FDG-PET imaging in the management of non-small-cell lung cancer

Advances in Non-Small Cell Lung Cancer: Current Insights and Future Directions

The leading cause of cancer deaths worldwide is attributed to non-small cell lung cancer (NSCLC), necessitating a continual focus on improving the diagnosis and treatment of this disease. In this review, the latest breakthroughs and emerging trends in managing NSCLC are highlighted. Major advancements in diagnostic methods, including better imaging technologies and the utilization of molecular biomarkers, are discussed. These advancements have greatly enhanced early detection and personalized treatment plans. Significant improvements in patient outcomes have been achieved by new targeted therapies and immunotherapies, providing new hope for individuals with advanced NSCLC. This review discusses the persistent challenges in accessing advanced treatments and their associated costs despite recent progress. Promising research into new therapies, such as CAR-T cell therapy and oncolytic viruses, which could further revolutionize NSCLC treatment, is also highlighted. This review aims to inform and inspire continued efforts to improve outcomes for NSCLC patients globally, by offering a comprehensive overview of the current state of NSCLC treatment and future possibilities.

Imaging phenotyping using 18F-FDG PET/CT radiomics to predict micropapillary and solid pattern in lung adenocarcinoma

OBJECTIVES

To develop and validate a machine learning model using 18F-FDG PET/CT radiomics signature and clinical features to predict the presence of micropapillary and solid (MP/S) components in lung adenocarcinoma.

METHODS

Eight hundred and forty-six patients who underwent preoperative PET/CT with pathologically confirmed adenocarcinoma were enrolled. After segmentation, 1688 radiomics features were extracted from PET/CT and selected to construct predictive models. Then, we developed a nomogram based on PET/CT radiomics integrated with clinical features. Receiver operating curves, calibration curves, and decision curve analysis (DCA) were performed for diagnostics assessment and test of the developed models for distinguishing patients with MP/S components from the patients without.

RESULTS

PET/CT radiomics-clinical combined model could well distinguish patients with MP/S components from those without MP/S components (AUC = 0.87), which performed better than PET (AUC = 0.829, p < 0.05) or CT (AUC = 0.827, p < 0.05) radiomics models in the training cohort. In test cohorts, radiomics-clinical combined model outperformed the PET radiomics model in test cohort 1 (AUC = 0.859 vs 0.799, p < 0.05) and the CT radiomics model in test cohort 2 (AUC = 0.880 vs 0.829, p < 0.05). Calibration curve indicated good coherence between all model prediction and the actual observation in training and test cohorts. DCA revealed PET/CT radiomics-clinical model exerted the highest clinical benefit.

CONCLUSION

18F-FDG PET/CT radiomics signatures could achieve promising prediction efficiency to identify the presence of MP/S components in adenocarcinoma patients to help the clinician decide on personalized treatment and surveillance strategies. The PET/CT radiomics-clinical combined model performed best. CRITICAL RELEVANCE STATEMENT: 18F-FDG PET/CT radiomics signatures could achieve promising prediction efficiency to identify the presence of micropapillary and solid components in adenocarcinoma patients to help the clinician decide on personalized treatment and surveillance strategies.

Is heterogeneity in stage 3 non-small cell lung cancer obscuring the potential benefits of dose-escalated concurrent chemo-radiotherapy in clinical trials?

The current standard of care for the management of inoperable stage 3 non-small cell lung cancer (NSCLC) is concurrent chemoradiotherapy (cCRT) using radiotherapy dose-fractionation and chemotherapy regimens that were established 3 decades ago. In an attempt to improve the chances of long-term control from cCRT, dose-escalation of the radiotherapy dose was assessed in the RTOG 0617 randomised control study comparing the standard 60 Gy in 30 fractions with a high-dose arm receiving 74 Gy in 37 fractions. Following the publication of this trial the thoracic oncology community were surprised to learn that there was worse survival in the dose-escalated arm and that for now the standard of care must remain with the lower dose. In this article we review the RTOG 0617 paper with subsequent analyses and studies to explore why the use of dose-escalated cCRT in stage 3 NSCLC has not shown the benefits that were expected. The overarching theme of this opinion piece is how heterogeneity between stage 3 NSCLC cases in terms of patient, tumour, and clinical factors may obscure the potential benefits of dose-escalation by causing imbalances in the arms of studies such as RTOG 0617. We also examine recent advances in the staging, management, and technological delivery of radiotherapy in NSCLC and how these may be employed to optimise cCRT trials in the future and ensure that any potential benefits of dose-escalation can be detected.

