FDG的PET和PET 头颈部肿瘤的CT临床应用.docx

FDG的PET和PET 头颈部肿瘤的CT临床应用.docx

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FDG的PET和PET头颈部肿瘤的CT临床应用

HindawiPublishingCorporation

JournalofOncology

Volume2009,ArticleID208725,13pages

doi:

10.1155/2009/208725

ReviewArticle

ClinicalApplicationsofFDGPETandPET/CTin

HeadandNeckCancer

AkramAl-Ibraheem,AndreasBuck,BerndJoachimKrause,KlemensScheidhauer,

andMarkusSchwaiger

DepartmentofNuclearMedicine,TechnischeUniversit¨atM¨unchen,IsmaningerStrasse22,81675Munich,Germany

CorrespondenceshouldbeaddressedtoAkramAl-Ibraheem,akramalibrahim@

Received28February2009;Accepted17June2009

RecommendedbyPaulHarari

18F-FDGPETplaysanincreasingroleindiagnosisandmanagementplanningofheadandneckcancer.HybridPET/CThas

promotedthefieldofmolecularimaginginheadandneckcancer.Thismodalityisparticularrelevantintheheadandneck

region,giventhecomplexanatomyandvariablephysiologicFDGuptakepatterns.Thevastmajorityof18F-FDGPETandPET/CT

applicationsinheadandneckcancerrelatedtoheadandnecksquamouscellcarcinoma.Clinicalapplicationsof18F-FDGPETand

PET/CTinheadandneckcancerincludediagnosisofdistantmetastases,identificationofsynchronous2ndprimaries,detection

ofcarcinomaofunknownprimaryanddetectionofresidualorrecurrentdisease.Emergingapplicationsareprecisedelineation

ofthetumorvolumeforradiationtreatmentplanning,monitoringtreatment,andprovidingprognosticinformation.Theclinical

roleof18F-FDGPET/CTinN0diseaseislimitedwhichisinlinewithfindingsofotherimagingmodalities.MRIisusuallyusedfor

TstagingwithanintensediscussionconcerningthepreferableimagingmodalityforregionallymphnodestagingasPET/CT,MRI,

andmulti-slicespiralCTareallimprovingrapidly.Isthisreview,wesummarizerecentliteratureon18F-FDGPETandPET/CT

imagingofheadandneckcancer.

Copyright?

2009AkramAl-Ibraheemetal.ThisisanopenaccessarticledistributedundertheCreativeCommonsAttribution

License,whichpermitsunrestricteduse,distribution,andreproductioninanymedium,providedtheoriginalworkisproperly

cited.

1.Introduction

In2008,headandneckcancersaccountedforapproximately

4%to5%ofallthemalignantdiseaseintheUnitedStates

[1].Headandnecksquamouscellcarcinoma（HNSCC）

comprisesthevastmajorityofheadandneckcancer（HNC）.

Oncologicimagingplaysanimportantroleinheadandneck

cancersasimagingfindingscanaidsignificantlydetection,

staging,restaging,andtherapyresponseassessmentof

thesetumors.Accuratestagingatthetimeofdiagnosisis

criticalforselectionoftheappropriatetreatmentstrategy.

Unfortunately,atthetimeofinitialdiagnosismorethan50%

ofpatientsalreadypresentwithregionalnodalmetastasesor

evendistantmetastases.

Diagnosisofaheadandneckcancerisusuallyachieved

byacombinationofpatienthistory,physicalexamination,

andeithernasopharyngoscopyand/orlaryngoscopywith

directedbiopsies.Panendoscopymaybenecessarytoreveal

theextentofatumor.Morphologicimagingwithcomputed

tomography（CT）and/ormagneticresonanceimaging

（MRI）withintravenouscontrastareoftenperformedeither

priortopanendoscopytononinvasivelyassesstheaerodigestive

tractorafterwardstoprovideinformationabout

primarytumorsize,infiltration,involvementofsurrounding

structures,andregionalnodalinvolvement.Thereisgrowing

evidence,however,thatthesemodalitieshavelimitations

intheirdiagnosticaccuracy.CTandMRimagingrelyon

criteriaofcontrast-enhancementpatternsandnodalsizefor

detectionoflymphnodemetastaseswhicharenotspecific

andmayescapedetectionofmetastaseswithinnormalsize

lymphnodes.Thereisalsogrowingevidencethat18F-FDG

PETimagingisaverysensitiveandvaluableimagingtool

inevaluationheadandneckcancer.Themaindrawbackof

18F-FDGPETaloneisthelimitationwithrespecttolesion

localization.However,theadventofPET/CTnowovercomes

thislimitationandpermitstheevaluationofbothmetabolic

andanatomiccharacteristicsofdisease,whichhasproven

tobeamajoradvanceforstaging,detectioncarcinomaof

2JournalofOncology

Table1:

StudiescomparingaccuracyofFDGPETandPET/CTwithCTandMRIfordetectionoflymphnodesmetastases.

AuthoryearNumberofpatientsTumorSubtypesResultsNotes

Beaketal.[2],200915PeriorbitalPET/CTaccuracy（98%）>

CT84%

-CT:

16slice.

-PETmodifiedTxin39%.

Rohetal.[3],2007167HNSCC

PETorPET/CTaccuracy

（92%-93%）>CT/MR

85%-86%

-PET/CTsignificantly

betterfordetectionof

primarytumor

Gordinetal.[4],200735NasopharyngealPET/CTaccuracy91%>

PET80%>CT60%

-Retrospective

-PET/CTmodifiedTXin

57%

Kimetal.[5],200732OropharyngealPETsensitivity21%higher

thanCT/MR（P<.05）

-PET/CTsignificantly

betterfordetectionof

primarytumor

Dammannetal.[6],200579OralcavityandoropharynxPETaccuracy96%>MRI

94%>CT92%

-NonhypridPET/CTused

Ngetal.[7],2005124OralcavitySCCPETaccuracy98.4%>

CT/MR87.1%

-Prospective

unknownprimary,treatmentmonitoring,andevaluationof

residualorrecurrentdisease.

