Head and neck squamous cell carcinoma (HNSCC)--detection of synchronous primaries with (18)F-FDG-PET/CT

Efficacy of 18FDG-PET/CT in Detecting Synchronous Malignancies in Patients With Head and Neck Cancer: A Systematic Review and Meta-analysis

OBJECTIVE

To assess the diagnostic accuracy of fluorine-18 fluorodeoxyglucose positron emission tomography and computed tomography (18FDG-PET/CT) in detecting second primary malignancies (SPMs) in patients with treatment naïve head and neck squamous cell carcinoma (HNSCC).

DATA SOURCES

Medline, Embase, Cochrane Library, and Scopus searched from 1946 to December 2022.

REVIEW METHODS

Studies reporting the performance of 18FDG-PET/CT in patients with treatment-naïve, index HNSCC for detection of SPMs were included. The reference standard was histopathology, clinical follow-up over the duration of study, and other imaging modalities. Multiple investigators completed depth full-text analysis. Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines were followed. Methodologic and diagnostic accuracy data were abstracted independently by multiple investigators. Risk of bias assessment was conducted using the Quality Assessment of Diagnostic Accuracy Studies tool independently. Bivariate random-effects model meta-analysis and multivariable meta-regression modeling were used.

RESULTS

Seventeen studies examining 4624 patients with a total of 475 SPMs were included in the final analysis. Eleven studies were found to be at low risk for bias, while the rest were in the high-risk category. 18FDG-PET/CT demonstrated pooled sensitivity and specificity of 0.73 (95% confidence interval [CI]: 0.49-0.88) and 0.99 (95% CI: 0.98-1.00) in detecting SPMs. Further subsite analysis revealed varied diagnostic performance across different anatomical regions, with sensitivity and specificity of esophageal SPMs being 0.47 (0.30-0.64) and 0.99 (0.98-1.00), and sensitivity and specificity of 0.86 (0.73-0.94) and 0.99 (0.98-1.00) for head and neck SPMs. Finally, this imaging modality showed sensitivity and specificity of 0.92 (0.84-0.96) and 0.99 (0.98-1.00) for lung SPMs.

CONCLUSION

The findings of this study suggest varied accuracy of 18FDG-PET/CT in detecting SPMs during initial workup for HNSCC, highlighting the importance of screening modalities such as esophagoscopy in high-risk patients.

Imaging Modalities for Head and Neck Cancer: Present and Future

Several imaging modalities are utilized in the diagnosis, treatment, and surveillance of head and neck cancer. First-line imaging remains computed tomography (CT); however, MRI, PET with CT (PET/CT), and ultrasound are often used. In the last decade, several new imaging modalities have been developed that have the potential to improve early detection, modify treatment, decrease treatment morbidity, and augment surveillance. Among these, molecular imaging, lymph node mapping, and adjustments to endoscopic techniques are promising. The present review focuses on existing imaging, novel techniques, and the recent changes to imaging practices within the field.

Head and neck cancer with synchronous nodules of the lung as a diagnostic and therapeutic challenge - A systematic review

Head and neck squamous cell carcinoma (HNSCC) often presents with synchronous nodules of the lung (sNL), which may be benign nodules, second primary malignancies or metastases of HNSCC. We sought to gain an insight into the incidence of sNL and synchronous second primary of the lung (sSPML) in HNSCC patients and current opinions on useful diagnostic and therapeutic approaches. We conducted a systematic search of the PubMed database for articles that reported the simultaneous detection of HNSCC and sNL/sPML, within the timeframe of diagnosis and staging. Only studies involving humans were included, without restrictions for sex, age, ethnicity, or smoking history. All articles were categorised according to the Oxford Centre of Evidence-Based Medicine levels and their data collected. Data from 24 studies were analysed. Amongst HNSCC, the mean overall incidence rate of sNL and sSPML was 11.4% (range: 1.3-27%) and 2.95% (range: 0.4-7.4%), respectively. The possibility of a sNL to be a sSPML cannot be ignored (mean: 35.2%). Studies investigating smoking habits showed that the majority (98-100%) of HNSCC patients with sSPML were previous or active smokers. Detection of human papillomavirus through DNA analysis, p16 immunohistochemistry, and identification of clonal evolution were useful in differentiating metastasis from sSPML. 18FDG-PET scan was the most reliable method to diagnose sSPML (sensitivity: 95%; specificity: 96%; positive predictive value: 80%). With early sSPML detection and curative treatment, the 5-year overall survival rate is 34-47%. However, the proposed advantage of early detection warrants further evidence-based justification.

Diagnostic Assessment (Imaging) and Staging of Laryngeal Cancer

Diagnosis of larynx cancer relies on a detailed history and physical and objective assessment with endoscopy and imaging. Endoscopy is needed to assess for vocal fold function that directly affects staging. Computed tomography and MRI can be used to assess for tumor extent in relation to intra- and extra-laryngeal structures, especially paraglottic and pre-epiglottic space involvement as well as cartilage invasion. Accurate staging is critical for subsequent treatment decision-making regarding larynx preservation.

Oral Squamous Cell Carcinoma and Concomitant Primary Tumors, What Do We Know? A Review of the Literature

Head and neck cancer is among the top ten cancers worldwide, with most lesions in the oral cavity. Oral squamous cell carcinoma (OSCC) accounts for more than 90% of all oral malignancies and is a significant public health concern. Patients with OSCC are at increased risk for developing concomitant tumors, especially in the oral cavity, due to widely genetically susceptible mucosa to carcinogenic factors. Based on fulfilling specific criteria, these concomitant tumors can be called second primary tumors (SPTs), which can be further categorized into metachronous and synchronous tumors. This research reviews the literature that investigated the concurrent OSCC with second or multiple primaries to improve understanding of the definition, classification guidelines, and its effect on cancer survival. It also highlights the current investigation methods, the variation of standard treatment approaches due to such a phenomenon, and preventive measures discussed in the literature.

