Combined 18F-fluorodeoxyglucose-positron emission tomography and computed tomography as a primary screening method for detecting second primary cancers and distant metastases in patients with head and neck cancer

Latin American Consensus on the Treatment of Head and Neck Cancer

Head and neck squamous cell carcinoma (HNSCC) is well known as a serious health problem worldwide, especially in low-income countries or those with limited resources, such as most countries in Latin America. International guidelines cannot always be applied to a population from a large region with specific conditions. This study established a Latin American guideline for care of patients with head and neck cancer and presented evidence of HNSCC management considering availability and oncologic benefit. A panel composed of 41 head and neck cancer experts systematically worked according to a modified Delphi process on (1) document compilation of evidence-based answers to different questions contextualized by resource availability and oncologic benefit regarding Latin America (region of limited resources and/or without access to all necessary health care system infrastructure), (2) revision of the answers and the classification of levels of evidence and degrees of recommendations of all recommendations, (3) validation of the consensus through two rounds of online surveys, and (4) manuscript composition. The consensus consists of 12 sections: Head and neck cancer staging, Histopathologic evaluation of head and neck cancer, Head and neck surgery-oral cavity, Clinical oncology-oral cavity, Head and neck surgery-oropharynx, Clinical oncology-oropharynx, Head and neck surgery-larynx, Head and neck surgery-larynx/hypopharynx, Clinical oncology-larynx/hypopharynx, Clinical oncology-recurrent and metastatic head and neck cancer, Head and neck surgery-reconstruction and rehabilitation, and Radiation therapy. The present consensus established 48 recommendations on HNSCC patient care considering the availability of resources and focusing on oncologic benefit. These recommendations could also be used to formulate strategies in other regions like Latin America countries.

Cost-Effectiveness Analysis of PET-CT Surveillance After Treatment of Human Papillomavirus-Positive Oropharyngeal Cancer

OBJECTIVE

To determine the cost-effectiveness of surveillance imaging with PET/CT scan among patients with human papillomavirus-positive oropharyngeal squamous cell carcinoma.

STUDY DESIGN

Cost-effectiveness analysis.

SETTING

Oncologic care centers in the United States with head and neck oncologic surgeons and physicians.

METHODS

We compared the cost-effectiveness of 2 posttreatment surveillance strategies: clinical surveillance with the addition of PET/CT scan versus clinical surveillance alone in human papillomavirus-positive oropharyngeal squamous cell carcinoma patients. We constructed a Markov decision model which was analyzed from a third-party payer's perspective using 1-year Markov cycles and a 30-year time horizon. Values for transition probabilities, costs, health care utilities, and their studied ranges were derived from the literature.

RESULTS

The incremental cost-effectiveness ratio for PET/CT with clinical surveillance versus clinical surveillance alone was $89,850 per quality-adjusted life year gained. Flexible fiberoptic scope exams during clinical surveillance would have to be over 51% sensitive or PET/CT scan cost would have to exceed $1678 for clinical surveillance alone to be more cost-effective. The willingness-to-pay threshold at which imaging surveillance was equally cost-effective to clinical surveillance was approximately $80,000/QALY.

CONCLUSION

Despite lower recurrence rates of human papillomavirus-positive oropharyngeal cancer, a single PET/CT scan within 6 months after primary treatment remains a cost-effective tool for routine surveillance when its cost does not exceed $1678. The cost-effectiveness of this strategy is also dependent on the clinical surveillance sensitivity (flexible fiberoptic pharyngoscopy), and willingness-to-pay thresholds which vary by country.

Diagnostic Value of Preoperative uPAR-PET/CT in Regional Lymph Node Staging of Oral and Oropharyngeal Squamous Cell Carcinoma: A Prospective Phase II Trial

The detection of lymph node metastases is a major challenge in oral and oropharyngeal squamous cell carcinoma (OSCC and OPSCC). 68Ga-NOTA-AE105 is a novel positron emission tomography (PET) radioligand with high affinity to urokinase-type plasminogen activator receptor (uPAR), a receptor expressed on the surfaces of tumor cells. The aim of this study was to investigate the diagnostic value of uPAR-PET/CT (computerized tomography) in detecting regional metastatic disease in patients with OSCC and OPSCC compared to the current imaging work-up. In this phase II trial, patients with OSCC and OPSCC referred for surgical treatment were prospectively enrolled. Before surgery, 68Ga-NOTA-AE105 uPAR-PET/CT was conducted, and SUVmax values were obtained from the primary tumor and the suspected lymph nodes. Histology results from lymph nodes were used as the standard of truth of metastatic disease. The diagnostic values of 68Ga-uPAR-PET/CT were compared to conventional routine preoperative imaging results (CT and/or MRI). The uPAR expression in resected primary tumors and metastases was determined by immunohistochemistry and quantified digitally (H-score). A total of 61 patients underwent uPAR-PET/CT. Of the 25 patients with histologically verified lymph node metastases, uPAR-PET/CT correctly identified regional metastatic disease in 14 patients, with a median lymph node metastasis size of 14 mm (range 3-27 mm). A significant correlation was found between SUVmax and the product of the H-score and tumor depth (r = 0.67; p = 0.003). The sensitivity and specificity of uPAR-PET/CT in detecting regional metastatic disease were 56% and 100%, respectively. When added to CT/MRI, uPAR-PET was able to upstage 2/11 (18%) of patients with occult metastases and increase the sensitivity to 64%. The sensitivity and specificity of 68Ga-NOTA-AE105 uPAR-PET/CT were equivalent to those of CT/MRI. The significant correlation between SUVmax and uPAR expression verified the target specificity of 68Ga-NOTA-AE105. Despite the target specificity, the sensitivity of imaging is too low for nodal staging and it cannot replace neck dissection.

