Impact of positron emission tomography/computed tomography surveillance at 12 and 24 months for detecting head and neck cancer recurrence

Patient perceptions underlying ctDNA molecular surveillance for HPV(+) oropharyngeal squamous cell carcinoma

OBJECTIVE

Circulating tumor DNA assays have robust potential as molecular surveillance tools. They may also exacerbate patient distress without improving outcomes. We investigate patient acceptability of a validated ctHPVDNA assay (NavDx) during cancer surveillance for HPV(+) oropharyngeal cancer (OPC).

METHODS

Consented HPV(+) OPC participants completed the NCCN Distress Thermometer, the Hospital Anxiety Depression Scale (HADS), and the Functional Assessment of Cancer Therapy-General (FACT-G) scale both (1) before NavDx blood draw, and (2) after results were provided. Patients then completed a series of focused questions related to their perceptions of the assay.

RESULTS

Overall, 55 patients completed the study, with 98.2 % showing no recurrence. For the NCCN Distress Thermometer, median patient distress decreased (2.0 (IQR 1-5) vs. 1.0 (IQR 0-3)) (p < 0.001) in association with NavDx. Using scores ≥ 4 as a cutoff point to define clinically elevated distress, scores also improved (36.4 % vs. 18.2 %, p = 0.031). For HADS, anxiety significantly improved (5.0 (IQR 2.0-7.0) vs. 3.0 (IQR 1.0-6.5)) (p = 0.037), but not depression (3.0 (IQR 1.0-7.0) vs. 3.0 (IQR 1.0-6.5)) (p = 0.870). FACT-G scores showed no substantial differences. On survey questionnaires, 95.5 % of patients believed the test to be helpful, and 100 % felt "somewhat" or "extremely" confident in the assay as a monitoring tool. While 59.1 % felt that it reduced anxiety, 88.4 % concordantly felt that it did not introduce anxiety.

CONCLUSION

ctHPVDNA as a molecular surveillance tool reduced distress levels in HPV(+) OPC patients, with notably high patient confidence in the approach. Further investigation is warranted to judiciously incorporate this emerging modality in surveillance guidelines.

Diagnostic Performance of 18F-FDG PET/CT According to Delay After Treatment to Detect Subclinical Recurrence of Head and Neck Squamous Cell Carcinoma

Head and neck squamous cell carcinoma (HNSCC) remains a malignancy with high rates of locoregional recurrence and poor prognosis for recurrent cases. Early detection of subclinical lesions is challenging but critical for effective patient management. Imaging surveillance after treatment, particularly 18F-FDG PET/CT, has shown promise in the diagnosis of HNSCC recurrence. The aim was to evaluate the diagnostic performance of 18F-FDG PET/CT according to delay after treatment in detecting subclinical recurrence (SCR) in HNSCC patients. Methods: In this retrospective study, all 18F-FDG PET/CT scans were performed at a single center. All adults with histologically proven HNSCC who were treated with curative intent between January 1, 2006, and December 31, 2021, were included. They had a normal clinical examination before each scan. Patients who underwent an intensive follow-up strategy after treatment had 18F-FDG PET/CT with an intravenous contrast agent at 3-6 mo and annually thereafter for 5 y. The primary endpoint was diagnostic performance (positive and negative predictive values, sensitivity, specificity, and accuracy). Results: In total, 2,566 18F-FDG PET/CT scans were performed among 852 patients, with an average of 3 scans per patient. The overall diagnostic performance measures were as follows: positive predictive value (88%), negative predictive value (98%), sensitivity (98%), specificity (89%), and accuracy (93%). There were no significant differences in diagnostic performance over time. The scans detected 126 cases of SCR (14.8%) and 118 cases of metachronous cancer (13.8%). The incidence of SCR decreased over time, with the highest detection rate in the first 2 y after treatment. Positive predictive value improved over time, reaching 90% for the digital Vision 600 system (third period) compared with 76% for the analog Gemini GXLi system (first period, P < 0.001). Multivariate analysis identified advanced stage, high body mass index, and initial PET/CT upstaging as predictive factors for detection of SCR. Conclusion: Our study demonstrates that 18F-FDG PET/CT has high diagnostic performance in detecting SCR during follow-up after treatment of HNSCC, especially in the first 2 y. Advanced tumor stage, initial PET/CT upstaging, and high body mass index were associated with a higher likelihood of SCR detection. The routine use of 18F-FDG PET/CT during follow-up seems justified for patients with HNSCC.

ctDNA as an Adjunct to Posttreatment PET for Head and Neck Cancer Recurrence Risk Assessment

OBJECTIVE

Circulating tumor DNA (ctDNA) detection is an emerging technique that identifies minimal residual disease in patients with solid tumors. ctDNA can act as an adjunct method to help overcome the limitations of positron emission tomography (PET) and select patients who are at high risk for recurrence.

STUDY DESIGN

Retrospective Single Institutional Study.

SETTING

University Hospital Setting.

METHODS

Twenty-nine patients who underwent definitive treatment for squamous cell carcinoma of the head and neck (HNSCC) from 8/2021 to 01/2023 had ctDNA levels analyzed at 1 to 3, 6, 9, and 12 months after definitive treatment. A personalized, tumor-informed, multiplex polymerase chain reaction (PCR) next-generation sequencing (NGS) assay was used to detect the ctDNA levels. The primary outcome was recurrence-free probability (RFP), and the secondary outcomes were overall survival (OS), sensitivity, specificity, and the test's negative (NPV) and positive predictive values (PPV).

RESULTS

The median age of patients was 65 years (interquartile range: 56-69), with majority being males (n = 22, 76%). The primary sites were larynx (n = 12), oropharynx (n = 10), and oral cavity (n = 6). Posttreatment ctDNA was detected in 7 patients, all of whom had disease recurrence. ctDNA detection after definitive treatment was associated with a higher risk of disease recurrence (hazard ratio: 9.94, 95% confidence interval: 1.56-63.3, P = .015). ctDNA identified recurrence with 100% specificity and 78% sensitivity. The NPV and PPV were 91% and 100%. PET had 78% sensitivity but only 68% specificity with 86% NPV, and 54% PPV.

CONCLUSION

Based on our data, ctDNA can be an excellent adjunct test for posttreatment PET and can help guide physicians in cases where PET results are inconclusive and difficult to interpret.

The Role of Biomarkers in HPV-Positive Head and Neck Squamous Cell Carcinoma: Towards Precision Medicine

Head and neck cancer (HNC) represents a significant global health challenge, with squamous cell carcinomas (SCCs) accounting for approximately 90% of all HNC cases. These malignancies, collectively referred to as head and neck squamous cell carcinoma (HNSCC), originate from the mucosal epithelium lining the larynx, pharynx, and oral cavity. The primary risk factors associated with HNSCC in economically disadvantaged nations have been chronic alcohol consumption and tobacco use. However, in more affluent countries, the landscape of HNSCC has shifted with the identification of human papillomavirus (HPV) infection, particularly HPV-16, as a major risk factor, especially among nonsmokers. Understanding the evolving risk factors and the distinct biological behaviors of HPV-positive and HPV-negative HNSCC is critical for developing targeted treatment strategies and improving patient outcomes in this complex and diverse group of cancers. Accurate diagnosis of HPV-positive HNSCC is essential for developing a comprehensive model that integrates the molecular characteristics, immune microenvironment, and clinical outcomes. The aim of this comprehensive review was to summarize the current knowledge and advances in the identification of DNA, RNA, and protein biomarkers in bodily fluids and tissues that have introduced new possibilities for minimally or non-invasive cancer diagnosis, monitoring, and assessment of therapeutic responses.

Imaging and Biomarker Surveillance for Head and Neck Squamous Cell Carcinoma: A Systematic Review and American Radium Society Appropriate Use Criteria Statement

Surveillance for survivors of head and neck cancer (HNC) is focused on early detection of recurrent or second primary malignancies. After initial restaging confirms disease-free status, the use of surveillance imaging for asymptomatic patients with HNC is controversial. Our objective was to comprehensively review literature pertaining to imaging and biomarker surveillance of asymptomatic patients treated for head and neck squamous cell carcinoma and to convene a multidisciplinary expert panel to provide appropriate use criteria for surveillance in representative clinical scenarios. The evidence base for the appropriate use criteria was gathered through a librarian-mediated search of literature published from 1990 to 2022 focused on surveillance imaging and circulating tumor-specific DNA for nonmetastatic head and neck squamous cell carcinoma using MEDLINE (Ovid), Embase, Web of Science Core Collection, and the Cochrane Central Register of Controlled Trials. The systematic review was reported according to PRISMA guidelines. Using the modified Delphi process, the expert panel voted on appropriate use criteria, providing recommendations for appropriate use of surveillance imaging and human papillomavirus (HPV) circulating tumor DNA. Of 5178 studies identified, 80 met inclusion criteria (5 meta-analyses/systematic reviews, 1 randomized control trial, 1 post hoc analysis, 25 prospective, and 48 retrospective cohort studies [with ≥50 patients]), reporting on 27,525 patients. No large, randomized, prospective trials examined whether asymptomatic patients who receive surveillance imaging or HPV circulating tumor DNA monitoring benefit from earlier detection of recurrence or second primary tumors in terms of disease-specific or quality-of-life outcomes. In the absence of prospective data, surveillance imaging for HNC survivors should rely on individualized recurrence-risk assessment accounting for initial disease staging, HPV disease status, and tobacco use history. There is an emerging surveillance role for circulating tumor biomarkers.

