18F-FDG PET-CT performed before and during radiation therapy of head and neck squamous cell carcinoma: Are they independent or complementary to each other?

INTRODUCTION

The aims of this study are to evaluate the prognostic value of metabolic parameters derived from (18) F-FDG PET-CT performed before definitive radiation therapy (RT) (prePET) in patients with mucosal primary head and neck squamous cell carcinoma (MPHNSCC) and to assess the additive prognostic values of FDG PET-CT performed during RT (iPET).

METHODS

One hundred patients with MPHNSCC treated with radical RT underwent staging prePET and iPET performed during the third week of treatment. The maximum standardized uptake value (SUVmax ), metabolic tumour volume (MTV) and total lesional glycolysis (TLG) of primary tumour were analysed for both prePET and iPET, and results were correlated with loco-regional recurrence-free survival (LRFS), disease-free survival (DFS), metastatic failure-free survival (MFFS) and overall survival (OS), using Kaplan-Meier analysis. Optimal cut-offs (OC) for prePET and iPET were derived from Receiver Operating Characteristic curves. Patients with metabolic parameters above/below the individual OC of prePET as well as iPET (i.e. combined prePET and iPET (comPET)) were evaluated against their outcomes.

RESULTS

Median age was 61 years (range 39-81), median follow-up of 20 months (range 4-70, mean 27), and AJCC 7th Edition clinical stage II, III and IV were 8, 24 and 68 patients respectively. Metabolic values below individual OC in comPET were found to be associated with statistically significant improvements (P < 0.05) in DFS, LRFS and OS. In addition, patients with SUVmax above the OC in comPET were associated with worse MFFS (P = 0.011) and confirmed on both univariate (P = 0.019) and multivariate analyses (P = 0.04).

CONCLUSION

Addition of iPET significantly improves the prognostic values of all three metabolic parameters and can potentially be used in future adaptive local and systemic therapy trials.

The Clinical Usefulness of (18)F-Fluorodeoxyglucose Positron Emission Tomography (PET) to Predict Oncologic Outcomes and PET-Based Radiotherapeutic Considerations in Locally Advanced Nasopharyngeal Carcinoma

Purpose

We investigated ¹⁸F-fluorodeoxyglucose positron emission tomography (PET)-derived parameters as prognostic indices for disease progression and survival in locally advanced nasopharyngeal carcinoma (NPC) and the effect of high-dose radiotherapy for a subpopulation with PET-based poor prognoses.

Materials and Methods

Ninety-seven stage III and Iva-b NPC patients who underwent definitive treatment and PET were reviewed. For each primary, nodal, and whole tumor, maximum standardized uptake value, metabolic tumor volume, and total lesion glycolysis (TLG) were evaluated.

Results

Based on the C-index (0.666) and incremental area under the curve (0.669), the whole tumor TLGwas the most useful predictorfor progression-free survival (PFS); thewhole tumor TLG cut-off value showing the best predictive performance was 322.7. In multivariate analysis, whole tumor TLG was a significant prognostic factor for PFS (hazard ratio [HR], 0.3; 95% confidence interval [CI], 0.14 to 0.65; p=0.002) and OS (HR, 0.29; 95% CI, 0.11 to 0.79; p=0.02). Patients with low whole tumor TLG showed the higher 5-year PFS in the subgroup for only patients receiving intensity modulated radiotherapy (77.4% vs. 53.0%, p=0.01). In the subgroup of patients with high whole tumor TLG, patients receiving an EQD₂ ≥ 70 Gy showed significantly greater complete remission rates (71.4% vs. 33.3%, p=0.03) and higher 5-year OS (74.7% vs. 19.6%, p=0.02).

Conclusion

Our findings demonstrated that whole tumor TLG could be an independent prognostic factor and high-dose radiotherapy could improve outcomes for NPC showing high whole tumor TLG.

Image findings of cranial nerve pathology on [18F]-2- deoxy-D-glucose (FDG) positron emission tomography with computerized tomography (PET/CT): a pictorial essay

This article aims to increase awareness about the utility of (18)F -FDG-PET/CT in the evaluation of cranial nerve (CN) pathology. We discuss the clinical implication of detecting perineural tumor spread, emphasize the primary and secondary (18)F -FDG-PET/CT findings of CN pathology, and illustrate the individual (18)F -FDG-PET/CT CN anatomy and pathology of 11 of the 12 CNs.

18F-fluorodeoxyglucose positron emission tomography for predicting tumor response to radiochemotherapy in nasopharyngeal carcinoma

PURPOSE

The aim of this study was to evaluate the value of (18)F-fluorodeoxyglucose (FDG) positron emission tomography (PET) in predicting tumor response to radiochemotherapy in nasopharyngeal carcinoma (NPC).

MATERIALS AND METHODS

From July 2012 to March 2014, 46 NPC patients who had undergone PET scanning before receiving definitive intensity-modulated radiotherapy (IMRT) treatment in our hospital were enrolled. Factors potentially affecting tumor response to treatment were studied by multiple logistic regression analysis.

RESULTS

After radiochemotherapy, 32 patients had a clinical complete response (CR), making the CR rate 69.6%. Multiple logistic regression analysis demonstrated that the maximal standard uptake value (SUV max) of the primary tumor was the only factor related to tumor response (p = 0.001), and that the logistic model had a high positive predictive value (90.6%). The area under the receiver operating characteristic (ROC) curve was 0.809, with a best cutoff threshold at 10.05. Patients with SUV max ≤ 10 had a higher CR rate than those with SUV max > 10 (p < 0.001).

CONCLUSION

The SUV max of the primary tumor before treatment is an independent predictor of tumor response in NPC.

