Prognostic value of 18F-fluorodeoxyglucose positron emission tomography/computed tomography metabolic parameters combined with serum apolipoprotein A1 in patients with diffuse large B-cell lymphoma: a clinical study

Introduction

Diffuse large B-cell lymphoma (DLBCL) is a highly aggressive tumor that originates from mature B cells. It is the most common subtype of non-Hodgkin lymphoma (NHL), comprising nearly one-third of all NHL cases (1). Annually, approximately 150,000 new cases of DLBCL are diagnosed worldwide (2). Treatment strategies for DLBCL are tailored according to disease stage; localized DLBCL is typically managed with combination therapies, while advanced stages necessitate comprehensive chemotherapy (3). The International Prognostic Index (IPI) and its derivatives, such as the National Comprehensive Cancer Network IPI (NCCN-IPI), are essential tools for prognostic assessment in DLBCL patients (4).

The high sensitivity of 18F-fluorodeoxyglucose positron emission tomography/computed tomography (¹⁸F-FDG PET/CT) has led to its widespread adoption over CT for initial staging, monitoring, and evaluating treatment response in lymphoma (5). Key metabolic parameters derived from ¹⁸F-FDG PET/CT include the standardized uptake value (SUV) and metabolic tumor volume (MTV). Baseline MTV serves as an indicator of the quantity of metabolically active tumor cells and has been demonstrated to predict progression-free survival (PFS) in DLBCL (6). Apolipoprotein A1 (APOA1), a principal component of lipoproteins primarily found in high-density lipoprotein (HDL), plays crucial biological and regulatory roles (7). Recent investigations have highlighted the prognostic relevance of ApoA1 in DLBCL, with low serum levels correlating with poor treatment response, reduced survival rates, and increased recurrence risk (8). ApoA1 has been recognized as a standalone prognostic indicator for both overall survival (OS) and PFS, prompting the development of a novel prognostic index that integrates the International Prognostic Index with ApoA1 (IPI-A) to refine risk stratification (9).

Considering the significant prognostic value of NCCN-IPI, ApoA1, and 18F-FDG PET/CT metabolic parameters in DLBCL, we hypothesize that their combined assessment may enhance prognostic capabilities in DLBCL. However, related research remains relatively sparse. We present this article in accordance with the REMARK reporting checklist (available at https://tcr.amegroups.com/article/view/10.21037/tcr-2025-963/rc).

Methods

Study design

This study is a cross-sectional investigation aimed at evaluating the predictive value of ¹⁸F-FDG PET/CT metabolic parameters combined with ApoA1 in forecasting the prognosis of DLBCL. We consecutively included newly diagnosed DLBCL patients at our institution from January 1, 2015, to December 31, 2019. All patients underwent ¹⁸F-FDG PET/CT scans upon admission to assess baseline MTV and maximum standardized uptake value (SUVmax), along with ApoA1 measurement.

Ethical statement

The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethics Committee of Bengbu Medical University (July 10, 2024, No. 205, 2024). Because the data were de-identified, the need for patient informed consent was waived.

Study population

Inclusion criteria

• Age ≥18 years, regardless of sex.
• Newly diagnosed DLBCL confirmed by histopathology.
• Preoperative ¹⁸F-FDG PET/CT and ApoA1 testing.
• Availability of postoperative follow-up data.

Exclusion criteria

• History of other malignancies.
• Primary central nervous system lymphoma.
• Pregnancy or lactation.
• Mental or neurological disorders affecting treatment or follow-up.

18F-FDG PET/CT imaging and analysis

The imaging with ¹⁸F-FDG PET/CT was conducted using a Siemens Biograph mCT PET/CT scanner. Typical results of ¹⁸F-FDG PET/CT imaging in patient were showed in Figure 1. Regions of interest (ROI) for multiple or single lesions were delineated, and the SUVmax of the most significant lesion was recorded. A threshold of 41% SUVmax was utilized to define the tumor boundary, with Medex software employed for automated delineation to calculate the MTV. The total MTV (tMTV) was obtained by summing the MTV of all lesions, with results verified by two additional physicians.

