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Clinical Trial
. 2011 Aug;38(8):1449-58.
doi: 10.1007/s00259-011-1789-x. Epub 2011 Apr 2.

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

Dominic A X Schinagl  1 , Paul N Span, Wim J Oyen, Johannes H A M Kaanders
Affiliations
Clinical Trial

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

Dominic A X Schinagl et al. Eur J Nucl Med Mol Imaging. 2011 Aug.

Abstract

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

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

Results: In oral cavity/oropharynx tumours PET(VIS) was the only volume-based method able to predict LC. Both PET(VIS) and GTV(CT) were able to predict DMFS, DFS and OS in these subsites. Integrated SUVs were associated with LC, DMFS, DFS and OS, while SUV(mean) and SUV(MAX) were not. In hypopharyngeal/laryngeal tumours none of the variables was associated with outcome.

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

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Figures

Fig. 1
Fig. 1
Planning CT image (a), corresponding FDG PET image (b) and fusion image (c) in a patient with T3N2bM0 oropharyngeal carcinoma show differences in target volume definition. Indicated are GTV delineated on the CT image (GTVCT; red, absolute volume of 34.0 cm3) and PET-based GTVs obtained by visual interpretation (PETVIS; light green, volume 33.8 cm3), applying an SUV isocontour of 2.5 (PET2.5; orange), using a fixed threshold of 40% (PET40%; yellow, volume 14.0 cm3) and 50% (PET50%; blue, volume 13.4 cm3) of the maximum signal intensity, and applying an adaptive threshold based on the SBR (PETSBR; dark green, volume 15.0 cm3). GTV2.5 was unsuccessful in this patient because of inclusion of large areas of normal background tissue. Note that on this transverse slice PET50% and PETSBR are indistinguishable
Fig. 2
Fig. 2
Box and whisker plot showing 5% and 95% confidence intervals (whiskers), 25% and 75% confidence intervals (boxes), and median of CT- and PET-based tumour volumes of oral cavity/oropharyngeal tumours (unfilled boxes) and hypopharyngeal/laryngeal tumours (filled boxes). There was a significant difference in the volumes of oral cavity and oropharyngeal tumours as compared to laryngeal and hypopharyngeal tumours (p ≤ 0.004, Mann-Whitney)
Fig. 3
Fig. 3
Panels showing GTVCT and PETVIS in relation to LC (a) and DFS (b) of oral cavity/oropharyngeal tumours with a follow-up of at least 24 months. Differences were analysed using the Mann-Whitney U test
See this image and copyright information in PMC

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