2017 Section 7 Green Book

The team also determines which treatment is appropriate

on the basis of the CWU stage, and then the decision was

written in medical records. Depending on the location of

the primary tumour and clinical stage, the treatment op-

tions are definitive definite radiotherapy (RT), chemo-

radiotherapy (CRT), induction chemotherapy (ICT),

and/or surgery.

During the study period, all patients underwent

F-

FDG PET/CT using a Biograph Sensation 16 or True

Point 40 System (Siemens Medical Systems, Knoxville,

TN) after CWU. Patients were required to fast for an

average time of 13.6 h (standard deviation [SD], 16.0;

range, 7

20). The average patient blood glucose level

was 102 (SD, 16.1; range, 67

149) mg/dL. Patients were

injected with an average of 398.6 (SD, 216.5; range,

372

555) MBq of

F-FDG and incubated for an

average period of 60.2 min (SD, 6.2; range, 51

70).

Before acquiring the PET emission data, spiral CT

scanning was performed in spiral mode from the skull

base to the proximal thigh at 100 mAs and 120 kV, with

a section width of 5 mm and collimation of 0.75 mm. No

oral or intravenous contrast medium was used. The PET

results were reconstructed using CT attenuation

correction, an attenuation-weighted algorithm (2 itera-

tions and 16 subsets), and a post-reconstruction

smoothing Gaussian filter (full width at half

maximum

6 mm). Images were reconstructed using a

168 168 matrix (pixel size

5.3 mm).

The PET/CT findings were then reviewed on the

workstation by an experienced nuclear medicine physi-

cian (J.S.K.) who was blinded to the CWU findings.

Increased focal

F-FDG uptake in the tumour and

metastatic nodes were graded from 1 to 4, where grades

3 and 4 were regarded as evidence of tumour involve-

ment. Visual and semiquantitative analyses were used to

determine abnormally increased focal

F-FDG uptake

in comparison with the background and blood-pool

activity in the mediastinum. But strict standardised up-

take value cutoffs were not used. The CT signs for

assessing nodal metastases are based on nodal size

(shortest axial diameter

11 mm in the jugulodigastric

regions or

10 mm in other cervical regions) and shape,

the presence of central necrosis, and the presence of a

localised group of nodes in an expected node-draining

area for a specific primary tumour. The cartilage or

bone destruction by tumour was also used for image

interpretation.

The PET/CT results were added to the CWU findings

during the separate decision-making meeting. Whether

this changed the TNM classification (i.e. the T, N, and/

or M stage was altered) and management plan was then

recorded prospectively. The impact of PET/CT on the

management plan was classified as follows

[10]

: high

(change in planned treatment modality or purpose,

e.g. surgery to CRT, curative to palliative), moderate

(change in delivery within the same treatment modality,

e.g. a change in the RT target volume or a change in

extent of surgical resection), low (no change in proposed

management), or no (PET/CT result ignored).

The validation was determined by assessing the his-

topathology for the only cases in which there was the

discrepant staging and/or management change between

CWU and CWU

PET/CT results. For some patients

who underwent nonsurgical treatment, subsequent serial

imaging and clinical follow-up were also considered

when histopathologic diagnosis was not obtained

because of difficulty in approaching the suspicious ma-

lignant lesions. Of these, the validation by clinical

follow-up was regarded as ‘not assessable’ in some cases

of the use of treatment intervention (e.g. RT/CRT was

applied both neck side in case of advanced T stage) that

could alter disease extent. The latter cases were not

included in the analysis.

After the initial treatment, all patients underwent

physical and endoscopic examinations at each clinic

visit, and serial imaging workups were performed

regularly.

Table 1

Patient characteristics (

248).

Characteristics

(%)

Gender

Male/female

208 (83.9)/40 (16.1)

Age, years

Median (IQR)

61 (54

69)

Smoking,

20 pack-year

144 (58.1)

Alcohol drinking, 1 drink per day

173 (69.8)

Site of primary tumour

Oral cavity

62 (25.0)

Oropharynx

56 (22.5)

Larynx

99 (40.0)

Hypopharynx

31 (12.5)

Histological grade

WD/MD/PD/NA

67 (27.0)/137 (55.2)/35

(14.1)/9 (3.7)

Treatment

Surgery alone

70 (28.2)

Surgery

RT/CRT

77 (31.0)

surgery RT/CRT

6 (2.4)

CRT surgery

17 (6.9)

RT/CRT/CT alone

37 (14.9)/40 (16.2)/1 (0.4)

Treatment intention

Curative

241 (97.2)

Palliative

7 (2.8)

Follow-up

Follow-up period, median (range),

months

38.0 (12.3

55.3)

Disease progression

68 (27.4)

Last status, NED/AWD/DOD/DOC 191 (77.0)/11 (4.4)/37

(15.0)/9 (3.6)

Synchronous SPC found at initial staging 18 (7.3)

The data are shown as number (%) unless otherwise indicated.

Abbreviations: AWD, alive with disease; CRT, chemoradiotherapy;

CT, chemotherapy; DOC, died of other cause; DOD, died of disease

(index cancer); ICT, induction chemotherapy; IQR, interquartile

range; MD, moderated differentiated; NA, not available; NED, no

evidence of disease; PD, poorly differentiated; RT, radiotherapy; SPC,

second primary cancer; WD, well differentiated.

I.S. Ryu et al. / European Journal of Cancer 63 (2016) 88