Open Access Research

A retrospective, deformable registration analysis of the impact of PET-CT planning on patterns of failure in stereotactic body radiation therapy for recurrent head and neck cancer

Kyle Wang1, Dwight E Heron12*, John C Flickinger13, Jean-Claude M Rwigema1, Robert L Ferris12, Gregory J Kubicek1, James P Ohr4, Annette E Quinn1, Cihat Ozhasoglu1 and Barton F Branstetter25

Author Affiliations

1 Departments of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, PA, USA

2 Otolaryngology, University of Pittsburgh Cancer Institute, Pittsburgh, PA, USA

3 Neurological Surgery, University of Pittsburgh Cancer Institute, Pittsburgh, PA, USA

4 Medical Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, PA, USA

5 Radiology, University of Pittsburgh Cancer Institute,, Pittsburgh, PA, USA

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Head & Neck Oncology 2012, 4:12  doi:10.1186/1758-3284-4-12

PUBLISHER'S NOTE: Based on the information available to BioMed Central, this article was apparently handled and peer reviewed only by Waseem Jerjes, an Editor-in-Chief of the journal at that time. There were no other peer reviewers and the manuscript was accepted without revision.

Published: 19 April 2012



Stereotactic body radiation therapy (SBRT) has seen increasing use as a salvage strategy for selected patients with recurrent, previously-irradiated squamous cell carcinoma of the head and neck (rSCCHN). PET-CT may be advantageous for tumor delineation and evaluation of treatment failures in SBRT. We analyzed the patterns of failure following SBRT for rSCCHN and assessed the impact of PET-CT treatment planning on these patterns of failure.


We retrospectively reviewed 96 patients with rSCCHN treated with SBRT. Seven patients (7%) were treated after surgical resection of rSCCHN and 89 patients (93%) were treated definitively. PET-CT treatment planning was used for 45 patients whereas non-PET-CT planning was used for 51 patients. Categories of failure were assigned by comparing recurrences on post-treatment scans to the planning target volume (PTV) from planning scans using the deformable registration function of VelocityAI™. Failures were defined: In-field (>75% inside PTV), Overlap (20-75% inside PTV), Marginal (<20% inside PTV but closest edge within 1cm of PTV), or Regional/Distant (more than 1cm from PTV).


Median follow-up was 7.4 months (range, 2.6–52 months). Of 96 patients, 47 (49%) developed post-SBRT failure. Failure distribution was: In-field–12.3%, Overlap–24.6%, Marginal–36.8%, Regional/Distant–26.3%. There was a significant improvement in overall failure-free survival (log rank p = 0.037) and combined Overlap/Marginal failure-free survival (log rank p = 0.037) for those receiving PET-CT planning vs. non-PET-CT planning in the overall cohort (n = 96). Analysis of the definitive SBRT subgroup (n = 89) increased the significance of these findings (overall failure: p = 0.008, Overlap/Marginal failure: p = 0.009). There were no significant differences in age, gender, time from prior radiation, dose, use of cetuximab with SBRT, tumor differentiation, and tumor volume between the PET-CT and non-PET-CT groups.


Most failures after SBRT treatment for rSCCHN were near misses, i.e. Overlap/Marginal failures (61.4%), suggesting an opportunity to improve outcomes with more sensitive imaging. PET-CT treatment planning showed the lowest rate of overall and near miss failures and is beneficial for SBRT treatment planning.

Stereotactic body radiotherapy; Recurrent head & neck cancer; Salvage; PET-CT; Patterns of failure