FDG-PET/CT Reduces Unnecessary Surgery in Head, Neck Cancer

TOPLINE:

For patients with head and neck squamous cell carcinoma, utilizing fluorodeoxyglucose-(FDG)-PET/CT imaging to assess their response to chemoradiation significantly increases the accuracy in identifying which patients would benefit from salvage neck dissection, ultimately reducing the number of patients who undergo unnecessary surgery.

METHODOLOGY:

• FDG-PET/CT is increasingly used alongside standard MRI or CT and ultrasound with fine needle aspiration to identify residual neck disease after chemoradiation for head and neck squamous cell carcinoma.
• To identify the impact of increasing use of FDG-PET/CT on the accuracy of patient selection for salvage neck dissection, researchers analyzed records for 908 consecutive patients with node-positive head and neck squamous cell carcinoma treated at their institution between 2008 and 2022.
• The primary endpoint was the positive predictive value of FDG-PET/CT for pathologic-confirmed residual disease after salvage neck dissection compared with MRI, CT, or ultrasound with fine needle aspiration. Secondary endpoints were oncologic outcomes.
• As part of the posttreatment response evaluation, 90% of patients received MRI or CT, 39% received ultrasound with fine needle aspiration, and 38% received FDG-PET/CT.

TAKEAWAY:

• Overall, 130 of 908 (14%) patients underwent salvage neck dissection due to suspicion or confirmed residual neck disease on one or more diagnostic test, but only 53 (41%) of these patients had pathologic-confirmed residual disease based on the salvage neck dissection specimens.
• FDG-PET/CT had significantly better positive predictive value (89%) for detecting pathologic-confirmed residual disease compared with MRI/CT plus ultrasound (65%). FDG-PET/CT significantly improved the accuracy of the detection of pathologic-confirmed residual disease, thereby reducing the number of patients undergoing unnecessary salvage neck dissection by 22%.
• Patients with complete response on FDG-PET/CT did not undergo salvage neck dissection, and this subgroup had favorable oncologic outcomes.
• The negative predictive value of FDG-PET/CT was 97.5%; only seven of 283 patients (2.5%) with complete response developed regional failure later.

IN PRACTICE:

“The growing body of evidence on the excellent performance of FDG-PET/CT in response evaluation justifies its pivotal role in the selection of patients for salvage [salvage neck dissection],” the authors concluded. In patients with complete metabolic response, salvage neck dissection “can safely be omitted,” while in patients with no complete metabolic response, salvage neck dissection is “strongly advocated,” the authors said. 

SOURCE:

The study, with first author Arash Navran, MD, Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, was published online on June 26, 2024, in Radiotherapy and Oncology.

LIMITATIONS:

The study was retrospective and included only patients with node-positive head and neck squamous cell carcinoma from different subsites and unknown primary sites. 

DISCLOSURES:

The study reported no specific funding. The authors declared no conflicts of interest.