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Kamigaichi A, Tsutani Y, Mimae T, Miyata Y, Adachi H, Shimada Y, Takeshima Y, Ito H, Ikeda N, Okada M. Discrepancy Between Radiological and Pathological Tumor Size in Early-Stage Non-Small Cell Lung Cancer: A Multicenter Study. Semin Thorac Cardiovasc Surg 2022; 36:273-281. [PMID: 36509147 DOI: 10.1053/j.semtcvs.2022.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 12/05/2022] [Indexed: 12/13/2022]
Abstract
Discrepancies between radiological whole tumor size (RTS) and pathological whole tumor size (PTS) are sometimes observed. Unexpected pathological upsize may lead to insufficient margins during procedures like sub lobar resections. Therefore, this study aimed to investigate the current status of these discrepancies and identify factors resulting in pathological upsize in patients with early-stage non-small cell lung cancer (NSCLC). Data from a multicenter database of 3092 patients with clinical stage 0-IA NSCLC who underwent pulmonary resection were retrospectively analyzed. Differences between the RTS and PTS were evaluated using Pearson's correlation analysis and Bland-Altman plots. Unexpected pathological upsize was defined as an upsize of ≥1 cm when compared to the RTS, and the predictive factors of this upsize were identified based on multivariable analyses. The RTS and PTS showed a positive linear relationship (r = 0.659), and the RTS slightly overestimated the PTS. The Bland-Altman plot showed 131 of 3092 (5.2%) cases were over the upper 95% limits of agreement. In multivariable analyses, a maximum standardized uptake value (SUVmax) of the primary tumor on 18-fluoro-2-deoxyglucose positron emission tomography/computed tomography (odds ratio [OR], 1.070; 95% confidence interval [CI], 1.035-1.107; P < 0.001) and the adenocarcinoma histology (OR, 1.899; 95% CI, 1.071-3.369; P =0.049) were independent predictors of unexpected pathological upsize. More of the adenocarcinomas with pathological upsize were moderately or poorly differentiated, when compared to those without. The RTS tends to overestimate the PTS; however, care needs to be taken regarding unexpected pathological upsize, especially in adenocarcinomas with a high SUVmax.
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Affiliation(s)
| | - Yasuhiro Tsutani
- Department of Surgical Oncology, Hiroshima University, Hiroshima, Japan
| | - Takahiro Mimae
- Department of Surgical Oncology, Hiroshima University, Hiroshima, Japan
| | - Yoshihiro Miyata
- Department of Surgical Oncology, Hiroshima University, Hiroshima, Japan
| | - Hiroyuki Adachi
- Department of Thoracic Surgery, Kanagawa Cancer Center, Yokohama, Japan
| | | | - Yukio Takeshima
- Department of Pathology, Hiroshima University, Hiroshima, Japan
| | - Hiroyuki Ito
- Department of Thoracic Surgery, Kanagawa Cancer Center, Yokohama, Japan
| | - Norihiko Ikeda
- Department of Surgery, Tokyo Medical University, Tokyo, Japan
| | - Morihito Okada
- Department of Surgical Oncology, Hiroshima University, Hiroshima, Japan..
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2
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Tibdewal A, Patil M, Misra S, Purandare N, Rangarajan V, Mummudi N, Karimundackal G, Jiwnani S, Agarwal J. Optimal Standardized Uptake Value Threshold for Auto contouring of Gross Tumor Volume using Positron Emission Tomography/Computed Tomography in Patients with Operable Nonsmall-Cell Lung Cancer: Comparison with Pathological Tumor Size. Indian J Nucl Med 2021; 36:7-13. [PMID: 34040289 PMCID: PMC8130683 DOI: 10.4103/ijnm.ijnm_134_20] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 07/14/2020] [Accepted: 07/29/2020] [Indexed: 11/29/2022] Open
Abstract
Purpose: Incorporating 18F-fluorodeoxyglucose positron emission tomography-computed tomography (18F-FDG-PET/CT) for gross tumor volume (GTV) delineation is challenging due to varying tumor edge based on the set threshold of the standardized uptake value (SUV). This study aims to determine an optimal SUV threshold that correlates best with the pathological tumor size. Materials and Methods: From January 2013 to July 2014, 25 consecutive patients of operable nonsmall-cell lung cancer (NSCLC) who underwent staging18F-FDG-PET/CT before surgical resection were included in the test cohort and 12 patients in the validation cohort. GTVs were delineated on the staging PET/CT by automatic delineation using various percentage threshold of maximum SUV (SUVmax) and absolute SUV. The maximum pathological tumor diameter was then matched with the maximum auto-delineated tumor diameter with varying SUV thresholds. First-order linear regression and Bland–Altman plots were used to obtain an optimal SUV threshold for each patient. Three radiation oncologists with varying degrees of experiences also delineated GTVs with the visual aid of PET/CT to assess interobserver variation in delineation. Results: In the test set, the mean optimal percentage threshold for GTV was SUVmax of 35.6%±18.6% and absolute SUV of 4.35 ± 1.7. In the validation set, the mean optimal percentage threshold SUV and absolute SUV were 36.9 ± 16.9 and 4.1 ± 1.6, respectively. After a combined analysis of all 37 patients, the mean optimal threshold was 36% ± 17.9% and 4.27 ± 1.7, respectively. Using Bland–Altman plots, auto-contouring with 40% SUVmax and SUV 4 was in greater agreement with the pathological tumor diameter. Conclusion: Automatic GTV delineation on PETCT in NSCLC with percentage threshold SUV of 40% and absolute SUV of 4 correlated best with pathological tumor size. Auto-contouring using these thresholds will increase the precision of radiotherapy contouring of GTV and will save time.
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Affiliation(s)
- Anil Tibdewal
- Department of Radiation Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Mangesh Patil
- Department of Radiation Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Shagun Misra
- Department of Radiation Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Nilendu Purandare
- Department of Nuclear Medicine, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Venkatesh Rangarajan
- Department of Nuclear Medicine, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Naveen Mummudi
- Department of Radiation Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - George Karimundackal
- Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Sabita Jiwnani
- Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Jaiprakash Agarwal
- Department of Radiation Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
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McPherson I, Bradley NA, Govindraj R, Kennedy ED, Kirk AJB, Asif M. The progression of non-small cell lung cancer from diagnosis to surgery. Eur J Surg Oncol 2020; 46:1882-1887. [PMID: 32847696 DOI: 10.1016/j.ejso.2020.08.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 08/02/2020] [Accepted: 08/12/2020] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES The IASLC 8th TNM Staging 8th differentiates between a greater number of T-stages. Resection remains the mainstay of curative treatment with often significant waiting times. This study aims to quantify the T-stage progression and growth of non-small cell lung cancers (NSCLCs) between radiological diagnosis and resection, and its impact on disease recurrence and survival. MATERIALS AND METHODS A retrospective analysis of NSCLC resections (289) in a high-volume centre between July 01, 2015 and June 30, 2016. Baseline demographics, time from diagnostic CT to surgery, tumour size (cm) and T-stage from diagnostic CT, PET-CT and post-operative histopathology reports were recorded. The primary outcome was increase in T-stage from diagnostic CT to resection. Kaplan-Meier and cox proportional hazard analyses were used to determine recurrence-free survival and survival. RESULTS Median increase in tumour size between diagnosis and resection was 0.3 cm (p < 0.0001). Median percentage increase in size was 13%. T-stage increased in 133 (46.0%) patients. N stage increased in 51 patients (17.7%), 32 (11.1%) to N2 disease. Mean survival in those upstaged was 43.5 (39.9-47.1) months versus 53.4 (50.0-56.8) months in patients not upstaged (p = 0.025). Mean recurrence-free survival in those upstaged was 39.1 (35.2-43.0) months versus 47.7 (43.9-51.4) months in patients not upstaged (p = 0.117). Upstaging was independently associated with inferior survival (HR 1.674, p = 0.006) and inferior recurrence-free survival (HR 1.423, p = 0.038). CONCLUSIONS A significant number of patients are upstaged between diagnostic and resection resulting in reduced survival and recurrence-free survival. A change in management pathways are required to improve outcomes in NSCLC.
