Tumor plasma flow determined by dynamic contrast-enhanced MRI predicts response to induction chemotherapy in head and neck cancer

Induction chemotherapy in locally advanced head and neck cancers, is there a best choice?

Locally advanced stages of squamous cancers of the head and neck (LAHNCs) acquire high propensity for local and systemic relapse. Addition of systemic therapy as an induction (IC) to the standard concurrent chemoradiotherapy (CCRT) has become an approach of many practitioners. This strategy has shown to reduce metastases but did not affect survival in unselected populations. Meanwhile, the induction regimen including docetaxel, cisplatin, 5-FU (TPF) has shown superiority over other combinations, however, a survival advantage was not detected when compared to CCRT alone. This may be attributed to its high toxicity profile, inducing treatment delay, resistance, or variations in tumor sites and responses. Currently, newer systemic therapy combinations are being tested and indicators of benefit are being identified. The focus of this review is on the development of the choice of combination regimen for induction. Subsequently, proposed alternatives and strategies for patient selection will be introduced.

Dynamic contrast-enhanced MRI and Doppler sonography in patients with squamous cell carcinoma of head and neck treated with induction chemotherapy

In view of the inherent limitations associated with performing dynamic contrast enhanced-magnetic resonance imaging (DCE-MRI) in clinical settings, current study was designed to provide a proof of principle that Doppler sonography and DCE-MRI derived perfusion parameters yield similar hemodynamic information from metastatic lymph nodes in squamous cell carcinomas of head and neck (HNSCCs). Strong positive correlations between volume fraction of plasma space in tissues (V_p ) and blood volume (r = 0.72, p = 0.02) and between V_p and %area perfused (r = 0.65, p = 0.04) were observed. Additionally, a moderate positive correlation trending towards significance was obtained between volume transfer constant (K^trans ) and %area perfused (r = 0.49, p = 0.09).

Correlations of tumour permeability parameters with apparent diffusion coefficient in nasopharyngeal carcinoma

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Vascular permeability is associated with diffusability in nasopharyngeal tumour.

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Both influx and reflux rates have inverse linear correlations with ADC.

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Reflux rate has the strongest inverse linear correlation with ADC.

Background and Purpose

Functional imaging has an established role in therapeutic monitoring of cancer treatments. This study evaluated the correlations of tumour permeability parameters derived from dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) and tumour cellularity derived from apparent diffusion coefficient (ADC) in nasopharyngeal carcinoma (NPC).

Material and Methods

Twenty NPC patients were examined with DCE-MRI and RESOLVE diffusion-weighted MRI (DW-MRI). Tumour permeability parameters were quantitatively measured with Tofts compartment model. Volume transfer constant (K^trans), volume of extravascular extracellular space (EES) per unit volume of tissue (V_e), and the flux rate constant between EES and plasma (K_ep) from DCE-MRI scan were measured. The time-intensity curve was plotted from the 60 dynamic phases of DCE-MRI. The initial area under the curve for the first 60 s of the contrast agent arrival (iAUC60) was also calculated. They were compared with the ADC value derived from DW-MRI with Pearson correlation analyses.

Results

Among the DCE-MRI permeability parameters, K_ep had higher linearity in inverse correlation with ADC value (r = −0.69, p = <0.05). K^trans (r = −0.60, p=<0.05) and iAUC60 (r = −0.64, p = <0.05) also had significant inverse correlations with ADC. V_e showed a significant positive correlation with ADC (r = 0.63, p = <0.05).

Conclusions

Nasopharyngeal tumour vascular permeability parameters derived from DCE-MRI scan were correlated linearly with tumour cellularity measured by free water diffusability with ADC. The clinical implementations of these linear correlations in the quantitative assessments of therapeutic response for NPC patients may be worth to further explore.

Normalized Parameters of Dynamic Contrast-Enhanced Perfusion MRI and DWI-ADC for Differentiation between Posttreatment Changes and Recurrence in Head and Neck Cancer

BACKGROUND AND PURPOSE

Differentiating recurrence from benign posttreatment changes has clinical importance in the imaging follow-up of head and neck cancer. This study aimed to investigate the utility of normalized dynamic contrast-enhanced MR imaging and ADC for their differentiation.

MATERIALS AND METHODS

This study included 51 patients with a history of head and neck cancer who underwent follow-up dynamic contrast-enhanced MR imaging with DWI-ADC, of whom 25 had recurrences and 26 had benign posttreatment changes. Quantitative and semiquantitative dynamic contrast-enhanced MR imaging parameters and ADC of the ROI and reference region were analyzed. Normalized dynamic contrast-enhanced MR imaging parameters and normalized DWI-ADC parameters were calculated by dividing the ROI by the reference region.