The role of routine clinical pretreatment 18F-FDG PET/CT in predicting outcome of colorectal liver metastasis

OBJECTIVE

The aim of this study was to determine the value of SUV-based metabolic parameters derived from pretreatment F-FDG PET/CT of colorectal liver metastases in predicting disease response, progression-free survival (PFS), and overall survival (OS).

PATIENTS AND METHODS

We retrospectively reviewed 70 colorectal patients with liver metastases who underwent pretreatment F-FDG PET/CT. SUVmean, SUVmax, TLG (total lesion glycolysis), metabolic tumor volume, and metabolic tumor diameter were the metabolic parameters derived from volume of interest analysis of the most FDG-avid liver lesion in each subject. Clinical and laboratory parameters were recorded. Tumor response was assessed by response evaluation criteria in solid tumors 1.1 criteria at 12 weeks after treatment. Associations between tumor response, metabolic parameters, and clinical/laboratory parameters were examined by 1-way analysis of variance. The relationship of the metabolic parameters with PFS and OS was determined by Kaplan-Meier analyses and further confirmed with multivariate Cox regression analyses.

RESULTS

SUVmean less than 4.48, SUVmax less than 6.59, TLG less than 75.2, metabolic tumor volume less than 4.49 cm, and hemoglobin level greater than or equal to 11 g/dL were associated with longer PFS (P < 0.05). Prior surgery or radiofrequency ablation to the liver metastases was the only additional factor shown to be associated with longer OS.

CONCLUSIONS

SUV-based metabolic parameters derived from pretreatment F-FDG PET/CT can predict PFS in colorectal liver metastases.

Lesion regression rate based on RECIST: prediction of treatment outcome in patients with head and neck cancer treated with chemoradiotherapy compared with FDG PET-CT

The aim of this study was to evaluate whether the lesion regression rate (ΔLR) based on the Response Evaluation Criteria in Solid Tumors (RECIST) criteria could be used for the prediction of treatment outcome in head and neck squamous cell carcinoma (HNSCC) patients treated with chemoradiotherapy (CRT) compared with FDG PET-CT. A total of 33 patients underwent MRI and PET-CT at pretreatment and at 8 weeks after CRT. We assessed the treatment outcome by analyzing the following parameters: the RECIST criteria, ΔLR, the European Organization for Research and Treatment of Cancer (EORTC) criteria, and pretreatment SUVmax of the primary tumor and node. The correlation between the analysis of the parameters and the results of the long-term follow-up of the patients was determined. The RECIST did not significantly correlate with locoregional control (LRC) or survival. The ΔLR was significantly lower for the lesions with locoregional failure (LRF) than for those with LRC. A threshold ΔLR of 48% revealed a sensitivity of 72.7% and specificity of 77.3% for the prediction of LRF. Progression-free survival (PFS) of patients with ΔLR ≥ 48% was significantly better than that of patients with ΔLR < 48% (P = 0.001), but not overall survival. There was a significant correlation between LRC and the EORTC (P = 0.02). The patients who achieved a complete response by the EORTC criteria showed significantly better PFS and overall survival (P = 0.01 and 0.04, respectively). The ΔLR was inferior to FDG PET-CT with respect to the prediction of patient survival; however, it may be useful for selecting patients in need of more aggressive monitoring after CRT.

Prognostic Value of (18)F-FDG PET-CT in Nasopharyngeal Carcinoma: Is Dynamic Scanning Helpful?

OBJECTIVES

To evaluate the differences in prognostic values of static and dynamic PET-CT in nasopharyngeal carcinoma (NPC).

MATERIAL AND METHODS

Forty-five patients who had static scan were recruited. Sixteen had dynamic scan. The primary lesions were delineated from standardized uptake value (SUV) maps from static scan and K i maps from dynamic scan. The average follow-up lasted for 34 months. The patients who died or those with recurrence/residual disease were considered "poor outcome"; otherwise they were considered "good outcome." Fisher's exact test and ROC analysis were used to evaluate the prognostic value of various factors.

RESULTS

Tumor volume thresholded by 40% of maximal SUV (VOLSUV40) significantly predicted treatment outcome (p = 0.024) in the whole cohort. In 16 patients with dynamic scan, all parameters by dynamic scan were insignificant in predicting the outcome. The combination of maximal SUV, maximal K i , VOLSUV40, and VOL K i 37 (the tumor volume thresholded by 37% maximal K i ) achieved the highest predicting accuracy for treatment outcome with sensitivity, specificity, and accuracy of 100% in these 16 patients; however this improvement compared to VOLSUV40 was insignificant.

CONCLUSION

Tumor volume from static scan is useful in NPC prognosis. However, the role of dynamic scanning was not justified in this small cohort.

[18F]-Fluorodeoxyglucose Positron Emission Tomography Standardized Uptake Value as a Predictor of Adjuvant Chemotherapy Benefits in Patients With Nasopharyngeal Carcinoma

BACKGROUND

The role of adjuvant chemotherapy for the treatment of nasopharyngeal carcinoma (NPC) is controversial, and the identification of adequate predictive factors is warranted. Therefore, we aimed to investigate whether the mean standardized uptake value (SUV) measured on [(18)F]-fluorodeoxyglucose (FDG) positron emission tomography (PET) could predict the survival benefits for NPC patients that receive adjuvant chemotherapy.

MATERIALS AND METHODS

The data for 174 NPC patients who underwent PET/computed tomography before chemoradiation between January 2004 and January 2012 were reviewed. The SUV75% was recorded for primary tumors. All patients received intensity-modulated radiotherapy and cisplatin-based chemotherapy. Adjuvant chemotherapy consisted of 3 cycles of 75 mg/m(2) cisplatin and 1,000 mg/m(2) fluorouracil for 4 days.

