PET-Directed Management of Node-Positive Head and Neck Cancers

Is neck dissection required routinely in the management of node-positive head and neck squamous cancer after definitive radiation therapy or chemoradiation therapy?

Background: Non-operative therapy is frequently employed in the management of patients with advanced cancer of the larynx and oropharynx. However, these patients commonly have bulky adenopathy. Some surgeons believe routine neck dissection after completion of radiation (R) or chemoradiation (CR) is essential. Others believe that only residual adenopathy requires neck dissection.

Study design: Consecutive patients who achieved complete response at the primary site after R or CR underwent PET/CT 12 weeks after treatment. Patients with equivocal PET underwent a repeat PET four to six weeks later. Patients deemed PET negative were uniformly observed regardless of residual nodal size. These data were collected prospectively in a cohort of patients having treatment with CR or R.

Setting: University-affiliated cancer centers in Brisbane, Australia.

Synopsis: A total of 112 patients with node-positive head and neck squamous cell carcinoma were available for study. Residual CT nodal abnormalities were present in 50 patients (45 percent). PET was negative in 41 of these 50 patients, while PET was positive in nine patients. None of the patients with PET-negative nodal abnormality developed failure in the neck. Patients with PET-positive residual disease underwent neck dissection.

Bottom line: PET and CT can be used to restage patients following definitive R or CR therapy. Neck dissection can be safety reserved only for patients with persistent PET-positive scans.

Reference: Porceddu SV, Pryor DI, Burmeister E, et al. Results of a prospective study of positron emission tomography-directed management of residual nodal abnormalities in node-positive head and neck cancer after definitive radiotherapy with or without systemic therapy. Head Neck. 2011;33(12):1675-1682.