Clinical value of 18FDG PET/CT in screening for distant metastases in head and neck squamous cell carcinoma

Objectives

The detection of distant metastases is of major importance in management of head and neck squamous cell carcinoma patients.

Design

All patients underwent ¹⁸FDG PET/CT for the detection of distant metastases.

Setting

Retrospective single‐centre study.

Participants

Head and neck squamous cell carcinoma patients with high‐risk factors for distant metastases.

Main outcome measures

Accuracy of ¹⁸FDG PET/CT for the detection of distant metastases using clinical development of distant metastases and a minimal follow‐up of twelve months as reference standard. Comparison of overall survival between patients diagnosed with distant metastases during initial screening and patients diagnosed with distant metastases during follow‐up.

Results

In 23 (12%) of the 190 patients, ¹⁸FDG PET/CT detected distant metastases at screening. Sensitivity and negative predictive value were 46.2% (95% CI 32.6‐59.7) and 82.6% (95% CI 76.8‐88.5). No difference in median overall survival from the time of distant metastases detection was found between patients diagnosed with DM during work‐up or during follow‐up.

Conclusions

In head and neck squamous cell carcinoma patients with high‐risk factors, ¹⁸FDG PET/CT has a high negative predictive value for the detection of distant metastases and should be used in daily clinical practice, although the sensitivity is limited when long‐term follow‐up is used as reference standard.     

Submandibular gland squamous metaplasia mimicking recurrent squamous cell carcinoma: diagnostic dilemma

New masses in the head and neck region of previously treated patients with cancer are considered suggestive of potential recurrence. Fine-needle aspiration is an excellent primary tool for evaluating these masses but may show atypical squamous cells that mislead clinicians to pursue aggressive treatment. We describe 3 patients in whom submandibular gland masses developed after radiation therapy for squamous cell carcinoma and for whom subsequent excisional biopsy findings showed benign squamous metaplasia. We review distinguishing clinical and histopathologic features that may allow these lesions to be identified. We also propose a treatment algorithm for this uncommon clinical scenario.     

Correlation between PET/CT and CT in the staging prior to the treatment of head and neck squamous cell carcinoma

IntroductionHead and neck squamous cell carcinoma is the seventh most common malignant tumor. The advances in treatment have improved the global survival rates in the past years, although the prognosis is still grave.ObjectiveThe aim of the present study is to evaluate the correlation between positron emission computed tomography and computed tomography at the time of staging a previously untreated head and neck squamous cell carcinoma, and to determine which of the two imaging techniques gives us more information at the time of initial diagnosis.MethodsData from all patients diagnosed in our hospital of head and neck squamous cell carcinoma by a biopsy of any location or unknown primary tumor was collected, between January 2012 and July 2017. In all cases, computed tomography and positron emission computed tomography were performed with a maximum of 30 days difference between them and patients had not received any prior treatment to staging. The stage given to each case was compared based solely on the physical examination, only on the computed tomography/positron emission computed tomography, with respect to the stage given by the tumor board, observing the concordance obtained through Cramer's V statistical test.ResultsWe performed a comparative analysis obtaining a correlation of 0.729 between the stage given by the tumor board and the one assigned based on the physical examination without imaging techniques. When only using computed tomography as an imaging method, the correlation was 0.848, whereas with only the use of positron emission computed tomography it was estimated at 0.957. When comparing the statistical association between staging using exclusively one of the two imaging techniques, correlation was 0.855.ConclusionPositron emission computed tomography is useful for the diagnosis of head and neck squamous cell carcinoma, improving the patient's staging especially when detecting cervical and distant metastases. Therefore, we consider that the use of positron emission computed tomography for the staging of patients with head and neck squamous cell carcinoma is a diagnostic test to be considered.     

FDG PET and PET/CT for the detection of the primary tumour in patients with cervical non-squamous cell carcinoma metastasis of an unknown primary

In patients with a neck metastasis from an unknown primary with non-squamous cell cancer (non-SCC) histology, the primary is often located outside the head and neck area. We retrospectively evaluated 326 patient records and found 14 patients with non-SCC neck lymph node metastasis from an unknown primary undergoing whole body F-18-fluorodeoxyglucose (FDG) positron emission tomography (PET) with or without coregistered computed tomography (PET/CT). The PET or PET/CT findings were verified by pathological work-up, additional imaging tests, and clinical follow-up. PET detected pathological FDG uptake suspicious for the primary in eight patients. PET or PET/CT findings were true positive in seven patients, true negative in 4, false positive in 1, and false negative in two patients. In one patient PET/CT revealed a synchronous ovarian carcinoma. The results suggest that whole body imaging with FDG PET and PET/CT can be useful to identify unknown primaries of non-SCC origin. However, the work-up of patients undergoing PET or PET/CT in our study was very heterogeneous and the primary was more likely found in patients without extensive imaging before PET scanning. Further studies should evaluate if the histology of a neck nodal metastasis should influence the choice of the imaging method and the role of PET and PET/CT imaging for the work up of patients with a non-SCC neck lymph node metastasis of an unknown primary.     

