Significant value of 18F-FDG-PET/CT in diagnosing small cervical lymph node metastases in patients with nasopharyngeal carcinoma treated with intensity-modulated radiotherapy

Quarter Century Positron Emission Tomography/Computed Tomography Transformation of Oncology: Head and Neck Cancer

During the last 2 decades, f-18 fluorodeoxyglucose positron emission tomography/computed tomography (18F FDG PET/CT) has transformed the clinical head and neck cancer imaging for patient management and predicting survival outcomes. It is now widely used for staging, radiotherapy planning, posttherapy assessment, and for detecting recurrence in head and neck cancers and is widely included in NCCN and other evidence based clinical practice guidelines. Future Directions would include evaluating the potential value of FAPI PET/CT for head and neck cancers, opportunity to use volumetric and tumor heterogeneity parameters and deploying AI in diagnostic and therapeutic assessments.

The feasibility of level Ib-sparing intensity-modulated radiation therapy in patients with nasopharyngeal carcinoma and high-risk factors classified based on the International Guideline

BACKGROUND AND PURPOSE

To examine the feasibility of level Ib-sparing intensity-modulated radiation therapy (IMRT) in patients with nasopharyngeal carcinoma (NPC) who had high-risk factors classified based on the International Guideline (IG).

MATERIALS AND METHODS

We evaluated 961 non-metastatic NPC cases based on IG recommendations for prophylactic Ib irradiation. Four high-risk factors were used to categorise patients into three cohorts: A, B, and C. Propensity score matching was used to balance baseline characteristics in Cohort C, resulting in a matched Cohort C. Recurrence rates at level Ib and regional relapse-free survival (RRFS) rates were evaluated.

RESULTS

Among patients with negative Ib lymph nodes (LNs), 18, 54, 420, and 444 exhibited involvement of structures that drain to level Ib as the first echelon (FES), involvement of the submandibular gland (SMG), level II LNs with radiologic extranodal extension (rENE), and level II nodes with a maximal axial diameter (MAD) ≥ 2 cm, respectively. The recurrence rate was highest in Cohort A (11.1 %). Cohort B had no level Ib recurrence. In matched Cohort C, recurrence rates were low in both groups (Ib-sparing group: 0.6 % vs. Ib-covering group: 0.6 %, P > 0.999). No significant differences were observed in 5-year RRFS rates between the two groups in cohort A (p = 0.208), cohort B (p = 0.905), and matched cohort C (p = 0.423).

CONCLUSIONS

Level Ib-sparing IMRT could be performed safely for NPC patients with level II LNs who had rENE and/or MAD ≥ 2 cm. Further research should determine the necessity of level Ib prophylactic irradiation for patients with FES or SMG involvement.

18F-FDG PET/CT Image Deep Learning Predicts Colon Cancer Survival

Colon cancer is a type of cancer that begins in the large intestine. In the process of efficacy evaluation, postoperative recurrence prediction and metastasis monitoring of colon cancer, traditional medical image analysis methods are highly dependent on the personal ability of the doctors. In the process of patient treatment, it not only increases the workload and work pressure for doctors, but also has some problems with traditional medical image analysis methods. Moreover, the traditional medical image analysis methods have problems such as insufficient prediction accuracy, slow prediction speed, and the risk of errors in prediction. When analyzing 18F-FDG PET/CT images by traditional medical image analysis methods, it is easy to cause problems such as untimely treatment plans and errors in diagnosis, which will adversely affect the survival of colon cancer patients. Although 18F-FDG PET/CT images have certain advantages in image clarity and accuracy compared with traditional medical imaging methods, the analysis method based on 18F-FDG PET/CT images also has certain effects in predicting the survival of colon cancer patients, but there are still many shortcomings: the 18F-FDG PET/CT image analysis method overly relies on the technical advantages of 8F-FDG PET/CT images; in the analysis and prediction of image data, it has not gotten rid of the dependence on the personal medical quality of the doctors; traditional medical image analysis methods are still used when analyzing and predicting images; there is no breakthrough in image analysis effects. In order to solve these problems, this paper combined deep learning theory, using three algorithms of the improved RBM algorithm, image feature extraction method based on deep learning, and regression neural network to analyze and predict 18F-FDG PET/CT images, and applied some algorithms to analyze and predict 18F-FDG PET/CT images, and also established a deep learning-based 18F-FDG PET/CT image survival analysis prediction model. Four aspects survival prediction accuracy, survival prediction speed, survival prediction precision, and physician satisfaction were studied through this model. The research results have shown that compared with traditional medical image analysis methods, the prediction accuracy of 18F-FDG PET/CT image survival analysis prediction model based on deep learning is improved by 0.83%, and the prediction speed is improved by 3.42%, as well as the prediction precision increased by 6.13%. The research results show that the deep learning-based 18F-FDG PET/CT image survival analysis prediction model established in this paper is of great significance to improve the survival rate of colon cancer patients, and also promotes the development of the medical industry.

