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Subramaniam RM. Quarter Century Positron Emission Tomography/Computed Tomography Transformation of Oncology: Head and Neck Cancer. PET Clin 2024; 19:125-129. [PMID: 38290968 DOI: 10.1016/j.cpet.2023.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Abstract
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.
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Affiliation(s)
- Rathan M Subramaniam
- Faculty of Medicine, Nursing & Midwifery and Health Sciences, University of Notre Dame Australia, Sydney, Australia; Department of Radiology, Duke University, Durham, NC, USA; Department of Medicine, University of Otago Medical School, Dunedin, New Zealand.
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2
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Key S, Chia C, Magarey M, Dixon B. Risk of malignancy in incidental oropharyngeal lesions exhibiting fluorodeoxyglucose uptake which proceed to tissue biopsy. ANZ J Surg 2024; 94:122-127. [PMID: 38115646 DOI: 10.1111/ans.18839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 12/02/2023] [Accepted: 12/11/2023] [Indexed: 12/21/2023]
Abstract
BACKGROUND Utilization of positron emission tomography/computed tomography (PET/CT) with fluorodeoxyglucose is increasing in use for a variety of indications, including surveillance of cancer patients. There is a paucity of evidence pertaining to the significance of incidental PET-avid oropharyngeal lesions. This study aims to examine the clinical and radiological features of these incidental oropharyngeal lesions in patients undergoing PET for indications other than head and neck cancer. METHODS Retrospective cohort study of three Australian tertiary hospitals, from 2015 to 2021, on adult patients undergoing biopsy of incidental PET-avid oropharyngeal lesions. Primary outcome of interest was the incidence of malignancy. Patients with a previous history of, or undergoing investigations for, head and neck cancer were excluded. RESULTS Thirty-one patients were included, wherein 21 patients had tonsillar uptake, and 13 patients had base of tongue uptake. Tonsillar disease was mostly asymmetrical (n = 15/21), bilateral (n = 11/21), and had median SUVmax 9.35 (n = 12, IQR 7.4-11.15). Base of tongue was mostly asymmetrical (n = 7/13, 54%), bilateral (n = 8/13, 62%), and had median SUVmax 8.2 (n = 10, IQR 6.9-12.65). Seven patients had malignancy confirmed on tissue biopsy: five biopsies confirmed the tissue diagnosis of suspected lymphoma, and two incidental findings of unexpected malignancies: one p16 positive tonsillar squamous cell carcinoma, and one metastatic breast cancer. CONCLUSION In 31 patients undergoing tissue biopsy for incidental PET-avid oropharyngeal lesions, there were two unexpected malignancies. Our study results indicate that although unexpected malignancies are uncommon, a malignant diagnosis cannot be excluded from clinical features alone.
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Affiliation(s)
- Seraphina Key
- Department of ENT, Head & Neck Surgery, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
| | - Clemente Chia
- Department of ENT, Head & Neck Surgery, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
| | - Matthew Magarey
- Division of Surgical Oncology, Peter MacCallum Cancer Centre, Parkville, Victoria, Australia
- Pinnacle Surgery, Epworth Hospital, Richmond, Victoria, Australia
- Department of Medical Education, University of Melbourne, Parkville, Victoria, Australia
| | - Benjamin Dixon
- Department of ENT, Head & Neck Surgery, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
- Pinnacle Surgery, Epworth Hospital, Richmond, Victoria, Australia
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3
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Reinholdt KB, Dias AH, Hoff CM, Gormsen LC, Klug TE. Incidental FDG-Avid Focuses in Palatine Tonsils on PET/CT. Laryngoscope 2022; 132:2370-2378. [PMID: 35226376 PMCID: PMC9790499 DOI: 10.1002/lary.30081] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 02/17/2022] [Accepted: 02/17/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVES The management of incidental findings of FDG-avid tonsils on PET/CT (IFT) is unclear. We aimed to explore the prevalence of malignancy in IFT, identify risk factors for malignancy, and calculate optimal cutoffs of maximum standardized uptake values (SUVmax ) to discriminate between benign and malignant lesions. METHODS All patients who were tonsillectomized at our institution because of IFT from October 2011 to December 2020 were included. Patients undergoing PET/CT due to suspected tonsillar disease or cancer of unknown primary were excluded. RESULTS In total, 77 patients were included, of which 11 (14%) of them had IFT malignancy. Dysphagia (p = 0.019) and alcohol abuse (p = 0.035) were associated with malignancy. Absolute SUVmax cutoff (≥9: sensitivity 100%; specificity 53%) was superior to SUVmax side-to-side ratio (≥1.5: sensitivity 64%; specificity 70%) to discriminate between benign and malignant lesions. CONCLUSION We recommend tonsillectomy for patients with IFT displaying SUVmax ≥ 9.0, ratio ≥ 1.5, or symptoms or findings suggesting malignancy. LEVEL OF EVIDENCE 3 Laryngoscope, 132:2370-2378, 2022.
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Affiliation(s)
- Kasper Basse Reinholdt
- Department of Otorhinolaryngology, Head and Neck SurgeryAarhus University HospitalAarhusDenmark
| | - André Henrique Dias
- Department of Nuclear Medicine and PET CentreAarhus University HospitalAarhusDenmark
| | - Camilla Molich Hoff
- Department of Nuclear Medicine and PET CentreAarhus University HospitalAarhusDenmark
| | | | - Tejs Ehlers Klug
- Department of Otorhinolaryngology, Head and Neck SurgeryAarhus University HospitalAarhusDenmark
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4
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PET Imaging of Oral Cavity and Oropharyngeal Cancers. PET Clin 2022; 17:223-234. [DOI: 10.1016/j.cpet.2021.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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5
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Incidental uptake of fluorodeoxyglucose in the Waldeyer's ring and risk of oropharyngeal malignancy. Eur Arch Otorhinolaryngol 2021; 279:2657-2664. [PMID: 34570264 PMCID: PMC8986689 DOI: 10.1007/s00405-021-07089-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Accepted: 09/12/2021] [Indexed: 10/27/2022]
Abstract
PURPOSE Fluorodeoxyglucose (FDG) positron emission tomography (PET) is increasingly used to diagnose and stage malignancy. The aim of this article is to investigate the significance of incidental FDG uptake in the Waldeyer's ring and to assess its value in predicting clinically occult oropharyngeal malignancy. METHODS All FDG-PET/CT scans performed in Imperial College NHS Foundation Trust, UK between January 2012 and November 2018 were included. Patients with known or suspected oropharyngeal malignancy or lymphoma were excluded. Minimum follow-up was 12 months. RESULTS A total of 724 scans revealed oropharyngeal uptake of FDG. Of these, 102 were included in the study. Most patients (62.1%) were scanned as part of staging for other malignancies. Oropharyngeal FDG uptake was asymmetrical in 57.3% of the cases. Uptake was more common in the tonsils (56.3%), followed by the tongue base (31.1%) and both sites (12.6%). In 41.7% of reports, appearance was described as likely physiological; however, 52.4% of reports advised direct visualisation, clinical correlation or ENT opinion. Only 24.3% (25/102) of patients were referred and seen by ENT, 14.6% (15/102) of which had an interval PET scan and 8.7% (9/102) proceeded to tissue diagnosis. There was one oropharyngeal cancer identified and one unexpected metastasis from esophageal cancer. CONCLUSION Incidental uptake on PET/CT in the oropharynx is common. However, malignancy is rare (1.9%) and, when present, is associated with high SUVmax and asymmetrical uptake. Imaging results must be correlated clinically. These patients should be seen by an ENT specialist yet most may not require further investigations.
