Elsevier

Leukemia Research

Volume 37, Issue 1, January 2013, Pages 58-63
Leukemia Research

Clinical value of metabolic tumor volume by PET/CT in extranodal natural killer/T cell lymphoma

https://doi.org/10.1016/j.leukres.2012.09.011Get rights and content

Abstract

This study investigated whether metabolic tumor volume (MTV) by PET/CT as indicator of extent of lymphoma burden would be a prognostic factor in stage IE/IIE extranodal natural killer/T cell lymphoma (ENKTCL). Eighty patients with stage IE/IIE ENKTCL in the upper aerodigestive tract underwent PET/CT at diagnosis were enrolled and 32 patients received upfront radiotherapy (RTx). MTV was measured on PET/CT images by the extranodal region above SUV, 2.5. Receiver operating curve analyses indicated that an MTV of 35.2 cm3 was the ideal cut-off to distinguish between low and high MTV groups. Clinical outcomes were compared according to several prognostic factors (age, stage, high performance status [PS], high International Prognostic Index, elevated lactate dehydrogenase [LDH], local tumor invasiveness [LTI], high MTV and up-front RT). High PS, elevated LDH, LTI, high MTV and upfront RT were associated with survivals. In multivariate analysis, high MTV (PFS, HR = 4.170, 95% CI = 1.714–10.147, p = 0.002; OS, HR = 4.102, 95% CI = 1.617–10.408, p = 0.003) and up-front RT (PFS, HR = 0.410, 95%CI = 0.178–0.946, p = 0.037; OS, HR = 0.365, 95% CI = 0.152–0.872, p = 0.023) were significant independent prognostic factors. Upfront RTx and extent of tumor burden, as measured by the MTV, had significant prognostic value in patients with ENKTCL.

Introduction

Extranodal natural killer (NK)/T-cell lymphoma, nasal type (ENKTCL) is a distinct clinicopathological entity that is very rare in Western populations [1], [2], [3], [4], [5] but rather common among Asians and Latin Americans [6], [7], [8], [9]. It frequently destroys the facial midline of the upper aerodigestive tract (UAT) and spreads to or relapses at extranodal sites including the skin, gastrointestinal tract, bone marrow, lung, extremities, orbit, adrenal gland, testis, or the central nervous system [10].

Ann Arbor staging, originally developed for Hodgkin's lymphoma, is unclear as a predictor of prognosis in more aggressive subgroups of non-Hodgkin's lymphoma [11], [12]. The International Prognostic Index (IPI) has also failed to predict survival in patients with ENKTCL [9], [13], [14]. Furthermore, poor drug delivery due to tissue necrosis related to angiodestruction and frequent expression of multidrug resistant phenotypes might be important contributing factors. Therefore, front-line use of radiotherapy (RTx) has produced superior survival compared to initial chemotherapy for localized ENKTCL [15].

The extent of ENKTCL is considered a prognostic factor [16], [17]. However, measurement of extent is simply based on the tumor-node-metastasis (TNM) staging system of the American Joint Committee (AJC). 18-Fluorine-fluorodeoxyglucose-positron emission tomography/computed tomography (18F-FDG-PET/CT) is a promising tool for assessing metabolic activity or treatment planning for active lesions in patients with ENKTCL [18], [19], [20], [21].

The objective of this study was to investigate whether metabolic tumor volume (MTV) of involved extranodal lesions is a prognostic factor in stage IE/IIE UAT-NKTCL.

Section snippets

Materials and methods

Between 2006 and 2011, 80 patients with Ann Arbor stage IE and IIE UAT-NKTCL underwent 18F-FDG PET/CT scans at the time of initial diagnosis and were enrolled at six medical centers, including Pusan National University Hospital, Chonnam National University Hospital, Kyungpook National University Hospital, Busan Paik Hospital, Kosin University Gospel Hospital, and Gyeongsang National University Hospital. Patient characteristics are summarized in Table 1. The male to female ratio was 1.42:1.

Patient clinical characteristics

The clinical characteristics of the 80 patients with ENKTCL of the head and neck are summarized in Table 1. Thirty-eight patients were >60 years of age. The primary site of the tumor was the nasal cavity in 63 patients, nasopharynx in 10 patients, and the oral cavity/oropharynx in seven patients. Fifty-one patients were in Ann Arbor stage IE (53.8%), and 29 patients were in stage IIE (45.2%). Thirteen patients (16.3%) had B symptoms and 11 patients (13.7%) had Eastern Cooperative Oncology Group

Discussion

Several clinical factors that have prognostic significance in nasal NKTCL include advanced Ann Arbor stage, systemic symptoms, age, and bulkiness of the tumor [27], [28], [29], [30], [31]. Among these factors, stage is the most frequently cited factor. However, an Italian study found no significant differences between early-stage and advanced diseases for CR or survival rates [32]. In addition, the staging system did not predict survival of early stage disease in Korean studies [14], [22]. Our

Conflict of interest statement

All authors have no conflict of interest to report.

Acknowledgement

None. No funding to declare.

Contributions: M.-K.S.: provided the conception and design of the study, acquisition of data, analysis and interpretation of data, drafting the article, revised it critically for important intellectual content, and final approval of the version to be submitted. J.-S.C.: revised the article critically for important intellectual content. Other authors: supplied the clinical data in the author's institute.

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