The prognostic value of 18F-FDG PET/CT in

postoperative recurrence of retroperitoneal

liposarcoma: a single center retrospective study
Hongcheng Shi 
(

shi.hongcheng@zs-hospital.sh.cn
)
Department of Nuclear Medicine, Zhongshan Hospital, Fudan University, No. 180 in Fenglin Road,
Shanghai 200032, People’s Republic of China
Juntao Lang 
Department of Nuclear Medicine, Zhongshan Hospital, Fudan University, No. 180 in Fenglin Road,
Shanghai 200032, People’s Republic of China
Wenshuai Liu 
Department of General Surgery, Zhongshan Hospital, Fudan University, No. 180 in Fenglin Road,
Shanghai 200032, People’s Republic of China
Guobing Liu 
Department of Nuclear Medicine, Zhongshan Hospital, Fudan University, No. 180 in Fenglin Road,
Shanghai 200032, People’s Republic of China
Siwei Liu 
Department of Nuclear Medicine, Zhongshan Hospital, Fudan University, No. 180 in Fenglin Road,
Shanghai 200032, People’s Republic of China
Yiqiu Zhang 
Department of Nuclear Medicine, Zhongshan Hospital, Fudan University, No. 180 in Fenglin Road,
Shanghai 200032, People’s Republic of China

Research Article

Keywords: Retroperitoneal liposarcoma, 2-[18F] fuoro-2-deoxy-D-glucose (18F-FDG), Positron emission

tomography/computed tomography (PET/CT), Prognosis

Posted Date: March 29th, 2022

DOI: https://doi.org/10.21203/rs.3.rs-1488120/v1

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Abstract
Purpose: Recurrence is the main cause of tumor-related death of retroperitoneal liposarcoma (RPLPS).
Different recurrence pattern was determined by variant subtype of retroperitoneal liposarcoma which
displayed diverse presentations on 2-[18F]-fluoro-2-deoxy-D-glucose (18F-FDG) positron emission
tomography/computed tomography (PET/CT). This study aims to analyze the characteristics of different
histologic subtypes of RPLPS on 18F-FDG PET/CT and their associations with recurrence and prognosis.

Methods: Clinical-pathological information, 18F-FDG PET/CT, recurrence and progression free survivals
(PFS) of 83 patients with RPLPS were collected. Maximum, and peak standardized uptake value (SUVmax
and SUVpeak, respectively) and mean CT value (CTmean) of tumors were measured; their correlations with
histologic subtype were analyzed. The predictability of SUVmax and CTmean for histologic subtype was
evaluated using the receiver operating characteristics (ROC) curve analysis. ROC curve was also
performed to analyze the predictive value of SUVmax and peak SUV (SUVpeak) for recurrence. The Kaplan-
Meier analysis was performed to analyze whether SUVmax and SUVpeak were risk factors for recurrence.

Results: Regarding the histology, 30.1% patients were well-differentiated liposarcoma (WDLPS), 56.6%
patients were dedifferentiated liposarcoma (DDLPS), 12.0% patients were myxoid/round cell
liposarcoma(MLPS), and 1.2% patients were pleomorphic liposarcoma (PMLPS). SUVmax of DDLPS were
significantly higher than those of WDLPS (P < 0.001) and MLPS(P = 0.001). CTmean of WDLPS was
significantly lower than those of MLPS (P = 0.001) and DDLPS (P < 0.001). ROC curve suggested 5.1 as
an approximate cutoff value of SUVmax for distinguishing DDLPS from non-DDLPS (sensitivity = 76.8%,
specificity = 88.0%), and 12.3Hu as cutoff value of CTmean for distinguishing WDLPS from non-WDLPS
(sensitivitty = 94.1%, specificity = 54.5%). When the cut-off values of SUVmax and SUVpeak were set at
10.7 and 6.9 respectively, the maximum performances for predicting recurrence were obtained. Kaplan-
Meier analyses showed that histologic subtype, SUVmax, and SUVpeak were risk factors that associated
with recurrence-free survival (P = 0.02, ＜0.001, and 0.001, respectively).

