FDG-PET and stereotactic body radiotherapy (SBRT) for stage I non-small-cell lung cancer

PURPOSE: To investigate the utility of positron emission tomography (PET) in patients treated with stereotactic body radiotherapy (SBRT) for stage I non-small-cell lung cancer (NSCLC) on prospective institutional trials. PATIENTS AND METHODS: Fifty-eight patients with medically inoperable stage I NSCLC who participated in prospective phase I and II trials of SBRT, had >or=2 years of follow-up, and received FDG-PET imaging are the focus of this evaluation. Fifty-seven of 58 patients received pre-SBRT FDG-PET to confirm stage I status. All patients received stereotactic body frame immobilization and treatment with 7-10 photon beams. SBRT total doses ranged from 24 to 72Gy in three fractions. No elective nodal irradiation was undertaken. Regular follow-up with planned CT imaging was performed on all patients. Post-SBRT FDG-PET was not mandated by protocol and was typically ordered upon concern for disease recurrence. Thirty-eight post-SBRT PET studies were performed in 28 patients at a median 17.3 months following SBRT. RESULTS: With a median follow-up of 42.5 months, the 3-year actuarial overall survival and local control for this select subset of our SBRT experience were 48.9% and 74.8%, respectively. Pre-SBRT FDG-PET SUV did not predict 3-year overall survival or local control. Fourteen of 57 patients eventually failed in nodal stations by CT and/or PET. Isolated first site of failure was nodal in 6 patients (10%). Out of 28 patients with post-SBRT PET, 4 (14%) had delayed PET imaging (22-26 months after SBRT) showing moderate hypermetabolic activity (SUV 2.5-5.07), but no evidence of local, nodal, or distant recurrence by clinical examination and conventional imaging performed 20-26 months following these concerning PET findings. CONCLUSIONS: Isolated nodal recurrence following PET-staged I NSCLC treated with SBRT is uncommon. Moderate post-SBRT PET hypermetabolic activity may persist 2 years following treatment without definite evidence of recurrence. Further study is needed to confirm these results in larger populations with longer follow-up.     

FDG uptake correlates with recurrence and survival after treatment of unresectable stage III non-small cell lung cancer with high-dose proton therapy and chemotherapy

ABSTRACT: BACKGROUND: We studied whether maximum standardized uptake values (SUV) from [18F] PET/CT predict clinical outcome after concurrent proton/chemotherapy for stage III non-small cell lung cancer (NSCLC). METHODS: Eighty-four patients were treated prospectively with 74 Gy(RBE) proton therapy and concurrent chemotherapy. PET/CT scans were available before (SUV1) and within 6 months after (SUV2) treatment. The predictive value of clinical and PET/CT factors were analyzed with univariate and multivariate Cox regression models. RESULTS: Median survival time was 29.9 months. At 3 years, the local recurrence-free survival (LRFS) rate was 34.8%; distant metastasis-free survival (DMFS), 35.4%; progression-free survival (PFS), 31.2%; and overall survival (OS), 37.2%. Patients with SUV2 [greater than or equal to] 3.6 (the median) had high rates of LR (p = 0.021). Of 12 clinicopathologic features evaluated in univariate analysis, only KPS, SUV1, and SUV2 predicted LRFS, DMFS, PFS, and OS (p <0.05). Multivariate analysis showed that KPS (p = 0.025) and SUV2 (p = 0.017) were independently prognostic for LRFS and that SUV1, SUV2, and KPS were independently prognostic for DMFS, PFS, and OS (p <0.05). CONCLUSIONS: SUV2 predicted LRFS, and SUV1 and SUV2 predicted DMFS, PFS, and OS, in patients with stage III NSCLC treated with concurrent chemotherapy and high-dose proton therapy.     

