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SLN with increased uptake not coinciding with the MM in the right axilla. MM without increased radiotracer uptake in the surroundings (A) and more caudally in the same patient, a SLN with increased uptake without MM inside is shown (B).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "D. Tamayo Carabaño, R. Álvarez Pérez, Á. De Bonilla Damiá, I. Acevedo Bañez, V.M. Pachón Garrudo, J.M. Jiménez-Hoyuela García" "autores" => array:6 [ 0 => array:2 [ "nombre" => "D." "apellidos" => "Tamayo Carabaño" ] 1 => array:2 [ "nombre" => "R." "apellidos" => "Álvarez Pérez" ] 2 => array:2 [ "nombre" => "Á." "apellidos" => "De Bonilla Damiá" ] 3 => array:2 [ "nombre" => "I." "apellidos" => "Acevedo Bañez" ] 4 => array:2 [ "nombre" => "V.M." "apellidos" => "Pachón Garrudo" ] 5 => array:2 [ "nombre" => "J.M." "apellidos" => "Jiménez-Hoyuela García" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S2253654X18301641" "doi" => "10.1016/j.remn.2018.11.006" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2253654X18301641?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2253808919300321?idApp=UINPBA00004N" "url" => "/22538089/0000003800000003/v1_201905020850/S2253808919300321/v1_201905020850/en/main.assets" ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial</span>" "titulo" => "Refining the staging of head and neck tumors. The role of Nuclear Medicine" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "137" "paginaFinal" => "139" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Africa Muxí, Sergi Vidal-Sicart, Isabel Vilaseca" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Africa" "apellidos" => "Muxí" "email" => array:1 [ 0 => "amuxi@clinic.cat" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Sergi" "apellidos" => "Vidal-Sicart" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Isabel" "apellidos" => "Vilaseca" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "aff0025" ] ] ] ] "afiliaciones" => array:5 [ 0 => array:3 [ "entidad" => "Comité Multidisciplinar de Tumores de Cabeza y Cuello, Servicio de Medicina Nuclear, Hospital Clínic, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Miembro del grupo de Investigación “Diagnòstic i Terapèutica en Oncologia” de AGAUR y del Centre d’Investigació Biomèdica Agustí Pi Sunyer (IDIBAPS), Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Grupo de trabajo de Cirugía Radioguiada de la SEMNIM, Servicio de Medicina Nuclear, Hospital Clínic, Barcelona, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Comité Multidisciplinar de Tumores de Cabeza y Cuello, Servicio de Otorrinolaringología, Hospital Clínic, Barcelona, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Facultad de Medicina, Universitat de Barcelona, Miembro Head Neck Clínic AGAUR y del Centre d’Investigació Biomèdica Agustí Pi Sunyer (IDIBAPS), Spain" "etiqueta" => "e" "identificador" => "aff0025" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Personalizando la estadificación en los tumores de cabeza y cuello. Papel de la Medicina Nuclear" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The use of imaging techniques such as computerized tomography (CT), positron emission tomography (PET), magnetic resonance (MR) or lymphoscintigraphy has increased notably in the last decades. These technological advancements provide a more accurate diagnosis of head and neck (H&N) tumors, by the acquisition of greater quality images which may be fused or co-registered, and provide morphometabolic information. Nonetheless, their implementation in clinical guidelines requires evaluation of diverse aspects such as the cost/benefit relationship, real knowledge of the clinical impact or the irradiation involved with the use of some of these techniques.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Cancer localized in the H&N region represents 4% of all cancers in Europe and constitutes a heterogeneous group of tumors localized in the oral cavity, paranasal sinuses, pharynx and larynx. In these cancers, CT is the gold standard among the diagnostic imaging techniques for the staging and planning of treatment whether this be surgical or by radiotherapy.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">1,2</span></a> Nonetheless, the use of PET co-registered with CT using fluorine-18 deoxyglucose (<span class="elsevierStyleSup">18</span>F-FDG) has shown better results than CT in the identification of tumor extension and lymph node infiltration, together with the possibility of detecting distant disease in the form of metastasis or second synchronic tumors.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">3–5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Correct staging based on the tumor, node, metastasis (TNM) staging system is essential in solid tumors for adequate therapeutic planning. This is especially important in H&N tumors in which delicate and important anatomical structures conjoin and are found very near the lesion. Tumoral infiltration of the lymph nodes is one of the most important prognostic factors, specifically in squamous carcinoma of the oral cavity in which the incidence of occult metastasis in patients with clinically negative lymph nodes is high, ranging from 20% to 30%.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">A risk of occult metastasis of 20% has classically been considered the level at which prophylactic lymph node dissection was performed,<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">7</span></a> although there are differences among centers with regard to whether or not lymphadenectomy is carried out and to what extent. With the expansion of minimally invasive transoral surgical techniques, this disjunction is even more relevant. Despite this, elective cervical lymph node dissection continues to be the standard treatment for some authors, since it is the only method which can accurately assess regional extension of the carcinoma and provide valuable prognostic information on tumoral stage.</p><p id="par0025" class="elsevierStylePara elsevierViewall">In 2016, Mehanna et al. published a prospective, randomized study comparing the efficacy and cost of the follow-up of patients with H&N tumors treated with radical chemoradiotherapy using PET/CT or systematic lymph node dissection.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">8</span></a> At two years of follow-up, the overall survival was similar between the two study arms (85% vs. 82%) and the number of lymph node emptying procedures required was 54 vs. 221, respectively. The following year the same group published an analysis of the long term costs and quality of life of the same cohort. They concluded that follow-up with PET/CT was cost-effective and suggested its implementation as a standard follow-up procedure.