Management of the neck in a randomized trial comparing concurrent chemotherapy and radiotherapy with radiotherapy alone in resectable stage III and IV squamous cell head and neck cancer

The Neck-Persistency-Net: a three-dimensional, convolution, deep neural network aids in distinguishing vital from non-vital persistent cervical lymph nodes in advanced head and neck squamous cell carcinoma after primary concurrent radiochemotherapy

PURPOSE

To evaluate the diagnostic performance (DP) of the high-resolution contrast computed tomography (HR-contrast-CT) based Neck-Persistency-Net in distinguishing vital from non-vital persistent cervical lymph nodes (pcLNs) in patients with advanced head and neck squamous cell carcinoma (HNSCC) following primary concurrent chemoradiotherapy (CRT) with [18F]-fluorodeoxyglucose positron emission tomography and high-resolution contrast-enhanced computed tomography ([18F]FDG-PET-CT). Furthermore, the Neck-Persistency-Net's potential to justify omitting post-CRT neck dissection (ND) without risking treatment delays or preventing unnecessary surgery was explored.

METHODS

All HNSCC patients undergoing primary CRT followed by post-CRT-ND for pcLNs recorded in the institutional HNSCC registry were analyzed. The Neck-Persistency-Net DP was explored for three scenarios: balanced performance (BalPerf), optimized sensitivity (OptSens), and optimized specificity (OptSpec). Histopathology of post-CRT-ND served as a reference.

RESULTS

Among 68 included patients, 11 were female and 32 had vital pcLNs. The Neck-Persistency-Net demonstrated good DP with an area under the curve of 0.82. For BalPerf, both sensitivity and specificity were 78%; for OptSens (90%), specificity was 62%; for OptSpec (95%), sensitivity was 54%. Limiting post-CRT-ND to negative results would have delayed treatment in 27%, 40%, and 7% for BalPerf, OptSens and OptSpec, respectively, versus 23% for [18F]FDG-PET-CT. Conversely, restricting post-CRT-ND to positive results would have prevented unnecessary post-CRT-ND in 78%, 60%, and 95% for BalPerf, OptSens and OptSpec, respectively, versus 55% for [18F]FDG-PET-CT.

CONCLUSION

The DP of the Neck-Persistency-Net was comparable to [18F]-FDG-PET-CT. Depending on the chosen decision boundary, the potential to justify the omission of post-CRT-ND without risking treatment delays in false negative findings or reliably prevent unnecessary surgery in false positive findings outperforms the [18F]-FDG-PET-CT.

Diagnostic accuracy of NI-RADS for prediction of head and neck squamous cell carcinoma: a systematic review and meta-analysis

OBJECTIVES

This study aimed to assess the diagnostic performance of NI-RADS for the prediction of recurrence in patients treated for Head and Neck Squamous Cell Carcinoma (HNSCC).

METHODS

A literature search was conducted using various databases to identify relevant articles published from June 2016 onwards. We included studies reporting the diagnostic accuracy of NI-RADS in distinguishing recurrence in patients undergoing imaging surveillance, with pathologic results and/or follow-up as the reference standard. Summary estimates of diagnostic accuracy in terms of sensitivity, specificity, positive likelihood ratio (LR +), negative likelihood ratio (LR -), and diagnostic odds ratio (DOR) were calculated with the hierarchical summary receiver operating characteristic (HSROC) model. Meta-regression and subgroup analyses were conducted to investigate different clinical settings. Study quality was evaluated using the Quality Assessment of Diagnostic Accuracy Studies-2 tool.

RESULTS

A total of 12 studies were included in the current meta-analysis. The pooled sensitivity and specificity were 0.69 (95% CI 0.59-0.79) and 0.94 (95% CI 0.89-0.97), respectively. For the primary site, the pooled summary estimates were 0.67 (95% CI 0.53-0.78) and 0.95 (95% CI 0.90-0.97), for the nodal sites were 0.64 (95% CI 0.44-0.80) and 0.99 (95% CI 0.98-0.99), respectively. The recurrence rate for NI-RADS categories 1-3 was 0.03 (95% CI 0.02-0.05), 0.13 (95% CI 0.10-0.15), and 0.77 (95% CI 0.73-0.81). Meta-regression revealed that the type of analysis (per person vs. per site) and number of sites (≤ 200 vs. > 200) were significant factors associated with heterogeneity.

CONCLUSIONS

NI-RADS demonstrated high specificity but moderate sensitivity in patients after treatment for HNSCC. Summary estimates showed a significantly higher malignancy rate for NI-RADS category 3 compared to category 2.

Clinical outcomes of high-risk cutaneous squamous cell carcinomas treated with Mohs surgery alone: An analysis of local recurrence, regional nodal metastases, progression-free survival, and disease-specific death

BACKGROUND

The incidence of cutaneous squamous cell carcinoma (cSCC) continues to increase, and it is now predicted that the number of deaths from cSCC will surpass that of melanoma within the next 5 years. Although most cSCCs are successfully treated, there exists an important subset of high-risk tumors that have the highest propensity for local recurrence (LR), nodal metastasis (NM), and disease-specific death (DSD).

OBJECTIVE

We investigated the clinical outcomes of high-risk cSCCs treated with Mohs surgery (MS) alone, analyzing LR, NM, distant metastasis, and DSD. In addition, we analyzed progression-free survival and DSD in patients who underwent salvage head/neck dissection for regional NMs.

METHODS

Retrospective review of all high-risk cSCC treated in our clinics between January 1, 2000, and January 1, 2020, with follow-up through April 1, 2020.

SETTING

Two university-affiliated, private-practice MS referral centers.

RESULTS

In total, 581 high-risk primary cSCCs were identified in 527 patients, of which follow-up data were obtained for 579 tumors. The 5-year disease-specific survival was 95.7%, with a mean survival time of 18.6 years. The 5-year LR-free survival was 96.9%, the regional NM-free survival was 93.8%, and the distant metastasis-free survival was 97.3%. The 5- and 10-year progression-free survival rates from metastatic disease were 92.6 and 90.0%, respectively. In patients who experienced regional NMs and underwent salvage head and neck dissection with or without radiation, the 2-year disease-specific survival was 90.5%.

CONCLUSION

Our cohort, which is the largest high-risk cSCC cohort treated with MS to date, experienced lower rates of LR, NM, and DSD than those reported with historical reference controls using both the Brigham and Women's Hospital and American Joint Committee on Cancer, Eighth Edition, staging systems. We demonstrated that MS confers a disease-specific survival advantage over historical wide local excision for high-risk tumors. Moreover, by improving local tumor control, MS appears to reduce the frequency of regional metastatic disease and may confer a survival advantage even for patients who develop regional metastases.

