¹⁸F-FDG-PET imaging in radiotherapy tumor volume delineation in treatment of head and neck cancer.

PURPOSE To determine the impact of (18)F-fluorodeoxyglucose positron emission tomography (PET) in radiotherapy target delineation and patient management for head and neck squamous cell carcinoma (HNSCC) compared to computed tomography (CT) alone. MATERIALS AND METHODS Twenty-nine patients with HNSCC were included. CT and PET/CT obtained for treatment planning purposes were reviewed respectively by a neuroradiologist and a nuclear medicine specialist who were blinded to the findings from each other. The attending radiation oncologist together with the neuroradiologist initially defined all gross tumor volume of the primary (GTVp) and the suspicious lymph nodes (GTVn) on CT. Subsequently, the same radiation oncologist and the nuclear medicine specialist defined the GTVp and GTVn on (18)F-FDG-PET/CT. Upon disagreement between CT and (18)F-FDG-PET on the status of a particular lymph node, an ultrasound-guided fine needle aspiration was performed. Volumes based on CT and (18)F-FDG-PET were compared with a paired Student's t-test. RESULTS For the primary disease, four patients had previous diagnostic tonsillectomy and therefore, FDG uptake occurred in 25 patients. For these patients, GTVp contoured on (18)F-FDG-PET (GTVp-PET) were smaller than the GTVp contoured on CT (GTVp-CT) in 80% of the cases, leading to a statistically significant volume difference (p=0.001). Of the 60 lymph nodes suspicious on PET, 55 were also detected on CT. No volume change was observed (p=0.08). Ten biopsies were performed for lymph nodes that were discordant between modalities and all were of benign histology. Distant metastases were found in two patients and one had a newly diagnosed lung adenocarcinoma. CONCLUSIONS GTVp-CT was significantly larger when compared to GTVp-PET. No such change was observed for the lymph nodes. (18)F-FDG-PET modified treatment management in three patients, including two for which no curative radiotherapy was attempted. Larger multicenter studies are needed to ascertain whether combined (18)F-FDG-PET/CT in target delineation can influence the main clinical outcomes.

[1]  L. Chiedozi,et al.  Fine Needle Aspiration Cytology of Head and Neck Masses , 2003, Acta Cytologica.

[2]  Gábor Székely,et al.  Assessment of 18F PET signals for automatic target volume definition in radiotherapy treatment planning. , 2006, Radiotherapy and oncology : journal of the European Society for Therapeutic Radiology and Oncology.

[3]  Gianluca Valentini,et al.  Radiotherapy planning: PET/CT scanner performances in the definition of gross tumour volume and clinical target volume , 2005, European Journal of Nuclear Medicine and Molecular Imaging.

[4]  Marco Brambilla,et al.  FDG-PET/CT imaging for staging and radiotherapy treatment planning of head and neck carcinoma , 2008, Radiation oncology.

[5]  David Schuster,et al.  Comparison of CT- and FDG-PET-defined gross tumor volume in intensity-modulated radiotherapy for head-and-neck cancer. , 2005, International journal of radiation oncology, biology, physics.

[6]  Massimo Bellomi,et al.  Perfusion Computed Tomography for Monitoring Induction Chemotherapy in Patients With Squamous Cell Carcinoma of the Upper Aerodigestive Tract: Correlation Between Changes in Tumor Perfusion and Tumor Volume , 2009, Journal of computer assisted tomography.

[7]  Philippe Lambin,et al.  The current status of FDG-PET in tumour volume definition in radiotherapy treatment planning. , 2006, Cancer treatment reviews.

[8]  Johan Bussink,et al.  Clinical evidence on PET-CT for radiation therapy planning in head and neck tumours. , 2010, Radiotherapy and oncology : journal of the European Society for Therapeutic Radiology and Oncology.

[9]  S. Rafla,et al.  The impact of positron emission tomography/computed tomography in edge delineation of gross tumor volume for head and neck cancers. , 2007, International journal of radiation oncology, biology, physics.

[10]  G Antoch,et al.  PET/CT for the staging and follow-up of patients with malignancies. , 2009, European journal of radiology.

[11]  J. Thie.  Understanding the standardized uptake value, its methods, and implications for usage. , 2004, Journal of nuclear medicine : official publication, Society of Nuclear Medicine.

