Utilization of 18F-FDG Standardized Uptake Value and Metabolic Tumor Volume to Predict Local Failure in Nasopharyngeal Carcinoma

INTRODUCTION

The aim was to evaluate the prognostic values of pretreatment 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography (PET) parameters for predicting local failure in nasopharyngeal carcinoma (NPC) patients in the intensity-modulated radiotherapy (IMRT) era.

METHODS

Retrospective analysis was performed on 759 patients with NPC who underwent pretreatment 18F-FDG PET. The optimal cutoff values for maximum standardized uptake value (SUVmax) and metabolic tumor volume (MTV) were determined by receiver operating characteristic curve analysis. Univariate and multivariate analysis was performed to identify the prognostic factors influencing local failure-free survival (LFFS). Survival curves for the different risk groups were plotted using the Kaplan-Meier survival analysis method and compared using the log-rank test.

RESULTS

The median follow-up period was 49.0 months (range: 3.0-118.0 months). The optimal cutoff of SUVmax and MTV were 7.44 and 22.21 mL, respectively. Patients with higher SUVmax and MTV were associated with worse LFFS. The survival curves of different groups were significantly separated. The univariate analysis showed the statistical significance of SUVmax, MTV, and their composite in LFFS (p = 0.002 for SUVmax; p = 0.001 for MTV; p < 0.002 for their composite). The multivariate analysis showed that higher SUVmax and MTV was an independent negative prognostic factor for LFFS (HR = 1.805, 95% CI: 1.004-3.245, p = 0.049). The subgroups of stages III-IV further confirmed the impact of SUVmax and MTV on LFFS (HR = 1.884, CI: 1.087-3.708, p = 0.026).

CONCLUSION

Patients with higher SUVmax and MTV were associated with local failure as well as in the III-IV advanced stage.

Prognostic value of pre-treatment 18F-FDG PET uptake for nasopharyngeal carcinoma

PURPOSE

To evaluate the prognostic value of maximal standardized uptake values (SUVmax) from serial fluor-18-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) in patients with nasopharyngeal carcinoma (NPC).

MATERIALS AND METHODS

Fifty-two patients with NPC who underwent 18F-FDG PET/CT scan before radiotherapy with/without chemotherapy were reviewed retrospectively. Twenty-seven patients (52%) were applied 3-D conformal radiotherapy and 25 patients (48%) applied intensity-modulated radiotherapy (IMRT). Fourteen (27%) patients were given neoadjuvant chemotherapy and forty-four (84.6%) patients were given concomitant and adjuvant chemotherapy.

RESULTS

Median follow-up time was 34 months (range 5.6-66.4 months). Forty-four (84.6%) patients were alive at last follow-up and eight (15.4%) had died. The best cut-off value of the SUVmax for the primary tumor site (SUVmax-PT) was 13 and 9 for the lymph nodes (SUVmax-LN). Patients with SUVmax-PT ≥ 13.0 and SUVmax-LN ≥ 9 had a significantly higher risk for the development of the distant metastases (p = 0.044 and p = 0.038). DFS was affected in patients with SUVmax-PT ≥ 13 (log rank χ 2 = 2.54, p = 0.017) and was significantly lower in patients with SUVmax-LN ≥ 9 for the lymph nodes (log rank χ 2 = 5.81, p = 0.013). OS was not affected by SUV levels. A multivariate Cox proportional hazard model of DFS included age (≥ 40), SUVmax-LN (< 9), T stage (T1-2) and neoadjuvant chemotherapy are significantly better prognosis for the DFS.

CONCLUSION

18F-FDG PET/CT uptake before treatment, as determined by SUVmax, may be a valuable tool to evaluate prognosis in NPC patients.

Future of Team-based Basic and Translational Science in Radiation Oncology

To further optimize radiotherapy, a more personalized treatment towards individual patient's risk profiles, dissecting both patient-specific tumor and normal tissue response to multimodality treatments is needed. Novel developments in radiobiology, using in vitro patient-specific complex tissue resembling 3D models and multiomics approaches at a spatial single-cell level, may provide unprecedented insight into the radiation responses of tumors and normal tissue. Here, we describe the necessary team effort, including all disciplines in radiation oncology, to integrate such data into clinical prediction models and link the relatively "big data" from the clinical practice, allowing accurate patient stratification for personalized treatment approaches.

Predictive significance of pretreatment 18F-FDG PET volumetric parameters on survival outcomes in pediatric patients with locally advanced undifferentiated nasopharyngeal carcinoma

BACKGROUND

Nasopharyngeal carcinoma (NPC) is a rare pediatric cancer. Most children are first diagnosed with advanced locoregional disease. Identification of patients at higher risk of treatment failure is crucial as they may benefit from more aggressive initial treatment approaches. 18Fluorine-labeled fluoro-2-deoxyglucose positron emission tomography (18F-FDG PET) has shown promise as a prognostic tool for predicting outcomes.

METHODS

Retrospective study of pediatric patients with locally advanced undifferentiated NPC who underwent 18F-FDG PET/CT prior to intial treatment. Predictive significance of metabolic PET parameters on survival outcomes were estimated.

RESULTS

Thirty-two children were included, age range was 7.1-18 years at the time of diagnosis. The median follow-up duration was 46.1 months. Three patients (9.4%) were classified as AJCC stage IIb, 13 patients (40.6%) as stage IIIa, eight patients (25%) as stage IIIb, and eight patients (25%) as stage IVa. Our findings revealed that high whole-body metabolic tumor volume at the threshold of hepatic reference SUVmean (WB-MTV-HR) (>135 mL) was associated with significantly lower event-free survival (EFS) compared to the low WB-MTV-HR group (≤135 mL) (3-year EFS: 50% ± 18% vs. 82% ± 8%; p = .015). Additionally, the 3-year overall survival (OS) rates differed significantly between the high whole-body metabolic tumor volume at the threshold of an SUV of 2.5 isocontour (WB-MTV-2.5) group (MTV >74 mL) and the low WB-MTV-2.5 group (MTV ≤74 mL) (63% ± 18% vs. 100%; p = .021).

CONCLUSION

Our study suggests that WB-MTV parameters could serve as significant prognostic factors for disease progression in pediatric patients with locally advanced undifferentiated NPC. However, further prospective studies with larger sample sizes are needed to validate these findings.

Radiomics-clinical nomogram based on pretreatment 18F-FDG PET-CT radiomics features for individualized prediction of local failure in nasopharyngeal carcinoma

To explore the prognostic significance of PET/CT-based radiomics signatures and clinical features for local recurrence-free survival (LRFS) in nasopharyngeal carcinoma (NPC). We retrospectively reviewed 726 patients who underwent pretreatment PET/CT at our center. Least absolute shrinkage and selection operator (LASSO) regression and the Cox proportional hazards model were applied to construct Rad-score, which represented the radiomics features of PET-CT images. Univariate and multivariate analyses were used to establish a nomogram model. The concordance index (C-index) and calibration curve were used to evaluate the predictive accuracy and discriminative ability. Receiver operating characteristic analysis was performed to stratify the local recurrence risk of patients. The nomogram was validated by evaluating its discrimination ability and calibration in the validation cohort. A total of eight features were selected to construct Rad-score. A radiomics-clinical nomogram was built after the selection of univariate and multivariable Cox regression analyses, including the Rad-score and maximum standardized uptake value (SUVmax). The C-index was 0.71 (0.67-0.74) in the training cohort and 0.70 (0.64-0.76) in the validation cohort. The nomogram also performed far better than the 8th T-staging system with an area under the receiver operating characteristic curve (AUC) of 0.75 vs. 0.60 for 2 years and 0.71 vs. 0.60 for 3 years. The calibration curves show that the nomogram indicated accurate predictions. Decision curve analysis (DCA) revealed significantly better net benefits with this nomogram model. The log-rank test results revealed a distinct difference in prognosis between the two risk groups. The PET/CT-based radiomics nomogram showed good performance in predicting LRFS and showed potential to identify patients at high-risk of developing NPC.

Prognostic value of pre-treatment FDG PET/CT SUVmax for metastatic lesions in de novo metastatic nasopharyngeal carcinoma following chemotherapy and locoregional radiotherapy

BACKGROUND

To explore the prognostic role of FDG PET/CT maximal standard uptake values of metastatic lesions (SUVmax-M) in patients with de novo metastatic nasopharyngeal carcinoma (mNPC) following palliative chemotherapy and locoregional radiotherapy (LRRT).

METHODS

We retrospectively collected the information of 86 eligible patients between Jan 2012 and Oct 2020. All the parameters involving SUVmax and serum lactate dehydrogenase (LDH) at diagnosis were evaluated and cutoff values were determined by the maximum log-rank statistic method. The multivariate analysis was performed using Cox proportional hazards regression to identify the independent prognostic factors associated with overall survival (OS). All estimated survival rates were conducted with Kaplan-Meier method.

RESULTS

Median survival and progression time in the cohort were 38.2 and 13.9 months, respectively. The univariable analysis showed that male, number of metastatic sites ≥ 4, presence of liver, serum LDH ≥ 229, SUVmax-M ≥ 10, SUVmax-M-sum ≥ 10, and SUVmax-M-mean ≥ 8.8 were significant prognostic factors. Five variables were identified after LASSO regression and entered into the multivariate analysis. Furthermore, liver involvement (P = 0.039), elevated LDH (≥ 229) (P = 0.05) and higher SUVmax-M (≥ 10) (P = 0.004) were significantly associated with worse OS.

