Deferring planned neck dissection following chemoradiation for stage IV head and neck cancer: the utility of PET-CT

OBJECTIVE: To determine whether combined positron emission tomography and computed tomography (PET-CT) may be of value in deferring planned neck dissections for patients with advanced head and neck squamous cell carcinoma (HNSCC). STUDY DESIGN: Observational study of patients with de novo cervical > or =N2 regional spread of HNSCC in a tertiary care academic medical center. METHODS: Forty-three patients were identified who underwent post-treatment PET-CT within 6 months of completing neoadjuvant chemotherapy combined with radiation therapy (CRT). The PET-CT was "positive" if the radiologist recommended tissue sampling or resection of cervical lymph nodes, or if there was progressive neck disease in the setting of distant metastatic disease. Patients who had positive PET-CT underwent confirmatory biopsy given clinical suspicion for regional cervical metastasis without distant disease. Patients with negative PET-CT were followed clinically and radiographically for a minimum of 5 months (median 18.1 months) after CRT. RESULTS: Ten (22%) of the 43 post-treatment PET-CT studies were positive. Seven of the 10 PET-CT scans (70% of positives) were true-positive given histologically-confirmed residual viable tumor or progressive disease including disease in the neck. The 3 remaining studies (30% of positives) were false-positive PET-CT results, given resolution of fluorodeoxyglucose (FDG) avidity on subsequent imaging or tissue sampling demonstrating absence of viable tumor cells. Of the 33 patients with negative PET-CTs in the neck, 1 patient had absence of FDG-avidity in the setting of malignant disease in the neck (3% false negatives); otherwise, patients with an initially negative PET-CT scan had no recurrences during the study (97% true negatives). This corresponds to a sensitivity of 87.5% (7/8), a specificity of 91% (32/35), a positive predictive value of 70% (7/10), a negative predictive value of 97% (32/33), and accuracy of 91% (39/43) for PET-CT scans in the detection of cervical metastatic disease after CRT. Overall, 37 (86%) of 43 patients were spared neck dissection using this technology without evidence of recurrent disease in the neck at extended follow-up. CONCLUSIONS: Our results suggest that planned neck dissection after CRT for HNSCC may be deferred in favor of serial PET-CT imaging, and that sampling of areas of suspicious FDG-avid uptake can be rationally considered prior to therapeutic neck dissection. These data also suggest that negative PET-CT scans are highly reliable for the absence of residual cervical nodal disease.     

Utility of positron emission tomography-computed tomography in identification of residual nodal disease after chemoradiation for advanced head and neck cancer

OBJECTIVES: Planned neck dissection after chemoradiation (CR) is often advocated in patients with head and neck squamous cell cancer (HNSCC) with advanced nodal disease who demonstrate a clinical complete response to CR because identification of residual occult nodal disease is difficult. We sought to investigate the utility of positron emission tomography-computed tomography (PET-CT) in identifying patients with occult nodal disease after CR. STUDY DESIGN: Nonrandomized retrospective cohort analysis. MATERIALS AND METHODS: The medical records of all patients treated with primary CR for advanced HNSCC with N2 or N3 disease from December 2003 to June 2005 were reviewed. Patients with a clinical complete response were eligible for inclusion if PET-CT performed at 8 to 10 weeks after CR showed no evidence of distant disease and they were treated with a planned neck dissection. RESULTS: Seventeen patients met study criteria. PET-CT was positive for residual nodal disease in 11 (64.7%) patients, with a standardized uptake value (SUV) range of 1.7 to 3.8. Pathologic examination revealed residual viable carcinoma in five (29.4%) patients, with tumor size ranging from 2.0 to 9.5 mm. Carcinoma was present in 2 of 11 (18.2%) patients with positive PET-CT scans and 3 of 6 (50%) patients with negative PET-CT scans. The sensitivity and specificity of PET-CT in predicting occult nodal disease was 40% and 25%, respectively. There was no correlation between PET-CT findings and histologic findings (P = .26) or between SUV and size of viable tumor (P = .67). CONCLUSIONS: A significant proportion of HNSCC patients with advanced neck disease harbor residual occult metastases after CR. PET-CT is not sufficiently specific or sensitive to reliably predict the need for posttreatment neck dissection.     

