i lker i skender *, salih zeki kad i o g lu # , hasan o g uz kap i c i ba si # ,

MAXIMUM STANDARDIZED UPTAKE VALUE PREDICTS SURVIVAL IN

SURGICALLY STAGED OR RESECTED NON-SMALL CELL LUNG CANCER

PATIENTS

Ilker Iskender*, Salih Zeki Kadioglu#, Hasan Oguz Kapicibasi#, Akif Turna#, Altug Kosar#, Ali Atasalihi#, Altan Kir#

*Cizre Dr. Selahattin Cizrelioglu State Hospital, Sirnak#Sureyyapasa Chest Diseases and Thoracic Surgery Training and Research

Hospital, Istanbul

Turkish Thoracic Society 13. Annual Congress, 5-9 May 2010, Istanbul

• The aim of this study was to find out whether maximum standardized uptake value (SUVmax) can predict survival in surgically staged or resected non-small cell lung cancer (NSCLC) patients.

Goal


• September 2005 – March 2009• Known or suspicious for NSCLC • 330 consecutive patients • Patients excluded from the study: n = 43

– Neoadjuvant therapy, n=23– Patients with previous history of NSCLC or other

malignancies in past 5 years, n=20

• Results of PET/CT and pathology were recorded prospectively

Material and Methods


• Complete history and physical examination• Blood analysis• Chest radiography • Spirometry• Cardiac investigation• Thorax CT• PET/CT• Cranial MRI

Material and Methods (2)


• PET/CT– 10 different center– 226 patients (%79), ®Siemens Biograph LSO HI-REZ

integrated PET/CT; 4 different center– Serum glucose concentration <150 mg/dl– Imaging from neck to hip– 90-150 minute after intravenous injection of FDG-18– Fusion of PET and CT images



– FDG uptake was considered to be positive in mediastinum if tracer activity was significantly higher than mediastinal background activity(*)

*Gonzalez-Stawinski GV, Lemaire A, Merchant F, et all. A comparative analysis of

positron emission tomography and mediastinoscopy in staging non-small cell lung cancer. J Thorac Cardiovasc Surg. 2003;126:1900-5.



• Surgical staging– Standard cervical mediastinoscopy– Extended cervical mediastinoscopy

• Mountain classification*– paratracheal (2R-2L), – tracheobronchial (4R-4L)– subcarinal (7)– Subaortic (5), paraaortic (6)

– Thoracotomy

*Mountain CF, Dresler CM. Regional lymph node classification for lung cancer staging. Chest 1997:111;1718-23



• Patients with negative mediastinoscopy underwent surgical resection and systematic lymph node sampling

• Pathological results were revised according to the 7th TNM staging system *.

*Groome AP, Bolejack V, Crowley JJ, et al. The IASLC lung cancer staging project: Validation of the proposals for revision of the T,N and M descriptors and consequent stage groupins in the forthcoming (seventh) edition of the TNM classification of malignant tumours. J Thorac Oncol 2007;2:694-705.



• Postoperative follow-up –First 2 years 3 months–After 6 months–CXR, Thorax CT, PET/CT

• Information was obtained–Patient’s history–Hospital computer system–Telephone calls



• Definitions– Disease-free survival Patients who were

alive without recurrence; R0 patients– Operative mortality Patient who died before

hospital discharge or within 30 days of the operative procedure.

• Statistical analysis – Survival analysis Kaplan-Meier method – Comparison X2, Log-rank and Cox analysis



• 287 patients; 263 male (91.6%)• Mean age 58.5 ± 9.3 years (33 – 81)• PET/CT – Surgery : 16.3 days (2 – 90)• The diagnosis was made on 221 (80.2%)

patients preoperatively• The mean SUVmax of primary tumor : 15.2 ± 6.8

Results


• Types of the operations (n: 287)– 54 Mediastinoscopy (N2/3+)– 233 Thoracotomy

• 11 Exploratory (4.7%)• 222 Resection

– 159 Lobectomy (71.6%)» 14 Sleeve Lobectomy

– 63 Pneumonectomy (28.4%)» 5 Right Sleeve Pneumonectomy

• 46/233 Extended resection (19.7%)

Results (2)


• Operative mortality: 22 (6.7%)• Lost to follow-up: 15 (4.5%)• Mean follow-up (n=250): 19 months (2 – 48)• Complete resection (R); N/A:54 + 11