Surgical site complications of post-chemoradiotherapy neck dissection: Urgent need for standard registration

Nowadays, a substantial number of head and neck cancer patients are treated by organ-preserving chemoradiation (CRT), with a possible increased risk of complications after planned or salvage neck dissections. We try to determine the risk pattern of surgical site complications (SSC) post-CRT.

Positron Emission Tomography-Computed Tomography Surveillance after (Chemo)Radiotherapy in Advanced Head and Neck Squamous Cell Cancer: Beyond the PET-NECK Protocol

AIMS

To evaluate the implementation of 18-fluorodeoxyglucose positron emission tomography-computed tomography (FDG PET-CT) surveillance after (chemo)radiotherapy, to compare outcomes for those who achieved a complete (CR), equivocal (EQR) and incomplete (ICR) nodal response on 12-week PET-CT according to their human papillomavirus (HPV) status, and to assess the safety of ongoing surveillance beyond 12 weeks in the HPV-positive EQR group.

MATERIALS AND METHODS

All patients with node-positive head and neck squamous cell carcinoma (HNSCC) treated with (chemo)radiotherapy between January 2013 and September 2017 were identified. PET-CT responses were classified as CR, ICR or EQR. Patient outcomes were obtained from electronic records.

RESULTS

In total, 236 patients with a minimum of 2 years of follow-up were identified. The mean age was 59 years; 79.3% had N2 disease; 77.1% of patients had oropharyngeal cancer and 10.1% had squamous cell carcinoma of unknown primary, of whom 82.0% (169) were HPV positive; 78.0% received chemoradiotherapy. The median time from the end of radiotherapy to PET-CT was 91 days. Of the HPV-related HNSCC, 60.4% achieved CR, 29.0% EQR and 10.6% ICR. With a median follow-up of 41.7 months, there was no difference in survival between patients with HPV-related HNSCC achieving CR and EQR (median overall survival not reached for both, P = 0.67) despite the omission of immediate neck dissection in 98.0% of the EQR group.

CONCLUSION

Patients with HPV-positive HNSCC who have achieved EQR have comparable survival outcomes to those who achieved a CR despite the omission of immediate neck dissections; this shows the safety of ongoing surveillance beyond 12 weeks in this group of patients.

FDG-PET/CT scan assessment of response 12 weeks post radical radiotherapy in oropharynx head and neck cancer: The impact of p16 status

PURPOSE

To evaluate the predictive value of FDG-PET/CT for detection of residual disease after radical radiotherapy for patients with squamous cell carcinoma (SCC) of the oropharynx, comparing p16 positive (+) versus p16 negative (-) disease.

METHODS AND MATERIALS

A retrospective analysis of patients with SCC of the oropharynx at our institution treated with radical radiotherapy between 2012 and 2016 was performed. The primary and lymph node metabolic responses were evaluated independently on the post-treatment FDG-PET/CT. The reference standard was pathology when available, subsequent post-treatment FDG-PET/CT results or clinical follow-up.

RESULTS

Median follow-up time was 32 (30-34) months. 556 patients had p16+ disease and 92 had p16- disease. The median time of post-treatment FDG-PET/CT was 96 (45-744) days after radiotherapy completion: 68% had complete metabolic response (CMR) defined as mild non-focal or no uptake, 10% residual primary disease, 11% residual regional lymph node disease, 5% residual primary and regional disease, and 6% distant metastatic disease. The local positive predictive value (PPV) was 26% for p16+ versus 54% for p16- (p = 0.01) and the regional PPV was 31% for p16+ versus 58% for p16- (p = 0.01). The local negative predictive value (NPV) was 100% regardless of p16 status and the regional NPV was 100% for p16+ versus 99% for p16- (p = 0.33). For p16+ cases, regional specificity was 76.2% versus 91.1% (p = 0.0003), local PPV was 0 versus 30% (p = 0.06) and the regional PPV was 12% versus 35% (p = 0.06) for FDG-PET/CT scans performed at ≤12 weeks versus >12 weeks. Five-year overall survival for those with CMR was 87% versus 51% without CMR (p ≤ 0.001).

CONCLUSIONS

Metabolic response on post-treatment FDG-PET/CT has excellent NPV regardless of p16 status. The PPV is significantly lower in those with p16+ versus p16- disease, with a significantly reduced regional specificity and a trend towards inferior predictive value if performed ≤12 weeks. CMR predicts for a significantly improved overall survival.

Comparison of salvage surgery for recurrent or residual head and neck squamous cell carcinoma

Objective

Concomitant chemoradiation therapy is a standard treatment for head and neck cancer. Thus, salvage surgery has become a necessary treatment. The aim of the study was to evaluate the results of salvage surgery by each site of the head and neck, especially the oropharynx, hypopharynx and larynx.

Methods

This was a retrospective, single-institute study. The primary endpoint was overall survival. Secondary endpoints were disease-free survival, the locoregional control rate after salvage surgery, the indication rate for salvage surgery, the reasons for contraindications to salvage surgery, the post-operative complication rate and the predictors of survival.

Results

Three-year overall survival after salvage surgery was 58.8% in the salvage surgery group and 8.59% in the other treatment group (P < 0.0001). Regarding overall survival and disease-free survival after salvage surgery, there was no difference among sites. Regarding locoregional control rate among sites, there was no significant difference. The oropharyngeal cancer group had the lowest rate of salvage primary resection. Surgical margin and local and regional recurrence or residual disease were predictors on univariate and multivariate analyses.

Conclusions

Salvage surgery is effective for recurrent or residual cases after concomitant chemoradiation therapy. For oropharyngeal cancer, local control is important, and for oropharyngeal cancer and hypopharyngeal cancer, distant metastasis is important.

Prognostic role of extracapsular spread in planned neck dissection after chemoradiotherapy

BACKGROUND

The purpose of this study is to evaluate the prognostic significance of nodes with extracapsular spread (ECS) in patients treated with a planned neck dissection after chemoradiotherapy.

METHODS

We carried out a retrospective study of 109 cN+ patients who achieved a complete response in the primary location after chemoradiotherapy and treated with a planned neck dissection.

RESULTS

The 5-year disease-specific survival for patients without residual metastatic nodes in the neck dissection (pN0, n = 69) was 75.7% (95% CI: 64.4%-87.0%). For patients with metastatic nodes without ECS (pN+/ECS-negative, n = 17), the corresponding figure was 74.0% (95% CI: 48.2%-99.8%), and for patients with metastatic neck nodes with ECS (pN+/ECS-positive, n = 23) it was 8.7% (95% CI: 0.0%-24.3%) (P = .0001).

CONCLUSION

The presence of ECS in the pathologic study of the planned neck dissections carried out after chemoradiotherapy in patients with human papillomavirus-negative (HPV-negative) head and neck squamous cell carcinoma (SCC) allows identification of a group of patients with a high risk of failure.