RESULTS

The optimal cutoff value was 8.35 for SUV75%, with 112 (64.4%) patients having lower SUV75% and 62 (35.6%) having higher SUV75%. Patients with lower SUV75% had significantly better 5-year overall survival (OS) and distant metastasis-free survival. Multivariate analysis revealed that tumor stage, SUV75%, and adjuvant chemotherapy were significant prognostic factors for OS. Patients with higher SUV75% had significantly higher 5-year OS rates with adjuvant chemotherapy than without adjuvant chemotherapy (84.3% vs. 32.4%, respectively; p < .001). However, in the lower SUV75% group, no differences in 5-year OS were observed between patients who received and those who did not receive adjuvant chemotherapy (92.4% vs. 93.3%, respectively; p = .682).

CONCLUSION

The SUV75% on FDG PET for primary tumors could successfully identify NPC patients who may benefit from adjuvant chemotherapy.

Nasopharyngeal carcinoma

Nasopharyngeal carcinoma is uncommon in the United States, with only 0.2 to 0.5 cases per 100,00 people; this is in contrast to southern China and Hong Kong, where the incidence is 25 to 50 per 100,000 people. There is a potential link between Epstein-Barr virus and the development of nasopharyngeal carcinoma. Radiotherapy alone as a single modality leads to similar 10-year survival rates in United States, Denmark, and Hong Kong (34%, 37%, and 43%, respectively). Multiple studies have shown an advantage to concurrent chemoradiation in the treatment of advanced disease. Radiation therapy remains the mainstay of salvage therapy, and modern techniques have allowed clinicians to achieve adequate local control without excessive toxicity.

Positron emission tomography-computed tomography before treatment is highly prognostic of distant metastasis in nasopharyngeal carcinoma patients after intensity-modulated radiotherapy treatment: a prospective study with long-term follow-up

OBJECTIVES

The utility of [18F]fluorodeoxyglucose (FDG) positron emission tomography (PET) in the prediction of distant metastasis after definitive treatment for non-disseminated NPC patients is not clear. We prospectively investigated the prognostic significance of (18)F-FDG PET-CT performed before treatment for the distant metastasis-free survival (DMFS) of NPC patients treated with intensity-modulated radiotherapy (IMRT) ± chemotherapy.

MATERIALS AND METHODS

The results of PET-CT scans performed at initial diagnosis were recorded and analyzed prospectively. Patients then received standard treatment per protocol independent of the PET-CT result. IMRT was administered to the nasopharynx and neck. Early stage patients received IMRT alone, whereas loco-regionally advanced patients received concurrent chemoradiation. Patient outcomes were evaluated.

RESULTS

One hundred and seventy-nine patients were analyzable. DM occurred in 33 patients and the 3-year DMFS rate of the whole cohort was 84.1%. The cut-off of the SUVmax at the primary site (SUVmax-P) for DMFS was 10.22 by ROC curve. The 3-year DMFS rates of the higher and lower SUVmax-P groups (SUVmax-P⩽or>10.22) were 93.2% and 75.1%, respectively, with an 18.1% difference (P=0.003). Multivariate analysis indicated that SUVmax-P was a risk factor independently associated with DMFS (HR, 2.672; 95%CI, 1.236-5.776; P=0.012) and OS (HR, 2.417; 95%CI, 1.313-4.448; P=0.005). Subgroup analysis indicated that the 5-year DMFS and OS in loco-regionally advanced patients with SUVmax-P⩽10.22 were similar to those of early stage patients, whereas those of loco-regionally advanced patients with SUVmax-P>10.22 patients predicted worse outcome.

CONCLUSION

SUVmax-P is a useful biomarker to predict distant metastasis of NPC patients treated with IMRT. Combining SUVmax-P with tumor overall stage, a more precise picture could be obtained to predict treatment outcome.

Adding maximum standard uptake value of primary lesion and lymph nodes in 18F-fluorodeoxyglucose PET helps predict distant metastasis in patients with nasopharyngeal carcinoma

Objective

To find out the most valuable parameter of ¹⁸F-Fluorodeoxyglucose positron emission tomography for predicting distant metastasis in nasopharyngeal carcinoma.

Methods

From June 2007 through December 2010, 43 non-metastatic NPC patients who underwent ¹⁸F-Fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) before radical Intensity-Modulated Radiation Therapy were enrolled and reviewed retrospectively. PET parameters including maximum standardized uptake value (SUVmax), mean standardized uptake value (SUVmean), metabolic tumor volume (MTV), and total lesion glucose (TLG) of both primary tumor and cervical lymph nodes were calculated. Total SUVmax were recorded as the sum of SUVmax of primary tumor and cervical lymph nodes. Total SUVmean, Total MTV and Total TLG were calculated in the same way as Total SUVmax.

Results

The median follow-up was 32 months (range, 23–68 months). Distant metastasis was the main pattern of treatment failure. Univariate analysis showed higher SUVmax, SUVmean, MTV, and TLG of primary tumor, Total SUVmax, Total MTV, Total TLG, and stage T3-4 were factors predicting for significantly poorer distant metastasis-free survival (p = 0.042, p = 0.008, p = 0.023, p = 0.023, p = 0.024, p = 0.033, p = 0.016, p = 0.015). In multivariate analysis, Total SUVmax was the independent predictive factor for distant metastasis (p = 0.046). Spearman Rank correlation analysis showed mediate to strong correlationship between Total SUVmax and SUVmax-T, and between Total SUVmax and SUVmax-N(Spearman coefficient:0.568 and 0.834;p = 0.000 and p = 0.000).

