Prospective assessment using 18F-FDG PET/CT as a novel predictor for early response to PD-1 blockade in non-small-cell lung cancer

18F-FDG-PET/CT Uptake by Noncancerous Lung as a Predictor of Interstitial Lung Disease Induced by Immune Checkpoint Inhibitors

RATIONALE AND OBJECTIVES

Immune checkpoint inhibitors (ICIs) have improved lung cancer prognosis; however, ICI-related interstitial lung disease (ILD) is fatal and difficult to predict. Herein, we hypothesized that pre-existing lung inflammation on radiological imaging can be a potential risk factor for ILD onset. Therefore, we investigated the association between high uptake in noncancerous lung (NCL) on 18F- FDG-PET/CT and ICI-ILD in lung cancer.

METHODS

Patients with primary lung cancer who underwent FDG-PET/CT within three months prior to ICI therapy were retrospectively included. Artificial intelligence was utilized for extracting the NCL regions (background lung) from the lung contralateral to the primary tumor. FDG uptake by the NCL was assessed via the SUVmax (NCL-SUVmax), SUVmean (NCL-SUVmean), and total glycolytic activity (NCL-TGA)defined as NCL-SUVmean×NCL volume [mL]. NCL-SUVmean and NCL-TGA were calculated using the following four SUV thresholds: 0.5, 1.0, 1.5, and 2.0.

RESULTS

Of the 165 patients, 28 (17.0%) developed ILD. Univariate analysis showed that high values of NCL-SUVmax, NCL-SUVmean2.0 (SUV threshold=2.0), and NCL-TGA1.0 (SUV threshold=1.0) were significantly associated with ILD onset (all p = 0.003). Multivariate analysis adjusted for age, tumor FDG uptake, and pre-existing interstitial lung abnormalities revealed that a high NCL-TGA1.0 (≥149.45) was independently associated with ILD onset (odds ratio, 6.588; p = 0.002). Two-year cumulative incidence of ILD was significantly higher in the high NCL-TGA1.0 group than in the low group (58.4% vs. 14.4%; p < 0.001).

CONCLUSION

High uptake of NCL on FDG-PET/CT is correlated with ICI-ILD development, which could serve as a risk stratification tool before ICI therapy in primary lung cancer.

The association of metabolic positron emission tomography/computed tomography parameters with survival in small cell lung cancer

BACKGROUND

Small cell lung cancer (SCLC) is a lung malignancy with a poor prognosis and metastases at the time of diagnosis. There is limited experience using positron emission tomography/computed tomography (PET/CT) for SCLC diagnosis, staging, and follow-up.

OBJECTIVE

Investigate the survival effect of primary tumor standardized uptake value max (SUVmax), SUV mean, metabolic tumor volume (MTV), total lesion glucose (TLG), bone marrow SUV (BM), and bone marrow to liver ratio (BLR) in SCLC.

DESIGN

Retrospective.

SETTING

Single center in Turkey.

PATIENTS AND METHODS

Patients who were cyto/histologically diagnosed with SCLC and had PET/CT simultaneous with the diagnosis were included in the study.

MAIN OUTCOME MEASURES

The effect of PET/CT parameters on overall survival (OS) and progression-free survival (PFS).

SAMPLE SIZE

304.

RESULTS

The 5-year OS median value was 14.62 months, and the 5-year PFS was 13.01 months. In Kaplan-Meier analysis, SUVmax, MTV, and TLG were statistically significant variables in OS (P=.03; P<.001; P<.001, respectively). MTV and TLG were significant in PFS (P<.001; P=.0003, respectively). In the multivariate analysis, MTV was an independent PET/CT parameter associated with OS (P=.003), stage of disease (P=.012), SUVmax (P=.003), MTV (P=.016), and TLG (P=.005) were significant variables in PFS.

CONCLUSION

In our study, MTV was an independent parameter that can be used to predict survival in SCLC. Considering the effect of MTV, a metabolic PET/CT parameter on survival, it can be recommended for clinical use as a standard measure of evaluation in PET/CT reports, just like SUVmax.