CONCLUSION

The high SUVmax of metastatic lesions (≥ 10), liver involvement, and elevated serum LDH (≥ 229) at diagnosis could independently predict poor survival for de novo mNPC patients treated with palliative chemotherapy following LRRT.

The prognostic value of the ratio of standard uptake value of lymph node to primary tumor before treatment of locally advanced nasopharyngeal carcinoma

BACKGROUND

To evaluate the prognostic value of the ratio of the standard uptake value of the lymph node and primary tumor before the treatment of locally advanced nasopharyngeal carcinoma and examine the prognostic value of the tumor metabolic parameters (SUVmax_, MTV, and TLG) of the lymph node and primary tumor of locally advanced nasopharyngeal carcinoma.

METHODS

A total of 180 patients with locally advanced nasopharyngeal carcinoma diagnosed pathologically from January 1, 2016 to December 31, 2018 were selected, and the MEDEX system was used to automatically delineate the SUVmax, MTV, and TLG of the lymph node metastases and nasopharyngeal carcinoma primary tumor. In addition, the ratio of LN-SUVmax (SUVmax of the lymph node metastases) to T-SUVmax (SUVmax of the nasopharyngeal carcinoma primary tumor) was calculated, and a ROC curve was drawn to obtain the best cut-off value. Kaplan-Meier and Cox regression models were used for survival and multivariate analyses, respectively.

RESULTS

The median follow-up period for participants was 32 (4-62) months. Univariate analysis showed that age (P = 0.013), LN-SUVmax (P = 0.001), LN-TLG (P = 0.007) and NTR (P = 0.001) were factors influencing the overall survival (OS). Factors affecting local progression-free survival (LPFS) were LN-SUVmax (P = 0.005), LN-TLG (P = 0.003) and NTR (P = 0.020), while clinical stage (P = 0.023), LN-SUVmax (P = 0.007), LN-TLG (P = 0.006), and NTR (P = 0.032) were factors affecting distant metastasis-free survival (DMFS). Multivariate analysis showed that NTR was an independent influencing factor of OS (HR 3.00, 95% CI 1.06-8.4, P = 0.038), LPFS (HR 3.08, 95% CI 1.27-7.50, P = 0.013), and DMFS (HR 1.84, 95% CI 0.99-3.42, P = 0.054). Taking OS as the main observation point, the best cut-off point of NTR was 0.95. Kaplan-Meier results showed that the 3-year OS (97.0% vs 85.4%, χ² = 11.25, P = 0.001), 3-year LPFS (91.3% vs 82.1%, χ² = 4.035, P = 0.045), and 3-year DMFS (92.3% vs 87.9%, χ² = 4.576, P = 0.032) of patients with NTR < 0.95 were higher than those with NTR > 0.95.

CONCLUSIONS

High NTR before treatment indicates a poor prognosis for patients with nasopharyngeal carcinoma. This can serve as a reference value for the reasonable treatment and prognosis monitoring of such patients.

Survival effect of pretreatment FDG-PET-CT on nasopharyngeal cancer

BACKGROUND/PURPOSE

Accurate staging is the first step for optimal treatment selection in patients with nasopharyngeal carcinoma (NPC). In this propensity-score-matched, population-based cohort study, we investigated the survival effects of pretreatment 8-fluorodeoxyglucose positron emission tomography-computed tomography (¹⁸FDG-PET-CT) on patients with NPC.

METHODS

We included patients with stage I-IVA NPC receiving radiotherapy or concurrent chemoradiotherapy and categorized them into two 1:1 propensity score-matched groups according to whether or not they underwent pretreatment ¹⁸FDG-PET-CT and compared their outcomes.

RESULTS

Of the 10,756 patients, propensity score matching yielded 4366 patients in each group. According to multivariable Cox regression analyses, the most prominent correlation between pretreatment ¹⁸FDG-PET-CT and all-cause death was observed in patients with stage II NPC (adjusted hazard ratio [aHR], 0.77; 95% confidence interval [CI], 0.60-0.90; P = .0433), followed by patients with stage III NPC (aHR, 0.81; 95% CI, 0.69-0.94; P = .0071) and patients with stage IVA NPC (aHR, 0.88; 95% CI, 0.79-0.97; P = .0091). This association was not significant in patients with stage I NPC (aHR, 1.20; 95% CI, 0.75-1.93; P = .4426).

CONCLUSION

Pretreatment ¹⁸FDG-PET-CT is associated with longer survival in patients with clinical stage II-IVA NPC but not in stage I NPC.

Prospective Investigation of 18FDG-PET/MRI with Intravoxel Incoherent Motion Diffusion-Weighted Imaging to Assess Survival in Patients with Oropharyngeal or Hypopharyngeal Carcinoma

To prospectively investigate the prognostic value of 18F-FDG PET/MRI in patients with oropharyngeal or hypopharyngeal squamous cell carcinomas (OHSCC) treated by chemoradiotherapy. The study cohort consisted of patients with OHSCC who had undergone integrated PET/MRI prior to chemoradiotherapy or radiotherapy. Imaging parameters derived from intravoxel incoherent motion (IVIM), dynamic contrast-enhanced MRI (DCE-MRI), and 18F-FDG PET were analyzed in relation to overall survival (OS) and recurrence-free survival (RFS). In multivariable analysis, T classification (p < 0.001), metabolic tumor volume (p = 0.013), and pseudo-diffusion coefficient (p = 0.008) were identified as independent risk factors for OS. The volume transfer rate constant (p = 0.015), initial area under the curve (p = 0.043), T classification (p = 0.018), and N classification (p = 0.018) were significant predictors for RFS. The Harrell’s c-indices of OS and RFS obtained from prognostic models incorporating clinical and PET/MRI predictors were significantly higher than those derived from the traditional TNM staging system (p = 0.001). The combination of clinical risk factors with functional parameters derived from IVIM and DCE-MRI plus metabolic PET parameters derived from 18F-FDG PET in integrated PET/MRI outperformed the information provided by traditional TNM staging in predicting the survival of patients with OHSCC.

The role of PET/CT in radiotherapy for nasopharyngeal carcinoma

Radiotherapy has already been developed as the standard of care for patients with nasopharyngeal carcinoma (NPC), and precision staging, target volume delineation, prognosis prediction, and post-treatment surveillance are essential in the management of NPC. Positron emission tomography/computed tomography (PET/CT) is increasingly recognized as an imaging modality to guide precision radiotherapy in these areas. The feasibility and efficacy of 18F-FDG PET/CT have been confirmed in tumor diagnosis, treatment planning, prognosis, surveillance, and assessment. Coupled with the capability of revealing tumor metabolic information, 18F-FDG PET/CT is more accurate in identifying primary lesions and metastases of NPC than other conventional imaging methods including CT and MRI and shows the independently diagnostic and prognostic value for radiotherapy. However, 18F-FDG has limitations due to its physiological distribution in brain tissue and increasing uptake in post-radiation inflammation. Novel PET radiotracers including FAPI, NaF, CHO, and FLT are explored as alternatives with potential superiority for radiotherapy in NPC. In this review, we summarized the evolving role of PET/CT in the management of radiotherapy in NPC patients, aiming to facilitate precision radiotherapy from a molecular imaging aspect.

Pretreatment [18F]FDG PET/CT and MRI in the prognosis of nasopharyngeal carcinoma

OBJECTIVE

The present study aimed to assess the prognostic interest of metabolic and anatomic parameters derived from 2-deoxy-2-[¹⁸F]fluoro-D-glucose positron emission tomography/computed tomography ([¹⁸F]FDG PET/CT) and head and neck magnetic resonance imaging (HN-MRI) for better management of nasopharyngeal carcinoma (NPC).

METHODS

In this study, pre-treatment [¹⁸F]FDG PET/CT and HN-MRI parameters of NPC patients diagnosed between January 2017 and December 2018, were prospectively investigated. Correlation between those parameters and 4-year patient's survival outcomes was evaluated using Kaplan-Meier and Cox-regression analyses.

RESULTS

Our results revealed a significant association between pre-treatment nodal-maximum standardized uptake value (N-SUV max) and N categories (p = 0.01), between pre-treatment node-to-tumor SUV ratio (NTR) and both tumor size (p = 0.01) and N categories (p = 0.009), as well as between metabolic tumor volume (MTV) and both tumor size and NPC overall stage (p < 0.000). In multivariate analyses, pre-treatment N-SUV max, NTR and MTV were significant independent predictors of overall survival, distant metastasis-free survival, and progression-free survival (PFS) (p < 0.05). N-SUV max and MTV were also found to be significant independent predictors of loco-regional recurrence-free survival (p < 0.05), whereas HN-MRI detection of skull-base bone invasion was an independent factor associated with worse PFS in NPC (p = 0.03).

CONCLUSIONS

The present study highlights N-SUV max, NTR and MTV derived from [¹⁸F]FDG PET/CT, and skull-base bone invasion defined by HN-MRI, as promising metabolic and anatomic prognosis biomarkers for NPC.

