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

Abstract

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

The role of initial neck dissection for patients with node-positive oropharyngeal squamous cell carcinomas

“…analyzed the long-term regional control rate for patients with node-positive OPSCC treated by definitive CRT [11]. They reported that the regional control rate of patients without any sign of residual nodal disease on PET/CT scans or other modalities was 97.7%.…”

Assessment of outcomes with delayed18F-FDG PET-CT response assessment in head and neck squamous cell carcinoma

“…6,7 The desire to avoid the morbidity of multimodality treatment has driven a shift in practice towards the use of neck dissection only for patients failing to achieve a clinical and/or radiological complete lymph node response post treatment. 3,5,[8][9][10] Within this approach, accurate radiological assessment of the nodal response is required to avoid unnecessary neck dissection.…”

Risk Stratification of Metastatic Neck Nodes by CT and PET in Patients with Head and Neck Cancer Receiving Definitive Radiotherapy

“…Therefore, the evaluation of nodal response became crucial to the adequate performance of salvage neck dissection. Although posttreatment CT or PET had a high accuracy in determining the regional control (4)(5)(6)(7)15), early recognition of patients at risk for nodal failure after curative nonsurgical treatment can optimize the individual treatment schemes by reducing the number of patients undergoing unsuitable treatment.…”

“…A planned adjunctive neck dissection has been suggested in patients with N2 or N3 disease, which was based on some studies that demonstrated that radiotherapy combined with surgery might improve neck control rates, compared with 1 modality alone (1)(2)(3). However, several studies advocated surveillance of neck diseases because a complete remission can be achieved when assessing the response using 18 F-FDG PET (4)(5)(6)(7). In patients with regional recurrence after chemoradiotherapy/radiotherapy, salvage neck dissection would be possible but was associated with additional morbidity and worse prognosis (8,9).…”