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6
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Marcus C, Sheikhbahaei S, Shivamurthy VKN, Avey G, Subramaniam RM. PET Imaging for Head and Neck Cancers. Radiol Clin North Am 2021; 59:773-788. [PMID: 34392918 DOI: 10.1016/j.rcl.2021.05.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Head and neck cancers are commonly encountered cancers in clinical practice in the United States. Fluorine-18-fluorodeoxyglucose (18F-FDG) PET/CT has been clinically applied in staging, occult primary tumor detection, treatment planning, response assessment, follow-up, recurrent disease detection, and prognosis prediction in these patients. Alternative PET tracers remain investigational and can provide additional valuable information such as radioresistant tumor hypoxia. The recent introduction of 18F-FDG PET/MR imaging has provided the advantage of combining the superior soft tissue resolution of MR imaging with the functional information provided by 18F-FDG PET. This article is a concise review of recent advances in PET imaging in head and neck cancer.
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Affiliation(s)
- Charles Marcus
- Department of Nuclear Medicine and Molecular Imaging, Emory University Hospital, Atlanta, GA, USA.
| | - Sara Sheikhbahaei
- Department of Radiology, Johns Hopkins Medical Institutions, 601 N. Caroline Street, JHOC 3235, Baltimore, MD 21287, USA
| | - Veeresh Kumar N Shivamurthy
- Epilepsy Center, St. Francis Hospital and Medical Center, Trinity Health of New England, 114 Woodland Street, Hartford, CT 06105, USA
| | - Greg Avey
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave #3284, Madison, WI 53792, USA
| | - Rathan M Subramaniam
- Dean's Office, Otago Medical School, University of Otago, 201 Great King Street, Dunedin 9016, New Zealand
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7
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Technical feasibility of radiomics signature analyses for improving detection of occult tonsillar cancer. Sci Rep 2021; 11:192. [PMID: 33420249 PMCID: PMC7794329 DOI: 10.1038/s41598-020-80597-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 12/21/2020] [Indexed: 02/02/2023] Open
Abstract
Diagnosis of occult palatine tonsil squamous cell carcinoma (SCC) using conventional magnetic resonance imaging (MRI) is difficult in patients with cervical nodal metastasis from an unknown primary site at presentation. We aimed to establish a radiomics approach based on MRI features extracted from the volume of interest in these patients. An Elastic Net model was developed to differentiate between normal palatine tonsils and occult palatine tonsil SCC. The diagnostic performances of the model with radiomics features extracted from T1-weighted image (WI), T2WI, contrast-enhanced T1WI, and an apparent diffusion coefficient (ADC) map had area under the receiver operating characteristic (AUROC) curve values of 0.831, 0.840, 0.781, and 0.807, respectively, for differential diagnosis. The model with features from the ADC alone showed the highest sensitivity of 90.0%, while the model with features from T1WI + T2WI + contrast-enhanced T1WI showed the highest AUROC of 0.853. The added sensitivity of the radiomics feature analysis were 34.6% over that of conventional MRI to detect occult palatine tonsil SCC. Therefore, we concluded that adding radiomics feature analysis to MRI may improve the detection sensitivity for occult palatine tonsil SCC in patients with a cervical nodal metastasis from cancer of an unknown primary site.
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8
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Kurtoğlu E, Göçer M. Clinical Significance of Increased FDG Uptake in the Waldeyer Ring and the Nasopharynx Region Identified by PET-CT in Postchemotherapy Follow-up in Patients With Lymphoma: When Should We Perform Biopsy? CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2020; 20:830-835. [PMID: 32917575 DOI: 10.1016/j.clml.2020.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 08/05/2020] [Accepted: 08/06/2020] [Indexed: 01/14/2023]
Abstract
PURPOSE To identify whether fluorodeoxyglucose (FDG) uptake in the Waldeyer ring (WR)/nasopharyngeal (NP) region by positron emission tomography-computed tomography (PET-CT) was physiologic or pathologic in the follow-up of lymphoma patients receiving postchemotherapy treatment. PATIENTS AND METHODS We retrospectively examined FDG uptake in the WR/NP region in 534 patients with lymphoma as assessed by PET-CT used for both diagnosis and follow-up. RESULTS Forty-nine patients had FDG uptake in the WR/NP region by PET-CT performed after completion of a chemotherapy regimen. Biopsy was performed for 11 of these patients in whom the uptake was considered to be pathologic, and results indicated the presence of reactive follicular hyperplasia. It was considered to be physiologic in 38 patients. PET-CT was repeated after 1 year, and no significant difference was identified between the standardized maximum uptake values (SUVmax; P = .107). The initial diagnosis of 20 patients was made via biopsy performed in the WR/NP region. The SUVmax for the FDG uptake in these patients, asymmetry, SUVmax of the coexisting lymphadenopathies in the neck, and FDG uptake with a counterpart finding by CT were significantly higher than other groups (P = .047, .001, and .005). CONCLUSION When deciding whether to resample after treatment completion, it should be taken into account that, in addition to the SUVmax of the lesion, asymmetry, and the SUVmax of the coexisting lymphadenopathy in the neck, a crucial criterion is whether the FDG uptake has a counterpart finding by CT.
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Affiliation(s)
- Erdal Kurtoğlu
- Division of Hematology, Department of Internal Medicine, Antalya Training and Research Hospital, Antalya, Turkey.
| | - Mesut Göçer
- Division of Hematology, Department of Internal Medicine, Antalya Training and Research Hospital, Antalya, Turkey
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9
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Tisekar O, Bhaskar M, Biraris P, Sridhar E, Tandon S. Primary tonsillar tuberculosis masquerading as carcinoma of the tonsil. Indian J Tuberc 2019; 67:386-388. [PMID: 32825875 DOI: 10.1016/j.ijtb.2019.11.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 11/03/2019] [Indexed: 11/17/2022]
Abstract
Primary tuberculosis (TB) of tonsil is a rare form of extra-pulmonary tuberculosis. Most tonsillar TB cases present with coexistent pulmonary tuberculosis. It can simulate tonsillar malignancy and poses a diagnostic challenge. Histopathological examination is often needed for confirmation. Herein, we report a case of primary tonsillar tuberculosis in a 55-year-old gentleman mimicking carcinoma of the tonsil.
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Affiliation(s)
- Owais Tisekar
- Department of Pulmonary Medicine, Tata Memorial Hospital & Homi Bhabha National Institute, India.
| | - Maheema Bhaskar
- Department of Pulmonary Medicine, Tata Memorial Hospital & Homi Bhabha National Institute, India
| | - Pavankumar Biraris
- Department of Pulmonary Medicine, Tata Memorial Hospital & Homi Bhabha National Institute, India
| | - Epari Sridhar
- Department of Pathology, Tata Memorial Hospital & Homi Bhabha National Institute, India
| | - Sandeep Tandon
- Department of Pulmonary Medicine, Tata Memorial Hospital & Homi Bhabha National Institute, India
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Albertson M, Chandra S, Sayed Z, Johnson C. PET/CT Evaluation of Head and Neck Cancer of Unknown Primary. Semin Ultrasound CT MR 2019; 40:414-423. [PMID: 31635768 DOI: 10.1053/j.sult.2019.07.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The diagnosis of carcinoma of unknown primary in the head and neck is made when there is a metastasis but no primary lesion is identified after physical exam and diagnostic CT or MR imaging. PET/CT is the first step in searching for a primary lesion, followed by more invasive techniques such as endoscopy and surgery. Knowledge of the different tumor histologic types, preferential locations of nodal spread, imaging pitfalls, and other special considerations such as cystic metastases can be helpful in the ultimate identification of primary tumors, which leads to improved overall patient survival.