Development and validation of radiologic scores for guiding individualized induction chemotherapy in T3N1M0 nasopharyngeal carcinoma

OBJECTIVES

We aimed to develop and validate radiologic scores from [¹⁸F]FDG PET/CT and MRI to guide individualized induction chemotherapy (IC) for patients with T3N1M0 nasopharyngeal carcinoma (NPC).

METHODS

A total of 542 T3N1M0 patients who underwent pretreatment [¹⁸F]FDG PET/CT and MRI were enrolled in the training cohort. A total of 174 patients underwent biopsy of one or more cervical lymph nodes. Failure-free survival (FFS) was the primary endpoint. The radiologic score, which was calculated according to the number of risk factors from the multivariate model, was used for risk stratification. The survival difference of patients undergoing concurrent chemoradiotherapy (CCRT) with or without IC was then compared in risk-stratified subgroups. Another cohort from our prospective clinical trial (N = 353, NCT03003182) was applied for validation.

RESULTS

The sensitivity of [¹⁸F]FDG PET/CT was better than that of MRI (97.7% vs. 87.1%, p < 0.001) for diagnosing histologically proven metastatic cervical lymph nodes. Radiologic lymph node characteristics were independent risk factors for FFS (all p < 0.05). High-risk patients (n = 329) stratified by radiologic score benefited from IC (5-year FFS: IC + CCRT 83.5% vs. CCRT 70.5%; p = 0.0044), while low-risk patients (n = 213) did not. These results were verified again in the validation cohort.

CONCLUSIONS

T3N1M0 patients were accurately staged by both [¹⁸F]FDG PET/CT and MRI. The radiologic score can correctly identify high-risk patients who can gain additional survival benefit from IC and it can be used to guide individualized treatment of T3N1M0 NPC.

KEY POINTS

• [¹⁸F]FDG PET/CT was more accurate than MRI in diagnosing histologically proven cervical lymph nodes. • Radiologic lymph node characteristics were reliable independent risk factors for FFS in T3N1M0 nasopharyngeal carcinoma patients. • High-risk patients identified by the radiologic score based on [¹⁸F]FDG PET/CT and MRI could benefit from the addition of induction chemotherapy.

Prognostic significance of metabolic tumour volume and maximum standard uptake value of fluor-18-fluorodeoxyglucose positron emission tomography with computed tomography in nasopharyngeal carcinoma

Aim of the study

To evaluate the prognostic role of markers of fluor-18-fluorodeoxyglucose positron emission tomography with computed tomography (¹⁸F-FDG-PET-CT), such as maximum standard uptake value (SUV_max) and metabolic tumour volume (MTV) measured at primary and nodal disease, and their clinical significance in terms of predicting treatment outcomes and survival.

Material and methods

Between January 2017 and January 2020, 20 case records of nasopharyngeal carcinoma patients who underwent ¹⁸F-FDG-PET-CT as part of staging workup before radiotherapy and as a part of response evaluation after radiotherapy were retrospectively reviewed.

Results

At a median follow-up of 34.7 months, the 2-year progression-free survival (PFS) was 70% and 2-year overall survival (OS) was 79%. Patients with a lower nodal SUV_max (SUV_max-N) had a better 2-year PFS (91% vs. 46%; p = 0.035) and 2-year OS (95% vs. 58%; p = 0.015). A high SUV_max-N of > 10.58 was a negative predictor of OS (95% confidence interval [CI]: 0.93-1; p = 0.003) as well as PFS (95% CI: 0.64-1; p = 0.017). Also, a high MTV > 25.8 cm³ was a negative predictor of PFS (95% CI: 0.58-0.98; p = 0.048). MTV was an independent predictor of PFS and OS on univariate analysis, whereas it was not significant in the Cox regression multivariate analysis.

Conclusions

High values of MTV and SUV_max-N can be considered as independent prognostic factors of OS and PFS in nasopharyngeal cancer patients treated with concurrent chemoradiation, highlighting the need for more intensified treatment.

Tumor Blood Flow Is a Predictor of Radiotherapy Response in Patients With Nasopharyngeal Carcinoma

Purpose

The aim of this study was to evaluate tumor blood flow (TBF) as a predictor of radiotherapy response for nasopharyngeal carcinoma (NPC).

Materials and Method

A total of 134 patients were divided into two groups, the complete response (CR) group and the partial response (PR) group based on RECIST 1.1 recommendations. The statistical difference was evaluated for pre- and mid- or post-treatment TBF and changes of TBF for tumors and metastatic lymph nodes between CR and PR, respectively. The receiver operation characteristic (ROC) curve was utilized to evaluate the accuracy of TBF in predicting the response of radiation therapy. The association between TBF and SUVmax was also investigated.

Results

The reduction of TBF in CR was significantly lower than that in PR for primary tumors (P <0.001) and metastatic lymph nodes (P <0.001). The multivariate logistic regression analysis indicated that the reduction of TBF is an independent predictor of the response of radiation therapy for primary tumors (P <0.001) and metastatic lymph nodes (P <0.001). The accuracy of TBF reduction in predicting the response of radiation therapy was 0.817 in primary tumors and 0.924 in metastatic lymph nodes, respectively. No significant correlation was observed between the TBF values and SUVmax of primary tumors (r = -0.008, P = 0.954) and metastasis lymph nodes (r = -0.061, P = 0.652).

Conclusion

This study suggests that the reduction of TBF is a promising parameter for evaluating the response of radiation therapy.

Methylation-associated silencing of miR-9-1 promotes nasopharyngeal carcinoma progression and glycolysis via HK2

Characteristically, cancer cells metabolize glucose through aerobic glycolysis, known as the Warburg effect. Accumulating evidence suggest that during cancer formation, microRNAs (miRNAs) could regulate such metabolic reprogramming. In the present study, miR‐9‐1 was identified as significantly hypermethylated in nasopharyngeal carcinoma (NPC) cell lines and clinical tissues. Ectopic expression of miR‐9‐1 inhibited NPC cell growth and glycolytic metabolism, including reduced glycolysis, by reducing lactate production, glucose uptake, cellular glucose‐6‐phosphate levels, and ATP generation in vitro and tumor proliferation in vivo. HK2 (encoding hexokinase 2) was identified as a direct target of miR‐9‐1 using luciferase reporter assays and Western blotting. In NPC cells, hypermethylation regulates miR‐9‐1 expression and inhibits HK2 translation by directly targeting its 3' untranslated region. MiR‐9‐1 overexpression markedly reduced HK2 protein levels. Restoration of HK2 expression attenuated the inhibitory effect of miR‐9‐1 on NPC cell proliferation and glycolysis. Fluorescence in situ hybridization results indicated that miR‐9‐1 expression was an independent prognostic factor in NPC. Our findings revealed the role of the miR‐9‐1/HK2 axis in the metabolic reprogramming of NPC, providing a potential therapeutic strategy for NPC.

Prediction of local recurrence and distant metastasis using radiomics analysis of pretreatment nasopharyngeal [18F]FDG PET/CT images

OBJECTIVES

To develop a radiomics signature to predict locoregional recurrence (LR) and distant metastasis (DM), as extracted from pretreatment 2-deoxy-2-[¹⁸F]fluoro-D-glucose ([18F]FDG) positron emission tomography/X-ray computed tomography (PET/CT) images in locally advanced nasopharyngeal carcinoma (NPC).

MATERIALS AND METHODS

Eighty-five patients with Stage III-IVB NPC underwent pretreatment [¹⁸F]FDG PET/CT scans and received radiotherapy or chemoradiotherapy. 53 of them achieved disease control, and 32 of them failed after treatment (15: LR, 17: DM). A total of 114 radiomic features were extracted from PET/CT images. For univariate analysis, Wilcoxon test and Chi-square test were used to compare median values of features between different treatment outcomes and predict the risk of treatment failure, respectively. For multivariate analysis, all features were grouped into clusters based on Pearson correlation using hierarchical clustering, and the representative feature of each cluster was chosen by the Relief algorithm. Then sequential floating forward selection (SFFS) coupled with a support vector machine (SVM) classifier were used to derive the optimized feature set in terms of the area under receiver operating characteristic (ROC) curve (AUC). The performance of the model was evaluated by leave-one-out-cross-validation, fivefold cross-validation, tenfold cross-validation.

RESULTS

Twenty features had significant differences between disease control and treatment failure. NPC patients with values of Compactness1, Compactness2, Coarseness_NGTDM or SGE_GLGLM above the median as well as patients with values of Irregularity, RLN_GLRLM or GLV_GLSZM below the median, showed a significant (p < 0.05) higher risk of treatment failure (about 50% vs. 25%). The derived radiomics signature consisted of 5 features with the highest AUC value of 0.8290 (sensitivity: 0.8438, specificity: 0.7736) using leave-one-out-cross-validation.

CONCLUSION

Locoregional recurrence (LR) and DM of locally advanced NPC can be predicted using radiomics analysis of pretreatment [¹⁸F]FDG PET/CT. The SFFS feature selection coupled with SVM classifier can derive the optimized feature set with correspondingly highest AUC value for pretreatment prediction of LR and/or DM of NPC.

