Gamma camera coincidence imaging with [18F]fluorodeoxyglucose in the pretreatment evaluation of patients with oesophageal cancer

Prognostic Significance of (18)F-fluorodeoxyglucose Positron Emission Tomography (FDG-PET)-Positive Lymph Nodes Following Neoadjuvant Chemotherapy and Surgery for Resectable Thoracic Esophageal Squamous Cell Carcinoma

PURPOSE

Patients with resectable thoracic esophageal squamous cell cancer (TESCC) and positron emission tomography (PET)-positive lymph nodes (PET-N positive) are likely to have ≥3 pathological lymph node metastases (pLNMs) and show a higher rate of postoperative recurrence despite curative resection than PET-N-negative TESCC patients. We examined the prognostic significance of (18)F-fluorodeoxyglucose uptake into lymph node metastases after neoadjuvant chemotherapy (NAC) for PET-N positive TESCC and aimed to propose the optimal NAC response criteria for these patients.

METHODS

Fifty-one patients with PET-N positive TESCC underwent two courses of NAC followed by surgery. Metabolic responses of primary tumors and LNs were prospectively evaluated and associations with clinicopathological data and patient survival assessed by univariate and multivariate analyses.

RESULTS

After NAC, 21 patients were post-treatment (post-) PET-N positive and 30 post-PET-N negative. A significantly (p < 0.001) high proportion of the post-PET-N-negative group had ≤2 pLNMs than the post-PET-N positive group (86.7 vs. 28.6 %). The PET-N negative group also had a significantly lower distant metastasis rate (23.3 vs. 75.0 %) and higher 5-year relapse-free survival (RFS) rate (69.0 vs. 20.0 %). Univariate and multivariate Cox's proportional hazard regression analyses identified post-PET-N negative status as the only significant favorable predictive factor for low postoperative recurrence (p = 0.015) independent of the primary tumor response.

CONCLUSIONS

PET-N negative status predicts ≤2 pLNMs and longer RFS in resectable TESCC patients even after NAC. Therefore, post-PET-N status, not the effects on the primary tumor, is a critical NAC treatment response criterion for evaluating prognosis and guiding subsequent treatment.

The impact of ¹⁸F-fluorodeoxyglucose positron emission tomography positive lymph nodes on postoperative recurrence and survival in resectable thoracic esophageal squamous cell carcinoma

BACKGROUND

Induction therapy is not always beneficial for all patients. Therefore, it is important to identify the patients with a high rate of recurrence. The occurrence of lymph node metastases (LNMs) strongly influences the postoperative survival in patients with esophageal cancer. We investigated the usefulness of an LN evaluation by initial (18)F-fluorodeoxyglucose (FDG) positron emission tomography (PET) in prediction of postoperative recurrence for patients with resectable esophageal squamous cell carcinoma (ESCC).

METHODS

A total of 76 ESCC patients who did not undergo induction therapy, but who did receive a curative resection were divided into PET-node (PET-N) positive (n = 26) and negative (n = 50) groups according to the presence or absence of FDG uptake in LNs. The PET-N status was compared with the size and the number of LNMs, as well as with the survival and failure patterns.

RESULTS

PET positive LNs involved a significantly larger size of metastatic nests than PET negative LNs (P = 0.002). The PET-N negative group showed a higher proportion of patients with 2 or fewer LNMs (92.0%), a higher 5-year relapse-free survival (75.1%) and a higher overall survival (70.0%), and a lower postoperative recurrence (24.0%) than the 15.4, 29.6, 30.3, and 69.2% values in the PET-N positive group, respectively, (P < 0.005). Multivariate analyses identified the PET-N status to be the most significant preoperative risk factor for postoperative recurrence (P = 0.031).

CONCLUSION

The preoperative PET-N status in patients with resectable ESCC was significantly associated with the size and the number of LNMs and was therefore found to reliably identify the high-risk population for postoperative recurrence.

Utility of response evaluation to neo-adjuvant chemotherapy by (18)F-fluorodeoxyglucose-positron emission tomography in locally advanced esophageal squamous cell carcinoma. Surgery. 2010;148:908-918. [PMID: 20378140 DOI: 10.1016/j.surg.2010.02.016]

BACKGROUND

Neoadjuvant chemotherapy (NACT) has been frequently used for locally advanced esophageal squamous cell cancer (ESCC). It is therefore important to establish criteria for evaluating the response to NACT based on survival analysis.

