Diagnostic accuracy of F-18 FDG PET or PET/CT for detection of lymph node metastasis in clinically node negative head and neck cancer patients; A systematic review and meta-analysis

N0 neck trial: Does intensification of follow-up (Ultrasound + Physical Examination) influence outcomes in early-stage oral cancer?

AIM OF THE STUDY

We previously reported a survival benefit of elective neck dissection (END) over therapeutic neck dissection (TND) in patients with clinically node-negative early-stage oral cancer. We now report the results of the second question in the same study addressing the impact of adding neck ultrasound to physical examination during follow-up on outcomes.

METHODS

Patients with lateralized T1/T2 oral squamous cell carcinoma (SCC) were randomized to END or TND and to follow-up with physical-examination plus neck ultrasound (PE+US) versus physical-examination (PE). The primary endpoint was overall survival (OS).

RESULTS

Between January 2004 and June 2014, 596 patients were enrolled. This is an intention to treat analysis of 592 analysable patients, of whom 295 were allocated to PE+US and 297 to PE with a median follow-up of 77.47 months (interquartile range (IQR) 54.51-126.48). There was no significant difference (unadjusted hazard ratio [HR], 0.92, 95% CI, 0.71-1.20, p = 0.54) in 5-year OS between PE+US (70.8%, 95% CI, 65.51-76.09) and PE (67.3%, 95% CI, 61.81-72.79). Among 131 patients with neck node relapse as the first event, the median time to relapse detection was 4.85 (IQR 2.33-9.60) and 7.62 (IQR 3.22-9.86) months in PE+US and PE arms, respectively. The N stage in the PE+US arm was N1 33.8%, N2a 7.4%, N2b/c 44.1% and N3 14.7% while in PE was N1 28.6%, N2a 9.5%, N2b/c 39.7%, N3 20.6% and unknown 1.6%.

CONCLUSION

Adding neck ultrasound to physical examination during follow-up detects nodal relapses earlier but does not improve overall survival.

Development of an evaluation and treatment strategy for olfactory neuroblastoma: a review of evidence from large-scale studies, including population-based and multicenter studies, and meta-analyses

Olfactory neuroblastoma is a rare sinonasal malignancy arising from the olfactory epithelium that is characterized by skull base involvement and a modest natural history. Because of its rarity and long course, identification of independent prognostic factors is dependent on multivariate analysis of large, long-term data. In this review, we outline evidence for the evaluation and treatment of olfactory neuroblastoma obtained from recent large-scale population-based studies, meta-analyses and multicenter studies. Hyams grade is currently the only pathological grade system for olfactory neuroblastoma. The modified Kadish staging and Dulguerov classification are available for clinical staging. The results of large-scale studies have confirmed Hyams, the modified Kadish and Dulguerov as independent prognostic factors. Surgery followed by radiotherapy provides the best overall survival and recurrence-free survival for resectable disease. The question of whether postoperative radiotherapy should be administered for all cases or only for those at risk of recurrence remains unanswered. Exclusively endoscopic resection is indicated for modified Kadish A/B cases without any increase in the risk of death or recurrence, and is also indicated for modified Kadish C cases if a negative surgical margin is ensured. For more advanced cases, such as those with extensive brain infiltration, the open approach is indicated. Elective nodal irradiation prevents late nodal recurrence of N0 patients. Chemotherapy has failed to show a benefit in survival or disease control. Current needs for olfactory neuroblastoma include the development and validation of refined staging systems suitable for current practice; expansion of indications for endoscopic surgery; less invasive surgery; definitive radiotherapy and novel systemic therapy.

Quarter Century Positron Emission Tomography/Computed Tomography Transformation of Oncology: Head and Neck Cancer

During the last 2 decades, f-18 fluorodeoxyglucose positron emission tomography/computed tomography (18F FDG PET/CT) has transformed the clinical head and neck cancer imaging for patient management and predicting survival outcomes. It is now widely used for staging, radiotherapy planning, posttherapy assessment, and for detecting recurrence in head and neck cancers and is widely included in NCCN and other evidence based clinical practice guidelines. Future Directions would include evaluating the potential value of FAPI PET/CT for head and neck cancers, opportunity to use volumetric and tumor heterogeneity parameters and deploying AI in diagnostic and therapeutic assessments.