RESULTS

Normalized plasma volume, volume transfer constant between extravascular extracellular space and blood plasma per minute (K ^trans), area under the curve, and wash-in were significantly higher in patients with recurrence than in those with benign posttreatment change (P = .003 to <.001). The normalized mean ADC was significantly lower in patients with recurrence than in those with benign posttreatment change (P < .001). The area under the receiver operating characteristic curve of the combination of normalized dynamic contrast-enhanced MR imaging parameters with significance (normalized plasma volume, normalized extravascular extracellular space volume per unit tissue volume, normalized K ^trans, normalized area under the curve, and normalized wash-in) and normalized mean ADC was 0.97 (95% CI, 0.93-1).

CONCLUSIONS

Normalized dynamic contrast-enhanced MR imaging parameters, normalized mean ADC, and their combination were effective in differentiating recurrence and benign posttreatment changes in head and neck cancer.

Predictive Biomarkers for Response and Toxicity of Induction Chemotherapy in Head and Neck Cancers

This review focuses on the molecular biology of head and neck squamous cell carcinomas and presents current and emerging biomarkers of the response of patients to induction chemotherapy. The usefulness of genes, proteins, and parameters from diagnostic clinical imaging as well as other clinicopathological parameters is thoroughly discussed. The role of induction chemotherapy before radiotherapy or before chemo-radiotherapy is still debated, as the data on its efficacy are somehow confusing. Despite the constant improvement of treatment protocols and the introduction of new cytostatics, there is still no consensus regarding the use of induction chemotherapy in the treatment of head and neck cancer, with the possible exception of larynx preservation. Such difficulties indicate that potential future treatment strategies should be personalized. Personalized medicine, in which individual tumor genetics drive the selection of targeted therapies and treatment plans for each patient, has recently emerged as the next generation of cancer therapy. Early prediction of treatment outcome or its toxicity may be highly beneficial for those who are at risk of the development of severe toxicities or treatment failure—a different treatment strategy may be applied to these patients, sparing them unnecessary pain. The literature search was carried out in the PubMed and ScienceDirect databases as well as in the selected conference proceedings repositories. Of the 265 articles and abstracts found, only 30 met the following inclusion criteria: human studies, analyzing prediction of induction chemotherapy outcome or toxicity based on the pretreatment (or after the first cycle, if more cycles of induction were administered) data, published after the year 2015. The studies regarding metastatic and recurrent cancers as well as the prognosis of overall survival or the outcome of consecutive treatment were not taken into consideration. As revealed from the systematic inspection of the papers, there are over 100 independent parameters analyzed for their suitability as prognostic markers in HNSCC patients undergoing induction chemotherapy. Some of them are promising, but usually they lack important features such as high specificity and sensitivity, low cost, high positive predictive value, clinical relevance, short turnaround time, etc. Subsequent studies are necessary to confirm the usability of the biomarkers for personal medicine.

PET Imaging of Tumor Perfusion: A Potential Cancer Biomarker?

Perfusion, as measured by imaging, is considered a standard of care biomarker for the evaluation of many tumors. Measurements of tumor perfusion may be used in a number of ways, including improving the visual detection of lesions, differentiating malignant from benign findings, assessing aggressiveness of tumors, identifying ischemia and by extension hypoxia within tumors, and assessing treatment response. While most clinical perfusion imaging is currently performed with CT or MR, a number of methods for PET imaging of tumor perfusion have been described. The inert PET radiotracer ¹⁵O-water PET represents the recognized gold standard for absolute quantification of tissue perfusion in both normal tissue and a variety of pathological conditions including cancer. Other cancer PET perfusion imaging strategies include the use of radiotracers with high first-pass uptake, analogous to those used in cardiac perfusion PET. This strategy produces more visually pleasing high-contrast images that provide relative rather than absolute perfusion quantification. Lastly, multiple timepoint imaging of PET tracers such as ¹⁸F-FDG, are not specifically optimized for perfusion, but have advantages related to availability, convenience, and reimbursement. Multiple obstacles have thus far blocked the routine use of PET imaging for tumor perfusion, including tracer production and distribution, image processing, patient body coverage, clinical validation, regulatory approval and reimbursement, and finally feasible clinical workflows. Fortunately, these obstacles are being overcome, especially within larger imaging centers, opening the door for PET imaging of tumor perfusion to become standard clinical practice. In the foreseeable future, it is possible that whole-body PET perfusion imaging with ¹⁵O-water will be able to be performed in a single imaging session concurrent with standard PET imaging techniques such as ¹⁸F-FDG-PET. This approach could establish an efficient clinical workflow. The resultant ability to measure absolute tumor blood flow in combination with glycolysis will provide important complementary information to inform prognosis and clinical decisions.

