Change of Maximum Standardized Uptake Value Slope in Dynamic Triphasic [18F]-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography Distinguishes Malignancy From Postradiation Inflammation in Head-and-Neck Squamous Cell Carcinoma: A Prospective Trial


      To evaluate dynamic [18F]-fluorodeoxyglucose (FDG) uptake methodology as a post–radiation therapy (RT) response assessment tool, potentially enabling accurate tumor and therapy-related inflammation differentiation, improving the posttherapy value of FDG–positron emission tomography/computed tomography (FDG-PET/CT).

      Methods and Materials

      We prospectively enrolled head-and-neck squamous cell carcinoma patients who completed RT, with scheduled 3-month post-RT FDG-PET/CT. Patients underwent our standard whole-body PET/CT scan at 90 minutes, with the addition of head-and-neck PET/CT scans at 60 and 120 minutes. Maximum standardized uptake values (SUVmax) of regions of interest were measured at 60, 90, and 120 minutes. The SUVmax slope between 60 and 120 minutes and change of SUVmax slope before and after 90 minutes were calculated. Data were analyzed by primary site and nodal site disease status using the Cox regression model and Wilcoxon rank sum test. Outcomes were based on pathologic and clinical follow-up.


      A total of 84 patients were enrolled, with 79 primary and 43 nodal evaluable sites. Twenty-eight sites were interpreted as positive or equivocal (18 primary, 8 nodal, 2 distant) on 3-month 90-minute FDG-PET/CT. Median follow-up was 13.3 months. All measured SUV endpoints predicted recurrence. Change of SUVmax slope after 90 minutes more accurately identified nonrecurrence in positive or equivocal sites than our current standard of SUVmax ≥2.5 (P=.02).


      The positive predictive value of post-RT FDG-PET/CT may significantly improve using novel second derivative analysis of dynamic triphasic FDG-PET/CT SUVmax slope, accurately distinguishing tumor from inflammation on positive and equivocal scans.
      To read this article in full you will need to make a payment
      ASTRO Member Login
      ASTRO Members, full access to the journal is a member benefit. Use your society credentials to access all journal content and features.

      Purchase one-time access:

      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


      1. American Society of Clinical Oncology. Cancer.Net. Available at: Accessed March 1, 2014.

        • Allal A.S.
        • Slosman D.O.
        • Kebdani T.
        • et al.
        Prediction of outcome in head-and-neck cancer patients using the standardized uptake value of 2-[18F]fluoro-2-deoxy-D-glucose.
        Int J Radiat Oncol Biol Phys. 2004; 59: 1295-1300
        • Andrade R.S.
        • Heron D.E.
        • Degirmenci B.
        • et al.
        Posttreatment assessment of response using FDG-PET/CT for patients treated with definitive radiation therapy for head and neck cancers.
        Int J Radiat Oncol Biol Phys. 2006; 65: 1315-1322
        • Coleman R.E.
        Is quantitation necessary for oncological PET studies?.
        Eur J Nucl Med Mol Imaging. 2002; 29: 133
        • Lowe V.J.
        • Boyd J.H.
        • Dunphy F.R.
        • et al.
        Surveillance for recurrent head and neck cancer using positron emission tomography.
        J Clin Oncol. 2000; 18: 651-658
        • Yao M.
        • Graham M.M.
        • Hoffman H.T.
        • et al.
        The role of post-radiation therapy FDG PET in prediction of necessity for post-radiation therapy neck dissection in locally advanced head-and-neck squamous cell carcinoma.
        Int J Radiat Oncol Biol Phys. 2004; 59: 1001-1010
        • Yao M.
        • Graham M.M.
        • Smith R.B.
        • et al.
        Value of FDG PET in assessment of treatment response and surveillance in head-and-neck cancer patients after intensity modulated radiation treatment: A preliminary report.
        Int J Radiat Oncol Biol Phys. 2004; 60: 1410-1418
        • Yao M.
        • Hoffman H.T.
        • Chang K.
        • et al.
        Is planned neck dissection necessary for head and neck cancer after intensity-modulated radiotherapy?.
        Int J Radiat Oncol Biol Phys. 2007; 68: 707-713
        • Yao M.
        • Luo P.
        • Hoffman H.T.
        • et al.
        Pathology and FDG PET correlation of residual lymph nodes in head and neck cancer after radiation treatment.
        Am J Clin Oncol. 2007; 30: 264-270
        • Yao M.
        • Smith R.B.
        • Graham M.M.
        • et al.
        The role of FDG PET in management of neck metastasis from head-and-neck cancer after definitive radiation treatment.
        Int J Radiat Oncol Biol Phys. 2005; 63: 991-999
        • Yao M.
        • Smith R.B.
        • Hoffman H.T.
        • et al.
        Clinical significance of postradiotherapy [18F]-fluorodeoxyglucose positron emission tomography imaging in management of head-and-neck cancer—a long-term outcome report.
        Int J Radiat Oncol Biol Phys. 2009; 74: 9-14
        • Schoder H.
        • Fury M.
        • Lee N.
        • et al.
        PET monitoring of therapy response in head and neck squamous cell carcinoma.
        J Nucl Med. 2009; 50: 74S-88S
        • Gupta T.
        • Jain S.
        • Agarwal J.P.
        • et al.
        Diagnostic performance of response assessment FDG-PET/CT in patients with head and neck squamous cell carcinoma treated with high-precision definitive (chemo)radiation.
        Radiother Oncol. 2010; 97: 194-199
        • Gupta T.
        • Master Z.
        • Kannan S.
        • et al.
        Diagnostic performance of post-treatment FDG PET or FDG PET/CT imaging in head and neck cancer: A systematic review and meta-analysis.
        Eur J Nucl Med Mol Imaging. 2011; 38: 2083-2095
        • Koike I.
        • Ohmura M.
        • Hata M.
        • et al.
        FDG-PET scanning after radiation can predict tumor regrowth three months later.
        Int J Radiat Oncol Biol Phys. 2003; 57: 1231-1238
        • Wang Q.
        • Wang R.F.
        • Zhang J.
        • et al.
        Differential diagnosis of pulmonary lesions by parametric imaging in (18)F-FDG PET/CT dynamic multi-bed scanning.
        J BUON. 2013; 18: 928-934
        • Hamberg L.M.
        • Hunter G.J.
        • Alpert N.M.
        • et al.
        The dose uptake ratio as an index of glucose metabolism: Useful parameter or oversimplffication?.
        J Nucl Med. 1994; 35: 1308-1312
        • Kubota K.
        • Itoh M.
        • Ozaki K.
        • et al.
        Advantage of delayed whole-body FDG-PET imaging for tumour detection.
        Eur J Nucl Med. 2001; 28: 696-703
        • Thie J.A.
        • Hubner K.F.
        • Smith G.T.
        Optimizing imaging time for improved performance in oncology PET studies.
        Mol Imaging Biol. 2002; 4: 238-244
        • Hustinx R.
        • Smith R.J.
        • Benard F.