Comparing three-dimensional and two-dimensional deep-learning, radiomics, and fusion models for predicting occult lymph node metastasis in laryngeal squamous cell carcinoma based on CT imaging: a multicentre, retrospective, diagnostic study

Background

The occult lymph node metastasis (LNM) of laryngeal squamous cell carcinoma (LSCC) affects the treatment and prognosis of patients. This study aimed to comprehensively compare the performance of the three-dimensional and two-dimensional deep learning models, radiomics model, and the fusion models for predicting occult LNM in LSCC.

Methods

In this retrospective diagnostic study, a total of 553 patients with clinical N0 stage LSCC, who underwent surgical treatment without distant metastasis and multiple primary cancers, were consecutively enrolled from four Chinese medical centres between January 01, 2016 and December 30, 2020. The participant data were manually retrieved from medical records, imaging databases, and pathology reports. The study cohort was divided into a training set (n = 300), an internal test set (n = 89), and two external test sets (n = 120 and 44, respectively). The three-dimensional deep learning (3D DL), two-dimensional deep learning (2D DL), and radiomics model were developed using CT images of the primary tumor. The clinical model was constructed based on clinical and radiological features. Two fusion strategies were utilized to develop the fusion model: the feature-based DLRad_FB model and the decision-based DLRad_DB model. The discriminative ability and correlation of 3D DL, 2D DL and radiomics features were analysed comprehensively. The performances of the predictive models were evaluated based on the pathological diagnosis.

Findings

The 3D DL features had superior discriminative ability and lower internal redundancy compared to 2D DL and radiomics features. The DLRad_DB model achieved the highest AUC (0.89-0.90) among all the study sets, significantly outperforming the clinical model (AUC = 0.73-0.78, P = 0.0001-0.042, Delong test). Compared to the DLRad_DB model, the AUC values for the DLRad_FB, 3D DL, 2D DL, and radiomics models were 0.82-0.84 (P = 0.025-0.46), 0.86-0.89 (P = 0.75-0.97), 0.83-0.86 (P = 0.029-0.66), and 0.79-0.82 (P = 0.0072-0.10), respectively in the study sets. Additionally, the DLRad_DB model exhibited the best sensitivity (82-88%) and specificity (79-85%) in the test sets.

Interpretation

The decision-based fusion model DLRad_DB, which combines 3D DL, 2D DL, radiomics, and clinical data, can be utilized to predict occult LNM in LSCC. This has the potential to minimize unnecessary lymph node dissection and prophylactic radiotherapy in patients with cN0 disease.

Funding

National Natural Science Foundation of China, Natural Science Foundation of Shandong Province.

Tata Memorial Centre Evidence Based Use of Nuclear medicine diagnostic and treatment modalities in cancer

ABSTRACT

PET/CT and radioisotope therapy are diagnostic and therapeutic arms of Nuclear Medicine, respectively. With the emergence of better technology, PET/CT has become an accessible modality. Diagnostic tracers exploring disease-specific targets has led the clinicians to look beyond FDG PET. Moreover, with the emergence of theranostic pairs of radiopharmaceuticals, radioisotope therapy is gradually making it's way into treatment algorithm of common cancers in India. We therefore would like to discuss in detail the updates in PET/CT imaging and radionuclide therapy and generate a consensus-driven evidence based document which would guide the practitioners of Oncology.

Comparing the Diagnostic Accuracy of Ultrasonography, CT, MRI, and PET/CT in Cervical Lymph Node Metastasis of Oral Squamous Cell Carcinoma

(1) Background: In oral cancer staging, ultrasonography (US), computed tomography (CT), magnetic resonance imaging (MRI), and 2-deoxy-2-[fluorine-18]fluoro-D-glucose (FDG) with positron emission tomography/computed tomography (PET/CT) are routinely used in clinical practice. The present study is a retrospective examination of the diagnostic accuracy of cervical lymph node metastasis using US, CT, MRI, and PET/CT, with histopathological diagnosis as a reference, to compare the different diagnostic imaging modalities. (2) Methods: The participants included 16 patients with oral squamous cell carcinoma who underwent US-, CT-, MRI-, and PET/CT-based preoperative diagnostic imaging and simultaneous primary lesion resection and neck dissection, including 82 level regions and 424 lymph nodes. We compared the sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of each imaging modality based on the imaging results and the pathology results of metastasis. (3) Results: Of the four diagnostic imaging modalities, PET/CT exhibited the highest sensitivity but the lowest specificity and accuracy. US, CT, and MRI had high specificities. Comparing each level region and lymph node showed that differences were observed in PET/CT. (4) Conclusions: PET/CT to diagnose lymph node metastasis requires a comprehensive evaluation because it produces more false positives than other diagnostic imaging modalities. Using US, CT, and MRI, which have excellent spatial resolution, improves diagnostic accuracy at the lymph node level.

