Impact of (18)f-fluorodeoxyglucose positron emission tomography/computed tomography scan on initial evaluation of head and neck squamous cell carcinoma: our experience at a tertiary care center in India

Impact of 18F-FDG PET, PET/CT, and PET/MRI on Staging and Management as an Initial Staging Modality in Breast Cancer: A Systematic Review and Meta-analysis

OBJECTIVES

We performed a systematic review and meta-analysis to evaluate the impact of 18F-FDG PET, PET/CT, and PET/MRI on staging and management during the initial staging of breast cancer.

METHODS

We searched the PubMed, Embase, Cochrane Library, and KoreaMed databases until March 2020 to identify studies that reported the proportion of breast cancer patients whose clinical stage or management were changed after PET scans. The proportion of changes was pooled using a random-effects model. Subgroup and metaregression analyses were performed to explore heterogeneity.

RESULTS

We included 29 studies (4276 patients). The pooled proportions of changes in stage and management were 25% (95% confidence interval [CI], 21%-30%) and 18% (95% CI, 14%-23%), respectively. When stage changes were stratified according to initial stage, the pooled proportions were 11% (95% CI, 3%-22%) in stage I, 20% (95% CI, 16%-24%) in stage II, and 34% (95% CI, 27%-42%) in stage III. The relative proportions of intermodality and intention-to-treat changes were 74% and 70%, respectively. Using metaregression analyses, the mean age and the proportion of initial stage III to IV and histologic grade II to III were significant factors affecting the heterogeneity in changes in stage or management.

CONCLUSIONS

Currently available literature suggests that the use of 18F-FDG PET, PET/CT, or PET/MRI leads to significant modification of staging and treatment in newly diagnosed breast cancer patients. Therefore, there may be a role for routine clinical use of PET imaging for the initial staging of breast cancer.

FDG-PET-CT/MRI in head and neck squamous cell carcinoma: Impact on pretherapeutic N classification, detection of distant metastases, and second primary tumors

BACKGROUND

To assess the effect of 18-fluorodeoxyglucose positron emission tomography (FDG-PET) in the pretherapeutic staging of N classification, detection rate of distant metastases, and second primaries.

METHODS

Retrospective study on patients with head and neck carcinoma. We compared pretherapeutic N classification by ultrasound, computed tomography (CT)/magnetic resonance imaging (MRI), and FDG-PET-CT/MRI.

RESULTS

A change in the N classification due to FDG-PET-CT/MRI was observed in 116 patients (39.5%) compared to N classification by ultrasound and fine-needle aspiration cytology. Patients with advanced nodal classification (>N2a) were more likely to be reclassified. Distant metastases were detected in 19 patients and a total of 36 second primaries were diagnosed by FDG-PET-CT/MRI. Detection of distant metastases was more likely in regional advanced disease (>N2a). Smokers (>10 py) had a significantly higher risk of second primary.

CONCLUSION

FDG-PET-CT/MRI leads to a significant change in pretherapeutic N classification. The cumulative incidence of distant metastases and second primaries was 18.7%.

Elective neck dissection versus positron emission tomography-computed tomography-guided management of the neck in clinically node-negative early oral cavity cancer: A cost-utility analysis

BACKGROUND

In early oral cavity cancer, elective neck dissection (END) for the clinically node-negative (cN0) neck improves survival compared with observation. This paradigm has been challenged recently by the use of positron emission tomography-computed tomography (PET-CT) imaging in the cN0 neck. To inform this debate, we performed an economic evaluation comparing PET-CT-guided therapy with routine END in the cN0 neck.

METHODS

Patients with T1-2N0 lateralized oral tongue cancer were analyzed. A Markov model over a 40-year time horizon simulated treatment, disease recurrence, and survival from a US health care payer perspective. Model parameters were derived from a review of the literature.

RESULTS

The END strategy was dominant, with a cost savings of $1576.30 USD, an increase of 0.055 quality-adjusted life years (QALYs), a net monetary benefit of $4303 USD, and a 0.22 life-year advantage. END was sensitive to variation in cost and utilities in deterministic and probabilistic sensitivity analyses. PET-CT became the preferred strategy when decreasing occult nodal disease to 18% and increasing the negative predictive value (NPV) of PET-CT to 89% in 1-way sensitivity analyses. In probabilistic sensitivity analysis, assuming a cost effectiveness threshold of $50,000 USD/QALY, END was dominant in 64% of simulations and cost effective in 69.8%.