Which evaluation criteria of the short-term efficacy can better reflect the long-term outcomes for patients with nasopharyngeal carcinoma?

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1D, 2D, and 3D measurements were all significantly correlated with PTV measurement.

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The 1D measurement more closely agreed with the PTV measurement than the 2D and 3D measurements.

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1D tumor response assessment of the short-term efficacy can reflect the PFS for patients with nasopharyngeal carcinoma.

Purpose

To compare the consistency of one-dimensional Response Evaluation Criteria in Solid Tumors (1D-RECIST), two-dimensional WHO criteria (2D-WHO), and three-dimensional (3D) measurement for therapeutic response assessment of nasopharyngeal carcinoma (NPC).

Materials and methods

Retrospective data of 288 newly diagnosed NPC patients were reviewed. Tumor size was assessed on magnetic resonance imaging (MRI) according to the 1D-RECIST, 2D-WHO, and 3D measurement criteria. Agreement between tumor responses was assessed using unweighted k statistics. The receiver operating characteristic (ROC) curve was used to determine the optimal cut-off point of the PTV. The Kaplan–Meier method and Cox regression were used for the survival analysis.

Results

The optimal cut-off point of the PTV for progression-free survival (PFS) was 29.6%. Agreement with PTV measurement was better for 1D measurement than for 2D and 3D measurements (kappa values of 0.646, 0.537, and 0.577 for 1D, 2D, and 3D measurements, respectively; P < 0.05). The area under the curve of the 1D measurement (AUC=0.596) was similar to that of the PTV measurement (AUC=0.621). Compared with 2D and 3D measurements, 1D measurement is superior for predicting prognosis in NPC (C-index of 0.672, 0.663, and 0.646 were for 1D, 2D, and 3D measurements, respectively; P < 0.005). Survival analysis showed that patients with non-responders had worse prognosis (P < 0.05).

Conclusions

The 1D measurement more closely agreed with the PTV measurement than the 2D and 3D measurements for predicting therapeutic responses in NPC. Therefore, we recommend using the less time-consuming 1D-RECIST criteria in routine clinical practice.

The Chinese Society of Clinical Oncology (CSCO) clinical guidelines for the diagnosis and treatment of nasopharyngeal carcinoma

Nasopharyngeal carcinoma (NPC) is a malignant epithelial tumor originating in the nasopharynx and has a high incidence in Southeast Asia and North Africa. To develop these comprehensive guidelines for the diagnosis and management of NPC, the Chinese Society of Clinical Oncology (CSCO) arranged a multi‐disciplinary team comprising of experts from all sub‐specialties of NPC to write, discuss, and revise the guidelines. Based on the findings of evidence‐based medicine in China and abroad, domestic experts have iteratively developed these guidelines to provide proper management of NPC. Overall, the guidelines describe the screening, clinical and pathological diagnosis, staging and risk assessment, therapies, and follow‐up of NPC, which aim to improve the management of NPC.

Radiotherapy Versus Surgery in Early-Stage HPV-positive Oropharyngeal Cancer

Purpose

To compare the outcomes of primary radiotherapy (RT) versus surgery in early-stage human papilloma virus-positive oropharyngeal squamous cell carcinoma (hpv+OPC), and investigate the preoperative clinical factors that can predict the requirement for postoperative adjuvant treatment.

