Paper IV suggests MTV in FDG-PET/CT as a potential useful tool in
8. Future perspectives
8. Future perspectives
Some future perspectives have already been highlighted, such as the need for cost-effectiveness studies of the implementation of new imaging tools like FDG-PET/CT (Incidental findings paragraph, 7.2.4). Analyses must, in addition to the cost/benefit of incidental findings, also consider the costs of imaging compared to the costs related to unnecessary and potentially harmful treatments and/or staging procedures. In the process of introducing new diagnostic tools, an evaluation of the existing diagnostic algorithm must be performed; including considerations regarding potential exclusion of currently employed diagnostic tests in the preoperative work-up.
The novel imaging biomarkers proposed in this thesis need to be consolidated in large, prospective study settings, where cut-offs are applied a priori for the cohort.
Such validation will be crucial in order to safely apply the results in an algorithm for individualized treatment. Furthermore, there is need for clinical implementation studies yielding long term outcome data, where risk stratification models are standardly applied. Another aspect worth considering regarding clinical implementation is the importance of robustness of the parameters. A future development of methods for automatic assessments of imaging parameters could potentially increase robustness by ruling out the subjective element of image interpretation, an issue of constant concern in all imaging based diagnostics.
The establishment of new imaging markers also gives an opportunity to relate these novel biomarkers to established biomarkers and create a diagnostic algorithm aiming to more accurately identify high-risk patients preoperatively and thereby tailor therapy coherently. In line with this, the tumor measurement cut-offs from Paper III will be included in the MoMaTEC2 trial as part of a risk stratification model.
Furthermore, it would be interesting to investigate the relation between tumor volumes measured on MRI (Paper III) and the metabolic tumor volumes measured on FDG-PET (Paper IV). We currently do not know how much the morphologic tumor volume contributes to the measured metabolic tumor volume, and further studies are due on this matter.
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