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Affiliation(s)
- Iain McPherson
- Department of Thoracic Surgery, Golden Jubilee National Hospital, Agamemnon St, Clydebank, G81 4DY, UK.
| | - Nicholas A Bradley
- Department of Thoracic Surgery, Golden Jubilee National Hospital, Agamemnon St, Clydebank, G81 4DY, UK
| | - Rohith Govindraj
- Department of Thoracic Surgery, Golden Jubilee National Hospital, Agamemnon St, Clydebank, G81 4DY, UK
| | - Ewan D Kennedy
- Department of Thoracic Surgery, Golden Jubilee National Hospital, Agamemnon St, Clydebank, G81 4DY, UK
| | - Alan J B Kirk
- Department of Thoracic Surgery, Golden Jubilee National Hospital, Agamemnon St, Clydebank, G81 4DY, UK
| | - Mohammed Asif
- Department of Thoracic Surgery, Golden Jubilee National Hospital, Agamemnon St, Clydebank, G81 4DY, UK
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Kojima I, Takanami K, Ogawa T, Sakamoto M, Nagai H, Miyashita H, Iikubo M. High detection sensitivity and reliable morphological correlation of PET with a silicon photomultiplier for primary tongue squamous cell carcinoma. Ann Nucl Med 2020; 34:643-652. [PMID: 32564300 DOI: 10.1007/s12149-020-01489-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 06/12/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE A positron emission tomography (PET) scanner using a silicon photomultiplier (SiPM PET) in place of a photomultiplier tube significantly improves the spatial and time resolution. It may also improve the evaluation of smaller lesions compared to conventional (non-SiPM) PET scanners. We compared the maximum standardized uptake value (SUVmax), detection sensitivity, and morphological correlation using magnetic resonance imaging (MRI) for primary tongue squamous cell carcinoma between the SiPM PET and non-SiPM PET scanner. METHODS We retrospectively reviewed the F-18 fluorodeoxyglucose (FDG) PET/CT features of tongue squamous cell carcinomas in consecutive, newly diagnosed, and pathologically verified patients. Twenty-five of 46 patients were scanned using SiPM PET scanner and the remaining 21 patients were scanned with a non-SiPM PET scanner. We compared the SUVmax and visual evaluation of primary tumor detectability, and the correlation between the PET-based and MRI-based tumor size (long axis, thickness, and volume). Differences in SUVmax and detection sensitivity for the primary tumor were analyzed using Welch's t test and Fisher's exact test, respectively. Correlations among the PET-based, MRI-based tumor size, and SUVmax were assessed using Spearman's rank correlation coefficient. RESULTS SUVmax of both T1/T2 and T3/T4 primary tumors were significantly higher for the SiPM PET (T1/T2 mean SUVmax: 6.6 ± 4.3, T3/T4 mean SUVmax: 18.2 ± 9.8) than that for the non-SiPM PET (T1/T2 mean SUVmax: 3.4 ± 1.4, T3/T4 mean SUVmax: 10.2 ± 4.9) (P < 0.05). While all cases of T3/T4 primary tumors were detected by both PET scanners, the detection sensitivity for T1/T2 primary tumors was significantly higher for the SiPM PET (80%) than that for the non-SiPM PET (36.4%) (P < 0.05). MRI-based tumor size correlated significantly with SiPM PET-based tumor long axis (ρ = 0.74) and volume (ρ = 0.91), but not with the non-SiPM PET-based tumor long axis and volume in T1/T2 primary lesions. Correlation between MRI-based tumor size and SUVmax was significant in both PET scanners; however, no significant difference was observed between the two scanners. CONCLUSIONS The SiPM PET provides better detection sensitivity and a reliable morphological correlation for the T1/T2 primary tongue tumors than the non-SiPM PET due to its high performance.
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Affiliation(s)
- Ikuho Kojima
- Department of Oral Diagnosis, Tohoku University Graduate School of Dentistry, 4-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8575, Japan. .,Head and Neck Cancer Center, Tohoku University Hospital, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan.
| | - Kentaro Takanami
- Department of Diagnostic Radiology, Tohoku University Hospital, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - Takenori Ogawa
- Department of Otolaryngology-Head and Neck Surgery, Tohoku University Hospital, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan.,Head and Neck Cancer Center, Tohoku University Hospital, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - Maya Sakamoto
- Department of Oral Diagnosis, Tohoku University Graduate School of Dentistry, 4-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8575, Japan.,Head and Neck Cancer Center, Tohoku University Hospital, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - Hirokazu Nagai
- Head and Neck Cancer Center, Tohoku University Hospital, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan.,Department of Oral and Maxillofacial Surgery, Tohoku University Graduate School of Dentistry, 4-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8575, Japan
| | - Hitoshi Miyashita
- Head and Neck Cancer Center, Tohoku University Hospital, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan.,Department of Oral and Maxillofacial Surgery, Tohoku University Graduate School of Dentistry, 4-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8575, Japan
| | - Masahiro Iikubo
- Department of Oral Diagnosis, Tohoku University Graduate School of Dentistry, 4-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8575, Japan.,Head and Neck Cancer Center, Tohoku University Hospital, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
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5
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Zhang J, Srivastava S, Wang C, Beckham T, Johnson C, Dutta P, Shepherd A, Mechalakos J, Hunt M, Wu A, Rimner A, Li G. Clinical evaluation of 4D MRI in the delineation of gross and internal tumor volumes in comparison with 4DCT. J Appl Clin Med Phys 2020; 20:51-60. [PMID: 31538719 PMCID: PMC6753727 DOI: 10.1002/acm2.12699] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Revised: 06/15/2019] [Accepted: 07/23/2019] [Indexed: 02/06/2023] Open
Abstract
Purpose To evaluate clinical utility of respiratory‐correlated (RC) four‐dimensional magnetic resonance imaging (4DMRI) for lung tumor delineation and motion assessment, in comparison with the current clinical standard of 4D computed tomography (4DCT). Methods and Materials A prospective T2‐weighted (T2w) RC‐4DMRI technique was applied to acquire coronal 4DMRI images for 14 lung cancer patients (16 lesions) during free breathing (FB) under an IRB‐approved protocol, together with a breath‐hold (BH) T1w 3DMRI and axial 4DMRI. Clinical simulation CT and 4DCT were acquired within 2 h. An internal navigator was applied to trigger amplitude‐binned 4DMRI acquisition whereas a bellows or real‐time position management (RPM) was used in the 4DCT reconstruction. Six radiation oncologists manually delineated the gross and internal tumor volumes (GTV and ITV) in 399 3D images using programmed clinical workflows under a tumor delineation guideline. The ITV was the union of GTVs within the breathing cycle without margin. Average GTV and motion range were assessed and ITV variation between 4DMRI and 4DCT was evaluated using the Dice similarity index, mean distance agreement (MDA), and volume difference. Results The mean tumor volume is similar between 4DCT (GTV4DCT = 1.0, as the reference) and T2w‐4DMRI (GTVT2wMR = 0.97), but smaller in T1w MRI (GTVT1wMR = 0.76), suggesting possible peripheral edema around the tumor. Average GTV variation within the breathing cycle (22%) in 4DMRI is slightly greater than 4DCT (17%). GTV motion variation (−4 to 12 mm) and ITV variation (∆VITV=−25 to 95%) between 4DCT and 4DMRI are large, confirmed by relatively low ITV similarity (Dice = 0.72 ± 0.11) and large MDA = 2.9 ± 1.5 mm. Conclusion Average GTVs are similar between T2w‐4DMRI and 4DCT, but smaller by 25% in T1w BH MRI. Physician training and breathing coaching may be necessary to reduce ITV variability between 4DMRI and 4DCT. Four‐dimensional magnetic resonance imaging is a promising and viable technique for clinical lung tumor delineation and motion assessment.
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Affiliation(s)
- Jingjing Zhang
- Department of Radiation Oncology, Zhongshan Hospital of Sun Yat-Sen University, Zhongshan, China.,Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Shreya Srivastava
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Chunyu Wang
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Thomas Beckham
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Christopher Johnson
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Pinaki Dutta
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Annemarie Shepherd
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - James Mechalakos
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Margie Hunt
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Abraham Wu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Guang Li
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
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Dosimetric comparison and biological evaluation of PET- and CT-based target delineation for LA-NSCLC using auto-planning. Phys Med 2019; 67:77-84. [DOI: 10.1016/j.ejmp.2019.09.080] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 08/08/2019] [Accepted: 09/11/2019] [Indexed: 12/28/2022] Open
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7
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Park CH, Kim TH, Lee S, Moon DH, Park HS. Correlation between maximal tumor diameter of fresh pathology specimens and computed tomography images in lung adenocarcinoma. PLoS One 2019; 14:e0211141. [PMID: 30682110 PMCID: PMC6347433 DOI: 10.1371/journal.pone.0211141] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Accepted: 01/08/2019] [Indexed: 02/08/2023] Open
Abstract
The authors compared maximal tumor diameters between fresh lung tissue and axial and multiplanar reformatted chest computed-tomography (CT) images in lung adenocarcinoma and investigated the factors affecting tumor-size discrepancies. This study included 135 surgically resected lung adenocarcinomas. An experienced pulmonary pathologist aimed to cut the largest tumor section and measured pathological tumor size (PTS) in fresh specimens. Radiological maximal tumor sizes (RTS) were retrospectively measured on axial (RTSax) and multiplanar reformatted (RTSre) chest CT images. Mean PTS, RTSax, and RTSre were 19.13 mm, 18.63 mm, and 20.80 mm, respectively. RTSre was significantly larger than PTS (mean difference, 1.68 mm; p<0.001). RTSax was also greater than PTS for 6−10-mm and 11−20-mm tumors. PTS and RTS were strongly positively correlated (RTSax, r2 = 0.719, p<0.001; RTSre, r2 = 0.833, p<0.001). The intraclass correlation coefficient was 0.915 between PTS and RTSax and 0.954 between PTS and RTSre. Postoperative down-staging occurred in 11.0% and 27.4% of tumors on performing radiological staging using RTSax and RTSre, respectively. Postoperative up-staging occurred in 12.3% and 1.4% of tumors on performing radiological staging using RTSax and RTSre, respectively. Multiple linear regression revealed that pleural dimpling (p = 0.024) was an independent factor affecting differences between PTS and RTSax. Specimen type (p = 0.012) and tumor location (p = 0.020) were independent factors affecting differences between PTS and RTSre. In conclusion, RTSre was significantly larger than PTS and caused postoperative down-staging in 27.4% of the tumors. Reliability analysis revealed that RTSre was more strongly correlated with PTS than RTSax. Specimen type and anatomical tumor location influenced the measured size differences between PTS and RTSre.