Conclusions: The SUV value and CT features on 18F-FDG PET/CT imaging may increase the confidence
in diagnosis and subtype distinguish of RPLPS. When inflammatory liposarcoma was excluded, patients
with SUVmax > 10.7 or SUVpeak > 6.9 suggest a poor prognosis.

Introduction
Soft tissue tumor is a relatively rare malignant tumor, with 15–20% occurring in the retroperitoneum,
accounting for about 1% of systemic malignant tumors [1]. Liposarcoma is the most common
retroperitoneal soft tissue sarcoma, accounting for about 50% of the retroperitoneal soft tissue sarcoma
[2]. According to the classification of soft tissue tumors by World Health Organization (WHO),
liposarcomas are divided into four subtypes: well-differentiated liposarcoma (WDLPS), dedifferentiated

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liposarcomas (DDLPS), myxoid/round cell liposarcoma (MLPS) and pleomorphic liposarcomas (PMLPS),
which have different biological behaviors [3].

Retroperitoneal liposarcomas are commonly WDLPS and DDLPS but rarely MLPS and PMLPS. Surgery is
an important treatment of retroperitoneal liposarcoma. Complete resection of the tumor reaching
negative margins (R0 resection) is critical for long-term survival [4]. Liposarcoma derives mainly from
mesenchymal tissue in retroperitoneal space, which is usually very large at the time of diagnosis. Half of
the retroperitoneal sarcomas had diameters > 20 cm when diagnosed, and usually closely related to the
surrounding important organs, rendering the operation very difficult [5]. Postoperative recurrences and the
consequent multiple operations affect greatly to the life quality and survival of patients. It is reported that
about 76% of patients have recurrences within 2 years after surgery, with the 5-year survival rate of about
67%. Furthermore, about 70% of patients died of recurrence without distant metastasis [2].

Previous studies have found that there were many factors affecting tumor recurrence, including histologic
subtype, grade, stage, tumor location, size, adjacent relationship, surgical situation, patient's age, physical
condition and so on [2, 6, 7]. Liposarcoma is characterized by heterogeneity, with significant differences
in biological characteristics among different histological types and even within the same histological
type can be found. Accurate preoperative evaluation is very important for the selection of surgical
methods and postoperative adjuvant therapy. At present, the most accurate preoperative evaluation is
puncture biopsy, which is invasive and challenging due to the large size and complex composition of
tumor tissue. However, different histologic subtypes of liposarcomas have distinctive imaging
characteristics.

Traditional imaging examinations, such as CT and MRI, are widely used in location, diagnosis and follow
up of RPLPS, but are insufficient in providing biological characteristics of tumors. As a noninvasive and
systemic molecular imaging method, 18F-FDG PET/CT provides not only morphological but also
metabolic information of tumors. The heterogeneity of liposarcoma determines the different glucose
metabolism of tumors. Several studies have found that high-level glucose metabolism portended high
potentials of malignancy, invasion and metastasis in patients with RPLPS[8–10]. In addition, 18F-FDG
PET/CT is also superior in accurate tumor staging, preoperative determination of surgical scope, and
guidance of biopsy and postoperative adjuvant treatment [10, 11]. In this study, 18F-FDG PET/CT imaging
features of a patient cohort with RPLPS were analyzed and their associations with recurrence and
prognosis were investigated.

Methods
This study was approved by the Ethics Committee of Zhongshan Hospital affiliated to Fudan University.
Informed consent was waived because of the retrospective nature of this study.

Patient inclusion and exclusion

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Patient inclusion: from 2015 to 2020, a total of 116 patients underwent PET/CT examination for
suspected RPLPS in our hospital were selected. RPLPS were confirmed in 95 patients by puncture biopsy
or postoperative pathology, and subtypes were classified according to the World Health Organization
(WHO) classification criteria in 2020[3]; these patients were eligible to this study. Exclusion criteria:
Twelve of the 95 patients were excluded because of radiotherapy, chemotherapy, immunotherapy, or
targeted therapy performed 6 months prior to PET/CT examination. Finally, 83 patients were eventually
enrolled in the study.

