PET-CT/MR Imaging in Head and Neck Cancer: Physiologic Variations, Pitfalls, and Directed Applications

  • Laurie A. Loevner


The strengths and potential pitfalls of functional FDG-positron emission tomographic imaging in patients with head and neck cancer, especially in those who have undergone surgery and/or chemoradiation therapy, will be covered and carefully reviewed. Positron emission tomography (PET) is currently performed using the radiopharmaceutical 18F-FDG, a d-glucose analog. The increased vascularity of tumors and glucose metabolism by neoplastic cells result in preferential uptake of FDG by these cells. The inability to process the metabolites of this modified glucose molecule causes intracellular accumulation of F18-containing radioisotopes in tumors. This has been invaluable in the evaluation of many cancer patients, and PET now plays a pivotal role in the diagnosis, staging, and re-staging of head and neck oncology patients. The ability to assess the functional status of tissue with FDG-PET has been remarkable, and addresses this well-known limitation of conventional cross-sectional computed tomography (CT) and magnetic resonance (MR) imaging. Conversely, the excellent spacial resolution and the ability to analyze the relationship of neoplasms relative to critical adjacent anatomic structures on CT and MR imaging are a very important adjuvant to, and limitation of, PET. This chapter will emphasize pertinent head and neck anatomy, and common physiologic variations in PET imaging, with particular attention to those seen in the treated neck, and will illustrate the complimentary roles that PET and cross-­sectional imaging play in assessing patients with newly diagnosed and treated head and neck cancers. The precise roles that functional and anatomic imaging will play in monitoring therapy, surveillance imaging, and their potential impact on patient outcomes continue to evolve.


Positron Emission Tomography Positron Emission Tomography Imaging Cricoid Cartilage Parapharyngeal Space Piriform Sinus 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Greene FL, Page DL, Fritz AG, et al. AJCC Cancer Staging Manual. 6th ed. New York: Verlag; 2002.Google Scholar
  2. 2.
    Day GL, Blot WJ. Second primary tumors in patients with oral cancer. Cancer. 1992;70:14–9.PubMedCrossRefGoogle Scholar
  3. 3.
    Narayana A, Vaughan AT, Fisher SG, Reddy SP. Second primary tumors in laryngeal cancer: results of long-term follow-up. Int J Radiat Oncol Biol Phys. 1998;42:557–62.PubMedCrossRefGoogle Scholar
  4. 4.
    Rennemo E, Zatterstrom U, Boysen M. Impact of second primary tumors on survival in head and neck cancer: an analysis of 2,063 cases. Laryngoscope. 2008;118:1350–6.PubMedCrossRefGoogle Scholar
  5. 5.
    Di ME, Sellhaus B, Hausmann R, Minkenberg R, Lohmann M, Esthofen MW. Survival in second primary malignancies of patients with head and neck cancer. J Laryngol Otol. 2002;116:831–8.Google Scholar
  6. 6.
    Vokes EE, Weichselbaum RR, Lippman SM, Hong WK. Head and neck cancer. N Engl J Med. 1993;328:184–94.PubMedCrossRefGoogle Scholar
  7. 7.
    van den Brekel MW, Stel HV, Castelijns JA, et al. Cervical lymph node metastasis: assessment of radiologic criteria. Radiology. 1990;177:379–84.PubMedGoogle Scholar
  8. 8.
    Cerezo L, Millan I, Torre A, Aragon G, Otero J. Prognostic factors for survival and tumor control in cervical lymph node metastases from head and neck cancer. A multivariate study of 492 cases. Cancer. 1992;69:1224–34.PubMedCrossRefGoogle Scholar
  9. 9.
    Schuller DE, McGuirt WF, McCabe BF, Young D. The prognostic significance of metastatic cervical lymph nodes. Laryngoscope. 1980;90:557–70.PubMedGoogle Scholar
  10. 10.
