A convolutional neural network with self-attention for fully automated metabolic tumor volume delineation of head and neck cancer in [Formula: see text]F]FDG PET/CT.

PURPOSE: PET-derived metabolic tumor volume (MTV) and total lesion glycolysis of the primary tumor are known to be prognostic of clinical outcome in head and neck cancer (HNC). Including evaluation of lymph node metastases can further increase the prognostic value of PET but accurate manual delineation and classification of all lesions is time-consuming and prone to interobserver variability. Our goal, therefore, was development and evaluation of an automated tool for MTV delineation/classification of primary tumor and lymph node metastases in PET/CT investigations of HNC patients. METHODS: Automated lesion delineation was performed with a residual 3D U-Net convolutional neural network (CNN) incorporating a multi-head self-attention block. 698 [Formula: see text]F]FDG PET/CT scans from 3 different sites and 5 public databases were used for network training and testing. An external dataset of 181 [Formula: see text]F]FDG PET/CT scans from 2 additional sites was employed to assess the generalizability of the network. In these data, primary tumor and lymph node (LN) metastases were interactively delineated and labeled by two experienced physicians. Performance of the trained network models was assessed by 5-fold cross-validation in the main dataset and by pooling results from the 5 developed models in the external dataset. The Dice similarity coefficient (DSC) for individual delineation tasks and the primary tumor/metastasis classification accuracy were used as evaluation metrics. Additionally, a survival analysis using univariate Cox regression was performed comparing achieved group separation for manual and automated delineation, respectively. RESULTS: In the cross-validation experiment, delineation of all malignant lesions with the trained U-Net models achieves DSC of 0.885, 0.805, and 0.870 for primary tumor, LN metastases, and the union of both, respectively. In external testing, the DSC reaches 0.850, 0.724, and 0.823 for primary tumor, LN metastases, and the union of both, respectively. The voxel classification accuracy was 98.0% and 97.9% in cross-validation and external data, respectively. Univariate Cox analysis in the cross-validation and the external testing reveals that manually and automatically derived total MTVs are both highly prognostic with respect to overall survival, yielding essentially identical hazard ratios (HR) ([Formula: see text]; [Formula: see text] vs. [Formula: see text]; [Formula: see text] in cross-validation and [Formula: see text]; [Formula: see text] vs. [Formula: see text]; [Formula: see text] in external testing). CONCLUSION: To the best of our knowledge, this work presents the first CNN model for successful MTV delineation and lesion classification in HNC. In the vast majority of patients, the network performs satisfactory delineation and classification of primary tumor and lymph node metastases and only rarely requires more than minimal manual correction. It is thus able to massively facilitate study data evaluation in large patient groups and also does have clear potential for supervised clinical application.

The utility of 18F-FDG PET/CT in brain tumours diagnosis.

Background: The purpose of the study was to discuss whether 2-deoxy-2-[18F]fluoro-D-glucose positron emission tomography/computed tomography (18F-FDG PET/CT) study protocol should include brain imaging. Materials and methods: Analysis of international societies recommendations compared with the original data obtained in over 1000 consecutive torso and brain 18F-FDG PET/CT studies collected in 2010. Results: According to the international societies recommendations, the 18F-FDG should not be the radiotracer of choice considering the brain region PET/CT study. However, it can be performed as an additional brain imaging tool. Based on at least a 3-year follow-up, we detected 8 cases of suspicious brain findings and no primary lesion among over 1000 consecutive torso and brain 18F-FDG PET/CT scans performed in 2010. However, in 5 out of 8 patients, the brain lesion was the only metastasis detected, affecting further therapy. Conclusions: The 18F-FDG PET/CT study may help detect malignant brain lesions and, therefore, including brain region imaging into the study protocol should be considered.

Comparison of positron emission tomography with computed tomography examination with histopathological assessment of pelvic lymph nodes in patients with cervical cancer treated surgically.

