Screening for distant metastases in head and neck cancer patients using FDG-PET and chest CT: validation of an algorithm

Predictors of distant metastatic recurrence in head and neck cutaneous squamous cell carcinoma with lymph node metastases treated with curative intent: A multicenter study

BACKGROUND

We aimed to identify predictors of distant metastatic recurrence (DMR) in patients with head and neck cutaneous squamous cell carcinoma (HNcSCC) with nodal metastases treated with curative intent.

METHODS

Predictors of DMR were identified using Cox regression in a multicenter study of 1151 patients.

RESULTS

The 5-year risk of DMR was 9.6%. On multivariate analysis, immunosuppression (HR 2.93; 95% CI: 1.70-5.05; p < 0.001), nodal size >6 cm [versus ≤3 cm (HR 2.77; 95% CI: 1.09-7.03; p = 0.032)], ≥5 nodal metastases [versus 1-2 (HR 2.79; 95% CI: 1.63-4.78; p < 0.001)], and bilateral disease (HR 3.11; 95% CI: 1.40-6.90; p = 0.005) predicted DMR. A DMR risk score was developed that stratified risk from 6.6% (no risk factors) to 100% (≥3 risk factors) (p < 0.001).

CONCLUSIONS

The risk of DMR in nodal metastatic HNcSCC increases with immunosuppression, nodal size >6 cm, ≥5 nodal metastases, and bilateral disease. A simple DMR risk score estimated prior to treatment may be clinically useful.

ACR Appropriateness Criteria® Staging and Post-Therapy Assessment of Head and Neck Cancer

Imaging of head and neck cancer at initial staging and as part of post-treatment surveillance is a key component of patient care as it guides treatment strategy and aids determination of prognosis. Head and neck cancer includes a heterogenous group of malignancies encompassing several anatomic sites and histologies, with squamous cell carcinoma the most common. Together this comprises the seventh most common cancer worldwide. At initial staging comprehensive imaging delineating the anatomic extent of the primary site, while also assessing the nodal involvement of the neck is necessary. The treatment of head and neck cancer often includes a combination of surgery, radiation, and chemotherapy. Post-treatment imaging is tailored for the evaluation of treatment response and early detection of local, locoregional, and distant recurrent tumor. Cross-sectional imaging with CT or MRI is recommended for the detailed anatomic delineation of the primary site. PET/CT provides complementary metabolic information and can map systemic involvement. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

The impact of multimodality integrated positron emission tomography-computed tomography on improving the staging and management of head and neck malignancy: a cross- sectional study

BACKGROUND

Clinical assessment of head and neck cancers is highly challenging owing to the complexity of regional anatomy and wide range of lesions. The diagnostic evaluation includes detailed physical examination, biopsy and imaging modalities for disease extent and staging. Appropriate imaging is done to enable determination of precise tumor extent and involvement of lymph nodes, and detection of distant metastases and second primary tumors.

OBJECTIVE

To evaluate the initial staging discrepancy between conventional contrasted computed tomography (CT) and 18F-fluorodeoxy-D-glucose positron emission tomography/computed tomography (18F-FDG PET/CT) and its impact on management plans for head and neck malignancies.

DESIGN AND SETTING

Prospective cross-sectional study in two tertiary-level hospitals.

METHODS

This study included 30 patients with primary head and neck malignant tumors who underwent contrasted computed tomography and whole-body 18F-FDG PET/CT assessments. The staging and treatment plans were compared with the incremental information obtained after 18F-FDG PET/CT.

RESULTS

18F-FDG PET/CT was found to raise the stage in 33.3% of the cases and the treatment intent was altered in 43.3% of them, while there was no management change in the remaining 56.7%. 18F-FDG PET/CT had higher sensitivity (96% versus 89.2%) and accuracy (93% versus 86.7%) than conventional contrast-enhanced computed tomography.

CONCLUSION

Our study demonstrated that 18F-FDG PET/CT had higher sensitivity and accuracy for detecting head and neck malignancy, in comparison with conventional contrast-enhanced computed tomography. 18F-FDG PET/CT improved the initial staging and substantially impacted the management strategy for head and neck malignancies.

Development and Validation of a Decision Analytical Model for Posttreatment Surveillance for Patients With Oropharyngeal Carcinoma

IMPORTANCE

Clinical practice regarding posttreatment radiologic surveillance for patients with oropharyngeal carcinoma (OPC) is neither adapted to individual patient risk nor fully evidence based.

OBJECTIVES

To construct a microsimulation model for posttreatment OPC progression and use it to optimize surveillance strategies while accounting for both tumor stage and human papillomavirus (HPV) status.

