Effect of [F-18]FMISO stratified dose-escalation on local control in FaDu hSCC in nude mice

Objective: To investigate the effect of radiation dose-escalation on local control in hypoxic versus non-hypoxic hypoxic tumours defined using [F-18]fluoromisonidazole ([F-18]FMISO) PET. Materials and methods: FaDu human squamous cell carcinomas (hSCCs) growing subcutaneously in nude mice were subjected to [F-18]FMISO PET before irradiation with single doses of 25 or 35 Gy under normal blood flow conditions. [F-18]FMISO hypoxic volume (HV) and maximum standardised uptake value (SUVmax) were used to quantify tracer uptake. The animals were followed up for at least 120 days after irradiation. The endpoints were permanent local tumour control and time to local recurrence. Results: HV varied between 38 and 291 mm(3) (median 105 mm(3)). Non-hypoxic tumours (HV below median) showed significantly better local control after single dose irradiation than hypoxic tumours (HV above median) (p = 0.046). The effect of dose was significant and not different in non-hypoxic and in hypoxic tumours (HR= 0.82 [95% Cl 0.71; 0.93], p = 0.002 and HR= 0.86 [0.78; 0.95], p = 0.001, respectively). Dose escalation resulted in an incremental increase of local tumour control from low-dose hypoxic, over low-dose non-hypoxic and high-dose hypoxic to high-dose non-hypoxic tumours. SUVmax did not reveal significant association with local control at any dose level. Conclusions: The negative effect of [F-18]FMISO HV on permanent local tumour control supports the prognostic value of the pre-treatment [F-18]FMISO HV. Making the assumption that variable [F-18]FMISO uptake in different FaDu tumours which all have the same genetic background may serve as an experimental model of intratumoural heterogeneity, the data support the concept of dose-escalation with inhomogeneous dose distribution based on pre-treatment [F-18]FMISO uptake. This result needs to be confirmed in other tumour models and using fractionated radiotherapy schedules.