Follow-up
Abdominal-pelvic enhanced CT and chest CT were examined every 3 months in the first two years after
surgery, and every 6 months in the next five years. Recurrence-free survival (RFS) was defined as the time
interval from surgery to the first time when recurrence or distant metastasis was found. Patients who
received palliative surgery were excluded. Until the last follow-up, patients who had no recurrence and
were followed up for less than 24 months were considered to be undetermined.

18
F-FDG PET/CT acquisition and analysis

18
F-FDG PET/CT scanning were performed using the GE Discovery VCT 64 PET/CT scanner (GE
Healthcare, Milwaukee, WI, USA), the uMI 550 PET/CT scanner (United Imaging Healthcare, Shanghai,
China) or the uMI 780 PET/CT scanner (United Imaging Healthcare, Shanghai, China). All patients fasted
for at least 6 hours before examination, and their blood glucose was controlled below 200 mg/dL before
examination. Patients were injected with 18F-FDG at a dose of 3.74 MBq/kg, and images were collected
60 minutes after injection, from the brain to the middle thigh. The CT scanning parameters were 140 kV,
200 mAs, and gantry rotation speed of 0.8 s. PET scan was acquired in the same position as CT (After
PET acquisition, CT scan was performed) in three dimensional (3D) mode for 2.5 min per bed position.

18
F-FDG PET/CT images were reviewed and interpreted by 2 experienced nuclear medicine physicians,
respectively. Two semi-quantitative PET/CT parameters were measured, including the maximum and
peak standardized uptake value (SUVmax and SUVpeak, respectively), by manually delineating the tumor
slice by slice to generate the volume of interest (VOI) of lesion. The SUV was calculated as: SUV =
(activity in region of interest [Bq/g])/ (injected dose [Bq]/body weight [g]). SUVmax was defined as the SUV
from the single highest pixel within the VOI, while SUVpeak was the mean SUV from a fxed 1-cm3 spherical
VOI centered over the highest metabolic part of the tumor.
Statistical analysis
All statistical analyses were performed using the SPSS statistical software (version 23, IBM SPSS Inc.,
Chicago, IL, USA), and all hypotheses were two sided with a significance level set at < 0.05. All patients
were divided into three groups by histological subtypes. Continuous variables were expressed as mean ± 
standard deviation or 95% confidence interval (95% CI) while categorical variables were expressed as
frequencies or percentages. Continuous variables were compared between groups using one-way ANOVA

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with Bonferroni test for post hoc tests when normal distribution were obtained, otherwise the Kruskal–
Wallis test with Tamhane’s T2 test for pairwise comparisons were used. The receiver operating
characteristic (ROC) curve analyses were performed, and the areas under curves (AUCs) were calculated
for evaluating values of semi-quantitative parameters in differentiating tumor subtypes and in predicting
patient’s recurrence. Optimal cutoffs were determined for dividing lesions with high and low 18F-FDG
metabolism according to the maximum Youden index criterion. The Kaplan-Meier analyses with the log-
rank test were conducted to compare RFS between groups.

Results
Basic information and follow-up results
Of the 83 patients included, 47 were males and 36 were females with a mean age of 54.3 ± 11.7 years
(21–76 years). A total of 102 lesions were identified. Forty-nine cases were primary, of which 42 were
single lesion and 7 were multiple. Thirty-four cases were recurrent, of which 24 were single and 10 were
multiple. Forty-three patients underwent radical operation and were followed up for 21.3 ± 16.7 months
(1–55 months), of which 34 (79.1%) patients had recurrence. Seven patients only performed palliative
operations while another seven patients only experienced conservative treatment. Five patients lost to
follow up, while 21 patients were followed up for less than 24 months without recurrence identified until
the close of this study; these 26 patients were treated as censored data when performing survival
analysis.

