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LETTER TO EDITOR
Year : 2014  |  Volume : 51  |  Issue : 3  |  Page : 390
 

Response assessment to Sunitinib by F-18 Fluorodeoxyglucose PET/CT in a case of venous tumor thrombosis from renal cell carcinoma


1 Department of Nuclear Medicine and PET, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Urology, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Web Publication10-Dec-2014

Correspondence Address:
Prof. B R Mittal
Department of Nuclear Medicine and PET, Postgraduate Institute of Medical Education and Research, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.146770

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How to cite this article:
Manohar K, Mittal B R, Agrawal K, Kashyap R, Bhattacharya A, Mandal A K. Response assessment to Sunitinib by F-18 Fluorodeoxyglucose PET/CT in a case of venous tumor thrombosis from renal cell carcinoma. Indian J Cancer 2014;51:390

How to cite this URL:
Manohar K, Mittal B R, Agrawal K, Kashyap R, Bhattacharya A, Mandal A K. Response assessment to Sunitinib by F-18 Fluorodeoxyglucose PET/CT in a case of venous tumor thrombosis from renal cell carcinoma. Indian J Cancer [serial online] 2014 [cited 2019 Dec 16];51:390. Available from: http://www.indianjcancer.com/text.asp?2014/51/3/390/146770


Sir,

F-18 Fluorodeoxyglucose (FDG) PET/CT has been shown to be useful in restaging, surveillance, and demonstration of unusual sites of metastases in patients with renal cell carcinoma. [1] We describe here a case of isolated tumor thrombosis of Inferior Vena Cava (IVC), in which F-18 FDG PET/CT was useful in predicting response to treatment to tyrosine kinase inhibitor sunitinib. A 49-year-old male patient underwent right radical nephrectomy was noted to have inferior vena caval tumor thrombus with invasion of wall intra-operatively. Tumor thrombus was unresectable due to IVC wall invasion. Patient was subjected to F-18 FDG PET/CT scan for restaging of disease and to identify the extent of tumor thrombus. Significant FDG uptake (SUVmax = 7.2) above liver background was noticed in tumor thrombus involving the entire intra- and infra-hepatic IVC and bilateral common iliac and bilateral external iliac veins. No abnormal FDG uptake was noted in rest of the body. Patient was started on sunitinib treatment, and repeat F-18 FDG PET/CT scan was done after 3 cycles of 21-day therapy. Interim FDG PET/CT was interpreted according to EORTC criteria for response assessment, and the scan showed decrease in SUVmax of tumor thrombus from 7.2 to 5.2 (decrease of 27%) coupled with visible reduction of uptake to less than liver background in greater than 50% extent of involvement (infra-hepatic IVC and bilateral iliac veins), compared to baseline scan fitting into partial response category according to EORTC criteria. [2] However, filling defect persisted on contrast CT images. This partial response on F-18 FDG PET/CT correlated well with prognosis of the patient, as patient remained progression-free till the last follow-up at 9 months. Tyrosine kinase inhibitors have shown to prolong the survival conventional response assessment criteria like RECIST. [3] SHARP trial is one of the landmark study, which highlighted the failure of anatomical response criteria in assessment of response to tyrosine kinase inhibitors. [4] Few studies with F18-FDG PET/CT have elucidated the potential role of F18-FDG PET/CT in assessment of response in this group of patients and making meaningful assessment of response with good correlation with progression-free survival. [5] As demonstrated in our case, probably the first in our knowledge, F-18 FDG PET/CT was able to predict response and progression-free survival in isolated tumor venous thrombosis in renal cell carcinoma. Metrics of SUVmax reduction of 25% and measurement of length of involvement using F-18 FDG PET/CT as described by EORTC criteria can be a useful methodology to assess response to therapy early in case of tumor venous thromboses as there are no clear guidelines to assess response to chemotherapy in tumor venous thromboses. [Figure 1]
Figure 1: (a) Pre-therapy coronal CeCT and FDG PET/CT images showing filling defect and increased FDG uptake (SUVmax = 7.2) in entire intra and infra-hepatic IVC and bilateral common iliac veins. (b) Post-therapy coronal FDG PET/CT images showing decrease in SUVmax of tumor thrombus from 7.2 to 5.2 (decrease of 27%) coupled with visible reduction of uptake to less than liver background in infra-hepatic IVC and bilateral iliac veins while filling defect persisted on CeCT images

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  References Top

1.
Kumar R, Shandal V, Shamim SA, Jeph S, Singh H, Malhotra A. Role of FDG PET-CT in recurrent renal cell carcinoma. Nucl Med Commun 2010;31:844-50.  Back to cited text no. 1
    
2.
Young H, Baum R, Cremerius U, Herholz K, Hoekstra O, Lammertsma AA, et al. Measurement of clinical and subclinicaltumour response using [18 F]-fluorodeoxyglucose and positron emission tomography: Review and 1999 EORTC recommendations. European Organizationfor Research and Treatment of Cancer (EORTC) PET Study Group. Eur J Cancer 1999;35:1773-82.  Back to cited text no. 2
    
3.
Forner A, Ayuso C, Varela M, Rimola J, Hessheimer AJ, de Lope CR et al. Evaluation of tumor response after locoregional therapies in hepatocellular carcinoma: Are response evaluation criteria in solid tumors reliable? Cancer 2009;115:616-23.  Back to cited text no. 3
    
4.
Llovet JM, Ricci S, Mazzaferro V, Hilgard P, Gane E, Blanc JF et al. Sorafenib in advanced hepatocellular carcinoma. N Engl J Med 2008;359:378-90.  Back to cited text no. 4
    
5.
Sunaga N, Oriuchi N, Kaira K, Yanagitani N, Tomizawa Y, Hisada T et al. Usefulness of FDG-PET for early prediction of the response to gefitinib in non-small cell lung cancer Lung Cancer 2008;59:203-10.  Back to cited text no. 5
    


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