Prognostic significance of metabolic parameters measured by 18F-fluorodeoxyglucose positron emission tomography/computed tomography in patients with small cell lung cancer
Introduction
Lung cancer is one of the most common types of cancer in both men and women all over the world. Small cell lung cancer (SCLC) accounts for 15–20% of all lung cancers [1]. When compared with non-small cell lung cancer (NSCLC), SCLC generally has a more rapid doubling time, a higher growth fraction, and earlier development of widespread metastases, all of which lead to frequent relapse and poor prognosis, despite highly sensitive to initial chemotherapy and radiotherapy [2], [3], [4].
Currently, tumor stage is the most important prognostic factor of SCLC, and other prognostic factors include performance status, weight loss, and serum lactate dehydrogenase (LDH) [5], [6]. Nonetheless, these prognostic factors may simply be a surrogate for the underlying tumor burden, which may be a more direct predictor of disease progression and survival. It is difficult to quantify tumor burden directly and systematically until now. The Veteran's Administration Lung Group two-stage classification scheme is routinely used to define the extent of disease in patients with SCLC, which divides SCLC into limited disease (LD) and extensive disease (ED). Despite its practical usefulness and prognostic advantage, the two-stage system is not accurate enough to reflect tumor burden, and it is inadequate for predicting survival in some patients. Therefore, more reliable prognostic markers, which might more properly represent tumor burden, would be needed to further stratify risk groups with the goal of developing individualized therapy strategies.
Positron emission tomography (PET) or fused positron emission tomography/computed tomography (PET/CT) imaging using the tracer 18F-fluorodeoxyglucose (18F-FDG) has emerged as an essential imaging tool for staging lung cancer. Recently, the degree of tumor uptake of 18F-FDG on PET as measured by standardized uptake value (SUV) was shown to be an important prognostic factor in lung cancer and some other malignant tumors [7], [8], [9], [10], [11]. Metabolic tumor volume (MTV), defined as the volume of tumor tissues with increased 18F-FDG uptake, also has been reported is an important independent prognostic factor in esophageal carcinoma and head-and-neck cancer [12], [13], [14], [15], [16]. Furthermore, La et al. reported that the integrated SUV (iSUV), defined as the product of MTV and average SUV (SUVmean), was related to disease free survival (DFS) of patients with head-and-neck cancer [14]. Xie et al. observed the similar results using “metabolic index” to predict long term survival of patients with nasopharyngeal carcinoma [17].
In this study, we evaluated the ability of MTV, iSUV, SUVmean and SUVmax measured in pre-treatment 18F-FDG PET/CT to predict survival in patients with SCLC treated by chemotherapy alone or with concurrent radiotherapy. Moreover, we conducted this study to determine whether the incorporation of some PET/CT parameters into the conventional two-stage classification system is more accurate for predicting survival than the tumor stage alone in patients with SCLC.
Section snippets
Patients
We retrospectively reviewed the medical records of all 127 patients with histologically or cytologically proven SCLC who underwent pre-treatment 18F-FDG PET/CT scanning at Shandong Cancer Hospital and Institute, Jinan, China, between October 2002 and February 2009. Patients that met the following inclusion criteria were selected for the present study: (1) histologically or cytologically confirmed diagnosis of primary SCLC; (2) adequate clinical data recorded in medical charts; (3) treatment
Patient characteristics
Clinical characteristics including patient age, gender, performance status (PS), tumor stage, LDH, weight loss and treatment response of these 98 patients are presented in Table 1. The median age of the patients was 58 years (range, 43–81 years). The total number of lesions analyzed was 328. The median size of the lesions included in the analysis was 4.8 cm. All of 98 patients had abnormal 18F-FDG uptake before treatment. Follow-up data were available through February 2010. At the time of
Discussion
This retrospective study shows that MTV, a volumetric parameter of 18F-FDG PET, is an important independent prognostic factor for overall survival and progression-free survival and that this parameter is a better predictor of survival than the primary tumor SUVmax in patients with SCLC. These results are consistent with those of Lee et al. who reported that high tumor burden assessed by PET MTV is an independent poor prognostic feature in lung cancer [20]. Our study differs from theirs in that
Conflict of interest
None declared.
Acknowledgements
The authors thank Dr. Huiqing Li and Yutao Diao for their assistance with this paper.
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