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Authors: Waldron JN, Gilbert RW, Eapen L, Hammond A, Hodson DI, Hendler A, Perez-Ordonez B, Gu C, Julian JA, Julian DH

Results of an Ontario Clinical Oncology Group (OCOG) prospective cohort study on the use of FDG PET/CT to predict the need for neck dissection following radiation therapy of head and neck cancer (HNC).

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Authors: Waldron JN, Gilbert RW, Eapen L, Hammond A, Hodson DI, Hendler A, Perez-Ordonez B, Gu C, Julian JA, Julian DH

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  1. Results of an Ontario Clinical Oncology Group (OCOG) prospective cohort study on the use of FDG PET/CT to predict the need for neck dissection following radiation therapy of head and neck cancer (HNC) Authors: Waldron JN, Gilbert RW, Eapen L, Hammond A, Hodson DI, Hendler A, Perez-Ordonez B, Gu C, Julian JA, Julian DH and MN Levine Reviewed by Dr. Stephanie Snow ASCO 2011 abstract 5504 Oral Session June 6, 2011 Date posted: June 2011

  2. Thank you for downloading this update. Please feel free to use it for educational purposes. Please acknowledge OncologyEducation.ca and Dr. Stephanie Snow when using these slides.

  3. Background • Upwards of 50% of node-positive head and neck cancer (HNC) patients will have residual nodes visible on CT following curative intent radiation +/- chemotherapy • ~1/3 of these will harbour residual cancer and can be cured by surgical neck dissection • CT, MRI and US guided FNA have limited sensitivity and/or specificity in detecting residual nodal disease • The question has been raised whether FDG-avidity on the post-therapy PET/CT can be used to better predict which patients are likely to need surgery: • 2 prospective case series reached differing conclusions

  4. Study Design • Prospective multi-centre study performed at four regional cancer centres in Ontario, Canada with n=398 • Subjects: • Squamous cell HNC with N2 or N3 neck disease • Post-curative intent treatment with radiation +/- chemotherapy with full dose radiation delivered to all suspected nodal disease • All subjects had CT and PET/CT performed before treatment and 8-10 weeks post therapy • Intervention: • All subjects with residual nodes >1cm axial dimension on post-treatment CT or positive PET-CT underwent neck dissection within four weeks of imaging • Pathologic results of neck dissection were correlated with post treatment imaging • Patients were then followed for two years

  5. Subject Characteristics

  6. RESULTS: PET/CT 353 subjects had post therapy PET/CT scan at a mean of 9.2 weeks (range 4-19) 151 underwent a neck dissection

  7. RESULTS: PET/CT

  8. RESULTS: CT 154 patients who had a post-treatment CT underwent a neck dissection

  9. RESULTS: CT

  10. STUDY COMMENTARY • Largest prospective trial to address this question to date • Canadian data  • There is significant potential for functional impairment and compromise in quality of life after a neck dissection • A test with high sensitivity and negative predictive value could help predict who does NOT have residual disease • In this trial, enhanced CT scan was superior to PET/CT in sensitivity and negative predictive value, and the authors concluded that PET/CT should NOT be used to determine need for neck dissection

  11. BOTTOM LINE FOR CANADIAN MEDICAL ONCOLOGISTS • This trial does not provide evidence for a clear role of PET/CT to assess for nodal disease post HNC therapy, however, the conclusion that PET/CT should not be used in neck dissection decisions may be pre-mature • This is a question that is still important to explore as there were a number of potentially confounding issues: • Impact of HPV status on radiographic nodal response rates is unknown and could have been important in this study with 73% oropharyngeal primaries • Optimal timing for post-treatment PET/CT – the positive prospective trial did PET/CT at 12 weeks

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