Coverage Policy Manual
Policy #: 2000023
Category: Radiology
Initiated: May 2000
Last Review: December 2023
  PET or PET/CT for Head and Neck Malignant Disease
Description:
Note:  This policy is intended for those members with contracts that do not have requirements for prior approval for imaging procedures through an independent imaging review organization.
 
 
Positron Emission Tomography (PET) imaging uses radiotracers that can reveal both anatomical and physiological information.  The glucose analog, 2-[fluorine-18]-Fluoro-2-deoxy-D-glucose (FDG) is useful in cancer imaging because it has been found that tumor cells show increased utilization of glucose compared to non-malignant tissue and is the most common radiotracer that is utilized. For certain malignancies PET scans have been shown to be more accurate than other non-invasive tests in detecting malignant disease.  However, as with all diagnostic tests, PET scans do not detect cancer 100% of the time that cancer is present (a false negative test), nor do all positive PET scans represent the presence of malignant disease (a false positive test).  A false negative test may occur because a critical volume of malignant cells is necessary for a PET scan to be positive. PET scans may be false positive in the presence of inflammation or granulomatous disease.
 
PET scans have been shown to be more accurate than other diagnostic modalities in identifying the site of an unknown head and neck primary tumor in patients who are found to have metastatic disease in lymph nodes which drain the head and neck region (36% using PET scans; 24% using other diagnostic tests).
 
PET scans have been shown to be more accurate than other diagnostic modalities such as Computed Tomography (CT) in identifying metastatic disease from known head and neck primary malignancies (Sensitivity of PET = 90%, Sensitivity of CT = 78%, Sensitivity of MRI = 76%; Specificity of PET = 94%, Specificity of CT = 79%, Specificity of MRI = 50%).
 
PET scans have been shown to be more accurate than other diagnostic modalities in detecting residual or recurrent disease in a small number of studies, although a few other studies showed no difference in the detection of residual or recurrent disease.  One study (29 patients) has shown that PET altered treatment in 9 of 29 patients.
 
The result of using of PET to monitor response to chemotherapy has been reported in a few series of small numbers of patients.  In these case series, the interval between tumor therapy and FDG-PET, as well as the method of quantification differ per study. Whether the result of monitoring chemotherapy or radiotherapy with PET improves health outcomes is unknown. Dynamic imaging is not a standard technique to evaluate tumor therapy.
 
PET for thyroid malignancy is addressed in policy # 2004024.
 
Definitions
 
Screening – testing in the absence of an established or clinically suspected diagnosis
 
Diagnosis - testing based on a reasonable clinical suspicion of a particular condition or disorder
 
Diagnostic Workup – initial staging of documented malignancy
 
Management – testing to direct therapy of an established condition, which may include preoperative or postoperative imaging, or imaging performed to evaluate the response to nonsurgical intervention. In oncologic imaging, management applies to patients with measurable disease and to imaging performed before or after planned treatment intervention, therapy response, restaging or clinically suspected recurrence.
 
Surveillance – periodic assessment following completion of therapy. In oncologic imaging, surveillance applies to asymptomatic patients in remission and/or without measurable disease
 
Cannot be performed or is nondiagnostic – applies when the test:
    • Is positive or indeterminate for clinically significant pathology when the information provided about the abnormality by the test is not sufficient to direct subsequent management
    • Is negative when the negative likelihood ratio of the test is both insufficient to confidently exclude the absence of suspected disease and unable to direct subsequent management. This typically applies in scenarios with moderate to high clinical pretest probability with negative testing or low pretest probability with clear evidence for net benefit
    • Has been previously nondiagnostic because of a persistent clinical factor (e.g., body habitus, immobility) that is very likely to make retesting nondiagnostic as well Cannot be performed due to a medical contraindication (e.g., contrast nephrotoxicity, allergy, or in highly radiation sensitive populations such as pediatrics and pregnancy) or reasonable unavailability related to lack of local expertise or service availability
Standard or conventional imaging: Refers to imaging that does not require a PET/CT. Depending on the clinical scenario and individual patient circumstances, this may include computed tomography, magnetic resonance imaging, ultrasound and/or scintigraphy.
 