Quarter Century Positron Emission Tomography/Computed Tomography Transformation of Oncology: Head and Neck Cancer

During the last 2 decades, f-18 fluorodeoxyglucose positron emission tomography/computed tomography (18F FDG PET/CT) has transformed the clinical head and neck cancer imaging for patient management and predicting survival outcomes. It is now widely used for staging, radiotherapy planning, posttherapy assessment, and for detecting recurrence in head and neck cancers and is widely included in NCCN and other evidence based clinical practice guidelines. Future Directions would include evaluating the potential value of FAPI PET/CT for head and neck cancers, opportunity to use volumetric and tumor heterogeneity parameters and deploying AI in diagnostic and therapeutic assessments.

Post-treatment surveillance imaging in head and neck cancer: a systematic review

BACKGROUND

In patients treated for head and neck cancer, imaging studies are usually obtained within 3-6 months after treatment for assessment of treatment response. After 6 months, most guidelines advocate clinical follow-up, with imaging reserved for patients with clinically suspect or equivocal findings. However, some guidelines do recommend systematic imaging surveillance, and many clinicians tend to include some type of imaging in their follow-up schemes.

OBJECTIVES

This systematic review focuses on the usefulness of routine (systematic) post-treatment imaging surveillance of head and neck cancer beyond the first 3-6-month baseline imaging study.

METHODS

A systematic literature search was conducted using PubMed and Google Scholar. Additional studies were identified by reviewing reference lists. Only original studies and review papers were considered. Results obtained with systematic post-treatment surveillance imaging were compared to symptom-directed imaging and/or clinical finding-directed imaging.

RESULTS

Five hundred twenty-one records were identified through the database search, and 44 additional records were identified through other sources. Forty-eight articles were selected for the final review. Analysis of these records showed that almost half of cases of locoregional recurrences and/or metastases were only detected by imaging (40.9%), and the mean time of detection of recurrent or metastatic disease (11.5 months) was well beyond the period of the first post-treatment scan. Most authors reported superior results with PET-CT when compared to other imaging techniques.

CONCLUSION

Strong arguments were found in favor of systematic imaging surveillance in locoregional advanced head and neck cancer during at least one and preferably 2 years after treatment.

CRITICAL RELEVANCE STATEMENT

Analysis of the selected records showed that almost half of cases of locoregional recurrences and/or metastases were only detected by imaging. This systematic review suggests that imaging may currently be underused in the post-treatment surveillance of patients with head and neck cancer.

KEY POINTS

• This systematic review focuses on the usefulness of long-term systematic imaging surveillance in patients treated for head and neck cancer. • Analysis of 521 articles revealed that systematic imaging allowed the initial detection of locoregional recurrences and/or metastases in more than 40% of patients. • Imaging may currently be underused in the post-treatment surveillance of patients with advanced head and neck cancer.

Negative Predictive Value of Circulating Tumor Tissue Modified Viral (TTMV)-HPV DNA for HPV-driven Oropharyngeal Cancer Surveillance

PURPOSE

Human papillomavirus (HPV) is causally linked to oropharyngeal squamous cell carcinoma (OPSCC). Consensus guidelines recommend clinical exams and imaging in decreasing frequency as part of posttreatment surveillance for recurrence. Plasma tumor tissue modified viral (TTMV)-HPV DNA testing has emerged as a biomarker which can inform disease status during surveillance.

EXPERIMENTAL DESIGN

This retrospective observational cohort study involved 543 patients who completed curative-intent therapy for HPV-associated OPSCC between February 2020 and January 2022 at eight U.S. cancer care institutions. We determined the negative predictive value (NPV) of TTMV-HPV DNA for recurrence when matched to physician-reported clinical outcome data (median follow-up time: 27.9 months; range: 4.5-154).

RESULTS

The cohort included mostly men with a median age of 61 who had locoregionally advanced disease. HPV status was determined by p16 positivity in 87% of patients, with a positive HPV PCR/ISH among 55%; while pretreatment TTMV-HPV DNA status was unknown for most (79%) patients. Patients had a mean of 2.6 tests and almost half had three or more TTMV-HPV DNA results during surveillance. The per-test and per-patient sensitivity of the assay was 92.5% [95% confidence interval (CI): 87.5-97.5] and 87.3% (95% CI: 79.1-95.5), respectively. The NPV for the assay was 99.4% (95% CI: 98.9-99.8) and 98.4% (95% CI: 97.3-99.5), respectively.

CONCLUSIONS

TTMV-HPV DNA surveillance testing yields few false negative results and few missed recurrences. These data could inform decisions on when to pursue reimaging following first disease restaging and could inform future surveillance practice. Additional study of how pretreatment TTMV-HPV DNA status impacts sensitivity for recurrence is needed.

Lead Time to Recurrence After Posttreatment Plasma and Saliva HPV DNA Testing in Patients With Low-Risk HPV Oropharynx Cancer

Importance

Head and neck squamous cell carcinoma is a highly lethal cancer that is often associated with human papillomavirus (HPV). Recent studies have shown promise in the use of HPV DNA detection in salivary rinses and plasma as a factor associated with a future diagnosis of HPV-positive oropharynx cancer (HPVOPC). However, the use of plasma and salivary HPV DNA detection in defining risk for recurrence in the context of a prospective, phase 3, clinical trial coupled with standardized clinical surveillance has not been reported.

Objective

To identify patients with low-risk HPVOPC at risk for recurrence by detection of HPV16 DNA in plasma and salivary rinses.

Design, Setting, and Participants

In this cohort study, 233 low-risk patients were recruited from 32 head and neck treatment centers in Ireland (1 [3.1%]), the Netherlands (1 [3.1%]), and the UK (30 [93.8%]) as part of the DE-ESCALATE HPV trial, an open-label, phase 3 randomized clinical trial examining treatment with cetuximab vs cisplatin for HPVOPC. Patients were assayed for the presence of HPV16 DNA in plasma and salivary rinse via a quantitative polymerase chain reaction-based assay.

Main Outcomes and Measures

Assay results were associated with risk of recurrence and lead time from HPV16 DNA detection to recurrence.

Results

Of 233 patients, 45 (19.3%) were women, and the mean (SD) age was 57.01 (8.45) years. A total 1040 salivary or blood samples were collected during the course of the study. With a median follow-up of 760 days, the sensitivity and specificity of combined plasma and salivary rinse HPV DNA assays for detecting recurrence were 65% and 87%, respectively. There was a median lead time of positive test to event/recurrence date of 19 days (range, 0-536 days) and mean (SD) of 122 (169.8) days.

Conclusion and Relevance

The results of this cohort study suggest that in the setting of a randomized, prospective, phase 3 trial for low-risk patients with HPVOPC, posttreatment presence of HPV DNA in plasma and salivary rinses is associated with recurrence; a lead time between test positivity and clinical recurrence offers a potential opportunity for earlier detection of recurrence.

An Intensive 18F-Fludeoxyglucose-Positron Emission Tomography With Computed Tomography-Based Strategy of Follow-Up in Patients Treated for Head and Neck Squamous Cell Carcinoma Who Are Clinically Asymptomatic

Importance

Patients with head and neck squamous cell carcinoma (HNSCC) have a significant risk of locoregional recurrence within the first 2 years, with approximately two-thirds of patients experiencing such recurrence. While early recurrence detection may be associated with improved patient outcomes, the association of such detection with survival remains uncertain.

Objective

To investigate the association of an intensive posttreatment follow-up strategy using 18F-fludeoxyglucose-positron emission tomography with computed tomography (18FDG-PET/CT) with survival among patients with HNSCC.

Design, Setting, and Participants

This case-control study was conducted among patients treated at 1 of 3 locations in Brest, France (University Hospital, Military Hospital, or Pasteur Clinic). The statistical analysis was conducted from January to June 2023. All adults with histologically proven HNSCC who were treated with curative intent between January 1, 2006, and December 31, 2019, and achieved a complete response on imaging at 3 to 6 months were included. They had a minimum of 3 years of follow-up.

