Analysis of Pretreatment FDG-PET SUV Parameters in Head-and-Neck Cancer: Tumor SUVmean Has Superior Prognostic Value

doi:10.1016/j.ijrobp.2010.11.050

International Journal of Radiation OncologyBiologyPhysics

Volume 82, Issue 2, 1 February 2012, Pages 548-553

https://doi.org/10.1016/j.ijrobp.2010.11.050 Get rights and content

Purpose

To evaluate the prognostic significance of different descriptive parameters in head-and-neck cancer patients undergoing pretreatment [F-18] fluoro-D-glucose-positron emission tomography (FDG-PET) imaging.

Patients and Methods

Head-and-neck cancer patients who underwent FDG-PET before a course of curative intent radiotherapy were retrospectively analyzed. FDG-PET imaging parameters included maximum (SUV_max), and mean (SUV_mean) standard uptake values, and total lesion glycolysis (TLG). Tumors and lymph nodes were defined on co-registered axial computed tomography (CT) slices. SUV_max and SUV_mean were measured within these anatomic regions. The relationships between pretreatment SUV_max, SUV_mean, and TLG for the primary site and lymph nodes were assessed using a univariate analysis for disease-free survival (DFS), locoregional control (LRC), and distant metastasis-free survival (DMFS). Kaplan-Meier survival curves were generated and compared via the log‒rank method. SUV data were analyzed as continuous variables.

Results

A total of 88 patients was assessed. Two-year OS, LRC, DMFS, and DFS for the entire cohort were 85%, 78%, 81%, and 70%, respectively. Median SUV_max for the primary tumor and lymph nodes was 15.4 and 12.2, respectively. Median SUV_mean for the primary tumor and lymph nodes was 7 and 5.2, respectively. Median TLG was 770. Increasing pretreatment SUV_mean of the primary tumor was associated with decreased disease-free survival (p = 0.01). Neither SUV_max in the primary tumor or lymph nodes nor TLG was prognostic for any of the clinical endpoints. Patients with pretreatment tumor SUV_mean that exceeded the median value (7) of the cohort demonstrated inferior 2-year DFS relative to patients with SUV_mean ≤ the median value of the cohort, 58% vs. 82%, respectively, p = 0.03.

Conclusion

Increasing SUV_mean in the primary tumor was associated with inferior DFS. Although not routinely reported, pretreatment SUV_mean may be a useful prognostic FDG-PET parameter and should be further evaluated prospectively.

Introduction

Head-and-neck cancer (HNC) is a heterogeneous disease. Clinical outcomes have improved substantially with the incorporation of concurrent, platinum-based chemotherapy and epidermal growth factor receptor targeted therapy 1, 2, 3, 4, 5, 6, but overall survival (OS) for patients with locally advanced disease remains suboptimal at 5 years 5, 7. The iden-tification of pretreatment prognostic factors to supplement conventional TNM staging could help to identify high-risk subpopulations of patients who might benefit from treatment intensification.

[F-18] fluoro-D-glucose-positron emission tomography (FDG-PET) imaging is based on tumor glucose metabolism and serves as a marker for tumor metabolic activity. Combining FDG-PET with computed tomography (CT) provides useful functional and anatomical information and has been increasingly integrated into the staging of patients with HNC. It improves the ability to detect occult nodal metastases relative to CT alone (8).

An unresolved question is whether or not quantification of FDG-PET standard uptake values (SUV) provides prognostic information. Traditionally, SUV_max has been the most common estimate of metabolic activity in clinical practice because it is thought to be the most reproducible. A limitation, however, is that it reflects the highest intensity of FDG uptake as measured in the highest pixels within a designated region of interest. SUV_mean represents the average of the intensity of uptake within a designated region of interest, and thus provides a more global picture of tumor metabolism than SUV_max alone. Although the SUV_max measurement is reproducible, the SUV_mean depends highly on how the region of interest is drawn or otherwise identified. For this study, we have attempted to minimize this variability by identifying the tumor region on the CT image and then applying the region to PET, using the alignment provided by the combined PET/CT scan.

Last, total lesion glycolysis (TLG) is a composite of tumor volume and SUV_mean, calculated by taking the product of the tumor volume and the SUV_mean (9). The purpose of the current study was to evaluate the prognostic value of pretreatment FDG-PET parameters including SUV_max, SUV_mean, and TLG in cohort of patients with HNC treated with curative intent radiotherapy at Duke University Medical Center.

Section snippets

Patient population

A retrospective study was performed on patients with newly diagnosed squamous cell carcinoma of the head and neck who underwent curative-intent radiation and FDG-PET imaging between January 2005 and September 2008 at Duke University Medical Center. Inclusion criteria included a pretreatment FDG-PET, squamous histology, radiotherapy with intensity-modulated radiotherapy (IMRT) technique, and curative-intent treatment. Patients with distant metastases, disease removed surgically before

Patient and treatment characteristics

Of the 324 patients with squamous HNC treated with IMRT from January 2005–September 2008, 88 patients met the study inclusion criteria and had pretreatment FDG-PET/CT scans available for analysis. Table 1 summarizes the study population. The median age at diagnosis was 59, and 84% of patients were male. The majority of patients presented with locally advanced disease (Stage III-IV, 97%). T3 and T4 disease comprised 52% of the study population, whereas 66% of patients had N2 or N3 disease. The

Discussion

FDG-PET imaging has become an important tool in the management of patients with HNC. It is particularly useful in delineating target volumes and can significantly alter volumes defined with CT alone (11) and aid in the detection of occult contralateral neck node involvement (8). Quantifying the prognostic value of FDG-PET is challenging, however, and is an area of active investigation. Various FDG-PET parameters including SUV_max, SUV_mean, TLG, and metabolic tumor volume (MTV) have recently been

Acknowledgments

The authors would like to thank Robin Davis, Robert Clough, and Thomas Hawk for their assistance with data retrieval.

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Clinical InvestigationAnalysis of Pretreatment FDG-PET SUV Parameters in Head-and-Neck Cancer: Tumor SUVmean Has Superior Prognostic Value

Purpose

Patients and Methods

Results

Conclusion

Introduction

Section snippets

Patient population

Patient and treatment characteristics

Discussion

Acknowledgments

Radiother Oncol

Int J Radiat Oncol Biol Phys

Clin Positron Imaging

Radiother Oncol

Int J Radiat Oncol Biol Phys

J Thorac Oncol

Int J Radiat Oncol Biol Phys

Lung Cancer

Hyperfractionated irradiation with or without concurrent chemotherapy for locally advanced head and neck cancer

N Engl J Med

An intergroup phase III comparison of standard radiation therapy and two schedules of concurrent chemoradiotherapy in patients with unresectable squamous cell head and neck cancer

J Clin Oncol

Clinical Investigation
Analysis of Pretreatment FDG-PET SUV Parameters in Head-and-Neck Cancer: Tumor SUV_mean Has Superior Prognostic Value