Policy/
Coverage:
EFFECTIVE APRIL 09, 2023
 
Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria
 
FDG-PET/CT for patients with Head and Neck Malignant Disease meets member benefit certificate primary coverage criteria for effectiveness in improving health outcomes for:
Diagnostic Workup:
Indicated in EITHER of the following scenarios:
        • Evaluation of locoregionally advanced cancers (T3-T4 primary or ≥ N1 nodal staging) of the oral cavity, oropharynx, hypopharynx, nasopharynx, larynx, and sinus; or
        • Following biopsy suggestive of a head and neck primary tumor (squamous cell cancer, adenocarcinoma, or anaplastic undifferentiated epithelial tumor) when CT or MRI evaluation of the neck has not detected a primary site of tumor
Management:
Indicated in ANY of the following scenarios:
        • Radiation planning for preoperative or definitive treatment only
        • Evaluation of disease following clinical response to treatment, no sooner than 12 weeks after completion of radiation therapy or concurrent chemoradiation therapy
        • Standard imaging cannot be performed or is nondiagnostic for recurrent or progressive disease
        • Follow up of an equivocal post-treatment PET scan, no sooner than 4 weeks after the study, to determine need for further intervention such as neck dissection
 
For all fully insured contracts, all self-funded church-sponsored health plans and all self-funded government-sponsored health plans other than the Arkansas State and Public School Employees program, the Federal Employee Health Benefit Program and Medicare Advantage plans, as required by Act 583 of the Arkansas Legislature, please see ABCBS policy 2021004, Surveillance and Other PET Oncologic Applications.
  
Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria
 
PET/CT for patients with Head and Neck Malignant Disease does not meet member benefit certificate primary coverage criteria for effectiveness in improving health outcomes for:
    • initial evaluation of lip and salivary gland cancers, regardless of stage.
    • adjuvant radiation therapy planning when all known disease has been removed.
    • surveillance*
For members with contracts without primary coverage criteria, PET/CT for patients with Head and Neck Malignant Disease is considered investigational and is not covered for any other indication not specifically listed as covered above including by not limited to:   
    • initial evaluation of lip and salivary gland cancers, regardless of stage.
    • adjuvant radiation therapy planning when all known disease has been removed.
    • surveillance*
Investigational services arespecific contract exclusions in most member benefit certificates of coverage.
 
*For all fully insured contracts, all self-funded church-sponsored health plans and all self-funded government-sponsored health plans other than the Arkansas State and Public School Employees program, the Federal Employee Health Benefit Program and Medicare Advantage plans, as required by Act 583 of the Arkansas Legislature, please see ABCBS policy 2021004, Surveillance and Other PET Oncologic Applications.
  
Note: Standard or conventional imaging: Refers to imaging that does not require a PET/CT. Depending on the clinical scenario and individual patient circumstances, this may include computed tomography, magnetic resonance imaging, ultrasound and/or scintigraphy.
 
 
Effective MARCH 13, 2022 to April 08, 2023
 
Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria
 
FDG-PET/CT for patients with Head and Neck Malignant Disease meets member benefit certificate primary coverage criteria for effectiveness in improving health outcomes for:
 
Diagnostic Workup:
Indicated in EITHER of the following scenarios:
        • Evaluation of stage III and IV cancers (tumors greater than 4 cm in size, or any evidence of regional node involvement) of the oral cavity, oropharynx, hypopharynx, nasopharynx, larynx, and sinus
        • Following biopsy suggestive of a head and neck primary tumor (squamous cell cancer, adenocarcinoma, or anaplastic undifferentiated epithelial tumor) when CT or MRI evaluation of the neck has not detected a primary site of tumor
 