Exposures

Patients undergoing an intensive posttreatment follow-up strategy had 18FDG-PET/CT (PET/CT group) at months 12, 24, and 36, chosen at the discretion of ear, nose, and throat surgeons.

Main Outcomes and Measures

Overall survival (OS) at 3 years.

Results

Among 782 patients with HNSCC (642 males [82.1%]; median [IQR] age, 61 [56-68] years), 497 patients had 18FDG-PET/CT during follow-up and 285 patients had conventional follow-up (CFU group). Cox regression analysis showed an association between undergoing 18FDG-PET/CT and lower risk of death (odds ratio, 0.71; 95% CI, 0.57-0.88; P = .002) after adjustment for covariates (age, sex, comorbidities, primary location, stage, surgeon, year of treatment, and treatment). The mean (SD) 3-year OS was significantly better in the PET/CT vs CFU group (72.5% [2.0%] vs 64.3% [2.9%]; P = .002). Analysis based on American Joint Committee on Cancer stage showed significantly better mean (SD) 3-year OS for advanced stages III and IV in the PET/CT group (373 patients) vs CFU group (180 patients; 68.5% [2.4%] vs 55.4% [3.8%]; P < .001), while no significant difference was observed between patients with stage I or II HNSCC. Analysis based on primary tumor site revealed significantly longer mean (SD) 3-year OS for oropharyngeal tumor in the PET/CT group (176 patients) than the CFU group (100 patients; 69.9% [3.5%] vs 60.5% [5.0%]; P = .04).

Conclusions and relevance

This case-control study found that use of 18FDG-PET/CT in the standard annual CFU of HNSCC was associated with a 3-year survival benefit, with a larger benefit for patients with advanced initial tumor stage (III-IV) and oropharyngeal disease.

Development of a high-performance multi-probe droplet digital PCR assay for high-sensitivity detection of human papillomavirus circulating tumor DNA from plasma

OBJECTIVES

To develop a high-performance droplet digital PCR (ddPCR) assay capable of enhancing the detection of human papillomavirus (HPV) circulating tumor DNA (ctDNA) in plasma from patients with HPV-associated oropharyngeal squamous cell carcinoma (HPV+ OPSCC).

MATERIALS AND METHODS

Plasma samples from subjects with HPV+ OPSCC were collected. We developed a high-performance ddPCR assay designed to simultaneously target nine regions of the HPV16 genome.

RESULTS

The new assay termed 'ctDNA HPV16 Assessment using Multiple Probes' (CHAMP- 16) yielded significantly higher HPV16 counts compared to our previously validated 'Single-Probe' (SP) assay and a commercially available NavDx® assay. Analytical validation demonstrated that the CHAMP-16 assay had a limit of detection (LoD) of 4.1 copies per reaction, corresponding to < 1 genome equivalent (GE) of HPV16. When tested on plasma ctDNA from 21 patients with early-stage HPV+ OPSCC and known HPV16 ctDNA using the SP assay, all patients were positive for HPV16 ctDNA in both assays and the CHAMP-16 assay displayed 6.6-fold higher HPV16 signal on average. Finally, in a longitudinal analysis of samples from a patient with recurrent disease, the CHAMP-16 assay detected HPV16 ctDNA signal ∼ 20 months prior to the conventional SP assay.

CONCLUSION

Increased HPV16 signal detection using the CHAMP-16 assay suggests the potential for detection of recurrences significantly earlier than with conventional ddPCR assays in patients with HPV16+ OPSCC. Critically, this multi-probe approach maintains the cost-benefit advantage of ddPCR over next generation sequencing (NGS) approaches, supporting the cost-effectiveness of this assay for both large population screening and routine post-treatment surveillance.

Long-Term Care and Follow-Up in Laryngeal Cancer Patients: A Multicenter Retrospective Analysis

PURPOSE

We conducted an outcome analysis on surgically treated laryngeal squamous cell carcinoma (LSCC) patients.

METHODS

A multicenter retrospective study with 352 patients was analyzed. A new nomogram that incorporates age, T- and N-classification, and treatment was created.

RESULTS

Recurrence was observed in 65 (18.5%) patients after a mean time of 16.5 months. After 60 months, 91 (25.9%) of patients developed secondary primary tumors (SPT), most commonly in the lungs (n = 29; 8.2%) followed by other head and neck cancers (n = 21; 6.0%). Notably, the mean time to occurrence of secondary head and neck cancers was twice that of lung cancer (101.1 vs. 47.5 months).

CONCLUSION

Recurrent disease is less common in LSCC patients and appears much earlier than SPT. Because one in every four laryngeal cancer patients develops SPTs within 5-10 years, long-term care and follow-up, including imaging studies, are highly recommended. The nomogram was useful for estimating survival.

Role of PET/CT in Oropharyngeal Cancers

Oropharyngeal squamous cell carcinoma (OPSCC) comprises cancers of the tonsils, tongue base, soft palate, and uvula. The staging of oropharyngeal cancers varies depending upon the presence or absence of human papillomavirus (HPV)-directed pathogenesis. The incidence of HPV-associated oropharyngeal cancer (HPV + OPSCC) is expected to continue to rise over the coming decades. PET/CT is a useful modality for the diagnosis, staging, and follow up of patients with oropharyngeal cancers undergoing treatment and surveillance.

Human β-Defensins in Diagnosis of Head and Neck Cancers

Head and neck cancers are malignant growths with high death rates, which makes the early diagnosis of the affected patients of utmost importance. Over 90% of oral cavity cancers come from squamous cells, and the tongue, oral cavity, and salivary glands are the most common locations for oral squamous cell carcinoma lesions. Human β-defensins (hBDs), which are mainly produced by epithelial cells, are cationic peptides with a wide antimicrobial spectrum. In addition to their role in antimicrobial defense, these peptides also take part in the regulation of the immune response. Recent studies produced evidence that these small antimicrobial peptides are related to the gene and protein expression profiles of tumors. While the suppression of hBDs is a common finding in head and neck cancer studies, opposite findings were also presented. In the present narrative review, the aim will be to discuss the changes in the hBD expression profile during the onset and progression of head and neck cancers. The final aim will be to discuss the use of hBDs as diagnostic markers of head and neck cancers.

Dysphagia and shortness-of-breath as markers for treatment failure and survival in oropharyngeal cancer after radiation

BACKGROUND

Post-treatment symptoms are a focal point of follow-up visits for head and neck cancer patients. While symptoms such as dysphagia and shortness-of-breath early after treatment may motivate additional work up, their precise association with disease control and survival outcomes is not well established.

METHODS

This prospective data cohort study of 470 oropharyngeal cancer patients analyzed patient-reported swallowing, choking and shortness-of-breath symptoms at 3-to-6 months following radiotherapy to evaluate their association with overall survival and disease control. Associations between the presence of moderate-to-severe swallowing, choking and mild-to-severe shortness-of-breath and treatment outcomes were analyzed via Cox regression and Kaplan-Meier. The main outcome was overall survival (OS), and the secondary outcomes were local, regional, and distant disease control.

RESULTS

The majority of patients (91.3%) were HPV-positive. Median follow-up time was 31.7 months (IQR: 21.9-42.1). Univariable analysis showed significant associations between OS and all three symptoms of swallowing, choking, and shortness-of-breath. A composite variable integrating scores of all three symptoms was significantly associated with OS on multivariable Cox regression (p = 0.0018). Additionally, this composite symptom score showed the best predictive value for OS (c-index = 0.75). Multivariable analysis also revealed that the composite score was significantly associated with local (p = 0.044) and distant (p = 0.035) recurrence/progression. Notably, the same significant associations with OS were seen for HPV-positive only subset analysis (p < 0.01 for all symptoms).

CONCLUSIONS

Quantitative patient-reported measures of dysphagia and shortness-of-breath 3-to-6 months post-treatment are significant predictors of OS and disease recurrence/progression in OPC patients and in HPV-positive OPC only.

Correlation between PET-CT and ct in the staging after the treatment of head and neck squamous cell carcinoma

OBJECTIVE

The aim of this study is to find out if a single imaging test is enough to follow-up on an oncological post-treatment patient. In such a case, we would know which was more valuable after comparing the two, by CT or PET-CT.

METHODS

Between January 2012 and July 2018, we collected data from all patients with previous medical history who were treated with a head and neck squamous cell carcinoma in our hospital, through surgery or by using an organ preservation protocol which we had done. Patients were required to have a CT and a PET-CT performed in a maximum period of 30 days between techniques. We compared the post post-treatment stage given to each case by using only the physical examination (only the CT and the PET-CT), with the ones given by the Tumor Board. After treatment, we analysed the similarity through Cramer's V statistic test.

