Integration of 18-FDG PET/CT in the Initial Work-Up to Stage Head and Neck Cancer: Prognostic Significance and Impact on Therapeutic Decision Making.

Background: The objective of this study was to assess the therapeutic and prognostic impact of integrating18F-fluorodeoxyglucose (18-FDG) positron emission tomography (PET)/computed tomography (CT) into work-up (WU) at initial staging of patients with head and neck squamous cell carcinoma (HNSCC). Method: 477 consecutive patients (414M/63F, mean age 62.3 ± 9.7 years) with newly diagnosed HNSCC who underwent pre-treatment 18-FDG PET/CT were retrospectively included. The 18-FDG PET/CT stage (sPET) was compared to the conventional work-up stage (sCWU). A group of cancer specialists determined whether integrating PET/CT into WU at initial staging had an impact on the therapeutic decision, classifying the clinical impact as high (change in therapeutic modality), medium (change in the radiotherapy or surgical procedure), or low (modification of TNM staging and/or detection of synchronous cancer without high or medium impact). Three-year overall survival (OS) was considered as primary endpoint of the prognostic analysis. Results: 18-FDG PET/CT had a clinical impact in 221 patients (46.3%) with a medium or high impact on management in 94 (19.5%) patients. Medium and high impact of 18-FDG PET/CT was statistically equivalent between sCWU-stage I/II and III/IV subgroups (p = 0.02). 42 patients were PET/CT-upstaged from early stage I/II to advanced stage III/IV and had a significantly lower 3-year OS than those with concordant CWU and 18-FDG PET/CT early stage (54.8 vs. 82.6%, p = 0.001). Conclusion: This study demonstrated that implementing 18-FDG PET/CT in the initial WU of HNSCC provides valuable staging information with a better prognostic stratification. Patient management was modified for any disease stage, even for early stage I-II, with consequences on survival.

Prognostic evaluation of percentage variation of metabolic tumor burden calculated by dual-phase (18) FDG PET-CT imaging in patients with head and neck cancer.

BACKGROUND: The purpose of this study was to investigate the prognostic value of percentage variation of metabolic tumor burden in patients with head and neck squamous cell carcinoma (HNSCC). METHODS: Patients referred to undergo (18) fluorodeoxyglucose (FDG) positron emission tomography (PET)-CT for staging of HNSCC were included in this study. Using a dual-phase method, standardized uptake value maximum (SUVmax), metabolic tumor volume (MTV), and total lesion glycolysis (TLG) were recorded and respectively used to calculate retention index (RI), %ΔMTV, and %ΔTLG. Recurrence-free survival (RFS) was determined by Kaplan-Meier method and compared with studied PET parameters in univariate and multivariate. RESULTS: Seventy patients (61 men/9 women; 62.9 ± 9.1 years old) were included. In univariate, SUVmax, RI, MTV, and TLG (p ≤ .0001) were significantly correlated with RFS, unlike %ΔMTV (p = 137) and %ΔTLG (p = .517). In multivariate, RI (p = .005) and MTV (p = .022) persisted as independent prognostic factors. CONCLUSION: Our results did not prove a prognostic interest of percentage variation of metabolic tumor burden in patients with HNSCC but confirmed that RI and MTV are independently correlated with RFS. © 2015 Wiley Periodicals, Inc. Head Neck 38: E600-E606, 2016.

Diagnostic performance of FDG PET/CT to detect subclinical HNSCC recurrence 6 months after the end of treatment.

PURPOSE: Posttreatment follow-up for the recurrence of head and neck squamous cell carcinoma (HNSCC) is a diagnostic challenge. Tissue distortion from radiation and surgery can obscure early detection of recurrence by conventional follow-up approaches such as physical examination or conventional imaging. Fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT is widely validated for the diagnosis of suspected recurrence. Moreover, we have shown in a previous prospective study the high effectiveness of FDG PET/CT in the assessment of subclinical recurrence 12 months after treatment. The aim of this prospective study was to evaluate the effectiveness of an earlier FDG PET/CT, at 6 months after the end of treatment. METHODS: All patients treated for histologically proven HNSCC from April 2009 to May 2012 at the University Hospital of Brest who did not show any findings suggestive of recurrence at 6 months of their usual follow-up underwent an FDG PET/CT examination. FDG PET/CT findings were correlated with histopathology or imaging follow-up. RESULTS: The study included 116 patients. FDG PET/CT examinations were performed within a mean period ± SD of 5.6 ± 1.8 months after treatment. FDG PET/CT examinations exhibited abnormal FDG uptake in 34 patients and found no suspected recurrence in 82 cases. Of these 82 FDG PET/CT considered as negative, only 1 had a recurrence. Among the 34 positive FDG PET/CT, 22 relapsed whereas 12 did not show evidence of recurrence. The sensitivity and specificity of FDG PET/CT in this study for the diagnosis of occult HNSCC recurrence were 96 (22/23) and 87 % (81/93), respectively. The positive predictive value was 65 % (22/34). The negative predictive value was 99 % (81/82). The overall accuracy was 89 % (103/116). Of the 116 patients, FDG PET/CT highlighted 22 (19 %) subclinical recurrences. CONCLUSION: Our study showed the high effectiveness of FDG PET/CT in the assessment of subclinical HNSCC recurrence 6 months after completion of treatment. These results confirmed that FDG PET/CT is more accurate than conventional follow-up physical examination alone in the assessment of recurrence after previous curative treatment for HNSCC, as we previously demonstrated in patients clinically asymptomatic at 12 months.

