Head & Neck | 2021
Rapid recurrence in postoperative head and neck cancer: Underappreciated or overcalled problem?
Abstract
We read the recently published article by Lee et al “Rapid recurrence in head and neck cancer: Underappreciated problem with poor outcome,” with interest. The authors reported 20% (39/194 patients) rapid recurrence rate on computed tomography (CT) simulation images in patients with head and neck cancer postsurgically. The median time from surgery to CT simulation was 37 days. In this retrospective study, the criterion for diagnosing “rapid recurrence” was CT images reviewed by a single radiologist (nodes larger than 1 cm in short axis/loss of central fatty hila/presence of central low attenuation/calcification/hyperenhancement, or abnormal enhancement at primary resection bed). CT as a pretreatment investigation for neck nodal disease is an accurate, but imperfect test—a meta-analysis demonstrated pooled sensitivity and specificity of 81% and 76%, respectively. The limitations of postradiotherapy CT in the detection of persistent nodal disease are well established, but early postoperative CT is less well understood. The authors criteria are broad and nonspecific (particularly as simulation, rather than diagnostic CT is used); postoperative inflammation at the primary tumor bed and reactive nodal enlargement would be plausible alternative explanations for several of the CT criteria used. In the authors study, no biopsy proof of recurrence was obtained; therefore the methodology raises the significant likelihood of false positive CT interpretation. Even in other studies, biopsy proof was available only in 21% to 41% which raises the question that the rate of “radiographic recurrence” is being overestimated. This leads to the clinical dilemma of producing either overdiagnosis with false-positive results with the anxiety and morbidity of intervention produced by the attendant salvage treatment which is not required for disease that does not exist; or missing early recurrence and to miss intervening with salvage treatment in a timely and appropriate manner. The associated worse prognosis for the recurrent group would seem to validate the assessment that 20% really had recurred, but this patient group had high rates of extra capsular spread (ECS) and more advanced initial disease, therefore some worse prognostic features were already present, for example, reactive nodes after major resection, and altered radiological anatomy from flap reconstruction. Irrespective of the percentage of patients with rapid recurrence, we agree with the authors that this problem does exist and there should be a plan to identify such cases so that a treatment plan should be optimized accordingly, for example, change in adjuvant radiotherapy dose to definitive radical radiotherapy dose. One pragmatic option could be that high-risk patients in particular with ECS, their CT simulation must be reviewed by a radiologist. Being able to work together as clinical/radiation oncologists and head and neck radiologists has always been highly valued in our institution. Ongoing clinical education for the oncologist and radiologist is an enduring benefit of this approach, while the authors paper underlines the clinical benefit for patients of this strategy.