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Affiliation(s)
- Megan Albertson
- Department of Radiology, University of Nebraska Medical Center, Omaha, NE.
| | - Srinivasa Chandra
- Division of Oral & Maxillofacial Surgery, Department of Head and Neck Surgery, University of Nebraska Medical Center, Omaha, NE
| | - Zafar Sayed
- Department of Otolaryngology - Head and Neck Oncology, University of Nebraska Medical Center, Omaha, NE
| | - Craig Johnson
- Department of Radiology, University of Nebraska Medical Center, Omaha, NE
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11
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Fernando PEA, Ongkeko EES. Role of [ 18F] Fluoro-2-Deoxy-D-Glucose Positron Emission Tomography/Computed Tomography in the Diagnosis of Tonsillar Carcinoma in a Patient with Multiple Primary Carcinomas. World J Nucl Med 2019; 18:194-197. [PMID: 31040756 PMCID: PMC6476251 DOI: 10.4103/wjnm.wjnm_33_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Tonsillar carcinoma is not easily diagnosed on [18F] fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography (18F-FDG PET/CT) scan; normal, inflamed, and infected tonsils also exhibit increased tracer uptake. We present a case of a 68-year-old male with colon and prostate carcinomas who was referred for a PET/CT scan. He presented with right cervical lymphadenopathy which, on fine-needle biopsy, was found to have atypical cells suspicious for malignancy. On PET/CT, the right cervical lymph nodes appeared hypermetabolic; subsequent excision biopsy revealed metastatic poorly differentiated carcinoma. Increased metabolic activity was also seen in the tonsils, the right more than the left, which was initially ascribed to be inflammatory or physiologic. On magnetic resonance imaging follow-up, however, a more prominent and more enhancing right palatine tonsil was observed, which on histopathology was consistent with squamous cell carcinoma. Determining the maximum standard uptake value ratio between the two tonsils could have been helpful in differentiating squamous cell tonsillar carcinoma from benign asymmetric FDG uptake in this case. On a background of enlarged cervical lymph nodes and known primary carcinomas, uptake in the tonsils should be thoroughly assessed before interpreting it as an inflammatory or physiologic variant, especially if there is asymmetry in FDG uptake.
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12
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Pencharz D, Dunn J, Connor S, Siddiqui A, Sriskandan N, Thavaraj S, Jeannon JP, Oakley R, Lei M, Guerrero-Urbano T, Cook GJ, Szyszko TA. Palatine tonsil SUVmax on FDG PET-CT as a discriminator between benign and malignant tonsils in patients with and without head and neck squamous cell carcinoma of unknown primary. Clin Radiol 2019; 74:165.e17-165.e23. [PMID: 30454841 DOI: 10.1016/j.crad.2018.10.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 10/16/2018] [Indexed: 11/22/2022]
Abstract
AIM To analyse the maximum standardised uptake value (SUVmax) ratio between tonsils in patients with and without tonsillar carcinoma to determine useful diagnostic thresholds. MATERIALS AND METHODS Positron-emission tomography (PET)/computed tomography (CT) examinations of patients with suspected head and neck squamous cell carcinoma (SCC) and controls from April 2013 to September 2016 were reviewed retrospectively. Tonsillar SUVmax ratios (ipsilateral/contralateral for malignant tonsils, maximum/minimum for patients without [controls]) were calculated and used to construct a receiver operating characteristic (ROC) curve. RESULTS Twenty-five patients had tonsillar carcinoma (mean SUVmax ratio of 2, range 0.89-5.4) and 86 patients acted as controls (mean SUVmax ratio of 1.1, range 1-1.5). Using the ROC, the most accurate SUVmax ratio for identifying malignancy was >1.2 (77% sensitivity, 86% specificity). A potentially more clinically useful SUVmax ratio is ≥1.6 with 62% sensitivity and 100% specificity. CONCLUSION An SUVmax ratio between tonsils of ≥1.6 is highly suspicious for SCC and could be used to direct site of biopsy. Some malignant tonsils had normal FDG uptake; therefore, PET/CT should not be used to exclude tonsillar cancer. Minor asymmetrical uptake is frequently seen in non-malignant tonsils and does not necessarily require further investigation. Due to the single centre nature of this study and the recognised variation in SUV measurements between PET scans, other centres may need to develop their own cut-offs.
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Affiliation(s)
- D Pencharz
- Department of Nuclear Medicine, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK.
| | - J Dunn
- King's College London and St Guy's and St Thomas' PET Centre, London, UK
| | - S Connor
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - A Siddiqui
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - N Sriskandan
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - S Thavaraj
- Head and Neck Pathology, King's College, London, UK
| | - J-P Jeannon
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - R Oakley
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - M Lei
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - G J Cook
- King's College London and St Guy's and St Thomas' PET Centre, London, UK
| | - T A Szyszko
- King's College London and St Guy's and St Thomas' PET Centre, London, UK
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13
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HPV-related Oropharyngeal Carcinoma: A Review of Clinical and Pathologic Features With Emphasis on Updates in Clinical and Pathologic Staging. Adv Anat Pathol 2018; 25:180-188. [PMID: 29394171 DOI: 10.1097/pap.0000000000000179] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
There has been a sharp increase in the incidence of the human papilloma virus-related oropharyngeal squamous cell carcinoma, partly due to the increasingly widespread awareness and recognition of this entity. This review assimilates the recent histopathologic classifications, staging systems, rapidly expanding research base and developments in management of human papilloma virus-related oropharyngeal squamous cell carcinoma and summarizes their implications for routine diagnostic practice. Differential diagnoses and their cytologic appearances are detailed and the utility of p16 staining and other immunohistochemistry testing is discussed.
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Pencharz D, Nathan M, Wagner TL. Evidence-based management of incidental focal uptake of fluorodeoxyglucose on PET-CT. Br J Radiol 2018; 91:20170774. [PMID: 29243502 DOI: 10.1259/bjr.20170774] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Focal incidental uptake, with or without CT abnormalities, is a common finding on fluorodeoxyglucose PET/CT and evidence-based management for this type of uptake is lacking. This article reviews the evidence on focal incidental uptake including the incidence of malignancy, differential diagnosis and imaging criteria which can be used to further characterize it. The article focusses on PET rather than CT criteria. The strength of the evidence base is highly variable ranging from systematic reviews and meta-analyses to a virtual absence of evidence. Caution needs to be used when using standardized uptake values (SUVs) reported in other studies due to interpatient and institution observed variation in SUVs. There is sufficient evidence to permit specific suggestions on how to interpret the foci and recommend further management in the: pituitary (investigate when SUVmax >4.1), thyroid (investigate all), breast (investigate all), lung parenchyma (if focus of fluorodeoxyglucose without a CT nodule, no further investigations), colon (investigate all foci with SUVmax >5.9, urgently if SUVmax >11.4), adrenals (criteria depend on if patient has cancer) and prostate gland (investigate in males aged >50 years or >40 years if peripheral uptake or patient has other risk factors). There is some evidence to guide further management for the parotid gland, naso-orophaynx, oesophagus, pancreas, uterus and ovaries. There is insufficient evidence to guide management for the liver, spleen, kidneys, gallbladder, testis and bone, for these organs patient characteristics and other guidelines will likely be of more use in determining further management.
