This document discusses head and neck PET/CT scans. It provides information on:
- The types of cancers that PET/CT scans are used for in the head and neck region.
- The superiority of PET/CT over CT and MRI for detecting lymph node involvement, distant metastases, and unknown primary cancers.
- The key applications of PET/CT including pretreatment staging, radiotherapy planning, monitoring treatment response, follow-up care, and detecting unknown primary cancers.
This document summarizes key aspects of radiation oncology for head and neck cancers. It discusses the history of radiation therapy, basics of radiation biology, and methods of administering radiation including teletherapy, brachytherapy, and stereotactic radiosurgery. Fractionation is described as reducing normal tissue toxicity while maximizing tumor control. Recent advances in radiation delivery techniques like IMRT allow higher precision in targeting tumors while sparing surrounding tissues. Concurrent chemotherapy with radiation is also shown to improve treatment outcomes for head and neck cancers.
CARCINOMA MAXILLARY SINUS MANAGEMENT RADIATION ONCOLOGYPaul George
This document discusses carcinoma of the maxilla, including epidemiology, histology, clinical presentation, staging, investigations, management, and prognosis. Squamous cell carcinoma is the most common type, presenting more in men in the 5th-6th decade. Clinical evaluation includes imaging like CT and MRI to determine extent. Treatment involves surgery like maxillectomy with clear margins followed by postoperative radiation therapy to improve outcomes. Prognosis remains poor at a 5-year survival of 35-45% even with multimodality treatment. A case example is presented of a 58-year-old female smoker found to have cT2N0M0 carcinoma of the left maxilla who underwent subtotal maxillectomy followed
The document discusses post-operative radiotherapy for oral cavity cancer. It notes that oral cavity cancer is the 11th most common cancer worldwide and is usually squamous cell carcinoma. For early stage disease, surgery or radiotherapy alone is effective, while advanced stages require multimodal therapy. Post-operative radiotherapy improves local control, especially for those with adverse features like positive margins or extracapsular nodal extension. Concurrent chemoradiotherapy using cisplatin is now standard for these high-risk patients based on trials showing improved survival outcomes.
This document provides an overview of Intensity Modulated Radiotherapy (IMRT). It discusses the shift from conventional to conformal radiotherapy using improved imaging and planning techniques. IMRT allows customization of radiation dose distributions through non-uniform beam intensities achieved using dynamic multileaf collimators or compensators. The clinical implementation of IMRT requires treatment planning and delivery systems. IMRT offers advantages over conventional radiotherapy for many cancer types and its use has increased substantially in recent decades.
Reirradiation can provide local tumor control for recurrent head and neck cancer when surgery is not possible. Modern radiation techniques like IMRT allow higher radiation doses to be safely delivered to the tumor while minimizing risks of severe toxicity. Outcomes from reirradiation include a median survival of 10-12 months and 2-year local control rates of 40-64%. Patient selection is important to balance potential benefits of local tumor control against risks of treatment-related side effects.
Stereotactic body radiation therapy (SBRT) uses advanced technology to deliver high ablative doses of radiation to tumors in a precise manner. SBRT has been shown to be effective in treating various tumor types with acceptable toxicity. However, long term toxicity requires further study. New techniques aim to reduce treatment margins and account for organ motion to minimize dose to surrounding healthy tissues while ensuring accurate dose delivery to the tumor. SBRT shows promise but further prospective clinical trials are needed to fully evaluate efficacy and safety.
Carcinoma nasopharynx anatomy to managementDrAyush Garg
The document provides information on carcinoma of the nasopharynx, including its anatomy, epidemiology, etiology, clinical features, patterns of spread, diagnostic evaluation, and metastatic workup. The key points are:
1) Nasopharyngeal carcinoma is most common in Southern Chinese populations and has a bimodal age distribution. Viral, genetic, and environmental factors like Epstein-Barr virus and salted fish contribute to its etiology.
2) The tumor can spread superiorly into the skull base, anteriorly into the nasal cavity/sinuses, and posteriorly into neck muscles and brain. Distant metastases most often involve bones and lungs.
3) Diagnostic evaluation includes endoscopic
This document summarizes key aspects of radiation oncology for head and neck cancers. It discusses the history of radiation therapy, basics of radiation biology, and methods of administering radiation including teletherapy, brachytherapy, and stereotactic radiosurgery. Fractionation is described as reducing normal tissue toxicity while maximizing tumor control. Recent advances in radiation delivery techniques like IMRT allow higher precision in targeting tumors while sparing surrounding tissues. Concurrent chemotherapy with radiation is also shown to improve treatment outcomes for head and neck cancers.
CARCINOMA MAXILLARY SINUS MANAGEMENT RADIATION ONCOLOGYPaul George
This document discusses carcinoma of the maxilla, including epidemiology, histology, clinical presentation, staging, investigations, management, and prognosis. Squamous cell carcinoma is the most common type, presenting more in men in the 5th-6th decade. Clinical evaluation includes imaging like CT and MRI to determine extent. Treatment involves surgery like maxillectomy with clear margins followed by postoperative radiation therapy to improve outcomes. Prognosis remains poor at a 5-year survival of 35-45% even with multimodality treatment. A case example is presented of a 58-year-old female smoker found to have cT2N0M0 carcinoma of the left maxilla who underwent subtotal maxillectomy followed
The document discusses post-operative radiotherapy for oral cavity cancer. It notes that oral cavity cancer is the 11th most common cancer worldwide and is usually squamous cell carcinoma. For early stage disease, surgery or radiotherapy alone is effective, while advanced stages require multimodal therapy. Post-operative radiotherapy improves local control, especially for those with adverse features like positive margins or extracapsular nodal extension. Concurrent chemoradiotherapy using cisplatin is now standard for these high-risk patients based on trials showing improved survival outcomes.
This document provides an overview of Intensity Modulated Radiotherapy (IMRT). It discusses the shift from conventional to conformal radiotherapy using improved imaging and planning techniques. IMRT allows customization of radiation dose distributions through non-uniform beam intensities achieved using dynamic multileaf collimators or compensators. The clinical implementation of IMRT requires treatment planning and delivery systems. IMRT offers advantages over conventional radiotherapy for many cancer types and its use has increased substantially in recent decades.
Reirradiation can provide local tumor control for recurrent head and neck cancer when surgery is not possible. Modern radiation techniques like IMRT allow higher radiation doses to be safely delivered to the tumor while minimizing risks of severe toxicity. Outcomes from reirradiation include a median survival of 10-12 months and 2-year local control rates of 40-64%. Patient selection is important to balance potential benefits of local tumor control against risks of treatment-related side effects.
Stereotactic body radiation therapy (SBRT) uses advanced technology to deliver high ablative doses of radiation to tumors in a precise manner. SBRT has been shown to be effective in treating various tumor types with acceptable toxicity. However, long term toxicity requires further study. New techniques aim to reduce treatment margins and account for organ motion to minimize dose to surrounding healthy tissues while ensuring accurate dose delivery to the tumor. SBRT shows promise but further prospective clinical trials are needed to fully evaluate efficacy and safety.
Carcinoma nasopharynx anatomy to managementDrAyush Garg
The document provides information on carcinoma of the nasopharynx, including its anatomy, epidemiology, etiology, clinical features, patterns of spread, diagnostic evaluation, and metastatic workup. The key points are:
1) Nasopharyngeal carcinoma is most common in Southern Chinese populations and has a bimodal age distribution. Viral, genetic, and environmental factors like Epstein-Barr virus and salted fish contribute to its etiology.
2) The tumor can spread superiorly into the skull base, anteriorly into the nasal cavity/sinuses, and posteriorly into neck muscles and brain. Distant metastases most often involve bones and lungs.
3) Diagnostic evaluation includes endoscopic
This document discusses brachytherapy techniques for head and neck cancers. It describes different types of brachytherapy based on positioning of the radionuclide (interstitial, intracavitary, surface moulds), dose rate (LDR, MDR, HDR, PDR), and technique (temporary, permanent). It also discusses dosimetry systems like Patterson-Parker, Quimby, Paris and computerized planning. Key aspects of treatment planning, delivery, and post-treatment care are summarized. Advantages include localized high dose with rapid falloff and organ preservation, while limitations include inaccessibility and quality dependence on implant. American Brachytherapy Society guidelines emphasize accurate assessment and dental
The document discusses craniospinal irradiation (CSI), which delivers radiation to the entire cranial-spinal axis to treat intracranial tumors. It was pioneered in the 1950s and is commonly used to treat tumors that may spread through the cerebrospinal fluid such as medulloblastoma. The document outlines the techniques, challenges, indications, and evolving approaches for CSI such as reduced dose protocols and hyperfractionated regimens. It discusses topics like patient positioning, target volumes, critical structures, field arrangements, and the use of newer technologies like virtual simulation.