Targeting the signaling in Epstein-Barr virus-associated diseases: mechanism, regulation, and clinical study

Epstein–Barr virus-associated diseases are important global health concerns. As a group I carcinogen, EBV accounts for 1.5% of human malignances, including both epithelial- and lymphatic-originated tumors. Moreover, EBV plays an etiological and pathogenic role in a number of non-neoplastic diseases, and is even involved in multiple autoimmune diseases (SADs). In this review, we summarize and discuss some recent exciting discoveries in EBV research area, which including DNA methylation alterations, metabolic reprogramming, the changes of mitochondria and ubiquitin-proteasome system (UPS), oxidative stress and EBV lytic reactivation, variations in non-coding RNA (ncRNA), radiochemotherapy and immunotherapy. Understanding and learning from this advancement will further confirm the far-reaching and future value of therapeutic strategies in EBV-associated diseases.

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.

Volumetric parameters derived from FLT-PET performed at completion of treatment predict efficacy of Carbon-ion Radiotherapy in patients with locally recurrent Nasopharyngeal Carcinoma

The purpose of this study was to investigate the role of 3'-deoxy-3'-[¹⁸F]fluorothymidine (FLT)-PET for predicting the outcome of patients with locally recurrent nasopharyngeal carcinoma (LR-NPC) treated by carbon-ion radiotherapy (CIRT). Patients received FLT-PET/CT scan one-week prior to or after completion of CIRT were enrolled in the study. All patients were from prospective trials or treated using a standardized protocol. Time-dependent receiver operator characteristics (ROC) were used to determine the optimal cutoff values for FLT-PET parameters. Univariable and multivariable analyses of local progression-free survival (LPFS) were performed using Cox regression, to examine the prognostic value of FLT-PET parameters, including SUV_max, metabolic tumor volume (MTV) and total lesion thymidine (TLT). A total of 41 patients were enrolled. Elevated MTV and TLT were significantly associated with worse LPFS, in both univariable and multivariable analyses. ROC analysis revealed that both an MTV value higher than 8.6 and a TLT value higher than 14.9 were predictive of increased risk of developing local recurrence, the adjusted HRs were 5.59 (p=0.009) and 7.76 (p=0.002), respectively. In conclusion, FLT-PET was found to be a promising prognostic tool for LR-NPC patients and might play a role in the treatment guidance.

Lymph node-to-primary tumor standardized uptake value ratio on PET predicts distant metastasis in nasopharyngeal carcinoma

OBJECTIVES

To investigate the prognostic value of the relative maximum standardized uptake value (SUV) ratio between neck lymph node and primary tumor (NTR) measured by pretreatment ¹⁸F-FDG PET in patients with nasopharyngeal carcinoma (NPC).

MATERIALS AND METHODS

We retrospectively reviewed patients with non-disseminated NPC who underwent PET scans before radical intensity-modulated radiotherapy (IMRT). Receiver operating characteristic analysis was performed to identify the optimal cut-off value for NTR. The prognostic value of NTR for distant metastasis-free survival (DMFS) was evaluated using Kaplan-Meier method for survival analyses and Cox regression for multivariable analysis.

RESULTS

Among the 437 eligible patients, the median follow-up time was 62.9 (range, 2.1-113.0) months. Patients with high NTR (NTR > 0.9181) experienced significantly worse DMFS (5-year 80.5% vs. 91.6%, P < 0.001). In the subgroup analysis, we found that patients with high NTR had significantly lower DMFS in T1-2 category (5-year 86.1% vs. 98.1%, P = 0.002), T3-4 category (5-year 71.5% vs. 86.2%, P = 0.010), N2-3 category (5-year 75.3% vs. 86.2%, P = 0.048), and stage IVA-B (5-year 69.8% vs. 85.4%, P = 0.012). Multivariable analysis showed that NTR was an independent prognostic factor for DMFS (HR 2.20, 95% CI 1.20-4.03, P = 0.011).

CONCLUSION

Pretreatment NTR is an easily accessible but potential prognosticator for DMFS in NPC patients treated by IMRT, which may help in providing more personalized treatment or designing future clinical trials.

Robust maximization of tumor control probability for radicality constrained radiotherapy dose painting by numbers of head and neck cancer

BACKGROUND AND PURPOSE

Radiotherapy with dose painting by numbers (DPBN) needs another approach than conventional margins to ensure a geometrically robust dose coverage for the tumor. This study presents a method to optimize DPBN plans that as opposed to achieve a robust dose distribution instead robustly maximize the tumor control probability (TCP) for patients diagnosed with head and neck cancer.

MATERIAL AND METHODS

Volumetric-modulated arc therapy (VMAT) plans were optimized with a robust TCP maximizing objective for different dose constraints to the primary clinical target volume (CTVT) for a set of 20 patients. These plans were optimized with minimax optimization together with dose-responses driven by standardized uptake values (SUV) from 18F-fluorodeoxyglucose positron emission tomography (18FDG-PET). The robustness in TCP was evaluated through sampling treatment scenarios with isocenter displacements.

RESULTS

The average increase in TCP with DPBN compared to a homogeneous dose treatment ranged between 3 and 20 percentage points (p.p.) which depended on the different dose constraints for the CTVT. The median deviation in TCP increase was below 1p.p. for all sampled treatment scenarios versus the nominal plans. The standard deviation of SUV multiplied by the CTVT volume were found to correlate with the TCP gain with R 2 ≥ 0.9.

CONCLUSIONS

Minimax optimization of DPBN plans yield, based on the presented TCP modelling, a robust increase of the TCP compared to homogeneous dose treatments for head and neck cancers. The greatest TCP gains were found for patients with large and SUV heterogeneous tumors, which may give guidance for patient selection in prospective trials.

Maximal standard uptake values of 18F-fluoro-2-deoxy-D-glucose positron emission tomography compared with Epstein-Barr virus DNA as prognostic indicators in de novo metastatic nasopharyngeal carcinoma patients

Background

This study aimed to evaluate the prognostic value of maximal standard uptake values (SUVmax) of ¹⁸F-fluoro-2-deoxy-D-glucose positron emission tomography (PET) comparing with Epstein-Barr virus (EBV) DNA levels in de novo metastatic nasopharyngeal carcinoma (NPC) patients.

Methods

From December 2006 to December 2016, 253 de novo metastatic NPC patients assessed by PET/ computed tomography were involved in current study. SUVmax-T, SUVmax-N, and SUVmax-M referred to the SUVmax at the primary tumor, cervical lymph nodes, and metastatic lesions respectively. Overall survival (OS) was the primary endpoint.

Result

Patients who died during the follow-up had significantly higher SUVmax-N, SUVmax-M, and EBV DNA level than those in the patients who were alive. SUVmax-N and SUVmax-M were positively correlated with EBV DNA level. The cut-off values of SUVmax-T, SUVmax-N, SUVmax-M, and EBV DNA were 17.0, 12.7, and 6.9, and 13,800 copies/mL respectively, which were determined by receiver operating characteristic (ROC) curve analysis. Patients with elevated SUVmax-N, SUVmax-M, and EBV DNA levels had a lower 3-year OS rate. In multivariate analysis, the independent prognostic factors of OS included EBV DNA, metastatic site, and locoregional radiotherapy application, while SUVmax was not an independent prognostic factor.

Conclusion

In de novo metastatic NPC patients, higher SUVmax-N and SUVmax-M were associated with worse prognosis. However, the predictive ability of SUVmax-N and SUVmax-M was poorer than that of EBV DNA.

Electronic supplementary material

The online version of this article (10.1186/s12885-019-6106-2) contains supplementary material, which is available to authorized users.

Prospective evaluation of plasma Epstein-Barr virus DNA clearance and fluorodeoxyglucose positron emission scan in assessing early response to chemotherapy in patients with advanced or recurrent nasopharyngeal carcinoma

BACKGROUND

Plasma Epstein-Barr virus (pEBV) DNA and fluorodeoxyglucose positron emission (PET) reflect tumour burden in advanced NPC. This study hypothesised that a dual endpoint based on assessing pEBV DNA clearance and PET response could predict early drug response.

METHODS

Eligible patients underwent a computed tomography (CT) scan and dual PET-CT at baseline, a PET-CT at 4 weeks, and then a CT scan at 10 weeks after starting palliative or induction chemotherapy. Plasma EBV DNA clearance was determined.

RESULTS

Fifty-eight out of 70 enrolled patients completed all imaging and 50/58 had falling pEBV DNA level, which allowed calculation of the clearance. At a median follow-up of 29.1 months, the dual endpoint (pEBV DNA clearance ≤ 10 days and > 50% drop in sum of SUVmax of target lesions) was an independent indicator of overall survival (hazard ratio (HR) = 0.135, 95% CI = 0.039 to 0.466, p = 0.0015) and progression-free survival (HR = 0.136, 95% CI = 0.048 to 0.385, p = 0002). This dual endpoint could predict subsequent response by Response Evaluation Criteria In Solid Tumours (RECIST) criteria at 10 weeks after chemotherapy.

CONCLUSIONS

Early PET-CT response and pEBV DNA clearance could predict survival and subsequent response. This dual endpoint is an innovative tool for assessing early drug response.