RESULTS

We performed a comparative analysis, obtaining a correlation of 0.426 between the stages given by the Tumor Board and the one assigned based on physical examination, without imaging techniques. By only using the computed tomography as an imaging method the correlation was 0.565, whereas with only the use of positron emission computed technology, it was estimated at 0.858. When we compared the statistical association between stages using exclusively one of the two imaging techniques, the correlation was 0.451.

CONCLUSION

Independent of the modality, we have demonstrated that in patients who have received previous treatment, there was a higher correlation in the stages with respect to the diagnostic method conducted by the Tumor Board using PET-CT as the sole image.

LEVEL OF EVIDENCE

Level 1.

Evaluation of Optimal Assessment Schedules for Surveillance After Definitive Locoregional Treatment of Locally Advanced Head and Neck Cancer: A Retrospective Cohort Study With Parametric Modeling of Event-Free Survival

Importance

In clinical practice, assessment schedules are often arbitrarily determined after definitive treatment of head and neck cancer (HNC), producing heterogeneous and inconsistent surveillance plans.

Objective

To establish an optimal assessment schedule for patients with definitively treated locally advanced HNC, stratified by the primary subsite and HPV status, using a parametric model of standardized event-free survival curves.

Design, Setting, and Participants

This was a retrospective study including 2 tertiary referral hospitals and a total of 673 patients with definitive locoregional treatment of locally advanced HNC (227 patients with nasopharyngeal cancer [NPC]; 237 patients with human papillomavirus-positive oropharyngeal cancer [HPV+ OPC]; 47 patients with HPV-negative [HPV-] OPC; 65 patients with hypopharyngeal cancer [HPC]; and 97 patients with laryngeal cancer [LC]). Patients had received primary treatment in 2008 through 2019. The median (range) follow-up duration was 57.8 (6.4-158.1) months. Data analyses were performed from April to October 2021.

Main Outcomes and Measures

Tumor recurrence and secondary malignant neoplasms. Event-free survival was defined as the period from the end of treatment to occurrence of any event. Event-free survival curves were estimated using a piecewise exponential model and divided into 3 phases of regular follow-up. A 5% event rate criterion determined optimal follow-up time point and interval.

Results

The median (range) age of the 673 patients at HNC diagnosis was 58 (15-83) years; 555 (82.5%) were men; race and ethnicity were not considered. The event rates of NPC, HPV+ OPC, HPV- OPC, HPC, and LC were 18.9% (43 of 227), 14.8% (35 of 237), 36.2% (17 of 47), 44.6% (29 of 65), and 30.9% (30 of 97), respectively. Parametric modeling demonstrated optimal follow-up intervals for HPC, LC, and NPC, respectively, every 2.1, 3.2, and 6.1 months; 3.7, 5.6, and 10.8 months; and 9.1, 13.8, and 26.5 months until 16.5, 16.5 to 25.0, and 25.0 to 99.0 months posttreatment (open follow-up thereafter). For HPV- OPC, assessment was recommended every 2.7, 4.8, and 11.8 months until 16.5, 16.5 to 25.0, and 25 to 99 months posttreatment, respectively. In contrast, HPV+ OPC optimal intervals were every 7.7, 13.7, and 33.7 months until 16.5, 16.5 to 25.0, and 25 to 99 months posttreatment, respectively. Five, 4, 12, 15, and 10 follow-up visits were recommended for NPC, HPV+ OPC, HPV- OPC, HPC, and LC, respectively.

Conclusions and Relevance

This retrospective cohort study using parametric modeling suggests that the HNC assessment schedules should be patient tailored and evidence based to consider primary subsites and HPV status. Given limited health care resources and rising detection rates and costs of HNC, the guidelines offered by these findings could benefit patients and health systems and aid in developing future consensus guidelines.

HPV DNA as a Biomarker in Oropharyngeal Cancer: A Step in the Right Direction

Lack of prospectively planned follow-up and minimal characterization of the patient population studied complicate interpretation of circulating human papillomavirus (HPV) DNA as a prognostic biomarker for patients with HPV-associated oropharyngeal carcinoma treated with curative intent. See related article by Berger et al., p. 4292.

Utilization of PET/CT Scan in Head and Neck Carcinoma: A Tertiary Care Hospital Experience

Objective

PET/CT scan has been increasingly used in assessment of Head and Neck cancer prior to treatment for evaluation and for surveillance. In this study we aim to assess the utilization of PET/CT scan at a tertiary care hospital.

Methods

Retrospectively data was reviewed of all patients of Head and Neck cancer who underwent PET/CT scan for workup or for follow-up between July 2018 and December 2019. PET/CT scan done in the pre-treatment assessment and post-treatment surveillance were analyzed for its utility.

Results

A total of 145 patients were included. The main indication for pre-treatment PET/CT scan was loco-regionally advanced disease (62 of 90 patients, 68.8%). No specific indication was noted in 19 patients (21%). A significant change in treatment decision was seen in pre-treatment patients based on M stage following a PET/CT scan. However, no change was noted on the basis of T or N stage. In the post-treatment surveillance there was a significant correlation of type of recurrence with clinical assessment and indication for PET/CT scan. 37 out of 87 patients (42.5%) underwent PET/CT scan for no specific reason, of which, 07 patients (18.9%) were detected to have distant metastasis.

Conclusion

Role of PET/CT in the pre-treatment assessment is very limited and maybe confined to advanced local or regional disease. Post-treatment surveillance with PET/CT scan has a promising role and must be done as a baseline during 1st follow up at 03 months in all patients who have advanced disease and have undergone multi-modality treatment for the same.

[Study on the indication of concurrent chemoradiotherapy for locally advanced laryngeal carcinoma]

Laryngeal cancer is one of the most common malignant cancer of the head and neck. Concurrent chemoradiotherapy is considered by the NCCN guideline to be the most effective organ protection strategy for locally advanced laryngeal cancer, which can preserve the larynx without reducing the survival rate of patients. Patients with non-T4 （T1-3） and high lymph node burden （N2-3） laryngeal cancer can benefit from concurrent chemoradiotherapy, which are more suitable for concurrent chemoradiotherapy than locally advanced laryngeal cancer with other stages. The indications of concurrent chemoradiotherapy were further discussed in this paper.

Development and Validation of a Decision Analytical Model for Posttreatment Surveillance for Patients With Oropharyngeal Carcinoma

IMPORTANCE

Clinical practice regarding posttreatment radiologic surveillance for patients with oropharyngeal carcinoma (OPC) is neither adapted to individual patient risk nor fully evidence based.

OBJECTIVES

To construct a microsimulation model for posttreatment OPC progression and use it to optimize surveillance strategies while accounting for both tumor stage and human papillomavirus (HPV) status.

DESIGN, SETTING, AND PARTICIPANTS

In this decision analytical modeling study, a Markov model of 3-year posttreatment patient trajectories was created. The training data source was the American College of Surgeon's National Cancer Database from 2010 to 2015. The external validation data set was the 2016 International Collaboration on Oropharyngeal Cancer Network for Staging (ICON-S) study. Training data comprised 2159 patients with OPC treated with primary radiotherapy who had known HPV status and disease staging information. Patients with American Joint Committee on Cancer, 7th edition stage III to IVB disease and those with clinical metastases during the time of primary treatment were included. Data were analyzed from August 1 to October 31, 2020.

MAIN OUTCOMES AND MEASURES

Main outcomes included disease stage and HPV status, specific disease transition probabilities, and latency of surveillance regimens, defined as time between recurrence incidence and disease discovery.

RESULTS

Training data consisted of 2159 total patients (1708 men [79.1%]; median age, 59.6 years [range, 40-90 years]; 401 with stage III disease, 1415 with stage IVA disease, and 343 with stage IVB disease). Cohorts predominantly had HPV-negative disease (1606 [74.4%]). With model-optimized regimens, recurrent disease was discovered a mean of 0.6 months (95% CI, 0.5-0.8 months) earlier than with a standard surveillance regimen based on current clinical guidelines. Recurrent disease was discovered using the optimized regimens without significant reduction in sensitivity. Compared with strategies based on reimbursement guidelines, the model-optimized regimens found disease a mean of 1.8 months (95% CI, 1.3-2.3 months) earlier.

CONCLUSIONS AND RELEVANCE

Optimized, risk-stratified surveillance regimens consistently outperformed nonoptimized strategies. These gains were obtained without requiring any additional imaging studies. This approach to risk-stratified surveillance optimization is generalizable to a broad range of tumor types and risk factors.

