TNM staging with FDG-PET/CT in patients with primary head and neck cancer

  • Patrick Veit-Haibach
  • Christopher Luczak
  • Isabel Wanke
  • Markus Fischer
  • Thomas Egelhof
  • Thomas Beyer
  • Gerlinde Dahmen
  • Andreas Bockisch
  • Sandra Rosenbaum
  • Gerald Antoch
Original Article



PET/CT, PET+CT, and CT were compared concerning accuracies in TNM staging and malignancy detection in head and neck cancer. The impact of PET/CT compared to the other imaging modalities on therapy management was assessed.

Materials and methods

Fifty-five patients with suspected head and neck primary cancer underwent whole-body FDG-PET/CT. PET/CT and PET+CT were evaluated by a nuclear medicine physician and a radiologist; CT was evaluated by two radiologists, PET by two nuclear physicians. Histopathology served as the standard of reference. Differences between the staging modalities were tested for statistical significance by McNemar’s test.


Overall TNM-staging and T-staging with PET/CT were more accurate than PET+CT and CT alone (p < 0.05). PET/CT was marginally more accurate than CT alone in N-staging (p = 0.04); no statistically significant difference was found when compared to PET+CT for N-staging. PET/CT altered further treatment in 13 patients compared to CT only and in 7 patients compared to PET+CT.


Combined PET/CT proved to be partly more accurate in assessing the overall TNM-stage than CT and PET+CT. These results were based on a higher accuracy concerning the T-stage, mainly in patients with metallic implants and marginally the N-stage. Therapy decisions have been influenced in a substantial number of patients. PET/CT might be considered as a first line diagnostic tool in patients with suspected primary head and neck cancer.


