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

• Published in: International journal of cancer Vol. 133; no. 5; pp. 1214 - 1221
• Main Authors: Goenka, Anuj, Morris, Luc G.T., Rao, Shyam S., Wolden, Suzanne L., Wong, Richard J., Kraus, Dennis H., Ohri, Nisha, Setton, Jeremy, Lok, Benjamin H., Riaz, Nadeem, Mychalczak, Borys R., Schoder, Heiko, Ganly, Ian, Shah, Jatin P., Pfister, David G., Zelefsky, Michael J., Lee, Nancy Y.
• Format: Journal Article
• Language: English
• Published: Hoboken, NJ Wiley-Blackwell 01.09.2013; Wiley Subscription Services, Inc
• Subjects: Adult; Aged; Biological and medical sciences; Cancer; Cancer therapies; Carcinoma, Squamous Cell - diagnostic imaging; Carcinoma, Squamous Cell - pathology; Carcinoma, Squamous Cell - therapy; Chemoradiotherapy; Chemotherapy; Dissection; Female; Head & neck cancer; Humans; Lymphatic Metastasis; Male; Medical imaging; Medical research; Medical sciences; Middle Aged; Multimodal Imaging; Multiple tumors. Solid tumors. Tumors in childhood (general aspects); Neck; neck dissection; observation; Oropharyngeal Neoplasms - diagnostic imaging; Oropharyngeal Neoplasms - pathology; Oropharyngeal Neoplasms - therapy; oropharyngeal squamous cell carcinoma; Otorhinolaryngology. Stomatology; Papillomaviridae - isolation & purification; PET; Positron-Emission Tomography; Tomography, X-Ray Computed; Tumors; Upper respiratory tract, upper alimentary tract, paranasal sinuses, salivary glands: diseases, semeiology; Radionuclide study; Squamous cell carcinoma; observation; Oropharynx cancer; Malignant tumor; Regional; Radiotherapy; Long term; Oropharynx squamous cell carcinoma; Chemotherapy; Treatment; Cancerology; Surgery; oropharyngeal squamous cell carcinoma; ENT disease; Pharynx disease; Combined treatment; neck dissection; Neck; Dissection; Positron emission tomography; PET; Cancer; Emission tomography
• ISSN: 0020-7136; 1097-0215
• DOI: 10.1002/ijc.28120

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. What's new? Traditionally, most patients with head and neck cancer and nodal metastases who are treated with chemoradiotherapy undergo a neck dissection after treatment in order to remove residual metastatic disease in the neck. However, not all of these patients' necks actually harbor residual disease. In fact, emerging data now reveals that patients who experience a complete response after chemoradiation therapy have a very low rate of residual disease identified in the neck. Furthermore, a PET/CT scan obtained after treatment is a highly accurate predictor of whether there will be any residual disease in neck lymph nodes. These findings have led many to hypothesize that patients achieving a complete response might not require post‐treatment neck dissections. The current study now presents the first comprehensive analysis of a large, uniform cohort of node‐positive head and neck cancer patients undergoing observation of the neck rather than neck dissection, provided that PET/CT indicates that a complete response after chemoradiation has been achieved. The rate of recurrence in these observed patients was very low, indicating that head and neck cancer patients experiencing a PET/CT‐confirmed complete response after chemoradiation therapy can be safely observed, rather than undergoing neck dissection.