全身PET/CT和VEGF-C检查对非小细胞肺癌诊治的应用价值

目的：探讨全身PET/CT和血浆血管内皮生长因子-C（VEGF-C）在非小细胞肺癌（NSCLC）诊断和治疗选择中的临床应用价值。方法：收集2005年1月17日～2007年1月17日86例病理确诊的NSCLC患者的PET/CT资料并留取血清样本备用。比较PET/CT、胸部CT、支气管镜活检及经皮肺穿刺切割活检4种不同方法对NSCLC的诊断敏感性;分析SUV值（standardized uptake value）和延迟相SUV对NSCLC的诊断价值;比较PET/CT与常规检查的TNM分期在淋巴结和远处转移中的检出率和检出分布上的差异。用双抗体夹心ELISA法试剂盒测定血清VEGF-C浓度辅助胸部CT评价N分期。结果：入组研究NSCLC患者86例,男性67例,女性19例;腺癌41例、鳞癌37例、混合型腺癌5例及大细胞癌3例。PET/CT和胸部CT、支气管镜活检、经皮肺穿切割活检术对NSCLC患者肺部原发病变的诊断敏感性分别为90.89%（78/86）、76.47%（60/86）、80%（36/45）和90%（45/50）,PET/CT与胸部CT在诊断敏感性上差异显著（P=0.02）。86例NSCLC患者PET/CT初始相SUV均值为8.27±4.90,其中46例患者延迟相SUV均值为8.35±5.29,高于其初始相SUV均值7.62±4.50（P=0.003）。PET/CT对N1、N2、N3分别检出10、24、26例,合计检出率为69.77%（60/86）;胸部CT/VEGF-C分别检出9、29、6例,合计53.88%（46/86）,PET/CT组与CT/VEGF-C组在阳性检出率和淋巴结分布上差异均非常显著（P=0.006和P=0.004）。本组PET/CT诊断Ⅳ期肺癌38例,与常规检查组诊断29例,两组在阳性发现率上无显著差异（P=0.211）,在分布上两组差异也不显著（P=0.712）。结论：PET/CT对NSCLC原发肿瘤的诊断敏感性显著优于胸部CT,延迟相SUV值对SUV初始值诊断NSCLC有重要参考价值。PET/CT对NSCLC的TNM分期比常规检查分期可能对治疗帮助更大。     

18FDG PET/CT标准摄取值与非小细胞肺癌临床分期关系的研究

目的:探讨非小细胞肺癌(non-small cell lung cancer,NSCLC)患者治疗前的18氟脱氧葡萄糖(18F-deoxyglucose,18 FDG) PET／CT标准摄取值(standard uptake value, SUV)与临床分期、原发肿瘤大小及病理学类型的关系。方法:对75例治疗前的NSCLC患者接受18FDG PET／CT检查获得最高SUV (SUVmax)。分析SUVmax与临床分期、原发肿瘤分期、肿瘤大小和病理学类型的关系,并研究SUV在四者组内差异是否有统计学意义。结果:SUVmax与临床分期和原发肿瘤大小均呈正相关(r=0．279,P=0．014;r= 0．645,P=0．001),与肿瘤病理学类型无关(r=-0．077,P=0．507);SUV在两组不同大小肿瘤组(≤3．0 cm和>3．0 cm)间差异有统计学意义,t=-0．647,P=0．015,在各个临床分期组(ⅠA～ⅡB、ⅢA和m B～Ⅳ)间差异有统计学意义,F=3．807,P=0．027,在4个原发肿瘤分期组(T1、T2、T3和T4)间差异有统计学意义,F=8．025,P=0．022,而在不同病理学类型组(鳞癌、腺癌和腺鳞癌)间差异无统计学意义,F=1．911,P=0．155。结论:18FDG PET／CT SUV随肿瘤大小和病期的增加呈升高趋势,可以作为评价NSCLC临床分期的辅助手段,但不能为无法取得病理学诊断的患者提供帮助。     

Stage Migration in Planning PET/CT Scans in Patients Due to Receive Radiotherapy for Non–Small-Cell Lung Cancer

IntroductionThis study examined rates of tumor progression in treatment-naive patients with non–small-cell lung cancer (NSCLC) as determined by repeat treatment-planning fluorine-18 (¹⁸F) fluorodeoxyglucose positron emission tomography/computed tomography (¹⁸F-FDG PET/CT).Methods and MaterialsThis study assessed patients who underwent PET/CT simulation for NSCLC stage II/III, radiation-naive, nonmetastatic NSCLC. It compared planning PET/CT with previous PET/CT images. Patients were analyzed for change in stage, treatment intent, or both. Progression was defined as a change in TNM status leading to upstaging, and standardized uptake value (SUV) velocity was defined as [(SUV_scan2 − SUV_scan1)/interscan interval in days].ResultsOf 149 consecutive patients examined between April 2009 and April 2011, 47 had prior PET/CT scans and were included. The median age was 68 years. New nodal disease or metastatic disease was identified in 24 (51%) of 47 patients. Fourteen (30%) had evidence of extrathoracic metastatic disease; the remaining 10 (21%) had new nodal disease that required substantial alteration of treatment fields. At a scan interval of 20 days, the rate of upstaging was 17%. SUV velocity was analyzed in the subset of patients who had their studies on the identical PET/CT scanner (n = 14). Nonupstaged patients had a mean SUV velocity of 0.074 units per day, compared with 0.11 units per day in patients that were upstaged by their second PET/CT scan (P = .020).ConclusionRadiation treatment planning with hybrid PET/CT scans repeated within 120 days of an initial staging PET/CT scan identified significant upstaging in more than half of patients. For a subset of patients who underwent both scans on the same instrument, SUV velocity predicts upstaging, and the difference between those upstaged and those not was statistically significant.     