Prediction of distant metastases in patients with squamous cell carcinoma of head and neck using DWI and DCE-MRI

BACKGROUND

The primary purpose was to evaluate the prognostic potential of diffusion imaging (DWI) and dynamic contrast enhanced magnetic resonance imaging (DCE-MRI) in predicting distant metastases in squamous cell carcinoma of head and neck (HNSCC) patients. The secondary aim was to examine differences in DWI and DCE-MRI-derived parameters on the basis of human papilloma virus (HPV) status, differentiation grade, and nodal stage of HNSCC.

METHODS

Fifty-six patients underwent pretreatment DWI and DCE-MRI. Patients were divided into groups who subsequently did (n = 12) or did not develop distant metastases (n = 44). Median values of apparent diffusion coefficient (ADC), volume transfer constant (K^trans ), and mean intracellular water-lifetime (τ_i ) and volume were computed from metastatic lymph nodes and were compared between two groups. Prognostic utility of HPV status, differentiation grading, and nodal staging was also evaluated both in isolation or in combination with MRI parameters in distinguishing patients with and without distant metastases. Additionally, MRI parameters were compared between two groups based on dichotomous HPV status, differentiation grade, and nodal stage.

RESULTS

Lower but not significantly different K^trans (0.51 ± 0.15 minute^-1 vs 0.60 ± 0.05 minute^-1 ) and not significantly different τ_i (0.13 ± 0.03 second vs 0.19 ± 0.02 second) were observed in patients who developed distant metastases than those who did not. Additionally, no significant differences in ADC or volume were found. τ_i, was the best parameter in discriminating two groups with moderate sensitivity (67%) and specificity (61.4%). Multivariate logistic regression analyses did not improve the overall prognostic performance for combination of all variables. A trend toward higher τ_i was observed in HPV-positive patients than those with HPV-negative patients. Also, a trend toward higher K^trans was observed in poorly differentiated HNSCCs than those with moderately differentiated HNSCCs.

CONCLUSION

Pretreatment DCE-MRI may be useful in predicting distant metastases in HNSCC.

Predictive Values of MRI and PET Derived Quantitative Parameters for Patterns of Failure in Both p16+ and p16- High Risk Head and Neck Cancer

Purpose: FDG-PET adds to clinical factors, such tumor stage and p16 status, in predicting local (LF), regional (RF), and distant failure (DF) in poor prognosis locally advanced head and neck cancer (HNC) treated with chemoradiation. We hypothesized that MRI-based quantitative imaging (QI) metrics could add to clinical predictors of treatment failure more significantly than FDG-PET metrics. Materials and methods: Fifty four patients with poor prognosis HNCs who were enrolled in an IRB approved prospective adaptive chemoradiotherapy trial were analyzed. MRI-derived gross tumor volume (GTV), blood volume (BV), and apparent diffusion coefficient (ADC) pre-treatment and mid-treatment (fraction 10), as well as pre-treatment FDG PET metrics, were analyzed in primary and individual nodal tumors. Cox proportional hazards models for prediction of LRF and DF free survival were used to test the additional value of QI metrics over dominant clinical predictors. Results: The mean ADC pre-RT and its change rate mid-treatment were significantly higher and lower in p16- than p16+ primary tumors, respectively. A Cox model identified that high mean ADC pre-RT had a high hazard for LF and RF in p16- but not p16+ tumors (p = 0.015). Most interesting, persisting subvolumes of low BV (TV_bv) in primary and nodal tumors mid-treatment had high-risk for DF (p < 0.05). Also, total nodal GTV mid-treatment, mean/max SUV of FDG in all nodal tumors, and total nodal TLG were predictive for DF (p < 0.05). When including clinical stage (T4/N3) and total nodal GTV in the model, all nodal PET parameters had a p-value of >0.3, and only TV_bv of primary tumors had a p-value of 0.06. Conclusion: MRI-defined biomarkers, especially persisting subvolumes of low BV, add predictive value to clinical variables and compare favorably with FDG-PET imaging markers. MRI could be well-integrated into the radiation therapy workflow for treatment planning, response assessment, and adaptive therapy.

