Validation and clinical application of computer-combined computed tomography and positron emission tomography with 2-[18F]fluoro-2-deoxy-D-glucose head and neck images

doi:10.1016/S0002-9610(96)00313-3

The American Journal of Surgery

Volume 172, Issue 6, December 1996, Pages 628-632

https://doi.org/10.1016/S0002-9610(96)00313-3 Get rights and content

Background

Positron emission tomography with 2-[18F]fluoro-2-deoxy-D-glucose (PET-FDG) improves the detection of head and neck squamous cell cancer (HNSCC), but lacks anatomical detail. The accuracy of registered computed tomography/magnetic resonance (CT/MR) and PET-FDG in delineation of HNSCC at the primary site and its clinical application was investigated.

Method

Preoperatively 30 patients were staged clinically and each had either CT (23), MR (5), or both CT and MR (2) scans, as well as CT/MR-PET-FDG registration. Tumor margins or infiltrationspecific anatomical landmarks on the different scans were compared and judged against histology.

Results

For primary tumors CT-PET-FDG (97%) and MR-PET-FDG (100%) delineated the tumor more accurately than CT (69%) or MR (40%) alone. Similarly, CT-PET-FDG (98%) and MR-PET-FDG (100%) were better than CT (70%) and MR alone (80%) in identifying tumor invasion of specific anatomical structures. Management was altered in 7 of 30 patients. The registered images were particularly useful in delineating tumor extension in the infratemporal fossa, maxilla and mandible, and identifying recurrences obscured by scar tissue.

Conclusions

It is possible to accurately register CT, MR, and PET-FDG data sets in the head and neck. The initial results show that registered CT/ MR-PET-FDG images provide additional clinically relevant information over that obtained from clinical evaluation or conventional CT imaging.