CT staging and surveillance of the thorax in patients with newly diagnosed and recurrent squamous cell carcinoma of the head and neck: is it necessary?

The detection of distant metastases or synchronous primary tumours at initial presentation, or at recurrence in patients with head and neck squamous cell carcinoma (HNSCC), frequently alters the selection of therapy in these patients. A number of series report appreciably high rates for these lesions. This study evaluated 108 computed tomography (CT) scans and chest radiographs (CXR) of the thorax, in 80 patients presenting with HNSCC over a 4 year period. There were three clinical settings; (a) at original diagnosis n = 61, (b) clinical evidence of local/regional recurrence n = 19 (c) suspicion of recurrence due to neck symptomatology n = 28. CT thorax detected two out of 61 (3%) distant metastases at the initial diagnosis stage (both were either stage III or IV) and one out of 19 (5%) patients evaluated at the time of loco/regional recurrence. CXR failed to reveal evidence of pulmonary metastases in the two patients at initial diagnosis stage, but correctly identified pulmonary metastases in the loco-regional recurrence patient. There was no thoracic malignancy detected in the surveillance CT scans, and no synchronous second primary tumour detected during the study. CT is known to be more sensitive than conventional CXR in detecting thoracic pathology in HNSCC patients, however, we feel CT is of limited value in stage I or II disease. We no longer carry out routine staging CT scans of the thorax in patients presenting with stage I or II HNSCC, or with neck symptomatology with no clinical evidence of recurrence.Presented at the Royal Academy of Medicine in Ireland, Otolaryngology Head and Neck Surgery Section 2005.     

The role of positron emission tomography/computed tomography in the management of recurrent papillary thyroid carcinoma

OBJECTIVES/HYPOTHESIS: The aim of the study was to evaluate the role of combined positron emission tomography/computed tomography (PET/CT) fusion imaging in the detection and management of recurrent papillary thyroid cancer. STUDY DESIGN: A retrospective analysis of 33 patients with suspected recurrent papillary thyroid carcinoma who had undergone PET/CT was performed. PET/CT was compared with standard imaging techniques in each patient to determine whether PET/CT contributed to the therapeutic management plan. Histopathological findings were correlated to PET/CT in patients who underwent surgery. METHODS: The senior author reviewed the charts of 33 patients with recurrent papillary thyroid carcinoma to determine the impact PET/CT had on management. PET/CT was compared with conventional imaging results. In surgical patients, PET/CT was compared with histopathological findings to determine its sensitivity, specificity, accuracy, positive predictive value, and negative predictive value. RESULTS: In 67% of the cases (22 of 33), PET/CT supplied additional information that altered or confirmed the management plan. Twenty of 33 patients underwent surgery with 36 sites assessed by histopathological analysis. PET/CT correlated with histopathological findings in 25 of 36 distinct anatomical sites, with an accuracy of 70%. The sensitivity of PET/CT in identifying recurrence was found to be 66%, with a specificity of 100%, a positive predictive value of 100%, and a negative predictive value of 27%. CONCLUSION: Combined PET/CT fusion scanning was most useful in the detection and management of recurrent papillary thyroid cancer in patients who had average thyroglobulin levels greater than 10 ng/mL and when the tumor no longer concentrated radioactive iodine. In 100% of the cases in which PET/CT localized a region suspicious for malignancy, histopathological analysis confirmed the results. When PET/CT is positive, it is a powerful tool for predicting exact locations of recurrent papillary thyroid cancer, thus making it a reliable guide for surgical planning. PET/CT is a supplement to conventional imaging and fine-needle aspiration in the workup of recurrent papillary thyroid cancer. A negative finding on PET/CT is not sufficiently reliable to preclude further investigation and treatment.     