Differential diagnostic value of diffusion-weighted and dynamic contrast-enhanced MR imaging in non-cystic lesions in floor of the mouth

METHODS:

A total of 82 patients were included in this study. The apparent diffusion coefficient (ADC) values and time-signal intensity curves (TICs) were measured. Clinical characteristics, ADC value, and TIC pattern were compared between benign and malignant FOM lesions. Receiver operating characteristic curve and logistic regression analyses were performed to evaluate respective and combined value of ADC value and TIC pattern for differential diagnosis. The retrospective study was approved by our institutional review board, and the need for informed consent was waived.

RESULTS:

The area under the curve ADC value and TIC pattern were 0.71 and 0.73, respectively. The combined use of ADC value and TIC pattern increased the area under the curve value to 0.81 [95% confidence interval (CI), (0.66-0.97)]. ADC < 1.23 × 10^-3 mm² s^-1 (odds ratio, 45.8; 95% CI, 2.8-737.9) and both the plateau and washout TIC patterns (OR, 6.8; 95% CI, 1.8-24.8) were significantly associated with malignancy of FOM lesions.

CONCLUSIONS:

Our results suggest that both diffusion-weighted imaging and DCE-MRI could contribute to the differential diagnosis of non-cystic FOM lesions, especially when used in combination.

Pre-treatment tumour perfusion parameters and initial RECIST response do not predict long-term survival outcomes for patients with head and neck squamous cell carcinoma treated with induction chemotherapy

Objectives

Previously, we showed that pre-treatment tumour plasma perfusion (F_p) predicts RECIST response to induction chemotherapy (ICT) in locoregionally advanced head and neck squamous cell carcinoma (HNSCC). The aim here was to determine whether the pre-treatment tumour F_p estimate, changes in tumour F_p or RECIST response post 2 cycles of ICT were prognostic for long-term survival outcomes.

Methods

A prospective study enrolled patients with high stage HNSCC treated with docetaxel (T), cisplatin (P) and 5-fluorouracil (F) (ICT) followed by synchronous cisplatin and intensity modulated radiotherapy. Dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) before and after two cycles of ICT was used to measure F_p and RECIST response.

Results

Forty-two patients were recruited and 37 underwent two scans. The median follow-up was 36 (range 23–49) months. Pre-treatment tumour F_p (stratified by median) was not prognostic for overall survival (p = 0.42), disease specific survival (p = 0.20) and locoregional control (p = 0.64). Neither change in tumour F_p nor RECIST response post two cycles of ICT was prognostic for any outcome (p>0.21).

Conclusion

DCE-MRI parameters do not predict long-term survival outcomes following ICT and RECIST response to ICT may not be an appropriate endpoint to determine early efficacy of a treatment in HNSCC patients.

Functional MRI for Treatment Evaluation in Patients with Head and Neck Squamous Cell Carcinoma: A Review of the Literature from a Radiologist Perspective

PURPOSE OF REVIEW

To show the role of functional MRI in patients treated for head and neck squamous cell carcinoma.

RECENT FINDINGS

MRI is commonly used for treatment evaluation in patients with head and neck tumors. However, anatomical MRI has its limits in differentiating between post-treatment effects and tumor recurrence. Recent studies showed promising results of functional MRI for response evaluation.

SUMMARY

This review analyzes possibilities and limitations of functional MRI sequences separately to obtain insight in the post-therapy setting. Diffusion, perfusion and spectroscopy show promise, especially when utilized complimentary to each other. These functional MRI sequences aid in the early detection which might improve survival by increasing effectiveness of salvage therapy. Future multicenter longitudinal prospective studies are needed to provide standardized guidelines for the use of functional MRI in daily clinical practice.

Taxane, platinum and 5-FU prior to chemoradiotherapy benefits patients with stage IV neck node-positive head and neck cancer and a good performance status

PURPOSE

The benefit of adding docetaxel, cisplatin and 5-fluorouracil (TPF) induction chemotherapy to chemoradiotherapy (CRT) in head and neck squamous cell carcinoma (HNSCC) remains uncertain. We aimed to investigate whether ICT is well tolerated when given with prophylactic treatment against predicted adverse effects and which patients benefit most.

METHODS

A single-centre audit identified 132 HNSCC patients with stage IVa/b neck node-positive disease, prescribed TPF followed by CRT. TPF involved three cycles of docetaxel (75 mg/m² IV) and cisplatin (75 mg/m² IV) on day 1 plus 5-FU (750 mg/m² IV) on days 2-5. Planned CRT was 66 Gy in 30 fractions of intensity-modulated radiotherapy with concurrent cisplatin (100 mg/m² IV) at the beginning of week 1 and 4 (days 1 and 22). All patients received prophylactic antibiotics and granulocyte colony-stimulating factor.

