Article Figures & Data
Figures
- FIG 1.
Correlation between pathology report and preoperative FDG-PET/CT in a 53-year-old female patient with ATC stage IVB, status post 3.5 months of neoadjuvant dabrafenib/trametinib. A, Lymph node cluster contoured in green, labeled as “Neck, left level IIB, dissection: 4 lymph nodes, negative for tumor (0/4)” on the pathology report. B, Lymph node cluster contoured in purple, labeled as “Neck, left level III, dissection: metastatic anaplastic thyroid carcinoma in 1 of 12 lymph nodes (1/12); tumor size of 1.5 cm with no extranodal extension” on the pathology report. C, Lymph node cluster contoured in yellow, labeled as “Neck, right level III, dissection: 4 lymph nodes, negative for tumor (0/4)” on the pathology report. D, Thyroid tissue contoured in bright blue, labeled as “Thyroid, total thyroidectomy: extensive treatment effect with complete response; exuberant lymphocytic thyroiditis and follicular atrophy with few remaining thyroid follicles” on the pathology report.
- FIG 2.
Boxplots illustrating the distribution of SULmax values by pathologic risk. High-risk lesions include anaplastic and PDTC thyroid carcinoma, and low-risk lesions include PTCs and those without residual tumor.
- FIG 3.
Boxplots illustrating the distribution of SULmax values across all 4 pathologic grades.
- FIG 4.
Representative cases for each of the 4 pathologic grades, illustrated with corresponding axial fusion FDG-PET/CT images, uniformly windowed across all studies. A, 66-year-old male patient with ATC stage IVB, status post 1 year of neoadjuvant dabrafenib/trametinib. Preoperative FDG-PET/CT shows a hypermetabolic right paratracheal lesion (purple) with an SULmax = 8.44. Postoperative pathology of this lesion revealed residual ATC. B, Same patient with prominent right level IV lymph node (bright blue) and low FDG uptake (SULmax = 1.58), which is negative for residual tumor on surgical pathology. C, 70-year-old female patient with ATC stage IVB, status post 16 months of neoadjuvant dabrafenib/trametinib. The right thyroid lobe lesion (yellow) on preoperative FDG-PET/CT has an SULmax of 4.92 and harbors PDTC cells on surgical specimen. D, 72-year-old male patient with ATC stage IVC, status post 5 months of neoadjuvant dabrafenib/trametinib. The prominent right level IV lymph node (green) on preoperative FDG-PET/CT has an SULmax of 3.12 and harbors residual PTC cells on biopsy.
- FIG 5.
ROC curve for the preoperative classification of lesions as high-risk or low-risk demonstrates an area under the curve of 0.793 [95% CI, 0.702–0.884], indicating acceptable performance of the SULmax-based classifier. An optimal SULmax threshold of 2.75 is identified and can identify high-risk lesions with a sensitivity, specificity, and accuracy of 0.784 [95% CI, 0.628–0.886], 0.702 [95% CI, 0.573–0.805], and 0.734 [95% CI, 0.637–0.813], respectively. A clinically meaningful cutoff of 1.36 is also identified to prioritize a higher sensitivity 0.919 [95% CI, 0.787–0.972] at the expense of the specificity and accuracy (0.544 [95% CI, 0.416–0.666] and 0.691 [95% CI, 0.592–0.776], respectively). Of note, the latter threshold falls within the physiologic range of background soft tissue uptake in the head and neck.
- FIG 6.
Kaplan-Meier curves comparing OS in patients with at least 1 high-risk lesion versus no high-risk lesion in the head and neck based on pathology results and FDG uptake. A, When pathologic risk group is determined via histopathologic assessment of surgically sampled specimens, median OS is 257 days for patients with at least 1 high-risk lesion versus not attained in patients with no high-risk lesions (P = .004, log-rank test). The right-censored cumulative survival for the latter group at the end of follow-up was 81.8% (9/11). B, When SULmax of 2.75 is used as a proxy for high-risk lesions, median OS is 259 days for patients with at least 1 lesion with SULmax ≥2.75 versus not attained in patients without lesion with SULmax ≥2.75 (P = .038, log-rank test) The right-censored cumulative survival for the latter group at the end of follow-up was 75.0% (6/8).
Tables
Baseline Characteristic Summary Statistic Age at surgery, mean (standard deviation) 66.5 (9.0) Sex, frequency (percent) Men 17 (56.7%) Women 13 (43.3%) AJCC Eighth Edition stage,30 frequency (percent) IVB 15 (50.0%) IVC 15 (50.0%) Days of neoadjuvant BRAF/MEK inhibitor therapy, median (IQR) 103.5 (79.8–196.5) Immunotherapy before and/or after surgery, frequency (percent) 28 (93.3%) Pembrolizumab 25 (89.3%) Atezolizumab 3 (10.7%) Surgically sampled lesions with known pathology Low risk (no tumor, PTC) 57 (60.6%) High risk (PDTC, ATC) 37 (39.4%) Note:—AJCC indicates American Joint Committee on Cancer Classification.
- Table 2:
Predicted pathology risk group on FDG-PET/CT by using the optimal SULmax cutoff of 2.75
Actual Pathology Risk Group High-Risk Low-Risk Total Predicted pathology High-risk 29 17 46 Risk group Low-risk 8 40 48 Total 37 57 94 This cutoff can identify high-risk lesions with a sensitivity, specificity, and accuracy of 0.784 [95% CI, 0.628–0.886], 0.702 [95% CI, 0.573–0.805], and 0.734 [95% CI, 0.637–0.813], respectively.
- Table 3:
Predicted pathology risk group on FDG-PET/CT by using the clinically meaningful SULmax cutoff of 1.36
Actual Pathology Risk Group High-Risk Low-Risk Total Predicted pathology High-risk 34 26 60 Risk group Low-risk 3 31 34 Total 37 57 94 Note:—This cutoff can identify high-risk lesions with a sensitivity, specificity, and accuracy of 0.919 [95% CI, 0.787–0.972], 0.544 [95% CI, 0.416–0.666], and 0.691 [95% CI, 0.592–0.776], respectively.
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