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 Table 1
Demographic and clinico-pathological information of the patients included.
Variables No. of patients Percent (%)

Patient number 83  

Sex    

Male 47 56.6%

Female 36 43.4%

Mean age of years (range) 54.3 ± 11.7(21–76)  

Disease status

Primary 49 59.0%

Recurrent 34 41.0%

Number of lesions

Single 66 79.5%

Multiple 17 20.5%

Histological subtype

WDLPS 25 30.1%

Inflammatory 4 4.8%

Non-inflammatory 21 25.3%

DDLPS 47 56.6%

MLPS 10 12.0%

PMLPS 1 1.2%

Resection    

R0/R1 63 75.9%

R2 7 8.4%

Follow-up 57 68.7%

Recurrence 34 79.1%

No recurrence 9 20.9%

Loss to follow-up 26 31.3%

Note: WDLPS, well-differentiated liposarcoma; DDLPS, dedifferentiated liposarcomas, MLPS,

myxoid/round cell liposarcoma; PMLPS, pleomorphic liposarcoma.

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Associations between findings on PET/CT and pathological
subtypes
Pathologically, WDLPS, DDLPS and MLP were confirmed in 25 (30.1%), 47 (56.6%) and 10 (12.0%) cases,
respectively. Of the 10 cases with MLP, 3 cases had primary foci outside the retroperitoneum. PMLPS was
found only in 1 (1.2%) case which was not included for statistical description in this study due to the
small number (Table 1). The mean SUVmax of the remaining three subtypes was 7.79 ± 6.01 (range, 1.50–
27.55), with the SUVmax of DDLPS being significantly higher than that of WDLPS (P < 0.001) and MLPS
(P = 0.001). The average CTmean of the three subtypes were 13.27 ± 32.31 Hu (range, -110.50–55.00 Hu),
which was significantly lower in WDLPS than MLPS (P = 0.001) and DDLPS (P < 0.001). The CTmean of
inflammatory WDLPS was significantly larger than that of non-inflammatory WDLPS (P = 0.037), but
there was no significant difference of SUVmax between these two types of WDLPS. A typical case of
inflammatory WDLPS was shown in Fig. 5.

Table 2
SUVmax and CTmean of different histological subtypes of liposarcoma.
Subtype Number of cases Number of lesions SUVmax CTmean (Hu)

WDLPS 25 30 4.21 ± 2.81 -6.79 ± 42.96*

Inflammatory 4 4 8.03 ± 4.21 25.85 ± 11.48*

Non-inflammatory 21 26 3.68 ± 2.18 -11.29 ± 43.83

MLPS 10 10 4.40 ± 1.93 20.66 ± 7.30

DDLPS 47 61 10.41 ± 6.48* 28.23 ± 9.99

Note: WDLPS, well-differentiated liposarcoma; DDLPS, dedifferentiated liposarcomas, MLPS,

myxoid/round cell liposarcoma; PMLPS, pleomorphic liposarcoma. *Significantly lower (P < 0.05).

ROC curve analysis indicated that a SUVmax cutoff at 5.1 reached a high sensitivity (77.6%) and
specificity (83.7%) in distinguishing DDLPS from non-DDLPS, with AUC of 0.867 (95% CI, 0.796–0.938, P 
< 0.001). The cutoff of CTmean at 12.3 Hu reached a sensitivity of 94.1% but an unsatisfactory specificity
(54.5%) for distinguishing WDLPS from non-WDLPS with the AUC of about 0.734 (95% CI, 0.616–0.851,
P < 0.001; Fig. 2). By integrating CTmean and SUVmax, the subtypes of liposarcoma can be differentiated. If
SUVmax ≤ 5.1 and CTmean ≤ 12.3Hu, WDLPS was diagnosed with high confidence. If SUVmax > 5.1 and
CTmean > 12.3 Hu, DDLPS is more likely to be diagnosed. If SUVmax ≤ 5.1 and CTmean > 12.3 Hu, MLPS
can be diagnosed with greater confidence. Inflammatory liposarcoma is a subtype of WDLPS. Its
inflammatory cell infiltrates show soft tissue density and high glucose metabolism on imaging, which is
difficult to distinguish from DDLPS, while the lipid composition is similar to that of other types of WDLPS.
For predicting tumor recurrence, the optimal cutoff value of SUVmax and SUVpeak was 10.7 and 6.9,

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leading to sensitivity of 42.4% and 51.5%, and specificity of 100.0% and 89.9%, with AUCs of about 0.700
(P = 0.068) and 0.707 (P = 0.059), respectively.