Prognostic value of volumetric parameters measured by 18F-FDG PET/CT in patients with head and neck squamous cell carcinoma.

PURPOSE: The objective of this study was to investigate the value of metabolic tumour volume (MTV) assessed with (18)F-FDG PET/CT in predicting event-free survival (EFS) and overall survival (OS) in patients with head and neck squamous cell carcinoma (HNSCC), and particularly to compare it with more conventional parameters such as maximum standardized uptake value (SUVmax). METHODS: Patients referred to our department for (18)F-FDG PET/CT for staging of HNSCC were prospectively included between February 2009 and March 2011. Each patient was scanned using a Philips Gemini PET/CT system at 1 h after injection. The MTV was calculated semiautomatically for the primary site using methods based on SUV with various thresholds: 3-D contour around voxels equal to or greater than 2.0, 2.5, 3.0, 3.5, 4.0, 4.5, 5.0, 5.5, 6.0, 6.5 and 7.0 times SUV, or more than 30%, 40% and 50% of SUVmax. ROC analysis was used to test the statistical significance of the differences among the calculated MTVs. EFS and OS were determined using the Kaplan-Meier method and compared with MTV in univariate and multivariate analyses, including the usual prognostic factors: age, sex, primary site, treatment, SCC histologic grade, AJCC stage, TNM classification, tumour SUVmax and SUVpeak. RESULTS: The study included 80 consecutive patients (70 men, 10 women; mean age 62.4 ± 9.0 years). ROC analysis revealed that pretreatment MTV using a threshold of 5.0 times SUV (MTV5.0) was the best parameter to predict recurrence and death after treatment. In univariate analysis, MTV5.0 >4.9 ml was predictive of poor EFS (p < 0.0001) and poor OS (p < 0.0001). In multivariate, MTV5.0 persisted as an independent predictive factor for EFS (p = 0.011) and OS (p = 0.010), while SUVmax became nonsignificant (p = 0.277 for EFS, p = 0.975 for OS). CONCLUSION: Our results suggest that MTV measured by (18)F-FDG PET/CT has independent prognostic value of in patients with HNSCC, stronger than SUVmax.

Prognostic value of dual-time-point 18F-FDG PET-CT imaging in patients with head and neck squamous cell carcinoma.

OBJECTIVE: The objective of this study was to investigate the independent prognostic value of dual-time-point (18)F-fluorodeoxyglucose ((18)F-FDG) PET-CT imaging in patients with head and neck squamous cell carcinoma (HNSCC). METHODS: Patients referred to our department to undergo (18)F-FDG PET-CT for staging of HNSCC were prospectively included. Each patient was scanned using a Philips Gemini PET-CT system 1 h (early acquisition) and 2 h (delayed acquisition) after injection. An intratumoral retention index (RI) of (18)F-FDG was measured for each examination by the dual-time-point method. Event-free survival (EFS) and overall survival (OS) were determined by the Kaplan-Meier method and compared with the conventional maximum standardized uptake value (SUV(max)) at 60 min, SUV(max) at 120 min, and RI in univariate and multivariate analyses including the usual prognostic factors such as age, sex, primary site, SCC histologic grade, and American Joint Committee on Cancer stage (I, II, III, and IV). RESULTS: Sixty-six consecutive patients (60 men and six women; mean age=61 ± 9 years) were included in the study. In univariate analysis, besides age and stage, RI was predictive of EFS (P=0.01) but not of OS (P=0.1), whereas SUV(max) at 60 min was not predictive of EFS (P=0.18) or OS (P=0.08) and SUV(max) at 120 min was predictive of OS (P=0.02) but not of EFS (P=0.05). In multivariate analysis, RI persisted as an independent predictive factor for EFS (P=0.02) but not SUV(max) at 120 min for OS (P=0.12). CONCLUSION: Our results suggest an additional prognostic interest of RI measured by dual-time-point (18)F-FDG PET-CT, independent of usual prognostic factors, in patients with HNSCC.

Early recurrence or submucosal residual of laryngeal squamous cell carcinoma: diagnosis by CT-guided endolaryngeal core biopsy on a transcutaneous approach.

BACKGROUND: Ultrasound and CT-guided biopsy is a common procedure for histologic diagnosis of recurrence of head and neck squamous cell carcinoma. The present study describes a novel CT-guided endolaryngeal puncture site. METHODS AND RESULTS: A 59-year-old man was treated for a T2N0M0 supraglottic laryngeal tumor by laser resection and bilateral lymph node dissection; exeresis was judged complete. Six-month follow-up found persistent dysphonia. Endoscopic examination and iterative biopsy gave reassuring results, but (18) fluorodeoxyglucose positron emission tomography-CT ((18) FDG PET-CT) found highly suspicious increased right hemilaryngeal metabolic activity. Diagnosis of residual tumor was confirmed on CT-guided endolaryngeal biopsy. CONCLUSIONS: Image-guided biopsy is the technique of choice in head and neck lesions that are deep or difficult to palpate and inaccessible to endoscopy. It is especially useful when recurrence is suspected after radiation therapy or cancer surgery. Many puncture sites have been reported in the literature; the present novel laryngeal approach extends the range of image-guided biopsy, although further studies will be needed to assess possible morbidity.

