

COV is a readily available quantitative indicator of metabolic heterogeneity for predicting survival of patients with early and locally advanced NSCLC manifesting as central lung cancer

OBJECTIVES

The aim of our study was to investigate the value of a simple metabolic heterogeneity parameter, COV (coefficient of variation), by 18 F-fluorodeoxyglucose (FDG) positron emission tomography (PET) in the prognosis prediction of central lung cancer in early and locally advanced non-small-cell lung cancer (NSCLC).

METHODS

Seventy-three patients with NSCLC manifesting as central lung cancer were included retrospectively, and we used the COV to evaluate metabolic heterogeneity. Univariate and multivariate analyses were used to evaluate the predictive value in terms of overall survival (OS) and progression-free survival (PFS).

RESULT

For all 73 patients with pathologically confirmed NSCLC, 69.9 % had SCC, and 30.1 % had ADC or other types of NSCLC. The COV was a statistically significant factor in the univariate analysis for the OS rate. The optimal cut-off value was 23.1366, with sensitivity = 0.737 and specificity = 0.771. The COV values were dichotomized by this value and included with atelectasis in the Cox multivariate analysis. Both COV and atelectasis were independent risk factors for OS as follows: for COV (HR, 3.162, P = 0.0002), the 2-year OS rate was 62.5 % and 26.9 % in the low and high COV groups, respectively. For atelectasis (HR 2.047, P = 0.041), the 2-year OS rate was 30.6 % and 65.2 % in the groups with and without atelectasis, respectively (P = 0.017). For PFS, only COV (HR, 2.636, P = 0.001) was a significant predictor. The 2-year PFS rate was 29.7 % in the low COV group and 8% in the high COV group.

CONCLUSION

The pre-treatment metabolic heterogeneity parameter COV is a simple and easy way to predict the OS and PFS of patients with NSCLC manifesting as central lung cancer. Therefore, COV plays an important role in prognostic risk classification in NSCLC. The presence of atelectasis could also be a risk factor for poor prognosis of OS.

Hybrid positron emission tomography imaging for initial staging of sinonasal tumors: Total lesion glycolysis as prognosticator of treatment response

BACKGROUND

To assess hybrid positron emission tomography (PET) imaging in the initial staging and outcome prediction of sinonasal malignancies.

METHODS

Retrospective study on patients with sinonasal malignancies undergoing hybrid PET imaging for initial staging.

RESULTS

Complete remission (CR) was achieved in 45 of 65 patients (69.2%). Overall sensitivity for detection of primaries using 18F-fluoro-deoxy-d-glucose PET (FDG-PET) was 95.4%, for lymph node metastases 100% and distant metastases (DM) 100%. On univariate analysis, PET parameter total lesion glycolysis (TLG) was associated with achieving CR after primary treatment (176.8 ± 157.2 vs 83.7 ± 110.8, P = .03). Multivariate logistic regression demonstrated that TLG adjusted for the T classification best predicted achievement of CR.

CONCLUSIONS

Hybrid PET imaging yields an excellent sensitivity in detecting primary tumors, lymph node metastases and DM in sinonasal malignancies. TLG of the primary tumor is an independent prognostic factor for achieving CR after initial treatment.

Prediction of occult lymph node metastasis using SUV, volumetric parameters and intratumoral heterogeneity of the primary tumor in T1-2N0M0 lung cancer patients staged by PET/CT

OBJECTIVE

The aim of this study was to identify whether PET/CT-related metabolic parameters of the primary tumor could predict occult lymph node metastasis (OLM) in patients with T1-2N0M0 NSCLC staged by ¹⁸F-FDG PET/CT.

METHODS

215 patients with clinical T1-2N0M0 (cT1-2N0M0) NSCLC who underwent both preoperative FDG PET/CT and surgical resection with the systematic lymph node dissection were included in the retrospective study. Heterogeneity factor (HF) was obtained by finding the derivative of the volume-threshold function from 40 to 80% of the maximum standardized uptake value (SUVmax). Univariate and multivariate stepwise logistic regression analyses were used to identify these PET parameters and clinicopathological variables associated with OLM.

RESULTS

Statistically significant differences were detected in sex, tumor site, SUVmax, mean SUV (SUVmean), metabolic tumor volume (MTV), total lesion glycolysis and HF between patients with adenocarcinoma (ADC) and squamous cell carcinoma (SQCC). OLM was detected in 36 (16.7%) of 215 patients (ADC, 27/152 = 17.8% vs. SQCC, 9/63 = 14.3%). In multivariate analysis, MTV (OR = 1.671, P = 0.044) in ADC and HF (OR = 8.799, P = 0.023) in SQCC were potent associated factors for the prediction of OLM. The optimal cutoff values of 5.12 cm³ for MTV in ADC, and 0.198 for HF in SQCC were determined using receiver operating characteristic curve analysis.

CONCLUSIONS

In conclusion, MTV was an independent predictor of OLM in cT1-2N0M0 ADC patients, while HF might be the most powerful predictor for OLM in SQCC. These findings would be helpful in selecting patients who might be considered as candidates for sublobar resection or new stereotactic ablative radiotherapy.

