Prognostic value of volume-based positron emission tomography/computed tomography in patients with nasopharyngeal carcinoma treated with concurrent chemoradiotherapy

Predictive significance of pretreatment 18F-FDG PET volumetric parameters on survival outcomes in pediatric patients with locally advanced undifferentiated nasopharyngeal carcinoma

BACKGROUND

Nasopharyngeal carcinoma (NPC) is a rare pediatric cancer. Most children are first diagnosed with advanced locoregional disease. Identification of patients at higher risk of treatment failure is crucial as they may benefit from more aggressive initial treatment approaches. 18Fluorine-labeled fluoro-2-deoxyglucose positron emission tomography (18F-FDG PET) has shown promise as a prognostic tool for predicting outcomes.

METHODS

Retrospective study of pediatric patients with locally advanced undifferentiated NPC who underwent 18F-FDG PET/CT prior to intial treatment. Predictive significance of metabolic PET parameters on survival outcomes were estimated.

RESULTS

Thirty-two children were included, age range was 7.1-18 years at the time of diagnosis. The median follow-up duration was 46.1 months. Three patients (9.4%) were classified as AJCC stage IIb, 13 patients (40.6%) as stage IIIa, eight patients (25%) as stage IIIb, and eight patients (25%) as stage IVa. Our findings revealed that high whole-body metabolic tumor volume at the threshold of hepatic reference SUVmean (WB-MTV-HR) (>135 mL) was associated with significantly lower event-free survival (EFS) compared to the low WB-MTV-HR group (≤135 mL) (3-year EFS: 50% ± 18% vs. 82% ± 8%; p = .015). Additionally, the 3-year overall survival (OS) rates differed significantly between the high whole-body metabolic tumor volume at the threshold of an SUV of 2.5 isocontour (WB-MTV-2.5) group (MTV >74 mL) and the low WB-MTV-2.5 group (MTV ≤74 mL) (63% ± 18% vs. 100%; p = .021).

CONCLUSION

Our study suggests that WB-MTV parameters could serve as significant prognostic factors for disease progression in pediatric patients with locally advanced undifferentiated NPC. However, further prospective studies with larger sample sizes are needed to validate these findings.

Cross-site prognosis prediction for nasopharyngeal carcinoma from incomplete multi-modal data

Accurate prognosis prediction for nasopharyngeal carcinoma based on magnetic resonance (MR) images assists in the guidance of treatment intensity, thus reducing the risk of recurrence and death. To reduce repeated labor and sufficiently explore domain knowledge, aggregating labeled/annotated data from external sites enables us to train an intelligent model for a clinical site with unlabeled data. However, this task suffers from the challenges of incomplete multi-modal examination data fusion and image data heterogeneity among sites. This paper proposes a cross-site survival analysis method for prognosis prediction of nasopharyngeal carcinoma from domain adaptation viewpoint. Utilizing a Cox model as the basic framework, our method equips it with a cross-attention based multi-modal fusion regularization. This regularization model effectively fuses the multi-modal information from multi-parametric MR images and clinical features onto a domain-adaptive space, despite the absence of some modalities. To enhance the feature discrimination, we also extend the contrastive learning technique to censored data cases. Compared with the conventional approaches which directly deploy a trained survival model in a new site, our method achieves superior prognosis prediction performance in cross-site validation experiments. These results highlight the key role of cross-site adaptability of our method and support its value in clinical practice.

Multiple Testing, Cut-Point Optimization, and Signs of Publication Bias in Prognostic FDG-PET Imaging Studies of Head and Neck and Lung Cancer: A Review and Meta-Analysis