The contribution of integrated PET/CT to the evolving definition of treatment volumes in radiation treatment planning in lung cancer

PURPOSE: Positron emission tomography (PET) with the glucose analog [18F]fluro-2-deoxy-D-glucose (FDG) has been accepted as a valuable tool for the staging of lung cancer, but the use of PET/CT in radiation treatment planning is still not yet clearly defined. By the use of (PET/computed tomography (CT) images in treatment planning, we were able to define a new gross treatment volume using anatomic biologic contour (ABC), delineated directly on PET/CT images. We prospectively addressed three issues in this study: (1) How to contour treatment volumes on PET/CT images, (2) Assessment of the degree of correlation between CT-based gross tumor volume/planning target volume (GTV/PTV) (GTV-CT and PTV-CT) and the corresponding PET/CT-based ABC treatment volumes (GTV-ABC and PTV-ABC), (3) Magnitude of interobserver (radiation oncologist planner) variability in the delineation of ABC treatment volumes (using our contouring method). METHODS AND MATERIALS: Nineteen patients with Stages II-IIIB non-small-cell lung cancer were planned for radiation treatments using a fully integrated PET/CT device. Median patient age was 74 years (range: 52-82 years), and median Karnofsky performance status was 70. Thermoplastic or vacuum-molded immobilization devices required for conformal radiation therapy were custom fabricated for the patient before the injection of [18]f-FDG. Integrated, coregistered PET/CT images were obtained and transferred to the radiation planning workstation (Xeleris). While the PET data remained obscured, a CT-based gross tumor volume (GTV-CT) was delineated by two independent observers. The PTV was obtained by adding a 1.5-cm margin around the GTV. The same volumes were recontoured using PET/CT data and termed GTV-ABC and PTV-ABC, correspondingly. RESULTS: We observed a distinct "halo" around areas of maximal standardized uptake value (SUV). The halo was identified by its distinct color at the periphery of all areas of maximal SUV uptake, independent of PET/CT gain ratio; the halo had an SUV of 2 +/- 0.4 and thickness of 2 mm +/- 0.5 mm. Whereas the center of our contoured treatment volume expressed the maximum SUV level, a steady decline of SUV was noted peripherally until SUV levels of 2 +/- 0.4 were reached at the peripheral edge of our contoured volume, coinciding with the observed halo region. This halo was always included in the contoured GTV-ABC. Because of the contribution of PET/CT to treatment planning, a clinically significant (> or =25%) treatment volume modification was observed between the GTV-CT and GTV-ABC in 10/19 (52%) cases, 5 of which resulted in an increase in GTV-ABC volume vs. GTV-CT. The modification of GTV between CT-based and PET/CT-based treatment planning resulted in an alteration of PTV exceeding 20% in 8 out of 19 patients (42%). Interobserver GTV variability decreased from a mean volume difference of 28.3 cm3 (in CT-based planning) to 9.12 cm3 (in PET/CT-based planning) with a respective decrease in standard deviation (SD) from 20.99 to 6.47. Interobserver PTV variability also decreased from 69.8 cm3 (SD +/- 82.76) in CT-based planning to 23.9 cm3 (SD +/- 15.31) with the use of PET/CT in planning. The concordance in treatment planning between observers was increased by the use of PET/CT; 16 (84%) had < or =10% difference from mean of GTVs using PET/CT compared to 7 cases (37%) using CT alone (p = 0.0035). Conclusion: Position emission tomography/CT-based radiation treatment planning is a useful tool resulting in modification of GTV in 52% and improvement of interobserver variability up to 84%. The use of PET/CT-based ABC can potentially replace the use of GTV. The anatomic biologic halo can be used for delineation of volumes.     

Repeat 18F-FDG PET for monitoring neoadjuvant chemotherapy in patients with stage III non-small cell lung cancer

PURPOSE: The relevance of (18)F-FDG PET for staging non-small cell lung cancer (NSCLC), in particular for the detection of lymph node or distant metastases, has been shown in several studies. The value of FDG-PET for therapy monitoring in NSCLC, in contrast, has not yet been sufficiently analysed. Aim of this study was to evaluate FDG-PET for monitoring treatment response during and after neoadjuvant radiochemotherapy (NARCT) in advanced NSCLC. METHODS: Sixty-five patients with histologically proven NSCLC stage III initially underwent three FDG-PET investigations, during NARCT prior to initiating radiation, and post-NARCT. Changes of FDG-uptake in the primary tumour at two time-points during NARCT were analysed concerning their impact on long-term survival. RESULTS: The mean maximum FDG uptake (standardized uptake value, SUVmax) of the whole group decreased significantly during NARCT (SUVmax PET 1: 14.9+/-4.0, SUVmax PET 3: 5.5+/-2.4, p=0.004). The difference between initial FDG uptake (PET 1) and uptake after induction chemotherapy (PET 2) was found to be highly predictive for long-term survival patients which had a greater than 60% decreases in their SUV change had a significantly longer survival than those below this threshold (5-year-survival 60% versus 15%, p=0.0007). Patients who had a lower than 25% decrease in their SUV change had a 5-years-survival lower than 5%. Furthermore, the difference between initial FDG uptake (PET 1) and uptake after completion of the whole NARCT (PET 3) was predictive for survival when 75% was applied as cut-off (p=0.02). However, the level of significance was considerably lower. CONCLUSION: FDG-PET is suitable for therapy monitoring in patients with stage III NSCLC. The decrease of FDG uptake during induction chemotherapy is highly predictive for patient outcome.     