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">9</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">All of the above demonstrates the growing need to improve the staging of H&N tumors before and after treatment. Nuclear medicine techniques with their different diagnostic methods seem destined to play an increasingly important role in this scenario. This issue of our journal specifies the role that Nuclear Medicine may have in the morphometabolic staging of tumors by <span class="elsevierStyleSup">18</span>F-FDG PET/CT and in using the detection of the sentinel lymph node, to provide more accurate knowledge of the lymphatic territories with the greatest risk of harboring possible metastases.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The article by Pedraza et al. mentions, as its main characteristic, the potential impact of PET/CT on the management of our patients, by comparing the results of the diagnosis of H&N tumors using this morphometabolic technique versus conventional methods.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The cohort study is robust and presents the results of the assessment of 100 consecutive patients evaluated by a multidisciplinary committee of a tertiary reference hospital after performing <span class="elsevierStyleSup">18</span>F-FDG PET/CT, highlighting the important clinical impact. The results are striking; <span class="elsevierStyleSup">18</span>F-FDG PET/CT detected 6% of patients with metastasis and 8% of patients with synchronic tumors, with 7% of the total being considered as candidates for palliative treatment. Tumor extension was modified in 28% of the cases and lymph node staging in 47%.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Nowadays PET/CT may be used in many ways depending on what specific information we wish to obtain. Therefore, it becomes necessary to obtain accurate clinical information to solve the diagnostic doubts proposed. The possibility of adding an acquisition of inspiratory chest CT or a diagnostic CT with iodine contrast can rationalize the resources and time as well as provide greater patient comfort, but requires joint work in a multidisciplinary team and effort on behalf of the clinicians when requesting a diagnostic test.</p><p id="par0050" class="elsevierStylePara elsevierViewall">From our point of view, we consider that perhaps we should go one step further. The TNM of H&N tumors has recently been updated due to the clinical importance of the human papilloma virus as an etiogenic factor of some oropharyngeal tumors. However, patients with H&N tumors share other risk factors which are basically alcohol and smoking. Should we continue to limit the staging with PET/CT to only tumors with a worse prognosis? Or perhaps should we perform PET/CT in cases initially considered as more benign which will undergo minimally invasive surgery and in which the morphometabolic study of the tumor in its entirety could have greater added value? In a world without budgetary limitations or in a patient who is a member of our family, would we all indicate PET/CT? Restricting the study to only some cases may be due to the fact that humans are reluctant to make changes, for purely economic reasons or the availability of resources, but overall due to the lack of scientific evidence. From this point of view, it remains in our hands to adequately analyze the value of this technique in the different scenarios proposed. Finally, the article by Pedraza et al. leaves the door open to new questions which remain unanswered and which are presented at the end of the discussion as limitations and should be addressed in future investigations. Can we conclude that the application of PET/CT in the diagnosis of advanced H&N tumors represents a clear increase in the survival and/or disease-free period? Can we demonstrate that the use of this diagnostic protocol carries a reduction in the toxicity associated with the treatment in both the short and long term? Will the maximum standard uptake value (SUVmax) of 40% be universally accepted as the threshold for radiotherapy planning?</p><p id="par0055" class="elsevierStylePara elsevierViewall">On the other hand, selective sentinel lymph node biopsy (SLNB), which has already be validated in other solid tumors, follows the philosophy that with a minimally invasive method we can determine the lymphatic map of this tumor and can even perform “surgical staging” to define a totally personalized treatment. It is considered that unnecessary cervical lymph node dissection can be avoided in approximately 75% of the patients with carcinoma of the oral cavity.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">11</span></a> However, SLNB is not yet widely accepted as a standard method for this localization, with several controversial aspects remaining to be solved before generalized use of this procedure.</p><p id="par0060" class="elsevierStylePara elsevierViewall">In this context, the Working Group of Radioguided Surgery of the Spanish Society of Nuclear Medicine and Molecular Imaging (SEMNIM) has summarized the presentations made by this working group during the 37th National Congress held in Oviedo in 2018. These presentations cover the most relevant aspects debated during the Consensus Conference on tumors of the oral cavity within the framework of the VIII Conference of Sentinel Lymph Nodes in Head and Neck held in April 2018 in London.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">12</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Taking into account that accurate resection of the sentinel lymph node in cancer of the oral cavity requires a series of procedures which integrate the collaboration of different medical specialties such as Nuclear Medicine, Radiology, Surgery and Anatomical Pathology, a group of experts selected 31 items requiring consensus in different areas (patient selection, surgery, positive sentinel lymph node, results and treatment, anatomical pathology, and aspects related to nuclear medicine). In the area of Nuclear Medicine, 7 of the 31 topics were evaluated and discussed in an interactive session in London (dose and injection, protocol of preoperative imaging, planar imaging and SPECT/CT, labeling of sentinel lymph nodes, intraoperative imaging and the elaboration of the nuclear medicine report).