Importance of PET/CT in Initial Workup of Head and Neck Squamous Cell Carcinoma

Objective

Assess the impact of positron emission tomography/computed tomography (PET/CT) on disease staging at presentation in patients with head and neck squamous cell carcinoma.

Study Design

Retrospective cross-sectional review.

Setting

Academic multicenter single institution (Geisinger Health System).

Methods

All patients who had PET/CT imaging during workup for head and neck squamous cell carcinoma were included in the study. Pre- and post-PET/CT clinical staging were recorded. Statistical analyses were performed for patients with a change in clinical staging or detection of second primary malignancies on PET/CT.

Results

A total of 292 patients were included in the study, 238 of whom underwent PET/CT imaging as part of their initial workup. Twenty-eight (11.9%) patients were clinically upstaged on PET/CT with 7 patients having treatment alterations based on imaging. Eighteen (7.6%) patients were found to have second primary malignancies on PET/CT.

Conclusion

The current study further illustrates the importance of PET/CT in the workup of head and neck squamous cell carcinoma. Without the inclusion of PET/CT imaging, 19.3% of patients would have either been staged inappropriately or had second primary malignancies missed, again confirming the necessity of comprehensive functional imaging during the initial pretreatment workup.

Pre-CCRT 18-fluorodeoxyglucose PET-CT improves survival in patients with advanced stages p16-negative oropharyngeal squamous cell carcinoma via accurate radiation treatment planning

PURPOSE

No large-scale prospective randomized study with a long-term follow-up period has evaluated the survival outcomes of preconcurrent chemoradiotherapy (CCRT) 18-fluorodeoxyglucose positron emission tomography-computed tomography (¹⁸FDG PET-CT) in patients with non-human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCC).

PATIENTS AND METHODS

We included patients with stage I-IVA p16-negative OPSCC receiving definitive CCRT and categorized them into two groups according to pre-CCRT ¹⁸FDG PET-CT and compared their outcomes: the case group consisted of patients who underwent pre-CCRT ¹⁸FDG PET-CT, whereas the comparison group consisted of patients who did not receive pre-CCRT ¹⁸FDG PET-CT.

RESULTS

The final cohort consisted of 3942 patients (1663 and 2279 in the case and comparison groups, respectively). According to multivariable Cox regression analysis, pre-CCRT ¹⁸FDG PET-CT was not a significant prognostic factor for overall survival in patients with stages I-II of p16-negative OPSCC receiving standard CCRT. The adjusted hazard ratio (95% confidence interval) of all-cause death for the patients with advanced stages (III-IVA) of p16-negative OPSCC receiving pre-CCRT ¹⁸FDG PET-CT was 0.75 (0.87-0.94, P = 0.0236).

CONCLUSIONS

Routine use of pre-CCRT ¹⁸FDG PET-CT is not necessary for each patient with p16-negative OPSCC. Pre-CCRT ¹⁸FDG PET-CT is associated with improved survival in patients with stage III-IVA p16-negative OSCC, but might be not in those with stage I-II p16-negative OPSCC. No large-scale prospective randomized study with a long-term follow-up period has evaluated the survival outcomes of preconcurrent chemoradiotherapy (CCRT) 18-fluorodeoxyglucose positron emission tomography-computed tomography (¹⁸FDG PET-CT) in patients with p16-negative oropharyngeal squamous cell carcinoma (OPSCC). Our study is the first, largest, homogenous modality study on PET-CT including a long-term follow-up cohort to examine the survival outcomes of pre-CCRT ¹⁸FDG PET-CT or non-pre-CCRT PET-CT for patients with p16-negative OPSCC receiving standard CCRT stratified by different clinical stages. Routine use of pre-CCRT ¹⁸FDG PET-CT is not necessary for each patient with p16-negative OPSCC. Pre-CCRT ¹⁸FDG PET-CT is associated with improved survival in patients with stage III-IVA p16-negative OPSCC, but might be not in those with stage I-II p16-negative OPSCC.

Detection of distant metastases and distant second primary cancers in head and neck squamous cell carcinoma: comparison of [18F]FDG PET/MRI and [18F]FDG PET/CT

PURPOSE

This prospective study aimed to compare the diagnostic performance of [¹⁸]FDG PET/MRI and PET/CT for the detection of distant metastases and distant second primary cancers in patients with head and neck squamous cell carcinoma (HNSCC).

METHODS

A total of 103 [¹⁸F]FDG PET/MRI examinations immediately followed by PET/CT were obtained in 82 consecutive patients for staging of primary HNSCC (n = 38), suspected loco-regional recurrence/follow-up (n = 41) or unknown primary HNSCC (n = 3). Histology and follow-up > 2 years formed the standard of reference. Blinded readers evaluated the anonymized PET/MRI and PET/CT examinations separately using a 5-point Likert score. Statistical analysis included: receiver operating characteristic (ROC) analysis, jackknife alternative free-response ROC (JAFROC) and region-of-interest (ROI)-based ROC to account for data clustering and sensitivity/specificity/accuracy comparisons for a score ≥ 3.

RESULTS

Distant metastases and distant second primary cancers were present in 23/103 (22%) examinations in 16/82 (19.5%) patients, and they were more common in the post-treatment group (11/41, 27%) than in the primary HNSCC group (3/38, 8%), p = 0.039. The area under the curve (AUC) per patient/examination/lesion was 0.947 [0.927-1]/0.965 [0.917-1]/0.957 [0.928-0.987] for PET/MRI and 0.975 [0.950-1]/0.968 [0.920-1]/0.944 [0.910-0.979] for PET/CT, respectively (p > 0.05). The diagnostic performance of PET/MRI and PET/CT was similar according to JAFROC (p = 0.919) and ROI-based ROC analysis (p = 0.574). Sensitivity/specificity/accuracy for PET/MRI and PET/CT for a score ≥ 3 was 94%/88%/89% and 94%/91%/91% per patient, 96%/90%/91% and 96%/93%/93% per examination and 95%/85%/90% and 90%/86%/88% per lesion, respectively, p > 0.05.