Correlation of PET standard uptake value and CT window-level thresholds for target delineation in CT-based radiation treatment planning

PURPOSE: To develop standardized correlates of [18F]fluoro-2-deoxy-d-glucose positron emission tomography (FDG-PET) standard uptake value (SUV) to computed tomography (CT)-based window and levels. METHODS AND MATERIALS: Nineteen patients with non-small-cell lung cancer who underwent imaging with positron emission tomography (PET) and CT were selected. A method of standardizing SUV within CT planning software was developed. A scale factor, determined by a sensitivity calibration of the PET scanner, converts voxel counts to activity per gram in tissue, allowing SUVs to be correlated to CT window and levels. A method of limiting interobserver variations was devised to enhance "edges" of regions of interest based on SUV thresholds. The difference in gross tumor volumes (GTVs) based on CT, PET SUV >or= 2.5, and regions of 40% maximum SUV were analyzed. RESULTS: The mean SUV was 9.3. Mean GTV volumes were 253 cc for CT, 221 cc for SUV >or= 2.5, and 97 cc for SUV40%Max. Average volume difference was -259% between >or=2.5 SUV and CT and -162% between SUV40%Max and CT. Percent difference between GTV >or= 2.5 SUV and SUV40%Max remained constant beyond SUV > 7. For SUVs 4-6, best correlation among SUV thresholds occurred at volumes near 90 cc. Mean percent change from GTVs contoured according to CT (GTV CT) was -260% for GTV2.5 and -162% for GTV40%Max. Using the SUV40%Max threshold resulted in a significant alteration of volume in 98% of patients, while the SUV2.5 threshold resulted in an alteration of volume in 58% of patients. CONCLUSIONS: Our method of correlating SUV to W/L thresholds permits accurate displaying of SUV in coregistered PET/CT studies. The optimal SUV thresholds to contour GTV depend on maximum tumor SUV and volume. Best correlation occurs with SUVs >6 and small volumes <100 cc. At SUVs >7, differences between the SUV threshold filters remain constant. Because of variability in volumes obtained by using SUV40%Max, we recommend using SUV >or= 2.5 for radiotherapy planning in non-small-cell lung cancer.     

Nonsmall cell lung cancer presenting with synchronous solitary brain metastasis

BACKGROUND: Solitary brain metastases occur in about 50% of patients with brain metastases from nonsmall cell lung cancer (NSCLC). The standard of care is surgical resection of solitary brain metastases, or stereotactic radiosurgery (SRS) plus whole brain radiation therapy (WBRT). However, the optimal treatment for the primary site of newly diagnosed NSCLC with a solitary brain metastasis is not well defined. The goal was to distinguish which patients might benefit from aggressive treatment of their lung primary in patients whose solitary brain metastasis was treated with surgery or SRS. METHODS: The cases of 84 newly diagnosed NSCLC patients presenting with a solitary brain metastasis and treated from December 1993 through June 2004 were retrospectively reviewed at The University of Texas M. D. Anderson Cancer Center. All patients had undergone either craniotomy (n = 53) or SRS (n = 31) for management of the solitary brain metastasis. Forty-four patients received treatment of their primary lung cancer using thoracic radiation therapy (median dose 45 Gy; n = 8), chemotherapy (n = 23), or both (n = 13). RESULTS: The median Karnofsky performance status score was 80 (range, 60-100). Excluding the presence of the brain metastasis, 12 patients had AJCC Stage I primary cancer, 27 had Stage II disease, and 45 had Stage III disease. The median follow-up was 9.7 months (range, 1-86 months). The 1-, 2-, 3-, and 5-year overall survival rates from time of lung cancer diagnosis were 49.8%, 16.3%, 12.7%, and 7.6%, respectively. The median survival times for patients by thoracic stage (I, II, and III) were 25.6, 9.5, and 9.9 months, respectively (P = .006). CONCLUSIONS: By applying American Joint Committee on Cancer staging to only the primary site, the thoracic Stage I patients in our study with solitary brain metastases had a more favorable outcome than would be expected and was comparable to Stage I NSCLC without brain metastases. Aggressive treatment to the lung may be justified for newly diagnosed thoracic Stage I NSCLC patients with a solitary brain metastasis, but not for locally advanced NSCLC patients with a solitary brain metastasis.     