Associations between semi-quantitative parameters on

PET/CT and patient follow-up result
Local recurrence occurred in 3 of the 9 cases of WDLPS, and postoperative pathology was DDLPS in 2 of
them, 1 patient developed pulmonary metastasis, which was pathologically confirmed as DDLPS (Fig. 6),
with a recurrence rate of 44.4% (4/9).

Of the 3 inflammatory liposarcoma patients, postoperative relapses were not found in 2 patients till
included to this study (follow-up intervals: 47 and 55 months, respectively), while recurrence occurred in 1
patient 30 months after surgery. Local recurrence occurred in 3 of the 4 MLPS patients, with a recurrence
rate of 75%, and a mean and median RFS of 31.0 ± 6.8 months and 29 months, respectively. Twenty-three
of the 27 patients with DDLP showed recurrence, with a recurrence rate of 85.2%, and a mean and median
RFS of 18.9 ± 3.7 months and 20 months, respectively. Kaplan-Meier survival analysis revealed that the
RFS of DDLPS was significantly shorter than that of non-DDLPS (P = 0.029). The recurrence rates at 1, 2,
3 and 4 years were 42.8%, 57.1%, 71.4% and 76.2%, respectively. According to the survival analysis based
on the SUVmax (10.7), the RFS of patients with SUVmax > 10.7 was significantly short than that of
patients with SUVmax ≤ 10.7 (11.1 ± 3.7 months vs. 30.4 ± 3.7 months, P < 0.001). In addition, patients
with tumors that with SUVpeak > 6.9 had significantly shorter RFS than those with tumors with SUVpeak ≤
6.9 (13.7 ± 3.6 months vs. 31.2 ± 4.0 months, P = 0.001; Fig. 4).

Discussion
It was reported that SUVmax of a variety of epithelial tumors and soft tissue sarcomas on 18F-FDG
PET/CT is correlated with prognosis of patients [12–16]. Retroperitoneal liposarcoma, however, as a kind
of rare malignant tumor, has high risk of recurrence because of its complex structure, heterogeneity and
diversity of biological behavior, which influence the prognosis of patients. Traditional imaging
examinations such as CT and MRI provide only anatomical information of tumors but fail to present
information related to biological activity. Pathological biopsy is a reliable method for determining the
pathological type and assessing the biological behavior of tumors, but misdiagnosis is common, due to
the huge size of tumors, the heterogeneity of LPS and the limited sampling of biopsy. 18F-FDG PET/CT
imaging provides additional metabolic information of tumors that is more indicative of tumor
malignancy, and thus is helpful in guidance of accurate biopsy, leading to improve diagnostic accuracy
of pathological examination [11]. Up till now, few studies have investigated the value of 18F-FDG PET/CT
on the prognosis of retroperitoneal liposarcoma, which remained to be further verified. In the present
study, different glucose metabolism and prognosis among different subtypes and grades of LPS were
revealed. In addition, significantly associations between imaging features of LPS on PET/CT and tumor
pathological subtypes, as well as patient prognosis, was identified. These results indicated that 18F-FDG
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PET/CT is valuable in indicating tumor subtypes and prognosis of patients with LPS. In malignant
tumors, the up-regulation of glucose transporter expression is common which always leads to increased
uptake of 18F-FDG. The SUVmax reflects the most active of glucose metabolism within a tumor. Since the
most aggressive component of tumor is always the most active, biologically, SUVmax may be a reliable
index in indicating tumor invasiveness and future relapse or metastasis.

