Planned Neck Dissection Research Articles

Clinical Practice in PET/CT for the Management of Head and Neck Squamous Cell Cancer.

The purpose of this article is to summarize the evidence for the value of PET/CT for the management of patients with head and neck squamous cell cancer and suggest best clinical practices. FDG PET/CT is a valuable imaging tool for identifying unknown primary tumors in patients with known cervical node metastases leading to management change and is the standard of care for the initial staging of stage III and IV head and neck squamous cell carcinomas (HNSCCs), for assessing therapy response when performed at least 12 weeks after chemoradiation therapy, and for avoiding unnecessary planned neck dissection. Neck dissection is avoided if PET/CT findings are negative-regardless of the size of the residual neck nodes-because survival outcomes are not compromised. FDG PET/CT is valuable in detecting recurrences and metastases during follow-up when suspected because of clinical symptoms and serves as a prognostic marker for patient survival outcomes, for 5 years. Using FDG PET/CT for routine surveillance of HNSCC after 6 months of treatment without any clinical suspicion should be discouraged.

The role of PET for predicting nodal response in locally advanced (LA) head and neck squamous cell carcinoma (HNSCC) treated with chemoradiotherapy (CRT): Results of a prospective multicenter trial.

6013 Background: Controversy about neck management after CRT in patients with LA HNSCC persists due to low accuracy of CT/MR to asses the neck. As already demonstrated (Mehanna, NEJM 374, 2016), PET is an alternative to planned neck dissection (ND) thanks to its high negative predictive value (NPV). However, no conclusion could be drawn for patients (pts) with equivocal response (e.g. suspicion of residual disease on CT/MR but negative PET) because pathologic confirmation was lacking. Methods: Multicenter, prospective, nonrandomized trial including pts with LA HNSCC of oral cavity, oro- hypopharynx, larynx, staged N1, N2, N3, treated with CRT and evaluated 12 weeks after CRT by overall assessment (OA): clinical examination (CE), PET and CT/MR. ND was performed in incomplete regional response based on at least 1 positive evaluation method. Pathologic analyses (HE and KI67) were performed on ND samples. Primary objective was to determine the NPV and accuracy of PET as a single examination in the post CRT nodal assessment. Primary outcome was 2-year regional recurrence free survival rate (RRFSR). Results: 264/318 pts included completed full treatment and had post CRT OA. Median follow up was 40 months. No ND was proposed in 119 patients because of a negative OA; 145 patients had ND. The presence of viable cells was reported in 27 ND (18.6%). Sensitivity, specificity, PPV, NPV, accuracy of OA were 90.0%, 49.6%, 18.6%, 97.5%, 54.2% vs 69.7%, 75.3.%, 28.8%, 94.6%, 74.6% for PET alone. Kappa coefficient was of 0.838, indicating an almost perfect agreement. In pts with negative OA, RRFSR was 61.3% vs. 56.6% in pts with positive OA and ND (p=0.45). Using post CRT assessment with PET alone, RRFSR in pts with negative PET was 63.0% vs. 48.8% in pts with positive PET (p=0.04). Using PET assessment alone, 65/145 ND (44.8%) could have been avoided without compromising RRFSR. Conclusions: NPV using PET alone is 94.6%. Post CRT evaluation using only PET would have resulted in considerably fewer ND without jeopardizing neck control. PET alone is more accurate and more discriminant for predicting pts outcome. Clinical trial information: NCT00634777.

Radiotherapy alone or combined with chemotherapy for base of tongue squamous cell carcinoma

