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Differentiation of tumor recurrence from radiation-induced pulmonary fibrosis after stereotactic ablative radiotherapy for lung cancer: characterization of 18F-FDG PET/CT findings

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Abstract

Objective

Stereotactic ablative radiotherapy (SABR), also known as stereotactic body radiotherapy (SBRT), is now a standard treatment option for patients with stage I non-small cell lung cancer or oligometastatic lung tumor who are medically inoperable or medically operable but refuse surgery. When mass-like consolidation is observed on follow-up CT after SABR, it is sometimes difficult to differentiate tumor recurrence from SABR-induced pulmonary fibrosis. In this study, we evaluated the role of 18F-fluorodeoxyglucose positron emission tomography combined with computed tomography (FDG-PET/CT) in differentiating tumor recurrence from radiation fibrosis after SABR.

Methods

Between June 2006 and June 2009, 130 patients received SABR for stage I non-small cell lung cancer or metastatic lung cancer at our institution. Fifty-nine patients of them were imaged with FDG-PET/CT after SABR. There were a total of 137 FDG-PET/CT scans for retrospective analysis. The FDG uptake in the pulmonary region was assessed qualitatively using a 3-point scale (0, none or faint; 1, mild; or 2, moderate to intense), and the shape (mass-like or non mass-like) was evaluated. For semi-quantitative analysis, the maximum standardized uptake value (SUVmax) was calculated.

Results

Sixteen of 59 patients had local failure. In recurrent tumor, the combination of intensity grade 2 and mass-like shape was most common (21/23; 91 %). By contrast, in cases of radiation fibrosis, the combination of intensity grade 0 or 1 and non mass-like shape was most common (48/59; 81 %). The SUVmax of tumor recurrence after 12 months was significantly higher than that of radiation fibrosis (8.0 ± 3.2 vs. 2.1 ± 0.9, p < 0.001), and all tumor recurrence showed the SUVmax > 4.5 at diagnosis of local failure. At ≥12 months after SABR, these two variables, the combination of intensity 2 and mass-like FDG uptake or SUVmax > 4.5 acquired a significant high predictive value of local recurrence, finding sensitivity 100 % and specificity 100 % for both of them.

Conclusions

The combination of FDG uptake patterns and SUVmax was useful for distinguishing tumor recurrence from radiation fibrosis after SABR.

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Acknowledgments

This research was supported in part by Grants-in-Aid for scientific research from the Ministry of Education, Culture, Sports, Science and Technology of Japan (Program for Enhancing Systematic Education in Graduate School).

Conflict of interest

The authors have no conflicts of interest to declare.

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Authors and Affiliations

  1. Department of Radiation Oncology, National Hospital Organization Shikoku Cancer Center, Kou-160, Minamiumemoto-machi, Matsuyama, Ehime, 791-0280, Japan

    Naomi Nakajima & Masaaki Kataoka

  2. Department of Diagnostic Radiology, National Hospital Organization Shikoku Cancer Center, Kou-160, Minamiumemoto-machi, Matsuyama, Ehime, 791-0280, Japan

    Yoshifumi Sugawara, Shinya Sakai, Tadaaki Takahashi & Makoto Kajihara

  3. Department of Diagnostic and Therapeutic Radiology, Ehime University Graduate School of Medicine, Toon, Ehime, 791-0295, Japan

    Yasushi Hamamoto, Takashi Ochi & Teruhito Mochizuki

  4. Department of Pathology, National Hospital Organization Shikoku Cancer Center, Kou-160, Minamiumemoto-machi, Matsuyama, Ehime, 791-0280, Japan

    Norihiro Teramoto

  5. Department of Surgery, National Hospital Organization Shikoku Cancer Center, Kou-160, Minamiumemoto-machi, Matsuyama, Ehime, 791-0280, Japan

    Motohiro Yamashita

Authors
  1. Naomi Nakajima
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  2. Yoshifumi Sugawara
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Correspondence to Naomi Nakajima.

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Nakajima, N., Sugawara, Y., Kataoka, M. et al. Differentiation of tumor recurrence from radiation-induced pulmonary fibrosis after stereotactic ablative radiotherapy for lung cancer: characterization of 18F-FDG PET/CT findings. Ann Nucl Med 27, 261–270 (2013). https://doi.org/10.1007/s12149-012-0682-4

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  • DOI: https://doi.org/10.1007/s12149-012-0682-4

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