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Early Prediction of Response to Chemotherapy and Survival in Malignant Pleural Mesothelioma Using a Novel Semiautomated 3-Dimensional Volume-Based Analysis of Serial ¹⁸F-FDG PET Scans

¹ Department of Nuclear Medicine/WA PET Centre, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia; ² Department of Medical Oncology, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia; ³ School of Medicine and Pharmacology, Faculty of Medicine and Dentistry and Health Science, University of Western Australia, Western Australia, Australia; ⁴ Cancer Council Clinical Trials Biostatistics Department, WA Institute for Medical Research, Sir Charles Gairdner Hospital, University of Western Australia, Nedlands, Western Australia, Australia; ⁵ Department of Radiology, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia; and ⁶ Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia

View larger version (73K): [in this window] [in a new window]   FIGURE 1.  Coronal slices of an 18F-FDG PET scan of a patient with mesothelioma demonstrating contiguous involvement of the right pleural surface, including infiltration of the oblique fissure. There is additional subcarinal, precarinal, right paratracheal, and right hilar lymph node involvement.

View larger version (62K): [in this window] [in a new window]   FIGURE 2.  Representative CT transaxial slices of a patient with mesothelioma (A) before chemotherapy and (B) after chemotherapy. Measurements according to modified RECIST criteria have been applied. The patient had a radiological partial response after 1 cycle of chemotherapy. The challenge of defining a measurement site to determine response is demonstrated. Representative 18F-FDG PET transverse, sagittal, and coronal slices in the same patient (C) before chemotherapy and (D) after 1 cycle of chemotherapy. A significant reduction in intensity and extent of 18F-FDG uptake in the left pleural cavity is demonstrated. The response is more clearly visualized on the 18F-FDG PET imaging, and the degree of change compared with baseline in the patient was greater (TGV fell to 11% of baseline on the postchemotherapy scan, compared with a fall to 63% of baseline on CT measurements).

View larger version (26K): [in this window] [in a new window]   FIGURE 3.  Representative 18F-FDG PET coronal slices in a patient with left pleural mesothelioma (A) before chemotherapy and (B) after 1 cycle of chemotherapy, demonstrating reduction in the extent and intensity of 18F-FDG activity. The region generated by the semiautomated region-growing algorithm is shown on the coronal slice (C) before chemotherapy and (D) after chemotherapy. (A–D) illustrate one representative coronal slice both before and after chemotherapy; however, in practice the region is grown in 3 dimensions to define an overall volume of interest (VOI). (E) Histogram of the SUV voxel values of the VOI generated by the region-growing algorithm in this patient before chemotherapy (red line) and after chemotherapy (green line). The histogram demonstrates both a reduction in the numerical SUV values and in the overall volume of metabolically active tumor. The TGV fell to 30% of the prechemotherapy value.

View larger version (6K): [in this window] [in a new window]   FIGURE 4.  18F-FDG PET TGV and SUVmax percentage response values compared with CT response values in the 7 patients with CT-defined PR (A) and 13 patients with CT-defined SD after 1 cycle of chemotherapy (B). All values are expressed as a percentage of the baseline value. The solid line represents the 70% value used in CT to define a PR.

View larger version (10K): [in this window] [in a new window]   FIGURE 5.  Kaplan–Meier survival curves illustrate the relationship between the degrees of reduction in TGV compared with baseline and survival. TGV <60% represents a reduction in TGV after 1 cycle of chemotherapy to less than 60% of the baseline value. TGV 60%–85% represents a reduction to 60%–85% of the baseline value. TGV >85% includes patients whose TGV after chemotherapy was 85% or greater than the baseline value and patients whose TGV increased after chemotherapy.