To scan or not to scan: the dilemma of post-treatment imaging surveillance of head and neck cancer

Locoregional recurrence remains common after treatment of head and neck cancer, warranting careful surveillance in follow-up. While randomized data support an initial PET/CT several months after treatment, evidence supporting subsequent imaging is limited, and most recurrences ultimately manifest clinically. Cooperative group studies and consensus guidelines vary widely in their recommendations regarding surveillance imaging. Patients with indeterminate findings, new symptoms, or areas difficult to examine in clinic may avoid invasive and potentially morbid interventions with judicious use of subsequent imaging. For any patient undergoing post-treatment imaging, standardized reporting criteria provide a framework for risk-stratification that can enhance communication and potentially guide management.

18F FDG imaging - response criteria in tumors

With the progress of medical oncology, it became apparent that anatomical imaging is oftentimes insufficient for therapy response evaluation. Hybrid imaging, namely ¹⁸F-FDG PET/CT has helped to overcome these limitations. The aim of this paper is to emphasize the utility and impact in clinical use of ¹⁸F-FDG PET/CT, and to give an overview of the most important ¹⁸F-FDG PET/CT tumor response criteria. We also focus on standardization of hybrid imaging techniques as this is of outmost importance to provide reliable imaging evaluation.

Surveillance for Patients with Oral Squamous Cell Carcinoma after Complete Surgical Resection as Primary Treatment: A Single-Center Retrospective Cohort Study

BACKGROUND

The surveillance methods oral squamous cell carcinoma (OSCC) patients may be chosen by considering the risk for recurrence, and it is important to establish appropriate methods during the period in which latent/dormant cancer cells become more apparent. To investigate the appropriate surveillance of patients with OSCC based on the individual risk for recurrence and/or metastasis, we performed a retrospective cohort study after the complete surgical resection of OSCC as the primary treatment.

METHODS

The study was performed in 324 patients with OSCC who had been primarily treated with surgery from 2007 to 2020 at our hospital. We investigated the period, timing, and methods (visual examination, palpation and imaging using FDG-PET/CT or CECT) for surveillance in each case that comprised postsurgical treatment.

RESULTS

Regarding the time to occurrence of postsurgical events, we found that half of cases of local recurrence, cervical lymph node metastasis, and distant metastasis occurred within 200 days, and 75% of all of these events occurred within 400 days. However, the mean time for second primary cancer was 1589 days. The postsurgical events were detected earlier by imaging examinations than they were by visual examination and palpation.

CONCLUSIONS

For the surveillance of patients with OSCC after primary surgery, it is desirable to perform FDG-PET/CT within 3-6 months and at 1 year after surgery and to consider CECT as an option in between FDG-PET/CT, while continuing history and physical examinations for about 5 years based on individual risk assessment.

Longitudinal detection of somatic mutations in saliva and plasma for the surveillance of oral squamous cell carcinomas

Purposes

Although clinical and radiological examinations can be used to diagnose oral cancer, and surgical pathology remains the gold standard, these conventional methods have limitations. We evaluated the feasibility of longitudinal next-generation sequencing-based liquid biopsy for oral squamous cell carcinoma surveillance.

Materials and methods

Eleven patients were enrolled, and plasma and saliva were collected before, and 1, 3, and 6 months after surgery. Tumor-specific mutations were selected using paired, whole-exome analyses of tumor tissues and whole blood. Genes frequently mutated in head and neck cancer were identified using the Cancer Genome Atlas (TCGA) and Catalogue of Somatic Mutations in Cancer (COSMIC) databases to design targeted deep sequencing panels.

Results

In five of the six patients with recurrent cancer, circulating tumor DNA (ctDNA) was detected earlier with liquid biopsy than with conventional monitoring techniques. Moreover, patients without recurrence exhibited decreased ctDNA allele frequency post-treatment.

Conclusions

Longitudinal liquid biopsy of plasma and saliva may be feasible for detecting somatic mutations associated with oral squamous cell carcinomas. It might be attributable to determine early tumor recurrence through genetic analysis of ctDNA.

Lip and Oral Cavity Squamous Cell Carcinoma

Lip and oral cavity squamous cell carcinoma (SCC) develop from progressive dysplasia of these mucosal structures. The cancers are often preceded by premalignant lesions, and any nonhealing ulcers of the lip or oral cavity should be biopsied. Some risk factors for these 2 subsites overlap and include tobacco use, alcohol use, and an immunocompromised state. Lip and oral cavity SCC are clinically staged based on physical examination and imaging. The 5-year overall survival for early-stage lip and oral cavity SCC is around 70% to 90% but decreases to about 50% for late-stage disease.

Detection of CAF-1/p60 in peripheral blood as a potential biomarker of HNSCC tumors

To date, a very small number of serum biomarkers have been identified for clinical use in squamous carcinomas of the head and neck region. Chromatin Assembly Factor-1 (CAF-1) heterotrimeric complex subunit CAF1/p60 expression levels have been reported to be of prognostic value in Oral Squamous Cell Carcinoma (OSCC), as well as in other human solid tumors. Here our aim was to detect and quantify CAF1/p60 in the peripheral blood of Head and Neck Squamous Cell Carcinoma (HNSCC) patients, and to investigate the possible associations between serum concentration of CAF-1/p60 and HNSCC tumors. A total of 63 HNSCC patients (51 OSCC, 8 OPSCC, 3 laryngeal SCC, and 1 rhinopharynx SCC) and 30 healthy controls were enrolled. The serum levels of CAF-1/p60 were measured by ELISA assay before and after surgery. Serum CAF-1/p60 concentration resulted significantly higher in cancer patients, compared with healthy controls, in pre-surgery samples (P < 0.05). Serum levels of CAF-1/p60 significantly decreased in serum samples taken after surgery (P < 0.05). Our results demonstrated that CAF-1/p60 may be detected in serum, suggesting a role for CAF-1/p60 as potential soluble biomarkers in HNSCC tumors.

Interrater Reliability of NI-RADS on Posttreatment PET/Contrast-enhanced CT Scans in Head and Neck Squamous Cell Carcinoma

Purpose To evaluate the interrater reliability among radiologists examining posttreatment head and neck squamous cell carcinoma (HNSCC) fluorodeoxyglucose PET/contrast-enhanced CT (CECT) scans using Neck Imaging Reporting and Data System (NI-RADS). Materials and Methods In this retrospective study, images in 80 patients with HNSCC who underwent posttreatment surveillance PET/CECT and immediate prior comparison CECT or PET/CECT (from June 2014 to July 2016) were uploaded to the American College of Radiology's cloud-based website, Cortex. Eight radiologists from seven institutions with variable NI-RADS experience independently evaluated each case and assigned an appropriate prose description and NI-RADS category for the primary site and the neck site. Five of these individuals were experienced readers (> 5 years of experience), and three were novices (< 5 years of experience). In total, 640 lexicon-based and NI-RADS categories were assigned to lesions among the 80 included patients by the eight radiologists. Light generalization of Cohen κ for interrater reliability was performed. Results Of the 80 included patients (mean age, 63 years ± 10 [standard deviation]), there were 58 men (73%); 60 patients had stage IV HNSCC (75%), and the most common tumor location was oropharynx (n = 32; 40%). Light κ for lexicon was 0.30 (95% CI: 0.23, 0.36) at the primary site and 0.31 (95% CI: 0.24, 0.37) at the neck site. Light κ for NI-RADS category was 0.55 (95% CI: 0.46, 0.63) at the primary site and 0.60 (95% CI: 0.48, 0.69) at the neck site. Percent agreement between lexicon and correlative NI-RADS category was 84.4% (540 of 640) at the primary site and 92.6% (593 of 640) at the neck site. There was no significant difference in interobserver agreement among the experienced versus novice raters. Conclusion Moderate agreement was achieved among eight radiologists using NI-RADS at posttreatment HNSCC surveillance imaging. Keywords: CT, PET/CT, Head/Neck, Neck, Neoplasms-Primary, Observer Performance Supplemental material is available for this article. © RSNA, 2021.

Best Practices: Application of NI-RADS for Posttreatment Surveillance Imaging of Head and Neck Cancer

Imaging surveillance is an important component of posttreatment management of head and neck cancers. There is variability in the surveillance regimen used by various practitioners and institutions, with no official National Comprehensive Cancer Network guidelines for patients showing no symptoms beyond 6 months posttreatment. Moreover, imaging of the neck after treatment is a complex examination with significant interreader heterogeneity, particularly in terms of the manner in which degree of suspicion for disease recurrence is expressed. The Neck Imaging Reporting and Data System (NI-RADS) was introduced by the American College of Radiology (ACR) in 2018 as a practical guide for the interpreting radiologist. NI-RADS is a proposed interpretive framework that can be applied to any standardized or institutional surveillance imaging protocol. NI-RADS simplifies communication between radiologists and referring clinicians and provides management guidance linked to specific levels of suspicion. The ACR NI-RADS Committee also provided general best practice recommendations for imaging surveillance modality and timing in the 2018 white paper. This article will review existing literature regarding choice of modality and timeline for surveillance in treated cancer of the head and neck. NI-RADS will then be presented as an approach to imaging reporting, interpretation, and design of next steps in management.