The predictive value of dominant nodules and the management of indeterminate group in multinodular goiter

The objectives of this study were to determine the predictive value of dominant nodules (DNs) in multinodular goiters (MNGs), and to stratify the risk of malignancy within the indeterminate category. The study design was retrospective study of patients with MNG. A total of 140 patients were reviewed. Fine needle aspiration biopsy (FNAB) findings for all DNs were categorized into four groups: (1) benign, (2) positive or suspicious for malignancy, (3) indeterminate, and (4) non-diagnostic. All FNAB specimens of the indeterminate group were also evaluated for the presence of Hurthle cell metaplasia and were categorized according to the presence of cytological atypia. Cytohistological comparison was then performed. Mean number and diameter of the DNs were 1.45 and 25.6 mm, respectively. Based on final histopathology, 22.14% of the patients had thyroid malignancy and 74.2% of thyroid carcinomas were located in DNs. The number of DNs was significantly larger in malignant thyroid glands than in benign ones. In total, 22.6% of the indeterminate FNABs were malignant. FNABs of the indeterminate group that included atypical cells had a statistically significant higher incidence of malignancy. The presence of Hurthle cells was not statistically different in malignant and benign nodules upon final histological diagnosis. In conclusion, FNAB of only DNs in MNG could determine thyroid malignancy in 75% of patients. The DN number might be required for the predictive value of malignancy. A subclassification of the indeterminate group, based on the presence or absence of cytological atypia, is necessary to better assess the risk of malignancy.     

The role of positron emission tomography scans in the management of the N-positive neck in head and neck squamous cell carcinoma after chemoradiotherapy

OBJECTIVE: The objective of this study was to determine the sensitivity, specificity, and predictive value of 18-fluorodeoxyglucose positron emission tomography (PET) in predicting residual cervical metastatic disease in patients with N-positive necks undergoing curative radiotherapy and chemoradiotherapy for squamous cell carcinoma (SCC) of the upper aerodigestive tract. METHODS: The authors studied a prospective case series of patients (2003-2005) of patients undergoing radiotherapy and chemoradiotherapy for advanced head and neck SSC. Study entry criteria included N-positive neck disease, a complete response to treatment at the primary tumor site, posttreatment PET scan (8-12 weeks after completion of treatment), followed by salvage neck dissection. The posttreatment PET scan neck findings were correlated to the salvage neck dissection pathology report. The sensitivity, specificity, and predictive values of the PET scan to predict residual cervical metastatic disease after curative chemoradiotherapy were calculated. RESULTS: Twenty-one neck dissections (pretreatment N1 = 5, N2a = 2, N2b = 8, N3 = 6) were entered into the protocol. Four (19.0%) of the 21 neck specimens were positive for residual cervical metastatic disease, whereas the remaining 17 (80.9%) specimens demonstrated no residual carcinoma. The overall sensitivity and specificity were 75.0% and 64.7%, respectively. The positive predictive value was 33% and the negative predictive value was 91.7%. CONCLUSIONS: Although the role of posttreatment neck dissection remains controversial, the surgeon must rely on clinical examination and imaging studies. Our practice has been to perform planned staged neck dissections on all N2 and N3 necks, as well as N1 necks with an incomplete response to treatment. Based on this small prospective study, it appears that PET imaging lacks adequate sensitivity and specificity to reliably predict the presence of residual cervical metastatic disease after completion of chemoradiotherapy. With a negative predictive value of 91.7%, however, a negative PET scan appears to be a reliable predictor of the absence of residual tumor.     

Evaluation of chest radiography versus chest computed tomography in screening for pulmonary malignancy in advanced head and neck cancer

OBJECTIVE: To evaluate the role of chest radiography versus chest computed tomography (CT) in screening for pulmonary malignancy in advanced head and neck squamous cell carcinoma (HNSCC). DESIGN: Retrospective review of imaging. SETTING: Head and neck cancer unit. METHOD: Over a period of 1 year, 26 patients with advanced HNSCC (T3/T4) were screened for pulmonary malignancy with both chest radiography and chest CT prior to definitive therapy. OUTCOME MEASURES: Radiologic evidence of malignancy. RESULTS: Twenty patients had a normal chest radiograph and a normal CT scan. Four patients had a normal chest radiograph but an abnormal CT scan. Three of these patients had a pulmonary malignancy and one had a suspicious lesion that resolved following surgery to the index tumour. Two patients had both an abnormal chest radiograph and CT scan. One of these had a pulmonary malignancy and one had a CT-guided biopsy of the chest lesion 4 weeks postoperatively, which was normal. Chest CT scanning therefore identified three chest malignancies that would have been missed by chest radiography alone. CONCLUSIONS: Chest CT is an effective tool in screening for malignant pulmonary disease in patients with advanced head and neck cancer and should be used instead of chest radiography to avoid false-negative results.     

