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I lker I skender *, Salih Zeki Kad i o g lu # , Hasan O g uz Kap i c i ba si # ,

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

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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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  1. 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 MAXIMUM STANDARDIZED UPTAKE VALUE PREDICTS SURVIVAL IN SURGICALLY STAGED OR RESECTED NON-SMALL CELL LUNG CANCER PATIENTS Turkish ThoracicSociety 13. Annual Congress, 5-9 May 2010, Istanbul

  2. Goal • 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. Turkish ThoracicSociety 13. Annual Congress, 5-9 May 2010, Istanbul

  3. Material and Methods • 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 Turkish ThoracicSociety 13. Annual Congress, 5-9 May 2010, Istanbul

  4. Material and Methods (2) • Complete history and physical examination • Blood analysis • Chest radiography • Spirometry • Cardiac investigation • Thorax CT • PET/CT • Cranial MRI Turkish ThoracicSociety 13. Annual Congress, 5-9 May 2010, Istanbul

  5. Material and Methods (3) • 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 Turkish ThoracicSociety 13. Annual Congress, 5-9 May 2010, Istanbul

  6. Material and Methods (4) • 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. Turkish ThoracicSociety 13. Annual Congress, 5-9 May 2010, Istanbul

  7. Material and Methods (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 Turkish ThoracicSociety 13. Annual Congress, 5-9 May 2010, Istanbul

  8. Material and Methods (6) • 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. Turkish ThoracicSociety 13. Annual Congress, 5-9 May 2010, Istanbul

  9. Material and Methods (7) • 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 Turkish ThoracicSociety 13. Annual Congress, 5-9 May 2010, Istanbul

  10. Material and Methods (8) • 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 Turkish ThoracicSociety 13. Annual Congress, 5-9 May 2010, Istanbul

  11. Results • 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 wasmade on 221 (80.2%) patients preoperatively • The mean SUVmaxof primary tumor : 15.2 ± 6.8 Turkish ThoracicSociety 13. Annual Congress, 5-9 May 2010, Istanbul

  12. Results (2) • 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%) Turkish ThoracicSociety 13. Annual Congress, 5-9 May 2010, Istanbul

  13. Results (3) • 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 Turkish ThoracicSociety 13. Annual Congress, 5-9 May 2010, Istanbul

  14. Mean and median survival time

  15. SUVmax as predictor of stage

  16. 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 ThoracicSociety 13. Annual Congress, 5-9 May 2010, Istanbul

  17. 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 ProjectBerghmans T, Dusart M, Paesmans M, et al. Journal of Thoracic Oncology. 3(1):6-12, January 2008.

  18. Positron Emission Tomography 18F-Fluorodeoxyglucose Uptake and Prognosis in Patients with Surgically Treated, Stage I Non-small Cell Lung Cancer: A Systematic ReviewNair SV, Krupitskaya Y, Gould MK.Journal of Thoracic Oncology. 4(12):1473-1479, December 2009. Conclusion (4) • 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. Turkish ThoracicSociety 13. Annual Congress, 5-9 May 2010, Istanbul

  19. Conclusion (5) • 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. Turkish ThoracicSociety 13. Annual Congress, 5-9 May 2010, Istanbul

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