    Snow GB, Annyas AA, van Slooten EA, Bartelink H, Hart AA. Prognostic factors of neck node metastasis. Clin Otolaryngol Allied Sci. 1982;7:185–92.PubMedCrossRefGoogle Scholar
  11. 11.
    de Bondt RB, Nelemans PJ, Hofman PA, et al. Detection of lymph node metastases in head and neck cancer: a meta-analysis comparing US, USgFNAC, CT and MR imaging. Eur J Radiol. 2007;64:266–72.PubMedCrossRefGoogle Scholar
  12. 12.
    Yamazaki Y, Saitoh M, Notani K, et al. Assessment of cervical lymph node metastases using FDG-PET in patients with head and neck cancer. Ann Nucl Med. 2008;22:177–84.PubMedCrossRefGoogle Scholar
  13. 13.
    Hannah A, Scott AM, Tochon-Danguy H, et al. Evaluation of 18 F-fluorodeoxyglucose positron emission tomography and computed tomography with histopathologic correlation in the initial staging of head and neck cancer. Ann Surg. 2002;236:208–17.PubMedCrossRefGoogle Scholar
  14. 14.
    Fleming Jr AJ, Smith Jr SP, Paul CM, et al. Impact of [18F]-2-­fluorodeoxyglucose-positron emission tomography/computed tomography on previously untreated head and neck cancer patients. Laryngoscope. 2007;117:1173–9.PubMedCrossRefGoogle Scholar
  15. 15.
    Zanation AM, Sutton DK, Couch ME, Weissler MC, Shockley WW, Shores CG. Use, accuracy, and implications for patient management of [18F]-2-fluorodeoxyglucose-positron emission/­computerized tomography for head and neck tumors. Laryngoscope. 2005;115:1186–90.PubMedCrossRefGoogle Scholar
  16. 16.
    Schoder H, Yeung HW, Gonen M, Kraus D, Larson SM. Head and neck cancer: clinical usefulness and accuracy of PET/CT image fusion. Radiology. 2004;231:65–72.PubMedCrossRefGoogle Scholar
  17. 17.
    Teknos TN, Rosenthal EL, Lee D, Taylor R, Marn CS. Positron emission tomography in the evaluation of stage III and IV head and neck cancer. Head Neck. 2001;23:1056–60.PubMedCrossRefGoogle Scholar
  18. 18.
    Hafidh MA, Lacy PD, Hughes JP, Duffy G, Timon CV. Evaluation of the impact of addition of PET to CT and MR scanning in the staging of patients with head and neck carcinomas. Eur Arch Otorhinolaryngol. 2006;263:853–9.PubMedCrossRefGoogle Scholar
  19. 19.
    Nakamoto Y, Cohade C, Tatsumi M, Hammoud D, Wahl RL. CT appearance of bone metastases detected with FDG PET as part of the same PET/CT examination. Radiology. 2005;237:627–34.PubMedCrossRefGoogle Scholar
  20. 20.
    Lell M, Baum U, Greess H, et al. Head and neck tumors: imaging recurrent tumor and post-therapeutic changes with CT and MRI. Eur J Radiol. 2000;33:239–47.PubMedCrossRefGoogle Scholar
  21. 21.
    Fukui MB, Blodgett TM, Snyderman CH, et al. Combined PET-CT in the head and neck: part 2. Diagnostic uses and pitfalls of oncologic imaging. Radiographics. 2005;25:913–30.PubMedCrossRefGoogle Scholar
  22. 22.
    Blodgett TM, Fukui MB, Snyderman CH, et al. Combined PET-CT in the head and neck: part 1. Physiologic, altered physiologic, and artifactual FDG uptake. Radiographics. 2005;25:897–912.PubMedCrossRefGoogle Scholar
  23. 23.
    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;179:1337–43.PubMedGoogle Scholar
  24. 24.
    Shreve PD, Anzai Y, Wahl RL. Pitfalls in oncologic diagnosis with FDG PET imaging: physiologic and benign variants. Radiographics. 1999;19:61–77.PubMedGoogle Scholar
  25. 25.
    de GM, Meeuwis AP, Kok PJ, Corstens FH, Oyen WJ. Influence of blood glucose level, age and fasting period on non-pathological FDG uptake in heart and gut. Eur J Nucl Med Mol Imaging. 2005;32:98–101.CrossRefGoogle Scholar
  26. 26.
