Minh Tam Truong

18F-FDG Metabolic Tumor Volume and Total Glycolytic Activity of Oral Cavity and Oropharyngeal Squamous Cell Cancer: Adding Value to Clinical Staging

18F-FDG metabolic tumor volume (MTV) and total glycolytic activity (TGA) have been proposed as potential prognostic imaging markers for patient outcome in human solid tumors. The purpose of this study was to establish whether MTV and TGA add prognostic information to clinical staging in patients with oral and oropharyngeal squamous cell carcinomas (SCCs). Methods: The Institutional Review Board approved this Health Insurance Portability and Accountability Act–compliant single-institution retrospective study. Forty-five patients with histologically proven oral or oropharyngeal SCC underwent PET/CT for initial cancer staging and were included in the study. MTV was measured using a gradient-based method (PET Edge) and fixed-threshold methods at 38%, 50%, and 60% of maximum standardized uptake value (SUV). The TGA is defined as MTV × mean SUV. Bland–Altman analysis was used to establish the reliability of the methods of segmentation. Outcome endpoints were overall survival (OS) and progression-free survival. Cox proportional hazards univariate and multivariate regression analyses were performed. Results: In Cox regression models, MTV and TGA were the only factors significantly associated with survival outcome after adjusting for all other covariates including American Joint Committee on Cancer (AJCC) stage, with hazards ratio of 1.06 (95% confidence interval, 1.01–1.10; P = 0.006) and 1.00 (95% confidence interval, 1.00–1.01; P = 0.02). The model fit was significantly better when MTV was added to AJCC stage in model I (χ2 value change, 1.16–6.71; P = 0.01) and when TGA was added to AJCC stage in model II (χ2 value change, 1.16–4.37; P = 0.04). The median cutoff point of 7.7 mL for primary tumor MTV was predictive of time to OS (log rank P = 0.04). The median cutoff point of 55 g for PET Edge primary tumor TGA was predictive of time to OS (log rank P = 0.08), though the result was not statistically significant. Conclusion: Gradient-based segmentations of primary tumor MTV and TGA are potential 18F-FDG markers for time to survival in patients with oral and oropharyngeal SCC and may provide prognostic information in addition to AJCC stage. These exploratory imaging markers need validation in larger cohort studies.

Use of 18F-FDG PET/CT as a Predictive Biomarker of Outcome in Patients With Head-and-Neck Non–Squamous Cell Carcinoma

OBJECTIVE The purpose of this article is to establish whether pretreatment (18)F-FDG uptake predicts disease-free survival (DFS) and overall survival in patients with head-and-neck non-squamous cell carcinoma (SCC). MATERIALS AND METHODS Eighteen patients (six women and 12 men; mean [± SD] age at diagnosis, 57.89 ± 13.54 years) with head-and-neck non-SCC were included. Tumor FDG uptake was measured by the maximum standardized uptake value (SUV(max)) and was corrected for background liver FDG uptake to derive the corrected SUV(max). Receiver operating characteristic analyses were used to predict the optimal corrected SUV(max) cutoffs for respective outcomes of DFS (i.e., absence of recurrence) and death. RESULTS The mean corrected SUV(max) of the 18 head-and-neck tumors was 5.63 ± 3.94 (range, 1.14-14.29). The optimal corrected SUV(max) cutoff for predicting DFS and overall survival was 5.79. DFS and overall survival were significantly higher among patients with corrected SUV(max) < 6 than among patients with corrected SUV(max) ≥ 6. The mean DFS for patients with corrected SUV(max) < 6 was 25.7 ± 11.14 months, and the mean DFS for patients with corrected SUV(max) ≥ 6 was 7.88 ± 7.1 months (p < 0.018). Among patients with corrected SUV(max) < 6, none died, and the mean length of follow-up for this group was 35.2 ± 9.96 months. All of the patients who died had corrected SUV(max) ≥ 6, and the overall survival for this group was 13.28 ± 12.89 months (p < 0.001). CONCLUSION FDG uptake, as measured by corrected SUV(max), may be a predictive imaging biomarker for DFS and overall survival in patients with head-and-neck non-SCC.

Posttreatment CT and MR imaging in head and neck cancer: what the radiologist needs to know.

