DOI: 10.1007/s00259-018-4151-8Pages: 1-8

Why harmonization is needed when using FDG PET/CT as a prognosticator: demonstration with EARL-compliant SUV as an independent prognostic factor in lung cancer

1. University Hospital, Nuclear Medicine Department

2. François Baclesse Cancer Centre, Nuclear Medicine Department

3. Normandie University, INSERM ANTICIPE

4. François Baclesse Cancer Centre, Clinical Research Department

5. François Baclesse Cancer Centre, Medical Informatics Department

6. François Baclesse Cancer Centre, Lung Cancer Unit

7. François Baclesse Cancer Centre, Regional Cancer Registry

Correspondence to:
Nicolas Aide
Tel: +33 231063244




To determine EARL-compliant prognostic SUV thresholds in a mature cohort of patients with locally advanced NSCLC, and to demonstrate how detrimental it is to use a threshold determined on an older-generation PET system with a newer PET/CT machine, and vice versa, or to use such a threshold with non-harmonized multicentre pooled data.

Materials and methods

This was a single-centre retrospective study including 139 consecutive stage IIIA-IIIB patients. PET data were acquired as per the EANM guidelines and reconstructed with unfiltered point spread function (PSF) reconstruction. Subsequently, a 6.3 mm Gaussian filter was applied using the EQ.PET (Siemens Healthineers) methodology to meet the EANM/EARL harmonizing standards (PSFEARL). A multicentre study including non-EARL-compliant systems was simulated by randomly creating four groups of patients whose images were reconstructed with unfiltered PSF and PSF with Gaussian post-filtering of 3, 5, and 10 mm. Identification of optimal SUV thresholds was based on a two-fold cross-validation process that partitioned the overall sample into learning and validation subsamples. Proportional Cox hazards models were used to estimate age-adjusted and multivariable-adjusted hazard ratios (HRs) and their 95% confidence intervals. Kaplan–Meier curves were compared using the log rank test.


Median follow-up was 28 months (1–104 months). For the whole population, the estimated overall survival rate at 36 months was 0.39 [0.31–0.47]. The optimal SUVmax cutoff value was 25.43 (95% CI: 23.41–26.31) and 8.47 (95% CI: 7.23–9.31) for the PSF and for the EARL-compliant dataset respectively. These SUVmax cutoff values were both significantly and independently associated with lung cancer mortality; HRs were 1.73 (1.05–2.84) and 1.92 (1.16–3.19) for the PSF and the EARL-compliant dataset respectively. When (i) applying the optimal PSF SUVmax cutoff on an EARL-compliant dataset and the optimal EARL SUVmax cutoff on a PSF dataset or (ii) applying the optimal EARL compliant SUVmax cutoff to a simulated multicentre dataset, the tumour SUVmax was no longer significantly associated with lung cancer mortality.


The present study provides the PET community with an EARL-compliant SUVmax as an independent prognosticator for advanced NSCLC that should be confirmed in a larger cohort, ideally at other EARL accredited centres, and highlights the need to harmonize PET quantitative metrics when using them for risk stratification of patients.

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  • Accepted: Aug 28, 2018
  • Online: Sep 14, 2018

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