FDG-PET/CT for treatment response assessment in head and neck squamous cell carcinoma: a systematic review and meta-analysis of diagnostic performance

PURPOSE

18-fluorodeoxyglucose positron emission tomography combined with computed tomography (FDG-PET/CT) is increasingly used to evaluate treatment response in head and neck squamous cell carcinoma (HNSCC). This analysis assessed the diagnostic value of FDG-PET/CT in detecting nodal disease within 6 months after treatment, considering patient and disease characteristics.

METHODS

A systematic review was performed using the MEDLINE and Web of Knowledge databases. The results were pooled using a bivariate random effects model of the sensitivity and specificity.

RESULTS

Out of 22 identified studies, a meta-analysis of 20 studies (1293 patients) was performed. The pooled estimates of sensitivity, specificity and diagnostic odds ratio (with 95% CI) were 85% (76-91%), 93% (89-96%) and 76 (35-165), respectively. With the prevalence set at 10%, the positive and negative predictive values were 58% and 98%. There was significant heterogeneity between the trials (p < 0.001). HPV positive tumors were associated with lower sensitivity (75% vs 89%; p = 0.01) and specificity (87% vs 95%; p < 0.005).

CONCLUSION

FDG-PET/CT within 6 months after (chemo)radiotherapy in HNSCC patients is a reliable method for ruling out residual/recurrent nodal disease and obviates the need for therapeutic intervention. However, FDG-PET/CT may be less reliable in HPV positive tumors and the optimal surveillance strategy remains to be determined.

Accuracy of [18Fluorine]-Fluoro-2-Deoxy-d-Glucose Positron Emission Tomography-Computed Tomography Response Assessment Following (Chemo)radiotherapy for Locally Advanced Laryngeal/Hypopharyngeal Carcinoma

INTRODUCTION

The accuracy of response assessment positron emission tomography (PET)-computed tomography (CT) following radiotherapy with or without chemotherapy for laryngeal/hypopharyngeal squamous cell carcinoma is uncertain.

METHODS

In all, 35 patients with laryngeal or hypopharyngeal squamous cell carcinoma who were treated between 2009 and 2014 with (chemo)radiotherapy were identified. The accuracy of response assessment PET-CT was made by correlation with clinical follow-up and pathological findings.

RESULTS

Of the 35 patients, 20 (57%) had an overall complete metabolic response. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for response assessment [18Fluorine]-fluoro-2-deoxy-d-glucose (FDG) PET-CT for primary and nodal sites, respectively, were 100%, 73%, 46%, and 100% and 83%, 95%, 83%, and 95%.

CONCLUSIONS

Response assessment FDG PET-CT following (chemo)radiotherapy for laryngeal and hypopharyngeal carcinomas has a high NPV for both primary site and lymph nodes and can be used to guide treatment decisions. The PPV of residual FDG uptake at the primary tumour site is limited and requires examination and biopsy confirmation.

PET-NECK: a multicentre randomised Phase III non-inferiority trial comparing a positron emission tomography-computerised tomography-guided watch-and-wait policy with planned neck dissection in the management of locally advanced (N2/N3) nodal metastases in patients with squamous cell head and neck cancer

BACKGROUND

Planned neck dissection (ND) after radical chemoradiotherapy (CRT) for locally advanced nodal metastases in patients with head and neck squamous cell carcinoma (HNSCC) remains controversial. Thirty per cent of ND specimens show histological evidence of tumour. Consequently, a significant proportion of clinicians still practise planned ND. Fludeoxyglucose positron emission tomography (PET)-computerised tomography (CT) scanning demonstrated high negative predictive values for persistent nodal disease, providing a possible alternative paradigm to ND. Evidence is sparse and drawn mainly from retrospective single-institution studies, illustrating the need for a prospective randomised controlled trial.

OBJECTIVES

To determine the efficacy and cost-effectiveness of PET-CT-guided surveillance, compared with planned ND, in a multicentre, prospective, randomised setting.

DESIGN

A pragmatic randomised non-inferiority trial comparing PET-CT-guided watch-and-wait policy with the current planned ND policy in HNSCC patients with locally advanced nodal metastases and treated with radical CRT. Patients were randomised in a 1 : 1 ratio. Primary outcomes were overall survival (OS) and cost-effectiveness [incremental cost per incremental quality-adjusted life-year (QALY)]. Cost-effectiveness was assessed over the trial period using individual patient data, and over a lifetime horizon using a decision-analytic model. Secondary outcomes were recurrence in the neck, complication rates and quality of life. The recruitment of 560 patients was planned to detect non-inferior OS in the intervention arm with a 90% power and a type I error of 5%, with non-inferiority defined as having a hazard ratio (HR) of no higher than 1.50. An intention-to-treat analysis was performed by Cox's proportional hazards model.

SETTINGS

Thirty-seven head and neck cancer-treating centres (43 NHS hospitals) throughout the UK.

PARTICIPANTS

Patients with locally advanced nodal metastases of oropharynx, hypopharynx, larynx, oral or occult HNSCC receiving CRT and fit for ND were recruited.

INTERVENTION

Patients randomised to planned ND before or after CRT (control), or CRT followed by fludeoxyglucose PET-CT 10-12 weeks post CRT with ND only if PET-CT showed incomplete or equivocal response of nodal disease (intervention). Balanced by centre, planned ND timing, CRT schedule, disease site and the tumour, node, metastasis stage.

RESULTS

In total, 564 patients were recruited (ND arm, n = 282; and surveillance arm, n = 282; 17% N2a, 61% N2b, 18% N2c and 3% N3). Eighty-four per cent had oropharyngeal cancer. Seventy-five per cent of tested cases were p16 positive. The median time to follow-up was 36 months. The HR for OS was 0.92 [95% confidence interval (CI) 0.65 to 1.32], indicating non-inferiority. The upper limit of the non-inferiority HR margin of 1.50, which was informed by patient advisors to the project, lies at the 99.6 percentile of this estimate (p = 0.004). There were no differences in this result by p16 status. There were 54 NDs performed in the surveillance arm, with 22 surgical complications, and 221 NDs in the ND arm, with 85 complications. Quality-of-life scores were slightly better in the surveillance arm. Compared with planned ND, PET-CT surveillance produced an incremental net health benefit of 0.16 QALYs (95% CI 0.03 to 0.28 QALYs) over the trial period and 0.21 QALYs (95% CI -0.41 to 0.85 QALYs) over the modelled lifetime horizon.

LIMITATIONS

Pragmatic randomised controlled trial with a 36-month median follow-up.

CONCLUSIONS

PET-CT-guided active surveillance showed similar survival outcomes to ND but resulted in considerably fewer NDs, fewer complications and lower costs, supporting its use in routine practice.