Management:
Indicated in ANY of the following scenarios:
        • Radiation planning for preoperative or definitive treatment only
        • Evaluation of disease following clinical response to treatment, no sooner than 12 weeks after completion of radiation therapy or concurrent chemoradiation therapy
        • Standard imaging cannot be performed or is nondiagnostic for recurrent or progressive disease
        • Follow up of an equivocal post-treatment PET scan, no sooner than 4 weeks after the study, to determine need for further intervention such as neck dissection
 
For all fully insured contracts, all self-funded church-sponsored health plans, and all self-funded government-sponsored health plans (e.g., state and public-school employee plans), other than the Federal Employee Health Benefit Program and Medicare Advantage plans, as required by Act 583 of the Arkansas Legislature, please see ABCBS policy 2021004, Surveillance and Other PET Oncologic Applications.
 
Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria
 
PET/CT for patients with Head and Neck Malignant Disease does not meet member benefit certificate primary coverage criteria for effectiveness in improving health outcomes for:
    • initial evaluation of lip and salivary gland cancers, regardless of stage.
    • adjuvant radiation therapy planning when all known disease has been removed.
    • surveillance*
For members with contracts without primary coverage criteria, PET/CT for patients with Head and Neck Malignant Disease is considered investigational and is not covered for any other indication not specifically listed as covered above including by not limited to:   
    • initial evaluation of lip and salivary gland cancers, regardless of stage.
    • adjuvant radiation therapy planning when all known disease has been removed.
    • surveillance*
Investigational services are Plan exclusions.
 
*For all fully insured contracts, all self-funded church-sponsored health plans, and all self-funded government-sponsored health plans (e.g., state and public-school employee plans), other than the Federal Employee Health Benefit Program and Medicare Advantage plans, as required by Act 583 of the Arkansas Legislature, please see ABCBS policy 2021004, Surveillance and Other PET Oncologic Applications.
 
Note: Standard or conventional imaging: Refers to imaging that does not require a PET/CT. Depending on the clinical scenario and individual patient circumstances, this may include computed tomography, magnetic resonance imaging, ultrasound and/or scintigraphy.
 
 
Effective Prior to MARCH 13, 2022
 
Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria
FDG-PET/CT for patients with Head and Neck Malignant Disease meets member benefit certificate primary coverage criteria for effectiveness in improving health outcomes for:
Diagnostic Workup:  
Indicated in EITHER of the following scenarios:  
        • Evaluation of stage III and IV cancers (tumors greater than 4 cm in size, or any evidence of regional node involvement) of the oral cavity, oropharynx, hypopharynx, nasopharynx, larynx, and sinus
        • Following biopsy suggestive of a head and neck primary tumor (squamous cell cancer, adenocarcinoma, or anaplastic undifferentiated epithelial tumor) when CT or MRI evaluation of the neck has not detected a primary site of tumor
Treatment Management:  
Indicated in ANY of the following scenarios:
        • Radiation planning for preoperative or definitive treatment only
        • Evaluation of disease following clinical response to treatment, no sooner than 12 weeks after completion of radiation therapy or concurrent chemoradiation therapy
        • Evaluation of suspected recurrence based on signs or symptoms, when CT or MRI cannot be performed or is nondiagnostic for recurrent disease
        • Follow up of an equivocal post-treatment PET scan, no sooner than 4 weeks after the study, to determine need for further intervention such as neck dissection
 
For all fully insured contracts, all self-funded church-sponsored health plans, and all self-funded government-sponsored health plans (e.g., state and public-school employee plans), other than the Federal Employee Health Benefit Program and Medicare Advantage plans, as required by Act 583 of the Arkansas Legislature, please see ABCBS policy 2021004, Surveillance and Other PET Oncologic Applications.
 
Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria
PET/CT for patients with Head and Neck Malignant Disease does not meet member benefit certificate primary coverage criteria for effectiveness in improving health outcomes for:
    • for initial evaluation of lip and salivary gland cancers, regardless of stage.
    • for adjuvant radiation therapy planning when all known disease has been removed.
    • for screening and surveillance*
    • for any other indication not specifically listed as covered above
 
*For all fully insured contracts, all self-funded church-sponsored health plans, and all self-funded government-sponsored health plans (e.g., state and public-school employee plans), other than the Federal Employee Health Benefit Program and Medicare Advantage plans, as required by Act 583 of the Arkansas Legislature, please see ABCBS policy 2021004, Surveillance and Other PET Oncologic Applications.
 
For members with contracts without primary coverage criteria, PET/CT for patients with Head and Neck Malignant Disease is considered investigational:  
    • for initial evaluation of lip and salivary gland cancers, regardless of stage.
    • for adjuvant radiation therapy planning when all known disease has been removed.
    • for screening and surveillance
    • for any other indication not specifically listed as covered above
Investigational services are Plan exclusions.
 
Notes:  
Standard or conventional imaging refers to imaging that does not require a PET/CT.
CT/MRI is usually considered first-line imaging.  
 
 
Effective Prior to August 2021
 
Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria
“PET scan” refers to FDG PET or PET/CT.
 
Positron emission tomography (PET) scanning meets primary coverage criteria for effectiveness and is covered for the initial staging of patients with head and neck cancer and is covered:
    • for the detection of residual disease 2-6 months after completion of chemoradiotherapy or 1-2 months after surgery
    • When recurrence is suspected on the basis of clinical or biochemical findings or by conventional imaging.
    • Evaluation of response to treatment.
 
Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria
The following uses of PET do not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes:
    • Repeat PET scanning for surveillance of asymptomatic patients
    • PET scanning for monitoring response to ongoing radiation and/or chemotherapy regimens
    • PET scanning with any radiotracer other than FDG
 
For contracts without primary coverage criteria, the following uses of PET scanning are considered investigational and are not covered:
    • Repeat PET scanning for surveillance of asymptomatic patients
    • PET scanning for monitoring response to ongoing radiation and/or chemotherapy regimens
    • PET scanning with any radiotracer other than FDG
 
Investigational services are an exclusion in the member benefit contract.
 
 
Effective prior to November 2018
 
Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria
“PET scan” refers to FDG PET or PET/CT.
 
Positron emission tomography (PET) scanning meets primary coverage criteria for effectiveness and is covered for the initial staging of patients with head and neck cancer and is covered:
    • for the detection of residual disease 2-6 months after completions of chemoradiotherapy or 1-2 months after surgery
    • when recurrence is suspected on the basis of clinical or biochemical findings or by conventional imaging.
 
Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria
 
The following uses of PET do not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes:
    • Repeat PET scanning for surveillance of asymptomatic patients
    • PET scanning for monitoring response to ongoing radiation and/or chemotherapy regimens
    • PET scanning with any radiotracer other than FDG
 
For contracts without primary coverage criteria, the following uses of PET scanning are considered investigational and are not covered:
    • Repeat PET scanning for surveillance of asymptomatic patients
    • PET scanning for monitoring response to ongoing radiation and/or chemotherapy regimens
    • PET scanning with any radiotracer other than FDG
 
Investigational services are an exclusion in the member benefit contract.
Rationale:
PET is generally not performed until two to three months after radiation or chemoradiation or one to two months after surgery due to the risk of false positive scans secondary to inflammation.  
 
Juweid and Cheson state periodic PET scanning in patients with no clinical or biochemical evidence of disease, even several years after treatment, will result in reduced cost-effectivness and should be avoided.
 
2013 Update:
A review of literature on PubMed through December 2012 was performed. There were no published articles identified that would prompt a change in the coverage statement.
 