Figure 1 Typical results of ¹⁸F-FDG PET/CT imaging in patient with diffuse large B-cell lymphoma. The maximum intensity projection highlights intense FDG uptake in the intrathoracic region, visualized on the horizontal plane (upper left) and sagittal plane (lower right). Corresponding CT anatomical images are displayed in the upper right, while the PET-CT fusion image is shown in the lower left. ¹⁸F-FDG PET/CT, 18F-fluorodeoxyglucose positron emission tomography/computed tomography.

Two senior nuclear-medicine physicians (each >10 years PET/CT experience, blinded to clinical data) independently outlined the regions of interest and recorded SUVmax and MTV for every scan. Agreement was quantified prospectively on a per‑patient basis: For SUVmax, the mean absolute difference between the two readers was 0.7±0.9, yielding an intraclass correlation coefficient (ICC) of 0.94 [95 % confidence interval (CI): 0.91–0.96]. Only 6 of the 138 patients (4.3%) met the predefined discordance threshold. For tMTV, the mean absolute difference was 11±18 mL, with an ICC of 0.92 (95% CI: 0.88–0.95). Discordance occurred in 8 of 138 patients (5.8%).

Discordance was defined a‑priori as an absolute SUVmax difference >2.5 or a tMTV difference >10% of the larger value. Each discordant dataset was re-evaluated jointly by the two primary readers, who reviewed segmentation slice-by-slice to identify the source of variation (e.g., partial-volume at lesion margins, physiologic uptake misclassified as tumor). If consensus remained elusive after joint review (occurred in 3/14 discordant metrics, i.e., 2.2% of all patients), a third senior reader (blinded to the initial measurements) adjudicated. The adjudicated or consensus value was entered into the database and used for all analyses. This process yielded a final 100% agreement, ensuring robustness of SUVmax and tMTV measurements used in the study.

Analytical variables

Post-admission, serum ApoA1 levels were measured using immunoturbidimetric methods on a Roche cobas8000 automated biochemical analyzer. Treatment regimens were categorized as CHOP-like or R-CHOP-like; molecular subtypes included GCB DLBCL, ABC DLBCL, and unclassified DLBCL. The lactate dehydrogenase (LDH) ratio was defined as the multiple of the normal upper limit of LDH. The data collected additionally included factors such as age, sex, Eastern Cooperative Oncology Group (ECOG) performance status, Ann Arbor staging, and the involvement of key extranodal organs. The primary outcome was defined as PFS, which refers to the time from randomization until disease progression, relapse, or death from any cause. Follow-up activities were last conducted on December 1, 2024, with information gathered from clinical records or via telephone interviews.All patients were managed with curative‑intent immunochemotherapy based on the CHOP backbone (cyclophosphamide, doxorubicin, vincristine, prednisone) every 21 days. Dose reductions followed institutional supportive‑care guidelines (e.g., for age >70 years or cardiac ejection fraction <50%), but the drug composition itself was not altered.

R-CHOP—full-dose CHOP plus rituximab 375 mg·m⁻² on day 1 (standard of care).

R-mini-CHOP—attenuated-dose CHOP (cyclophosphamide 400 mg·m⁻², doxorubicin 25 mg·m⁻², vincristine 1 mg flat dose, prednisone 40 mg·m⁻² d 1–5) plus rituximab, used in frail patients ≥80 years following the GELA protocol.

CHOP-like—identical cytotoxic backbone but without rituximab: either CHOP alone (pre-2010 diagnoses) or mini‑CHOP alone; this group existed because of cost or insurance constraints at the time of treatment initiation.

Sample size

Because this investigation was a single‑center, retrospective cohort that enrolled all consecutive DLBCL patients imaged with baseline ¹⁸F-FDG PET/CT between from January 1, 2015, to December 31, 2019, we did not perform a prospective sample‑size calculation before data collection. Nonetheless, we performed a post‑hoc power assessment to confirm that the cohort was large enough to address the primary objective—namely, to detect whether a low baseline ApoA1 level (≤0.94 g/L, median split) is associated with shorter PFS.

Assumptions: two-sided α=0.05; 80 % power (1 – β=0.80); expected hazard ratio (HR) for low vs. high ApoA1 ≈0.55; event (progression/relapse/death) rate ≈40% over 3 years (observed 56/138 events). Method: Schoenfeld’s formula for Cox proportional‑hazards models. Required number of events = [(Z_α/2 + Z_β)²] / [(ln HR) ²]→ (1.96 + 0.84)² / (ln 0.55)² ≈46 events.