In patients with head and neck cancer, posttreatment imaging can be complicated and difficult to interpret because of the complexity of the surgical procedures performed and the postirradiation changes, but such imaging is critical for the evaluation of (a) the response to therapy and (b) tumor control. Posttreatment changes are affected by the type of surgery performed, reconstruction, neck dissection, and radiation therapy. Three types of flaps are used for reconstruction in the head and neck region: (a) the local flap, with geometric repositioning of adjacent tissue; (b) the pedicle flap, with rotation of donor tissue and preservation of the original vascular system; and (c) the free flap, with transfer of tissue that is revascularized by using microvascular surgical techniques. The posttreatment imaging findings in patients with head and neck cancer can be divided into four groups: altered anatomy secondary to surgical reconstruction, tumor recurrence, potential postsurgical complications, and possible postirradiation changes. Potential postsurgical complications are wound infection, abscess, fistula, flap necrosis, hematoma, chylous fistula, and serous retention. Possible postirradiation changes include mucosal necrosis, osteoradionecrosis, radiation-induced vasculopathy, radiation pneumonitis, radiation lung fibrosis, radiation-induced brain necrosis, and radiation-induced secondary malignancies. A familiarity with the imaging characteristics of posttreatment changes and of the potential complications caused by surgery and irradiation and an ability to differentiate these findings from tumor recurrence are essential for posttreatment surveillance and follow-up management of patients with head and neck cancer.

Parotid Gland Tumors: Preliminary Data for the Value of FDG PET/CT Diagnostic Parameters

OBJECTIVE The purpose of this article is to establish (18)F-FDG metabolic imaging parameters to differentiate benign and malignant tumors of the parotid gland. MATERIALS AND METHODS Forty-nine patients with increased FDG uptake in the parotid gland were selected for the study group (29 men and 20 women; mean age, 63.14 ± 12.32 years). Another 49 patients without head and neck malignancies were selected as the control group (24 men and 25 women; mean age, 65.80 ± 11.51 years); they did not have a parotid lesion or increased FDG uptake in the parotid gland. Maximum standardized uptake value (SUV(max)) was obtained for all patients. Metabolic tumor volume and total glycolytic activity were measured in patients with a discrete parotid lesion (n = 24). Nonparameteric Student t test (Mann-Whitney U test) was performed for between-group analysis. RESULTS The median SUV(max) of the increased diffuse uptake (2.55; interquartile range [IQR], 1.03-4.07) was significantly lower than the median SUV(max) of tumors (8.48; IQR, 1.46-15.5) (p < 0.01). The median SUV(max) of malignant tumors (11.8; IQR, 4.45-19.15) was significantly (p < 0.05) higher than that of benign tumors (6.4; IQR, 3.4-9.0). There was significant difference (p = 0.003) in the median metabolic tumor volume for malignant tumors (8.9; IQR, 5.1-25.5) and benign tumors or lesions (1.4; IQR, 1.00-2.9). Similar results were found for total glycolytic activity for malignant tumors (67.9; IQR, 24.2-137.6) and benign tumors or lesions (8.4; IQR, 3.9-13.6) (p = 0.002). CONCLUSION FDG PET/CT SUV(max), metabolic tumor volume, and total glycolytic activity are imaging parameters to differentiate benign and malignant tumors of the parotid gland.

FDG PET Metabolic Tumor Volume Segmentation and Pathologic Volume of Primary Human Solid Tumors

OBJECTIVE The purpose of this study was to establish the correlation and reliability among the pathologic tumor volume and gradient and fixed threshold segmentations of (18)F-FDG PET metabolic tumor volume of human solid tumors. MATERIALS AND METHODS There were 52 patients included in the study who had undergone baseline PET/CT with subsequent resection of head and neck, lung, and colorectal tumors. The pathologic volume was calculated from three dimensions of the gross tumor specimen as a reference standard. The primary tumor metabolic tumor volume was segmented using gradient and 30%, 40%, and 50% maximum standardized uptake value (SUVmax) threshold methods. Pearson correlation coefficient, intraclass correlation coefficient, and Bland-Altman analyses were performed to establish the correlation and reliability among the pathologic volume and segmented metabolic tumor volume. RESULTS The mean pathologic volume; gradient-based metabolic tumor volume; and 30%, 40%, and 50% SUVmax threshold metabolic tumor volumes were 13.46, 13.75, 15.47, 10.63, and 7.57 mL, respectively. The intraclass correlation coefficients among the pathologic volume and the gradient-based and 30%, 40%, and 50% SUVmax threshold metabolic tumor volumes were 0.95, 0.85, 0.80, and 0.76, respectively. The Bland-Altman biases were -0.3, -2.0, 2.82, and 5.9 mL, respectively. Of the small tumors (< 10 mL), 23 of the 35 patients had PET segmented volume outside 50% of the pathologic volume, and among the large tumors (≥ 10 mL) three of the 17 patients had PET segmented volumes that were outside 50% of pathologic volume. CONCLUSION FDG PET metabolic tumor volume estimated using gradient segmentation had superior correlation and reliability with the estimated ellipsoid pathologic volume of the tumors compared with threshold method segmentation.

