Is %ΔSUVmax a Useful Indicator of Survival in Patients with Advanced Nonsmall-Cell Lung Cancer?

Hindawi Publishing Corporation The Scientific World Journal Volume 2013, Article ID 910957, 4 pages http://dx.doi.org/10.1155/2013/910957 Research Article Is %ΔSUVmax a Useful Indicator of Survival in Patients with Advanced Nonsmall-Cell Lung Cancer? Angelina Cistaro,1,2,3 Natale Quartuccio,4 Alireza Mojtahedi,5 Piercarlo Fania,1 Pier Luigi Filosso,6 Mariapaola Cucinotta,4 Alfredo Campennì,4 Umberto Ficola,7 and Sergio Baldari4 1 Positron Emission Tomography Centre, IRMET S.p.A., Euromedic, V.O. Vigliani 89, 10136 Turin, Italy PET Pediatric AIMN InterGroup, 10136 Turin, Italy 3 Institute of Cognitive Sciences and Technologies, National Research Council, 00185 Rome, Italy 4 Department of Biomedical Sciences and of Morphological and Functional Images, Nuclear Medicine Unit, University of Messina, 98125 Messina, Italy 5 Nuclear Medicine Service, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA 6 Department of Thoracic Surgery, S. Giovanni Battista Hospital, 10126 Turin, Italy 7 Department of Nuclear Medicine, La Maddalena Hospital, 90146 Palermo, Italy 2 Correspondence should be addressed to Angelina Cistaro; Received 7 August 2013; Accepted 17 September 2013 Academic Editors: H. Abdel-Dayem, C.-H. Kao, and T. Smith Copyright © 2013 Angelina Cistaro et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Purpose. To investigate the impact of the maximum standardized uptake value (SUVmax), size of primary lung lesion, and %ΔSUVmax on outcome (overall survival (OS) and 2-year disease-free survival (2-year DFS)) of patients with advanced nonsmallcell lung cancer (NSCLC). Materials and Methods. 86 stage III-IV NSCLC patients underwent 18 F-FDGPET/CT, before and after chemotherapy, and were classified into subgroups according to the response criteria of the European Organization for Research and Treatment of Cancer. SUVmax values and tumor size with the best prognostic significance were searched. Correlation between the SUVmax value and the initial response to therapy (best response) and the relationship between %ΔSUVmax and OS were assessed. Results. In patients in PD (20/86), the average pretreatment SUVmax was 11.8 ± 5.23, and the mean size of the primary lesion was 43.35 mm ± 16.63. In SD, PR, and CR patients (66/86), the average pretreatment SUVmax was 12.7 ± 8.05, and the mean size of the primary lesion was 41.6 mm ± 21.15. Correlation was identified only for %ΔSUVmax; patients with PD (ΔSUVmax > +25%) showed a worse OS than patients with ΔSUVmax < +25% (CR, PR, and SD) (𝑃 = 0.0235). Conclusions. In stage III-IV NSCLC, among the assessed factors, only %ΔSUVmax may be considered as a useful prognostic factor. 1. Introduction Among worldwide oncologic causes of death, lung cancer is the leading one [1]. Cross-sectional imaging using computed tomography (CT) combined with positron-emission tomography (PET) provides excellent information about anatomic and metabolic evaluation of malignancies. In order to stage, restage, and evaluate the treatment response in lung cancer, 2-deoxy-2-[18F]fluoro-D-glucose positron-emission tomography (18 F-FDG PET/CT) is widely used [2, 3]. PET/CT has been utilized in the evaluation of response to treatment, and several studies demonstrated the correlation between decreased metabolic activity of the tumor following treatment and survival. Cisplatin-based chemotherapy is currently a key strand for treatment of advanced (stages III-IV) nonsmall-cell lung cancer (NSCLC). Despite the introduction of modern treatment protocols, prognosis of advanced NSCLC still remains poor, especially in comparison with disease in early stage [1]. While FDG-PET/CT has been demonstrated to provide additional prognostic information for patients with stages I-II NSCLC before treatment [2, 4], it has a limited prognostic role in stages III-IV [3]. However, 2 The Scientific World Journal Table 1: Characteristics of population. Number of patients Sex Mean age Histotypes Adenocarcinoma Squamous Large cell Others 86 67 M 19 F 63.5 y (range: 37–80) 41 16 9 20 M: male; F: female; y: years. previous study has demonstrated that FDG-PET/CT can be considered as a helpful tool in assessing therapeutic efficacy of chemotherapy in NSCLC [5]. According to the response criteria recommended by the European Organization for Research and Treatment of Cancer (EORTC), a metabolic response correlates with survival [6]. The early metabolic response, with significant reduction of tracer uptake compared with the baseline study before therapy, has been found predictive of favorable prognosis. Instead a slight reduction or an increased uptake is predictive of treatment failure or disease progression [5–7]. The aim of this study was to identify the possible cutoff values for SUVmax and size of primary lung lesion that have correlation with clinical outcome (OS and DFS) in patients with advanced (stages III-IV) NSCLC. We also evaluated the correlation between the pretreatment SUVmax and the initial response to therapy (best response) and between %ΔSUVmax (the change between SUVmax before and after chemotherapy) and outcome. 2. Materials and Methods Eighty-six patients (67 M and 19 F; M/F ratio = 3.5 : 1; mean age = 63.5 years; range = 37–80) were referred to IRMET Positron Emission Center S.p.A., Euromedic, in Turin, Italy, and Unit of Nuclear Medicine of La Maddalena Hospital in Palermo, Italy, for evaluation of their advanced non-small cell lung cancer. The histotypes were 41 (48%) adenocarcinomas, 16 (19%) squamous cell carcinomas, 9 (10%) large cell carcinomas, and 20 (23%) uncommon histotypes (others) (Table 1). Patients were staged according to the TNM 7th edition [8] in stages IIIA, IIIB, and IV via information gathered through patient’s chart including physical examination, routine blood test, bronchoscopy, contrast-enhanced computed tomography (CT) of the chest and upper abdomen, and brain CT. Survival and death information were retrieved by means of the hospitals databases. The research proposal was approved by Institutional Review Board and Ethics Committee. All patients underwent chemotherapeutic treatment based on cisplatin and taxanes drugs (135 mg of paclitaxel per square meter of body-surface area, administered over a 24-hour period on day 1, followed by 75 mg of cisplatin per square meter on day 2, every three weeks) and two FDG PET/CT whole body scan, one before (T0) and one after treatment (T1: one month). IIIA patients undergoing neoadjuvant chemotherapy and subsequent surgery were excluded from the study. Patients were excluded from the study also in case of (a) poor performance status; (b) Charlson Combined Age-Comorbidity Index ≥ 6; (c) histological diagnosis of “bronchioloalveolar cell carcinoma” (BAC) subtype. PET/CT images were acquired at both centres (Turin and Palermo) on a (...truncated)