Role of Repeat PET/CT Imaging in Head and Neck Cancer Following Initial Incomplete PET/CT Response to Chemoradiation

Simple Summary

Following completion of chemotherapy and radiation for the treatment of head and neck cancer, a PET/CT scan is typically obtained 3 months later to assess how well the patient responded to treatment. The results of this PET/CT are often difficult to interpret because radiation can cause inflammation around the area being treated that can take months to resolve. We looked at 57 patients who had a repeat PET/CT scan performed after initial post-treatment imaging was unclear to examine whether this was helpful in determining whether these patients require further testing. Among this group, 48% of patients converted to having a complete response to treatment and none went on to develop treatment failure. Based on our findings, repeat PET/CT imaging can provide valuable information for head and neck cancer patients that can reduce the incidence of unnecessary biopsies and surgeries.

Abstract

Despite waiting 13 weeks to perform a PET/CT scan after completion of chemoradiation for head and neck squamous cell carcinoma (HNSCC), equivocal findings are often found that make assessing treatment response difficult. This retrospective study examines the utility of a repeat PET/CT scan in HNSCC patients following an incomplete response on initial post-treatment imaging. For this cohort of 350 patients, initial PET/CT was performed 13 weeks after completion of treatment. For select patients with an incomplete response, repeat PET/CT was performed a median of 91 days later. Primary endpoints were conversion rate to complete response (CR) and the predictive values of repeat PET/CT imaging. Of 179 patients who did not have an initial complete response, 57 (32%) received a repeat PET/CT scan. Among these patients, 26 of 57 (48%) had a CR on repeat PET/CT. In patients with CR conversion, there were no cases of disease relapse. The sensitivity, specificity, PPV, and NPV for the repeat PET/CT for locoregional disease were 100%, 59%, 42%, and 100%. Repeat PET/CT in HNSCC patients with an incomplete post-treatment scan can be valuable in obtaining diagnostic clarity. This can reduce the incidence of unnecessary biopsies and neck dissections.

Reliability of NI-RADS criteria in the interpretation of contrast-enhanced magnetic resonance imaging considering the potential role of diffusion-weighted imaging

OBJECTIVES

To assess inter- and intrareader agreement of the Neck Imaging Reporting and Data System (NI-RADS) used in contrast-enhanced magnetic resonance imaging (MRI) including analysis of diffusion-weighted imaging (DWI), which is currently not part of the NI-RADS criteria.

METHODS

This retrospective study included anonymized surveillance contrast-enhanced MRI datasets of 104 patients treated for different head and neck cancers. Three radiologists experienced in head and neck imaging reported findings for the primary site and the neck using NI-RADS criteria in a first step and evaluated DWI sequences for the primary site in a second step. Thirty randomly selected imaging datasets were again presented to the readers. Kappa statistics and observed agreement (A_o) were calculated.

RESULTS

Interreader agreement across all MRI datasets was moderate (κ_Fleiss = 0.53) for NI-RADS categories assigned to the primary site, substantial for NI-RADS categories of the neck (κ_Fleiss = 0.67), and almost perfect for DWI of the primary site (κ_Fleiss = 0.83). Interreader agreement for the primary site was particularly low in cases of cancer recurrence (κ_Fleiss = 0.35) and when categories 2a, 2b, and 3 were combined (κ_Fleiss = 0.30). Intrareader agreement was considerably lower for NI-RADS categories of the primary site (range A_o = 53.3-70.0%) than for NI-RADS categories of the neck (range A_o = 83.3-90.0%) and DWI of the primary site (range A_o = 93.3-100.0%).

CONCLUSION

Interreader agreement of NI-RADS for reporting contrast-enhanced MRI findings is acceptable for the neck but limited for the primary site. Here, DWI has the potential to serve as a reliable additional criterion.

KEY POINTS

• NI-RADS was originally designed for contrast-enhanced computed tomography with or without positron emission tomography but can also be used for contrast-enhanced magnetic resonance imaging alone. • Overall interreader agreement was acceptable for NI-RADS categories assigned to the neck but should be improved for the primary site, where it was inferior to DWI; similar tendencies were found for intrareader agreement. • DWI is currently no criterion of NI-RADS, but has shown potential to improve its reliability, especially for categories 2a, 2b, and 3 of the primary site.

Impact of provider type and number of providers on surveillance testing among survivors of head and neck cancers

BACKGROUND

Guidelines for follow-up after head and neck cancer (HNC) treatment recommend frequent clinical examinations and surveillance testing. Here, the authors describe real-world follow-up care for HNC survivors and variations in surveillance testing.

METHODS

Using Surveillance, Epidemiology, and End Results (SEER)-Medicare data, this study examined a population-based cohort of HNC survivors between 2001 and 2011 Usage of cross-sectional head and neck imaging (CHNI), chest imaging (CI), positron emission tomography (PET), fiberoptic nasopharyngolaryngoscopy (FNPL), and, in irradiated patients, thyroid function testing (TFT) was captured over 2 consecutive surveillance years. Multivariate modeling with logistic regression analyses was used to assess variations by clinical factors, nonclinical factors, number and types of providers seen and their evolution over time.

RESULTS

Among 13,836 HNC survivors, the majority saw a medical, radiation, or surgical oncologist and a primary care provider (PCP; 81.7%) in their first year of surveillance. However, only 58.1% underwent either PET or CHNI, 47.8% underwent CHNI, 64.1% underwent CI, 32.5% underwent PET scans, 55.0% underwent FNPL, and 55.9% underwent TFT. In multivariate analyses, patients who followed up with more providers and those who followed up with both a PCP and an oncologist were more likely to undergo surveillance testing (P < .007). However, adjusting for providers seen did not explain the variations in surveillance testing rates based on age, race, education, income level, and place of residence. Over time, there was a gradual increase in the use of PET scans and TFT during surveillance years.

CONCLUSIONS

In this large SEER-Medicare data study, only half of HNC survivors received the recommended testing, and greater compliance was seen in those who followed up with both an oncologist and a PCP. More attention is needed to minimize variations in surveillance testing across sociodemographic groups.

John MA. Time for a Paradigm Shift in Head and Neck Cancer Management During the COVID-19 Pandemic

OBJECTIVE

The coronavirus disease 2019 (COVID-19) pandemic has caused physicians and surgeons to consider restructuring traditional cancer management paradigms. We aim to review the current evidence regarding the diagnosis and management of head and neck cancer, with an emphasis on the role of the multidisciplinary team (MDT) during a pandemic.

DATA SOURCES

COVID-19 resources from PubMed, Google Scholar, the American Academy of Otolaryngology-Head and Neck Surgery, and the American Head and Neck Society were examined.

REVIEW METHODS

Studies and guidelines related to the multidisciplinary management of head and neck cancer in the COVID-19 setting were reviewed. A total of 54 studies were included. Given the continuously evolving body of literature, the sources cited include the latest statements from medical and dental societies.

RESULTS

The unpredictable fluctuation of hospital resources and the risk of the nosocomial spread of SARS-CoV-2 have direct effects on head and neck cancer management. Using an MDT approach to help define "essential surgery" for immediately life- or function-threatening disease processes in the context of available hospital resources will help to maximize outcomes. Early enrollment in an MDT is often critical for considering nonsurgical options to protect patients and health care workers. The role of the MDT continues after cancer treatment, if delivered, and the MDT plays an essential role in surveillance and survivorship programs in these challenging times.

CONCLUSION

Head and neck cancer management during the COVID-19 pandemic poses a unique challenge for all specialists involved. Early MDT involvement is important to maximize patient outcomes and satisfaction in the context of public and community safety.

Imaging of the post-treatment neck

Post-treatment imaging of the neck is complex. It is important to have an understanding of the expected treatment related appearances as well as the possible complications. Common findings after radiation therapy include generalised soft-tissue oedema and thickening of the skin and platysma muscle. There are a number of complications of radiation that may be seen on imaging, including osteoradionecrosis, chondronecrosis, and accelerated atherosclerosis. Surgical procedures are variable depending on the primary tumour site and extent. The use of flap reconstructions can further complicate the imaging appearances. Any new nodule of enhancement or bone/cartilage erosion should raise concern for tumour recurrence. It is also important to assess for nodal recurrence. A standardised approach to reporting may help to increase accuracy and guide treatment decisions.

