Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

At a glance: The STEP trials

A round-up of the STEP phase 3 clinical trials evaluating semaglutide for weight loss in people with overweight or obesity.
ADVANCED SEARCH
Log in
Top
Insights into Imaging
Published in: Insights into Imaging 5/2014

Open Access 01-10-2014 | Pictorial Review

FDG-PET/CT pitfalls in oncological head and neck imaging

Authors: Bela S. Purohit, Angeliki Ailianou, Nicolas Dulguerov, Christoph D. Becker, Osman Ratib, Minerva Becker

Published in: Insights into Imaging | Issue 5/2014

Login to get access

Abstract

Objectives

Positron emission tomography-computed tomography (PET/CT) with fluorine-18-fluorodeoxy-D-glucose (FDG) has evolved from a research modality to an invaluable tool in head and neck cancer imaging. However, interpretation of FDG PET/CT studies may be difficult due to the inherently complex anatomical landmarks, certain physiological variants and unusual patterns of high FDG uptake in the head and neck. The purpose of this article is to provide a comprehensive approach to key imaging features and interpretation pitfalls of FDG-PET/CT of the head and neck and how to avoid them.

Methods

We review the pathophysiological mechanisms leading to potentially false-positive and false-negative assessments, and we discuss the complementary use of high-resolution contrast-enhanced head and neck PET/CT (HR HN PET/CT) and additional cross-sectional imaging techniques, including ultrasound (US) and magnetic resonance imaging (MRI).

Results

The commonly encountered false-positive PET/CT interpretation pitfalls are due to high FDG uptake by physiological causes, benign thyroid nodules, unilateral cranial nerve palsy and increased FDG uptake due to inflammation, recent chemoradiotherapy and surgery. False-negative findings are caused by lesion vicinity to structures with high glucose metabolism, obscuration of FDG uptake by dental hardware, inadequate PET scanner resolution and inherent low FDG-avidity of some tumours.

Conclusions

The interpreting physician must be aware of these unusual patterns of FDG uptake, as well as limitations of PET/CT as a modality, in order to avoid overdiagnosis of benign conditions as malignancy, as well as missing out on actual pathology.