CONCLUSIONS

In HNSCC patients, PET/MRI and PET/CT had a high and similar diagnostic performance for detecting distant metastases and distant second primary cancers.

Incidence of synchronous contralateral tonsillar malignancy in a known case of unilateral tonsillar carcinoma

OBJECTIVE

The literature is divided with regards to contralateral tonsillectomy in a known/suspected case of ipsilateral tonsillar malignancy. In this study, we evaluate the incidence of indolent synchronous contralateral tonsillar malignancy (SCTC) in patients with known ipsilateral tonsillar malignancy.

METHODS

All patients diagnosed with ipsilateral tonsillar carcinoma (TC) at a tertiary teaching center between January 2016 and December 2019 were screened. None of the patients were suspected to have bilateral TC. All patients underwent appropriate imaging in the form of Magnetic resonance imaging and computed tomography of head and neck region and then underwent bilateral tonsillectomy. The prevalence of bilateral tonsillar malignancy and the factors predicting them were analyzed.

RESULTS

In all 59 patients were included in the study. The mean and median age of the patient population was 60.8 and 59 years, respectively, with a male to female ratio of 3.2:1. The incidence of bilateral tonsillar malignancy in carcinoma of unknown primary (CUP) was 3/10 (33.3%). Among the remaining 49 patients, incidence of synchronous contralateral tonsillar carcinoma (SCTC) was 2/49 (4.08%). Overall, 5/59 (8.5%) patients had synchronous bilateral tonsillar malignancy. Furthermore, dysplasia was found in the contralateral tonsil in 4/10 (40%) CUP patients. Among the remaining 49 patients, dysplasia was seen in the contralateral tonsil in 20/49 (40.8%) patients. The absence of p16 expression predicted higher probability of SCTC. Factors like gender, T stage, nodal status or smoking did not predict SCTC.

CONCLUSION

We recommend bilateral tonsillectomy in all patients with suspected or proven TC (unilateral or bilateral) and CUP as it helps identify indolent SCTC and it does not add any significant morbidity to the patients.

LEVEL OF EVIDENCE

III.

KSNM60 in Clinical Nuclear Oncology

Since the foundation of the Korean Society of Nuclear Medicine in 1961, clinical nuclear oncology has been a major part of clinical nuclear medicine in Korea. There are several important events for the development of clinical nuclear oncology in Korea. First, a scintillating type gamma camera was adopted in 1969, which enabled to perform modern oncological gamma imaging. Second, Tc-99 m generator was imported to Korea since 1979, which promoted the wide clinical use of gamma camera imaging by using various kinds of Tc-99 m labeled radiopharmaceuticals. Third, a gamma camera with single photon emission tomography (SPECT) capability was first installed in 1980, which has been used for various kinds of tumor SPECT imaging. Fourth, in 1994, clinical positron emission tomography (PET) scanner and cyclotron with a production of F-18 fluorodeoxyglucose were first installed in Korea. Fifth, Korean Board of Nuclear Medicine was established in 1995, which contributed in the education and manpower training of dedicated nuclear medicine physicians in Korea. Finally, an integrated PET/CT scanner was first installed in 2002. Since that, PET/CT imaging has been a major imaging tool in clinical nuclear oncology in Korea. In this review, a brief history of clinical nuclear oncology in Korea is described.

Multiple Primary Malignancies in Head and Neck Cancer: A University Hospital Experience Over a Five-Year Period

Introduction

With an estimated incidence of 2%-4% per year, the development of a second primary malignancy (SPM) in patients with head and neck tumors (HNTs) is not a rare event. The present study aimed to (i) assess the frequency of SPMs in patients with HNTs treated in a university hospital over a five-year period and (ii) provide a demographic characterization of these patients.

Methods

Retrospective single-centre study of patients with more than one primary tumor (including at least one HNT) diagnosed between January 1, 2015, and December 31, 2019. Data were retrieved from patients’ clinical records and anonymized for analysis purposes.

Results

A total of 53 out of 824 (6.43%) patients with multiple primary malignancies were identified, 18 of which synchronous and 35 metachronous. The median follow-up was 25 months. Thirteen patients were diagnosed with more than one HNT. Forty patients were diagnosed with at least one HNT and one non-HNT. The most frequently diagnosed non-HNT SPMs were lung cancer (n=17) and esophageal cancer (n=8). The five-year survival rate was 53% for patients with multiple HNSCCs and 47% for patients with at least one non-HNT (log-rank p=0.729). The median overall survival was 14 months for synchronous and 58 months for metachronous SPMs (log-rank p=0.002).

Conclusion

Findings from this study highlight the importance of long-term follow-up of HNT patients for early detection of SPMs, increasing the chance of providing treatment with curative intent and improving patient outcomes and survival.

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.

Distant metastases and synchronous malignancies on FDG-PET/CT in patients with head and neck cancer: a retrospective study

Background

Fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) has been proven to be a good method to detect distant spread of head and neck cancer (HNC). However, most prior studies are based on Asian populations and may not be directly transferable to western populations.

Purpose

To investigate the frequency and distribution of distant metastases and synchronous malignancies detected by PET/CT in HNC in a northern Swedish population.

Material and Methods

All primary whole-body FDG-PET/CT examinations performed on the suspicion of HNC (n = 524 patients) between 1 January 2013 and 31 December 2016 at Umeå University Hospital in Sweden were retrospectively reviewed . After the exclusion of 189 examinations without evidence of primary HNC, 335 examinations were analyzed.