•   Three studies identified that used other diagnostic modalities to attempt to identify a primary tumor in patients with positive cervical lymph nodes, PET found more primary tumors than other modalities in 2 studies and identified similar proportions in 1 study. (6) When data from these 3 studies are pooled, PET was found to identify tumor in 38% of cases and other modalities found tumor in 21% of cases.
•   When PET is used to initially stage the cervical lymph nodes (i.e., the status of the cervical nodes is unknown), the addition of PET to other imaging modalities increased the proportion of patients who were correctly staged, as confirmed histologically. When compared head to head with other imaging modalities, the pooled data from a variety of studies suggested that PET had a better diagnostic performance compared to CT and MRI.
•   Of 8 studies focusing on the use of PET to detect residual or recurrent disease, 5 found PET to be more specific and sensitive, 2 reported mixed or equivalent results, and 1 reported worse results compared to CT.
 
Rudmik and colleagues (2011) published the results of NCT 00656760, a non-randomized prospective, single-blinded study using PET as an adjunct in the diagnosis of metastatic head and neck squamous cell carcinoma with an unknown primary.  Twenty (20) subjects with cervical metastases from an unknown head and neck primary were included in the study.  A standard protocol was used in both clinic and operating room (OR). Study surgeons were blinded to the PET/CT result upon completion of the standard work-up.  Results:  PET/CT increased the detection of a primary site from 25% to 55% (5 vs 11 subjects). This difference was statistically and clinically significant (p = .03, McNemar's test). There was 1 false negative PET/CT scan.  The authors concluded from the study that an unknown primary should be diagnosed only after a complete head and neck examination, flexible endoscopy, and CT or MRI and that PET/CT performed prior to panendoscopy will increase the diagnostic yield in the unknown head and neck primary population, leading to more targeted, and less morbid, treatment.
 
Newbold and Powell (2012), published an article on the use of PET/CT as an option in radiotherapy planning for head and neck cancer.  Reasons included better identification of the disease extent, i.e., staging, and the ability to identify biological target volumes either for escalation or radiation dose or to predict the requirement for the addition of a radiosensitizer or alternative treatment strategies by characterizing the biological behavior of the disease, such as areas of hypoxia, rich or poor vascularity, or high cell proliferation.
The authors also included the following limitations of PET/CT imaging in radiation planning:
•   Maintenance of collaborative links with diagnostic physicians in order to assure correct interpretation of the functional imaging acquired.
•   Finite resolution of PET. Preclinical studies have shown discrepancies between imaging with a small-animal PET scanner with a spatial resolution of 2.7 mm and the underlying microscopic reality represented by autoradiography. Such a discrepancy means the macroscopic assessment of tumors with molecular imaging might not necessarily reflect their microregional distribution. Negative scan findings cannot, therefore, exclude the presence of microscopic tissue involvement, and precise anatomic localization of the signal can be difficult in certain anatomic regions.  
•   The utility of molecular and functional imaging is yet to be implemented into routine clinical practice. The reason for this is multi-factorial and relates to much of the data being generated from single institutions series with variations in imaging modality, sequence acquisition, data processing, and analysis tools.  As preliminary findings are validated in larger studies, so attention to standardization of protocols and image processing and data analysis must occur. This is necessary not only for implementing findings from studies performed at other institutions but, most importantly, in the design of multi-center trials which must include rigorous QA (quality assurance). For example, metabolic treatment volumes are often defined in relation to SUVmax, which is highly dependent on contrast recovery and noise properties that vary across scanners and reconstructive protocols. Hence there is a need for standardization in relation to the use of SUVs and SUV changes in studies of treatment response assessments.
 
NCCN GUIDELINES Version 1.2012, Head and Neck Cancers:
•   After either radiation therapy (RT) or chemoradiation, post-treatment evaluation with imaging (e.g., CT and/or MRI with contrast, PET-CT) guides the use of neck dissection.  If PET-CT is used for follow-up, the first scan should be performed at approximately 12 weeks after treatment to reduce the false-positive rate.
•   Imaging studies to evaluate mandibular involvement is particularly important for staging and planning therapy for oral cavity cancers.  For patients who appear to have stage III-IV disease, PET-CT may alter management by upstaging patients.
•   A PET-CT scan should only be done (before biopsy) if other test do not reveal a primary.
•   For mucosal melanoma of the head and neck, PET-CT scanning may be considered to define the presence of distant disease in more advanced situations.
 
