Screening bone scintigraphy in the staging of locally advanced head and neck cancer

Multiple Regression Analysis of Predictors of Bone Scintigraphy Positivity in Patients with Head and Neck Cancers

Purpose

The value of bone scintigraphy (BS) in patients with head and neck cancers (HNCs) has been questioned, with conflicting findings regarding positivity yield with some reports recommending BS be omitted from work-up of HNC patients since it rarely yields positive results. This study aims to determine the positivity yield of BS in HNCs and to determine predictors for BS positivity to help tailor appropriate BS utilization.

Methods

BS studies of HNC patients were reviewed, the positivity yield was determined. Clinical predictors for BS positivity including age, sex, site of cancer, staging, histological grading were analyzed using univariable and multivariable logistic regression.

Results

Among the 259 BS studies included, 35 (13.5%), 194 (74.9%), and 30 (11.6%) were positive, negative, and equivocal for bone metastasis, respectively. After exclusion of equivocal cases, 229 were analyzed in the regression models. Independent predictors of BS positivity include site of tumor at the nasopharynx (OR 4.37, 95% C.I. 1.04-18.41, p = 0.044), age less than 45 years (OR 3.01, 95% C.I. 1.24-7.33, p = 0.015), and presence of distant metastasis to other organs (OR 3.84, 95% C.I. 1.19-12.43, p = 0.025).

Conclusions

In contrast to several studies, bone metastasis as detected by BS was found in a relatively high proportion of patients with HNCs. Independent predictors of BS positivity include the age of less than 45 years, tumor site at the nasopharynx, and the presence of extraskeletal distant metastasis. BS could be useful in patients with these characteristics which enhance the pretest probability of bone metastasis.

Initial staging examinations for head and neck squamous cell carcinoma: are they appropriate?

OBJECTIVES

The presence of distant metastases affects the therapeutic regime in patients with head and neck squamous cell carcinoma. This study evaluated the necessity to undertake bone scanning, chest computed tomography and abdominal ultrasonography in patients presenting with primary advanced head and neck squamous cell carcinoma.

STUDY DESIGN

Retrospective analysis, university setting.

METHODS

One hundred and sixty-three patients with head and neck squamous cell carcinoma who were scheduled for major surgery underwent screening for distant metastases. Chest, head and neck computed tomography, abdominal ultrasonography and bone scanning were performed in all patients.

RESULTS

Distant metastases were detected in 5.52 per cent of the 163 patients. All of these patients had locoregional advanced (stage IV) tumours. Computed tomography scanning of the lungs revealed metastases in six patients. Bone metastases were found in three patients. Only one patient with primary liver metastases was detected by abdominal ultrasonography; this patient also had pulmonary metastases.

CONCLUSIONS

Computed tomography of the thorax is the most important technique for screening patients with head and neck squamous cell carcinoma.

[Scintigraphy in staging upper aerodigestive tract epidermoid carcinomas]

OBJECTIVES

To determine the value of technetium-99m bone scintigraphy in the screening of bone metastases in the systematic initial extension assessment of upper aerodigestive tract suamous cell carcinomas; to identify risk factors of these bone metastases for better screening.

MATERIAL AND METHODS

In this prospective study, the initial assessment of tumoral extension was systematically associated with bone scintigraphy. Only patients with no malignant tumors were included in the study. Any skeletal fixation identified was then analyzed with standard radiography and/or tomodensitometry and with the patient's clinical progression to confirm whether or not the fixation was metastatic. The sensitivity and specificity of bone scintigraphy was then calculated. A correlation between bone pain or hypercalcemia and confirmed bone metastases was also systematically sought to determine whether these factors were predictive of bone metastases so as to better target the screening.

