2-[18F]-Fluoro-2-deoxy-D-glucose positron emission tomography as guidance for primary treatment in patients with advanced-stage resectable squamous cell carcinoma of the larynx and hypopharynx

Post-cricoid and Upper Oesophagus Cancers Treated with Organ Preservation Using Intensity-modulated Image-guided Radiotherapy: a Phase II Prospective Study of Outcomes, Toxicity and Quality of Life

AIMS

To prospectively examine the outcomes, toxicity and quality of life (QoL) of patients with post-cricoid and upper oesophagus (PCUE) cancers treated with an organ-preservation approach of (chemo)-radiotherapy using intensity-modulated image-guided radiotherapy (IM-IGRT).

MATERIALS AND METHODS

This phase II prospective study was conducted at a tertiary cancer centre from February 2017 to January 2020. Forty patients with squamous cell carcinoma of PCUE of stage T1-3, N0-2, M0 were accrued. Gross exolaryngeal extension/dysfunctional larynx were major exclusion criteria. Patients received 63-66 Gy in once-daily fractions using volumetric modulated arc therapy with daily IGRT. Outcome measures included disease-related outcomes, patterns of failure, Radiation Therapy Oncology Group toxicities, feeding tube dependency and QoL.

RESULTS

The median follow-up was 22 months. Twenty-six (87.5%) patients had locoregionally advanced disease and 34 (85%) patients received (chemo)-radiotherapy. A complete response was observed in 26 (65%) patients. The 2-year locoregional control, event-free survival and cause-specific survival were 59.6%, 40.2% and 44.8%, respectively. The volume of primary tumour (GTVPvol) exceeding 28 cm³ had inferior overall survival (P = 0.005) on univariate analysis. Multivariable analysis showed GTVPvol and positron emission tomography-computed tomography maximum standardised uptake value to be independently predictive for event-free and overall survival. A feeding tube requirement at presentation was seen in 11 (27.5%) patients, whereas long-term feeding tube dependency at 6 months was seen in 10 (37%) patients. For QoL, a statistical improvement in pain, appetite loss and swallowing was observed over time.

CONCLUSION

Although the outcomes of PCUE cancers remain dismal, the use of state of the art diagnostic modalities, careful case selection and modern radiotherapy techniques improved outcomes as compared with before in this exclusive analysis of PCUE cancers.

Correlations between DW-MRI and 18 F-FDG PET/CT parameters in head and neck squamous cell carcinoma following definitive chemo-radiotherapy

BACKGROUND

Posttreatment diffusion-weighted magnetic resonance imaging (DW-MRI) and 18F-fluorodeoxygluocose (18 F-FDG) positron emission tomography (PET) with computed tomography (PET/CT) have potential prognostic value following chemo-radiotherapy (CRT) for head and neck squamous cell carcinoma (HNSCC). Correlations between these PET/CT (standardized uptake value or SUV) and DW-MRI (apparent diffusion coefficient or ADC) parameters have only been previously explored in the pretreatment setting.

AIM

To evaluate stage III and IV HNSCC at 12-weeks post-CRT for the correlation between SUVmax and ADC values and their interval changes from pretreatment imaging.

METHODS

Fifty-six patients (45 male, 11 female, mean age 59.9 + - 7.38) with stage 3 and 4 HNSCC patients underwent 12-week posttreatment DW-MRI and 18 F-FDG PET/CT studies in this prospective study. There were 41/56 patients in the cohort with human papilloma virus-related oropharyngeal cancer (HPV OPC). DW-MRI (ADCmax and ADCmin) and 18 F-FDG PET/CT (SUVmax and SUVmax ratio to liver) parameters were measured at the site of primary tumors (n = 48) and the largest lymph nodes (n = 52). Kendall's tau evaluated the correlation between DW-MRI and 18 F-FDG PET/CT parameters. Mann-Whitney test compared the post-CRT PET/CT and DW-MRI parameters between those participants with and without 2-year disease-free survival (DFS).

RESULTS

There was no correlation between DW-MRI and 18 F-FDG PET/CT parameters on 12-week posttreatment imaging (P = .455-.794; tau = -0.075-0.25) or their interval changes from pretreatment to 12-week posttreatment imaging (P = .1-.946; tau = -0.194-0.044). The primary tumor ADCmean (P = .03) and the interval change in nodal ADCmin (P = .05) predicted 2-year DFS but none of the 18 F-FDG PET/CT parameters were associated with 2-year DFS.

CONCLUSIONS

There is no correlation between the quantitative DWI-MRI and 18 F-FDG PET/CT parameters derived from 12-week post-CRT studies. These parameters may be independent biomarkers however in this HPV OPC dominant cohort, only selected ADC parameters demonstrated prognostic significance. Study was prospectively registered at http://www.controlled-trials.com/ISRCTN58327080.

Multiple Testing, Cut-Point Optimization, and Signs of Publication Bias in Prognostic FDG-PET Imaging Studies of Head and Neck and Lung Cancer: A Review and Meta-Analysis

Positron emission tomography (PET) imaging with 2-deoxy-2-[¹⁸F]-fluorodeoxyglucose (FDG) was proposed as prognostic marker in radiotherapy. Various uptake metrics and cut points were used, potentially leading to inflated effect estimates. Here, we performed a meta-analysis and systematic review of the prognostic value of pretreatment FDG–PET in head and neck squamous cell carcinoma (HNSCC) and non-small cell lung cancer (NSCLC), with tests for publication bias. Hazard ratio (HR) for overall survival (OS), disease free survival (DFS), and local control was extracted or derived from the 57 studies included. Test for publication bias was performed, and the number of statistical tests and cut-point optimizations were registered. Eggers regression related to correlation of SUVmax with OS/DFS yielded p = 0.08/p = 0.02 for HNSCC and p < 0.001/p = 0.014 for NSCLC. No outcomes showed significant correlation with SUVmax, when adjusting for publication bias effect, whereas all four showed a correlation in the conventional meta-analysis. The number of statistical tests and cut points were high with no indication of improvement over time. Our analysis showed significant evidence of publication bias leading to inflated estimates of the prognostic value of SUVmax. We suggest that improved management of these complexities, including predefined statistical analysis plans, are critical for a reliable assessment of FDG–PET.