METHODS

This study analyzed 100 patients with ESCC (cT1, 2/3/4:25/57/18, cN0/1/M1lym: 5/59/36) who received NACT (5-fluorouracil, adriamycin, and cisplatin) followed by surgical resection. NACT response was monitored using (18)F-fluorodeoxyglucose-positron emission tomography (PET) and computed tomography by measuring pre- and post-NACT maximal standardized uptake value (SUVmax) and area of primary tumor, respectively. The associations between NACT and clinicopathological factors including prognosis were analyzed.

RESULTS

The mean ± SEM values of pre- and post-NACT SUVmax were 12.23 ± 4.62 and 6.31 ± 5.41, respectively, and the mean/median SUVmax reduction was 59.50%/73.45%. The most significant difference in survival between responders and non-responders was at 70% of cutoff value based on every 10% stepwise cutoff analysis (2-year progression-free survival [PFS]: 57.7% vs 25.1%; hazard ratio [HR] = 2.864; P = .0004). Univariate analysis indicated a correlation between PFS and number of cN before NACT, SUVmax reduction, decrease in tumor area, pT, and number of pN, while cT before NACT and pathological response to NACT showed no association. Multivariate analysis identified number of cN before NACT (HR = 2.537; P = .0092), SUVmax reduction (HR = 3.202; P = .0072), and number of pN (HR = 2.226; P = .0146) as independent prognostic predictors.

CONCLUSION

By determining the optimal cutoff value based on survival analysis, we evaluated patient responses to NACT using PET. Such evaluation could be valuable in formulating treatment strategies for ESCC.

Use of (18)F-fluorodeoxyglucose-positron emission tomography to evaluate responses to neo-adjuvant chemotherapy for primary tumor and lymph node metastasis in esophageal squamous cell carcinoma. Surgery. 2008;144:793-802. [PMID: 19081023 DOI: 10.1016/j.surg.2008.06.026]

BACKGROUND

Neoadjuvant chemotherapy (NACT) targets lymph node metastasis (LN), as well as the primary tumor (PT) in esophageal squamous cell carcinomas (ESCC). (18)F-fluorodeoxyglucose-positron emission tomography (FDG-PET) reflects viable tumor volume and may be more useful for evaluating NACT responses than conventional radiography. Moreover, FDG-PET may elucidate the clinical significance of NACT responses for LN, which is not always identical to those for PT.

PATIENTS AND METHODS

We retrospectively investigated prognostic factors in 38 node-positive ESCC patients who had undergone NACT (5-fluorouracil, adriamycin, and cisplatin) and surgical resection. The NACT response was evaluated separately by both PET and computed tomography (CT) for each PT and LN.

RESULTS

Although NACT effect for PT and LN was similar by PET evaluation (SUVmax reduction; average 70.58% vs 71.57%), they did not show significant correlation, revealing discordance for 13 (34.2%) patients when SUVmax reduction of more than 70% was classified as a PET responder. An opposite relationship existed in that the pre-NACT SUVmax of PT was significantly lower in PET responders than in PET non-responders (9.92 +/- 4.3 vs 12.96 +/- 3.8, P = .032), while that of LN tended to be higher in responders than in non-responders (5.70 +/- 3.2 vs 3.77 +/- 0.9, P = .072). Multivariate analysis identified the number of PET-positive LN (P = .018, HR = 5.464) and PET response for PT (P = .015, HR = 4.620) and for LN (P = .028, HR = 3.854) as independent prognostic predictors. The NACT response for PT or LN on CT evaluation was not a significant prognostic predictor.

CONCLUSION

PET is superior to CT for evaluating the NACT response from the viewpoint of survival analysis. The NACT response should be evaluated for both LN and PT because of their different behaviors during chemotherapy. Further studies of larger sample number should be conducted in the future.

Lack of fludeoxyglucose F 18 uptake in posttreatment positron emission tomography as a significant predictor of survival after subsequent surgery in multimodality treatment for patients with locally advanced esophageal squamous cell carcinoma

OBJECTIVE

Patients with advanced esophageal squamous cell carcinoma receive neoadjuvant chemotherapy or chemoradiotherapy to improve survival, but benefits are observed only in those with histologic response. Positron emission tomography with fludeoxyglucose F 18 (INN fludeoxyglucose [(18)F]) detects accumulation of glucose analog in viable cancer cells. This study investigated the usefulness of positron emission tomography with fludeoxyglucose F 18 in assessment of response of advanced esophageal squamous cell carcinoma to neoadjuvant treatment to establish new criteria to predict postoperative long-term survival.