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Affiliation(s)
- Chul Hwan Park
- Department of Radiology, Research Institute of Radiological Science, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Tae Hoon Kim
- Department of Radiology, Research Institute of Radiological Science, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sungsoo Lee
- Department of Thoracic and Cardiovascular Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Duk Hwan Moon
- Department of Thoracic and Cardiovascular Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Heae Surng Park
- Department of Pathology, Ewha Womans University Mokdong Hospital, Seoul, Korea
- * E-mail:
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Abstract
Over the last few decades, advances in radiation therapy technology have markedly improved radiation delivery. Advancements in treatment planning with the development of image-guided radiotherapy and techniques such as proton therapy, allow precise delivery of high doses of radiation conformed to the tumor. These advancements result in improved locoregional control while reducing radiation dose to surrounding normal tissue. The radiologic manifestations of these techniques can differ from radiation induced lung disease seen with traditional radiation therapy. Awareness of these radiologic manifestations and correlation with radiation treatment plans are important to differentiate expected radiation induced lung injury from recurrence, infection and drug toxicity.
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9
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Benveniste MF, Welsh J, Viswanathan C, Shroff GS, Betancourt Cuellar SL, Carter BW, Marom EM. Lung Cancer: Posttreatment Imaging: Radiation Therapy and Imaging Findings. Radiol Clin North Am 2018; 56:471-483. [PMID: 29622079 DOI: 10.1016/j.rcl.2018.01.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
In this review, we discuss the different radiation delivery techniques available to treat non-small cell lung cancer, typical radiologic manifestations of conventional radiotherapy, and different patterns of lung injury and temporal evolution of the newer radiotherapy techniques. More sophisticated techniques include intensity-modulated radiotherapy, stereotactic body radiotherapy, proton therapy, and respiration-correlated computed tomography or 4-dimensional computed tomography for radiotherapy planning. Knowledge of the radiation treatment plan and technique, the completion date of radiotherapy, and the temporal evolution of radiation-induced lung injury is important to identify expected manifestations of radiation-induced lung injury and differentiate them from tumor recurrence or infection.
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Affiliation(s)
- Marcelo F Benveniste
- Department of Diagnostic Radiology, The University of Texas, MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA.
| | - James Welsh
- Department of Radiation Oncology, The University of Texas, MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| | - Chitra Viswanathan
- Department of Diagnostic Radiology, The University of Texas, MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| | - Girish S Shroff
- Department of Diagnostic Radiology, The University of Texas, MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| | - Sonia L Betancourt Cuellar
- Department of Diagnostic Radiology, The University of Texas, MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| | - Brett W Carter
- Department of Diagnostic Radiology, The University of Texas, MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| | - Edith M Marom
- Department of Diagnostic Radiology, The University of Texas, MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA; Department of Diagnostic Imaging, The Chaim Sheba Medical Center, Affiliated with Tel Aviv University, Tel Aviv, 2 Derech Sheba, Ramat Gan 5265601, Israel
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10
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Heidinger BH, Anderson KR, Moriarty EM, Costa DB, Gangadharan SP, VanderLaan PA, Bankier AA. Size Measurement and T-staging of Lung Adenocarcinomas Manifesting as Solid Nodules ≤30 mm on CT: Radiology-Pathology Correlation. Acad Radiol 2017; 24:851-859. [PMID: 28256438 DOI: 10.1016/j.acra.2017.01.009] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Revised: 01/10/2017] [Accepted: 01/12/2017] [Indexed: 12/20/2022]
Abstract
RATIONALE AND OBJECTIVES This study aimed to compare long-axis diameter to average computed tomography (CT) diameter measurements of lung adenocarcinomas manifesting as solid lung nodules ≤30 mm on CT, as referenced to pathologic measurements, and to determine the impact of the two CT measurement approaches on tumor (T)-staging of nodules. MATERIALS AND METHODS This institutional review board-approved study included all 274 radiologic solid adenocarcinomas resected at our institution over 10 years. Two observers measured long- and short-axis diameters on pre-resection chest CT in lung and mediastinal windows. T-stages were determined. CT measurements and T-stages were compared to pathology measurements and T-stages using Wilcoxon signed rank test and McNemar test. Inter- and intraobserver variability was determined with intraclass correlation coefficients (ICC) and Bland-Altman plots. RESULTS For lung and mediastinal windows, nodule size was significantly larger using long-axis diameter rather than average diameter (16.93 vs. 14.92 mm, P <.001; and 14.02 vs. 12.17 mm, P <.001, respectively). The correlation of CT with pathologic measurements was stronger with long-axis than with average diameter (ICC 0.808 vs. 0.730; and 0.731 vs. 0.621, respectively). Lung window measurements correlated stronger with pathology than mediastinal window measurements. CT T-stages differed from pathology T-stages in more than 20% of nodules (P <.001). Inter- and intraobserver variability was small with long-axis and average diameter (ICC range 0.96-0.991, and 0.970-0.993, respectively), but long-axis diameter showed wider scatter on Bland-Altman plots. CONCLUSIONS Long-axis CT diameter is preferable for T-staging because it better reflects the pathology T-stage. Average CT diameter might be used for longitudinal nodule follow-up because it shows less measurement variability and is more conservative in size assessment.
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Affiliation(s)
- Benedikt H Heidinger
- Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA; Department of Biomedical Imaging and Image-guided Therapy, Vienna General Hospital, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria.
| | - Kevin R Anderson
- Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Eoin M Moriarty
- Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA
| | - Daniel B Costa
- Internal Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Sidhu P Gangadharan
- Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Paul A VanderLaan
- Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Alexander A Bankier
- Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA
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Effect of different segmentation algorithms on metabolic tumor volume measured on 18F-FDG PET/CT of cervical primary squamous cell carcinoma. Nucl Med Commun 2017; 38:259-265. [PMID: 28118260 PMCID: PMC5318156 DOI: 10.1097/mnm.0000000000000641] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background and purpose It is known that fluorine-18 fluorodeoxyglucose PET/computed tomography (CT) segmentation algorithms have an impact on the metabolic tumor volume (MTV). This leads to some uncertainties in PET/CT guidance of tumor radiotherapy. The aim of this study was to investigate the effect of segmentation algorithms on the PET/CT-based MTV and their correlations with the gross tumor volumes (GTVs) of cervical primary squamous cell carcinoma. Materials and methods Fifty-five patients with International Federation of Gynecology and Obstetrics stage Ia∼IIb and histologically proven cervical squamous cell carcinoma were enrolled. A fluorine-18 fluorodeoxyglucose PET/CT scan was performed before definitive surgery. GTV was measured on surgical specimens. MTVs were estimated on PET/CT scans using different segmentation algorithms, including a fixed percentage of the maximum standardized uptake value (20∼60% SUVmax) threshold and iterative adaptive algorithm. We divided all patients into four different groups according to the SUVmax within target volume. The comparisons of absolute values and percentage differences between MTVs by segmentation and GTV were performed in different SUVmax subgroups. The optimal threshold percentage was determined from MTV20%∼MTV60%, and was correlated with SUVmax. The correlation of MTViterative adaptive with GTV was also investigated. Results MTV50% and MTV60% were similar to GTV in the SUVmax up to 5 (P>0.05). MTV30%∼MTV60% were similar to GTV (P>0.05) in the 5<SUVmax≤10 group. MTV20%∼MTV60% were similar to GTV (P>0.05) in the 10<SUVmax≤15 group. MTV20% and MTV30% were similar to GTV (P>0.05) in the SUVmax of at least 15 group. MTViterative adaptive was similar to GTV in both total and different SUVmax groups (P>0.05). Significant differences were observed among the fixed percentage method and the optimal threshold percentage was inversely correlated with SUVmax. The iterative adaptive segmentation algorithm led to the highest accuracy (6.66±50.83%). A significantly positive correlation was also observed between MTViterative adaptive and GTV (Pearson’s correlation r=0.87, P<0.0001). Conclusion MTViterative adaptive is independent of SUVmax, more accurate, and correlated with GTV. Iterative adaptive algorithm segmentation may be more suitable than the fixed percentage threshold method to estimate the tumor volume of cervical primary squamous cell carcinoma.