Results

Distant metastases were detected in 10 (3%) patients, all with advanced primary tumors corresponding to TNM stage 3–4, most frequently in salivary gland adenocarcinoma, where 50% of patients had distant spread. Four patients had metastases below the diaphragm, representing 20% of the salivary gland malignancies. In the remaining six patients, metastases were supraphrenic, of which all but one were identified by CT alone. Synchronous malignancies were discovered in 14 (4.2%) patients, of which five were below the diaphragm.

Conclusion

The overall frequency of distant spread and synchronous malignancy in primary HNC was generally low. However, the risk for distant metastases below the diaphragm was relatively higher in salivary gland adenocarcinoma, supporting whole-body FDG-PET/CT in the primary diagnostic work-up in these patients.

Clinical utility of 18F-FDG PET/CT for patients with recurrent head and neck squamous cell carcinoma

Background: The accurate detection of distant metastases can facilitate appropriate treatment planning for patients with recurrent head and neck squamous cell carcinoma (HNSCC). Objectives: We evaluated the role of ¹⁸F-FDG PET/CT for distant metastasis diagnosis and survival prediction in patients with recurrent HNSCC. Materials and methods: This study included 95 consecutive patients with recurrent HNSCC and salvage treatments. McNemar's test was used to compare the detection of distant metastasis at recurrence using ¹⁸F-FDG PET/CT and contrast-enhanced chest and neck CT, and bone scintigraphy. Results: Thirty-two patients (34%) had distant metastases at recurrence. The sensitivity, specificity, accuracy, and positive and negative predictive values of ¹⁸F-FDG PET/CT for detecting chest and bone metastases were comparable to those of conventional imaging (p > .1). However, ¹⁸F-FDG PET/CT detected two additional distant metastatic lesions. After controlling for clinicopathological factors, a recurrent lesion with maximum standardized uptake value (SUV_max) >8.7 was identified as an independent predictor of poor overall survival (p = .001). Conclusions and significance: ¹⁸F-FDG PET/CT or conventional imaging is comparable with regard to detecting distant metastases of recurrent HNSCC. However, ¹⁸F-FDG PET/CT may detect additional metastatic lesions in unusual distant sites and the recurrent lesion SUV_max may predict patient survival after salvage treatments.

Predictive Value of Pretherapeutic Maximum Standardized Uptake Value (Suvmax) In Laryngeal and Hypopharyngeal Cancer

The aim of the study was to evaluate whether pretherapeutic metabolic tumor parameters from 18-fluorodeoxyglucose positron emission tomography (FDG-PET) imaging could predict larynx preservation in laryngeal and hypopharyngeal cancer patients prior to primary chemoradiation. Tumor metabolic parameters [maximum standardized uptake value (SUV_max), metabolic tumor volume (MTV), and total lesion glycolysis (TLG)] were retrospectively assessed in a consecutive cohort of laryngeal and hypopharyngeal cancer patients undergoing primary (chemo-)radiation. Main outcome measures were larynx preservation and survival. The study included 97 patients with a median follow-up of 32 months (IQR 20-54.5). For hypopharyngeal cancer, multivariable analysis showed that patients with a primary tumor's SUV_max > 9.5 entailed a higher risk of undergoing salvage pharyngolaryngectomy after chemoradiation (HR = 8.64, 95% CI = 1.1-67.3, P = 0.040). In laryngeal cancer, SUV_max did not predict the need for salvage laryngectomy. The only predictor for larynx preservation in laryngeal cancer patients was T-classification at initial diagnosis (HR = 6.67, 95% CI = 0.82-53.9, P = 0.039). In conclusion, SUV_max of primary tumor could be used as a predictor of larynx preservation prior to primary chemoradiation in hypopharyngeal cancer patients. This information may be important for patient counseling, as high SUV_max was correlated with reduced probability of larynx preservation. However, in laryngeal cancer patients, SUV_max does not seem to be predictive of outcome.

Head and neck cancer prevention: from primary prevention to impact of clinicians on reducing burden

Survival from head and neck cancers (HNCs) of the lip, oral cavity, pharynx, and larynx has increased by 10% over the past few decades. Little over half of patients who develop HNCs will survive beyond 5 years. Survival is lower for individuals in many countries where traditional risk factors such as tobacco smoking, alcohol drinking, and betel quid chewing are highly prevalent but tertiary health care center access is limited or unavailable. Early diagnosis of HNC is the most important prognostic factor for each tumor site. Molecular-based research on HNC tumors holds promise for early stage detection, screening, vaccination, disease follow-up, and progression. Future investments for HNC control must consider both effectiveness and sustainability for both high- and low-resource countries alike, with priority toward risk factor prevention and earlier diagnosis.

Up-front PET/CT changes treatment intent in patients with head and neck squamous cell carcinoma

PURPOSE

In patients with newly diagnosed head and neck squamous cell carcinoma (HNSCC), we wanted to examine the differences in overall treatment decisions, i.e. curative versus palliative treatment intent, reached by a multidisciplinary team conference (MDTC) based on 18F-fluoro-deoxy-glucose-positron emission tomography/computed tomography (PET/CT) or chest X-ray + MRI of the head and neck (CXR/MRI).

PATIENTS AND METHODS

This was a prospective blinded cohort study based on paired data. Consecutive patients with histologically verified primary HNSCC were invited to participate. All included patients underwent CXR/MRI and PET/CT before diagnostic biopsy. An ordinary MDTC using all available imaging was conducted as per standard practice. After at least 3 months (to eliminate recall bias in the team), the first project MDTC was conducted, based on either CXR/MRI or PET/CT, and the tumor board drew conclusions regarding treatment. After an additional 3 months, a second project MDTC was conducted using the complementary imaging modality.