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Affiliation(s)
- Deborah Pencharz
- 1 Department of Nuclear Medicine, Brighton and Sussex University Hospitals NHS Trust , Brighton, East Sussex , UK
| | - Malavika Nathan
- 2 Department of Nuclear Medicine, Royal Free Hospital NHS Foundation Trust , London , UK
| | - Thomas L Wagner
- 2 Department of Nuclear Medicine, Royal Free Hospital NHS Foundation Trust , London , UK
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15
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Szyszko TA, Cook GJR. PET/CT and PET/MRI in head and neck malignancy. Clin Radiol 2018; 73:60-69. [PMID: 29029767 DOI: 10.1016/j.crad.2017.09.001] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 08/13/2017] [Accepted: 09/05/2017] [Indexed: 01/09/2023]
Abstract
Combined 2-[18F]-fluoro-2-deoxy-d-glucose (FDG) positron-emission tomography (PET)/computed tomography (CT) has an established role in the staging of difficult cases of head and neck (HN) squamous cell carcinoma (SCC), looking for an unknown primary, assessing response post-chemotherapy at 3-6 months, and differentiating relapse from treatment effects in patients suspected to have tumour recurrence. The PET NECK trial, comparing PET/CT surveillance versus neck dissection in advanced head and neck cancer showed survival was similar among patients who underwent PET/CT-guided surveillance and those who underwent planned neck dissection, but surveillance was more cost-effective. There is growing interest in the use of hypoxia PET tracers, especially in targeting radiotherapy, where the radiotherapy dose can be boosted in regions of hypoxia; the use of 68Ga peptide tracers in neuroendocrine malignancy and also in the growing field of combined PET/magnetic resonance imaging (MRI). PET/MRI has the advantage of increased anatomical detail and radiation dose reduction combined with the molecular and metabolic data from PET, although PET/CT has the advantage in better sensitivity for imaging lung metastases. Thus far, there is good agreement between PET/CT and PET/MRI with high correlation between semi-quantitative measurements in primary, nodal, osseous, and soft-tissue lesions imaging. PET/MRI may indeed provide greater accuracy than the currently available imaging procedures in the staging and later treatment response evaluation in HNSCC.
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Affiliation(s)
- T A Szyszko
- King's College London and Guy's & St Thomas' PET Centre, Division of Imaging Sciences and Biomedical Engineering, King's College London, SE1 7EH, UK; Department of Cancer Imaging, Division of Imaging Sciences and Biomedical Engineering, King's College London, UK.
| | - G J R Cook
- King's College London and Guy's & St Thomas' PET Centre, Division of Imaging Sciences and Biomedical Engineering, King's College London, SE1 7EH, UK; Department of Cancer Imaging, Division of Imaging Sciences and Biomedical Engineering, King's College London, UK
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16
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Dziegielewski PT, Boyce BJ, Old M, Teknos TN, Agrawal A, Patwa H, Ozer E. Transoral robotic surgery for tonsillar cancer: Addressing the contralateral tonsil. Head Neck 2017; 39:2224-2231. [DOI: 10.1002/hed.24887] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Revised: 04/21/2017] [Accepted: 06/15/2017] [Indexed: 12/16/2022] Open
Affiliation(s)
- Peter T. Dziegielewski
- Department of Otolaryngology; University of Florida; Gainesville Florida
- University of Florida Health Cancer Center; University of Florida; Gainesville Florida
| | - Brian J. Boyce
- Department of Otolaryngology; University of Florida; Gainesville Florida
| | - Matthew Old
- Department of Otolaryngology - Head and Neck Surgery; The Ohio State University Wexner Medical Center; Columbus Ohio
- Comprehensive Cancer Center; Arthur G. James Cancer Hospital and Richard J. Solove Research Institute; Columbus Ohio
| | - Theodoros N. Teknos
- Department of Otolaryngology - Head and Neck Surgery; The Ohio State University Wexner Medical Center; Columbus Ohio
- Comprehensive Cancer Center; Arthur G. James Cancer Hospital and Richard J. Solove Research Institute; Columbus Ohio
| | - Amit Agrawal
- Department of Otolaryngology - Head and Neck Surgery; The Ohio State University Wexner Medical Center; Columbus Ohio
- Comprehensive Cancer Center; Arthur G. James Cancer Hospital and Richard J. Solove Research Institute; Columbus Ohio
| | - Hafiz Patwa
- Department of Otolaryngology - Head and Neck Surgery; The Ohio State University Wexner Medical Center; Columbus Ohio
| | - Enver Ozer
- Department of Otolaryngology - Head and Neck Surgery; The Ohio State University Wexner Medical Center; Columbus Ohio
- Comprehensive Cancer Center; Arthur G. James Cancer Hospital and Richard J. Solove Research Institute; Columbus Ohio
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Prognostic Value of FDG PET/CT-Derived Parameters in Pancreatic Adenocarcinoma at Initial PET/CT Staging. AJR Am J Roentgenol 2015; 204:1093-9. [PMID: 25905947 DOI: 10.2214/ajr.14.13156] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE The purpose of this study is to evaluate the performance of PET-derived parameters as prognostic markers for overall survival (OS) and progression-free survival (PFS) outcome in patients with pancreatic adenocarcinoma. MATERIALS AND METHODS We conducted a retrospective study of 106 patients (62 men and 44 women) with histologically proven pancreatic adenocarcinoma who underwent initial staging FDG PET/CT before treatment. Peak standardized uptake value (SUV), maximum SUV (SUVmax), metabolic tumor volume, and tumor glycolytic activity of the primary pancreatic tumor were measured. Two segmentation methods were performed to obtain the metabolic tumor volume and tumor glycolytic activity for all tumors: a gradient-based segmentation model (metabolic tumor volume and tumor glycolytic activity by gradient edge detection) and a fixed-threshold model with a threshold of 50% of the lesion's SUVmax and peak SUV. Univariate and multivariate Cox regression models were developed including clinical and imaging parameters for OS and PFS. RESULTS Multivariate Cox regression analysis showed a statistically significant association between PFS and age, SUVmax, peak SUV, and tumor glycolytic activity by gradient edge detection. There was a statistically significant difference in PFS for patients with values above and below the median cutoff points for SUVmax (hazard ratio [HR], 1.12; p < 0.01), peak SUV (HR, 1.25; p < 0.02), and tumor glycolytic activity measured by gradient edge detection (HR, 1.00; p < 0.02) of the primary tumor. However, multivariate Cox regression analysis showed a statistically significant association only between tumor glycolytic activity by gradient edge detection and OS (p = 0.04), and there was a statistically significant difference in OS between patients with values above and below the median cutoff point for the tumor glycolytic activity by gradient edge detection of the primary tumor (HR, 1.42; p = 0.05). CONCLUSION Age, SUVmax, peak SUV, and total lesion glycolysis (i.e., tumor glycolytic activity) of the primary tumor are associated with PFS, and tumor glycolytic activity is associated with OS in patients with pancreatic adenocarcinoma.
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Abstract
OBJECTIVE CT remains the imaging modality of choice in the diagnosis of colorectal cancer (CRC) and anal cancer. However, advances in imaging have expanded the role of MRI and PET/CT. This article focuses on the evolving role of FDG PET/CT in the diagnosis, radiation therapy planning, therapy assessment, and posttherapy monitoring of CRC and anal cancer. CONCLUSION FDG PET/CT is a valuable imaging modality that impacts the clinical management of patients with CRC and those with anal cancer.