LIMITATIONS

The first limitation was the single-center and retrospective design of the study. Due to the retrospective design of the study, weight loss, performance status, and smoking history could not be obtained from every patient. Second, inaccurate registration of PET and CT images due to patient respiratory movements may affect measurements.

Clinical significance of visual cardiac 18F-FDG uptake in advanced non-small cell lung cancer

BACKGROUND

Two-deoxy-2-[fluorine-18]-fluoro-d-glucose (18F-FDG) positron emission tomography (PET) is useful for detecting malignant lesions; however, the clinical significance of cardiac 18F-FDG uptake in patients with cancer remains unclear. This preliminary study explored the relationship between cardiac 18F-FDG uptake and advanced diseases such as cancer cachexia in non-small cell lung cancer (NSCLC).

METHODS

Forty-three patients with advanced NSCLC who underwent 18F-FDG PET and complained of weight loss before the first-line systemic therapy were retrospectively included in this study. Visual assessment using a 5-point scale based on 18F-FDG uptake was performed; a cut-off score of 3 was determined, a low score was 1, 2, or 3, and a high score was 4 or 5).

RESULTS

High and low visual cardiac 18F-FDG uptakes were observed in 27 (62.8%) and 16 (37.2%) patients, respectively. Of the 43 patients, 17 (39.5%) definitely had cachexia, and 26 (60.5%) did not. A low visual score and standardized uptake valuemax for cardiac 18F-FDG uptake were significantly associated with high metabolic tumor activity (p = 0.009, and p = 0.009, respectively) and a high neutrophil-to-lymphocyte ratio (p = 0.016, and p = 0.047, respectively), whereas a low visual score for cardiac 18F-FDG uptake and high metabolic tumor activity were significantly associated with cachexia (p = 0.004). The amount of cardiac 18F-FDG accumulation depicted a close relationship with body mass index, low weight loss, and inflammation. The combination of cachexia and low visual cardiac 18F-FDG uptake was identified as a significant predictor for poor overall survival (OS) (p = 0.034).

CONCLUSION

Decreased visual cardiac 18F-FDG uptake was associated with poor nutritional status and OS, and cachexia in patients with advanced NSCLC.

Baseline and early 18F-FDG PET/CT evaluations as predictors of progression-free survival in metastatic breast cancer patients treated with targeted anti-CDK therapy

BACKGROUND

Exploring the value of baseline and early 18F-FDG PET/CT evaluations in prediction PFS in ER+/HER2- metastatic breast cancer patients treated with a cyclin-dependent kinase inhibitor in combination with an endocrine therapy.

METHODS

Sixty-six consecutive breast cancer patients who underwent a pre-therapeutic 18F-FDG PET/CT and a second PET/CT within the first 6 months of treatment were retrospectively included. Metabolic tumour volume (MTV) and total lesion glycolysis (TLG) and Dmax, which represents tumour dissemination and is defined as the distance between the two most distant lesions, were computed. The variation in these parameters between baseline and early evaluation PET as well as therapeutic evaluation using PERCIST were assessed as prognosticators of PFS at 18 months.

RESULTS

The median follow-up was equal to 22.5 months. Thirty progressions occurred (45.4%). The average time to event was 17.8 ± 10.4 months. At baseline, Dmax was the only predictive metabolic parameter. Patients with a baseline Dmax ≤ 18.10 cm had a significantly better 18 m-PFS survival than the others: 69.2% (7.7%) versus 36.7% (8.8%), p = 0.017. There was no association between PERCIST evaluation and 18 m-PFS status (p = 0.149) and there was no difference in 18 m-PFS status between patients classified as complete, partial metabolic responders or having stable metabolic disease.

CONCLUSION

Disease spread at baseline PET, as assessed by Dmax, is predictive of an event occurring within 18 months. In the absence of early metabolic progression, which occurs in 15% of patients, treatment should be continued regardless of the quality of the initial response to treatment.