A search on www.cllinicaltrials.gov revealed the following NCTs:
•   NCT00147472 - Positron Emission Tomography (PET) Imaging in Post Radiation Evaluation of Head and Neck Tumors (PET PREVENT Trial)_(Canada); Interventional, Non-randomized study; Enrollment 400.  Study completed, but results not published
•   NCT00983697 - A Multicenter Trial of FDG-PET/CT Staging of Head and Neck Cancer and Its Impact on the N0 Neck Surgical Treatment in Head and Neck Cancer Patients_NCI, sponsored, estimated enrollment: 292; estimated completion date of July, 2011, but according to website is still recruiting.
 
2014 Update
 
A literature search conducted through April 2014 did not reveal any new information that would prompt a change in the coverage statement.
 
Meta-analyses in 2013 have reported good sensitivities and specificities with PET-CT for detecting head and neck cancer metastases (better than bone scintigraphy [Yi, 2013)]) and recurrence (Gao, 2013). The NCCN guidelines on head and neck cancer indicate PET-CT may be appropriate for stage III-IV disease evaluation, for detection of metastases or recurrence, and for evaluation of response to treatment (NCCN, 2013).
  
2015 Update
 
A literature search conducted through January 2015 did not reveal any new information that would prompt a change in the coverage statement. The key identified literature is summarized below.
 
Meta-analyses in 2013 and 2014 reported good sensitivities and specificities with PET/CT for diagnosing head and neck squamous cell cancers (better than CT and MRI [Rohde, 2014]) and for detecting head and neck cancer metastases (better than bone scintigraphy [Yi, 2013]) and recurrence (Gao, 2013). Current NCCN guidelines for head and neck cancer indicate that PET/CT may be appropriate for stage III-IV disease evaluation, for detection of metastases or recurrence, and for evaluation of response to treatment (NCCN, 2014).
 
2018 Update
 Annual policy review completed with a literature search using the MEDLINE database through February 2018. No new literature was identified that would prompt a change in the coverage statement. The key identified literature is summarized below.
 
HEAD AND NECK CANCER AND 18F-FDG-PET AND 18F-FDG-PET/CT
A 2016 meta-analysis by Chen et al compared MRI, CT, and 18F-FDG-PET/CT in the detection of local
and metastatic nasopharyngeal carcinomas (Chen, 2016). A literature search, conducted through April 2015, identified 23 studies (total N=2413 patients) for inclusion.
 
A 2016 meta-analysis by Wei et al compared diagnostic capabilities of 18F-FDG-PET/CT, MRI, and single photon emission computed tomography in patients with residual or recurrent nasopharyngeal Carcinoma (Wei, 2016). The literature search, conducted through December 2014, identified 17 studies for inclusion. All studies scored at least 9 of 14 in the QUADAS tool. Pooled sensitivity and specificity for 18F-FDGPET/CT (n=12 studies) were 90% (95% CI, 85% to 94%) and 93% (95% CI, 90% to 95%), respectively. Pooled sensitivity and specificity for single-photon emission computed tomography (n=8 studies) were 85% (95% CI, 77% to 92%) and 91% (95% CI, 85% to 95%), respectively. Pooled sensitivity and specificity for MRI (n=9 studies) were 77% (95% CI, 70% to 83%) and 76% (95% CI, 73% to 79%), respectively.
 
Two meta-analyses evaluated 18F-FDG-PET or 18F-FDG-PET/CT in the detection of residual or recurrent head and neck cancer at various times following treatment(Cheung, 2016;Sheikhbahaei, 2015).                  
 