双源CT诊断非金属可疑食管异物的队列研究

目的通过分析双源CT诊断非金属食管异物的敏感性和特异性,评价双源CT对非金属可疑食管异物的诊断意义。方法应用前瞻性队列研究,选取2015年1月1日～2016年12月31日符合纳入标准的患者153例双源CT和正侧位平片对照。结果93例双源CT阳性示食管异物,其中57例平片阳性;内镜检查证实并取出92例,内镜检查阴性1例。本组病例中双源CT敏感性100%（92/92）,特异性98.4%（60/61）,阴性预测值100%（60/60）。结论双源CT检查非金属食管异物敏感性、特异性、阴性预测值高,能明确异物类型及异物位置。双源CT可作为非金属食管异物的常规检查,及时诊断,避免不必要的食管内镜检查。     

Sentinel node biopsy for oral and oropharyngeal squamous cell carcinoma of the head and neck

OBJECTIVES: The aims were to assess the technical feasibility of sentinel node biopsy (SNB), to validate SNB against elective neck dissection, and to report the results of the clinical application of the SNB concept for early oral and oropharyngeal squamous cell carcinoma. STUDY DESIGN: Prospective consecutive cohort analysis. METHODS: Between 2000 and 2006, a total of 79 patients were included. Lymphatic mapping consisted of preoperative lymphoscintigraphy and intraoperative use of a hand-held gammaprobe. Twenty-eight patients were assessed for feasibility and validation; the SNB was done in context with an elective neck dissection. Fifty-one patients were evaluated in an observational trial; elective neck dissection was performed only in case of positive SNB. RESULTS: Validation revealed a sentinel node detection rate by lymphoscintigraphy of 93%, with the gammaprobe of 100%. The negative predictive value of a negative SNB was 100%. During the observational trial 40% of the patients were upstaged as a result of a positive SNB. Intraoperative frozen section analysis showed a negative predictive value of 83%. Two patients (6%) with negative SNB experienced a neck recurrence, the negative predictive value of SNB was therefore 94%. Patients with positive SNB were treated successfully with elective neck dissection. CONCLUSIONS: SNB is technically feasible and reproducible with a high sentinel node detection rate. Validation against elective neck dissection revealed a negative predictive value of 100%. Application of the SNB concept in clinical practice was very successful. The recurrence rate within the neck was very low and the morbidity and cost of an elective neck dissection could be spared to 60% of the patients.     

Is there a role for fluorodeoxyglucose positron emission tomography/computed tomography in cytologically indeterminate thyroid nodules?

OBJECTIVE: The aim of this study was to determine the accuracy of the fluorine 18 ((18)F)-labeled fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) scan in the evaluation of thyroid nodules in which the cytopathology of fine-needle aspiration (FNA) biopsies are classified as "indeterminate," ie, either follicular or Hürthle cell lesion. METHODS: At an academic medical center, we conducted a prospective pilot study of 15 patients with thyroid nodules in whom adequate FNA was diagnosed as indeterminate. All patients underwent a whole-body FDG-PET/CT scan followed by thyroidectomy. Preoperative FDG-PET/CT results and the histopathology of the surgical specimen were compared and statistically analyzed. RESULTS: The FNA demonstrated follicular cells in 11 (73%) patients, Hürthle cells in 3 (20%) patients, and both types of cells in 1 (7%) patient. The histopathology of the surgical specimen revealed thyroid cancer in 7 (47%) patients. The FDG-PET/CT scan was positive in 8 patients; 4 (50%) patients were found to have cancer. The FDG-PET/CT scan was negative in 7 patients. Four of these patients had benign lesions and 3 had thyroid carcinoma. Thus, 4 (27%) patients had false-positive FDG-PET/CT scans and 3 (20%) patients had false-negative studies. The sensitivity of FDG-PET/CT to detect a malignant focus was 57% with a specificity of 50%. The positive predictive value was 50% and the negative predictive value was 57%. CONCLUSIONS: In this pilot study of patients with cytologically indeterminate thyroid nodules, FDG-PET/CT was not a predictable indicator of benign or malignant disease. Although a larger series may elucidate a role for FDG-PET/CT, the relatively low predictability shown in this study should caution clinicians about using FDG-PET/CT to consider foregoing thyroidectomy for cytologically indeterminate nodules.     