Clinical outcome and predictors of survival and pneumonitis after stereotactic ablative radiotherapy for stage I non-small cell lung cancer

ABSTRACT: BACKGROUND: Stereotactic ablative radiotherapy (SABR) can achieve excellent local control rates in early-stage non-small cell lung cancer (NSCLC) and has emerged as a standard treatment option for patients who cannot undergo surgery or those with isolated recurrences. However, factors that may predict toxicity or survival are largely unknown. We sought here to identify predictors of survival and pneumonitis after SABR for NSCLC in a relatively large single-institution series. METHODS: Subjects were 130 patients with stage I NSCLC treated with four-dimensional computed tomography (4D CT) --planned, on-board volumetric image--guided SABR to 50 Gy in 4 fractions. Disease was staged by positron emission tomography/computed tomography (PET/CT) and scans were obtained again at the second follow-up after SABR. RESULTS: At a median follow-up time of 26 months, the 2-year local control rate was 98.5%. The median overall survival (OS) time was 60 months, and OS rates were 93.0% at 1 year, 78.2% at 2 years, and 65.3% at 3 years. No patient experienced grade 4--5 toxicity; 15 had radiation pneumonitis (12 [9.3%] grade 2 and 3 [2.3%] grade 3). Performance status, standardized uptake value (SUV)max on staging PET/CT, tumor histology, and disease operability were associated with OS on univariate analysis, but only staging SUVmax was independently predictive on multivariate analysis (P = 0.034). Dosimetric factors were associated with radiation pneumonitis on univariate analysis, but only mean ipsilateral lung dose >=9.14 Gy was significant on multivariate analysis (P = 0.005). CONCLUSIONS: OS and radiation pneumonitis after SABR for stage I NSCLC can be predicted by staging PET SUVmax and ipsilateral mean lung dose, respectively.     

Stereotactic Body Radiation Therapy for Salvage Treatment of Recurrent Non-Small Cell Lung Cancer

PurposeThis study analyzes the outcomes and toxicity of stereotactic body radiation therapy (SBRT) as salvage treatment for recurrent non-small cell lung cancer (NSCLC).Methods and MaterialsThis retrospective analysis considered patients treated with thoracic SBRT and a history of prior external beam radiation therapy (EBRT), SBRT, or surgical resection for NSCLC. Follow-up included positron emission tomography and computed tomography imaging at 2- to 3-month intervals. Key outcomes were presented with the Kaplan–Meier method.ResultsForty patients with 52 treatments were included at a mean of 11.82 months after treatment with EBRT (n = 21), SBRT (n = 15), surgical resection (n = 9), and SBRT after EBRT (n = 7). Median imaging and clinical follow-up were 13.39 and 19.01 months, respectively. SBRT delivered a median dose of 40 Gy in 4 fractions. Median biologically effective dose (BED) was 79.60 Gy. Median gross tumor volume and planning target volume were 10.80 and 26.25 cm³, respectively. Local control was 65%, with a median time to local failure of 13.52 months. Local control was 87% after previous SBRT but only 33% after surgery. Median overall survival was 24.46 months, and median progression-free survival (PFS) was 14.11 months. Patients presenting after previous SBRT had improved local control (P = .021), and the same result was obtained including patients with SBRT after EBRT (P = .0037). Treatments after surgical resection trended toward worse local control (P = .061). Patients with BED ≥80 Gy had improved local PFS (P = .032), PFS (P = .021), time without any treatment failure (P = .033), and time to local failure (P = .041). Using the Kaplan–Meier method, BED ≥80 Gy was predictive of improved local PFS (P = .01) and PFS (P < .005). Toxicity consisted of 10 instances of grade <3 toxicity (16%) and no grade ≥3 toxicity.ConclusionsSalvage treatment for recurrent NSCLC with SBRT was effective and well tolerated, particularly after initial treatment with SBRT. When possible, salvage SBRT should aim to achieve a BED of ≥80 Gy.     

Value of 18F-fluoro-2-deoxy-D-glucose-positron emission tomography/computed tomography in non-small-cell lung cancer for prediction of pathologic response and times to relapse after neoadjuvant chemoradiotherapy.