[12]  Matthew C. Miller,et al.  Correlation of Positron Emission Tomography with Fine Needle Aspiration Biopsies in Head and Neck Malignancy , 2010, Acta Cytologica.

[13]  D. Gor,et al.  Imaging of cervical lymph nodes in head and neck cancer: the basics. , 2006, Radiologic clinics of North America.

[14]  Mithat Gonen,et al.  Clinical implications of different image reconstruction parameters for interpretation of whole-body PET studies in cancer patients. , 2004, Journal of nuclear medicine : official publication, Society of Nuclear Medicine.

[15]  Peter A S Johnstone,et al.  FDG-PET in radiotherapy treatment planning: Pandora's box? , 2004, International journal of radiation oncology, biology, physics.

[16]  M Partridge,et al.  Advanced imaging applied to radiotherapy planning in head and neck cancer: a clinical review. , 2006, The British journal of radiology.

[17]  A. Riegel,et al.  Variability of gross tumor volume delineation in head-and-neck cancer using CT and PET/CT fusion. , 2005, International journal of radiation oncology, biology, physics.

[18]  Agnese Cecconi,et al.  Combined 18F-FDG-PET/CT imaging in radiotherapy target delineation for head-and-neck cancer. , 2009, International journal of radiation oncology, biology, physics.

[19]  J. Buatti,et al.  Pathology and FDG PET Correlation of Residual Lymph Nodes in Head and Neck Cancer After Radiation Treatment , 2007, American journal of clinical oncology.

[20]  Mithat Gonen,et al.  Diagnostic and Prognostic Value of [18F]Fluorodeoxyglucose Positron Emission Tomography for Recurrent Head and Neck Squamous Cell Carcinoma , 2002 .

[21]  Tomio Inoue,et al.  Use of PET and PET/CT for radiation therapy planning: IAEA expert report 2006-2007. , 2009, Radiotherapy and oncology : journal of the European Society for Therapeutic Radiology and Oncology.

[22]  Elisabeth Kjellén,et al.  FDG PET studies during treatment: Prediction of therapy outcome in head and neck squamous cell carcinoma , 2002, Head and Neck.

[23]  Anil Sethi,et al.  Correlation of PET standard uptake value and CT window-level thresholds for target delineation in CT-based radiation treatment planning. , 2007, International journal of radiation oncology, biology, physics.

[24]  David Schuster,et al.  F‐18 FDG PET‐CT fusion in radiotherapy treatment planning for head and neck cancer , 2005, Head & neck.

[25]  John P A Ioannidis,et al.  F-Fluorodeoxyglucose Positron Emission Tomography to Evaluate Cervical Node Metastases in Patients With Head and Neck Squamous Cell Carcinoma: A Meta-analysis , 2008 .

[26]  Cyrill Burger,et al.  [18FDG] PET-CT-based intensity-modulated radiotherapy treatment planning of head and neck cancer. , 2007, International journal of radiation oncology, biology, physics.

[27]  M Schwaiger,et al.  Comparison of fluorine-18-fluorodeoxyglucose PET, MRI and endoscopy for staging head and neck squamous-cell carcinomas. , 1995, Journal of nuclear medicine : official publication, Society of Nuclear Medicine.

[28]  Paul Kinahan,et al.  SUV varies with time after injection in (18)F-FDG PET of breast cancer: characterization and method to adjust for time differences. , 2003, Journal of nuclear medicine : official publication, Society of Nuclear Medicine.

[29]  J. Lee,et al.  Segmentation of positron emission tomography images: some recommendations for target delineation in radiation oncology. , 2010, Radiotherapy and oncology : journal of the European Society for Therapeutic Radiology and Oncology.

[30]  S. Berlangieri,et al.  Evaluation of 18F-Fluorodeoxyglucose Positron Emission Tomography and Computed Tomography With Histopathologic Correlation in the Initial Staging of Head and Neck Cancer , 2002 .

[31]  Dwight E Heron,et al.  Hybrid PET-CT simulation for radiation treatment planning in head-and-neck cancers: a brief technical report. , 2004, International journal of radiation oncology, biology, physics.

[32]  Dean Billheimer,et al.  Prospective feasibility trial of radiotherapy target definition for head and neck cancer using 3-dimensional PET and CT imaging. , 2004, Journal of nuclear medicine : official publication, Society of Nuclear Medicine.

[33]  P. Flamen,et al.  Role of positron emission tomography in the management of head and neck cancer in the molecular therapy era , 2008, Current opinion in oncology.

