title: Inter-observer agreement improves with PERCIST 1.0 as opposed to qualitative evaluation in non-small cell lung cancer patients evaluated with F-18-FDG PET/CT early in the course of chemo-radiotherapy.
abstract: BACKGROUND
  The purpose of this study is to determine whether a qualitative approach or a semi-quantitative approach provides the most robust method for early response evaluation with 2'-deoxy-2'-[(18)F]fluoro-D-glucose (F-18-FDG) positron emission tomography combined with whole body computed tomography (PET/CT) in non-small cell lung cancer (NSCLC). In this study eight Nuclear Medicine consultants analyzed F-18-FDG PET/CT scans from 35 patients with locally advanced NSCLC. Scans were performed at baseline and after 2 cycles of chemotherapy. Each observer used two different methods for evaluation: (1) PET response criteria in solid tumors (PERCIST) 1.0 and (2) a qualitative approach. Both methods allocate patients into one of four response categories (complete and partial metabolic response (CMR and PMR) and stable and progressive metabolic disease (SMD and PMD)). The inter-observer agreement was evaluated using Fleiss' kappa for multiple raters, Cohens kappa for comparison of the two methods, and intraclass correlation coefficients (ICC) for comparison of lean body mass corrected standardized uptake value (SUL) peak measurements.
  
  
  RESULTS
  The agreement between observers when determining the percentage change in SULpeak was "almost perfect", with ICC = 0.959. There was a strong agreement among observers allocating patients to the different response categories with a Fleiss kappa of 0.76 (0.71-0.81). In 22 of the 35 patients, complete agreement was observed with PERCIST 1.0. The agreement was lower when using the qualitative method, moderate, having a Fleiss kappa of 0.60 (0.55-0.64). Complete agreement was achieved in only 10 of the 35 patients. The difference between the two methods was statistically significant (p < 0.005) (chi-squared). Comparing the two methods for each individual observer showed Cohen's kappa values ranging from 0.64 to 0.79, translating into a strong agreement between the two methods.
  
  
  CONCLUSIONS
  PERCIST 1.0 provides a higher overall agreement between observers than the qualitative approach in categorizing early treatment response in NSCLC patients. The inter-observer agreement is in fact strong when using PERCIST 1.0 even when the level of instruction is purposely kept to a minimum in order to mimic the everyday situation. The variability is largely owing to the subjective elements of the method.
authors.affiliation: Department of Nuclear Medicine, Herning Regional Hospital, 7400, Herning, Denmark. joan.fledelius@rm.dk.
authors.forename: Joan
authors.identifier: http://orcid.org/0000-0002-7825-7418
authors.initials: J
authors.lastname: Fledelius
authors.affiliation: Department of Oncology, Aarhus University Hospital, Aarhus, Denmark.
authors.forename: Azza
authors.initials: A
authors.lastname: Khalil
authors.affiliation: Department of Nuclear Medicine & PET-Centre, Aarhus University Hospital, Aarhus, Denmark.
authors.forename: Karin
authors.initials: K
authors.lastname: Hjorthaug
authors.affiliation: Department of Nuclear Medicine & PET-Centre, Aarhus University Hospital, Aarhus, Denmark.
authors.forename: Jørgen
authors.initials: J
authors.lastname: Frøkiær
keywords: F-18-FDG PET/CT; Inter-observer agreement; Lung cancer; PERCIST 1.0; Response evaluation