Prognostic value of quantitative FDG-PET in the prediction of survival and local recurrence for patients with advanced oral cancer treated with superselective intra-arterial chemoradiotherapy

The current study aimed to evaluate the relationship between 18F-fluorodeoxyglucose positron emission tomography with computed tomography (FDG-PET-CT) standardized uptake value (SUV) [pre-treatment SUV (pre-SUV) and post-treatment SUV (post-SUV)] and treatment results in patients with advanced oral cancer treated with superselective intra-arterial chemoradiotherapy (SSIACRT). A total of 37 patients with advanced oral cancer were treated with SSIACRT. The treatment consisted of superselective intra-arterial chemotherapy (docetaxel (DOC) 40 mg/mm² and nedaplatin (CDGP) 80 mg/mm²) and concurrent radiotherapy (60-70 Gy) for a period of seven weeks. Pre-SUV and post-SUV of the primary tumor were measured. Overall survival (OS) and local control (LC) rates were selected as endpoints to evaluate prognosis. The median follow-up was 40 months (range 6-112 months). The 5-year OS and LC rates were 64.5 and 85.5%, respectively, and SSIACRT achieved high LC rate even in advanced oral cancers. In the log-rank test, post-SUV was a significant prognostic factor for OS and LC rates. The results of the current study demonstrated that SSIACRT is a reliable treatment with respect to survival in advanced oral cancer and post-SUV was a significant prognostic factor for OS and LC rates.

Predictive Value of Pretherapeutic Maximum Standardized Uptake Value (Suvmax) In Laryngeal and Hypopharyngeal Cancer

The aim of the study was to evaluate whether pretherapeutic metabolic tumor parameters from 18-fluorodeoxyglucose positron emission tomography (FDG-PET) imaging could predict larynx preservation in laryngeal and hypopharyngeal cancer patients prior to primary chemoradiation. Tumor metabolic parameters [maximum standardized uptake value (SUV_max), metabolic tumor volume (MTV), and total lesion glycolysis (TLG)] were retrospectively assessed in a consecutive cohort of laryngeal and hypopharyngeal cancer patients undergoing primary (chemo-)radiation. Main outcome measures were larynx preservation and survival. The study included 97 patients with a median follow-up of 32 months (IQR 20-54.5). For hypopharyngeal cancer, multivariable analysis showed that patients with a primary tumor's SUV_max > 9.5 entailed a higher risk of undergoing salvage pharyngolaryngectomy after chemoradiation (HR = 8.64, 95% CI = 1.1-67.3, P = 0.040). In laryngeal cancer, SUV_max did not predict the need for salvage laryngectomy. The only predictor for larynx preservation in laryngeal cancer patients was T-classification at initial diagnosis (HR = 6.67, 95% CI = 0.82-53.9, P = 0.039). In conclusion, SUV_max of primary tumor could be used as a predictor of larynx preservation prior to primary chemoradiation in hypopharyngeal cancer patients. This information may be important for patient counseling, as high SUV_max was correlated with reduced probability of larynx preservation. However, in laryngeal cancer patients, SUV_max does not seem to be predictive of outcome.

Role of pretreatment fluorodeoxyglucose positron emission tomography quantitative parameters in prognostication of head-and-neck squamous cell carcinoma

In spite of the good organ preservation strategies available for locally advanced head-and-neck squamous cell carcinoma (HNSCC), failure rates have been reported to be as high as 35%–50%. There has been an increasing interest in predicting response to treatment, to aid early intervention and better outcomes. Fluoro-2-deoxy-D-glucose-positron emission tomography (FDG-PET) is a standard modality for posttreatment evaluation; however, it is still underutilized as a pretreatment investigative modality. Several articles have described quantitative parameters in pretreatment FDG-PET to prognosticate patients and determine the likelihood of response to treatment; however, they are still not used commonly. This article was a review of the literature available on pretreatment FDG-PET quantitative parameters and their value in predicting failure. A thorough review of literature from MEDLINE and EMBASE was performed on pretreatment quantitative parameters in HNSCC. Metabolic tumor volume (MTV) and total lesion glycolysis (TLG) were reliable parameters to predict response to organ preservation therapy, disease-free survival, and overall survival. Maximum SUV (SUVmax) was an inconsistent parameter. MTV and TLG may help predict poor response to organ preservation to initiate early surgical salvage or modify therapeutic decisions to optimize clinical outcomes. Routine use may provide additional information over SUVmax alone.