INTRODUCTION: According to the literature, fluor-18-fluorodeoxyglucose positron emission tomography with computed tomography (18F-FDG-PET-CT) is the most effective technique for the examination and detection of metastases in the lymph nodes in patients with cervical cancer. This study aimed to compare the diagnostic value of the preoperative evaluation using 18F-FDG-PET-CT with a histopathological examination of the lymph nodes removed during radical hysterectomy and pelvic lymph node dissection in patients with cervical cancer. MATERIAL AND METHODS: Retrospective analysis covered the medical records of 42 patients with cervical cancer (stage IA-IB according to International Federation of Gynaecology and Obstetrics 2009) treated with radical Piver type III hysterectomy and pelvic lymph node dissection. The preoperative diagnosis was made using a PET/CT examination. Results: The result of the 18F-FDG-PET-CT examination highlighted a suspicion of lymph node metastases in 13 patients (31%). The histopathological examination confirmed this in 12 patients (29%). Metastatic lymph nodes were correctly diagnosed using 18F-FDG-PET-CT in 8 out of the 12 cases confirmed by the histopathological examination. In the patient-based study, sensitivity, specificity, positive predictive value, negative predictive value and accuracy were 66.8%, 83.3%, 61.5%, 86.2 % and 78.6%, respectively. CONCLUSIONS: We confirmed the usefulness of PET in the preoperative assessment of cervical cancer advancement, especially in correlation with the new 2018 International Federation of Gynaecology and Obstetrics staging system.

Coexistence of a ruptured ectopic pregnancy and cervical cancer: how to avoid a diagnostic error when the same symptoms present two different diagnoses.

An ectopic pregnancy occurs in approximately 0.5-2% of all pregnancies. The number of cases of cervical cancer in women under 30 years of age in Poland is less than 100 cases per year. The case presented herein concerns a rare clinical situation of a 29-year-old woman admitted to the Gynaecological Oncology Department with a diagnosis of cervical cancer. The main symptom resulting in the patient's referral was ascites. The presence of free fluid in the peritoneal cavity in patients diagnosed with a malignant tumour suggests a high degree of progression of the underlying disease, though this could not be confirmed in a clinical study in this case. An interview, examination, and laboratory tests confirmed a coexisting life-threatening ruptured tubal pregnancy. The consequences of not recognising both an ectopic pregnancy and cervical cancer in a patient presenting with nonspecific clinical symptoms could pose a serious threat to health and life.

Evaluation of physiologic and abnormal glucose uptake in palatine tonsils: differential diagnostics with sequential dual-time-point 2-deoxy-2-[18F]FDG PET/CT.

BACKGROUND: The aim of this article was to evaluate the usefulness of sequential dual-time-point 2-deoxy-2-[18F]fluoro-D-glucose positron emission tomography/computed tomography (DTP [18F]FDG PET/CT) in distinguishing physiologic, inflammatory and malignant palatine tonsils as difficult to differentiate in the oncological practice. METHODS: A total of 90 patients before the treatment underwent sequential DTP [18F]FDG PET/CT examinations. We analyzed 104 structures in 90 patients: 31 physiologic tonsils, 28 histopathologically confirmed inflammatory tonsils of non-specified origin, 31 histopathologically confirmed palatine tonsils cancer and 14 non-malignant contralateral tonsils in patients with histopathologically confirmed unilateral palatine tonsil malignancy. Patients underwent sequential [18F]FDG PET/CT examinations at 60 and 90 minutes post-injection of the [18F]FDG. We analyzed the SUVmax and SUVmean values at 60 and 90 minutes post-injection changes over time and the Retention Index (RI-SUVmax). To find the predictive SUV value and the RI cut-off between physiology, inflammatory and malignancy, we used the ROC analysis. RESULTS: The average SUVmax values at 60 and 90minutes post-injection within physiologic palatine tonsils were 1.36±0.26 and 1.31±0.26, respectively, P>0.05. The average SUVmax values at 60 and 90 minutes post-injection within inflammatory and malignant tonsils were 3.74±1.45, 3.80±1.47 (P>0.05) and 5.19±2.19, 5.81±2.50 (P<0.05), respectively. The RI-SUVmax fluctuation over time were 5±28% within physiologic, -4±11% within contralateral non-malignant tonsils in patients with one tonsil involved, 2±11% within inflammatory and 13±13% within malignant tonsils. CONCLUSIONS: The sequential dual-time-point [18F]FDG PET/CT examinations may increase the sensitivity and the specificity of the PET/CT method in differential palatine tonsils diagnosis.