Teaching points

• Knowledge of key imaging features of physiological and non-physiological FDG uptake is essential for the interpretation of head and neck PET/CT studies.
• Precise anatomical evaluation and correlation with contrast-enhanced CT, US or MRI avoid PET/CT misinterpretation.
• Awareness of unusual FDG uptake patterns avoids overdiagnosis of benign conditions as malignancy.
Literature
1.
Subramaniam RM, Truong M, Peller P, Sakai O, Mercier G (2010) Fluorodeoxyglucose-positron-emission tomography imaging of head and neck squamous cell cancer. AJNR Am J Neuroradiol 31:598–604PubMedCrossRef
2.
Blodgett TM, Fukui MB, Snyderman CH et al (2005) Combined PET-CT in the head and neck: part 1. Physiologic, altered physiologic, and artifactual FDG uptake. Radiographics 25:897–912PubMedCrossRef
3.
Fukui MB, Blodgett TM, Snyderman CH et al (2005) Combined PET-CT in the head and neck: part 2. Diagn Pitfalls Oncol Imaging Radiogr 25:913–930
4.
Schöder H (2013) Head and neck cancer. In: Strauss HW, Mariani G, Volterrani D, Larson SM (eds) Nuclear oncology: pathophysiology and clinical applications. Springer, New York, pp 269–295CrossRef
5.
6.
Kostakoglu L, Hardoff R, Mirtcheva R, Goldsmith SJ (2004) PET-CT fusion imaging in differentiating physiologic from pathologic FDG uptake. Radiographics 24:1411–1431PubMedCrossRef
7.
El-Haddad G, Alavi A, Mavi A, Bural G, Zhuang H (2004) Normal variants in [18 F]-fluorodeoxyglucose PET imaging. Radiol Clin North Am 42:1063–1081PubMedCrossRef
8.
Bhargava P, Rahman S, Wendt J (2011) Atlas of confounding factors in head and neck PET/CT imaging. Clin Nucl Med 36:e20–e29PubMedCrossRef
9.
Castaigne C, Muylle K, Flamen P (2006) Positron emission tomography in head and neck cancer. In: Hermans R (ed) Head and neck cancer imaging. Springer, Berlin Heidelberg, pp 329–343
10.
Metser U, Miller E, Lerman H, Even-Sapir E (2007) Benign nonphysiologic lesions with increased 18 F-FDG uptake on PET/CT: characterization and incidence. AJR Am J Roentgenol 189:1203–1210PubMedCrossRef
11.
Rodrigues RS, Bozza FA, Christian PE et al (2009) Comparison of whole-body PET/CT, dedicated high-resolution head and neck PET/CT, and contrast-enhanced CT in preoperative staging of clinically M0 squamous cell carcinoma of the head and neck. J Nucl Med 50:1205–1213PubMedCrossRef
12.
Rangaswamy B, Fardanesh MR, Genden EM et al (2013) Improvement in the detection of locoregional recurrence in head and neck malignancies: F-18 fluorodeoxyglucose-positron emission tomography/computed tomography compared to high-resolution contrast-enhanced computed tomography and endoscopic examination. Laryngoscope 123:2664–2669PubMedCrossRef
13.
Chatziioannou SN, Georgakopoulos AT, Pianou NK, Kafiri GT, Pavlou SN, Kallergi M (2014) Recurrent thyroid cancer diagnosis: ROC study of the effect of a high-resolution head and neck 18 F-FDG PET/CT scan. Acad Radiol 21:58–63PubMedCrossRef
14.
Haerle SK, Strobel K, Ahmad N, Soltermann A, Schmid DT, Stoeckli SJ (2011) Contrast-enhanced (18)F-FDG-PET/CT for the assessment of necrotic lymph node metastases. Head Neck 33:324–329PubMed
15.
Boellaard R, O’Doherty MJ, Weber WA et al (2010) FDG PET and PET/CT: EANM procedure guidelines for tumour PET imaging: version 1.0. Eur J Nucl Med Mol Imaging 37:181–200PubMedPubMedCentralCrossRef
16.
Chen YK, Su CT, Chi KH, Cheng RH, Wang SC, Hsu CH (2007) Utility of 18 F-FDG PET/CT uptake patterns in Waldeyer’s ring for differentiating benign from malignant lesions in lateral pharyngeal recess of nasopharynx. J Nucl Med 48:8–14PubMed
17.
Davison JM, Ozonoff A, Imsande HM, Grillone GA, Subramaniam RM (2010) Squamous cell carcinoma of the palatine tonsils: FDG standardized uptake value ratio as a biomarker to differentiate tonsillar carcinoma from physiologic uptake. Radiology 255:578–585PubMedCrossRef