RESULTS

Among the 55 patients included in the study, three had confirmed bone metastases. All were detected by the bone scintigraphy, with a sensitivity of 100%. However, the 20 false-positive results gave a low specificity of 62%. Bone pain was described by two patients, but they were among the three metastatic patients. Specificity was 100%, but the sensitivity was only 67%. Three patients had hypercalcemia: the three metastatic patients. The sensitivity and specificity were 100%. In the tumoral status of the three patients with bone metastasis, tumors were small, classified as T1 or T2, but with substantial node involvement, classified N3, and with invasion of the internal jugular vein in two cases.

CONCLUSION

The incidence of bone metastases in the initial extension assessment was low; consequently, they are not sought systematically. However, their presence radically changes the prognosis and the therapeutic management, raising the question of screening. The technetium-99m bone scintigraphy has limits, with many false-positive resulting the need for additional investigations. Defining the risk factors for bone metastases would improve screening. Two questions remain: what factors are involved? The bone pain and the hypercalcemia must be analyzed with a larger number of cases, but they seem to be nonspecific. The node involvement stage could be a more reliable parameter, in particular in cases of jugular vein invasion; what method should be used? In the future, the PET scan could be the key procedure not only in the locoregional extension assessment, but also for general extensions, in a single procedure investigating the whole body.

Nuclear medicine imaging for the assessment of primary and recurrent head and neck carcinoma using routinely available tracers

This article reviews the literature on the use of fluorine-18 fluorodeoxyglucose positron emission tomography (FDG PET) and thallium-201, technetium-99m sestamibi and technetium-99m tetrofosmin single-photon emission tomography (SPET) for the diagnosis and staging of primary and recurrent squamous cell carcinoma of the head and neck (SCCHN). A search of the MEDLINE and CancerLit databases covering articles entered between 1989 and February 2003 was performed. In the case of FDG PET, only full-ring PET studies that included comparison with conventional morphological imaging were considered. Due to the wide variation in methodology, a straightforward meta-analysis of FDG PET literature was impossible. Instead, indicative summary receiver-operating curves of FDG PET and morphological imaging techniques were generated and a paired comparison of the sensitivities and specificities of FDG PET and morphological imaging performed. Compared with conventional morphological imaging, FDG PET proved as sensitive and specific for the detection of primary SCCHN but more sensitive and specific for the detection of cervical lymph node involvement (CLNI) and recurrence of SCCHN. Additional studies addressing the role of FDG PET in screening for distant metastases and synchronous primary tumours are mandatory. Following negative conventional evaluations, FDG PET identifies occult primary tumours in 20-50% of patients presenting with CLNI. As regards the use of 201Tl, 99mTc-sestamibi and 99mTc-tetrofosmin, more studies are required to define whether these imaging agents could form part of the current diagnostic armamentarium in SCCHN patients. It is concluded that FDG PET either is superior to or offers added value when compared with conventional morphological imaging techniques for the purpose of diagnosis and staging of primary and recurrent SCCHN.

Evaluation of 67 Ga citrate and 99m Tc bone scintigraphy at initial examination for primary oral squamous cell carcinoma

PURPOSE

This study was carried out to evaluate the diagnostic utility of gallium citrate Ga 67 ((67)Ga) and technetium Tc 99m bone scintigraphy as initial screening methods for distant metastasis and synchronous malignancies in patients with oral cancer.

PATIENTS AND METHODS

Ga and/or bone scintigraphy was performed for 123 patients with primary squamous cell carcinoma (SCC). Abnormal accumulation sites detected with scintigraphy were reevaluated with radiography or computed tomography. Whether the accumulation sites were metastatic was determined according to the radiographic findings and the later clinical course of the patients.

RESULTS

Ga scintigraphy did not detect distant metastases or 4 synchronous cancers at other sites and provided no useful information on the emergence of delayed pulmonary metastases that developed in 3 cases after a few months. Ga scintigraphy showed an abnormal accumulation in 53% of primary tumors and 25% of metastatic cervical lymph nodes, and the detection of accumulation was closely related to the size of the lesion. Bone scintigraphy showed 1 case (0.9%) with distant metastasis to the vertebra; however, there were numerous false-positive cases that required additional radiographic confirmation.

