18F-FDG-PET/CT predicts survival in hypopharyngeal squamous cell carcinoma

Self-expandable metallic stent as bridge to surgery vs. emergency resection in obstructive right-sided colon cancer: a systematic review and meta-analysis

BACKGROUND

Emergency resection is common for malignant right-sided obstructive colon cancer. As there is evidence showing a potential benefit of self-expandable metal stents as a bridge to surgery, a new debate has been initiated.

OBJECTIVE

The aim of this study was to compare self-expandable metal stents with emergency resection in right-sided obstructive colon cancer.

DATA SOURCE

A systematic search was conducted accessing Medline/PubMed, Scopus, Embase, and the Cochrane Database of Systematic Reviews.

STUDY SELECTION

Studies reporting either emergency surgery or stent placement in right-sided obstructive colon cancer were included.

INTERVENTION

Stent or emergency resection in right-sided obstructive colon cancer.

MAIN OUTCOME MEASURES

Morbidity rate, mortality rate, stoma rate, laparoscopic resection rate, anastomotic insufficiency rate, success rate of stent.

RESULTS

A total of 6343 patients from 16 publications were analyzed. The stent success rate was 0.92 (95% CI, 0.87 to 0.95) with perforation of 0.03 (95% CI, 0.01 to 0.06). Emergency resection was performed laparoscopically at a rate of 0.15 (95% CI, 0.09 to 0.24). Primary anastomosis rate in emergency resection was 0.95 (95% CI, 0.91 to 0.97) with an anastomotic insufficiency rate of 0.07 (95% CI, 0.04 to 0.11). The mortality rate after emergency resection was 0.05 (95% CI, 0.02 to 0.09). Primary anastomosis and anastomotic insufficiency rate were similar between the two groups (RR: 1.02; 95% CI, 0.95 to 1.1; p = 0.56 and RR: 0.53; 95% CI, 0.14 to 1.93; p = 0.33). The mortality rate in emergency resection was higher compared to stent (RR: 0.51, 95% CI 0.30 to 10.89, p = 0.016).

LIMITATION

No randomized controlled trials are available.

CONCLUSION

Stent is a safe and successful alternative to emergency resection and may increase the rate of minimally invasive surgery. Emergency resection, however, remains safe and did not result in higher rate of anastomotic insufficiency. Further high-quality comparative studies are warranted to assess long-term outcomes.

18F-FDG-PET/CT can be used to predict distant metastasis in hypopharyngeal squamous cell carcinoma

Background

Hypopharyngeal squamous cell carcinoma (HPSCC) has a high rate of distant metastasis, resulting in poor prognosis. The role of the maximum standardized uptake value (SUVmax), which was assessed via pretreatment 18-fluorodeoxyglucose positron emission tomography (FDG-PET), and computed tomography (CT) was examined, for predicting distant metastasis and survival.

Methods

This study included 121 patients who underwent pretreatment FDG-PET/CT scanning and subsequent treatment for HPSCC. The SUVmax was measured via FDG-PET/CT. A receiver operating characteristic (ROC) curve analysis was used to determine whether the SUVmax was a predictor of distant metastasis and to select the best cutoff value. Univariate and multivariate Cox hazard regression analyses were used in identifying associations between the SUVmax and other clinicopathological factors with distant metastasis-free survival.

Results

Distant metastases were identified in 33 patients during the median follow-up of 24 months after treatment. The ROC curve analysis determined that SUVmax was predictive of distant metastasis and identified a SUVmax of 13.9 as the best potential cutoff value. The univariate analysis showed that T and N classification, clinical stage, and SUVmax were significantly related to distant metastasis. However, in multivariate analysis, an SUVmax ≥ 13.9 was the only independent predictor of distant metastasis. Patients with high SUVmax values displayed significantly shorter distant metastasis-free survival and overall survival.

Conclusions

SUVmax determined via pretreatment FDG-PET/CT is useful for predicting distant metastasis, distant metastasis-free survival, and overall survival in patients with HPSCC.

Graphical Abstract

Post-cricoid and Upper Oesophagus Cancers Treated with Organ Preservation Using Intensity-modulated Image-guided Radiotherapy: a Phase II Prospective Study of Outcomes, Toxicity and Quality of Life

AIMS

To prospectively examine the outcomes, toxicity and quality of life (QoL) of patients with post-cricoid and upper oesophagus (PCUE) cancers treated with an organ-preservation approach of (chemo)-radiotherapy using intensity-modulated image-guided radiotherapy (IM-IGRT).