Significant value of 18F-FDG-PET/CT in diagnosing small cervical lymph node metastases in patients with nasopharyngeal carcinoma treated with intensity-modulated radiotherapy

BACKGROUND

Little is known about the nature of metastasis to small cervical lymph nodes (SCLNs) in the patients with nasopharyngeal carcinoma (NPC) examined by using 18-fluoro-2-deoxy-glucose (¹⁸F-FDG) positron emission tomography/computed tomography (PET/CT). The present study aimed to evaluate the diagnostic values of PET/CT in identifying metastasis in SCLNs in NPC patients.

METHODS

Magnetic resonance images (MRI) and PET/CT scans for 470 patients with newly diagnosed, non-distant metastatic NPC were analyzed. Metastatic rates of SCLNs were defined by the positive number of SCLNs on PET/CT scans and total number of SCLNs on MRI scans. Receiver operating characteristic curve was applied to compare PET/CT-determined stage with MRI-determined stage.

RESULTS

In total, 2082 SCLNs were identified, with 808 (38.8%) ≥ 5 and < 6 mm in diameter (group A), 526 (25.3%) ≥ 6 and < 7 mm in diameter (group B), 374 (18.0%) ≥ 7 and < 8 mm in diameter (group C), 237 (11.4%) ≥ 8 and < 9 mm in diameter (group D), and 137 (6.5%) ≥ 9 and < 10 mm in diameter (group E). The overall metastatic rates examined by using PET/CT for groups A, B, C, D, and E were 3.5%, 8.0%, 31.3%, 60.0%, and 83.9%, respectively (P < 0.001). In level IV/Vb, the metastatic rate for nodes ≥ 8 mm was 84.6%. PET/CT examination resulted in modification of N category and overall stage for 135 (28.7%) and 46 (9.8%) patients, respectively. The areas under curve of MRI-determined and PET/CT-determined overall stage were 0.659 and 0.704 for predicting overall survival, 0.661 and 0.711 for predicting distant metastasis-free survival, and 0.636 and 0.663 for predicting disease-free survival.

CONCLUSIONS

PET/CT was more effective than MRI in identifying metastatic SCLNs, and the radiologic diagnostic criteria for metastatic lymph nodes in level IV/Vb should be re-defined.

Establishment of an integrated model incorporating standardised uptake value and N-classification for predicting metastasis in nasopharyngeal carcinoma

Background

Previous studies reported a correlation between the maximum standardised uptake value (SUV_max) obtained by ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) positron emission tomography (PET) and distant metastasis in nasopharyngeal carcinoma (NPC). However, an integrated model incorporating SUV_max and anatomic staging for stratifying metastasis risk has not been reported.

Results

The median SUV_max for primary tumour (SUV-T) and cervical lymph nodes (SUV-N) was 13.6 (range, 2.2 to 39.3) and 8.4 (range, 2.6 to 40.9), respectively. SUV-T (HR, 3.396; 95% CI, 1.451-7.947; P = 0.005), SUV-N (HR, 2.688; 95%CI, 1.250-5.781; P = 0.011) and N-classification (HR, 2.570; 95%CI, 1.422-4.579; P = 0.001) were identified as independent predictors for DMFS from multivariate analysis. Three valid risk groups were derived by RPA: low risk (N0-1 + SUV-T <10.45), medium risk (N0-1 + SUV-T >10.45) and high risk (N2-3). The three risk groups contained 100 (22.3%), 226 (50.3%), and 123 (27.4%) patients, respectively, with corresponding 3-year DMFS rates of 99.0%, 91.5%, and 77.5% (P <0.001). Moreover, multivariate analysis confirmed the RPA-based prognostic grouping as the only significant prognostic indicator for DMFS (HR, 3.090; 95%CI, 1.975-4.835; P <0.001).

Methods

Data from 449 patients with with histologically-confirmed, stage I-IVB NPC treated with radiotherapy or chemoradiotherapy were retrospectively analysed. A prognostic model for distant metastasis-free survival (DMFS) was derived by recursive partitioning analysis (RPA) combining independent predictors identified by multivariate analysis.

Conclusion

SUV-T, SUV-N and N-classification were identified as independent predictors for DMFS. An integrated RPA-based prognostic model for DMFS incorporating SUV-N and N-classification was proposed.

Prognostic value of nodal SUVmax of 18F-FDG PET/CT in nasopharyngeal carcinoma treated with intensity-modulated radiotherapy

Purpose

To investigate the predictive role of maximum standardized uptake value (SUV_max) of 2-[¹⁸F]fluoro-2-deoxy-D-glucose (¹⁸F-FDG) positron emission tomography/computed tomography (PET/CT) in nasopharyngeal cancer patients treated with intensity-modulated radiotherapy (IMRT).

Materials and Methods

Between October 2006 and April 2016, 53 patients were treated with IMRT in two institutions and their PET/CT at the time of diagnosis was reviewed. The SUV_max of their nasopharyngeal lesions and metastatic lymph nodes (LN) was recorded. IMRT was delivered using helical tomotherapy. All patients except for one were treated with concurrent chemoradiation therapy (CCRT). Correlations between SUV_max and patients’ survival and recurrence were analyzed.

Results

At a median follow-up time of 31.5 months (range, 3.4 to 98.7 months), the 3-year overall survival (OS) and disease-free survival (DFS) rates were 83.2% and 77.5%, respectively. In univariate analysis, patients with a higher nodal pre-treatment SUV_max (≥ 13.4) demonstrated significantly lower 3-year OS (93.1% vs. 55.5%; p = 0.003), DFS (92.7% vs. 38.5%; p < 0.001), locoregional recurrence-free survival (100% vs. 50.5%; p < 0.001), and distant metastasis-free survival (100% vs. 69.2%; p = 0.004), respectively. In multivariate analysis, high pre-treatment nodal SUV_max (≥ 13.4) was a negative prognostic factor for OS (hazard ratio [HR], 7.799; 95% confidence interval [CI], 1.506–40.397; p = 0.014) and DFS (HR, 9.392; 95% CI, 1.989–44.339; p = 0.005).

conclusions

High pre-treatment nodal SUV_max was an independent prognosticator of survival and disease progression in nasopharyngeal carcinoma patients treated with IMRT in our cohort. Therefore, nodal SUV_max may provide important information for identifying patients who require more aggressive treatment.

Report on the development and application of PET/CT in mainland China

PURPOSE

To examine the development and application of systems combining positron emission and x-ray-computed tomography systems (PET/CTs) in mainland China.

METHODS

Using a questionnaire, we surveyed Chinese medical institutions on a variety topics relating to their PET/CT systems and its use. The respondents had PET/CTs installed and in clinical use before 31 December 2015. We examined the clinical scenarios to which Chinese PET/CTs were applied by reviewing the related Chinese and international literature from the start of 1995 to the end of 2013; these papers were found by searching the Wanfang and PubMed databases, respectively. The data were then classified and analyzed statistically.

RESULTS

At the end of 2015, there were 240 PET/CTs and 101 medical cyclotrons in mainland China. The total number of PET studies performed in 2015 was 469,364. The main clinical applications of PET were found to be diagnostic fludeoxyglucose (¹⁸F-FDG) imaging and oncological imaging. A minority of PET/CT studies were performed using ¹¹C-choline and other imaging agents. The number of papers relating to clinical use of PET/CT in mainland China increased each year over the period of study, in both the Chinese and international literature. Despite this progress, important problems were also apparent, including unbalanced regional development and the limited quality of the research.

CONCLUSIONS

This study provides detailed information for understanding the development PET/CT technology in mainland China, along with its geographical distribution and clinical application. It may thus prove a useful reference for all those involved in planning the future of PET/CT in China.

Progression of understanding for the role of Epstein-Barr virus and management of nasopharyngeal carcinoma

Nasopharyngeal carcinoma (NPC) is very common in southern China and Southeast Asia. In regions where NPC is endemic, undifferentiated subtypes constitute most cases and are invariably associated with Epstein-Barr virus (EBV) infection, whereas the differentiated subtype is more common in other parts of the world. Undifferentiated NPC is a unique malignancy with regard to its epidemiology, etiology, and clinical presentation. Clinically, NPC is highly invasive and metastatic, but sensitive to both chemotherapy and radiotherapy (RT). Overall prognosis has dramatically improved over the past three decades because of advances in management, including the improvement of RT technology, the broader application of chemotherapy, and more accurate disease staging. Despite the excellent local control with modern RT, distant failure remains a challenging problem. Advances in molecular technology have helped to elucidate the molecular pathogenesis of NPC. This article reviews the contribution of EBV gene products to NPC pathogenesis and the current management of NPC.

Prognostic value of maximum standard uptake value, metabolic tumor volume, and total lesion glycolysis of positron emission tomography/computed tomography in patients with nasopharyngeal carcinoma: A systematic review and meta-analysis

BACKGROUND

The maximal standard uptake value (SUVmax), metabolic tumor volume (MTV), and total lesion glycolysis (TLG) of positron emission tomography/computed tomography (PET/CT) in patients with nasopharyngeal carcinoma (NPC) perform as new prognostic factors, but the outcomes of the published articles were inconclusive. In this meta-analysis, we evaluated the prognostic value of SUVmax, MTV, and TLG of PET/CT in patients with NPC.

METHODS

Relevant English articles were searched in PubMed and EMBASE. The data of patients and the survival outcomes were extracted. Pooled hazard ratios (HRs) were accounted to assess the prognostic value of the SUVmax, MTV, and TLG.