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PET-CT for Staging and Detection of Recurrence of Head and Neck Cancer
2021, Seminars in Nuclear Medicine
Citation Excerpt :
The value of positron emission tomography (PET) for head and neck (H&N) cancer was recognised very early in the history of PET. H&N cancer was identified as one of the first clinical indications for PET.1,2 The advent PET-CT saw an acceleration of the clinical utility of this technique.
FDG PET-CT is one the main investigations for squamous cell (Sq) head and neck (H&N) cancer patients. FDG PET-CT has a key role for the staging of patients with T4 cancer of the hypopharynx and nasopharynx and patients with N3 nodal disease. It is effective in detecting recurrent disease accurately. In addition, it has an emerging role in the surveillance of Sq H&N cancer survivors. In patients with advanced neck nodal disease treated with chemoradiotherapy, there is compelling evidence that patients with no FDG uptake in the neck 12 weeks following completion of treatment do not require neck dissection. There is considerable interest in using FDG PET-CT for develop more effective clinical pathways for the surveillance of Sq H&N cancer. Currently, the detection rate of recurrence in patients who attend regular clinical follow-up is poor, less than 1% in asymptomatic patients. FDG PET-CT may enable survivors to be stratified into groups based on the likelihood of having recurrent disease. Optimal surveillance pathways can be developed, reserving most intense imaging regimes and most frequent follow-up for survivors at high risk of recurrence. FDG PET CT is sometimes considered for patients with non Sq H&N cancer. If used in this context, a baseline FDG PET-CT should be done to ensure that the tumour is avid. Most H&N malignant tumours are avid. However, salivary gland cancers, and tumours with muco-epidermoid, adenoid cystic and clear cell histology show paucity of FDG avidity, especially when they recur. In addition, peri-neural invasion cannot be detected reliably with FDG PET-CT.
The role of FDG PET in the diagnosis of occult primary with cervical lymph node metastases: A meta-analysis study
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Detection of the primary tumor has a key role in the management of patients with unknown primary tumors (UPT).
The aim of this study is to assess the efficacy of ¹⁸F-FDG PET in locating occult primary lesions in patients with metastatic cervical lymphadenopathy.
A systematic search was performed by the PubMed/MEDLINE to identify and select the relevant studies published within the last 20 years (up to 25/08/2011). Reported detection rates, sensitivities and specificities were metaanalyzed. Subgroup analyses were performed if results of individual studies were heterogeneous.
Thirty studies met the inclusion criteria. The overall sensitivity, specificity and accuracy rates of FDG-PET in detecting unknown primary tumors were 80.6%, 82.1% and 81.5% respectively.
Furthermore, FDG-PET detected 33.5% of tumors that were not apparent after conventional workup. Whereas PET/CT scans’ overall sensitivity, specificity and accuracy were 82.5%, 80.2% and 81.4% respectively. Furthermore, PET/CT detected 30.7% of tumors that were not apparent after conventional workup. There were no significant differences between the diagnostic accuracies of FDGPET and PET/CT scans.
¹⁸F-FDG PET could be useful in patients with UPT for the detection of the primary tumor. ¹⁸F-FDG PET has high sensitivity, indicating the existence of few false-negative results, an important feature in the management of oncologic patients that could suggest its utility in the initial stages of the management process.
Target volume delineation in oropharyngeal cancer: Impact of PET, MRI, and physical examination
2012, International Journal of Radiation Oncology Biology Physics
Sole utilization of computed tomography (CT) scans in gross tumor volume (GTV) delineation for head-and-neck cancers is subject to inaccuracies. This study aims to evaluate contributions of magnetic resonance imaging (MRI), positron emission tomography (PET), and physical examination (PE) to GTV delineation in oropharyngeal cancer (OPC).
Forty-one patients with OPC were studied. All underwent contrast-enhanced CT simulation scans (CECTs) that were registered with pretreatment PETs and MRIs. For each patient, three sets of primary and nodal GTV were contoured. First, reference GTVs (GTVref) were contoured by the treating radiation oncologist (RO) using CT, MRI, PET, and PE findings. Additional GTVs were created using fused CT/PET scans (GTVctpet) and CT/MRI scans (GTVctmr) by two other ROs blinded to GTVref. To compare GTVs, concordance indices (CI) were calculated by dividing the respective overlap volumes by overall volumes. To evaluate the contribution of PE, composite GTVs derived from CT, MRI, and PET (GTVctpetmr) were compared with GTVref.
For primary tumors, GTVref was significantly larger than GTVctpet and GTVctmr (p < 0.001). Although no significant difference in size was noted between GTVctpet and GTVctmr (p = 0.39), there was poor concordance between them (CI = 0.62). In addition, although CI (ctpetmr vs. ref) was low, it was significantly higher than CI (ctpet vs. ref) and CI (ctmr vs. ref) (p < 0.001), suggesting that neither modality should be used alone. Qualitative analyses to explain the low CI (ctpetmr vs. ref) revealed underestimation of mucosal disease when GTV was contoured without knowledge of PE findings. Similar trends were observed for nodal GTVs. However, CI (ctpet vs. ref), CI (ctmr vs. ref), and CI (ctpetmr vs. ref) were high (>0.75), indicating that although the modalities were complementary, the added benefit was small in the context of CECTs. In addition, PE did not aid greatly in nodal GTV delineation.