Impact of preoperative ultrasonographic staging of the neck in papillary thyroid carcinoma

OBJECTIVE: To determine the frequency of occult macroscopic metastasis detected by preoperative US evaluation of the neck in patients with PTC. Papillary thyroid carcinoma (PTC) is a malignancy with a high rate of lymph node metastasis. The findings of routine thyroid ultrasonography (US) and physical examination may underestimate metastatic disease. Thus, we propose that patients diagnosed as having PTC undergo preoperative US staging of the neck. DESIGN: This prospective study included 60 patients diagnosed as having PTC from January 1 through June 30, 2006. Patients had undergone previous thyroid US evaluation with no palpable adenopathy. Lymph nodes were deemed suspicious by US findings with a minor axis greater than 10 mm, a minor axis greater than 50% of the major axis, or hyperechogenicity with or without microcalcifications. Metastasis was confirmed by fine-needle aspiration biopsy or frozen section analysis. Patients with confirmed metastasis underwent a neck dissection. The location of adenopathy reported by US was correlated with the pathological report. RESULTS: The US evaluation identified 12 of 60 patients (20%) with adenopathy suggestive of metastasis. Metastasis was confirmed in 11 of 12 patients (92%). Metastasis was found in 1 of 48 patients who had a negative US finding. Overall, sensitivity, specificity, and positive and negative predictive values were 92%, 98%, 92%, and 98%, respectively. All neck levels with suspicious adenopathy detected by US evaluation, with 1 exception, were confirmed by pathological findings. Nine patients had additional neck levels involved with microscopic disease undetected by the US evaluation. CONCLUSIONS: In patients with PTC, preoperative US evaluation of the neck is effective in detecting nonpalpable metastasis. Therefore, routine preoperative neck US evaluation is recommended to optimize primary surgical planning.     

Detection of FDG-PET and FDG-PET/CT in head and neck squamous cell carcinoma

We evaluated the accuracy of staging in 159 patients with head and neck squamous cell carcinoma (HNSCC) scanned by FDG-PET and 116 patients with the same cancer scanned by FDG-PET/computed tomography (CT). The accuracy was measured by comparing the FDG-PET/FDG-PET/CT findings at the primary tumor site, cervical node sites and distant metastatic sites with the clinical diagnosis. Especially, accuracy at cervical sites was evaluated from the screening point of view. Both examinations yielded an accuracy rate of more than 80% for each site, and a negative predictive value of more than 90% for the cervical sites. For the cervical sites, the positive predictive value (PPV) of FDG-PET was 78% and of FDG-PET/CT was 82%. When one cervical lymph node metastasis was detected by FDG-PET, the PPV was 63%, which appears to be comparatively low. Both examinations showed high accuracy for staging of HNSCC. In the near future, excellent screening examination might become possible with the spread of FDG-PET/CT. However, both examinations do not yield the direct image of the carcinoma itself, but only the status of glucose metabolism in the carcinoma. Care must always be exercised in the interpretation, as there are not a few false negative and false positive cases.     

Fine-needle aspiration biopsy of salivary gland lesions in a selected patient population