Correlation between the malignancy and prognosis of oral squamous cell carcinoma in the maximum standardized uptake value

Positron emission tomography/computed tomography (PET/CT) examinations are indispensable in determining the stage, evaluating the treatment response, and diagnosing recurrence and metastasis during oral cancer treatment. In this study, we examined the correlation between the maximum standardized uptake value (SUVmax) for ¹⁸F-FDG PET/CT and the progressive factors, biological characteristics, and prognosis of oral cancer. We included 52 cases of oral squamous cell carcinoma with surgery as the initial treatment. Inclusion criteria included tumor diameter of ≥ 1 cm excluding superficial cancer. We performed 18F-FDG PET/CT examinations before surgery and determined the correlation between SUVmax and clinicopathological factors, such as histological grade, Ki-67 expression, as well as progress factors. SUVmax was significantly correlated with clinical T stage, vascular invasion, lymphatic invasion, Ki-67 expression, and postoperative event (recurrence or metastasis) in Student's t test. Using a cut-off SUVmax of 8.0, clinical T stage, lymph node metastasis, vascular invasion, infiltrative pattern, and Ki-67 expression significantly correlated in chi-squared test. Although observed and expected 3-year overall survival rates were not significantly different, observed and expected 3-year disease-free survival rates were significantly different. Analyzing each clinicopathological factor using various data obtained from ¹⁸F-FDG PET/CT scans may be useful to determine prognosis during oral cancer treatment.

Prognostic value of maximum standardized uptake value measured by pretreatment 18F-FDG PET/CT in locally advanced head and neck squamous cell carcinoma

PURPOSE/OBJECTIVES

To evaluate the prognostic impact of maximum standardized uptake value (SUV_max) in patients with locally advanced head and neck squamous cell carcinoma (HNSCC) undergoing pretreatment [F-18] fluoro-D-glucose-positron emission tomography/computed tomography (FDG PET/CT) imaging.

MATERIALS/METHODS

Fifty-eight patients undergoing FDG PET/CT before radical treatment with definitive radiotherapy (±concomitant chemotherapy) or surgery + postoperative (chemo)radiation were analyzed. The effects of clinicopathological factors (age, gender, tumor location, stage, Karnofsky Performance Status (KPS), and treatment strategy) including primary tumor SUV_max and nodal SUV_max on overall survival (OS), disease-free survival (DFS), locoregional control (LRC), and distant metastasis-free survival (DMFS) were evaluated. Kaplan-Meier survival curves were generated and compared with the log-rank test.

RESULTS

Median follow-up for the whole population was 31 months (range 2.3-53.5). Two-year OS, LRC, DFS and DMFS, for the entire cohort were 62.1, 78.3, 55.2 and 67.2%, respectively. Median pretreatment SUV_max for the primary tumor and lymph nodes was 11.85 and 5.4, respectively. According to univariate analysis, patients with KPS < 80% (p < 0.001), AJCC stage IVa or IVb vs III (p = 0.037) and patients undergoing radiotherapy vs surgery (p = 0.042) were significantly associated with worse OS. Patients with KPS < 80% (p = 0.003) or age ≥65 years (p = 0.007) had worse LRC. The KPS < 80% was the only factor associated with decreased DFS (p = 0.001). SUV_max of the primary tumor or the lymph nodes were not associated with OS, DFS or LRC. The KPS < 80% (p = 0.002), tumor location (p = 0.047) and AJCC stage (p = 0.025) were associated with worse cancer-specific survival (CSS). According to Cox regression analysis, on multivariate analysis KPS < 80% was the only independent parameter determining worse OS, DFS, CSS. Regarding LRC only patients with IK < 80% (p = 0.01) and ≥65 years (p = 0.01) remained statistically significant. Nodal SUV_max was the only factor associated with decreased DMFS. Patients with a nodal SUV_max > 5.4 presented an increased risk for distant metastases (HR, 3.3; 95% CI 1.17-9.25; p = 0.023).

CONCLUSIONS

The pretreatment nodal SUV_max in patients with locally advanced HNSCC is prognostic for DMFS. However, according to our results primary tumor SUV_max and nodal SUV_max were not significantly related to OS, DFS or LRC. Patients presenting KPS < 80% had worse OS, DFS, CSS and LRC.

Positron-emission tomography/computed tomography imaging in head and neck oncology: An update

Cancers of the head and neck account for more than half a million cases worldwide annually, with a significant majority diagnosed as squamous cell carcinoma (HNSCC). Imaging studies such as contrast-enhanced computed tomography (CT), magnetic resonance imaging (MRI) and ¹⁸F-2-fluoro-2-deoxy-D-glucose positron-emission tomography/computed tomography (¹⁸F-FDG PET/CT) are widely used to determine the presence and extent of tumors and metastatic disease, both before and after treatment. Advances in PET/CT imaging have allowed it to emerge as a superior imaging modality compared to both CT and MRI, especially in detection of carcinoma of unknown primary, cervical lymph node metastasis, distant metastasis, residual/recurrent cancer and second primary tumors, often leading to alteration in management. PET/CT biomarker may further provide an overall assessment of tumor aggressiveness with prognostic implications. As new developments emerged leading to better understanding and use of PET/CT in head and neck oncology, the aim of this article is to review the roles of PET/CT in both pre- and post-treatment management of HNSCC and PET-derived parameters as prognostic indicators.

Combining standardized uptake value of FDG-PET and apparent diffusion coefficient of DW-MRI improves risk stratification in head and neck squamous cell carcinoma

OBJECTIVES

To assess the independent prognostic value of standardized uptake value (SUV) and apparent diffusion coefficient (ADC), separately and combined, in order to evaluate if the combination of these two variables allows further prognostic stratification of patients with head and neck squamous cell carcinomas (HNSCC).

METHODS

Pretreatment SUV and ADC were calculated in 57 patients with HNSCC. Mean follow-up was 21.3 months. Semiquantitative analysis of primary tumours was performed using SUV_maxT/B, ADC_mean, ADC_min and ADC_max. The prognostic value of SUV_maxT/B, ADC_mean, ADC_min and ADC_max in predicting disease-free survival (DFS) was evaluated with log-rank test and Cox regression models.