Outcomes in head and neck oncologic surgery at academic medical centers in the united states

To evaluate the impact of case volume and other variables on outcomes after head and neck oncologic surgery was performed at academic medical centers in the United States.

Long-Term Results of Conformal Radiotherapy for Progressive Airway Amyloidosis

PURPOSE To evaluate the efficacy of conformal external beam radiotherapy (RT) for local control of progressive airway amyloidosis. METHODS AND MATERIALS We conducted a retrospective review of patients with biopsy-proven progressive airway amyloidosis treated with conformal RT between 2000 and 2006 at Boston Medical Center. The patients were evaluated for performance status and pulmonary function, with computed tomography and endoscopy after RT compared with the pretreatment studies. Local control was defined as the lack of progression of airway wall thickening on computed tomography imaging and stable endobronchial deposits by endoscopy. RESULTS A total of 10 symptomatic airway amyloidosis patients (3 laryngeal and 7 tracheobronchial) received RT to a median total dose of 20 Gy in 10 fractions within 2 weeks. At a median follow-up of 6.7 years (range, 1.5-10.3), 8 of the 10 patients had local control. The remaining 2 patients underwent repeat RT 6 and 8.4 months after initial RT, 1 for persistent bronchial obstruction and 1 for progression of subglottic amyloid disease with subsequent disease control. The Eastern Cooperative Oncology Group performance status improved at a median of 18 months after RT compared with the baseline values, from a median score of 2 to a median of 1 (p = .035). Airflow (forced expiratory volume in 1 second) measurements increased compared with the baseline values at each follow-up evaluation, reaching a 10.7% increase (p = .087) at the last testing (median duration, 64.8 months). Acute toxicity was limited to Grade 1-2 esophagitis, occurring in 40% of patients. No late toxicity was observed. CONCLUSIONS RT prevented progressive amyloid deposition in 8 of 10 patients, resulting in a marginally increased forced expiratory volume in 1 second, and improved functional capacity, without late morbidity.

Racial disparities in laryngeal cancer treatment and outcome: A population-based analysis of 24,069 patients

To determine the impact of race on laryngeal preservation strategies and overall survival (OS) for laryngeal squamous cell carcinoma (SCC).

Radiation Dose to the Brachial Plexus in Head-and-Neck Intensity-Modulated Radiation Therapy and Its Relationship to Tumor and Nodal Stage

PURPOSE The purpose of this retrospective study was to determine tumor factors contributing to brachial plexus (BP) dose in head-and-neck cancer (HNC) patients treated with intensity-modulated radiotherapy (IMRT) when the BP is routinely contoured as an organ at risk (OAR) for IMRT optimization. METHODS AND MATERIALS From 2004 to 2011, a total of 114 HNC patients underwent IMRT to a total dose of 69.96 Gy in 33 fractions, with the right and left BP prospectively contoured as separate OARs in 111 patients and the ipsilateral BP contoured in 3 patients (total, 225 BP). Staging category T4 and N2/3 disease were present in 34 (29.8%) and 74 (64.9%) patients, respectively. During IMRT optimization, the intent was to keep the maximum BP dose to ≤60 Gy, but prioritizing tumor coverage over achieving the BP constraints. BP dose parameters were compared with tumor and nodal stage. RESULTS With a median follow-up of 16.2 months, 43 (37.7%) patients had ≥24 months of follow-up with no brachial plexopathy reported. Mean BP volume was 8.2 ± 4.5 cm(3). Mean BP maximum dose was 58.1 ± 12.2 Gy, and BP mean dose was 42.2 ± 11.3 Gy. The BP maximum dose was ≤60, ≤66, and ≤70 Gy in 122 (54.2%), 185 (82.2%), and 203 (90.2%) BP, respectively. For oropharynx, hypopharynx, and larynx sites, the mean BP maximum dose was 58.4 Gy and 63.4 Gy in T0-3 and T4 disease, respectively (p = 0.002). Mean BP maximum dose with N0/1 and N2/3 disease was 52.8 Gy and 60.9 Gy, respectively (p < 0.0001). CONCLUSIONS In head-and-neck IMRT, dose constraints for the BP are difficult to achieve to ≤60 to 66 Gy with T4 disease of the larynx, hypopharynx, and oropharynx or N2/3 disease. The risk of brachial plexopathy is likely very small in HNC patients undergoing IMRT, although longer follow-up is required.

Head and neck squamous cell cancer (stages III and IV) induction chemotherapy assessment: Value of FDG volumetric imaging parameters

To evaluate whether the change in the metabolic tumour volume (MTV) or total lesion glycolysis (TLG) of the primary tumour, before and after induction chemotherapy, predicts outcome for patients with advanced head and neck squamous cell cancer (SCC).