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Meijer TWH, de Geus-Oei LF, Visser EP, Oyen WJG, Looijen-Salamon MG, Visvikis D, Verhagen AFTM, Bussink J, Vriens D. Tumor Delineation and Quantitative Assessment of Glucose Metabolic Rate within Histologic Subtypes of Non-Small Cell Lung Cancer by Using Dynamic 18F Fluorodeoxyglucose PET. Radiology 2016; 283:547-559. [PMID: 27846378 DOI: 10.1148/radiol.2016160329] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Purpose To assess whether dynamic fluorine 18 (18F) fluorodeoxyglucose (FDG) positron emission tomography (PET) has added value over static 18F-FDG PET for tumor delineation in non-small cell lung cancer (NSCLC) radiation therapy planning by using pathology volumes as the reference standard and to compare pharmacokinetic rate constants of 18F-FDG metabolism, including regional variation, between NSCLC histologic subtypes. Materials and Methods The study was approved by the institutional review board. Patients gave written informed consent. In this prospective observational study, 1-hour dynamic 18F-FDG PET/computed tomographic examinations were performed in 35 patients (36 resectable NSCLCs) between 2009 and 2014. Static and parametric images of glucose metabolic rate were obtained to determine lesion volumes by using three delineation strategies. Pathology volume was calculated from three orthogonal dimensions (n = 32). Whole tumor and regional rate constants and blood volume fraction (VB) were computed by using compartment modeling. Results Pathology volumes were larger than PET volumes (median difference, 8.7-25.2 cm3; Wilcoxon signed rank test, P < .001). Static fuzzy locally adaptive Bayesian (FLAB) volumes corresponded best with pathology volumes (intraclass correlation coefficient, 0.72; P < .001). Bland-Altman analyses showed the highest precision and accuracy for static FLAB volumes. Glucose metabolic rate and 18F-FDG phosphorylation rate were higher in squamous cell carcinoma (SCC) than in adenocarcinoma (AC), whereas VB was lower (Mann-Whitney U test or t test, P = .003, P = .036, and P = .019, respectively). Glucose metabolic rate, 18F-FDG phosphorylation rate, and VB were less heterogeneous in AC than in SCC (Friedman analysis of variance). Conclusion Parametric images are not superior to static images for NSCLC delineation. FLAB-based segmentation on static 18F-FDG PET images is in best agreement with pathology volume and could be useful for NSCLC autocontouring. Differences in glycolytic rate and VB between SCC and AC are relevant for research in targeting agents and radiation therapy dose escalation. © RSNA, 2016 Online supplemental material is available for this article.
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Affiliation(s)
- Tineke W H Meijer
- From the Departments of Radiation Oncology (T.W.H.M., J.B.), Radiology and Nuclear Medicine (L.F.d.G.O., E.P.V., W.J.G.O.), Pathology (M.G.L.S.), and Cardiothoracic Surgery (A.F.T.M.V.), Radboud University Medical Center, PO Box 9101, 6500 HB Nijmegen, the Netherlands; Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands (L.F.d.G.O., D. Vriens); Biomedical Photonic Imaging Group, MIRA Institute, University of Twente, Enschede, the Netherlands (L.F.d.G.O.); Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, England (W.J.G.O.); and INSERM, UMR 1101, LaTIM, Université de Bretagne Occidentale, Brest, France (D. Visvikis)
| | - Lioe-Fee de Geus-Oei
- From the Departments of Radiation Oncology (T.W.H.M., J.B.), Radiology and Nuclear Medicine (L.F.d.G.O., E.P.V., W.J.G.O.), Pathology (M.G.L.S.), and Cardiothoracic Surgery (A.F.T.M.V.), Radboud University Medical Center, PO Box 9101, 6500 HB Nijmegen, the Netherlands; Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands (L.F.d.G.O., D. Vriens); Biomedical Photonic Imaging Group, MIRA Institute, University of Twente, Enschede, the Netherlands (L.F.d.G.O.); Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, England (W.J.G.O.); and INSERM, UMR 1101, LaTIM, Université de Bretagne Occidentale, Brest, France (D. Visvikis)
| | - Eric P Visser
- From the Departments of Radiation Oncology (T.W.H.M., J.B.), Radiology and Nuclear Medicine (L.F.d.G.O., E.P.V., W.J.G.O.), Pathology (M.G.L.S.), and Cardiothoracic Surgery (A.F.T.M.V.), Radboud University Medical Center, PO Box 9101, 6500 HB Nijmegen, the Netherlands; Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands (L.F.d.G.O., D. Vriens); Biomedical Photonic Imaging Group, MIRA Institute, University of Twente, Enschede, the Netherlands (L.F.d.G.O.); Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, England (W.J.G.O.); and INSERM, UMR 1101, LaTIM, Université de Bretagne Occidentale, Brest, France (D. Visvikis)
| | - Wim J G Oyen
- From the Departments of Radiation Oncology (T.W.H.M., J.B.), Radiology and Nuclear Medicine (L.F.d.G.O., E.P.V., W.J.G.O.), Pathology (M.G.L.S.), and Cardiothoracic Surgery (A.F.T.M.V.), Radboud University Medical Center, PO Box 9101, 6500 HB Nijmegen, the Netherlands; Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands (L.F.d.G.O., D. Vriens); Biomedical Photonic Imaging Group, MIRA Institute, University of Twente, Enschede, the Netherlands (L.F.d.G.O.); Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, England (W.J.G.O.); and INSERM, UMR 1101, LaTIM, Université de Bretagne Occidentale, Brest, France (D. Visvikis)
| | - Monika G Looijen-Salamon
- From the Departments of Radiation Oncology (T.W.H.M., J.B.), Radiology and Nuclear Medicine (L.F.d.G.O., E.P.V., W.J.G.O.), Pathology (M.G.L.S.), and Cardiothoracic Surgery (A.F.T.M.V.), Radboud University Medical Center, PO Box 9101, 6500 HB Nijmegen, the Netherlands; Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands (L.F.d.G.O., D. Vriens); Biomedical Photonic Imaging Group, MIRA Institute, University of Twente, Enschede, the Netherlands (L.F.d.G.O.); Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, England (W.J.G.O.); and INSERM, UMR 1101, LaTIM, Université de Bretagne Occidentale, Brest, France (D. Visvikis)
| | - Dimitris Visvikis
- From the Departments of Radiation Oncology (T.W.H.M., J.B.), Radiology and Nuclear Medicine (L.F.d.G.O., E.P.V., W.J.G.O.), Pathology (M.G.L.S.), and Cardiothoracic Surgery (A.F.T.M.V.), Radboud University Medical Center, PO Box 9101, 6500 HB Nijmegen, the Netherlands; Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands (L.F.d.G.O., D. Vriens); Biomedical Photonic Imaging Group, MIRA Institute, University of Twente, Enschede, the Netherlands (L.F.d.G.O.); Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, England (W.J.G.O.); and INSERM, UMR 1101, LaTIM, Université de Bretagne Occidentale, Brest, France (D. Visvikis)
| | - Ad F T M Verhagen
- From the Departments of Radiation Oncology (T.W.H.M., J.B.), Radiology and Nuclear Medicine (L.F.d.G.O., E.P.V., W.J.G.O.), Pathology (M.G.L.S.), and Cardiothoracic Surgery (A.F.T.M.V.), Radboud University Medical Center, PO Box 9101, 6500 HB Nijmegen, the Netherlands; Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands (L.F.d.G.O., D. Vriens); Biomedical Photonic Imaging Group, MIRA Institute, University of Twente, Enschede, the Netherlands (L.F.d.G.O.); Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, England (W.J.G.O.); and INSERM, UMR 1101, LaTIM, Université de Bretagne Occidentale, Brest, France (D. Visvikis)
| | - Johan Bussink
- From the Departments of Radiation Oncology (T.W.H.M., J.B.), Radiology and Nuclear Medicine (L.F.d.G.O., E.P.V., W.J.G.O.), Pathology (M.G.L.S.), and Cardiothoracic Surgery (A.F.T.M.V.), Radboud University Medical Center, PO Box 9101, 6500 HB Nijmegen, the Netherlands; Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands (L.F.d.G.O., D. Vriens); Biomedical Photonic Imaging Group, MIRA Institute, University of Twente, Enschede, the Netherlands (L.F.d.G.O.); Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, England (W.J.G.O.); and INSERM, UMR 1101, LaTIM, Université de Bretagne Occidentale, Brest, France (D. Visvikis)
| | - Dennis Vriens
- From the Departments of Radiation Oncology (T.W.H.M., J.B.), Radiology and Nuclear Medicine (L.F.d.G.O., E.P.V., W.J.G.O.), Pathology (M.G.L.S.), and Cardiothoracic Surgery (A.F.T.M.V.), Radboud University Medical Center, PO Box 9101, 6500 HB Nijmegen, the Netherlands; Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands (L.F.d.G.O., D. Vriens); Biomedical Photonic Imaging Group, MIRA Institute, University of Twente, Enschede, the Netherlands (L.F.d.G.O.); Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, England (W.J.G.O.); and INSERM, UMR 1101, LaTIM, Université de Bretagne Occidentale, Brest, France (D. Visvikis)
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Berberoğlu K. Use of Positron Emission Tomography/Computed Tomography in Radiation Treatment Planning for Lung Cancer. Mol Imaging Radionucl Ther 2016; 25:50-62. [PMID: 27277321 PMCID: PMC5096621 DOI: 10.4274/mirt.19870] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Radiotherapy (RT) plays an important role in the treatment of lung cancer. Accurate diagnosis and staging are crucial in the delivery of RT with curative intent. Target miss can be prevented by accurate determination of tumor contours during RT planning. Currently, tumor contours are determined manually by computed tomography (CT) during RT planning. This method leads to differences in delineation of tumor volume between users. Given the change in RT tools and methods due to rapidly developing technology, it is now more significant to accurately delineate the tumor tissue. F18 fluorodeoxyglucose positron emission tomography/CT (F18 FDG PET/CT) has been established as an accurate method in correctly staging and detecting tumor dissemination in lung cancer. Since it provides both anatomic and biologic information, F18 FDG PET decreases inter-user variability in tumor delineation. For instance, tumor volumes may be decreased as atelectasis and malignant tissue can be more accurately differentiated, as well as better evaluation of benign and malignant lymph nodes given the difference in FDG uptake. Using F18 FDG PET/CT, the radiation dose can be escalated without serious adverse effects in lung cancer. In this study, we evaluated the contribution of F18 FDG PET/CT for RT planning in lung cancer.