PURPOSE: To determine the value of combined positron emission tomography/computed tomography (PET/CT) during induction chemotherapy (CTx) followed by chemoradiotherapy (CTx/RTx) for non-small-cell lung cancer to predict histopathologic response in primary tumor and mediastinum and prognosis of the patient. EXPERIMENTAL DESIGN: Fifty consecutive patients with locally advanced non-small-cell lung cancer received induction therapy and, if considered resectable, proceeded to surgery (37 of 50 patients). Patients had at least two repeated 18F-2-fluoro-2-deoxy-D-glucose (FDG)-PET/CT scans either before treatment (t0) or after induction CTx (t1) or CTx/RTx (t2). Variables from the PET/CT studies [e.g., lesion volume and corrected maximum standardized glucose uptake values (SUV(max,corr))] were correlated with histopathologic response (graded as 3, 2b, or 2a: 0%, >0-10%, or >10% residual tumor cells) and times to failure. RESULTS: Primary tumors showed a percentage decrease in SUV(max,corr) during induction significantly larger in grade 2b/3 than in grade 2a responding tumors (67% versus 34% at t(1), 73% versus 49% at t(2); both P < 0.005). SUV(max,corr) at t(2) was significantly correlated with histopathologic response in tumors smaller than the median volume (7.5 cm(3); r = -0.54, P = 0.02). In the mediastinal lymph nodes, SUV(max,corr) values at t2 predicted an ypN0 status with a sensitivity and specificity of 73% and 89%, respectively (SUV(max,corr) threshold of 4.1, r = -0.54, P = 0.0005). Freedom from extracerebral relapse was significantly better in grade 2b/3 patients (86% at 16 months versus 20% in 2a responders; P = 0.003) and in patients with a greater percentage decrease in SUV(max,corr) in the primary tumor at t2 in relation to t0 than in patients with lesser response (83% at 16 months versus 43%; P = 0.03 for cutoff points between 0.45 and 0.55). CONCLUSIONS: SUV(max,corr) values from two serial PET/CT scans, before and after three chemotherapy cycles or later, allow prediction of histopathologic response in the primary tumor and mediastinal lymph nodes and have prognostic value.     

18F-FDG PET/CT 与常规CT评价非小细胞肺癌早期化疗疗效的对照研究*

目的:探讨18F-FDGPET/CT 的早期肿瘤代谢疗效与常规CT依据R ECIST 标准（实体瘤疗效评价标准）,评价非小细胞肺癌（non-smallcelllungcancer ,NSCLC ）化疗最佳客观疗效之间的关系。方法:收集2009年9 月至2014年12月山西省肿瘤医院经病理学确诊初治不可切除的局部晚期和晚期非小细胞肺癌（NSCLC ）患者40例,行含铂双药方案全身化疗。PET/CT按SUV 标准（化疗1 个周期后肺部原发癌灶的最高SUV 值下降> 30%）评价肿瘤客观疗效,CT采用RECIST标准评价。配对计数资料采用χ2检验和κ 系数检验,将第1 个周期化疗后的代谢缓解率分别与第1 周期及第2 周期化疗后的最佳客观疗效进行比较,判断两者之间是否具有差异性及一致性。结果:第1 个周期化疗后按SUV 值评价的代谢缓解率与化疗后RECIST评价标准之间差异具有统计学意义（χ2= 5.063,P < 0.05）,并且具有较差的一致性（κ = 0.240,P = 0.085）,与2 个周期化疗后RECIST评价标准差异无统计学意义（χ2=2.083,P > 0.05）,并且具有较好的一致性（κ = 0.413,P = 0.006）;18F-FDGPET/CT 预测NSCLC 2 个周期化疗后最佳客观疗效的灵敏度、特异度、准确度、阳性预测值和阴性预测值分别为 82.4%（14/ 17）、60.9%（14/ 23）、70.0%（28/ 40）、60.9%（14/ 23）和82.4（14/17）% 。结论:18F-FDGPET/CT 能够预测局部晚期和晚期NSCLC 化疗后按RECIST标准评价的最佳客观疗效;18F-FDGPET/CT 相对于常规CT可以更早并准确的评价NSCLC 的化疗疗效。      

Positron emission tomography is superior to computed tomography scanning for response-assessment after radical radiotherapy or chemoradiotherapy in patients with non-small-cell lung cancer.

PURPOSE: To prospectively study the capacity of positron emission tomography (PET) and computed tomography (CT) to determine response soon after radical radiotherapy or chemoradiotherapy and, thereby, predict survival. PET is known to provide a more accurate estimate of true extent of disease than CT when used to stage non-small-cell lung cancer (NSCLC). PATIENTS AND METHODS: Seventy-three patients with NSCLC underwent [(18)F]fluorodeoxyglucose PET and CT scans before and after radical radiotherapy (n = 10) or chemoradiotherapy (n = 63). Follow-up PET scans were performed at a median of 70 days after radiotherapy. The median PET-CT interval was 1 day. Each patient had determinations of response to therapy made with PET and CT, categorized as complete response, partial response, no response, progressive disease, or nonassessable. Responses were correlated with subsequent survival. RESULTS: Median survival after follow-up PET was 24 months. There was poor agreement between PET and CT responses (weighted kappa = 0.35), which were identical in only 40% of patients. There were significantly more complete responders on PET (n = 34) than CT (n = 10), whereas fewer patients were judged to be nonresponders (12 patients on PET v 20 on CT) or nonassessable (zero patients on PET v six on CT) by PET. Both CT and PET responses were individually significantly associated with survival duration; but on multifactor analysis that included the known prognostic factors of CT response, performance status, weight loss, and stage, only PET response was significantly associated with survival duration (P <.0001). CONCLUSION: In NSCLC, a single, early, posttreatment PET scan is a better predictor of survival than CT response, stage, or pretreatment performance status.     