RESULTS

Median follow-up was 39.5 months. 92.4% of patients completed three cycles of TPF; 95.5% of patients started chemoradiotherapy. Grade 3/4 adverse events were low (febrile neutropenia 3.0%), with no toxicity-related deaths. 3-year overall survival was 67.2%; disease-specific survival was 78.7%; locoregional control was 78.3%. Distant metastases rate was 9.8% (3.0% in those without locoregional recurrence). Good performance status (p = 0.002) and poor tumour differentiation (p = 0.018) were associated with improved overall survival on multivariate analysis.

CONCLUSION

With prophylactic antibiotics and granulocyte colony-stimulating factor TPF was well tolerated with good survival outcomes. TPF should remain a treatment option for stage IV neck node-positive patients with a good performance status. The use of tumour grade to aid patient selection for TPF warrants investigation.

Dynamic Contrast-Enhanced MRI-Derived Intracellular Water Lifetime (τ i ): A Prognostic Marker for Patients with Head and Neck Squamous Cell Carcinomas

BACKGROUND AND PURPOSE

Shutter-speed model analysis of dynamic contrast-enhanced MR imaging allows estimation of mean intracellular water molecule lifetime (a measure of cellular energy metabolism) and volume transfer constant (a measure of hemodynamics). The purpose of this study was to investigate the prognostic utility of pretreatment mean intracellular water molecule lifetime and volume transfer constant in predicting overall survival in patients with squamous cell carcinomas of the head and neck and to stratify p16-positive patients based upon survival outcome.

MATERIALS AND METHODS

A cohort of 60 patients underwent dynamic contrast-enhanced MR imaging before treatment. Median, mean intracellular water molecule lifetime and volume transfer constant values from metastatic nodes were computed from each patient. Kaplan-Meier analyses were performed to associate mean intracellular water molecule lifetime and volume transfer constant and their combination with overall survival for the first 2 years, 5 years, and beyond (median duration, >7 years).

RESULTS

By the last date of observation, 18 patients had died, and median follow-up for surviving patients (n = 42) was 8.32 years. Patients with high mean intracellular water molecule lifetime (4 deaths) had significantly (P = .01) prolonged overall survival by 5 years compared with those with low mean intracellular water molecule lifetime (13 deaths). Similarly, patients with high mean intracellular water molecule lifetime (4 deaths) had significantly (P = .006) longer overall survival at long-term duration than those with low mean intracellular water molecule lifetime (14 deaths). However, volume transfer constant was a significant predictor for only the 5-year follow-up period. There was some evidence (P < .10) to suggest that mean intracellular water molecule lifetime and volume transfer constant were associated with overall survival for the first 2 years. Patients with high mean intracellular water molecule lifetime and high volume transfer constant were associated with significantly (P < .01) longer overall survival compared with other groups for all follow-up periods. In addition, p16-positive patients with high mean intracellular water molecule lifetime and high volume transfer constant demonstrated a trend toward the longest overall survival.

CONCLUSIONS

A combined analysis of mean intracellular water molecule lifetime and volume transfer constant provided the best model to predict overall survival in patients with squamous cell carcinomas of the head and neck.

Chapter 8 On the Horizon: Advanced Imaging Techniques to Improve Noninvasive Assessment of Cervical Lymph Nodes

Conventional imaging modalities are limited in the evaluation of lymph nodes as they predominantly rely on size and morphology, which have suboptimal sensitivity and specificity for malignancy. In this review we will explore the role of "on the horizon" advanced imaging modalities that can look beyond the size and morphologic features of a cervical lymph node and explore its molecular nature and can aid in personalizing therapy rather than use the "one-size-fits-all" approach.

Evaluation of Head and Neck Tumors with Functional MR Imaging

Head and neck cancer is one of the most common cancers worldwide. MR imaging-based diffusion and perfusion techniques enable the noninvasive assessment of tumor biology and physiology, which supplement information obtained from standard structural scans. Diffusion and perfusion MR imaging techniques provide novel biomarkers that can aid monitoring in pretreatment, during treatment, and posttreatment stages to improve patient selection for therapeutic strategies; provide evidence for change of therapy regime; and evaluate treatment response. This review discusses pertinent aspects of the role of diffusion and perfusion MR imaging and computational analysis methods in studying head and neck cancer.