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Clinical Role of ¹⁸F-FDG PET/CT in the Management of Squamous Cell Carcinoma of the Head and Neck and Thyroid Carcinoma

¹ Division of Nuclear Medicine, Department of Radiology, Stanford University Medical Center, Stanford, California; ² Division of Neuroradiology, Department of Radiology, Stanford University Medical Center, Stanford, California; ³ Department of Radiation Oncology, Stanford University Medical Center, Stanford, California; ⁴ Division of Oncology, Department of Internal Medicine, Stanford University Medical Center, Stanford, California; and ⁵ Department of Otolaryngology and Head and Neck Surgery, Stanford University Medical Center, Stanford, California

View larger version (27K): [in this window] [in a new window]   FIGURE 1.  Detection of unexpected malignant involvement of lymph nodes at initial staging. Patient with locally advanced nasopharyngeal cancer was referred for initial staging evaluation. Contrast-enhanced CT (A) and MRI (B) revealed 2 lymph nodes that were within normal limits by size criteria and for which the presence of malignant disease was uncertain (red arrows). (C) These 2 nodes clearly had abnormal activity on 18F-FDG PET/CT (yellow arrows), and radiation treatment field was adjusted to accommodate these regions.

View larger version (16K): [in this window] [in a new window]   FIGURE 2.  Algorithm for initial staging of HNSCC. *Primarily to detect distant metastatic disease, additional regional lymph nodes with metastatic disease, and synchronous tumors. +Primarily to serve as baseline before therapy. Bx+ = biopsy positive; Bx– = biopsy negative; FNA = fine-needle aspiration.

View larger version (16K): [in this window] [in a new window]   FIGURE 3.  Algorithm for evaluation of unknown primary malignancy with cervical lymph node metastases. *Ipsilateral base of tongue, tonsillar fossa (TF), nasopharynx, and, in some cases, pyriform sinus and other TF. +PET/CT may be helpful in this setting for detecting distant metastatic disease, additional regional lymph nodes with metastatic disease, and synchronous tumors. Bx+ = biopsy positive; Bx– = biopsy negative; FNA = fine-needle aspiration.

View larger version (46K): [in this window] [in a new window]   FIGURE 4.  HNSCC metastasis from unknown primary tumor. Patient had enlarging 3-cm left neck mass felt on physical examination. (A) Contrast-enhanced CT depicted space-occupying lesion (red arrows) in left neck. Biopsy of lesion was obtained by fine-needle aspiration, and lesion was proven to be lymph node metastatic squamous cell carcinoma. There was no clear evidence of primary tumor except for subtle asymmetry at left tonsillar fossa (blue arrow) that was of uncertain significance. 18F-FDG PET (B) and fusion PET/CT (C) clearly identified primary tumor at left tonsillar fossa (yellow arrows); finding was confirmed by endoscopic biopsy.

View larger version (81K): [in this window] [in a new window]   FIGURE 5.  Monitoring chemoradiation. (A) Pretreatment transaxial 18F-FDG PET/CT revealed intensely hypermetabolic primary carcinoma at base of tongue (red arrows). (B) 18F-FDG PET/CT after chemoradiation revealed complete resolution of abnormal activity without evidence of residual disease in treated region.

View larger version (38K): [in this window] [in a new window]   FIGURE 6.  PET/CT for detection of recurrence. (A) Surveillance 18F-FDG PET/CT after therapy revealed prominent physiologic mandibular muscle uptake without evidence of recurrent disease. (B) Interval follow-up 18F-FDG PET/CT revealed new subtle hypermetabolic focus in left retropharyngeal region (red arrows) suspected of indicating recurrence. (C) T1-weighted contrast-enhanced MRI confirmed presence of suspect subcentimeter retropharyngeal lymph node (yellow arrow).

View larger version (17K): [in this window] [in a new window]   FIGURE 7.  Algorithm for evaluation of treatment response. *Time after completion of radiotherapy. Bx+ = biopsy positive; Bx– = biopsy negative; FNA = fine-needle aspiration.

View larger version (42K): [in this window] [in a new window]   FIGURE 8.  Use of PET/CT to assist in radiation treatment planning. (A) MRI depicted asymmetric tissue in left nasopharynx. Radiotherapy contour line encircled this region (red line). (B) PET/CT revealed abnormal metabolic activity crossing midline from left nasopharynx to right nasopharynx, suggesting extent of tumor larger than that suggested by MRI. Radiotherapy contour line was adjusted accordingly (red line).

View larger version (29K): [in this window] [in a new window]   FIGURE 9.  Algorithm for evaluation of thyroid carcinoma. FNA = fine-needle aspiration; rhTSH = recombinant human TSH; XRT = radiation therapy.

View larger version (68K): [in this window] [in a new window]   FIGURE 10.  18F-FDG PET/CT for detecting scintigraphically occult metastatic thyroid cancer. Patient had persistently elevated Tg levels after thyroidectomy and 131I ablation. (A) Whole-body 131I scan appeared normal and did not reveal source of abnormal Tg production. (B and C) Follow-up 18F-FDG PET/CT detected several paratracheal lymph node metastases (red arrow) and lung metastasis (yellow arrow).