Conclusions

Preliminary results indicated that Total SUVmax was an independently predictive factor for distant metastasis in patients of nasopharyngeal carcinoma treated with Intensity-Modulated Radiation Therapy.

Volumetric PET/CT parameters predict local response of head and neck squamous cell carcinoma to chemoradiotherapy

It is not well established whether pretreatment ¹⁸F-FDG PET/CT can predict local response of head and neck squamous cell carcinoma (HNSCC) to chemoradiotherapy (CRT). We examined 118 patients: 11 with nasopharyngeal cancer (NPC), 30 with oropharyngeal cancer (OPC), and 77 with laryngohypopharyngeal cancer (LHC) who had completed CRT. PET/CT parameters of primary tumor, including metabolic tumor volume (MTV), total lesion glycolysis (TLG), and maximum and mean standardized uptake value (SUV_max and SUV_mean), were correlated with local response, according to primary site and human papillomavirus (HPV) status. Receiver-operating characteristic analyses were made to access predictive values of the PET/CT parameters, while logistic regression analyses were used to identify independent predictors. Area under the curve (AUC) of the PET/CT parameters ranged from 0.53 to 0.63 in NPC and from 0.50 to 0.54 in OPC. HPV-negative OPC showed AUC ranging from 0.51 to 0.58, while all of HPV-positive OPCs showed complete response. In contrast, AUC ranged from 0.71 to 0.90 in LHC. Moreover, AUCs of MTV and TLG were significantly higher than those of SUV_max and SUV_mean (P < 0.01). After multivariate analysis, high MTV >25.0 mL and high TLG >144.8 g remained as independent, significant predictors of incomplete response compared with low MTV (odds ratio [OR], 13.4; 95% confidence interval [CI], 2.5–72.9; P = 0.003) and low TLG (OR, 12.8; 95% CI, 2.4–67.9; P = 0.003), respectively. In conclusion, predictive efficacy of pretreatment ¹⁸F-FDG PET/CT varies with different primary sites and chosen parameters. Local response of LHC is highly predictable by volume-based PET/CT parameters.

Estimate of the impact of FDG-avidity on the dose required for head and neck radiotherapy local control

Background and purpose

Although FDG-avid tumors are recognized as a potential target for dose escalation, there is no clear basis for selecting a boost dose to counter this apparent radioresistance. Using a novel analysis method, based on the new concept of an outcome-equivalent dose, we estimate the extra dose required to equalize local control between FDG-avid and non-avid head and neck tumors.

Materials and methods

Based on a literature review, five reports of head and neck cancer (423 patients in total), along with an internal validation dataset from our institution (135 oropharynx patients), were used in this analysis. To compensate for the heterogeneity among multi-institutional patient cohorts and corresponding treatment techniques, local control data of the cohorts were fit to a single dose–response curve with a clinically representative steepness (γ₅₀ = 2), thereby defining an ‘outcome-equivalent dose’ (OED) for each institutional cohort. Separate dose–response curves were then determined for the FDG-avid and FDG-non-avid patient cohorts, and the ratio of TD₅₀ (tumor dose required for 50% of control) values between the high- and low-FDG-uptake groups (TD_50,high/TD_50,low) was estimated, resulting in an estimated metabolic dose-modifying factor (mDMF) due to FDG-avidity.

Results

For individual datasets, the estimated mDMFs were found to be in the range of 1.07–1.62, decreasing if the assumed slope (γ₅₀) increased. Weighted logistic regression for the six datasets resulted in a mDMF of 1.19 [95% CI: 1.04–1.34] for a γ₅₀ value of 2, which translates to a needed dose increase of about 1.5 Gy per unit increase in the maximum standardized uptake value (SUV_m) of FDG-PET [95% CI: 0.3–2.7]. Assumptions of lower or higher γ₅₀ values (1.5 or 2.5) resulted in slightly different mDMFs: 1.26 or 1.15, respectively. A validation analysis with seven additional datasets, based on relaxed criteria, was consistent with the estimated mDMF.

Conclusions

We introduced a novel outcome-equivalent dose analysis method to estimate the dose– response modifying effect of FDG uptake variation. To reach equal response rates, FDG-avid tumors are likely to require 10% to 30% more dose than FDG-non-avid tumors. These estimates provide a rational starting point for selecting IMRT boosts for FDG-avid tumors. However, independent tests and refinements of the estimated dose-modifying effect, using high-quality prospective clinical trial data, are needed.

The Predictive Value of Pretreatment 18-F-FDG-PET-CT in Locally Advanced Nasopharyngeal Cancer Patients Treated Definitively with Induction Chemotherapy Followed by Concurrent Chemo-Radiotherapy

Aims

This study aimed to evaluate the role of pretreatment 18F-Fluorodeoxyglucose positron emission tomography (¹⁸F-FDG-PET-CT) as a predictor of disease-free survival (DFS), and overall survival (OS) in locally advanced nasopharyngeal carcinoma (LANPC) patients treated definitively with docetaxel-based induction chemotherapy followed by concurrent chemoradiation (CRT).

Materials and methods

This is a retrospective study approved by the institutional review board and included LANC patients treated definitively and consecutively between January 2008 and December 2012 with induction chemotherapy; docetaxel, cisplatin, and 5-flurouracil (TPF) followed by CRT utilizing weekly cisplatin. All patients had baseline pretreatment ¹⁸F-FDG-PET-CT. We studied the association between the baseline primary tumor maximum standardized uptake value (SUVmax) and the treatment outcomes; OS and DFS.