Potential predictors of the pathologic response after neoadjuvant chemoimmunotherapy in resectable non-small cell lung cancer: a narrative review

Background and Objective

Neoadjuvant chemoimmunotherapy (NACI) is the standard of care for patients with resectable non-small cell lung cancer (NSCLC). Although the pathological complete response (pCR) after NACI reportedly exceeds 20%, an optimal predictor of pCR is yet to be established. This review aims to examine the possible predictors of pCR after NACI.

Methods

We identified research article published between 2018 and 2022 in English by the PubMed database. Fifty research studies were considered as relevant article, and were examined to edit information for this narrative review.

Key Content and Findings

Recently, several studies have explored potential biomarkers for the pathological response after NACI. For example, 18F-fluorodeoxyglucose positron emission tomography (18F-FDG-PET) imaging, tumor microenvironment (TME), genetic alternation such as circulating tumor DNA (ctDNA), and clinical markers such as neutrophil-to-lymphocyte ratio (NLR) and smoking signature were assessed in patients with resectable NSCLC to predict the pathological response after NACI. Based on the PET response criteria, the complete metabolic response (CMR) achieved a positive predictive value (PPV) of 71.4% for predicting pCR, and the decreasing rate of post-therapy maximum standardized uptake value (SUVmax) after NACI substantially correlated with the major pathological response (MPR). TME, as a significant marker for MPR in tumor specimens, was identified as an increase in CD8+ T cells and decrease in CD3+ T cells or Foxp3 T cells. Considering blood samples, TME comprised an increase in CD4+PD-1+ cells or natural killer cells and a decrease in CD3+CD56+CTLA4+ cells, total T cells, Th cells, myeloid-derived suppressor cells (MDSCs), or regulatory T cells. Although low pretreatment levels of ctDNA and undetectable ctDNA levels after NACI were markedly associated with survival, the relationship between ctDNA levels and pCR remains elusive. Moreover, the patients with a high baseline NLR had a low incidence of pCR. Heavy smoking (>40 pack-years) was favorable for predicting pathological response.

Conclusions

A reduced rate of 18F-FDG uptake post-NACI and TME-related surface markers on lymphocytes could be optimal predictors for pCR. However, the role of these pCR predictors for NACI remains poorly validated, warranting further investigations. This review focuses on predictive biomarkers for pathological response after NACI in patients with resectable NSCLC.

Pretreatment 18-FDG-PET/CT parameters can serve as prognostic imaging biomarkers in recurrent NSCLC patients treated with reirradiation-chemoimmunotherapy

BACKGROUND AND PURPOSE

Our study aimed to assess whether quantitative pretreatment 18F-FDG-PET/CT parameters could predict prognostic clinical outcome of recurrent NSCLC patients who may benefit from ablative reirradiation.

MATERIALS AND METHODS

Forty-eight patients with recurrent NSCLC of all UICC stages who underwent ablative thoracic reirradiation were analyzed. Twenty-nine (60%) patients received immunotherapy with or without chemotherapy in addition to reirradiation. Twelve patients (25%) received reirradiation only and seven (15%) received chemotherapy and reirradiation. Pretreatment 18-FDG-PET/CT was mandatory in initial diagnosis and recurrence, based on which volumetric and intensity quantitative parameters were measured before reirradiation and their impact on overall survival, progression-free survival, and locoregional control was assessed.

RESULTS

With a median follow-up time of 16.7 months, the median OS was 21.8 months (95%-CI: 16.2-27.3). On multivariate analysis, OS and PFS were significantly influenced by MTV (p < 0.001 for OS; p = 0.006 for PFS), TLG (p < 0.001 for OS; p = 0.001 for PFS) and SUL peak (p = 0.0024 for OS; p = 0.02 for PFS) of the tumor and MTV (p = 0.004 for OS; p < 0.001 for PFS) as well as TLG (p = 0.007 for OS; p = 0.015 for PFS) of the metastatic lymph nodes. SUL peak of the tumor (p = 0.05) and the MTV of the lymph nodes (p = 0.003) were only PET quantitative parameters that significantly impacted LRC.