RESULTS

This meta-analysis combined 10 primary studies including 941 patients with NPC. The combined HRs (95% confidence interval [CI] of higher SUVmax, higher MTV, and higher TLG for event-free survival were 2.33 (95% CI, 1.39-3.91, P = .001), 2.51 (95% CI, 1.61-3.91, P < .0001), and 2.74 (95% CI, 1.91-3.93, P < .00001), respectively. Regarding overall survival, the combined HRs were 2.50 (95%CI, 1.65-3.78, P < .0001) with higher SUVmax, 3.30 (95% CI, 1.92-5.69, P < .0001) with higher MTV and 3.18 (95% CI, 1.70-5.96, P = .0003) with higher TLG.

CONCLUSION

SUVmax, MTV, and TLG were significant prognostic predictors in patients with NPC. And the results suggested that higher SUVmax, MTV, and TLG were associated with worse prognosis.

Prognostic value of primary gross tumor volume and standardized uptake value of 18F-FDG in PET/CT for distant metastasis in locoregionally advanced nasopharyngeal carcinoma

Distant metastasis has become the predominant model of treatment failures in patients with locoregionally advanced nasopharyngeal carcinoma. Effort should therefore be made to stratify locoregionally advanced nasopharyngeal carcinoma patients into different groups based on the risk of metastasis to improve prognosis and tailor individualized treatments. This study aims to assess the value of primary gross tumor volume and the maximum standardized uptake value for predicting distant metastasis-free survival of patients with locoregionally advanced nasopharyngeal carcinoma. A total of 294 locoregionally advanced nasopharyngeal carcinoma patients who were identified from prospectively maintained database and underwent fluor-18-fluorodeoxyglucose positron emission tomography/computed tomography imaging before treatment were included. The maximum standardized uptake value was recorded for the primary tumor (SUVmax-P) and neck lymph nodes (SUVmax-N). Computed tomography-derived primary gross tumor volume was measured using the summation-of-area technique. At 5 years, the distant metastasis-free survival rate was 83.7%. The cut-off of the SUVmax-P, SUVmax-N, and primary gross tumor volume for distant metastasis-free survival was 8.95, 5.75, and 31.3 mL, respectively, by receiver operating characteristic curve. In univariate analysis, only SUVmax-N (hazard ratio: 7.01; 95% confidence interval: 1.70-28.87; p < 0.01) and clinical stage (hazard ratio: 3.03; 95% confidence interval: 1.67-5.47; p = 0.007) were confirmed as independent predictors of distant metastasis-free survival. A prognostic model was derived by SUVmax-N and clinical stage: low risk (SUVmax-N < 5.75 regardless of clinical stage), medium risk (stage III and SUVmax-N ≥ 5.75), and high risk (stage IV and SUVmax-N ≥ 5.75). Multivariate analysis revealed that SUVmax-N and the prognostic model remained independent prognostic factors for distant metastasis-free survival (p = 0.023 and p < 0.001, respectively), but the clinical stage became insignificant (p = 0.133). Furthermore, the adjusted hazard ratios for the prognostic model were higher than SUVmax-N (hazard ratio = 6.27 vs 5.21, respectively). In summary, compared with SUVmax-P, SUVmax-N may be a better predictor of distant metastasis-free survival for patients with locoregionally advanced nasopharyngeal carcinoma. Combining SUVmax-N with clinical stage gives a more precise picture in predicting distant metastasis.

JMJD2A promotes the Warburg effect and nasopharyngeal carcinoma progression by transactivating LDHA expression

BACKGROUND

Jumonji C domain 2A (JMJD2A), as a histone demethylases, plays a vital role in tumorigenesis and progression. But, its functions and underlying mechanisms of JMJD2A in nasopharyngeal carcinoma (NPC) metabolism are remained to be clarified. In this study, we investigated glycolysis regulation by JMJD2A in NPC and the possible mechanism.

METHODS

JMJD2A expression was detected by Western blotting and Reverse transcription quantitative real-time PCR analysis. Then, we knocked down and ectopically expressed JMJD2A to detect changes in glycolytic enzymes. We also evaluated the impacts of JMJD2A-lactate dehydrogenase A (LDHA) signaling on NPC cell proliferation, migration and invasion. ChIP assays were used to test whether JMJD2A bound to the LDHA promoter. Finally, IHC was used to verify JMJD2A and LDHA expression in NPC tissue samples and analyze their correlation between expression and clinical features.

RESULTS

JMJD2A was expressed at high levels in NPC tumor tissues and cell lines. Both JMJD2A and LDHA expression were positively correlated with the tumor stage, metastasis and clinical stage. Additionally, the level of JMJD2A was positively correlated with LDHA expression in NPC patients, and higher JMJD2A and LDHA expression predicted a worse prognosis. JMJD2A alteration did not influence most of glycolytic enzymes expression, with the exception of PFK-L, PGAM-1, LDHB and LDHA, and LDHA exhibited the greatest decrease in expression. JMJD2A silencing decreased LDHA expression and the intracellular ATP level and increased LDH activity, lactate production and glucose utilization, while JMJD2A overexpression produced the opposite results. Furthermore, JMJD2A could combine to LDHA promoter region and regulate LDHA expression at the level of transcription. Activated JMJD2A-LDHA signaling pathway promoted NPC cell proliferation, migration and invasion.

CONCLUSIONS

JMJD2A regulated aerobic glycolysis by regulating LDHA expression. Therefore, the novel JMJD2A-LDHA signaling pathway could contribute to the Warburg effects in NPC progression.

Prognostic value of 18F-FDG-PET/CT in patients with nasopharyngeal carcinoma: a systematic review and meta-analysis

BACKGROUND

The prognostic role of 18F-fluorodeoxyglucose positron emission tomography CT (18F-FDG PET/CT) parameters is still controversial in nasopharyngeal carcinoma patients. We sought to perform a systematic review and meta-analysis to explore the prognostic value of maximal standardized uptake value (SUVmax), metabolic tumor volume (MTV) and total lesion glycolysis (TLG) on event-free survival (EFS) and overall survival (OS) in nasopharyngeal carcinoma patients.

RESULTS

Fifteen studies comprising 1,938 patients were included in this study. The combined hazard ratios (HRs) for EFS were 2.63 (95%CI 1.71-4.05) for SUVmax, 2.55 (95%CI 1.49-4.35) for MTV, and 3.32 (95%CI 1.23-8.95) for TLG. The pooled HRs for OS were 2.07 (95%CI 1.54-2.79) for SUVmax, 3.86 (95%CI 1.85-8.06) for MTV, and 2.60 (95%CI 1.55-4.34) for TLG. The prognostic role of SUVmax, MTV and TLG remained similar in the sub-group analyses.

METHODS

A systematic literature search was performed to identify studies which associated 18F-FDG PET/CT to clinical survival outcomes of nasopharyngeal carcinoma patients. The summarized HRs for EFS and OS were estimated by using fixed- or random-effect models according to heterogeneity between trials.

CONCLUSIONS

The present meta-analysis confirms that high values of SUVmax, MTV and TLG predicted a higher risk of adverse events or death in patients with nasopharyngeal carcinoma, despite clinically heterogeneous nasopharyngeal carcinoma patients and the various methods adopted between these studies.

Prognostic value of pretreatment 18F-FDG PET-CT for nasopharyngeal carcinoma patients

BACKGROUND

Nasopharyngeal carcinoma (NPC) is a special subtype of head and neck cancer (HNC). At present, there are no highly specific prognostic markers to aid in tumor grading and guide patient treatment modalities for NPC. The prognostic value of pretreatment F-fluorodeoxyglucose positron emission tomography-computed tomography (F-PET-CT) in NPC patients is controversial and no consensus exists as to its predictive capability.

METHODS

To analyze the predictive efficacy of F-PET-CT imaging in NPC patients, data from MEDLINE, EMBASE, the Cochrane library, CBM, CNKI, and VIP (inception to July 2016) were accessed. Results from prospective and retrospective observational studies that used F-FDG PET to predict disease prognosis in NPC patients were used for analysis. Two authors independently assessed study quality and extracted data. Event-free survival (EFS) was considered the primary endpoint and overall survival rate (OS) was considered the secondary endpoint.

RESULTS

Data from 14 studies and 1134 patients were included in our analysis. The hazard ratios (HRs) of maximum standardized uptake value of primary tumor (SUVmax-T), metabolic tumor volume of primary tumor (MTV-T), and total lesional glycolysis of primary tumor (TLG-T) for EFS were 1.31 (95% confidence interval [CI], 1.11-1.55, P = .001), 2.38 (95% CI 1.53-3.70, P < .001), and 1.65 (95% CI 0.76-3.59, P = .21), respectively. Among studies including TLG-T, those with a fixed SUV of 2.5 had an HR of 3.55 (95% CI, 1.42-8.84, P = .007). The HRs of SUVmax-T and MTV-T for OS were 2.19 (95% CI, 1.47-3.27, P < .001) and 2.69 (95% CI, 1.01-7.17, P = .05), respectively. Among studies including MTV-T, those with a fixed SUV of 2.5 had an HR of 4.07 (95% CI, 2.22-7.46, P < .001). Tests used for assessing predictive value of pretreatment SUVmax, MTV, and TLG of lymph nodes for EFS and OS showed that these parameters did not have significant predictive value (P>.05).

