ArticleCancers2025
Multi-Institutional Verification of a Novel Predictor (Volume-Scaled SUVmax) for Successful Biology-Guided Radiotherapy Delivery of Small Targets.
Article in Cancers, 2025. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
BACKGROUND/
objectivesThe aim of this study was to establish the relationship between target size and the required diagnostic PET maximum standard uptake value (SUVmax) thresholds needed for successful Biology-guided Radiotherapy (BgRT) delivery on RefleXion X1 PET-linac. The current clinical eligibility recommendation is an SUVmax ≥ 6 at simulation, but the RefleXion system subsequently evaluates Activity Concentration (AC), which must exceed 5 kBq/mL for successful BgRT planning.
methodsA custom 3D-printed phantom containing six spherical targets (8 to 20 mm diameter) was used with varying target-to-background ratios (5:1 to 20:1) of 18F-FDG to systematically achieve a range of SUVmax values for each target size. Images were acquired on Siemens Biograph mCT for SUVmax quantification and RefleXion X1 for AC measurements. Twenty-four BgRT plans were evaluated, and delivery accuracy was validated using ArcCHECK. Additionally, retrospective data from 18 patients across four institutions were analyzed to validate the phantom-derived findings.
resultsThe PET-linac successfully planned treatments for 13/24 experiments, all achieving an AC > 5 kBq/mL. SUVmax requirements varied by target size: 16-20 mm targets required an SUVmax > 6, consistent with current recommendations, while smaller targets required higher thresholds (e.g., 13 mm: SUVmax > 10, and 11 mm: SUVmax > 15). 8 and 9 mm targets failed to meet AC requirements even at SUVmax 14. Successful deliveries maintained acceptable accuracy, with gamma passing rates of 92.4% ± 5.0% (3%/2 mm) and 97.6% ± 1.9% (3%/3 mm). Analysis revealed that Volume (cc) × SUVmax > 11 consistently predicted successful BgRT planning across all target sizes. This threshold was validated using multi-institutional PET-CT patient data (mean: 11.36, 95% CI: 9.1-12.9), correctly predicting treatment eligibility in 15 of 18 cases.
conclusionsTarget size significantly influences BgRT eligibility. We derived a new criterion, Volume(cc) × SUVmax > 11 (95% CI: 9.1-12).
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