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

Authors: Goenka, A.; Morris, L. G. T.; Rao, S. S.; Wolden, S. L.; Wong, R. J.; Kraus, D. H.; Ohri, N.; Setton, J.; Lok, B. H.; Riaz, N.; Mychalczak, B. R.; Schoder, H.; Ganly, I.; Shah, J. P.; Pfister, D. G.; Zelefsky, M. J.; Lee, N. Y.
Article Title: 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. 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. Copyright © 2013 UICC.
Keywords: adult; treatment response; aged; middle aged; major clinical study; cancer recurrence; intensity modulated radiation therapy; neck dissection; salvage therapy; squamous cell carcinoma; carcinoma, squamous cell; bevacizumab; cisplatin; fluorouracil; paclitaxel; cancer patient; cancer staging; lymph node metastasis; antineoplastic agent; lymphatic metastasis; carboplatin; clinical assessment; cohort analysis; cetuximab; computer assisted emission tomography; patient safety; oropharynx cancer; neck; cancer control; pet; chemoradiotherapy; oropharyngeal neoplasms; clinical examination; observation; papillomaviridae; positron-emission tomography and computed tomography; adjuvant chemoradiotherapy; oropharyngeal squamous cell carcinoma
Journal Title: International Journal of Cancer
Volume: 133
Issue: 5
ISSN: 0020-7136
Publisher: John Wiley & Sons  
Date Published: 2013-02-22
Start Page: 1214
End Page: 1221
Language: English
DOI: 10.1002/ijc.28120
PROVIDER: scopus
PUBMED: 23436584
PMCID: PMC4570243
Notes: - "Export Date: 1 July 2013" - "CODEN: IJCNA" - "Source: Scopus"
Citation Impact
MSK Authors
  1. Michael J Zelefsky
    745 Zelefsky
  2. Dennis Kraus
    268 Kraus
  3. Suzanne L Wolden
    530 Wolden
  4. Nadeem Riaz
    365 Riaz
  5. Nancy Y. Lee
    785 Lee
  6. Heiko Schoder
    480 Schoder
  7. David G Pfister
    360 Pfister
  8. Richard J Wong
    359 Wong
  9. Anuj Goenka
    18 Goenka
  10. Luc Morris
    240 Morris
  11. Shyam S Rao
    83 Rao
  12. Ian Ganly
    385 Ganly
  13. Jatin P Shah
    693 Shah
  14. Benjamin H Lok
    62 Lok
  15. Nisha Ohri
    5 Ohri
  16. Jeremy Setton
    84 Setton
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