Earlier and more specific detection of persistent neck disease with diffusion‐weighted MRI versus subsequent PET/CT after definitive chemoradiation for oropharyngeal squamous cell carcinoma

Diffusion-Weighted MRI for Recurrent/Persistent Head and Neck Squamous-Cell Carcinoma After Radiotherapy: Systematic Review and Meta-Analysis

OBJECTIVE

To evaluate the accuracy of diffusion-weighted magnetic resonance imaging (DWI-MRI) in diagnosing persistent/recurrent head and neck squamous cell carcinomas (HNSCCs) after primary chemoradiotherapy (CRT).

DATA SOURCES

Scopus, PubMed/MEDLINE, and Cochrane Library databases were searched for relevant publications until April 18, 2023.

REVIEW METHODS

A systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses of Diagnostic Test Accuracy statement. The search was conducted independently by 2 investigators. Methodological quality of included studies was assessed using the Quality Assessment of Diagnostic Studies-2 questionnaire. Extracted data were used to calculate the pooled DWI-MRI sensitivity, specificity, diagnostic odds ratio, and positive and negative likelihood ratio.

RESULTS

A total of 618 patients from 10 studies were included for calculation of diagnostic accuracy parameters. At the level of the primary tumor, the pooled sensitivity and specificity were, respectively, 0.96 (95% confidence interval [CI]: 0.89-1.00) and 0.81 (95% CI: 0.54-0.98) in the case of qualitative analysis, and, respectively, 0.79 (95% CI: 0.66-0.89) and 0.88 (95% CI: 0.77-0.96) for quantitative analysis. At the level of the neck, the pooled sensitivity and specificity were, respectively, 0.87 (95% CI: 0.75-0.95) and 0.84 (95% CI: 0.74-0.93) when images were analyzed qualitatively, and 0.79 (95% CI: 0.60-0.94) and 0.90 (95% CI: 0.82-0.97) when analyzed quantitatively.

CONCLUSION

DWI-MRI showed high diagnostic accuracy and should be considered if persistent/recurrent HNSCCs is suspected after primary CRT. No significant differences were found between qualitative and quantitative imaging assessment.

Circulating HPV Tumor DNA and Molecular Residual Disease in HPV-Positive Oropharyngeal Cancers: A Scoping Review

The aim of this review is to assess the utility of circulating HPV tumor DNA (ctHPVDNA) clearance in the monitoring of molecular residual disease in HPV-related oropharyngeal squamous cell carcinoma (OPSCC) patients. Recently, ctHPVDNA in patient plasma was found to be a promising biomarker for HPV OPSCC. Changes in this biomarker appear to be associated with treatment response and may be useful for identifying molecular residual disease. A review of the literature was performed using PubMed/MEDLINE, EMBASE, and Cochrane Library databases according to the PRISMA criteria for scoping reviews (from 2017 to July 2024). A total of 5 articles and 562 patients have been included. Three studies examine the role of ctHPVDNA clearance in CRT, while the remaining two studies consider surgery as a treatment option. The results of this scoping review indicate that ctHPVDNA has a potential role to serve as a valuable biomarker in the assessment of molecular residual disease. Further studies are required to confirm the efficacy of this marker for stratifying this group of patients.

Diagnostic value of 18F-FDG PET/CT versus diffusion-weighted MRI in detection of residual or recurrent tumors after definitive (chemo) radiotherapy for laryngeal and hypopharyngeal squamous cell carcinoma: A prospective study

BACKGROUND

Despite advances in treatment, residual or recurrent tumors after definitive (chemo) radiotherapy for laryngeal and hypopharyngeal squamous cell carcinoma (SCC) remain a challenge in clinical management and require accurate and timely detection for optimal salvage therapy. This study aimed to compare the diagnostic value of Fluorine 18 (18F) fluorodeoxyglucose (FDG) positron emission tomography (PET)/computed tomography (CT) and diffusion-weighted magnetic resonance imaging (DW-MRI) in detecting residual or recurrent tumors after definitive (chemo) radiotherapy for laryngeal and hypopharyngeal SCC.

METHODS

A prospective study was conducted on 30 patients who presented with new symptoms after definitive (chemo) radiotherapy for laryngeal (n = 21) and hypopharyngeal (n = 9) carcinoma. Both 18F-FDG PET/CT and DW-MRI were performed and histopathologic analysis served as the standard of reference.

RESULTS

Histopathology showed 20 patients as positive and 10 as negative for tumors. 18F-FDG PET/CT detected all tumors correctly but was falsely positive in one case. DW-MRI detected tumors in 18 out of 20 positive patients and correctly excluded tumors in all negative patients. The sensitivity and specificity of 18F-FDG PET/CT were 100% and 90%, respectively, while the values for DW-MRI were 90% and 100%, respectively.