FUTURE WORK

PET-CT surveillance is cost-effective in the short term, and long-term cost-effectiveness could be addressed in future work.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN13735240.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 17. See the NIHR Journals Library website for further project information.

Neck Dissection Followed by Chemoradiotherapy for Stage IV (N+) Oropharynx Cancer

PURPOSE: This study evaluated the strategy of performing neck dissection (ND) without primary tumor resection prior to definitive chemoradiotherapy (CRT) for N2+ oropharynx cancer.

METHODS: We analyzed records of 25 patients who underwent ND before concurrent CRT with weekly low-dose concurrent paclitaxel and a platinum compound. The extent of ND was highly customized (1 to 39 nodes) and median radiotherapy dose was 70 Gy.

RESULTS: Median follow-up was 36 months. Two-year and 3-year actuarial locoregional control rates were 95% and 88%. No patient had regional neck nodal failure. Two-year rate of freedom from distant metastases was 91%. The 2- and 3-year event-free survival rates were 88% and 75%. Fifteen percent had Grade 3+ late toxicity; none had permanent gastrostomy tube dependence.

CONCLUSIONS: Neck dissection without primary tumor resection before definitive chemoradiotherapy for oropharynx cancer is a safe and effective management program and warrants further exploration.

Planned Neck Dissection after Definitive Radiotherapy or Chemoradiation for Base of Tongue Cancers

OBJECTIVES: The study goal was to analyze the role of planned neck dissection for squamous cell carcinoma of the base of the tongue treated with definitive radiotherapy or chemoradiation.

STUDY DESIGN, SETTING: We conducted a retrospective study of patients with squamous cell carcinoma of the base of the tongue undergoing planned neck dissection after definitive radiotherapy or chemoradiation.

RESULTS: Twenty-two of 41 (53.7%) patients had one to six positive residual lymph nodes after receiving definitive radiotherapy or chemoradiation. Neck control rates were 92.3% and 88.3% at two and five years, respectively. Three of 22 (13.6%) patients with pathological residual nodal disease had regional or locore-gional failures, compared with 1 of 19 (5.3%) patients with a pathologically complete response ( P = 0.39).

CONCLUSIONS: We observed a high incidence of pathologically residual lymph nodes after definitive radiotherapy or chemoradiation.

SIGNIFICANCE: Planned neck dissection following definitive radiotherapy or chemoradiation is highly effective in achieving regional control of squamous cell carcinoma of the base of the tongue.

PET-CT Surveillance versus Neck Dissection in Advanced Head and Neck Cancer

BACKGROUND

The role of image-guided surveillance as compared with planned neck dissection in the treatment of patients with squamous-cell carcinoma of the head and neck who have advanced nodal disease (stage N2 or N3) and who have received chemoradiotherapy for primary treatment is a matter of debate.

METHODS

In this prospective, randomized, controlled trial, we assessed the noninferiority of positron-emission tomography-computed tomography (PET-CT)-guided surveillance (performed 12 weeks after the end of chemoradiotherapy, with neck dissection performed only if PET-CT showed an incomplete or equivocal response) to planned neck dissection in patients with stage N2 or N3 disease. The primary end point was overall survival.

RESULTS

From 2007 through 2012, we recruited 564 patients (282 patients in the planned-surgery group and 282 patients in the surveillance group) from 37 centers in the United Kingdom. Among these patients, 17% had nodal stage N2a disease and 61% had stage N2b disease. A total of 84% of the patients had oropharyngeal cancer, and 75% had tumor specimens that stained positive for the p16 protein, an indicator that human papillomavirus had a role in the causation of the cancer. The median follow-up was 36 months. PET-CT-guided surveillance resulted in fewer neck dissections than did planned dissection surgery (54 vs. 221); rates of surgical complications were similar in the two groups (42% and 38%, respectively). The 2-year overall survival rate was 84.9% (95% confidence interval [CI], 80.7 to 89.1) in the surveillance group and 81.5% (95% CI, 76.9 to 86.3) in the planned-surgery group. The hazard ratio for death slightly favored PET-CT-guided surveillance and indicated noninferiority (upper boundary of the 95% CI for the hazard ratio, <1.50; P=0.004). There was no significant difference between the groups with respect to p16 expression. Quality of life was similar in the two groups. PET-CT-guided surveillance, as compared with neck dissection, resulted in savings of £1,492 (approximately $2,190 in U.S. dollars) per person over the duration of the trial.

CONCLUSIONS

Survival was similar among patients who underwent PET-CT-guided surveillance and those who underwent planned neck dissection, but surveillance resulted in considerably fewer operations and it was more cost-effective. (Funded by the National Institute for Health Research Health Technology Assessment Programme and Cancer Research UK; PET-NECK Current Controlled Trials number, ISRCTN13735240.).

Imaging strategy for response evaluation to chemoradiotherapy of the nodal disease in patients with head and neck squamous cell carcinoma

BACKGROUND

Definitive chemoradiotherapy (CRT) is used to treat lymph node metastatic head and neck cancer patients. Regional control of the neck disease is important to improve the prognosis, and the accuracy of the method used to evaluate the metastatic lymph node(s) after CRT is crucial to the decision-making process for any following salvage surgery.

METHODS

Patients undergoing CRT were divided in two groups of patients of those showing complete clinical response (CR) and those showing clinical non-response (non-CR), as assessed by computed tomography (CT) and/or magnetic resonance imaging (MRI), ultrasonography, fluorodeoxyglucose-positron emission tomography (FDG-PET), and fine needle aspiration cytology. The responses (CR vs. non-CR) were compared with the actual clinical outcomes. For the interim analysis, the study period was broken down into two periods, namely, the exploratory phase (patients treated between January 2002 and April 2012) and the validating phase (patients treated between May 2012 and January 2014).

RESULTS

The sensitivity, specificity, and accuracy were as follows: CT and/or MRI, 66.7, 73.8, and 72.8 %, respectively, in the exploratory phase; ultrasonography, 91.7, 70.6, and 73.4 %, respectively, in the exploratory phase and 80.0, 82.8, and 82.4 %, respectively, in the validating phase; FDG-PET, 50.0, 97.5, and 91.3 %, respectively, in the exploratory phase and 60.0, 100, and 94.1 %, respectively, in the validating phase; cytology, 68.4, 95.9, and 90.3 %, respectively, in the exploratory phase and 66.7, 100, and 85.7 %, respectively, in the validating phase.

CONCLUSIONS

Based on our results, CT and/or MRI appear to be inadequate methods for the evaluation of the response of lymph node(s) to CRT. In contrast, ultrasonography appears to be a highly sensitive and useful tool for positive screening at 6-8 weeks after CRT, and FDG-PET appears to be a highly specific and useful tool for negative screening at 8-12 weeks after CRT.