Given an anticipated 40% event rate, the minimum sample size needed was ~116 patients (46/0.40). Actual cohort: 138 patients with 56 PFS events. Achieved power (post-hoc) ≈87 % to detect the prespecified HR of 0.55. Therefore, although the study was not prospectively powered, the final cohort exceeds the calculated requirement and provides adequate statistical power to test the primary hypothesis.

Statistical analysis

All statistical analyses and graphical presentations were performed using R programming language (R Core Team, Vienna, Austria). Chi-squared tests were employed to compare categorical variables, while non-parametric tests were utilized for continuous variables with non-normal distributions. SUVmax, MTV, and ApoA1 were grouped based on median levels, and Kaplan-Meier analysis (two-sided statistical testing) was conducted to assess prognostic efficacy. Univariate and multivariable Cox regression analyses were performed to determine any statistical relationships between each independent variable and survival rates. All variables identified in the univariate analysis were incorporated into the multivariable analysis. To assess the independent risk factors linked to lipid levels, HRs and 95% CIs were computed. A statistical significance threshold was established at P<0.05.

Results

A total of 138 patients were included, the patients’ ages ranged from 23 to 84 years, with a median age of 62 years; 52.9% were male. All cases were pathologically confirmed and classified using the Hans algorithm: 42.8% were ABC subtype, 42.0% were GCB subtype, and 15.2% were unclassified.

Baseline evaluations were performed in accordance with NCCN guidelines. All patients underwent bone marrow biopsy at diagnosis, with marrow involvement identified in 19 patients (13.8%). Clinical staging using the Ann Arbor system revealed that 34.8% of patients were stage IV, and 38.4% had at least one extranodal site of disease, including bone marrow, gastrointestinal tract, or central nervous system. ECOG performance status was ≥2 in 23.2% of patients. Risk stratification by NCCN-IPI classified 16.7% as low risk, 32.6% as low-intermediate, 36.2% as high-intermediate, and 14.5% as high risk.

Regarding treatment, 110 patients (79.7%) received rituximab-containing regimens (94 R-CHOP, 16 R-mini-CHOP), and 28 patients (20.3%) received CHOP-based chemotherapy without rituximab. Treatment response was evaluable in 134 patients. After completing at least 6 cycles of first-line therapy, 89 patients (66.4%) achieved complete remission (CR), 21 (15.7%) achieved partial remission (PR), 9 (6.7%) had stable disease (SD), and 15 (11.2%) experienced progressive disease (PD), resulting in an overall response rate (CR + PR) of 81.3%. Demographic data of the included patients are presented in Table 1.

Based on a median follow-up duration of 34 months (range, 6–72 months), a total of 56 PFS events (relapse, progression, or death) were documented among the 138 patients. Kaplan-Meier survival analysis revealed significant differences in PFS when stratified by key baseline biomarkers. Using the median cut-off values for each parameter—ApoA1 (0.94 g/L), total metabolic tumor volume (tMTV, 343 mL), and SUVmax (18.6)—patients with low ApoA1 (≤0.94 g/L) had a markedly shorter median PFS compared to those with high ApoA1 (>0.94 g/L) (log-rank P=0.003). Similarly, those with high tMTV (>343 mL) and high SUVmax (>18.6) had significantly worse PFS outcomes compared to their counterparts with lower tumor burden and metabolic activity (log-rank P=0.004 and P=0.02, respectively).

Multivariable Cox regression confirmed that low ApoA1 (HR: 2.07; 95% CI: 1.15–3.74; P=0.02), high tMTV (HR: 1.89; 95% CI: 1.05–3.38; P=0.03), and high SUVmax (HR: 1.72; 95% CI: 1.01–2.96; P=0.046) were each independently associated with inferior PFS, after adjusting for NCCN-IPI risk, ECOG status, and treatment regimen. These findings support the clinical relevance of combining serological and imaging-derived biomarkers for prognostic stratification in DLBCL.

Figure 2 shows the PFS curves for all patients (Figure 2A) and when stratified by tMTV (Figure 2B), ApoA1 level (Figure 2C), and SUVmax (Figure 2D). These data highlight the significantly poorer survival associated with adverse biomarker profiles.