[34]  V. Lowe,et al.  Positron emission tomography in the pretreatment evaluation and follow-up of non-small cell lung cancer patients treated with radiotherapy: preliminary findings. , 1996, American Journal of Clinical Oncology.

[35]  T. Yen,et al.  Detection of recurrent or persistent nasopharyngeal carcinomas after radiotherapy with 18-fluoro-2-deoxyglucose positron emission tomography and comparison with computed tomography. , 1998, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[36]  Curtis B Caldwell,et al.  The impact of (18)FDG-PET on target and critical organs in CT-based treatment planning of patients with poorly defined non-small-cell lung carcinoma: a prospective study. , 2002, International journal of radiation oncology, biology, physics.

[37]  V. Lowe,et al.  Correlation of Fine Needle Aspiration Biopsy and Fluoride-18 Fluorodeoxyglucose Positron Emission Tomography in the Assessment of Locally Recurrent and Metastatic Head and Neck Neoplasia , 1998, Acta Cytologica.

[38]  C. Rübe,et al.  Comparison of different methods for delineation of 18F-FDG PET-positive tissue for target volume definition in radiotherapy of patients with non-Small cell lung cancer. , 2005, Journal of nuclear medicine : official publication, Society of Nuclear Medicine.

[39]  N. Tamaki,et al.  Assessment of cervical lymph node metastases using FDG-PET in patients with head and neck cancer , 2008, Annals of nuclear medicine.

[40]  C C Ling,et al.  Towards multidimensional radiotherapy (MD-CRT): biological imaging and biological conformality. , 2000, International journal of radiation oncology, biology, physics.

[41]  Philippe Lambin,et al.  Effects of radiotherapy planning with a dedicated combined PET-CT-simulator of patients with non-small cell lung cancer on dose limiting normal tissues and radiation dose-escalation: a planning study. , 2005, Radiotherapy and oncology : journal of the European Society for Therapeutic Radiology and Oncology.

[42]  S. Cerovic,et al.  Fine needle aspiration cytology in the diagnosis of head and neck masses: accuracy and diagnostic problems. , 2009, Journal of B.U.ON. : official journal of the Balkan Union of Oncology.

[43]  Karin Haustermans,et al.  PET-based treatment planning in radiotherapy: a new standard? , 2007, Journal of nuclear medicine : official publication, Society of Nuclear Medicine.

[44]  Anne Bol,et al.  Tri-dimensional automatic segmentation of PET volumes based on measured source-to-background ratios: influence of reconstruction algorithms. , 2003, Radiotherapy and oncology : journal of the European Society for Therapeutic Radiology and Oncology.

[45]  F. Fazio,et al.  Feasibility of [18F]FDG-PET and coregistered CT on clinical target volume definition of advanced non-small cell lung cancer. , 2005, The quarterly journal of nuclear medicine and molecular imaging : official publication of the Italian Association of Nuclear Medicine (AIMN) [and] the International Association of Radiopharmacology (IAR), [and] Section of the Society of....

[46]  T S Koh,et al.  Perfusion CT in Squamous Cell Carcinoma of the Upper Aerodigestive Tract: Long-Term Predictive Value of Baseline Perfusion CT Measurements , 2010, American Journal of Neuroradiology.

[47]  A. Lammertsma,et al.  Monitoring response to therapy in cancer using [18F]-2-fluoro-2-deoxy-d-glucose and positron emission tomography: an overview of different analytical methods , 2000, European Journal of Nuclear Medicine.

[48]  D P Dearnaley,et al.  Intensity modulated radiation therapy: a clinical review. , 2000, The British journal of radiology.

[49]  Daniela Thorwarth,et al.  Physical radiotherapy treatment planning based on functional PET/CT data. , 2010, Radiotherapy and oncology : journal of the European Society for Therapeutic Radiology and Oncology.

[50]  R Mohan,et al.  The potential for sparing of parotids and escalation of biologically effective dose with intensity-modulated radiation treatments of head and neck cancers: a treatment design study. , 2000, International journal of radiation oncology, biology, physics.

[51]  Lale Kostakoglu,et al.  Correlation of positron emission tomography standard uptake value and pathologic specimen size in cancer of the head and neck. , 2008, International journal of radiation oncology, biology, physics.