DESIGN, SETTING, AND PARTICIPANTS

In this decision analytical modeling study, a Markov model of 3-year posttreatment patient trajectories was created. The training data source was the American College of Surgeon's National Cancer Database from 2010 to 2015. The external validation data set was the 2016 International Collaboration on Oropharyngeal Cancer Network for Staging (ICON-S) study. Training data comprised 2159 patients with OPC treated with primary radiotherapy who had known HPV status and disease staging information. Patients with American Joint Committee on Cancer, 7th edition stage III to IVB disease and those with clinical metastases during the time of primary treatment were included. Data were analyzed from August 1 to October 31, 2020.

MAIN OUTCOMES AND MEASURES

Main outcomes included disease stage and HPV status, specific disease transition probabilities, and latency of surveillance regimens, defined as time between recurrence incidence and disease discovery.

RESULTS

Training data consisted of 2159 total patients (1708 men [79.1%]; median age, 59.6 years [range, 40-90 years]; 401 with stage III disease, 1415 with stage IVA disease, and 343 with stage IVB disease). Cohorts predominantly had HPV-negative disease (1606 [74.4%]). With model-optimized regimens, recurrent disease was discovered a mean of 0.6 months (95% CI, 0.5-0.8 months) earlier than with a standard surveillance regimen based on current clinical guidelines. Recurrent disease was discovered using the optimized regimens without significant reduction in sensitivity. Compared with strategies based on reimbursement guidelines, the model-optimized regimens found disease a mean of 1.8 months (95% CI, 1.3-2.3 months) earlier.

CONCLUSIONS AND RELEVANCE

Optimized, risk-stratified surveillance regimens consistently outperformed nonoptimized strategies. These gains were obtained without requiring any additional imaging studies. This approach to risk-stratified surveillance optimization is generalizable to a broad range of tumor types and risk factors.

Role of molecular signature to differentiate second primary lung cancer from metastasis in a patient with squamous cell carcinoma of oral cavity

Background

Lung is the most common site of distant metastasis for patients with head and neck squamous cell carcinoma (HNSCC). However, differentiating second primary lung cancers from metastasis may be difficult for p16 negative HNSCC.

Case

We describe a case of oral cavity squamous cell carcinoma (SCC) who was found to have lung nodule and hilar lymphadenopathy (LAD) after surgery and radiation therapy. Hilar node was consistent with SCC however, it was difficult to differentiate second primary lung cancer and metastasis from oral cavity SCC.

Next‐generation sequencing was done for the primary oral cavity and the hilar node. Both samples had the same type of TP53 mutation and variants of unknown significance suggesting metastatic HNSCC. He was treated with a chemotherapy regimen for metastatic HNSCC.

Conclusion

Molecular studies can help to differentiate metastasis from second primary lung cancers for p16 negative HNSCC.

Choice of imaging modality for pre-treatment staging of head and neck cancer impacts TNM staging

PURPOSE

The purpose of this retrospective cohort study was to determine whether there is a difference in the sensitivity of chest computed tomography (CT) versus ¹⁸F-fluorodeoxyglucose positron emission tomography with low-dose nonenhanced CT (¹⁸F-FDG PET/CT or PET/CT) in the detection of distant metastases in head and neck cancer, within a tertiary care setting.

MATERIALS AND METHODS

Patients with head and neck cancer, and known distant metastases, who underwent both ¹⁸F-FDG PET/CT with integrated low-dose nonenhanced CT and diagnostic chest CT prior to initiation of therapy from 2008 to 2017 were included. Two head and neck radiologists, blinded to all patient information and to each other's readings, reviewed the PET/CT or CT chest images for each patient and identified whether distant metastases were present. No radiologist read both modalities for a single patient. Concordance between imaging modalities was quantitatively analyzed using McNemar's test.

RESULTS

27 patients were included. McNemar's mid p-value analysis showed no significant difference in the detection of distant metastases (p = .6875). However, PET/CT detected distant metastases in three patients that chest CT did not, while chest CT identified distant metastatic disease in two patients that were negative on PET/CT.

CONCLUSIONS

While this study did not identify a statistically significant difference in sensitivity, five patients had distant metastases identified on only one of the two modalities. Use of a single modality would have resulted in inaccurate staging in 7-11% of patients in our study. The use of both modalities offers the greatest accuracy when providing stage-adapted oncologic treatment.