Positron emission tomography (PET) imaging with 2-deoxy-2-[¹⁸F]-fluorodeoxyglucose (FDG) was proposed as prognostic marker in radiotherapy. Various uptake metrics and cut points were used, potentially leading to inflated effect estimates. Here, we performed a meta-analysis and systematic review of the prognostic value of pretreatment FDG–PET in head and neck squamous cell carcinoma (HNSCC) and non-small cell lung cancer (NSCLC), with tests for publication bias. Hazard ratio (HR) for overall survival (OS), disease free survival (DFS), and local control was extracted or derived from the 57 studies included. Test for publication bias was performed, and the number of statistical tests and cut-point optimizations were registered. Eggers regression related to correlation of SUVmax with OS/DFS yielded p = 0.08/p = 0.02 for HNSCC and p < 0.001/p = 0.014 for NSCLC. No outcomes showed significant correlation with SUVmax, when adjusting for publication bias effect, whereas all four showed a correlation in the conventional meta-analysis. The number of statistical tests and cut points were high with no indication of improvement over time. Our analysis showed significant evidence of publication bias leading to inflated estimates of the prognostic value of SUVmax. We suggest that improved management of these complexities, including predefined statistical analysis plans, are critical for a reliable assessment of FDG–PET.

Radiomics Analysis and Correlation With Metabolic Parameters in Nasopharyngeal Carcinoma Based on PET/MR Imaging

Objective: Accurate staging is of great importance in treatment selection for patients with nasopharyngeal carcinoma (NPC). The aims of this study were to construct radiomic models of NPC staging based on positron emission tomography (PET) and magnetic resonance (MR) images and to investigate the correlation between metabolic parameters and radiomic features.

Methods: A total of 100 consecutive cases of NPC (70 in training and 30 in the testing cohort) with undifferentiated carcinoma confirmed pathologically were recruited. Metabolic parameters of the local lesions of NPC were measured. A total of 396 radiomic features based on PET and MRI images were calculated [including histogram, Haralick, shape factor, gray level co-occurrence matrix (GLCM), and run length matrix (RLM)] and selected [using maximum relevance and minimum redundancy (mRMR) and least shrinkage and selection operator (LASSO)], respectively. The logistic regression models were established according to these features. Finally, the relationship between the metabolic parameters and radiomic features was analyzed.

Results: We selected the nine most relevant radiomic features (six from MR images and three from PET images) from local NPC lesions. In the PET model, the area under the receiver operating characteristic (ROC) curve (AUC), accuracy, sensitivity, and the specificity of the training group were 0.84, 0.75, 0.90, and 0.69, respectively. In the MR model, those metrics were 0.85, 0.83, 0.75, and 0.86, respectively. Pearson's correlation analysis showed that the metabolic parameters had different degrees of correlation with the selected radiomic features.

Conclusion: The PET and MR radiomic models were helpful in the diagnosis of NPC staging. There were correlations between the metabolic parameters and radiomic features of primary NPC based on PET/MR. In the future, PET/MR-based radiomic models, with further improvement and validation, can be a more useful and economical tool for predicting local invasion and distant metastasis of NPC.

Prognostic value of neutrophil-to-lymphocyte ratio in older patients with head and neck cancer

INTRODUCTION

Neutrophil-to-lymphocyte ratio (NLR), may predict treatment response and outcomes in some human malignancies. However, NLR has rarely been examined in older patients with head and neck squamous cell carcinoma (HNSCC). This study evaluated factors, including pre-treatment evaluation tests, predictive of mortality in older patients with HNSCC.

METHODS

This study prospectively enrolled 233 consecutive HNSCC patients aged 65 years or older. Pre-treatment evaluations included patient demographics, comorbidity, body weight loss, voice handicap index, dysphagia, Beck's depression inventory, comprehensive geriatric assessment, and circulating biomarkers. Cumulative incidence and cause-specific hazard functions were used to analyse the risk factors for overall mortality (OM), cancer mortality (CM), and non-cancer mortality (NCM).

RESULTS

Multivariate analyses showed that age, performance scale, NLR, and nodal stage were independent predictors of OM and CM (all P < .05). Age, body weight loss, frailty, and NLR were independent predictors of NCM (all P < .05). Older age ≥ 75 years and NLR showed strong association with all OM, CM, and NCM (all P < .05). NLR >2.5 was related to a higher risk of OM (hazard ratio [HR] = 1.77, 95% confidence interval [CI]: 1.05-2.97, P = .031), CM (HR = 1.89, 95% CI: 1.09-3.29, P = .023), and NCM (HR = 6.29, 95% CI: 2.16-18.37, P = .001).

