Patterns of disease progression on 18F-fluorodeoxyglucose positron emission tomography-computed tomography in patients with malignant pleural mesothelioma undergoing multimodality therapy with pleurectomy/decortication

Our plain-English summary of Patterns of disease progression on 18F-fluorodeoxyglucose positron emission tomography-computed tomography in patients with malignant pleural mesothelioma undergoing multimodality therapy with pleurectomy/decortication, by A. Bille, S. Chicklore, L. Okiror, et al (Nuclear Medicine Communications, 2013).

The study

• Authors: A. Bille, S. Chicklore, L. Okiror, G.J. Cook, J. Spicer, D. Landau, L. Lang-Lazdunski
• Journal: Nuclear Medicine Communications
• Published: 2013;34(11):1075-83
• Cited by: 10 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Introduction: The aim of this study was to evaluate the patterns of disease progression in patients treated with pleurectomy/decortication (P/D), hyperthermic pleural lavage with povidone-iodine, prophylactic radiotherapy and adjuvant chemotherapy, using F-fluorodeoxyglucose (18F-FDG) PET/computed tomography (PET/CT).

Materials And Methods: This was a retrospective study of 65 patients treated with a multimodality therapy including P/D between October 2004 and March 2012. Thirty-two patients underwent 18F-FDG PET/CT within 6 weeks of completion of adjuvant chemotherapy and 6-monthly thereafter at our institution. The first site of relapse on 18F-FDG PET/CT was recorded, and all scans were reviewed by an independent observer.

Results: Thirty-two patients (27 male, median age 61 years, range 45-73) underwent their 18F-FDG PET/CT scans at our institution. Eighteen of the 32 patients were alive at last follow-up (median follow-up 42 months, range 16-76). Nine patients were alive with disease recurrence. Fourteen patients died of disease progression (median survival 24.7 months, range 15-38). The median maximum standardized uptake value (SUVmax) in relapsing mesothelioma was 10.9 (range 4.9-27.3). There was a statistically significant correlation between the SUVmax and tumour lesion glycolysis of recurrent mesothelioma and overall survival (P=0.05). The site of disease recurrence was the pleura in the majority of the alive patients and was extrapleural in the dead patients. There was a statistically significant correlation between disease-free survival and complete macroscopic resection (P=0.02).

Conclusion: After P/D with hyperthermic pleural lavage with povidone-iodine, prophylactic radiotherapy and adjuvant chemotherapy, the most frequent site of recurrence is the pleural cavity. Peritoneal seeding is rare. The tumour SUVmax and tumour lesion glycolysis correlate significantly with overall survival.

In plain English

This retrospective study from Guy's & St Thomas' Hospital in London used PET/CT to track where malignant pleural mesothelioma returned after combined treatment. The treatment was surgery removing the pleura (pleurectomy/decortication), a heated povidone-iodine wash of the chest, preventive radiotherapy and chemotherapy. Of 65 patients treated from October 2004, the 32 scanned at the hospital were analysed. The article did not study asbestos exposure. At last follow-up, 18 of the 32 were alive and 14 had died of disease progression. Among the living, 9 had recurrence, mostly in the pleural cavity. Only 4 of the 14 who died had recurrence in the same-side pleural cavity alone. Others had disease in the mediastinum, the other pleural cavity, lymph nodes, bone or, in one patient, the peritoneum. Of patients with complete macroscopic resection (removal of all visible tumour), 13 of 23 stayed disease-free over 2 years, against 2 of 9 with incomplete resection. Higher tumour activity on scans was linked to shorter survival. The authors concluded that the pleural cavity was the most common recurrence site, and called their study small and retrospective.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Retrospective single-centre study of patients followed with 18F-FDG PET/CT after multimodality treatment
• Who was studied: Patients with malignant pleural mesothelioma at Guy's & St Thomas' Hospital, London. Of 65 consecutive patients treated from October 2004, 32 who had PET/CT at the same centre were analysed; follow-up ran until December 2012. The article gives 27 male in its abstract and 28 male in its table; median age was 61 years (range 45 to 73).
• Exposure: The article did not study asbestos exposure or fiber type. What it studied was a treatment: pleurectomy/decortication, hyperthermic pleural lavage with povidone-iodine, prophylactic radiotherapy (21 Gy in three daily fractions) and adjuvant chemotherapy (gemcitabine and cisplatin before 2007, then pemetrexed and cisplatin), followed by 18F-FDG PET/CT every 6 months.
• Main results:
  • Of the 32 patients, 18 were alive at last follow-up (median follow-up 42 months, range 16 to 76). 14 died of disease progression (median survival 24.7 months, range 15 to 38).
  • Among living patients, 9 had no recurrence. 9 had recurrence: 6 in the pleural cavity, 1 in the pleural cavity and mediastinum, and 2 around the diaphragmatic mesh.
  • Among patients who died, recurrence sites were:
• the pleural cavity in 4
• the pleural cavity and mediastinum in 2
• both pleural cavities in 1
• a supraclavicular lymph node in 1
• coeliac lymph nodes in 2
• the vertebrae (bone) in 2
• the peritoneum in 1