CONCLUSION

END is a cost-effective strategy compared with PET-CT in patients who have node-negative oral cancer. Although lower PET standardized uptake value thresholds would result in fewer false negatives and improved NPV, it is still uncertain that PET-CT would be cost effective, as this would likely result in more false positive tests.

FDG-PET/CT and Pathology in Newly Diagnosed Head and Neck Cancer: ACRIN 6685 Trial, FDG-PET/CT cN0

OBJECTIVE

FDG-PET/CT (fluorodeoxyglucose-positron emission tomography/computed tomography) is effective to assess for occult neck nodal disease. We report risks and patterns of nodal disease based on primary site and nodal level from data on the dissected cN0 per the results from ACRIN 6685.

STUDY DESIGN

Prospective nonrandomized enrollment included participants with first-time head and neck squamous cell carcinoma and at least 1 cN0 neck side to be dissected.

SETTING

Twenty-four ACRIN-certified centers internationally (American College of Radiology Imaging Network).

METHODS

A total of 287 participants were enrolled. Preoperative FDG-PET/CT findings were centrally reviewed and compared with pathology. Incidence, relative risk, pattern of lymph node involvement, and impact upon neck dissection were reported.

RESULTS

An overall 983 nodal levels were dissected (n = 261 necks, n = 203 participants). The highest percentages of ipsilateral positive nodes by primary location and nodal level were oral cavity (level I, 17/110, 15.5%), pharynx (level II, 6/30, 20.0%), and larynx (level VI, 1/3, 33.3%).

CONCLUSION

Levels at greatest risk for nodal disease in cN0 in terms of ipsilateral neck dissection are level I (oral cavity), II (pharynx), and VI (larynx). These data should be considered when treating patients presenting with cN0. This is the first study to comprehensively report the incidence, location, and risk of metastases in cN0 in the FDG-PET/CT era.

EUS of the neck: A comprehensive anatomical reference for the staging of head and neck cancer (with videos)

The use of EUS has application in the nodal staging of head and neck cancer. The technique and the anatomy of head and neck region using EUS have not been described. EUS from three stations in thoracic esophagus, cervical esophagus, and hypopharynx can allow imaging of head and neck. In this article we describe the normal structures from the three stations. The EUS imaging of head and neck can give relevant and additional information in malignancies of head and neck.

The value of whole-body contrast-enhanced 18F-FDG PET/CT imaging in the diagnosis and staging of patients with laryngeal carcinoma

PURPOSE

This study aimed to determine whether intravenous contrast-enhanced dual-phase fluorine-18--fluorodeoxyglucose (F-FDG) PET/CT scans provide additional diagnostic information compared with the MRI/CT in patients with laryngeal carcinoma during the initial staging.

PATIENTS AND METHODS

Forty-five consecutive patients (44 men, one woman; mean age±SD, 67.0±9.0 years, range: 45-80 years) with carcinoma of the larynx who had MRI/CT and intravenous contrast-enhanced PET/CT were enrolled. Each patient was scanned on the PET/CT system 1 h (early) and 2 h (delayed) after injection. The maximum standardized uptake values of the primary tumor, nodal, and distant metastatic lesions were measured using the dual-time-point method. Double-blinded F-FDG PET/CT and MRI/CT staging data were compared. The diagnostic accuracy of each modality was compared for primary tumors, nodal metastasis, and the tumor staging.

RESULTS

For primary tumor detection, the sensitivity of PET/CT was higher (100%) than MRI/CT (93.3%). The accuracy for N status was 88.8% for PET/CT, being superior to MRI, which had an accuracy of 66.6%. The sensitivity and specificity for the detection of nodal metastasis were 100 and 84.6% for PET/CT compared with 100 and 50% for MRI/CT, respectively. As an initial TNM-staging method, the PET/CT had a diagnostic accuracy of 86.6% compared with 44.4% for MRI/CT.

CONCLUSION

The results suggest that contrast-enhanced dual-phase PET/CT imaging contributes additional diagnostic information compared with the conventional methods for the initial evaluation of primary laryngeal tumors. F-FDG PET/CT has a good diagnostic performance for the detection of regional nodal and distant metastasis, and also synchronous tumors in patients with laryngeal carcinoma.