The heterogeneity of liposarcoma is related to their unique genetic variation, leading to differed
histomorphological appearance, and differences in anatomical, metabolic and biological behavior of
each subtype [10]. Pathologically, WDLPS is generally of low-degree of malignancy with low FDG uptake,
as it is mainly composed of proliferated mature adipose cells, hyperchromatic stromal cells and fibrous
septa. In contrast, DDLPS is more invasive that commonly with obvious higher FDG uptake than WDLPS,
because it is mainly composed of high-grade non-lipogenic sarcoma, dedifferentiated osteosarcoma,
chondrosarcoma, or undifferentiated pleomorphic sarcoma. However, some DDLPS may be composed of
low-grade non-lipogenic sarcoma and exhibited hypoglycemic metabolism as shown in the current study.
The density and glucose metabolism of MLPS were between those of DDLPS and WDLPS. Cystic
degeneration with similar density to tumor components but lack of glucose metabolism in addition with a
small amount of fat components is commonly observed in MLPS. Typically, MLPS is composed of
extracellular mucous matrix and high-degree tumor cells, which can be round cells, pleomorphic cells or
dedifferentiated cells. The amount of tumor cells determines the biological behavior of MLPS, as well as
its glucose metabolism level. Especially, the higher proportion of round cells, the higher glucose
metabolism. PMLPS is relatively rare, accounting for approximately 5% of all LPS; it is defined as a high-
grade pleomorphic sarcoma showing variable amounts of lipoblastic differentiation, and thus always
presented as soft tissue masses with significantly increased glucose metabolism. Fat components and
necrosis with deficiency of glucose metabolism are rare in MPLPS. In this study, all WDLPS (except
inflammatory liposarcoma) showed large component of fat and fibrous septa, with low glucose
metabolism, while all DDLPS presented as soft tissue masses with significantly increased glucose
metabolism, and the density and metabolism of MLPS levels between WDLPS and DDLPS; these findings
were consistent with previous studies [9, 10]. Inflammatory liposarcoma in WDLPS can reach to a soft-
tissue density with improved glucose metabolism due to infiltration of inflammatory cells, causing
dilemma in distinguishing it from dedifferentiated liposarcoma on PET/CT [17]. In this study, SUVmax =
5.1 was taken as the threshold to distinguish DDLPS from WDLPS and MLPS, which was slightly higher
than the cutoff value reported in previous studies[8, 10]. This may because a certain proportion of
inflammatory liposarcomas was included in this study. –

There are many factors influencing the prognosis of liposarcoma, such as pathological type, surgical
method, degree of malignancy, and glucose metabolism level, etc. It was reported that the recurrence rate
of WDLPS and DDLPS were among 40–60% and 40–80% respectively [6, 18, 19]. The recurrence rate of
WDLPS (44.4%) and DDLPS (85.2%) identified in our study were almost the same with these results.
Brenner W et al [8] revealed that SUV on 18F-FDG PET was a useful parameter for risk assessment and
prognosis prediction in patient with liposarcoma. In our study, with cut-off of lesion SUVmax set at 10.7 as

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the prognosis of patients above this threshold was significantly worse than those below this threshold.
The recurrence rate was different among different subtypes. In WDLPS, if there are components with
significantly high glucose metabolism, their biological behavior is similar to that of highly malignant
liposarcoma, which is prone to recurrence and metastasis, as shown in Fig. 6. If pathological results
suggest DDLPS, but its SUVmax is relatively low, its activity and aggressiveness may be relatively low, and
thus is not easy to relapse. Inflammatory liposarcoma is a subtype of WDLPS with appearance on
PET/CT similar to DDLPS, as shown in Fig. 5; but its prognosis is consistent with WDLPS, as relapse in 2
of the 3 patients with inflammatory WDLPS was not identified in our study.