OBJECTIVE: To report the role of selective use of preoperative fine-needle aspiration biopsy (FNAB) in patients with major salivary gland lesions at a tertiary care cancer center. DESIGN: Retrospective review of FNAB results compared with final histologic diagnosis as the criterion standard. SETTING: An academic tertiary care cancer center. PATIENTS: A consecutive series of 258 patients who underwent FNAB of major salivary gland lesions between 1996 and 2000, of whom 169 had surgical resection. MAIN OUTCOME MEASURES: Predictive value, sensitivity, specificity, and accuracy. RESULTS: FNAB was performed in 169 (37%) of 463 salivary gland lesions undergoing surgical procedures. A total of 126 lesions were in the parotid gland and 44 in the submandibular gland. Seventy-nine lesions (46%) were malignant. There were 150 FNAB specimens (89%) that were satisfactory for evaluation. The FNAB diagnosis of malignant or suspicious lesion had positive and negative predictive values of 84% and 77%, respectively. Ten of 20 false-negative FNAB results were low-grade lymphoma on final histologic assessment. Fine-needle aspiration biopsy diagnosis of a benign neoplasm had positive and negative predictive values of 83% and 88%, respectively. A cytopathologic diagnosis of a nonneoplastic lesion was predictive in only 47% of cases. Fifteen (47%) of 32 lymphocyte-predominant FNAB specimens were lymphoma on final histologic assessment. Ten (20%) of 49 patients with history of a solid, non-head and neck malignancy had evidence of distant metastasis to the salivary gland by histologic and/or cytopathologic assessment. CONCLUSIONS: An FNAB diagnosis of malignant or neoplastic major salivary gland disease is generally predictive of final histologic diagnosis. The predictive value of a negative FNAB finding is low, and should not supersede clinical suspicion. Cytologic findings of a lymphocyte-predominant lesion should prompt further workup to rule out lymphoma.     

Positron-emission tomography for surveillance of head and neck cancer

OBJECTIVES/HYPOTHESIS: To determine the diagnostic accuracy and the ideal timing of fluoro-fluorodeoxyglucose positron-emission tomography (PET) in the posttreatment surveillance of head and neck mucosal squamous cell carcinoma (HNSCC). STUDY DESIGN: Retrospective chart review. METHODS: Our sample includes 103 adult patients with 118 posttreatment PET scans who had undergone treatment for HNSCC. We correlated PET results with surgical pathology and clinical outcome in the subsequent 6 months. RESULTS: For the detection of locoregional persistent or recurrent HNSCC, PET scans had a sensitivity of 82%, specificity of 92%, positive predictive value (PPV) of 64%, negative predictive value (NPV) of 97%, and overall accuracy of 90%. For the detection of distant metastases, PET scans had a sensitivity of 89%, specificity of 97%, PPV of 85%, NPV of 98%, and overall accuracy of 96%. PET scans of the head and neck region performed greater than 1 month after the completion of radiation compared with scans performed within 1 month had a significantly higher sensitivity of 95% versus 55% (P < .01) and NPV of 99% versus 90% (P < .01). CONCLUSION: PET is effective in detecting distant metastases in the posttreatment surveillance for HNSCC patients. A negative PET is highly reliable for all sites. However, a positive PET in the head and neck region is unreliable because of a high false-positivity rate. PET of the head and neck region has a statistically significant risk of a false-negative reading when performed within 1 month of radiation.     

甲状腺细胞病理学Bethesda报告系统的临床应用:肿瘤专科医院5729例样本的回顾性分析

目的分析肿瘤专科医院甲状腺细胞病理学Bethesda报告系统的数据特点,评价甲状腺细针穿刺(fine needle aspiration,FNA)的诊断能力。方法回顾性分析2017年1月至2018年12月中国医学科学院肿瘤医院行甲状腺FNA检查的5729个组织的临床资料,来自5011例患者,其中男1174例,女3837例,年龄7~88岁,中位年龄45岁。以术后组织病理学结果为金标准,分析Bethesda分级系统各诊断级别的恶性风险和甲状腺FNA的诊断能力。结果5729个细胞学诊断包括:无法诊断或标本不满意(nondiagnostic or unsatisfactory,ND/UNS)456个(8.0%),良性(benign)1055个(18.4%),意义不明确的非典型病变或意义不明确的滤泡性病变(atypia of undetermined significance or follicular lesion of undetermined significance,AUS/FLUS)409个(7.1%),滤泡性肿瘤或可疑滤泡性肿瘤(follicular neoplasm or suspicious for a follicular neoplasm,FN/SFN)80个(1.4%),可疑恶性(suspicious for malignancy,SUS)982个(17.1%),恶性(malignant)2747个(47.9%)。3239个有术后病理结果,其中恶性者3109个(95.99%)。各诊断级别的恶性风险分别为:ND/UNS 75.00%,良性40.91%,AUS/FLUS 77.67%,FN/SFN 41.67%,SUS 96.86%,恶性99.96%。FNA诊断的敏感性、特异性、准确性、阳性预测值和阴性预测值分别为98.8%、60.5%、97.7%、98.9%和59.1%。结论肿瘤专科医院甲状腺Bethesda报告系统的数据具有恶性诊断占比高和各诊断级别恶性风险高的特点。FNA诊断准确性高,且有较高的阳性预测值。     