RESULTS

A total of 307 patients were included. Based on CXR/MRI, 303 patients (99%) were recommended for curative treatment and only four patients (1%) for palliative treatment. Based on PET/CT, the MDTC concluded that 278 (91%) patients were suitable for curative treatment and 29 (9%) patients for palliative treatment. The absolute difference of 8% was statistically significant (95% CI: 4.8%-11.5%, p < 0.001).

CONCLUSIONS

A PET/CT-based imaging strategy significantly changed the decisions regarding treatment intent made by a MDTC for patients diagnosed with HNSCC, when compared with the standard imaging strategy of CXR/MRI.

A PET/CT-Based Strategy Is a Stronger Predictor of Survival Than a Standard Imaging Strategy in Patients with Head and Neck Squamous Cell Carcinoma

Our purpose was to examine whether staging of head and neck squamous cell carcinoma (HNSCC) by upfront ¹⁸F-FDG PET/CT (i.e., on the day of biopsy and before the biopsy) discriminates survival better than the traditional imaging strategies based on chest x-ray plus head and neck MRI (CXR/MRI) or chest CT plus head and neck MRI (CCT/MRI). Methods: We performed a masked prospective cohort study based on paired data. Consecutive patients with histologically verified primary HNSCC were recruited from Odense University Hospital from September 2013 to March 2016. All patients underwent CXR/MRI, CCT/MRI, and PET/CT on the same day. Tumors were categorized as localized (stages I and II), locally advanced (stages III and IVB), or metastatic (stage IVC). Discriminative ability for each imaging modality with respect to HNSCC staging were compared using Kaplan-Meier analysis, Cox proportional hazards regression with the Harrell C-index, and net reclassification improvement. Results: In total, 307 patients with histologically verified HNSCC were included. Use of PET/CT significantly altered the stratification of tumor stage when compared with either CXR/MRI or CCT/MRI (χ², P < 0.001 for both). Cancer stages based on PET/CT, but not CXR/MRI or CCT/MRI, were associated with significant differences in mortality risk on Kaplan-Meier analyses (P ≤ 0.002 for all PET/CT-based comparisons). Furthermore, overall discriminative ability was significantly greater for PET/CT (C-index, 0.712) than for CXR/MRI (C-index, 0.675; P = 0.04) or CCT/MRI (C-index, 0.657; P = 0.02). Finally, PET/CT was significantly associated with a positive net reclassification improvement when compared with CXR/MRI (0.184, P = 0.03) but not CCT/MRI (0.094%, P = 0.31). Conclusion: Tumor stages determined by PET/CT were associated with more distinct prognostic properties in terms of survival than those determined by standard imaging strategies.

Reirradiation with IMRT for recurrent head and neck cancer: A single-institutional report on disease control, survival, and toxicity

AIM

To study and explores the feasibility and efficacy of re-irradiation (Re-RT) for locally recurrent head and neck cancer (HNC) and second primary (SP) malignancies.

BACKGROUND

The most common form of treatment failure after radiotherapy (RT) for HNC is loco-regional recurrence (LRR), and around 20-50% of patients develop LRR. Re-irradiation (Re-RT) has been the primary standard of care in the last decade for unresectable locally recurrent/SP HNC.

MATERIALS AND METHODS

It was a retrospective analysis in which we reviewed the medical records of 51 consecutive patients who had received Re-RT to the head and neck region at our institute between 2006 and 2015.

RESULTS

Forty-eight patients were included for assessment of acute and late toxicities, response evaluation at 3 months post Re-RT, and analyses of locoregional control (LRC) and overall survival (OS). The median LRC was 11.2 months, and at 2 and 5 years the LRC rates were 41% and 21.2%, respectively. A multivariate analysis revealed two factors: initial surgical resection performed prior to Re-RT, and achievement of CR at 3 months after completion of Re-RT to be significantly associated with a better median LRC. The median OS was 28.2 months, and at 1, 2, and 5 years, OS were 71.1%, 55.9% and 18%, respectively. A multivariate analysis revealed initial surgical resection performed prior to Re-RT, and achievement of CR at 3 months post completion of Re-RT being only two factors significantly associated with a better median OS. Acute toxicity reports showed that no patients developed grade 5 toxicity, and 2 patients developed grade 4 acute toxicities.

CONCLUSION

Re-RT for the treatment of recurrent/SP head and neck tumors is feasible and effective, with acceptable toxicity. However, appropriate patient selection criteria are highly important in determining survival and treatment outcomes.

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.

Clinical implications of nonspecific pulmonary nodules identified during the initial evaluation of patients with head and neck squamous cell carcinoma

OBJECTIVE

We aimed to identify the clinical implications of nonspecific pulmonary nodules (NPNs) detected in the initial staging workup for patients with head and neck squamous cell carcinoma (HNSCC).

METHODS

Medical records of patients who had been diagnosed and treated in our hospital were retrospectively analysed. After definite treatment, changes of NPNs detected on initial evaluation were monitored via serial chest computed tomography. The associations between NPNs and the clinicopathological characteristics of primary HNSCC were evaluated. Survival analyses were performed according to the presence of NPNs.

RESULTS

The study consisted of 158 (49.4%) patients without NPNs and 162 (50.6%) patients with NPNs. The cumulative incidence of probabilities of pulmonary malignancy (PM) development at 2 years after treatment were 9.0% and 6.2% in NPN-negative and NPN-positive patients, respectively. Overall and PM-free survival rates were not significantly different according to NPN status. Cervical lymph node (LN) involvement and a platelet-lymphocyte ratio (PLR) ≥126 increased the risk of PMs (both P <0.05).

CONCLUSIONS

NPNs detected in the initial evaluation of patients with HNSCC did not predict the risk of pulmonary malignancies. Cervical LN involvement and PLR ≥126 may be independent prognostic factors affecting PM-free survival regardless of NPN status.