To evaluate the long-term disease control, survival, and complications after definitive radiotherapy (RT) alone or combined with adjuvant chemotherapy with or without planned neck dissection for base of tongue squamous cell carcinoma (SCC). We retrospectively reviewed the medical records of 467 patients treated at the University of Florida with definitive RT alone or combined with adjuvant chemotherapy between 1964 and 2011 for base of tongue SCC. Median follow-up was 5.6 years. Median total dose to the primary site was 74.4 Gy. Eighty-seven patients (19%) were treated with once-daily fractionation, and 380 (81%) received altered fractionation schedules. Intensity-modulated RT was used in 128 patients (27%). Chemotherapy was administered to 173 (37%) patients. Planned neck dissection after RT was performed in 226 patients (48%). Data regarding p16 pathway activation were available for 25 patients. At 5 years, the local, local-regional, and regional control rates were 85.5%, 80.0%, and 90.0%, respectively. The 5-year overall, cause-specific, and distant metastasis-free survival rates were 59.1%, 71.5%, and 84.1%, respectively. Sixty-four patients (14%) developed one or more severe late complications. Fifty patients (11%) required late gastrostomy tube placement. This study supports the continued use of RT alone or combined with adjuvant chemotherapy for patients with base of tongue SCC, as this treatment yields high rates of cause-specific survival and disease control, with a relatively low rate of late complications. 4. Laryngoscope, 127:1589-1594, 2017.

Sentinel lymph node biopsy for early oral cancers: Westmead Hospital experience.

Sentinel lymph node biopsy (SLNB) has become an alternative option to elective neck dissection (END) for early oral cavity squamous cell carcinoma (OCSCC) outside of Australia. We sought to assess the technical feasibility of SLNB and validate its accuracy against that of END in an Australian setting. We performed a prospective cohort study consisting of 30 consecutive patients with cT1-2 N0 OCSCC referred to the Head and Neck Cancer Service, Westmead Hospital, Sydney, between 2011 and 2014. All patients underwent SLNB followed by immediate selective neck dissection (levels I-III). A total of 30 patients were diagnosed with an early clinically node-negative OCSCC (seven cT1 and 23 cT2), with the majority located on the oral tongue. A median of three (range: 1-14) sentinel nodes were identified on lymphoscintigraphy, and all sentinel nodes were successfully retrieved, with 50% having a pathologically positive sentinel node. No false-negative sentinel nodes were identified using selective neck dissection as the gold standard. The negative predictive value (NPV) of SLNB was 100%, with 40% having a sentinel node identified outside the field of planned neck dissection on lymphoscintigraphy. Of these, one patient had a positive sentinel node outside of the ipsilateral supraomohyoid neck dissection template. SLNB for early OCSCC is technically feasible in an Australian setting. It has a high NPV and can potentially identify at-risk lymphatic basins outside the traditional selective neck dissection levels even in well-lateralized lesions.

Radiation Therapy Variation in the Randomized Phase 3 Positron Emission Tomography Neck Study

Five hundred sixty-four patients with squamous cell carcinoma of the head and neck receiving definitive chemoradiation in the PET Neck phase 3 trial were randomized to either planned neck dissection or PETCT scan guided surveillance. The primary endpoint for this study has been previously reported. As the trial spanned the period of IMRT introduction in the United Kingdom, a pragmatic approach to radiotherapy fractionation and technique was adopted and thus three-dimensional conformal radiotherapy (3D-CRT) or intensity modulated radiotherapy (IMRT) were permitted as were 4, 6, or 7 week radiotherapy schedules.

952PD - PET-CT surveillance for advanced head and neck cancer: a cost-effective alternative to planned neck dissection?

Background: Despite controversy, planned neck dissection (ND) remains standard treatment for patients with locally advanced head and neck squamous cell carcinoma after radical chemo-radiotherapy. FDG-PET-CT scanning has demonstrated high negative predictive values for persistent disease, and could thereby enable low risk patients to be spared from unnecessary surgery. Evidence of the cost-effectiveness of PET-CT surveillance strategies is limited however, and no evaluations have yet been conducted from a UK perspective. Methods: An economic evaluation was conducted to assess the lifetime cost-effectiveness of PET-CT surveillance versus planned ND from a UK secondary care perspective. Cost and health outcomes associated with the initial 6-month treatment period (CRT +/- ND) were derived from individual data on 564 patients from a recent UK multicentre randomised controlled trial (PET-Neck). Subsequent outcomes were derived using a constructed Markov model to track patients through four health states: disease-free, local recurrence, distant recurrence and dead. Model inputs were derived from trial data and literature sources. Results: PET-CT surveillance results in a lifetime cost saving of -£1,485 (95% CI: -2,815 to 159) and health gain of +0.13 (95% CI: -0.49 to +0.79) quality-adjusted life-years (QALYs) per patient. The intervention therefore dominates standard care, being more effective and less costly, with an incremental net benefit (INB) of +0.21 QALYs (95% CI: -0.41 to +0.85). At a willingness-to-pay per QALY threshold of £20,000, PET-CT is associated with a 75% probability of being cost-effective, dropping to 68% at a £100,000/QALY threshold. The intervention remained cost-effective when considering a broader NHS and personal social services perspective; however, uncertainty around the mean cost-effectiveness values was wide. Conclusions: PET-CT surveillance appears to be cost-effective, leading to expected lifetime cost savings and a marginal health increment. There is significant uncertainty in the longer term which may warrant additional survivor-ship research.