Pulmonary injury and tumor response after stereotactic body radiotherapy (SBRT): results of a serial follow-up CT study.

PURPOSE: To evaluate the CT morphological pattern of tumor response and pulmonary injury after stereotactic body radiotherapy (SBRT) for early stage non-small lung cancer (NSCLC) and pulmonary metastases. MATERIALS AND METHODS: Seventy patients (lesions n=86) with pulmonary metastases (n=48) or primary early stage NSCLC (n=38) were analyzed. Patients were treated with hypofractionated SBRT (three to eight fractions with a single dose between 6 and 12.5 Gy; n=56) or with radiosurgery (26 Gy; n=30). The pattern and sequence of pulmonary injury and of tumor response was evaluated in 346 follow-up CT studies, 4.9 on average. RESULTS: Symptomatic pneumonitis was observed in 10% after a median interval of 5 months. No pulmonary reaction was observed in most patients 6 weeks after treatment; spotted-streaky condensations were characteristic between 3 months and 6 months. Dense consolidation and retraction started after 9 months and the fibrotic remodelling process continued for years. Ten targets relapsed after a median of 7 months. At 12 months complete response was seen in 43% and the differentiation of residual tumor from pulmonary reaction was not possible in 33%. CONCLUSIONS: A typical sequence of pulmonary reactions was observed without differences between hypofractionated treatment and radiosurgery. Onset of pneumonitis was later compared to conventionally fractionated radiotherapy.     

Clinical impact of (18)F fluorodeoxyglucose positron emission tomography in patients with non-small-cell lung cancer: a prospective study.

PURPOSE: To prospectively study the impact of (18)F fluorodeoxyglucose (FDG) positron emission tomography (PET) on clinical management of patients with non-small-cell lung cancer (NSCLC). PATIENTS AND METHODS: One hundred five consecutive patients with NSCLC undergoing (18)F FDG PET were analyzed. Before PET, referring physicians recorded scan indication, conventional clinical stage, and proposed treatment plan. PET scan results were reported in conjunction with available clinical and imaging data, including results of computed tomography (CT). Subsequent management and appropriateness of PET-induced changes were assessed by follow-up for at least 6 months or until the patient's death. RESULTS: Indications for PET were primary staging (n = 59), restaging (n = 34), and suspected malignancy subsequently proven to be NSCLC (n = 12). In 27 (26%) of 105 of cases, PET results led to a change from curative to palliative therapy by upstaging disease extent. Validity of the PET result was established in all but one case. PET appropriately downstaged 10 of 16 patients initially planned for palliative therapy, allowing either potentially curative treatment (four patients) or no treatment (six patients). PET influenced the radiation delivery in 22 (65%) of 34 patients who subsequently received radical radiotherapy. Twelve patients considered probably inoperable on conventional imaging studies were downstaged by PET and underwent potentially curative surgery. PET missed only one primary tumor (5-mm scar carcinoma). CT and PET understaged three of 20 surgical patients (two with N1 lesions < 5 mm and one with unrecognized atrial involvement), and PET missed one small intrapulmonary metastasis apparent on CT. No pathological N2 disease was missed on PET. CONCLUSION: FDG PET scanning changed or influenced management decisions in 70 patients (67%) with NSCLC. Patients were frequently spared unnecessary treatment, and management was more appropriately targeted.     

18 F-PSMA-1007 PET/CT在初诊前列腺癌精准评估中的价值及对临床治疗决策的影响

背景与目的： ¹⁸ F-前列腺特异性膜抗原（prostate-specific membrane antigen,PSMA）-1007 PET/CT是目前针对前列腺癌（prostate cancer,PCa）的先进影像学评估方法。探讨 ¹⁸ F-PSMA-1007 PET/CT在初诊PCa中对原发灶和转移灶精准诊断的价值及对临床治疗决策的影响。方法：回顾性分析2018年11月—2019年2月在四川省肿瘤医院确诊并行 ¹⁸ F-PSMA-1007PET/CT检查的18例未治疗PCa患者的临床资料,由核医学医师对PET/CT图像进行盲法阅片分析。采用感兴趣区方法半定量计算肿瘤放射性摄取,以最大标准化摄取值（maximum standardized uptake value,SUV max ）表示。评价 ¹⁸ F-PSMA-1007PET/CT对PCa原发灶和远处转移灶的诊断效能,以及对临床治疗决策的影响,并比较PCa组织放射性摄取与PSA及Gleason评分的相关性。结果： ¹⁸ F-PSMA-1007 PET/CT准确诊断了全部18例PCa,肿瘤组织呈局灶性放射性摄取,灵敏度、阳性预测值和准确率均为100%。发现无转移5例（27.8%）,转移13例（72.2%）,其中10例淋巴结转移（包括4例单纯盆腔淋巴结转移和6例腹膜后等区域外淋巴结转移）,10例骨转移,3例内脏（肺）转移,7例（38.9%）符合高肿瘤负荷PCa。18例PCa患者的前列腺原发灶的中位SUV _max 为13.05,PSA和Gleason评分均与SUV _max 没有显著相关性（P＞0.05）。临床治疗策略方面,除1例患者（合并原发性肺癌）放弃治疗,最终有8例改变了原治疗方案,改变方案率为47.1%（8/17）。结论：¹⁸ F-PSMA-1007 PET/CT对PCa原发灶和转移灶均具有很好的诊断价值和诊断效能,有利于精准分期和对患者制订个体化的治疗方案,并显著影响临床治疗决策。     