CONCLUSION

Cancer and non-cancer mortalities among older patients with HNSCC may be predicted by several clinical and haematological data. NLR might be used as a circulating prognostic marker for mortality in older patients with HNSCC.

Risk factors for competing non-cancer mortality after definitive treatment for advanced-stage head and neck cancer

OBJECTIVE

Patients with head and neck cancer (HNC) can die of index tumor progression and second tumor or non-cancer causes. Here, we investigated the risk factors for competing non-cancer mortality (NCM) in a prospective cohort of patients with advanced-stage HNC.

MATERIALS AND METHODS

A prospective observational study was conducted with 604 patients who underwent definitive treatment for advanced-stage HNC between 2010 and 2015. Main outcomes were NCM and cancer mortality (CM) defined as death from non-cancer causes and HNC or second cancers, respectively. Cumulative incidence and cause-specific hazard functions were used to analyze the risk factors of NCM and CM.

RESULTS

Age, smoking, Charlson comorbidity index (CCI), performance status, body mass index, rural residence, education and hemoglobin level at diagnosis, and chemotherapy were significantly associated with NCM (all p < 0.05). Multivariate analyses showed that age, CCI, and hemoglobin were independent factors of NCM. Age (≥65 years), CCI (≥2), and hemoglobin (<11 g/dl) were related to 4.5-, 3.2-, and 2.7-fold increased adjusted risk of NCM, respectively.

CONCLUSIONS

Old age, comorbidity, and hemoglobin at diagnosis were independent predictors of NCM. The risk factors could be used to predict non-cancer death after definitive treatment for advanced-stage HNC.

Prognostic Value of Volume-Based Positron Emission Tomography/Computed Tomography in Nasopharyngeal Carcinoma Patients after Comprehensive Therapy

Objective

We assessed the prognostic value of standardized uptake value (SUV) and volume-based methods including whole-body metabolic tumor volume (WBMTV) and whole-body total lesion glycolysis (WBTLG) using ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) of patients with nasopharyngeal carcinoma (NPC) after therapy.

Methods

A total of 221 posttherapy NPC cases were enrolled, all of whom had undergone PET/CT scanning and follow-up in this retrospective study. The diagnostic results of PET/CT were analyzed and compared with histopathological diagnosis or clinical follow-up. Receiver operator characteristic curves, the Kaplan-Meier method, and the log-rank test were used to assess the optimal cutoff values for WBMTV and WBTLG to identify independent predictors of survival.

Results

The detection rates of the threshold SUV were 2.5, 20%, and 40%, and SUV background methods were 65.6% (378/576), 80.2% (462/576), 71.5% (412/576), and 90.4% (521/576), respectively (P < 0.005). Patients with a WBMTV < 8.10 and/or a WBTLG < 35.58 had significantly better 5-year overall survival than those above the cutoffs (90.7% versus 51.2%, P < 0.001; 91.7% versus 50.4%, P < 0.001), respectively. Multivariate Cox regression modeling showed both WBTLG (RR, 1.002; P = 0.004) and age (RR, 1.046; P = 0.006) could be used to predict overall survival. WBTLG (RR, 1.003; P < 0.001) may have predictive relevance in estimating disease-free survival.

Conclusions

SUV volume-based threshold background methodology had a significantly higher detection rate for metastatic lesions. WBTLG could be used as an independent prognostic indicator for posttherapy NPC.

Prognostic value of nodal SUVmax of 18F-FDG PET/CT in nasopharyngeal carcinoma treated with intensity-modulated radiotherapy

Purpose

To investigate the predictive role of maximum standardized uptake value (SUV_max) of 2-[¹⁸F]fluoro-2-deoxy-D-glucose (¹⁸F-FDG) positron emission tomography/computed tomography (PET/CT) in nasopharyngeal cancer patients treated with intensity-modulated radiotherapy (IMRT).