2.Staging

Accuratestagingatthetimeofdiagnosisisthemost

importantfactorfortreatmentplanninganddetermination

ofprognosis[8].Oneattractivefeatureof18F-FDGPETas

amodalityforinitialTNMstagingisthatitcoversmost

ofthebodywithinasinglestudy.PETthereforeprovides

informationontheprimarytumor,nodalmetastases,distant

metastases,andpotential2ndprimarycarcinomas.A

literaturesurveyontheuseof18F-FDGPETinheadand

neckcancer（HNC）comparedtoCTindicatesthatPEThas

ahighersensitivity（87%versus62%）andspecificity（89%

versus73%）forstagingcancer[9].AdditionofPET/CTto

initialstagingofpatientswithHNChasalsobeenshownto

haveameasurableimpactonthetreatmentselection[10,11].

2.1.PrimaryTumor.Numerousreportsoninitialstaging

haveshownthat18F-FDGPETisatleastassensitiveasMRI

orCTindetectingtheprimarytumor[3,7,10–17].Thisis

relatedtothefactthatsmallerorsubmucosalmalignancies

maybedifficulttodistinguishfromadjacenttissueson

anatomicalimaging.Abettersensitivityof18F-FDGPET

fordetectingprimarytumorcomparingtoCT/MRIimaging

hasbeenshowninoralcavitycancer[18,19].However,

thecurrentpracticeisnotinfavorofutilizing18F-FDG

PETforlocalstagingofallnewlydiagnosedheadandneck

squamouscellcarcinoma（HNSCC）.Thisisduetothe

higheranatomicresolutionofMRIandcontrastenhanced

multisliceCTcomparedto18F-FDGPET.Nevertheless,in

arecentstudybyBaeketal.including40patientswith

oralcavitycanceranddentalartifactsonCTorMRI,

itwasdemonstratedthat18F-FDGPET/CTcanprovide

moreusefulclinicalinformationandhighersensitivity,

particularlyindeeptumors,comparedtoCTandMR.The

diagnosticperformanceforthedetectionoftheprimary

tumorsintheoralcavitywas96.3%forPET/CT,77.8%for

CT,and85.2%forMRI[20].

2.2.NodalMetastases.Nodalstaginghasasignificantimpact

onoutcomeintermsofdiseasefreesurvivalandoverall

survivalaftertherapy[21].Metastaticlymphnodedisease

isfoundinapproximately50%ofthepatientsatthetime

ofprimarydiagnosis[6,22].Severalreportshaveverified

that18F-FDGPEThasahighersensitivityandspecificity

thanCTorMRimagingfordetectionoflymphnode

metastasesinheadandneckcancer[23,24].Inareviewby

Sch¨oderandYeung,anaveragesensitivityof87%–90%anda

specificityof80%–93%werereportedfor18F-FDGPET/CT;

asensitivityof61%–97%andspecificityof21%–100%were

reportedformorphologicimagingmodalitiesincludingMRI

andCT[25].Severalrecentstudiescomparing18F-FDG

PET,18F-FDGPET/CT,andCT/MRaresummarizedin

Table1.Resultsshowedthatintegrated18F-FDGPET/CT

mayplayanimportantroleinidentifyinglymphnode

metastasesinheadandnecksquamouscellcarcinoma

（HNSCC）.However,MRIisusuallyusedforlocalstagingas

itprovidesalmostcomparableaccuracyto18F-FDGPETin

locoregionalmetastasesinadditiontobestprimarytumor

delineation[26].

Occultlymphnodes（clinicalN0disease）stillrepresent

adilemmaforbothimagingmodalitiesandsurgeons.

AlthoughearlierreportshavefavoredPEToverother

anatomicimagingmodalitiesasPEThasbeenshowntohave

asensitivityof78%andanaccuracyof92%（compared

withasensitivityof57%andanaccuracyof76%forCT）

forthedetectionofnodalmetastasesinclinicalN0disease

[27].TworecentreportsbyNahmiasetal.andSchoderet

al.comprising47and37patients,respectively,demonstrated

that18F-FDGPET/CTisnotaccurateenoughfordetection

JournalofOncology3

Figure1:

A61-year-oldmanwithnasopharyngealSCCandbilateralcervicallymphnodemetastasesunderwentPET/CTforstaging.Axial

PET,CT,PET/CT,andmaximumintensityprojection（MIP）imagesareshown.PET/CTrevealedfocalFDGuptakeintherightliverlobe

indicatinglivermetastasis（black,whitearrows）.PET/CTalsorevealedmultiplefocalFDGuptakesinthelumbarspine,sternum,andribs

indicatingmultiplebonemetastases（redarrows）.PET/CTwasvaluablefordetectiondistantmetastases.

ofoccultnodaldiseaseinpreviouslyuntreatedpatientand

wouldnothelpthesurgeoninthemanagementstrategy

ofthepatient,particularlyifthestudyisnegative.They

reportedsensitivityandaspecificityrangingfrom67%to

79%and82%to95%,respectively.Falsenegativefindings

werelikelyrelatedtoeitherthepresenceofmicroscopic

metastasesnotdetectedbyPET/CT,orbytheproximityof

nodalmetastasestotheprimar