Diagnostic performance of 18F-FDG PET-CT in patients presenting with secondary neck nodes from an unknown primary

Document Type: Original Article

Authors

Department of Nuclear Medicine and Molecular Imaging, Amrita Institute of Medical Sciences and Research Center, Cochin, Kerala, India

Abstract

Introduction: Clinical examination and even anatomical imaging may fail to identify primary site of malignancy in patients presenting with cervical nodal metastasis. 18F-Fluorodeoxyglucose Positron Emission Computed Tomography (18F-FDG PET-CT) is known to overcome the limitations of anatomic imaging.
Methods: Sixty-three (63) patients (male:female=55:8, age range=32-83 years, mean age=61.14 ±12.6 years) with one or more metastatic neck node (s) from occult primary underwent 18F-FDG PET-CT. Nodal cytological/biopsy findings, IHC of cervical nodal biopsy (whenever available), scan findings, subsequent biopsy findings (PET guided/ directed)  of suggested occult primaries were correlated. Subsequent detection of any primary malignancy in whom 18F-FDG PET-CT failed to localize a primary was also documented.
Results: Malignancy was confirmed in eighteen (18) out of those twenty-four (24) patients in whom site of possible occult primary malignancy was suggested out of total sixty-three (63) patients. In five (5) patients out of remaining thirty-nine (39) patients, a site of primary malignancy was detected or a site of primary malignancy was considered based on IHC subsequently. The detection rate of occult primary, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and false positivity rate was calculated to be 28.5%, 78.2%, 85%, 75%, 87.1% and 15% respectively. 18F-FDG PET-CT also detected other lymph nodal and organ metastases in 46% and 23.8% patients respectively.
Conclusion: 18F-FDG PET-CT is a useful modality for detecting unknown primary and other nodal /distant metastases in patients presenting with neck nodal metastases.