Dual-time-point PET/CT study protocol can improve the larynx cancer diagnosis.

AIM: To evaluate whether the sequential dual-time-point fluorine-18-fluorodeoxyglucose positron emission tomography/computed tomography (DTP 18F-FDG PET/CT) study improves the differential diagnosis in the larynx. BACKGROUND: In some cases, the clinical and metabolic similarity of laryngitis and larynx cancer make differential diagnostics difficult when performing standard 18F-FDG PET/CT examinations; therefore, an additional study protocol performance seems to be of reasonable value. MATERIALS AND METHODS: 90 patients (mean age: 61 ± 11 years, range: 41-84 years): 23 women (mean age: 63 ± 10 years, range: 51-84 years) and 67 men (mean age: 61 ± 11 years, range: 41-80 years) underwent delayed 18F-FDG PET/CT examinations at 60 and 90 min post intravenous injection (p.i.) of the radiopharmaceutical 18F-FDG. We compared the metabolic activity of 90 structures divided into following groups: normal larynx (30 patients), laryngitis (30 lesions) and larynx cancer (30 tumors) with maximal and mean standardized uptake value (SUVmax, SUVmean) and the retention index (RI-SUVmax). We used the receiver operating characteristics (ROC) curve to evaluate the SUVmax cut-off values. RESULTS: The SUVmax cut-off value at 60 and 90 min p.i. of 2.3 (sensitivity/specificity: 96.4%/100%) and 2.4 (94.2%/100%), respectively, distinguished normal and abnormal metabolic activity in the larynx. When laryngitis and tumors were compared, the SUVmax cut-off values obtained after initial and delayed imaging were 3.6 (87.5%/52.0%) and 6.1 (58.3%/84%), respectively. The RI-SUVmax of 1.3% (71.4%/88.1%) suggested abnormality, while RI-SUVmax of 6.6%, malignant etiology (75.0%/80.0%). CONCLUSIONS: In this study, the sequential DTP scanning protocol improved the sensitivity and specificity of the PET/CT method in terms of differential diagnosis within the larynx.

Will Rogers phenomenon in the oesophageal cancer patients staging - CT versus 18F-FDG PET/CT: retrospective study.

OBJECTIVE: The oesophageal cancer is one of the most common and aggressive malignancies, especially in elder man. The method of choice in diagnosis of the oesophageal cancer patients are the contrast-enhanced computed tomography (CT) and the 2-deoxy-2-[18F]fluoro-D-glucose positron emission tomography/computed tomography (18F-FDG PET/CT) examinations. AIM: This study is to evaluate and compare the contrast-enhanced CT and the 18F-FDG PET/CT methods of imaging in terms of the oesophageal cancer staging and restaging using the eighth edition of the tumor-node-metastasis (TNM) classification. MATERIALS AND METHODS: The studied group consisted of 25 retrospectively analyzed patients (23 men, 2 women; mean age±SD: 60±11 years, range: 33-78 years, median: 62 years, p=0.09) who underwent the contrast-enhanced CT and the 18F-FDG PET/CT scanning within one to eight weeks. All mentioned lesions were histopathologically examined. Among these patients, 12 did not receive any treatment and 13 subjects have been treated with the chemotherapy and the external beam radiotherapy using comparable therapeutic protocols. RESULTS: In 13 subjects PET/CT method occurred as more sensitive in terms of pre- and posttreatment staging than CT and in 10 from 13 cases, involving the 18F-FDG PET/CT imaging into diagnostic management affected the therapeutic protocol. In 11 cases both methods showed comaparable or similar stage of the disease and in 1 patient both methods showed no pathology. CONCLUSION: In this material, the 18F-FDG PET/CT seems to be more accurate in terms of staging in case of the oesophageal cancer TNM classification.

The effect of different segmentation methods on primary tumour metabolic volume assessed in 18F-FDG-PET/CT in patients with cervical cancer, for radiotherapy planning.

