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Review
. 2024 Sep 23;14(18):2104.
doi: 10.3390/diagnostics14182104.

[18F]FDG PET/CT Integration in Evaluating Immunotherapy for Lung Cancer: A Clinician's Practical Approach

Juliette Brezun  1 , Nicolas Aide  2 , Evelyne Peroux  3 , Jean-Laurent Lamboley  4 , Fabrice Gutman  5 , David Lussato  6 , Carole Helissey  1
Affiliations
Review

[18F]FDG PET/CT Integration in Evaluating Immunotherapy for Lung Cancer: A Clinician's Practical Approach

Juliette Brezun et al. Diagnostics (Basel). .

Abstract

The advent of immune checkpoint inhibitors (ICIs) has revolutionized the treatment paradigm of lung cancer, resulting in notable enhancements in patient survival. Nevertheless, evaluating treatment response in patients undergoing immunotherapy poses distinct challenges due to unconventional response patterns like pseudoprogressive disease (PPD), dissociated response (DR), and hyperprogressive disease (HPD). Conventional response criteria such as the RECIST 1.1 may not adequately address these complexities. To tackle this issue, novel response criteria such as the iRECIST and imRECIST have been proposed, enabling a more comprehensive assessment of treatment response by incorporating additional scans and considering the best overall response even after radiologic progressive disease evaluation. Additionally, [18F]FDG PET/CT imaging has emerged as a valuable modality for evaluating treatment response, with various metabolic response criteria such as the PERCIMT, imPERCIST, and iPERCIST developed to overcome the limitations of traditional criteria, particularly in detecting pseudoprogression. A multidisciplinary approach involving oncologists, radiologists, and nuclear medicine specialists is crucial for effectively navigating these complexities and enhancing patient outcomes in the era of immunotherapy for lung cancer. In this review, we delineate the key components of these guidelines, summarizing essential aspects for radiologists and nuclear medicine physicians. Furthermore, we provide insights into how imaging can guide the management of individual lung cancer patients in real-world multidisciplinary settings.

Keywords: [18F]FDG PET/CT imaging; immune checkpoint inhibitors; lung cancer; treatment response assessment.

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Conflict of interest statement

The authors declare no conflicts of interest.

Figures

Figure 1
Figure 1
Tumor response according RECIST 1.1. SLD: sum of the longest diameters. CR: complete response. PR: partial response. SD: stable disease. PD: progressive disease.
Figure 2
Figure 2
iRECIST.
Figure 3
Figure 3
PET/CT imaging of patient with metastatic non-small cell lung cancer: evaluating pseudoprogression during treatment. Whole-body maximum intensity projection views are presented in panels (a,c,e). Corresponding fused transaxial PET/CT slices at the level of the thoracic disease and the left adrenal metastasis are shown in panels (b,d,f). (a,b) Baseline PET/CT images of a 58-year-old male patient with metastatic non-small cell lung cancer, showing a left upper lobe tumor (head arrow), bulky nodal disease (red arrow), and oligometastatic disease with a soft tissue lesion adjacent to the right hip and left adrenal metastasis (red dotted arrow). (c,d) Two months after initiation of chemotherapy plus immunotherapy, partial metabolic response is observed, with increased tracer uptake in the left adrenal metastasis (red dotted arrow). According to conventional criteria (PERCIST or EORTC), this would classify the patient as having progressive disease. However, using imPERCIST, the patient is classified as a partial metabolic responder. As the patient did not experience deterioration in performance status, treatment was continued. Evaluation two months later (e,f) revealed a complete metabolic response of distant metastases and nodal disease, along with an almost complete metabolic response of the primary tumor (head arrow).
Figure 4
Figure 4
The usefulness of PET/CT imaging of patient with metastatic non-small cell lung cancer: patient experiencing good response to treatment followed by progression. A 54-year-old male patient diagnosed with metastatic adenocarcinoma of the left upper lobe treated with chemotherapy (paclitaxel and carboplatin) and immunotherapy (pembrolizumab). 18F-FDG PET/CT (a–d) maximum-intensity views depicting at baseline (a) high uptake with a rim-like pattern in the primary tumor (red dotted arrow), along with bulky nodal disease involving the mediastinum and the left hilum (red arrows), as well as two bone metastases in the axial and appendicular skeleton. 18F-FDG PET/CT after 3 cycles of treatment (b) shows a partial metabolic response of the primary lesion (red dotted arrow) and the nodal disease with only one residual nodal uptake remaining at the level of station 2R (red arrow). Additionally, complete metabolic response is noted in both bone lesions. Subsequent 18F-FDG PET/CT after 5 months of treatment (c) shows only residual uptake in the primary tumor (red dotted arrow). Maintenance immunotherapy was initiated, and a follow-up PET examination at 10 months reveals an increase in both the size and metabolic activity of the primary tumor (red dotted arrow), with adjacent rib involvement (d). Corresponding fused PET/CT transverse slices at the level of the primary tumor (red dotted arrow) are depicted in panels (e–h).
Figure 5
Figure 5
A checklist for the PET reader.
Figure 6
Figure 6
Algorithm for care pathway for patients with lung cancer receiving immunotherapy.
See this image and copyright information in PMC

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