Figure 2 Kaplan-Meier estimates of progression-free survival. (A) Entire cohort. (B) Stratified by tMTV. (C) Stratified by ApoA1 level. (D) Stratified by SUVmax. ApoA1, apolipoprotein A1; H, high; L, low; SUVmax, maximum standardized uptake value; tMTV, total metabolic tumor volume.

To further explore the prognostic impact of ApoA1, tMTV, and SUVmax, we performed univariate and multivariable Cox proportional hazards analyses, with PFS as the outcome. Variables with P<0.10 in univariate analysis were entered into the multivariable model. After adjusting for NCCN-IPI risk category and molecular subtype, low ApoA1, high SUVmax, and high tMTV each remained independent predictors of poorer PFS.

Specifically, patients with high ApoA1 levels (≥0.938 g/L) had significantly worse outcomes compared to those with low levels (<0.938 g/L) in both univariate (HR: 2.36; 95% CI: 1.34–4.16; P=0.003) and multivariable analyses (HR: 1.82; 95% CI: 1.09–3.34; P=0.02). Similarly, patients with high SUVmax values (≥18.6) had shorter PFS (HR: 1.97; 95% CI: 1.12–3.47; P=0.02) in univariate and remained significant in the multivariable model (HR: 1.55; 95% CI: 1.15–2.84; P=0.005). High tMTV (≥343 mL) was also independently associated with inferior PFS (multivariable HR: 1.64; 95% CI: 1.11–2.16; P=0.006).

Among covariates, NCCN-IPI grade strongly influenced outcomes. Compared to the high-risk group, patients in the low-, low-intermediate-, and high-intermediate-risk categories had substantially reduced hazard ratios for PFS (all P<0.01). Although GCB subtype showed improved PFS relative to ABC subtype in univariate analysis (HR: 0.50; 95% CI: 0.28–0.90; P=0.02), the difference was no longer statistically significant in the multivariable model (P=0.10).

These results underscore the additive prognostic value of ApoA1 and PET/CT metabolic parameters beyond established clinical indices, as detailed in Table 2.

Discussion

The NCCN-IPI is a clinically established prognostic tool that incorporates five factors: age, tumor stage, serum LDH levels, performance status, and the number of extranodal involvement sites (10). The NCCN-IPI has enhanced risk stratification for DLBCL patients in the rituximab era, improving the distinction between low-risk and high-risk subgroups. It has been validated in both newly diagnosed and transformed DLBCL cases, demonstrating superior prognostic accuracy compared to the original IPI (11). However, the NCCN-IPI primarily evaluates disease extent and severity without accounting for tumor volume, complicating the development of novel treatment strategies based on precise risk stratification. In our study, baseline measurements of ApoA1, SUVmax, and tMTV were identified as independent prognostic indicators for PFS in DLBCL patients, which can inform decisions regarding intensified treatment and participation in clinical trials.

Our results indicate that elevated SUVmax and MTV are indicative of poor patient prognosis. While SUVmax and MTV are the most frequently employed metabolic parameters derived from ¹⁸F-FDG PET/CT, their prognostic significance remains a subject of ongoing debate (12,13). SUV reflects the metabolic activity of tumors, correlating positively with tumor cell proliferation and invasiveness; thus, a high baseline SUVmax is often associated with unfavorable outcomes (14,15). Conversely, according to Gallicchio et al., patients with higher baseline SUVmax had noticeably better PFS than those with lower baseline SUVmax, potentially due to the immediate treatment responses observed in patients with heightened metabolic activity (16). MTV serves as a crucial predictor of treatment response and disease relapse or progression, directly measuring viable tumor volume and providing a more accurate representation of tumor burden than clinical factors such as Ann Arbor staging or LDH levels (17). However, a retrospective analysis involving 73 newly diagnosed DLBCL patients indicated that SUVmax, MTV, and total lesion glycolysis (TLG) did not yield additional prognostic information beyond what is already provided by the NCCN-IPI (18). Additionally, Ding et al. found that the prognostic value of pre-treatment ¹⁸F-FDG PET/CT-derived SUVmax, MTV, and TLG in predicting outcomes for stage III-IV DLBCL patients was ambiguous, suggesting that these metrics alone cannot reliably inform prognosis (19). This discrepancy may arise from the multifactorial influences affecting ¹⁸F-FDG PET/CT uptake, including oncogene expression, apoptosis, viable cell components, hypoxia, inflammatory cell infiltration, and tumor location (nodal versus extranodal), leading to significant variability in uptake among patients (20,21). The utility of MTV and SUVmax has also been corroborated in other malignancies; for instance, Huang et al. demonstrated that baseline 18F-FDG PET/CT-derived MTV and SUVmax could serve as prognostic biomarkers for non-small cell lung cancer patients undergoing immunotherapy (22). Furthermore, high SUVmax and MTV have been associated with poorer OS in patients with neuroblastoma, pancreatic cancer, and other malignancies (23-25).