Keywords

Main Subjects


  1. Abbruzzese JL, Abbruzzese MC, Lenzi R, Hess KR, Raber MN. Analysis of a diagnostic strategy for patients with suspected tumors of unknown origin. J Clin Oncol. 1995 Aug;13(8):2094-103.
  2. Saghatchian M, Fizazi K, Borel C, Ducreux M, Ruffié P, Le Chevalier T, Théodore C. Carcinoma of an unknown primary site: a chemotherapy strategy based on histological differentiation--results of a prospective study. Ann Oncol. 2001 Apr;12(4):535-40.
  3. Agarwal V, Branstetter BF 4th, Johnson JT. Indications for PET/CT in the Head and Neck. Otolaryngol Clin North Am. 2008 Feb;41(1):23-49.
  4. van de Wouw AJ, Jansen RL, Speel EJ, Hillen HF. The unknown biology of the unknown primary tumour: a literature review. Ann Oncol. 2003 Feb;14(2):191-6.
  5. Issing WJ, Taleban B, Tauber S. Diagnosis and management of carcinoma of unknown primary in the head and neck. Eur Arch Otorhinolaryngol. 2003 Sep;260(8):436-43.
  6. Muraki AS, Mancuso AA, Harnsberger HR. Metastatic cervical adenopathy from tumors of unknown origin: the role of CT. Radiology. 1984 Sep;152(3):749-53.
  7. Pavlidis N, Fizazi K. Carcinoma of unknown primary (CUP). Crit Rev Oncol Hematol. 2009 Mar;69(3):271-8.
  8. Som P, Atkins HL, Bandoypadhyay D, Fowler JS, MacGregor RR, Matsui K, Oster ZH, Sacker DF, Shiue CY, Turner H, Wan CN, Wolf AP, Zabinski SV. A fluorinated glucose analog, 2-fluoro-2-deoxy-D-glucose (F-18): nontoxic tracer for rapid tumor detection. J Nucl Med. 1980 Jul;21(7):670-5.
  9. Warburg O. On the origin of cancer cells. Science. 1956 Feb 24;123(3191):309-14.
  10. Belkacémi Y, Tsoutsou P, Magné N, Castadot P, Azria D. Metabolic functional imaging for tumor radiosensitivity monitoring. Crit Rev Oncol Hematol. 2007 Jun;62(3):227-39.
  11. Mawlawi O, Townsend DW. Multimodality imaging: an update on PET/CT technology. Eur J Nucl Med Mol Imaging. 2009 Mar;36 Suppl 1:S15-29.
  12. Hanasono MM, Kunda LD, Segall GM, Ku GH, Terris DJ. Uses and limitations of FDG positron emission tomography in occult primary head and neck cancer. Laryngoscope. 1999 Jun;109: 880-5.
  13. Branstetter BF 4th, Blodgett TM, Zimmer LA, Snyderman CH, Johnson JT, Raman S, Meltzer CC. Head and neck malignancy: is PET/CT more accurate than PET or CT alone? Radiology. 2005 May;235(2):580-6.
  14. Fleming Jr AJ, Smith Jr SP, Paul CM, Hall NC, Daly BT, Agrawal A, Schuller DE. Impact of [18F]-2-fluorodeoxyglucose-positron emission tomography/computed tomography on previously untreated head and neck cancer patients. Laryngoscope. 2007 Jul;117(7):1173–9.
  15. Rusthoven KE, Koshy M, Paulino AC. The role of fluorodeoxyglucose positron emission tomography in cervical lymph node metastases from an unknown primary tumor. Cancer. 2004 Dec 1;101(11):2641-9.
  16. Johansen J, Buus S, Loft A, Keiding S, Overgaard M, Hansen HS, Grau C, Bundgaard T, Kirkegaard J, Overgaard J. Prospective study of 18FDG-PET in the detection and management of patients with lymph node metastases to the neck from an unknown primary tumor. Results from the DAHANCA-13 study. Head Neck. 2008 Apr;30(4):471-8.
  17. Kwee TC, Kwee RM. Combined FDG-PET/CT for the detection of unknown primary tumors: systematic review and meta-analysis. Eur Radiol. 2009 Mar;19(3):731-44.
  18. Hassan O, Hamdy TA, Medany MM. The role of FDG PET in the diagnosis of occult primary with cervical lymph node metastases: A meta-analysis study. Egypt. J Ear Nose Throat Allied Sci. 2014; March (15): 7-16.
  19. AAssar OS, Fischbein NJ, Caputo GR, Kaplan MJ, Price DC, Singer MI, Dillon WP, Hawkins RA. Metastatic head and neck cancer: role and usefulness of FDG PET in locating occult primary tumors. Radiology. 1999 Jan;210(1):177-81.
  20. Rudmik L, Lau HY, Matthews TW, Bosch JD, Kloiber R, Molnar CP, Dort JC. Clinical utility of PET/CT in the evaluation of head and neck squamous cell carcinoma with an unknown primary: a prospective clinical trial. Head Neck. 2011 Jul;33(7):935-40.
  21. Wang G, Wu Y, Zhang W, Li J, Wu P, Xie C. Clinical value of whole-body F-18 fluorodeoxyglucose positron emission tomography/computed tomography in patients with carcinoma of unknown primary. J Med Imaging Radiat Oncol. 2013 Feb;57(1):65-71.
  22. Breuer N, Behrendt FF, Heinzel A, Mottaghy FM, Palmowski M, Verburg FA. Prognostic relevance of (18)F-FDG PET/CT in carcinoma of unknown primary. Clin Nucl Med. 2014 Feb;39(2):131-5.
  23. Dong MJ, Zhao K, Lin XT, Zhao J, Ruan LX, Liu ZF. Role of fluorodeoxyglucose-PET versus fluorodeoxyglucose-PET/computed tomography in detection of unknown primary tumor: a meta-analysis of the literature. Nucl Med Commun. 2008 Sep;29(9):791-802.
  24. Stokkel MP, Terhaard CH, Hordijk GJ, van Rijk PP. The detection of unknown primary tumors in patients with cervical metastases by dual-head positron emission tomography. Oral Oncol. 1999 Jul;35(4):390-4.
  25. Lim HS, Yoon W, Chung TW, Kim JK, Park JG, Kang HK, Bom HS, Yoon JH. PET/CT for the detection and evaluation of breast diseases: usefulness and limitations. Radiographics. 2007 Oct;27 Suppl 1:S197-213.
  26. 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 Oct;135(10):1024-9.
  27. Wartski M, Le Stanc E, Gontier E, Vilain D, Banal A, Tainturier C, Pecking AP, Alberini JL. In search of an unknown primary tumour presenting with cervical metastases: Performance of hybrid FDG PET–CT. Nucl Med Commun. 2007 May;28(5):365-71.
  28. Roh JL, Kim JS, Lee JH, Cho KJ, Choi SH, Nam SY, Kim SY. Utility of combined (18)F-fluorodeoxyglucose-positron emission tomography and computed tomography in patients with cervical metastases from unknown primary tumors. Oral Oncol. 2009 Mar;45(3):218-24.
  29. Troell RJ, Terris DJ. Detection of metastases from head and neck cancers. Laryngoscope. 1995 Mar;105(3 Pt 1):247-50.
  30. Dietl B, Marienhagen J, Schaefer C, Pohl F, Murthum T, Kölbl O. Survival with distant metastatic disease in head and neck cancer. A retrospective analysis. HNO. 2007 Oct;55(10):785-6, 788-91.