Robert Liebman, MD, PGY-1 OtolaryngologyEastern Virginia Medical School Department of OtolaryngologyEmail: LiebmaRM@evms.eduPhone: (770)-355-5714

Contact 1. Tantiwongkosi B, Yu F, Kanard A, Miller FR. Role of (18)F-FDG PET/CT in pre and post treatment evaluation in head and neck carcinoma. World J Radiol. 2014 May 28;6(5):177-91. doi: 10.4329/wjr.v6.i5.177. Review. PubMed PMID: 24876922; PubMed Central PMCID: PMC4037544.

2. Xi K, Xie X, Xi S. Meta-analysis of ¹⁸ fluorodeoxyglucose positron emission tomography-CT for diagnosis of lung malignancies in patients with head and neck squamous cell carcinomas. Head Neck. 2014 May 22. doi: 10.1002/hed.23774. [Epub ahead of print] PubMed PMID: 24850267.

3. Haerle SK, Schmid DT, Ahmad N, Hany TF, Stoeckli SJ. The value of (18)F-FDG PET/CT for the detection of distant metastases in high-risk patients with head and neck squamous cell carcinoma. Oral Oncol. 2011 Jul;47(7):653-9. doi: 10.1016/j.oraloncology.2011.05.011. Epub 2011 Jun 11. PubMed PMID: 21658990.

4. Lonneux M, Hamoir M, Reychler H, Maingon P, Duvillard C, Calais G, Bridji B, Digue L, Toubeau M, Grégoire V. 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 Mar 1;28(7):1190-5. doi: 10.1200/JCO.2009.24.6298. Epub 2010 Feb 1. PubMed PMID: 20124179.

5. Yamamoto T, Sakairi Y, Nakajima T, Suzuki H, Tagawa T, Iwata T, Mizobuchi T, Yoshida S, Nakatani Y, Yoshino I. Comparison between endobronchial ultrasound-guided transbronchial needle aspiration and 18F-fluorodeoxyglucose positron emission tomography in the diagnosis of postoperative nodal recurrence in patients with lung cancer. Eur J Cardiothorac Surg. 2014 May 28. pii: ezu214. [Epub ahead of print] PubMed PMID: 24872477.

6. Wildi SM, Fickling WE, Day TA, Cunningham CD 3rd, Schmulewitz N, Varadarajulu S, Roberts SS, Ferguson B, Hoffman BJ, Hawes RH, Wallace MB. Endoscopic ultrasonography in the diagnosis and staging of neoplasms of the head and neck.Endoscopy. 2004 Jul;36(7):624-30. PubMed PMID: 15243886.

7. Nguyen NC, Kaushik A, Wolverson MK, Osman MM. Is there a common SUV threshold in oncological FDG PET/CT, at least for some common indications? A retrospective study. Acta Oncol. 2011 Jun;50(5):670-7. doi: 10.3109/0284186X.2010.550933. Epub 2011 Jan 19. PubMed PMID: 21247262.

8. Gilbert MR, Branstetter BF 4th, Kim S. Utility of positron-emission tomography/computed tomography imaging in the management of the neck in recurrent laryngeal cancer. Laryngoscope. 2012 Apr;122(4):821-5. doi: 10.1002/lary.22428. Epub 2012 Feb 16. PubMed PMID: 22344673.

References

Outcome: Attendees can expect to (1) understand the

proportion of patients presenting to Head and Neck tumor

board at an academic institution in which chest metastases

cannot be ruled out based on PET findings, (2) appreciate the

proportion of patients in which metastatic disease is confirmed

following workup of suspicious PET findings (3) appreciate any

difference in time to primary treatment between patients who

were worked up for suspected chest metastases versus those

who were not.

Methods: This study was conducted as a retrospective chart

review. Patients included were adults with pathologically

confirmed head and neck malignancy who were presented at

Head and Neck Tumor Board (TB) through December 2015

(N=496). Outcomes measured included (1) presence of a PET

scan in the initial workup of head and neck cancer, (2) whether

or not the PET scan could rule out chest metastases, (3)

whether a tissue diagnosis of metastatic disease was sought

after, (4) the date of patients' presentations at TB, (5) the date

on which patients began their primary treatment, and (6) the

amount of time (in days) between presentation and primarytreatment.