RESULTS

Patients with SUV_maxT/B ≥5.75 had an overall worse prognosis (p = 0.003). After adjusting for lymph node status and diameter, SUV_maxT/B and ADC_min were both significant predictors of DFS with hazard ratio (HR) = 10.37 (95 % CI 1.22-87.95) and 3.26 (95 % CI 1.20-8.85) for SUV_maxT/B ≥5.75 and ADC_min ≥0.58 × 10^-3 mm²/s, respectively. When the analysis was restricted to subjects with SUV_maxT/B ≥5.75, high ADC_min significantly predicted a worse prognosis, with adjusted HR = 3.11 (95 % CI 1.13-8.55).

CONCLUSIONS

The combination of SUV_maxT/B and ADC_min improves the prognostic role of the two separate parameters; patients with high SUV_maxT/B and high ADC_min are associated with a poor prognosis.

KEY POINTS

• High SUV _maxT/B is a poor prognostic factor in HNSCC • High ADC _min is a poor prognostic factor in HNSCC • In patients with high SUV _maxT/B , high ADC _min identified those with worse prognosis.

Pretreatment tumor standardized uptake value as a prognostic factor in primary head and neck squamous cell carcinoma

Our objective was to conduct a systematic review and meta-analysis of studies assessing the diagnostic performance of primary tumor standardized uptake value (SUV) in head and neck squamous cell carcinoma (HNSCC), as measured by positron emission tomography. A systematic search of the indexed medical literature was conducted using appropriate keywords to identify relevant studies. Six articles were identified by searching electronic databases. A statistical analysis was performed with RevMan 4.2.2 software. SUV measurement and the SUV threshold for defining high SUV were studied dependently. For each publication, we first obtained an estimate of the relative risk (RR) for comparing patients with a low and those with a high SUV. Subsequently, we aggregated the individual RRs into a combined RR using the fixed-effects model to yield weighted mean pooled estimates with 95% confidence intervals (CIs). Publication bias was assessed with a funnel plot. A total of 6 clinical trials involving 453 patients were included in the meta-analysis. The combined RR from the 6 reports for local control was 0.72 (95% CI: 0.63-0.81). The funnel plot revealed symmetrical distribution, indicating no evidence of significant publication bias. The increase in the SUV of the primary tumor was found to be a poor prognostic marker for patients with HNSCC in the meta-analysis, which requires further confirmation in a meta-analysis based on individual patient data.

Supraclavicular lymphadenopathy: should it be perceived as the virchow's node of head and neck tumors?

BACKGROUND

In this study, we aimed to determine the correlation between supraclavicular lymph node involvement (SLNI) and metastatic potential, frequency, and metastases predilection sites in patients diagnosed with various head and neck tumors (HNT) and staged via positron emission tomography/computed tomography (PET/CT) imaging. We also investigated the impact of different variables on SLNI.

PATIENTS AND METHODS

270 patients diagnosed with HNT were enrolled in the study (194 males and 96 females, mean age 54.9 ± 14.7 years (range 18-89 years)).

RESULTS

Nasopharyngeal carcinoma demonstrated significant SLNI (p < 0.01); however, other subtypes of HNT did not. In all HNT studied, no apparent metastatic predilection tendency for the supraclavicular region was observed, as opposed to the well-described Virchow's node. Age, gender, tumor size, and systemic metastases were not identified as statistically significant variables contributing to SLNI. Multivariate regression analysis revealed an increased cervical (p < 0.01) and thoracic (p = 0.001) lymph node involvement in patients with SLNI.

CONCLUSION

SLNI with the possibility of metastasis was more frequently observed in nasopharyngeal carcinoma, advancing the nodal status without significantly influencing the T and M stages. A careful evaluation of this very small region is of critical importance for proper nodal staging in nasopharyngeal cancer patients.

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.

18F-FDG-PET/CT predicts survival in hypopharyngeal squamous cell carcinoma

OBJECTIVES

We investigated the relationship between overall survival of patients and pretreatment [(18)F]-2-fluorodeoxyglucose ((18)F-FDG) uptake, assessed by positron emission tomography combined with computed tomography (PET/CT) in hypopharyngeal squamous cell carcinoma.

METHODS

Thirty-one patients who were newly diagnosed as resectable hypopharyngeal squamous cell carcinoma underwent pretreatment (18)F-FDG-PET/CT. We used the maximum standardized uptake value (SUVmax) as (18)F-FDG uptake. Overall survival rate was calculated by the Kaplan-Meier method.

RESULTS

The median SUVmax was 11.53 (range 2.49-22.33). Patients with SUVmax ≥ 13 significantly exhibited shorter overall survival in univariate analysis (p < 0.01). Moreover, by Cox proportional hazards model of multivariate analysis, SUVmax ≥ 13 was a significant prognostic factor independent of clinical T and N classification, and treatment group (p < 0.02).

CONCLUSIONS

These results suggested that SUVmax obtained by pretreatment (18)F-FDG PET/CT assessment is an important prognostic factor in patients with hypopharyngeal squamous cell carcinoma.

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.

Prognostic value of volume-based (18)F-fluorodeoxyglucose PET/CT parameters in patients with clinically node-negative oral tongue squamous cell carcinoma

Objective

To evaluate the prognostic value of volume-based metabolic parameters measured with ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) positron emission tomography (PET) in patients with clinically node-negative (cN0) oral tongue squamous cell carcinoma (OTSCC) as compared with other prognostic factors.

Materials and Methods

In this study, we included a total of 57 patients who had been diagnosed with cN0 tongue cancer by radiologic, ¹⁸F-FDG PET/CT, and physical examinations. The maximum standardized uptake value (SUV_max), average SUV (SUV_avg), metabolic tumor volume (MTV), and total lesion glycolysis (TLG) for primary tumors were measured with ¹⁸F-FDG PET. The prognostic significances of these parameters and other clinical variables were assessed by Cox proportional hazards regression analysis.