Impact of whole-body ¹⁸F-fluorodeoxyglucose positron emission tomography on therapeutic management of non-small cell lung cancer

BACKGROUND AND OBJECTIVE

Accurate staging at the time of diagnosis is very important in deciding on the appropriate treatment for cancer patients. FDG PET indicates metabolic changes in cancer cells, enabling the early detection of lesions. This has the advantage of allowing more accurate staging than is possible with conventional staging tools, and has led to the incorporation of FDG PET in the initial work-up protocols for lung cancer patients. In this study, we evaluated the clinical impact of FDG PET as an initial staging tool, on the therapeutic management of patients with non-small cell lung cancer (NSCLC).

METHODS

Patients diagnosed with NSCLC by histopathology were retrospectively identified and both chest CT and FDG PET were performed for initial staging. Information was collected regarding the results of conventional versus FDG PET staging, and any resulting modifications of treatment were evaluated.

RESULTS

Among the 537 patients who were evaluated FDG PET resulted in upstaging of the tumour in 91 (17%) and downstaging of the tumour in 68 (13%). Consequently, therapeutic management was modified in 118 patients (22%). Furthermore, use of FDG PET resulted in the detection of a second primary cancer in six patients.

CONCLUSIONS

This study confirms that FDG PET has a considerable impact on the initial staging and therapeutic management of patients with NSCLC.

Diagnostic performance of (18)F-FDG PET/CT for lymph node staging in patients with operable non-small-cell lung cancer and inflammatory lung disease

As (18)F-fluorodeoxyglucose (FDG) is taken up by inflammatory lymph nodes, it could be falsely interpreted as metastasis. Therefore, we evaluated the diagnostic ability of positron emission tomography/computed tomography (PET/CT) for lymph node staging of lung cancer when inflammatory lung disease coexisted. Patients with operable non-small-cell lung cancer and FDG-avid lymph nodes were retrospectively classified into two groups; those with inflammatory lung disease (ILD) and those without it (NILD). Receiver operating characteristic (ROC) curve analysis was performed for maximum standardized uptake value (SUVmax), pattern of FDG uptake, maximum Hounsfield unit, and size, and then the areas under the ROC curves (AUCs) were compared between subgroups. There were 124 patients (ILD/NILD = 38/86) and 396 FDG-avid lymph nodes (ILD/NILD = 140/256). The average number of FDG-avid lymph nodes was greater in ILD (3.7 vs. 2.9, p = 0.039), whereas the proportion of metastasis was higher in NILD (25.4% vs. 11.4%, p = 0.002). With all N1-N3 lymph nodes and the NILD group, the AUC values of all four parameters were significantly greater than 0.5 (p < 0.05), and SUVmax was the most valuable parameter for lymph node metastasis. However, in the ILD group, only the AUC value of SUVmax was significantly greater than 0.5. These results were reproduced when analyses were performed with N1-N2 lymph nodes. In conclusion, SUVmax was the most valuable PET/CT parameter for assessment of lymph node metastasis in patients with operable non-small-cell lung cancer. In addition, it was the only valuable parameter when inflammatory lung disease coexisted.

Predictive and prognostic value of FDG-PET in nonsmall-cell lung cancer: a systematic review

For several years, molecular imaging with (18)F-fluorodeoxyglucose positron emission tomography (FDG-PET) has become part of the standard of care in presurgical staging of patients with nonsmall-cell lung cancer (NSCLC), focusing on the detection of malignant lesions at early stages, early detection of recurrence, and metastatic spread. Currently, there is an increasing interest in the role of FDG-PET beyond staging, such as the evaluation of biological characteristics of the tumor and prediction of prognosis in the context of treatment stratification and the early assessment of tumor response to therapy. In this systematic review, the literature on the value of the evolving applications of FDG-PET as a marker for prediction (ie, therapy response monitoring) and prognosis in NSCLC is addressed, divided in sections on the predictive value of FDG-PET in locally advanced and advanced disease, the prognostic value of FDG-PET at diagnosis, after induction treatment, and in recurrent disease. Furthermore, the background and recommendations for the application of FDG-PET for these indications will be discussed.

