PET/MR in Cancers of the Head and Neck

doi:10.1053/j.semnuclmed.2014.12.005

Seminars in Nuclear Medicine

Volume 45, Issue 3, May 2015, Pages 248-265

https://doi.org/10.1053/j.semnuclmed.2014.12.005 Get rights and content

One early application of PET/MRI in clinical practice may be the imaging of head and neck cancers. This is because the morphologic imaging modalities, CT and MR, are recognized as similarly effective tools in cross-sectional oncological imaging of the head and neck. The addition of PET with FDG is believed to enhance the accuracy of both modalities to a similar degree. However, there are a few specific scenarios in head and neck cancer imaging where MR is thought to provide an edge over CT, including perineural spread of tumors and the infiltration of important anatomical landmarks, such as the prevertebral fascia and great vessel walls. Here, hybrid PET/MR might provide higher diagnostic certainty than PET/CT or a separate acquisition of PET/CT and MR. Another advantage of MR is the availability of several functional techniques. Although some of them might enhance the imaging of head and neck cancer with PET/MR, other functional techniques actually might prove dispensable in the presence of PET. In this overview, we discuss current trends and potential clinical applications of PET/MR in the imaging of head and neck cancers, including clinical protocols. We also discuss potential benefits of implementing functional MR techniques into hybrid PET/MRI of head and neck cancers.

Section snippets

Clinical Status Quo: PET/CT and MR in Head and Neck Cancer

Both CT and MR with contrast enhancement are accepted clinical imaging tools for the local staging of head and neck cancer. The preference of either modality depends on a variety of factors, the most important one being specific questions about a tumor asked by the surgeon. Other reasons for preferring one or the other are the radiologist׳s personal experience with a particular modality, infrastructural conditions such as limited availability of MR services, or even geographic habits, with MR

Current Trends in PET/MR in Oncological Imaging of the Head and Neck

The potential role of PET/MR for head and neck cancers has been initially studied in 2011, when a pilot study by Boss et al¹¹ showed the feasibility of simultaneous hybrid examinations with excellent image quality, optimal spatial and temporal coregistration, and only slight streak artifacts without compromising the visualization of tumors. These first results suggested that replacing PET/CT imaging in certain clinical situations with PET/MR was feasible, and this claim has been supported in

PET/MR Protocols

The optimization of PET/MR protocols is mandatory for PET/MR to be a valuable alternative to PET/CT for whole-body staging. Efficient imaging protocols need to be developed, selecting adequate MR pulse sequences that provide information mostly complementing PET information.²¹ Another article in this issue focuses specifically on protocol evaluation and discussion in PET/MR. The standard protocols that have been tested so far in simultaneous PET/MR for assessing head and neck cancer usually

Clinical Applications of PET/MR in Head and Neck Cancer

An overview of major clinical PET/MR studies of the head and neck is given in Table 2. A potential role for PET/MR in the assessment of head and neck cancers was first indicated by the retrospective fusion of PET and MR. Such fused PET/MR overall proved to be comparable to PET/CT, and more reliable than CT and MR, in terms of sensitivity and specificity for assessing primary tumors, nodal metastasis, and recurrent disease.8, 13, 15, 28

More recent data are available now that show potential

PET/MR: Functional Techniques

Recent advances in MRI techniques represent a hot topic in oncologic imaging. DWI and DCE MRI are used at some major centers for the assessment of primary tumors and nodal metastases from head and neck cancers. Studies have also shown their potential for predicting the outcome of patients.⁷⁷ MR spectroscopy (MRS) and blood oxygenation level–dependent imaging (BOLD) are being investigated in patients with squamous cell carcinoma of the head and neck.⁵⁸ Molecular, nongadolinium MR contrast agents

Conclusion

PET/MR is a new promising tool for the clinical assessment of patients with head and neck cancer. There are encouraging first results in the literature which indicate that PET/MR might be at least as accurate and effective as today׳s standards of reference in cross-sectional diagnostic imaging, PET/CT and MR. An optimization of PET/MR protocols is required to avoid redundant information and to propagate its use in clinical routine.

PET/MR may outdo PET/CT in the delineation of primary tumors,

Acknowledgments

The authors are indebted to Gaspar Delso, PhD, and Miguel Porto, MRT, who helped with the preparation of this manuscript.

