Standardised FDG uptake: A prognostic factor for inoperable non-small cell lung cancer

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Abstract

The aim of this study was to investigate the relationship between standardised uptake value (SUV) obtained from [18F]fluorodeoxyglucose positron emission tomography (FDG PET) and treatment response/survival of inoperable non-small cell lung cancer (NSCLC) patients treated with high dose radiotherapy. Fifty-one patients were included recording stage, performance, weight loss, tumour volume, histology, lymph node involvement, SUV, and delivered radiation dose. The maximum SUV (SUVmax) within the primary tumour was a sensitive and specific factor for predicting treatment response. Apart from SUVmax, stage and performance were also independent predictive factors for treatment response. In a multivariate disease-specific survival (DSS) analysis, SUVmax (P = 0.01), performance status (P = 0.008) and stage (P = 0.04) were prognostic factors. For overall survival (OS), SUVmax (P = 0.001) and performance (P = 0.06) were important prognostic factors. SUVmax was an important prognostic factor for survival of inoperable NSCLC patients and a predictive factor for treatment response. Although the number of patients was small, the treatment was not homogeneous and the use of FDG SUV may have had constraints, we still conclude that the FDG SUV is potentially a good indicator for selecting patients for different treatment strategies.

Introduction

TNM stage, performance status and weight loss are important prognostic factors used to stratify non-small cell lung cancer (NSCLC) patients for the most optimal treatment regimen [1]. However, these factors do not always provide a satisfactory explanation for differences in outcome between patients. Molecular markers and other features, such as tumour doubling time, are also closely related to prognosis [2]. These factors are, however, not always available in cases of inoperable NSCLC patients (e.g., no pathology). A non-invasive prognostic classifier may improve selection of inoperable NSCLC patients for individually adapted therapy (dose escalation, chemoradiation) and to potentially improve their poor prognosis.

Neoplastic cells demonstrate upregulation of glucose metabolism in order to obtain energy needed for proliferation [3]. Consequently, uptake of glucose or glucose analogues like deoxy-glucose is increased. Labelling deoxy-glucose with the positron emitting radionuclide 18F to form [18F]fluorodeoxyglucose (FDG) renders these cells detectable using positron emitting tomography (PET) as FDG is not a substrate for hexokinase and is therefore trapped inside the cells. The standardised uptake value (SUV) is a semi-quantitative method for assessing glucose metabolism, which is often used in clinical studies. Higher SUVs were observed in NSCLC with higher proliferation rates [4], [5], [6]. Moreover, it was demonstrated that SUV was a significant prognostic factor in the survival analysis of NSCLC patients [7], [8], [9], [10], [11], [12].

The purpose of the present study was to investigate whether SUV could also be used as a classifier for predicting which patients will have favorable treatment response and to assess the significance of SUV as a prognostic factor in survival analysis of inoperable NSCLC patients treated with high dose radiotherapy.

Section snippets

Patients

Patients included in this study were diagnosed and treated at the Department of Radiation Oncology in The Netherlands Cancer Institute – Antoni van Leeuwenhoek Hospital. The FDG scan was performed at the Department of Nuclear Medicine and PET research of the VU University Medical Centre, Amsterdam. PET imaging was requested for the evaluation of mediastinal lymph node involvement and as a screening method for the presence of clinically unsuspected distant metastasis in patients diagnosed with

Treatment response and follow up

Thirty-three percent (n = 17) of the patients experienced a complete response (CR). These patients had a median survival of 38 months. Fifty percent (n = 25) of the patients had a partial response (PR) with a median survival of 14 months. Stable disease (SD) was achieved in 8% (n = 4, 10 months median survival) of the patients and 10% (n = 5) of the patients suffered from progressive disease (PD, 9 months median survival) (Table 2).

The overall median follow-up was 17 months (range: 3–57 months). Of the

Discussion

In the present study, FDG SUVmax was predictive for treatment response and the median SUVmax was a good variable to predict complete response in inoperable NSCLC patients. The multivariate survival analysis showed that SUVmax was an explanatory prognostic factor for both disease-specific (DSS) and overall (OS) survival. We could not perform a disease free survival analysis because only 2 patients with complete response (n = 17) developed metastases or progression of disease.

Differences in

Conflict of interest statement

None declared.

Acknowledgements

The authors thank Prof. H. Bartelink, Prof. M. van Herk, Dr. O.S. Hoekstra and Dr. B. Mijnheer for critical reading of the manuscript and J. Wolthaus for software assistance.

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