A systematic review by Sheikhbahaei et al calculated the predictive value of intratherapy or
posttherapy 18F-FDG-PET or PET/CT for overall survival (OS) and event-free survival (Sheikhbahaei, 2015). The literature search, conducted through November 2014, identified 9 studies (n=600 patients) for inclusion in OS calculations and 8 studies (n=479 patients) for inclusion in event-free survival calculations. Patients with a positive scan had significantly worse OS compared with patients with negative scans (hazard ratio, 3.5; 95% CI, 2.3% to 5.4%). The pooled hazard ratio for event-free survival was 4.7 (95% CI, 2.6 to 8.6). Two year and 3- to 5-year relative risks for death or recurrence or progression were calculated, based on timing of 18F-FDG-PET or -PET/CT.
2019 Update
Annual policy review completed with a literature search using the MEDLINE database through February 2019. No new literature was identified that would prompt a change in the coverage statement.
 
2020 Update
A literature search was conducted through February 2020.  There was no new information identified that would prompt a change in the coverage statement.   
 
2021 Update
Annual policy review completed with a literature search using the MEDLINE database through January 2021. No new literature was identified that would prompt a change in the coverage statement.
 
December 2021 Update
A literature review was performed through September 2021. Following is a summary of the key literature to date.
 
DIAGNOSTIC WORKUP
Head and neck cancers are staged using the American Joint Committee on CancerTNM system. When compared to physical exam alone, CT results in a change of stage in 54% of patients. (1) However, CT is relatively poor at identifying invasion of non-osseous cartilage. Newer techniques have improved sensitivity and specificity of CT to almost 90% and 96%, respectively, (2) but up to 67% of pathologic lymph nodes may still be missed. (3) MRI may be indicated as an adjunct to CT, particularly in the management of nasopharyngeal cancers. In a meta-analysis of 10 studies, diffusion-weighted MRI for evaluation of head and neck squamous cell carcinomas improved overall accuracy from 66% to 86%. (4)
 
In a retrospective study conducted by Fleming et al., PET/CT had an accuracy of 90%, true positive rate of 82.9%, and false positive rate of 12.2%. In patients with unknown primary, PET/CT was able to identify the primary site in 72.7% of patients. Distant metastases were detected in 15.4% of patients, and overall treatment was altered in 30.9% of patients. (5) In a meta-analysis of 8 studies, sensitivity and specificity of PET/PET-CT for detecting distant metastatic disease were 83% and 96% compared with conventional anatomic imaging, 44% and 96%, respectively. (6) The accuracy of PET in early stage head and neck cancers without lymph node involvement is less clear. Multiple small studies have shown relatively poor sensitivity ranging from 25% to 63% for detecting occult lymph node metastases. (7, 8)
 
MANAGEMENT
A prospective randomized trial by Mehanna et al. found that PET/CTperformed 12 weeks after chemoradiation therapy for treatment response for patients with N2/3 disease resulted in substantially fewer neck dissections with no adverse impact on survival. (9) A meta-analysis of 23 studies looking at accuracy of PET/CT found a pooled sensitivity and specificity of 92% and 87%, respectively, for detection of recurrence. A second meta-analysis of 27 studies confirmed these results, with pooled sensitivity and specificity of PET for detecting residual or recurrent head and neck squamous cell carcinoma reported to be 94% and 82%, respectively. However, sensitivity was adversely affected when PET/CT imaging was done within 10 weeks of completion of treatment. (10) A negative PET/CT corresponds with a 90% chance of disease eradication.11 These findings were corroborated by 2 additional retrospective studies. (12, 13)
 
SURVEILLANCE
Most recurrences are discovered by patients and not by serial imaging or physical exam. AIM guidelines are in accordance with National Comprehensive Cancer Network Guidelines for Head and Neck Cancers. (14)
 