</p><p id="par0070" class="elsevierStylePara elsevierViewall">The optimal protocol for presurgical lymphoscintigraphy should include sequential images (dynamic study) as well as early (20–30<span class="elsevierStyleHsp" style=""></span>min) and delayed (2<span class="elsevierStyleHsp" style=""></span>h) static images. The performance of SPECT/CT is unavoidable (provided that this possibility is available) and should follow the delayed planar images. It is important to note that the sentinel lymph nodes to be evaluated should be those which were defined in the presurgical study and excised during surgery and not those based only on the activity obtained during surgery. In this point intraoperative imaging provides added value for the localization of these sentinel lymph nodes in complex territories as has already been described in previous studies.<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">13,14</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">It should be noted that these proposals focused on Nuclear Medicine obtained 85% of concordance and acceptance among nuclear medicine physicians who voted in the session in Oviedo. This suggests that the protocols used in different centers in the country are quite homogeneous and standardized, with minimal methodological discrepancies. The availability of hybrid equipment (SPECT/CT) and the possibility of performing intraoperative imaging are limiting factors.</p><p id="par0080" class="elsevierStylePara elsevierViewall">One of the most important aspects of the meetings in London and Oviedo, in relation to the daily work in nuclear medicine, was the request that the reports made in nuclear medicine include a description of anatomical references (based on the SPECT/CT findings) as well as the positioning of the sentinel lymph nodes in the different cervical levels. This would generate accurate information for the surgeon and facilitate the intraoperative search for the sentinel lymph node. Although these requisites might increase the time required to make the final report by the nuclear medicine physicians, 83% agreed to provide this information.</p><p id="par0085" class="elsevierStylePara elsevierViewall">However, outside the setting of nuclear medicine techniques, the clinical/surgical aspects which were submitted for consensus obtained mixed results in accordance with the existing controversy. For example, the possibility of performing SLNB only in patients with a physical condition sufficient to undergo a second operation (in cases with sentinel lymph node infiltration) was only approved by 35% of the voters in Oviedo. In relation to the known “10% rule” as being valid for resecting radioactive lymph nodes only in the area of the sentinel lymph node indicated by the preoperative image, 55% agreed with this affirmation. This demonstrates that presurgical evaluation of the images cannot be foregone, at least by nuclear medicine physicians.</p><p id="par0090" class="elsevierStylePara elsevierViewall">Nonetheless, it seems evident that the progress in the staging of tumors of the oral cavity has a powerful ally in SLNB in the pathway to providing maximum diagnostic power with minimal surgical aggressiveness.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">15</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Consequently, some international guidelines already include SLNB in the diagnostic strategies of some of these tumors, and the appearance of possible new technologies and more specific radiotracers for the localization of sentinel lymph nodes have opened the way for expanding the indications of SLNB in the remaining H&N neoplasias. The synergy with the PET/CT findings also provides a pathway for expansion to further improve the staging of these tumors.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">16</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Nonetheless, clinicians and surgeons (otorhinolaryngologists and general or maxillofacial surgeons) who are involved in the integral management of these tumors should, in turn, agree on the inclusion or not of SLNB in this type of tumors, taking into account the posterior management of the patient based on the results obtained.</p><p id="par0105" class="elsevierStylePara elsevierViewall">As with life, medicine is never ending. We have technological improvements in both the acquisition of images with better quality and shorter acquisition time, we have new methods for processing or segmenting, which are more reproducible and enable better delimination of viable tumoral disease, differentiating it from other entities such as inflammation, and new radiotracers are being marketed. However, advances always require knowledge, an objective view, which may be critical at times, toward where we want to go. Physicians want better, more personalized medicine, and to achieve this we need to continue working. We must recognize that multidisplinary work in 2019 is the only possible way to progress, and we have to have consensus as to how to do this with specific Standardized Work Procedures which consider different suppositions and which, in turn, facilitate specific adjustments in specific patients. It is necessary to continue designing transversal, ideally multicenter, studies which rationalize resources and confirm the best option that we can provide our patients in order to give them a longer disease-free period, and a greater quality of life which is undoubtedly the real motive of medicine in any of its multiple dimensions.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Pradas AM, Vidal-Sicart S, Vilaseca I. Personalizando la estadificación en los tumores de cabeza y cuello. Papel de la Medicina Nuclear. Rev Esp Med Nucl Imagen Mol. 2019. <a class="elsevierStyleInterRef" target="_blank" id="intr0005" href="https://doi.org/10.1016/j.remn.2019.03.003">https://doi.org/10.1016/j.remn.2019.03.003</a></p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:15 [ 0 => array:3 [ "identificador" => "bib0085" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Head and neck cancer (version 2.2018)" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "National Comprehensive Cancer Network" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:1 [ "fecha" => "2018" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0090" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Functional imaging in radiation therapy planning for head and neck cancer" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "L.A. 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