KEY POINTS

• We aimed to identify the clinical implications of nonspecific pulmonary nodules (NPNs). • NPNs in head and neck cancer patients do not lead to pulmonary malignancies (PMs). • NPNs are not associated with overall or PM-free survival (PMFS). • Cervical lymph node involvement is an independent prognostic factor affecting PMFS. • Platelet-lymphocyte ratio ≥126 is another predictor of PMFS regardless of NPN presence.

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.

Positron-emission tomography/computed tomography imaging in head and neck oncology: An update

Cancers of the head and neck account for more than half a million cases worldwide annually, with a significant majority diagnosed as squamous cell carcinoma (HNSCC). Imaging studies such as contrast-enhanced computed tomography (CT), magnetic resonance imaging (MRI) and ¹⁸F-2-fluoro-2-deoxy-D-glucose positron-emission tomography/computed tomography (¹⁸F-FDG PET/CT) are widely used to determine the presence and extent of tumors and metastatic disease, both before and after treatment. Advances in PET/CT imaging have allowed it to emerge as a superior imaging modality compared to both CT and MRI, especially in detection of carcinoma of unknown primary, cervical lymph node metastasis, distant metastasis, residual/recurrent cancer and second primary tumors, often leading to alteration in management. PET/CT biomarker may further provide an overall assessment of tumor aggressiveness with prognostic implications. As new developments emerged leading to better understanding and use of PET/CT in head and neck oncology, the aim of this article is to review the roles of PET/CT in both pre- and post-treatment management of HNSCC and PET-derived parameters as prognostic indicators.

Value of FDG PET/CT in staging of oral cancer: four simultaneous primary malignancies

Patients with squamous cell cancer (SCC) of the head and neck are at increased risk for second primary malignancies (SPMs). We report on a 53-year-old patient with primary diagnosis of SCC in the anterior floor of the mouth. Panendoscopy suspected an SPM of the right vocal cord. FDG PET/CT, as a whole-body imaging method, confirmed this suspicion and raised concern for further SPM of both esophagus and colon. All malignancies were confirmed by biopsy. Subsequently, the patient underwent radiochemotherapy. In summary, FDG PET/CT revealed unexpected multiple SPMs, prevented unnecessary resection of the oral SCC, and enabled individualized therapeutic management.

Comparing staging by positron emission tomography with contrast-enhanced computed tomography and by pathology in head and neck squamous cell carcinoma

Objective:

This study aimed to evaluate the ability of positron emission tomography with contrast-enhanced computed tomography to correctly stage head and neck squamous cell carcinomas, in comparison with pathological staging.

Methods:

Positron emission tomography computed tomography was used to determine the tumour–node–metastasis classification and overall cancer stage in 85 head and neck squamous cell carcinoma patients who underwent pre-operative imaging using this modality and primary surgery between July 2010 and January 2013. Staging by positron emission tomography computed tomography was retrospectively compared with staging using pathological specimens. Agreement between imaging stage and pathological stage was examined by univariate and multivariate analysis both overall and for each primary tumour site.

Results:

This imaging modality was 87.5 per cent sensitive and 44.8 per cent specific in identifying regional cervical metastases, and had false positive and false negative rates of 18.8 per cent and 8.2 per cent, respectively. The positive predictive and negative predictive values were 75.4 per cent and 65.0 per cent, respectively. Univariate and multivariate analyses revealed a significant agreement between positron emission tomography computed tomography and pathological node classification in older patients and for the oral cavity primary tumour site. There was significant agreement between both methods in the overall classification only for tumours classified as T3 or greater.

Conclusion:

Positron emission tomography computed tomography should be used with caution for the pre-operative staging of head and neck cancers because of its high false positive and false negative rates.

Use of PET in Head and Neck Cancers

Head and neck cancer imaging is especially necessary for staging. Computed tomography and magnetic resonance imaging are the techniques frequently used for this purpose. These methods are valuable for displaying detailed anatomical structures; however, they may be inadequate for making the distinction between recurrence, residual tumor, fibrosis, and normal tissues with an altered anatomy after treatments such as surgery, radiotherapy, and chemotherapy and for the detection of metastases. From this point, positron emission tomography may be a promising imaging method. Scanning the entire body with a single method is an important advantage of positron emission tomography. It may be useful in the detection of synchronous tumors, which are a serious problem in head and neck cancers. Positron emission tomography may provide additional contribution for neck metastases, where the primary site is unknown and is undetectable by other imaging techniques.

Clinical significance of incidental findings on staging positron emission tomography for oesophagogastric malignancies

INTRODUCTION

The aim of this retrospective study was to determine the clinical significance of incidental findings detected on positron emission tomography (PET) in patients undergoing staging of oesophagogastric malignancies.

METHODS

Patients with oesophagogastric malignancies who underwent PET between June 2007 and May 2012 were included in the study. PET was performed according to hospital protocol. All imaging was interpreted by two consultant radiologists in nuclear medicine. Incidental findings that were unrelated to the primary malignancy were recorded and patients were recommended to have further investigations (imaging, endoscopy and biopsy).

RESULTS

Overall, 333 patients (240 male, 93 female; mean age: 67 years) with upper gastrointestinal malignancies were eligible for inclusion in the study. Eighty-nine of these patients had PET demonstrating one or more incidental findings. Two patients were found to have a second primary malignancy. One patient had a distant metastasis of his primary cancer and six patients had a premalignant lesion.

CONCLUSIONS

In this study, incidental findings were discovered in 26.7% of patients with known oesophagogastric cancer. A second primary cancer or premalignant lesion was found in 8.4% of patients with incidental findings. Patients with these findings should be investigated to rule out further malignancy. There were a high proportion of false positive results in our study. It is recommended that each patient is considered on an individual basis and assessed with simultaneous PET and computed tomography.