    Israel O, Weiler-Sagie M, Rispler S, et al. PET/CT quantitation of the effect of patient-related factors on cardiac 18F-FDG uptake. J Nucl Med. 2007;48:234–9.PubMedGoogle Scholar
  27. 27.
    Jabour BA, Choi Y, Hoh CK, et al. Extracranial head and neck: PET imaging with 2-[F-18]fluoro-2-deoxy-d-glucose and MR imaging correlation. Radiology. 1993;186:27–35.PubMedGoogle Scholar
  28. 28.
    Cohade C, Osman M, Pannu HK, Wahl RL. Uptake in supraclavicular area fat (“USA-Fat”): description on 18F-FDG PET/CT. J Nucl Med. 2003;44:170–6.PubMedGoogle Scholar
  29. 29.
    Hany TF, Gharehpapagh E, Kamel EM, Buck A, Himms-Hagen J, von Schulthess GK. Brown adipose tissue: a factor to consider in symmetrical tracer uptake in the neck and upper chest region. Eur J Nucl Med Mol Imaging. 2002;29:1393–8.PubMedCrossRefGoogle Scholar
  30. 30.
    Shipchandler TZ, Lorenz RR. Unilateral submandibular gland aplasia masquerading as cancer nodal metastasis. Am J Otolaryngol. 2008;29:432–4.PubMedCrossRefGoogle Scholar
  31. 31.
    Davis E, Solis V, Rosenberg RJ, Spencer RP. Asymmetric tongue muscle uptake of F-18 FDG: possible marker for cranial nerve XII paralysis. Clin Nucl Med. 2004;29:531–3.PubMedCrossRefGoogle Scholar
  32. 32.
    Wong WL, Gibson D, Sanghera B, Goodchild K, Saunders M. Evaluation of normal FDG uptake in palatine tonsil and its potential value for detecting occult head and neck cancers: a PET CT study. Nucl Med Commun. 2007;28:675–80.PubMedCrossRefGoogle 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;234:879–85.PubMedCrossRefGoogle Scholar
  34. 34.
    Chen YK, Su CT, Chi KH, Cheng RH, Wang SC, Hsu CH. Utility of 18F-FDG PET/CT uptake patterns in Waldeyer’s ring for ­differentiating benign from malignant lesions in lateral pharyngeal recess of nasopharynx. J Nucl Med. 2007;48:8–14.PubMedGoogle Scholar
  35. 35.
    Alkhawaldeh K, Alavi A. Quantitative assessment of FDG uptake in brown fat using standardized uptake value and dual-time-point scanning. Clin Nucl Med. 2008;33(10):663–66.PubMedCrossRefGoogle Scholar
  36. 36.
    Jacene HA, Goudarzi B, Wahl RL. Scalene muscle uptake: a potential pitfall in head and neck PET/CT. Eur J Nucl Med Mol Imaging. 2008;35:89–94.PubMedCrossRefGoogle Scholar
  37. 37.
    Jackson RS, Schlarman TC, Hubble WL, Osman MM. Prevalence and patterns of physiologic muscle uptake detected with whole-body 18F-FDG PET. J Nucl Med Technol. 2006;34:29–33.PubMedGoogle Scholar
  38. 38.
    Lee M, Ramaswamy MR, Lilien DL, Nathan CO. Unilateral vocal cord paralysis causes contralateral false-positive positron emission tomography scans of the larynx. Ann Otol Rhinol Laryngol. 2005;114:202–6.PubMedGoogle Scholar
  39. 39.
    Heller MT, Meltzer CC, Fukui MB, et al. Superphysiologic FDG Uptake in the Non-Paralyzed Vocal Cord. Resolution of a False-Positive PET Result with Combined PET-CT Imaging. Clin Positron Imaging. 2000;3:207–11.PubMedCrossRefGoogle Scholar
  40. 40.
    Berger KL, Nicholson SA, Dehdashti F, Siegel BA. FDG PET evaluation of mucinous neoplasms: correlation of FDG uptake with histopathologic features. AJR Am J Roentgenol. 2000;174:1005–8.PubMedGoogle Scholar
  41. 41.