        • et al.
        Dual time point fluorine-18 fluorodeoxyglucose positron emission tomography: A potential method to differentiate malignancy from inflammation and normal tissue in the head and neck.
        Eur J Nucl Med. 1999; 26: 1345-1348
        • Zhuang H.
        • Pourdehnad M.
        • Lambright E.S.
        • et al.
        Dual time point 18F-FDG PET imaging for differentiating malignant from inflammatory processes.
        J Nucl Med. 2001; 42: 1412-1417
        • Patel C.N.
        • Goldstone A.R.
        • Chowdhury F.U.
        • et al.
        FDG PET/CT in oncology: “Raising the bar”.
        Clin Radiol. 2010; 65: 522-535
        • Young H.
        • Baum R.
        • Cremerius U.
        • et al.
        Measurement of clinical and subclinical tumour response using [18F]-fluorodeoxyglucose and positron emission tomography: Review and 1999 EORTC recommendations. European Organization for Research and Treatment of Cancer (EORTC) PET Study Group.
        Eur J Cancer. 1999; 35: 1773-1782
        • Papathanassiou D.
        • Bruna-Muraille C.
        • Liehn J.C.
        • et al.
        Positron emission tomography in oncology: Present and future of PET and PET/CT.
        Crit Rev Oncol Hematol. 2009; 72: 239-254
        • Roh J.L.
        • Park J.P.
        • Kim J.S.
        • et al.
        18F fluorodeoxyglucose PET/CT in head and neck squamous cell carcinoma with negative neck palpation findings: A prospective study.
        Radiology. 2014; 271: 153-161
        • Lan X.L.
        • Zhang Y.X.
        • Wu Z.J.
        • et al.
        The value of dual time point (18)F-FDG PET imaging for the differentiation between malignant and benign lesions.
        Clin Radiol. 2008; 63: 756-764
        • Visser E.P.
        • Philippens M.E.
        • Kienhorst L.
        • et al.
        Comparison of tumor volumes derived from glucose metabolic rate maps and SUV maps in dynamic 18F-FDG PET.
        J Nucl Med. 2008; 49: 892-898
        • Lin Y.Y.
        • Chen J.H.
        • Ding H.J.
        • et al.
        Potential value of dual-time-point (1)(8)F-FDG PET compared with initial single-time-point imaging in differentiating malignant from benign pulmonary nodules: A systematic review and meta-analysis.
        Nucl Med Commun. 2012; 33: 1011-1018
        • Suga K.
        • Kawakami Y.
        • Hiyama A.
        • et al.
        Dual-time point 18F-FDG PET/CT scan for differentiation between 18F-FDG-avid non-small cell lung cancer and benign lesions.
        Ann Nucl Med. 2009; 23: 427-435
        • Suga K.
        • Kawakami Y.
        • Hiyama A.
        • et al.
        Differential diagnosis between (18)F-FDG-avid metastatic lymph nodes in non-small cell lung cancer and benign nodes on dual-time point PET/CT scan.
        Ann Nucl Med. 2009; 23: 523-531
        • Dimitrakopoulou-Strauss A.
        • Hohenberger P.
        • Pan L.
        • et al.
        Dynamic PET with FDG in patients with unresectable aggressive fibromatosis: Regression-based parametric images and correlation to the FDG kinetics based on a 2-tissue compartment model.
        Clin Nucl Med. 2012; 37: 943-948
        • Nakamoto Y.
        • Higashi T.
        • Sakahara H.
        • et al.
        Delayed (18)F-fluoro-2-deoxy-D-glucose positron emission tomography scan for differentiation between malignant and benign lesions in the pancreas.
        Cancer. 2000; 89: 2547-2554
        • Carlson E.R.
        • Schaefferkoetter J.
        • Townsend D.
        • et al.
        The use of multiple time point dynamic positron emission tomography/computed tomography in patients with oral/head and neck cancer does not predictably identify metastatic cervical lymph nodes.
        J Oral Maxillofac Surg. 2013; 71: 162-177
        • Thie J.A.
        Understanding the standardized uptake value, its methods, and implications for usage.
        J Nucl Med. 2004; 45: 1431-1434


      Commenting Guidelines

      To submit a comment for a journal article, please use the space above and note the following:

      • We will review submitted comments as soon as possible, striving for within two business days.
      • This forum is intended for constructive dialogue. Comments that are commercial or promotional in nature, pertain to specific medical cases, are not relevant to the article for which they have been submitted, or are otherwise inappropriate will not be posted.
      • We require that commenters identify themselves with names and affiliations.
      • Comments must be in compliance with our Terms & Conditions.
      • Comments are not peer-reviewed.