INTRODUCTION: Gynaecological cancers, including cervical cancer, often require a multidisciplinary approach that includes external beam radiotherapy, chemotherapy, and/or surgical treatment. Biological parameters of the tumour evaluated in 18F-FDG-PET/CT are used for target volume delineation in radiotherapy planning. The choice of segmentation method may affect the assessment of metabolic tumour volume (MTV) in 18F-FDG-PET/CT. AIM OF THE STUDY: To find the optimal segmentation method for the assessment of primary MTV in 18F-FDG-PET/CT in cervical cancer patients for radiotherapy planning. MATERIAL AND METHODS: Retrospective analysis was performed on a group of 30 patients with newly diagnosed, histologically confirmed cervical cancer. The primary MTVs were assessed by SUVmax and SUVmean values; three segmentation methods were used to assess the primary MTV: constant threshold of SUVmax of 2.5, threshold of SUVmax 35%, and threshold of SUV max 45%. The MTVs were compared with the tumour volumes obtained in magnetic resonance imaging (MRI), which was the "gold standard", to select the best optimal segmentation method reflecting the tumour size. Wilcoxon-Mann-Whitney and t-test were used for statistical analysis. RESULTS: Depending on the segmentation method chosen, significant differences in the MTVs were obtained (p < 0.001). The highest volumes were obtained using the method based on constant SUVmax of 2.5, while the smallest in case of threshold of SUVmax of 45%. Regarding the volume determined by MRI, a 35% SUVmax threshold was chosen as the most reliable method. CONCLUSIONS: The choice of appropriate segmentation method has a significant impact on the primary MTV assessment in 18F-FDG-PET/CT in patients with cervical cancer.

Sequential 18F-FDG PET/CT imaging parameters for differentiating benign from malignant lymph nodes in head and neck carcinoma.

OBJECTIVE: The aim of this study was to differentiate between benign and malignant head and neck lymph nodes by sequential imaging. SUBJECTS AND METHODS: The total of 56 retrospectively analysed patients with suspected or histopathologically confirmed head and neck malignancy (nasopharyngeal cancers mainly; 28 patients), before any treatment, underwent sequential fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) examinations for staging purposes. Remaining 28 patients with physiologic and histopathologically confirmed inflammatory (of non-specified origin) lymph nodes were included into this analysis. Patients underwent sequential PET/CT scans 60 and 90min post injection (p.i.) of the 18F-FDG. Semi-quantitative analysis of metabolic activity within lymph nodes was based on the standardized uptake value (SUV) evaluation. To compare the metabolic activity fluctuation over time, the retention index (RI) was used. For SUV value and RI cut-off evaluation, the receiver operating characteristic (ROC) analysis was performed. RESULTS: The SUVmax value at 60min p.i. of physiologic, inflammatory and malignant (metastatic) lymph nodes were 1.09±0.33, 2.36±0.60 and 6.31±2.74, respectively. The SUVmax value at 90min p.i. were: 1.01±0.32, 2.48±0.61, and 7.17±2.91, respectively, and there was statistically significant difference between physiologic and inflammatory and physiologic and the metastatic lymph nodes (P<0.001). The values of early and delayed SUVmax were significantly different between physiologic and inflammatory and physiologic and metastatic lymph nodes (P<0.001). The SUVmax, SUVmean values at 60 and at 90min p.i. between malignant and inflammatory lymph nodes were statistically insignificant (P=0.33). The RI at 60 and at 90min p.i. was: -6%±16% for physiologic, 6%±14% for inflammatory and 15%±13% for the metastatic lymph nodes. The SUVmax changes over time (the RI) were statistically significant for physiologic and metastatic and physiologic and inflammatory lymph nodes (P<0.001) and significant between malignant and inflammatory lymph nodes (P=0.02). CONCLUSION: Sequential delayed 18F-FDG PET/CT examinations may increase specificity of this scan and provide information for the differentiation benign and malignant lymph nodes in the cases of head and neck cancer.

Metabolic activity in bone metastases of breast and prostate cancer were similar as studied by 18F-FDG PET/CT. The role of 99mTc-MDP.