The document discusses intensity-modulated radiation therapy (IMRT) for head and neck cancers. It describes how IMRT improves target coverage and sparing of organs-at-risk like the parotid glands compared to conventional radiation therapy. Studies show IMRT reduces the risk of xerostomia and improves quality of life outcomes for patients.
This document outlines the steps for 2D planning in brain tumor treatment. It describes using a clinical simulator and digitizer to outline the tumor on sequential CT slices using landmarks from a localization image. Points are marked on each slice and connected to generate the tumor contour. Margins are added to create the treatment field. Examples are given of different beam arrangements like parallel opposed pairs and wedge combinations. Quality assurance procedures like checking port films are also discussed. Examples of plans for conditions like pituitary tumors and whole brain radiotherapy are included. The importance of sparing organs at risk is emphasized.
This document discusses the anatomy, staging, treatment and techniques for carcinoma of the nasopharynx. It describes the parapharyngeal space and lymphatic drainage of the nasopharynx. It discusses the AJCC staging system and Ho's staging system. It covers treatment techniques including two-field and three-field approaches, doses used, treatment volumes, nodal volumes, planning and field matching considerations.
This document discusses image-guided radiation therapy (IGRT) and various IGRT techniques. It describes how IGRT aims to increase the accuracy and precision of radiotherapy delivery by applying image-based target relocalization. Common IGRT techniques mentioned include portal imaging, on-board cone-beam CT (CBCT), in-room CT, ultrasound and real-time tumor tracking. CBCT allows visualization of the tumor location using kilovoltage or megavoltage X-rays rotating around the patient. Real-time tumor tracking involves synchronizing radiation delivery with the respiratory cycle using implanted fiducial markers and fluoroscopy.
This document discusses the use of radiation therapy for various benign diseases. It provides an overview of indications for radiation therapy in benign tumors and conditions of the nervous system, head and neck region, orbits, skin and soft tissues, and skeletal system. Risks of secondary malignancies from radiation are outlined. The document reviews evidence-based radiation doses and techniques for specific benign diseases.
This document discusses treatment options for head and neck cancer including radiation therapy. It notes that treatment decisions should be made by a multidisciplinary team including surgeons, radiation oncologists, medical oncologists, and support staff. For early stage cancer, options are surgery or radiation alone, while more advanced cancers may receive chemo-radiation or surgery plus radiation and chemotherapy. Radiation uses CT and PET imaging to precisely target the tumor and spare normal tissues. Short term side effects include skin irritation, mouth sores, and difficulty swallowing. Long term side effects can include permanent dry mouth and dental problems. The document provides images showing results of treatment and side effects over time.
Fractionation in radiotherapy refers to dividing the total radiation dose into smaller doses given over multiple treatment sessions. This allows healthy cells to repair sublethal damage between fractions while maximizing cancer cell kill through mechanisms like redistribution and reoxygenation. The "5 R's" of radiobiology explain fractionation: repair of sublethal damage in normal cells; redistribution of tumor cells to sensitive phases; reoxygenation of hypoxic tumor cells; repopulation of tumor cells during prolonged treatment; and intrinsic radiosensitivity differences between cell types. Fractionation schedules are tailored based on these factors to improve the therapeutic ratio for different cancers and patients.
Radiotherapy techniques, indications and evidences in oral cavity and oropha...Dr.Amrita Rakesh
This document discusses indications, evidence, and radiation therapy techniques for oral cavity and oropharyngeal cancers. It covers:
- Anatomy of the oral cavity and oropharynx.
- Staging principles and indications for surgery vs systemic therapy.
- Principles of surgery including adequate resection margins and neck management.
- Use of adjuvant radiation therapy or chemoradiation to improve local control, especially for high-risk features like positive margins or extracapsular extension.
- Radiation techniques for oral cavity cancers including field design, dose recommendations, and advantages of IMRT for sparing parotid glands.
the role of brachytherapy in oral cavity carcinoma.
physics of brachytherapy
radiobiology of brachytherapy
clinical application in tongue, buccal mucosa cancer
Imaging HNF(head neck and face) -canceramol lahoti
1. Imaging plays an important role in head and neck cancer for tumor detection, characterization, staging, treatment planning, and monitoring treatment response and recurrence. MRI is often the preferred initial imaging modality, while CT and PET are also used.
2. Ultrasound is useful for imaging neck lymph nodes and salivary glands. CT is better for evaluating bone involvement. PET is used for detecting distant metastases.
3. Imaging also guides biopsies and interventions such as embolization prior to surgery. Advances include functional MRI, PET/CT, and intra-arterial chemotherapy.
Radiotherapy in hepatocellular carcinomasPratap Tiwari
External Radiotherapy in hepatocellular carcinomas (HCC). A brief summary of the guidelines statements on radiotherapy role in hepatocellular carcinoma (hcc).
Nasopharyngeal carcinoma is typically treated with radiation therapy. Concurrent chemotherapy and radiation is the standard for locally advanced disease and improves survival compared to radiation alone. Intensity-modulated radiation therapy provides better tumor coverage and reduces side effects. Surgery has a limited role except for biopsy or salvaging recurrent tumors. Temporal lobe necrosis is a serious potential complication, so fractional doses above 2Gy should be avoided. Close follow-up is needed due to risk of recurrence or late effects.
Intensity modulated radiation therapy (IMRT) is an advanced form of 3D conformal radiation therapy that uses computer-controlled linear accelerators to modulate beam intensities within each beam's projection. This allows for higher radiation doses to be delivered to tumors while reducing doses to surrounding healthy tissues. Treatment planning for IMRT involves inverse planning where optimization software determines the optimal beam intensities to meet dose requirements. Intensity is modulated during treatment using multileaf collimators which shape the beam as it is delivered. IMRT has applications in treating many types of cancer as it improves target dose conformity and reduces doses to organs-at-risk compared to other radiation therapy techniques.
This document discusses the anatomy, clinical presentation, management, and treatment of cancers affecting the paranasal sinuses. It begins with an overview of the anatomy of the different paranasal sinuses and their relationships to surrounding structures. It then discusses the clinical presentation of sinus cancers, which can include nasal obstruction, eye symptoms, facial pain or numbness. The document reviews imaging techniques like CT and MRI to evaluate tumor extent. Management options are also summarized, including surgical resection with or without radiation therapy or chemotherapy based on tumor size and spread. Post-operative radiation techniques like IMRT and proton beam therapy are mentioned. Overall survival rates from historical studies on paranasal sinus cancer treatment are provided.
PET and radiotherapy for head and neck cancer provides essential information for target volume selection and delineation. Functional imaging with FDG-PET is more sensitive and specific than CT or MRI for detecting metastatic lymph nodes. Integrating PET into the treatment planning process allows more accurate gross tumor volume definition compared to CT alone. Adaptive radiotherapy using serial PET imaging during treatment may enable biological target volume adaptation and improved dose distribution optimization. Future applications include exploring other PET tracers and integrating multi-modality image registration with dose adaptation.
Mr. Sunil, a 72-year-old male, presented with a 3-month history of a left neck swelling. Further examinations revealed metastatic squamous cell carcinoma in the left neck lymph nodes. He was diagnosed with carcinoma of unknown primary (CUP) and underwent radical neck dissection, followed by chemotherapy and radiotherapy. CUP describes metastatic cancers where the primary site cannot be identified despite various examinations and evaluations. Treatment options for CUP include surgery, radiation therapy, chemotherapy, or concurrent chemoradiation depending on the lymph node involvement and other factors. Prognosis depends on the stage and presence of extracapsular extension, with 5-year survival rates ranging from 30% for upper cervical nodes to 5%
This document outlines the key aspects of radiotherapy treatment planning for rectal cancer, including:
1) The epidemiology of rectal cancer, stages of disease, and patient positioning and immobilization techniques.
2) How to define the target volumes including the gross tumor, clinical target volume, and planning target volume based on disease stage and risk of lymph node involvement.
3) Typical three-field beam arrangements and doses of 45-50.4 Gy given in 1.8 Gy fractions for preoperative or postoperative radiotherapy, with additional boost doses sometimes used.
