Review Distant metastases from head and neck squamous cell carcinoma. Part II. Diagnosis q Remco de Bree a , Missak Haigentz Jr. b,c , Carl E. Silver c,d , Daniela Paccagnella e , Marc Hamoir f , Dana M. Hartl g,h , Jean-Pascal Machiels i , Vinidh Paleri j , Alessandra Rinaldo k , Ashok R. Shaha l , Robert P. Takes m , C. René Leemans a , Alfio Ferlito k,⇑ a Department of Otolaryngology-Head and Neck Surgery, VU University Medical Center, Amsterdam, The Netherlands b Department of Medicine (Oncology), Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, USA c Department Otorhinolaryngology-Head and Neck Surgery, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, USA d Department of Surgery, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, USA e Division of Gastroenterology, S. Antonio Hospital, Padua, Italy f Department of Head and Neck Surgery, Head and Neck Oncology Program, Saint-Luc University Hospital and Cancer Center, Université Catholique de Louvain, Brussels, Belgium g Department of Otolaryngology-Head and Neck Surgery, Institut Gustave Roussy, Villejuif Cedex, France h Laboratoire de Phonétique et de Phonologie, Sorbonne Nouvelle, Paris, France i Department of Medical Oncology, Head and Neck Oncology Program, Saint Luc University Hospital and Cancer Center, Université Catholique de Louvain, Brussels, Belgium j Department of Otolaryngology-Head and Neck Surgery, Newcastle upon Tyne Foundation Hospitals NHS Trust, Newcastle upon Tyne, UK k ENT Clinic, University of Udine, Udine, Italy l Head and Neck Service, Memorial Sloan-Kettering Cancer Center, New York, NY, United States m Department of Otolaryngology-Head and Neck Surgery, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands article info Article history: Received 14 November 2011 Received in revised form 9 March 2012 Accepted 17 March 2012 Available online 18 April 2012 Keywords: Distant metastases Diagnostic techniques CT FDG-PET Risk factors Head and neck squamous cell carcinoma summary The detection of distant metastases is critical for prognostication and for the choice of treatment in patients with head and neck squamous cell carcinoma (HNSCC). Pretreatment screening for distant metastases should be conducted particularly for patients with high risk factors, prior to locoregional treatment decisions. Different diagnostic techniques are discussed. Unfortunately, most studies lack sufficient follow-up to reliably assess false-negative results. Moreover, the designs of most studies vary substantially with regard to homogeneity of groups (tumor types and stages), timing (pretreatment, follow-up) and definition of risk factors (patient selection). Therefore, only a few studies are comparable. The combination of F-18 fluoro-D-glucose-positron emission tomography (FDG-PET) and a dedicated CT (at least of the chest) is the most important imaging protocol at the present time. Eventually, whole- body-MRI (WB-MRI) may possibly replace PET-CT for screening patients for distant metastases. Ó 2012 Elsevier Ltd. All rights reserved. Introduction A usual feature of head and neck squamous cell carcinoma (HNSCC) is that distant metastases tend to occur late in the course of the disease. 1,2 The incidence of distant metastases at presenta- tion varies from 4.2% to 23.8%, while at autopsy incidences up to 57% have been reported. 3 If distant metastases are present, in gen- eral no curative options are currently available. Once distant metastases have been detected, the prognosis is dismal. The med- ian time to death from the diagnosis of distant metastases ranges from 1 to 12 months. 1–6 About 88% of patients with distant metas- tases will die within 12 months. 1 Thus, the detection of distant metastases is critical for prognostication and for the choice of treatment in patients with HNSCC. 3 Patients with known distant metastatic disease can possibly be spared the toxicities of aggres- sive and often unnecessary locoregional therapy. The currently available techniques and new developments in the assessment of distant metastasis will be discussed. Diagnostic tests for different sites of distant metastasis Various tests have been used to detect distant metastases. Some of these are not primarily screening tests, but if abnormal warrant additional examinations to rule out or detect distant metastases. During the last decade, advancements in imaging techniques have improved the detection of distant metastases. In order of fre- quency, metastases occur in the lungs, bone and liver. 3 1368-8375/$ - see front matter Ó 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.oraloncology.2012.03.014 q This paper was written by members and invitees of the International Head and Neck Scientific Group (www.IHNSG.com). ⇑ Corresponding author. Address: ENT Clinic, University of Udine, Piazzale S. Maria della Misericordia, I-33100 Udine, Italy. Tel.: +39 0432 559302; fax: +39 0432 559339. E-mail address: a.ferlito@uniud.it (A. Ferlito). Oral Oncology 48 (2012) 780–786 Contents lists available at SciVerse ScienceDirect Oral Oncology journal homepage: www.elsevier.com/locate/oraloncology