Utility of response assessment PET-CT to predict residual disease in neck nodes: A comparison with the Histopathology

ObjectiveTo assess the ability of Positron Emission Tomography-Computed Tomography (PET-CT) scans to detect residual disease in neck nodes with the Histopathology (HPR) as the gold standard. To obtain a Standardized Uptake Value max cutoff in these patients to predict residual disease in neck.MethodsHead and neck squamous cell carcinoma patients who underwent Salvage neck dissection with or without primary site surgery post Concurrent Chemo-Radiotherapy (CCRT) during the period January 2008–December 2017 were included. All patients had response assessment PET-CT scan at 10–14 weeks. Agreement analysis was performed between PET-CT and HPR, fine needle aspiration cytology and HPR. Positive predictive value, Negative predictive value of PET-CT to detect residual neck nodal disease in comparison to HPR was analyzed. A Receiver Operating Characteristic (ROC) curve was plotted between the SUV max values and the HPR. A SUV max cutoff value was obtained from the ROC curve.ResultsA total of 75 patients were included. Thirty-one underwent salvage neck dissection along with surgery for primary disease and 45 underwent salvage neck dissection alone. PET-CT showed good agreement with the HPR to detect residual disease in neck nodes (Kappa = 0.604). PET-CT had a PPV and NPV of 87.5% and 79.15% respectively as compared against the HPR. A SUV max cutoff of 4.62 had a specificity of 92.3% and sensitivity of 73.5% to detect residual disease in neck nodes on the HPR.ConclusionPET-CT surveillance is an accepted treatment strategy. A neck node with SUV max of 4.62 and above is most likely to harbor residual nodal disease.Level of evidence: Level 2b     

Diagnostic utility of positron emission tomography-computed tomography for predicting malignancy in cystic neck masses in adults

OBJECTIVES: Combined positron emission tomography and computed tomography (PET-CT) is used for the diagnostic evaluation and staging of squamous cell carcinoma of the head and neck (SCCHN). By superimposing anatomic localization of CT with the physiologic data of PET, occult primary and metastatic neoplasms might be identified. Because the diagnostic algorithm for cystic neck masses in adults often overlaps with the work-up of cancer of unknown primary site, we evaluated the utility of PET-CT scans to identify the presence of malignancy and the location of primary tumor. STUDY DESIGN: Single-institution retrospective case review series. METHODS: We reviewed the PET-CT imaging of cystic neck masses occurring in five patients over 40 years of age with significant risk factors for SCCHN and correlated this information with histopathology. RESULTS: In each patient in our series, the PET portion of a combined PET-CT was misleading, whereas the CT examination was more suggestive of the correct pathology. Ultimately, clinical judgment and endoscopic evaluation, guided by CT findings, were most valuable for distinguishing malignant versus benign processes and identifying the primary tumor sites. CONCLUSIONS: PET-CT may not be a reliable modality for identifying malignancy in adults with suspicious cystic neck masses. A thorough clinical evaluation by an experienced head and neck surgeon, in conjunction with contrast-enhanced CT, may be sufficient to facilitate the optimal management of such patients.     