4) The acute and chronic complications of radiotherapy and dose constraints for organs at risk like the small bowel and bladder.
1. FDG PET/CT is a valuable tool for diagnosing, staging, and monitoring treatment response in head and neck cancers. It provides both functional imaging of glucose metabolism from PET and anatomic details from CT.
2. PET/CT is especially useful for detecting oral cavity tumors when CT and MRI are limited by dental artifacts, and for identifying unknown primary tumors that are otherwise not detectable with other imaging.
3. A negative PET/CT scan after treatment indicates a high likelihood of complete response, but non-cancerous inflammatory changes can sometimes mimic residual tumor on PET scans. Patient preparation and protocol are important for accurate PET/CT interpretation.
This document discusses advances in oncological PET imaging. It begins by outlining limitations of current PET/CT imaging related to false positives, false negatives, and radiation exposure. It then describes several advances in PET imaging including new radiotracers for tumor characterization, instrumentation improvements, software enhancements to reduce radiation dose, and hybrid PET/MRI imaging. The document provides examples of how various new radiotracers beyond FDG can provide clinical benefits for tumor imaging and characterization.
This document discusses brachytherapy techniques for head and neck cancers. It describes different types of brachytherapy based on positioning of the radionuclide (interstitial, intracavitary, surface moulds), dose rate (LDR, MDR, HDR, PDR), and technique (temporary, permanent). It also discusses dosimetry systems like Patterson-Parker, Quimby, Paris and computerized planning. Key aspects of treatment planning, delivery, and post-treatment care are summarized. Advantages include localized high dose with rapid falloff and organ preservation, while limitations include inaccessibility and quality dependence on implant. American Brachytherapy Society guidelines emphasize accurate assessment and dental
The document discusses craniospinal irradiation (CSI), which delivers radiation to the entire cranial-spinal axis to treat intracranial tumors. It was pioneered in the 1950s and is commonly used to treat tumors that may spread through the cerebrospinal fluid such as medulloblastoma. The document outlines the techniques, challenges, indications, and evolving approaches for CSI such as reduced dose protocols and hyperfractionated regimens. It discusses topics like patient positioning, target volumes, critical structures, field arrangements, and the use of newer technologies like virtual simulation.
The document discusses intensity-modulated radiation therapy (IMRT) for head and neck cancers. It describes how IMRT improves target coverage and sparing of organs-at-risk like the parotid glands compared to conventional radiation therapy. Studies show IMRT reduces the risk of xerostomia and improves quality of life outcomes for patients.
This document outlines the steps for 2D planning in brain tumor treatment. It describes using a clinical simulator and digitizer to outline the tumor on sequential CT slices using landmarks from a localization image. Points are marked on each slice and connected to generate the tumor contour. Margins are added to create the treatment field. Examples are given of different beam arrangements like parallel opposed pairs and wedge combinations. Quality assurance procedures like checking port films are also discussed. Examples of plans for conditions like pituitary tumors and whole brain radiotherapy are included. The importance of sparing organs at risk is emphasized.
This document discusses the anatomy, staging, treatment and techniques for carcinoma of the nasopharynx. It describes the parapharyngeal space and lymphatic drainage of the nasopharynx. It discusses the AJCC staging system and Ho's staging system. It covers treatment techniques including two-field and three-field approaches, doses used, treatment volumes, nodal volumes, planning and field matching considerations.
This document discusses image-guided radiation therapy (IGRT) and various IGRT techniques. It describes how IGRT aims to increase the accuracy and precision of radiotherapy delivery by applying image-based target relocalization. Common IGRT techniques mentioned include portal imaging, on-board cone-beam CT (CBCT), in-room CT, ultrasound and real-time tumor tracking. CBCT allows visualization of the tumor location using kilovoltage or megavoltage X-rays rotating around the patient. Real-time tumor tracking involves synchronizing radiation delivery with the respiratory cycle using implanted fiducial markers and fluoroscopy.
This document discusses the use of radiation therapy for various benign diseases. It provides an overview of indications for radiation therapy in benign tumors and conditions of the nervous system, head and neck region, orbits, skin and soft tissues, and skeletal system. Risks of secondary malignancies from radiation are outlined. The document reviews evidence-based radiation doses and techniques for specific benign diseases.
This document discusses treatment options for head and neck cancer including radiation therapy. It notes that treatment decisions should be made by a multidisciplinary team including surgeons, radiation oncologists, medical oncologists, and support staff. For early stage cancer, options are surgery or radiation alone, while more advanced cancers may receive chemo-radiation or surgery plus radiation and chemotherapy. Radiation uses CT and PET imaging to precisely target the tumor and spare normal tissues. Short term side effects include skin irritation, mouth sores, and difficulty swallowing. Long term side effects can include permanent dry mouth and dental problems. The document provides images showing results of treatment and side effects over time.
Fractionation in radiotherapy refers to dividing the total radiation dose into smaller doses given over multiple treatment sessions. This allows healthy cells to repair sublethal damage between fractions while maximizing cancer cell kill through mechanisms like redistribution and reoxygenation. The "5 R's" of radiobiology explain fractionation: repair of sublethal damage in normal cells; redistribution of tumor cells to sensitive phases; reoxygenation of hypoxic tumor cells; repopulation of tumor cells during prolonged treatment; and intrinsic radiosensitivity differences between cell types. Fractionation schedules are tailored based on these factors to improve the therapeutic ratio for different cancers and patients.
Radiotherapy techniques, indications and evidences in oral cavity and oropha...Dr.Amrita Rakesh
This document discusses indications, evidence, and radiation therapy techniques for oral cavity and oropharyngeal cancers. It covers:
- Anatomy of the oral cavity and oropharynx.
- Staging principles and indications for surgery vs systemic therapy.
- Principles of surgery including adequate resection margins and neck management.
- Use of adjuvant radiation therapy or chemoradiation to improve local control, especially for high-risk features like positive margins or extracapsular extension.
- Radiation techniques for oral cavity cancers including field design, dose recommendations, and advantages of IMRT for sparing parotid glands.
the role of brachytherapy in oral cavity carcinoma.
physics of brachytherapy
radiobiology of brachytherapy
clinical application in tongue, buccal mucosa cancer
Imaging HNF(head neck and face) -canceramol lahoti
1. Imaging plays an important role in head and neck cancer for tumor detection, characterization, staging, treatment planning, and monitoring treatment response and recurrence. MRI is often the preferred initial imaging modality, while CT and PET are also used.
2. Ultrasound is useful for imaging neck lymph nodes and salivary glands. CT is better for evaluating bone involvement. PET is used for detecting distant metastases.
3. Imaging also guides biopsies and interventions such as embolization prior to surgery. Advances include functional MRI, PET/CT, and intra-arterial chemotherapy.
Radiotherapy in hepatocellular carcinomasPratap Tiwari
External Radiotherapy in hepatocellular carcinomas (HCC). A brief summary of the guidelines statements on radiotherapy role in hepatocellular carcinoma (hcc).
Nasopharyngeal carcinoma is typically treated with radiation therapy. Concurrent chemotherapy and radiation is the standard for locally advanced disease and improves survival compared to radiation alone. Intensity-modulated radiation therapy provides better tumor coverage and reduces side effects. Surgery has a limited role except for biopsy or salvaging recurrent tumors. Temporal lobe necrosis is a serious potential complication, so fractional doses above 2Gy should be avoided. Close follow-up is needed due to risk of recurrence or late effects.
Intensity modulated radiation therapy (IMRT) is an advanced form of 3D conformal radiation therapy that uses computer-controlled linear accelerators to modulate beam intensities within each beam's projection. This allows for higher radiation doses to be delivered to tumors while reducing doses to surrounding healthy tissues. Treatment planning for IMRT involves inverse planning where optimization software determines the optimal beam intensities to meet dose requirements. Intensity is modulated during treatment using multileaf collimators which shape the beam as it is delivered. IMRT has applications in treating many types of cancer as it improves target dose conformity and reduces doses to organs-at-risk compared to other radiation therapy techniques.
This document discusses the anatomy, clinical presentation, management, and treatment of cancers affecting the paranasal sinuses. It begins with an overview of the anatomy of the different paranasal sinuses and their relationships to surrounding structures. It then discusses the clinical presentation of sinus cancers, which can include nasal obstruction, eye symptoms, facial pain or numbness. The document reviews imaging techniques like CT and MRI to evaluate tumor extent. Management options are also summarized, including surgical resection with or without radiation therapy or chemotherapy based on tumor size and spread. Post-operative radiation techniques like IMRT and proton beam therapy are mentioned. Overall survival rates from historical studies on paranasal sinus cancer treatment are provided.