Materials and Methods

This multicenter study included 166 patients with AJCC 8th edition-Stages I-II hpv+OPC. Sixty (36.1%) and 106 (63.9%) patients underwent primary (CC)RT and surgery, respectively. Seventy-eight (73.6%) patients in the surgery group received postoperative (CC)RT.

Results

With a median follow-up of 45.6 months for survivors, the 2-year overall survival (OS), progression-free survival (PFS), and locoregional control (LC) for radiotherapy/surgery were 97.8%/96.4%, 91.1%/92.0%, and 92.9%/93.3%, respectively. In multivariate analyses, patients with synchronous radiologic extranodal extension and conglomeration (ENEcong) of metastatic LNs showed significantly poorer OS (p=0.047), PFS (p=0.001) and LC (p=0.003). In patients undergoing primary surgery, two or more clinically positive LN metastases (OR, 5.15; p=0.004) and LN metastases with ENEcong (OR, 3.75; p=0.009) were predictors of postoperative chemoradiotherapy. No patient in the primary radiotherapy group demonstrated late severe toxicity whereas 3 (2.8%), 1 (0.9%), and 1 (0.9%) patient in the surgery group showed grade 3 dysphagia, grade 3 xerostomia, and fatal oral cavity bleeding.

Conclusion

We found no differences in OS, PFS, and LC between upfront radiotherapy and surgery in stage I-II hpv+OPC which warrants comparison through a prospective trial in the treatment de-escalation era. However, most early-stage hpv+OPC patients undergoing surgery received adjuvant (CC)RT. Pretreatment LN findings were prognostic and predictive for adjuvant treatment.

A head-to-head comparison of 68Ga-DOTA-FAPI-04 and 18F-FDG PET/MR in patients with nasopharyngeal carcinoma: a prospective study

PURPOSE

To conduct a head-to-head comparison of the diagnostic ability of ⁶⁸Ga-DOTA-FAPI-04 (⁶⁸Ga-FAPI) and ¹⁸F-FDG PET/MR in nasopharyngeal carcinoma (NPC) patients.

METHODS

Patients diagnosed with NPC were prospectively enrolled. All patients underwent head-and-neck ⁶⁸Ga-FAPI PET/MR and ¹⁸F-FDG PET/MR within 1 week. Primary tumor, lymph node numbers, and tracer uptake were compared by SUVmax and visual evaluation. The primary tumor volumes derived from ⁶⁸Ga-FAPI, ¹⁸F-FDG PET, and MRI were also compared.

RESULTS

Fifteen patients were enrolled from June to August 2020. Both ⁶⁸Ga-FAPI and ¹⁸F-FDG PET had 100% detection rate of the primary tumor. The ⁶⁸Ga-FAPI SUVmax of primary tumors (13.87 ± 5.13) was lower than that of ¹⁸F-FDG (17.73 ± 6.84), but the difference was not significant (p = 0.078). Compared with ¹⁸F-FDG, ⁶⁸Ga-FAPI PET improved the delineation of skull-base invasion in eight out of eight patients and intracranial invasion in four out of four patients. When 25%SUVmax of ⁶⁸Ga-FAPI or 20%SUVmax of ¹⁸F-FDG was utilized as a threshold for determining tumor volume, it was highly consistent with MRI. ¹⁸F-FDG PET detected much more positive lymph nodes than ⁶⁸Ga-FAPI (100 vs 48). The SUVmax of 48 paired lymph nodes was significantly lower on ⁶⁸Ga-FAPI than ¹⁸F-FDG (8.67 ± 3.88 vs 11.79 ± 6.17, p < 0.001). Additionally, ⁶⁸Ga-FAPI further detected four highly suspected small, distant metastases in three patients. Compared with ¹⁸F-FDG, ⁶⁸Ga-FAPI changed overall staging in six of fifteen patients, with three patients being up-staged, and three down-staged.

CONCLUSION

⁶⁸Ga-FAPI outperforms ¹⁸F-FDG in delineating the primary tumor and detecting suspected distant metastases, particularly in the evaluation of skull-base and intracranial invasion, suggesting ⁶⁸Ga-FAPI hybrid PET/MR has the potential to serve as a single-step staging modality for patients with NPC. However, its value regarding lymph node and distant metastases evaluation needs further study.

