Prognostic value of intratumoral metabolic heterogeneity on F-18 fluorodeoxyglucose positron emission tomography/computed tomography in locally advanced cervical cancer patients treated with concurrent chemoradiotherapy

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// Gun Oh Chong 1, * , Won Kee Lee 2, * , Shin Young Jeong 3 , Shin-Hyung Park 4 , Yoon Hee Lee 1 , Sang-Woo Lee 3 , Dae Gy Hong 1 , Jae-Chul Kim 4 and Yoon Soon Lee 1 1 Department of Obstetrics and Gynecology, Kyungpook National University Medical Center, School of Medicine, Daegu, Republic of Korea 2 Medical Research Collaboration Center in KNUH, Kyungpook National University, School of Medicine, Daegu, Republic of Korea 3 Department of Nuclear Medicine, Kyungpook National University Medical Center, School of Medicine, Daegu, Republic of Korea 4 Department of Radiation Oncology, Kyungpook National University Medical Center, School of Medicine, Daegu, Republic of Korea * These authors contributed equally to this work as co-first authors Correspondence to: Shin Young Jeong, email: syjeongnm@gmail.com Keywords: intratumoral metabolic heterogeneity, locally advanced cervical cancer, 18F-FDG PET/CT, concurrent chemoradiotherapy, prognosis Received: April 19, 2017 Accepted: June 11, 2017 Published: June 28, 2017 ABSTRACT Objective: To evaluate the prognostic value for predicting tumor recurrence of intratumoral metabolic heterogeneity and traditional quantitative metabolic parameters on pre-treatment F-18-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) in patients with locally advanced cervical cancer treated with concurrent chemoradiotherapy (CCRT). Materials and Methods: Ninety-three patients with biopsy-proven cervical cancer and treated with CCRT (FIGO stage IIB-IV) were enrolled in this study. The traditional metabolic parameters of the primary tumor, regional lymph node, and whole body (maximum standardized uptake value [SUVmax], metabolic tumor volume [MTV], and total lesion glycolysis), and intratumoral heterogeneity factor (HF) were measured on pre-treatment 18F-FDG PET/CT images. Univariate and multivariate analyses for disease-free survival (DFS) were performed using clinical and metabolic parameters. The additional HF prognostic value was evaluated by means of time-dependent receiver operating characteristic curve, integrated discrimination improvement, and net reclassification improvement. Results: On multivariate analysis, nodal SUVmax (hazard ratio 3.60; 95% CI, 1.66–7.85; p = 0.0012) and whole body MTV (WBMTV; hazard ratio 3.15; 95% CI, 1.17–8.53; p = 0.0236) were significant prognostic factors for DFS. When HF was combined with nodal SUVmax and WBMTV, a significant improvement in discrimination for recurrence was observed compared with nodal SUVmax alone (area under curve 0.817 vs. 0.732; p = 0.0028). Conclusions: HF did not show superiority over traditional metabolic parameters. However, when HF was combined with nodal SUVmax and WBMTV, the predictive value for tumor recurrence improved. Therefore, HF may be a useful additional prognostic biomarker to improve the prognostic value of traditional metabolic parameters on 18F-FDG PET/CT.