Head and Neck Cancers, Version 2.2020, NCCN Clinical Practice Guidelines in Oncology

Treatment is complex for patients with head and neck (H&N) cancers with specific site of disease, stage, and pathologic findings guiding treatment decision-making. Treatment planning for H&N cancers involves a multidisciplinary team of experts. This article describes supportive care recommendations in the NCCN Guidelines for Head and Neck Cancers, as well as the rationale supporting a new section on imaging recommendations for patients with H&N cancers. This article also describes updates to treatment recommendations for patients with very advanced H&N cancers and salivary gland tumors, specifically systemic therapy recommendations.

Follow up imaging of oral, oropharyngeal and hypopharyngeal cancer patients: Comparison of PET-CT and MRI post treatment

There is currently no consensus as to the ideal timing, frequency and modality of imaging for follow up of head and neck cancer patients. The aim of this study was to analyze the diagnostic accuracy of PET-CT versus MRI, and imaging at 3 versus 6 months for follow up of head and neck cancer patients treated with curative intent with no clinical signs of treatment failure.

MATERIALS AND METHODS

A retrospective study was performed for all head and neck cancers treated with curative intent at the Royal Derby Hospital. Data collected included demographic information, site of primary cancer, staging, treatment provided, type of follow up imaging performed and results of follow up imaging. Inclusion in the study was for oral, oropharyngeal and hypopharyngeal cancers treated with curative intent, asymptomatic patients, those who have had follow up imaging within 6 months of treatment, and those followed up for at least 2.5 years since treatment.

RESULTS

A total of 140 patients were included in the study. 25% of patients had evidence of recurrent/metastatic disease on imaging, 60% of which were identified within 6 months post treatment. The majority (60%) of failures were due to distant metastases. The sensitivity and specificity of both MRI and PET-CT was higher at 6 months post-treatment compared to 3 months post-treatment. Overall the sensitivity and specificity for PET-CT and MRI within 3-6 months post treatment were 94.7% and 83.5% and 60% and 85.7% respectively for identifying treatment failure.

CONCLUSION

Follow up Imaging at 6 months post treatment is more likely to accurately identify treatment failures with fewer false positives than imaging at 3 months. PET-CT is preferable to MRI for identifying post treatment locoregional and distant treatment failure.

Primary vs nodal site PET/CT response as a prognostic marker in oropharyngeal squamous cell carcinoma treated with intensity-modulated radiation therapy

BACKGROUND

Positron emission tomography/computed tomography (PET/CT) in staging of advanced oropharyngeal squamous cell carcinoma (OPSCC) and at 3 months posttreatment (PETpost) is often utilized to assess response. The significance of lymph node vs primary site treatment response is incompletely understood.

METHODS

We reviewed 230 patients treated with radiation therapy. PETpost response was graded at primary and nodal sites and correlated with survival.

RESULTS

Median age was 58, and 83% were p16-positive. Median follow-up was 24.3 months. Nodal response at PETpost predicted improved 2-year local recurrence-free survival (LRFS) (93% vs 72%, P =.004), 2-year disease-free survival (DFS) (80% vs 61.3%, P =.021), and 2-year overall survival (OS) (89% vs 83%, P =.051), while primary response only predicted improved 2-year LRFS (91% vs 76% P = .035).

CONCLUSION

In OPSCC patients, both nodal and primary response at 3 months on PET/CT predicted for improved LRFS, but only nodal response predicted DFS and OS.

Follow-Up of Head and Neck Cancer Survivors: Tipping the Balance of Intensity

The traditional concept of post-treatment surveillance in head and neck cancer patients relies on examinations directed at early detection of disease recurrence and/or second primary tumors. They are usually provided by ear, nose and throat specialists with complementary input from radiation oncologists and medical oncologists. Emerging evidence underscores the importance of monitoring and effective management of late adverse events. One of the major drawbacks is a lack of prospective controlled data. As a result, local institutional policies differ, and practice recommendations are subject to continuing debate. Due to the economic burden and impact on emotional comfort of patients, intensity and content of follow-up visits are a particularly conflicting topic. According to the current evidence-based medicine, follow-up of head and neck cancer patients does not prolong survival but can improve quality of life. Therefore, an approach giving priority to a multidisciplinary care involving a speech and swallowing expert, dietician, dentist, and psychologist may indeed be more relevant. Moreover, on a case-by-case basis, some patients need more frequent consultations supplemented by imaging modalities. Human papillomavirus positive oropharyngeal cancer tends to develop late failures at distant sites, and asymptomatic oligometastatic disease, especially in the lungs, can be successfully salvaged by local ablation, either surgically or by radiation. The deep structures of the skull base related to the nasopharynx are inaccessible to routine clinical examination, advocating periodic imaging supplemented by nasofibroscopy as indicated. Anamnesis of heavy smoking justifies annual low-dose computed tomography screening of the thorax and intensive smoking cessation counseling. Finally, some cancer survivors feel more comfortable with regular imaging, and their voice should be taken into consideration. Future development of surveillance strategies will depend on several variables including identification of reliable predictive factors to select those who could derive the most benefit from follow-up visits, the availability of long-term follow-up data, the results of the first randomized trials, resource allocation patterns, infrastructure density, and the therapeutic landscape of locally advanced and recurrent and/or metastatic disease, which is rapidly changing with the advent of immune checkpoint inhibitors and better utilization of local approaches.

Surveillance imaging for patients with head and neck cancer treated with definitive radiotherapy: A partially observed Markov decision process model

BACKGROUND

A possible surveillance model for patients with head and neck cancer (HNC) who received definitive radiotherapy was created using a partially observed Markov decision process. The goal of this model is to guide surveillance imaging policies after definitive radiotherapy.

METHODS

The partially observed Markov decision process model was formulated to determine the optimal times to scan patients. Transition probabilities were computed using a data set of 1508 patients with HNC who received definitive radiotherapy between the years 2000 and 2010. Kernel density estimation was used to smooth the sample distributions. The reward function was derived using cost estimates from the literature. Additional model parameters were estimated using either data from the literature or clinical expertise.

RESULTS

When considering all forms of relapse, the model showed that the optimal time between scans was longer than the time intervals used in the institutional guidelines. The optimal policy dictates that there should be less time between surveillance scans immediately after treatment compared with years after treatment. Comparable results also held when only locoregional relapses were considered as relapse events in the model. Simulation results for the inclusive relapse cases showed that <15% of patients experienced a relapse over a simulated 36-month surveillance program.

CONCLUSIONS

This model suggests that less frequent surveillance scan policies can maintain adequate information on relapse status for patients with HNC treated with radiotherapy. This model could potentially translate into a more cost-effective surveillance program for this group of patients.

Impact of routine surveillance imaging on detecting recurrence in human papillomavirus associated oropharyngeal cancer

OBJECTIVES

This study examines the utility of surveillance imaging in detecting locoregional failures (LRF), distant failures (DF) and second primary tumors (SPT) in patients with human papillomavirus (HPV) associated oropharyngeal cancer (OPC) after definitive chemoradiotherapy (CRT).

METHODS AND MATERIALS

An institutional database identified 225 patients with biopsy proven, non- metastatic HPV+ OPC treated with definitive CRT between 2004 and 2015, whose initial post-treatment imaging was negative for disease recurrence (DR). Two groups were defined: patients with <2 scans/year Group 1 and patients with ≥2 scans/year Group 2. The Mann-Whitney test or Chi-square was used to determine differences in baseline characteristics between groups. Fine & Gray regression was used to detect an association between imaging frequency, DR and diagnosis of SPT.

RESULTS

Median follow up was 40.8 months. 30% of patients had ≥T3 disease and 90% had ≥ N2 disease (AJCC 7th edition). Twenty one failures (9.3%) were observed, 7 LRF and 15 DF. Six LRF occurred within 24 months and 14 DF occurred within 36 months of treatment completion. Regression analysis showed Group 2 had increased risk of DR compared to Group1 (HR 10.3; p = 0.002) albeit with more advanced disease at baseline. Five SPT were found (2 lung, 2 esophagus, and 1 oropharynx) between 4.5 and 159 months post-CRT.

CONCLUSION

Surveillance imaging seems most useful in the first 2-3 years post treatment, and is particularly important in detecting DF. Surveillance scans for SPT has a low yield, but should be considered for those meeting lung cancer screening guidelines.

Perceived value drives use of routine asymptomatic surveillance PET/CT by physicians who treat head and neck cancer

BACKGROUND

Why physicians use surveillance imaging for asymptomatic cancer survivors despite recommendations against this is not known.

METHODS

Physicians surveilling head and neck cancer survivors were surveyed to determine relationships among attitudes, beliefs, guideline familiarity, and self-reported surveillance positron-emission-tomography/computed-tomography use.