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Chirindel A, Alluri KC, Tahari AK, Chaudhry M, Wahl RL, Lodge MA, Subramaniam RM. Liver standardized uptake value corrected for lean body mass at FDG PET/CT: effect of FDG uptake time. Clin Nucl Med 2015; 40:e17-22. [PMID: 24873794 PMCID: PMC5413863 DOI: 10.1097/rlu.0000000000000446] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE The objective of this study is to establish the magnitude change and interreader reliability of the liver standardized uptake value corrected for lean body mass (SULmean) in dual-time-point imaging at 1 and 2 hours and 1 and 4 hours. PATIENTS AND METHODS Early and delayed FDG PET/CT scans were included for 28 patients (13 men and 15 women) who had normal liver by CT or ultrasound. The average uptake time between the early and delayed scans were 55 minutes (range, 44-69 minutes) for pancreatic adenocarcinoma patients (n = 19) and 184 minutes (range, 140-197 minutes) for neurofibromatosis patients (n = 9). A 30-mm-diameter spherical volume of interest was placed within the right lobe of the liver above, below, and at the level of the main portal vein by 2 independent readers. Correlation coefficients, analysis of variance, intraclass correlation coefficient, and Bland-Altman analysis were performed. RESULTS The mean liver SULmean was between 1.39 and 1.42 and between 1.28 and 1.3 in early and delayed images, respectively (P = 0.001). There is time-dependent reduction in the mean liver SULmean at 2-hour (7%-8%) and 4-hour uptake time (15%-21%) compared with 1-hour uptake time. The correlation coefficient between delayed uptake time and liver SULmean reduction is 0.39 to 0.41 at the upper aspect of the liver. The intraclass correlation coefficient for 2 readers varied between 0.997 and 0.998 and between 0.995 and 0.999 in early and delayed images, respectively (P = 0.001). CONCLUSIONS There is time-dependent reduction of mean liver SULmean, about 7% to 8% within the clinically relevant FDG uptake time, in the same patient with excellent interreader agreement in early and delayed images within the right lobe of the liver. Therefore, liver SULmean could represent a useful reference parameter in quantitative analysis of dual-phase FDG PET/CT in malignancy or atypical infection/inflammatory disease. Furthermore, it may be suitable as a normalization factor in currently available formulae quantifying therapy response on PET imaging.
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Affiliation(s)
- Alin Chirindel
- From the Russell H Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, MD
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FDG volumetric parameters and survival outcomes after definitive chemoradiotherapy in patients with recurrent head and neck squamous cell carcinoma. AJR Am J Roentgenol 2014; 203:W139-45. [PMID: 25055289 DOI: 10.2214/ajr.13.11654] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The purpose of this study was to establish the predictive value of (18)F-FDG parameters for overall survival in biopsy-proven recurrent head and neck squamous cell cancer (HNSCC) patients after definitive chemoradiotherapy. MATERIALS AND METHODS We conducted a retrospective study including 34 patients with HNSCC who had biopsy-proven recurrence between April 2004 and March 2012 and underwent FDG PET/CT at our institution at the time of recurrence. Maximum standardized uptake value (SUVmax), peak SUV (SUVpeak), metabolic tumor volume (MTV), and total lesion glycolysis (TLG) were measured. The primary outcome measure was overall survival. ROC analysis, univariate and multivariate Cox regression models, and Kaplan-Meir survival curves were performed. RESULTS In univariate analyses, human papillomavirus (HPV) status (p = 0.04), primary site recurrence of MTV (p = 0.03), metastasis of MTV (p = 0.02), metastasis of TLG (p = 0.02), total MTV (p = 0.002), and total TLG (p = 0.04) were significantly associated with overall survival outcome. Total MTV remained as significant independent prognostic factor when adjusted for all other covariates except for primary site recurrence SUVmax and SUVpeak and lymph node SUVmax and SUVpeak. There was a significant difference in time to survival between patients with total MTV above and below the 50th percentile (Mantel-Cox log-rank test, p = 0.05 and Gehan-Breslow-Wilcoxon test, p = 0.03) and the optimum threshold of 16.8 mL (Mantel-Cox log-rank test, p = 0.01 and Gehan-Breslow-Wilcoxon test, p = 0.01; hazard ratio [HR], 0.25). CONCLUSION FDG PET/CT-based total MTV and clinical HPV status may be significant prognostic markers for overall survival of patients with recurrent HNSCC after definitive chemoradiotherapy.
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FDG PET/CT imaging of oropharyngeal squamous cell carcinoma: characteristics of human papillomavirus-positive and -negative tumors. Clin Nucl Med 2014; 39:225-31. [PMID: 24152652 DOI: 10.1097/rlu.0000000000000255] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective of this study was to assess differences in morphological and glycolytic characteristics of primary tumors and locoregional nodal disease between human papillomavirus (HPV)-positive and HPV-negative oropharyngeal head and neck squamous cell carcinoma. METHODS This was a retrospective analysis of 123 baseline FDG PET/CT scans from patients (aged 57.0 ± 10.6 years) with newly diagnosed oropharyngeal SCC between January 2003 and June 2012. There were 98 HPV-positive and 25 HPV-negative patients. SUVmax, SUVpeak, and SUVmean based on lean body mass, as well as RECIST (Response Evaluation Criteria In Solid Tumors) dimensions, metabolic tumor volume (gradient and threshold-segmentation methods) and total lesion glycolysis, were determined for primary and locoregional nodal disease. RESULTS Human papillomavirus-negative primary tumors were significantly larger as measured by RECIST longest diameter (P = 0.002) and slightly more heterogeneous as measured by the heterogeneity index (P = 0.07), higher SUVmax (P < 0.01), SUVpeak (P = 0.01), SUVmean (P = 0.01), metabolic tumor volume (P = 0.002), and total lesion glycolysis (P = 0.001), for both segmentation methods. Index parameters of HPV-positive nodal disease tend to be larger, but some with no statistical significance (P > 0.05). There was no significant difference in the metabolic parameters of primary tumor or nodal metastases for HPV-positive patients with and without smoking history. CONCLUSIONS Index morphologic and glycolytic parameters as measured in FDG PET/CT are significantly larger in HPV-negative as compared with HPV-positive primary oropharyngeal carcinoma. In contrast, the same parameters trended to be larger in HPV-positive regional nodal disease.
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FDG-PET/CT pitfalls in oncological head and neck imaging. Insights Imaging 2014; 5:585-602. [PMID: 25154759 PMCID: PMC4195840 DOI: 10.1007/s13244-014-0349-x] [Citation(s) in RCA: 117] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Revised: 07/08/2014] [Accepted: 07/21/2014] [Indexed: 10/26/2022] Open
Abstract
OBJECTIVES Positron emission tomography-computed tomography (PET/CT) with fluorine-18-fluorodeoxy-D-glucose (FDG) has evolved from a research modality to an invaluable tool in head and neck cancer imaging. However, interpretation of FDG PET/CT studies may be difficult due to the inherently complex anatomical landmarks, certain physiological variants and unusual patterns of high FDG uptake in the head and neck. The purpose of this article is to provide a comprehensive approach to key imaging features and interpretation pitfalls of FDG-PET/CT of the head and neck and how to avoid them. METHODS We review the pathophysiological mechanisms leading to potentially false-positive and false-negative assessments, and we discuss the complementary use of high-resolution contrast-enhanced head and neck PET/CT (HR HN PET/CT) and additional cross-sectional imaging techniques, including ultrasound (US) and magnetic resonance imaging (MRI). RESULTS The commonly encountered false-positive PET/CT interpretation pitfalls are due to high FDG uptake by physiological causes, benign thyroid nodules, unilateral cranial nerve palsy and increased FDG uptake due to inflammation, recent chemoradiotherapy and surgery. False-negative findings are caused by lesion vicinity to structures with high glucose metabolism, obscuration of FDG uptake by dental hardware, inadequate PET scanner resolution and inherent low FDG-avidity of some tumours. CONCLUSIONS The interpreting physician must be aware of these unusual patterns of FDG uptake, as well as limitations of PET/CT as a modality, in order to avoid overdiagnosis of benign conditions as malignancy, as well as missing out on actual pathology. TEACHING POINTS • Knowledge of key imaging features of physiological and non-physiological FDG uptake is essential for the interpretation of head and neck PET/CT studies. • Precise anatomical evaluation and correlation with contrast-enhanced CT, US or MRI avoid PET/CT misinterpretation. • Awareness of unusual FDG uptake patterns avoids overdiagnosis of benign conditions as malignancy.
