Ashraf Farrag

Can 18-FDG-PET during radiotherapy replace post-therapy scanning for detection/demonstration of tumor response in head-and-neck cancer?

PURPOSE In routine practice, the tumor response in head-and-neck cancer (HNC) is assessed 3-4 months after radiotherapy (RT). We compared the results of fluorodeoxyglucose-positron emission tomography (FDG-PET) during (47 Gy) and 4 months after RT. METHODS AND MATERIALS In 40 patients with HNC, PET was performed before (PET1), at the end of Week 4 (47 Gy) (PET2), and 4 months after RT (PET3). Visual analysis classified patients as having a complete response (CR) or a non-CR (NCR). The sensitivity, specificity, accuracy, negative predictive value, and positive predictive value for PET2 and PET3 were determined. The 2-year overall survival (OS) rate for a CR and NCR was calculated for both response evaluation points. RESULTS After a median follow-up of 26 months, 10 patients had died, 6 had residual disease, and 24 remained disease free. The overall sensitivity, specificity, negative predictive value, positive predictive value, and accuracy of PET2 vs. PET3 for the detection of a CR was 28.6%, 81.8%, 31.0%, 80.0%, and 42.5% vs. 78.6%, 75.0%, 60.0%, 88.0%, and 77.5%, respectively. The 2-year OS rate determined at 47 Gy was 90.0% and 71.8% for a CR and NCR, respectively, and did not appear to be significantly different (p = .50). For the study, at 4 months, the OS was significantly better in the CR group (91.8%) than in the NCR group (49.9%; p = .0055). CONCLUSION The high specificity and positive predictive value for the evaluation of tumor response with PET2 and PET3 might avoid unnecessary salvage surgery in patients with a CR. In contrast to PET3, the sensitivity of PET 2 was low, and the difference in OS between the CR and NCR groups was not significantly different. Therefore, the evaluation of the tumor response with FDG-PET at 4 months after RT completion cannot be replaced by FDG-PET during RT at 47 Gy.

Can 18F-FDG-PET response during radiotherapy be used as a predictive factor for the outcome of head and neck cancer patients?

ObjectivesWe investigated if (18F) fluoro-2-deoxy-D-glucose positron emission tomography (18F-FDG-PET) during radiotherapy or concurrent chemoradiotherapy adds information about the treatment outcome compared with an 18FDG-PET study before treatment. MethodsForty-three patients with head and neck cancer were treated with helical tomotherapy. 18F-FDG-PET was performed at baseline and during the treatment after 47 Gy. Tracer accumulation at the tumor site was assessed visually and semiquantitatively using the maximal standardized uptake values (SUVmax). With median SUVmax of both the studies as cutoff, patients were categorized into low and high SUVmax groups. For visual analysis, two independent observers classified patients as complete metabolic responders (CMR) or noncomplete metabolic responders (NCMR). ResultsAt baseline the median SUVmax was 8.11 (2.41–15.13). The overall survival (OS) and disease-free survival (DFS) were 81 and 67% versus 50 and 40% for the low and high SUVmax, respectively. OS was significantly different (P=0.027). During therapy, median SUVmax was 4.03 (1.94–7.58). OS and DFS were 82 and 63%, versus 47 and 42% for the low and high SUVmax group, respectively. OS was significantly different (P=0.026). No significant differences between CMR versus NCMR in OS (72 vs. 60%), and DFS (56 vs. 49%) were found. ConclusionCategorizing patients on the basis of a semiquantitative approach resulted in significant differences in OS for both the scans before and during therapy. Future work on a larger number of patients is warranted to determine SUVmax cutoff values which could be used for the early identification of patients with poor treatment outcome or perhaps other therapeutic approaches.