18.
Basu S, Houseni M, Alavi A (2008) Significance of incidental fluorodeoxyglucose uptake in the parotid glands and its impact on patient management. Nucl Med Commun 29:367–373PubMedCrossRef
19.
Hadiprodjo D, Ryan T, Truong MT, Mercier G, Subramaniam RM (2012) Parotid gland tumors: preliminary data for the value of FDG PET/CT diagnostic parameters. AJR Am J Roentgenol 198:W185–W190PubMedCrossRef
20.
Roh JL, Ryu CH, Choi SH et al (2007) Clinical utility of 18 F-FDG PET for patients with salivary gland malignancies. J Nucl Med 48:240–246PubMed
21.
Terraz S, Poletti PA, Dulguerov P et al (2013) How reliable is sonography in the assessment of sialolithiasis? AJR Am J Roentgenol 201:W104–W109PubMedCrossRef
22.
23.
Abdullah A, Rivas FF, Srinivasan A (2013) Imaging of the salivary glands. Semin Roentgenol 48:65–74PubMedCrossRef
24.
Bajaj Y, Singh S, Cozens N, Sharp J (2005) Critical clinical appraisal of the role of ultrasound guided fine needle aspiration cytology in the management of parotid tumours. J Laryngol Otol 119:289–292PubMedCrossRef
25.
Friedman ER, Saindane AM (2013) Pitfalls in the staging of cancer of the major salivary gland neoplasms. Neuroimaging Clin N Am 23:107–122PubMedCrossRef
26.
Celebi I, Mahmutoglu AS, Ucgul A, Ulusay SM, Basak T, Basak M (2013) Quantitative diffusion-weighted magnetic resonance imaging in the evaluation of parotid gland masses: a study with histopathological correlation. Clin Imaging 37:232–238PubMedCrossRef
27.
Zhu Z, Chou C, Yen TC, Cui R (2001) Elevated F-18 FDG uptake in laryngeal muscles mimicking thyroid cancer metastases. Clin Nucl Med 26:689–691PubMedCrossRef
28.
Jacene HA, Goudarzi B, Wahl RL (2008) Scalene muscle uptake: a potential pitfall in head and neck PET/CT. Eur J Nucl Med Mol Imaging 35:89–94PubMedCrossRef
29.
Su HC, Huang CK, Bai YL, Lin CY, Hung GU (2009) Physiologically variant FDG uptake in scalene muscle mimicking neck lymph node metastasis in a patient with lung cancer. Ann Nucl Med Sci 22:239–243
30.
Perkins AC, Mshelia DS, Symonds ME, Sathekge M (2013) Prevalence and pattern of brown adipose tissue distribution of 18 F-FDG in patients undergoing PET-CT in a subtropical climatic zone. Nucl Med Commun 34:168–174PubMedCrossRef
31.
Rousseau C, Bourbouloux E, Campion L et al (2006) Brown fat in breast cancer patients: analysis of serial (18)F-FDG PET/CT scans. Eur J Nucl Med Mol Imaging 33:785–791PubMedCrossRef
32.
Tsuchiya T, Osanai T, Ishikawa A, Kato N, Watanabe Y, Ogino T (2006) Hibernomas show intense accumulation of FDG positron emission tomography. J Comput Assist Tomogr 30:333–336PubMedCrossRef
33.
Schmalfuss I (2012) Positron emission tomography in head and neck cancer. In: Hermans R (ed) Head and neck cancer imaging, 2nd edn. Springer, Berlin Heidelberg, pp 363–385
34.
Zhuang H, Yu JQ, Alavi A (2005) Applications of fluorodeoxyglucose-PET imaging in the detection of infection and inflammation and other benign disorders. Radiol Clin North Am 43:121–134PubMedCrossRef
35.
Walter MA, Melzer RA, Schindler C, Muller-Brand J, Tyndall A, Nitzsche EU (2005) The value of [18 F]FDG-PET in the diagnosis of large-vessel vasculitis and the assessment of activity and extent of disease. Eur J Nucl Med Mol Imaging 32:674–681PubMedCrossRef
36.
Jezovnik MK, Zidar N, Lezaic L, Gersak B, Poredos P (2014) Identification of inflamed atherosclerotic lesions in vivo using PET-CT. Inflammation 37:426–434PubMedCrossRef
37.
Harrigal C, Branstetter BF, Snyderman CH, Maroon J (2005) Teflon granuloma in the nasopharynx: a potentially false-positive PET/CT finding. AJNR Am J Neuroradiol 26:417–420PubMed
38.
Wong RJ, Lin DT, Schoder H et al (2002) Diagnostic and prognostic value of [(18)F]fluorodeoxyglucose positron emission tomography for recurrent head and neck squamous cell carcinoma. J Clin Oncol 20:4199–4208PubMedCrossRef