Contrast-enhanced PET/CT TNM staging Head and neck cancer Therapeutic influence 


  1. 1.
    Jemal A, Murray T, Ward E, Samuels A, Tiwari RC, Ghafoor A, et al. Cancer statistics, 2005. CA Cancer J Clin 2005;55(1):10–30.PubMedCrossRefGoogle Scholar
  2. 2.
    NCCN. In: National Comprehensive Cancer Network.
  3. 3.
    Caponigro F, Milano A, Basile M, Ionna F, Iaffaioli RV. Recent advances in head and neck cancer therapy: the role of new cytotoxic and molecular-targeted agents. Curr Opin Oncol 2006;18(3):247–52.PubMedCrossRefGoogle Scholar
  4. 4.
    Cohen EE, Rosen F, Stadler WM, Recant W, Stenson K, Huo D, et al. Phase II trial of ZD1839 in recurrent or metastatic squamous cell carcinoma of the head and neck. J Clin Oncol 2003;21(10):1980–7.PubMedCrossRefGoogle Scholar
  5. 5.
    Colevas AD. Chemotherapy options for patients with metastatic or recurrent squamous cell carcinoma of the head and neck. J Clin Oncol 2006;24(17):2644–52.PubMedCrossRefGoogle Scholar
  6. 6.
  7. 7.
  8. 8.
    Pauleit D, Zimmermann A, Stoffels G, Bauer D, Risse J, Fluss MO, et al. 18F-FET PET Compared with 18F-FDG PET and CT in Patients with Head and Neck Cancer. J Nucl Med 2006;47(2):256–61.PubMedGoogle Scholar
  9. 9.
    Wong WL, Saunders M. The impact of FDG PET on the management of occult primary head and neck tumours. Clin Oncol (R Coll Radiol) 2003;15(8):461–6.Google Scholar
  10. 10.
    Yousem DM, Montone KT. Head and neck lesions. Radiologic-pathologic correlations. Radiol Clin North Am 1998;36(5):983–1014, vii.PubMedCrossRefGoogle Scholar
  11. 11.
    Kau RJ, Alexiou C, Laubenbacher C, Werner M, Schwaiger M, Arnold W. Lymph node detection of head and neck squamous cell carcinomas by positron emission tomography with fluorodeoxyglucose F 18 in a routine clinical setting. Arch Otolaryngol Head Neck Surg 1999;125(12):1322–8.PubMedGoogle Scholar
  12. 12.
    Wong WLCE, McGurk M, Hussain K, Davis J, Beaney R, Baddeley H, et al. A prospective study of PET-FDG imaging for the assessment of head and neck squamous cell carcinoma. Clin Otolaryngol Allied Sci 1997;22(3):209–14.:209–14.PubMedCrossRefGoogle Scholar
  13. 13.
    Branstetter BFt, Blodgett TM, Zimmer LA, Snyderman CH, Johnson JT, Raman S, et al. Head and neck malignancy: is PET/CT more accurate than PET or CT alone? Radiology 2005;235(2):580–6.PubMedCrossRefGoogle Scholar
  14. 14.
    Goshen E, Davidson T, Yahalom R, Talmi YP, Zwas ST. PET/CT in the evaluation of patients with squamous cell cancer of the head and neck. Int J Oral Maxillofac Surg 2006;35(4):332–6.PubMedCrossRefGoogle Scholar
  15. 15.
    Ha PK, Hdeib A, Goldenberg D, Jacene H, Patel P, Koch W, et al. The role of positron emission tomography and computed tomography fusion in the management of early-stage and advanced-stage primary head and neck squamous cell carcinoma. Arch Otolaryngol Head Neck Surg 2006;132(1):12–6.PubMedCrossRefGoogle Scholar
  16. 16.
    Schoder H, Carlson DL, Kraus DH, Stambuk HE, Gonen M, Erdi YE, et al. 18F-FDG PET/CT for detecting nodal metastases in patients with oral cancer staged N0 by clinical examination and CT/MRI. J Nucl Med 2006;47(5):755–62.PubMedGoogle Scholar
  17. 17.
    Antoch G, Jentzen W, Freudenberg LS, Stattaus J, Mueller SP, Debatin JF, et al. Effect of oral contrast agents on computed tomography-based positron emission tomography attenuation correction in dual-modality positron emission tomography/computed tomography imaging. Invest Radiol 2003;38(12):784–9.PubMedGoogle Scholar
  18. 18.
    Antoch G, Kuehl H, Kanja J, Lauenstein TC, Schneemann H, Hauth E, et al. Dual-modality PET/CT scanning with negative oral contrast agent to avoid artifacts: introduction and evaluation. Radiology 2004;230(3):879–85.PubMedCrossRefGoogle Scholar
  19. 19.
    Beyer T, Antoch G, Blodgett T, Freudenberg LF, Akhurst T, Mueller S. Dual-modality PET/CT imaging: the effect of respiratory motion on combined image quality in clinical oncology. Eur J Nucl Med Mol Imaging 2003;30(4):588–96.PubMedCrossRefGoogle Scholar
  20. 20.
    Beyer T, Tellmann L, Nickel I, Pietrzyk U. On the use of positioning aids to reduce misregistration in the head and neck in whole-body PET/CT studies. J Nucl Med 2005;46(4):596–602.PubMedGoogle Scholar
  21. 21.
    Biehl KJ, Kong FM, Dehdashti F, Jin JY, Mutic S, El Naqa I, et al. 18F-FDG PET definition of gross tumor volume for radiotherapy of non-small cell lung cancer: is a single standardized uptake value threshold approach appropriate? J Nucl Med 2006;47(11):1808–12.PubMedGoogle Scholar
  22. 22.
