title: FDG-PET/CT-guided intensity modulated head and neck radiotherapy: a pilot investigation.
abstract: BACKGROUND
  2-deoxy-2[(18)F]fluoro-D-glucose-positron emission tomography (FDG-PET) imaging can be registered with CT images and can potentially improve neck staging sensitivity and specificity in patients with head and neck squamous cell cancer. The intent of this study was to examine the use of registered FDG-PET/CT imaging to guide head and neck intensity modulated radiotherapy (IMRT) planning.
  
  
  METHODS
  Twenty patients with squamous cell carcinoma of the oral cavity, oropharynx, larynx, or hypopharynx underwent FDG-PET and contrast-enhanced CT imaging of the head and neck before neck dissection surgery. Combined FDG-PET/CT images were created by use of a nonrigid image registration algorithm. All IMRT plans were theoretical and were not used for treatment. We prescribed 66 Gy in 30 fractions to FDG-avid CT abnormalities and nodal zones directly involved with disease, without prophylactic coverage of uninvolved neck levels. Matched CT-guided IMRT plans designed according to the specifications of Radiation Therapy Oncology Group (RTOG) H-0022 were available for comparison. We investigated the feasibility of FDG-PET/CT-directed IMRT dose escalation in five patients with FDG-avid disease located away from critical normal structures. After 66 Gy, FDG-avid disease with 0.5-cm margins was boosted in 220 cGy increments until dose-limiting criteria were reached.
  
  
  RESULTS
  Elimination of prophylactic coverage to FDG-PET/CT-negative neck levels markedly reduced mean dose (Dmean) to the contralateral parotid gland (p < .001) and Dmean to the laryngeal cartilage (p = .001). No FDG-PET/CT-directed plan missed pathologically verified nodal disease. During the dose escalation exercise, we successfully increased the dose to 95% of the planning target volume (PTV95%) to a mean of 7490 cGy (range, 7153-8098 cGy).
  
  
  CONCLUSIONS
  We demonstrate early proof of the principle that FDG-PET/CT-guided IMRT planning can selectively target and intensify treatment of head and neck disease while reducing critical normal tissue doses. Routine clinical use of such planning should not be engaged until the accuracy of FDG-PET/CT is fully validated. Future directions, including refinement of treatment to gross disease and radiologically uninvolved neck nodal levels, are discussed.
authors.affiliation: Department of Radiation Oncology, University of Washington, Seattle, Washington, 1660 S. Columbian Way [174], Seattle, WA 98108-1597, USA. docdls@mdanderson.org
authors.forename: David L
authors.initials: DL
authors.lastname: Schwartz
authors.forename: Eric C
authors.initials: EC
authors.lastname: Ford
authors.forename: Joseph
authors.initials: J
authors.lastname: Rajendran
authors.forename: Bevan
authors.initials: B
authors.lastname: Yueh
authors.forename: Marc D
authors.initials: MD
authors.lastname: Coltrera
authors.forename: Jeffery
authors.initials: J
authors.lastname: Virgin
authors.forename: Yoshimi
authors.initials: Y
authors.lastname: Anzai
authors.forename: David
authors.initials: D
authors.lastname: Haynor
authors.forename: Barbara
authors.initials: B
authors.lastname: Lewellen
authors.forename: David
authors.initials: D
authors.lastname: Mattes
authors.forename: Paul
authors.initials: P
authors.lastname: Kinahan
authors.forename: Juergen
authors.initials: J
authors.lastname: Meyer
authors.forename: Mark
authors.initials: M
authors.lastname: Phillips
authors.forename: Michael
authors.initials: M
authors.lastname: Leblanc
authors.forename: Kenneth
authors.initials: K
authors.lastname: Krohn
authors.forename: Janet
authors.initials: J
authors.lastname: Eary
authors.forename: George E
authors.initials: GE
authors.lastname: Laramore
mesh_terms: D000328:Adult; D000368:Aged; D002294:Carcinoma, Squamous Cell / Q000000981:diagnostic imaging / Q000532:radiotherapy*; D005260:Female; D019788:Fluorodeoxyglucose F18; D006801:Humans; D008297:Male; D008875:Middle Aged; D009062:Mouth Neoplasms / Q000000981:diagnostic imaging / Q000532:radiotherapy*; D010865:Pilot Projects; D049268:Positron-Emission Tomography; D019275:Radiopharmaceuticals; D011879:Radiotherapy Dosage; D011880:Radiotherapy Planning, Computer-Assisted; D014057:Tomography, X-Ray Computed
chemical_list: D019275:Radiopharmaceuticals; D019788:Fluorodeoxyglucose F18