60 / 220
showed that initial PET/CT is important not only for
staging and management planning but also for prog-
nostic stratification.
In conclusion, this large prospective study demon-
strated that incorporating
18
F-FDG PET/CT in CWU
staging provided valuable additional information that
altered the management plan in 15.7% of patients,
largely because this modality detected metastatic disease
or SPCs. PET/CT staging was significantly more pre-
dictive of OS and PFS outcomes than CWU staging.
Our findings suggest that the incorporation of PET/CT
into routine clinical practice for the primary staging of
HNSCC could aid the planning of treatment and the
prediction of survival outcomes.
Fig. 2. Kaplan
e
Meier curves of progression-free survival (PFS) (A) and overall survival (OS) (B) according to the impact of PET/CT on
the conventional workup-determined management plan of all patients. Patients with high impact had significantly worse PFS and OS than
those with no/low impact (3-year PFS
Z
28.6% versus 74.6%,
P
0.001; 3-year OS
Z
40% versus 85.7%,
P
<
0.001). However, patients with
moderate impact did not significantly differ in terms of PFS or OS from patients with no/low impact.
Table 3
Factors affecting progression-free and overall survival outcomes in the study patients (
N
Z
248).
Variable
Progression-free survival
Overall survival
Univariate
Multivariate
Univariate
Multivariate
HR 95% CI
P
HR 95% CI
P
a
HR 95% CI
P
HR 95% CI
P
a
Age
>
60 years
1.48 0.91
e
2.40 0.111
1.43 0.80
e
2.58 0.224
Sex, female
1.68 0.94
e
2.98 0.075
1.142 0.53
e
2.45 0.733
Smoking
>
20 pack-year
1.20 0.43
e
13.32 0.718
1.04 0.58
e
1.87 0.878
Alcohol 1 drink per day 1.05 0.62
e
1.78 0.831
1.428 0.72
e
2.81 0.304
Tumour site
Non-oropharynx
1.87 0.95
e
3.67 0.066
1.44 0.67
e
3.10 0.343
Tumour differentiation, poor 1.30 0.73
e
2.32 0.366
1.56 0.34
e
7.13 0.565
Primary treatment
b
Nonsurgical treatment
0.73 0.43
e
1.21 0.226
0.93 0.51
e
1.70 0.826
Conventional workup staging
Nodal classification, N2
e
3 1.76 1.09
e
2.85
0.020
2.67 1.49
e
4.77
0.001
TNM stage, III
e
IV
1.71 1.04
e
2.59
0.031
3.83 1.90
e
7.73
<
0.001
PET/CT staging
Nodal classification, N2
e
3 1.67 1.02
e
2.76
0.009
3.11 1.69
e
5.72
<
0.001
TNM stage, III
e
IV
2.10 1.26
e
3.52
0.005
2.05 1.25
e
3.44
0.007
5.21 2.33
e
11.67
<
0.001
4.70 2.08
e
10.60
<
0.001
Second primary cancer
2.63 1.34
e
5.17
0.005
2.30 1.16
e
4.54
0.016
4.01 1.99
e
8.10
<
0.001
3.07 1.51
e
6.23
0.002
Abbreviations: CI, confidence interval; CT, computed tomography CRT, concurrent chemoradiation therapy; HR, hazard ratio; ICT, induction
chemotherapy; PET, positron emission tomography; RT, radiotherapy.
a
In multivariate analysis, Cox proportional hazard regression analyses were performed with backward elimination using variables with
P
values
<
0.05 on univariate analyses. Values in bold indicate
P
<
0.05.
b
The treatment modalities were divided into two major categories as follows: surgical treatment included surgery alone, surgery plus adjuvant
RT or CRT, and ICT followed by definite surgery. Non-surgical treatment included definite CRT or RT and ICT followed by definite CRT with
or without salvage surgery.
I.S. Ryu et al. / European Journal of Cancer 63 (2016) 88
e
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