TRIAL REGISTRATION

NCT04554719. Registered September 8, 2020 - retrospectively registered, http://clinicaltrails.gov/show/NCT04554719.

Nomogram for the prediction of primary distant metastasis of nasopharyngeal carcinoma to guide individualized application of FDG PET/CT

PURPOSE

This study aimed to establish an effective nomogram to predict primary distant metastasis (DM) in patients with nasopharyngeal carcinoma (NPC) to guide the application of PET/CT.

METHODS

In total, 3591 patients with pathologically confirmed NPC were consecutively enrolled. The nomogram was constructed based on 1922 patients treated between 2007 and 2014. Multivariate logistical regression was applied to identify the independent risk factors of DM. The predictive value of the nomogram was evaluated using the concordance index (C-index), calibration curve, probability density functions (PDFs), and clinical utility curve (CUC). The results were validated in 1669 patients enrolled from 2015 to 2016. Net reclassification improvement (NRI) was applied to compare performances of the nomogram with other clinical factors. The best cut-off value of the nomogram chosen for clinical application was analyzed.

RESULTS

A total of 355 patients showed primary DM among 3591 patients, yielding an incidence rate of 9.9%. Sex, N stage, EBV DNA level, lactate dehydrogenase level, and hemoglobin level were independent predictive factors for primary DM. C-indices in the training and validation cohort were 0.796 (95% CI, 0.76-0.83) and 0.779 (95% CI, 0.74-0.81), respectively. The NRI indices demonstrated that this model had better predictive performance than plasma EBV DNA level and N stage. We advocate for a threshold probability of 3.5% for guiding the application of PET/CT depending on the clinical utility analyses.

CONCLUSION

This nomogram is a useful tool to predict primary DM of NPC and guide the clinical application of PET/CT individually at the initial staging.

MR-guided simulation is superior than FDG/PET-guided simulation for local control in nasopharyngeal cancer patients treated with intensity-modulated radiotherapy

BACKGROUND

MRI and PET/CT scans are the main supportive methods for nasopharyngeal cancer (NPC) for staging and planning. The aim of this study is to compare MRI and PET/CT scanning in terms of survival in patients with NPC who had MRI or PET/CT-simulated radiotherapy planning.

METHODS

Pathological diagnosed nonkeratinized undifferentiated type and stage II-IVA 91 NPC patients with treated intensity-modulated radiotherapy plus chemotherapy were scanned. The patients were immobilized by a customized thermoplastic mask for fusion images both MRI scans and PET/CT scans. CTVs were created via MR-guided simulation and PET/CT-guided simulation.

RESULTS

PET/CT-guided simulation was performed with 44 patients (56.4%) and MR-guided simulation was performed with 34 patients (43.6%). Local recurrence-free survival (LRFS) of patients was 68.1 months. LRFS of patients with PET/CT-guided simulation was 59.9, while LRFS of patients with MR-guided was 66.9 months. There was a statistically significant difference between groups (P = .03). In the subgroup analyses, the patients were assessed by dividing into the three groups for the T1-T2 stage, T-3 stage, and T-4 stage. In the patients with T1-T2 stage, 5-year LRFS rates were found %74.4 for PET/CT-guided simulation and %83.3 for MR-guided simulation. There was no statistically significant difference between groups (P = .33). In the patients with T-3 stage, 5-year LRFS rates were found %55.6 for PET/CT-guided simulation and %83.3 for MR-guided simulation. There was not a statistically significant difference between groups (P = .59). In the patients with T-4 stage, 5-year LRFS rates were found %42.2 for PET/CT-guided simulation and %85.1 for MR-guided simulation. The difference between groups was found to be statistically significant (P = .04).

CONCLUSION

In this study, we founded that MR-guided simulation has better than PET/CT-guided simulation for LRFS.

Long-term outcomes and safety after reirradiation in locally recurrent nasopharyngeal carcinoma in a non-endemic area

PURPOSE

To determine outcomes and toxicities after reirradiation for locally recurrent nasopharyngeal carcinoma (rNPC) and to apply a prognostic index in a non-endemic region.

