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Prognostic Impact of Hypoxia Imaging with ¹⁸F-Misonidazole PET in Non-Small Cell Lung Cancer and Head and Neck Cancer Before Radiotherapy

¹ Department of Nuclear Medicine, University of Tuebingen, Tuebingen, Germany
² Department of Radiation Oncology, University of Tuebingen, Tuebingen, Germany
³ Section of Radiopharmacy, University of Tuebingen, Tuebingen, Germany

View larger version (16K): [in a new window]   FIGURE 1. FMISO time–activity curves: typical examples of types 1 (rapid washout), 2 (intermediate), and 3 (accumulation).

View larger version (94K): [in a new window]   FIGURE 2. Findings of 18F-FDG (top 2 rows) and FMISO PET (bottom 2 rows) for patient 24. 18F-FDG data are used to demonstrate viable tumor tissue. Lymph node metastasis shows high FMISO uptake, whereas large primary tumor and other lymph node metastasis reveal only moderate uptake. External marker is behind left ear.

View larger version (20K): [in a new window]   FIGURE 3. FMISO curves of different areas of large HNC tumor (fused image is at right). Necrosis () shows poor perfusion (missing peak) and increasing FMISO accumulation, presumably reflecting hypoxia. Viable tumor () shows high perfusion and subsequent rapid washout, reflecting good oxygenation. Tumor tissue surrounding necrosis () shows impaired perfusion (low peak) followed by accumulation, reflecting hypoxia.

View larger version (14K): [in a new window]   FIGURE 4. Outcome for patients with characteristic curve types: patients with type 1 (washout type; no disease recurrence) (A) and patients with type 3 (accumulation type; recurrence in 5 of 6 patients) (B).

View larger version (14K): [in a new window]   FIGURE 5. Outcome vs. curve type and early FMISO uptake: All patients with type 1 were responders. Patients with type 2 or 3 could further be discriminated by analyzing SUV 0–2 min after injection (A) and 5–14 min after injection (B). Area enclosed by rectangle represents area of high risk: All patients with data within this range experienced relapse.

View larger version (19K): [in a new window]   FIGURE 6. Correlation of FMISO uptake and clinical outcome. (A and B) SUV 2 and 4 h after injection vs. outcome for NSCLC (A) and HNC (B). In HNC, high correlation between 2-h and 4-h SUV is observed. In both tumors, a cutoff SUV of >2.0 separates only patients with tumor recurrence; in HNC, a cutoff of <1.4 separates disease-free patients. (C and D) T/Rs at 2 and 4 h after injection vs. outcome for NSCLC (C) and HNC (D). Using appropriate cut-offs (a T/Me of >2.0 at 4 h [NSCLC]; a T/Mu of >1.6 at 4 h [HNC]), 10 of 13 patients with tumor recurrence can be identified.

View larger version (10K): [in a new window]   FIGURE 7. Comparison of 18F-FDG uptake and clinical outcome (available for 5 patients with NSCLC and 8 with HNC).