Materials and Methods

Between October 2006 and April 2016, 53 patients were treated with IMRT in two institutions and their PET/CT at the time of diagnosis was reviewed. The SUV_max of their nasopharyngeal lesions and metastatic lymph nodes (LN) was recorded. IMRT was delivered using helical tomotherapy. All patients except for one were treated with concurrent chemoradiation therapy (CCRT). Correlations between SUV_max and patients’ survival and recurrence were analyzed.

Results

At a median follow-up time of 31.5 months (range, 3.4 to 98.7 months), the 3-year overall survival (OS) and disease-free survival (DFS) rates were 83.2% and 77.5%, respectively. In univariate analysis, patients with a higher nodal pre-treatment SUV_max (≥ 13.4) demonstrated significantly lower 3-year OS (93.1% vs. 55.5%; p = 0.003), DFS (92.7% vs. 38.5%; p < 0.001), locoregional recurrence-free survival (100% vs. 50.5%; p < 0.001), and distant metastasis-free survival (100% vs. 69.2%; p = 0.004), respectively. In multivariate analysis, high pre-treatment nodal SUV_max (≥ 13.4) was a negative prognostic factor for OS (hazard ratio [HR], 7.799; 95% confidence interval [CI], 1.506–40.397; p = 0.014) and DFS (HR, 9.392; 95% CI, 1.989–44.339; p = 0.005).

conclusions

High pre-treatment nodal SUV_max was an independent prognosticator of survival and disease progression in nasopharyngeal carcinoma patients treated with IMRT in our cohort. Therefore, nodal SUV_max may provide important information for identifying patients who require more aggressive treatment.

Metabolic Tumor Volume and Total Lesion Glycolysis in Oropharyngeal Cancer Treated With Definitive Radiotherapy: Which Threshold Is the Best Predictor of Local Control?

PURPOSE

In the context of oropharyngeal cancer treated with definitive radiotherapy, the aim of this retrospective study was to identify the best threshold value to compute metabolic tumor volume (MTV) and/or total lesion glycolysis to predict local-regional control (LRC) and disease-free survival.

METHODS

One hundred twenty patients with a locally advanced oropharyngeal cancer from 2 different institutions treated with definitive radiotherapy underwent FDG PET/CT before treatment. Various MTVs and total lesion glycolysis were defined based on 2 segmentation methods: (i) an absolute threshold of SUV (0-20 g/mL) or (ii) a relative threshold for SUVmax (0%-100%). The parameters' predictive capabilities for disease-free survival and LRC were assessed using the Harrell C-index and Cox regression model.

RESULTS

Relative thresholds between 40% and 68% and absolute threshold between 5.5 and 7 had a similar predictive value for LRC (C-index = 0.65 and 0.64, respectively). Metabolic tumor volume had a higher predictive value than gross tumor volume (C-index = 0.61) and SUVmax (C-index = 0.54). Metabolic tumor volume computed with a relative threshold of 51% of SUVmax was the best predictor of disease-free survival (hazard ratio, 1.23 [per 10 mL], P = 0.009) and LRC (hazard ratio: 1.22 [per 10 mL], P = 0.02).

CONCLUSIONS

The use of different thresholds within a reasonable range (between 5.5 and 7 for an absolute threshold and between 40% and 68% for a relative threshold) seems to have no major impact on the predictive value of MTV. This parameter may be used to identify patient with a high risk of recurrence and who may benefit from treatment intensification.

Prognostic value of maximum standard uptake value, metabolic tumor volume, and total lesion glycolysis of positron emission tomography/computed tomography in patients with nasopharyngeal carcinoma: A systematic review and meta-analysis

BACKGROUND

The maximal standard uptake value (SUVmax), metabolic tumor volume (MTV), and total lesion glycolysis (TLG) of positron emission tomography/computed tomography (PET/CT) in patients with nasopharyngeal carcinoma (NPC) perform as new prognostic factors, but the outcomes of the published articles were inconclusive. In this meta-analysis, we evaluated the prognostic value of SUVmax, MTV, and TLG of PET/CT in patients with NPC.