MATERIALS AND METHODS

This phase II prospective study was conducted at a tertiary cancer centre from February 2017 to January 2020. Forty patients with squamous cell carcinoma of PCUE of stage T1-3, N0-2, M0 were accrued. Gross exolaryngeal extension/dysfunctional larynx were major exclusion criteria. Patients received 63-66 Gy in once-daily fractions using volumetric modulated arc therapy with daily IGRT. Outcome measures included disease-related outcomes, patterns of failure, Radiation Therapy Oncology Group toxicities, feeding tube dependency and QoL.

RESULTS

The median follow-up was 22 months. Twenty-six (87.5%) patients had locoregionally advanced disease and 34 (85%) patients received (chemo)-radiotherapy. A complete response was observed in 26 (65%) patients. The 2-year locoregional control, event-free survival and cause-specific survival were 59.6%, 40.2% and 44.8%, respectively. The volume of primary tumour (GTVPvol) exceeding 28 cm³ had inferior overall survival (P = 0.005) on univariate analysis. Multivariable analysis showed GTVPvol and positron emission tomography-computed tomography maximum standardised uptake value to be independently predictive for event-free and overall survival. A feeding tube requirement at presentation was seen in 11 (27.5%) patients, whereas long-term feeding tube dependency at 6 months was seen in 10 (37%) patients. For QoL, a statistical improvement in pain, appetite loss and swallowing was observed over time.

CONCLUSION

Although the outcomes of PCUE cancers remain dismal, the use of state of the art diagnostic modalities, careful case selection and modern radiotherapy techniques improved outcomes as compared with before in this exclusive analysis of PCUE cancers.

FDG-PET/CT predicts survival and lung metastasis of hypopharyngeal cancer in a multi-institutional retrospective study

OBJECTIVES

We investigated a possible correlation between the maximum standardized uptake value (SUV_max), which is assessed by pretreatment ¹⁸F-fluorodeoxyglucose positron emission tomography with computed tomography, and the overall survival (OS) in patients with hypopharyngeal squamous cell carcinoma from two institutions on long-term follow-up, and examined whether SUV_max is correlated with several survival outcomes, including lung metastasis-free survival.

METHODS

A total of 81 patients were enrolled. The survival rate was calculated by the Kaplan-Meier method. Both univariate and multivariate survival analyses were assessed by a Cox proportional hazards model.

RESULTS

SUV_max ≥15.2 in institution A (p = 0.0306) or SUV_max ≥8 in institution B (p = 0.0132) was significantly predictor of a lower OS. We disaggregated the data by high SUV_max (SUV_max ≥15.2 from institution A and SUV_max ≥8 from institution B) and low SUV_max (SUV_max <15.2 from institution A and SUV_max <8 from institution B). Patients with a high SUV_max exhibited a significantly lower OS in both univariate (p = 0.001) and multivariate (p = 0.0046) analyses for adjusted for the clinical stage and treatment group. The patients with a high SUV_max exhibited significantly shorter disease-specific (p = 0.0068), distant metastasis-free (p = 0.0428), and lung metastasis-free (p = 0.0328) survivals.

CONCLUSIONS

High SUV_max was significantly correlated with a lower OS, disease-specific survival, distant metastasis-free survival, and lung metastasis-free survival in a multi-institutional retrospective study.

Metabolic Activity by 18F-FDG-PET/CT Is Prognostic for Stage I and II Pancreatic Cancer

PURPOSE

Metabolic activity, as defined by F-FDG uptake on PET, is a prognostic marker for multiple malignancies; however, no study has examined the prognostic value of imaging with FDG PET in stage I and II pancreatic cancer. We examined the value of PET FDG uptake in early-stage pancreatic cancer patients.

METHODS

We identified patients with early-stage pancreatic cancer (I-II) who had FDG PET scan performed as part of their preoperative evaluation. The patients were divided into either high or low FDG uptake according to the median primary tumor standard uptake value (SUVmax). Our primary end points were overall survival (OS) and recurrence-free survival (RFS). Kaplan-Meier estimate was used for survival analysis. Pathologic data were compared using the Fisher exact and χ tests.