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Imaging of head and neck cancer at initial staging and as part of post-treatment surveillance is a key component of patient care as it guides treatment strategy and aids determination of prognosis. Head and neck cancer includes a heterogenous group of malignancies encompassing several anatomic sites and histologies, with squamous cell carcinoma the most common. Together this comprises the seventh most common cancer worldwide. At initial staging comprehensive imaging delineating the anatomic extent of the primary site, while also assessing the nodal involvement of the neck is necessary. The treatment of head and neck cancer often includes a combination of surgery, radiation, and chemotherapy. Post-treatment imaging is tailored for the evaluation of treatment response and early detection of local, locoregional, and distant recurrent tumor. Cross-sectional imaging with CT or MRI is recommended for the detailed anatomic delineation of the primary site. PET/CT provides complementary metabolic information and can map systemic involvement.
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In cancer treatment precise definition of the tumor volume is essential, but despite development in imaging modalities, this remains a challenge. Here, pathological tumor volumes from the surgical specimens were obtained and compared to tumor volumes defined from modern PET/MRI hybrid imaging. The purpose is to evaluate mismatch between the volumes defined from imaging and pathology was estimated and potential clinical impact.
Twenty-five patients with head and neck squamous cell carcinoma were scanned on an integrated PET/MRI system prior to surgery. Three gross tumor volumes (GTVs) from the primary tumor site were delineated defined from MRI (GTV_MRI), PET (GTV_PET) and one by utilizing both anatomical images and clinical information (GTV_ONCO). Twenty-five primary tumor specimens were extracted en bloc, scanned with PET/MRI and co-registered to the patient images. Each specimen was sectioned in blocks, sliced and stained with haematoxylin and eosin. All slices were digitalized and tumor delineated by a head and neck pathologist. The pathological tumor areas in all slices were interpolated yielding a pathological 3D tumor volume (GTV_PATO). GTV_PATO was compared with the imaging GTV’s and potential mismatch was estimated.
Thirteen patients were included. The mean volume of GTV_ONCO was larger than the GTV’s defined from PET or MRI. The mean mismatch of the GTV_PATO compared to the GTV_PET, GTV_MRI and GTV_ONCO was 31.9 %, 54.5 % and 27.9 % respectively, and the entire GTV_PATO was only fully encompassed in GTV_ONCO in 1 of 13 patients. However, after the addition of a clinical 5 mm margin the GTV_PATO was fully encompassed in GTV_ONCO in 11 out of 13 patients.
Despite modern hybrid imaging modalities, a mismatch between imaging and pathological defined tumor volumes was observed in all patients. A 5 mm clinical margin was sufficient to ensure inclusion of the entire pathological volume in 11 out of 13 patients.
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Squamous cell carcinoma, the most common cancer of the head and neck, is often used synonymously with the phrase head and neck cancer. Head and neck squamous cell carcinoma is associated with a multitude of risk factors. The head and neck region are characterized by complex anatomy, and imaging plays a vital role in the evaluation of head and neck malignancies, including detecting the primary tumor in patients presenting with metastatic cervical lymphadenopathy, assessing treatment response, and differentiating posttreatment changes from recurrences. Studies have shown that PET/MRI, with few exceptions, is noninferior to PET/CT in evaluating head and neck cancer, and is often advantageous, due to its superior soft tissue contrast and less patient exposure to ionizing radiation.
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Hence, the minimum requirements consist of the following MR pulse sequences: T1-weighted non-enhanced (axial), T2-weighted fat-suppressed (axial), T1-weighted contrast-enhanced fat-suppressed (axial + coronal/sagittal). Specific protocols may vary depending on the exact clinical question, the location and extent of the primary tumor and regional metastases (eg, skull base tumors, sinonasal tumors, possible vessel infiltration).2,3,8 The whole-body PET/MR scan usually consists of several bins or body sections of a Dixon-type T1-weighted MR pulse sequence, such as Liver Acquisition with Volume Acceleration (LAVA)-flex, yielding different tissue contrasts, acquired in axial plane, and a T2-weighted MR pulse sequence with or without fat suppression, acquired in a different plane, typically coronal.
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Evidence from several studies suggests that PET/MR overall performs equally well as PET/CT in the staging and restaging of head and neck cancer and in radiation therapy planning. PET/MR appears to offer advantages in the characterization and prognostication of head and neck malignancies through multiparametric imaging, which demands an exact preparation and validation of imaging modalities, however. The majority of available clinical PET/MR studies today covers FDG imaging of squamous cell carcinoma arising from a broad spectrum of locations in the upper aerodigestive tract. In the future, specific PET/MR studies are desired that address specific histopathological tumor entities, nonepithelial malignancies, such as major salivary gland tumors, squamous cell carcinomas arising in specific locations, and malignancies imaged with non-FDG radiotracers.
With the advent of digital PET/CT scanners, PET/MR is expected to partake in future technical developments, such as novel iterative reconstruction techniques and deviceless motion correction for respiration and gross movement in the head and neck region. Owing to the still comparably high costs of PET/MR scanners and facility requirements on the one hand, and the concentration of multidisciplinary head and neck cancer treatment mainly at academic centers on the other hand, a more widespread use of this imaging modality outside major hospitals is currently limited.