PET and radiotherapy for head and neck cancer provides essential information for target volume selection and delineation. Functional imaging with FDG-PET is more sensitive and specific than CT or MRI for detecting metastatic lymph nodes. Integrating PET into the treatment planning process allows more accurate gross tumor volume definition compared to CT alone. Adaptive radiotherapy using serial PET imaging during treatment may enable biological target volume adaptation and improved dose distribution optimization. Future applications include exploring other PET tracers and integrating multi-modality image registration with dose adaptation.
Mr. Sunil, a 72-year-old male, presented with a 3-month history of a left neck swelling. Further examinations revealed metastatic squamous cell carcinoma in the left neck lymph nodes. He was diagnosed with carcinoma of unknown primary (CUP) and underwent radical neck dissection, followed by chemotherapy and radiotherapy. CUP describes metastatic cancers where the primary site cannot be identified despite various examinations and evaluations. Treatment options for CUP include surgery, radiation therapy, chemotherapy, or concurrent chemoradiation depending on the lymph node involvement and other factors. Prognosis depends on the stage and presence of extracapsular extension, with 5-year survival rates ranging from 30% for upper cervical nodes to 5%
This document outlines the key aspects of radiotherapy treatment planning for rectal cancer, including:
1) The epidemiology of rectal cancer, stages of disease, and patient positioning and immobilization techniques.
2) How to define the target volumes including the gross tumor, clinical target volume, and planning target volume based on disease stage and risk of lymph node involvement.
3) Typical three-field beam arrangements and doses of 45-50.4 Gy given in 1.8 Gy fractions for preoperative or postoperative radiotherapy, with additional boost doses sometimes used.
4) The acute and chronic complications of radiotherapy and dose constraints for organs at risk like the small bowel and bladder.
1. FDG PET/CT is a valuable tool for diagnosing, staging, and monitoring treatment response in head and neck cancers. It provides both functional imaging of glucose metabolism from PET and anatomic details from CT.
2. PET/CT is especially useful for detecting oral cavity tumors when CT and MRI are limited by dental artifacts, and for identifying unknown primary tumors that are otherwise not detectable with other imaging.
3. A negative PET/CT scan after treatment indicates a high likelihood of complete response, but non-cancerous inflammatory changes can sometimes mimic residual tumor on PET scans. Patient preparation and protocol are important for accurate PET/CT interpretation.
This document discusses advances in oncological PET imaging. It begins by outlining limitations of current PET/CT imaging related to false positives, false negatives, and radiation exposure. It then describes several advances in PET imaging including new radiotracers for tumor characterization, instrumentation improvements, software enhancements to reduce radiation dose, and hybrid PET/MRI imaging. The document provides examples of how various new radiotracers beyond FDG can provide clinical benefits for tumor imaging and characterization.
This document discusses stereotactic body radiation therapy (SBRT) for head and neck cancers. It provides an overview of SBRT indications, efficacy, toxicity profiles, quality of life outcomes, fractionation schedules, target definition, constraints, and the role of cetuximab. Several studies on SBRT for recurrent head and neck cancers, primary cancers metastatic to the head and neck region, and target volume delineation are summarized. Toxicities are generally low but carotid blowout syndrome remains a concern, especially for tumors adjacent to carotid arteries.
Induction chemotherapy followed by concurrent ct rt versus ct-rt in advanced ...Santam Chakraborty
Induction chemotherapy followed by concurrent chemoradiation (CT-RT) has been studied as an alternative to primary CT-RT for locally advanced head and neck cancers. Meta-analyses have found induction chemotherapy provides no survival benefit compared to primary CT-RT and is associated with increased toxicity. Recent large randomized trials could not demonstrate an improvement with induction chemotherapy due to inadequate accrual and poor compliance with subsequent CT-RT. While induction chemotherapy may improve organ preservation or outcomes for select subgroups like HPV-negative cancers, current evidence indicates primary CT-RT remains the standard of care for most patients.
PET scans use radioactive tracers to detect metabolic activity in cells that can indicate cancer. The document discusses PET scans and PET-CT scans, how they work, and their main uses in pulmonology such as characterizing lung nodules, staging lung cancer, detecting metastases, and monitoring treatment response. PET scans have high sensitivity and specificity for detecting malignant lung lesions and lymph node involvement compared to CT alone.
This document provides an overview of CT staging for carcinoma of the esophagus, including:
- The AJCC 8th edition TNM staging system which includes clinical, pathologic, and post-neoadjuvant pathologic classifications.
- The roles of various imaging modalities like CT, PET/CT, EUS in evaluating tumor invasion, nodal status, metastasis, and post-treatment assessment.
- Key points in evaluating resectability, postsurgical complications, and emerging trends like the use of other tracers beyond FDG-PET.
Role Of Integrated Pet-Ct In Cancer of Unknown PrimaryApollo Hospitals
1. The study evaluated the role of integrated PET-CT in detecting the primary tumor in 69 patients with cancer of unknown primary.
2. PET-CT was able to detect the primary tumor in 49 patients (71%), with the most common sites being the lung (31%) and head and neck (26%).
3. PET-CT identified the primary tumor or provided additional useful information in staging in about half of the cases compared to CT alone.
- Induction chemotherapy has a role in borderline resectable or unresectable oral cavity cancers, converting 30-40% to resectable. Patients who undergo surgery after chemotherapy have superior survival.
- The 3-drug TPF regimen is more effective than 2-drug PF, but more toxic. Concurrent chemoradiation is standard for locally advanced cases.
- Adjuvant radiation improves outcomes for T2N1 and higher-risk T1N1 oral cancers, especially with factors like positive margins, ECE, LVSI. Adjuvant chemoradiation benefits patients with 2-4 positive nodes.
Management of differentiated thyroid canncer.pptxMohammed rabei
Differentiated thyroid cancers include papillary, follicular, and Hürthle cell cancers. Thyroid nodules are common, and thyroid cancer incidence is rising, though deaths have remained stable. Most thyroid cancers have an indolent course. Evaluation involves history, exam, ultrasound, thyroid function tests, and fine needle aspiration if indicated. Treatment depends on risk stratification based on staging, with options including active surveillance, hemithyroidectomy, or total thyroidectomy.
Multidisciplinary consensus statement on the clinical management of patient w...ssuser118306
This document presents a multidisciplinary consensus statement on the clinical management of patients with stage III non-small cell lung cancer (NSCLC) from several Spanish scientific societies. It discusses the heterogeneity of stage III NSCLC and the importance of accurate staging and multidisciplinary treatment planning. The summary provides guidelines on non-invasive and invasive staging techniques and recommends surgical staging when non-surgical methods are negative or non-conclusive to accurately determine tumor involvement and develop optimal treatment plans.
Diagnosis: Prompt and accurate diagnosis is crucial. It involves imaging tests such as X-rays, CT scans, and MRIs, as well as biopsies to confirm the presence of pleural mesothelioma.
Treatment options: The management of pleural mesothelioma typically involves a multidisciplinary approach, which may include surgery, chemotherapy, and radiation therapy. The choice of treatment depends on the stage and extent of the disease, as well as the patient's overall health.
Surgical interventions: Surgical options may include pleurectomy/decortication (removal of the affected tissue lining the lungs) or extrapleural pneumonectomy (removal of the affected lung, lining, and nearby structures). These procedures aim to remove as much of the cancerous tissue as possible.
Chemotherapy: Chemotherapy drugs are often used to kill or slow the growth of cancer cells. They can be administered orally or through intravenous infusions. Sometimes, chemotherapy is given before surgery to shrink tumors and after surgery to target any remaining cancer cells.
Radiation therapy: This treatment involves the use of high-energy X-rays or other radiation sources to target and destroy cancer cells. It can be used before or after surgery, or as a standalone treatment to alleviate symptoms and manage the disease.
Palliative care: Palliative care focuses on improving the quality of life for patients by managing pain, reducing symptoms, and providing emotional and psychological support. It can be integrated into the treatment plan at any stage of the disease.
This document discusses the management of carcinoma of the esophagus. It begins by outlining treatment approaches for localized versus metastatic disease, including definitive and palliative therapies. It then reviews the evolution of esophageal cancer treatment, including non-surgical approaches using radiation therapy alone or combined modality therapy, as well as surgical treatments. Several studies evaluating different treatment regimens are summarized, including the benefits of concurrent chemoradiation therapy over radiation alone. The role of preoperative chemoradiation is discussed. Techniques for radiation therapy delivery are also outlined. The document concludes by discussing palliative care approaches for esophageal cancer patients.