Pattern of Failure after Helical Tomotherapy in Head and Neck Cancer

Background and Purpose:Helical tomotherapy (HT, Hi-Art TomoTherapy®) is a recently developed radiation device delivering highly conformal dose with a rotational gantry resulting in more uniform target doses and better avoidance of organs at risk. Treatment failure patterns in head and neck cancer (HNC) patients treated with HT were analyzed.Patients and Methods:63 patients with a biopsy-proven HNC were treated with HT. In patients with locoregional failure, the volume of failure (Vf) was contoured and co-registered with the initial planning computed tomography scan. With the use of dose-volume histogram (DVH) analysis, the Vf was classified as “in-field” (InF), “marginal” (MF) or “outside-field” (OutF), if ≥ 95%, 20–94%, and < 20% of Vf, respectively, were within the 95% isodose.Results:Median follow-up time was 25 months (95% confidence interval 19.4–28 months). 2-year overall survival, disease-free survival, and locoregional control were 66%, 54%, and 77%, respectively. 13 patients developed a locoregional failure (four local, eight regional, and one local and regional). After DVH analysis, there were ten InF and two MF recurrences as well as one OutF recurrence.Conclusion:Target delineation and coverage were adequate. The majority of locoregional failures were InF, i.e., in the high-dose region. Future work on dose escalation to the highest risk regions is recommended.ZusammenfassungHintergrund und Ziel:Bei der helikalen Tomotherapie (HT, Hi-Art TomoTherapy®) handelt es sich um ein neuartiges Bestrahlungsgerat, welches mit Hilfe einer rotierenden Gantry hochkonformale Dosisverteilungen erreicht. Dies fuhrt zu gleich - masigerer Abdeckung des Zielvolumens und besserer Schonung von Risikoorganen. Ruckfallmuster bei Patienten mit Tumoren in der Kopf-Hals-Gegend (HNC), die mit HT behandelt worden waren, wurden analysiert.Patienten und Methodik:63 Patienten mit bioptisch bewiesenen HNC wurden mit HT behandelt. Bei Patienten mit lokoregionalem Rezidiv wurde das Rezidivvolumen („volume of failure“ [Vf]) eingezeichnet und mit dem ursprunglichen Planungscomputertomogramm verglichen. Mit Hilfe der Analyse von Dosis-Volumen-Histogrammen (DVHs) wurde das Vf eingeteilt in „in-field“ (InF; innerhalb des ursprunglichen Zielvolumens), „marginal“ (MF, Randrezidiv) oder „outside-field“ (OutF, auserhalb des ursprunglichen Zielvolumens), wenn sich jeweils ≥ 95%, 20–94% oder < 20% des Vf innerhalb der 95%-Isodose befanden.Ergebnisse:Die mediane Nachbeobachtungszeit betrug 25 Monate (95%-Konfidenzintervall 19,4–28 Monate). Die 2-Jahres- Uberlebensrate, das krankheitsfreie Uberleben und die lokoregionale Kontrollrate betrugen 66%, 54% und 77%. 13 Patienten entwickelten ein lokoregionales Rezidiv. Nach DVH-Analyse handelte es sich um zehn InF- und zwei MF-Rezidive sowie ein OutF-Rezidiv.Schlussfolgerung:Zielvolumendefinition und -abdeckung waren ausreichend. Der groste Teil der lokoregionalen Rezidive waren InF, d. h. im Hochdosisbereich. Weitere Studien uber Dosiseskalationen in Regionen mit hohem Rezidivrisiko werden empfohlen.

Atypical diffuse bilateral cystic lung changes secondary to erlotinib treatment in a patient with metastatic non‑small cell lung carcinoma: A case report and literature review

Erlotinib is a first-generation epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor (TKI) approved in the first-line treatment of advanced non-small-cell lung cancer (NSCLC) patients with sensitizing epidermal growth factor receptor (EGFR) mutations. The response rate to erlotinib is ~60% and the incidence of erlotinib-induced interstitial lung disease (ILD) is ~1-4%. The Response Evaluation Criteria in Solid Tumours (RECIST) tool is commonly used to assess response to erlotinib; however, evaluation of response and subsequent progression in the presence of atypical cystic lung changes may be challenging. We herein present a rare case of diffuse cystic lung changes secondary to erlotinib treatment in a patient with EGFR mutation-positive metastatic NSCLC. Challenges in assessing atypical tumour response to erlotinib, pitfalls in using RECIST and differential diagnosis of TKI-related ILD are discussed in detail.

Intracranial meningioma as primary presentation for an undiagnosed collision metastatic breast cancer: Case report and literature review

Intracranial metastasis from breast cancer is a relatively common finding, however, the appearance of breast cancer metastasis in a meningioma is very rare. Several cases of tumor-to-tumor metastasis and collision tumors have been reported previously, with meningioma being implicated as the most common benign intracranial neoplasm to harbour the metastasis. Occasionally, the discovery of a tumor-to-meningioma metastasis may herald the diagnosis of an occult primary malignancy. Careful histopathological assessment of the resected meningioma specimen is pivotal to the management of these patients, as this will alter the treatment plan and prognosis considerably. Intracranial meningioma with collision breast cancer as primary presentation of an undiagnosed metastatic breast cancer is extremely rare. The current study presents a case of intracranial meningioma with collision breast cancer as a primary presentation, and reviews the available evidence for this unusual disease entity.