Complete pathologic response as a prognostic factor for squamous cell carcinoma of the oropharynx post-chemoradiotherapy

Introduction

Chemoradiotherapy for squamous cell carcinoma of the oropharynx (SCCO) provides good results for locoregional disease control, with high rates of complete clinical and pathologic responses, mainly in the neck.

Objective

To determine whether complete pathologic response after chemoradiotherapy is related to the prognosis of patients with SCCO.

Methods

Data were prospectively extracted from clinical records of N2 and N3 SCCO patients submitted to a planned neck dissection after chemoradiotherapy.

Results

A total of 19 patients were evaluated. Half of patients obtained complete pathologic response in the neck. Distant or locoregional recurrence occurred in approximately 42% of patients, and 26% died. Statistical analysis showed an association between complete pathologic response and lower disease recurrence rate (77.8% vs. 20.8%; p = 0.017) and greater overall survival (88.9% vs. 23.3%; p = 0.049).

Conclusion

The presence of a complete pathologic response after chemoradiotherapy positively influences the prognosis of patients with SCCO.

Risk stratification of metastatic neck nodes by CT and PET in patients with head and neck cancer receiving definitive radiotherapy

The aim of this study was to investigate the prognostic impact of CT and (18)F-FDG PET/CT on the outcome of metastatic neck node (MNN) in patients with head and neck cancer receiving definitive radiotherapy or chemoradiotherapy.

METHODS

This patient-based study included 91 patients diagnosed with pharyngeal cancers with MNN (N1, 15; N2, 70; N3, 6). All had pretreatment CT and PET/CT before definitive chemoradiotherapy/radiotherapy. Parameters of MNNs for each patient, including maximal diameter, nodal volume, radiologic central necrosis, maximum standardized uptake value, metabolic tumor volume, and total lesion glycolysis (TLG), were retrieved for the analysis. Nodal relapse-free survival (NRFS) and survivals were calculated using the Kaplan-Meier method. Independent predictors were identified using Cox regression analysis.

RESULTS

After a median follow-up of 18 mo, 64 patients remained nodal relapse-free, and 27 experienced neck recurrence. Multivariate analysis showed that the application of 40% of the maximal uptake of nodal TLG (N-TLG40%) 38 g or greater (P = 0.03; hazard ratio, 2.63; 95% confidence interval, 1.10-6.30) and radiologic necrosis on CT scan (P = 0.001; hazard ratio, 10.99; 95% confidence interval, 2.56-47.62) were 2 adverse features for NRFS. Patients who had an N-TLG40% 38 g or greater and central radiologic necrosis had a significantly inferior 2-y NRFS (53% vs. 77% and 45% vs. 95%, respectively).

CONCLUSION

The outcome of MNNs in patients with head and neck cancer receiving chemoradiotherapy/radiotherapy can be predicted according to radiologic necrosis and N-TLG40% value. The 2 adverse features should be validated in future trials. In this way, patients can be treated alternatively or aggressively.

Early detection of recurrent disease by FDG-PET/CT leads to management changes in patients with squamous cell cancer of the head and neck

OBJECTIVE

The objective of this study was to compare the efficacy of surveillance high-resolution computed tomography (HRCT) and physical examination/endoscopy (PE/E) with the efficacy of fluorodeoxyglucose (FDG)-positron emission tomography (PET)/HRCT for the detection of relapse in head and neck squamous cell carcinoma (HNSCC) after primary treatment.

METHODS

This is a retrospective analysis of contemporaneously performed FDG-PET/HRCT, neck HRCT, and PE/E in 99 curatively treated patients with HNSCC during post-therapy surveillance to compare performance test characteristics in the detection of early recurrence or second primary cancer.

RESULTS

Relapse occurred in 19 of 99 patients (20%) during a median follow-up of 21 months (range: 9-52 months). Median time to first PET/HRCT was 3.5 months. The median time to radiological recurrence was 6 months (range: 2.3-32 months). FDG-PET/HRCT detected more disease recurrences or second primary cancers and did so earlier than HRCT or PE/E. The sensitivity, specificity, and positive and negative predictive values for detecting locoregional and distant recurrence or second primary cancer were 100%, 87.3%, 56.5%, and 100%, respectively, for PET/HRCT versus 61.5%, 94.9%, 66.7%, and 93.8%, respectively, for HRCT versus 23.1%, 98.7%, 75%, and 88.6%, respectively, for PE/E. In 19 patients with true positive PET/HRCT findings, a significant change in the management of disease occurred, prompting either salvage or systemic therapy. Of the 14 curatively treated patients, 11 were alive with without disease at a median follow-up of 31.5 months.

CONCLUSION

FDG-PET/HRCT has a high sensitivity in the early detection of relapse or second primary cancer in patients with HNSCC, with significant management implications. Given improvements in therapy and changes in HNSCC biology, appropriate modifications in current post-therapy surveillance may be required to determine effective salvage or definitive therapies.

Lymph node positive head and neck carcinoma after curative radiochemotherapy: a long lasting debate on elective post-therapeutic neck dissections comes to a conclusion

There has been a long lasting debate, whether planned neck dissections after curative radio(chemo)therapy for locally advanced head and neck squamous cell carcinomas offer some benefit in tumor control or survival. We did a thorough literature research on that topic. The results of several recently published studies are described, summarized, and reviewed. Patients with residual disease in clinical or radiographic examinations (CT or MRI scans) up to 3 months after completion of radiochemotherapy profit from neck dissections. In patients with an initial or delayed clinical complete remission after completion of radiochemotherapy, a neck dissection can be safely omitted. In conclusion, there is no longer evidence for a benefit of prophylactic post-radiochemotherapy neck dissections, but strong evidence for a therapeutic post-radiochemotherapy neck dissection in this group of patients.

Long-term regional control in the observed neck following definitive chemoradiation for node-positive oropharyngeal squamous cell cancer

Traditionally, patients treated with chemoradiotherapy for node-positive oropharyngeal squamous cell carcinoma (N+ OPSCC) have undergone a planned neck dissection (ND) after treatment. Recently, negative post-treatment positron-emission tomography (PET)/computed tomography (CT) imaging has been found to have a high negative predictive value for the presence of residual disease in the neck. Here, we present the first comprehensive analysis of a large, uniform cohort of N+ OPSCC patients achieving a PET/CT-based complete response (CR) after chemoradiotherapy, and undergoing observation, rather than ND. From 2002 to 2009, 302 patients with N+ OPSCC treated with 70 Gy intensity-modulated radiation therapy and concurrent chemotherapy underwent post-treatment clinical assessment including PET/CT. CR was defined as no evidence of disease on clinical examination and post-treatment PET/CT. ND was reserved for patients with <CR on either PET/CT, clinical examination, or other imaging. 260 patients (86.1%) had clinical and radiographic CRs, and underwent neck observation (rate of regional control, 97.7%; 5-year overall survival, 79.8%). The four observed patients experiencing neck recurrence had initial staging of N1 (n = 2), N2b (n = 1), and N2c (n = 1). Three of four were successfully surgically salvaged. There was no association between N stage and rate of neck recurrence (p = 0.74). 52 and 25% of patients undergoing ND had viable tumor in the neck after positive and negative PET/CT, respectively. We conclude that patients achieving CRs after chemoradiation, based on clinical and PET/CT assessment, have a high probability of regional control, with a 2.3% regional failure rate, and may be safely observed without planned ND.