The document discusses using intensity-modulated radiation therapy (IMRT) for the treatment of anal cancer. Dosimetric studies and small clinical trials show that IMRT reduces radiation dosing and toxicity to normal tissues compared to conventional radiation therapy, without decreasing treatment effectiveness or local cancer control. Larger clinical trials are still needed to further evaluate IMRT for anal cancer and detect possible small variations in outcomes. The Radiation Therapy Oncology Group is currently conducting a phase II trial to further evaluate dose-painted IMRT for anal cancer.
Radiotherapy plays an important role in the management of urinary bladder cancers. It can be used as part of bladder-preserving protocols for muscle-invasive bladder cancer or as palliative treatment in elderly patients. Combined modality treatment with transurethral resection and concurrent chemoradiotherapy provides 5-year overall survival of 50-65% and bladder preservation in 38-43% of patients. External beam radiotherapy is typically delivered with a 4-field box technique to the whole pelvis at 45-50 Gy followed by a bladder boost to 60-65 Gy.
Radiotherapy contouring guideline for non-hodgkin lymphomaketan kalariya
This document provides guidelines for modern radiation therapy for nodal non-Hodgkin lymphoma. It outlines a new concept of involved-site radiation therapy using reduced treatment volumes based on imaging to define target volumes. Guidelines are provided for radiation therapy as primary treatment, as part of combined modality treatment, and for recurrent or refractory disease. Recommended doses and techniques such as IMRT are discussed depending on the clinical situation and disease stage. The goal is to restrict radiation therapy to limited involved sites to reduce normal tissue exposure while maintaining local tumor control.
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The principles of head and neck PET/CT
1. The principles of head and neck
PET/CT scan
Tehran University of Medical Sciences
Shariati Hospital
Nuclear Medicine Department
Dr. Mustafa Al-Thabhawee
2. The term head and neck cancer (HNC) generally encompasses malignant neoplasms of soft
tissue origin of the oral cavity, lips, nasal cavity, paranasal sinuses, pharynx, larynx and
salivary glands, as well as sarcomas arising in this region.
The skin is sometimes included as well. About 95% are squamous cell carcinomas (or
variants) arising from the mucosa or adenocarcinomas from the associated secretory
glands. Infection by the human papillomavirus is recognized as an important predisposing
condition for the development of squamous cell carcinomas of the head and neck.
Positron emission tomography (PET) imaging with the radiolabelled glucose analogue 2-
deoxy-2-[18F]fluoro-d-glucose ([18F]FDG) plays an increasingly important role in the
pretreatment staging, radiotherapy planning, treatment response assessment and post-
therapy follow-up in various HNSCCs. [18F]FDG PET/CT is superior to contrast-enhanced
computed tomography (CT) and magnetic resonance imaging (MRI) in the detection of
carcinomas of unknown primary (CUP), of cervical lymph node involvement and in the
identification of distant metastases.
3. Q. What are the factors that determine the initial treatment?
The factors that determine the initial treatment are those:
1. Related to tumor characteristics (size, location, histology and nodal and metastatic
involvement).
2. The patient (age and general condition) and the factors depending on availability.
Most patients present with complicated locally advanced disease requiring multidisciplinary
treatment plans based on variable combinations of surgery, radiation therapy and
chemotherapy.
4. Q. What are the indications to perform PET/CT in head and neck
tumors?
1. Pretreatment Staging
Numerous of reports on initial staging indicate that the sensitivity of PET/CT is equivalent to or
superior to that of MRI and CT. In comparison to morphological imaging methods (CT or MRI),
PET/CT is particularly advantageous in allowing:
assessment of neck lymph nodes.
potential distant metastases.
synchronous second primaries in a single examination (see Figs. 19.1 and 19.2). The
sensitivity and specificity of [18F]FDG PET/CT in staging nodal disease of about 79–85% and
84–86%, respectively, whereas sensitivity and specificity of conventional diagnostic tests
(MRI, CT and ultrasounds) were 75% and 79%, respectively
5. Approximately 4–15.4% of patients with HNSCC have distant metastases at initial presentation.
The most common sites of metastasis include the lung, bone and abdomen.
Whole-body [18F]FDG PET/CT is more accurate than conventional imaging for detection of
metastatic foci.
In addition, [18F]FDG PET/CT detects distant metastases or a second primary tumor in up to 15%
patients with squamous cell carcinoma, which can significantly alter treatment plans.
In 2017, the National Comprehensive Center Network updated the clinical practice guidelines
for PET/CT imaging of head and neck cancer and suggested the use of PET/CT for initial staging
of oral cavity, oropharyngeal, hypopharyngeal, glottic and supraglottic cancers for stage III–IV
disease, as well as mucosal melanoma and nasopharyngeal Carcinoma.
6.
7.
8. Q. What is the Synchronous Lesions?
The most common areas for second primary tumors are the lung and aero digestive tract .The overall incidence of
coincidental secondary primary tumors is 5 to 10%. PET has an accuracy of 80% for coincidental lung lesions. PET/CT
detected 84% of synchronous primaries, and therapy was changed in 80% of patients due to detection of synchronous
primaries. In another study, PET/CT was superior to pan-endoscopy for the detection of synchronous primaries, and the
authors suggest that the extent of endoscopy can be reduced to the area of the primary tumor if PET/CT is negative.
9. Staging, Grading, & Classification
• General
○ Most sites of H&N use same AJCC (2010) TNM staging system, including lip, oral cavity, oropharynx, hypopharynx, larynx,
and salivary glands
• Tumor (some site specific criteria for advanced staging)
○ T1: ≤ 2 cm
○ T2: > 2 cm and ≤ 4 cm
○ T3: > 4 cm
○ T4: Moderately advanced local disease
• Nodes (same for most H&N sites)
○ NX: Regional LNs cannot be assessed
○ N0: No regional LN metastases
○ N1: Single ipsilateral LN ≤ 3cm
○ N2
– N2a: Single ipsilateral LNs, 3-6 cm in greatest dimension.
– N2b: Multiple ipsilateral LNs, ≤ 6 cm in greatest dimension.
– N2c: Bilateral or contralateral LNs, ≤ 6cm in greatest Dimension.
○ N3: LNs > 6 cm in greatest dimension.
10. Although PET/CT is more accurate than CT or MRI for nodal metastases. it does not
detect very small metastatic deposits ( < 5 mm). Neck dissection in patients with a
negative PET may be performed on pretest likelihood of metastatic disease (e.g.,
based on T -stage and histopathologic features). In patients with T4 disease, false-
negative results are more likely and PET is less helpful. PET is more helpful in patients
with 11 to T3 disease. The use of PET in this population can reduce the probability of
occult neck metastases to less than 15%. In addition, false-positive results are not
infrequent and are more common in the contralateral neck side, and in clinical NO
necks. Pathologic confirmation should be considered for PET positive nodes. PET/CT
may have the most potential value where the probability of occult nodal metastases
is higher (e.g., in patients with oral or oropharyngeal cancer). The sensitivity of PET in
this setting is variable. ranging from 33 to 67%.
The role of PET in nodal metastases
11. 2. Radiotherapy Planning
The importance of PET/CT in the planning of radiotherapy in HNSSC patients has been
extensively demonstrated. [18F] FDG PET/CT defined tumor volume more definitively than
diagnostic CT without contrast medium. [18F]FDG PET/CT modified staging and radio-
therapeutic planning in up to one-third of untreated HNSSC patients.
Abramyuk et al. compared the staging modifications determined by [18F]FDG PET/CT in 102
patients with untreated primary HNSSC. [18F]FDG PET/CT imaging led to modification in RT
planning in 14 of 102 patients (13.7%).
As such, [18F]FDG PET/CT improved selection of candidates for curative and palliative RT.
12. Potential applications of PET in radiotherapy planning are as following:
1. Co-registration of PET and treatment planning by CT.
2. Detection of additional/distant disease by PET.
3. Delineation of radiation therapy target volume. Gross tumor volume (GIV) assessment by PET is
closer to the surgical specimen than CT or MRI. although all imaging modalities overestimate tumor
extension.
PET/CT has several potential advantages: reduction in size of the GTV, reduction of inter observer
variability in GTV delineation, identifying parts of the GTV potentially requiring additional radiation dose,
and identifying tumor extension missed by CT or MRI.