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

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.

Management of advanced nodal disease in patients treated with primary chemoradiotherapy.

The management of advanced nodal disease in patients treated with chemoradiotherapy has been a controversial topic for many years. New data have recently been reported, including the results of a multicentre randomized trial making this review timely. The PET-NECK trial showed that PET-computer tomography (CT) surveillance is as effective as planned neck dissection in terms of overall survival, but results in much fewer neck dissections, less complications and is more cost effective. Cost-effectiveness data from a single centre study demonstrated that strategies that include PET-CT were more effective than CT-alone-guided strategies. There is now level 1 evidence to support image-guided surveillance strategies as the standard of care for advanced nodal disease in patients treated with primary chemoradiotherapy.

PET-CT Surveillance versus Neck Dissection in Advanced Head and Neck Cancer

BackgroundThe role of image-guided surveillance as compared with planned neck dissection in the treatment of patients with squamous-cell carcinoma of the head and neck who have advanced nodal disease (stage N2 or N3) and who have received chemoradiotherapy for primary treatment is a matter of debate.MethodsIn this prospective, randomized, controlled trial, we assessed the noninferiority of positron-emission tomography–computed tomography (PET-CT)–guided surveillance (performed 12 weeks after the end of chemoradiotherapy, with neck dissection performed only if PET-CT showed an incomplete or equivocal response) to planned neck dissection in patients with stage N2 or N3 disease. The primary end point was overall survival.ResultsFrom 2007 through 2012, we recruited 564 patients (282 patients in the planned-surgery group and 282 patients in the surveillance group) from 37 centers in the United Kingdom. Among these patients, 17% had nodal stage N2a disease and 61% had stage N2b disease. A total of 84% of the patients had oropharyngeal cancer, and 75% had tumor specimens that stained positive for the p16 protein, an indicator that human papillomavirus had a role in the causation of the cancer. The median follow-up was 36 months. PET-CT–guided surveillance resulted in fewer neck dissections than did planned dissection surgery (54 vs. 221); rates of surgical complications were similar in the two groups (42% and 38%, respectively). The 2-year overall survival rate was 84.9% (95% confidence interval [CI], 80.7 to 89.1) in the surveillance group and 81.5% (95% CI, 76.9 to 86.3) in the planned-surgery group. The hazard ratio for death slightly favored PET-CT–guided surveillance and indicated noninferiority (upper boundary of the 95% CI for the hazard ratio, <1.50; P=0.004). There was no significant difference between the groups with respect to p16 expression. Quality of life was similar in the two groups. PET-CT–guided surveillance, as compared with neck dissection, resulted in savings of £1,492 (approximately $2,190 in U.S. dollars) per person over the duration of the trial.ConclusionsSurvival was similar among patients who underwent PET-CT–guided surveillance and those who underwent planned neck dissection, but surveillance resulted in considerably fewer operations and it was more cost-effective. (Funded by the National Institute for Health Research Health Technology Assessment Programme and Cancer Research UK; PET-NECK Current Controlled Trials number, ISRCTN13735240.)

Radiotherapy alone or combined with chemotherapy as definitive treatment for squamous cell carcinoma of the tonsil.

