pet scan markers for survival in patients with soft tissue sarcomas
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University of Pennsylvania Department of Orthopaedic Surgery
Joseph King, Eileen Crawford, Abass Alavi, Arthur Staddon, Lee Hartner, Richard Lackman
and Christian Ogilvie
PET Scan Markers for Survival in Patients with Soft Tissue Sarcomas
University of Pennsylvania Department of Orthopaedic Surgery
Background
• Soft tissue sarcomas (STS) are a heterogeneous group of malignant tumors
• Prognosis determined by CT, MRI, and biopsy • Problems/challenges:
– Local extent, metastasis, recurrence– Diagnosis, grading, monitoring treatment response
University of Pennsylvania Department of Orthopaedic Surgery
Background• FDG uptake proportional to growth rate of
neoplastic cells• PET SUVmax > 6 in sarcomas related to survival
and progression1
• PET has shown promise in predicting survival for lung and breast carcinomas2-4
• Poor PET response to chemotherapy in STS (< 40% decline in FDG uptake) associated with increased rate of recurrence and death5
1) Eary et al 20022) Kramer et al. 20063) Chen et al. 20044) Schwartz et al. 20055) Sheutz et al. 2005
University of Pennsylvania Department of Orthopaedic Surgery
Purpose
• Determine predictors of survival based on FDG-PET imaging for patients with soft tissue sarcomas– SUVmax– Response to chemotherapy– PET active lung nodules
University of Pennsylvania Department of Orthopaedic Surgery
Hypothesis
• Predictors for decreased survival will include:– High maximum standard uptake value (SUV)– FDG-enhancing lung nodules– Poor SUV-based response to chemotherapy
University of Pennsylvania Department of Orthopaedic Surgery
Materials and Methods
• Study Design: Retrospective review
• Study Group:– Treated with chemotherapy +/- resection
• High or intermediate grade sarcoma• Primary tumor > 5 cm, or metastatic disease
– PET scans done between 2003-2006– 1st PET done before all disease resected– Minimum follow-up 6 months– 14 patients with pre- and post-chemo PET scans
University of Pennsylvania Department of Orthopaedic Surgery
Materials and Methods
• Study Group:– 32 patients with STS– 14 excluded
• Bone sarcoma• Also had carcinoma• No gross disease at time of initial scan• Inadequate documented follow up
University of Pennsylvania Department of Orthopaedic Surgery
Materials and Methods
• Outcome Measures:1. Maximum SUV (primary sarcoma or metastasis)2. Number and location of PET detected metastatic lesions3. SUV-based response to chemotherapy
– Response: ≥ 40% decrease in SUV in over ½ of lesions– Stability: < 40% decrease in SUV in over ½ of lesions– Progression: SUV increase or new lesions
University of Pennsylvania Department of Orthopaedic Surgery
Patient Characteristics
Diagnosis NLeiomyosarcoma 10Synovial sarcoma 7Liposarcoma 4Malignant fibrous histiocytoma 4Sarcoma NOS 2Rhabdomyosarcoma 1Myxofibrosarcoma 1Atrial sarcoma 1Desmoplastic round cell tumor 1Extraosseous Ewing sarcoma 1
• Mean age = 47 (range 20-74) • 13 had mets on presentation• 15 developed mets during f/u
Location NLower extremity 11Pelvis 6Chest 5Abdomen 5Upper extremity 4Back 1
University of Pennsylvania Department of Orthopaedic Surgery
Results
• Mean follow-up = 49 months (range 7-172 months) • 10 alive at last f/u 6 with NED, 4 with metastatic disease• 5 patients had local recurrence after resection mean time to LR was 2.4 years
Prognostic factor N Mean Survival (months) P-value
SUVmax < 6 22 15.1 0.93
SUVmax ≥ 6 10 14.7
No nodules 19 21.6 0.007
1-3 nodules 9 10.7
No nodules 19 21.6 0.003
4+ nodules 4 6.2
1-3 nodules 9 10.7 0.20
4+ nodules 4 6.2
Progression 6 3.9 0.05
No progression 8 16.8
University of Pennsylvania Department of Orthopaedic Surgery
p=0.76
University of Pennsylvania Department of Orthopaedic Surgery
p=0.01p=0.01
University of Pennsylvania Department of Orthopaedic Surgery
p=0.001
University of Pennsylvania Department of Orthopaedic Surgery
Conclusions
• PET scan markers for decreased survival in patients with high grade STS include:– Presence of FDG-enchancing lung nodules– SUV-based disease progression during
chemotherapy
• SUVmax ≥ 6 was not a predictor for decreased survival
University of Pennsylvania Department of Orthopaedic Surgery
Discussion
• Obtaining pre- and post-treatment PET scans to evaluate treatment response of localized or metastatic STS provides useful prognostic information
• Maximum SUV was not found to have prognostic significance in this study– Lots of metastatic disease: selection bias with under
representation of patients with lower histologic grade and better prognosis?
University of Pennsylvania Department of Orthopaedic Surgery
Future directions
• Larger prospective studies of response to chemotherapy underway
• Data on histologic subtypes– Liposarcoma: Brenner et al. 2006– Rhabdomyosarcoma: Klem et al. 2007
• Probes other that glucose– Hypoxia– Apoptosis
University of Pennsylvania Department of Orthopaedic Surgery
Thank You!
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