The GTV identified by PET is dependent on the segmentation method used (e.g.. visual interpretation
results in higher volumes than semiautomatic methods). All methods show a smaller tumor
volume on PET/CT compared to only CT.
Also, PET/CT often suggests tumor extension outside the CT-based tumor volume.
13. In radiotherapy planning,
[18F]FDG PET/CT results in
significant reduction of
metabolic gross tumor
volume (GTV) with respect
to GTV planning with CT.
14. Radiation effect
Diffuse FDG uptake in the radiation field is usually
secondary to Post-radiation inflammation. Increased
laryngeal or oropharyngeal uptake can be noted for
prolonged periods after chemoradiotherapy. Typically,
this uptake is diffuse and of mild to moderate intensity.
Focal, asymmetric uptake greater than surrounding
tissues, particularly muscle, is suspicious for residual or
recurrent disease as long as it does not fuse to
anatomic structures.
15. 3. Monitoring of Response to Therapy
Chemoradiation has been used for the treatment of locoregionally advanced HNSCC. It has been
accepted as a part of the definitive treatment after surgery. PET/CT has significant advantages
for treatment response assessment as it is a functional imaging approach, and does not rely on
morphological changes.
A 63-year-old man with right tonsil carcinoma
(T3N0M0) treated with neoadjuvant
chemoradiotherapy. Transaxial slices of CT,
[18F]FDG PET and fused PET/CT images prior to
treatment (top row) show intense
hypermetabolism in right tonsil. Transaxial
slices of CT, [18F]FDG PET and fused PET/CT
images 3 months after treatment (bottom row)
show disappearance of tumor lesion
suggesting complete response to treatment.
16. In general,
Focal and asymmetric [18F]FDG uptake with intensity greater than in surrounding
normal tissues (in particular, muscle) and blood vessels should be considered
suggestive of residual disease.
Other hand, diffuse (non-focal) [18F]FDG uptake within the radiation field is usually
an indicator of post-radiation inflammation.
The authors support the use of PET/CT 12 weeks post-treatment for the assessment of
residual or recurrent disease, whereas the potential clinical utility of PET for early
response assessment (PET interim) during chemo-radiotherapy has not been explored
systematically.
17. 4. Follow-Up
The need and frequency of post-treatment imaging assessment for patients treated for HNSCC
are still highly controversial. It is unclear whether patients with distant relapse, but without
symptoms, benefit from early detection of disease.
Early detection of locoregional recurrence may potentially improve survival by facilitating timely
salvage treatment.
Overall sensitivity and negative predictive value (NPV) for locoregional recurrence were higher
using PET/CT (92.5% and 94.8%, respectively) than conventional imaging (55% and 76.9%,
respectively).
They concluded that, for routine surveillance, the initial PET scan should be performed within 6
months after completion of treatment and the proper timing of next routine PET scan for
subclinical patient with initial negative PET result might be 1 year after initial PET scan.
18. 5. Prognosis:
Pretreatment tumor FDG uptake Is an independent prognostic factor
in a meta-analysis, low FDG uptake before treatment is correlated
with better disease-free survival, overall survival and local Control.
19. 6. Cervical Carcinoma of Unknown Origin
An unknown primary tumor in the neck is diagnosed when a patient presents with a
neck metastasis, but no primary tumor is found.
The treatment of an unknown primary tumor can consist of:
Neck dissections.
Tonsillectomies.
Radiation therapy for all mucosal sites and both sides of the neck.
According to several studies, [18F]FDG PET/CT is very helpful in localization of primary
tumor. 18F FDG PET/CT showed higher sensitivity (69%) for detection of occult primary
tumors than did CT (16%) (P < 0.001) or combined CT and MRI (41%, P = 0.039) in
patients with cervical metastasis from an unknown primary tumor.
20. A 70-year-old man with metastatic neck
lymph node of unknown primary tumor.
Coronal, sagittal and Transaxial slices of
CT, [18F]FDG PET and fused PET/CT
images show hypermetabolism in lymph
node left neck area (thin arrow) and
hypermetabolism in left tonsil (thick
arrow).
Surgical histopathology demonstrated a
primary tonsil tumor.
21. Key Learning Points
• The performance of [18F]FDG PET/CT is equivalent to or superior to that of CT and MRI for
initial pretreatment staging of patients with head and neck cancers.
• Distant metastatic sites in patients with head and neck cancers are detected by [18F]FDG
PET/CT with greater sensitivity and specificity than conventional imaging with either CT or MRI.
• NCCN guidelines recommend [18F]FDG PET/CT for initial staging of oral cavity, oropharyngeal,
hypopharyngeal, glottic and supraglottic cancers for stage III–IV disease.
• In a substantial fraction of patients with head and neck cancers, integration of [18F]FDG PET/CT
in the pretreatment imaging protocol planning results in modification of radiotherapy planning.
• [18F]FDG PET/CT has greater sensitivity and specificity than either CT or MRI for assessing
response to therapy in patients with head and neck cancers submitted to chemotherapy and/or
radiotherapy.
• During post-therapy follow-up of patients treated for head and neck cancer, [18F]FDG PET/CT
has greater sensitivity and negative predictive value than conventional imaging.
• [18F]FDG PET/CT has greater sensitivity than either CT or combined CT and MRI for detecting
occult primary tumors in the head and neck region.
22. Contraindications (Relative)
1. Pregnancy
For any diagnostic procedure in a female patient known or suspected to be pregnant, a
clinical decision is necessary in which the benefits are weighed against the possible harm.
The International Commission on Radiological Protection (ICRP) reports that for an adult
patient, the administration of 259 MBq (7 mCi) of [18F]FDG results in an absorbed radiation
dose of 4.7 mGy to the non-gravid uterus (i.e.1.8 × 10–2 mGy/MBq).
A pregnancy test may help with the decision, provided the 10-day post-ovulation blackout is
Understood.
23. 2. Breast-Feeding
The ICRP does not recommend interruption of breast-feeding after [18F]FDG administration,
since little [18F]FDG is excreted in the milk. However, as the lactating breast accumulates
[18F]FDG, it is suggested that contact between mother and child be limited for 12 h after
injection of [18F]FDG in order to reduce the radiation dose that the infant receives from
external exposure to radiation emitted by the mother.
3. Lack of Cooperation
The lack of cooperation or the inability to cooperate with the procedure may be relative
contraindication.
24. Patient Preparation
The main purpose of patient preparation is to reduce tracer uptake in normal tissue (kidneys, bladder,
skeletal muscle, myocardium, brown fat) while maintaining and optimizing tracer uptake in the target
structures (tumor tissue) while at the same time keeping patient radiation exposure levels as low as
reasonably possible (ALARA).
1. Before reporting to the Nuclear Medicine Centre, nondiabetic patients should not consume any food,
simple carbohydrates or liquids other than plain (un-flavored) water for at least 4 h prior to the start of
the [18F]FDG PET/CT study. Type I and insulin-dependent type II diabetic patients should not have insulin
injections for at least 4 h before [18F]FDG injection, and they should be made to achieve normal glycemic
values prior to the study. Type II non-insulin-dependent diabetic patients should continue to take oral
medication to control their blood sugar level.
2. The blood glucose level should be checked before [18F] FDG administration. Tumor uptake of [18F]FDG is
reduced in hyperglycemic states. Most institutions reschedule the patient if the blood glucose level is
greater than 150–200 mg/dL. Reducing the serum glucose level by administering insulin can be
considered, but the administration of [18F]FDG should be delayed 4 h after insulin administration.
3. When a diagnostic CT scan with intravenous contrast agent enhancement is to be performed as part of
the [18F] FDG PET/CT study, indications, contraindications and restrictions have to be assessed by a
qualified physician.
4. Medication that interacts with intravenous contrast agent (e.g. metformin for the treatment of diabetes)
and relevant medical history (e.g. compromised renal function, adverse reactions or claustrophobia)
25. Radiopharmaceutical
Activity: The minimum recommended administered [18F] FDG activity and PET acquisition
duration for each bed position must be adjusted. Therefore, one may decide to apply a higher
activity and reduce the duration of the study or, preferably, to use a reduced activity and
increase the study duration, thereby keeping ALARA principles in mind as well.
There are different methods for determining the minimum [18F]FDG administered dose in adults.
One specification is 3.7 MBq/kg (0.1 mCi/kg), while other specifications include the time per bed
position and patient weight.