RESULTS

One hundred five patients were identified: 51 patients with low FDG uptake and 54 patients with high FDG uptake. Eighty-five patients (81%) had PET avid tumors, whereas 20 (19%) patients did not. High FDG uptake correlated with pathologic stage (P = 0.012). Patients with low FDG uptake had significantly better median OS than patients with high FDG uptake (28 vs. 16 months; P = 0.036). Patients with low-FDG uptake had significantly longer median RFS than patients with high FDG uptake (14 vs. 12 months; P = 0.049).

CONCLUSIONS

Low FDG uptake in PET scans in patients with stage I and II pancreatic cancer correlates with improved OS and RFS. This supports the concept that glucose metabolic pathways are important in pancreatic cancer biology and that PET scan activity can be used as a prognostic biomarker after pancreatectomy.

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.

Increased Expression of the Glucose Transporter Type 1 Gene Is Associated With Worse Overall Survival in Resected Pancreatic Adenocarcinoma

OBJECTIVES

There is currently no reliable method to predict the risk of relapse after curative resection of early-stage pancreatic adenocarcinoma. Increased glucose metabolism observed on F-fluorodeoxyglucose positron emission tomography (PET) by malignant cells, the Warburg effect, is a well-known characteristic of the malignant phenotype. We investigated the role of glucose transporter type 1 (GLUT-1) gene expression, a glucose cell plasma membrane transporter, in early-stage pancreatic cancer.

METHODS

Associations between GLUT-1 gene expression with PET maximum standardized uptake values and histologic grade were investigated in early-stage pancreatic adenocarcinoma patients. Multivariate analysis was conducted to determine predictors of prognosis. Cox proportional hazard model was used for survival analysis.

RESULTS

Sixty-three patients had GLUT-1 gene analysis performed, and 50 patients had both GLUT-1 analysis and PET scan. Patients with high GLUT-1 gene expression had a decreased overall survival by univariate analysis using Cox proportional hazard model (hazard ratio, 2.82; P = 0.001) and remained significant on multivariate analysis (hazard ratio, 2.54; P = 0.03). There was no correlation of GLUT-1 gene expression with histologic grade or PET maximum standardized uptake values.

CONCLUSIONS

Increased GLUT-1 gene expression was associated with a decreased overall survival in pancreatic adenocarcinoma. This supports increased GLUT-1 gene expression as a potential prognostic marker in resected pancreatic adenocarcinoma.

Impact of total lesion glycolysis measured by 18F-FDG-PET/CT on overall survival and distant metastasis in hypopharyngeal cancer

The present study investigated the possible correlation between ¹⁸F-2-fluorodeoxyglucose (¹⁸F-FDG)-uptake parameters and clinicopathological parameters in hypopharyngeal squamous cell carcinoma (HPSCC). A total of 53 patients, newly diagnosed with HPSCC, received pretreatment ¹⁸F-FDG-positron emission tomography/computed tomography (PET/CT). Metabolic tumor volume (MTV), total lesion glycolysis (TLG), and maximum and peak standardized uptake values (SUVmax and SUVpeak) were calculated as ¹⁸F-FDG-uptake parameters of the primary tumor. Tumor thickness, depth of invasion and pathological tumor volume were pathologically measured. Upon univariate survival analysis, SUVmax ≥28.5, SUVpeak ≥19, MTV ≥12 and TLG ≥42 were significantly associated with a shorter overall survival (OS) time, and MTV ≥12 and TLG ≥42 were significantly associated with a shorter distant metastasis-free survival (DMFS) time. Upon multivariate analysis with adjustment for clinical T category and treatment group, patients with SUVmax ≥28.5 exhibited a significantly shorter OS time, while TLG ≥42 was significantly correlated with shorter OS and DMFS times. Upon simple regression analysis, TLG was found to be significantly associated with tumor thickness and depth of invasion, while MTV was found to be closely associated with pathological tumor volume. In conclusion, pretreatment ¹⁸F-FDG-PET/CT is likely to provide valuable prognostic parameters in HPSCC.

Predictors of Distant Metastasis after Radical Surgery Followed by Postoperative Radiotherapy with or without Chemotherapy for Oropharyngeal Cancer

Purpose

We investigated the prognostic factors for distant metastasis (DM) in patients with locally advanced oropharyngeal cancer (OPC) treated with surgery and adjuvant radiotherapy with or without concurrent chemotherapy.