    Goldenberg D, Sciubba J, Koch WM. Cystic metastasis from head and neck squamous cell cancer: a distinct disease variant? Head Neck. 2006;28:633–8.PubMedCrossRefGoogle Scholar
  42. 42.
    Inohara H, Enomoto K, Tomiyama Y, et al. The role of CT and (18)F-FDG PET in managing the neck in node-positive head and neck cancer after chemoradiotherapy. Acta Otolaryngol. 2009;129(8):893–9.PubMedCrossRefGoogle Scholar
  43. 43.
    Nakagawa T, Yamada M, Suzuki Y. 18F-FDG uptake in reactive neck lymph nodes of oral cancer: relationship to lymphoid follicles. J Nucl Med. 2008;49(7):1053–9.PubMedCrossRefGoogle Scholar
  44. 44.
    Ishizumi T, Tateishi U, Watanabe S, Maeda T, Arai Y. F-18 FDG PET/CT imaging of low-grade mucoepidermoid carcinoma of the bronchus. Ann Nucl Med. 2007;21:299–302.PubMedCrossRefGoogle Scholar
  45. 45.
    Chang CY, Fan YM, Bai CY, Cherng SC. Schwannoma mimicking lung cancer metastases demonstrated by PET/CT. Clin Nucl Med. 2006;31:644–5.PubMedCrossRefGoogle Scholar
  46. 46.
    Hamada K, Ueda T, Higuchi I, et al. Peripheral nerve schwannoma: two cases exhibiting increased FDG uptake in early and delayed PET imaging. Skeletal Radiol. 2005;34:52–7.PubMedCrossRefGoogle Scholar
  47. 47.
    Otsuka H, Graham MM, Kogame M, Nishitani H. The impact of FDG-PET in the management of patients with salivary gland malignancy. Ann Nucl Med. 2005;19:691–4.PubMedCrossRefGoogle Scholar
  48. 48.
    Subramaniam RM, Durnick DK, Peller PJ. F-18 FDG PET/CT imaging of submandibular gland oncocytoma. Clin Nucl Med. 2008;33:472–4.PubMedCrossRefGoogle Scholar
  49. 49.
    Shah VN, Branstetter BF. Oncocytoma of the parotid gland: a potential false-positive finding on 18F-FDG PET. AJR Am J Roentgenol. 2007;189:W212–4.PubMedCrossRefGoogle Scholar
  50. 50.
    Schwarz E, Hurlimann S, Soyka JD, Bortoluzzi L, Strobel K. FDG-positive Warthin’s tumors in cervical lymph nodes mimicking metastases in tongue cancer staging with PET/CT. Otolaryngol Head Neck Surg. 2009;140:134–5.PubMedCrossRefGoogle Scholar
  51. 51.
    Ohtsuka T, Nomori H, Watanabe K, et al. False-positive findings on [18F]FDG-PET caused by non-neoplastic cellular elements after neoadjuvant chemoradiotherapy for non-small cell lung cancer. Jpn J Clin Oncol. 2005;35:271–3.PubMedCrossRefGoogle Scholar
  52. 52.
    Tomita M, Ichinari H, Tomita Y, et al. A case of non-small cell lung cancer with false-positive staging by positron emission tomography. Ann Thorac Cardiovasc Surg. 2003;9:397–400.PubMedGoogle Scholar
  53. 53.
    Yang SN, Liang JA, Lin FJ, Kwan AS, Kao CH, Shen YY. Differentiating benign and malignant pulmonary lesions with FDG-PET. Anticancer Res. 2001;21:4153–7.PubMedGoogle Scholar
  54. 54.
    Mackie GC, Pohlen JM. Mediastinal histoplasmosis: F-18 FDG PET and CT findings simulating malignant disease. Clin Nucl Med. 2005;30:633–5.PubMedCrossRefGoogle Scholar
  55. 55.
    Ahmadzadehfar H, Palmedo H, Strunk H, Biersack HJ, Habibi E, Ezziddin S. False positive 18F-FDG-PET/CT in a patient after talc pleurodesis. Lung Cancer. 2007;58:418–21.PubMedCrossRefGoogle Scholar
  56. 56.
