Voxel-based dual-time ¹⁸F-FDG parametric imaging for rectal cancer: Differentiation of residual tumor from postchemoradiotherapy changes

INTRODUCTION: F-Fluorodeoxyglucose (F-FDG) PET/computed tomography (CT) has been used for evaluation of the response of rectal cancer to neoadjuvant chemoradiotherapy (CRT), but differentiating residual tumor from post-treatment changes remains a problem. We propose a voxel-based dual-time F-FDG PET parametric imaging technique for the evaluation of residual rectal cancer after CRT. MATERIALS AND METHODS: Eighty-six patients with locally advanced rectal cancer who underwent neoadjuvant CRT between March 2009 and February 2011 were selected retrospectively. Standard 60-min postinjection PET/CT scans followed by 90-min delayed images were coregistered by rigid-body transformation. A dual-time parametric image was generated, which divided delayed standardized uptake value (SUV) by 60-min SUV on a voxel-by-voxel basis. Maximum delayed-to-standard SUV ratios (DSR) measured on the parametric images as well as the percentage of SUV decrease from pre-CRT to post-CRT scans (pre/post-CRT response index) were obtained for each tumor and correlated with pathologic response classified by the Dworak tumor regression grade (TRG). RESULTS: With respect to the false-positive lesions in the nine post-CRT patients with false-positive standard F-FDG scans in case groups who responded to therapy (TRG 3 or 4 tumors), eight were undetectable on dual-time parametric images (P<0.05). The maximum DSR showed significantly higher accuracy for identification of tumor regression compared with the pre/post-CRT response index in receiver-operating characteristic analysis (P<0.01). With a 1.25 cutoff value for the maximum DSR, 85.0% sensitivity, 95.5% specificity, and 93.0% overall accuracy were obtained for identification of good response. CONCLUSION: A voxel-based dual-time parametric imaging technique for evaluation of post-CRT rectal cancer holds promise for differentiating residual tumor from treatment-related nonspecific F-FDG uptake.