Early prediction of survival following induction chemotherapy with DCF (docetaxel, cisplatin, 5-fluorouracil) using FDG PET/CT imaging in patients with locally advanced head and neck squamous cell carcinoma.

PURPOSE: Locally advanced head and neck squamous cell carcinoma (HNSCC) has a high rate of recurrence. Induction chemotherapy with DCF (docetaxel, cisplatin, 5-fluorouracil) before chemoradiotherapy could lead to the best disease control of inoperable stage III/IV HNSCC but with an increased risk of acute toxicity. Early assessment of therapeutic efficacy is a key issue in considering the benefit of escalation in a poor prognosis population. METHODS: Patients with stage III/IV HNSCC, in whom DCF induction chemotherapy followed by concurrent chemoradiotherapy had been validated by a multidisciplinary team, were prospectively included in the study. FDG PET/CT scans were performed in all patients before and after two of the three cycles of DCF. EORTC99 criteria were used to evaluate PET responses as follows: group 1 (metabolic responders) showing a complete response (CR) or partial response (PR), and subgroup 0 (metabolic nonresponders) showing stable disease (SD) or progressive disease (PD). The primary endpoint for monitoring patients was event-free survival (EFS). EFS probabilities between the two groups were estimated by the Kaplan-Meier method and statistically compared using the log-rank test. RESULTS: Fifteen consecutive patients (14 men, 1 woman; age 57.5 ± 6.2 years, mean ± SD) were analysed. Therapeutic assessment by PET/CT demonstrated CR in four patients, PR in six, SD in four and PD in one. Among the ten patients with a metabolic response (group 1), none had relapsed at the time of this report, while four of five patients with no metabolic response (group 0) showed recurrence within an average of 9.0 ± 1.6 months. Median EFS was, respectively, 18.9 months (3.8-25.3 months) and 10.2 months (7.5-12.7 months) in group 1 and group 0. The corresponding 1-year EFS rates were 100 % and 20 %, respectively. The difference in EFS between the two groups was statistically significant (p = 0.0014). CONCLUSION: Early therapeutic response demonstrated on FDG PET/CT after two cycles of induction chemotherapy with DCF in patients with inoperable stage III/IV HNSCC seems to be a predictive factor for EFS.

Prognostic value of fluorine-18 fluorodeoxyglucose positron-emission tomography imaging in patients with head and neck squamous cell carcinoma.

BACKGROUND: High tumor uptake of fluorodeoxyglucose (FDG) is associated with an unfavorable outcome in patients with cancer. We evaluated FDG uptake as a prognostic factor in patients with head and neck squamous cell carcinoma. METHODS: Maximum standardized uptake values (SUVmax) of tumor, liver, and pulmonary artery were recorded. Ratios of SUVmax from tumor to liver (T/L) and from tumor to pulmonary artery (T/PA) were calculated for each patient. Clinical data, tumor, and SUVmax ratios were compared with disease-free survival (DFS) and overall survival (OS). RESULTS: Eighty-nine patients were included: 48 presented a local recurrent disease or distant metastases and 42 died. For both DFS and OS, tumor SUVmax value of 7 was the best cutoff value and 4 and 5 for T/L and T/PA ratios. Multivariate analysis confirmed the independent prognostic value of these 3 thresholds for DFS and OS. CONCLUSIONS: FDG uptake has a significant and independent relationship with recurrence and survival.

Does 18fluoro-fluorodeoxyglucose positron emission tomography improve recurrence detection in patients treated for head and neck squamous cell carcinoma with negative clinical follow-up?

BACKGROUND: The aim of this study was to determine the benefits of 18fluoro-fluorodeoxyglucose positron emission tomography (18F-FDG PET) in the detection of head and neck squamous cell carcinoma (HNSCC) recurrence in patients with negative clinical follow-up. METHODS: Whole-body 18FDG-PET was performed in 30 patients treated for HNSCC without any clinical element for recurrence. RESULTS: Twenty-one negative PET and 9 positive results were seen. One patient with abnormal 18F-FDG uptake in the laryngeal area did not have recurrent HNSCC (false positive). Eight had proven recurrence. The sensitivity and specificity of 18F-FDG PET for the diagnosis of HNSCC recurrence were 100% (8/8) and 95% (21/22), respectively. The positive predictive value was 89% (8/9). The negative predictive value was 100% (21/21). The overall accuracy was 97% (29/30). CONCLUSION: The results of our study confirm the high effectiveness of 18F-FDG PET in assessment of HNSCC recurrence and suggest that it is more accurate than conventional physical examination follow-up alone.