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Lee HS, Kim JS, Roh JL, Choi SH, Nam SY, Kim SY. Clinical values for abnormal 18F-FDG uptake in the head and neck region of patients with head and neck squamous cell carcinoma. Eur J Radiol 2014; 83:1455-60. [DOI: 10.1016/j.ejrad.2014.05.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Revised: 05/09/2014] [Accepted: 05/12/2014] [Indexed: 12/14/2022]
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Abstract
OBJECTIVE Thyroid cancer is the most common endocrine cancer. This review evaluates the established use of (18)F-FDG PET/CT in papillary, follicular, Hürthle cell, anaplastic, and medullary thyroid cancers. The significance of incidental diffuse and focal thyroid FDG uptake is discussed. The evolving value of non-FDG radiotracers, including (124)I, (18)F-dihydroxyphenylalanine, and (68)Ga somatostatin analogs, is summarized. CONCLUSION PET/CT is a valuable imaging test, in the appropriate clinical context, for the management of thyroid cancers.
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Marcus C, Ciarallo A, Tahari AK, Mena E, Koch W, Wahl RL, Kiess AP, Kang H, Subramaniam RM. Head and neck PET/CT: therapy response interpretation criteria (Hopkins Criteria)-interreader reliability, accuracy, and survival outcomes. J Nucl Med 2014; 55:1411-6. [PMID: 24947059 DOI: 10.2967/jnumed.113.136796] [Citation(s) in RCA: 134] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
UNLABELLED There has been no established qualitative system of interpretation for therapy response assessment using PET/CT for head and neck cancers. The objective of this study was to validate the Hopkins interpretation system to assess therapy response and survival outcome in head and neck squamous cell cancer patients (HNSCC). METHODS The study included 214 biopsy-proven HNSCC patients who underwent a posttherapy PET/CT study, between 5 and 24 wk after completion of treatment. The median follow-up was 27 mo. PET/CT studies were interpreted by 3 nuclear medicine physicians, independently. The studies were scored using a qualitative 5-point scale, for the primary tumor, for the right and left neck, and for overall assessment. Scores 1, 2, and 3 were considered negative for tumors, and scores 4 and 5 were considered positive for tumors. The Cohen κ coefficient (κ) was calculated to measure interreader agreement. Overall survival (OS) and progression-free survival (PFS) were analyzed by Kaplan-Meier plots with a Mantel-Cox log-rank test and Gehan Breslow Wilcoxon test for comparisons. RESULTS Of the 214 patients, 175 were men and 39 were women. There was 85.98%, 95.33%, 93.46%, and 87.38% agreement between the readers for overall, left neck, right neck, and primary tumor site response scores, respectively. The corresponding κ coefficients for interreader agreement between readers were, 0.69-0.79, 0.68-0.83, 0.69-0.87, and 0.79-0.86 for overall, left neck, right neck, and primary tumor site response, respectively. The sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy of the therapy assessment were 68.1%, 92.2%, 71.1%, 91.1%, and 86.9%, respectively. Cox multivariate regression analysis showed human papillomavirus (HPV) status and PET/CT interpretation were the only factors associated with PFS and OS. Among the HPV-positive patients (n = 123), there was a significant difference in PFS (hazard ratio [HR], 0.14; 95% confidence interval, 0.03-0.57; P = 0.0063) and OS (HR, 0.01; 95% confidence interval, 0.00-0.13; P = 0.0006) between the patients who had a score negative for residual tumor versus positive for residual tumor. A similar significant difference was observed in PFS and OS for all patients. There was also a significant difference in the PFS of patients with PET-avid residual disease in one site versus multiple sites in the neck (HR, 0.23; log-rank P = 0.004). CONCLUSION The Hopkins 5-point qualitative therapy response interpretation criteria for head and neck PET/CT has substantial interreader agreement and excellent negative predictive value and predicts OS and PFS in patients with HPV-positive HNSCC.
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Affiliation(s)
- Charles Marcus
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Anthony Ciarallo
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Abdel K Tahari
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Esther Mena
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Wayne Koch
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland Department of Oncology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Richard L Wahl
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins School of Medicine, Baltimore, Maryland Department of Oncology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Ana P Kiess
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland; and
| | - Hyunseok Kang
- Department of Oncology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Rathan M Subramaniam
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins School of Medicine, Baltimore, Maryland Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland Department of Oncology, Johns Hopkins School of Medicine, Baltimore, Maryland Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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FDG PET Metabolic Tumor Volume Segmentation and Pathologic Volume of Primary Human Solid Tumors. AJR Am J Roentgenol 2014; 202:1114-9. [DOI: 10.2214/ajr.13.11456] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Impact of concurrent diagnostic level CT with PET/CT on the utilization of stand-alone CT and MRI in the management of head and neck cancer patients. Clin Nucl Med 2014; 38:790-4. [PMID: 23917783 DOI: 10.1097/rlu.0b013e31829f8ca5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF THE REPORT This study aims to determine if the expansion of a PET/CT service to include simultaneous contrast-enhanced CT with PET (PET/DCT) leads to a reduction of supplemental diagnostic CT (sCT) performed within a 6-month period centered around PET/CT for initial treatment planning of patients with head and neck cancers. PATIENTS AND METHODS There were 91 patients with head and neck cancers who had a non-contrast-enhanced PET/CT with CT (PET/aCT), and 153 patients had a PET/DCT. We compared the utilization of sCT before and after PET/aCT or PET/DCT. Logistic regression analysis, unpaired t test, and analysis of variance were performed. RESULTS Among the 75 patients who had sCT scans in the 3 months before their PET/CT, 44 (58.7%) scans were performed in patients who had a PET/aCT and 31 (41.3%) scans were performed in patients who had a PET/DCT (P < 0.001). Among the 36 patients who had a CT in the 3 months after their baseline PET/CT, 23 (63.9%) were performed in patients who had a baseline PET/aCT and 13 (36.1%) were performed in patients who had a baseline PET/DCT (P < 0.001). The adjusted odds ratio for performing an sCT within 3 months before and after baseline PET/DCT scan as opposed to a PET/aCT scan was 0.24 (P < 0.001) and 0.31 (P < 0.01), respectively. CONCLUSIONS The opportunity to order simultaneous diagnostic CT imaging with PET/CT (PET/DCT) reduced the referrals for stand-alone CT neck imaging in the initial treatment plan of head and neck cancer patients when compared to a service that only offered the PET/CT scan with CT for attenuation correction (PET/aCT).
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Interreader Agreement and Variability of FDG PET Volumetric Parameters in Human Solid Tumors. AJR Am J Roentgenol 2014; 202:406-12. [DOI: 10.2214/ajr.13.10841] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Subramaniam RM, Alluri KC, Tahari AK, Aygun N, Quon H. PET/CT Imaging and Human Papilloma Virus–Positive Oropharyngeal Squamous Cell Cancer: Evolving Clinical Imaging Paradigm. J Nucl Med 2014; 55:431-8. [DOI: 10.2967/jnumed.113.125542] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
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Paidpally V, Tahari AK, Lam S, Alluri K, Marur S, Koch W, Wahl RL, Subramaniam RM. Addition of 18F-FDG PET/CT to Clinical Assessment Predicts Overall Survival in HNSCC: A Retrospective Analysis with Follow-up for 12 Years. J Nucl Med 2013; 54:2039-45. [DOI: 10.2967/jnumed.113.121285] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Abstract
OBJECTIVE. Cervical cancer is the second most common malignancy in women worldwide and the third most common cause of cancer mortality in the United States. The aim of this article is to describe cervical cancer and outline the value of (18)F-FDG PET/CT in the management of cervical malignancy. CONCLUSION. The value of PET/CT has been found in staging and treatment strategy for cervical cancer. FDG PET/CT facilitates decision-making and radiation treatment planning and provides important information about treatment response, disease recurrence, and long-term survival.