Abstract

Introduction

The names and medical records of the patients presented at the

Medical College of Georgia’s Multidisciplinary Head and Neck

Tumor Board between 1/1/2013 and 12/31/2105 were collected

with the respective dates each patient was presented. These

were compiled together in an encrypted Excel (Microsoft,

Redmond, WA) spreadsheet. Redundant patients (discussions)

were removed. Several patients were treated primarily at the

Charlie Norwood VA Hospital; these patients were removed.

Further, other patient records were inaccessible due to incorrectnames or medical record numbers given on the TB logs.

Methods and Materials

There was an observed greater time to treatment from both the time ofPET/CT scan and time from Tumor Board presentation for the group ofpatients who underwent workup with either pulmonology orcardiothoracic surgery. However, this observed difference in time totreatment failed to reach level of statistical significance.

DiscussionThere is not, at present, any data generated from this study regarding overallsurvival or disease progression between the group that had workup formetastases and thus delayed, though not significant, time to treatmentcompared to patients not receiving workup; this represents one potentialfuture area of study. It is felt by the authors that the failure to reachstatistical significance for the extended time to treatment is a result of bothsmall cohort size in those who underwent workup for possible chestmetastases and a large standard of deviation in both groups. Reasons for thishigh degree of variability is likely multi-factorial. This study raises questionsregarding the order of workup and treatment of head and neck malignanciesgiven that such a large number of patients had PET/CTs that were notconcerning for metastatic disease in the chest (70.9%) and only 6.6% ofpatients had scans that were suggestive of metastases. Unfortunately therewere no meaningful prognostic factors from this study with respect toneoplasm location or stage that would guide physicians to more aggressivelypursue possible metastases before treating the primary disease site.

ConclusionsResults

In the last decade PET/CT has become the preferred modality

for TNM staging of head and neck malignancy because of its

ability to detect metastases to loco-regional lymph nodes, distant

metastases, and detection of second, primary malignancies.[1][2]

PET/CT studies are costly to both healthcare institutions and

patients with respect to time and limited resources. Through

documents obtained at the authors’ institutions, Medicare

reimburses $1,348 for the PET study; not including the

radiologist’s fee. Further, time to diagnosis of distant metastases

has not been shown to have a beneficial effect on overall

survival.[3] One study reports that PET and conventional imaging

were discordant in 43% of cases regarding TNM staging and the

therapeutic plan was only altered in 13.7% of patients.[4]

Alternative methods of thoracic lymph node metastases

detection that are potentially less costly and more accurate have

been described.[5][6] There is also dissent amongst medical

professionals regarding the best parameters to use for

determining positive metastases on PET scans, especially those

in the chest.[7][8] At our institution, much of the time patients are

recommended PET/CT before definitive treatment is initiated yet

they oftentimes yield negative or inconclusive results..

Work-Up of Suspected Chest Metastases in H & N Cancer: Worth the

Wait?Robert M. Liebman, MD, Christopher Leto, MD, J. Kenneth Byrd, MD, Michael W. Groves, MD

Department of Otolaryngology-Head and Neck Surgery, Medical College of Georgia at Augusta University

Augusta, Georgia

Methods and Materials

Data collected were age at tumor board presentation, sex,

diagnosis, TNM tumor staging, and the presence of a PET/CT scan

before primary treatment of their tumor. Patients who did not have

PET/CT prior to treatment were then excluded. The thorax and

lungs sections of the radiologists’ reports of the PET/CT scans

were read and graded as either No, Equivocal, or Yes depending

on language used to assess for the presence of chest metastases.

The dates of the PET/CT scans were recorded. It was noted if a

patient had a workup with either pulmonology or CT surgery for a

possible metastasis. The biopsy results were recorded for sampled

lesions. Finally, modality of primary treatment (surgery, radiation

with chemotherapy, chemo therapy, radiation, observation, or

palliative and the date on which the patient began their primary

treatment were recorded. Days between tumor board presentation

and primary treatment initiation were calculated as well as days

between peri-treatment PET/CT and initiation of treatment.

