Dynamic Contrast-enhanced Area-detector CT vs Dynamic Contrast-enhanced Perfusion MRI vs FDG-PET/CT: Comparison of Utility for Quantitative Therapeutic Outcome Prediction for NSCLC Patients Undergoing Chemoradiotherapy

Abstract

Purpose: To directly compare the utility for therapeutic outcome prediction of dynamic first-pass contrast-enhanced (CE)-perfusion area-detector computed tomography (ADCT), MR imaging assessed with the same mathematical method and 2-[fluorine-18]-fluoro-2-deoxy-d-glucose-positron emission tomography combined with CT (PET/CT) for non-small cell lung cancer (NSCLC) patients treated with chemoradiotherapy.

Materials and methods: Forty-three consecutive stage IIIB NSCLC patients, consisting of 25 males (mean age ± standard deviation: 66.6 ± 8.7 years) and 18 females (66.4 ± 8.2 years) underwent PET/CT, dynamic CE-perfusion ADCT and MR imaging, chemoradiotherapy, and follow-up examination. In each patient, total, pulmonary arterial, and systemic arterial perfusions were calculated from both perfusion data and SUVmax on PET/CT, assessed for each targeted lesion, and averaged to determine final values. Receiver operating characteristics analyses were performed to compare the utility for distinguishing responders from non-responders using Response Evaluation Criteria in Solid Tumor (RECIST) 1.1 criteria. Overall survival (OS) assessed with each index were compared between two groups by means of the Kaplan-Meier method followed by the log-rank test.

Results: Area under the curve (Az) for total perfusion on ADCT was significantly larger than that of pulmonary arterial perfusion (P < 0.05). Az of total perfusion on MR imaging was significantly larger than that of pulmonary arterial perfusion (P < 0.05). Mean OS of responder and non-responder groups were significantly different for total and systemic arterial (P < 0.05) perfusion.

Conclusion: Dynamic first-pass CE-perfusion ADCT and MR imaging as well as PET/CT are useful for early prediction of treatment response by NSCLC patients treated with chemoradiotherapy.

Keywords: computed tomography; magnetic resonance imaging; non-small cell lung cancer; positron emission tomography combined with computed tomography; therapeutic effect.

Conflict of interest statement

Conflicts of Interest

Drs. Ohno, Yoshikawa and Seki had research grants from Grants-in-Aid for Scientific Research from the Japanese Ministry of Education, Culture, Sports, Science and Technology (JSTS.KAKEN; No. 24591762), Canon Medical Systems Corporation, Bayer Pharma and Guerbet Japan. Dr. Ohno and Ms. Fujisawa had research grant from the Adaptive and Seamless Technology Transfer Program through Target Driven R & D from the Japan Science and Technology (JST) Agency (AS2511335P).

Four of the authors (Yasuko Fujisawa, Masao Yui, Shigeharu Ohyu and Naoki Sugihara), who are employees of Canon Medical Systems Corporation, developed the software, but had no control over any data or information submitted for publication or any control over any parts of data and information included in this study.

Figures

Fig. 1

A 81-year-old male patient with squamous cell carcinoma treated with chemoradiotherapy and assessed as NC. Progression-free and overall survival at 15 and 24 months. (a) Thin-section MPR image from thin-section CT data (L to R: MPR images obtained pre- and post-treatment at lung window setting) show lung cancer in the right upper lobe. This case was assessed as NC by response evaluation criteria in solid tumors (RECIST ver.1.1). (b) Perfusion maps derived from dynamic first-pass CE-perfusion area detector CT assessed with the dual-input maximum slope method (L to R: pulmonary arterial perfusion, systemic arterial perfusion and total perfusion maps) for the same targeted lesion. Pulmonary arterial perfusion, systemic arterial perfusion and total perfusion were 13.6, 18.9, and 32.5 ml/100 ml/min, respectively. This case was assessed as a RECIST-based non-responder for systemic arterial and total perfusions, and as true-positive. (c) Source image and perfusion maps on dynamic first-pass CE-perfusion MR imaging assessed with the dual-input maximum slope method (L to R: source image, pulmonary arterial perfusion, systemic arterial perfusion, and total perfusion maps) for the same targeted lesion. Pulmonary arterial perfusion, systemic arterial perfusion, and total perfusion were 9.2, 28.9, and 38.1 ml/100 ml/min, respectively. This case was also assessed as a RECIST-based non-responder for systemic arterial and total perfusions, and as true-positive. However, this case was evaluated as responder and as false-positive on the basis of pulmonary arterial perfusion findings. (d) PET/CT demonstrates high uptake of 2-[fluorine-18]-fluoro-2-deoxy-d-glucose, and SUVmax was evaluated as 4.7. This case was evaluated as a RECIST-responder and assessed as false-negative. PR, partial response; MPR, multiplanar reformatted; RECIST, Response Evaluation Criteria in Solid Tumor; CE, contrast-enhanced; SUV, standardized uptake value; PET, positron emission tomography.

Fig. 2

Receiver operating characteristics analysis of radiological indices disclosed significant differences between the RECIST responder and non-responder groups (red line: total perfusion on dynamic first-pass CE-perfusion ADCT; blue line: pulmonary arterial perfusion on dynamic first-pass CE-perfusion ADCT; green line: systemic arterial perfusion on dynamic first-pass CE-perfusion ADCT; pink line: total perfusion on dynamic first-pass CE-perfusion MR imaging; sky blue line: pulmonary arterial perfusion on dynamic first-pass CE-perfusion MR imaging; yellow-green line: systemic arterial perfusion on dynamic first-pass CE-perfusion MR imaging; yellow: SUVmax). AZs for indices on dynamic first-pass CE-perfusion ADCT were as follows: total perfusion, Az = 0.87; pulmonary arterial perfusion, Az = 0.72; systemic arterial perfusion, Az = 0.84. Moreover, Az for indices on dynamic first-pass CE-perfusion MR imaging were as follows: total perfusion, Az = 0.90; pulmonary arterial perfusion, Az = 0.72; systemic arterial perfusion, Az = 0.84. In addition, Az of SUVmax was assessed as 0.78. Az for total perfusion on dynamic first-pass CE-perfusion ADCT was significantly larger than that for pulmonary arterial perfusion using either method (ADCT: P = 0.003, MR imaging: P = 0.003). In addition, Az for total perfusion on dynamic first-pass CE-perfusion MR imaging was significantly larger than that for pulmonary arterial perfusion using either method (ADCT: P = 0.002, MR imaging: P = 0.002). The feasible threshold values for all indices were determined for dynamic CE-perfusion ADCT (total perfusion, 29.2 ml/100 ml/min; pulmonary arterial perfusion, 15.5 ml/100 ml/min; systemic arterial perfusion, 11.0 ml/100 ml/min), dynamic CE-perfusion MR imaging (total perfusion, 37.5 ml/100 ml/min; pulmonary arterial perfusion, 16.3 ml/100 ml/min; systemic arterial perfusion, 16.5 ml/100 ml/min) and PET/CT (5.7 for SUVmax). ADCT, area-detector computed tomography; CE, contrast-enhanced; SUV, standardized uptake value; Az, area under the curve; PET/CT, positron emission tomography combined with CT.