Materials and Methods

Eighty-five patients treated between January 1995 and August 2014 were evaluated retrospectively. Data regarding the pathological tumour and nodal status, human papillomavirus (HPV) status, treatment characteristics, and pretreatment maximum standardized uptake value (SUVmax) of 18-fluoro-2-deoxyglucose positron emission tomography–computed tomography scan (¹⁸F-FDG PET-CT) were evaluated, and their influence on DM and survival outcomes were analyzed.

Results

Median follow-up period was 48.0 months. Recurrence was observed in 20 patients, including locoregional recurrence and DM. DM was observed in 13 patients. A multivariate analysis confirmed that the presence of lymphovascular invasion (p=0.031), lower neck lymph node (LN) involvement (p=0.006), SUVmax ≥ 9.7 (p=0.014), and tumour size ≥ 3 cm (p=0.037) significantly affected DM. HPV status was not associated with DM. Perineural invasion (p=0.048), lower neck LNinvolvement (p=0.008), SUVmax ≥ 9.7 (p=0.019), and tumour size ≥ 3 cm (p=0.033) were also significant factors for the DM-free survival rate.

Conclusion

Lower neck LN involvement, high SUVmax in pretreatment ¹⁸F-FDG PET-CT, and large tumour size were predictive factors for DM in patients of OPC.

Interaction of quantitative (18)F-FDG-PET-CT imaging parameters and human papillomavirus status in oropharyngeal squamous cell carcinoma

BACKGROUND

Patients with human papillomavirus (HPV)-positive oropharyngeal squamous cell carcinoma (SCC) have a better survival than with HPV-negative oropharyngeal SCC. An (18) F-fluorodeoxyglucose positron emission tomography-CT ((18) F-FDG-PET-CT) may also provide prognostic information. We evaluated glycolytic characteristics in HPV-negative and HPV-positive oropharyngeal SCC.

METHODS

Forty-four patients underwent pretreatment (18) F-FDG-PET-CT. Standardized uptake values (SUVs) and metabolic active tumor volumes (MATVs) were determined for primary tumors. HPV status was determined with p16 immunostaining, followed by high-risk HPV DNA detection on the positive cases.

RESULTS

Twenty-seven patients were HPV-positive (61.4%). Median MATV was 2.8 mL (range = 1.6-5.1 mL) for HPV-positive and 6.0 mL (range = 4.4-18.7 mL) for HPV-negative tumors (p < .001). SUV values are volume dependent (partial volume effect), therefore, MATV was included as covariate in multivariate analysis. In this multivariate analysis, the maximum SUV in HPV-positive tumors was 3.9 units lower than in HPV-negative tumors (p = .01).

CONCLUSION

The (18) F-FDG-PET-CT parameters are lower in HPV-positive than in HPV-negative patients. Low pretreatment SUV values in HPV-positive oropharyngeal SCC may be at least partly explained by HPV-induced tumor changes.

Primary tumor standardized uptake value predicts survival in head and neck squamous cell carcinoma

BACKGROUND

The purpose of this study was to determine whether the pretreatment primary tumor standardized uptake value (SUV), as measured by positron emission tomography (PET), can add prognostic information for predicting survival in patients with head and neck squamous cell carcinoma (HNSCC).

MATERIALS AND METHODS

7 articles were identified by searching electronic databases. Statistical analysis was performed with RevMan 4.2.2. SUV measurement and SUV threshold for defining high SUV were studied dependently. For each publication, we first obtained an estimate of the relative risk (RR) for comparing patients with a low or a high SUV. Subsequently, we aggregated the individual RRs into a combined RR, using a fixed-effect model. Publication bias was assessed using a funnel plot.

RESULTS

The study included 7 clinical trials dedicated to HNSCC, involving 674 patients who underwent fluoro-2-deoxy-D-glucose-PET scanning before treatment. The combined RR from the 7 reports for the survival was 0.53 (95% confidence interval: 0.46-0.62). The funnel plot showed symmetrical distribution, indicating no evidence of any substantial publication bias.

CONCLUSION

Our meta-analysis indicates that patients with HNSCC who have a primary tumor with a high SUV have poor survival; this should be further confirmed in a meta-analysis based on individual patient data.