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Affiliation(s)
- Kezban Berberoğlu
- Anadolu Medical Center, Clinic of Nuclear Medicine, İstanbul, Turkey, Phone: +90 532 584 62 56 E-mail:
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Quantification of metabolic tumor activity and burden in patients with non-small-cell lung cancer: Is manual adjustment of semiautomatic gradient-based measurements necessary? Nucl Med Commun 2016; 36:782-9. [PMID: 25888358 DOI: 10.1097/mnm.0000000000000317] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE Metabolic tumor burden (MTB) measurements including metabolic tumor volume and total lesion glycolysis have been shown to have prognostic value in non-small-cell lung cancer (NSCLC). The calculation of MTB typically utilizes software to semiautomatically draw volumes of interest around the tumor, which are subsequently manually adjusted by the radiologist to include the entire tumor. The manual adjustment step can be time-consuming and observer-dependent. We compared the agreement of MTB values obtained using the semiautomatic method with and without manual adjustment in NSCLC patients. METHODS This IRB-approved prospective study included 134 patients with histologically proven NSCLC who underwent fluorine-18 fluorodeoxyglucose PET/computed tomography. The MTB of the primary tumor was measured with a semiautomatic gradient-based method without manual adjustment (the semiautomatic gradient method) and with manual adjustment (the manually adjusted semiautomatic gradient method) by two radiologists using the MIM PETedge tool. The paired t-test, Wilcoxon signed-rank test, and concordance correlation coefficient (CCC) were calculated to evaluate the agreement between MTB measures obtained with these two methods, as well as agreement between the two radiologists for each method. RESULTS Maximum standardized uptake value was identical between the two methods. No statistically significant difference was present for peak standardized uptake value, metabolic tumor volume, and total lesion glycolysis values between the two methods (P=0.23, 0.45, and 0.37, respectively). Excellent agreement between the two methods was found in terms of CCC (CCC>0.98 for all measures). Interobserver reliability was excellent for all measures (CCC>0.90). CONCLUSION The semiautomatic gradient-based tumor-segmentation method can be used without the additional manual adjustment step for MTB quantification of primary NSCLC tumors.
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Chi A, Nguyen NP. The utility of positron emission tomography in the treatment planning of image-guided radiotherapy for non-small cell lung cancer. Front Oncol 2014; 4:273. [PMID: 25340040 PMCID: PMC4187610 DOI: 10.3389/fonc.2014.00273] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Accepted: 09/20/2014] [Indexed: 11/17/2022] Open
Abstract
In the thorax, the extent of tumor may be more accurately defined with the addition of 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) to computed tomography (CT). This led to the increased utility of FDG-PET or PET/CT in the treatment planning of radiotherapy for non-small cell lung cancer (NSCLC). The inclusion of FDG-PET information in target volume delineation not only improves tumor localization but also decreases the amount of normal tissue included in the planning target volume (PTV) in selected patients. Therefore, it has a critical role in image-guided radiotherapy (IGRT) for NSCLC. In this review, the impact of FDG-PET on target volume delineation in radiotherapy for NSCLC, which may increase the possibility of safe dose escalation with IGRT, the commonly used methods for tumor target volume delineation FDG-PET for NSCLC, and its impact on clinical outcome will be discussed.
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Affiliation(s)
- Alexander Chi
- Department of Radiation Oncology, Mary Babb Randolph Cancer Center, West Virginia University , Morgantown, WV , USA
| | - Nam P Nguyen
- International Geriatric Radiotherapy Group , Tucson, AZ , USA
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Obara P, Pu Y. Prognostic value of metabolic tumor burden in lung cancer. Chin J Cancer Res 2014; 25:615-22. [PMID: 24385688 DOI: 10.3978/j.issn.1000-9604.2013.11.10] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Accepted: 11/29/2013] [Indexed: 12/20/2022] Open
Abstract
Accurate prognosis in patients with lung cancer is important for clinical decision making and treatment selection. The TNM staging system is currently the main method for establishing prognosis. Using this system, patients are grouped into one of four stages based on primary tumor extent, nodal disease, and distant metastases. However, each stage represents a range of disease extent and may not on its own be the best reflection of individual patient prognosis. (18)F-fluorodeoxyglucose-positron emission tomography ((18)F-FDG-PET) can be used to evaluate the metabolic tumor burden affecting the whole body with measures such as metabolic tumor volume (MTV) and total lesion glycolysis (TLG). MTV and TLG have been shown to be significant prognostic factors in patients with lung cancer, independent of TNM stage. These metabolic tumor burden measures have the potential to make lung cancer staging and prognostication more accurate and quantitative, with the goal of optimizing treatment choices and outcome predictions.
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Affiliation(s)
- Piotr Obara
- Department of Radiology, University of Chicago, Chicago 60637, USA
| | - Yonglin Pu
- Department of Radiology, University of Chicago, Chicago 60637, USA
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Dubray B, Thureau S, Nkhali L, Modzelewski R, Doyeux K, Ruan S, Vera P. FDG-PET imaging for radiotherapy target volume definition in lung cancer. Ing Rech Biomed 2014. [DOI: 10.1016/j.irbm.2013.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Comparison of Multiplanar Reformatted CT Lung Tumor Measurements to Axial Tumor Measurement Alone: Impact on Maximal Tumor Dimension and T Stage. AJR Am J Roentgenol 2013; 201:959-63. [DOI: 10.2214/ajr.12.10033] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Mahasittiwat P, Yuan S, Xie C, Ritter T, Cao Y, Ten Haken RK, Kong FMS. Metabolic Tumor Volume on PET Reduced More than Gross Tumor Volume on CT during Radiotherapy in Patients with Non-Small Cell Lung Cancer Treated with 3DCRT or SBRT. ACTA ACUST UNITED AC 2013; 2:191-202. [PMID: 23795245 DOI: 10.1007/s13566-013-0091-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE We have previously demonstrated that tumor reduces in activity and size during the course of radiotherapy (RT) in a limited number of patients with non-small cell lung cancer (NSCLC). This study aimed to quantify the metabolic tumor volume (MTV) on PET and compare its changes with those of gross tumor volume (GTV) on CT during-RT for 3D conformal radiotherapy (3DCRT) and stereotactic body radiotherapy (SBRT). METHODS Patients with stage I-III NSCLC treated with a definitive course of RT ± chemotherapy were eligible for this prospective study. FDG-PET/CT scans were acquired within 2 weeks before RT (pre-RT) and at about two thirds of total dose during-RT. PET-MTVs were delineated using a method combining the tumor/aorta ratio autosegmentation and CT anatomy based manual editing. Data is presented as mean (95% confident interval). RESULTS The MTV delineation methodology was first confirmed to be highly reproducible by comparing volumes defined by different physicians and using different systems (coefficiency >0.98). Fifty patients with 88 primary and nodal lesions were evaluated. The mean ratios of MTV/GTV were 0.70(-0.07~1.47) and 0.33(-0.30~0.95) for pre-RT and during-RT, respectively. PET-MTV reduced by 70% (62-77%), while CT-GTV by 41% (33-49%) (p< 0.001) during-RT. MTV reduction was 72.9% and 15.4% for 3DCRT and SBRT, respectively (p< 0.001). CONCLUSION PET-MTV reduced more than CT-GTV during-RT, while patients treated with 3DCRT reduced more than SBRT. RTOG1106 is using during-RT PET-MTV to adapt radiation therapy in 3DCRT.
