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Sequential FDG-PET/CT reliably predicts response of locally advanced rectal cancer to neo-adjuvant chemo-radiation therapy

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Abstract

Purpose

Prediction of rectal cancer response to preoperative, neo-adjuvant chemo-radiation therapy (CRT) provides the opportunity to identify patients in whom a major response is expected and who may therefore benefit from alternative surgical approaches. Traditional morphological imaging techniques are effective in defining tumour extension in the initial diagnostic and staging work-up, but perform poorly in distinguishing residual neoplastic tissue from scarring post CRT, when restaging the patient before surgery. Fluorine-18 fluorodeoxyglucose positron emission tomography (FDG-PET) is a promising tool for monitoring the effect of anti-tumour therapy. The aim of this study was to prospectively assess the value of sequential FDG-PET scans in predicting the response of locally advanced rectal cancer to neo-adjuvant CRT.

Methods

Forty-four consecutive patients with locally advanced (cT3–4) primary rectal cancer and four patients with pelvic recurrence of rectal cancer were enrolled in this prospective study. Treatment consisted of external beam intensified radiotherapy (50 Gy to the posterior pelvis, 56 Gy to the tumour), chemotherapy (in most cases PVI 5-FU at 300 mg/m2 per day) and, 8–10 weeks later, surgery with curative intent. All patients underwent FDG-PET/CT both before CRT and 5–6 weeks after completing CRT. One patient died before surgery because of acute myocardial infarction, and was therefore excluded from further analysis. Semi-quantitative measurements of FDG uptake (SUVmax), absolute difference (ΔSUVmax) and percent SUVmax difference (Response Index, RI) between pre- and post-CRT PET scans were considered. Results were correlated with pathological response, assessed both by histopathological staging of the surgical specimens (pTNM) and by the tumour regression grade (TRG) according to Mandard’s criteria (patients with TRG1–2 being defined as responders and patients with TRG3–5 as non-responders).

Results

Following neo-adjuvant CRT, of the 45 patients submitted to surgery, 23 (51.1%) were classified as responders according to Mandard’s criteria (8 TRG1 and 15 TRG2), while the remaining 22 (48.9%) were non-responders (9 TRG3 and 13 TRG4–5). Considering all patients, the mean pre-CRT SUVmax was 15.6, significantly higher than the mean value of 5.4 post CRT (p < 0.001). Nevertheless, when stratifying patients according to response to CRT (using Mandard’s criteria), the mean RI was significantly higher in responders than in non-responders (75.9% versus 46.9%,p = 0.0015). Using a 66.2% SUVmax decrease as the cut-off value (identified by ROC analysis) for defining response to therapy, the following parameters were obtained: 79.2% specificity, 81.2% sensitivity, 77% positive predictive value, 89% negative predictive value and 80% overall accuracy.

Conclusion

The results suggest the potential utility of FDG-PET as a complementary diagnostic and prognostic procedure in the assessment of neo-adjuvant CRT response of locally advanced rectal cancer. ΔSUVmax and RI seem the best predictors of CRT response.

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Author information

Authors and Affiliations

  1. Division of Radiotherapy, “S. Maria della Misericordia” Hospital, Rovigo, Italy

    Carlo Capirci

  2. Nuclear Medicine and PET Service, “S. Maria della Misericordia” Hospital, Viale tre Martiri, 140, 45100, Rovigo, Italy

    Lucia Rampin & Elena Banti

  3. Regional Center of Nuclear Medicine, University of Pisa Medical School, Pisa, Italy

    Paola A. Erba & Giuliano Mariani

  4. Division of Surgery, “S. Maria della Misericordia” Hospital, Rovigo, Italy

    Fabrizio Galeotti

  5. Division of Oncology, “S. Maria della Misericordia” Hospital, Rovigo, Italy

    Giorgio Crepaldi

  6. Medical Physics Service, “S. Maria della Misericordia” Hospital, Rovigo, Italy

    Marcello Gava

  7. Department of Nuclear Medicine, PET Unit, ‘Policlinico S. Orsola-Malpighi’, Bologna, Italy

    Stefano Fanti

  8. Department of Radiology, Istituto Oncologico Veneto (IOV)-IRCCS, Padova, Italy

    Pier Carlo Muzzio

  9. Nuclear Medicine Service, PET Unit, “S. Maria della Misericordia” Rovigo Hospital, Istituto Oncologico Veneto (IOV)-IRCCS, Italy Viale Tre Martiri, 140, 45100, Rovigo, Italy

    Domenico Rubello

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  1. Carlo Capirci
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Correspondence to Domenico Rubello.

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Capirci, C., Rampin, L., Erba, P.A. et al. Sequential FDG-PET/CT reliably predicts response of locally advanced rectal cancer to neo-adjuvant chemo-radiation therapy. Eur J Nucl Med Mol Imaging 34, 1583–1593 (2007). https://doi.org/10.1007/s00259-007-0426-1

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  • DOI: https://doi.org/10.1007/s00259-007-0426-1

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