This study is aimed at updating our institution's experience with definitive radiotherapy (RT) for squamous cell carcinoma of the tonsil. We reviewed 531 patients treated between 1983 and 2012 with definitive RT for squamous cell carcinoma of the tonsil. Of these, 179 patients were treated with either induction (n=19) or concomitant (n=160) chemotherapy. Planned neck dissection was performed on 217 patients: unilaterally in 199 and bilaterally in 18 patients. Median follow-up was 5.2years for all patients (range 0.1-31.6years) and 8.2years for living patients (range 1.9-31.6years). The 5-year local control rates by T stage were as follows: T1, 94%; T2, 87%; T3 79%; T4, 70%; and overall, 83%. Multivariate analysis revealed that local control was significantly influenced by T stage and neck dissection. The 5-year cause-specific survival rates by overall stage were as follows: I, 94%; II, 88%; III, 87%; IVA, 75%; IVB, 52%; and overall, 78%. Multivariate analysis revealed that cause-specific survival was significantly influenced by T stage, N stage, overall stage, fractionation, neck dissection, sex, and ethnicity. Of 77 patients treated with ipsilateral fields only, contralateral neck failure occurred in 1%. The rate of severe complications was 12%. Definitive RT for patients with tonsillar squamous cell carcinoma provides control rates equivalent to other modalities with a comparatively low incidence of late complications. Patients with anterior tonsillar pillar or tonsillar fossa primaries that are well lateralized with no base of tongue or soft palate extension may be treated with ipsilateral fields.

Accuracy of Ultrasonography-Guided Fine-Needle Aspiration in Detecting Persistent Nodal Disease After Chemoradiotherapy.

Few patients with persistent adenopathy following chemoradiotherapy (CRT) for head and neck squamous cell carcinoma harbor viable disease. Improved selectivity for surgical salvage is needed to prevent unnecessary salvage neck dissection. To determine whether ultrasonography-guided fine-needle aspiration (FNA) can be used to identify viable cancer cells in the lymph nodes of patients with persistent radiographic adenopathy following CRT. A pilot study included patients undergoing preoperative ultrasonography-guided FNA of lymph nodes considered suspicious on radiography prior to planned neck dissection at a quaternary care facility from February 28, 2011, to March 18, 2013. Data analysis was performed from April 28 to December 24, 2013. Patients treated for head and neck squamous cell carcinoma with CRT who were determined to have persistent neck disease on a 6-week posttreatment computed tomographic scan of the neck and scheduled for salvage neck dissection were considered candidates for this pilot study. All patients enrolled in the study underwent ultrasonography-guided FNA of the suspicious lymph nodes within 2 weeks of the planned neck dissection. The cytopathologist reading the samples was blinded to the patient's identity. Fine-needle aspiration with a 23- to 25-gauge needle following CRT. The accuracy of ultrasonography-guided FNA cytologic results was compared with the standard of surgical pathologic examination of neck dissection specimens. Fourteen patients (11 [79%] men; mean [SD] age, 57.8 [11.2] years) were enrolled in this pilot study; data were collected on 17 lymph nodes. Among these 14 patients with incomplete radiographic clinical response, 17 lymph node aspirations were performed. Ultrasonography-guided FNA identified squamous cell carcinoma in the aspirates of 4 (80%) of the 5 nodes with squamous cell carcinoma identified on pathologic testing and confirmed the absence of disease in the remaining 12 (71%) lymph nodes. The statistical analysis of these results revealed a sensitivity of 80%; specificity, 100%; positive predictive value, 100%; and negative predictive value, 92.3%. The diagnostic accuracy of ultrasonography-guided FNA at detecting residual persistent cancer was 88%. This pilot study suggests that ultrasonography-guided FNA may be a feasible ancillary diagnostic imaging tool to imaging to assess patients with radiographic persistent disease prior to consideration of salvage neck dissection.