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.

Comparable Accuracy of Quantitative and Visual Analyses of [18F]FDG PET/CT for the Detection of Lymph Node Metastases from Head and Neck Squamous Cell Carcinoma

BACKGROUND

In head and neck squamous cell carcinoma (HNSCC), [18F]FDG PET/CT is recommended for detecting recurrent disease and in the initial staging for evaluating distant metastases, but its use in detecting cervical lymph metastases remains unclear. The aim of this study is to evaluate and compare the diagnostic accuracy of [8F]FDG-PET/CT using visual and semi-quantitative analyses for detecting the nodal involvement in HNSCC.

METHODS

We analyzed consecutive patients who underwent a preoperative [18F]FDG-PET/CT and neck dissection for HNSCC at our tertiary hospital. A blinded evaluation of the [18F]FDG uptake in each neck level was performed using a semi-quantitative approach (SUVmax and SUVR) and a visual grading system (uptake superior to the internal jugular vein for grade 1 and superior to the liver for grade 2). Analyses were compared to the histological results.

RESULTS

In our 211 patients, analyses demonstrated similar diagnostic accuracy using a semi-quantitative approach or a visual grading system. Regarding the visual grading system, [18F]FDG-PET/CT detected nodal metastases with a specificity of 83% for lymph nodes classified as grade 1 and 98% for those classified as grade 2. The sensitivity was moderate, ranging from 60 to 63%.

CONCLUSIONS

[18F]FDG PET/CT has a high specificity for detecting lymph node metastases in HNSCC and therefore must be considered in the nodal clinical staging.

Imaging of Neck Nodes in Head and Neck Cancers - a Comprehensive Update

Cervical lymph node metastases from head and neck squamous cell cancers significantly reduce disease-free survival and worsen overall prognosis and, hence, deserve more aggressive management and follow-up. As per the eighth edition of the American Joint Committee on Cancer staging manual, extranodal extension, especially in human papillomavirus-negative cancers, has been incorporated in staging as it is important in deciding management and significantly impacts the outcome of head and neck squamous cell cancer. Lymph node imaging with various radiological modalities, including ultrasound, computed tomography and magnetic resonance imaging, has been widely used, not only to demonstrate nodal involvement but also for guided histopathological evaluation and therapeutic intervention. Computed tomography and magnetic resonance imaging, together with positron emission tomography, are used widely for the follow-up of treated patients. Finally, there is an emerging role for artificial intelligence in neck node imaging that has shown promising results, increasing the accuracy of detection of nodal involvement, especially normal-appearing nodes. The aim of this review is to provide a comprehensive overview of the diagnosis and management of involved neck nodes with a focus on sentinel node anatomy, pathogenesis, imaging correlates (including radiogenomics and artificial intelligence) and the role of image-guided interventions.

A prediction model of nodal metastasis in cN0 oral squamous cell carcinoma using metabolic and pathological variables

BACKGROUND

The efficacy of ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) Positron Emission Tomography/Computed Tomography(PET/CT) in evaluating the neck status in clinically node-negative (cN0) oral squamous cell carcinoma(OSCC) patients was still unsatisfying. We tried to develop a prediction model for nodal metastasis in cN0 OSCC patients by using metabolic and pathological variables.

METHODS

Consecutive cN0 OSCC patients with preoperative ¹⁸F-FDG PET/CT, subsequent surgical resection of primary tumor and neck dissection were included. Ninety-five patients who underwent PET/CT scanning in Shanghai ninth people's hospital were identified as training cohort, and another 46 patients who imaged in Shanghai Universal Medical Imaging Diagnostic Center were selected as validation cohort. Nodal-status-related variables in the training cohort were selected by multivariable regression after using the least absolute shrinkage and selection operator (LASSO). A nomogram was constructed with significant variables for the risk prediction of nodal metastasis. Finally, nomogram performance was determined by its discrimination, calibration, and clinical usefulness.