Whole-body-MR imaging including DWIBS in the work-up of patients with head and neck squamous cell carcinoma: a feasibility study

OBJECTIVES

To assess the feasibility of whole-body magnetic resonance imaging (WB-MRI) including diffusion-weighted whole-body imaging with background-body-signal-suppression (DWIBS) for the evaluation of distant malignancies in head and neck squamous cell carcinoma (HNSCC); and to compare WB-MRI findings with (18)F-fluorodeoxyglucose positron emission tomography/computed tomography ((18)F-FDG-PET/CT) and chest-CT.

METHODS

Thirty-three patients with high risk for metastatic spread (26 males; range 48-79 years, mean age 63 ± 7.9 years (mean ± standard deviation) years) were prospectively included with a follow-up of six months. WB-MRI protocol included short-TI inversion recovery and T1-weighted sequences in the coronal plane and half-fourier acquisition single-shot turbo spin-echo T2 and contrast-enhanced-T1-weighted sequences in the axial plane. Axial DWIBS was reformatted in the coronal plane. Interobserver variability was assessed using weighted kappa and the proportion specific agreement (PA).

RESULTS

Two second primary tumors and one metastasis were detected on WB-MRI. WB-MRI yielded seven clinically indeterminate lesions which did not progress at follow-up. The metastasis and one second primary tumor were found when combining (18)F-FDG-PET/CT and chest-CT findings. Interobserver variability for WB-MRI was κ=0.91 with PA ranging from 0.82 to 1.00. For (18)F-FDG-PET/CT κ could not be calculated due to a constant variable in the table and PA ranged from 0.40 to 0.99.

CONCLUSIONS

Our WB-MRI protocol with DWIBS is feasible in the work-up of HNSCC patients for detection and characterization of distant pathology. WB-MRI can be complementary to (18)F-FDG-PET/CT, especially in the detection of non (18)F-FDG avid second primary tumors.

The value of 18F-FLT PET for detecting second primary cancers and distant metastases in head and neck cancer patients

OBJECTIVE

Diagnostic efficacy of (18)F-FLT PET was compared with that of (18)F-FDG PET regarding second primary cancers and distant metastases of head and neck squamous cell cancers (HNSCCs).

METHODS

A total of 88 patients with HNSCCs were qualitatively examined with FLT PET and FDG PET for regions of focally increased metabolism. Final diagnoses of second primary cancer and distant metastasis were established on the basis of histological findings or clinical follow-up.

RESULTS

FDG PET had 1 false-negative finding with lung metastasis, and FLT PET had 4 false-negative findings with 1 liver metastasis, 1 bone metastasis, and 2 lung metastases. There were no false-positive findings with FLT PET in contrast to 9 with FDG PET (1 in lung, 4 in mediastinum, 1 in rectum, and 3 in stomach). Overall accuracy of FDG PET and FLT PET for pretreatment metastasis staging was 92% and 98%, respectively. Five distant metastases in 3 patients occurred after the initiation of chemoradiotherapy. FLT PET missed 2 metastatic lesions (1 in liver and 1 in lung), whereas FDG PET could not discriminate intracranial metastasis because of FDG uptake in the brain.

CONCLUSIONS

FLT PET does not appear to be recommendable to replace FDG PET for pretreatment metastasis staging in HNSCC cases because of its lower sensitivity and higher background activity in the liver and bone marrow. However, it might provide additional diagnostic specificity and biological information.

Utility of quantitative 18 F-fluorodeoxyglucose uptake measurement to identify occult tonsillar carcinoma in patients with cervical metastasis of unknown primary tumours: a retrospective case-control study

OBJECTIVES

Due to relatively high (18) F-fluorodeoxyglucose accumulation in the tonsillar region, the detection of occult tonsillar cancers by (18) F-fluorodeoxyglucose positron emission tomography/computerised tomography remains controversial. Therefore, we assessed the usefulness of quantitative tonsil (18) F-fluorodeoxyglucose uptake in identifying occult tonsillar squamous cell carcinoma.

DESIGN

A case-control study of retrospective cohorts.

SETTING

University Teaching Hospital.

MAIN OUTCOME MEASURES

We assessed all patients diagnosed with tonsillar cancers or cervical lymph node metastasis of unknown primary tumours between 2005 and 2010 who underwent (18) F-fluorodeoxyglucose positron emission tomography/computerised tomography. The subjects were grouped into A (apparent early pT-stage tonsillar squamous cell carcinoma; n = 27), B (occult tonsillar squamous cell carcinoma, primary tumours were found by surgery; n = 21), C (cervical metastasis of unknown primary tumour, primary tumours were not found by surgery and for follow-up; n = 16) and D (33 healthy controls). Tonsillar maximum standardised uptake values were bilaterally measured and compared between groups.

RESULTS

The sensitivity and specificity of qualitative assessment of (18) F-fluorodeoxyglucose positron emission tomography/computerised tomography for detection of occult tonsillar cancers were 67% and 69%, respectively. Mean maximum standardised uptake values of tonsils with cancer were 11.19 ± 5.46 in group A and 8.12 ± 4.52 in group B, which were significantly higher than that of group C (4.62 ± 1.76) or group D (4.57 ± 1.62) (P < 0.01). The mean maximum standardised uptake value differences of groups A (6.35) and B (3.11) were significantly greater than those of groups C (0.32) and D (0.59) (P < 0.01). Similarly, the mean maximum standardised uptake value ratios of groups A (2.47) and B (1.73) were significantly greater than those of groups C (1.06) and D (1.16) (P < 0.01).

CONCLUSION

(18) F-fluorodeoxyglucose positron emission tomography/computerised tomography with tonsil SUVmax measurement is useful to identify occult tonsillar squamous cell carcinoma.