    Kamel EM, McKee TA, Calcagni ML, et al. Occult lung infarction may induce false interpretation of 18F-FDG PET in primary staging of pulmonary malignancies. Eur J Nucl Med Mol Imaging. 2005;32:641–6.PubMedCrossRefGoogle Scholar
  57. 57.
    Tahon F, Berthezene Y, Hominal S, et al. Exogenous lipoid pneumonia with unusual CT pattern and FDG positron emission tomography scan findings. Eur Radiol. 2002;12(3):S171–3. Epub;%2002 Oct 1.:S171-S173.PubMedGoogle Scholar
  58. 58.
    Schroeder U, Dietlein M, Wittekindt C, et al. Is there a need for positron emission tomography imaging to stage the N0 neck in T1-T2 squamous cell carcinoma of the oral cavity or oropharynx? Ann Otol Rhinol Laryngol. 2008;117:854–63.PubMedGoogle Scholar
  59. 59.
    Nahmias C, Carlson ER, Duncan LD, et al. Positron emission tomography/computerized tomography (PET/CT) scanning for preoperative staging of patients with oral/head and neck cancer. J Oral Maxillofac Surg. 2007;65:2524–35.PubMedCrossRefGoogle Scholar
  60. 60.
    Tan A, Adelstein DJ, Rybicki LA, et al. Ability of positron emission tomography to detect residual neck node disease in patients with head and neck squamous cell carcinoma after definitive chemoradiotherapy. Arch Otolaryngol Head Neck Surg. 2007;133:435–40.PubMedCrossRefGoogle Scholar
  61. 61.
    Ng SH, Yen TC, Chang JT, et al. Prospective study of [18F]­fluorodeoxyglucose positron emission tomography and computed tomography and magnetic resonance imaging in oral cavity squamous cell carcinoma with palpably negative neck. J Clin Oncol. 2006;24:4371–6.PubMedCrossRefGoogle Scholar
  62. 62.
    Stoeckli SJ, Steinert H, Pfaltz M, Schmid S. Is there a role for ­positron emission tomography with 18F-fluorodeoxyglucose in the initial staging of nodal negative oral and oropharyngeal squamous cell carcinoma. Head Neck. 2002;24:345–9.PubMedCrossRefGoogle Scholar
  63. 63.
    Isles MG, McConkey C, Mehanna HM. A systematic review and meta-analysis of the role of positron emission tomography in the follow up of head and neck squamous cell carcinoma following radiotherapy or chemoradiotherapy. Clin Otolaryngol. 2008;33:210–22.PubMedCrossRefGoogle Scholar
  64. 64.
    Waltonen JD, Ozer E, Hall NC, Schuller DE, Agrawal A. Metastatic carcinoma of the neck of unknown primary origin: evolution and efficacy of the modern workup. Arch Otolaryngol Head Neck Surg. 2009;135(10):1024–9.PubMedCrossRefGoogle Scholar
  65. 65.
    Cianchetti M, Mancuso AA, Amdur RJ, Werning JW, Kirwan J, Morris CG, et al. Diagnostic evaluation of squamous cell carcinoma metastatic to cervical lymph nodes from an unknown head and neck primary site. Laryngoscope. 2009;119(12):2348–54.PubMedCrossRefGoogle Scholar
  66. 66.
    Yabuki K, Tsukuda M, Horiuchi C, Taguchi T, Nishimura G. Role of 18F-FDG PET in detecting primary site in the patient with primary unknown carcinoma. Eur Arch Otorhinolaryngol. 2010;267(11):1785–92.PubMedCrossRefGoogle Scholar
  67. 67.
    Lonneux et al. Positron emission tomography with [18F] fluorodeoxyglucose improves staging and patient management in patients with head and neck squamous cell carcinoma: a multicenter prospective study. J Clin Oncol. 2010;28(7):1190–1195Google Scholar

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© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  1. 1.Division of Neuroradiology, Department of RadiologyUniversity of PennsylvaniaPhiladelphiaUSA

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