Visual Versus Quantitative Assessment of Intratumor 18F-FDG PET Uptake Heterogeneity: Prognostic Value in Non-Small Cell Lung Cancer

The goal of this study was to compare visual assessment of intratumor F-18-FDG PET uptake distribution with a textural-features (TF) automated quantification and to establish their respective prognostic value in non small cell lung cancer (NSCLC). Methods: The study retrospectively included 102 consecutive patients. Only primary tumors were considered. Intratumor heterogeneity was visually scored (3-level scale [H-visu]) by 2 nuclear medicine physicians. Tumor volumes were automatically delineated, and heterogeneity was quantified with TF. Mean and maximum standardized uptake value were also included. Visual interobserver agreement and correlations with quantitative assessment were evaluated using the K test and Spearman rank (rho) coefficient, respectively. Association with overall survival and recurrence-free survival was investigated using the Kaplan-Meier method and Cox regression models. Results: Moderate correlations (0.4 < rho < 0.6) between TF parameters and H-visu were observed. lnterobserver agreement for H-visu was moderate (K = 0.64, discrepancies in 27% of the cases). High standardized uptake value, large metabolic volumes, and high heterogeneity according to TF were associated with poorer overall survival and recurrence-free survival and remained an independent prognostic factor of overall survival with respect to clinical variables. Conclusion: Quantification of F-18-FDG uptake heterogeneity in NSCLC through TF was correlated with visual assessment by experts. However, TF also constitutes an objective heterogeneity quantification, with reduced interobserver variability, and independent prognostic value potentially useful for patient stratification and management.