title: Should PET/CT be implemented in the routine imaging work-up of locally advanced head and neck squamous cell carcinoma? A prospective analysis.
abstract: OBJECTIVE
  The objective of this study was to determine the incremental staging information provided by positron emission tomography/computed tomography (PET/CT) and its impact on management plans in patients with untreated stage III-IV head and neck squamous cell carcinoma (HNSCC).
  
  
  METHODS
  We prospectively studied, between September 2011 and February 2013, 84 consecutive patients [median age 63.5 years (39-84); 73 men] with histologically confirmed HNSCC. First, based on a conventional work-up (physical examination, CT imaging of the head, neck and chest), the multidisciplinary Head and Neck Tumour Board documented the TNM stage and a management plan for each patient, outlining the modalities to be used, including surgery, radiation therapy (RT), chemotherapy or a combination. After release of the PET/CT results, new TNM staging and management plans were agreed on by the multidisciplinary Tumour Board. Any changes in stage or intended management due to the PET/CT findings were then analysed. The impact on patient management was classified as: low (treatment modality, delivery and intent unchanged), moderate (change within the same treatment modality: type of surgery, radiation technique/dose) or high (change in treatment intent and/or treatment modality → curative to palliative, or surgery to chemoradiation or detection of unknown primary tumour or a synchronous second primary tumour). TNM stage was validated by histopathological analysis, additional imaging or follow-up. Accuracy of the conventional and PET/CT-based staging was compared using McNemar's test.
  
  
  RESULTS
  Conventional and PET/CT stages were discordant in 32/84 (38 %) cases: the T stage in 2/32 (6.2 %), the N stage in 21/32 (65.7 %) and the M stage 9/32 (28.1 %). Patient management was altered in 22/84 (26 %) patients, with a moderate impact in 8 (9.5 %) patients and high impact in 14 (16.6 %) patients. PET/CT TNM classification was significantly more accurate (92.5 vs 73.7 %) than conventional staging with a p value < 0.001 (McNemar's test).
  
  
  CONCLUSIONS
  PET/CT should be implemented in the routine imaging work-up of stage III-IV HNSCC.
authors.affiliation: Radiation Oncology Department, Cruces University Hospital, c/Plaza de Cruces s/n, 48903, Barakaldo, Bizkaia (Basque Country), Spain, jon.cacicedofernandezbobadilla@osakidetza.net.
authors.forename: Jon
authors.initials: J
authors.lastname: Cacicedo
authors.forename: Iratxe
authors.initials: I
authors.lastname: Fernandez
authors.forename: Olga
authors.initials: O
authors.lastname: Del Hoyo
authors.forename: Ainara
authors.initials: A
authors.lastname: Dolado
authors.forename: Javier
authors.initials: J
authors.lastname: Gómez-Suarez
authors.forename: Eduardo
authors.initials: E
authors.lastname: Hortelano
authors.forename: Aintzane
authors.initials: A
authors.lastname: Sancho
authors.forename: Jose I
authors.initials: JI
authors.lastname: Pijoan
authors.forename: Julio
authors.initials: J
authors.lastname: Alvarez
authors.forename: Jose M
authors.initials: JM
authors.lastname: Espinosa
authors.forename: Ayman
authors.initials: A
authors.lastname: Gaafar
authors.forename: Pedro
authors.initials: P
authors.lastname: Bilbao
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002294:Carcinoma, Squamous Cell / Q000000981:diagnostic imaging* / Q000473:pathology / Q000628:therapy; D005260:Female; D019788:Fluorodeoxyglucose F18; D006258:Head and Neck Neoplasms / Q000000981:diagnostic imaging* / Q000473:pathology / Q000628:therapy; D006801:Humans; D008297:Male; D008875:Middle Aged; D064847:Multimodal Imaging; D009367:Neoplasm Staging; D049268:Positron-Emission Tomography; D011446:Prospective Studies; D012680:Sensitivity and Specificity; D014057:Tomography, X-Ray Computed
chemical_list: D019788:Fluorodeoxyglucose F18