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Clinical utility of [18F]FDG PET/CT in the assessment of mediastinal lymph node disease after neoadjuvant chemoimmunotherapy for non-small cell lung cancer

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Abstract

Objectives

The performance of positron emission tomography/computed tomography (PET/CT) for the prediction of ypN2 disease in non-small cell lung cancer (NSCLC) after neoadjuvant chemoimmunotherapy has not been reported. This multicenter study investigated the utility of PET/CT to assess ypN2 disease in these patients.

Methods

A total of 181 consecutive patients (chemoimmunotherapy = 86, chemotherapy = 95) at four institutions were enrolled in this study. Every patient received a PET/CT scan prior to surgery and complete resection with systematic nodal dissection. The diagnostic performance was evaluated through area under the curve (AUC). Kaplan–Meier method and Cox analysis were performed to identify the risk factors affecting recurrences.

Results

The sensitivity, specificity, and accuracy of PET/CT for ypN2 diseases were 0.667, 0.835, and 0.779, respectively. Therefore, the AUC was 0.751. Compared with the false positive cases, the mean value of max standardized uptake value (SUVmax) (6.024 vs. 2.672, p < 0.001) of N2 nodes was significantly higher in true positive patients. Moreover, the SUVmax of true positive (7.671 vs. 5.976, p = 0.365) and false (2.433 vs. 2.339, p = 0.990) positive cases were similar between chemoimmunotherapy and chemotherapy, respectively. Survival analysis proved that pathologic N (ypN) 2 patients could be stratified by PET/CT-N2(+ vs. -) for both chemoimmunotherapy (p = 0.023) and chemotherapy (p = 0.010).

Conclusions

PET/CT is an accurate and non-invasive test for mediastinal restaging of NSCLC patients who receive neoadjuvant chemoimmunotherapy. The ypN2 patients with PET/CT-N2( +) are identified as an independent prognostic factor compared with PET/CT-N2(-).

Clinical relevance statement

Imaging with 18F-fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) plays an integral role during disease diagnosis, staging, and therapeutic response assessments in patients with NSCLC. PET/CT could be an effective non-invasive tool for predicting ypN2 diseases after neoadjuvant chemoimmunotherapy.

Key Points

• PET/CT could serve as an effective non-invasive tool for predicting ypN2 diseases.

• The ypN2 patients with PET/CT-N2( +) were a strong and independent prognostic factor.

• The application of PET/CT for restaging should be encouraged in clinical practice.

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Abbreviations

AUC:

Area under the curves

CI:

Confidence interval

CR:

Complete response

EBUS-TBNA:

Endobronchial ultrasound–guided transbronchial needle aspiration

EFS:

Event-free survival

IASLC:

International Association for the Study of Lung Cancer

ICIs:

Immune checkpoint inhibitors

MPR:

Major pathologic response

NCCN:

National Comprehensive Cancer Network

NIF:

Nodal immune flare

NPV:

Negative predictive value

NSCLC:

Non-small cell lung cancer

OS:

Overall survival

pCR:

Pathologic complete response

PD:

Progressive disease

PET/CT:

Positron emission tomography/computed tomography

pN:

Pathologic N

PPV:

Positive predictive value

PR:

Partial response

RECIST:

The Response Evaluation Criteria In Solid Tumors

RFS:

Recurrence-free survival

ROC:

Receiver operating characteristic

SD:

Stable disease

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Funding

This study was supported by National Key Research and Development Program of China (2021YFC2500904 and 2021YFC2500905), Shanghai Municipal Health Commission (202040322), and Shanghai Hospital Development Center (SHDC22021217).

Author information

Author notes

  1. Lei Zhang, Haoran E, Jia Huang, and Junqi Wu contributed equally to this work.

Authors and Affiliations

  1. Department of Thoracic Surgery, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, No. 507 Zhengmin Road, Shanghai, 200443, China

    Lei Zhang, Haoran E, Junqi Wu, Chongwu Li, Chenyang Dai, Jiajun Deng, Yijiu Ren, Deping Zhao & Chang Chen

  2. Shanghai Lung Cancer Center, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, People’s Republic of China

    Jia Huang & Qingquan Luo

  3. Department of Nuclear Medicine, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, People’s Republic of China

    Qiang Li

  4. Department of Pathology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, People’s Republic of China

    Likun Hou

  5. Department of Thoracic Surgery, Ningbo No. 2 Hospital, Chinese Academy of Sciences, Zhejiang, People’s Republic of China

    Minglei Yang

  6. Department of Thoracic Surgery, The First Hospital of Lanzhou University, Gansu, People’s Republic of China

    Minjie Ma

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  1. Lei Zhang
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Corresponding authors

Correspondence to Deping Zhao or Chang Chen.

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Guarantor

Dr. Chang Chen has been identified as the guarantor, taking responsibility for the content of the manuscript, including the data and analysis.

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The authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article.

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One of the authors has significant statistical expertise.

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Written informed consent was waived by the Institutional Review Board.

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• retrospective

• cross sectional study

• multicenter study

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Zhang, L., E, H., Huang, J. et al. Clinical utility of [18F]FDG PET/CT in the assessment of mediastinal lymph node disease after neoadjuvant chemoimmunotherapy for non-small cell lung cancer. Eur Radiol 33, 8564–8572 (2023). https://doi.org/10.1007/s00330-023-09910-8

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