[Historic landmarks in the study of lung cancer]

This study reviews the milestones which have been reached in the study of lung cancer, from its first early descriptions up until the end of the twentieth century. The study accompanies the birth of this new clinical entity, underlining the difficulties inherent in its diagnosis, its ever-growing increase and traces the growth of its aetiological factors, placing particular emphasis on smoking. In tandem with this, the study delves into the clinical aspects, along with new discoveries in imaging techniques and endoscopic and bioscopic techniques. It also looks at the histopathological classifications of bronchopulmonary tumours and the various staging systems which have been used over the course of time as well as the importance of mapping the disease and the different treatment weapons which have successively become available in the fight against it. The study also takes a look at the scales used in evaluating patients' physiological condition, the criteria used in evaluating response to oncostatic treatment and the role some international and national scientific societies and medical associations have played in adding to the increasing medical knowledge of lung cancer. The study clearly shows to whom we are indebted for each advance. This is a fascinating sweep of history - as is the story of all medical progress - and one we feel is important to understand, in order for us to see more clearly where we are now.

The Impact of Positron Emission Tomography on Clinical Decision Making in a University-Based Multidisciplinary Lung Cancer Practice

INTRODUCTION

Positron emission tomography (PET) scanning has gained increasing application as a diagnostic and staging tool in the evaluation of lung cancer. Although PET scanning has been demonstrated to be a cost-effective adjunct to lung cancer diagnosis, its global impact on clinical decision making has not been assessed.

STUDY OBJECTIVES

To evaluate the impact of the systematic use of PET scanning on clinical decision making.

DESIGN

Retrospective study.

SETTING

A university-based multidisciplinary lung cancer practice.

PATIENTS

All patients undergoing diagnostic or staging PET scans from December 31, 2000, to December 31, 2002.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

One hundred ninety-eight patients underwent PET for diagnosis (161 patients) or staging (37 patients). PET scan results and clinical outcomes were retrospectively reviewed to determine the frequency with which PET scan findings (1) upstaged patients, (2) downstaged patients, (3) changed the diagnostic workup, (4) altered therapy, (5) resulted in a significant additional diagnosis, and (6) triggered evaluations that ultimately proved fruitless. PET upstaged 32 of 198 patients (16.2%) and downstaged 12 patients (6.1%), facilitating curative resection in 4 patients. Overall, PET scan findings changed the stage in 44 patients (22.2%). PET scan findings changed diagnostic management in 105 of 198 patients (53%), among whom biopsy was deferred in 65 patients (61.9%) and was triggered or guided in 40 patients (38.1%). PET scan findings altered treatment decisions in 38 patients (19.2%), leading to neoadjuvant therapy in 6 patients and resection in 5 patients, and forestalling noncurative thoracotomy in 6 patients. PET scan findings prompted or redirected chemotherapy or radiotherapy in the remainder of the patients. Overall, PET scan findings changed management in 143 patients (72.2%). PET scan findings triggered additional diagnostic testing in 32 patients (16.2%), resulting in no new diagnosis in 16 patients (50%) and a critical change in management in 7 patients (21.9%). PET scan findings were solely responsible for a significant non-lung cancer diagnosis in eight patients (4%).

CONCLUSIONS

Systematically applied PET scanning has a significant impact on patient management, altering diagnostic or therapeutic interventions in 72.2% of patients, changing staging in 22.2% of patients, and identifying serious unsuspected diagnoses in 4.0% of patients, with potentially life-saving consequences in 2.0%. Key Words: diagnosis; lung neoplasms; positron emission tomography.

PET imaging for suspected residual tumour or thoracic recurrence of non-small cell lung cancer after pneumonectomy

F-18 fluorodeoxyglucose-positron emission tomography (PET) was investigated in patients with suspected residual disease or intrathoracic recurrence after pneumonectomy. Patients were identified from a prospective database. Impact of PET on staging and patient management was assessed. Clinical outcome was used to assess appropriateness of management. PET was performed in 17 cases, either post-operatively (n = 8), or later for suspected recurrence (n = 9) in patients with good performance status and without extensive disease on conventional imaging. PET changed treatment in 10 cases (59%). In five patients (29%), PET changed treatment intent (curative versus non-curative) from radical radiotherapy (RT) to palliative RT (n = 1), or observation or supportive care (n = 3), or from palliative to radical RT (n = 1). In a further patient with unexplained pain, PET appropriately showed no evidence of disease. In additional five cases (29%), PET influenced choice of RT dose and the use of concurrent chemotherapy (n = 3) or target volume (n = 2). Patients without tumour or with limited disease on PET had favourable outcomes whereas those with extensive disease suffered early tumour progression. PET was discordant with conventional assessment in >50% of cases. PET may be valuable after pneumonectomy if the patient is being considered for adjuvant or salvage radiotherapy although specificity may be reduced due to post-operative inflammatory changes.