OBJECTIVE: The aim of this study was to compare the metabolic activity of metastatic foci from breast and prostate cancer patients as scanned by fluorine-18-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) and by technetium-99m methyl diphosphonate (99mTc-MDP) bone scan (BS). SUBJECTS AND METHODS: Forty one patients were studied, divided into 2 groups based on histologically confirmed diagnosis: a) Breast cancer group, 23 women, mean age: 61±12 years, range: 37-79 years and, b) Prostate cancer group, 18 men, mean age 68±8 years, range: 52-82 years. Another group of 17 non cancer atherosclerotic subjects 9 women and 8 men, of mean age and age range similar to the above were also studied for comparison. The R index (the total count rate in bone metastases divided by the total count rate in a contralateral area), the maximum semi-quantitative standardized uptake value (SUVmax) of BS lesions and the mean number of metastases were evaluated. For the metastatic findings in the PET/CT scans the automatic method of contouring with 50% background cut-off was used, while for the 99mTc-MDP BS metastases were delineated manually. RESULTS: The mean R index of the bone metastatic foci studied by 18F-FDG PET/CT was 1.89±0.69 for Groups I and II patients. There was no significant difference of the R index between prostate cancer and breast cancer metastases (1.95±0.86 vs 1.83±0.52). The average SUVmax value was significantly higher in breast cancer patients than in prostate cancer patients (5.15±2.54 vs 4.01±1.71; P<0.05). There was no significant correlation in both cancer groups between R index and SUVmax values. The number of metastatic foci diagnosed by the 99mTc-MDP BS scan was much less than by the 18F-FDG PET/CT. CONCLUSION: No significant correlation was noticed in the metabolic activity-glucose utilization of metastatic bone foci between breast and prostate cancer cases. This observation validates the independent value of analyzed diagnostic methods and suggests negligible influence of glucose utilization in bone re-modeling in the above metastatic cancer cells. The 18F-FDG PET/CT bone scan was much better in diagnosing metastases compared to the 99mTc-MDP scan.

Strategy and early results of treatment of advanced cervical cancer patients with synchronous cancers observed in PET-CT imaging.

OBJECTIVES: The aim of this study was to present strategy and early results of treatment of advanced cervical cancer patients with synchronous cancers observed in PET-CT imaging, treated at the Greater Poland Cancer Center. MATERIAL AND METHODS: The study included a group of 200 patients with diagnosed stage IIB-IIIB cervical cancer who received PET-CT for the purpose of radiotherapy treatment planning. RESULTS: Among our study group, four patients (2%) were found to have a synchronous cancer. Two of the cases were diagnosed as breast cancer. However, cancers diagnosed in the other two patients were head and neck malignancies - hypopharyngeal and laryngeal cancer. The choice of an optimal therapeutic approach requires taking into account characteristics of particular malignancies, their stage and histopathology. The whole therapy included radiotherapy of cervical cancer with various combinations of systemic treatment, radiotherapy or surgery of synchronous cancer. According to treatment results, patients diagnosed with breast cancer and hypopharyngeal cancer achieved complete remission of both primary and secondary tumour. Patient diagnosed with laryngeal malignancy, despite achieving complete remission of cervical cancer, finished radiotherapy of the synchronous cancer at a palliative dose. CONCLUSIONS: The growing availability of PET-CT and other imaging methods in cancer diagnosis will increase the number of diagnosed synchronous cancers. Second primary cancers are often detected at an early stage, where radical treatment can be performed for both primary and secondary tumour. However, treatment of such complicated clinical cases as synchronous cancers should be carried out by multidisciplinary teams.

Carcinoma of unknown primary in the head and neck: The evaluation of the effectiveness of (18)F-FDG-PET/CT, own experience.