Evaluation of neck node response after radiotherapy: minimizing equivocal results

About two-thirds of patients with head and neck squamous cell carcinoma(HNSCC)originatingfromthemucosal linings of the upper aerodigestive tract present with advanced stage disease. If the primary tumour is located in the pharynx or larynx, patients are generally treated with radiotherapy with or without chemotherapy. In patients with functionally unresectable HNSCC (resectable but high morbidity of surgical treatment expected) who are treated with this nonsurgical treatment, salvage surgery is kept in reserve in case residual disease occurs. The decision to perform a neck dissection following (chemo)radiotherapy isclear whenpatientshaveprovenresidual nodal disease in the neck. However, distinguishing between residual metastasis and radiotherapy sequelae is difficult in most patients with a residual neck mass, since posttreatment induration and fibrosis make accurate clinical assessment difficult. Because no reliable clinical parameters are available to predict pathological neck status after (chemo)radiotherapy, routine planned neck dissection is performed in many institutions. The integration of planned neck dissection into the multidisciplinary management of patients with locoregionally advanced head and neck cancer treated with concomitant chemoradiotherapy is highly effective in controlling residual neck nodal disease. However, in the majority of neck dissection specimens, no viable tumour cells are found. Moreover, neck dissection after radiotherapy is associated with a significant risk of wound healing problems and shoulder morbidity. On the other hand, late recurrences in the neck are rarely surgically salvageable and are associated with an increased risk of metastatic spread to distant sites. Therefore, early detection of residual neck disease after (chemo)radiotherapy is important [1–4].

Role of Neck Dissection in Locoregionally Advanced Head and Neck Cancer Treated with Primary Chemoradiotherapy

1.1. Introduction: Planned neck dissection after chemoradiotherapy (CRT) in locoregionally advanced head and neck cancer is controversial. The objective of the present study was to evaluate the influence of neck dissection on the long-term locoregional control and survival of patients with stage III-IV head and neck squamous cell carcinoma (HNSCC) after primary CRT. 1.2. Methods/Patients: We retrospectively analysed locoregional control, locoregional relapse-free survival (LRFS), and overall survival (OS) in 67 patients with locally-advanced HNSCC treated with exclusive CRT at our department between January 1998 and December 2013. 1.3. Results: Complete clinical response was achieved in 36 of 67 patients (53.7%), partial response > 50% in 17 pts (25.4%), stable disease in 3 (4.5%); 9 patients (13.4%) developed disease progression during treatment. At a median follow-up of 35 months, LRFS and OS were 100% in patients with complete response and neck dissection versus 77.9% and 79.8%, respectively, in patients who did not undergo neck dissection (p = ns). The only independent prognostic factor for locoregional control was complete response to CRT. 1.4. Conclusions: Patients who achieve a complete clinical response to CRT have a very low risk of isolated neck recurrence and, therefore, planned neck dissection may not be justified in such cases. Clinical and radiographic identification of patients with residual disease following CRT who could benefit from neck dissection remains challenging.

Individualized Risk Estimation for Postoperative Complications After Surgery for Oral Cavity Cancer.

Postoperative complications after head and neck surgery carry the potential for significant morbidity. Estimating the risk of complications in an individual patient is challenging. To develop a statistical tool capable of predicting an individual patient's risk of developing a major complication after surgery for oral cavity squamous cell carcinoma. Retrospective case series derived from an institutional clinical oncologic database, augmented by medical record abstraction, at an academic tertiary care cancer center. Participants were 506 previously untreated adult patients with biopsy-proven oral cavity squamous cell carcinoma who underwent surgery between January 1, 2007, and December 31, 2012. The primary end point was a major postoperative complication requiring invasive intervention (Clavien-Dindo classification grades III-V). Patients treated between January 1, 2007, and December 31, 2008 (354 of 506 [70.0%]) comprised the modeling cohort and were used to develop a nomogram to predict the risk of developing the primary end point. Univariable analysis and correlation analysis were used to prescreen 36 potential predictors for incorporation in the subsequent multivariable logistic regression analysis. The variables with the highest predictive value were identified with the step-down model reduction method and included in the nomogram. Patients treated between January 1, 2007, and December 31, 2008 (152 of 506 [30.0%]) were used to validate the nomogram. Clinical characteristics were similar between the 2 cohorts for most comparisons. Thirty-six patients in the modeling cohort (10.2%) and 16 patients in the validation cohort (10.5%) developed a major postoperative complication. The 6 preoperative variables with the highest individual predictive value were incorporated within the nomogram, including body mass index, comorbidity status, preoperative white blood cell count, preoperative hematocrit, planned neck dissection, and planned tracheotomy. The nomogram predicted a major complication with a validated concordance index of 0.79. Inclusion of surgical operative variables in the nomogram maintained predictive accuracy (concordance index, 0.77). A statistical tool was developed that accurately estimates an individual patient's risk of developing a major complication after surgery for oral cavity squamous cell carcinoma.

