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March 26, 2020

Evaluation of the Prognostic Value of FDG PET/CT Parameters for Patients With Surgically Treated Head and Neck Cancer: A Systematic Review

Author Affiliations
  • 1Department of Otolaryngology–Head and Neck Surgery, Rennes University Hospital, Rennes, France
  • 2Department of Nuclear Medicine, Centre Eugène Marquis, Rennes, France
  • 3University of Applied Sciences and Arts Western Switzerland, Lausanne, Switzerland
  • 4LTSI (Image and Signal Processing Laboratory), INSERM, U1099, Rennes, France
  • 5Department of Radiation Oncology, Cancer Institute Eugène Marquis, Rennes, France
JAMA Otolaryngol Head Neck Surg. 2020;146(5):471-479. doi:10.1001/jamaoto.2020.0014
Key Points

Question  Is there an association between parameters of fluorodeoxyglucose F 18–labeled positron emission tomography and computed tomography (FDG-PET/CT) and prognosis among patients with surgically treated head and neck cancer?

Findings  This systematic review of 36 studies that included 3585 unique patients highlights the prognostic value of FDG-PET/CT parameters, especially volumetric parameters, as biomarkers of overall survival, disease-free survival, and distant metastasis among patients with surgically treated head and neck cancer.

Meaning  The findings of this review suggest that FDG-PET/CT parameters may be used to identify patients with a higher risk of postsurgical disease progression who could then receive early therapeutic intensification to improve their prognosis without increasing iatrogenic toxic effects; however, further research is required to define a reproducible, reliable FDG-PET/CT–based prognostic model of patients’ mortality and recurrence risks.


Importance  Head and neck squamous cell cancer (HNSCC) represents the seventh most frequent cancer worldwide. More than half of the patients diagnosed with HNSCC are treated with primary surgery.

Objective  To report the available evidence on the value of quantitative parameters of fluorodeoxyglucose F 18–labeled positron emission tomography and computed tomography (FDG-PET/CT) performed before surgical treatment of HNSCC to estimate overall survival (OS), disease-free survival (DFS), and distant metastasis (DM) and to discuss their limitations.

Evidence Review  A systematic review of the English-language literature in PubMed/MEDLINE and ScienceDirect published between January 2003 and February 15, 2019, was performed between March 1 and July 27, 2019, to identify articles addressing the association between preoperative FDG-PET/CT parameters and oncological outcomes among patients with HNSCC. Articles included those that addressed the following: (1) cancer of the oral cavity, oropharynx, hypopharynx, or larynx; (2) surgically treated (primary or for salvage); (3) pretreatment FDG-PET/CT; (4) quantitative or semiquantitative evaluation of the FDG-PET/CT parameters; and (5) the association between the value of FDG-PET/CT parameters and clinical outcomes. Quality assessment was performed using the Oxford Centre for Evidence-Based Medicine level of evidence.

Findings  A total of 128 studies were retrieved from the databases, and 36 studies met the inclusion criteria; these studies comprised 3585 unique patients with a median follow-up of 30.6 months (range, 16-53 months). Of these 36 studies, 32 showed an association between at least 1 FDG-PET/CT parameter and oncological outcomes (OS, DFS, and DM). The FDG-PET/CT volumetric parameters (metabolic tumor volume [MTV] and total lesion glycolysis [TLG]) were independent prognostic factors in most of the data, with a higher prognostic value than the maximum standard uptake value (SUVmax). For example, in univariate analysis of OS, the SUVmax was correlated with OS in 5 of 11 studies, MTV in 11 of 12 studies, and TLG in 6 of 9 studies. The spatial distribution of metabolism via textural indices seemed promising, although that factor is currently poorly evaluated: only 3 studies analyzed data from radiomics indices.

Conclusions and Relevance  The findings of this study suggest that the prognostic effectiveness of FDG-PET/CT parameters as biomarkers of OS, DFS, and DM among patients with HNSCC treated with surgery may be valuable. The volumetric parameters (MTV and TLG) seemed relevant for identifying patients with a higher risk of postsurgical disease progression who could receive early therapeutic intervention to improve their prognosis. However, further large-scale studies including exclusively surgery-treated patients stratified according to localization and further analysis of the textural indices are required to define a reliable FDG-PET/CT–based prognostic model of mortality and recurrence risk for these patients.

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