Residual metabolic tumor activity after chemo-radiotherapy is mainly located in initially high FDG uptake areas in rectal cancer

Purpose: Recent literature suggests that tumor cells and areas within tumors with a high initial FDG uptake might be more resistant to (chemo)radiotherapy ((C)RT). This study was undertaken to test this hypothesis in rectal cancer using rigid and non-rigid image registration. Patients and methods: Twenty-eight patients, diagnosed with locally advanced rectal cancer and referred for pre-operative treatment with CRT were included in this study. All patients underwent FDG-PET-CT imaging prior to and after CRT. Rigid and non-rigid image registration was performed to compensate organ deformations between the pre- and post-treatment PET-CT scans. The tumor was contoured on both PET-scans using SUV iso-contouring based on the SBR-method. The voxels with residual increased FDG uptake were studied and correlated to their pre-treatment FDG uptake level. Two SUV-volume-histograms were made based on the pre-treatment PET-data, one for the voxels within the pre-treatment tumor PET-based iso-contour and one for the voxels within the PET-based iso-contour of the residual tumor non-rigidly registered onto the pre-treatment scan. Results: For the voxels with a pre-treatment FDG uptake of >50% of SUVmax, 70.6 ± 5.6% of the voxels were still metabolic active in the residual tumor, whereas for voxels with an FDG uptake of <50% of SUVmax only 51.1 ± 6.7% were present in the metabolic active residual tumor. Conclusion: This study presents areas in rectal tumors with an initially high FDG uptake to be most likely to show residual disease after CRT. This could indicate a higher (C)RT-resistance for tumor regions with a high FDG uptake prior to treatment.