Results

In the univariate analysis, pathological node (pN) stage, American Joint Committee on Cancer (AJCC) stage, SUV_max, SUV_avg, MTV, and TLG were significant predictors for survival. On a multivariate analysis, pN stage (hazard ratio = 10.555, p = 0.049), AJCC stage (hazard ratio = 13.220, p = 0.045), and MTV (hazard ratio = 2.698, p = 0.033) were significant prognostic factors in cN0 OTSCC patients. The patients with MTV ≥ 7.78 cm³ showed a worse prognosis than those with MTV < 7.78 cm³ (p = 0.037).

Conclusion

The MTV of primary tumor as a volumetric parameter of ¹⁸F-FDG PET, in addition to pN stage and AJCC stage, is an independent prognostic factor for survival in cN0 OTSCC.

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.

FDG PET/CT and diffusion-weighted imaging of head and neck squamous cell carcinoma: comparison of prognostic significance between primary tumor standardized uptake value and apparent diffusion coefficient

PURPOSE

To compare primary tumor (18)F-fluorodeoxyglucose (FDG) maximum standardized uptake value (SUV(max)) and diffusion-weighted imaging (DWI) apparent diffusion coefficient (ADC) obtained in the same patients with head and neck squamous cell carcinoma (HNSCC) to clarify the prognostic significance of both indexes.

MATERIALS AND METHODS

The study population comprised 26 patients with HNSCC visible on both pretreatment FDG PET/CT and DWI. Correlation between SUV(max) and ADC (b values; 0 and 800 seconds/mm(2)) was analyzed by the Spearman's rank test. Disease-free survival (DFS) was calculated by the Kaplan-Meier method. Prognostic significance was assessed by the long-rank test and Cox proportional hazards analysis.

RESULTS

SUV(max) and ADC correlated significantly and negatively (ρ = -0.566, P = 0.005). High (>12.1) SUV(max) (P < 0.001), low (≤ 0.88) ADC (P = 0.009), high (T3-4) T stage (P = 0.030), and high (N2-3) N stage (P = 0.007) were significant in predicting poor 2-year DFS. The accuracy for predicting disease events was 81% (21/26) for SUV(max) (>12.1) and 73% (19/26) for ADC(≤ 0.88) without significant difference between them (P = 0.52). Disease event hazards ratios for significant unadjusted SUV(max) (P = 0.015) and ADC (P = 0.039) remained significant when adjusted for other dichotomized clinical covariates (SUV(max); P = 0.009-0.039, ADC; P = 0.017-0.037) except SUV(max) for ADC and ADC for SUV(max) and T stage.

CONCLUSION

These results suggest that pretreatment primary tumor SUV(max) and ADC correlate significantly and negatively and both may have similar potential to predict DFS or disease events of HNSCC.

Up-front neck dissection followed by concurrent chemoradiation in patients with regionally advanced head and neck cancer

BACKGROUND

The appropriate management of the neck in patients with regionally advanced head and neck cancer remains controversial. The purpose of this study was to retrospectively analyze our institutional experience with up-front neck dissection followed by definitive chemoradiotherapy.

METHODS

Fifty-five patients with radiographic evidence of large or necrotic lymph nodes underwent up-front neck dissection followed by definitive chemoradiation.

RESULTS

The 5-year overall survival (OS) and progression-free survival (PFS) rates were estimated at 71.3% and 64.7%, respectively. There were 2 failures in the dissected neck, for a control rate of 96.7%. There were 7 locoregional failures and 12 distant failures, for locoregional and distant control rates of 87.3% and 78.2%, respectively.

CONCLUSION

Up-front neck dissection followed by chemoradiotherapy resulted in excellent locoregional control, OS, and PFS. Utilization of this strategy should be considered in carefully selected patients with regionally advanced head and neck cancer. © 2012 Wiley Periodicals, Inc. Head Neck, 2012.

Prognostic value of metabolic tumor volume and velocity in predicting head-and-neck cancer outcomes

PURPOSE

We previously showed that metabolic tumor volume (MTV) on positron emission tomography-computed tomography (PET-CT) predicts for disease recurrence and death in head-and-neck cancer (HNC). We hypothesized that increases in MTV over time would correlate with tumor growth and biology, and would predict outcome. We sought to examine tumor growth over time in serial pretreatment PET-CT scans.

METHODS AND MATERIALS

From 2006 to 2009, 51 patients had two PET-CT scans before receiving HNC treatment. MTV was defined as the tumor volume ≥ 50% of maximum SUV (SUV(max)). MTV was calculated for the primary tumor, nodal disease, and composite (primary tumor + nodes). MTV and SUV velocity were defined as the change in MTV or SUV(max) over time, respectively. Cox regression analyses were used to examine correlations between SUV, MTV velocity, and outcome (disease progression and overall survival).

RESULTS

The median follow-up time was 17.5 months. The median time between PET-CT scans was 3 weeks. Unexpectedly, 51% of cases demonstrated a decrease in SUV(max) (average, -0.1 cc/week) and MTV (average, -0.3 cc/week) over time. Despite the variability in MTV, primary tumor MTV velocity predicted disease progression (hazard ratio 2.94; p = 0.01) and overall survival (hazard ratio 1.85; p = 0.03).

CONCLUSIONS

Primary tumor MTV velocity appears to be a better prognostic indicator of disease progression and survival in comparison to nodal MTV velocity. However, substantial variability was found in PET-CT biomarkers between serial scans. Caution should be used when PET-CT biomarkers are integrated into clinical protocols for HNC.