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Affiliation(s)
- Pawinee Mahasittiwat
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI ; Division of Radiation Oncology, Department of Radiology, Faculty of Medicine Siriraj Hospital, Thailand
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Li J, Xiao Y. Application of FDG-PET/CT in Radiation Oncology. Front Oncol 2013; 3:80. [PMID: 23596565 PMCID: PMC3622875 DOI: 10.3389/fonc.2013.00080] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2012] [Accepted: 03/28/2013] [Indexed: 01/19/2023] Open
Abstract
Positron emission tomography (PET)/computed tomography (CT), which combines the advantages of high sensitivity and specificity of PET and high resolution of CT, is a unique tool for cancer management. PET/CT has been widely used in cancer diagnosis and treatment. The article reviews the recent applications of PET/CT in radiation oncology, with a focus on 18F-fluorodeoxyglucose (FDG)-PET/CT, addressing the applications in treatment planning and treatment response assessment of radiation therapy.
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Affiliation(s)
- Jun Li
- Department of Radiation Oncology, Thomas Jefferson University Philadelphia, PA, USA
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Prognostic value of volumetric parameters measured by F-18 FDG PET/CT in surgically resected non-small-cell lung cancer. Nucl Med Commun 2012; 33:613-20. [PMID: 22407127 DOI: 10.1097/mnm.0b013e328351d4f5] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate the usefulness of the tumor burden as characterized by the metabolic tumor volume (MTV) and total lesion glycolysis (TLG) measured by F-18 fluoro-2-deoxyglucose (F-18 FDG) PET-computed tomography (CT) in predicting recurrence-free survival (RFS) and overall survival (OS) in surgically resected non-small-cell lung cancer (NSCLC) patients. METHODS We retrospectively reviewed 91 patients with pathologically documented stages I-IIIA NSCLC. MTV and TLG were obtained according to various thresholds of the standard uptake value (SUV) of primary tumor using preoperative F-18 FDG PET-CT. We used comparison receiver-operating characteristic curve analysis to test the statistical significance of the differences among the multiple volumetric parameters calculated by various SUV cutoff values. RFS and OS were evaluated with the Kaplan-Meier method and Cox regression analysis. RESULTS On comparison receiver-operating characteristic curve analysis, no significant difference was found among the volumetric parameters calculated using various thresholds of SUV. Regardless of the thresholds, patients with smaller MTV and lower TLG showed longer RFS and OS. MTV and TLG measured by F-18 FDG PET-CT were found to have better predictive performance than SUVmax for recurrence and death. According to multivariate analyses, MTV2.5 was revealed as a significant prognostic factor for RFS. Tumor size over 3 cm was selected as a significant prognostic indicator of OS. CONCLUSION Volume-based parameters of F-18 FDG PET-CT may have a role in providing prognostic information in NSCLC patients who have received surgical treatment.
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Zhang H, Wroblewski K, Pu Y. Prognostic value of tumor burden measurement using the number of tumors in non-surgical patients with non-small cell lung cancer. Acta Radiol 2012; 53:561-8. [PMID: 22661603 DOI: 10.1258/ar.2012.120080] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND No study to test the feasibility and prognostic value of the number of primary tumors, the number of positive lymph nodes, and the total number of tumors in the whole body as tumor burden measurements on FDG PET/CT imaging has been reported. PURPOSE To determine whether the number of tumors seen in 18F-FDG PET scans can be a prognostic factor in non-surgical patients with non-small cell lung cancer (NSCLC). MATERIAL AND METHODS One hundred and forty patients with histologically proven NSCLC and baseline 18F-FDG PET scan before therapy were identified in this retrospective analysis. The total number of tumors (TTn) in the whole body, the number of primary tumors (Tn), positive lymph nodes (Nn), and distant metastases (Mn), along with the maximum standardized uptake values (SUV(max)) of the tumors were measured. Inter-observer variability of the total number of tumors, counted by two radiologists, was assessed. Survival analyses were performed to determine the prognostic value of the number of tumors. RESULTS Concordance correlation coefficients for the TTn, Tn, Nn, and Mn were all greater than 0.85. TTn and Nn were strong prognostic factors of NSCLC patients' overall survival (OS). In univariate Cox regression models, gender, stage, TTn, Nn, and Mn were statistically significant factors (P = 0.016, 0.032, <0.001, <0.001, and 0.006, respectively). In multivariate Cox regression models, TTn and Nn remained as statistically significant predictors for survival with hazard ratios (HR) of 1.06 (P = 0.001) and 1.11 (P = 0.002), respectively, after adjusting for clinical stage based 7th edition of TNM staging system, age, gender, and SUV(max). Patients with a TTn ≤4 (cutpoint based on median value) had a median OS of 15.2 months compared with 9.0 months for those with TTn >4. CONCLUSION Measuring the number of tumors on FDG PET imaging is easy to perform with minimal inter-observer variability. The total number of tumors and number of nodal metastases, as metabolic tumor burden measurements in 18F-FDG PET/CT, are prognostic markers independent of clinical stage, age, gender, and SUV measurement in non-surgical patients with NSCLC.
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Affiliation(s)
- Hao Zhang
- Department of Radiology, First Hospital of Lanzhou University, Lanzhou, Gansu, China
- Department of Health Studies, University of Chicago, Chicago, Illinois, USA
| | | | - Yonglin Pu
- Department of Health Studies, University of Chicago, Chicago, Illinois, USA
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Sörensen J. How Does the Patient Benefit from Clinical PET? Am J Cancer Res 2012; 2:427-36. [PMID: 22768023 PMCID: PMC3360196 DOI: 10.7150/thno.3794] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2011] [Accepted: 02/26/2012] [Indexed: 11/25/2022] Open
Abstract
Clinical molecular imaging by use of PET and PET/CT is increasingly important in routine oncological practice worldwide. A vast majority of clinical PET investigations are performed with [18F]-fluorodeoxyglucose (FDG), but there is a growing interest in novel molecular probes among scientists and clinicians. Beyond FDG, a small number of different tracers have been shown to be of clinical value. With a growing commercial interest in tracer development, many more are under investigation. This review provides some examples of clinical situations where tracers other than FDG have been found useful and an outlook towards technical and regulatory development needed to allow the full impact of clinical PET to benefit the individual patient.
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van Loon J, Siedschlag C, Stroom J, Blauwgeers H, van Suylen RJ, Knegjens J, Rossi M, van Baardwijk A, Boersma L, Klomp H, Vogel W, Burgers S, Gilhuijs K. Microscopic Disease Extension in Three Dimensions for Non–Small-Cell Lung Cancer: Development of a Prediction Model Using Pathology-Validated Positron Emission Tomography and Computed Tomography Features. Int J Radiat Oncol Biol Phys 2012; 82:448-56. [DOI: 10.1016/j.ijrobp.2010.09.001] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2010] [Revised: 09/09/2010] [Accepted: 09/15/2010] [Indexed: 10/18/2022]
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Hollingdale AE, Roques TW, Curtin J, Martin WMC, Horan G, Barrett A. Multidisciplinary collaborative gross tumour volume definition for lung cancer radiotherapy: a prospective study. Cancer Imaging 2011; 11:202-8. [PMID: 22157168 PMCID: PMC3277425 DOI: 10.1102/1470-7330.2011.0024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Variability in gross tumour volume (GTV) definition is a major source of systematic error in conformal radiotherapy. This prospective study assesses the role of multidisciplinary collaboration between oncologists and radiologists in defining lung cancer volumes. Twenty patients with non-small cell lung cancer due to receive three-dimensional conformal radiotherapy formed the study population. GTVs were defined by a radiologist (GTVrad) and an oncologist (GTVonc) using available clinical information and imaging. A collaborative meeting was then held to agree on a final, common GTV (GTVfin) to be used for treatment planning, and differences analysed. The collaboration changed the GTV in 19/20 patients with a total of 50 regions being edited. Changes made were categorized as (a) differentiation of tumour from atelectasis or ground glass shadowing, (b) separation of tumour from vasculature, and (c) defining mediastinal extent of tumour. Oncologists were more confident in the GTVfin than the GTVonc. The radiologist took longer to define the GTV than the oncologist. Real-time collaborative GTV definition by a radiologist and oncologist is practical and feasible. This approach allows specific areas of uncertainty to be categorized and focussed on, reducing systematic error in GTV definition. The physician's approach to risk and decision making for each patient may also play a role.
