Relationship between primary lesion FDG uptake and clinical stage at PET–CT for non-small cell lung cancer patients: An observation
Introduction
Histological classification and staging are cornerstones for diagnosis and treatment in lung cancer. Non-small cell lung cancer (NSCLC) accounts for more than 80% of lung cancer and includes the following histologic types: adenocarcinoma, squamous cell carcinoma, large cell carcinoma, and other histologies. Squamous cell carcinoma and adenocarcinoma are the two most common types of lung cancer seen in China. Certain prognostic factors are predictive of survival in patients with NSCLC. Good prognostic factors include early-stage disease at diagnosis, good performance status, no significant weight loss, and female gender. To date, the TNM staging system is the most powerful prognostic tool for predicting survival rates [1].
FDG-PET is an accepted and widely used clinical functional imaging tool in oncology. FDG uptake correlates with the rate of glycolysis, which is known to be markedly greater in neoplastic tissues than in the normal tissues. Standardized uptake value (SUV), as a semi-quantitative measurement of FDG uptake, could provide much intrinsic molecular–biological information of tumor, which suggests that FDG PET should have great potential to tailor treatment strategies based on tumor characteristics in an individual patient [2], [3]. In NSCLC, FDG-PET is now an important molecular imaging tool for diagnosis, staging and estimating radiotherapeutic or chemotherapeutic responses [4], [5], [6]. PET–CT has proven to be significantly more accurate than computed tomography (CT) in the distinction between benign and malignant lesions and in the evaluation of metastatic spread to locoregional lymph nodes or distant sites. And strong evidence from a growing number of retrospective studies demonstrates that the intensity of FDG uptake of the primary tumor expressed as the SUVmax is highly correlated with disease recurrence and survival [7], [8], [9], [10], [11], [12], [13] in NSCLC patients. It is clear to experienced clinicians that there is wide spectrum of biological behavior and different recurrence modal or survival for even those same stage patients in lung cancer. The mechanism of FDG uptake for prognosis has not been clarified. And the prognostic potential of FDG PET seems to be determined mainly by exact nodal and metastatic staging and by its ability to detect recurrent disease [4]. Considering that the TNM stage is the most significant prognostic factor for NSCLC, we proposed to examine the relationship between FDG uptake of primary lesion and clinical stage in NSCLC and to determine if FDG uptake is independently prognostic of NSCLC outcome.
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Inclusion and exclusion criteria
From December 2003 to November 2007, we reviewed all patients who were proven or suspected to be lung cancer and recommended for FDG PET/CT staging in the nuclear medicine center of Shandong Cancer Hospital. Patient criteria included having a definited histologic or cytologic evidence to be adenocarcinoma or squamous cell carcinoma. None of the included patients had received prior treatment. Patients were also excluded if they had type I diabetes. Patients with pleural effusion and obstructive
Results
Two hundred and sixty-six patients (age range 31–90 years, median 62 years) were enrolled and analyzed (Table 1), which included 161 AC and 105 SCC patients. The T-N-M status was established for all subjects based on the method above, including stages I, 58 cases; II, 35 cases; III, 64 cases; and IV, 109 cases. Significant correlations were found between the SUVmax and tumor size in all patients (Pearson, r = 0.651, P < 0.001; Fig. 1), and for either AC group (Pearson, r = 0.632, P < 0.001) or SCC
Discussion
Non-small cell lung cancer is a heterogeneous group of carcinomas with different biologic behaviors and prognoses. The TNM staging system does not, however, always satisfactorily explain individual patient survival. Structural imaging alone may not provide the clinician with all of the information that is necessary to fully characterize cancer patients. FDG-PET provides complementary information to structural imaging techniques for diagnosis, staging and assessment of treatment response of lung
Conflicts of interest statement
None declared.
Acknowledgment
This work was supported by a Grant for Project Research (Y2008C133) from Shandong Provincial Natural Science Foundation, China.
References (21)
- et al.
Prognostic factors in non-small cell lung cancer: a decade of progress
Chest
(2002) - et al.
Seeking a home for a PET. Part 3. Emerging applications of positron emission tomography imaging in the management of patients with lung cancer
Chest
(2004) - et al.
Positron-emission tomography in prognostic and therapeutic assessment of lung cancer: systematic review
Lancet Oncol
(2004) - et al.
The maximum standardized uptake values on positron emission tomography of a non-small cell lung cancer predict stage, recurrence, and survival
J Thorac Cardiovasc Surg
(2005) - et al.
18F-FDG uptake as a biologic factor predicting outcome in patients with resected non-small-cell lung cancer
Chin Med J
(2007) - et al.
FDG uptake, glucose transporter type 1, and Ki-67 expressions in non-small-cell lung cancer: correlations and prognostic values
Eur J Radiol
(2007) - et al.
Lung tumor growth correlates with glucose metabolism measured by fluoride-18 fluorodeoxy glucose positron emission tomography
Ann Thorac Surg
(1995) - et al.
Biological correlates of FDG uptake in non-small cell lung cancer
Lung Cancer
(2007) - et al.
Uptake rates of 18F-fluorodeox-yglucose and 11C-choline in lung cancer and pulmonary tuberculosis: a positron emission tomography study
Chest
(2003) - et al.
(18)F-FDG PET provides high-impact and powerful prognostic stratification in staging newly diagnosed non-small cell lung cancer
J Nucl Med
(2001)
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