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Lee HJ, Kim JS, Roh JL, Lee JH, Cho KJ, Park GC, Choi SH, Nam SY, Kim SY. 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. Clin Otolaryngol 2013; 38:30-8. [PMID: 23167514 DOI: 10.1111/coa.12055] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/14/2012] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- H J Lee
- Department of Otolaryngology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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FDG PET/CT in the Management of Primary Pleural Tumors and Pleural Metastases. AJR Am J Roentgenol 2013; 201:W215-26. [DOI: 10.2214/ajr.13.10572] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Abstract
OBJECTIVE Multiple myeloma is the most common cause of primary malignancy in bones. Radiography has been the imaging reference standard for decades. However, the growing use of CT, MRI, and PET technology has led to earlier diagnosis of multiple myeloma, more accurate therapy assessment, and better prediction of patient outcome. This article is focused on the evolving role of (18)F-FDG PET/CT in multiple myeloma diagnosis, therapy assessment, and prognosis. CONCLUSION FDG PET/CT is a valuable imaging modality in diagnosis, therapy assessment, and prognosis of multiple myeloma.
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Viner M, Mercier G, Hao F, Malladi A, Subramaniam RM. Liver SULmean at FDG PET/CT: interreader agreement and impact of placement of volume of interest. Radiology 2013; 267:596-601. [PMID: 23297330 DOI: 10.1148/radiol.12121385] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
PURPOSE To evaluate how interreader agreement and the site of the volume of interest (VOI) affect the agreement and variability of liver mean standardized uptake value normalized to lean body mass (SUL(mean)) at fluorine 18 fluorodeoxyglucose (FDG) positron emission tomography (PET)/computed tomography (CT). MATERIALS AND METHODS Institutional review board approval was obtained for this HIPAA-compliant retrospective review of PET/CT images and patient records. PET/CT images were reviewed in 116 randomly selected patients who had undergone a baseline PET/CT examination and who had normal livers according to imaging and biochemical test results. A 30-mm-diameter spherical VOI was placed within the right lobe of the liver above, below, and at the level of the main portal vein. Two readers performed all measurements independently. Analysis of variance, intraclass correlation coefficient (ICC) analysis, and Bland-Altman analysis were performed. RESULTS The mean SUL(mean) was between 2.11 and 2.17 at the upper, portal, and lower levels of the right lobe of the liver. The coefficient of variance was between 21.0% and 23.1%, without significant differences for location, with the least variance in the upper level. The ICC of the two readers varied between 0.98 and 0.99 (95% confidence interval [CI]: 0.97, 0.99; P = .0001) at each level. The greatest precision (narrowest CI) was also in the upper level. Bias was 0.025 ± 0.10 (standard deviation) at the upper level, was 0.004 ± 0.14 at the lower level, and was 0.047 ± 0.10 at the portal vein (P = .02). For each reader, there was almost perfect reliability between the SUL(mean) measurements made at the three levels, with an ICC of 0.98 (95% CI: 0.98, 0.99; P = .0001). CONCLUSION Liver SUL(mean) at FDG PET/CT has excellent interreader agreement, with similar values and variance whether measured at the upper, lower, or portal vein levels within the right lobe of the liver.
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Affiliation(s)
- Maya Viner
- Department of Radiology and Radiation Oncology, Boston University School of Medicine, Boston, Mass, USA
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Malladi A, Viner M, Jackson T, Mercier G, Subramaniam RM. PET/CT mediastinal and liver FDG uptake: effects of biological and procedural factors. J Med Imaging Radiat Oncol 2012; 57:169-75. [PMID: 23551774 DOI: 10.1111/1754-9485.12015] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2012] [Accepted: 08/28/2012] [Indexed: 01/04/2023]
Abstract
INTRODUCTION To establish the effects of biological and procedural factors on mediastinal and liver [(18) F]-fluorodeoxyglucose (FDG) uptake in oncological FDG positron emission tomography/computed tomography (PET/CT). METHODS This retrospective study included 557 patients who had a baseline FDG PET/CT scan in 2008 and 2009. Mediastinal and liver standardised uptake values mean normalised to lean body mass (SUVlbm mean) were measured in each patient. Univariate and multivariate regression models were established. Study population was then dichotomised into low and high body mass index (BMI) groups, and linear regression models were established for the effects of age, incubation period and blood glucose levels. RESULTS BMI had the highest adjusted effect (standardised beta coefficient, b = 0.43) (P < 0.001) and partial correlation, adjusting for covariates included in the final model (r = 0.45; P < 0.001) on mediastinal FDG uptake. Partial correlations (r) were 0.22 for age, -0.17 for male gender, -0.25 for incubation period and 0.14 for blood glucose (P < 0.001). The linear regression models showed significant differences in mediastinal FDG uptake between the low and high BMI groups and the effects of age, incubation period and basal blood glucose levels (P < 0.001). Similar results were observed for liver FDG uptake except the partial correlation for incubation period was r = -0.09 (P = 0.02). CONCLUSION BMI has the highest effect and correlation on mediastinal and liver FDG uptake. FDG uptake time has a greater effect on mediastinal than liver SUVlbm mean.
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Affiliation(s)
- Ashish Malladi
- Department of Radiology, Boston Medical Center and Boston University, School of Medicine, Boston, MA, USA
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Intra-reader reliability of FDG PET volumetric tumor parameters: effects of primary tumor size and segmentation methods. Ann Nucl Med 2012; 26:707-14. [PMID: 22797818 DOI: 10.1007/s12149-012-0630-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2012] [Accepted: 06/25/2012] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To establish the effects of size and segmentation methods on intra-reader reliability of primary tumor metabolic tumor volume (MTV) and total glycolytic activity (TGA) in human solid tumors. METHODS This is a retrospective study of 121 patients who had a baseline FDG PET/CT scan for oncologic staging. Volumetric parameter readings were performed in random order on two separate occasions, 12 weeks apart, by the same reader. The MTV and TGA were segmented using gradient and fixed maximum standardized uptake value (SUVmax) threshold methods. Intra-reader reliability was established by the intraclass correlation coefficient (ICC) and Bland-Altman analysis. RESULTS The biases for MTV were 2.95, 14.76 and 11.13% for gradient segmentation, 38 and 50% SUVmax fixed threshold segmentations, respectively (p < 0.0001). For TGA, the corresponding biases were 0.76, 10.36 and 7.46% (p < 0.0001). There were no statistically significant differences in the biases between the first and second reads for MTV segmented for small and large volume tumors by the gradient method (p < 0.34) or 50% SUVmax threshold segmentation (p < 0.08). However, there were statistically significant differences in the corresponding biases for the 38% SUVmax threshold segmentation (p < 0.04). There were no statistically significant differences in the biases between the first and second reads for TGA segmented for small and large volume tumors (p < 0.98). CONCLUSION Intra-reader reliability for primary tumor FDG MTV and TGA is affected by the tumor size and segmentation methods. The segmentation bias was smaller for gradient method than percentage fixed threshold method for MTV. The segmentation biases were smaller for TGA than MTV.