METHODS

We retrospectively reported progression-free survival (PFS), overall survival (OS), and treatment-related toxicities in patients treated with curative intent for locally rNPC. We applied the prognostic model for OS and grade 5 radiotherapy (RT)-related toxicities published by Li et al. and evaluated its prognostic accuracy by receiver operating characteristic (ROC) curve analysis.

RESULTS

Between 2005 and 2018, 33 patients were treated for rNPC in our institution. Median follow-up was 60 months. The mean time to local recurrence was 75 months. Six (18%) patients had a persistent grade 3 toxicity from a previous RT course. The median re-RT dose was 66 Gy. After re-RT, 13 patients had local failure and 3 patients had metastatic recurrence. Median PFS was 18 months with a 5-year PFS rate of 29%. Median OS was 35 months with a 5-year OS rate of 37%. Grade 3 or higher toxicities rate was 74%. There were 21% grade 5 toxicities. The median time to a grade 5 toxicity was less than 6 months following re-RT. The prognostic nomogram was not predictive for OS or grade 5 toxicities.

CONCLUSION

Reirradiation of rNPC is an effective treatment but is associated with a high rate of life-threatening toxicity. Stratification of patients based on their risk of developing severe toxicity is needed to select patients who will most likely benefit from re-RT.

Minimally invasive surgery alone compared with intensity-modulated radiotherapy for primary stage I nasopharyngeal carcinoma

Background

The National Comprehensive Cancer Network guidelines recommend intensity-modulated radiotherapy (IMRT) as the primary curative treatment for newly diagnosed nasopharyngeal carcinoma (NPC), but the radiation-related complications and relatively high medical costs remain a consequential burden for the patients. Endoscopic nasopharyngectomy (ENPG) was successfully applied in recurrent NPC with radiation free and relatively low medical costs. In this study, we examined whether ENPG could be an effective treatment for localized stage I NPC.

Methods

Ten newly diagnosed localized stage I NPC patients voluntarily received ENPG alone from June 2007 to September 2017 in Sun Yat-sen University Cancer Center. Simultaneously, the data of 329 stage I NPC patients treated with IMRT were collected and used as a reference cohort. The survival outcomes, quality of life (QOL), and medical costs between two groups were compared.

Results

After a median follow-up of 59.0 months (95% CI 53.4–64.6), no death, locoregional recurrence, or distant metastasis was observed in the 10 patients treated with ENPG. The 5-year overall survival, local relapse-free survival, regional relapse-free survival, and distant metastasis-free survival among the ENPG-treated patients was similar to that among the IMRT-treated patients (100% vs. 99.1%, 100% vs. 97.7%, 100% vs. 99.0%, 100% vs. 97.4%, respectively, P > 0.05). In addition, compared with IMRT, ENPG was associated with decreased total medical costs ($ 4090.42 ± 1502.65 vs. $ 12620.88 ± 4242.65, P < 0.001) and improved QOL scores including dry mouth (3.3 ± 10.5 vs. 34.4 ± 25.8, P < 0.001) and sticky saliva (3.3 ± 10.5 vs. 32.6 ± 23.3, P < 0.001).

Conclusions

ENPG alone was associated with promising long-term survival outcomes, low medical costs, and satisfactory QOL and might therefore be an alternative strategy for treating newly diagnosed localized stage I NPC patients who refused radiotherapy. However, the application of ENPG should be prudent, and prospective clinical trials were needed to further verify the results.

The evolution of nasopharyngeal carcinoma staging

The prevalence of nasopharyngeal carcinoma is characterized by an unbalanced distribution: the disease is particularly prevalent in East and Southeast Asia. In this article, we review the evolution of the International Union Against Cancer/American Joint Committee on Cancer staging system for nasopharyngeal carcinoma. With the increasing using of newer imaging methods, more advanced radiotherapy techniques and systemic chemotherapy, we also discuss newer clinical features that might affect staging. Finally, we propose the future direction of staging and potential prognostic factors that have a major influence on the treatment outcomes of this disease.

Prognostic Value of Deep Learning PET/CT-Based Radiomics: Potential Role for Future Individual Induction Chemotherapy in Advanced Nasopharyngeal Carcinoma

PURPOSE

We aimed to evaluate the value of deep learning on positron emission tomography with computed tomography (PET/CT)-based radiomics for individual induction chemotherapy (IC) in advanced nasopharyngeal carcinoma (NPC).