    Drever L, Roa W, McEwan A, Robinson D. Iterative threshold segmentation for PET target volume delineation. Med Phys 2007;34(4):1253–65.PubMedCrossRefGoogle Scholar
  23. 23.
    Delbeke D, Martin WH, Sandler MP, Chapman WC, Wright JK Jr, Pinson CW. Evaluation of benign vs malignant hepatic lesions with positron emission tomography. Arch Surg 1998;133(5):510–5; discussion 515–6.PubMedCrossRefGoogle Scholar
  24. 24.
    Valk PE, Bailey DL, Townsend DW, Maisey MN. Positron Emission Tomography: Basic Science and Clinical Practice. London, Berlin, Heidelberg: Springer, 2003.Google Scholar
  25. 25.
    AJCC. AJCC Cancer Staging Manual. 6 th. Edition ed. Stuttgart, Heidelberg, New York: Springer; 2002.Google Scholar
  26. 26.
    Daisne JF, Duprez T, Weynand B, Lonneux M, Hamoir M, Reychler H, et al. Tumor volume in pharyngolaryngeal squamous cell carcinoma: comparison at CT, MR imaging, and FDG PET and validation with surgical specimen. Radiology 2004;233(1):93–100.PubMedCrossRefGoogle Scholar
  27. 27.
    Tango T. Equivalence test and confidence interval for the difference in proportions for the paired-sample design. Stat Med 1998;17(8):891–908.PubMedCrossRefGoogle Scholar
  28. 28.
    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.PubMedCrossRefGoogle Scholar
  29. 29.
    Schoder H, Yeung HW. Positron emission imaging of head and neck cancer, including thyroid carcinoma. Semin Nucl Med 2004;34(3):180–97.PubMedCrossRefGoogle Scholar
  30. 30.
    Anzai Y, Carroll WR, Quint DJ, Bradford CR, Minoshima S, Wolf GT, et al. Recurrence of head and neck cancer after surgery or irradiation: prospective comparison of 2-deoxy-2-[F-18]fluoro-D-glucose PET and MR imaging diagnoses. Radiology 1996;200(1):135–41.PubMedGoogle Scholar
  31. 31.
    Goerres GW, Schmid DT, Schuknecht B, Eyrich GK. Bone invasion in patients with oral cavity cancer: comparison of conventional CT with PET/CT and SPECT/CT. Radiology 2005;237(1):281–7.PubMedCrossRefGoogle Scholar
  32. 32.
    Goerres GW, Von Schulthess GK, Hany TF. Positron emission tomography and PET CT of the head and neck: FDG uptake in normal anatomy, in benign lesions, and in changes resulting from treatment. AJR Am J Roentgenol 2002;179(5):1337–43.PubMedGoogle Scholar
  33. 33.
    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.PubMedCrossRefGoogle Scholar
  34. 34.
    Steinkamp HJ, Hosten N, Richter C, Schedel H, Felix R. Enlarged cervical lymph nodes at helical CT. Radiology 1994;191(3):795–8.PubMedGoogle Scholar
  35. 35.
    Steinkamp HJ, Keske U, Schedel J, Hosten N, Felix R. The spiral CT of cervical lymph node enlargements. The initial clinical results. Rofo 1994;160(6):500–5.PubMedGoogle Scholar
  36. 36.
    Connell A, Corry J, Milner AD, Hogg A, Hicks RJ, Rischin D, et al. Clinical impact of, and prognostic stratification by, F-18 FDG PET/CT in head and neck mucosal squamous cell carcinoma. Head Neck 2007.Google Scholar
  37. 37.
    Wong WL, Hussain K, Chevretton E, Hawkes DJ, Baddeley H, Maisey M, et al. Validation and clinical application of computer-combined computed tomography and positron emission tomography with 2-[18F]fluoro-2-deoxy-D-glucose head and neck images. Am J Surg 1996;172(6):628–32.PubMedCrossRefGoogle Scholar
  38. 38.
    Sanghera B, Wong WL, Lodge MA, Hain S, Stott D, Lowe J, et al. Potential novel application of dual time point SUV measurements as a predictor of survival in head and neck cancer. Nucl Med Commun 2005;26(10):861–7.PubMedCrossRefGoogle Scholar
  39. 39.
    Gutzeit A, Antoch G, Kuhl H, Egelhof T, Fischer M, Hauth E, et al. Unknown primary tumors: detection with dual-modality PET/CT-initial experience. Radiology 2005;234(1):227–34.PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2007

Authors and Affiliations

  • Patrick Veit-Haibach
    • 1
    • 5
  • Christopher Luczak
    • 1
  • Isabel Wanke
    • 1
  • Markus Fischer
    • 2
  • Thomas Egelhof
    • 1
  • Thomas Beyer
    • 3
  • Gerlinde Dahmen
    • 4
  • Andreas Bockisch
    • 3
  • Sandra Rosenbaum
    • 3
  • Gerald Antoch
    • 1
  1. 1.Department of Diagnostic and Interventional Radiology and NeuroradiologyUniversity Hospital EssenEssenGermany
  2. 2.Department of Oto-Rhino-LaryngologyUniversity Hospital EssenEssenGermany
  3. 3.Department of Nuclear MedicineUniversity Hospital EssenEssenGermany
  4. 4.Institute of Medical Biometry and StatisticsUniversity at LuebeckLuebeckGermany
  5. 5.Department for Nuclear MedicineUniversity Hospital ZuerichZuerichSwitzerland

Personalised recommendations