No discussion of head and neck imaging would be complete without a discussion of the occult primary presumed to be within the upper aerodigestive tract. If one looks at the larger picture of patients with metastatic adenopathy above the clavicles, the role of imaging has increasing value. CT of the neck, chest, abdomen and pelvis usually follows the traditional method of panendoscopy and exam under anesthesia after an unproductive office exam. The advent of FDG-PET can obviate the need for such comprehensive searching60 and might even be sequenced between the office exam and any subse-
quent procedure requiring anesthesia. The results of the PET scan can show other sites of adenopathy and locate the primary tumor25 (see Figure 3-9). PET images are best reviewed in correlation with a cross-
sectional exam of the neck. The majority of patients with positive FDG-PET scans are found to have a corresponding tumor and most of those with negative scans never manifest a head or neck primary on follow-up (after treatment).61,62 At the very least, patients with no identifiable primary or one localized to the head and neck have a better prognosis than those discovered to have a visceral primary below the clavicles.63
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