Skip to main navigation menu Skip to main content Skip to site footer

Original article

Vol. 145 No. 0708 (2015)

Post-treatment surveillance of head and neck cancer: pitfalls in the interpretation of FDG PET-CT/MRI

  • Christian Martin Meerwein
  • Marcelo A Queiroz
  • Spyros Kollias
  • Martin Hüllner
  • Patrick Veit-Haibach
  • Gerhard Frank Huber
DOI
https://doi.org/10.4414/smw.2015.14116
Cite this as:
Swiss Med Wkly. 2015;145:w14116
Published
08.02.2015

Summary

QUESTIONS UNDER STUDY: We investigated non-malignancy-associated (18F)fluoro-deoxy-D-glucose (FDG) uptake in the head and neck cancer (HNC) post-treatment follow-up with positron emission tomography – computed tomography / magnetic resonance imaging (PET-CT/MRI). A retrospective study on HNC patients undergoing follow-up or re-staging PET-CT/MRI examinations was performed. Thereby, FDG-positive regions were morphologically correlated to the CT and MRI images and a statement regarding tumour persistence/recurrence.

METHODS: FDG-positive lesions were assessed according to their anatomical localisation and categorised as true positive, true negative, false positive or false negative findings. The gold standard for verification of an FDG-positive lesion was the cytological or histopathological examination of the region of interest. The most likely aetiology was assessed according to the following categories: (1.) physiological uptake (2.) post-surgical, inflammatory uptake, (3.) post-irradiation, inflammatory uptake and (4.) reactive, not otherwise specified.

RESULTS: Tumour recurrence / tumour persistence was found in 14/87 patients (16.1%). A total of 159 non-malignancy-associated FDG-positive lesions were found. Every PET-CT/MRI examination revealed 2.1 ± 1.5 FDG-positive lesions in the head and neck. A total of 107 FDG-positive lesions (67.3%) were categorised as physiological, 52 FDG-positive lesions (32.7%) as inflammatory (post-surgical: n = 14, 8.8%; post-irradiation: n = 9, 5.7%; reactive, not otherwise specified: n = 29, 18.2%). Eight patients (11.8%) underwent invasive diagnostic procedures to clarify indistinct findings.

CONCLUSIONS: Post-treatment follow-up of HNC patients requires interdisciplinary management and familiarity with the patient’s past medical history. Awareness of common confounders of FDG positivity often allows clarification of indistinct lesions. However, a substantial number of approximately 12% of FDG-positive lesions remain unclear unless invasive diagnostic procedures are performed.