Our findings highlight the potential of baseline ApoA1 levels and PET/CT-derived metabolic tumor burden (tMTV, SUVmax) as independent prognostic indicators in DLBCL. However, it is essential to acknowledge that DLBCL is a biologically and genetically heterogeneous disease. Beyond the GCB and ABC subtypes defined by immunohistochemistry, recent molecular classifications using circulating tumor DNA (ctDNA) and next-generation sequencing have identified distinct genetic clusters with divergent clinical behaviors. As emphasized by Almasri et al. (26), liquid biopsy is emerging as a minimally invasive tool that captures tumor heterogeneity in real-time and has shown promise in both B- and T-cell lymphomas for diagnosis, prognostication, and treatment monitoring.

In this context, integrating imaging biomarkers (such as PET-based tMTV) and serologic markers (such as ApoA1) with ctDNA profiling may significantly enhance risk stratification and treatment tailoring. Recent work by Moia et al. (27) demonstrated that molecular clustering based on ctDNA provided superior prognostic resolution compared to ctDNA levels alone, particularly in predicting early refractoriness and disease progression in DLBCL. These advances point toward a future framework where dynamic, multimodal monitoring—including functional imaging, serum metabolic markers, and liquid biopsy—can be combined to improve outcome prediction and guide adaptive therapeutic strategies in DLBCL.

Genes and products associated with lipid metabolism play a significant role in tumorigenesis and can serve as biomarkers for tumor diagnosis and prognosis. ApoA1, a key component of the apolipoprotein family, is involved in reverse cholesterol transport and lipid metabolism. Its prognostic potential has been established across various malignancies, including colorectal cancer, cervical cancer, and osteosarcoma (28-30). Wang et al. found a correlation between low serum ApoA1 levels and both PFS and OS in patients with DLBCL; however, they did not consider it an independent prognostic factor for survival (31). Conversely, Yu et al. identified low serum ApoA1 levels as independent negative prognostic factors for both OS and PFS in a study involving 105 DLBCL patients (9). Our study aligns with previous findings, demonstrating that low ApoA1 levels are associated with poorer PFS (8).

This study preliminarily affirms the prognostic value of ¹⁸F-FDG PET/CT metabolic parameters and ApoA1 in DLBCL; however, it has certain limitations. Firstly, as a retrospective study relying on medical records and telephone interviews for PFS follow-up, it did not include assessments of OS, which may introduce bias in estimating outcome event rates. Secondly, being a single-center study, the generalizability of the results may be restricted.

Conclusions

In patients with DLBCL, elevated levels of metabolic parameters (SUVmax and MTV) derived from ¹⁸F-FDG PET/CT, along with low serum ApoA1 levels, are indicative of poorer survival outcomes and serve as potential biomarkers for treatment response and survival prognosis.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the REMARK reporting checklist. Available at https://tcr.amegroups.com/article/view/10.21037/tcr-2025-963/rc

Data Sharing Statement: Available at https://tcr.amegroups.com/article/view/10.21037/tcr-2025-963/dss

Peer Review File: Available at https://tcr.amegroups.com/article/view/10.21037/tcr-2025-963/prf

Funding: This work was supported by the Key Program of Anhui Educational Committee (No. 2023AH052016) and the Key Natural Science Project of Bengbu Medical College (No. 2021byzd126).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tcr.amegroups.com/article/view/10.21037/tcr-2025-963/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethics Committee of Bengbu Medical University (July 10, 2024, No. 205, 2024). Because the data were de-identified, the need for patient informed consent was waived.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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