RESULTS

Nodal maximum standardized uptake value(nodal SUVmax) and pathological T stage were selected as significant variables. A prediction model incorporating the two variables was used to plot a nomogram. The area under the curve was 0.871(Standard Error [SE], 0.035; 95% Confidence Interval [CI], 0.787-0.931) in the training cohort, and 0.809(SE, 0.069; 95% CI, 0.666-0.910) in the validation cohort, with good calibration demonstrated.

CONCLUSIONS

A prediction model incorporates metabolic and pathological variables has good performance for predicting nodal metastasis in cN0 OSCC patients. However, further studies with large populations are needed to verify our findings.

Development and Testing of a Machine Learning Model Using 18F-Fluorodeoxyglucose PET/CT-Derived Metabolic Parameters to Classify Human Papillomavirus Status in Oropharyngeal Squamous Carcinoma

OBJECTIVE

To develop and test a machine learning model for classifying human papillomavirus (HPV) status of patients with oropharyngeal squamous cell carcinoma (OPSCC) using ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) PET-derived parameters in derived parameters and an appropriate combination of machine learning methods in patients with OPSCC.

MATERIALS AND METHODS

This retrospective study enrolled 126 patients (118 male; mean age, 60 years) with newly diagnosed, pathologically confirmed OPSCC, that underwent ¹⁸F-FDG PET-computed tomography (CT) between January 2012 and February 2020. Patients were randomly assigned to training and internal validation sets in a 7:3 ratio. An external test set of 19 patients (16 male; mean age, 65.3 years) was recruited sequentially from two other tertiary hospitals. Model 1 used only PET parameters, Model 2 used only clinical features, and Model 3 used both PET and clinical parameters. Multiple feature transforms, feature selection, oversampling, and training models are all investigated. The external test set was used to test the three models that performed best in the internal validation set. The values for area under the receiver operating characteristic curve (AUC) were compared between models.

RESULTS

In the external test set, ExtraTrees-based Model 3, which uses two PET-derived parameters and three clinical features, with a combination of MinMaxScaler, mutual information selection, and adaptive synthetic sampling approach, showed the best performance (AUC = 0.78; 95% confidence interval, 0.46-1). Model 3 outperformed Model 1 using PET parameters alone (AUC = 0.48, p = 0.047) and Model 2 using clinical parameters alone (AUC = 0.52, p = 0.142) in predicting HPV status.

CONCLUSION

Using oversampling and mutual information selection, an ExtraTree-based HPV status classifier was developed by combining metabolic parameters derived from ¹⁸F-FDG PET/CT and clinical parameters in OPSCC, which exhibited higher performance than the models using either PET or clinical parameters alone.

ADC Values of Cytologically Benign and Cytologically Malignant 18 F-FDG PET-Positive Lymph Nodes of Head and Neck Squamous Cell Carcinoma

Simple Summary

In squamous cell carcinoma of the head and neck, 18F-fluordeoxyglucose positron emission tomography (FDG-PET), diffusion-weighted magnetic resonance imaging (DW-MRI) and ultrasound-guided fine needle aspiration are commonly used imaging tools for nodal staging (N-staging). Although FDG-PET has good performance in nodal detection, it is still difficult to distinguish between PET-positive reactive and malignant nodes for the purpose of selecting nodes to be aspirated. DW-MRI can help to detect small lymph node metastases, and an inverse correlation with FDG uptake is expected. We found a mild negative correlation between SUVmax and ADC. Comparing the apparent diffusion coefficient (ADC) values between PET-positive and PET-negative nodes, ADC was significantly higher in PET-negative nodes. Whereas no significantly lower ADC value of cytological malignant nodes could be found overall, in the subgroup of non-HPV-related nodes, the ADC values of cytologically malignant PET-positive nodes were significantly lower than in cytologically benign nodes. This finding might be helpful in selecting nodes for puncture.

