Early Detection of Recurrent Disease by FDG-PET/CT Leads to Management Changes in Patients With Squamous Cell Cancer of the Head and Neck

Abstract

Objective. The objective of this study was to compare the efficacy of surveillance high-resolution computed tomography (HRCT) and physical examination/endoscopy (PE/E) with the efficacy of fluorodeoxyglucose (FDG)-positron emission tomography (PET)/HRCT for the detection of relapse in head and neck squamous cell carcinoma (HNSCC) after primary treatment. Methods. This is a retrospective analysis of contemporaneously performed FDG-PET/HRCT, neck HRCT, and PE/E in 99 curatively treated patients with HNSCC during post-therapy surveillance to compare performance test characteristics in the detection of early recurrence or second primary cancer. Results. Relapse occurred in 19 of 99 patients (20%) during a median follow-up of 21 months (range: 9 -52 months). Median time to first PET/HRCT was 3.5 months. The median time to radiological recurrence was 6 months (range: 2.3-32 months). FDG-PET/ HRCT detected more disease recurrences or second primary cancers and did so earlier than HRCT or PE/E. The sensitivity, specificity,andpositiveandnegativepredictivevaluesfordetectinglocoregionalanddistantrecurrenceorsecondprimarycancer were 100%, 87.3%, 56.5%, and 100%, respectively, for PET/HRCT versus 61.5%, 94.9%, 66.7%, and 93.8%, respectively, for HRCT versus 23.1%, 98.7%, 75%, and 88.6%, respectively, for PE/E. In 19 patients with true positive PET/HRCT findings, a significant change in the management of disease occurred, prompting either salvage or systemic therapy. Of the 14 curatively treated patients, 11 were alive with without disease at a median follow-up of 31.5 months. Conclusion. FDG-PET/HRCT has a high sensitivity in the early detection of relapse or second primary cancer in patients with HNSCC, with significant management implications. Given improvements in therapy and changes in HNSCC biology, appropriate modifications in current post-therapy surveillance may be required to determine effective salvage or definitive therapies. The Oncologist 2013;18:1108 -1117 Implications for Practice: The role of PET/CT in the post-therapy surveillance of head and neck cancer is not defined by prospective studies, but cumulative retrospective data support the use of FDG-PET/CT in this setting. By corroborating prior results, we believe that we have an important message for physicians and health insurance carriers, that after completion of primary definitive treatment, surveillance PET/CT detects relapse earlier than both diagnostic CT and NCCN-recommended conventional methods. Although retrospectively, we report a significant change in disease management after PET/CT results suggested a survival benefit compared with reported historical data. We found that most patients had recurrence in the first 2 years after completion of therapy, and PET/CT detected most recurrences within the first 6-month period. Our findings corroborate those of other authors, and therefore, there is merit to recommending a post-therapy scan 3-4 months after completion of therapy, followed by another scan within the first year and scanning every 6 months ...

Detection of subclinical recurrence or second primary cancer using 18F‐FDG PET/CT in patients treated curatively for head and neck squamous cell carcinoma

“…13,14,[17][18][19] In a study of 99 curatively treated patients with HNSCC during posttherapy surveillance, Kostakoglu et al 19 showed that 43% of recurrent lesions were identified at the first scan, which was performed at a median of 3.5 months after completion of therapy. The recommendation of a posttherapy PET scan at 3 to 4 months after completion of therapy 19 is in line with our proposal. In contrast, Abgral et al 13 prospectively evaluated the effectiveness of 18 F-FDG PET/CT for detecting subclinical recurrence of HNSCC and concluded that systematic use of 18 F-FDG PET/CT was effective at 12 months after therapy, which is relatively later than in most reports.…”

“…In contrast, Abgral et al 13 prospectively evaluated the effectiveness of 18 F-FDG PET/CT for detecting subclinical recurrence of HNSCC and concluded that systematic use of 18 F-FDG PET/CT was effective at 12 months after therapy, which is relatively later than in most reports. 14,15,[17][18][19] Recurrence in 30 of 91 patients (33%) with HNSCC was detected by surveillance 18 F-FDG PET/CT at 12 months after therapy and salvage surgery was performed for 17 patients. 13 Information on the curative or palliative nature of the salvage therapy and the clinical course after the therapy was not given.…”

“…6 Positron emission tomography (PET) with 18 F-fluorodeoxyglucose ( 18 F-FDG) is also widely used in oncology, and is particularly useful for head and neck cancer staging, 7 detection of simultaneous cancers in different organs, 8 detection of an unknown primary tumor presenting with cervical metastases, 9 assessment of chemotherapy response, 10 and prediction of survival. 11,12 The 18 F-FDG PET/CT is also important in posttreatment surveillance of HNSCC [13][14][15][16][17][18][19] because it can distinguish recurrent HNSCC from posttreatment changes and is more effective for detection of recurrent tumors than physical examination, CT, or MRI. 20,21 The potential value of surveillance 18 F-FDG PET/CT is relatively high, 15,19 but there is no clear consensus on the timing, interval, and frequency of scans after curative treatment for HNSCC.…”

“…11,12 The 18 F-FDG PET/CT is also important in posttreatment surveillance of HNSCC [13][14][15][16][17][18][19] because it can distinguish recurrent HNSCC from posttreatment changes and is more effective for detection of recurrent tumors than physical examination, CT, or MRI. 20,21 The potential value of surveillance 18 F-FDG PET/CT is relatively high, 15,19 but there is no clear consensus on the timing, interval, and frequency of scans after curative treatment for HNSCC. We hypothesized that serial follow-up 18 F-FDG PET/CT for posttreatment surveillance in patients with asymptomatic HNSCC would permit early detection of a subclinical lesion, and that this could lead to improved survival.…”

SNMMI Comment on ASCO 2013 “Choosing Wisely” Recommendation on Use of PET/CT in Recurrent Cancer Surveillance

“…For example, in patients with cancers of the head and neck, disease detection with 18 F-FDG PET/CT leads to improved outcomes (2,3). Similarly, in patients with colorectal carcinoma with rising carcinoembryonic antigen levels and negative findings on conventional imaging, 18 F-FDG PET/CT shows incremental benefit in the detection of the site of recurrence, which could lead to directed therapy such as stereotactic radiotherapy (4).…”