Management of advanced nodal disease following chemoradiation for head and neck squamous cell carcinoma: Role of magnetic resonance imaging

Department of Otolaryngology-Head and Neck Surgery, UCSF Comprehensive Cancer Center, San Francisco, CA, USA.
The Journal of otolaryngology (Impact Factor: 0.5). 01/2008; 36(6):350-6. DOI: 10.2310/7070.2007.0055
Source: PubMed


The purpose of this study was to determine the role of magnetic resonance imaging (MRI) to predict persistent nodal disease in head and neck cancer treated with chemoradiation.
Retrospective chart review of 38 patients with head and neck cancer and N2/N3 neck disease who were treated with chemoradiation and who had an MRI 6 to 8 weeks following treatment.
Sixteen patients had MRI findings suggestive of persistent nodal disease and were managed with neck dissections, three of whom had a persistent tumour. All of these patients have remained disease free in the neck (average follow-up 15 months). Among 22 patients without evidence of nodal disease on post-treatment MRI, 2 patients have had recurrence in the neck (average follow-up 26 months).
Concomitant chemoradiation is effective for the treatment of advanced nodal disease in selected patients. Patients without MRI evidence of persistent nodal disease following chemoradiation who were observed had a low incidence (9%) of eventual neck recurrence, whereas those with evidence of persistent nodes on MRI had a 19% likelihood of residual pathologic neck disease. The optimal strategy for the evaluation of the neck following chemoradiation requires further investigation.

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    ABSTRACT: To determine what findings on postchemoradiation (post-CRT) neck computed tomography (CT) may predict removal of the internal jugular vein (IJV) or sternocleidomastoid muscle (SCM) and to examine whether pretreatment CT had any bearing on the ultimate posttreatment neck dissection with regard to the IJV and SCM. Retrospective review of CT, intraoperative, and pathologic findings. Tertiary care academic medical center. Thirty-four patients who underwent 43 planned post-CRT hemi-neck dissections for pretreatment N2 or greater disease. Of the 43 neck dissections, 39 (91%) were selective neck dissections, 2 (5%) were modified radical dissections, and 2 (5%) were radical neck dissections. The IJV was removed in 6 of the 39 selective neck dissections (15%), in 1 of the 2 modified radical dissections, and in both of the 2 radical neck dissections. The SCM was removed in the 2 modified radical dissections and 2 radical neck dissections. The IJV was removed in 7 of the 9 dissections (78%) in which the IJV was abnormal on preoperative CT (filling defect or thrombosed) vs 2 of the 34 dissections (6%) with a normal IJV on CT (P < .001; positive predictive value, 78%; negative predictive value, 94%). The SCM was removed in 4 of the 11 dissections (36%) in which the tissue plane between the carotid sheath and the SCM was indistinct on CT vs 0 of the 32 dissections with a radiographically normal SCM tissue plane (P = .003; positive predictive value, 36%; negative predictive value, 100%). In 27 patients with pre-CRT CTs for comparison, the IJV normalized in 3 of the 8 patients (38%) with an abnormal IJV on pre-CRT CT, and the tissue plane around the SCM normalized in 15 of the 24 patients (63%) with an indistinct tissue plane on pre-CRT CT. Filling defects or thrombosis of the IJV is highly predictive of need for removal intraoperatively, which may affect planning especially in bilateral neck dissections in which an effort may be made to preserve at least 1 vein. Presence of a clear tissue plane between the SCM and carotid sheath predicts the ability to preserve this muscle. Changes in the status of the IJV and SCM seen on CT that occur as a result of CRT may make preservation of these structures more feasible, even in patients with advanced neck disease.
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    ABSTRACT: The aim of this study was to describe the outcome in patients with head-and neck-squamous cell carcinoma (HNSCC) followed up without neck dissection (ND) after concomitant chemoradiotherapy (CRT) based on computed tomography (CT) response. The second objective was to establish CT characteristics that can predict which patients can safely avoid ND. Between 1998 and 2007, 369 patients with node-positive HNSCC were treated with primary CRT at our institution. After a clinical and a radiologic evaluation based on CT done 6 to 8 weeks after CRT, patients were labeled with a complete neck response (CR) or with a partial neck response (PR). The median follow-up was 44 months. The number of patients presenting with N3, N2, or N1 disease were 54 (15%), 268 (72%), and 47 (13%), respectively. After CRT, 263 (71%) patients reached a CR, and 253 of them did not undergo ND. Ninety-six patients reached a PR and underwent ND. Of those, 34 (35%) had residual disease on pathologic evaluation. A regression of the diameter of ≥ 80% and a residual largest diameter of 15 mm of nodes had negative pathologic predictive values of 100% and 86%, respectively. The 3-year regional control and survival rates were not different between patients with CR who had no ND and patients with PR followed by ND. Node-positive patients presenting a CR as determined by CT evaluation 6 to 8 weeks after CRT had a low rate of regional recurrence without ND. This study also suggests that lymph node residual size and percentage of regression on CT after CRT may be useful criteria to guide clinical decisions regarding neck surgery. Those results can help diminish the number of ND procedures with negative results and their associated surgical complications.
    International journal of radiation oncology, biology, physics 02/2011; 82(2):567-73. DOI:10.1016/j.ijrobp.2010.11.066 · 4.26 Impact Factor
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    Report number: KCE Reports 227. D/2013/10.273/58, Affiliation: Belgian Health Care
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