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Affiliation(s)
- Abigail E Hollingdale
- Department of Oncology, Norfolk and Norwich University Hospital NHS Foundation Trust, Norwich, UK
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Hatt M, Cheze-le Rest C, van Baardwijk A, Lambin P, Pradier O, Visvikis D. Impact of tumor size and tracer uptake heterogeneity in (18)F-FDG PET and CT non-small cell lung cancer tumor delineation. J Nucl Med 2011; 52:1690-7. [PMID: 21990577 DOI: 10.2967/jnumed.111.092767] [Citation(s) in RCA: 112] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
UNLABELLED The objectives of this study were to investigate the relationship between CT- and (18)F-FDG PET-based tumor volumes in non-small cell lung cancer (NSCLC) and the impact of tumor size and uptake heterogeneity on various approaches to delineating uptake on PET images. METHODS Twenty-five NSCLC cancer patients with (18)F-FDG PET/CT were considered. Seventeen underwent surgical resection of their tumor, and the maximum diameter was measured. Two observers manually delineated the tumors on the CT images and the tumor uptake on the corresponding PET images, using a fixed threshold at 50% of the maximum (T(50)), an adaptive threshold methodology, and the fuzzy locally adaptive Bayesian (FLAB) algorithm. Maximum diameters of the delineated volumes were compared with the histopathology reference when available. The volumes of the tumors were compared, and correlations between the anatomic volume and PET uptake heterogeneity and the differences between delineations were investigated. RESULTS All maximum diameters measured on PET and CT images significantly correlated with the histopathology reference (r > 0.89, P < 0.0001). Significant differences were observed among the approaches: CT delineation resulted in large overestimation (+32% ± 37%), whereas all delineations on PET images resulted in underestimation (from -15% ± 17% for T(50) to -4% ± 8% for FLAB) except manual delineation (+8% ± 17%). Overall, CT volumes were significantly larger than PET volumes (55 ± 74 cm(3) for CT vs. from 18 ± 25 to 47 ± 76 cm(3) for PET). A significant correlation was found between anatomic tumor size and heterogeneity (larger lesions were more heterogeneous). Finally, the more heterogeneous the tumor uptake, the larger was the underestimation of PET volumes by threshold-based techniques. CONCLUSION Volumes based on CT images were larger than those based on PET images. Tumor size and tracer uptake heterogeneity have an impact on threshold-based methods, which should not be used for the delineation of cases of large heterogeneous NSCLC, as these methods tend to largely underestimate the spatial extent of the functional tumor in such cases. For an accurate delineation of PET volumes in NSCLC, advanced image segmentation algorithms able to deal with tracer uptake heterogeneity should be preferred.
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Lampen-Sachar K, Zhao B, Zheng J, Moskowitz CS, Schwartz LH, Zakowski MF, Rizvi NA, Kris MG, Ginsberg MS. Correlation between tumor measurement on Computed Tomography and resected specimen size in lung adenocarcinomas. Lung Cancer 2011; 75:332-5. [PMID: 21890229 DOI: 10.1016/j.lungcan.2011.08.001] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2011] [Accepted: 08/05/2011] [Indexed: 10/17/2022]
Abstract
OBJECTIVE To compare preoperative size of stage I and stage II lung adenocarcinoma as measured by Computed Tomography (CT) and as assessed on gross pathology specimens. MATERIALS AND METHODS 47 patients diagnosed with stage I or II lung adenocarcinoma were evaluated. Institutional Review Board permission was obtained. Tumor contours were delineated using a semi-automated segmentation algorithm and adjusted based on a radiologist's input. Based on the tumor perimeter, maximal in-plane tumor diameter was calculated automatically. The largest single diameter from the pathology gross report was utilized. A paired t-test was used to examine the measurement difference between CT and pathology. RESULTS The mean largest diameter of the tumors at CT and pathology was 29.53 mm and 24.04 mm, respectively. There was a statistically significant difference between the mean CT measurement and mean pathology measurement of 5.49 mm (standard deviation 9.08 mm, p<0.001). The percent relative difference between the two measurements was 18.3% (standard deviation 28.2%). CONCLUSION There is a statistically significant difference between the tumor diameter as measured by CT and on pathology gross specimen. These differences could have implications in the treatment and prognosis of patients with early stage lung adenocarcinoma.
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Kerhet A, Small C, Quon H, Riauka T, Schrader L, Greiner R, Yee D, McEwan A, Roa W. Application of machine learning methodology for PET-based definition of lung cancer. ACTA ACUST UNITED AC 2011; 17:41-7. [PMID: 20179802 PMCID: PMC2826776 DOI: 10.3747/co.v17i1.394] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
We applied a learning methodology framework to assist in the threshold-based segmentation of non-small-cell lung cancer (nsclc) tumours in positron-emission tomography–computed tomography (pet–ct) imaging for use in radiotherapy planning. Gated and standard free-breathing studies of two patients were independently analysed (four studies in total). Each study had a pet–ct and a treatment-planning ct image. The reference gross tumour volume (gtv) was identified by two experienced radiation oncologists who also determined reference standardized uptake value (suv) thresholds that most closely approximated the gtv contour on each slice. A set of uptake distribution-related attributes was calculated for each pet slice. A machine learning algorithm was trained on a subset of the pet slices to cope with slice-to-slice variation in the optimal suv threshold: that is, to predict the most appropriate suv threshold from the calculated attributes for each slice. The algorithm’s performance was evaluated using the remainder of the pet slices. A high degree of geometric similarity was achieved between the areas outlined by the predicted and the reference suv thresholds (Jaccard index exceeding 0.82). No significant difference was found between the gated and the free-breathing results in the same patient. In this preliminary work, we demonstrated the potential applicability of a machine learning methodology as an auxiliary tool for radiation treatment planning in nsclc.
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Affiliation(s)
- A Kerhet
- Department of Oncology, University of Alberta, Edmonton, AB.
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van Loon J, van Baardwijk A, Boersma L, Ollers M, Lambin P, De Ruysscher D. Therapeutic implications of molecular imaging with PET in the combined modality treatment of lung cancer. Cancer Treat Rev 2011; 37:331-43. [PMID: 21320756 DOI: 10.1016/j.ctrv.2011.01.005] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2010] [Revised: 01/13/2011] [Accepted: 01/21/2011] [Indexed: 12/23/2022]
Abstract
Molecular imaging with PET, and certainly integrated PET-CT, combining functional and anatomical imaging, has many potential advantages over anatomical imaging alone in the combined modality treatment of lung cancer. The aim of the current article is to review the available evidence regarding PET with FDG and other tracers in the combined modality treatment of locally advanced lung cancer. The following topics are addressed: tumor volume definition, outcome prediction and the added value of PET after therapy, and finally its clinical implications and future perspectives. The additional value of FDG-PET in defining the primary tumor volume has been established, mainly in regions with atelectasis or post-treatment effects. Selective nodal irradiation (SNI) of FDG-PET positive nodal stations is the preferred treatment in NSCLC, being safe and leading to decreased normal tissue exposure, providing opportunities for dose escalation. First results in SCLC show similar results. FDG-uptake on the pre-treatment PET scan is of prognostic value. Data on the value of pre-treatment FDG-uptake to predict response to combined modality treatment are conflicting, but the limited data regarding early metabolic response during treatment do show predictive value. The FDG response after radical treatment is of prognostic significance. FDG-PET in the follow-up has potential benefit in NSCLC, while data in SCLC are lacking. Radiotherapy boosting of radioresistant areas identified with FDG-PET is subject of current research. Tracers other than (18)FDG are promising for treatment response assessment and the visualization of intra-tumor heterogeneity, but more research is needed before they can be clinically implemented.
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Affiliation(s)
- Judith van Loon
- Maastricht University Medical Centre, Department of Radiation Oncology, MAASTRO Clinic, GROW Research Institute, The Netherlands.
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Abstract
Testicular cancer is a rare tumor, subdivided into seminomatous and nonseminomatous tumors. Whereas there are no serum tumor markers in the first group, they are present in nonseminomatous tumors, and are also important prognostic factors. Overall, the prognosis for testicular cancers is good, which makes the choice of accurate treatment intensity between under- and overtreatment often difficult. Residual masses in advanced clinical stages occur frequently but are nonvital tissue. PET with F-18 FDG has no defined role in imaging of primary tumors where CT is the first-choice imaging modality. For assessing the success of chemotherapy in the presence of residual masses, especially in pure seminoma, F-18 FDG PET is an important tool. In nonseminomatous tumors, it is hampered by the false-negative results in mature teratoma, for which reason false-negative results are a common problem. F-18 FDG PET performs best in predicting relapse in seminoma residuals larger than 3 cm. So far, no alternative to F-18 FDG for PET imaging of testicular cancer has been found. PET-CT has not yet been proven to be superior to PET alone in testicular cancer.