The role of neck dissection after radical chemoradiation for locally advanced head and neck cancer: should we move back?

Until a few decades ago neck dissection (ND) was the standard surgical approach for node-positive tumours. Nowadays patients with locally advanced head and neck cancer can be treated with definitive chemoradiation (CRT), which includes the treatment of the neck; however, results on residual viable tumour after conservative treatment are heterogeneous and depend on initial node stage and primary treatment. Many authors accept adjuvant surgery in patients with N2-3 disease. Regardless of the results of upfront CRT, even if there is no evidence of lymph node metastases, when the risk for persistent positive neck nodes exceeds 15-20%, elective ND might be indicated. However, despite the diffusion of innovative technologies and therapies, there are controversies about both response evaluation and surgical management of initially involved neck nodes after definitive CRT and organ preservation treatment. In this paper we will analyse state of art of neck evaluation after CRT and discuss the role of ND.

Persistent neck disease after chemoradiation for head and neck squamous cell carcinoma

OBJECTIVE

This study aimed to identify the incidence of residual viable neck disease in patients with mucosal squamous cell carcinoma of the upper aero-digestive tract, following primary chemoradiation at a tertiary centre.

STUDY DESIGN

Retrospective review.

METHODS

Retrospective chart review of patients treated with primary chemoradiation for squamous cell carcinoma of the aero-digestive tract between August 2001 and August 2008. Neck status pre- and post-treatment was the primary focus.

RESULTS

Forty-two patients with node-positive disease prior to chemoradiation were included. Thirty-seven (88.1 per cent) achieved complete response to treatment: no patient in this group underwent neck dissection, five died due to recurrence at the primary site or distant metastasis, and none suffered neck recurrence. Five (11.9 per cent) patients achieved partial response to chemoradiation and underwent neck dissection; viable tumour was found in one patient.

CONCLUSION

Our data support conservative management of the neck in patients with complete response to chemoradiation, and consolidation neck dissection in patients with partial response.

Node-positive hypopharyngeal cancer treated by (chemo)radiotherapy: impact of up-front neck dissection on outcome, toxicity, and quality of life

BACKGROUND

To investigate the impact of up-front neck dissection on the outcome of patients with node-positive hypopharyngeal cancer (HPC) treated with (chemo)radiation.

METHODS

Of 135 consecutive patients with node-positive HPC, 32 patients underwent up-front neck dissection followed by (chemo)radiation (group 1), and 103 patients received definitive (chemo)radiation (group 2).

RESULTS

The 3-year regional, local and distant control for groups 1 and 2 were 92% versus 87% (p = .37), 84% versus 72% (p = .15), and 80% versus 62% (p = .08), respectively. High T classification was the only significant predictor for poor overall survival on multivariate analysis (OR = 3.0, p = .02). Acute and late toxicities and the prospectively assessed quality of life were comparable in both groups.

CONCLUSION

Upfront neck dissection followed by (chemo)radiation did not negatively impact on oncologic outcomes, toxicity, or quality of life and therefore is to be regarded as a safe and effective treatment option for small HPC with bulky nodal disease, especially in busy radiation departments with unacceptably long waiting time for definitive (chemo)radiation.

The role of FDG PET-CT in the therapeutic evaluation for HNSCC patients

F-18 FDG PET/CT has been widely used to diagnose primary tumors and lymph node metastases and to evaluate the response of head and neck squamous cell carcinoma (HNSCC) to therapy. The advantage of using PET/CT is that this combination allows metabolic information to be precisely overlapped with anatomical information, thereby improving the identification of sites with an abnormal accumulation of F-18 FDG. The role of FDG PET/CT in the therapeutic evaluation (such as in treatment planning, the therapeutic response, and the surveillance and examination of HNSCC patients) is discussed in this manuscript. When evaluating the post-treatment outcome via FDG PET/CT, it is important to exclude the post-treatment inflammation-related increase in glucose metabolism in lymph nodes, salivary gland, muscles, and soft tissues. The influence of inflammation can be eliminated if PET/CT is performed after 12 weeks, by which time post-treatment inflammation subsides. Further, FDG PET/CT affords a high negative predictive value. Based on the results of an FDG PET/CT test, some invasive tests that are performed to detect recurrence can be omitted.

Prediction of neck dissection requirement after definitive radiotherapy for head-and-neck squamous cell carcinoma

BACKGROUND

This analysis was undertaken to assess the need for planned neck dissection in patients with a complete response (CR) of involved nodes after irradiation and to determine the benefit of a neck dissection in those with less than CR by tumor site.

METHODS

Our cohort included 880 patients with T1-4, N1-3M0 squamous cell carcinoma of the oropharynx, larynx, or hypopharynx who received treatment between 1994 and 2004. Survival curves were calculated by the Kaplan-Meier Method, comparisons of rates with the log-rank test and prognostic factors by Cox's proportional hazard model.

RESULTS

Nodal CR occurred in 377 (43%) patients, of whom 365 patients did not undergo nodal dissection. The 5-year actuarial regional control rate of patients with CR was 92%. Two hundred sixty-eight of the remaining patients (53%) underwent neck dissections. The 5-year actuarial regional control rate for patients without a CR was 84%. Those who had a neck dissection fared better with 5-year actuarial regional control rates of 90% and 76% for those operated and those not operated (p < 0.001). Variables associated with poorer regional control rates included higher T and N stage, non-oropharynx cancers, non-CR, both clinical and pathological.

CONCLUSIONS

With 92% 5-year neck control rate without neck dissection after CR, there is little justification for systematic neck dissection. The addition of a neck dissection resulted in higher neck control after partial response though patients with viable tumor on pathology specimens had poorer outcomes. The identification of that subgroup that benefits from additional treatment remains a challenge.

Neck dissection can be avoided after sequential chemoradiotherapy and negative post-treatment positron emission tomography-computed tomography in N2 head and neck squamous cell carcinoma

AIMS

This study assessed neck control in patients with N2 head and neck squamous cell carcinoma (HNSCC) treated with sequential chemoradiotherapy (SCRT) and the incidence of neck recurrence when neck dissection was withheld in those with negative post-treatment fluorine-18 fluorodeoxyglucose positron emission tomography (FDG PET).