Significance of smoking history and FDG uptake for pathological N2 staging in clinical N2-negative non-small-cell lung cancer

BackgroundThis study was conducted to evaluate whether smoking history and the standardized uptake value (SUV) of 2-[fluorine-18]fluoro-2-deoxy-D-glucose (FDG) uptake are associated with unexpected pathological N2 status (pN2) in non-small-cell lung cancer (NSCLC).Patients and methodsWe analyzed the data of 220 patients who underwent surgical resection with clinical N2-negative status on computed tomography (CT) and positron emission tomography (PET)–CT. The maximum SUV of primary tumor was chosen for logistic analysis.ResultsSeventy-two patients (33%) had never smoked. The SUV ranged from 1.0 to 29.0 (median 9.1). In univariate analysis, adenocarcinomas (P = 0.019), female gender (P = 0.010), N1 on CT (P = 0.025), and N1 PET–CT (P = 0.001) were associated with a high probability of pN2. The proportion of pN2 in never smokers was higher than in ever smokers (26% versus 10% respectively; P = 0.002). The SUV remained on a multivariate logistic model (odds ratio 1.1; 95% confidence interval 1.0–1.2; P = 0.010) and it had a better predictive value in never smokers than in ever smokers (P = 0.017).ConclusionsThis study indicates an association between smoking history and pN2 in clinically negative N2 NSCLC. The different roles of FDG uptake were also suggested based on smoking history.     

Local control for clinical stage I non-small cell lung cancer treated with 5-fraction stereotactic body radiation therapy is not associated with treatment schedule

Purpose

Clinical concern remains regarding the relationship between consecutive (QD) versus nonconsecutive (QoD) lung stereotactic body radiation therapy (SBRT) treatment schedules and outcomes for clinical stage I non-small cell lung cancer (NSCLC). We examined a multi-institutional series of patients receiving 5-fraction lung SBRT to compare the local failure rates and overall survival between patients receiving QD versus QoD treatment.

Phase II study of stereotactic body radiotherapy to primary tumor and metastatic locations in oligometastatic nonsmall-cell lung cancer patients

BackgroundStereotactic body radiotherapy (SBRT) has emerged as a treatment modality in patients presenting with oligometastatic nonsmall-cell lung cancer (NSCLC). SBRT is used as a local consolidative treatment to metastatic disease sites. The majority of patients included in SBRT trials for oligometastatic NSCLC have controlled primary tumors and brain metastases.Patients and methodsOligometastatic NSCLC patients with ≤5 metastatic lesions were included in a prospective phase II trial to evaluate efficacy and toxicity of SBRT to all disease sites, primary tumor and metastatic locations. SBRT to a dose of 50 Gy in 10 fractions was delivered. Positron emission tomography–computed tomography (PET-CT) was carried out at baseline and 3 months after SBRT to evaluate the metabolic response rate according to PET Response Criteria in Solid Tumors (PERCIST). The progression-free survival (PFS) and overall survival (OS) were calculated using Kaplan–Meier method from start of chemotherapy or radiotherapy. Side-effects were scored using the National Cancer Institute Common Terminology Criteria for Adverse Events (NCI CTCAE) version 3.0.ResultsTwenty-six patients received SBRT after induction chemotherapy (n = 17) or as a primary treatment (n = 9). Median follow-up was 16.4 months. Overall metabolic response rate was 60% with seven patients (30%) achieving a complete metabolic remission and 7 (30%) a partial metabolic response. Any acute grade 2 toxicity was observed in four patients (15%) and grade 3 pulmonary toxicity in two patients (8%). Median PFS and OS were 11.2 and 23 months. The 1-year PFS and 1-year OS rate were 45% and 67%, respectively.ConclusionSBRT to all disease sites, primary tumor and metastatic locations, in oligometastatic NSCLC patients produced an acceptable median PFS of 11.2 months.