18F–fluorodeoxyglucose uptake of hepatocellular carcinoma as a prognostic predictor in patients with sorafenib treatment

  • Pil Soo Sung
  • Hye Lim Park
  • Keungmo Yang
  • Seawon Hwang
  • Myeong Jun Song
  • Jeong Won Jang
  • Jong Young Choi
  • Seung Kew Yoon
  • Ie Ryung YooEmail author
  • Si Hyun BaeEmail author
Original Article



Sorafenib, an oral multikinase inhibitor, is a recommended treatment option available for patients with Barcelona Clinic Liver Cancer (BCLC)-C stage hepatocellular carcinoma (HCC). This study aimed to evaluate the performance of 18F–fluorodeoxyglucose positron emission tomography (18F–FDG PET) for predicting tumour progression during sorafenib treatment.


We formed a retrospective cohort comprising patients treated with sorafenib for at least 30 days and undergoing 18F–FDG PET/CT within 1 month before treatment. For statistical analyses, the tumour-to-liver standardised uptake value (SUV) ratio (TLR) of the most hypermetabolic lesion was measured.


Among a total of 35 patients, two obtained partial remission, and 11 showed stable disease after the first response evaluation. Patients with a TLR ≥ 2.9 (n = 17) had a median overall survival (OS) of 3.7 months after sorafenib treatment, whereas patients with a TLR < 2.9 (n = 18) had median OS of 12.2 months (P < 0.001), although the disease control rate was not significantly different between the two groups. Pretreatment TLR ≥ 2.9 (hazard ratio [HR] = 6.318, P = 0.002) and Child-Pugh class B (HR = 4.316, P = 0.044) were poor prognostic factors for OS, and a TLR ≥ 2.9 (HR = 2.911, P = 0.024) was the only poor prognostic factor for progression-free survival in a multivariate analysis.


Pretreatment tumour metabolic activity assessed by 18F–FDG PET is an independent prognostic factor for survival in patients with BCLC-C stage HCC receiving sorafenib monotherapy, although it may not predict tumour response to the treatment.


18F–FDG pet Prognosis Sorafenib Tumour response Time to progression 



This work was supported by Research Fund of Seoul St. Mary’s Hospital, The Catholic University of Korea. This research was supported by the Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Science, ICT & Future Planning (2017R1A2B4010197).

Compliance with ethical standards

Conflict of interests

There are no conflicts of interest in this study.

Ethics approval

Ethics approval was provided by the Institutional Ethics Review Board of The Catholic University of Korea (KC17RESI0241).

Supplementary material

259_2017_3871_MOESM1_ESM.pdf (186 kb)
ESM 1 (PDF 186 kb)