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PET/MR in Cancers of the Head and Neck

Section snippets

Clinical Status Quo: PET/CT and MR in Head and Neck Cancer

Current Trends in PET/MR in Oncological Imaging of the Head and Neck

PET/MR Protocols

Clinical Applications of PET/MR in Head and Neck Cancer

PET/MR: Functional Techniques

Conclusion

Acknowledgments

Am J Surg

Eur J Radiol

Semin Nucl Med

Eur J Radiol

Cancer Epidemiol

Clin Oncol (R Coll Radiol)

Clin Oncol (R Coll Radiol)

Oral Oncol

Semin Nucl Med

Eur J Radiol

Int J Radiat Oncol Biol Phys

Eur J Radiol

Int J Radiat Oncol Biol Phys

Oral Oncol

Biomaterials

The role of fluorodeoxyglucose positron emission tomography in cervical lymph node metastases from an unknown primary tumor

Cancer

Recurrence at the primary site in head and neck cancer and the significance of neck lymph node metastases as a prognostic factor

Cancer

The level of cervical lymph node metastases: Their prognostic relevance and relationship with head and neck squamous carcinoma primary sites

Clin Otolaryngol Allied Sci

FDG-PET-CT in Head and Neck Cancer

Positron emission tomography (PET) in the staging of head neck cancer: Comparison between PET and CT

Acta Otorhinolaryngol Ital

Prospective comparison of 18 F-FDG PET with conventional imaging modalities (CT, MRI, US) in lymph node staging of head and neck cancer

Eur J Nucl Med

Diagnostic accuracy of ultrasound, 18F-FDG-PET/CT, and fused 18F-FDG-PET-MR images with DWI for the detection of cervical lymph node metastases of HNSCC

Clin Oral Investig

CT, MR, US,18F-FDG PET/CT, and their combined use for the assessment of cervical lymph node metastases in squamous cell carcinoma of the head and neck

Eur Radiol

Screening for distant metastases in patients with head and neck cancer

Laryngoscope

Feasibility of simultaneous PET/MR imaging in the head and upper neck area

Eur Radiol

PET-MRI in the head and neck area: Challenges and new directions

Eur Radiol

Contrast-enhanced PET/MR imaging versus contrast-enhanced PET/CT in head and neck cancer: How much MR information is needed?

J Nucl Med

Clinical value of image fusion from MR and PET in patients with head and neck cancer

Mol Imaging Biol

Oncologic PET/MRI, part 1: Tumors of the brain, head and neck, chest, abdomen, and pelvis.

J Nucl Med

PET/MRI in head and neck cancer: Initial experience

Eur J Nucl Med Mol Imaging

Human papillomavirus (HPV) in head and neck cancer. An association of HPV 16 with squamous cell carcinoma of Waldeyer׳s tonsillar ring

Cancer

Human papillomavirus in oral exfoliated cells and risk of head and neck cancer

J Natl Cancer Inst

Whole-body nonenhanced PET/MR versus PET/CT in the staging and restaging of cancers: Preliminary observations

Radiology

Approaches for the optimization of MR protocols in clinical hybrid PET/MRI studies

MAGMA

Qualitative and quantitative performance of 18F-FDG-PET/MRI versus 18F-FDG-PET/CT in patients with head and neck cancer

Am J Neuroradiol

Imaging in head and neck squamous cell carcinoma: The potential role of PET/MRI

Br J Radiol

Usefulness of integrated PET/MRI in head and neck cancer: A preliminary study

Nucl Med Mol Imaging

Use of diffusion-weighted imaging (DWI) in PET/MRI for head and neck cancer evaluation

Eur J Nucl Med Mol Imaging

A comparative study of fused FDG PET/MRI, PET/CT, MRI, and CT imaging for assessing surrounding tissue invasion of advanced buccal squamous cell carcinoma

Clin Nucl Med

Detection and quantification of focal uptake in head and neck tumours: 18F-FDG PET/MR versus PET/CT

Eur J Nucl Med Mol Imaging

Initial clinical results of simultaneous 18 F-FDG PET/MRI in comparison to 18 F-FDG PET/CT in patients with head and neck cancer

Eur J Nucl Med Mol Imaging

Detection rate, location, and size of pulmonary nodules in trimodality PET/CT-MR: Comparison of low-dose CT and Dixon-based MR imaging

Invest Radiol

Clinical impact of PET/MR imaging in patients with cancer undergoing same-day PET/CT: Initial experience in 134 patients—A hypothesis-generating exploratory study

Radiology

Neoplastic invasion of laryngeal cartilage: Reassessment of criteria for diagnosis at MR imaging

Diagnostic accuracy of ultrasound, ¹⁸F-FDG-PET/CT, and fused ¹⁸F-FDG-PET-MR images with DWI for the detection of cervical lymph node metastases of HNSCC

CT, MR, US,¹⁸F-FDG PET/CT, and their combined use for the assessment of cervical lymph node metastases in squamous cell carcinoma of the head and neck

Qualitative and quantitative performance of ¹⁸F-FDG-PET/MRI versus ¹⁸F-FDG-PET/CT in patients with head and neck cancer

Detection and quantification of focal uptake in head and neck tumours: ¹⁸F-FDG PET/MR versus PET/CT

Head and neck squamous cell carcinoma (HNSCC)—Detection of synchronous primaries with ¹⁸F-FDG-PET/CT