AIM: The aim of the present study was to estimate the clinical effectiveness of (18)F-FDG-PET/CT in the detection of the primary tumor in patients with histologically proven squamous cell carcinoma cervical lymph nodes metastasis from an unknown primary. BACKGROUND: (18)F-fluorodeoxyglucose positron emission tomography combined with CT ((18)F-FDG-PET/CT) is believed to be very helpful in localization of primary tumor in CUP Syndrome patients. MATERIAL AND METHOD: 41 patients referred to Poznan Medical University Department of Head and Neck Surgery from January 2010 to December 2013 with CUP Syndrome were included in the study. All patients presented fine-needle biopsy proven squamous cell carcinoma metastasis of the upper-, or mid neck lymph nodes. The final results were obtained from the histopathologic reports of tissue samples from anatomical regions suspected for primary tumor, additional imaging exams as well as clinical follow-up data. RESULTS: The (18)F-FDG-PET/CT successfully detected primary tumor in 7 out of 41 patients (17%). In two more cases the primary tumor was indicated in the lung. 24 of 41 patients (58.5%) analyzed in our study remained without evidence of a primary tumor. In 4 cases (9.75%) we did not reveal any pathology within the localizations indicated by PET/CT on panendoscopy. In 4 cases we obtained histological confirmation of neoplasm on panendoscopy despite the negative results of PET/CT examinations. CONCLUSION: We may suppose a relatively high usefulness of (18)F-FDG-PET/CT in the diagnosis process of CUP Syndrome patients. High NPV may indicate patients with no symptoms of primary tumor, which allows to avoid extensive resection or extra imaging.

Diagnosis and treatment of lung cancer using nuclear medicine techniques - current state of the art.

Lung cancer is the leading cause of cancer-related death worldwide. Planar radiography and computed tomography are the most common imaging modalities used in diagnosis, staging, and therapy response assessment. However, the role of nuclear methods in assessing the severity of the disease and the effectiveness of treatment has increased in recent years. Introducing these diagnostic modalities into standard practice in lung cancer may contribute to the personalization of treatment. In this review, we summarize the current knowledge of nuclear medicine techniques in the diagnosis and treatment of lung cancer.

Asphericity derived from [18F]FDG PET as a new prognostic parameter in cervical cancer patients.

The objective of this study was to assess the prognostic value of asphericity (ASP) and standardized uptake ratio (SUR) in cervical cancer patients. Retrospective analysis was performed on a group of 508 (aged 55 ± 12 years) previously untreated cervical cancer patients. All patients underwent a pretreatment [18F]FDG PET/CT study to assess the severity of the disease. The metabolic tumor volume (MTV) of the cervical cancer was delineated with an adaptive threshold method. For the resulting ROIs the maximum standardized uptake value (SUVmax) was measured. In addition, ASP and SUR were determined as previously described. Univariate Cox regression and Kaplan-Meier analysis with respect to event free survival (EFS), overall survival (OS), freedom from distant metastasis (FFDM) and locoregional control (LRC) was performed. Additionally, a multivariate Cox regression including clinically relevant parameters was performed. In the survival analysis, MTV and ASP were shown to be prognostic factors for all investigated endpoints. Tumor metabolism quantified with the SUVmax was not prognostic for any of the endpoints (p > 0.2). The SUR did not reach statistical significance either (p = 0.1, 0.25, 0.066, 0.053, respectively). In the multivariate analysis, the ASP remained a significant factor for EFS and LRC, while MTV was a significant factor for FFDM, indicating their independent prognostic value for the respective endpoints. The alternative parameter ASP has the potential to improve the prognostic value of [18F]FDG PET/CT for event-free survival and locoregional control in radically treated cervical cancer patients.

Combination of tumor asphericity and an extracellular matrix-related prognostic gene signature in non-small cell lung cancer patients.