CONCLUSIONS

The study concludes that 18F-FDG PET/CT is slightly superior to DW-MRI in detecting residual or recurrent tumors after definitive (chemo) radiotherapy for laryngeal and hypopharyngeal SCC. The combined use of 18F-FDG PET/CT and DW-MRI can potentially improve specificity in therapy response evaluation.

Circulating tumor HPV DNA in the management of HPV+ oropharyngeal cancer and its correlation with MRI

BACKGROUND

First aim was to compare ddPCR assays of ctHPVDNA with p16 IHC and qualitative HPV PCR. Second aim was to carry out longitudinal blood sampling to test for association of ctHPVDNA with histological confirmed recurrence. Third aim was to perform a multidimensional assessment which included: (1) clinical features; (2) ctHPVDNA; (3) MRI-based tumor size measurements of primary tumor (PT) and cervical lymph node metastases (CLNM).

METHODS

Plasma samples were collected before treatment and during follow-up, and ddPCR assay comprising E6 of HPV16 and HPV 33 and HPV 35 was used.

RESULTS

Present study was conducted at diagnosis in 117 patients and revealed a ctHPVDNA sensitivity of 100% (95% CI 95.5-100) and a specificity of 94.4 (95% CI 81.3-99.3), positive predictive value (PPV) of 94.4 (95% CI 81.3-99.3), and negative predictive value (NPP) of 100% (95% CI 89.7-100). During follow-up ctHPVDNA had a sensitivity of 100% (95% CI 72.1-100)% and specificity of 98.4% (95% CI 91.7-100)%, PPV% of 90.9% (95% CI 62.3-98.4) and NPV% of 100% (95% CI 94.3-100) for ability to detect recurrence. Correlation between both the CLNM volume and the sum of PT and CLNM volume was observed.

CONCLUSIONS

ctHPVDNA was superior to p16 in identification of HPV-OPSCC at diagnosis. Introduction of ctHPVDNA, beyond diagnostic setting, represents a great opportunity to improve follow-up protocol of OPSCC patients.

The landscape of circulating tumor HPV DNA and TTMV-HPVDNA for surveillance of HPV-oropharyngeal carcinoma: systematic review and meta-analysis

BACKGROUND

Human papilloma virus (HPV) related cancers of the oropharynx are rapidly increasing in incidence and may soon represent the majority of all head and neck cancers. Improved monitoring and surveillance methods are thus an urgent need in public health.

MAIN TEXT

The goal is to highlight the current potential and limitations of liquid biopsy through a meta analytic study on ctHPVDNA and TTMV-HPVDNA. It was performed a Literature search on articles published until December 2023 using three different databases: MEDLINE, Embase, and Cochrane Library. Studies that evaluated post-treatment ctHPVDNA and TTMV-HPVDNA in patients with HPV + OPSCC, studies reporting complete data on the diagnostic accuracy in recurrence, or in which the number of true positives, false positives, true negatives, and false negatives was extractable, and methods of detection of viral DNA clearly defined. The meta-analysis was conducted following the Meta-analysis Of Observational Studies in Epidemiology (MOOSE) reporting guidelines. The aim of this meta-analysis was to evaluate the sensitivity, specificity, and accuracy of ctHPVDNA and TTMV by ddPCR to define its efficacy in clinical setting for the follow up of HPV-OPSCC.

CONCLUSION

The 12 studies included in the meta-analysis provided a total of 1311 patients for the analysis (398 valuated with ctHPVDNA and 913 with TTMV-HPVDNA). Pooled sensitivity and specificity were 86% (95% CI: 78%-91%) and 96% (95% CI: 91%-99%), respectively; negative and positive likelihood ratios were 0.072 (95% CI: 0.057-0.093) and 24.7 (95% CI: 6.5-93.2), respectively; pooled DOR was 371.66 (95% CI: 179.1-918). The area under the curve (AUC) was 0.81 (95% CI, 0.67-0.91). Liquid biopsy for the identification of cell free DNA might identify earlier recurrence in HPV + OPSCC patients. At the present time, liquid biopsy protocol needs to be standardized and liquid biopsy cannot yet be used in clinical setting. In the future, a multidimensional integrated approach which links multiple clinical, radiological, and laboratory data will contribute to obtain the best follow-up strategies for the follow-up of HPV-OPSCC.

Systematic review and meta-analysis of the diagnostic effectiveness of positron emission tomography-computed tomography versus magnetic resonance imaging in the post-treatment surveillance of head and neck squamous cell carcinoma

OBJECTIVE

There is currently no consensus on the ideal protocol of imaging for post-treatment surveillance of head and neck squamous cell carcinoma. This study aimed to consolidate existing evidence on the diagnostic effectiveness of positron emission tomography-computed tomography versus magnetic resonance imaging.