PET and MRI are complementary and combined use is ideal. However, the low CI (ctpetmr vs. ref) particularly for primary tumors underscores the limitations of defining GTVs using imaging alone. PE is invaluable and must be incorporated.
18F-fluorodeoxyglucose Positron Emission Tomography/Computed Tomography in the Assessment of Occult Primary Head and Neck Cancers - An Audit and Review of Published Studies
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Citation Excerpt :
However, FDG PET provides limited anatomical information and localisation of small foci of tracer uptake is a challenge even with morphological imaging side by side with PET. Image fusion algorithms, which combine FDG PET to computed tomography (CT) or magnetic resonance (MR), have been successfully developed in the head and neck, but their implementation into a clinical setting is difficult because application of these techniques is both labour intensive and time consuming [14]. Another important limitation of image fusion is that some misregistration is almost inevitable, even if the patient’s head and neck is in identical positions for the two separate scans.
To assess the value of 18F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) in patients with squamous cell and undifferentiated cancer neck nodes and no primary site on conventional assessment.
Seventy-eight patients with neck nodal metastases from an unknown primary cancer were studied. PET/CT was carried out in all patients, 1 h after FDG injection.
Uptake suspicious of an occult primary cancer was found in 46/78 (59.0%) patients. Subsequent investigations confirmed a primary site in the base of the tongue in 14, pharyngeal palatine tonsil in 14, post cricoid in one, lung in one. PET/CT diagnosed primary cancers in 30/78 patients (38.5%); sensitivity, specificity, positive predictive value, negative predictive value: 30/30 (100.0%), 32/48 (66.7%), 30/46 (65.2%), 32/32 (100.0%), respectively. PET/CT detected additional disease in four patients: contralateral nodal disease in two, mediastinal nodal disease in one and liver metastases in one.
FDG PET/CT is of value in the assessment of patients with occult head and neck primary cancers. However, false-positive results remain a limitation of the investigation.
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Citation Excerpt :
More importantly, the ground truth behind these images is nearly out of reach. In order to measure the tumour volume and its contours, the physician needs to acquire images with another modality than PET (e.g., CT) and/or to surgically extract the tumour [12,23,67,68]. Both ways are paved with difficulties.
Positron emission tomography can be used in radiation oncology for the delineation of target volumes in the treatment planning stage. Numerous publications deal with this topic and the scientific community has investigated many methodologies, ranging from simple uptake thresholding to very elaborate probabilistic models. Nevertheless, no consensus seems to emerge. This paper reviews delineation techniques that are popular in the literature. Special attention is paid to threshold-based techniques and the caveats of this methodology are pointed out by formal analysis. Next, a simple model of positron emission tomography is suggested in order to shed some light on the difficulties of target delineation and how they might be eventually overcome. Validation aspects are considered as well. Finally, a few recommendations are gathered in the conclusion.
Metabolic markers of the head and neck cancers - Clinical applications and the biochemical background
2009, Otolaryngologia Polska
The problem of diagnosis in the field of head and neck region is still valid. Specific diagnosis and precise estimation of the tumor's size with the use of CT and MRI imaging is generally unsatisfactory. The Positron Emission Tomography (PET) supports this process with additional information about the tumor's metabolism. Numerous publications show that PET-CT has a great influence on the evaluation of the size of the tumor, presence of lymph node metastases, choice of treatment and the prognosis of the recurrence. Cancer cells represent a specific metabolic state. These cells intake large quantities of glucose and utilize it in the process of glycolysis. The oxidative phosphorylation is not efficient in the transformed cells and defects in mitochondrial functions are at the heart of malignant cell transformation. Disruption of the oxidative phosphorylation chain has been described in the neoplasms. As a consequence, in cancer the glycolysis is active even in the normoxic environment. This metabolic shift in cell transformation has been described in early XX century and so called Warburg's hypothesis profoundly influenced the present perception of cancer metabolism, positioning what is termed aerobic glycolysis in the mainstream of clinical oncology. Today we know that neoplastic cells differ at the proteomic level. A subset of different proteins such as hexokinase II or HIF are upregulated. These abnormalities might be used as the neoplastic markers.

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Validation and clinical application of computer-combined computed tomography and positron emission tomography with 2-[18F]fluoro-2-deoxy-D-glucose head and neck images

Background

Method

Results

Conclusions

Clin Radiol

Magnetic Resonance imaging vs palpation of cervical lymph node metastases

Arch Otoloaryngol

Radiologic diagnosis and staging of head and neck squamous cell carcinoma

Radiol Clin North Am-Staging Neoplasms

On the origin of cancer cells

Science

The application of PET in clinical oncology

J Nucl Med

Positron emission tomography: a new, precise imaging modality for detection of primary head and neck tumours and assessment of cervical adenopathy

Laryngoscope

Glucose uptake, perfusion, and cell proliferation in head and neck tumours: relation of positron emission tomography to flow cytometry

J Nucl Med