[Metabolic Tumor Imaging in Head and Neck Oncology]

Metabolic Tumor Imaging in Head and Neck Oncology Abstract. Fluorodeoxyglucose with position emission tomography combined with CT or MRI (FDG-PET) has become an important diagnostic and staging method in head and neck squamous cell carcinoma. Some regard FDG-PET merely as a tool able of displaying cancer cells as bright spots on imaging. However, quantification of FDG uptake can be used as a surrogate marker for tumor aggressiveness and predict tumor response before (chemo)-radiation. The FDG uptake of the primary tumor can also predict surgical outcome measures such as depth of invasion, occult nodal metastasis, or bone invasion for oral cancer and/or organ preservation in hypopharyngeal cancer.

Utilization of PET/CT Scan in Head and Neck Carcinoma: A Tertiary Care Hospital Experience

Objective

PET/CT scan has been increasingly used in assessment of Head and Neck cancer prior to treatment for evaluation and for surveillance. In this study we aim to assess the utilization of PET/CT scan at a tertiary care hospital.

Methods

Retrospectively data was reviewed of all patients of Head and Neck cancer who underwent PET/CT scan for workup or for follow-up between July 2018 and December 2019. PET/CT scan done in the pre-treatment assessment and post-treatment surveillance were analyzed for its utility.

Results

A total of 145 patients were included. The main indication for pre-treatment PET/CT scan was loco-regionally advanced disease (62 of 90 patients, 68.8%). No specific indication was noted in 19 patients (21%). A significant change in treatment decision was seen in pre-treatment patients based on M stage following a PET/CT scan. However, no change was noted on the basis of T or N stage. In the post-treatment surveillance there was a significant correlation of type of recurrence with clinical assessment and indication for PET/CT scan. 37 out of 87 patients (42.5%) underwent PET/CT scan for no specific reason, of which, 07 patients (18.9%) were detected to have distant metastasis.

Conclusion

Role of PET/CT in the pre-treatment assessment is very limited and maybe confined to advanced local or regional disease. Post-treatment surveillance with PET/CT scan has a promising role and must be done as a baseline during 1st follow up at 03 months in all patients who have advanced disease and have undergone multi-modality treatment for the same.

Real-Life Performance of F-18-FDG PET/CT in Patients with Cervical Lymph Node Metastasis of Unknown Primary Tumor

Background: Neoplasms in the head and neck region possess higher glycolytic activity than normal tissue, showing increased glucose metabolism. F-18-Flourodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) can identify an unknown primary tumor (CUP). Aim: The aim of this study was to assess the real-life performance of F-18-FDG-PET/CT in detecting primary sites in patients with cervical lymph node metastasis of CUP. Methods: A retrospective data analysis of 31 patients who received FDG-PET/CT between June 2009 and March 2015 in a CUP context with histologically confirmed cervical lymph node metastasis was included. Results: In 48% of the patients (15/31), PET/CT showed suspicious tracer accumulation. In 52% of the patients (16/31), there was no suspicious radiotracer uptake, which was confirmed by the lack of identification of any primary tumor in 10 cases until the end of follow-up. FDG-PET/CT had a sensitivity of 67%, specificity of 91%, PPV of 92%, and NPV of 63% in detecting the primary tumor. Additionally, PET/CT showed suspicious tracer accumulation according to further metastasis in 32% of the patients (10/31). Conclusion: FDG-PET/CT imaging is a useful technique for primary tumor detection in patients in a cervical CUP context. Furthermore, it provides information on the ulterior metastasis of the disease.

Endoscopic Screening for Second Primary Tumors of the Esophagus Among Head and Neck Cancer Patients

Malignancies of the head and neck (HN) region and esophagus are among the most common cancers worldwide. Due to exposure to common carcinogens and the theory of field cancerization, HN cancer patients have a high risk of developing second primary tumors (SPTs). In our review of 28 studies with 51,454 HN cancer patients, the prevalence of SPTs was 12%. The HN area is the most common site of SPTs, followed by the lungs and esophagus, and 13% of HN cancer patients have been reported to have esophageal high-grade dysplasia or invasive carcinoma. The prognosis of HN cancer patients with concomitant esophageal SPTs is poor, and therefore identifying esophageal SPTs as early as possible is of paramount importance for risk stratification and to guide the treatment strategy. Image-enhanced endoscopy, especially using narrow-band imaging endoscopy and Lugol’s chromoendoscopy, has been shown to improve the diagnostic performance in detecting esophageal neoplasms at an early stage. Moreover, the early detection and minimally invasive endoscopic treatment of early esophageal neoplasm has been shown to improve the prognosis. Well-designed prospective studies are warranted to establish appropriate treatment and surveillance programs for HN cancer patients with esophageal SPTs.

FDG-PET/CT identified distant metastases and synchronous cancer in squamous cell carcinoma of the head and neck: the impact of smoking and P16-s

PURPOSE

Whole-body FDG-PET-CT is widely used at diagnosis of squamous cell carcinoma of the head and neck (SCCHN) but may identify suspicious lesions outside the neck that require investigation. This study evaluated the impact of smoking and P16-status on the incidence of malignant disease outside the head and neck region in newly diagnosed patients with SCCHN.

METHODS

All PET-positive foci outside the head-neck area were registered in 1069 patients planned for postoperative or curative intent radiotherapy with whole-body FDG-PET/CT from 2006 to 2012. All patient files were retrospectively investigated and clinical parameters, tobacco use, HPV (P16)-status and subsequent malignant disease registered.

RESULTS

Malignancy outside the neck was diagnosed in 9% of smokers, 2% of never-smokers, and 5% of patients with P16-positive oropharyngeal squamous cell carcinoma (OPSCC). Clinically suspicious PET-positive foci outside the head-neck were malignant in 55% of smokers, 34% of never-smokers, and in 38% of P16-pos OPSCC. All but two patients with cancer occurring outside the head and neck region were smokers.

