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Management of the neck after definitive chemoradiation in patients with HPV-associated oropharyngeal cancer: An institutional experience.

Abstract

PURPOSE

To investigate the multidisciplinary management of patients with Human Papilloma Virus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCC) and an incomplete nodal response on restaging PET/CT after definitive chemoradiation (CRT).

MATERIALS AND METHODS

A retrospective chart review was performed of patients diagnosed with node-positive HPV-associated OPSCC from 2012 to 2017, who underwent definitive upfront CRT, and had an incomplete response on post-therapy PET/CT according to NCCN criteria. Post-CRT PET/CT results, management decisions, and clinical outcomes were recorded.

RESULTS

Seventy-four patients with node-positive HPV-associated OPSCC were identified; 20 patients with incomplete neck response on PET/CT according to NCCN criteria were included in the final case series. Median follow-up time was 33 months. Patients were managed as follows: 8 underwent observation and surveillance imaging, 6 underwent ultrasound-guided fine needle aspiration (FNA), and 6 had immediate neck dissection. All the observed patients were disease-free at most recent follow-up. None of the patients who underwent immediate neck dissection had residual neck disease on pathological examination; two patients in this group ultimately developed metastatic disease. Among the 6 who underwent FNA, 1 individual had positive pathology, along with residual primary disease, for which the patient underwent salvage surgery. The 5 remaining individuals had negative FNA results, were subsequently observed, and remained free of disease.

CONCLUSIONS

This institutional experience supports the notion of a high threshold for neck dissection in this low-risk population; only 1 of 20 patients with suspicious PET/CT findings had residual disease in the neck. Moreover, these patients should be managed by a multidisciplinary tumor board (MTB) since current algorithms do not universally include HPV status. Finally, the use of restaging PET/CT to guide management of the neck can be improved with changes in terminology and consideration of FDG-avidity at the primary site and on pre-therapy scans.

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  • Authors+Show Affiliations

    ,

    Department of Radiation Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, USA.

    ,

    Department of Radiation Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, USA.

    ,

    Department of Radiation Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, USA.

    ,

    Department of Otolaryngology - Head and Neck Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, USA.

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    Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, USA.

    ,

    Department of Otolaryngology - Head and Neck Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, USA.

    ,

    Department of Otolaryngology - Head and Neck Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, USA.

    ,

    Department of Otolaryngology - Head and Neck Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, USA.

    Department of Radiation Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, USA. Electronic address: steckie@northwell.edu.

    Source

    Pub Type(s)

    Journal Article

    Language

    eng

    PubMed ID

    31229365

    Citation

    Wotman, Michael, et al. "Management of the Neck After Definitive Chemoradiation in Patients With HPV-associated Oropharyngeal Cancer: an Institutional Experience." American Journal of Otolaryngology, 2019.
    Wotman M, Ghaly M, Massaro L, et al. Management of the neck after definitive chemoradiation in patients with HPV-associated oropharyngeal cancer: An institutional experience. Am J Otolaryngol. 2019.
    Wotman, M., Ghaly, M., Massaro, L., Tham, T., Seetharamu, N., Kamdar, D., ... Teckie, S. (2019). Management of the neck after definitive chemoradiation in patients with HPV-associated oropharyngeal cancer: An institutional experience. American Journal of Otolaryngology, doi:10.1016/j.amjoto.2019.06.003.
    Wotman M, et al. Management of the Neck After Definitive Chemoradiation in Patients With HPV-associated Oropharyngeal Cancer: an Institutional Experience. Am J Otolaryngol. 2019 Jun 12; PubMed PMID: 31229365.
    * Article titles in AMA citation format should be in sentence-case
    TY - JOUR T1 - Management of the neck after definitive chemoradiation in patients with HPV-associated oropharyngeal cancer: An institutional experience. AU - Wotman,Michael, AU - Ghaly,Maged, AU - Massaro,Luke, AU - Tham,Tristan, AU - Seetharamu,Nagashree, AU - Kamdar,Dev, AU - Frank,Douglas, AU - Kraus,Dennis, AU - Teckie,Sewit, Y1 - 2019/06/12/ PY - 2019/04/29/received PY - 2019/06/12/accepted PY - 2019/6/24/entrez PY - 2019/6/24/pubmed PY - 2019/6/24/medline JF - American journal of otolaryngology JO - Am J Otolaryngol N2 - PURPOSE: To investigate the multidisciplinary management of patients with Human Papilloma Virus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCC) and an incomplete nodal response on restaging PET/CT after definitive chemoradiation (CRT). MATERIALS AND METHODS: A retrospective chart review was performed of patients diagnosed with node-positive HPV-associated OPSCC from 2012 to 2017, who underwent definitive upfront CRT, and had an incomplete response on post-therapy PET/CT according to NCCN criteria. Post-CRT PET/CT results, management decisions, and clinical outcomes were recorded. RESULTS: Seventy-four patients with node-positive HPV-associated OPSCC were identified; 20 patients with incomplete neck response on PET/CT according to NCCN criteria were included in the final case series. Median follow-up time was 33 months. Patients were managed as follows: 8 underwent observation and surveillance imaging, 6 underwent ultrasound-guided fine needle aspiration (FNA), and 6 had immediate neck dissection. All the observed patients were disease-free at most recent follow-up. None of the patients who underwent immediate neck dissection had residual neck disease on pathological examination; two patients in this group ultimately developed metastatic disease. Among the 6 who underwent FNA, 1 individual had positive pathology, along with residual primary disease, for which the patient underwent salvage surgery. The 5 remaining individuals had negative FNA results, were subsequently observed, and remained free of disease. CONCLUSIONS: This institutional experience supports the notion of a high threshold for neck dissection in this low-risk population; only 1 of 20 patients with suspicious PET/CT findings had residual disease in the neck. Moreover, these patients should be managed by a multidisciplinary tumor board (MTB) since current algorithms do not universally include HPV status. Finally, the use of restaging PET/CT to guide management of the neck can be improved with changes in terminology and consideration of FDG-avidity at the primary site and on pre-therapy scans. SN - 1532-818X UR - https://www.unboundmedicine.com/medline/citation/31229365/Management_of_the_neck_after_definitive_chemoradiation_in_patients_with_HPV-associated_oropharyngeal_cancer:_An_institutional_experience L2 - https://linkinghub.elsevier.com/retrieve/pii/S0196-0709(19)30309-6 DB - PRIME DP - Unbound Medicine ER -