METHODS

Relevant English articles were searched in PubMed and EMBASE. The data of patients and the survival outcomes were extracted. Pooled hazard ratios (HRs) were accounted to assess the prognostic value of the SUVmax, MTV, and TLG.

RESULTS

This meta-analysis combined 10 primary studies including 941 patients with NPC. The combined HRs (95% confidence interval [CI] of higher SUVmax, higher MTV, and higher TLG for event-free survival were 2.33 (95% CI, 1.39-3.91, P = .001), 2.51 (95% CI, 1.61-3.91, P < .0001), and 2.74 (95% CI, 1.91-3.93, P < .00001), respectively. Regarding overall survival, the combined HRs were 2.50 (95%CI, 1.65-3.78, P < .0001) with higher SUVmax, 3.30 (95% CI, 1.92-5.69, P < .0001) with higher MTV and 3.18 (95% CI, 1.70-5.96, P = .0003) with higher TLG.

CONCLUSION

SUVmax, MTV, and TLG were significant prognostic predictors in patients with NPC. And the results suggested that higher SUVmax, MTV, and TLG were associated with worse prognosis.

Prognostic value of 18F-FDG-PET/CT in patients with nasopharyngeal carcinoma: a systematic review and meta-analysis

BACKGROUND

The prognostic role of 18F-fluorodeoxyglucose positron emission tomography CT (18F-FDG PET/CT) parameters is still controversial in nasopharyngeal carcinoma patients. We sought to perform a systematic review and meta-analysis to explore the prognostic value of maximal standardized uptake value (SUVmax), metabolic tumor volume (MTV) and total lesion glycolysis (TLG) on event-free survival (EFS) and overall survival (OS) in nasopharyngeal carcinoma patients.

RESULTS

Fifteen studies comprising 1,938 patients were included in this study. The combined hazard ratios (HRs) for EFS were 2.63 (95%CI 1.71-4.05) for SUVmax, 2.55 (95%CI 1.49-4.35) for MTV, and 3.32 (95%CI 1.23-8.95) for TLG. The pooled HRs for OS were 2.07 (95%CI 1.54-2.79) for SUVmax, 3.86 (95%CI 1.85-8.06) for MTV, and 2.60 (95%CI 1.55-4.34) for TLG. The prognostic role of SUVmax, MTV and TLG remained similar in the sub-group analyses.

METHODS

A systematic literature search was performed to identify studies which associated 18F-FDG PET/CT to clinical survival outcomes of nasopharyngeal carcinoma patients. The summarized HRs for EFS and OS were estimated by using fixed- or random-effect models according to heterogeneity between trials.

CONCLUSIONS

The present meta-analysis confirms that high values of SUVmax, MTV and TLG predicted a higher risk of adverse events or death in patients with nasopharyngeal carcinoma, despite clinically heterogeneous nasopharyngeal carcinoma patients and the various methods adopted between these studies.

Prognostic value of pretreatment 18F-FDG PET-CT for nasopharyngeal carcinoma patients

BACKGROUND

Nasopharyngeal carcinoma (NPC) is a special subtype of head and neck cancer (HNC). At present, there are no highly specific prognostic markers to aid in tumor grading and guide patient treatment modalities for NPC. The prognostic value of pretreatment F-fluorodeoxyglucose positron emission tomography-computed tomography (F-PET-CT) in NPC patients is controversial and no consensus exists as to its predictive capability.

METHODS

To analyze the predictive efficacy of F-PET-CT imaging in NPC patients, data from MEDLINE, EMBASE, the Cochrane library, CBM, CNKI, and VIP (inception to July 2016) were accessed. Results from prospective and retrospective observational studies that used F-FDG PET to predict disease prognosis in NPC patients were used for analysis. Two authors independently assessed study quality and extracted data. Event-free survival (EFS) was considered the primary endpoint and overall survival rate (OS) was considered the secondary endpoint.

