The clinical implications of FDG-PET/CT differ according to histology in advanced gastric cancer

Hong Jae Chon^{1

2}, Chan Kim¹, Arthur Cho³, Yoo Min Kim⁴, Su Jin Jang⁵, Bo Ok Kim⁶, Chan Hyuk Park⁷, Woo Jin Hyung⁸, Joong Bae Ahn⁹, Sung Hoon Noh⁸, Mijin Yun¹⁰, Sun Young Rha¹¹

Affiliations

¹ Medical Oncology, CHA Bundang Medical Center, CHA University, Seongnam, South Korea.
² Yonsei Graduate School, Yonsei University College of Medicine, Seoul, South Korea.
³ Department of Nuclear Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-ku, Seoul, 120-752, South Korea.
⁴ Department of Surgery, CHA Bundang Medical Center, CHA University, Seongnam, South Korea.
⁵ Department of Nuclear Medicine, CHA Bundang Medical Center, CHA University, Seongnam, South Korea.
⁶ Biostatistics Collaboration Unit, Department of Research Affairs, Yonsei University College of Medicine, Seoul, South Korea.
⁷ Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, South Korea.
⁸ Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea.
⁹ Department of Internal Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-ku, Seoul, 120-752, South Korea.
¹⁰ Department of Nuclear Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-ku, Seoul, 120-752, South Korea. yunmijin@yuhs.ac.
¹¹ Department of Internal Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-ku, Seoul, 120-752, South Korea. rha7655@yuhs.ac.

PMID: 29948387
PMCID: PMC6314995
DOI: 10.1007/s10120-018-0847-5

The clinical implications of FDG-PET/CT differ according to histology in advanced gastric cancer

Hong Jae Chon et al. Gastric Cancer. 2019 Jan.

. 2019 Jan;22(1):113-122.

doi: 10.1007/s10120-018-0847-5. Epub 2018 Jun 9.

Authors

Affiliations

¹ Medical Oncology, CHA Bundang Medical Center, CHA University, Seongnam, South Korea.
² Yonsei Graduate School, Yonsei University College of Medicine, Seoul, South Korea.
³ Department of Nuclear Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-ku, Seoul, 120-752, South Korea.
⁴ Department of Surgery, CHA Bundang Medical Center, CHA University, Seongnam, South Korea.
⁵ Department of Nuclear Medicine, CHA Bundang Medical Center, CHA University, Seongnam, South Korea.
⁶ Biostatistics Collaboration Unit, Department of Research Affairs, Yonsei University College of Medicine, Seoul, South Korea.
⁷ Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, South Korea.
⁸ Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea.
⁹ Department of Internal Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-ku, Seoul, 120-752, South Korea.
¹⁰ Department of Nuclear Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-ku, Seoul, 120-752, South Korea. yunmijin@yuhs.ac.
¹¹ Department of Internal Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-ku, Seoul, 120-752, South Korea. rha7655@yuhs.ac.

PMID: 29948387
PMCID: PMC6314995
DOI: 10.1007/s10120-018-0847-5

Abstract

Background: The prognostic impact of preoperative ¹⁸F-FDG PET/CT in advanced gastric cancer (AGC) remains a matter of debate. This study aims to evaluate the prognostic impact of SUV_max in preoperative ¹⁸F-FDG PET/CT of AGC according to histologic subtype, with a focus on the differences between tubular adenocarcinoma and signet ring cell (SRC) carcinoma.

Methods: As a discovery set, a total of 727 AGC patients from prospective database were analyzed according to histologic subtype with Cox proportional hazard model and p-spline curves. In addition, another 173 patients from an independent institution was assessed as an external validation set.

Results: In multivariate analysis, high SUV_max in preoperative ¹⁸F-FDG PET/CT of AGC was negatively correlated with disease-free survival (DFS) and overall survival (OS) in patients with diffuse type (DFS: HR 2.17, P < 0.001; OS: HR 2.47, P < 0.001) or SRC histology (DFS: HR 2.26, P = 0.005; OS: HR 2.61, P = 0.003). This negative prognostic impact was not observed in patients with intestinal type or well or moderately differentiated histology. These findings have been consistently confirmed in a validation set. The p-spline curves also showed a gradual increase in log HR as SUV_max rises only for SRC histology and for diffuse-type AGC. Finally, a novel predictive model for recurrence of AGC with diffuse type or SRC histology was generated and validated based on the preoperative SUV_max.

Conclusions: Preoperative high SUV_max of AGC is a poor prognostic factor in those with diffuse type or SRC histology. This study is the first to demonstrate the differential prognostic impact of preoperative PET/CT SUV_max in AGC according to histologic subtype and provide a clue to explain previous discrepancies in the prognostic impact of preoperative PET/CT in AGC. Prospective studies are required to validate the role of preoperative SUV_max in AGC.

Keywords: Advanced gastric cancer; Diffuse type; PET/CT; Prognostic impact; Signet ring cell carcinoma.

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Conflict of interest statement

Ethical standards

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1964 and later versions. Informed consent to be included in the study, or the equivalent, was obtained from all patients.

Conflict of interest

Research grants from funding agencies: the National Research Foundation of Korea (NRF) Grant funded by the Ministry of Science, ICT and Future Planning (Grant NRF-2016M3A9E8941664 to H.C. NRF-2016R1C1B2014671 to C.K.) and the Grant from the National R&D Program for Cancer Control, Ministry of Health and Welfare (Grant 1520190 to S.Y.R). Honoraria for speaking at symposia: no. Financial support for attending symposia: no. Financial support for educational programs: no. Employment or consultation: no. Support from a project sponsor: no. Position on advisory board or board of directors or other type of management relationships: no. Multiple affiliations: no. Financial relationships, for example equity ownership or investment interest: no. Intellectual property rights (e.g. patents, copyrights and royalties from such rights). Holdings of spouse and/or children that may have financial interest in the work: no.

Figures

**Fig. 1**
The preoperative ¹⁸F-FDG PET/CT SUVmax of advanced gastric cancer (AGC) according to histologic subtype. a The SUV_max correlates with the histologic type of AGC by both the WHO and Lauren classifications. b The SUV_max correlates well with the maximal size of the tumor in AGC with well to moderately differentiated (WMD) histology or intestinal type. *P < 0.05

**Fig. 2**
Kaplan–Meier survival curves comparing the high- and low-SUV_max groups in each histologic subtype. **a, b** High SUV_max only had a negative prognostic impact on disease-free survival (DFS) in AGC with SRC histology or diffuse type. **c, d** High SUV_max only had a negative prognostic impact on overall survival (OS) in AGC with SRC histology or diffuse type

**Fig. 3**
p-spline curves for DFS after adjusting for sex, age, and disease stage. The p-spline curves show a gradual increase in log HR as SUV_max rises only for SRC histology (a, right) and for diffuse type (b, right). There was no definite trend for WMD and PD histology (a, left) or intestinal type (b, left)

**Fig. 4**
Predictive model for recurrence based on preoperative SUV_max in SRC (a) or diffuse-type AGC (b)

**Fig. 5**
Calibration curves for the performance of predictive model in SRC (a) or diffuse-type AGC (b)

See this image and copyright information in PMC

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