Clinical significance of the distance between the cricoid cartilage and upper edge of the tumor using PET-CT in cervical esophageal cancer

Cervical esophageal squamous cell carcinoma (CESCC) is less common compared with thoracic esophageal cancer, and few studies have investigated the clinicopathological features of CESCC. The present study analyzed 69 patients with CESCC who underwent various therapies at the University Hospital of Kyoto Prefectural University of Medicine between January 2000 and December 2016. The distance between the inferior border of the cricoid cartilage and upper edge of the tumor was evaluated using positron emission tomography and computed tomography. Positive and negative values indicated oral and anal directions, respectively. Using receiver operating characteristic curves, the cut-off value for laryngeal preservation was calculated as -5 mm. According to this value, the patients were divided into two groups: The short group (distance from the cricoid cartilage ≥-5 mm) and long group (distance from the cricoid cartilage <-5 mm). There were no significant differences in clinicopathological factors between the two groups except for body mass index. In univariate analysis, the 3-year overall survival rate was significantly lower in short group (45.4 vs. 79.6%; P=0.009). In multivariate analysis, short group was an independent prognostic risk factor (hazard ratio=2.65; P=0.039). This may be due to lymphatic flow around the cervical esophagus.

Comparison between squamous cell carcinoma and inflammatory diseases of the oral and maxillofacial region using gallium-67 scintigraphy with computed tomography and magnetic resonance imaging

Purpose

This study aimed to compare squamous cell carcinoma (SCC) with inflammatory diseases of the oral and maxillofacial region using gallium 67 (⁶⁷Ga) scintigraphy with computed tomography (CT) and magnetic resonance imaging (MRI).

Material and methods

Seventy patients with SCC and 15 patients with inflammatory diseases of the oral and maxillofacial region underwent ⁶⁷Ga scintigraphy with CT and MRI. A comparison between imaging features of ⁶⁷Ga scintigraphy, CT, and MRI and lesions was performed with the Pearson’s chi-squared test.

Results

⁶⁷Ga scintigraphy was positive for 25 of 39 patients with SCC positive on CT and/or MRI (64.1%) and for 13 of 15 patients with inflammatory diseases positive on CT and/or MRI (86.7%). The detection of inflammatory diseases with ⁶⁷Ga scintigraphy was higher than that of SCC (p = 0.104).

Conclusions

This study compared SCC with inflammatory diseases of the oral and maxillofacial region using ⁶⁷Ga scintigraphy with CT and MRI. ⁶⁷Ga scintigraphy is an effective technique for detection of inflammatory diseases of the oral and maxillofacial region.

Diagnostic value of diffusion-weighted imaging and 18F-FDG-PET/CT for the detection of unknown primary head and neck cancer in patients presenting with cervical metastasis

BACKGROUND AND PURPOSE

Head and neck squamous cell carcinoma (HNSCC) may present with cervical metastases without an apparent primary tumor. Detecting the primary tumor results in more targeted treatment. Acquisition of DWI is improving with less artifacts and image distortion. We assessed the diagnostic value of DWI and ¹⁸F-FDG-PET/CT for detecting primary tumors in patients presenting with nodal metastasis of an unknown primary HNSCC.

MATERIALS AND METHODS

For this retrospective study we included 31 patients (male/female ratio = 23/8, median age = 66 years, age range = 40-80 years) who presented with a pathologically proven cervical nodal metastasis from HNSCC without overt primary tumor location between January 2013 and November 2016 and underwent both DWI and ¹⁸F-FDG-PET/CT. Both modalities were assessed qualitatively and quantitatively. With ROC analysis we determined the optimal cut-off for imaging parameters in separating occult malignancy from benign tissue.

RESULTS

Qualitative analysis of MRI including DWI resulted in a sensitivity of 81.3% (95%CI) = 53.7-95.0) and specificity of 73.3% (95%CI = 44.8-91.1). With qualitative scoring of ¹⁸F-FDG-PET/CT a sensitivity and specificity of 93.8% (95%CI = 67.8-99.7) and 73.3% (95%CI = 44.8-91.1) were found. With quantitative analysis sensitivity and specificity of SUV_max were 81.3% (95%CI = 53.6-95.0) and 93.3% (95%CI = 66.0-99.7), respectively. Combining DWI and ¹⁸F-FDG-PET/CT resulted in a sensitivity of 93.8% (95%CI = 67.7-99.7%) and specificity of 60.0% (95%CI = 32.9-82.5%).

CONCLUSION

In this study on HNSCC patients presenting with clinically UP lesions the diagnostic accuracy of qualitative analysis with DWI and ¹⁸F-FDG-PET/CT and quantitative analysis of ¹⁸F-FDG-PET/CT using SUV_max were high. Adding DWI did not improve the accuracy of ¹⁸F-FDG-PET/CT.

