Heterogeneity of 18F‐FDG PET combined with expression of EGFR may improve the prognostic stratification of advanced oropharyngeal carcinoma

The Ang's risk profile (based on p16, smoking and cancer stage) is a well‐known prognostic factor in oropharyngeal squamous cell carcinoma (OPSCC). Whether heterogeneity in 18F‐fluorodeoxyglucose (FDG) positron emission tomographic (PET) images and epidermal growth factor receptor (EGFR) expression could provide additional information on clinical outcomes in advanced‐stage OPSCC was investigated. Patients with stage III–IV OPSCC who completed primary therapy were eligible. Zone‐size nonuniformity (ZSNU) extracted from pretreatment FDG PET scans was used as an index of image heterogeneity. EGFR and p16 expression were examined by immunohistochemistry. Disease‐specific survival (DSS) and overall survival (OS) served as outcome measures. Kaplan–Meier estimates and Cox proportional hazards regression models were used for survival analysis. A bootstrap resampling technique was applied to investigate the stability of outcomes. Finally, a recursive partitioning analysis (RPA)‐based model was constructed. A total of 113 patients were included, of which 28 were p16‐positive. Multivariate analysis identified the Ang's profile, EGFR and ZSNU as independent predictors of both DSS and OS. Using RPA, the three risk factors were used to devise a prognostic scoring system that successfully predicted DSS in both p16‐positive and ‐negative cases. The c‐statistic of the prognostic index for DSS was 0.81, a value which was significantly superior to both AJCC stage (0.60) and the Ang's risk profile (0.68). In patients showing an Ang's high‐risk profile (N = 77), the use of our scoring system clearly identified three distinct prognostic subgroups. It was concluded that a novel index may improve the prognostic stratification of patients with advanced‐stage OPSCC. What's new? Advanced‐stage oropharyngeal squamous cell carcinoma (OPSCC) generally is associated with poor outcome, and existing classification schemes provide for only limited risk stratification. One of the most promising validated prognostic approaches in OPSCC is based on the Ang's risk profile, which is characterized by cancer stage, p16 status and smoking. In the present study, Ang's profile, EGFR expression and zone‐size nonuniformity (ZSNU) were found to independently predict OPSCC survival. A novel index that incorporated the three factors successfully predicted disease‐specific survival for both p16‐positive and p16‐negative cases. The new scoring system could significantly improve prognostic stratification in