Results

The study included 70 eligible LANPC patients. The 4-year OS and DFS rates were 86.7% and 78.6%, respectively. The median OS and DFS intervals were not reached. On a univariate analysis, the 4-years DFS was significantly higher in patients with pretreatment SUVmax <8 compared versus ≥ 8 (95% vs 57.7%, P=0.002). Furthermore, DFS was significantly correlated with pretreatment T stage (P=0.01), N stage (P=0.02), treatment response (P<0.001) and treatment breaks (P<0.001). On a multivariate analysis, the SUVmax category was the only factor correlated with 4-year DFS (Hazard ratio=10.2, 95% C I 1.3-116.8, P=0.035) but not OS (P=0.085).

Disclosure statement

There is no actual or potential conflict of interest with the production and publication of this work. No author has a direct or indirect commercial financial incentive associated with the publication of this article.

Conclusion

This study shows that the pretreatment primary tumor ¹⁸F-FDG-PET-CT SUVmax is a potential independent prognostic predictor of clinical outcomes in patients with LANC treated definitively with TPF induction chemotherapy followed by CRT. Further controlled clinical trials are worthwhile.

Functional imaging in radiation therapy planning for head and neck cancer

Functional imaging and its application to radiotherapy (RT) is a rapidly expanding field with new modalities and techniques constantly developing and evolving. As technologies improve, it will be important to pay attention to their implementation. This review describes the main achievements in the field of head and neck cancer (HNC) with particular remarks on the unsolved problems.

Inhibition of LDH-A by oxamate induces G2/M arrest, apoptosis and increases radiosensitivity in nasopharyngeal carcinoma cells

An elevated rate of glucose consumption and the dependency on aerobic glycolysis for ATP generation have long been observed in cancer cells, a phenomenon known as the Warburg effect. the altered energy metabolism in cancer cells provides an attractive opportunity for developing novel cancer therapeutic strategies. Lactate dehydrogenase (LDH), which catalyzes the transformation of pyruvate to lactate, plays a vital role in the process of glycolysis. It has been reported that the level of LDH-A expression is increased both in head and neck cancer cells and in the blood serum of nasopharyngeal carcinoma (NPC) patients, and is associated with poor prognosis. However, the effect of LDH-A inhibition on NPC cells remains unknown. Here, in the present study, we found that oxamate, a classical inhibitor of LDH-A, suppressed cell proliferation in a dose- and time-dependent manner both in CNE-1 and CNE-2 cells, two NPC cancer cell lines. LDH inhibition by oxamate induced G2/M cell cycle arrest via downregulation of the CDK1/cyclin B1 pathway and promoted apoptosis through enhancement of mitochondrial ROS generation. N-acetylcysteine, a specific scavenger of ROS, significantly blocked the growth inhibition effect induced by oxamate. We also identified that oxamate increased sensitivity to ionizing radiation in the two NPC cancer cell lines. Furthermore, we verified similar results in tumor xenograft models. collectively, these results suggest that LDH-A may serve as a promising therapeutic target for NPC treatment.

The SUVmax for (18)F-FDG correlates with molecular subtype and survival of previously untreated metastatic breast cancer

AIM

The objectives of this study were to determine if the baseline SUVmax measured by F-FDG PET/CT correlates with molecular subtype and to explore the impact of baseline SUVmax on the survival of patients with metastatic breast cancer (MBC).

METHODS

Patients with MBC were screened with PET/CT from February 2007 until December 2010. Multivariate linear regression analysis was performed to identify independent variable correlation with SUVmax. Prognostic variables identified by univariate analysis, with P < 0.1, were analyzed in the multivariate Cox model.

RESULTS

A total of 244 MBC patients were eligible for this study. Multivariate linear regression analysis showed that molecular subtype, visceral metastasis, and number of metastatic organs could be used to predict the logarithmic values of SUVmax (lgSUVmax) for previous untreated MBC patients, whereas for those with 1 or more line previous treatment, the number of metastatic organs was identified as the only independent variable correlating with lgSUVmax. Cox regression analysis indicated that only in patients with previously untreated MBC did baseline SUVmax (continuous variable) act as an independent prognostic factor (hazard ratio = 1.049 for progression-free survival, 1.124 for overall survival).

CONCLUSIONS

Baseline SUVmax correlates with molecular subtypes only in previously untreated MBC patients. PET/CT imaging can be used as a potential prognostic tool for patients with newly diagnosed MBC.

FDG-PET/CT imaging biomarkers in head and neck squamous cell carcinoma

This article discusses the value of ¹⁸F-fluoro-2-deoxyglucose PET/CT imaging biomarkers in head and neck squamous cell carcinoma. ¹⁸F-fluoro-2-deoxyglucose PET/CT is valuable at baseline staging, radiotherapy planning, therapy response assessment and in the follow-up of patients with head and neck squamous cell carcinoma. Maximum and peak standardized uptake value (SUV_max and SUV_peak), metabolic tumor volume and total lesion glycolysis are the common ¹⁸F-fluoro-2-deoxyglucose quantitative parameters that have been studied, along with qualitative assessments. These parameters will be evaluated with respect to their established or potential role as noninvasive biomarkers for patient risk stratification, treatment response and survival outcome.

Pretreatment (18)F-FDG PET standardized uptake value of primary tumor and neck lymph nodes as a predictor of distant metastasis for patients with nasopharyngeal carcinoma

OBJECTIVES

To evaluate the prognostic value of maximum standardized uptake value (SUVmax) measured in [(18)F]-fluorodeoxyglucose positron emission tomography ((18)F-FDG PET) for patients with non-disseminated nasopharyngeal carcinoma (NPC).

