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. 2008 Nov;2(6):287-94.

The Value of PET Imaging in Patients with Localized Gastroesophageal Cancer

Katja Ott  1 , Ken Herrmann, Bernd-Joachim Krause, Florian Lordick
Affiliations

The Value of PET Imaging in Patients with Localized Gastroesophageal Cancer

Katja Ott et al. Gastrointest Cancer Res. 2008 Nov.

Abstract

Preoperative induction therapy in stages II and III adenocarcinoma of the esophagogastric junction (AEG) and gastric cancer is now an accepted treatment choice in the Western world. Patients who respond to induction therapy have significantly improved survival compared to nonresponding patients. Until recently, however, no prospectively tested markers for predicting response and/or prognosis in this settingwere available. The MUNICON I study recently showed the utility of fluorodeoxyglucose-positron emission tomography (FDG-PET) in predicting response and prognosis in AEG and indicated the feasibility of a PET-guided treatment algorithm. These findings are an important step forward in tailoring multimodal treatment to tumor biology. In gastric cancer, the issue is more complicated, because approximately 30% of these cancers cannot be visualized with sufficient contrast for quantification. Insufficient FDG uptake is mostly associated with diffusetype gastric cancer with signet cells and mucinous content. In FDG avid patients, FDG-PET can be used for response evaluation. The prognosis of nonavid patients is similar to metabolic nonresponders. The addition of new tracers (eg, fluorothymidine) might increase the accuracy of these tests in the future. In AEG types I and II, PET-guided induction therapy is feasible and will undergo further evaluation in a randomized multicenter trial. In gastric cancer, there should be consideration of such treatment concepts as immediate resection after 2 weeks of induction therapy with or without adjuvant treatment in metabolic nonresponders or modified chemotherapy regimens possibly including biologically targeted drugs in FDG non-avid tumors.

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Figures

Figure 1.
Figure 1.
Comparison of overall survival of (A) patients with complete chemotherapy for 3 months and (B) patients with metabolic response-based neoadjuvant treatment. The median survival was 26 months in metabolic nonresponding patients with immediate resection after 2 weeks and 18 months in patients with complete chemotherapy in the historical control group. Stopping chemotherapy, thus, seems not to worsen prognosis of metabolic nonresponding patients.
Figure 2.
Figure 2.
Design of the planned EUROCON study with randomization of nonresponding patients after 2 weeks of chemotherapy (CTx) to immediate resection or chemoradiation therapy (Radio-CTx) followed by surgery. Abbreviation: d = day.
Figure 3:
Figure 3:
Overall survival of patients with locally advanced gastric cancer who had metabolic response or metabolic nonresponse calculated from the beginning of chemotherapy (A) and from time of complete resection (B). On both analyses, metabolic responders had significantly improved survival compared to metabolic nonresponders. Adapted with permission from Ott et al.
Figure 4:
Figure 4:
Overall survival of FDG-avid metabolic responding patients (green line), FDG-avid metabolic nonresponding patients (blue line), and FDG non-avid patients (red line). Prognosis of metabolic responding patients is significantly improved compared to metabolic nonresponding patients (P = .037). Prognosis of patients with non-avid tumors and FDG-avid nonresponding patients is not statistically different (P = .46). There is a trend for improved survival of metabolic responding patients compared to FDG non-avid patients (P = .11). Adapted with permission from Ott et al.
Figure 5.
Figure 5.
Visualization of locally advanced gastric cancer with FDG-PET and FLT-PET.
Figure 6:
Figure 6:
Theoretical model of an individualized FDG-PET–based treatment strategy in locally advanced gastric cancer (ca). Abbreviations: CTx = chemotherapy; d = day.
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