Since SUVmax represents the metabolism from a single pixel anywhere within the tumor, it may not
accurately reflect the whole metabolic activity of tumor. Furthermore, it is vulnerable to noise, although its
repeatability is good. In contrast, the SUVpeak represents the highest mean SUV from a fixed 1-cm3
spherical volume of interest (VOI) centered over the highest metabolic part of the tumor, and thus is more
stable. In the present study, SUVpeak was also found to be a prognostic indicator of patients with LPS, and
it is more suitable to be used in clinical practice, especially for treatment response assessment such as
adjuvant therapy in patients with LPS [20].

In this study, the proportion of subtypes of retroperitoneal liposarcoma was 30.1% for WDLPS, 56.6% for
DDLPS, 12.0% for MLPS and 1.2% for pleomorphic liposarcoma. It has been reported that WDLPS can
occur in the limbs and the retroperitoneum, while DDLPS occur mostly in the retroperitoneum but rarely in
the limbs. The incidence sites of MLPS are mainly in the limbs, with retroperitoneal MLPS being generally
considered to be metastatic or derived from mesenteric fat. In this study, 2 of the 10 MLPS had primary
lesions in the lower limbs. Pleomorphic liposarcoma arises most often in the limbs of elderly patients, but
rarely in retroperitoneum. In this study, all of the four types LPS were found in retroperitoneum with
DDLPS exhibited the largest number; these findings were slightly different from the previous results [6],
and thus enriched the recognition of LPS.

Several limitations of this study should be mentioned. First, this study is a single-center retrospective
study with a small sample size. Therefore, it is uncertain if the result of this study can be extroplated to
other populations. Second, patients without pathological diagnosis were excluded from this study, this
might have caused bias to the results of this study. Third, the follow-up time of some patients were too
short to catch recurrence or metastasis, which may have impacted the efficiency of survival analysis.

Conclusion
Different subtypes of RPLPS presented distinctly on 18F-FDG PET/CT. The degree 18F-FDG uptake of the
lesion (in terms of SUVmax and SUVpeak) and the CT value significantly correlated with tumor recurrence
and patients’ prognosis. Inflammatory liposarcoma may characterize between WDLPS and DDLPs on
18
F-FDG PET/CT, leading to dilemma in accurate diagnosis.

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Figures

Figure 1

Comparisons of SUVmax (A) and CTmean (B) of lesions between different pathological subtypes.

Page 12/17
Figure 2

ROC curves illustrating the performances of SUVmax (A) and CTmean (B) in distinguishing DDLPS and
non-DDLPS.

Figure 3

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ROC curves illustrating the performances of SUVmax (A) and SUVpeak (B) in distinguishing patients with
recurrence from those without recurrence.

Figure 4

Kaplan-Meier analysis of recurrence of liposarcoma of different histologic subtype and SUV.

Page 14/17
Figure 5

A 69-year-old man admitted with discomfort in left upper abdomen for 1 month. PET/CT images revealed
a lager mass in left retroperitoneum, which was about 114.3×83.6mm in size, with a CTmean of 34.3Hu
and a SUVmax of 13.5. Postoperative pathology confirmed that the lesion was inflammatory liposarcoma.

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Figure 6

A 49-year-old man who admitted because of a retroperitoneal mass identified by physical examination 1
month ago. A. PET/CT images showed a large retroperitoneal mass, about 255.6 × 249.8mm in size, with
a FDG-avid area in it which is 45.8 × 33.3mm in size (CTmean = 13.9Hu, SUVmax = 12.9). The CTmean and
SUVmax in the rest area of the mass are -14.5 HU and 2.7, respectively. Postoperative pathology confirmed
that the mas was WDLPS. B. One year after surgery, one lesion was found in the lung of this patient by
the follow-up chest CT examination. Then a second PET/CT was performed which reveal a solid round-
like mass in the posterior basal segment of the lower lobe of the left lung, with a diameter of about

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31.4mm, a CTmean of 38.0Hu, and a SUVmax of 4.4. Postoperatively, the lesion was confirmed DDLPS by
pathology.

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