EXPERIMENTAL DESIGN

We constructed radiomics signatures and nomogram for predicting disease-free survival (DFS) based on the extracted features from PET and CT images in a training set (n = 470), and then validated it on a test set (n = 237). Harrell's concordance indices (C-index) and time-independent receiver operating characteristic (ROC) analysis were applied to evaluate the discriminatory ability of radiomics nomogram, and compare radiomics signatures with plasma Epstein-Barr virus (EBV) DNA.

RESULTS

A total of 18 features were selected to construct CT-based and PET-based signatures, which were significantly associated with DFS (P < 0.001). Using these signatures, we proposed a radiomics nomogram with a C-index of 0.754 [95% confidence interval (95% CI), 0.709-0.800] in the training set and 0.722 (95% CI, 0.652-0.792) in the test set. Consequently, 206 (29.1%) patients were stratified as high-risk group and the other 501 (70.9%) as low-risk group by the radiomics nomogram, and the corresponding 5-year DFS rates were 50.1% and 87.6%, respectively (P < 0.0001). High-risk patients could benefit from IC while the low-risk could not. Moreover, radiomics nomogram performed significantly better than the EBV DNA-based model (C-index: 0.754 vs. 0.675 in the training set and 0.722 vs. 0.671 in the test set) in risk stratification and guiding IC.

CONCLUSIONS

Deep learning PET/CT-based radiomics could serve as a reliable and powerful tool for prognosis prediction and may act as a potential indicator for individual IC in advanced NPC.

Nasopharyngeal carcinoma

Nasopharyngeal carcinoma is characterised by distinct geographical distribution and is particularly prevalent in east and southeast Asia. Epidemiological trends in the past decade have shown that its incidence has declined gradually but progressively, and mortality has been reduced substantially. These findings probably reflect lifestyle and environmental changes, enhanced understanding of the pathogenesis and risk factors, population screening, advancements in imaging techniques, and individualised comprehensive chemoradiotherapy strategies. In particular, plasma Epstein-Barr virus (EBV) DNA has been used for population screening, prognostication, predicting treatment response for therapeutic adaptation, and disease surveillance. Moreover, the widespread application of intensity-modulated radiotherapy and optimisation of chemotherapy strategies (induction, concurrent, adjuvant) have contributed to improved survival with reduced toxicities. Among the existing developments in novel therapeutics, immune checkpoint therapies have achieved breakthroughs for treating recurrent or metastatic disease and represent a promising future direction in nasopharyngeal carcinoma.

The role of initial 18F-FDG PET/CT in the management of patients with suspected extramedullary plasmocytoma

Background

Extramedullary plasmacytoma (EMP) is a plasma cell malignancy that originates in soft tissues without evidence of systemic spread, and its management differs from other plasma cell neoplasms. The purpose of the present study was to evaluate the role of initial ¹⁸F-FDG PET/CT in the management of patients with clinical suspected EMP.

Methods

¹⁸F-FDG PET/CT scans performed in 21 patients (M/F = 12/9, mean age 51.1 ± 15.3 years) with clear suspicion of EMP from 2006 to 2015 were analysed retrospectively. The detection of new lesions and the change in treatment were evaluated.

Results

PET/CT detected new lesions in 38.1% (8/21) of patients with 17 lesions, and lymph nodes were the most common site, accounting for 70.6% (12/17) of all lesions, followed by bone (n = 2), and less frequently, breast (n = 1), lung (n = 1), and stomach (n = 1). These findings resulted in treatment changes in 7 patients with EMP. Among these, 4 patients had major treatment changes and 3 patients had minor changes. Of the 21 patients, progression to MM was observed in 8 patients (8/21, 38.1%). In univariate analysis, tumour size > 4 cm and partial response (PR) after treatment were significant prognostic factors for Progression-free survival (PFS).

Conclusions

Our data indicated that ¹⁸F-FDG PET/CT is helpful in the detection of additional lesions throughout the body, including lymph node involvement and distant additional lesion, which may have resulted in treatment change.