Prediction of survival with combining quantitative 18 F-FDG PET/CT and DW-MRI parameters in sinonasal malignancies

BACKGROUND

We aimed to establish the prognostic value of ¹⁸ F-fluoro-deoxy-glucose positron emission/CT (¹⁸ F-FDG PET/CT) and diffusion-weighted (DW) MRI in determining overall survival (OS), progression-free survival (PFS), and distant metastasis-free survival (DMFS) of sinonasal malignancies.

METHODS

Sixty-eight patients with sinonasal cancer who underwent both pretreatment ¹⁸ F-FDG PET/CT scan and head-neck MRI from January 2009 through August 2017 were retrospectively reviewed. Kaplan-Meier survival analysis of ¹⁸ F-FDG PET/CT and DW-MRI parameters were performed for OS, PFS, and DMFS.

RESULTS

Cox regression analysis determined that all the quantitative ¹⁸ F-FDG PET/CT and DW-MRI parameters were independently correlated with PFS, DMFS, and OS (P < .05). After controlling for imaging variables, perineural invasion (P = .02) and ill-defined margin (P = .02) were found to be significantly correlated with shorter OS; while the perineural invasion was significantly correlated with shorter PFS (P = .02).

CONCLUSIONS

The pretreatment DW-MRI and ¹⁸ F-FDG PET/CT parameters could be substantial surrogate markers for sinonasal malignancies.

Gross tumor volume in sinonasal tract cancer as a predictor of local recurrence after chemoradiotherapy

Objective

This study investigated whether gross tumor volume of the primary tumor before treatment was a predictor for local recurrence in patients with resectable sinonasal tract squamous cell carcinoma who were treated by chemoradiotherapy.

Methods

A total of 24 patients were enrolled. Pretreatment gross tumor volume of primary tumor was assessed by palpitation, perception and imaging. The cut-off value of the gross tumor volume for local recurrence was determined by receiver-operating curve analysis. A log-rank test and Cox's proportional hazards model were used for univariate and multivariate analyses with adjustment for the clinical T category (cT1-T4a/cT4b), respectively.

Results

In the univariate analysis, patients with the gross tumor volume ≥83.7 ml were significantly associated with shorter local recurrence-free rate (P = 0.0023) and disease-free survival (P = 0.0064) than those with gross tumor volume <83.7 ml. In the multivariate analysis, gross tumor volume ≥83.7 ml were significantly associated with shorter local recurrence-free rate (P = 0.041).

Conclusions

Pretreatment gross tumor volume of primary tumor ≥83.7 ml was significantly associated with local recurrence-free rate in resectable sinonasal tract squamous cell carcinoma.

Utility of first positron emission tomography-computed tomography scan as a prognostic tool following treatment of sinonasal and skull base malignancies

BACKGROUND

The prognostic value of the first posttreatment whole body integrated positron emission tomography-computed tomography (PET/CT) scanning in patients with sinonasal/skull base malignancies is undetermined.

METHODS

We retrospectively reviewed the data of all patients that underwent surgery for sinonasal/skull base malignancies in 2000-2015. The results of the pretreatment and posttreatment PET/CT findings and the clinical course were retrieved.

RESULTS

Thirty-eight patients (average age 60.6 years, 20 males) were included. Sensitivity and specificity, positive predictive value, and negative predictive value of the first PET/CT scan for predicting persistent/recurrent disease were 85.7%, 87.5%, 80%, and 91.3%, respectively. Overall 5-year survival was significantly lower in the first posttreatment PET/CT-positive group (35%) compared to the PET/CT-negative group (93%) (P = .0008).

CONCLUSION

Posttreatment PET/CT findings are highly prognostic in patients with sinonasal/skull base malignancies. Negative findings on the first posttreatment PET/CT scan predict a significantly better overall survival.

Prognostic significance of standardized uptake value on F18-FDG PET/CT in patients with extranodal nasal type NK/T cell lymphoma: A multicenter, retrospective analysis

OBJECTIVES

The purpose of this study was to evaluate the value of parameters assessed with F18-flurodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) in predicting relapse free survival and overall survival in patients with extranodal nasal type NK/T cell lymphoma.

METHODS

Thirty-six patients with extranodal nasal type NK/T cell lymphoma, and who underwent PET/CT prior to curative treatment, were enrolled at five institutions. Volumes of interest covering the entire tumor volume were delineated on PET/CT images, and the maximum standardized uptake value (SUVmax), mean SUV (SUVmean), metabolic tumor volume (MTV), and total lesion glycolysis (TLG) were measured using thresholds of 40% of SUVmax. Furthermore, we compared the difference in F18-FDG avidity according to Epstein-Barr virus (EBV) infection status.

RESULTS

The SUVmax (p=0.041) and SUVmean (p=0.049) in patients who died were higher than the respective values of those who survived. A higher TLG (>45.8) was associated with relapse free survival (HR 7.856, p=0.034). Ann Arbor stage (III-IV, HR 14.12, p=0.004), and a higher SUVmax (>12.6, p=0.024) and SUVmean (>6.4, p=0.024) were associated with poor survival. However, neither the MTV nor the TLG (volumetric parameters) were significant predictors of death. The PET parameters SUVmax (p=0.181), SUVmean (p=0.237), MTV (p=0.636), and TLG (p=0.469) did not differ significantly between patients with and without EBV infections.

CONCLUSIONS

High TLG was the only significant predictive factor on relapse free survival. The SUVmax and SUVmean measured by F18-FDG PET/CT could be significant prognostic factors in patients with extranodal nasal type NK/T cell lymphoma.