MATERIALS AND METHODS

Thirty-four consecutive patients with N2 HNSCC who were treated with radical intent using SCRT were included. Twenty-seven patients received concomitant platinum-based chemotherapy with their radiotherapy. Nineteen patients were treated with intensity-modulated radiotherapy. PET-computed tomography (PET-CT) was obtained 3 months after the completion of radical radiotherapy. Neck dissection was carried out only in those with increased FDG uptake in the neck.

RESULTS

The median follow-up was 39.1 months. One patient had increased FDG uptake in the neck post-treatment, which was false positive for malignancy. The remaining 33 patients were observed without neck dissection. No regional recurrence occurred. The negative predictive value (NPV) of post-treatment PET-CT was 100%.

CONCLUSIONS

Good disease control in the neck can be achieved in patients with N2 HNSCC with SCRT. Post-treatment PET-CT has a high NPV. Neck dissection can be avoided if post-treatment PET-CT is negative.

Phase I/II study of oncolytic HSV GM-CSF in combination with radiotherapy and cisplatin in untreated stage III/IV squamous cell cancer of the head and neck

PURPOSE

This study sought to define the recommended dose of JS1/34.5-/47-/GM-CSF, an oncolytic herpes simplex type-1 virus (HSV-1) encoding human granulocyte-macrophage colony-stimulating factor (GM-CSF), for future studies in combination with chemoradiotherapy in patients with squamous cell cancer of the head and neck (SCCHN).

EXPERIMENTAL DESIGN

Patients with stage III/IVA/IVB SCCHN received chemoradiotherapy (70 Gy/35 fractions with concomitant cisplatin 100 mg/m(2) on days 1, 22, and 43) and dose-escalating (10(6), 10(6), 10(6), 10(6) pfu/mL for cohort 1; 10(6), 10(7), 10(7), 10(7) for cohort 2; 10(6), 10(8), 10(8), 10(8) for cohort 3) JS1/34.5-/47-/GM-CSF by intratumoral injection on days 1, 22, 43, and 64. Patients underwent neck dissection 6 to 10 weeks later. Primary end points were safety and recommended dose/schedule for future study. Secondary end points included antitumor activity (radiologic, pathologic). Relapse rates and survival were also monitored.

RESULTS

Seventeen patients were treated without delays to chemoradiotherapy or dose-limiting toxicity. Fourteen patients (82.3%) showed tumor response by Response Evaluation Criteria in Solid Tumors, and pathologic complete remission was confirmed in 93% of patients at neck dissection. HSV was detected in injected and adjacent uninjected tumors at levels higher than the input dose, indicating viral replication. All patients were seropositive at the end of treatment. No patient developed locoregional recurrence, and disease-specific survival was 82.4% at a median follow-up of 29 months (range, 19-40 months).

CONCLUSIONS

JS1/34.5-/47-/GM-CSF combined with cisplatin-based chemoradiotherapy is well tolerated in patients with SCCHN. The recommended phase II dose is 10(6), 10(8), 10(8), 10(8). Locoregional control was achieved in all patients, with a 76.5% relapse-free rate so far. Further study of this approach is warranted in locally advanced SCCHN.

Viable tumor in postchemoradiation neck dissection specimens as an indicator of poor outcome

BACKGROUND

The objective of this study was to determine the prognostic significance of viable tumor in postchemoradiation neck dissection specimens in patients with squamous cell carcinoma of the laryngopharynx.

METHODS

Retrospective analysis identified 181 patients treated with primary concurrent chemoradiation for carcinoma of the laryngopharynx at Memorial Sloan-Kettering Cancer Center between the years 1995 and 2005. Of these, 56 patients had a comprehensive neck dissection either as a planned or salvage procedure. Neck dissection specimens were analyzed by a single pathologist for the presence of viable tumor. The presence of viable tumor was correlated to the timing of neck dissection after chemoradiation and to tumor response. Overall survival (OS), disease-specific survival (DSS), and recurrence-free survival (RFS) were determined by the Kaplan-Meier method, and correlation to tumor viability was determined with the log-rank test.

RESULTS

Nineteen (33%) patients had viable tumor in their neck dissection specimens. Viable tumor was higher in patients who had a less-than-complete response to chemoradiation compared with those who had a complete response (42% vs 25%, p = .1). There was no correlation to timing of neck dissection. The 5-year OS, DSS, and RFS were significantly lower in patients who had viable tumor in their neck dissection specimens (OS 49% vs 93%, p = .0005; DSS 56% versus 93%, p = .003; RFS 40% vs 75%, p = .004).

CONCLUSIONS

Patients with viable tumor in postchemoradiation neck dissection specimens had a poorer outcome compared with patients with no viable tumor.

Utilizing computed tomography as a road map for designing selective and superselective neck dissection after chemoradiotherapy

OBJECTIVE

To determine whether computed tomography can distinguish low risk neck levels that can be omitted when neck dissection is undertaken after chemoradiotherapy.

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary care center.

SUBJECTS AND METHODS

Head and neck squamous cell carcinoma patients undergoing neck dissection after chemoradiotherapy between January 1998 and June 2008. We compared computed tomography findings after chemoradiotherapy with neck dissection pathology results; used primary location and computed tomography findings to design selective or superselective neck dissection; and determined whether these surgeries would have contained all metastatic disease.

RESULTS

A total of 104 patients were identified, providing 110 heminecks, 531 neck levels, and 3009 lymph nodes for analysis. Neck dissections were positive in 20 (19%) of 104 patients, corresponding to 20 hemineck dissections, 31 neck levels, and 53 lymph nodes. The negative predictive value for computed tomography was 95 percent. The negative predictive value for computed tomography per neck level was as follows: I, 100 percent; II, 96 percent; III, 96 percent; IV, 97 percent; and V, 96 percent. A selective neck dissection or a superselective neck dissection, guided by level specific computed tomography findings and limited to necks with post treatment partial response in one level, would have captured all disease in 52 (95%) of 55 and 51 (93%) of 55 heminecks.

CONCLUSION

Negative computed tomography accurately predicts pathologic complete response at neck dissection. Neck dissection can be avoided in these patients. Additionally, computed tomography reliably identifies low risk neck levels that do not require dissection, permitting selective neck dissection or superselective neck dissection in partial response patients with limited residual disease.