CONCLUSION

Malignancy outside the neck at diagnosis was more frequent in smokers compared to non-smokers or P16-pos OPSCC. A high proportion of clinically suspicious PET-positive foci were non-malignant.

FDG-PET-CT/MRI in head and neck squamous cell carcinoma: Impact on pretherapeutic N classification, detection of distant metastases, and second primary tumors

BACKGROUND

To assess the effect of 18-fluorodeoxyglucose positron emission tomography (FDG-PET) in the pretherapeutic staging of N classification, detection rate of distant metastases, and second primaries.

METHODS

Retrospective study on patients with head and neck carcinoma. We compared pretherapeutic N classification by ultrasound, computed tomography (CT)/magnetic resonance imaging (MRI), and FDG-PET-CT/MRI.

RESULTS

A change in the N classification due to FDG-PET-CT/MRI was observed in 116 patients (39.5%) compared to N classification by ultrasound and fine-needle aspiration cytology. Patients with advanced nodal classification (>N2a) were more likely to be reclassified. Distant metastases were detected in 19 patients and a total of 36 second primaries were diagnosed by FDG-PET-CT/MRI. Detection of distant metastases was more likely in regional advanced disease (>N2a). Smokers (>10 py) had a significantly higher risk of second primary.

CONCLUSION

FDG-PET-CT/MRI leads to a significant change in pretherapeutic N classification. The cumulative incidence of distant metastases and second primaries was 18.7%.

Metachronous primary cancer of the tongue and malignant lymphoma of the small intestine: A case report

RATIONALE

Oral cancer often causes secondary primary cancers in the upper gastrointestinal tract. However, there are no reports of secondary primary cancers in patients with oral squamous cell carcinoma and malignant lymphoma of the small intestine. This report describes a case of metachronous multiple primary cancers of the tongue and small intestine malignant lymphoma.

PATIENTS CONCERNS

The patient was admitted to our department with the chief complaint of pain in the right tongue. Partial tongue resection and supraomohyoid neck dissection were performed. One year after surgery, the patient experienced abdominal pain and bloody stools.

DIAGNOSIS

Diffuse large B-cell lymphoma (DLBCL) was diagnosed via histological examination.

INTERVENTIONS

A terminal ileum resection was performed. Postoperatively, the patient received 6 courses of rituximab, cyclophosphamide, doxorubicin hydrochloride, vincristine, and prednisone (R-CHOP).

OUTCOMES

Five years after his initial diagnosis, there is no evidence of recurrence, metastasis, or other primary cancer.

LESSONS

Oral cancer patients should always be followed up owing to a possibility of malignant tumors in other areas.

Predictive value of suvmax changes between two sequential post-therapeutic FDG-pet in head and neck squamous cell carcinomas

18-flurodesoxyglucose position emission tomography (FDG-PET) with computed tomography (CT) or magnetic resonance imaging (MRI) is a broadly accepted tool for pretherapeutic staging and post-therapeutic assessment of response. The prognostic value of sequential post-therapeutic FDG-PETs and the impact of change in metabolic activity has been scarcely reported so far. We hypothesized that an increase in metabolic activity (as measured by maximum standardized uptake value, SUVmax) would be predictive for recurrence. We retrospectively assessed all oral, oropharyngeal, laryngeal, and hypopharyngeal squamous cell carcinoma patients treated at the Department of Otorhinolaryngology-Head and Neck Surgery, University Hospital Zurich between April 1st, 2010 and September 30th, 2018 (N = 337). After a negative post-treatment FDG-PET at 3 months, we measured the SUVmax of the local tumor area and the regional lymph nodes on follow-up FDG-PET at 9 months. We then correlated SUVmax difference between 9 and 3 months with tumor recurrence using Kaplan Meier analysis. During follow-up, 68 patients (20.2%) had local recurrence and 53 had regional recurrence (15.7%) at a median time of 9.0 (IQR 4.25-14) and 7.0 (IQR 5.25-23) months, respectively. An increase in local and/or regional SUVmax from the 3 months to the 9 months post-therapeutic FDG-PET resulted in a poorer recurrence-free survival (Log rank, P = 0.001, for both). An increase in local SUVmax between 3 and 9 months was associated with a hazard ratio of 4.17 for recurrence (95%CI 1.89-9.2, P = 0.0003). In conclusion, an increase in metabolic activity/SUVmax between two post-therapeutic FDG-PETs requires a histological examination as it is associated with tumor recurrence.

PET/CT in Surgical Planning for Head and Neck Cancer

Fluorine-18 (¹⁸F)-fluorodeoxyglucose (FDG) positron emission tomography fused with computed tomography (PET/CT) is a valuable tool in surgical planning for head and neck squamous cell carcinoma (HNSCC). If performed prior to biopsy or other surgical intervention, FDG-PET/CT has high sensitivity for the detection of the primary site in patients with cervical lymph node metastases from unknown primary origin and can be used to direct the surgical workup. FDG-PET/CT is superior to CT alone for detection of nodal metastases outside the expected pattern or distant metastases or second primary cancers and can greatly affect determination of appropriate management including surgical eligibility. Prior to the advent of PET/CT, many patients undergoing (chemo)radiation-based therapy had planned post-treatment neck dissection; FDG-PET/CT now has a proven role in the evaluation of recurrent or persistent disease amenable to salvage surgery and enables safe avoidance of planned postradiation neck dissection with a high negative predictive value. Specifically for this important application, two standardized reporting metrics may be used in the head and neck anatomic region: the "Hopkins criteria" and the "Neck Imaging Reporting and Data System"; both systems produce a formalized evaluation and recommendation based on PET/CT findings. The role of PET/CT as a replacement for elective neck dissection or examination under anesthesia remains controversial but deserves further study. FDG-PET/CT has a wide-ranging impact on the surgical management of patients with HNSCC and should be used routinely in patients with unknown primary nodal disease and those presenting with advanced-stage cancers at initial staging and to assess treatment response.

