Combing MRI Perfusion and (18)F-FDG PET/CT Metabolic Biomarkers Helps Predict Survival in Advanced Nasopharyngeal Carcinoma: A Prospective Multimodal Imaging Study

SIMPLE SUMMARY: Among various types of head and neck cancers, nasopharyngeal carcinoma (NPC) has a distinct epidemiology and prognosis. Tumor recurrence in NPC poses significant clinical challenges and identifying novel prognostic biomarkers is crucial. Imaging biomarkers derived from positron emission tomography (PET) and magnetic resonance imaging (MRI) reflect different biological facets of tumors. However, whether pretreatment PET and MRI imaging biomarkers can complement each other in the survival prediction of NPC patients has not been determined. This prospective study aimed to analyze the prognostic value of imaging biomarkers derived from pretreatment MRI and PET in NPC. The model integrating the MRI perfusion markers with PET metabolic parameter demonstrated higher prognostic performance than the traditional staging system and individual model with either MRI or PET alone. A staging work-up for NPC including both functional MRI and PET parameters may provide clinicians with supplementary prognostic information in addition to morphologic assessment of tumor extent. ABSTRACT: We prospectively investigated the prognostic value of imaging parameters for nasopharyngeal carcinoma (NPC) using dynamic contrast-enhanced MRI (DCE-MRI), diffusion-weighted imaging (DWI), and 2-deoxy-2-[fluorine-18]fluoro-D-glucose positron emission tomography ((18)F-FDG PET)/computed tomography (CT). Patients with stage III–IVb NPC underwent F-FDG PET/CT, DCE-MRI, and DWI before treatment. Kaplan-Meier and Cox-regression analyses were used to assess associations of PET and MRI imaging biomarkers with overall survival (OS) and recurrence-free survival (RFS). We used independent prognosticators to establish prognostic models; model performance was examined using Harrell’s concordance index (c-index). Sixty-one patients were available for analysis, as 13 patients died and 20 experienced recurrence. Total lesion glycolysis (TLG) (p = 0.002) from PET/CT and the initial area under the curve (iAUC) (p = 0.036) from DCE-MRI were identified as independent prognosticators of OS; Epstein-Barr virus (EBV) DNA (p = 0.027), the extracellular volume fraction (V(e)) (p = 0.027) from DCE-MRI, and TLG/iAUC (p = 0.025) were significant predictors of RFS. The c-indices of the prognostic models incorporating TLG + iAUC in predicting OS and incorporating EBV DNA + V(e) + TLG/iAUC in predicting RFS were 0.79 and 0.76, respectively. These were significantly higher than the corresponding c-indices of the TNM staging system (p = 0.047 and 0.025, respectively); they were also higher than those of models with only MRI or PET biomarkers. In conclusion, the combination of pretreatment DCE-MRI and (18)F-FDG PET/CT imaging biomarkers helps survival prediction in advanced NPC. Integrating MRI perfusion with PET metabolism and plasma EBV information may aid clinicians in planning the optimal personalized management strategy.