Can FDG PET predict radiation treatment outcome in head and neck cancer? Results of a prospective study

Purpose

In head and neck cancer (HNC) various treatment strategies have been developed to improve outcome, but selecting patients for these intensified treatments remains difficult. Therefore, identification of novel pretreatment assays to predict outcome is of interest. In HNC there are indications that pretreatment tumour ¹⁸F-fluorodeoxyglucose (FDG) uptake may be an independent prognostic factor. The aim of this study was to assess the prognostic value of FDG uptake and CT-based and FDG PET-based primary tumour volume measurements in patients with HNC treated with (chemo)radiotherapy.

Methods

A total of 77 patients with stage II–IV HNC who were eligible for definitive (chemo)radiotherapy underwent coregistered pretreatment CT and FDG PET. The gross tumour volume of the primary tumour was determined on the CT (GTV_CT) and FDG PET scans. Five PET segmentation methods were applied: interpreting FDG PET visually (PET_VIS), applying an isocontour at a standardized uptake value (SUV) of 2.5 (PET_2.5), using fixed thresholds of 40% and 50% (PET_40%, PET_50%) of the maximum intratumoral FDG activity (SUV_MAX) and applying an adaptive threshold based on the signal-to-background (PET_SBR). Mean FDG uptake for each PET-based volume was recorded (SUV_mean). Subsequently, to determine the metabolic volume, the integrated SUV was calculated as the product of PET-based volume and SUV_mean. All these variables were analysed as potential predictors of local control (LC), regional recurrence-free survival (RRFS), distant metastasis-free survival (DMFS), disease-free survival (DFS) and overall survival (OS).

Results

In oral cavity/oropharynx tumours PET_VIS was the only volume-based method able to predict LC. Both PET_VIS and GTV_CT were able to predict DMFS, DFS and OS in these subsites. Integrated SUVs were associated with LC, DMFS, DFS and OS, while SUV_mean and SUV_MAX were not. In hypopharyngeal/laryngeal tumours none of the variables was associated with outcome.

Conclusion

There is no role yet for pretreatment FDG PET as a predictor of (chemo)radiotherapy outcome in HNC in daily routine. However, this potential application needs further exploration, focusing both on FDG PET-based primary tumour volume, integrated SUV and SUV_MAX of the primary tumour.

Prognostic Value of Metabolic Tumor Volume Measured by (18)F-FDG PET/CT in Locally Advanced Head and Neck Squamous Cell Carcinomas Treated by Surgery

PURPOSE

We assessed the prognostic value of metabolic tumor volume (MTV) measured using(18)F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) inpatients with locally advanced head and neck squamous cell carcinoma (HNSCC).

METHODS

We retrospectively reviewed 56 patients (51 men, five women; mean age 56.0 ± 8.8years) who had locally advanced HNSCC and underwent FDG PET/CT for initial evaluation. All patients had surgical resection and radiotherapy with or without concurrent chemotherapy. The peak standardized uptake value (SUVpeak) and MTV of the target lesion, including primary HNSCC andmetastatic cervical lymph nodes, were measured from FDG PET/CT images. We compared SUVpeak, MTV, and clinicopathologic variables such as age, Eastern Cooperative Oncology Group (ECOG) performance status, pN stage, pT stage, TNM stage, histologic grade and treatment modality to disease-free survival (DFS) and overall survival (OS).

RESULTS

On the initial FDG PET/CT scans, the median SUVpeak was 7.8 (range, 1.8-19.0) and MTV was17.0 cm(3) (range, 0.1-131.0 cm(3)). The estimated 2-year DFS and OS rates were 67.2% and 81.8%. The cutoff points of SUVpeak 6.2 and MTV 20.7 cm(3) were the best discriminative values for predicting clinical outcome. MTV and ECOG performance status were significantly related to DFS and OS on univariate and multivariate analyses (p < 0.05).

CONCLUSION

The MTV obtained from initial FDG PET/CT scan is a significant prognostic factor for disease recurrence and mortality in locally advanced HNSCC treated with surgery and radiotherapy with or without chemotherapy.

Usefulness of interim FDG-PET after induction chemotherapy in patients with locally advanced squamous cell carcinoma of the head and neck receiving sequential induction chemotherapy followed by concurrent chemoradiotherapy

PURPOSE

Induction chemotherapy (ICT) has been used to select patients for organ preservation and determine subsequent treatments in patients with locally advanced squamous cell carcinoma of the head and neck (LASCCHN). Still, the clinical outcomes of LASCCHN patients who showed response to ICT are heterogeneous. We evaluated the efficacy of interim 18-fluoro-2-deoxy-glucose positron emission tomography (FDG-PET) after ICT in this specific subgroup of LASCCHN patients who achieved partial response (PR) after ICT to predict clinical outcomes after concurrent chemoradiotherapy (CCRT).

METHODS AND MATERIALS

Twenty-one patients with LASCCHN who showed PR to ICT by Response Evaluation Criteria In Solid Tumors before definitive CCRT were chosen in this retrospective analysis. FDG-PET was performed before and 2-4 weeks after ICT to assess the extent of disease at baseline and the metabolic response to ICT, respectively. We examined the correlation of the metabolic response by the percentage decrease of maximum standardized uptake value (SUVmax) on the primary tumor or lymph node after ICT or a specific threshold of SUVmax on interim FDG-PET with clinical outcomes including complete response (CR) rate to CCRT, progression-free survival (PFS), and overall survival (OS).