RESULTS

Data from 14 studies and 1134 patients were included in our analysis. The hazard ratios (HRs) of maximum standardized uptake value of primary tumor (SUVmax-T), metabolic tumor volume of primary tumor (MTV-T), and total lesional glycolysis of primary tumor (TLG-T) for EFS were 1.31 (95% confidence interval [CI], 1.11-1.55, P = .001), 2.38 (95% CI 1.53-3.70, P < .001), and 1.65 (95% CI 0.76-3.59, P = .21), respectively. Among studies including TLG-T, those with a fixed SUV of 2.5 had an HR of 3.55 (95% CI, 1.42-8.84, P = .007). The HRs of SUVmax-T and MTV-T for OS were 2.19 (95% CI, 1.47-3.27, P < .001) and 2.69 (95% CI, 1.01-7.17, P = .05), respectively. Among studies including MTV-T, those with a fixed SUV of 2.5 had an HR of 4.07 (95% CI, 2.22-7.46, P < .001). Tests used for assessing predictive value of pretreatment SUVmax, MTV, and TLG of lymph nodes for EFS and OS showed that these parameters did not have significant predictive value (P>.05).

CONCLUSION

Our results suggested that SUVmax, MTV, and TLG (with a fixed SUV of 2.5) of primary tumors before treatment initiation may be independent prognostic factors for NPC patients; however, SUVmax, MTV, and TLG of metastatic lymph nodes are not.

A PET-based nomogram for oropharyngeal cancers

PURPOSE

In the context of locally advanced oropharyngeal cancer (LAOC) treated with definitive radiotherapy (RT) (combined with chemotherapy or cetuximab), the aims of this study were: (1) to identify PET-FDG parameters correlated with overall survival (OS) from a first cohort of patients; then (2) to compute a prognostic score; and (3) finally to validate this scoring system in a second independent cohort of patients.

MATERIALS AND METHODS

A total of 76 consecutive patients (training cohort from Rennes) treated with chemoradiotherapy or RT with cetuximab for LAOC were used to build a predictive model of locoregional control (LRC) and OS based on PET-FDG parameters. After internal calibration and validation of this model, a nomogram and a scoring system were developed and tested in a validation cohort of 46 consecutive patients treated with definitive RT for LAOC in Lausanne.

RESULTS

In multivariate analysis, the metabolic tumour volume (MTV) of the primary tumour and the lymph nodes were independent predictive factors for LRC and OS. Internal calibration showed a very good adjustment between the predicted OS and the observed OS at 24 months. Using the predictive score, two risk groups were identified (median OS 42 versus 14 months, p < 0.001) and confirmed in the validation cohort from Lausanne (median OS not reached versus 26 months, p=0.008).

CONCLUSIONS

This is the first report of a PET-based nomogram in oropharyngeal cancer. Interestingly, it appeared stronger than the classical prognostic factors and was validated in independent cohorts markedly diverging in many aspects, which suggest that the observed signal was robust.

Postdiagnostic use of β-blockers and other antihypertensive drugs and the risk of recurrence and mortality in head and neck cancer patients: an observational study of 10,414 person-years of follow-up

INTRODUCTION

Growing evidence indicates that norepinephrine promotes cancer growth and metastasis whereas β-blockers decrease these risks. This study aimed to examine the clinical impact of β-blockers and other hypertensive drugs on disease recurrence and survival in patients with head and neck squamous cell carcinoma (HNSCC).

MATERIALS AND METHODS

This study analyzed a cohort of 1274 consecutive patients who received definitive treatments for previously untreated HNSCC at our tertiary referral center between January 2001 and December 2012. Antihypertensive use was considered positive if patients were on medication from HNSCC diagnosis to at least 1 year after treatment initiation. Cox proportional hazard models were utilized to determine associations between antihypertensive drugs and recurrence, survival, and second primary cancer (SPC) occurrence.

RESULTS

Hypertension itself was not a significant variable of recurrence and survival and no antihypertensive drug use affected SPC occurrence (all P > 0.1). After controlling for clinical factors, calcium-channel blocker use remained an independent variable for index cancer recurrence, and β-blocker use was significantly associated with poor cancer-specific mortality, competing mortality, and all-cause mortality (all P < 0.05). β-blocker use significantly affected competing and all-cause mortalities in normotensive patients, and calcium-channel blocker use affected index cancer recurrence in normotensive patients (all P < 0.05).

