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Tumor hypoxia is associated with radiation resistance and can be longitudinally monitored by 18 F-fluoromisonidazole ( 18 F-FMISO)-PET/CT. Our study aimed at evaluating radiomics dynamics of 18 F-FMISO-hypoxia imaging during chemo-radiotherapy (CRT) as predictors for treatment outcome in head-and-neck squamous cell carcinoma (HNSCC) patients. We prospectively recruited 35 HNSCC patients undergoing definitive CRT and longitudinal 18 F-FMISO-PET/CT scans at weeks 0, 2 and 5 (W0/W2/W5). Patients were classified based on peritherapeutic variations of the hypoxic sub-volume (HSV) size (increasing/stable/decreasing) and location (geographically-static/geographically-dynamic) by a new objective classification parameter (CP) accounting for spatial overlap. Additionally, 130 radiomic features (RF) were extracted from HSV at W0, and their variations during CRT were quantified by relative deviations (∆ RF ). Prediction of treatment outcome was considered statistically relevant after being corrected for multiple testing and confirmed for the two 18 F-FMISO-PET/CT time-points and for a validation cohort. HSV decreased in 64% of patients at W2 and in 80% at W5. CP distinguished earlier disease progression (geographically-dynamic) from later disease progression (geographically-static) in both time-points and cohorts. The texture feature low grey-level zone emphasis predicted local recurrence with AUC W2 = 0.82 and AUC W5 = 0.81 in initial cohort ( N = 25) and AUC W2 = 0.79 and AUC W5 = 0.80 in validation cohort. Radiomics analysis of 18 F-FMISO-derived hypoxia dynamics was able to predict outcome of HNSCC patients after CRT.

18F-FMISO-PET Hypoxia Monitoring for Head-and-Neck Cancer Patients: Radiomics Analyses Predict the Outcome of Chemo-Radiotherapy