Results (3)

R Durumu

209 72.8 72.8 72.811 3.8 72.8 76.72 .7 .7 77.4

65 22.6 22.6 100.0287 100.0 100.0

R0R1R2N/ATotal

Frequency Percent Valid PercentCumulative

Percent


Means and Medians for Survival Time

29.531 1.222 27.136 31.926 29.000 4.391 20.394 37.606Estimate Std. Error Lower Bound Upper Bound

95% Confidence IntervalEstimate Std. Error Lower Bound Upper Bound

95% Confidence IntervalMean Median

Overall Comparisons

39.414 5 .000Log Rank (Mantel-Cox)Chi-Square df Sig.

Mean and median survival time

Means and Medians for Survival Time

41.999 2.391 37.313 46.685 . . . .35.902 2.953 30.115 41.689 . . . .32.453 3.142 26.296 38.611 . . . .26.978 2.699 21.687 32.269 23.000 6.104 11.036 34.96422.272 1.691 18.957 25.587 18.000 3.863 10.428 25.57214.097 1.911 10.350 17.843 10.000 1.259 7.532 12.46829.531 1.222 27.136 31.926 29.000 4.391 20.394 37.606

7th TNM staging1A1B2A2B3A3BOverall

Estimate Std. Error Lower Bound Upper Bound95% Confidence Interval

Estimate Std. Error Lower Bound Upper Bound95% Confidence Interval

Mean Median

Overall Comparisons


Overall Comparisons


Overall Comparisons


SUVmax as predictor of stage

TNM stage No. of patients Median SUVmax

T1N0M0 35 11.7T2N0M0 64 14.1T3N0M0 48 16.8T4N0M0 21 13

N0M0 168 13.9N1M0 49 15.1N2M0 58 15.4N3M0 12 16.1

Overall Comparisons


Overall Comparisons

.712 2 .700Log Rank (Mantel-Cox)Chi-Square df Sig.

Conclusion• *SUVmax predicts;

– stage, – recurrence,– survival

• Median SUVmax: The maximum pixel value within the entire primary tumor.

• Median PVC SUVmax: The partial volume corrected SUVmax

*Bryant AS, Cerfolio RJ, Klemm KM, et al. Maximum standard uptake value of mediastinal lymph nodes on integreted FDG-PET-CT predicts pathology in patients with non-small cell lung cancer. Ann Thorac Surg 2006;82:417-23.


Primary Tumor Standardized Uptake Value (SUVmax) Measured on Fluorodeoxyglucose

Positron Emission Tomography (FDG-PET) is of Prognostic Value for Survival in Non-small Cell Lung Cancer (NSCLC): A Systematic Review and Meta-Analysis (MA) by the European Lung Cancer Working Party for the IASLC Lung Cancer Staging Project

Berghmans T, Dusart M, Paesmans M, et al. Journal of Thoracic Oncology. 3(1):6-12,

January 2008.

http://journals.lww.com/jto/Fulltext/2008/01000/Primary_Tumor_Standardized_Uptake_Value__SUVmax_.3.aspx






Overall Comparisons

.093 1 .761Log Rank (Mantel-Cox)Chi-Square df Sig.

Positron Emission Tomography 18F-Fluorodeoxyglucose Uptake and Prognosis in Patients with Surgically Treated, Stage I Non-small Cell Lung Cancer: A Systematic Review

Nair SV, Krupitskaya Y, Gould MK.Journal of Thoracic Oncology. 4(12):1473-1479,

December 2009.

• Conclusion: Current evidence suggests that increasing tumor FDG uptake is associated with worse survival in patients with stage I NSCLC. FDG uptake has the potential to be used as a biomarker for identifying stage I patients who are at increased risk of death or recurrence and therefore could identify candidates for participation in future trials of adjuvant therapy.

Conclusion (4)


http://journals.lww.com/jto/Fulltext/2009/12000/Positron_Emission_Tomography.5.aspx



• The SUVmax of a pulmonary nodule on PET/CT scanning is an independent predictor of an NSCLC’s biologic aggressiveness or its in vivo virulence.

• SUVmax predicted survival in patients with NSCLC staged according to new staging system

• Prospective trials of adjuvant chemotherapy in patients with early stage NSCLC and high SUVmax should be considered.

Conclusion (5)


i lker i skender *, salih zeki kad i o g lu # , hasan o g uz kap i c i ba si # ,

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