11LBA Differences in the quality of life (QoL) and functional outcomes of treatment between HPV associated (HPV+) and HPV- patients receiving primary chemoradiotherapy in PET-NECK - a multi-centre randomized phase III controlled trial (RCT) comparing PETCT guided active surveillance with planned neck dissection (ND) for locally advanced (N2/N3) nodal metastases (LANM) in patients with head and neck squamous cell cancer

11LBA LATE-BREAKING ABSTRACT Differences in the quality of life (QoL) and functional outcomes of treatment between HPV associated (HPV+) and HPV− patients receiving primary chemoradiotherapy in PET-NECK − a multi-centre randomized phase III controlled trial (RCT) comparing PETCT guided active surveillance with planned neck dissection (ND) for locally advanced (N2/N3) nodal metastases (LANM) in patients with head and neck squamous cell cancer (HNC) treated with primary radical chemoradiotherapy (CRT)

Ipsilateral radiotherapy for squamous cell carcinoma of the tonsil

The purpose of this study is to update our institution's experience with ipsilateral radiation therapy (RT) for squamous cell carcinoma of the tonsillar area. Outcome study of 76 patients treated between 1984 and 2012 with ipsilateral RT for squamous cell carcinoma of the tonsil. Patients had either cT1 (n=41, 54%) or cT2 (n=35, 46%) primaries and cN0 (n=27, 36%), cN1 (n=15, 20%), cN2a (n=8, 11%), or cN2b (n=26, 34%) nodal disease. Of these, 32 (42%) patients underwent a planned neck dissection and 21 (28%) patients received concomitant chemotherapy. Median follow-up for all patients was 7.1years (range 0.1-27.2) and 7.8years (range 2.1-27.2years) for living patients. The 2- and 5-year control and survival rates were as follows: local control, 98.6 and 96.9%; local-regional control 95.8 and 92.6%; cause-specific survival 95.9 and 93.1%; and overall survival, 92.1 and 83.8%. One patient failed in the contralateral, non-radiated neck 3years after primary treatment. Univariate analysis revealed that overall survival was significantly influenced by whether the patient had a primary tumor in the anterior tonsillar pillar versus the tonsillar fossa with the latter performing better. The incidence of severe late complications was 16%. Ipsilateral RT for patients with squamous cell carcinoma of the anterior tonsillar pillar or tonsillar fossa with no base of tongue or soft palate extension is an efficacious treatment that provides excellent control rates with a relatively low incidence of late complications.

Complete pathologic response as a prognostic factor for squamous cell carcinoma of the oropharynx post-chemoradiotherapy

IntroductionChemoradiotherapy for squamous cell carcinoma of the oropharynx (SCCO) provides good results for locoregional disease control, with high rates of complete clinical and pathologic responses, mainly in the neck. ObjectiveTo determine whether complete pathologic response after chemoradiotherapy is related to the prognosis of patients with SCCO. MethodsData were prospectively extracted from clinical records of N2 and N3 SCCO patients submitted to a planned neck dissection after chemoradiotherapy. ResultsA total of 19 patients were evaluated. Half of patients obtained complete pathologic response in the neck. Distant or locoregional recurrence occurred in approximately 42% of patients, and 26% died. Statistical analysis showed an association between complete pathologic response and lower disease recurrence rate (77.8% vs. 20.8%; p=0.017) and greater overall survival (88.9% vs. 23.3%; p=0.049). ConclusionThe presence of a complete pathologic response after chemoradiotherapy positively influences the prognosis of patients with SCCO.