Abstract

Nodal staging (N-staging) in head and neck squamous cell carcinoma (HNSCC) is essential for treatment planning and prognosis. 18F-fluordeoxyglucose positron emission tomography (FDG-PET) has high performance for N-staging, although the distinction between cytologically malignant and reactive PET-positive nodes, and consequently, the selection of nodes for ultrasound-guided fine needle aspiration cytology (USgFNAC), is challenging. Diffusion-weighted magnetic resonance imaging (DW-MRI) can help to detect nodal metastases. We aim to investigate the potential of the apparent diffusion coefficient (ADC) as a metric to distinguish between cytologically reactive and malignant PET-positive nodes in order to improve node selection criteria for USgFNAC. PET-CT, real-time image-fused USgFNAC and DW-MRI to calculate ADC were available for 78 patients offered for routine N-staging. For 167 FDG-positive nodes, differences in the ADC between cytologically benign and malignant PET-positive nodes were evaluated, and both were compared to the ADC values of PET-negative reference nodes. Analyses were also performed in subsets of nodes regarding HPV status. A mild negative correlation between SUVmax and ADC was found. No significant differences in ADC values were observed between cytologically malignant and benign PET-positive nodes overall. Within the subset of non-HPV-related nodes, ADC_b0-200-1000 was significantly lower in cytologically malignant PET-positive nodes when compared to benign PET-positive nodes. ADC_b0-1000 and ADCb_0-200-1000 were significantly lower (p = 0.018, 0.016, resp.) in PET-negative reference nodes than in PET-positive nodes. ADC was significantly higher in PET-negative reference nodes than in PET-positive nodes. The non-HPV-related subgroup showed significantly (p = 0.03) lower ADC values in cytologically malignant than in cytologically benign PET-positive nodes, which should help inform the node selection procedure for puncture.

Sentinel node biopsy in node negative early oral cancers: Solution to the conundrum!

Ideal management of the node-negative neck in early oral cancers is a debated issue. Elective neck dissection (END) is recommended in these patients as it offers a survival benefit. However, about 50-70% of patients who do not harbor occult metastasis are overtreated with this approach. Surgery is associated with morbidity, predominantly shoulder dysfunction. Numerous attempts have been made to identify true node-negative patients through imaging and prediction models but none have high diagnostic accuracy to safely spare the neck dissection. The recent publications of 2 large randomized controlled trials comparing the outcomes of sentinel node biopsy (SNB) and END have spurred interest in SNB. Both the trials reported SNB to be an oncologically safe procedure and spared unnecessary neck dissections. The functional outcomes of the trials showed that SNB limits the morbidity compared to END, which albeit evens out at the end of one-year post-surgery. Despite its benefits, SNB has failed to gain widespread acceptability due to various limitations including the need for infrastructure, equipment costs, staff, and multidisciplinary collaboration of nuclear medicine, surgical, and pathology fraternity. The labor-intensive pathology protocol with serial step sectioning and immunohistochemistry poses a challenge to the feasibility at a high-volume center. This perspective discusses these limitations and propose plausible solutions to the conundrum. To make it widely applicable and feasible across the globe efforts should be directed to understand biology better, find novel solutions, and implement the lessons learned over decades from other sites.

Radiopharmaceuticals for PET and SPECT Imaging: A Literature Review over the Last Decade

Positron emission tomography (PET) uses radioactive tracers and enables the functional imaging of several metabolic processes, blood flow measurements, regional chemical composition, and/or chemical absorption. Depending on the targeted processes within the living organism, different tracers are used for various medical conditions, such as cancer, particular brain pathologies, cardiac events, and bone lesions, where the most commonly used tracers are radiolabeled with 18F (e.g., [¹⁸F]-FDG and NA [¹⁸F]). Oxygen-15 isotope is mostly involved in blood flow measurements, whereas a wide array of ¹¹C-based compounds have also been developed for neuronal disorders according to the affected neuroreceptors, prostate cancer, and lung carcinomas. In contrast, the single-photon emission computed tomography (SPECT) technique uses gamma-emitting radioisotopes and can be used to diagnose strokes, seizures, bone illnesses, and infections by gauging the blood flow and radio distribution within tissues and organs. The radioisotopes typically used in SPECT imaging are iodine-123, technetium-99m, xenon-133, thallium-201, and indium-111. This systematic review article aims to clarify and disseminate the available scientific literature focused on PET/SPECT radiotracers and to provide an overview of the conducted research within the past decade, with an additional focus on the novel radiopharmaceuticals developed for medical imaging.