MATERIALS AND METHODS

From January 2002 to July 2008, 371 NPC patients who underwent (18)F-FDG-PET before radical intensity-modulated radiotherapy (IMRT) were recruited. The SUVmax was recorded for the primary tumor (SUVmax-T) and neck lymph nodes (SUVmax-N).

RESULTS

The median follow-up was 64months. The optimal cutoff value was 9.3 for SUVmax-T and 7.4 for SUVmax-N. Patients with a lower SUVmax-T or SUVmax-N had a significantly better 5-year distant metastasis-free survival (DMFS), but showed no significant difference in local control or regional control. Patients were divided into four groups by SUVmax, as follows: (a) both lower SUVmax-T and SUVmax-N, (b) higher SUVmax-T only, (c) higher SUVmax-N only, and d) both higher SUVmax-T and SUVmax-N. There were significant differences between these four groups in 5-year DMFS: (a) 95.5%, (b) 90.0%, (c) 83.3%, and (d) 79.9%, respectively (p=0.004). When looking at the stage of disease, the 5-year DMFSs in group a, b, c, d were 96.9%, 94.6%, 97.4%, and 84.3%, respectively in stage I-III patients (p=0.037) and were 91.6%, 82.9%, 68.5%, and 76.7% in stage IVA-B patients (p=0.145). Using multivariate analysis, the SUVmax grouping, gender, and stage were independent factors for DMFS.

CONCLUSION

The SUVmax of the primary tumor and neck lymph nodes were independent prognostic factors for DMFS in NPC patients treated with IMRT.

The role of 18F-FDG PET/CT metabolic tumour volume in predicting survival in patients with metastatic nasopharyngeal carcinoma

OBJECTIVES

To investigate the role of PET-derived imaging markers in predicting metastatic nasopharyngeal carcinoma (NPC) outcomes.

MATERIALS AND METHODS

A total of 56 patients with metastatic NPC were enrolled. Before treatment, all of the participants underwent (18)F-FDG PET/CT. The following (18)F-FDG PET parameters were assessed: standardised uptake value, metabolic tumour volume (MTV), and total lesion glycolysis. Multivariate Cox proportional hazards models were used to identify the independent predictors of survival.

RESULTS

The multivariate analysis showed that performance status>1 (P=0.007), Epstein-Barr virus (EBV) DNA titre>5000 copies/mL (P=0.001), and MTV>110 mL (P=0.013) were independent risk factors for progression-free survival (PFS). Male sex (P=0.004), performance status>1 (P<0.0001), EBV DNA level>5000 copies/mL (P<0.0001), and MTV>110 mL (P=0.003) independently predicted overall survival (OS). The 2-year PFS and OS rates of the patients with MTV≤110 mL were 23.2% and 43%, respectively, compared with 0% and 9.1%, respectively, for those with MTV>110 mL. Combining the MTV with the EBV DNA titre allowed further survival stratification by dividing the patients into three groups with distinct PFS (2-year rates=30.8%, 7.1%, and 0%, P<0.0001) and OS (2-year rates=68.4%, 40%, and 0%, P<0.0001) rates.

CONCLUSION

The MTV appears to be an independent risk factor in metastatic NPC patients. This factor is complementary to the EBV DNA titre for predicting survival in metastatic NPC.

The Application of FDG-PET as Prognostic Indicators in Head and Neck Squamous Cell Carcinoma

This article discusses the role of FDG-PETederived parameters as prognostic indicators in patients with squamous cell carcinoma of the head and neck. The basic underlying biology of FDG-PET scans and the quantitative information that can be derived are discussed. A review of the literature is performed. Potential applications in the management of head and neck cancer and future directions in clinical trials are discussed.

Nasopharyngeal carcinoma: investigation of intratumoral heterogeneity with FDG PET/CT

OBJECTIVE

The purpose of this study was to quantitatively evaluate the role of intratumoral heterogeneity of (18)F-FDG uptake in characterizing nasopharyngeal carcinoma (NPC).

SUBJECTS AND METHODS

Forty consecutively registered patients with newly diagnosed NPC underwent PET/CT. The heterogeneity factor, defined as the derivative of a volume threshold function, was computed for each tumor. The relations between heterogeneity factor and maximum standardized uptake value (SUV(max)), tumor volume, and TNM category were determined by two-tailed Spearman correlation. Factors that potentially affect outcome determined by disease-free survival were studied by Kaplan-Meier analysis with a log-rank test for univariate analysis and the Cox proportional hazard model for multivariate analysis.

RESULTS

The heterogeneity factor ranged from -1.80 to -0.13 (mean, -0.40 [SD, 0.40]) and significantly correlated with SUV(max) (r = -0.372; p = 0.018), tumor volume (r = -0.983; p < 0.001), and T category (r = -0.457; p = 0.003) but not with N and M categories. There was a significant difference in heterogeneity factor between T1 and T2 tumors and T3 and T4 tumors (p = 0.012). The 2-year disease-free survival rate among the 38 patients was 67.4%. According to the results of Kaplan-Meier analysis with the log-rank test, heterogeneity factor and M category significantly affected disease-free survival. Patients with tumors that had a heterogeneity factor greater than -0.24 (less-heterogeneous group) (p = 0.0498) or M0 status (p < 0.001) had better disease-free survival rates. Multivariate analysis showed only M category to be an independent predictor of disease-free survival (p < 0.001).

CONCLUSION

The intratumoral heterogeneity of FDG uptake varies across NPC tumors, significantly correlates with tumor aggressiveness, and is predictive of patient outcome. These findings may be useful for characterizing NPC, predicting survival, and improving patient care.