RESULTS

A SUVmax of 4.8 on interim FDG-PET could predict clinical CR after CCRT (100% vs. 20%, p=0.001), PFS (median, not reached vs. 8.5 mo, p<0.001), and OS (median, not reached vs. 12.0 months, p=0.001) with a median follow-up of 20.3 months in surviving patients. A 65% decrease in SUVmax after ICT from baseline also could predict clinical CR after CCRT (100% vs. 33.3%, p=0.003), PFS (median, not reached vs. 8.9 months, p<0.001) and OS (median, not reached vs. 24.4 months, p=0.001) of the patients.

CONCLUSION

These data suggest that interim FDG-PET after ICT might be a useful determinant to predict clinical outcomes in patients with LASCCHN receiving sequential ICT followed by CCRT.

FDG-PET staging and importance of lymph node SUV in head and neck cancer

Objectives

The role of positron emission tomography (PET) with fluoro-deoxy-glucose (FDG) in the staging of head and neck cancer (HNC) is unclear. The NCCN guidelines do not recommend FDG-PET as a part of standard workup. The purpose of this report is to examine the role of FDG-PET imaging in altering management and providing prognostic information for HNC.

Methods

Retrospective review of HNC patients who had a staging FDG-PET scan performed at either Thomas Jefferson University or University of Kansas Medical Center between the years 2001 and 2007. A total of 212 PET scans were performed in patients who went on to receive radiotherapy.

Results

The median follow-up time for all patients was 469 days. The PPV and NPV of PET imaging to correctly identify lymph node status was 94% and 89% respectively. Lymph nodes with extracapsular extension (ECE) had higher SUVs than nodes without ECE, 11.0 vs. 5.0 (p < 0.0007). Maximum SUV for the primary tumor > 8.0 was predictive of worse overall survival (p < 0.045), while the SUV of the lymph nodes was predictive for distant recurrence at one year--with a mean SUV value of 10.4 for patients with distant failure vs. 7.0 without (p < 0.05).

Conclusions

FDG-PET staging in head and neck cancer has good positive and negative predictive values in determining lymph node status. The maximum SUV of the primary tumor is predictive of overall survival. This is the first report to find that the SUV of a lymph node is predictive for ECE and also for distant recurrence.

Standardized uptake value is of prognostic value for outcome in head and neck squamous cell carcinoma

CONCLUSIONS

The literature-based meta-analysis confirmed that increased standardized uptake value (SUV) of the primary tumor is a poor prognostic factor in patients with head and neck squamous cell carcinoma (HNSCC), which should be further confirmed in a meta-analysis based on individual patient data.

OBJECTIVES

Primary tumor SUV, as measured by positron emission tomography (PET), has been studied as a potential prognostic factor for local control, disease-free survival, and overall survival. However, the limited sample sizes of the studies in the past led us to conduct a meta-analysis to improve the precision in estimating the effect of SUV on the prognosis of HNSCC.

METHODS

Eight articles were identified by searching electronic databases. Statistical analysis was performed with RevMan 4.2.2. SUV measurement and SUV threshold for defining high SUV were studied dependently. For each publication, we first obtained an estimate of the relative risk (RR) for comparing patients with a low and a high SUV. Subsequently, we aggregated the individual RRs into a combined RR, using a fixed-effects model. Publication bias was assessed with funnel plot.

RESULTS

We identified eight clinical trials dedicated to HNSCC. The combined RR from five reports for the local control was 0.71 (95% confidence interval [CI]: 0.63-0.81). The combined RR of the disease-free survival from six reports was 0.63 (95% CI: 0.54-0.73). Meanwhile, the combined RR of the overall survival from three reports was 0.57 (95% CI: 0.44-0.74). The funnel plot showed symmetrical distribution, indicating no evidence of substantial publication bias.

Clinical usefulness of [18F] fluoro-2-deoxy-D-glucose uptake in 178 head-and-neck cancer patients with nodal metastasis treated with definitive chemoradiotherapy: consideration of its prognostic value and ability to provide guidance for optimal selection of patients for planned neck dissection

PURPOSE

To evaluate the clinical effectiveness of pretreatment [18F] fluoro-2-deoxy-D-glucose-positron emission tomography for head-and-neck squamous cell carcinoma patients with nodal metastasis treated with chemoradiotherapy.

METHODS AND MATERIALS

Between March 2002 and December 2006, 178 patients with head-and-neck squamous cell carcinoma and nodal metastasis underwent fluoro-2-deoxy-D-glucose positron emission tomography before chemoradiotherapy. Fluoro-2-deoxy-D-glucose uptake by both the primary lesion and the neck node was measured using the standard uptake value (SUV). The overall survival, disease-free survival, local control, nodal progression-free survival, and distant metastasis-free survival rates were calculated, and several prognostic factors were evaluated.

RESULTS

The patients with a nodal SUV≥6.00 had a significantly lower 3-year disease-free survival rate than those with a lower SUV (44% vs. 69%, p=.004). On multivariate analysis, a high SUV of nodal disease also proved to be a significantly unfavorable factor for disease-free survival (p=.04, 95% confidence interval [CI], 1.02-3.23), nodal progression-free survival (p=.05; 95% CI, 1.00-4.15), and distant metastasis-free survival (p=.016; 95% CI, 1.25-8.92). Among the patients with a greater nodal SUV (≥6.00), those treated with planned neck dissection had better nodal progression-free survival than those in the observation group (p=.04, hazard ratio, 2.36; 95% CI, 1.00-5.85).

CONCLUSION

Among head-and-neck squamous cell carcinoma patients treated with chemoradiotherapy, the pretreatment SUV of nodal disease was one of the strongest prognostic factors and also provided important information for the selection of patients suitable for planned neck dissection.