正电子发射计算机断层-CT融合显像在头颈肿瘤中的诊断价值

目的探讨^18氟-脱氧葡萄糖(18-nuorinenuorodeoxyducose，^18F-FDG)正电子发射计算机断层显像(positron emission tomography，PET)-CT融合显像在头颈肿瘤的原发灶诊断、复发的检测和诊断分析未知原发肿瘤转移癌中的诊断价值。方法27例已确诊头颈部原发肿瘤或转移癌，进行^18F-FDGPET-CT全身显像，并与临床资料对照。结果鼻咽癌组治疗前4例PET-CT均查出原发灶，其中2例确诊有颈淋巴结转移，与病理检查结果一致。鼻咽癌放疗后12例中4例PET-CT检查鼻咽部及颈部淋巴结均为阴性表现，符合临床和病理诊断；2例放疗后原发灶复发经病理检查证实，其中1例查出颈部淋巴结及全身多处转移经随访证实；6例鼻咽原发灶PET-CT检查阴性表现．但4例颈部显示淋巴结转移经病理检查证实，2例肺部、纵隔等有转移灶未经病理检查证实。未知原发肿瘤颈淋巴转移组4例患者PET-CT均检出原发灶，3例病理检查证实，另1例未经病理检查证实。其他头颈肿瘤组7例治疗后患者中，2例患者无复发转移表现，5例不同部位肿瘤检出原发部位复发或颈淋巴结转移，有4例经病理检查证实，1例放弃治疗未经病理检查证实。结论^18F-FDGPFT-CT将PET提供的肿瘤代谢图像和CT提供的解剖图像结合，对头颈原发肿瘤诊断，检测治疗后肿瘤复发，不明原因转移癌原发灶的诊断及远处转移灶的诊断具有较大的临床价值。     

Sentinel lymph node biopsy in N0 squamous cell carcinoma of the oral cavity and oropharynx

OBJECTIVES: To ascertain the feasibility of sentinel lymph node (SLN) localization by preoperative lymphoscintigraphy and intraoperative gamma probe radiolocalization and to determine the predictive value of the SLN for occult metastasis of the neck in N0 squamous cell carcinoma of the oral cavity and oropharynx. DESIGN: A prospective study of 20 consecutive patients with N0 squamous cell carcinoma of the head and neck who underwent lymphoscintigraphy and SLN biopsy. INTERVENTIONS: On the day before surgery, each patient who completed the study underwent a submucosal peritumoral injection of unfiltered technetium 99m sulfur colloid followed by lymphoscintigraphy. Focal areas of radioactivity were marked on the overlying skin. The following day, the patients underwent resection of the primary tumor, elevation of subplatysmal flaps, identification and removal of the SLNs as identified by gamma probe, and complete neck dissections. RESULTS: Lymphoscintigraphy and gamma probe radiolocalization accurately identified 1 or more SLNs in all 20 patients. In 4 (20%) of the 20 patients, the SLN correctly identified metastatic disease. In no instance was the SLN negative when the lymphadenectomy specimen was positive. CONCLUSIONS: In this study, the SLN had a negative predictive value of 100%. Sentinel lymph node biopsy is feasible and appears to accurately predict the presence of occult metastatic disease. Although further study is warranted, SLN biopsy could potentially guide head and neck oncologists to the patient with N0 disease who would benefit most from selective neck dissection and prevent the morbidity of unnecessary neck dissection.     

Identification of patients with head and neck cancer using serum protein profiles

BACKGROUND: New and more consistent biomarkers of head and neck squamous cell carcinoma (HNSCC) are needed to improve early detection of disease and to monitor successful patient management. OBJECTIVE: To determine if a new proteomic technology can correctly identify protein expression profiles for cancer in patient serum samples as well as detect the presence of a known tumor marker. DESIGN: Direct proteomic analysis and comparison. METHODS: The surface-enhanced laser desorption/ionization time of flight mass spectrometry (SELDI-TOF) ProteinChip system was used to screen for differentially expressed proteins in serum samples from 99 patients with HNSCC, 25 "healthy" smokers, and 102 healthy (normal) controls. Protein peak clustering and classification analyses of the SELDI spectral data were performed. RESULTS: Several proteins, with masses ranging from 2778 to 20,800 Da, were differentially expressed between patients with HNSCC and the normal controls. The serum protein expression profiles were used to develop a classification tree algorithm, which achieved a sensitivity of 83.3% and a specificity of 90% in discriminating HNSCC from normal and healthy smoker controls. The positive and negative predictive values were 80% and 92%, respectively. A peak with an average mass of 10,068 Da was detected in sera from HNSCC patients and identified as the known biomarker metallopanstimulin-1 (MPS-1), based on mass. Peak relative intensity of the 10,068-Da protein correlated consistently with MPS-1 levels detected by radioimmunoassay in serum samples of HNSCC patients and controls. The 10,068-Da peak was provisionally identified as MPS-1 by SELDI immunoassay. CONCLUSION: We propose that this technique may allow for the development of a reliable screening test for the early detection and diagnosis of HNSCC, as well as the potential identification of tumor biomarkers.