Biomarkers for use in monitoring responses of nasopharyngeal carcinoma cells to ionizing radiation

Nasopharyngeal carcinoma (NPC) is a common head and neck cancer. The incidence rate is higher in southern China and Southeast Asia in comparison with the Western countries. Radiotherapy is the standard treatment of NPC as the cancer cells are sensitive to ionizing radiation. Radiation treatment has good local control to patients with early NPC. It is essential to monitor the response of the NPC cells to radiation treatment in advance in order to select suitable treatment choice for the patients. This review aims to discuss the potential use of biomarkers in monitoring the responsiveness of NPC cells to radiation treatment.

Biological response of nasopharyngeal carcinoma to radiation therapy: a pilot study using serial 18F-FDG PET/CT scans

We used serial (18)F-fluorodeoxyglucose positron emission tomography/computed tomography ((18)F-FDG PET/CT) to evaluate tumors' maximum standardized uptake value (SUV(max)) before, during, and after radiotherapy to explore the biological behavior of and response to radiation therapy in various subtypes of nasopharyngeal carcinoma (NPC). Sixty-one patients with pathologically diagnosed NPC were prospectively enrolled into the study. WHO type II(B) disease had a higher initial SUV(max) and more significant biological response at the primary site as compared with type II(A) subtype. The two subtypes of WHO type II NPC may significantly differ in their biological behavior and response to radiotherapy.

Superior prognostic utility of gross and metabolic tumor volume compared to standardized uptake value using PET/CT in head and neck squamous cell carcinoma patients treated with intensity-modulated radiotherapy

OBJECTIVE

To compare the prognostic utility of the 2-[(18)F] fluoro-2-deoxy-D: -glucose (FDG) maximum standardized uptake value (SUV(max)), primary gross tumor volume (GTV), and FDG metabolic tumor volume (MTV) for disease control and survival in patients with head and neck squamous cell carcinoma (HNSCC) undergoing intensity-modulated radiotherapy (IMRT).

METHODS

Between 2007 and 2011, 41 HNSCC patients who underwent a staging positron emission tomography with computed tomography and definitive IMRT were identified. Local (LC), nodal (NC), distant (DC), and overall (OC) control, overall survival (OS), and disease-free survival (DFS) were assessed using the Kaplan-Meier product-limit method.

RESULTS

With a median follow-up of 24.2 months (range 2.7-56.3 months) local, nodal, and distant recurrences were recorded in 10, 5, and 7 patients, respectively. The median SUV(max), GTV, and MTV were 15.8, 22.2 cc, and 7.2 cc, respectively. SUV(max) did not correlate with LC (p = 0.229) and OS (p = 0.661) when analyzed by median threshold. Patients with smaller GTVs (<22.2 cc) demonstrated improved 2-year actuarial LC rates of 100 versus 56.4 % (p = 0.001) and OS rates of 94.4 versus 65.9 % (p = 0.045). Similarly, a smaller MTV (<7.2 cc) correlated with improved 2-year actuarial LC rates of 100 versus 54.2 % (p < 0.001) and OS rates of 94.7 versus 64.2 % (p = 0.04). Smaller GTV and MTV correlated with improved NC, DC, OC, and DFS, as well.

CONCLUSION

GTV and MTV demonstrate superior prognostic utility as compared to SUV(max), with larger tumor volumes correlating with inferior local control and overall survival in HNSCC patients treated with definitive IMRT.

PET/CT for staging and follow-up of pediatric nasopharyngeal carcinoma

PURPOSE

While FDG PET/CT for the evaluation of nasopharyngeal carcinoma (NPC) in adult patients has documented advantages and disadvantages compared with conventional imaging, to our knowledge, no studies of FDG PET/CT for the evaluation of NPC in pediatric patients have been performed. In this investigation, we studied the utility of FDG PET/CT in children with NPC.

METHODS

The study group comprised 18 children with biopsy-proven NPC who underwent FDG PET/CT and MRI (total 38 pairs of images). All baseline and follow-up FDG PET/CT and MRI studies were independently reviewed for restaging of disease.

RESULTS

The concordance between FDG PET/CT and MRI in T, N, and overall staging was 29%, 64%, and 43%, respectively. Compared with MRI, FDG PET/CT yielded lower T and overall staging and showed less cervical and retropharyngeal lymphadenopathy. The concordance between follow-up FDG PET/CT and MRI was 79% overall and 100% 9 months after therapy. In patients who achieved complete remission, FDG PET/CT showed disease clearance 3-6 months earlier than MRI. There were no false-positive or false-negative FDG PET/CT scans during follow-up.

CONCLUSION

FDG PET/CT may underestimate tumor extent and regional lymphadenopathy compared with MRI at the time of diagnosis, but it helps to detect metastases and clarify ambiguous findings. FDG PET/CT is sensitive and specific for follow-up and enables earlier determination of disease remission. FDG PET/CT is a valuable imaging modality for the evaluation and monitoring of NPC in pediatric patients.

Prognostic significance of 18F-FDG PET parameters and plasma Epstein-Barr virus DNA load in patients with nasopharyngeal carcinoma

The plasma concentration of Epstein-Barr virus (EBV) DNA is associated with tumor burden and prognosis in patients with nasopharyngeal carcinoma (NPC), but data on the relationship between viral load and (18)F-FDG PET functional parameters are lacking. We examined the association of (18)F-FDG PET functional parameters and EBV DNA load with the clinicopathologic characteristics and clinical outcomes of patients with NPC.