Clinical Utility of Contrast-enhanced Ultrasound for the Diagnosis of Lymphadenopathy

This meta-analysis aimed to evaluate the diagnostic accuracy of contrast-enhanced ultrasonography (CEUS) in identifying lymphazdenopathy. PubMed, Web of Science, Embase and the Cochrane Library were searched for relevant articles through September 2020. A total of 16 articles, which included 1787 participants, were analyzed. The summary sensitivity, specificity, positive likelihood ratio (LR), negative LR and diagnostic odds ratio of CEUS for diagnosing lymphadenopathy were 0.88 (0.86-0.90), 0.90 (0.88-0.92), 6.04 (3.67-9.95), 0.15 (0.10-0.21) and 47.38 (23.45-95.66), respectively. The summary receiver operating characteristic (SROC) area under the curve (AUC) was 0.9405. After omitting outliers identified in a bivariate box plot and forest plot, heterogeneity was decreased, and the pooled sensitivity and specificity were 0.87 (0.84-0.90) and 0.87 (0.84-0.90), respectively. Furthermore, the SROC AUC was 0.9327. In conclusion, CEUS has the potential to be a valuable tool for characterizing lymphadenopathy and could provide clinical decision support.

PET-CT scan-based maximum standardized uptake value as a prognostic predictor in oropharynx squamous cell cancer

INTRODUCTION

Positron emission tomography with 2-deoxy-2-[fluorine-18]fluoro-D-glucose integrated with computed tomography (18F-FDG PET-CT) is clinically useful and extensively used in initial staging and follow-up of patients with head and neck squamous cell carcinoma (HNSCC). We studied the potential prognostic significance of primary tumor maximum standard uptake value (SUVmax) by 18F-FDG PET-CT in oropharyngeal cancer.

METHODS

Sixty patients with early and locally advanced histopathologically proven oropharyngeal squamous cell cancer were staged using FDG PET-CT at diagnosis. All patient received radiation therapy and concurrent chemotherapy (in stage III and IVA disease) and were assessed prospectively for treatment outcome. Groups were created based on stage and cut off for SUVmax. The association of SUVmax of primary tumour and stage with disease-free survival and overall survival was analyzed by univariate and multivariate statistics.

RESULTS

In univariate analysis, a primary tumour SUVmax of greater than 13.0 and advanced stage (IVA) predicted inferior disease-free survival (P=0.0241 and 0.0005, respectively) and overall survival (P=0.0510, toward significance and 0.0003, respectively). In proportional hazards analysis, stage was significant only when adjusted for primary SUVmax.

CONCLUSION

SUVmax failed to demonstrate predictive significance in oropharyngeal cancer, and an increase in primary tumor uptake is possibly a direct effect of advanced disease and consequently increased metabolic activity and aggressiveness.

[Current diagnostic imaging and treatment planning for laryngeal cancer]

CLINICAL/METHODICAL ISSUE

Laryngeal cancer is the third most common malignancy in the head and neck region. Endoscopic laryngoscopy with assessment of vocal fold function, microlaryngoscopy with biopsy and computed tomography (CT)/magnetic resonance imaging (MRI) remain the cornerstones of diagnostic workup. Thus, in the context of therapy planning, consideration of individual functional and socioeconomic aspects is of major importance.

STANDARD RADIOLOGICAL METHODS

Due to the short acquisition time and the possibility to perform functional maneuvers, CT is the tool of choice. MRI allows better soft tissue differentiation, but is more susceptible to movement artifacts and is complicated by disease-specific symptoms. The choice of examination method therefore depends on the patient's physical resilience.

PERFORMANCE

Depending on the study, the information on the sensitivity of CT with regard to the question of cartilage infiltration varies between 62 and 87% with a specificity between 75 and 98%. For MRI, sensitivity between 64 and 95% and specificity between 56 and 88% are stated.

ACHIEVEMENTS

The synthesis of the findings from endoscopy, biopsy and imaging is prerequisite for initiation of stage-appropriate treatment. For image interpretation, knowledge of the anatomical landmarks is essential. However, the assessment of posttherapeutic changes also poses a challenge for the radiologist.

PRACTICAL RECOMMENDATIONS

Regular interdisciplinary dialogue between radiologists, otorhinolaryngologists and radiotherapists in the context of primary diagnostics, therapy planning and aftercare is essential.