METHOD

Systematic electronic searches were conducted using Medline, Embase and Cochrane Library (updated February 2021) to identify studies directly comparing positron emission tomography-computed tomography and magnetic resonance imaging scans for detecting locoregional recurrence or residual disease for post-treatment surveillance.

RESULTS

Searches identified 3164 unique records, with three studies included for meta-analysis, comprising 176 patients. The weighted pooled estimates of sensitivity and specificity for scans performed three to six months post-curative treatment were: positron emission tomography-computed tomography, 0.68 (95 per cent confidence interval, 0.49-0.84) and 0.89 (95 per cent confidence interval, 0.84-0.93); magnetic resonance imaging, 0.72 (95 per cent confidence interval, 0.54-0.88) and 0.85 (95 per cent confidence interval, 0.79-0.89), respectively.

CONCLUSION

Existing studies do not provide evidence for superiority of either positron emission tomography-computed tomography or magnetic resonance imaging in detecting locoregional recurrence or residual disease following curative treatment of head and neck squamous cell carcinoma.

Magnetic Resonance-Guided Radiation Therapy for Head and Neck Cancers

Despite the significant evolution of radiation therapy (RT) techniques in recent years, many patients with head and neck cancer still experience significant toxicities during and after treatments. The increased soft tissue contrast and functional sequences of magnetic resonance imaging (MRI) are particularly attractive in head and neck cancer and have led to the increasing development of magnetic resonance-guided RT (MRgRT). This approach refers to the inclusion of the additional information acquired from a diagnostic or planning MRI in radiation treatment planning, and now extends to online high-quality daily imaging generated by the recently developed MR-Linac. MRgRT holds numerous potentials, including enhanced baseline and planning evaluations, anatomical and functional treatment adaptation, potential for hypofractionation, and multiparametric assessment of response. This article offers a structured review of the current literature on these established and upcoming roles of MRI for patients with head and neck cancer undergoing RT.

Improving post-CRT neck assessment in patients with HPV-associated OPSCC (Review)

The positive predictive value (PPV) of 12-week post-therapy FDG-PET/CT is low in patients with Human Papillomavirus (HPV)-associated Oropharyngeal Squamous Cell Carcinoma (OPSCC) after treatment with definitive chemoradiation (CRT). Moreover, the diagnostic performance of post-CRT fine needle aspiration (FNA) in detecting persistent disease is unknown in this population. Given these important shortcomings in post-CRT treatment assessment, head and neck oncologists are limited in appropriately selecting patients for consolidative neck dissection, which results in over-treatment of a favorable risk population. Using the PubMed database, we performed a literature review of published series in HPV-associated OPSCC to investigate potential strategies for improvement of post-CRT neck assessment. Several different approaches were found, including continued surveillance with PET/CT, delayed timing of restaging PET/CT, initial response evaluation with multimodality or alternative imaging, and detection of circulating HPV DNA. At present, the optimal approach to post-CRT treatment assessment is unclear; further investigation and incorporation of new technologies and surveillance protocols will be highly beneficial for patients with HPV-associated OPSCC.

Comparison of diffusion-weighted MR imaging and 18F Fluorodeoxyglucose PET/CT in detection of residual or recurrent tumors and delineation of their local spread after (chemo) radiotherapy for head and neck squamous cell carcinoma

PURPOSE

To compare the diagnostic accuracy of diffusion-weighted magnetic resonance imaging (DW-MRI) and fluorine 18 fluorodeoxyglucose positron emission tomography/computed tomography (¹⁸F-FDG PET/CT) in detection of residual or recurrent tumors and their local extension in patients with head and neck squamous cell carcinoma after treatment with (chemo) radiotherapy (CRT).

METHOD

Twenty-five patients (17 men, 8 women, median age 64 years, range 49-79) who underwent surgical salvage for residual or recurrent tumors after CRT were included. The histopathologic analysis after the surgical salvage served as the gold standard.

RESULTS

Both DW-MRI and ¹⁸F-FDG PET/CT had a sensitivity of 92 % (23/25) in the detection of residual or recurrent tumors. MRI had a sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for detecting perineural spread of 62 % (5/8), 88 % (15/17), 71 % (5/7) and 83 % (15/18), respectively; in comparison, PET/CT did not detect any cases of perineural spread. The sensitivity, specificity, PPV and NPV of MRI in detecting muscle infiltration was 75 % (9/12), 77 % (10/13), 75 % (9/12) and 77 % (10/13) respectively, while the values for ¹⁸F-FDG PET/CT were 58 % (7/12), 69 % (9/13), 64 % (7/11) and 64 % (9/14).