Prognostic value of preoperative 18F-FDG PET/CT for primary head and neck squamous cell carcinoma

¹⁸F-FDG PET/CT is clinically useful in the initial staging and follow-up of patients with head and neck squamous cell carcinoma (HNSCC). We studied the potential prognostic significance of preoperative ¹⁸F-FDG PET/CT in HNSCC. The medical records of 294 patients who underwent preoperative ¹⁸F-FDG PET/CT for HNSCC were retrospectively reviewed. The median SUV_max of the primary lesions (SUV_max-p) and cervical lymph nodes (SUV_max-n) was 7.98 ± 5.04 (range 1.2–28.7) and 3.34 ± 3.70 (range 1.0–20.4), respectively. There was a significant difference between with and without recurrence in SUV_max-p (11.14 ± 5.36 vs. 6.78 ± 4.35, p < 0.001) and SUV_max-n (5.60 ± 4.22 vs. 1.75 ± 1.46, p < 0.001). The cut-off values of SUV_max-p and SUV_max-n in the context of recurrence and cancer-related death were 8.5 and 3.5. The 5-year disease-free survival of patients with SUV_max-p < 8.5 and SUV_max-n < 3.5 was 79 and 79 %, respectively, whereas that of patients with SUV_max-p ≥ 8.5 and SUV_max-n ≥ 3.5 was 39 and 30 %, respectively. Multivariate analysis confirmed the significant association between 5-year disease-free survival and SUV_max-p ≥ 8.5 (hazard ratio (HR) 2.68, p < 0.001) and SUV_max-n ≥ 3.5 (HR 2.29, p = 0.007). Furthermore, SUV_max-p ≥ 8.5 (HR 3.20, p = 0.012) and SUV_max-n ≥ 3.5 (HR 2.14, p < 0.001) were associated with 5-year overall survival. ¹⁸F-FDG PET/CT cut-off values of SUV_max-p ≥ 8.5 or SUV_max-n ≥ 3.5 are associated with a recurrence and survival in HNSCC.     

PET/CT for assessing mandibular invasion by intraoral squamous cell carcinomas

? Evaluation of mandible invasion in cancer of the oral cavity and oropharynx is a major challenge. ? Today, CT scans are the most frequent imaging technique used, with sensitivity of 53 to 92% and specificity of 83 to 96%. ? Positron emission tomography is known as one of the most sensitive imaging techniques for head and neck cancer, but has poor anatomical resolution. ? Our study associates positron emission tomography with CT scans, fusioning both images to maximise data information. ? Positron emission tomography/CT fusion shows sensitivity of 100% with specificity of 85%. This result encourages the use of positron emission tomography/CT when assessing mandibular invasion.     

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

Abstract

Background: The accurate detection of distant metastases can facilitate appropriate treatment planning for patients with recurrent head and neck squamous cell carcinoma (HNSCC).

Objectives: We evaluated the role of ¹⁸F-FDG PET/CT for distant metastasis diagnosis and survival prediction in patients with recurrent HNSCC.

Materials and methods: This study included 95 consecutive patients with recurrent HNSCC and salvage treatments. McNemar’s test was used to compare the detection of distant metastasis at recurrence using ¹⁸F-FDG PET/CT and contrast-enhanced chest and neck CT, and bone scintigraphy.

Results: Thirty-two patients (34%) had distant metastases at recurrence. The sensitivity, specificity, accuracy, and positive and negative predictive values of ¹⁸F-FDG PET/CT for detecting chest and bone metastases were comparable to those of conventional imaging (p?>?.1). However, ¹⁸F-FDG PET/CT detected two additional distant metastatic lesions. After controlling for clinicopathological factors, a recurrent lesion with maximum standardized uptake value (SUV_max) >8.7 was identified as an independent predictor of poor overall survival (p?=?.001).

Conclusions and significance: ¹⁸F-FDG PET/CT or conventional imaging is comparable with regard to detecting distant metastases of recurrent HNSCC. However, ¹⁸F-FDG PET/CT may detect additional metastatic lesions in unusual distant sites and the recurrent lesion SUV_max may predict patient survival after salvage treatments.     

Unknown primary squamous cell carcinoma metastatic to the neck

We analyzed retrospectively 157 cases of metastatic neck squamous cell carcinoma from unknown primary sites, treated with surgery, radiotherapy, excisional biopsy, and combined modalities. Median follow-up was 74 months, and overall actuarial survival was 55% at 5 years. The surgery-treated group, despite a higher rate of manifesting primary tumors, had significantly better survival at 5 years compared with those receiving radiation therapy, of whom 23% had residual disease after treatment. Primary tumors were discovered during follow-up in 16% overall. Different treatments yielded comparable results in lower-staged neck disease (NX, N1, N2a), while surgery appeared more effective in controlling advanced disease (N2b, N3a). Factors that affected survival include neck stage, connective tissue invasion, and presence of recurrent or residual disease after treatment.     