Uptake period: for [18F]FDG: The recommended interval between [18F]FDG administration and
the start of acquisition is 60 min.
Following the injection, it is important for the patient to rest quietly during this period, as
excessive motion may result in muscle uptake; talking should be avoided to minimize vocal cord
activity.
Patients may go to the toilet while waiting, preferably more than 30 min after injection. Patients
should empty their bladder 5 min before the start of the [18F]FDG PET/CT study.
26. Acquisition
1. PET/CT imaging from the skull base to proximal thigh: the arms should be elevated over the
head if the patient can tolerate this position. The CT scan is used for attenuation correction of
the PET images as well as for anatomic localization. The head and neck region is typically
included in routine skull base-to-proximal thigh PET study.
The strategy is:
• CT topogram: 120 kV; 10 mA
• Low-dose CT scan: 140 kV; 80 or 50 mA
• PET acquisition from the skull base to proximal thigh (time per bed between 1.5 and 3 min).
2. PET/CT imaging of the neck: the arms should be down to eliminate streak artefacts from the
humerus. To improve the spatial resolution, a smaller field of view can be used.
The strategy is:
• CT topogram: 120 kV; 10 mA
• Intravenous contrast-enhanced diagnostic CT scan
• Head and neck PET acquisition (with 30 s of delay) If the PET/CT data are used for radiotherapy
planning, the PET/CT imaging of the neck should be performed in the position used for
radiotherapy treatment, employing the same dedicated positioning devices (e.g. the same
radiotherapy table top, laser alignment, immobilization mask and measures).
27. Physiological [18F]FDG Distribution
1. Physiologic uptake of [18F]FDG can be seen to some extent in every viable tissue, including the
tonsils and at the base of the tongue due to physiological accumulation in the lymphatic tissue
of Waldeyer’s ring. Non-pathological hypermetabolism can be identified in salivary glands,
muscles of the floor of the mouth and ocular extrinsic, cervical or masticatory muscle
A 82-year-old man in surveillance after
treatment of T3N1M0 carcinoma of oral
cavity. Coronal and transaxial slices of CT,
[18F]FDG PET and fused PET/CT images
show an intense hypermetabolism in
vestibular/gingival mucosa due to
inflammatory processes caused by bad
oral hygiene (thin arrow). There is also
bilateral uptake in digastric musculature
that must be considered as physiological
28. 2. Uptake in cervicothoracic brown fat is observed more often in young patients and -
when the ambient temperature is low. Brown fat uptake is often identified by matching
regions of fat attenuation on CT with the PET/CT fused images.
Volumetric display (MIP),
coronal and transaxial slices of
CT, [18F]FDG PET and fused
CT/PET images showing a very
intense and symmetrical
[18F]FDG uptake in
cervicothoracic brown fat.
Hypermetabolic areas are
located in low-density areas
visualized in CT, corresponding
to fat tissue.
29. 3. Bilateral uptake in vocal cords can be observed when the patient speaks during the uptake
interval after [18F]FDG administration, with greater uptake of the healthy cord as a compensation
for a contralateral recurrent nerve paralysis.
4. The lymph node anatomy of the head and neck is complex and must be well known to
correctly interpret the findings of PET/CT.
5. Increased uptake of [18F]FDG can be seen in granulation tissue (e.g. healing wounds),
infections and other inflammatory processes as well as in benign salivary gland tumors, such as
the pleomorphic adenoma and Warthin’s tumor, which may present high uptake of [18F]FDG.
A detailed description of pitfalls and situations that can lead to false-positive (benign processes
that can show [18F]FDG uptake) or false-negative [18F] FDG PET/CT interpretation has been
published.
30. Key Learning Points
• Display of images from an [18F]FDG PET/CT scan in patients with head and neck cancers follows
the general format and modalities as for other regions of the body.
• Particular attention should be paid to evaluation of the non-CT attenuation-corrected images.
• Physiological uptake of [18F]FDG with variable intensity can be observed in normal structures of
the head and neck including the lymphatic Waldeyer’s ring; major salivary glands; muscles of the
floor of the mouth; ocular extrinsic, cervical or masticatory muscles; brown fat; and vocal cords.
• Good knowledge of the complex anatomy of lymph nodes of the head and neck is mandatory
to correctly interpret the [18F]FDG PET/CT scan.
• The possibility of increased [18F]FDG uptake in inflamed/healing tissues (such as early after
surgery or radiotherapy) as well as in some benign tumors must adequately be taken into
account when interpreting an [18F]FDG PET/CT scan of the head and neck.
• [18F]FDG accumulation at tumor sites must be adequately correlated with anatomic
abnormalities observed in the CT component of the PET/CT scan.
31. Normal uptake (sagittal). On sagittal images, there is normally an inverted C' shape
composed of the mylohyoid muscles and sublingual glands, soft palate, and
tonsils).
These are the most common areas of normal uptake.
32.
33. Soft palate (axial)
The soft palate can appear as a prominent focus of activity on axial
images. Soft palate uptake is more prominent in males.
34. Tonsils (coronal)
Normal uptake in the palatine and lingual tonsils) forms two
vertical linear bands of uptake on coronal images .This may be
prominent In cold/temperate climates and is also prominent In
children.
a) Asymmetric physiologic tonsil uptake can be difficult to
differentiate from tonsillar carcinoma.
ln one study, 23 a ratio of SUVmax between the tonsils (with a
cutoff of 1.48) was effective in differentiating tonsillar cancer
from asymmetric physiologic uptake.
b) There is less uptake with increasing age in the
palatine tonsils. Salivary glands.
Salivary gland uptake is more variable than tonsillar uptake.
Salivary gland uptake, if seen, is usually less than tonsillar uptake.
35. a) There is less uptake with increasing
age ln the sublingual glands.
b) The submandibular glands are in
close proximity to submandibular
nodes and submandibular nodal
uptake can be difficult to distinguish
from normal glandular uptake even
with PET/CT.
36. Nasopharyngeal uptake:
Nasopharyngeal uptake is sometimes seen as a normal variant although larger degrees of uptake could be secondary to
inflammation or tumor. Uptake in the lateral pharyngeal recess can be symmetric or asymmetric.
a) Asymmetric uptake. Asymmetric uptake in the lateral pharyngeal recess, cervical nodal uptake, and asymmetric wall
thickening In the lateral pharyngeal recess on CT are associated with nasopharyngeal carcinoma.
• However, in patient populations where nasopharyngeal carcinoma is less frequent. asymmetric uptake in the lateral
pharyngeal recesses is often Inflammatory.
b) An SUV cutoff of< 3.9 and a lateral pharyngeal recess-to-palatine tonsil uptake ratio of< 1.5 are helpful in
differentiating benign from malignant lateral pharyngeal recess uptake.
c) Uptake in the midline roof the nasopharynx could be secondary to uptake in adenoidal tissue or nasopharyngeal
carcinoma.
In one study, 0an SUV level of less than 4.61 and a midline roof-to-palatine tonsil ratio of< 1.14 were helpful in
differentiation. Although there was stilt overlap between neoplastic and non-neoplastic uptake levels. Additional findings
were necessary to increase the accuracy of PET. For example. associated increased FDG uptake in Waldeyer's ring and the
salivary glands occurred in benign but not malignant lesions. Symmetric uptake in the lateral pharyngeal regions was
associated with benign etiologies.
37. Presentation
• Most common signs/symptoms
○ May present with pain associated with primary mass or neck mass.
○ Other symptoms may include mouth sores, sore throat, dysphagia, otalgia, odynophagia, voice changes
Treatment
• Radiation therapy ― chemotherapy
• Radical, modified radical, or selective neck dissection.
○ Radical neck dissection: Excision of levels I-V LNs, SCM, internal jugular vein and cranial
nerve XI.
○ Modified radical neck dissection: Excision of levels I-V LNs and cranial nerve XI
○ Selective neck dissection: Excision of selective nodal groups.
38. (Left) Lateral graphic of the neck depicts nodal levels. I: Submental-submandibular; II: High jugular; III:
Mid jugular; IV: Low jugular; VA and VB: High and low spinal accessory; and VI: Anterior cervical.
(Right) Axial fused F-18 FDG PET/CT shows primary squamous cell carcinoma near the base of tongue
ſt. Some primary lesions are too small to be detected on F-18 FDG PET/CT.
39.
40.
41.
42.