39.
Metser U, Even-Sapir E (2007) Increased (18)F-fluorodeoxyglucose uptake in benign, nonphysiologic lesions found on whole-body positron emission tomography/computed tomography (PET/CT): accumulated data from four years of experience with PET/CT. Semin Nucl Med 37:206–222PubMedCrossRef
40.
Porceddu SV, Jarmolowski E, Hicks RJ et al (2005) Utility of positron emission tomography for the detection of disease in residual neck nodes after (chemo)radiotherapy in head and neck cancer. Head Neck 27:175–181PubMedCrossRef
41.
Schoder H, Fury M, Lee N, Kraus D (2009) PET monitoring of therapy response in head and neck squamous cell carcinoma. J Nucl Med 50(Suppl 1):74S–88SPubMedCrossRef
42.
Kapoor V, Fukui MB, McCook BM (2005) Role of 18FFDG PET/CT in the treatment of head and neck cancers: posttherapy evaluation and pitfalls. AJR Am J Roentgenol 184:589–597PubMedCrossRef
43.
Becker M, Schroth G, Zbaren P et al (1997) Long-term changes induced by high-dose irradiation of the head and neck region: imaging findings. Radiographics 17:5–26PubMedCrossRef
44.
Nabil S, Samman N (2012) Risk factors for osteoradionecrosis after head and neck radiation: a systematic review. Oral Surg Oral Med Oral Pathol Oral Radiol 113:54–69PubMedCrossRef
45.
46.
Alhilali L, Reynods AR, Fakhran S (2014) Osteoradionecrosis after radiation therapy for head and neck cancer: differentiation from recurrent disease with CT and PET/CT imaging. AJNR Am J Neuroradiol 35:1405-1411PubMedCrossRef
47.
Thoeny HC, De Keyzer F, King AD (2012) Diffusion-weighted MR imaging in the head and neck. Radiology 263:19–32PubMedCrossRef
48.
49.
Boss A, Stegger L, Bisdas S et al (2011) Feasibility of simultaneous PET/MR imaging in the head and upper neck area. Eur Radiol 21:1439–1446PubMedCrossRef
50.
Vargas MI, Becker M, Garibotto V et al (2013) Approaches for the optimization of MR protocols in clinical hybrid PET/MRI studies. MAGMA 26:57–69PubMedCrossRef
51.
Varoquaux A, Rager O, Poncet A et al (2014) Detection and quantification of focal uptake in head and neck tumours: (18)F-FDG PET/MR versus PET/CT. Eur J Nucl Med Mol Imaging 41:462–475PubMedPubMedCentralCrossRef
52.
Desmouliere A, Redard M, Darby I, Gabbiani G (1995) Apoptosis mediates the decrease in cellularity during the transition between granulation tissue and scar. Am J Pathol 146:56–66PubMedPubMedCentral
53.
Kumar V, Abbas AK, Aster JC (2012) Inflammation and repair. In: Kumar V, Abbas AK, Aster JC (eds) Robbins basic pathology, 9th edn. Elsevier Saunders, Philadelphia, pp 29–74
54.
Romo LV, Curtin HD (1999) Atrophy of the posterior cricoarytenoid muscle as an indicator of recurrent laryngeal nerve palsy. AJNR Am J Neuroradiol 20:467–471PubMed
55.
Heller MT, Meltzer CC, Fukui MB et al (2000) Superphysiologic FDG uptake in the non-paralyzed vocal cord. Resolution of a false-positive PET result with combined PET-CT imaging. Clin Positron Imaging 3:207–211PubMedCrossRef
56.
Pai M, Kim HK, Kim HS (2006) Hypermetabolism of compensatory laryngeal muscles in unilateral vocal cord palsy: comparison study between speech and silence with normal subjects by co-registered PET-CT fusion images. Nucl Med Mol Imaging 40:23–27
57.
Paquette CM, Manos DC, Psooy BJ (2012) Unilateral vocal cord paralysis: a review of CT findings, mediastinal causes, and the course of the recurrent laryngeal nerves. Radiographics 32:721–740PubMedCrossRef
58.
Becker M, Leuchter I, Platon A, Becker CD, Dulguerov P, Varoquaux A (2014) Imaging of laryngeal trauma. Eur J Radiol 83:142–154PubMedCrossRef
59.
Policeni BA, Smoker WR (2008) Pathologic conditions of the lower cranial nerves IX, X, XI, and XII. Neuroimaging Clin N Am 18:347–368PubMedCrossRef
60.
Becker M, Kohler R, Vargas MI, Viallon M, Delavelle J (2008) Pathology of the trigeminal nerve. Neuroimaging Clin N Am 18:283–307PubMedCrossRef
