Positron emission tomography-CT surveillance versus neck dissection in advanced head and neck cancer: time for a paradigm shift in management

Abstract

Prior to the introduction of the positron emission tomography-CT (PET-CT), the role of planned neck dissection before or following definitive chemoradiation (CRT) was controversial. Most patients who presented with N3 disease would undergo routine post-CRT neck dissection, and practitioners struggled to determine whether the post-treatment neck with N2a/N2b disease was completely treated (1). This is particularly true when post-treatment neck dissection specimens contained disease, but the viability of the disease remained in question (2). Improvements in both structural and functional imaging have gradually allowed head and neck oncologists to consider radiographic resolution of disease as sufficient for surveillance. Over the past decade there has been an ongoing shift to relying on PET-CT/MRI as an indicator of response to treatment, particularly at academic centers in the United States. PET-CT/PET-MRI provides precise anatomical correlation to the FDG-glucose avidity and is especially useful since the physical exam has limitations after CRT secondary to lymphedema and fibrosis. Until now, however, there has been no level I evidence on the efficacy of PET-CT for post-treatment surveillance when compared to planned neck dissection.