Maximum standard uptake value of Superscript18/

Authors: Yukihiro Miyazaki Yuichiro Nawa Masao Miyagawa Sumiko Kohashi Koichi Nakase Masaki Yasukawa Masamichi Hara

Publish Date: 2012/10/19

Volume: 92, Issue: 2, Pages: 239-244

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Abstract

The treatment of patients with diffuse large B cell lymphoma DLBCL would be greatly facilitated with a rapid method for determining prognosis that can be performed more easily and earlier than cytological or specific pathological examinations It has been suggested that newly diagnosed patients with DLBCL who have low maximum standard uptake value SUVmax on 18Ffluorodeoxyglucose positron emission tomography FDGPET are more likely to be successfully treated and remain in remission compared with patients with high SUVmax but this concept has been poorly studied We retrospectively analyzed 50 patients with de novo DLBCL to evaluate the relationship between the SUVmax and disease progression For patients with low SUVmax n = 10 and high SUVmax n = 40 P = 0255 respectively the 3year overall survival rates were 90 and 72  and the progressionfree survival PFS rates were 90 and 39  P = 0012 By multivariate analysis the revised International Prognostics Index RIPI and SUVmax at diagnosis were shown to predict longer PFS The 3year PFS for patients with low SUVmax classified into the good prognosis group by RIPI was 100 vs 62  for those with high SUVmax P = 0161 and patients with low SUVmax classified into the poor prognosis group by RIPI was 80 vs 18  for those with high SUVmax P = 0050 We conclude that the SUVmax on FDGPET for newly diagnosed patients with DLBCL is an important predictor of disease progression especially for patients with poor prognosis by RIPIDiffuse large B cell lymphoma DLBCL is the most common aggressive form of nonHodgkin’s lymphoma Combination chemotherapy with rituximab is initially administered to most newly diagnosed patients with DLBCL 1 2 3 4 However if the patients relapse after the initial chemotherapy their lymphoma can be poorly managed because most DLBCL cases ultimately become chemotherapyresistant unless treated with highdose chemotherapy with autologous stem cell transplantation ASCT 5 6 Instead of combination chemotherapy with rituximab other treatments including more intensive chemotherapy upfront ASCT after the first remission or other newly developed drugs are required to improve survival of the patients who are at high risk of relapse 7 8 Therefore defining prognostic factors that can easily and accurately classify patients with untreated DLBCL into appropriate risk groups for relapse is highly important for disease managementAlthough 18Ffluorodeoxyglucose positron emission tomography FDGPET imaging for DLBCL have been widely utilized to evaluate the staging and residual lesions after treatment with high sensitivity 9 10 11 12 the relevance of the maximum standard uptake value SUVmax in this technique to disease outcome has been poorly studied The SUVmax at the biopsy site of nonHodgkin’s lymphoma patients has been reported to correlate with the proliferation potential 13 Anecdotal cases from our hospital unpublished also suggest that patients with low SUVmax DLBCL before treatment are more likely to remain in remission while those with high SUVmax DLBCL are more likely to relapse However this idea has not been confirmed by a systematic analysis of clinical cases Therefore in this study we retrospectively analyzed 50 patients with DLBCL in order to examine the relationship between the initial SUVmax of FDGPET and disease progressionIn this study patients with de novo DLBCL excluding those with transformation from indolent lymphoma diagnosed between April 2006 and December 2009 at Ehime Prefectural Central Hospital Matsuyama Japan were retrospectively analyzed FDGPET imaging was performed in all patients before the treatment and the SUVmax at the primary lesion was measured The patients subsequently received combination chemotherapy with rituximab Patients whose primary lesions were excised surgically before FDGPET imaging or who were treated palliatively including only radiotherapy or only rituximab were excluded from this study The observation period was from April 2006 to March 2011FDGPET/CT imaging was performed using a multislice PET/CT camera Discovery STE with 16slice CT GE Healthcare All patients had fasted for a minimum of 6 h with a blood glucose level of 80–120 mg/dL before intravenous administration of 18FFDG A wholebody image was obtained exactly 60 min after the intravenous administration of 222–370 MBq 6–10 mCi of 18FFDG The PET emission images were corrected for measured attenuation and reconstructed using an orderedsubset expectation maximization iterative algorithm per the manufacturer’s instructions Integrated PET and CT images were reviewed on Advantage Workstations GE Healthcare Display field of view was 60 × 60 cm which consisted of 192 × 192 matrixes on the display Voxel size was 3125 × 3125 × 327 mm3 For each PET data set in patients with multiple lesions the tumor with the most intense FDG uptake among all foci was identified by the maximal counts A volumetric region of interest was approximately 8 cm3 250 voxels or more and set on the axial fusion images of PET and CT to calculate SUVmax A volumetric region of interest encompassing the entire tumor was drawn to ensure correct identification of the maximal counts and the SUVmax was calculatedAll patients received rituximabcontaining combination chemotherapy as an initial treatment The cyclophosphamide doxorubicin vincristine and prednisolone with rituximab RCHOP regimen was administered to younger patients 70 years old with DLBCL and the pirarubicin cyclophosphamide vincristine and prednisolone with rituximab RTHPCOP regimen was administered to elderly patients ≥70 years old Most patients with advancedstage disease defined as Ann Arbor stages III or IV or stage I and II with bulky disease ≥10 cm received six to eight cycles of RCHOP or RTHPCOP every 21 days Only the patients who had Ann Arbor stages I and II without bulky disease received three cycles of RCHOP or RTHPCOP and field radiation therapy Complete remission CR was defined by FDGPET scan according to the recently published criteria 9 All relapsed patients received salvage chemotherapy and ASCT was performed in eligible casesOverall survival OS was defined as the time from the start of chemotherapy to death from any cause Progressionfree survival PFS was defined as the time from the start of chemotherapy to relapse or death The Mann–Whitney U test was used to calculate the differences between two groups The probabilities of OS and PFS were estimated by the Kaplan–Meier method The association of various factors with the hazards of failure for the timetoendpoint PFS was estimated using the Cox proportional hazard regression model A P value of 005 was considered statistically significant SPSS version 170 was used for all analyses

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