CONCLUSIONS

DW-MRI- and ¹⁸F-FDG PET/CT-imaging have an identical detection rate of residual or recurrent tumors after (chemo) radiotherapy. MRI has a higher sensitivity in detecting local perineural spread, has a better accuracy in the detection of muscle infiltration and more accurately correlates the lesion size to the histopathologic specimen.

Safety and Efficacy of MRI Scans in Patients With Implanted Microvascular Coupling Devices

OBJECTIVE

To demonstrate the safety and compatibility of microvascular couplers in patients undergoing postoperative magnetic resonance imaging (MRI) scans.

STUDY DESIGN

Retrospective case series.

METHODS

A consecutive review of 1,252 patients undergoing free tissue transfer for head and neck reconstruction at Oregon Health and Sciences University (OHSU) between 2010 and 2017 who had microvascular coupler Synovis, Baxter Deerfield, IL (Synovis Life Technologies, Saint Paul, MN) implantation were reviewed. One hundred fifteen patients had a subsequent MRI scan, which consisted of a variety of Phillips (Amsterdam, Netherlands) MRI machines ranging from 1.0 to 3.0 Tesla (T) in magnetic strength.

RESULTS

These 115 patients underwent 121 free flaps with 131 couplers (including 32 flow couplers) utilized for venous anastomoses. Couplers ranged in size from 1.5 to 4.0 mm (3.0 mm [42%] followed by 3.5 mm [21%], 2.5 mm [19%], 2.0 mm [10%], 4.0 mm [6%], and 1.5 mm [2%]. Three hundred fifty-nine MRI scans (2 days to 91 months postoperatively) were obtained with 233 MRIs for cancer surveillance, and the remaining were obtained for neurologic disease, injury, or evaluation for metastases. No complications occurred related to the MRI and the metallic components of the coupler or other metal implants, such as reconstruction bars, vascular clips, or metallic surgical mesh. Additionally, no radiology report commented on MRI distortion due to the coupler placement, which contrasts the distortion seen with the other metallic implants.

CONCLUSION

Microvascular couplers and their constitutive stainless-steel pins have not been found to cause any complications in a large series of consecutive patients undergoing multiple MRIs with magnetic strength up to 3 T. The U.S. Food and Drug Administration advocates medical alert notification for patients with couplers; however, hesitation regarding potential MRI scanning for surveillance or otherwise is unwarranted.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:1428-1430, 2020.

Use of Diffusion-Weighted Imaging and 18F-Fluorodeoxyglucose Positron Emission Tomography Combined With Computed Tomography in the Response Assessment for (Chemo)radiotherapy in Head and Neck Squamous Cell Carcinoma

AIMS

Our purpose was to assess the diagnostic accuracy and prognostic value of diffusion-weighted imaging (DWI) and ¹⁸F-fluorodeoxyglucose positron emission tomography combined with computed tomography (¹⁸F-FDG-PET/CT) carried out 3-6 months after (chemo)radiotherapy in head and neck squamous cell carcinoma.

MATERIALS AND METHODS

For this retrospective cohort study we included 82 patients with advanced-stage head and neck squamous cell carcinoma treated between 2012 and 2015. Primary tumours and lymph nodes were assessed separately. DWI was analysed qualitatively and quantitatively. ¹⁸F-FDG-PET/CT was evaluated using the Hopkins criteria. Dichotomous qualitative analysis was carried out for both modalities. Cox regression analysis was used for univariate analysis of recurrence-free survival (RFS). Significant univariate parameters were included in multivariate analysis.

RESULTS

In 12 patients, locoregional recurrence occurred. With all imaging strategies, either single-modality or multi-modality, a high negative predictive value (NPV) was achieved (94.3-100%). In response evaluation of the primary site, the preferred strategy is ¹⁸F-FDG-PET/CT only, which resulted in a sensitivity of 85.7%, specificity of 86.5%, positive predictive value (PPV) of 37.5% and NPV of 98.5%. For response evaluation of the neck, the best results were obtained with a sequential approach only including the second modality in positive reads of the first modality. It did not matter which modality was assessed first. This strategy for lymph node assessment resulted in a sensitivity, specificity, PPV and NPV of 83.3%, 95.6%, 62.5%, and 98.5%, respectively. After correction for received treatment and human papillomavirus status, primary tumour (P = 0.009) or lymph node (P < 0.001) Hopkins score ≥4 on ¹⁸F-FDG-PET/CT remained significant predictors of RFS.

CONCLUSION

For response evaluation of the primary tumour ¹⁸F-FDG-PET/CT only is the preferred strategy, whereas for the neck a sequential approach including both DWI and ¹⁸F-FDG-PET/CT resulted in the best diagnostic accuracy for follow-up after (chemo)radiotherapy. Qualitative analysis of ¹⁸F-FDG-PET/CT is a stronger predictor of RFS than DWI analysis.