References

  1. Ang KK, Trotti A, Brown BW, Garden AS, Foote RL, Morrison WH, et al. Randomized trial addressing risk features and time factors of surgery plus radiotherapy in advanced head-and-neck cancer. Int J Radiat Oncol Biol Phys. 2001;51(3):571–8.
  2. Leemans CR, Tiwari R, Nauta JJ, van der Waal I, Snow GB. Recurrence at the primary site in head and neck cancer and the significance of neck lymph node metastases as a prognostic factor. Cancer. 1994;73(1):187–90.
  3. F.P. Kuhn MH, S.S. Kollias, G.K. Von Schulthess, P. Veit‑Haibach. Comparison of contrast-enhanced PET/MRI and contrast-enhanced PET/CT in patients with head and neck cancers Volume ECR Abstracts, Insights Imaging 2013;4(Suppl 1):S145–S3842013.
  4. Adams S, Baum RP, Stuckensen T, Bitter K, Hor G. Prospective comparison of 18F-FDG PET with conventional imaging modalities (CT, MRI, US) in lymph node staging of head and neck cancer. Eur J Nucl Med. 1998;25(9):1255–60.
  5. Kitagawa Y, Nishizawa S, Sano K, Ogasawara T, Nakamura M, Sadato N, et al. Prospective comparison of 18F-FDG PET with conventional imaging modalities (MRI, CT, and 67Ga scintigraphy) in assessment of combined intraarterial chemotherapy and radiotherapy for head and neck carcinoma. J Nucl Med. 2003;44(2):198–206.
  6. Kunkel M, Forster GJ, Reichert TE, Jeong JH, Benz P, Bartenstein P, et al. Detection of recurrent oral squamous cell carcinoma by [18F]-2–fluorodeoxyglucose-positron emission tomography: implications for prognosis and patient management. Cancer. 2003;98(10):2257–65.
  7. Wong RJ, Lin DT, Schoder H, Patel SG, Gonen M, Wolden S, et al. Diagnostic and prognostic value of [(18)F]fluorodeoxyglucose positron emission tomography for recurrent head and neck squamous cell carcinoma. J Clin Oncol. 2002;20(20):4199–208.
  8. Abgral R, Querellou S, Potard G, Le Roux PY, Le Duc-Pennec A, Marianovski R, et al. Does 18F-FDG PET/CT improve the detection of posttreatment recurrence of head and neck squamous cell carcinoma in patients negative for disease on clinical follow-up? J Nucl Med. 2009;50(1):24–9.
  9. Ryan WR, Fee WE, Jr., Le QT, Pinto HA. Positron-emission tomography for surveillance of head and neck cancer. Laryngoscope. 2005;115(4):645–50.
  10. F.P. Kuhn MH, S.S. Kollias, G.K. Von Schulthess, P. Veit‑Haibach. Comparison of contrast-enhanced PET/MRI and contrast-enhanced PET/CT in patients with head and neck cancers (ECR Abstracts). Insights Imaging. 2013;4(Suppl):S 145–S 384.
  11. Queiroz MA, Hüllner M, Kuhn F, Huber G, Meerwein C, Kollias S, et al. PET/MRI and PET/CT in follow-up of head and neck cancer patients. Eur J Nucl Med Mol Imaging 2014.
  12. Ghanooni R, Delpierre I, Magremanne M, Vervaet C, Dumarey N, Remmelink M, et al. ¹⁸F-FDG PET/CT and MRI in the follow-up of head and neck squamous cell carcinoma. Contrast Media Mol Imaging. 2011;6(4):260–6.
  13. Edge SB, Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti A. The American Joint Committee on Cancer: the 7th edition of the AJCC cancer staging manual and the future of TNM. Springer; 2010.
  14. Bhargava P, Rahman S, Wendt J. Atlas of confounding factors in head and neck PET/CT imaging. Clin Nucl Med. 2011;36(5):e20–9.
  15. Krabbe CA, Pruim J, Dijkstra PU, Balink H, van der Laan BF, de Visscher JG, Roodenburg JL. 18F-FDG PET as a routine posttreatment surveillance tool in oral and oropharyngeal squamous cell carcinoma: a prospective study. J Nucl Med. 2009;50(12):1940–7.
  16. Nakamoto Y, Tatsumi M, Hammoud D, Cohade C, Osman MM, Wahl RL. Normal FDG distribution patterns in the head and neck: PET/CT evaluation. Radiology. 2005;234(3):879–85.
  17. Abouzied MM, Crawford ES, Nabi HA. 18F-FDG imaging: pitfalls and artifacts. J Nucl Med Technol. 2005;33(3):145–55; quiz 162–3.
