Effects of Tumor Burden on Reference Tissue Standardized Uptake for PET Imaging: Modification of PERCIST Criteria

Abstract

Purpose To examine the effect metabolic burden (tumor and/or cardiac myocyte uptake) has on fluorine 18 fluorodeoxyglucose (FDG) distribution in organs and tissues of interest. Materials and Methods Positron emission tomographic (PET)/computed tomographic (CT) scans at the Ann Arbor Veterans Affairs hospital from January to July 2015 were reviewed. A total of 107 scans (50 patients; mean age, 64.3 years ± 13.2 [standard deviation]) had metabolic tissue burden assessed by using total lesion glycolysis (TLG) obtained from autosegmentation of the tumor and/or cardiac tissue. Standardized uptake value (SUV) and subsequent normalized SUV uptake in target organs and tissues were compared with 436 FDG PET/CT scans previously reported in 229 patients as a function of TLG to describe the effect(s) that metabolic burden has on reference tissue (blood pool, liver, and brain) FDG uptake. Subsequent regression by using linear mixed-effects models was used. If the slope of the regression was significantly (P < .05) different than zero, then an effect from TLG was present. Results There was a negative inverse relationship (P < .0001) between FDG uptake within reference tissues (blood pool, liver, and brain) and TLG in comparison to the study population at similar blood glucose levels. This TLG effect was no longer statistically significant (P > .05) when FDG uptake was normalized to a reference tissue (eg, blood pool or liver). Conclusion Metabolic tissue burden can have a significant effect on SUV measurements for PET imaging. This effect can be mitigated by normalizing FDG uptake to a reference tissue. RSNA, 2018.

The PET-Derived Tumor-to-Liver Standard Uptake Ratio (SUVTLR) Is Superior to Tumor SUVmax in Predicting Tumor Response and Survival After Chemoradiotherapy in Patients With Locally Advanced Esophageal Cancer

“…In addition, SUVmax is also affected by some technical factors, for example, errors in scanner calibration, reconstruction settings, and the attenuation-corrected protocol ( 33 ). Moreover, it was reported that FDG uptake and biodistribution are affected by tumor burden, tumor volume, and the volume of interest ( 34 – 36 ). In light of this variation, recent reports have suggested that applying a standardized SUVmax, i.e., tumor SUVmax normalized by an appropriate reference background, may overcome this problem in some instances ( 36 , 37 ).…”

Effect of blood glucose level on standardized uptake value (SUV) in 18F- FDG PET-scan: a systematic review and meta-analysis of 20,807 individual SUV measurements

“…We speculate that these results could be explained by overexpression and augmented capability of glucose transporters in the cellular membranes of tumoral cells [28,[79][80][81][82]. In other words, glucose transporters are in such abundance in the malignant tissue that they cannot be saturated even in case of excessive endogenous glucose; thus there is less, if any, competition between FDG and endogenous glucose to enter tumoral cells [83]. Saturation or otherwise is not the issue and would make no difference.…”

Blood pool activity on F-18 FDG PET/CT as a possible imaging biomarker of metabolic syndrome

“…However, the interaction of the biodistribution of FDG in normal tissues or tumors is complex 27 . Previous studies have shown that metabolic burden from oncologic patients could change the biodistribution of FDG, and therefore, the metabolic activity of reference organs, such as the liver or blood pool, could be affected 28 . In case of FDG PET/CT on healthy subjects, blood pool activity may be the overall result of the metabolism of the whole body, which would be closely related to the metabolic state.…”