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Wanet M, Lee JA, Weynand B, De Bast M, Poncelet A, Lacroix V, Coche E, Grégoire V, Geets X. Gradient-based delineation of the primary GTV on FDG-PET in non-small cell lung cancer: a comparison with threshold-based approaches, CT and surgical specimens. Radiother Oncol 2010; 98:117-25. [PMID: 21074882 DOI: 10.1016/j.radonc.2010.10.006] [Citation(s) in RCA: 122] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2010] [Revised: 10/01/2010] [Accepted: 10/03/2010] [Indexed: 11/30/2022]
Abstract
PURPOSE The aim of this study was to validate a gradient-based segmentation method for GTV delineation on FDG-PET in NSCLC through surgical specimen, in comparison with threshold-based approaches and CT. MATERIALS AND METHODS Ten patients with stage I-II NSCLC were prospectively enrolled. Before lobectomy, all patients underwent contrast enhanced CT and gated FDG-PET. Next, the surgical specimen was removed, inflated with gelatin, frozen and sliced. The digitized slices were used to reconstruct the 3D macroscopic specimen. GTVs were manually delineated on the macroscopic specimen and on CT images. GTVs were automatically segmented on PET images using a gradient-based method, a source to background ratio method and fixed threshold values at 40% and 50% of SUV(max). All images were finally registered. Analyses of raw volumes and logarithmic differences between GTVs and GTV(macro) were performed on all patients and on a subgroup excluding the poorly defined tumors. A matching analysis between the different GTVs was also conducted using Dice's similarity index. RESULTS Considering all patients, both lung and mediastinal windowed CT overestimated the macroscopy, while FDG-PET provided closer values. Among various PET segmentation methods, the gradient-based technique best estimated the true tumor volume. When analysis was restricted to well defined tumors without lung fibrosis or atelectasis, the mediastinal windowed CT accurately assessed the macroscopic specimen. Finally, the matching analysis did not reveal significant difference between the different imaging modalities. CONCLUSIONS FDG-PET improved the GTV definition in NSCLC including when the primary tumor was surrounded by modifications of the lung parenchyma. In this context, the gradient-based method outperformed the threshold-based ones in terms of accuracy and robustness. In other cases, the conventional mediastinal windowed CT remained appropriate.
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Affiliation(s)
- Marie Wanet
- Department of Radiation Oncology, Center of Molecular Imaging and Experimental Radiotherapy, Université Catholique de Louvain, Brussels, Belgium
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Coche E, Lonneux M, Geets X. Lung cancer: Morphological and functional approach to screening, staging and treatment planning. Future Oncol 2010; 6:367-80. [PMID: 20222794 DOI: 10.2217/fon.10.7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Lung cancer is a major problem in public health and constitutes the leading cause of cancer-related mortality in the world. Lung cancer screening with low-dose computed tomography is promising but needs to overcome many difficulties, such as the large number of incidentally discovered nodules, the radiation dose delivered to the patient during a whole screening program and its cost. The ultimate target point represented by the reduction of lung cancer-related mortality needs to be proved in large, well-designed, randomized, multicenter, prospective trials. Lung cancer staging by morphological tools seems to be limited owing to the presence of metastases in normal-sized lymph nodes. In this context, multidetector computed tomography cannot be used alone but is useful in conjunction with molecular imaging and MRI. Today, flurodeoxglucose PET-CT appears to be the most accurate method for lung cancer staging and may prevent unnecessary thoracotomies. For treatment planning, flurodeoxglucose PET-CT is playing an increasing role in radiotherapy planning at the target selection and definition steps.
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Affiliation(s)
- Emmanuel Coche
- Department of Medical Imaging, Université Catholique de Louvain, Cliniques Universitaires St-Luc, Brussels, Belgium.
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Zaidi H, El Naqa I. PET-guided delineation of radiation therapy treatment volumes: a survey of image segmentation techniques. Eur J Nucl Med Mol Imaging 2010; 37:2165-87. [PMID: 20336455 DOI: 10.1007/s00259-010-1423-3] [Citation(s) in RCA: 230] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2009] [Accepted: 02/20/2010] [Indexed: 12/23/2022]
Abstract
Historically, anatomical CT and MR images were used to delineate the gross tumour volumes (GTVs) for radiotherapy treatment planning. The capabilities offered by modern radiation therapy units and the widespread availability of combined PET/CT scanners stimulated the development of biological PET imaging-guided radiation therapy treatment planning with the aim to produce highly conformal radiation dose distribution to the tumour. One of the most difficult issues facing PET-based treatment planning is the accurate delineation of target regions from typical blurred and noisy functional images. The major problems encountered are image segmentation and imperfect system response function. Image segmentation is defined as the process of classifying the voxels of an image into a set of distinct classes. The difficulty in PET image segmentation is compounded by the low spatial resolution and high noise characteristics of PET images. Despite the difficulties and known limitations, several image segmentation approaches have been proposed and used in the clinical setting including thresholding, edge detection, region growing, clustering, stochastic models, deformable models, classifiers and several other approaches. A detailed description of the various approaches proposed in the literature is reviewed. Moreover, we also briefly discuss some important considerations and limitations of the widely used techniques to guide practitioners in the field of radiation oncology. The strategies followed for validation and comparative assessment of various PET segmentation approaches are described. Future opportunities and the current challenges facing the adoption of PET-guided delineation of target volumes and its role in basic and clinical research are also addressed.
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Affiliation(s)
- Habib Zaidi
- Geneva University Hospital, Geneva 4, Switzerland.
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Pinilla I, Gómez León N. [The usefulness of PET/CT in lung cancer]. RADIOLOGIA 2009; 51:248-60. [PMID: 19406442 DOI: 10.1016/j.rx.2009.01.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2008] [Accepted: 01/09/2009] [Indexed: 12/20/2022]
Abstract
Lung cancer is the leading cause of cancer-related death. Accurate staging is essential for the optimal management and treatment of these patients. Positron emission tomography (PET) and, more recently, PET/CT have been introduced into the diagnostic algorithms for oncologic patients because they provide valuable functional information. The hybrid PET/CT technique acquires both anatomic (CT) and metabolic (PET) images in a single session, combining the benefits of each modality and minimizing their limitations. This article reviews the role of PET/CT in lung cancer staging, with emphasis on non-small cell carcinoma, evaluating the advantages and limitations of the technique. Other applications of the technique, such as planning radiotherapy, are also discussed.
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Affiliation(s)
- I Pinilla
- Servicio de Radiodiagnóstico, Hospital Universitario La Paz, Madrid, España.
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Feng M, Kong FM, Gross M, Fernando S, Hayman JA, Ten Haken RK. Using fluorodeoxyglucose positron emission tomography to assess tumor volume during radiotherapy for non-small-cell lung cancer and its potential impact on adaptive dose escalation and normal tissue sparing. Int J Radiat Oncol Biol Phys 2009; 73:1228-34. [PMID: 19251094 DOI: 10.1016/j.ijrobp.2008.10.054] [Citation(s) in RCA: 120] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2008] [Revised: 10/28/2008] [Accepted: 10/30/2008] [Indexed: 12/25/2022]
Abstract
PURPOSE To quantify changes in fluorodeoxyglucose (FDG)-avid tumor volume on positron emission tomography/computed tomography (PET/CT) during the course of radiation therapy and examine its potential use in adaptive radiotherapy for tumor dose escalation or normal tissue sparing in patients with non-small-cell lung cancer (NSCLC). METHODS AND MATERIALS As part of a pilot study, patients with Stage I-III NSCLC underwent FDG-PET/CT before radiotherapy (RT) and in mid-RT (after 40-50 Gy). Gross tumor volumes were contoured on CT and PET scans obtained before and during RT. Three-dimensional conformal RT plans were generated for each patient, first using only pretreatment CT scans. Mid-RT PET volumes were then used to design boost fields. RESULTS Fourteen patients with FDG-avid tumors were assessed. Two patients had a complete metabolic response, and 2 patients had slightly increased FDG uptake in the adjacent lung tissue. Mid-RT PET scans were useful in the 10 remaining patients. Mean decreases in CT and PET tumor volumes were 26% (range, +15% to -75%) and 44% (range, +10% to -100%), respectively. Designing boosts based on mid-RT PET allowed for a meaningful dose escalation of 30-102 Gy (mean, 58 Gy) or a reduction in normal tissue complication probability (NTCP) of 0.4-3% (mean, 2%) in 5 of 6 patients with smaller yet residual tumor volumes. CONCLUSIONS Tumor metabolic activity and volume can change significantly after 40-50 Gy of RT. Using mid-RT PET volumes, tumor dose can be significantly escalated or NTCP reduced. Clinical studies evaluating patient outcome after PET-based adaptive RT are ongoing.
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Affiliation(s)
- Mary Feng
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI 48109, USA
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