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Clinical Challenges in Otolaryngology |

A Head and Neck Radiologist’s Perspective on Best Practices for the Usage of PET/CT Scans for the Diagnosis and Treatment of Head and Neck Cancers

Lauren V. Zollinger, MD, MPH; Richard H. Wiggins, MD, CIIP
Arch Otolaryngol Head Neck Surg. 2012;138(8):754-758. doi:10.1001/archoto.2012.1408.
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Hypothesis: Although positron emission tomography–computed tomography (PET/CT) is frequently overused, there are certain clinical scenarios for which PET/CT is indicated and clinically useful in patients with head and neck cancer.

Lauren V. Zollinger, MD, MPH

Richard H. Wiggins III, MD, CIIP

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Lauren V. Zollinger, MD, MPH

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Richard H. Wiggins III, MD, CIIP

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Figure 1. Unknown primary cancer. A, Axial contrast-enhanced soft-tissue neck computed tomographic (CT) scan in a 61-year-old man with a palpable neck mass, 1.7 × 2.3-cm cystic IIA LN (black arrow). B, Axial positron emission tomographic (PET) image at the same level, shows necrotic node (black arrow), and asymmetric right tonsillar activity (black arrowhead). Right palatine tonsil has a maximum standardized uptake value (SUV) of 15.3. C, Axial PET-CT image at same level shows a metabolically active lymph node with an SUV of 17.0 (black arrow). Asymmetric uptake is noted in the inferior right palatine tonsil (black arrowhead) indicating the location of the primary tumor.

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Figure 2. Staging/lymph node evaluation. An 86-year-old man referred to the ear, nose, and throat department for evaluation of a Merkel cell cancer in the left ear helix with adenopathy. This patient has a long history of multiple skin cancers, including both basal cell and squamous cell carcinoma. A positron emission tomographic–computed tomographic (PET/CT) scan was ordered to look for local lymph node involvement as well as for distant metastatic disease. A, Axial PET/CT images show the hypermetabolic primary lesion with a standardized uptake value (SUV) of 20 (white arrow). B, Enlarged, morphologically abnormal, and hypermetabolic lymph nodes were identified within the right side of the neck, including a 2-cm intraparotid lymph node that had an SUV of 18.0 (white arrow). C, Coronal PET/CT images show the primary ear lesion, metastatic lymph nodes in the right side of the neck, as well as a distant metastatic lesion to the left lung (white arrow). This central necrotic lesion has a SUV of 13.4. D, Coronal PET maximum intensity projection shows the extent of disease within the head, neck, and chest (black arrows).

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Figure 3. Treatment surveillance. This is a 43-year-old man with a sinonasal carcinoma. A, Axial T1 postcontrast image shows the enhancing, expansile mass (white arrows) within the nasal cavity causing an ostiomeatal unit pattern of obstructive sinus disease. B, Axial T1 postcontrast image at the level of the epiglottis shows a 2-cm enhancing level IIA LN on the right (white arrow).

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Figure 4. Treatment surveillance continued. A, Axial positron emission tomographic–computed tomographic image obtained 2 years following endoscopically assisted transnasal resection of carcinoma and dissection of the right side of the neck shows postsurgical changes within the right side of the neck. Morphologically abnormal, and metabolically active right level IB (standardized uptake value [SUV], 2.8; white arrow), and a left IB (SUV, 5.5; white arrowhead) which were proven to be abnormal on surgical resection. B, Axial image from contrast-enhanced soft-tissue neck CT at the same level, shows the morphologically abnormal and enhancing lymph nodes within the neck (black arrows).

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Figure 5. Treatment surveillance. A 60-year-old man with history of advanced oropharyngeal squamous cell carcinoma. A, Baseline axial positron emission tomographic–computed tomographic (PET/CT) imaging was obtained for staging, and radiation treatment planning, demonstrating the left tonsillar primary (white arrow), and the contralateral Level II node (white arrowhead). B, Baseline coronal PET maximum intensity projection (MIP) image shows the extent of the primary lesion (black arrow) as well as metastatic disease within the neck (black arrowheads). C, Three-month follow up axial PET/CT shows significant treatment response at the site of the original primary lesion. D, Three-month follow-up coronal PET MIP also shows this treatment response within the neck.

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