Current References
    1. Prehn RB, Pasic TR, Harari PM, et al. Influence of computed tomography on pretherapeutic tumor staging in head and neck cancer patients. Otolaryngol Head Neck Surg. 1998;119(6):628-33. PMID: 9852538
    2. Kuno H, Onaya H, Iwata R, et al. Evaluation of cartilage invasion by laryngeal and hypopharyngeal squamous cell carcinoma with dual-energy CT. Radiology. 2012;265(2):488-96. PMID: 22984188
    3. Don DM, Anzai Y, Lufkin RB, et al. Evaluation of cervical lymph node metastases in squamous cell carcinoma of the head and neck. Laryngoscope. 1995;105(7 Pt 1):669-74. PMID: 7603268
    4. Driessen JPvK, P. M.;van der Heijden, G. J.;Philippens, M. E.;Pameijer, F. A.;Stegeman, I.;Terhaard, C. H.;Janssen, L. M.;Grolman, W. Diffusion-weighted imaging in head and neck squamous cell carcinomas: a systematic review. Head Neck. 2015;37(3):440-8. PMID: 24347513
    5. Fleming AJ, Jr., Smith SP, Jr., Paul CM, et al. Impact of [18F]-2-fluorodeoxyglucose-positron emission
    6. tomography/computed tomography on previously untreated head and neck cancer patients. Laryngoscope. 2007;117(7):1173-9. PMID: 17603315
6. Xu G, Li J, Zuo X, et al. Comparison of whole body positron emission tomography (PET)/PET-computed tomography and conventional anatomic imaging for detecting distant malignancies in patients with head and neck cancer: a meta-analysis. Laryngoscope. 2012;122(9):1974-8. PMID: 22753007
7. Stoeckli SJ, Steinert H, Pfaltz M, et al. Is there a role for positron emission tomography with 18Ffluorodeoxyglucose in the initial staging of nodal negative oral and oropharyngeal squamous cell carcinoma. Head Neck. 2002;24(4):345-9. PMID: 11933176
8. Liao LJ, Hsu WL, Wang CT, et al. Analysis of sentinel node biopsy combined with other diagnostic tools in staging cN0 head and neck cancer: A diagnostic meta-analysis. Head Neck. 2016;38(4):628-34. PMID: 25524256
9. Mehanna H, Wong WL, McConkey CC, et al. PET-CT surveillance versus neck dissection in advanced head and neck cancer. N Engl J Med. 2016;374(15):1444-54. PMID: 27007578
10. Isles MG, McConkey C, Mehanna HM. A systematic review and meta-analysis of the role of positron emission tomography in the follow up of head and neck squamous cell carcinoma following radiotherapy or chemoradiotherapy. Clin Otolaryngol. 2008;33(3):210-22. PMID: 18559026
11. Abgral R, Querellou S, Potard G, et al. Does 18F-FDG PET/CT improve the detection of posttreatment recurrence of head and neck squamous cell carcinoma in patients negative for disease on clinical follow-up? J Nucl Med. 2009;50(1):24-9. PMID: 19091901
12. Nayak JV, Walvekar RR, Andrade RS, et al. Deferring planned neck dissection following chemoradiation for stage IV head and neck cancer: the utility of PET-CT. Laryngoscope. 2007;117(12):2129-34. PMID: 17921898
13. Ong SC, Schoder H, Lee NY, et al. Clinical utility of 18F-FDG PET/CT in assessing the neck after concurrent chemoradiotherapy for locoregional advanced head and neck cancer. J Nucl Med. 2008;49(4):532-40. PMID: 18344440
14. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Head and Neck Cancers (Version 12.2021). Available at http://www.nccn.org. ©National Comprehensive Cancer Network, 2021.
 
2022 Update
Annual policy review completed with a literature search using the MEDLINE database through September 2022. No new literature was identified that would prompt a change in the coverage statement.
 
NCCN Guidelines Head and Neck Cancers (Version 2.2022) were reviewed with no change from Version 2021 with regard to PET applications in Head and Neck cancer.
 
2023 Update
Annual policy review completed with a literature search using the MEDLINE database through November 2023. No new literature was identified that would prompt a change in the coverage statement.
CPT/HCPCS:
78811Positron emission tomography (PET) imaging; limited area (eg, chest, head/neck)
78812Positron emission tomography (PET) imaging; skull base to mid thigh
78813Positron emission tomography (PET) imaging; whole body
78814Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; limited area (eg, chest, head/neck)
78815Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid thigh
78816Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; whole body
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