Valor da PET/CT na abordagem do câncer de cabeça e pescoço

OBJETIVO: Avaliar a PET/CT na abordagem de pacientes com câncer de cabeça e pescoço. MATERIAIS E MÉTODOS: Estudo retrospectivo de 63 prontuários e exames de PET/CT de pacientes com câncer de cabeça e pescoço. RESULTADOS: Foram encontradas alterações em 76% dos exames. Destes, 7 (11%) foram considerados falso-positivos, com SUV < 5,0. A PET/CT mostrou-se negativa em 15 situações (24%). Dos 14 casos nos quais se utilizou o exame para estadiamento, em 3 (22%) houve aumento no estadiamento. CONCLUSÃO: A PET/CT mostra-se como exame de potencial valor na rotina de avaliação de pacientes com câncer de cabeça e pescoço, entretanto, necessitamos de maior número de casos para definirmos protocolo de uso.

Performance of whole-body PET/CT for the detection of distant malignancies in various cancers: a systematic review and meta-analysis

At present, there is no ideal imaging modality for the diagnosis of distant metastases and second primary cancers in cancer patients. We aimed to assess the accuracy of whole-body PET/CT for the overall assessment of distant malignancies in patients with various cancers.

METHODS

Studies about whole-body PET/CT for the detection of distant malignancies in cancer patients were systematically searched in MEDLINE and EMBASE. We determined sensitivities and specificities across studies, calculated positive and negative likelihood ratios, and constructed summary receiver operating characteristic curves using hierarchical regression models for whole-body PET/CT.

RESULTS

Across 41 studies (4,305 patients), the sensitivity and specificity of whole-body PET/CT were 0.93 (95% confidence interval [CI], 0.88-0.96) and 0.96 (95% CI, 0.95-0.96), respectively. Subgroup analysis showed that the sensitivity and specificity of whole-body PET/CT for various cancers, respectively, were as follows: head and neck cancer, 0.90 (95% CI, 0.83-0.95) and 0.95 (95% CI, 0.94-0.96); lung cancer, 0.91 (95% CI, 0.76-0.97) and 0.96 (95% CI, 0.94-0.98); breast cancer, 0.97 (95% CI, 0.93-0.99) and 0.95 (95% CI, 0.90-0.97); and cancer of digestive system, 0.92 (95% CI, 0.68-0.98) and 0.97 (95% CI, 0.91-0.99).

CONCLUSION

Whole-body PET/CT has excellent diagnostic performance for the overall assessment of distant malignancies in patients with various cancers, especially head and neck cancer, breast cancer, and lung cancer.

Value of fluoro-2-deoxy-D-glucose-positron emission tomography for detecting metastatic lesions in head and neck cancer

OBJECTIVES

The role of positron emission tomography (PET) scans in the staging of head and neck cancer (HNC) is unclear. The National Comprehensive Cancer Network guidelines do not recommend routine metastatic workup beyond physical examination, chest x-ray, and laboratory tests. The purpose of this report is to examine the accuracy of staging PET scans for detecting distant metastatic disease in patients with HNC.

METHODS

Retrospective review of 182 consecutive newly diagnosed HNC patients who had a staging PET scan at Thomas Jefferson University Hospital between 2003 and 2007.

RESULTS

The overall incidence of confirmed distant metastatic disease in this population was 5.0%. About 26 of the staging PET scans had areas suspicious for a metastatic lesion(s). Of total, 23 patients were further evaluated with imaging and/or biopsy, revealing 9 (39%) true positives, and 14 (60%) false positives. Of the 156 negative PET scans, there was 1 false negative and 155 true negatives. Thus, the sensitivity of PET was 90% and specificity was 92%. Positive predictive value was 39% and negative predictive value was 99.4%. No patients with pre-PET clinical stage I or II cancer had confirmed distant metastases. The only statistically significant predictor for metastatic disease was clinical stage IV versus all other stages (P=0.03).

CONCLUSIONS

Given the marked differences in the treatment of locally advanced/nonmetastatic HNC versus metastatic HNC, we recommend PET for clinical stage IV disease. Although the sensitivity, specificity, and negative predictive value rates were acceptable, the positive predictive value was suboptimal. Patients found to have a PET scan "positive" for metastatic disease require confirmatory imaging or ideally biopsy.

Evidence-based guideline recommendations on the use of positron emission tomography imaging in head and neck cancer

AIMS

To provide evidence-based practice guideline recommendations on the use of fluoro-2-deoxy-D-glucose positron emission tomography (PET) for diagnosis, staging and assessing treatment response, restaging or recurrence of head and neck cancer.

MATERIALS AND METHODS

A systematic review by Facey et al. (Health Technology Assessment 2007;11(44):iii-iv, xi-267) was used as the evidence base for recommendation development. As the review was limited to August 2005, the evidence base was updated to July 2011 using the same search strategies for MEDLINE and EMBASE used in the original review. The authors of the current systematic review drafted recommendations, which were reviewed, adapted and accepted by consensus by the Ontario provincial Head and Neck Disease Site Group and a special meeting of clinical experts.

RESULTS

The results of the Facey et al. review for head and neck cancer included five other systematic reviews and 31 primary studies. The 2005 to 2011 update search included four additional systematic reviews and 53 primary studies. Recommendations were developed based on this evidence and accepted by consensus.

CONCLUSIONS

PET is recommended in the M and bilateral nodal staging of all patients with head and neck squamous cell carcinoma where conventional imaging is equivocal, or where treatment may be significantly modified. PET is recommended in all patients after conventional imaging and in addition to, or prior to, diagnostic panendoscopy where the primary site is unknown. PET is recommended for the staging and assessment of recurrence of patients with nasopharyngeal carcinoma if conventional imaging is equivocal. PET is recommended for restaging patients who are being considered for major salvage treatment, including neck dissection.