Cancers of the oral cavity and oropharynx: FDG PET with contrastenhanced CT in the posttreatment setting

The combined use of fluorine 18 fluorodeoxyglucose (FDG) positron emission tomography (PET) and contrast material-enhanced computed tomography (CT) for posttreatment monitoring of cancers of the oral cavity and oropharynx has steadily increased in recent years. FDG PET/ CT offers many advantages for evaluating the effects of therapy, determining whether residual or recurrent disease is present, and assessing the extent of nodal disease. Because of the high negative predictive value of this imaging test, some have advocated the deferral of neck dissection in patients with negative findings at FDG PET/CT after chemotherapy and radiation therapy; positive findings may have a similarly heavy influence on the future course of treatment. Thus, the accuracy of image interpretation is crucial. However, the interpretation of posttreatment FDG PET images is challenging, with multiple potential pitfalls and limitations that could lead to an incorrect analysis. Accuracy depends on a detailed knowledge of the patient's treatment history and a thorough understanding of the kinds of changes that might result from treatment. Awareness of the principles underlying the selection of the optimal interval between the completion of treatment and the first follow-up FDG PET/CT examination is especially important, since an interval that is too short could lead to false-positive or false-negative findings. A period of 12 weeks or more is generally recommended, but the optimal waiting period depends on the extent of therapy and other factors. If recurrence or progression is suspected during the waiting period, contrast-enhanced CT or magnetic resonance imaging should be performed without FDG PET.