Lessons from a standardized program using PET–CT to avoid neck dissection after primary radiotherapy for N2 squamous cell carcinoma of the oropharynx

To report the results of a standardized program using positron emission tomography (PET)-computed tomography (CT) approximately 12 weeks after primary radiotherapy to determine the need for a planned neck dissection in patients with radiographic N2 squamous cell carcinoma (SCC) of the oropharynx. Fifty consecutive patients with T1-4 and hemineck radiographic stage N2A-B SCC of the oropharynx for whom the only indication for planned neck dissection was a positive PET-CT performed ∼12 weeks after completing primary treatment with radiotherapy. Results of PET-CT to identify residual neck disease were as follows: sensitivity and positive predictive value, 0%; specificity, 89%; negative predictive value, 91%; potential neck recurrence from using this 12-week PET-CT program, 2%. The time between negative PET-CT and detection of neck recurrence was 0.5, 0.6, 1.2, and 2.0 years. The rate of successful (>1 year) salvage of neck recurrence was 25% (1/4). PET-CT approximately 12 weeks after radiotherapy for oropharyngeal cancer is an excellent way to identify patients who do not need neck dissection. Approximately half of neck recurrences present over 1 year after negative PET-CT and the chance of successful salvage is low.

Primary radiotherapy for squamous cell carcinoma of the pyriform sinus

The objective of this study is to report the long-term outcomes of primary radiotherapy (RT) for patients with T1-T2 squamous cell carcinomas (SCC) of the pyriform sinus. Between November 1964 and March 2008, 135 patients with T1-T2 pyriform sinus SCC were treated with primary RT at the University of Florida. Adjuvant chemotherapy was employed in 21 patients (16%) and 62 patients (46%) underwent a planned neck dissection. Median follow-up was 3.5years (range 0.2-24.7years); median follow-up on living patients was 8.3years (range 3.8-24.0years). The 5-year outcomes were as follows: local control, 85%; regional control, 81%; local-regional control, 71%; distant metastasis-free survival, 76%; cause-specific survival, 62%; and overall survival, 38%. The 5-year local control rate was 88% for T1 cancers and 84% for those with T2 SCCs (p=0.5429). Sixteen patients (12%) experienced severe late complications. Primary RT results in a high probability of cure with a relatively modest risk of severe late complications for patients with T1-T2 SCCs of the pyriform sinus.

No benefit for regional control and survival by planned neck dissection in primary irradiated oropharyngeal cancer irrespective of p16 expression.

The aim of the study was to assess regional control and survival in primary irradiated oropharyngeal cancer patients with advanced neck disease (≥cN2a) receiving planned neck dissection (PND) irrespective of the nodal response compared to salvage neck dissection (SND) in case of regional persistence or reccurence in relation to tumoral p16 overexpression. 96 consecutive patients treated at the University Hospital of Zurich, Switzerland were included. Tissue microarray-based scoring of p16 expression was obtained. 5years overall (OS) and disease-specific survival (DSS) in the PND and SND cohort were 70 vs. 57% (p=0.20) and 80 vs. 65% (p=0.14), respectively. Regional control in PND and SND achieved 95 vs. 87% (p=0.29), respectively. There was no statistically significant impact of neck treatment (PND vs. SND) on regional control or survival among patients with p16-negative tumors (5years OS 59 vs. 50%, p=0.66; 5years DSS 59 vs. 57%, p=0.89) nor among patients with p16-positive tumors (5years OS 84 vs. 67%, p=0.21; 5years DSS 95 vs. 81%, p=0.24). The type of neck dissection after primary intensity-modulated radiotherapy (IMRT) had no impact on regional control and survival even in human papillomavirus (HPV)-associated disease. Therefore we are convinced that based on the accuracy of newer diagnostic modalities the surveillance of a radiologically negative neck after primary chemoradiation (CRT) is oncologically safe irrespective of p16 expression of the tumor.