Approach to oligometastatic disease in head and neck cancer, on behalf of the GORTEC

Median survival for recurrent/metastatic head and neck squamous cell cancer (HNSCC) patients is about 10 months after first-line best systemic treatment. We aimed to assess current approaches of oligometastatic HNSCC patients by the analysis of current concept and published data (1995–2017) in this population. Five-year survival rates are over 20% in selected patients who undergo metastasis-directed therapy by either surgery or stereotactic irradiation. Human papillomavirus(+) HNSCC patients have more disseminated metastases but respond more favorably and also benefit from ablative treatments. Treatments of oligometastases are expanding rapidly. Unmet needs include revised imaging follow-up strategies to detect metastases earlier, identification of predictive noninvasive biomarkers for treatment guidance, assessment and corrections of biases in current studies and randomized clinical trials.

AHNS Series: Do you know your guidelines? Evidence-based management of oral cavity cancers

Oral cavity squamous cell carcinoma (OCSCC) is the most common nonmelanoma head and neck cancer in the world, with an estimated 405 000 new cases expected each year. Subsites of the oral cavity include the alveolar ridge, buccal mucosa, anterior tongue, tonsillar pillar, retromolar trigone, hard palate, gingiva, and floor of the mouth. In this issue of the AHNS "Do you know your guidelines?" series, we review the evidence-based approach to the management of oral cavity carcinomas based on the framework provided by the National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology.

Usefulness of esophagogastroduodenoscopy and 18F-fluorodeoxyglucose positron-emission tomography in detecting synchronous multiple primary cancers with oral cancer

PURPOSE

The purpose of this study is to compare the value of screening for synchronous multiple primary cancers in other organs by esophagogastroduodenoscopy (EGD) or ¹⁸F-fluorodeoxyglucose positron-emission tomography (PET-CT) in patients newly diagnosed with oral cancer.

METHODS

We retrospectively examined consecutive Japanese patients who were diagnosed with oral squamous cell carcinoma (OSCC) and were screened for synchronous multiple primary cancers in other organs by EGD and/or PET-CT between January 2010 and December 2015 at our institution. The study included 190 patients (106 males and 84 females) from 36 to 93 years of age (median age 68.8 years). The patients were screened by EGD, PET-CT, or both before beginning treatment for OSCC.

RESULTS

Of 190 Japanese patients with OSCC, 15 had multiple primary cancers: 13 patients had double cancer and two had triple cancers. The sites of the 17 multiple primary cancers were gastric (6), esophageal (4), and lung (3), and ovarian, colon, liver, and thyroid (1 each). All of the gastric and esophageal cancers were found by EGD and were not detected by PET-CT. For three patients, the detection of multiple cancers affected the treatment modality or order of treatment selected for the OSCC. In two cases, the oral cancer and multiple primary cancer(s) in another organ were resected simultaneously by joint surgical teams.

CONCLUSIONS

PET-CT for oral cancer patients is an effective supporting diagnostic tool. However, the ability of PET-CT has some limitations. Especially for early detection of the upper gastrointestinal cancers, it is necessary to be supplemented by EGD.

The adverse impact of surveillance intervals on the sensitivity of FDG-PET/CT for the detection of distant metastases in head and neck cancer patients

The presence of distant metastases at initial evaluation influences treatment selection, since no effective systemic treatment for disseminated head and neck squamous cell carcinoma (HNSCC) is currently available. The reported sensitivity for the detection of distant metastases by contrast-enhanced (ce)CT and FDG-PET(/CT) differs substantially between studies. We hypothesized that these sensitivity values are highly dependent on the reference standard use, e.g., follow-up term. Therefore, we analyze our results of FDG-PET/CT (including chest ceCT) with long-term follow-up and compare these findings with data from the literature, with particular interest in the different reference standards. Forty-six HNSCC patients with high-risk factors underwent pretreatment screening for distant metastases by FDG-PET/CT (including chest ceCT). In 16 (35%) patients, distant metastases were detected during screening (6 patients) or during a mean follow-up of 39.4 months after screening (10 patients). The sensitivity and negative predictive value were 83.3 and 97.2% when 6 months, 60.0 and 89.9% when 12 months, and 37.5 and 72.2% when 30 months follow-up were used as reference standard, respectively. This is comparable with reported studies with similar reference standards. This critical appraisal on the reference standards used in our and reported studies shows room for improvement for the detection of distant metastases to refrain more patients from unnecessary extensive locoregional treatment for occult metastatic HNSCC.