Measurement of tumor volume by PET to evaluate prognosis in patients with head and neck cancer treated by chemo-radiation therapy

PURPOSE

To evaluate the prognostic value of the metabolic tumor volume measured on 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) imaging and other clinical factors in patients treated for locally advanced head-and-neck cancer (HNC) at a single institution.

MATERIALS AND METHODS

Between June 2005 and August 2008, 59 patients with HNC that underwent pretreatment FDG-PET studies received neoadjuvant chemotherapy and radiation therapy. Metabolically active tumor regions were delineated on the pretreatment PET scans by a fixed SUV of 2.5. We evaluated the relationship of the 18F-fluorodeoxyglucose-PET maximum standardized uptake value (SUV) and the metabolic tumor volume (MTV) with the progression-free survival (PFS) and overall survival (OS).

RESULTS

The MTV and lymph node metastasis were predictive of the PFS and OS. The lymph node status did not correlate with the MTV. A higher MTV of 9.3 cm(3) was significantly associated with an increased risk of recurrence (2.19-fold, p = 0.006) and death (1.62-fold, p = 0.051). Separation of patients with tumor volumes <or= 9.3 cm(3) and no lymph node disease vs. any other combination was strongly predictive of the PFS and the OS.

CONCLUSIONS

MTV and lymph node status were prognostic values associated with survival. Quantitative measurement of tumor volume separates patients with a good prognosis from those with a poorer prognosis. A subset of patients with relatively small tumors and no lymph node involvement did very well.

Metabolic tumor volume predicts for recurrence and death in head-and-neck cancer

PURPOSE

To evaluate the prognostic value of metabolic tumor volume measured on 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) imaging and other clinical factors in patients treated for locally advanced head-and-neck cancer (HNC) at a single institution.

MATERIALS AND METHODS

Between March 2003 and August 2007, 85 patients received positron emission tomography (PET)/computed tomography-guided chemoradiotherapy for HNC. Metabolically active tumor regions were delineated on pretreatment PET scans semiautomatically using custom software. We evaluated the relationship of (18)F-fluorodeoxyglucose-PET maximum standardized uptake value (SUV) and total metabolic tumor volume (MTV) with disease-free survival (DFS) and overall survival (OS).

RESULTS

Mean follow-up for surviving patients was 20.4 months. The estimated 2-year locoregional control, DFS, and OS for the group were 88.0%, 69.5%, and 78.4%, respectively. The median time to first failure was 9.8 months among the 16 patients with relapse. An increase in MTV of 17.4 mL (difference between the 75th and 25th percentiles) was significantly associated with an increased hazard of first event (recurrence or death) (1.9-fold, p < 0.001), even after controlling for Karnofsky performance status (KPS) (1.8-fold, p = 0.001), and of death (2.1-fold, p < 0.001). We did not find a significant relationship of maximum SUV, stage, or other clinical factors with DFS or OS.

CONCLUSIONS

Metabolic tumor volume is an adverse prognostic factor for disease recurrence and death in HNC. MTV retained significance after controlling for KPS, the only other significant adverse prognostic factor found in this cohort. MTV is a direct measure of tumor burden and is a potentially valuable tool for risk stratification and guiding treatment in future studies.

Pretreatment FDG-PET standardized uptake value as a prognostic factor for outcome in head and neck cancer

BACKGROUND

We studied the potential prognostic significance of pretreatment 18-fluorodeoxyglucose-positron emission tomography (FDG-PET) standardized uptake value (SUV) in squamous cell carcinoma of the head and neck (SCCHN).

METHODS

A retrospective review of the pretreatment FDG-PET scans of 60 patients with SCCHN was performed. All patients received radiotherapy and 37 also received concurrent chemotherapy. SUV was calculated by 2 nuclear-medicine physicians who were blinded to the clinical data. Disease-free survival (DFS) was analyzed with respect to SUV (and other potential prognostic factors).

RESULTS

The median SUV was 7.2 (range, 1-24.7); 34 patients (57%) had SUV < 9.0 compared with 26 patients (43%) with an SUV > or = 9.0. The group with low SUV had significantly better 2-year DFS compared with the high SUV group (72% vs 37%), p = .007. On multivariate analysis, stage and age were also associated with DFS, but SUV remained an independent predictor of DFS (hazard ratio: 1.08; p = .016).

CONCLUSION

SUV was significantly associated with outcome after modern definitive therapy of SCCHN.

Prognostic Value of FDG-PET in patients with oropharyngeal carcinoma treated with concurrent chemoradiotherapy

Purpose

The purpose of this study was to evaluate the predictive value of 2-deoxy-2-[F-18]fluoro-d-glucose-positron emission tomography (FDG-PET) following concurrent chemoradiotherapy (CRT) on survival in patients with carcinoma of the oropharynx (OPC).

Methods

Eighteen patients with primary OPC who underwent PET pre- and post-CRT were evaluated prospectively for survival. The prognostic performance of post-CRT PET and CT for recurrence was compared.

Results

Patients with positive post-CRT PET exhibited significantly lower 2-year cause-specific survival and disease-free survival (50% vs. 91%, P < 0.05 and 0% vs. 83%, P < 0.0001); however, patients with positive post-CRT CT did not exhibit any significant difference (67% vs. 83%, P = 0.416 and 50% vs. 75%, P = 0.070). Other factors, such as clinical and pre-CRT PET variables, also did not indicate any significant difference. The accuracy of prediction of residual and local recurrence for post-CRT PET and CT (local%/regional%) was 83%/94% and 83%/78%, respectively.

Conclusion

OPC patients with positive post-CRT PET exhibit poor survival. The prognostic accuracy of post-CRT PET is superior to that of CT. The results of post-CRT FDG-PET should be included in the management of the OPC patients.