PET/CT Variants and Pitfalls in Head and Neck Cancers Including Thyroid Cancer

PET/CT imaging is a dual-modality diagnostic technology that merges metabolic and structural imaging. There are several currently available radiotracers, but ¹⁸F-FDG is the most commonly utilized due to its widespread availability. ¹⁸F-FDG PET/CT is a cornerstone of head and neck squamous cell carcinoma imaging. ⁶⁸Ga-DOTA-TOC is another widely used radiotracer. It allows for whole-body imaging of cellular somatostatin receptors, commonly expressed by neuroendocrine tumors and is the standard of reference for the characterization and staging of neuroendocrine tumors. The normal biodistribution of these PET radiotracers as well as the technical aspects of image acquisition and inadequate patient preparation affect the quality of PET/CT imaging. In addition, normal variants, artifacts and incidental findings may impede accurate image interpretation and can potentially lead to misdiagnosis. In order to correctly interpret PET/CT imaging, it is necessary to have a comprehensive knowledge of the normal anatomy of the head and neck and to be cognizant of potential imaging pitfalls. The interpreter must be familiar with benign conditions which may accumulate radiotracer potentially mimicking neoplastic processes and also be aware of malignancies which can demonstrate low radiotracer uptake. Appropriate use of structural imaging with either CT, MR or ultrasound can serve a complimentary role in several head and neck pathologies including local tumor staging, detection of bone marrow involvement or perineural spread, and classification of thyroid nodules. It is important to be aware of the role of these complementary modalities to maximize diagnostic accuracy and patient outcomes. The purpose of this article is to outline the basic principles of PET/CT imaging, with a focus on ¹⁸F-FDG PET/CT and ⁶⁸Ga-DOTA PET/CT. Basic physiology, variant imaging appearances and potential pitfalls of image interpretation are presented within the context of common use cases of PET technology in patients with head and neck cancers and other pathologies, benign and malignant.