Nodal size of metastatic squamous cell carcinoma of the neck

The preoperative use of computed tomographic (CT) scanning continues to be the best diagnostic method for preoperative detection of metastatic neck disease. Current accepted criteria for CT diagnosis of nodal disease are not uniform, although nodal size, nodal grouping, and central necrosis correlate strongly with malignancy. To assess the relationship of nodal size and malignancy, a multicenter study was designed to evaluate the nodes from 100 neck dissections. Sixty-nine positive neck dissections were analyzed, and every node was measured. The relationship of central necrosis was also compared with node size. Our results showed that CT scanning continues to provide a reliable picture of the histologic status of lymph nodes. Using the criterion of central necrosis or node size larger than 1 cm, only 7% of necks had nodal disease that would have been missed by CT interpretation. This study supports the continued use of preoperative CT evaluation for metastatic neck disease.     

舌鳞状细胞癌颈部淋巴结转移的治疗

目的 分析舌鳞状细胞癌颈部淋巴结转移性的分布规律,探讨舌鳞状细胞癌cN0患者的颈部处理。方法 回顾性分析1975年1月-2000年12月初次在我院诊治的329例舌鳞状细胞癌患者的临床资料。cN0 179例,cN1 131例,cN2＋3 19例（2例出现双侧颈淋巴结转移）。在cN0患者中,肩胛舌骨肌上清扫或单纯颔下清扫20例,根治性颈清扫93例,扩大的肩胛舌骨上（包括Ⅳ区）清扫8例。在cN1患者中,30例接受颈部单纯放疗;肩胛舌骨肌上清扫6例,根治性颈清扫94例,扩大的肩胛舌骨上清扫1例。所有cN2＋3患者均行根治性颈清扫。结果 舌鳞状细胞癌颈部淋巴结隐性转移率为8．3％（10／121）,其中T1为1．3％（1／76）,T2为4．3％（4／93）,T3为44．4％（4／9）,T4 100％（1／1）。实际颈部淋巴结转移率为71．7％（81／113）。91例患者组织学检查发现颈清扫标本中淋巴结转移阳性,Ⅰ区淋巴结转移占39．6％（36／91）、Ⅱ区71．4％（65／91）、Ⅲ区19．8％（18／91）和Ⅳ区8．8％（8／91）。有2例患者发生对侧Ⅰ、Ⅱ和Ⅳ区的淋巴结转移。在cN0患者中,颈部单纯放疗的同侧颈部复发率为7．5％（3／40）,综合治疗为7．5％（6／80）,单纯手术为2．4％（1／41）,等待观察为16．7％（3／18）;颈部单纯放疗的5年生存率分别为42.0％,综合治疗为55．6％,单纯手术为79．6％,等待观察为48．6％。结论 Ⅱ区是舌鳞状细胞癌最易转移的部位,不主张对所有cN0患者实施择区性颈清扫,对T3和T4患者可考虑扩大的肩胛舌骨肌上清扫（Ⅰ～Ⅳ）。     

Nivolumab for recurrent/metastatic hypopharyngeal squamous cell carcinoma in a liver transplant recipient

Nivolumab administration to patients with organ transplantation history requires careful management. Herein, we report the case of a living-donor liver-transplant recipient, a 52-year-old man, with recurrent and metastatic hypopharyngeal cancer treated with nivolumab. He was diagnosed with T2N2bM0 stage IVA hypopharyngeal squamous cell carcinoma. While using oral immunosuppressants (cyclosporine and mycophenolate mofetil), the patient underwent right neck dissection followed by radiotherapy as an initial treatment. Three months after radiotherapy, positron emission tomography scans revealed multiple bone metastases. We administered two courses of the EXTREME regimen, comprising cisplatin, 5-fluorouracil, and cetuximab, as the first-line treatment for distal metastasis, but the patient presented with progressive disease. The patient was administered nivolumab as the second-line treatment. The programmed death-ligand 1 (PD-L1) expression level in a biopsy specimen of the primary hypopharyngeal tumor and resected specimen of the cervical lymph node metastasis was 40% and 10%, respectively. PD-L1 expression was not detected in hepatocytes of the liver biopsy sample obtained before nivolumab introduction. The patient received four courses of nivolumab 240 mg. Although liver dysfunction was alleviated by adjusting the dose of the hepatoprotective agent and cyclosporine, the progressive disease status persisted after completing nivolumab courses. The patient died of hypopharyngeal cancer progression.