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FDG PET/CT interobserver agreement in head and neck cancer: FDG and CT measurements of the primary tumor site. Nucl Med Commun 2012; 33:305-12. [PMID: 22227560 DOI: 10.1097/mnm.0b013e32834e5397] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Interobserver agreement in measuring positron emission tomography (PET)/computed tomography (CT) parameters is critical for head and neck cancer management. The purpose of this study is to assess the interobserver agreement when measuring the standardized uptake value (SUV) parameters and the diameter of primary head and neck tumors between readers with varied experience in PET/CT. METHODS PET/CT images of 47 patients (59.8 ± 10.6 years, range 26-86 years) with head and neck cancer who had a baseline PET/CT at our institution (January 2007-May 2009) were retrieved and independently reviewed by four readers with varying experience reading PET/CT. Novice reader 1 was a preinternship medical student; novice reader 2 was a fourth-year radiology resident; expert reader 1 was a board-certified radiologist with a nuclear radiology fellowship and a junior faculty; and expert reader 2 was a dual radiology and nuclear medicine board-certified radiologist and a senior faculty. Intraclass correlation coefficients (ICCs) were estimated separately across novice and expert readers, between novice 1 and expert 1, and between novice 2 and expert 1 readers. RESULTS The ICCs (95% confidence interval) for primary tumor diameter, primary tumor SUVmax, and primary tumor SUVmax normalized to liver SUVmean within novices were 0.36 (0.09-0.59) (slight agreement), 0.60 (0.38-0.80) (fair agreement), and 0.91 (0.84-0.94) (almost perfect agreement), respectively. ICCs within experts were 0.84 (0.73-0.90) (almost perfect agreement), 0.91 (0.84-0.94) (almost perfect agreement), and 0.91 (0.84-0.95) (almost perfect agreement), respectively. The ICCs between novice 1 and experts are lower than those between novice 2 and experts for all parameters, and this disparity is greater for anatomic diameter than for fluorodeoxyglucose metabolic parameters. CONCLUSION Fluorodeoxyglucose metabolic parameters have higher interobserver agreement than anatomic diameter measurement and are more robust in the setting of varied reading experiences.
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Dibble EH, Alvarez ACL, Truong MT, Mercier G, Cook EF, Subramaniam RM. 18F-FDG metabolic tumor volume and total glycolytic activity of oral cavity and oropharyngeal squamous cell cancer: adding value to clinical staging. J Nucl Med 2012; 53:709-15. [PMID: 22492732 DOI: 10.2967/jnumed.111.099531] [Citation(s) in RCA: 187] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
UNLABELLED (18)F-FDG metabolic tumor volume (MTV) and total glycolytic activity (TGA) have been proposed as potential prognostic imaging markers for patient outcome in human solid tumors. The purpose of this study was to establish whether MTV and TGA add prognostic information to clinical staging in patients with oral and oropharyngeal squamous cell carcinomas (SCCs). METHODS The Institutional Review Board approved this Health Insurance Portability and Accountability Act-compliant single-institution retrospective study. Forty-five patients with histologically proven oral or oropharyngeal SCC underwent PET/CT for initial cancer staging and were included in the study. MTV was measured using a gradient-based method (PET Edge) and fixed-threshold methods at 38%, 50%, and 60% of maximum standardized uptake value (SUV). The TGA is defined as MTV × mean SUV. Bland-Altman analysis was used to establish the reliability of the methods of segmentation. Outcome endpoints were overall survival (OS) and progression-free survival. Cox proportional hazards univariate and multivariate regression analyses were performed. RESULTS In Cox regression models, MTV and TGA were the only factors significantly associated with survival outcome after adjusting for all other covariates including American Joint Committee on Cancer (AJCC) stage, with hazards ratio of 1.06 (95% confidence interval, 1.01-1.10; P = 0.006) and 1.00 (95% confidence interval, 1.00-1.01; P = 0.02). The model fit was significantly better when MTV was added to AJCC stage in model I (χ(2) value change, 1.16-6.71; P = 0.01) and when TGA was added to AJCC stage in model II (χ(2) value change, 1.16-4.37; P = 0.04). The median cutoff point of 7.7 mL for primary tumor MTV was predictive of time to OS (log rank P = 0.04). The median cutoff point of 55 g for PET Edge primary tumor TGA was predictive of time to OS (log rank P = 0.08), though the result was not statistically significant. CONCLUSION Gradient-based segmentations of primary tumor MTV and TGA are potential (18)F-FDG markers for time to survival in patients with oral and oropharyngeal SCC and may provide prognostic information in addition to AJCC stage. These exploratory imaging markers need validation in larger cohort studies.
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Affiliation(s)
- Elizabeth H Dibble
- Department of Radiology, Boston University School of Medicine, Boston, Massachusetts, USA
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Moon SH, Choi JY, Lee HJ, Son YI, Baek CH, Ahn YC, Park K, Lee KH, Kim BT. Prognostic value of 18F-FDG PET/CT in patients with squamous cell carcinoma of the tonsil: comparisons of volume-based metabolic parameters. Head Neck 2012; 35:15-22. [PMID: 22307893 DOI: 10.1002/hed.22904] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2011] [Revised: 09/10/2011] [Accepted: 11/02/2011] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The prognostic significance of volume-based metabolic parameters measured by (18)F-fluorodeoxyglucose positron emission tomography/CT ((18) F-FDG PET/CT) is not established. We evaluated the prognostic value of metabolic parameters in patients with squamous cell carcinoma (SCC) of the tonsil. METHODS We enrolled a total of 69 patients with SCC of the tonsil who underwent pretreatment (18)F-FDG PET/CT. We measured maximum standardized uptake value (SUV(max)), metabolic tumor volume (MTV), total lesion glycolysis (TLG), and asymmetry indices (of SUV(max), MTV, and TLG). The prognostic significance of these parameters and clinical variables was assessed by Cox proportional hazards regression analysis. RESULTS Multivariate analyses with adjustments for age, sex, and American Joint Committee on Cancer stage showed that only TLG (hazard ratio = 1.020, 95% confidence interval 1.003-1.037, p = .023) was an independent predictive factor associated with decreased overall survival. CONCLUSION TLG is a significant independent metabolic prognostic factor for overall survival in patients with SCC of the tonsil.
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Affiliation(s)
- Seung Hwan Moon
- Department of Nuclear Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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Parotid Gland Tumors: Preliminary Data for the Value of FDG PET/CT Diagnostic Parameters. AJR Am J Roentgenol 2012; 198:W185-90. [DOI: 10.2214/ajr.11.7172] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Use of 18F-FDG PET/CT as a predictive biomarker of outcome in patients with head-and-neck non-squamous cell carcinoma. AJR Am J Roentgenol 2011; 197:976-80. [PMID: 21940588 DOI: 10.2214/ajr.10.4884] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of this article is to establish whether pretreatment (18)F-FDG uptake predicts disease-free survival (DFS) and overall survival in patients with head-and-neck non-squamous cell carcinoma (SCC). MATERIALS AND METHODS Eighteen patients (six women and 12 men; mean [± SD] age at diagnosis, 57.89 ± 13.54 years) with head-and-neck non-SCC were included. Tumor FDG uptake was measured by the maximum standardized uptake value (SUV(max)) and was corrected for background liver FDG uptake to derive the corrected SUV(max). Receiver operating characteristic analyses were used to predict the optimal corrected SUV(max) cutoffs for respective outcomes of DFS (i.e., absence of recurrence) and death. RESULTS The mean corrected SUV(max) of the 18 head-and-neck tumors was 5.63 ± 3.94 (range, 1.14-14.29). The optimal corrected SUV(max) cutoff for predicting DFS and overall survival was 5.79. DFS and overall survival were significantly higher among patients with corrected SUV(max) < 6 than among patients with corrected SUV(max) ≥ 6. The mean DFS for patients with corrected SUV(max) < 6 was 25.7 ± 11.14 months, and the mean DFS for patients with corrected SUV(max) ≥ 6 was 7.88 ± 7.1 months (p < 0.018). Among patients with corrected SUV(max) < 6, none died, and the mean length of follow-up for this group was 35.2 ± 9.96 months. All of the patients who died had corrected SUV(max) ≥ 6, and the overall survival for this group was 13.28 ± 12.89 months (p < 0.001). CONCLUSION FDG uptake, as measured by corrected SUV(max), may be a predictive imaging biomarker for DFS and overall survival in patients with head-and-neck non-SCC.
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