  1. 1.
    Llovet JM, Zucman-Rossi J, Pikarsky E, Sangro B, Schwartz M, Sherman M, et al. Hepatocellular carcinoma. Nat Rev Dis Primers. 2016;2:16018. Scholar
  2. 2.
    Bruix J, Reig M, Sherman M. Evidence-based diagnosis, staging, and treatment of patients with Hepatocellular carcinoma. Gastroenterology. 2016;150:835–53. Scholar
  3. 3.
    Na SJ, Oh JK, Hyun SH, Lee JW, Hong IK, Song BI, et al. 18F-FDG PET/CT can predict survival of advanced hepatocellular carcinoma patients: a multicenter retrospective cohort study. J Nucl Med. 2016.
  4. 4.
    Kim DY, Kim HJ, Han KH, Han SY, Heo J, Woo HY, et al. Real-life experience of Sorafenib treatment for Hepatocellular carcinoma in Korea: from GIDEON data. Cancer Res Treat. 2016;48:1243–52. Scholar
  5. 5.
    Yu SJ. A concise review of updated guidelines regarding the management of hepatocellular carcinoma around the world: 2010-2016. Clin Mol Hepatol. 2016;22:7–17. Scholar
  6. 6.
    Llovet JM, Ricci S, Mazzaferro V, Hilgard P, Gane E, Blanc JF, et al. Sorafenib in advanced hepatocellular carcinoma. N Engl J Med. 2008;359:378–90. Scholar
  7. 7.
    Cheng AL, Kang YK, Chen Z, Tsao CJ, Qin S, Kim JS, et al. Efficacy and safety of sorafenib in patients in the Asia-Pacific region with advanced hepatocellular carcinoma: a phase III randomised, double-blind, placebo-controlled trial. Lancet Oncol. 2009;10:25–34. Scholar
  8. 8.
    Shao YY, Hsu CH, Cheng AL. Predictive biomarkers of sorafenib efficacy in advanced hepatocellular carcinoma: are we getting there? World J Gastroenterol. 2015;21:10336–47. Scholar
  9. 9.
    Lee JH, Park JY, Kim DY, Ahn SH, Han KH, Seo HJ, et al. Prognostic value of 18F-FDG PET for hepatocellular carcinoma patients treated with sorafenib. Liver Int. 2011;31:1144–9. Scholar
  10. 10.
    Sugiyama M, Sakahara H, Torizuka T, Kanno T, Nakamura F, Futatsubashi M, et al. 18F-FDG PET in the detection of extrahepatic metastases from hepatocellular carcinoma. J Gastroenterol. 2004;39:961–8. Scholar
  11. 11.
    Hong CM, Ahn BC, Jang YJ, Jeong SY, Lee SW, Lee J. Prognostic value of metabolic parameters of 18F-FDG PET/CT and apparent diffusion coefficient of MRI in Hepatocellular carcinoma. Clin Nucl Med. 2017;42:95–9. Scholar
  12. 12.
    Hyun SH, Eo JS, Lee JW, Choi JY, Lee KH, Na SJ, et al. Prognostic value of (18)F-fluorodeoxyglucose positron emission tomography/computed tomography in patients with Barcelona clinic liver cancer stages 0 and a hepatocellular carcinomas: a multicenter retrospective cohort study. Eur J Nucl Med Mol Imaging. 2016;43:1638–45. Scholar
  13. 13.
    Eo JS, Paeng JC, Lee DS. Nuclear imaging for functional evaluation and theragnosis in liver malignancy and transplantation. World J Gastroenterol. 2014;20:5375–88. Scholar
  14. 14.
    Lee JW, Paeng JC, Kang KW, Kwon HW, Suh KS, Chung JK, et al. Prediction of tumor recurrence by 18F-FDG PET in liver transplantation for hepatocellular carcinoma. J Nucl Med. 2009;50:682–7. Scholar
  15. 15.
    Kitamura K, Hatano E, Higashi T, Seo S, Nakamoto Y, Yamanaka K, et al. Preoperative FDG-PET predicts recurrence patterns in hepatocellular carcinoma. Ann Surg Oncol. 2012;19:156–62. Scholar
  16. 16.
    Kornberg A, Kupper B, Thrum K, Katenkamp K, Steenbeck J, Sappler A, et al. Increased 18F-FDG uptake of hepatocellular carcinoma on positron emission tomography independently predicts tumor recurrence in liver transplant patients. Transplant Proc. 2009;41:2561–3. Scholar
  17. 17.
    Lee JW, Yun M, Cho A, Han KH, Kim DY, Lee SM, et al. The predictive value of metabolic tumor volume on FDG PET/CT for transarterial chemoembolization and transarterial chemotherapy infusion in hepatocellular carcinoma patients without extrahepatic metastasis. Ann Nucl Med. 2015;29:400–8. Scholar
