Clinical investigation: head and neck
Prediction of outcome in head-and-neck cancer patients using the standardized uptake value of 2-[18f]fluoro-2-deoxy-d-glucose

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Abstract

Purpose

Tumor uptake of 2-[18F] fluoro-2-deoxy-D-glucose (FDG) may relate to outcome in cancer patients. Pretreatment FDG uptake was evaluated as a predictor of local control (LC) and disease-free survival (DFS) in patients with head-and-neck cancer managed primarily either by radiotherapy (RT) or surgery.

Patients and methods

Tumor FDG uptake using the Standardized Uptake Value (SUV) was measured in 120 patients studied prospectively using positron emission tomography (PET). Treatment consisted of either radical RT with or without chemotherapy (73 patients) or radical surgery with or without postoperative RT (47 patients). Median follow-up of the surviving patients was 48 months.

Results

The median SUV was higher in 46 patients who failed treatment than in the remaining controlled patients (5.8 vs. 3.6, p = 0.002). In monovariate analysis, patients with tumors having high FDG uptake (SUV > median, 4.76) had poorer LC (p = 0.003) and DFS (p = 0.005). This difference was also observed when the RT and surgery groups were analyzed separately. In the multivariate analysis T-category (p = 0.005) and SUV (p = 0.046) remained independent adverse factors for LC, whereas N-category (p = 0.004), T-category (p = 0.02) and SUV (p = 0.05) were independent determinants of DFS.

Conclusion

These results suggest that pretreatment tumor FDG uptake represents an independent prognostic factor in patients with head-and-neck cancers, whatever the primary treatment modality. Tumors having high FDG uptake are at greater risk of failure and should be considered for more aggressive multimodality therapy.

Introduction

According to tumor stage, the treatment of head-and-neck carcinoma is based upon radical radiotherapy (RT) or surgery or both, with or without chemotherapy. While locoregional disease control can be achieved in most patients, failure above the clavicles occurs in as many as 30%–40% of cases 1, 2. Locally recurrent tumors not only threaten patients' survival but also seriously impair their quality of life, as many such patients will die with symptomatic local tumor progression. Moreover, patients with advanced disease are submitted to intensive treatment combinations, and those who are destined to relapse suffer from severe acute toxicity with little benefit (3). Despite careful evaluation of the traditional clinical factors such as tumor size/stage, lymph node involvement, and anatomic subsite, it is impossible to reliably predict the outcome after a selected treatment (4). Identification of novel pretreatment factors that potentially predict outcome is thus of great interest. Patients whose prognoses are likely to be unfavorable with current approaches might be selected for alternative strategies, either by moving away from single-modality therapy to multidisciplinary approaches, by intensifying radiochemotherapy schedules, or by adding innovative biologic agents.

There is increasing current interest in the metabolic imaging of cancers, particularly that based upon tumor uptake of 2-[18F] fluoro-2-deoxy-D-glucose (FDG) as measured by positron emission tomography (PET). This noninvasive imaging technique has been applied to the staging and follow-up of patients with head-and-neck carcinomas as well as other tumor types 5, 6. Furthermore, it has been suggested that tumor FDG uptake may have prognostic significance, in that patients with high FDG uptake generally have a less favorable outcome 7, 8, 9. However, most clinical reports have been based on limited series of patients selected for treatment either with predominantly surgical 7, 8 or nonsurgical (10) approaches. As a consequence it is unknown whether the predictive value of FDG uptake pertains to the response to specific therapies, or rather might reflect the biologic aggressiveness of the disease, independently of the chosen modality. The present study was undertaken to assess the prognostic value of the FDG uptake in unselected series of patients who took part in a prospective study of PET scanning in head-and-neck cancers whatever the treatment they received. The standardized uptake value (SUV), a semiquantitative measurement of tumor FDG uptake, was correlated with local control (LC) and disease free-survival (DFS).

Section snippets

Patients

Patients enrolled in a prospective PET scanning study (11), aiming at optimizing diagnostic evaluation and posttreatment follow-up, form the basis of this analysis. Patient selection and study design were previously described (10). Briefly, participation was solicited of all patients presenting with a suspicious lesion of the head-and-neck region. The study was approved by a Geneva University Hospital ethics committee, and patients were enrolled after signed informed consent was obtained. In

Overall results

Median follow-up for surviving patients was 48 months (range, 7–66 months). Seventy-one patients were alive at last follow-up and 49 had died (37 from head-and-neck cancer, 5 from second cancers, 1 from complications of treatment, and 6 from intercurrent disease). Forty-six patients presented with at least 1 event (32 locally or regionally persistent, or both, or recurrent disease and 20 distant metastases). At 4 years actuarial LC was 75% (95% confidence interval [CI], 67%–84%), DFS was 59%

Discussion

Positron emission tomography imaging represents an area of very active research in oncology. Besides providing useful diagnostic information regarding pretreatment staging and posttreatment follow-up 5, 14, intensity of FDG uptake is emerging as a valuable predictive factor regarding treatment outcome 7, 9. In a previous analysis we have shown that high FDG uptake, as measured by the SUV, was correlated with lower LC and DFS in patients treated by radiotherapy with or without chemotherapy for

Acknowledgements

The authors thank Professor John M. Kurtz, Division of Radiation Oncology, University Hospital, Geneva, Switzerland, for reviewing the manuscript.

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    This work was supported by the Swiss National Science Foundation (Grant no. 31–45955.95).

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