43. Pearls/Pitfalls
1. Knowledge of the common sites and incidence of cervical metastases for different primary tumors is helpful in the
interpretation of PET Scans.
a) Oral cavity tumors have high incidence of metastases despite being clinically node negative.
b) Laryngeal tumors have a low incidence of metastases even in advanced stages of disease.
c) Supraglottic larynx tumors often spread to nodes.
d) Nasopharyngeal tumors often spread to nodes bilaterally and to the posterior triangle.
2. The most common site of reactive lymphadenopathy is the jugulodigastric node. Reactive nodes are often enlarged and
less intense than the primary and nodal Metastases.
3. SUV volume: It is helpful to include the abdomen and pelvis in the scan volume because of the possibility of
coincidental tumors and distant metastases.
4.Bone invasion: ln a meta-analysis,32 PET/CT had a mean sensitivity of 83% and a mean specificity of 90% for the
detection of mandibular invasion by head and neck cancers, compared to 96 and 66%, respectively, for SPECT. In patients
with oral cancer. PET does not improve identification of bone infiltration compared to CT.
5. SUV: The use of size-based SW cutoffs may be helpful for nodal staging. In one study, SUV cutoffs of 1.9. 2.5, and 3.0 for
lymph nodes< 10mm,10 to 15mm,and>15mm yielded a 79% sensitivity and 99% specificity for nodal staging. 34 The use
of the ratio of nodal/ li~ SUVmax is helpful in correcting for inter scanner variability. In one report, 35 a nodal/liver ratio
of ~ 0.90 yielded a sensitivity of 74% and specificity of93%.
6. Hardware artifact: Non-removable metallic dental implants can generate artifacts adjacent to dental implants that
mimic FDG uptake on attenuation-corrected images.
44. PET has limitations in assessing response to postoperative adjuvant chemoradiotherapy.
a) Postsurgical inf1unmatory reactions can cause false positive results and therefore render subsequent
response assessment inaccurate.
b) Microscopic residual disease cannot be Detected.
2 . Timing: As in all settings, there should be substantial time interval between radiotherapy and PET
imaging. Typically false-negative results are more commonly seen if imaging is performed early after
radiation. NCCN guidelines t suggest a minimum delay of 12 weeks after treatment In a systematic review,
sensitivity was greater fur scans performed 10 weeks or more after therapy. In a met analysis, l9 specificity
was greater for scans performed more than 12 weeks after radiotherapy with or without chemotherapy. If
post radiotherapy neck dissection is being considered, PET may be more valuable if it can be accurately
performed earlier after therapy (within 12 weeks), as fibrosis can increase the technical difficulty and
morbidity of delayed neck dissection.
3. Visual grading criteria. such as the Deauville's criteria used for lymphoma or similar criteria are also
effective in therapy response assessment in patients with head and neck cancer.
4. Osteoradionecrosis can cause false-positive results. As mean and maximum SUVs can overlap between
patients with osteoradionecrosis and tumor recurrence, the CT findings may be more reliable. A solid or
cystic mass is associated with tumor recurrence. while bony sclerosis is associated with osteoradionecrosis.
Dual time point PET may also be helpful, as the SUV may decrease over time in osteoradionecrosis.
45. Comparison with Other Modalities
1. Other radionuclides. PET is more sensitive than sestamibi, tetrofosmin,
or thallium. Specificity is comparable. However, sestamibi or tetrofosmin
combined with CT is comparable to PET.
47. 1. Parotid lesions:
PET cannot distinguish between benign and malignant parotid tumors Warthin's tumors and pleomorphic adenomas can
have FDG uptake. High-grade salivary gland tumors tend to have more uptake than lower grade tumors, but there is
substantial overlap. In addition. some malignant parotid lesions, such as adenoid cystic carcinoma, low-grade
mucoepidermoid carcinoma. and necrotic squamous cell carcinoma can have minimal. FDG uptake. so ln a meta-analysis,
the pooled risk of malignancy of focal parotid incidental uptake was 9.6% in all detected lesions. However, in patients with
head and neck cancer/melanoma, lymphoma. or FDG-avid cervical lymph nodes. there are higher odds that the focal
parotid uptake represents metastases. PET and PET/CT may be superior to CT for staging patients with known salivary gland
malignancies.
48. Pleomorphic sarcoma. A 51-year-old male with
biopsy-proven pleomorphic sarcoma of the right
parotid gland.
FDG PET/CT demonstrated an FDG avid lesion in
the right parotid gland (a,c), corresponding to a 12
x 10 mm Soft tissue density on the CT image (b),
with moderate enhancement on contrast-
enhanced CT (d).
49. 2. Cystic neck masses:
PET/CT may not be accurate in identifying malignancy
in adults with cystic neck masses.
50. PET/CT
PET /CT is of particular value in head and neck evaluations given the complex anatomy and
relative lack of anatomic landmarks on PET.
1. The use of PET/CT compared to PET alone will decrease fraction of equivocal lesions by 53%,
greatly improve lesion localization, slightly improve accuracy, and change management in 18%
of cases.
2. Particular attention must be paid to the possibility of mislocalization on PET/CT studies due to
movement of the head between the CT
and PET studies.
3. If PET /CT or fusion with CT or MRI is not available, potential anatomic landmarks that can be
used to aid in localization include the tonsils, palate, tongue, floor of mouth, salivary glands,
mandible, and cervical spine.
51. PET Image Reconstruction
• The PET emission data must be corrected for several factors before
further processing.
• The reconstructed voxel size should be 3–4 mm in any direction
through selection of adequate matrix size and zoom factors.
• The PET emission data should be reconstructed both with and
without attenuation correction in order to identify artefacts in the CT
attenuation-corrected images due to highly attenuating materials.
• The PET emission data can be reconstructed in either the 2D mode or
the 3D mode, using suitable procedures.
• Current reconstruction methods are based on iterative approaches.
• CT image reconstruction follows standard protocols commonly
employed for routine clinical imaging.
52. Data Interpretation and Reporting
1. Fusion images must be evaluated using an SUV scale in the axial,
coronal and sagittal planes as well as maximum intensity projection
(MIP) images for review in the 3D cine mode.
2. [18F]FDG PET images with and without attenuation correction should
be available for review.
3. Quantitative information with respect to size and [18F] FDG uptake
(SUV) can be retrieved.
4. Image data should be stored on an approved PACS system and in
DICOM format.
53. Interpretation Criteria
1. Increased uptake of [18F]FDG can be seen in granulation tissue (e.g. healing wounds), infections and other
inflammatory processes as well as in benign salivary gland tumors, such as the pleomorphic adenoma and
Warthin’s tumor, which may present high uptake of [18F]FDG. A detailed description of pitfalls and situations
that can lead to false-positive (benign processes that can show [18F]FDG uptake) or false negative [18F] FDG
PET/CT interpretation has been published.
2. In neoplastic processes, tracer accumulation in anatomic abnormalities seen on CT scan or other imaging
may be particularly significant. When appropriate, the report should correlate PET/CT findings with those of
other diagnostic tests. These tests should be reinterpreted in the context of all available data imaging and
clinical data.
3. For response assessment, the images should be viewed over the same dynamic grey scale or color scale
range. In clinical trials, criteria for visual analysis should be defined a priori within the study protocol.
4. SUV (normalized to body weight) measurement is widely used in clinical studies in addition to visual
assessments. SUV normalized to lean body mass (LBM) is a recommended quantitative measure of [18F]FDG
uptake for response assessment studies, when large changes in body weight may occur during the course of
the treatment.
54. 5. Although there are no conclusive data on the optimum interval between chemotherapy and
[18F]FDG PET/CT, an interval of at least 10 days between the last treatment and the [18F]FDG
PET/CT examination is generally considered adequate for measurement of response [39]. This is
because of the balance between any possible effects on tumor metabolism (such as
macrophage impairment) and systemic effects (such as bone marrow activation following bone
marrow depression, which may or may not be caused by growth factors). If an interval of 10
days is not possible, [18F]FDG PET/CT should be delayed as long as possible after the previous
chemotherapy administration (i.e. until as close as possible to the next treatment cycle).
6. It is assumed that the side effects of radiotherapy are longer-lasting; investigations of patients
with head and neck carcinoma treated with radiation have shown that radiation-induced
inflammation can be seen on the [18F] FDG PET/CT images for 2–3 months after the end of
treatment . Waiting 2 or 3 months following completion of radiation therapy before obtaining a
PET/ CT scan is clinically appropriate, as patients rarely develop clinical problems in the first 3
months after Treatment.