RESULTS

Among 459 responses, 79% reported using PET/CT on some asymptomatic patients; 39% reported using PET/CT on more than half of patients. Among attitudes/beliefs, perceived value of surveillance imaging (O.R. 3.57, C.I. 2.42-5.27, P = <.0001) was the strongest predictor of high imaging, including beliefs about outcome (improved survival) and psychological benefits (reassurance, better communication). Twenty-four percent of physicians were unfamiliar with guideline recommendations against routine surveillance imaging. Among physicians with high perceived-value scores, those less familiar with guidelines imaged more (O.R. 3.55, C.I. 1.08-11.67, P = .037).

CONCLUSIONS

Interventions to decrease routine surveillance PET/CT use for asymptomatic patients must overcome physicians' misperceptions of its value. Education about guidelines may modify the effect of perceived value.

Diagnostic Tumor Markers in Head and Neck Squamous Cell Carcinoma (HNSCC) in the Clinical Setting

Head and neck squamous cell carcinoma (HNSCC) represents a group of tumors arising in the oral cavity, oropharynx, and larynx. Although HNSCC is traditionally associated with tobacco and alcohol consumption, a growing proportion of head and neck tumors, mainly of the oropharynx, are associated with Human Papilloma Virus (HPV). Recurrent/metastatic disease is characterized by dismal prognosis and there is an unmet need for the development of biomarkers for detection of early disease, accurate prediction of prognosis, and appropriate selection of therapy. Based on the REMARK guidelines, a variety of diagnostic and prognostic biomarkers are being evaluated in clinical trials but their clinical significance is doubtful. Herein, we will focus on biomarkers in HNSCC used in the clinical setting and we will illustrate their clinical relevance.

Predictive Value of First Posttreatment Imaging Using Standardized Reporting in Head and Neck Cancer

OBJECTIVE

The Neck Imaging Reporting and Data System (NI-RADS) is a standardized numerical reporting template for surveillance of head and neck squamous cell carcinoma (HNSCC). Our aim was to analyze the accuracy of NI-RADS on the first posttreatment fluorodeoxyglucose positron emission tomography/contrast-enhanced computed tomography (PET/CECT).

STUDY DESIGN

Retrospective cohort study.

SETTING

Academic tertiary hospital.

SUBJECT AND METHODS

Patients with HNSCC with a 12-week posttreatment PET/CECT interpreted using the NI-RADS template and 9 months of clinical and radiologic follow-up starting from treatment completion between June 2014 and July 2016 were included. Treatment failure was defined as positive tumor confirmed by biopsy or Response Evaluation Criteria in Solid Tumors criteria. Cox proportional hazards models were performed.

RESULTS

This study comprised 199 patients followed for a median of 15.5 months after treatment completion (25% quartile, 11.8 months; 75% quartile, 20.2 months). The rates of treatment failure increased with each incremental increase in NI-RADS category from 1 to 3 (4.3%, 9.1%, and 42.1%, respectively). A Cox proportional hazards model demonstrated a strong association between NI-RADS categories and treatment failure at both primary and neck sites (hazard ratio [HR], 2.60 and 5.22, respectively; P < .001). In the smaller treatment subgroup analysis, increasing NI-RADS category at the primary site in surgically treated patients and treatment failure did not achieve statistically significant association (HR, 0.88; P = .82).

CONCLUSION

Increasing NI-RADS category at the baseline posttreatment PET/CECT is strongly associated with increased risk of treatment failure in patients with HNSCC.

Timing and Impact of Posttreatment PET/CT After First 6 Months on Patient Management and Outcomes in Oropharyngeal Squamous Cell Carcinoma

OBJECTIVE. The objective of this study was to investigate the impact of PET/CT on patient management and outcomes of oropharyngeal squamous cell carcinoma (OPSCC) after the first 6 months following treatment. MATERIALS AND METHODS. We retrospectively identified patients with OPSCC who underwent chemoradiation therapy and had at least 2 years of posttreatment follow-up. Patients were grouped on the basis of whether they underwent PET/CT, as a result of clinical suspicion of recurrence or routine follow-up, in the last 18 months of the 2-year posttreatment period (experimental group) or not (control group). Association between PET/CT use and change in management was tested using chi-square analysis. Survival analyses were performed with Cox and Kaplan-Meier analyses. RESULTS. In total, 149 patients underwent 294 PET/CT studies in the 2-year follow-up period. Eighty-three patients (55.7%) underwent PET/CT in the last 18 months of the 2 years. This group underwent 223 PET/CT studies, 22 (9.9%) of which were positive. Sixteen of the 22 (72.7%) changed management. Sixty-six patients (44.3%) did not undergo PET/CT in the last 18 months. This group underwent 71 PET/CT studies, six (8.5%) of which were positive. Two of the six studies (33.3%) changed management. Of first-time positive PET/CT studies in the last 18 months, five of nine (55.6%) were performed 6-12 months after treatment. PET/CT in the last 18 months was positively associated with change in management (odds ratio, 4.88; p = 0.02). Patients with positive PET/CT findings had worse overall survival (hazard ratio [HR], 31.6; p < 0.0001) and progression-free survival (HR, 40.8; p < 0.0001). CONCLUSION. PET/CT in the last 18 months of the 2-year posttreatment period impacted patient management. Most first-time positive PET/CT studies in the last 18 months of the 2 years were performed 6-12 months after treatment.

Clinical Utility of Pretreatment and 3-Month 18F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography Standardized Uptake Value in Predicting and Assessing Recurrence in T3-T4 Laryngeal Carcinoma Treated With Definitive Radiation

OBJECTIVES

The aim of this study was to investigate the utility of pretreatment and 3-month ¹⁸F-fluorodeoxyglucose positron emission tomography (PET)/computed tomography (CT) standardized uptake value (SUV) in predicting and assessing recurrence in T3-T4 laryngeal carcinoma treated with definitive radiation therapy (RT).

METHODS

Patients with newly diagnosed T3-T4 laryngeal squamous cell carcinoma treated with definitive RT from 2004 to 2014 were reviewed. Patients who underwent pretreatment or 3-month PET/CT 2 to 4 months after treatment were included. Those with prior systemic, surgical, or RT treatment were excluded. The primary objective was to assess whether pretreatment or posttreatment maximum SUV of the primary site (pSUV) of disease was associated with local recurrence-free survival. Overall survival was a secondary end point. Sensitivity, specificity, positive predictive value, and negative predictive value were calculated to assess the accuracy of 3-month PET/CT at the larynx primary.

RESULTS

Twenty-eight patients were eligible for analysis. Median follow-up time was 34.7 months (range, 5.3-138.7 months), and median age was 57 years. Most patients had supraglottic (71.4%), T3 (89.3%), N2 (50.0%) disease, received chemotherapy (96.4%), and had histories of tobacco use (96.4%). On univariate analysis, 3-month posttreatment pSUV was associated with local recurrence-free survival ( P < .01), while pretreatment pSUV was not ( P = .41). No other associations were found with local recurrence-free survival. Neither pretreatment nor 3-month pSUV was significantly associated with overall survival. The calculated sensitivity, specificity, positive predictive value, and negative predictive value of 3-month PET/CT at the primary site were 33%, 85%, 40%, and 81%, respectively.

CONCLUSIONS

High initial fluorodeoxyglucose uptake in T3-T4 laryngeal primaries did not show an association with the risk for postradiation local relapse or overall survival, while increased fluorodeoxyglucose uptake at 3 months was associated with increased local recurrence. At 3 months, the relatively low sensitivity and positive predictive value may limit the utility of PET/CT in the assessment of persistent advanced laryngeal cancer after definitive radiation.

De-escalation of post-treatment surveillance in oropharyngeal cancer

BACKGROUND

The majority of new oropharyngeal squamous cell carcinoma (OPSCC) cases are associated with human papillomavirus and favorable prognosis. Post-treatment follow-up should be targeted to patients at greatest risk for disease recurrence.

METHODS

To assess the benefits of routine clinical surveillance in OPSCC, we reviewed all follow-up visits conducted in 2014 at Helsinki University Hospital Department of Otorhinolaryngology.

RESULTS

Of 366 visits, 26 (7%) were from patients presenting with a new symptom, and disease recurrence was detected in four. The presence of a new symptom was significantly associated with disease recurrence (P < 0.001). Of 366 visits, 340 (93%) were from patients presenting without new symptoms, and not a single recurrence was found during these visits.

CONCLUSIONS

Based on our findings, and previous studies assessing the prognosis and pattern of recurrent OPSCC, we concluded that the number of routine post-treatment visits can be reduced. Follow-up should rather focus on symptom-directed examinations.