No patient relapsed in the thoracotomy scar.

• Disease-free survival was linked to complete macroscopic resection (P = 0.02). 13 (56.5%) of 23 patients with macroscopic complete resection were disease-free for more than 2 years, compared with 2 (22%) of 9 with macroscopic incomplete resection.
• There was no statistical correlation between TNM staging and disease-free or overall survival. There was also no statistical correlation between site of recurrence and overall or disease-free survival (P = 0.2 and 0.1).
• Median SUVmax (a measure of tumour activity on PET) in recurrent mesothelioma was 10.9 (range 4.9 to 27.3). Patients with recurrence and SUVmax of 10.9 or less had 2- and 5-year survival of 100% and 57%. Those with SUVmax above 10.9 had 2-year survival of 54%, and none were alive at 5 years (P = 0.02).
• Patients with tumour lesion glycolysis (TLG) under 97 had 2- and 5-year survival of 91% and 56%. Those with TLG of at least 97 had 48% and 0% (P = 0.004).
• In multivariate analysis, only TLG was an independent prognostic factor for overall survival (P = 0.014; hazard ratio 1.002, 95% confidence interval 1.00 to 1.002).
• The authors' conclusion: The authors concluded that the pleural cavity was the most frequent site of recurrence and that peritoneal seeding and distant metastases were rare. They also concluded that tumour SUVmax and TLG correlated significantly with overall survival and could help predict prognosis.
• Limitations the authors state:
  • The authors described the study as small and retrospective.
  • The authors stated that the results need prospective confirmation.
  • The authors noted that image noise affects SUV accuracy. They also noted that non-cancer uptake from scarring and inflammation after treatment can blur how far a recurrence extends.

Topics

The National Library of Medicine indexes this study under subjects our site covers: Mesothelioma.

Medical terms in this study, explained in our Lexicon: Disease Progression, Pleural Mesothelioma, Multimodal Therapy, Pleurectomy/Decortication (P/D), Chemotherapy, CT Scan, Median Survival, Mesothelioma.

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• Clinical value of fluorodeoxyglucose-positron emission tomography/computed tomography in differentiation of malignant mesothelioma from asbestos-related benign pleural disease: an observational pilot study — H. Yildirim, M. Metintas, et al. (2009)
• The role of fluorodeoxyglucose-positron emission tomography/computed tomography in differentiating between benign and malignant adrenal lesions — P. Ozcan Kara, T. Kara, et al. (2011)
• Clinical implications of 18F-fluorodeoxyglucose positron emission tomography/computed tomography at delayed phase for diagnosis and prognosis of malignant pleural mesothelioma — Y. Abe, K. Tamura, et al. (2012)
• 18-Fluorodeoxyglucose positron emission tomography as a tool for response prediction in solid tumours — D.J. De Maeseneer, B. Lambert, et al. (2010)

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