Prognostic value of tumour blood flow, [¹⁸F]EF5 and [¹⁸F]FDG PET/CT imaging in patients with head and neck cancer treated with radiochemotherapy

PURPOSE

In order to improve the treatment of squamous cell carcinoma of the head and neck, precise information on the treated tumour's biology is required and the prognostic importance of different biological parameters needs to be determined. The aim of our study was to determine the predictive value of pretreatment PET/CT imaging using [(18)F]FDG, a new hypoxia tracer [(18)F]EF5 and the perfusion tracer [(15)O]H₂O in patients with squamous cell cancer of the head and neck treated with radiochemotherapy.

METHODS

The study group comprised 22 patients with confirmed squamous cell carcinoma of the head and neck who underwent a PET/CT scan using the above tracers before any treatment. Patients were later treated with a combination of radiochemotherapy and surgery. Parametric blood flow was calculated from dynamic [(15)O]H₂O PET images using a one-tissue compartment model. [(18)F]FDG images were analysed by calculating standardized uptake values (SUV) and metabolically active tumour volumes (MATV). [(18)F]EF5 images were analysed by calculating tumour-to-muscle uptake ratios (T/M ratio). A T/M ratio of 1.5 was considered a significant threshold and used to determine tumour hypoxic subvolumes (HS) and hypoxic fraction area. The findings were finally correlated with the pretreatment clinical findings (overall stage and TNM stage) as well as the outcome following radiochemotherapy in terms of local control and overall patient survival.

RESULTS

Tumour stage and T-classification did not show any significant differences in comparison to the patients' metabolic and functional characteristics measured on PET. Using the Cox proportional hazards model, a shorter overall survival was associated with MATV (p = 0.008, HR = 1.108), maximum [(18)F]EF5 T/M ratio (p = 0.0145, HR = 4.084) and tumour HS (p = 0.0047, HR = 1.112). None of the PET parameters showed a significant effect on patient survival in the log-rank test, although [(18)F]EF5 maximum T/M ratio was the closest (p = 0.109). By contrast, tumour blood flow was not correlated with any of the clinical endpoints. There were no statistically significant correlations among [(18)F]FDG SUVmax, [(18)F]EF5 T/M ratio and blood flow.

CONCLUSION

Our study in a limited number of patients confirmed the importance of MATV in the prognosis of locally advanced squamous cell carcinoma of the head and neck. It is of interest that high uptake of the hypoxia tracer [(18)F]EF5 showed a stronger correlation with a poor clinical outcome than [(18)F]FDG uptake. This confirms the importance of hypoxia in treatment outcome and suggests that [(18)F]EF5 may act as a surrogate marker of radioresistance.

Prognostic value of post-treatment (18)F-FDG PET/CT for advanced head and neck cancer after combined intra-arterial chemotherapy and radiotherapy

OBJECTIVE

To clarify the prognostic value of post-treatment (18)F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/computed tomography (CT) in patients with advanced head and neck squamous cell carcinoma (HNSCC) after combined intra-arterial chemotherapy and radiotherapy (IACR).

METHODS

Thirty-six patients with HNSCC who underwent IACR were recruited. The period from the end of IACR to the last post-treatment (18)F-FDG PET/CT examination was 8-12 weeks. Both patient-based and lesion-based analyses were used to evaluate the PET/CT images. For lesion-based analysis, 36 regions (12 lesions of recurrences and 24 scars at primary sites) were selected. The Kaplan-Meier method was used to assess the overall survival (OS) stratified by (18)F-FDG uptake or visual interpretation results.

RESULTS

Twelve patients with recurrence were identified by six months after IACR. The sensitivity and specificity in the patient-based analysis were 67% (8/12) and 88% (21/24), respectively. The mean OS was estimated to be 12.1 months (95% CI, 6.3-18.0 months) for the higher maximum standardized uptake value (SUVmax) group (n=7) and 44.6 months (95% CI, 39.9-49.3 months) for the lower SUVmax group (n=29). OS in the higher SUVmax group (cut-off point, 6.1) or positive visual interpretation group was significantly shorter than that in the lower SUVmax or negative visual interpretation group (P<0.001 and P<0.05, respectively).

CONCLUSIONS

The SUVmax and visual interpretation of HNSCC on post-IACR (18)F-FDG PET/CT can provide prognostic survival estimates.