CONCLUSIONS

Our data show that β-blocker use is associated with decreased survival and calcium-channel blockers is associated with increased cancer recurrence in patients of HNSCC.

Nrf2 inhibition reverses the resistance of cisplatin-resistant head and neck cancer cells to artesunate-induced ferroptosis

Artesunate, an anti-malarial drug, has been repurposed as an anticancer drug due to its induction of cell death via reactive oxygen species (ROS) production. However, the molecular mechanisms regulating cancer cell death and the resistance of cells to artesunate remain unclear. We investigated the molecular mechanisms behind the antitumor effects of artesunate and an approach to overcome artesunate resistance in head and neck cancer (HNC). The effects of artesunate and trigonelline were tested in different HNC cell lines, including three cisplatin-resistant HNC cell lines. The effects of these drugs as well as the inhibition of Keap1, Nrf2, and HO-1 were assessed by cell viability, cell death, glutathione (GSH) and ROS production, protein expression, and mouse tumor xenograft models. Artesunate selectively killed HNC cells but not normal cells. The artesunate sensitivity was relatively low in cisplatin-resistant HNC cells. Artesunate induced ferroptosis in HNC cells by decreasing cellular GSH levels and increasing lipid ROS levels. This effect was blocked by co-incubation with ferrostatin-1 and a trolox pretreatment. Artesunate activated the Nrf2-antioxidant response element (ARE) pathway in HNC cells, which contributed to ferroptosis resistance. The silencing of Keap1, a negative regulator of Nrf2, decreased artesunate sensitivity in HNC cells. Nrf2 genetic silencing or trigonelline reversed the ferroptosis resistance of Keap1-silenced and cisplatin-resistant HNC cells to artesunate in vitro and in vivo. Nrf2-ARE pathway activation contributes to the artesunate resistance of HNC cells, and inhibition of this pathway abolishes ferroptosis-resistant HNC.

CONDENSED ABSTRACT

Our results show the effectiveness and molecular mechanism of artesunate treatment on head and neck cancer (HNC). Artesunate selectively killed HNC cells but not normal cells by inducing an iron-dependent, ROS-accumulated ferroptosis. However, this effect may be suboptimal in some cisplatin-resistant HNCs because of Nrf2-antioxidant response element (ARE) pathway activation. Inhibition of the Nrf2-ARE pathway increased artesunate sensitivity and reversed the ferroptosis resistance in resistant HNC cells.

Prognostic value of tumoral heterogeneity and volumetric parameters as measured by F18-FDG PET/CT in sinonasal cancer

The objective of this study was to investigate the value of parameters assessed with F18-FDG PET/CT in predicting recurrence-free survival (RFS) and disease-specific survival (DSS) in patients with cancer of nasal cavity and paranasal sinus. Thirty-eight patients with cancer of nasal cavity (n = 14) and paranasal sinus (n = 24) who underwent PET/CT prior to curative treatment were enrolled. A volume of interest was placed on PET/CT images covering the entire tumor volume, and the maximum SUV (SUV_max), the mean SUV (SUV_mean), and volumetric parameters of metabolic tumor volume (MTV) and total lesion glycolysis (TLG) were measured using thresholds of 40 % of SUV_max. The heterogeneity factor (HF) defined as the derivative of volume-threshold function from 40 to 80 % of SUV thresholds. RFS and DSS were defined as the time from the diagnosis to recurrence and death. Median values of SUV_max, SUV_mean, MTV, TLG, and HF were 14.81, 9.16, 25.84, 150.74, and -0.496. SUV_max was higher in patients with advanced stage and nodal metastasis. High MTV and low HF group showed shorter RFS. Cox proportional hazards regression analysis revealed low HF was the only significant predictive factor on RFS. Furthermore, high TLG was associated with shorter DSS. High TLG was potent predictor of DSS by Cox proportional hazards regression analysis. In conclusion, the tumoral heterogeneity and volumetric parameters as measured by F18-FDG PET/CT could be significant prognostic surrogate markers in patients with sinonasal cancer.