Selective neck dissection in the management of the neck after (chemo)radiotherapy for advanced head and neck cancer. Proposal for a classification update

For patients with advanced regional disease, neck dissection following (chemo)radiotherapy remains controversial. Selective neck dissection (SND) was reported as suitable after chemoradiation in patients with advanced regional disease. Reduced morbidity represents the major advantage of SND. In a situation in which there is a major fibrosis around the previously invaded nodes, resection of 1 or more nonlymphatic structures may be required. The current classification of SND could be implemented by the addition of extended selective neck dissection (ESND). The standard basic procedures for SND spare the sternocleidomastoid muscle (SCM), the internal jugular vein (IJV), and the spinal accessory nerve (SAN). When an SND is associated with the resection of 1 or more nonlymphatic structures, it should be termed ESND. All additional nonlymphatic structure(s) removed should be identified in parentheses. The proposal to subclassify SND not only in accord with the resected lymph node levels but also upon the nonlymphatic structures removed may be of some help to avoid potential misinterpretation.

Neck dissection after chemoradiation for carcinoma of the upper aerodigestive tract: indications and complications

PURPOSE OF REVIEW

Chemoradiation has become a common approach in the treatment of advanced head and neck cancer. Its effectiveness in eradicating associated nodal metastases has resulted in modifications in the traditional paradigms for managing this aspect.

RECENT FINDINGS

Regardless of the pretreatment neck staging, patients who have a complete response to chemoradiation are unlikely to have residual viable tumor in this region, thus putting in question the need for planned neck dissection. F-Fluorodeoxyglucose positron emission tomography/computed tomography has become a standard tool to assess disease response to chemoradiotherapy, including the associated nodal disease. However, there remains an ongoing debate about its timing. The extent of neck dissection is trending toward an approach for selective procedures in order to minimize the long-term sequelae of extensive neck fibrosis.

SUMMARY

Post-chemoradiotherapy neck dissection is an effective procedure for selected patients with advanced head and neck cancer but is becoming a less needed intervention.

Planned neck dissection for patients with complete response to chemoradiotherapy: a concept approaching obsolescence

The question of efficacy of "planned" neck dissection following complete response to chemoradiation of head and neck cancer is discussed. There is general agreement that preemptive neck dissection in patients who present initially with low volume (N1) neck disease is not necessary. However, routine performance of planned neck dissection for patients who present initially with high volume (> or =N2) disease remains controversial. The authors reviewed a large number of studies reported in the recent literature and discuss how they affect this debate.Twenty-four of the reviewed studies indicate a benefit in regional control obtained by "planned" neck dissection among patients who had bulky neck disease pretreatment. All these studies are retrospective, they do not assess treatment response prior to surgery, although they do show very good regional control rates. Twenty-six studies demonstrate no benefit from "planned" neck dissection after complete clinical response. The reasons for these different conclusions include the development of more effective chemoradiation regimens which have improved the initial locoregional control rates of patients undergoing primary chemoradiation treatment, and improvements in diagnostic technology which have increased ability to detect low volume persistent tumor in the post treatment period. When neck dissection is necessary for persistent or recurrent disease, recent studies have shown that selective or superselective neck dissection may produce results therapeutically equivalent to those obtained with more extensive procedures, with less morbidity.There is now a large body of evidence, based on long-term clinical outcomes, that patients who have achieved a complete clinical (including radiologic) response to chemoradiation have a low rate of isolated neck failure, and the continued use of planned neck dissection for these patients cannot be justified.

Salvage surgery after concomitant chemoradiation in head and neck squamous cell carcinomas - stratification for postsalvage survival

BACKGROUND

Salvage surgery after concomitant chemoradiation therapy (CCRT) for patients with head and neck squamous cell carcinomas (HNSCC) is challenging because of its associated morbidity/mortality and the poor prognoses of these patients.

METHODS

The outcome analysis of prospectively collected data from 93 patients with HNSCC with local and/or regional shows treatment failures but without distant metastasis after CCRT.

RESULTS

Thirty-eight patients underwent salvage surgery, whereas 55 underwent palliative treatment, with 2-year overall survival rates of 43.4% and 0%, respectively. Initial stage IV tumors (p = .017) and concurrent local and regional failures (p = .003) were independent predictors for decreased survival after salvage surgery. Two-year overall survival rates for patients with 2, 1, or none of these predictive factors were 0%, 49%, and 83%, respectively (p = .0005).

CONCLUSION

Salvage surgery after CCRT has acceptable outcomes. Initial stage IV tumors and concurrent local and regional failures were independent predictors that can stratify patients into distinct prognostic groups for postsalvage survival.

PET-CT for response assessment and treatment adaptation in head and neck cancer

Preferred treatment strategies for advanced-stage squamous cell carcinoma of the head and neck have shifted from surgery to organ-preservation approaches such as radiotherapy, which can be combined with chemotherapy or giving of biologically modifying molecules. Preclinical and clinical researchers aim to customise these treatments on the basis of biological tumour characteristics, including tumour cell proliferation, hypoxia, and apoptosis--important resistance mechanisms for cytotoxic antitumour therapy. Monitoring of these biologically relevant variables before and early during treatment could improve patient selection for specific treatment strategies and guide adaptation of treatment at an early stage. PET provides a non-invasive molecular imaging method with the potential ability to undertake repetitive non-invasive quantification of relevant tumour characteristics. We discuss the role of PET scanning and available radiopharmaceutical tracers for treatment selection, early response monitoring, and treatment adaptation in head and neck cancer.

Revisiting the role of positron-emission tomography/computed tomography in determining the need for planned neck dissection following chemoradiation for advanced head and neck cancer

OBJECTIVES/HYPOTHESIS

Planned neck dissection following chemoradiation (CR) has been advocated in patients with head and neck squamous cell cancer (HNSCC) with advanced nodal disease and a clinical complete response to CR because of the potential for residual occult nodal disease. The utility of positron-emission tomography/computed tomography (PET-CT) in identifying occult nodal disease in this scenario is controversial.

METHODS

The medical records of all patients treated with CR for advanced HNSCC with N2 or N3 disease from December 2003 to June 2007 were reviewed. Patients with a complete clinical response were included if PET-CT performed 8 to 11 weeks after CR showed no distant disease and they underwent planned neck dissection.

RESULTS

Thirty-two patients met study criteria. PET-CT was positive for residual nodal disease in 20 patients (63%). Pathology revealed carcinoma in 10 patients (31%): six of 20 patients with positive PET-CT scans (30%) and four of 12 patients with negative PET-CT scans (33%). The sensitivity and specificity of PET-CT was 60% and 36%. Regional recurrence developed in two patients (6%) who were not successfully salvaged.

CONCLUSIONS

PET-CT performed 8 to 11 weeks after CR does not reliably predict the need for planned post-treatment neck dissection in patients with a complete clinical response following CR. Regional recurrence rates are comparable to those reported for patients observed with PET-CT, suggesting no advantage for planned neck dissection, and salvage rates were poor. These data suggest that delaying the timing of PET-CT, with surgery reserved for positive findings, is a reasonable alternative to planned neck dissection to avoid unnecessary surgery.