Impact of PET/CT on Staging and Treatment of Advanced Head and Neck Squamous Cell Carcinoma

OBJECTIVE

To understand the effects of positron emission tomography/computed tomography (PET/CT) evaluation on patients with previously untreated head and neck squamous cell carcinoma (HNSCC) with clinical evidence of regional lymph node involvement.

STUDY DESIGN

Prospective blinded study.

SETTING

Tertiary care cancer center.

SUBJECTS AND METHODS

Informed consent was obtained and data collected from 52 consecutive previously untreated patients with HNSCC and clinical evidence of cervical metastasis. All patients underwent conventional evaluation for HNSCC and whole body PET/CT. Data were evaluated by 5 independent reviewers, who performed TNM staging per the American Joint Committee on Cancer (seventh edition) manual and proposed a treatment plan prior to viewing, and after reviewing, PET/CT. Cases where at least 3 of 5 reviewers agreed were considered significant.

RESULTS

There were 0 patients for whom review of the PET/CT altered the T-class assessment (95% CI, 0-6.8), 12 (23.1%) for whom PET/CT altered N classification (95% CI, 12.5-34.5), and 2 (3.8%) for whom PET/CT altered the M classification (95% CI, 0.5-13.2). For 5 patients (9.6%), overall stage was altered per PET/CT review (95% CI, 3.2-21). For 3 patients (5.8%), PET/CT findings prompted reviewers to alter treatment recommendations (95% CI, 1.2-15.9).

CONCLUSION

When added to more conventional patient evaluation, PET/CT results in changes to the TNM categories, but overall staging and treatment were less frequently affected. Whether PET/CT should be used routinely for patients with stage III and IV HNSCC is still subjective and merits further study.

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

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

Preoperative 18F-FDG-PET/CT vs Contrast-Enhanced CT to Identify Regional Nodal Metastasis among Patients with Head and Neck Squamous Cell Carcinoma

Objective Our objective was to compare the accuracy of preoperative positron emission tomography (PET)/computed tomography (CT) and contrast-enhanced CT (CECT) in detecting cervical nodal metastases in patients treated with neck dissection and to scrutinize the ability of each modality to determine nodal stage. Study Design Case series with chart review. Setting Montefiore Medical Center, Bronx, New York. Subjects and Methods Patients who underwent neck dissection at our institution for primary treatment of head and neck squamous cell carcinoma (HNSCC) and had received preoperative PET/CT and CECT were included in this study. Imaging studies were reinterpreted by 3 specialists within the field and compared for interreader agreement. Concordance between radiology and histopathology was measured using neck levels and sides, along with patient nodal stage. Sensitivity, specificity, accuracy, positive predictive value, negative predictive value, and agreement coefficients were calculated. Results Seventy-three patients were included in the study. Sensitivity was 0.69 and 0.94 (level and side) for PET/CT vs 0.53 and 0.66 for CECT ( P = .056, P = .001). Specificity was 0.86 and 0.56 for PET/CT vs 0.91 and 0.76 for CECT ( P = .014, P = .024). No significant difference was found in overall accuracy ( P = .33, P = .88). The overall agreement percentages between N stage called by imaging modality and pathology were 52% and 55% for PET/CT and CECT, respectively. Conclusion No significant difference in sensitivity was found between PET/CT and CECT. CECT was found to have superior specificity compared with PET/CT. The information gleaned from each modality in the pretreatment evaluation of HNSCC appears to be complementary.

Imaging of spaces of neck and mediastinum by endoscopic ultrasound

Endoscopic ultrasound (EUS) of the mediastinum was pioneered by gastroenterologists, and it was taken up by pulmonologists when the smaller-diameter endobronchial ultrasound (EBUS) scope was designed after a few years. The pulmonologists’ approach remained largely confined to entry from the trachea, but they soon realized that the esophagus was an alternative route of entry by the EBUS scope. The new generations of interventionists are facing the challenge of learning two techniques (EUS and EBUS) from two routes (esophagus and trachea). The International Association for the Study of Lung Cancer (IASLC) proposed a classification of mediastinal lymph nodes at different stations that lie within the boundaries of specific spaces. These interventionists need clear definitions of landmarks and clear techniques to identify the spaces. There are enough descriptions of spaces of the neck and the mediastinum in the literature, yet the topic mentioned above has never been discussed separately. The anatomical structures, landmarks, and boundaries of spaces will be important to interventionists in the near future during performances of endosonography. This article combines the baseline anatomy of the spaces with the actual imaging during EUS.