CT Chest Imaging for Newly Diagnosed Tonsillar Cancer

Primary Imaging Recommendation

The American College of Radiology recommends CT chest with IV contrast as the preferred imaging modality for initial staging of oropharyngeal (tonsillar) cancer, as it improves detection of mediastinal and hilar adenopathy and aids in delineating soft tissue extension of skeletal metastatic disease 1, 2
CT chest is the preferred imaging modality because contrast administration improves detection of mediastinal adenopathy and thoracic skeletal metastases, according to the American College of Radiology 1, 2

CT chest is far more sensitive than chest radiography for detecting pulmonary metastatic disease, with chest X-ray sensitivity as low as 28% compared to CT, as reported by the American College of Radiology 1, 2, 3
Synchronous second primary lung cancers occur in 7-14% of patients with head and neck squamous cell carcinoma at initial staging, according to the American College of Radiology 1, 2, 4

The American College of Radiology recommends CT chest for patients with advanced stage disease (T3-T4 or N2-N3), smoking history, or multiple/bilateral nodal metastases 1, 2
Patients with ≥3 nodal metastases or bilateral nodal disease should undergo CT chest, as recommended by the American College of Radiology 1, 2
Heavy smoking history is a risk factor for both non-HPV-related head and neck cancer and primary lung cancer, and patients meeting USPSTF criteria qualify for lung cancer screening, according to the American College of Radiology and Praxis Medical Insights 1, 2, 5

PET/CT has similar detection rates to CT chest for pulmonary metastatic disease in recurrent disease settings, as reported by the American College of Radiology 6
CT chest without IV contrast can accurately identify pulmonary metastases, but contrast is preferred because it improves detection of mediastinal adenopathy and thoracic skeletal metastases, according to the American College of Radiology 1, 2

The American College of Radiology advises against relying on chest radiography alone, as it misses up to 72% of pulmonary lesions detected on CT and does not improve outcomes 1, 2, 3
The American College of Radiology recommends against skipping chest imaging in patients with cervical nodal metastases, as there is a significant correlation between neck node metastases and positive chest CT findings 1, 2
The American College of Radiology advises against ordering CT chest without and with IV contrast, as there is no literature supporting dual-phase imaging for this indication 1, 2