CONCLUSION

Pretreatment tumor and metastastic lymph node MTV, TLG and tumor SUL peak significantly correlated with clinical outcome in recurrent NSCLC patients treated with reirradiation-chemoimmunotherapy.

Comparative analysis of different response criteria at early phase after PD-1 blockade in non-small lung cancer

PURPOSE

To compare different response criteria using computed tomography (CT) and positron emission tomography (PET) in measuring response and survival in the early phase after programmed death-1 (PD-1) blockade monotherapy in patients with advanced non-small cell lung cancer (NSCLC).

METHODS

A total of 54 patients with advanced NSCLC who had 2-deoxy-2-[fluorine-18]-fluoro-D-glucose PET or CT at baseline, and 4 and 9 weeks after PD-1 blockade, were registered. Therapeutic response was assessed according to the Response Evaluation Criteria in Solid Tumors (RECIST), the immune-modified RECIST (irRECIST), the PET Response Criteria in Solid Tumors (PERCIST), the immune-modified PERCIST (iPERCIST), and the European Organization for Research and Treatment of Cancer (EORTC) criteria for dichotomous groups, such as responders vs. non-responders and controlled vs. uncontrolled diseases. Cohen's κ was used to evaluate the concordance among the different criteria.

RESULTS

The concordance between CT and PET response criteria was fair or slight for responders vs. non-responders, but the agreement between iPERCIST and irRECIST was moderate for controlled vs. uncontrolled diseases. The agreement between EORTC and PERCIST or iPERCIST in detecting responders was higher in the application of metabolic tumor volume (MTV) and total lesion glycolysis (TLG) than in the standardized uptake value corrected for lean body mass (SUL)_peak. To distinguish controlled from uncontrolled disease, RECIST, irRECIST, and PET criteria (PERCIST, iPERCIST, and EORTC) defined by MTV or TLG were found to be significant predictors of progression-free survival. To distinguish responders from non-responders, iPERCIST by SUL_peak or EORTC by TLG were identified as significant indicators. The EORTC criteria using TLG for the detection of responders or uncontrolled diseases had a significantly higher predictive value for response assessment.

CONCLUSIONS

The EORTC criteria based on TLG for the early detection of responders and uncontrolled disease were effective as a response assessment at 4 weeks after the PD-1 blockade. When SUL_peak was not used but MTV or TLG was, the agreement between EORTC and PERCIST or iPERCIST was almost perfect.

Overview of MicroRNAs as Diagnostic and Prognostic Biomarkers for High-Incidence Cancers in 2021

MicroRNAs (miRNAs) are small non-coding RNAs (ncRNAs) about 22 nucleotides in size, which play an important role in gene regulation and are involved in almost all major cellular physiological processes. In recent years, the abnormal expression of miRNAs has been shown to be associated with human diseases including cancer. In the past ten years, the link between miRNAs and various cancers has been extensively studied, and the abnormal expression of miRNAs has been reported in various malignant tumors, such as lung cancer, gastric cancer, colorectal cancer, liver cancer, breast cancer, and prostate cancer. Due to the high malignancy grade of these cancers, it is more necessary to develop the related diagnostic and prognostic methods. According to the study of miRNAs, many potential cancer biomarkers have been proposed for the diagnosis and prognosis of diseases, especially cancer, thus providing a new theoretical basis and perspective for cancer screening. The use of miRNAs as biomarkers for diagnosis or prognosis of cancer has the advantages of being less invasive to patients, with better accuracy and lower price. In view of the important clinical significance of miRNAs in human cancer research, this article reviewed the research status of miRNAs in the above-mentioned cancers in 2021, especially in terms of diagnosis and prognosis, and provided some new perspectives and theoretical basis for the diagnosis and treatment of cancers.