METHODS

One hundred eight patients with NPC who underwent (18)F-FDG PET before treatment were included in this study. We determined total lesion glycolysis (TLG) of the primary tumor, the cervical nodes, and their combination and the maximal standardized uptake value of the primary tumor and cervical lymph nodes. EBV DNA was measured by real-time polymerase chain reaction.

RESULTS

EBV DNA was significantly associated with total TLG (R(2) = 0.589). Total TLG values had the highest correlation with EBV DNA load and were significantly associated with tumor, nodal, and overall stages. However, tumor TLG greater than the median (>65 g) was the only parameter significantly associated with overall, local recurrence-free, disease-free, and distant metastasis-free survivals (P = 0.033, 0.014, <0.001, and 0.023, respectively). After allowance for potential confounders, tumor TLG retained its independent significance for overall and disease-free survival rates (P = 0.045 and 0.006, respectively).

CONCLUSION

Total TLG values are primarily associated with tumor burden and clinical stage, whereas tumor TLG is the best predictor of patient survival after treatment.

Prognostic impact of standardized uptake value of F-18 FDG PET/CT in nasopharyngeal carcinoma

PURPOSE

We evaluated the use of metabolic parameters of F-18 fluorodeoxyglucose positron emission tomography (FDG PET) for the assessment of the primary tumor and nodal metastasis in predicting survival in nasopharyngeal carcinoma (NPC) patients.

MATERIALS AND METHODS

The F-18 FDG PET/CT (computed tomography) scans of 46 consecutive newly diagnosed NPC patients were retrospectively reviewed. Maximal standardized uptake value (SUVmax) corrected for lean body mass of primary tumor (pSUVmax) and highest SUVmax of cervical lymph nodes (nSUVmax) were recorded. The association of FDG uptake and 2-year disease-free survival (DFS) was examined.

RESULTS

Significantly better DFS was found in patients with pSUVmax <7.5 and nSUVmax <6.5 (P = 0.042 and P = 0.019, respectively). In multivariate analysis, both pSUVmax and nSUVmax were significant independent predictors of DFS.

CONCLUSIONS

The SUVmax of the primary tumor and nodal metastasis are useful parameters for predicting DFS in NPC patients.

18F-FDG PET or PET-CT to evaluate prognosis for head and neck cancer: a meta-analysis

PURPOSE

The purpose of this meta-analysis was to evaluate the prognostic value of standard uptake value (SUV) from serial Fluorine-18-fluorodeoxyglucose positron emission tomography/computed tomography ((18)F-FDG PET/CT) in patients with head and neck cancer.

METHODS

We searched for articles limited to head and neck cancer, dealt with the impact of SUV on survival and published in English. The endpoints were disease-free survival (DFS), overall survival (OS), and local control (LC). Two reviewers extracted data independently.

RESULTS

Thirty-five studies were identified; of which, 26 studies involving 1,415 patients met the inclusion criteria. Pooled survival data suggested better DFS, OS, and LC in patients with low SUV of pre-treatment, and the odds ratio (OR) was 0.23, 0.24, and 0.27, respectively. Patients having tumors with low SUV of post-treatment also had significantly better DFS (OR = 0.17) and OS (OR = 0.28) than those with high SUV.

CONCLUSIONS

The present meta-analysis showed that (18)F-FDG uptake, as measured by the SUV before treatment and metabolic response after treatment, are valuable for predicting long-term survival in head and neck cancer. High (18)F-FDG uptake may be useful for identifying patients requiring more aggressive treatment.

Prediction of surgical outcome using plasma Epstein-Barr virus dna and (18)F-FDG PET-CT scan in recurrent nasopharyngeal carcinoma

BACKGROUND

This study was carried out to determine the role of plasma Epstein-Barr virus (pEBV)-DNA and positron-emission tomography (PET)-CT scan in predicting the outcome of nasopharyngectomy and cervical lymphadenectomy for recurrent nasopharyngeal carcinoma (NPC).

METHODS

Between 2007 and 2009, we recruited patients who had local or regional recurrent NPC after radiotherapy. The relationship between preoperative pEBV-DNA level, maximal standard uptake value (SUVmax), and surgical outcome was analyzed.

RESULTS

Forty-two patients had local tumor recurrence. Their median pEBV-DNA level and SUVmax were 348 copies and 4.7, respectively. Both values were significantly lower than those with palliative nasopharyngectomy. Twenty-two patients had regional failure. Their mean pEBV-DNA level and tumor SUVmax were 626 copies and 7.6, respectively. The metastatic lymph nodes with extracapsular spread had a significantly higher mean SUVmax.

CONCLUSIONS

Preoperative pEBV-DNA and PET-CT predict the surgical outcome of nasopharyngectomy for recurrent NPC. Similarly, PET-CT scan predicts the presence of extracapsular spread of metastatic lymph nodes. These patients may warrant further postoperative adjuvant therapy.

Serum CYFRA21-1 as a prognostic marker for patients with undifferentiated nasopharyngeal carcinoma

The purpose of this study was to evaluate the potential of serum CYFRA21-1 and carcinoembryonic antigen (CEA) as prognostic markers in patients with undifferentiated nasopharyngeal carcinoma. Sixty-one patients who received definitive radiotherapy/chemoradiotherapy were analysed retrospectively. We investigated the association of the follow-up results with pretreatment level, post-treatment level and change of serum CYFRA21-1 and CEA, respectively. Patients with low pretreatment CYFRA21-1 had a significantly better overall survival. There were no significant associations among the remaining serum markers, and the survival and recurrence rates on multivariate analysis. The present study shows that pretreatment CYFRA21-1 level is a potential factor for predicting long-term survival.