18F-fludrodeoxyglucose maximal standardized uptake value and metabolic tumor burden are associated with major chemotherapy-related tumor markers in NSCLC patients

Objective

Metabolic activity and tumor burden are significant for prognosis and metastasis of non-small cell lung cancer (NSCLC), including maximum standardized uptake value (SUV_max), metabolic tumor volume (MTV), and total lesion glycolysis (TLG). Chemotherapy resistance is a great challenge for treating NSCLC patients and is also closely related with several biomarkers such as epidermal growth factor receptor (EGFR), p53, and excision repair cross-complementing group 1 protein (ERCC1). Our purpose was to determine the correlation between positron emission tomography/computed tomography (PET/CT) parameters and tumor markers-related chemotherapy resistance in NSCLC.

Methods

Forty-six NSCLC chemotherapy-naïve patients were enrolled. The SUV_max, MTV, and TLG were calculated by PET/CT imaging, and expression of EGFR, p53, and ERCC1 were analyzed by immunohistochemistry on tissues. SUV_max, MTV, and TLG compared for their performance in predicting the expression of EGFR, p53, and ERCC1 were illustrated with statistical analysis.

Results

SUV_max was significantly correlated with p53 expression (P=0.001), and MTV and TLG were significantly associated with ERCC1 (P=0.000; P=0.000). Furthermore, multiple stepwise regression analysis revealed that SUV_max was the primary predictor for p53, MTV and TLG was the primary predictor for ERCC1. SUV_max had a sensitivity of 91% and specificity of 50% for the detection of p53 positive. The sensitivities of MTV and TLG were 83% and 80%, and specificities were 69% and 75% for the detection of ERCC1 positive, respectively. When we suggested p53 or ERCC1 positive, the cutoff value of SUV_max, MTV, and TLG were 7.68, 23.62, and 129.65 cm³, respectively.

Conclusion

SUV_max, MTV, and TLG were closely associated with p53 and ERCC1’ expressions. Therefore, ¹⁸F-fludrodeoxyglucose PET/CT could be a new way of predicting p53 or ERCC1-related chemotherapy effect in NSCLC patients with more convenience.

Prognostic Significance of ¹⁸F-FDG Uptake in Hepatocellular Carcinoma Treated with Transarterial Chemoembolization or Concurrent Chemoradiotherapy: A Multicenter Retrospective Cohort Study

This study aimed to assess the prognostic value of (18)F-FDG uptake in hepatocellular carcinoma (HCC) patients who had transarterial chemoembolization (TACE) or concurrent intraarterial chemotherapy with external-beam radiotherapy (CCRT) and to compare the prognosis between patients treated with TACE and those with CCRT according to (18)F-FDG uptake.

METHODS

Two hundred fourteen intermediate-to-advanced-stage HCC patients without extrahepatic metastasis who underwent staging (18)F-FDG PET/CT before TACE (153 patients) or CCRT (61 patients) were recruited from 7 hospitals. Progression-free survival (PFS) and overall survival (OS) were compared using an optimal cutoff value for tumor-to-normal liver uptake ratio (TLR). Further, PFS and OS were compared according to treatment modalities (TACE vs. CCRT) using the same TLR cutoff value.

RESULTS

On multivariate analysis, age and TLR were independent prognostic factors for PFS (P< 0.050). For OS, Child-Pugh classification and TLR were independent prognostic factors (P< 0.050). When the TLR was greater than 2.0, patients treated with CCRT showed significantly better PFS and OS than those treated with TACE after adjusting for tumor size and number (P= 0.014, for all). In contrast, there was no significant difference in PFS and OS between patients treated with TACE or CCRT when the TLR was 2.0 or less.

CONCLUSION

(18)F-FDG uptake was an independent prognostic factor for PFS and OS in HCC patients treated with TACE or CCRT. Especially, in HCCs with high (18)F-FDG uptake, patients treated with CCRT showed better survival than those treated with TACE. (18)F-FDG PET/CT may help determine the treatment modality for intermediate-to-advanced-stage HCCs.