Comparison of standardized uptake value and standardized uptake lean body mass metrics in 18F-fluorodeoxyglucose positron emission tomography for assessing transformation in chronic lymphocytic leukemia and follicular lymphoma

Abstract

Background: The maximum standardized uptake value normalized to body weight (BW) (SUVmax) is a commonly used metric in ¹⁸F-fluorodeoxyglucose (FDG) positron emission tomography (PET) imaging for assessing tumor aggressiveness and response to therapy. However, SUVmax is sensitive to changes in BW, potentially leading to inaccuracies in patients with cancer cachexia or obesity. The maximum standardized uptake value normalized to lean body mass (SULmax) has been proposed as a more reliable alternative, particularly in contexts where BW fluctuations are significant. This study aimed to evaluate the relative performance of SUVmax and SULmax in identifying high-grade transformation of chronic lymphocytic leukemia (CLL) and follicular lymphoma (FL) into more aggressive lymphomas.

Methods: We conducted a retrospective, single-center analysis of PET/computed tomography (CT) scans from patients with CLL or FL, measuring the most avid lesion using both SUVmax and SULmax. High-grade transformation was identified through pathological records within 3 months after the scan, and receiver operating characteristic curves were used to compare the diagnostic performance of SUVmax and SULmax.

Results: A total of 32 patients with CLL and 58 with FL were included. Some patients had more than one biopsy, giving a total of 43 samples for CLL and 91 samples for FL. The receiver operating curve analysis showed insufficient evidence (P=0.92) of a statistical difference between SUVmax and SULmax in predicting transformation for CLL, with an area under the curve (AUC) of 0.918 for SUVmax and 0.921 for SULmax. In FL, SULmax also showed similar performance (AUC =0.754) to SUVmax (AUC =0.745) for predicting transformation to diffuse large B-cell lymphoma, with the difference again not significant (P=0.93). When grade 3B FL was also considered to be transformed lymphoma, SUVmax was effectively equal (P=0.96) to SULmax (AUC =0.932 and 0.931, respectively). Optimal cutoffs were about 7 to 8 for both diseases using SUVmax, and 5 for CLL or transformation of FL to a higher-grade lymphoma, but 9 if grade 3B was not counted.

Conclusions: Both SUVmax and SULmax can be reliably used for assessing the transformation of CLL and FL to aggressive lymphomas on 18F-FDG PET/CT. Given SULmax's stability with respect to weight changes, it may be more appropriate for assessing therapeutic response in patients with significant weight fluctuations. Further studies are needed to refine the use of these metrics in clinical practice.

Keywords: Standardized uptake value (SUV); lymphoma; positron emission tomography (PET); quantitation; transformation.

Figure 1

Flow of patients through study. CLL, chronic lymphocytic leukemia; PET, positron emission tomography.

Figure 2

BMI plotted against the ratio of total body weight to lean body mass (the conversion factor from SUL to SUV) for the described patient cohort. The two roughly parallel curves are due to the different coefficients in the James equation for men and women. BMI, body mass index; SUL, standardized uptake value normalized to lean body mass; SUV, standardized uptake value normalized to total body weight.

Figure 3

ROC curves for the transformation of follicular lymphoma to a higher-grade lymphoma for SUV and SUL. AUC, area under the curve; ROC, receiver operating characteristic; SUL, standardized uptake value normalized to lean body mass; SUV, standardized uptake value normalized to total body weight.

Figure 4

ROC curves for the transformation of lower grades of follicular lymphoma to grade 3B for SUV and SUL. AUC, area under the curve; ROC, receiver operating characteristic; SUL, standardized uptake value normalized to lean body mass; SUV, standardized uptake value normalized to total body weight.

Figure 5

ROC curves for the transformation of chronic lymphocytic leukemia to higher-grade lymphoma for SUV and SUL. AUC, area under the curve; ROC, receiver operating characteristic; SUL, standardized uptake value normalized to lean body mass; SUV, standardized uptake value normalized to total body weight.

Figure 6

SUL (left) and SUV (right) on a patient with a particularly large difference using a 10-step color map. The SUL of the axillary node is 2.7; the SUV, 7.5. SUL, standardized uptake value normalized to lean body mass; SUV, standardized uptake value normalized to total body weight.