METHODS

Fifty patients with locally advanced esophageal squamous cell carcinoma who received neoadjuvant therapy (chemotherapy 35, chemoradiotherapy 15) underwent positron emission tomography with fludeoxyglucose F 18 before surgical resection in evaluation of posttreatment maximum standardized uptake value, residual tumor size (maximum square area of longitudinal axis), histologic response, and postoperative survival.

RESULTS

After treatment, uptake was not noted in 21 patients (posttreatment maximum standardized uptake value < 2.5, negative) but was detected in 29 (> or = 2.5, positive). Residual tumor size ranged from 0 to 54.0 mm(2) for negative results and 55.0 to 676.0 mm(2) for positive, clearly distinguishing histologic major response from nonresponse. The negative group demonstrated significantly higher 5-year cause-specific survival (67.7%) and lower hematogenous recurrence (4.8%) than the 36.5% and 37.0% values in the positive group, (P < .0042 and P = .0083, respectively). Univariate Cox regression analyses identified posttreatment maximum standardized uptake value (cutoff 2.5) as the only preoperative prognostic factor (P = .0071).

CONCLUSION

Posttreatment positron emission tomography with fludeoxyglucose F 18 reliably predicted histologic response and postoperative survival in advanced esophageal squamous cell carcinoma. This tool could potentially be used to tailor optimal treatment according to individual responses.

Correlation of GLUT-1 overexpression, tumor size, and depth of invasion with 18F-2-fluoro-2-deoxy-D-glucose uptake by positron emission tomography in colorectal cancer

We investigated the wide variability of 18F-2-fluoro-2-deoxy-D: -glucose (FDG) uptake, semiquantified as standardized uptake value (SUV), in positron emission tomography (PET) scanning, in 20 patients with colorectal cancer (CRC), including 1 with synchronous hepatic metastasis. The sensitivity of PET in CRC diagnosis was 100%, with a mean SUV of 8.0 (3.1-11.9). Tumor size and depth of invasion were associated with higher SUVs (P=.0004, .042, respectively). Strong glucose transporter-1 (GLUT-1) expression had significantly positive correlation with the SUV (r=.619, P=.003). GLUT-1 expression revealed positive staining in 17 (85%) of the 20 primary lesions. The central part of the tumor, thought to be relatively hypoxic, had stronger GLUT-1 expression and a higher SUV than the periphery, in both the primary tumor and hepatic metastatic foci. Our data suggest that the SUVs of FDG uptake in PET may be a noninvasive biomarker for advanced CRC, indicative of a large hypoxic tumor with deep invasion.

Value of 2-[18F]-Fluoro-2-Deoxy-D-Glucose Imaging With Dual-Head Gamma Camera in Coincidence Mode

OBJECTIVE

The aim of the present study was to assess the value of dual-head gamma-camera (DHGC) imaging in the coincidence mode using 2-[18F]-fluoro-2-deoxy-D-glucose in differentiating recurrent tumor from posttreatment changes in previously treated head and neck cancer.

METHODS

This was a single-center prospective study performed with the approval of our Institutional Review Board. Twenty-nine patients with suspected recurrent head and neck cancers were prospectively enrolled in this study. Dual-head gamma-camera imaging in the coincidence mode followed computed tomography (CT; n = 24)/magnetic resonance imaging (MRI; n = 5) within a period of 1 week (mean = 3.5 days) in all patients. Thirteen patients had definite pathologic confirmation of recurrence by undergoing a biopsy. Sixteen patients, however, did not have a definite pathologic confirmation and were followed clinically. The mean duration of follow-up for the subgroup of patients who were followed clinically was 22.8 months (range: 4-48 months). Sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) for CT/MRI and DHGC imaging in the coincidence mode were calculated.

RESULTS

The sensitivity, specificity, PPV, NPV, and accuracy of CT/MRI in the detection of recurrent cancer were 76.5%, 58.3%, 72.2%, 63.6%, and 69%, respectively. In contrast, the sensitivity (100%), NPV (100%), and accuracy (82.8%) of DHGC imaging in the coincidence mode were superior to that of CT/MRI. Dual-head gamma-camera imaging in the coincidence mode had a specificity (58.3%) and PPV (77.3%) comparable to those of CT/MRI.

CONCLUSION

Our data suggest that modified positron emission tomography with DHGC imaging in the coincidence mode is a useful tool in the assessment of recurrent head and neck cancer.