  18. Blodgett TM, Fukui MB, Snyderman CH, Branstetter BFt, McCook BM, Townsend DW, Meltzer CC. Combined PET-CT in the head and neck: part 1. Physiologic, altered physiologic, and artifactual FDG uptake. Radiographics. 2005;25(4):897–912.
  19. Kawabe J, Okamura T, Shakudo M, Koyama K, Sakamoto H, Ohachi Y, et al. Physiological FDG uptake in the palatine tonsils. Ann Nucl Med. 2001;15(3):297–300.
  20. Jackson RS, Schlarman TC, Hubble WL, Osman MM. Prevalence and patterns of physiologic muscle uptake detected with whole-body 18F-FDG PET. J Nucl Med Technol. 2006;34(1):29–33.
  21. Rikimaru H, Kikuchi M, Itoh M, Tashiro M, Watanabe M. Mapping energy metabolism in jaw and tongue muscles during chewing. J Dent Res. 2001;80(9):1849–53.
  22. Haerle SK, Hany TF, Ahmad N, Burger I, Huber GF, Schmid DT. Physiologic [18F]fluorodeoxyglucose uptake of floor of mouth muscles in PET/CT imaging: a problem of body position during FDG uptake? Cancer Imaging. 2013;13(1):1–7.
  23. Kamel EM, Goerres GW, Burger C, von Schulthess GK, Steinert HC. Recurrent laryngeal nerve palsy in patients with lung cancer: detection with PET-CT image fusion – report of six cases. Radiology. 2002;224(1):153–6.
  24. Roach MC, Turkington TG, Higgins KA, Hawk TC, Hoang JK, Brizel DM. FDG-PET assessment of the effect of head and neck radiotherapy on parotid gland glucose metabolism. Int J Radiat Oncol Biol Phys. 2012;82(1):321–6.
  25. Greven KM, Williams DW, 3rd, McGuirt WF, Sr., Harkness BA, D’Agostino RB, Jr., Keyes JW, Jr., Watson NE, Jr. Serial positron emission tomography scans following radiation therapy of patients with head and neck cancer. Head Neck. 2001;23(11):942–6.
  26. Greven KM, Williams DW, 3rd, Keyes JW, Jr., McGuirt WF, Watson NE, Jr., Randall ME, Raben M, Geisinger KR, Cappellari JO. Positron emission tomography of patients with head and neck carcinoma before and after high dose irradiation. Cancer. 1994;74(4):1355–9.
  27. Fukui MB, Blodgett TM, Snyderman CH, Johnson JJ, Myers EN, Townsend DW, et al. Combined PET-CT in the head and neck: part 2. Diagnostic uses and pitfalls of oncologic imaging. Radiographics. 2005;25(4):913–30.
  28. Zhuang H, Yu JQ, Alavi A. Applications of fluorodeoxyglucose-PET imaging in the detection of infection and inflammation and other benign disorders. Radiol Clin North Am. 2005;43(1):121–34.
  29. King KG, Kositwattanarerk A, Genden E, Kao J, Som PM, Kostakoglu L. Cancers of the oral cavity and oropharynx: FDG PET with contrast-enhanced CT in the posttreatment setting. Radiographics. 2011;31(2):355–73.
  30. Liu Y. Clinical significance of thyroid uptake on F18–fluorodeoxyglucose positron emission tomography. Ann Nucl Med. 2009;23(1):17–23.
  31. Stokkel MP, Bongers V, Hordijk GJ, van Rijk PP. FDG positron emission tomography in head and neck cancer: pitfall or pathology? Clin Nucl Med. 1999;24(12):950–4.
  32. Goerres GW, Hany TF, Kamel E, von Schulthess GK, Buck A. Head and neck imaging with PET and PET/CT: artefacts from dental metallic implants. Eur J Nucl Med Mol Imaging. 2002;29(3):367–70.
  33. Delso G, Wollenweber S, Lonn A, Wiesinger F, Veit-Haibach P. MR-driven metal artifact reduction in PET/CT. Phys Med Biol. 2013;58(7):2267–80.
  34. Wang CH, Liang JA, Yen KY, Hsieh TC, Sun SS, Wu YC, Lin YY, Kao CH. Tl-201 SPECT in clarifying false positive FDG PET findings caused by osteoradionecrosis in a case of nasopharyngeal carcinoma. Clin Nucl Med. 2009;34(8):515–7.
  35. Hung GU, Tsai SC, Lin WY. Extraordinarily high F-18 FDG uptake caused by radiation necrosis in a patient with nasopharyngeal carcinoma. Clin Nucl Med. 2005;30(8):558–9.

Most read articles by the same author(s)