The Utility of Gastrointestinal Endoscopic Examination Versus Positron Emission Tomography-Computed Tomography in the Detection of Second Primary Lesions in Korean Patients With Head and Neck Cancer

OBJECTIVE

Head and neck cancer often accompany a synchronous secondary primary lesion in the digestive tract. The aim of this study was to compare detection rates between positron emission tomography-computed tomography (PET-CT) and esophagogastroduodenoscopy (G-fiber) or colonoscopy (C-fiber) in the initial staging and to analyze risk factors for premalignant, malignant, and total synchronous secondary primary lesions.

METHODS

A total of 739 patients with head and neck cancer who underwent PET-CT, G-fiber, or C-fiber were analyzed retrospectively.

RESULTS

Positron emission tomography-CT did not definitely detect any premalignant synchronous secondary primary lesions (0 [0%] of 739) but definitely detected 10 malignant synchronous secondary primary lesions (10 [1.35%] of 739). Esophagogastroduodenoscopy or C-fiber detected all 20 premalignant synchronous secondary primary lesions (20 [2.71%] of 739) and all 37 malignant synchronous secondary primary lesions (37 [5.00%] of 739). The patients with nasopharynx cancer tended to have premalignant synchronous secondary primary lesions (odds ratio [OR]: 3.793; 95% CI: 1.414-10.171; P = .008). Those with distant metastasis tended to have premalignant (OR: 4.743; 95% CI: 1.508-14.916; P = .009), malignant (OR: 3.803; 95% CI: 1.486-9.731; P = .005), and total synchronous secondary primary lesions (OR: 2.753; 95% CI: 1.159-6.538; P = .022).

CONCLUSIONS

Premalignant or malignant synchronous secondary primary lesions that were not definitely detected by PET-CT could be found in the endoscopic examination.

Integration of 18-FDG PET/CT in the Initial Work-Up to Stage Head and Neck Cancer: Prognostic Significance and Impact on Therapeutic Decision Making

Background: The objective of this study was to assess the therapeutic and prognostic impact of integrating18F-fluorodeoxyglucose (18-FDG) positron emission tomography (PET)/computed tomography (CT) into work-up (WU) at initial staging of patients with head and neck squamous cell carcinoma (HNSCC).

Method: 477 consecutive patients (414M/63F, mean age 62.3 ± 9.7 years) with newly diagnosed HNSCC who underwent pre-treatment 18-FDG PET/CT were retrospectively included. The 18-FDG PET/CT stage (sPET) was compared to the conventional work-up stage (sCWU). A group of cancer specialists determined whether integrating PET/CT into WU at initial staging had an impact on the therapeutic decision, classifying the clinical impact as high (change in therapeutic modality), medium (change in the radiotherapy or surgical procedure), or low (modification of TNM staging and/or detection of synchronous cancer without high or medium impact). Three-year overall survival (OS) was considered as primary endpoint of the prognostic analysis.

Results: 18-FDG PET/CT had a clinical impact in 221 patients (46.3%) with a medium or high impact on management in 94 (19.5%) patients. Medium and high impact of 18-FDG PET/CT was statistically equivalent between sCWU-stage I/II and III/IV subgroups (p = 0.02). 42 patients were PET/CT-upstaged from early stage I/II to advanced stage III/IV and had a significantly lower 3-year OS than those with concordant CWU and 18-FDG PET/CT early stage (54.8 vs. 82.6%, p = 0.001).

Conclusion: This study demonstrated that implementing 18-FDG PET/CT in the initial WU of HNSCC provides valuable staging information with a better prognostic stratification. Patient management was modified for any disease stage, even for early stage I-II, with consequences on survival.

[Evaluation of oesophagoscopy for staging and restaging of head and neck squamous cell carcinoma]

OBJECTIVE

Oesophagoscopy is important in diagnostic and follow up investigation in patients with head and neck squamous cell carcinoma (HNSCC). Second primary malignancies of the oesophagus have major impact on therapy of the primary tumour. Considering the low incidence of oesophageal second primaries and the serious complication of oesophageal perforation routine oesophagoscopy is being discussed.

MATERIAL AND METHODS

Incidence of oesophageal second primaries and complication rates in oesophagoscopy were identified in a systematic review. A retrospective analysis was performed in our own patient collective. To evaluate the current practice at German ENT Clinics a survey was conducted.

RESULTS

1053 oesophagoscopies in 800 patients were analysed. In 800 patients seven (0.9 %) synchronous secondary malignancies of the oesophagus occurred. In 253 follow up oesophagoscopies five (2 %) metachronous secondary malignancies were discovered. 14 (1.3 %) complications were detected; oesophageal perforation was only detected in one case (0.1 %). There was no association of certain risk factors with the incidence of secondary malignancies. The review of literature showed an incidence of secondary malignancies for Europe/USA of 1.8 % and for Asia of 4.1 %. Incidence of oesophageal perforation was 0-0.2 %. Survey results showed routine oesophagoscopy in staging (100 %) and regularly in follow up (65.3 %).

CONCLUSIONS

Oesophagoscopy is a convenient method to detect secondary malignancies of the oesophagus. To allow a selection of patients developing secondary malignancies according to risk profiles further prospective multicentre studies are required.

Metformin may be associated with false-negative cancer detection in the gastrointestinal tract on PET/CT

OBJECTIVE

Concurrent therapy with the antihyperglycemic drug metformin can hinder the detection of malignancy in the abdominal and pelvic portions of 18F-fluordeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) imaging performed for the diagnosis or staging of malignancy, as well as for treatment response and radiation therapy planning. This is due to the metformin-induced increase in intestinal FDG radiotracer uptake. We aim to bring this potentially important interaction to the attention of clinicians who care for cancer patients with diabetes.