One important aim of precision oncology is a personalized treatment of patients. This can be achieved by various biomarkers, especially imaging parameters and gene expression signatures are commonly used. So far, combination approaches are sparse. The aim of the study was to independently validate the prognostic value of the novel positron emission tomography (PET) parameter tumor asphericity (ASP) in non small cell lung cancer (NSCLC) patients and to investigate associations between published gene expression profiles and ASP. This was a retrospective evaluation of PET imaging and gene expression data from three public databases and two institutional datasets. The whole cohort comprised 253 NSCLC patients, all treated with curative intent surgery. Clinical parameters, standard PET parameters and ASP were evaluated in all patients. Additional gene expression data were available for 120 patients. Univariate Cox regression and Kaplan-Meier analysis was performed for the primary endpoint progression-free survival (PFS) and additional endpoints. Furthermore, multivariate cox regression testing was performed including clinically significant parameters, ASP, and the extracellular matrix-related prognostic gene signature (EPPI). In the whole cohort, a significant association with PFS was observed for ASP (p < 0.001) and EPPI (p = 0.012). Upon multivariate testing, EPPI remained significantly associated with PFS (p = 0.018) in the subgroup of patients with additional gene expression data, while ASP was significantly associated with PFS in the whole cohort (p = 0.012). In stage II patients, ASP was significantly associated with PFS (p = 0.009), and a previously published cutoff value for ASP (19.5%) was successfully validated (p = 0.008). In patients with additional gene expression data, EPPI showed a significant association with PFS, too (p = 0.033). The exploratory combination of ASP and EPPI showed that the combinatory approach has potential to further improve patient stratification compared to the use of only one parameter. We report the first successful validation of EPPI and ASP in stage II NSCLC patients. The combination of both parameters seems to be a very promising approach for improvement of risk stratification in a group of patients with urgent need for a more personalized treatment approach.

The quality-adjusted life-years in the oncological patients' health-related quality of life.

The oncological treatment can significantly affect patients' health-related quality of life (HRQoL), which should be monitored to ensure our patients' well-being. The often-used HRQoL measurer is the quality-adjusted life-year (QALY) indicator of the disease burden, describing both quality and quantity of life lived. The main aim of the study was to discuss the methodology and usefulness of evaluating QALYs using the HRQoL questionnaires: EuroQoL (EQ)-5 dimensions-3 levels (EQ-5D-3L) and EQ visual analogue scale (EQ-VAS) in 32 cervical cancer patients. We obtained the questionnaire and calculated QALYs based on the Gross Domestic Product (GDP) method. In our study, the total scoring of the EQ-Index, EQ-VAS evaluation was 2620 and 2409 points, respectively, which corresponds with the QALYs value of 26.2 and 24.9, respectively. We expressed the QALYs outcome into the economic equivalent of nearly 900,000 US dollars (USD) as the total health profit for both the patients and the healthcare system. Obtaining the QALY factor can help establish the medical management's influence on the patients' HRQoL and improve the healthcare services to ensure the best health outcomes.

Influence of Semiquantitative [18F]FDG PET and Hematological Parameters on Survival in HNSCC Patients Using Neural Network Analysis.

The aim of this study is to assess the influence of semiquantitative PET-derived parameters as well as hematological parameters in overall survival in HNSCC patients using neural network analysis. Retrospective analysis was performed on 106 previously untreated HNSCC patients. Several PET-derived parameters (SUVmax, SUVmean, TotalSUV, MTV, TLG, TLRmax, TLRmean, TLRTLG, and HI) for primary tumor and lymph node with highest activity were assessed. Additionally, hematological parameters (LEU, LEU%, NEU, NEU%, MON, MON%, PLT, PLT%, NRL, and LMR) were also assessed. Patients were divided according to the diagnosis into the good and bad group. The data were evaluated using an artificial neural network (Neural Analyzer version 2.9.5) and conventional statistic. Statistically significant differences in PET-derived parameters in 5-year survival rate between group of patients with worse prognosis and good prognosis were shown in primary tumor SUVmax (10.0 vs. 7.7; p = 0.040), SUVmean (5.4 vs. 4.4; p = 0.047), MTV (23.2 vs. 14.5; p = 0.010), and TLG (155.0 vs. 87.5; p = 0.05), and mean liver TLG (27.8 vs. 30.4; p = 0.031), TLRmax (3.8 vs. 2.6; p = 0.019), TLRmean (2.8 vs. 1.9; p = 0.018), and in TLRTLG (5.6 vs. 2.3; p = 0.042). From hematological parameters, only LMR showed significant differences (2.5 vs. 3.2; p = 0.009). Final neural network showed that for ages above 60, primary tumors SUVmax, TotalSUV, MTV, TLG, TLRmax, and TLRmean over (9.7, 2255, 20.6, 145, 3.6, 2.6, respectively) are associated with worse survival. Our study shows that the neural network could serve as a supplement to PET-derived parameters and is helpful in finding prognostic parameters for overall survival in HNSCC.