  18. 18.
    Kim MJ, Kim YS, Cho YH, Jang HY, Song JY, Lee SH, et al. Use of (18)F-FDG PET to predict tumor progression and survival in patients with intermediate hepatocellular carcinoma treated by transarterial chemoembolization. Korean J Intern Med. 2015;30:308–15. Scholar
  19. 19.
    Lee JW, Oh JK, Chung YA, Na SJ, Hyun SH, Hong IK, et al. Prognostic significance of (1)(8)F-FDG uptake in Hepatocellular carcinoma treated with Transarterial Chemoembolization or concurrent Chemoradiotherapy: a multicenter retrospective cohort study. J Nucl Med. 2016;57:509–16. Scholar
  20. 20.
    Lee JW, Hwang SH, Kim DY, Han KH, Yun M. Prognostic value of FDG uptake of portal vein tumor thrombosis in patients with locally advanced Hepatocellular carcinoma. Clin Nucl Med. 2017;42:e35–40. Scholar
  21. 21.
    Song MJ, Bae SH, Lee SW, Song DS, Kim HY, Yoo Ie R, et al. 18F-fluorodeoxyglucose PET/CT predicts tumour progression after transarterial chemoembolization in hepatocellular carcinoma. Eur J Nucl Med Mol Imaging. 2013;40:865–73. Scholar
  22. 22.
    Jreige M, Mitsakis P, Van Der Gucht A, Pomoni A, Silva-Monteiro M, Gnesin S, et al. 18F-FDG PET/CT predicts survival after 90Y transarterial radioembolization in unresectable hepatocellular carcinoma. Eur J Nucl Med Mol Imaging 2017.
  23. 23.
    Hartenbach M, Weber S, Albert NL, Hartenbach S, Hirtl A, Zacherl MJ, et al. Evaluating treatment response of Radioembolization in intermediate-stage Hepatocellular carcinoma patients using 18F-Fluoroethylcholine PET/CT. J Nucl Med. 2015;56:1661–6. Scholar
  24. 24.
    Sabet A, Ahmadzadehfar H, Bruhman J, Sabet A, Meyer C, Wasmuth JC, et al. Survival in patients with hepatocellular carcinoma treated with 90Y-microsphere radioembolization. Prediction by 18F-FDG PET. Nuklearmedizin. 2014;53:39–45. Scholar
  25. 25.
    Lencioni R, Llovet JM. Modified RECIST (mRECIST) assessment for hepatocellular carcinoma. Semin Liver Dis. 2010;30:52–60. Scholar
  26. 26.
    Upadhyay M, Samal J, Kandpal M, Singh OV, Vivekanandan P. The Warburg effect: insights from the past decade. Pharmacol Ther. 2013;137:318–30. Scholar
  27. 27.
    Pimiento JM, Davis-Yadley AH, Kim RD, Chen DT, Eikman EA, Berman CG, et al. Metabolic activity by 18F-FDG-PET/CT is prognostic for stage I and II pancreatic cancer. Clin Nucl Med. 2016;41:177–81. Scholar
  28. 28.
    Song DS, Song MJ, Bae SH, Chung WJ, Jang JY, Kim YS, et al. A comparative study between sorafenib and hepatic arterial infusion chemotherapy for advanced hepatocellular carcinoma with portal vein tumor thrombosis. J Gastroenterol. 2015;50:445–54. Scholar
  29. 29.
    Edeline J, Boucher E, Rolland Y, Vauleon E, Pracht M, Perrin C, et al. Comparison of tumor response by response evaluation criteria in solid Tumors (RECIST) and modified RECIST in patients treated with sorafenib for hepatocellular carcinoma. Cancer. 2012;118:147–56. Scholar

Copyright information

© Springer-Verlag GmbH Germany 2017

Authors and Affiliations

  • Pil Soo Sung
    • 1
  • Hye Lim Park
    • 2
  • Keungmo Yang
    • 1
  • Seawon Hwang
    • 1
  • Myeong Jun Song
    • 1
  • Jeong Won Jang
    • 1
  • Jong Young Choi
    • 1
  • Seung Kew Yoon
    • 1
  • Ie Ryung Yoo
    • 2
    Email author
  • Si Hyun Bae
    • 1
    Email author
  1. 1.Division of Hepatology, Department of Internal Medicine, The Catholic University Liver Research Center, College of MedicineThe Catholic University of KoreaSeoulSouth Korea
  2. 2.Division of Nuclear Medicine, Department of Radiology, College of MedicineThe Catholic University of KoreaSeoulSouth Korea

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