METHODS

We searched MEDLINE (from 1970 to January 2014) and Google Scholar for relevant English-language articles using the following search terms: "metformin and FDG/PET, metformin and bowel uptake, metformin, and cancer, metformin and the intestine, metformin pharmacokinetics, hyperglycemia and FDG/PET." We reviewed the reference lists of pertinent articles with respect to metformin gut physiology, impact on FDG uptake and the effect on diagnostic accuracy of abdominalpelvic PET/CT scans with concurrent metformin therapy.

RESULTS

We reviewed the action of metformin in the intestine, with particular emphasis on the role of metformin in PET/CT imaging and include a discussion of clinical studies on the topic to help refine knowledge and inform practice. Finally, we discuss aspects pertinent to the management of type 2 diabetes (T2D) patients on metformin undergoing PET/CT.

CONCLUSIONS

Metformin leads to intense, diffusely increased FDG uptake in the colon, and to a lesser degree, the small intestine, which limits the diagnostic capabilities of FDG PET/CT scanning and may mask gastrointestinal malignancies. We suggest that metformin be discontinued 48 hours before FDG PET/CT scanning is performed in oncology patients. More rigorous data are needed to support the widespread generalizability of this recommendation.

Triple primary cancer of the head and neck, skin and prostate: A case report and literature review

Second primary cancer (SPC) is an important prognostic factor for patients with head and neck cancer (HNC); therefore, the association between the prognosis and development of SPC has been well-reported. The use of 2-[18F]-fluoro-2-deoxy-D-glucose-positron emission tomography (FDG-PET) is valuable to examine cancer stage, evaluate treatment responses and investigate suspected relapses or metastases. In the present study, the case of a male patient who was diagnosed with three primary cancer types, including well to moderately differentiated squamous cell carcinoma (SCC) of the mandible, axillary cutaneous poorly differentiated SCC and prostate adenocarcinoma, was described. Among these, mandible cancer was the first diagnosed when the patient was 70 years of age. Synchronous skin and prostate cancer (PRC) types then developed 3 years later. To the best of our knowledge, this is the first report of the aforementioned combination of cancer types. Postoperative FDG-PET was not performed as no lesions of recurrence or metastases of mandible cancer were found. Three years later, the PRC was asymptomatic and was incidentally detected by FDG-PET performed for a preoperative evaluation of skin cancer. It was indicated that FDG-PET could be utilized in patients with HNC due to there being no accurate FDG-PET protocol to detect SPC over a long-term follow-up.

Clinical and Prognostic Analysis of Hypopharyngeal Squamous Cell Carcinoma with Synchronous and Metachronous Multiple Malignancies

BACKGROUND/AIM

To analyze the clinical features and prevalence of synchronous and metachronous second primary malignancies (SPMs) in patients with hypopharyngeal squamous cell carcinoma (HSCC), their associated risk factors, and cause-specific mortality.

PATIENTS AND METHODS

We retrospectively reviewed 136 patients treated with curative intent at our hospital. Statistical analyses were performed to determine factors predictive of SPM and cause-specific mortality.

RESULTS

Sixty-three of 136 patients (46.3%) developed SPM; of these, 41 (30.1%) and 42 (30.9%) had synchronous and metachronous SPMs, respectively, with patient overlap. The most common site of synchronous and metachronous SPMs was the oesophagus (65.8% and 24.4%, respectively); the corresponding overall survival rates were 34.1% and 66.5%, respectively. Furthermore, heavy drinking was significantly correlated with synchronous SPM (p<0.001).

CONCLUSION

Oesophageal cancer surveillance is recommended for patients with HSCC, especially heavy drinkers. Our findings may help identify and properly manage HSCC patients at high risk of SPMs.

Assessment of tumor margins in head and neck cancer using a 3D-navigation system based on PET/CT image-fusion - A pilot study

OBJECTIVES

Determination of tumor margins in patients with squamous cell carcinoma of the head and neck (SCCHN) is mostly based on preoperative magnetic resonance imaging (MRI) or computed tomography scans (CT). Local recurrence of disease is often correlated with the presence of positive resection margins after surgical treatment. Positron emission tomography/computed tomography (PET/CT) imaging plays a crucial role in the assessment of patients with SCCHN. The purpose of this study was to determine whether PET/CT could predict tumor extension.

METHODS

In 12 patients who underwent surgical treatment of primary SCCHN (Stage III-IV) F18-FDG PET/CT image-fusion was performed on a 3D navigation-system based workstation. Image-guided needle biopsies were obtained from four different, color-coded metabolic areas within the tumor. The histopathological findings were correlated with findings on corresponding PET/CT scans.

RESULTS

81.3% of biopsies from the central area were positive. Specimens taken from the outer metabolic zone were positive in 66.7% of the patients. The highest incidence of positive biopsies was found in the zone adjacent to the outermost area. There was a statistically significant difference in positive tumor histopathology when comparing the various metabolic zones (p = 0.03).

CONCLUSION

Exact determination of tumor is an important research topic, although results remain controversial. The results of this study suggest that in some cases PET scans may overestimate tumor extension.

PET/CT and PET/MRI in head and neck malignancy

Combined 2-[18F]-fluoro-2-deoxy-d-glucose (FDG) positron-emission tomography (PET)/computed tomography (CT) has an established role in the staging of difficult cases of head and neck (HN) squamous cell carcinoma (SCC), looking for an unknown primary, assessing response post-chemotherapy at 3-6 months, and differentiating relapse from treatment effects in patients suspected to have tumour recurrence. The PET NECK trial, comparing PET/CT surveillance versus neck dissection in advanced head and neck cancer showed survival was similar among patients who underwent PET/CT-guided surveillance and those who underwent planned neck dissection, but surveillance was more cost-effective. There is growing interest in the use of hypoxia PET tracers, especially in targeting radiotherapy, where the radiotherapy dose can be boosted in regions of hypoxia; the use of 68Ga peptide tracers in neuroendocrine malignancy and also in the growing field of combined PET/magnetic resonance imaging (MRI). PET/MRI has the advantage of increased anatomical detail and radiation dose reduction combined with the molecular and metabolic data from PET, although PET/CT has the advantage in better sensitivity for imaging lung metastases. Thus far, there is good agreement between PET/CT and PET/MRI with high correlation between semi-quantitative measurements in primary, nodal, osseous, and soft-tissue lesions imaging. PET/MRI may indeed provide greater accuracy than the currently available imaging procedures in the staging and later treatment response evaluation in HNSCC.

