Prognostic value of pretreatment FDG PET in pediatric neuroblastoma
Introduction
Neuroblastoma is the most common extracranial pediatric malignancy and accounts for 8% of malignancies of children [1], [2]. At the time of diagnosis, approximately 70% of patients have distant metastasis, and the most common sites of metastasis are bone and bone marrow [3]. Although the 5-year event-free survival rate in patients with localized stage I disease is as high as 99%, the 5-year overall survival rate in neuroblastoma is 69%, and patients with distant metastasis have a 5-year event-free survival rate of less than 50% [4], [5], [6]. Hence, it is important to verify prognostic factors, which can be used to identify patients who are likely to fail treatment and have a worse prognosis. Several clinicohistopathological factors, including tumor stage, involvement of bone marrow, age at diagnosis, molecular pathologies, such as MYCN oncogene amplification, serum lactate dehydrogenase (LDH), neuron-specific enolase (NSE), and ferritin levels, and extent of radioiodine-labeled metaiodobenzylguanidine (MIBG) uptake, are known to be correlated with prognosis [5], [7], [8], [9], [10], [11].
18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) is a widely used imaging tool for many types of malignancies and metastasis, and FDG uptake by various types of malignant lesions has been shown to be a prognostic factor for predicting clinical outcomes [12], [13], [14], [15]. However, although the use of FDG PET in pediatric malignancies continues to evolve [16], few studies have evaluated the clinical role of FDG PET in pediatric neuroblastoma. Most of previous studies mainly focused on diagnostic performance of FDG PET and showed high accuracy to detect neuroblastoma lesion, even better than radioiodine-labeled MIBG scan in a selected population [16], [17], [18]. Meanwhile, only a single published study evaluated the prognostic significance of FDG PET in pediatric neuroblastoma [19].
In the present study, we aimed to evaluate the prognostic value of pretreatment FDG PET in pediatric patients with neuroblastoma and to compare its predictive value with those of other conventional prognostic factors.
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Patients
The study has been approved by the institutional review board, and the need for written informed consent was waived. The electric medical records of 167 pediatric patients, who underwent diagnostic work-up for neuroblastoma in our medical center between 2003 and 2011, were retrospectively reviewed. Among them, a total of 50 patients with neuroblastoma, who underwent FDG PET as part of the diagnostic work-up before any treatment, were enrolled in the present study (Table 1). Patients, who had
Patient characteristics
Among the enrolled 50 patients, 15 patients (30.0%) experienced disease progression and 21 patients (42.0%) died during the follow-up period. The 2-year PFS and OS rates were 62.1% and 64.5%, respectively. Of the 50 patients, one patient showed disseminated hepatic metastases and Lmean could not be measured; therefore, the values of Tmax/Lmean were calculated in the remaining 49 patients. Of these 49 patients, two patients showed Pmax values which were less than the Lmean, and one patient
Discussion
Radioiodine-labeled MIBG scintigraphy has been used as the nuclear imaging modality of choice for pediatric neuroblastoma, but, recently, several studies have evaluated the diagnostic performance of FDG PET. Previous studies have demonstrated that radioiodine-labeled MIBG scintigraphy is superior to FDG PET in assessing the extent of neuroblastoma, especially metastatic lesions in the bone and bone marrow, mainly due to physiological accumulation of FDG in the bone marrow [16], [19], [20]. They
Conclusions
The present study demonstrated that FDG uptake measured on pretreatment FDG PET is an independent prognostic factor for predicting OS in patients with neuroblastoma. Patients with low FDG uptake have significantly better prognoses than patients with high FDG uptake. In addition, FDG PET remained a significant prognostic factor in a subgroup of patients with stage IV disease. FDG PET can effectively provide information on prognosis in neuroblastoma patients.
Conflicts of interest
None.
Acknowledgements
This study was supported by the National Research Foundation of Korea Grant funded by the Korean Government (Nos. 2012027176, NRF-2012R1A1A2041563) and National R&D Program for Cancer Control, Ministry of Health and Welfare (1320210).
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