Unpaired T-tests (GraphPad, LaJolla, CA) were used to assess for

statistical significance.

Figure 1: flow chart demonstrating work flow to achieve final pool of patients from which the results are derived. *Many patients were treated at outside hospitals/clinics; others declined treatment, and some had incomplete records of their treatment.

TB Patients (2013-2015)

N=496

Met Inclusion Criteria N=435

PET/CT Before Tx

N=272

Complete TxData

N=221

Yes (probable Metastases)

Equivocal (cannot rule

out Metastasis)

No (no definite

metastasis

Incomplete Data/No Tx

N=51No PET/CT before Tx

N=163

Failed To Meet

Inclusion Criteria N=61

Qualitative

Radiology Read Total

CT/Pulm

Work-up

No

Bx: Benign Malignant

Malignancy

Rate (w/wup):

Malignancy

Rate Net:

Benign rate

(w/wup):

Yes 18 12 2 2 8 66.7% 44.4% 16.7%

Equivocal 61 10 4 4 2 20.0% 3.3% 40.0%

No 193 3 1 2 0 0.0% 0.0% 66.7%

Totals 272 25 7 8 10 40.0% 3.7% 32.0%

XRT:5.5%

Chemo:3.0%

No treatment:3.3%

Chemo/XRT31.4%

Hospice:2.6%

Palliative XRT:1.1%

Palliative Chemo

1.8%

Surgery:51.3%

Other: 17%

SCCA Nasopharynx

2%

SCCA Oropharynx

23%

SCCA Skin2%

SCCA Unknown Primary

1%

SCCA Larynx:13%

SCCA maxillary sinus

3%Melanoma

2%

Salivary gland 4%

SCCA Hypopharynx

5%

SCCA Oral Cavity26%

Lymphoma2%

W/out workup

Mean

W/ workup

Mean

W/out workup

Median W/ workup Median P-value CI (95%)

Time (days) from

PET/CT to Tx 26.67 35.47 19 32 0.12(-2.33,

19.92)Time (days) from

Tumor Board to

Tx 27.99 34.26 22 29 0.22(-3.79,

16.33)

Figure 2: Percentage breakdown of neoplasm type of the 272 patients presented at H &N MD Tumor Board that had PET/CT scans in the peri-presentation period.

Figure 3: Distribution of recommended treatment modality bestowed by the H & N MD TB on the 272 patients with PET/CT scans in the peri-presentation

Table 1: distribution of qualitative radiologists reads taken from the mediastinal and lung parenchymal sections of reading radiologists’ reports. Workup included consultation, EBUS, CT guided biopsy, mediastinoscopy with biopsy, Super-D or repeat imaging.

Table 2: results of unpaired t-tests used to compare the means of time in days to cancer treatment between patients who were subsequently worked up for suspected metastases after imaging versus those patients who were not.

The average age at TB presentation among our 272 patients with PET/CTscans performed was 61.3 years. There was a male to female ratio of 2.4: 1.The neoplasm anatomic locations of these patients were noted to be 26%located at the oral cavity and 23% at the oropharynx; these represent thetwo most common locations ; the full distribution is demonstrated in Figure2 . Likewise, the recommended or patient selected primary treatmentmodalities are visualized in figure 3; surgery represented the most commonrecommendation at 51%. Of the 272 PET/CT reports read 193 or 70.9% weregraded as “No,” 61 or 22.4% were graded as “Equivocal,” and 18 scans or6.6% were graded as “Yes.” 221 of the 272 patients had detailed treatmentdata available in their medical records. Among those without workup forpossible chest metastases (N=202) the mean time in days from PET/CT scanto treatment in was 26.7 and mean time from TB to treatment was 28.0days. Among those with workup for possible chest metastases (N= 19) meantimes from PET to treatment and TB to treatment were 35.5 and 34.3 daysrespectively. The p-values of the difference in means between the twogroups were p=0.12 (CI -2.33, 19.92) for time from PET to treatment andp=0.22 CI (-3.79, 16.33) for time from TB to treatment.