CONCLUSION

Our results suggested that SUVmax, MTV, and TLG (with a fixed SUV of 2.5) of primary tumors before treatment initiation may be independent prognostic factors for NPC patients; however, SUVmax, MTV, and TLG of metastatic lymph nodes are not.

Multiparametric imaging using 18F-FDG PET/CT heterogeneity parameters and functional MRI techniques: prognostic significance in patients with primary advanced oropharyngeal or hypopharyngeal squamous cell carcinoma treated with chemoradiotherapy

Background

In this study, PET heterogeneity was combined with functional MRI techniques to refine the prediction of prognosis in patients with oropharyngeal or hypopharyngeal squamous cell carcinoma (OHSCC).

Methods

A total of 124 patients with primary advanced OHSCC who underwent pretreatment ¹⁸F-FDG PET/CT, dynamic contrast-enhanced MR imaging (DCE-MRI), and diffusion-weighted MR imaging (DWI) were enrolled. Conventional and heterogeneity parameters from ¹⁸F-FDG PET as well as perfusion parameters from DCE-MRI and diffusion parameter from DWI of primary tumors were analyzed in relation to recurrence-free survival (RFS) and overall survival (OS).

Results

Multivariate analysis identified hypopharyngeal tumors (P = 0.038), alcohol drinking (P = 0.006), K^trans ≤ 0.5512 (P = 0.017), and K_ep ≤ 0.8872 (P = 0.005) as adverse prognostic factors for RFS. Smoking (p = 0.009), K^trans ≤ 0.5512 (P = 0.0002), K_ep ≤ 0.8872 (P = 0.004), and the PET heterogeneity parameter uniformity ≤ 0.00381 (P = 0.028) were independent predictors of poor OS. The combination of PET uniformity with DCE-MRI parameters and smoking allowed distinguishing four prognostic groups, with 3-year OS rates of 100%, 76.6%, 57.4%, and 7.1%, respectively (P < 0.0001). This prognostic system appeared superior to both the TNM staging system (P = 0.186) and the combination of conventional PET parameters with DCE-MRI (P = 0.004).

Conclusions

Multiparametric imaging based on PET heterogeneity and DCE-MRI parameters combined with clinical risk factors is superior to the concomitant use of functional MRI coupled with conventional PET parameters. This approach may improve the prognostic stratification of OHSCC patients.

The role of changes in maximum standardized uptake value of FDG PET-CT for post-treatment surveillance in patients with head and neck squamous cell carcinoma treated with chemoradiotherapy: preliminary findings

OBJECTIVE

No clear consensus exists regarding the optimal interval and frequency of follow-up positron emission tomography (PET)-CT in patients with head and neck squamous cell carcinoma (HNSCC) treated with chemoradiotherapy (CRT). Here, we sought to clarify whether the changes in the maximum standardized uptake value (ΔSUV_max) may be a valid parameter to help decision-making for surveillance management after CRT.

METHODS

40 patients underwent PET-CT at pre-treatment and 3 months after CRT. Patients were followed by sequential PET-CT for 2 years after CRT. The ΔSUV_max of the primary tumour and the metastatic nodes were calculated between pre-treatment and 3 months after the CRT, and we evaluated the associations between ΔSUV_max and the manifestation of recurrence, time to recurrence and the patient survival.

RESULTS

The ΔSUV_max of the primary tumour was significantly lower for the lesions with recurrence than that for those with non-recurrence for both the primary site and the nodal site (p = 0.007, 0.02). A significant correlation was found between the time to recurrence and the ΔSUV_max of the primary tumour (r = 0.63, p < 0.05). The threshold ΔSUV_max of the primary tumour of 1.04 revealed 76.9% sensitivity and 86.4% specificity for distinguishing recurrence from non-recurrence. The progression-free survival and overall survival of the two patient groups divided by the ΔSUV_max of the primary tumour at 1.04 showed a significant difference (p = 0.003, 0.02). The ΔSUV_max of the metastatic nodes did not show a significant association with recurrence or patient survival.

CONCLUSION

The ΔSUV_max of the primary tumour showed a significant association with recurrence and patient survival. Advances in knowledge: The ΔSUV_max of the primary tumour may be a valid clinical parameter to help decision-making for the surveillance management of patients with HNSCC after CRT.

Prognostic Significance of Standardized Uptake Value on 18Fluorine-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography in Patients with Nasopharyngeal Carcinoma

The aim of this study was to investigate the prognostic significance of standardized uptake value (SUV) on 18 fluorine-fluorodeoxyglucose (¹⁸F-FDG) positron emission tomography/computed tomography (PET/CT) in patients with nasopharyngeal carcinoma (NPC). Thirty-four patients who have histologically proven NPC and underwent ¹⁸F-FDG PET/CT were included in this study. After ¹⁸F-FDG PET/CT, all the patients received radiation therapy and 32 of them received concomitant weekly chemotherapy. The maximum SUV (SUV_max) at the primary tumor and the SUV_maxof the highest neck nodes were determined. The SUV_max-T ranged from 5.00 to 30.80 (mean: 15.37 ± 6.10) and there was no difference between SUV_max-T values for early and late stages (P = 0.99). The SUV_max-N ranged from 3.10 to 23.80 (mean: 13.23 ± 5.76). There was no correlation between SUV_max-T and SUV_max-N (r = 0.111, P = 0.532). There was no difference between the SUV_max-T and the positivity of neck lymph nodes (P = 0.169). The ability of SUV_maks-N to predict stage was obtained by a receiver operating characteristic (ROC) analysis. The area under the curve is 0.856 and the best cut-off value is 7.88. There was a good correlation between SUV_max-N and stage. While the mean SUV_max-T for the alive patients was slightly lower than that for the dead (14.65 ± 5.58 vs. 20.30 ± 7.92, P = 0.061), the difference between the groups was not statistically significant. Furthermore, there was no statistically significant difference for SUV_max-N between these two groups (P: 0.494). Cox-regression analysis showed that an increase in SUV_max-T and SUV_max-N was associated with death risk (relative risk [RR]: 1.13, P = 0.078 and RR: 1.052, P = 0.456, respectively). SUV_max-T and SUV_max-N were independent prognostic factors for survival in NPC patients. This will help the clinicians in choosing suitable candidates for more aggressive treatment modalities.

Lymph node standardized uptake values at pre-treatment 18F-fluorodeoxyglucose positron emission tomography as a valuable prognostic factor for distant metastasis in nasopharyngeal carcinoma

Objective:

The aim of the present study was to evaluate prognostic values of pre-treatment fluorine-18 fludeoxyglucose (¹⁸F-FDG) positron emission tomography (PET) parameters for predicting the distant metastasis (DM) of nasopharyngeal cancer.

Methods:

73 patients diagnosed with nasopharyngeal cancer with regional lymph node (LN) involvement, who underwent pre-treatment ¹⁸F-FDG PET evaluation between January 2005 and December 2012, were retrospectively reviewed. We assessed the ¹⁸F-FDG PET parameters of the primary tumours (T–) and regional LNs (N–). For patients with bilateral retropharyngeal, bilateral neck and/or supraclavicular LN involvement, we also assessed the ¹⁸F-FDG PET parameters of the farthest LN station [N(f)–]. The following ¹⁸F-FDG PET parameters were evaluated: maximum standardized uptake value (SUV_max), mean standardized uptake value (SUV_mean), peak standardized uptake value (SUV_peak), metabolic tumour volumes (MTVs) (MTV₃₀–MTV₇₀, which were calculated as the tumour volume with 30%, 40%, 50%, 60% and 70% of the SUV_max as the threshold, respectively) and total lesion glycolysis (TLG) (TLG₃₀–TLG₇₀, which were determined by the product of each MTV and the corresponding SUV_mean within that MTV). Distant metastasis-free survival (DMFS) rates were estimated from the date of the start of radiotherapy to the date of DM or last follow-up by the Kaplan–Meier method. Univariate and multivariate analyses were performed to identify prognostic factors for DMFS. The median follow-up period was 53 months (range 12–110 months).

Results:

Most patients (95%) received concurrent chemoradiotherapy. The major failure pattern was DM (15 of all patients, 21%) and the 5-year DMFS was 79%. In univariate analysis, the T–SUV_max, T–SUV_mean, T–SUV_peak, N–SUV_max, N–SUV_peak, N(f)–SUV_max and N(f)–SUV_peak were significant prognostic factors for DMFS. In multivariate analysis, the T–SUV_max, T–SUV_peak, N(f)–SUV_max and N(f)–SUV_peak were significant prognostic factors for DMFS. Of these parameters, the N(f)–SUV_max (hazard ratio = 6.524; p = 0.001) and N(f)–SUV_peak (hazard ratio = 5.399; p = 0.001) were the strongest prognostic factors for DMFS.

Conclusion:

In patients with nasopharyngeal cancer with LN involvement, the standardized uptake value parameter of the farthest LN station seems to be an important ¹⁸F-FDG PET parameter for predicting DM. Further studies are needed to validate its clinical significance.

Advances in knowledge:

We found that pre-treatment ¹⁸F-FDG PET parameters of primary tumours and regional LNs (the SUV_max and SUV_peak of the primary tumour and the farthest LN station) were significant prognostic factors for DMFS in patients with nasopharyngeal carcinoma with LN involvement.