Predictive Value of Occult Metastasis and Survival Significance of Metabolic Tumor Volume Determined by PET-CT in cT1-2N0 Squamous Cell Carcinoma of the Tongue

Objectives

Our goal was to analyze the possibility of using metabolic tumor volume (MTV) to predict occult cervical metastasis and survival in cT1-2N0 squamous cell carcinoma (SCC) of the tongue.

Methods

Data on the primary tumor MTV and cervical node status as determined by the maximum standardized uptake value were retrieved. The sensitivity and specificity in predicting occult metastasis were calculated with a fourfold table. Associations between occult metastasis and clinicopathological variables were evaluated by univariate and multivariate analyses. The main study endpoints were locoregional control (LRC) and disease-specific survival (DSS).

Results

A total of 24 (20.3%) of 118 patients had occult metastasis. An MTV cutoff value of 4.3 cm³ showed a sensitivity of 50.0% and a specificity of 76.6% in predicting occult metastasis. The sensitivity and specificity of PET-CT in predicting occult metastasis in cT1 tumors were 66.6 and 89.8%, respectively, with values of 83.3 and 67.3%, respectively, when combined with the MTV. The sensitivity and specificity of PET-CT in predicting occult metastasis in cT2 tumors were 72.2 and 82.2%, respectively, with values of 88.9 and 57.8%, respectively, when combined with the MTV. Patients with MTV ≥4.3 cm³ had a higher occult metastasis rate than patients with MTV <4.3 cm³. The 5-year LRC and DSS rates were 86 and 94%, respectively, in patients with MTV <4.3 cm³ and 54 and 72%, respectively, in patients with MTV ≥4.3 cm³. Both differences were found to be significant in univariate and multivariate analyses.

Conclusions

MTV ≥4.3 cm³ was associated with an increased probability of occult metastasis and lower LRC and DSS rates in early-stage SCC of the tongue.

Head and Neck Cancers, Version 2.2020, NCCN Clinical Practice Guidelines in Oncology

Treatment is complex for patients with head and neck (H&N) cancers with specific site of disease, stage, and pathologic findings guiding treatment decision-making. Treatment planning for H&N cancers involves a multidisciplinary team of experts. This article describes supportive care recommendations in the NCCN Guidelines for Head and Neck Cancers, as well as the rationale supporting a new section on imaging recommendations for patients with H&N cancers. This article also describes updates to treatment recommendations for patients with very advanced H&N cancers and salivary gland tumors, specifically systemic therapy recommendations.

Safety and Feasibility of PARP1/2 Imaging with 18F-PARPi in Patients with Head and Neck Cancer

PURPOSE

We performed a first-in-human clinical trial. The aim of this study was to determine safety and feasibility of PET imaging with ¹⁸F-PARPi in patients with head and neck cancer.

PATIENTS AND METHODS

Eleven patients with newly diagnosed or recurrent oral and oropharyngeal cancer were injected with ¹⁸F-PARPi (331 ± 42 MBq), and dynamic PET/CT imaging was performed between 0 and 25 minutes postinjection. Static PET/CT scans were obtained at 30, 60, and 120 minutes postinjection. Blood samples for tracer concentration and metabolite analysis were collected. Blood pressure, ECG, oxygen levels, clinical chemistry, and complete blood count were obtained before and after tracer administration.

RESULTS

¹⁸F-PARPi was well-tolerated by all patients without any safety concerns. Of the 11 patients included in the analysis, ¹⁸F-PARPi had focal uptake in all primary lesions (n = 10, SUV_max = 2.8 ± 1.2) and all ¹⁸F-FDG-positive lymph nodes (n = 34). ¹⁸F-PARPi uptake was seen in ¹⁸F-FDG-negative lymph nodes of 3 patients (n = 6). Focal uptake of tracer in primary and metastatic lesions was corroborated by CT alone or in combination with ¹⁸F-FDG. The overall effective dose with ¹⁸F-PARPi PET was 3.9 mSv - 5.2 mSv, contrast was high [SUV_max(lesion)/SUV_max(trapezius muscle) = 4.5] and less variable than ¹⁸F-FDG when compared with the genioglossus muscle (1.3 vs. 6.0, P = 0.001).

CONCLUSIONS

Imaging of head and neck cancer with ¹⁸F-PARPi is feasible and safe. ¹⁸F-PARPi detects primary and metastatic lesions, and retention in tumors is longer than in healthy tissues.