18F-Fluorodeoxyglucose Positron Emission Tomography of Head and Neck Cancer: Location and HPV Specific Parameters for Potential Treatment Individualization.

Purpose: 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) is utilized for staging and treatment planning of head and neck squamous cell carcinomas (HNSCC). Some older publications on the prognostic relevance showed inconclusive results, most probably due to small study sizes. This study evaluates the prognostic and potentially predictive value of FDG-PET in a large multi-center analysis. Methods: Original analysis of individual FDG-PET and patient data from 16 international centers (8 institutional datasets, 8 public repositories) with 1104 patients. All patients received curative intent radiotherapy/chemoradiation (CRT) and pre-treatment FDG-PET imaging. Primary tumors were semi-automatically delineated for calculation of SUVmax, SUVmean, metabolic tumor volume (MTV) and total lesion glycolysis (TLG). Cox regression analyses were performed for event-free survival (EFS), overall survival (OS), loco-regional control (LRC) and freedom from distant metastases (FFDM). Results: FDG-PET parameters were associated with patient outcome in the whole cohort regarding clinical endpoints (EFS, OS, LRC, FFDM), in uni- and multivariate Cox regression analyses. Several previously published cut-off values were successfully validated. Subgroup analyses identified tumor- and human papillomavirus (HPV) specific parameters. In HPV positive oropharynx cancer (OPC) SUVmax was well suited to identify patients with excellent LRC for organ preservation. Patients with SUVmax of 14 or less were unlikely to develop loco-regional recurrence after definitive CRT. In contrast FDG PET parameters deliver only limited prognostic information in laryngeal cancer. Conclusion: FDG-PET parameters bear considerable prognostic value in HNSCC and potential predictive value in subgroups of patients, especially regarding treatment de-intensification and organ-preservation. The potential predictive value needs further validation in appropriate control groups. Further research on advanced imaging approaches including radiomics or artificial intelligence methods should implement the identified cut-off values as benchmark routine imaging parameters.

Pretreatment [18F]FDG PET/CT Prognostic Factors in Patients with Squamous Cell Cervical Carcinoma FIGO IIIC1.

PURPOSE: This study aims to determine whether semiquantitative parameters obtained from both the primary tumor and metastatic pelvic lymph nodes (PLN) diagnosed in fluoro-18-deoxy-glucose positron emission tomography (FDG-PET-CT) are associated with disease-free survival (DFS), local control (LC), distant metastasis-free survival (DMFS) and overall survival (OS) in patients with locally advanced squamous cervical cancer (LACC) and metastatic pelvic lymph nodes. MATERIALS: Retrospective analysis was performed on 93 female patients with FIGO IIIC1. The median age was 53 years (27-75). The PET parameters both in the primary tumor and metastatic pelvic lymph nodes, including SUVmax, SUVmean, TLG, MTV, heterogeneity, along with clinical variables, before radical cisplatin-based radiochemotherapy (RCT) were analyzed. The p-values < 0.05 were considered statistically significant. RESULTS: Median follow-up was 38 months (4.5-92.6). Three years and five years OS were 75% and 70% respectively. Patients with SUVmax above 12.6, SUVmean above 7.6 and with TLG in tumors >245.7 lived longer (p < 0.05). The higher SUVmax or SUVmean reduced increased DMFS (HR 0.3 95%CI 0.56-0.96 and 0.59 95%CI 0.37-0.93). The clinical factors and other FDG PET CT parameters were not found to be statistically relevant in terms of OS, DFS, DM and LC. CONCLUSIONS: This study is the first report showing that in LACC patient population with PLN involvement treated with definitive RCT, high SUVmean, SUVmax and TLG of the primary tumor in FDG-PET-CT were linked with longer OS. Lower SUVmean and SUVmax were linked with shorter DMFS. None of the clinical factors and the nodal FDG-PET-CT parameters influenced the outcome.