Chapter 8 On the Horizon: Advanced Imaging Techniques to Improve Noninvasive Assessment of Cervical Lymph Nodes

Conventional imaging modalities are limited in the evaluation of lymph nodes as they predominantly rely on size and morphology, which have suboptimal sensitivity and specificity for malignancy. In this review we will explore the role of "on the horizon" advanced imaging modalities that can look beyond the size and morphologic features of a cervical lymph node and explore its molecular nature and can aid in personalizing therapy rather than use the "one-size-fits-all" approach.

FDG-PET/CT in the Postoperative Period: Utility, Expected Findings, Complications, and Pitfalls

FDG-PET/CT as a modality is increasingly used for detection of recurrence and for restaging in patients with clinical suspicion of malignancy, as well as in patients with elevated tumor markers. However, there are many pitfalls in the interpretation of these scans when the studies are performed after some treatment. Some of these are attributed to normal physiological distribution and are compounded when there are inflammatory changes occurring after surgery. The body's inherent response to the surgical insult results in this inflammation. In addition, there are also complications that can happen following surgery, causing increased FDG uptake. Despite various fallacies, FDG-PET/CT provides valuable information in evaluation of residual and recurrent malignant disease. In this article, we aim to describe some of these postsurgical changes secondary to inflammation, common surgical complications, and finally, the utility of FDG-PET/CT in these patients to detect recurrent disease, even in the background of postsurgical changes.

Chapter 3 The Role of PET/CT in Squamous Cell Carcinoma of the Head and Neck

Head and neck squamous cell carcinoma is an important cause of cancer morbidity worldwide and has been stratified into human papillomavirus-related and human papillomavirus-unrelated subgroups that affect prognosis and now staging. Conventional anatomical imaging methods are suboptimal for the detection of regional and distant metastases that are important prognosticators associated with poor outcomes. Functional imaging with (F18)-fluorodeoxyglucose-positron emission tomography/computed tomography (PET/CT) is a useful tool in the management of head and neck squamous cell carcinoma, providing complementary physiological and anatomical information. In this article, optimal PET/CT technique will be reviewed and the pretreatment and posttreatment applications of PET/CT will be described. A simplified approach to imaging interpretation, including review of pearls and pitfalls will be discussed. An initial framework for follow-up evaluation will be provided.

[PET-CT in head and neck cancer]

The importance of ¹⁸F-fluorodesoxyglucose positron-emission tomography (FDG-PET) for the diagnosis of malignant disease is increasing. On one hand, this is due to the high sensitivity of this method, on the other, because the entire body can be examined. FDG-PET can be particularly advantageous for the diagnosis of head and neck tumors, where tumor staging is an important prognostic parameter and essentially determines the therapeutic regimen. This article presents the different possibilities for combined evaluation with PET and computed tomography (CT) for the diagnosis of patients with head and neck cancer. Special focus is placed on primary staging and tumor follow-up, as well as on the role of PET-CT in the diagnosis of patients with cancer of unknown primary origin (CUP). The use of PET-CT for radiotherapy planning and new aspects of PET technology are also discussed.

Korean Society of Thyroid-Head and Neck Surgery Guideline Task Force, Ahn SH, Hong HJ, Kwon SY, Kwon KH, Roh JL, Ryu J, Park JH, Baek SK, Lee GH, Lee SY, Lee JC, Chung MK, Joo YH, Ji YB, Hah JH, Kwon M, Park YM, Song CM, Shin SC, Ryu CH, Lee DY, Lee YC, Chang JW, Jeong HM, Cho JK, Cha W, Chun BJ, Choi IJ, Choi HG, Lee KD. Guidelines for the Surgical Management of Laryngeal Cancer: Korean Society of Thyroid-Head and Neck Surgery

Korean Society of Thyroid-Head and Neck Surgery appointed a Task Force to develop clinical practice guidelines for the surgical treatment of laryngeal cancer. This Task Force conducted a systematic search of the EMBASE, MEDLINE, Cochrane Library, and KoreaMed databases to identify relevant articles, using search terms selected according to the key questions. Evidence-based recommendations were then created on the basis of these articles. An external expert review and Delphi questionnaire were applied to reach consensus regarding the recommendations. The resulting guidelines focus on the surgical treatment of laryngeal cancer with the assumption that surgery is the selected treatment modality after a multidisciplinary discussion in any context. These guidelines do not, therefore, address non-surgical treatment such as radiation therapy or chemotherapy. The committee developed 62 evidence-based recommendations in 32 categories intended to assist clinicians during management of patients with laryngeal cancer and patients with laryngeal cancer, and counselors and health policy-makers.

NBI utility in the pre-operative and intra-operative assessment of oral cavity and oropharyngeal carcinoma

PURPOSE

Despite advances in the surgical management of head and neck squamous cell carcinoma, the identification of synchronous lesions, precancerous lesions around the main tumor, or the unknown primary in the case of neck metastasis remains a problem, as these lesions may be invisible to the naked eye or with standard white light (WL) endoscopy. However, the advent of tools such as narrow-band imaging (NBI) could help the clinician. The purpose of this study was to assess the impact of NBI during the pre-operative and intra-operative stages of management of oral and oropharyngeal cancers.

