i lker i skender *, salih zeki kad i o g lu # , hasan o g uz kap i c i ba si # ,
DESCRIPTION
I lker I skender *, Salih Zeki Kad i o g lu # , Hasan O g uz Kap i c i ba si # , Akif Turna # , Altu g Ko s ar # , Ali Atasalihi # , Altan K i r # *Cizre Dr. Selahattin Cizrelio g lu State Hospital , Si rnak # Sureyyapasa Chest Diseases and Thoracic Surgery Training and Research - PowerPoint PPT PresentationTRANSCRIPT
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
Turkish Thoracic Society 13. Annual Congress, 5-9 May 2010, Istanbul
• 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
Turkish Thoracic Society 13. Annual Congress, 5-9 May 2010, Istanbul
• Complete history and physical examination• Blood analysis• Chest radiography • Spirometry• Cardiac investigation• Thorax CT• PET/CT• Cranial MRI
Material and Methods (2)
Turkish Thoracic Society 13. Annual Congress, 5-9 May 2010, Istanbul
• 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
Material and Methods (3)
Turkish Thoracic Society 13. Annual Congress, 5-9 May 2010, Istanbul
– 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.
Material and Methods (4)
Turkish Thoracic Society 13. Annual Congress, 5-9 May 2010, Istanbul
• 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
Material and Methods (5)
Turkish Thoracic Society 13. Annual Congress, 5-9 May 2010, Istanbul
• 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.
Material and Methods (6)
Turkish Thoracic Society 13. Annual Congress, 5-9 May 2010, Istanbul
• 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
Material and Methods (7)
Turkish Thoracic Society 13. Annual Congress, 5-9 May 2010, Istanbul
• 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
Material and Methods (8)
Turkish Thoracic Society 13. Annual Congress, 5-9 May 2010, Istanbul
• 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
Turkish Thoracic Society 13. Annual Congress, 5-9 May 2010, Istanbul
• 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)
Turkish Thoracic Society 13. Annual Congress, 5-9 May 2010, Istanbul
• 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
Turkish Thoracic Society 13. Annual Congress, 5-9 May 2010, Istanbul
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
23.297 2 .000Log Rank (Mantel-Cox)Chi-Square df Sig.
Overall Comparisons
1.850 2 .397Log Rank (Mantel-Cox)Chi-Square df Sig.
Overall Comparisons
5.270 2 .072Log Rank (Mantel-Cox)Chi-Square df Sig.
Overall Comparisons
4.906 1 .027Log Rank (Mantel-Cox)Chi-Square df Sig.
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
4.177 1 .041Log Rank (Mantel-Cox)Chi-Square df Sig.
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.
Turkish Thoracic Society 13. Annual Congress, 5-9 May 2010, Istanbul
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.
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)
Turkish Thoracic Society 13. Annual Congress, 5-9 May 2010, Istanbul
• 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)
Turkish Thoracic Society 13. Annual Congress, 5-9 May 2010, Istanbul