61.
Werner MK, Pfannenberg C, Oksuz MO (2011) Nonspecific FDG uptake in the tongue mimicking the primary tumor in a patient with cancer of unknown primary. Clin Imaging 35:405–407PubMedCrossRef
62.
Chen W, Parsons M, Torigian DA, Zhuang H, Alavi A (2009) Evaluation of thyroid FDG uptake incidentally identified on FDG-PET/CT imaging. Nucl Med Commun 30:240–244PubMedCrossRef
63.
Choi JY, Lee KS, Kim HJ et al (2006) Focal thyroid lesions incidentally identified by integrated 18 F-FDG PET/CT: clinical significance and improved characterization. J Nucl Med 47:609–615PubMed
64.
Lin EC (2002) Thyroid nodule mimicking cervical adenopathy on FDG positron emission tomographic imaging. Clin Nucl Med 27:656–657PubMedCrossRef
65.
Weiler-Sagie M, Bushelev O, Epelbaum R et al (2010) (18)F-FDG avidity in lymphoma readdressed: a study of 766 patients. J Nucl Med 51:25–30PubMedCrossRef
66.
Purohit BS, Dulguerov P, Burkhardt K, Becker M (2014) Dedifferentiated laryngeal chondrosarcoma: combined morphologic and functional imaging with positron-emission tomography/magnetic resonance imaging. Laryngoscope 124:E274–E277PubMedCrossRef
67.
Avril NE, Weber WA (2005) Monitoring response to treatment in patients utilizing PET. Radiol Clin North Am 43:189–204PubMedCrossRef
68.
Harvey RJ, Pitzer G, Nissman DB et al (2010) PET/CT in the assessment of previously treated skull base malignancies. Head Neck 32:76–84PubMed
69.
70.
King AD, Ma BB, Yau YY et al (2008) The impact of 18 F-FDG PET/CT on assessment of nasopharyngeal carcinoma at diagnosis. Br J Radiol 81:291–298PubMedCrossRef
71.
Goerres GW, Hany TF, Kamel E, von Schulthess GK, Buck A (2002) Head and neck imaging with PET and PET/CT: artefacts from dental metallic implants. Eur J Nucl Med Mol Imaging 29:367–370PubMedCrossRef
72.
Abdoli M, Ay MR, Ahmadian A, Dierckx RA, Zaidi H (2010) Reduction of dental filling metallic artifacts in CT-based attenuation correction of PET data using weighted virtual sinograms optimized by a genetic algorithm. Med Phys 37:6166–6177PubMedCrossRef
73.
Park HH, Shin JY, Lee J et al (2013) A study on the artifacts generated by dental materials in PET/CT image. Conf Proc IEEE Eng Med Biol Soc 2013:2465–2468PubMed
74.
Nahmias C, Lemmens C, Faul D et al (2008) Does reducing CT artifacts from dental implants influence the PET interpretation in PET/CT studies of oral cancer and head and neck cancer? J Nucl Med 49:1047–1052PubMedCrossRef
75.
Delso G, Wollenweber S, Lonn A, Wiesinger F, Veit-Haibach P (2013) MR-driven metal artifact reduction in PET/CT. Phys Med Biol 58:2267–2280PubMedCrossRef
Metadata
Title
FDG-PET/CT pitfalls in oncological head and neck imaging
Authors
Bela S. Purohit
Angeliki Ailianou
Nicolas Dulguerov
Christoph D. Becker
Osman Ratib
Minerva Becker
Publication date
01-10-2014
Publisher
Springer Berlin Heidelberg
Published in
Insights into Imaging / Issue 5/2014
Electronic ISSN: 1869-4101
DOI
https://doi.org/10.1007/s13244-014-0349-x

Other articles of this Issue 5/2014

Insights into Imaging 5/2014 Go to the issue

Pictorial Review

Radiological diagnosis of dialysis-associated complications

Pictorial Review

Idiopathic scoliosis in children and adolescents: assessment with a biplanar X-ray device

Original Article

Radiation knowledge and perception of referral practice among radiologists and radiographers compared with referring clinicians

Pictorial Review

Cardiac multidetector computed tomography in infective endocarditis: a pictorial essay

Pictorial Review

Computed Tomography and Magnetic Resonance Imaging of the Coronary Sinus: Anatomic Variants and Congenital Anomalies

Original Article

Medical student knowledge regarding radiology before and after a radiological anatomy module: implications for vertical integration and self-directed learning