MATERIALS AND METHODS

NBI was used pre-operatively in 47 patients with oral or oropharyngeal squamous cell carcinoma to identify the involvement of adjacent subsites, multifocality, synchronous lesions or an unknown primary. NBI was used intra-operatively in 30 patients to better define the tumor limits and guide the resection. The advantage of NBI versus WL endoscopy was analyzed by calculating the true and false positive rate pre-operatively, and the need for resection enlargements, histology of the enlargement, and the rate of clear margins at definitive histology, intra-operatively.

RESULTS

Pre-operatively, the diagnostic gain of NBI was 8.5%, allowing identification of three synchronous tumors and one unknown primary. Intra-operatively, NBI improved the definition of tumor limits in 67.7% of cases, with resection enlargements showing dysplasia and carcinoma in 8 and 12 patients, respectively; we obtained 74.2% negative margins at histology.

CONCLUSIONS

NBI could represent an added value in the pre-operative and intra-operative assessment of oral cavity and oropharyngeal carcinoma.

Role of fluorine-18 fluorodeoxyglucose PET/CT in head and neck oncology: the point of view of the radiation oncologist

Squamous cell carcinoma is the most common malignant tumour of the head and neck. The initial TNM staging, the evaluation of the tumour response during treatment, and the long-term surveillance are crucial moments in the approach to head and neck squamous cell carcinoma (HNSCC). Thus, at each of these moments, the choice of the best diagnostic tool providing the more precise and larger information is crucial. Positron emission tomography with fluorine-18 fludeoxyglucose integrated with CT (¹⁸F-FDG-PET/CT) rapidly gained clinical acceptance, and it has become an important imaging tool in routine clinical oncology. However, controversial data are currently available, for example, on the role of ¹⁸F-FDG-PET/CT imaging during radiotherapy planning, the prognostic value or its real clinical impact on treatment decisions. In this article, the role of ¹⁸F-FDG-PET/CT imaging in HNSCC during pre-treatment staging, radiotherapy planning, treatment response assessment, prognosis and follow-up is reviewed focusing on current evidence and controversial issues. A proposal on how to integrate ¹⁸F-FDG-PET/CT in daily clinical practice is also described.

PET/MR in cancers of the head and neck

One early application of PET/MRI in clinical practice may be the imaging of head and neck cancers. This is because the morphologic imaging modalities, CT and MR, are recognized as similarly effective tools in cross-sectional oncological imaging of the head and neck. The addition of PET with FDG is believed to enhance the accuracy of both modalities to a similar degree. However, there are a few specific scenarios in head and neck cancer imaging where MR is thought to provide an edge over CT, including perineural spread of tumors and the infiltration of important anatomical landmarks, such as the prevertebral fascia and great vessel walls. Here, hybrid PET/MR might provide higher diagnostic certainty than PET/CT or a separate acquisition of PET/CT and MR. Another advantage of MR is the availability of several functional techniques. Although some of them might enhance the imaging of head and neck cancer with PET/MR, other functional techniques actually might prove dispensable in the presence of PET. In this overview, we discuss current trends and potential clinical applications of PET/MR in the imaging of head and neck cancers, including clinical protocols. We also discuss potential benefits of implementing functional MR techniques into hybrid PET/MRI of head and neck cancers.

Clinical outcomes of synchronous head and neck and esophageal cancer

Purpose

To investigate clinical outcomes of synchronous head and neck and esophageal cancer (SHNEC).

Materials and Methods

We retrospectively reviewed 27 SHNEC patients treated with curative intent at a single institution. The treatment modality for individual cases was usually determined on a case by case basis.

Results

The median follow-up duration for the surviving patients was 28.2 months. The most common site of head and neck cancer was hypopharyngeal carcinoma (n = 21, 77.7%). The lower esophagus was the most common location of esophageal carcinoma (n = 16, 59.3%). The 2-year progression-free survival (PFS) and overall survival (OS) rates were 57.5% and 39.6%. Major pattern of failure was locoregional recurrence in the study patients. Esophageal cancer stage, the Eastern Cooperative Oncology Group (ECOG) performance status, and pretreatment weight loss were significant prognostic factors for OS in univariate analysis. Treatment-related death was observed in two patients, and one patient developed a grade 4 late treatment-related complication.

Conclusion

Although the survival outcome for SHNEC is poor, long-term survival might be achievable with aggressive treatment with stage I-II esophageal cancer and good performance.

Accuracy of (18) FDG PET-CT for treatment evaluation 3 months after completion of chemoradiotherapy for head and neck squamous cell carcinoma: 2-year minimum follow-up

BACKGROUND

The purpose of this study was to assess the accuracy of (18) F-fluorodeoxyglucose positron emission tomography ((18) FDG PET)-CT in detecting residual or recurrent disease after nonsurgical treatment for head and neck squamous cell carcinoma (HNSCC).

METHODS

We conducted a retrospective analysis of patients with oral cavity, oropharynx, larynx, hypopharynx, or cervical lymph node location of SCC treated with chemoradiotherapy. Twelve weeks posttreatment, (18) FDG PET-CT results were compared to histology if residual disease was suspected. Patients with complete response received a minimum of 24-month follow-up.

RESULTS

Forty-seven patients were included with 40 months of median follow-up: 46 with a squamous cell carcinoma (SCC) at the primary site and 43 in the neck. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were 86.7%, 90%, 76.5%, and 93.1%, respectively, at the primary site and 100%, 97.2%, 87.5%, 100%, respectively, in the neck.

CONCLUSION

(18) FDG PET-CT seems effective in detecting residual disease and in predicting recurrent disease within the first 2 years of follow-up after nonsurgical treatment. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1271-E1276, 2016.

