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

Anuj Goenka, Luc G.T. Morris, Shyam Rao, Suzanne L. Wolden, Richard J. Wong, Dennis H. Kraus, Nisha Ohri, Jeremy Setton, Benjamin H. Lok, Nadeem Riaz, Borys R. Mychalczak, Heiko Schoder, Ian Ganly, Jatin P. Shah, David G. Pfister, Michael J. Zelefsky, Nancy Y. Lee

Research output: Contribution to journalArticle

25 Citations (Scopus)

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.

Original languageEnglish (US)
Pages (from-to)1214-1221
Number of pages8
JournalInternational Journal of Cancer
Volume133
Issue number5
DOIs
StatePublished - Sep 1 2013
Externally publishedYes

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Oropharyngeal Neoplasms
Squamous Cell Neoplasms
Neck
Neck Dissection
Chemoradiotherapy
Head and Neck Neoplasms
Therapeutics
Observation
Recurrence
Positron Emission Tomography Computed Tomography

Keywords

  • neck dissection
  • observation
  • oropharyngeal squamous cell carcinoma
  • PET

ASJC Scopus subject areas

  • Oncology
  • Cancer Research

Cite this

Long-term regional control in the observed neck following definitive chemoradiation for node-positive oropharyngeal squamous cell cancer. / Goenka, Anuj; Morris, Luc G.T.; Rao, Shyam; 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.

In: International Journal of Cancer, Vol. 133, No. 5, 01.09.2013, p. 1214-1221.

Research output: Contribution to journalArticle

Goenka, A, Morris, LGT, Rao, S, Wolden, SL, Wong, RJ, Kraus, DH, Ohri, N, Setton, J, Lok, BH, Riaz, N, Mychalczak, BR, Schoder, H, Ganly, I, Shah, JP, Pfister, DG, Zelefsky, MJ & Lee, NY 2013, 'Long-term regional control in the observed neck following definitive chemoradiation for node-positive oropharyngeal squamous cell cancer', International Journal of Cancer, vol. 133, no. 5, pp. 1214-1221. https://doi.org/10.1002/ijc.28120
Goenka, Anuj ; Morris, Luc G.T. ; Rao, Shyam ; 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. / Long-term regional control in the observed neck following definitive chemoradiation for node-positive oropharyngeal squamous cell cancer. In: International Journal of Cancer. 2013 ; Vol. 133, No. 5. pp. 1214-1221.
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T1 - Long-term regional control in the observed neck following definitive chemoradiation for node-positive oropharyngeal squamous cell cancer

AU - Goenka, Anuj

AU - Morris, Luc G.T.

AU - Rao, Shyam

AU - Wolden, Suzanne L.

AU - Wong, Richard J.

AU - Kraus, Dennis H.

AU - Ohri, Nisha

AU - Setton, Jeremy

AU - Lok, Benjamin H.

AU - Riaz, Nadeem

AU - Mychalczak, Borys R.

AU - Schoder, Heiko

AU - Ganly, Ian

AU - Shah, Jatin P.

AU - Pfister, David G.

AU - Zelefsky, Michael J.

AU - Lee, Nancy Y.

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N2 - 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.

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