Preoperative evaluation of patients with primary head and neck cancer using dual-head 18fluorodeoxyglucose positron emission tomography.

OBJECTIVE: To evaluate the value of 18fluorodeoxyglucose (FDG) positron emission tomography (PET) in primary head and neck cancer. BACKGROUND DATA: Head and neck carcinomas tend to metastasize to regional lymph nodes rather than to spread hematogenously. With nodal metastases, cure rates decrease by approximately 50%. Moreover, in approximately 3% of the patients, a second primary tumor is found at initial presentation. METHODS: Fifty-four consecutive patients (31 men and 23 women; mean age 60 years, range 34-81 years) with previously untreated squamous cell carcinomas of the oral cavity or oropharynx were studied. Before surgery and within a period of 3 weeks, clinical examination, chest x-ray, computed tomography (CT), ultrasonography with fine-needle aspiration cytology (US/ FNAC), and FDG-PET were performed. All study results were scored per neck side and were also classified as 0 (no metastases), 1 (single metastasis), or 2 (multiple metastases). RESULTS: The sensitivity for the detection of lymph node metastases per neck side was 96%, 85%, and 64% for FDG-PET, CT, and US/FNAC, respectively. The specificity was 90%, 86%, and 100% for FDG-PET, CT, and US/FNAC, respectively. In terms of the classification, FDG-PET showed the best correlation with the histologic data. Finally, in nine patients (17%), a second primary tumor was detected by FDG-PET and confirmed by histologic evaluation. CONCLUSION: Because of the high prevalence of second primary tumors detected by FDG-PET and the decreased error rate in the assessment of lymph node involvement compared with CT and US, FDG-PET should be routinely performed in patients with primary head and neck cancer.

18F-fluorodeoxyglucose dual-head positron emission tomography as a procedure for detecting simultaneous primary tumors in cases of head and neck cancer.

BACKGROUND: Second primary tumors are a leading cause of death among patients with head and neck cancer; therefore, early detection of these tumors is necessary. In the current study, the authors aimed to evaluate the diagnostic capacity of (18)F-fluorodeoxyglucose dual-head positron emission tomography (FDG-PET) for detecting second primary tumors in patients presenting with primary head and neck cancer. METHODS: The authors prospectively studied a case series of 68 consecutive patients with a primary tumor in the oral cavity or oropharynx. Within a period of 3 weeks, clinical examination, chest X-ray, computed tomography, and ultrasonography of the head and neck were performed on all patients. Irrespective of the results, patients underwent FDG-PET of the head, neck, and chest. Due to its low yield in the detection of second primary tumors, panendoscopy was not used in this study. All patients were followed up for at least 6 months to assess the number of simultaneous and synchronous tumors missed by FDG-PET. RESULTS: In 12 of 68 patients (18%; 95% confidence interval [CI]: 8-28%), a second simultaneous primary malignant tumor was found by FDG-PET. Five of these tumors (7%; 95% CI: 1-13%) were also detected by clinical or radiologic examination (P = 0.016). With one exception, all tumors were found in the epithelium of the upper digestive and respiratory tract. However, even when the patient with a second primary tumor in the thyroid was excluded from evaluation, FDG-PET significantly improved the detection rate of second primaries (P = 0.031). In none of the 68 patients studied were additional simultaneous or synchronous primary tumors found during follow-up. CONCLUSIONS: The use of FDG-PET significantly increases the rate of detection of simultaneous second primary tumors. The results of our study suggest that most of the second primary tumors are detected in an early stage.

Preoperative assessment of cervical lymph nodes in head and neck cancer with fluorine-18 fluorodeoxyglucose using a dual-head coincidence camera: a pilot study.

The aim of this study was to investigate whether in patients with head and neck cancer, staging is possible with fluorine-18 fluorodeoxyglucose (18F-FDG) using a dual-head positron emission tomography (PET) camera. Twenty patients (ten men, ten women; mean age: 60 years) were studied using 185 MBq (5 mCi) 18F-FDG. Two of these patients who were suspected of having recurrence in the neck were restaged 19 and 12 months, respectively, after the resection of the primary tumour. The images were visually analyzed and the results were correlated with computed tomography (CT) (n = 18), ultrasonography (n = 17) and pathological findings. With respect to the primary tumour, FDG dual-head PET and CT revealed a sensitivity of 100% and 59%, respectively (P < 0.001). In seven patients lymph node metastases were found in the neck specimen. Two of them had bilateral metastases. FDG dual-head PET correctly identified all nine pathological neck sides whereas CT and ultrasonography depicted eight of nine and seven of eight pathological sides, respectively. In three patients, false-positive FDG uptake was seen, which was due to a preceding biopsy in two cases. The sensitivity of FDG dual-head PET, CT and ultrasonography in the identification of pathological neck sides was 100%, 89% and 87%, respectively, and the specificity was 90%, 93% and 50%, respectively. With knowledge of the preceding biopsies, the specificity of FDG dual-head PET would have been 97%. The smallest lymph node metastasis detected by FDG dual-head PET that was missed by CT had a diameter of 0.6 cm. Measurement of 18F-FDG with a dual-head PET camera is very sensitive in the detection of primary head and neck cancers and accurate in the preoperative assessment of lymph node metastases. The results justify a prospective study on the identification of metastases in patients with head and neck cancer. In addition, it is justified to start a study on the detection of unknown primary tumours in patients with cervical metastases.