Combining plasma Epstein-Barr virus DNA and nodal maximal standard uptake values of 18F-fluoro-2-deoxy-D-glucose positron emission tomography improved prognostic stratification to predict distant metastasis for locoregionally advanced nasopharyngeal carcinoma

Background

This study aimed to evaluate the value of combining the nodal maximal standard uptake values (SUVmax) of ¹⁸ F-fluoro-2-deoxy-D-glucose positron emission tomography with Epstein-Barr virus DNA(EBV DNA) levels to predict distant metastasis for nasopharyngeal carcinoma (NPC) patients

Patients and Methods

Eight hundred seventy-four patients with stage III-IVa-b NPC were evaluated for the effects of combining SUVmax and EBV DNA levels on distant metastasis-free survival (DMFS), disease-free survival (DFS) and overall survival (OS).

Results

The optimal cutoff value was 6,220 copies/mL for EBV DNA and 7.5 for SUVmax-N. Patients with lower EBV DNA levels or SUVmax-N had a significantly better 3-year DMFS, DFS, and OS. Patients were divided into four groups based on EBV DNA and SUVmax-N, as follows: low EBV DNA and low SUVmax-N (LL), low EBV DNA and high SUVmax-N (LH), high EBV DNA and low SUVmax-N (HL), and high EBV DNA and high SUVmax-N (HH). There were significant differences between the four mentioned groups in 3-year DMFS: 95.7%, 92.2%, 92.3%, and 80.1%, respectively (P^trend < 0.001). When looking at the disease stage, the 3-year DMFS in group LL, LH, HL, HH were 94.2%, 92.9%, 95.0%, and 81.1%, respectively, in stage III patients (P^trend < 0.001) and 92.7%, 87.2%, 86.3%, and 77.0% in stage IVa–b patients (P^trend = 0.026).

Conclusion

Pretreatment EBV DNA and SUVmax of neck lymph nodes were independent prognostic factors for distant metastasis in NPC patients. Combining EBV DNA and SUVmax-N led to an improved risk stratification for distant metastasis in advanced-stage disease.

Variations in target volume definition and dose to normal tissue using anatomic versus biological imaging (18 F-FDG-PET) in the treatment of bone metastases: results from a 3-arm randomized phase II trial

INTRODUCTION

To report the impact on target volume delineation and dose to normal tissue using anatomic versus biological imaging (¹⁸ F-FDG-PET) for bone metastases.

METHODS

Patients with uncomplicated painful bone metastases were randomized (1:1:1) and blinded to receive either 8 Gy in a single fraction with conventionally planned radiotherapy (ConvRT-8 Gy) or 8 Gy in a single fraction with dose-painting-by-numbers (DPBN) dose range between 6 and 10 Gy) (DPBN-8 Gy) or 16 Gy in a single fraction with DPBN (dose range between 14 and 18 Gy) (DPBN-16 Gy). The primary endpoint was overall pain response at 1 month. Volumes of the gross tumour volume (GTV) - both biological (GTV_PET ) and anatomical (GTV_CT ) -, planning target volume (PTV), dose to the normal tissue and maximum standardized-uptake values (SUV_MAX ) were analysed (secondary endpoint).

RESULTS

Sixty-three percent of the GTV_CT volume did not show ¹⁸ F-FDG-uptake. On average, 20% of the GTV_PET volume was outside GTV_CT . The volume of normal tissue receiving 4 Gy, 6 Gy and 8 Gy was at least 3×, 6× and 13× smaller in DPBN-8 Gy compared to ConvRT-8 Gy and DPBN-16 Gy (P < 0.05).

CONCLUSION

Positron emitting tomography-information potentially changes the target volume for bone metastases. DPBN between 6 and 10 Gy significantly decreases dose to the normal tissue compared to conventional radiotherapy.

The role of PET/CT in the management of patients affected by head and neck tumors: a review of the literature

The management of head and neck tumor (HNSCC) has been changing over the years, especially due to the aid of imaging techniques that help physicians to attain a correct diagnosis. These techniques represent a valuable tool to help tailor treatment and during follow-up of patients affected by malignancies. The aim of this review is to summarize the results of the most recent and relevant studies about the use of PET imaging in HNSCCs. This review is divided into six chapters: (1) The role of PET/CT in the pre-treatment phase; (2) PET/CT and radiotherapy planning; (3) PET/CT in the post-treatment setting; (4) PET/CT and SUVmax for prediction of prognosis; (5) miscellanea on the utility of PET in specific HNSCCs; (6) non-FDG PET tracers used in HNSCC. Promising results have been obtained so far. Despite the encouraging outcomes, more investigations are needed to warrant the value of this technique, especially in the pre-treatment setting.

Tumor heterogeneity measured on F-18 fluorodeoxyglucose positron emission tomography/computed tomography combined with plasma Epstein-Barr Virus load predicts prognosis in patients with primary nasopharyngeal carcinoma

OBJECTIVES/HYPOTHESIS

Plasma Epstein-Barr virus (EBV) DNA concentrations predict prognosis in patients with nasopharyngeal carcinoma (NPC). Recent evidence also indicates that intratumor heterogeneity on F-18 fluorodeoxyglucose positron emission tomography (¹⁸ F-FDG PET) scans is predictive of treatment outcomes in different solid malignancies. Here, we sought to investigate the prognostic value of heterogeneity parameters in patients with primary NPC.

STUDY DESIGN

Retrospective cohort study.

METHODS

We examined 101 patients with primary NPC who underwent pretreatment ¹⁸ F-FDG PET/computed tomography. Circulating levels of EBV DNA were measured in all participants. The following PET heterogeneity parameters were collected: histogram-based heterogeneity parameters, second-order texture features (uniformity, contrast, entropy, homogeneity, dissimilarity, inverse difference moment), and higher-order (coarseness, contrast, busyness, complexity, strength) texture features.

RESULTS

The median follow-up time was 5.14 years. Total lesion glycolysis (TLG), tumor heterogeneity measured by histogram-based parameter skewness, and the majority of second-order or higher-order texture features were significantly associated with overall survival (OS) and/or recurrence-free survival (RFS). In multivariate analysis, age (P =.005), EBV DNA load (P = .0002), and uniformity (P = .001) independently predicted OS. Only skewness retained the independent prognostic significance for RFS. Tumor stage, standardized uptake value, or TLG did not show an independent association with survival endpoints. The combination of uniformity, EBV DNA load, and age resulted in a more reliable prognostic stratification (P < .001).

CONCLUSIONS

Tumor heterogeneity is superior to traditional PET parameters for predicting outcomes in primary NPC. The combination of uniformity with EBV DNA load can improve prognostic stratification in this clinical entity.

LEVEL OF EVIDENCE

4 Laryngoscope, 127:E22-E28, 2017.

Prognostic utility of (18)F-FDG PET-CT performed prior to and during primary radiotherapy for nasopharyngeal carcinoma: Index node is a useful prognostic imaging biomarker site

PURPOSE

To evaluate the prognostic value of (18)F-FDG-PET-CT performed prior to (prePET) and during the third week (iPET) of radiation therapy (RT) in nasopharyngeal carcinoma (NPC).

MATERIALS AND METHODS

Thirty-patients with newly diagnosed loco-regionally advanced NPC treated with radical RT underwent prePET and iPET. The median follow-up was 26months (8-66.9). The maximum-standardised-uptake-value (SUVmax), metabolic-tumour-volume (MTV) and total-lesional-glycolysis (TLG) of the primary tumour (PT), index-node (IN) (lymph node with highest TLG), total-lymph-nodes (TN) and combined primary-tumour and nodal (PTN), and their % reductions in iPET were analysed, and results were correlated with 2-year Kaplan-Meier loco-recurrence-free-survival (LRFS), regional-failure-free-survival (RFFS), distant-metastatic-failure-free-survival (DMFFS), disease-free-survival (DFS), and overall-survival (OS). Optimal-cutoffs (OC) were derived from Receiver-Operating-Characteristic curves.

RESULTS

For LRFS, the only predictor was reduction in PT MTV by >50%: 95.2% vs. 75.0%, p=0.024. For other treatment outcomes, only nodal or PTN predicted outcomes. The IN SUVmax (pre-PET-OC=10.45g/mL and iPET-OC=8.15) and TLG (prePET-OC=90g and iPET-OC=33.4) were the best predictors of outcome: RFFS (iPET SUVmax/TLG): 100% vs. 50%, p<0.001 and 100% vs. 44%, p=0.032; DMFFS (prePET SUVmax/TLG); 100% vs. 51.9%, p=0.004 and 100% vs. 47.6%, p=0.002; DFS (prePET TLG and iPET SUVmax): 87.5% vs. 33%, p=0.045 and 78.7% vs. 20%, p=0.01; and OS (prePET TLG): 100% vs 66.3%, p=0.036.

CONCLUSIONS

We have demonstrated IN of prePET and iPET to be a feasible and potentially useful novel imaging biomarker to predict for patients with NPC who have a high risk of regional or distant metastatic failure. Future work is required to validate our findings in a well-powered, prospective study with a standardised treatment protocol, and their potential use to guide individualised therapy for NPC.