The value of (18) F-FDG-PET/CT imaging in oral cavity cancer patients following surgical reconstruction

OBJECTIVE

Follow-up of patients with oral cavity squamous cell carcinoma (OCSCC) after tumor resection and reconstruction with tissue transfer is challenging. We compared contrast-enhanced computed tomography (ceCT), (18) F-fluorodeoxyglucose-positron emission tomography combined with noncontrast enhanced CT ((18) F-FDG-PET/CT), and (18) F-FDG-PET combined with ceCT ((18) F-FDG-PET/ceCT) to determine the accuracy for detection of residual/recurrent disease after flap reconstruction for OCSCC.

STUDY DESIGN AND METHODS

Two readers (R1, R2) retrospectively reviewed a total of 27 (18) F-FDG-PET/ceCT scans in patients after resection of stage II to IV OCSCC. They recorded the presence of local persistence/recurrence (LR), lymph node metastasis, or distant metastasis independently for ceCT, (18) F-FDG-PET/CT, and (18) F-FDG-PET/ceCT. Histological workup, imaging follow-up, or clinical follow-up served as the standard of reference. Maximum standardized uptake value (SUVmax) was evaluated to discriminate between physiological uptake and LR.

RESULTS

The highest accuracy to detect LR was achieved with (18) F-FDG-PET/ceCT, with a sensitivity/specificity of 88%/89% and 88%/79% for R1 and R2, respectively, as compared to ceCT with 75%/79% for R1 and 88%/68% for R2 and (18) F-FDG-PET/CT with 88%/58% for both R1 and R2. Receiver-operating-characteristic analysis determined a cutoff value for SUVmax of 7.2, yielding a sensitivity and specificity of 75% and 94%, respectively, to distinguish LR from physiological (18) F-FDG uptake.

CONCLUSION

(18) F-FDG-PET/ceCT seems to be the most reliable tool for locoregional surveillance of OCSCC patients after resection and reconstruction.

LEVEL OF EVIDENCE

4.

FDG-PET/CT in the Assessment of Treatment Response after Oncologic Treatment of Head and Neck Squamous Cell Carcinoma

BACKGROUND

In many centers, ¹⁸F-fluorodeoxyglucose-positron emission tomography/computed tomography (FDG-PET/CT) is used to monitor treatment response after definitive (chemo)radiotherapy [(C)RT] for head and neck squamous cell carcinoma (HNSCC), but its usefulness remains somewhat controversial. We aimed at assessing the accuracy of FDG-PET/CT in detecting residual disease after (C)RT.

METHOD

All HNSCC patients with FDG-PET/CT performed to assess treatment response 10–18 weeks after definitive (C)RT at our institution during 2008–2010 were included. The patient charts were reviewed for FDG-PET/CT findings, histopathologic findings, and follow-up data. The median follow-up time for FDG-PET/CT negative patients was 26 months.

RESULTS

Eighty-eight eligible patients were identified. The stage distribution was as follows: I, n = 1; II, n = 15; III, n = 17; IV, n = 55. The negative predictive value, positive predictive value, specificity, sensitivity, and accuracy of FDG-PET/CT in detecting residual disease were 87%, 81%, 94%, 65%, and 85%, respectively. The corresponding specific figures for the primary tumor site were 91%, 71%, 94%, 59%, and 86% and for the neck 93%, 100%, 100%, 75%, and 94%, respectively.

CONCLUSIONS

In patients who have received definitive (C)RT for HNSCC, post-treatment FDG-PET/CT has good potential to guide clinical decision-making. Patients with negative scan can safely be followed up clinically only, while positive scan necessitates tissue biopsies or a neck dissection to rule out residual disease.

Application of fluorodeoxyglucose positron emission tomography in the management of head and neck cancers

The use of fluorodeoxyglucose positron emission tomography (FDG PET) scan technology in the management of head and neck cancers continues to increase. We discuss the biology of FDG uptake in malignant lesions and also discuss the physics of PET imaging. The various parameters described to quantify FDG uptake in cancers including standardized uptake value, metabolic tumor volume and total lesion glycolysis are presented. PET scans have found a significant role in the diagnosis and staging of head and neck cancers. They are also being increasingly used in radiation therapy treatment planning. Many groups have also used PET derived values to serve as prognostic indicators of outcomes including loco-regional control and overall survival. FDG PET scans are also proving very useful in assessing the efficacy of treatment and management and follow-up of head and neck cancer patients. This review article focuses on the role of FDG-PET computed tomography scans in these areas for squamous cell carcinoma of the head and neck. We present the current state of the art and speculate on the future applications of this technology including protocol development, newer imaging methods such as combined magnetic resonance and PET imaging and novel radiopharmaceuticals that can be used to further study tumor biology.

Perineural spread in head and neck malignancies: clinical significance and evaluation with 18F-FDG PET/CT

Certain tumors of the head and neck use peripheral nerves as a direct conduit for tumor growth away from the primary site by a process known as perineural spread. Perineural spread is associated with decreased survival and a higher risk of local recurrence and metastasis. Radiologists play an important role in the assessment and management of head and neck cancer, and positron emission tomography/computed tomography (PET/CT) with 2-[fluorine 18]fluoro-2-deoxy-d-glucose (FDG) is part of the work-up and follow-up of many affected patients. Awareness of abnormal FDG uptake patterns within the head and neck is fundamental for diagnosing perineural spread. The cranial nerves most commonly affected by perineural spread are the trigeminal and facial nerves. Risk of perineural spread increases with a midface location of the tumor, male gender, increasing tumor size, recurrence after treatment, and poor histologic differentiation. Focal or linear increased FDG uptake along the V2 division of the trigeminal nerve or along the medial surface of the mandible, or asymmetric activity in the masticator space, foramen ovale, or Meckel cave should raise suspicion for perineural spread. If FDG PET/CT findings suggest perineural spread, the radiologist should look at available results of other imaging studies, especially magnetic resonance imaging, to confirm the diagnosis. Knowledge of common FDG PET/CT patterns of neoplastic involvement along the cranial nerves and potential diagnostic pitfalls is of the utmost importance for adequate staging and treatment planning.