[52]  S U Berlangieri,et al.  The contribution of 18F-fluoro-2-deoxy-glucose positron emission tomographic imaging to radiotherapy planning in lung cancer. , 1998, Lung cancer.

[53]  J C Rosenwald,et al.  CT and (18)F-deoxyglucose (FDG) image fusion for optimization of conformal radiotherapy of lung cancers. , 2001, International journal of radiation oncology, biology, physics.

[54]  Tohru Shiga,et al.  Image fusion between 18FDG-PET and MRI/CT for radiotherapy planning of oropharyngeal and nasopharyngeal carcinomas. , 2002, International journal of radiation oncology, biology, physics.

[55]  Jeroen J. Bax,et al.  Diagnostic and Prognostic Value , 2012 .

[56]  Cyrill Burger,et al.  Radiation treatment planning with an integrated positron emission and computer tomography (PET/CT): a feasibility study. , 2003, International journal of radiation oncology, biology, physics.

[57]  K Schnabel,et al.  18F-deoxyglucose positron emission tomography (FDG-PET) for the planning of radiotherapy in lung cancer: high impact in patients with atelectasis. , 1999, International journal of radiation oncology, biology, physics.

[58]  R. Boellaard,et al.  Effects of noise, image resolution, and ROI definition on the accuracy of standard uptake values: a simulation study. , 2004, Journal of nuclear medicine : official publication, Society of Nuclear Medicine.

[59]  Reubendra Jeganathan,et al.  Does pre-operative estimation of oesophageal tumour metabolic length using 18F-fluorodeoxyglucose PET/CT images compare with surgical pathology length? , 2011, European Journal of Nuclear Medicine and Molecular Imaging.

[60]  J. A. Lee,et al.  Rôle potentiel de la TEP-FDG pour la définition du volume tumoral macroscopique (GTV) des cancers des voies aérodigestives supérieures et du poumon , 2009 .

[61]  Giuseppe Lucio Cascini,et al.  Current status of PET/CT for tumour volume definition in radiotherapy treatment planning for non-small cell lung cancer (NSCLC). , 2007, Lung cancer.

[62]  J L Roodenburg,et al.  Detection of lymph node metastases of squamous-cell cancer of the head and neck with FDG-PET and MRI. , 1995, Journal of nuclear medicine : official publication, Society of Nuclear Medicine.

[63]  Sasa Mutic,et al.  Impact of FDG-PET on radiation therapy volume delineation in non-small-cell lung cancer. , 2004, International journal of radiation oncology, biology, physics.

[64]  Slobodan Devic,et al.  Impact of FDG-PET/CT on radiotherapy volume delineation in non-small-cell lung cancer and correlation of imaging stage with pathologic findings. , 2008, International journal of radiation oncology, biology, physics.

[65]  X Allen Li,et al.  Initial experience of FDG-PET/CT guided IMRT of head-and-neck carcinoma. , 2006, International journal of radiation oncology, biology, physics.

[66]  B. Nowak,et al.  Diagnosis and staging of head and neck cancer: a comparison of modern imaging modalities (positron emission tomography, computed tomography, color-coded duplex sonography) with panendoscopic and histopathologic findings. , 2000, Archives of otolaryngology--head & neck surgery.

[67]  Vincent Grégoire,et al.  Positron emission tomography with [18F]fluorodeoxyglucose improves staging and patient management in patients with head and neck squamous cell carcinoma: a multicenter prospective study. , 2010, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[68]  T. Turkington,et al.  Clinical applications of PET in oncology. , 2004, Radiology.

[69]  Peter H Ahn,et al.  Positron emission tomography/computed tomography for target delineation in head and neck cancers. , 2008, Seminars in nuclear medicine.

[70]  E. Hall,et al.  Radiation oncology: a century of achievements , 2004, Nature Reviews Cancer.

[71]  P. Grigsby,et al.  Measurement of tumor volume by PET to evaluate prognosis in patients with advanced cervical cancer treated by radiation therapy. , 2002, International journal of radiation oncology, biology, physics.

[72]  R K Ten Haken,et al.  Conformal and intensity modulated irradiation of head and neck cancer: the potential for improved target irradiation, salivary gland function, and quality of life. , 1999, Acta oto-rhino-laryngologica Belgica.

[73]  Jean-François Daisne,et al.  Tumor volume in pharyngolaryngeal squamous cell carcinoma: comparison at CT, MR imaging, and FDG PET and validation with surgical specimen. , 2004, Radiology.