CONCLUSIONS

These results suggested that Ga and bone scintigraphy at the initial examination of patients with primary oral SCC are ineffective for detecting distant metastasis and other malignancies because of the low incidence of these lesions and the diagnostic inaccuracy of scintigraphy.

Screening for distant metastases in patients with head and neck cancer

OBJECTIVES

The detection of distant metastases at initial evaluation may alter the selection of therapy in patients with head and neck squamous cell carcinoma (HNSCC). In this study the value of screening for distant metastases is evaluated.

STUDY DESIGN

Retrospective analysis.

METHODS

The results of screening for distant metastases were retrospectively analyzed in 101 consecutive HNSCC patients with high-risk factors who were scheduled for major surgery. All patients had computed tomography (CT) scan of the thorax, bone scintigraphy, examination of the liver by ultrasound and/or CT scan, and blood tests.

RESULTS

Distant metastases were found in 17% of the patients. Patients with four or more clinical lymph node metastases or low jugular lymph node metastases had the highest incidence of distant metastases (33%). CT scan of the thorax detected in 12 patients, lung metastases; in 4, mediastinal lymph node metastases; and in 2, primary lung tumors. Bone scintigraphy detected in four patients bone metastases; in all four patients lung or mediastinal lymph node metastases were also found. Ultrasound and/or CT scan of the liver revealed one patient with metastases. Blood tests did not show any significant difference between patients with or without bone or liver metastases.

CONCLUSIONS

Screening in patients with three or more lymph node metastases, bilateral lymph node metastases, lymph nodes of 6 cm or larger, low jugular lymph node metastases, locoregional tumor recurrence, and second primary tumors revealed distant metastases in 10% or more. CT scan of the thorax is currently the single most important diagnostic technique for screening of distant metastases.

The utility of bone scans in rheumatology

PURPOSE

Bone scanning is the most common diagnostic imaging service requested by Australian rheumatologists, who order $50,000 (Australian) worth of bone scans annually.

METHODS

To determine why rheumatologists request bone scans and how they affect their patient management, the authors administered a two-part prospective survey before and after every bone scan ordered by four rheumatologists during a 6-month period in 1996.

RESULTS

A total of 136 bone scans were requested. The primary indications for scanning were to confirm a clinical diagnosis (38%), to exclude a diagnosis (34%), and to localize the site of pain (17%). The common diseases that rheumatologists were attempting to confirm or exclude with bone scanning were inflammatory arthritis, malignancy, and fracture. However, the most common provisional and final diagnosis was soft tissue rheumatism (18%), followed by inflammatory arthritis (15%) and osteoarthritis (11%). Bone scans were successful in excluding a diagnosis in 87% and confirming a diagnosis in 80%. In 32%, bone scans altered the clinical diagnosis, and in 43% they changed the course of disease management. Bone scan results prevented further investigations in 60%.

Skeletal metastases and bone marrow infiltration from squamous cell carcinoma of the buccal mucosa

Distant metastasis from head and neck cancer is an extremely rare phenomenon. Squamous carcinomas of the buccal mucosa is not known to spread to distant organs. We report a case of buccal mucosal carcinoma with biopsy proven metastasis to bone and bone marrow.

Accuracy in the diagnosis of mandibular involvement by oral cancer

Cancer of the mandibular region usually has a poor prognosis; this is particularly correlated to invasion of the mandible. To reduce the consequences of poor therapeutic planning, careful preoperative assessment of bone infiltration is necessary. We have examined the records of 50 patients evaluated by clinical examination, conventional radiography, computed tomography (CT), bone scintigraphy with 99mTc and magnetic resonance imaging (MRI). The highest sensitivity (100%) was attained by scintigraphy; the highest values of specificity (96.3%) were reached by CT scan and MRI. A CT scan showed the highest predictive positive value (95.4%) and efficiency (94%), this plus MRI have good values and the associated sensitivity and efficiency are higher than when these techniques are used alone.