Increased expression of epidermal growth factor receptor in normal epithelium adjacent to head and neck carcinomas independent of tobacco and alcohol abuse.

OBJECTIVE: In this study we examined if expression of the epidermal growth factor receptor (EGFR) in normal epithelium adjacent to head and neck squamous cell carcinomas (HNSCC) is increased and if this increase is due to the use of tobacco and alcohol. MATERIALS AND METHODS: Cut sections of formalin-fixed and paraffin-embedded material of histologically normal epithelium adjacent to HNSCC from 25 patients who smoke excessively and abuse alcohol, and 17 HNSCC patients who do not abuse tobacco and alcohol were compared with cut sections of normal epithelium from 27 control individuals. The sections were immunohistochemically stained for the EGFR. RESULTS: We show an elevation of the expression of the EGFR in patients who smoke and drink excessively, that could also be ascertained, to a lesser extent, in patients that do not have a history of smoking or drinking (P = 0.08). We also find that the closer the epithelium lies to the HNSCC the higher the expression of the EGFR is. CONCLUSIONS: Expression of the EGFR is increased in tumour-adjacent epithelium and this is not only due to the use of tobacco and/or alcohol. We suggest that paracrine effects of the HNSCC and migration of tumour cells may also play a role in this increased expression.

Overexpression of c-Src in areas of hyperproliferation in head and neck cancer, premalignant lesions and benign mucosal disorders.

To examine which proteins are responsible for the elevated protein tyrosine kinase (PTK) activity in human head and neck squamous cell carcinoma (HNSCC) and adjacent histologically normal epithelium, paraffin embedded sections of these tissues were stained for PTK c-Src. Using double labeling techniques and antibodies against both the proliferation marker Ki-67 and PTK c-Src, we have shown that c-Src is overexpressed in areas of hyperproliferation in HNSCC, dysplastic epithelium, benign papillomas and inflamed normal tissue. Our data indicate that c-Src is (one of) the protein(s) responsible for the increased PTK activity in HNSCC. We could not demonstrate that c-Src expression is responsible for the increased PTK activity in normal epithelium adjacent to tumour tissue. We assume that c-Src plays a role in the increased proliferation seen in (pre)malignant and benign epithelial lesions as well as in reactive inflammatory epithelial hyperplasia.

The role of FDG PET in the clinical management of head and neck cancer.

Positron emission tomography (PET) with fluorodeoxyglucose (FDG) allows the visualization of metabolic tissue activity. Use of FDG in in-vivo cancer imaging is based on enhanced glycolysis in tumor cells. In vivo experiments have demonstrated the potential use of FDG PET in squamous-cell head and neck tumors and the detection of tumor involvement in lymph nodes. Since its introduction in this area, several papers have appeared on the use of this imaging modality. Indications for the use of FDG PET in patients with head and neck cancer are discussed.

Transvenous embolisation of an arteriovenous malformation of the mandible via a femoral approach.

Arteriovenous malformations (AVM) of the mandible are uncommon but can give rise to sudden massive haemorrhage. Transarterial or direct transosseous embolisation can be used to treat this condition but is not always effective. We describe a case of mandibular AVM with a single draining vein which was embolised successfully via a femoral transvenous approach.

Disease-specific survival and locoregional control in tonsillar carcinoma.

In a nationwide survey on oropharyngeal carcinoma in the Netherlands (1986-1990), 380 patients with a tonsillar carcinoma were retrospectively studied. The records of 268 (71%) men and 112 (29%) women with a median age of 59 yr (range 31-91), who had squamous cell carcinoma (272 patients, 98%) or undifferentiated carcinoma (8 patients, 2%) were reviewed with respect to treatment, disease-specific survival and locoregional control. Distribution by stage according to the UICC'92 system was: 27 patients (7%) stage I, 59 (15%) stage II, 99 (26%) stage III, 182 (48%) stage IV and 13 patients (3%) unknown stage. Using a previously reported revised staging system the following distribution was obtained: 118 patients (31%) stage I, 120 (31%) stage II, 67 (18%) stage III, 54 (14%) stage IV and 21 patients (6%) with an unknown stage. Treatment consisted of radiotherapy alone in 231 patients (61%), surgery and radiotherapy in 101 (27%), surgery alone in 30 (8%), chemotherapy in 5 (2%) and 13 patients (3%) did not receive any treatment. At 5-yr the overall survival was 32%, the disease-specific survival 42% and the locoregional control 61%. In patients treated with radiotherapy alone the disease-specific survival was 39%, for surgery and radiotherapy 53% and for surgery alone 83%. The disease-specific survival according to UICC'92 stage was 71% in stage I, 59% in II, 50% in III and 32% in stage IV (P < 0.0001). In the revised staging the survival figures were 63% in stage I, 43% in II, 31% in III and 9% in IV (P < 0.0001). The two staging systems appeared to be comparable in prognostic discrimination; the clinical relevance of the revised stage might, however, be slightly superior to the UICC'92 version. The difference in results after radiotherapy alone and surgery + radiotherapy remained significant, also after adjusting for stage (P < 0.0001).