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Positron Emission Tomography Paradigm Fuzzier Than Reported

State University of New York Upstate Medical University, Syracuse, NY

To the Editor:

Kovacs et al¹ report an interesting prospective trial evaluating the utility of positron emission tomography (PET) and sentinel node biopsy (SNB) in patients with oral and oropharyngeal squamous cell carcinoma (OOSCC). I agree that their management paradigm results in fewer neck dissections for patients staged with PET and SNB than for patients staged by computed tomography (CT) and SNB. I disagree however with their contention that their new proposed management paradigm is better than the current standard of care for the clinical N0 neck. Many if not most centers use radiation therapy and/or chemotherapy rather than surgery as the initial therapy in patients with oropharyngeal cancer. Patients with OOSCC and a N0 neck after triple endoscopy, CT scan, and physical exam staging are well served by the strategy developed by Fletcher et al² in the 1970s. If the primary tumor is controlled, recurrences after radiation therapy administration at 50 Gy in 5 weeks to an N0 neck are exceedingly rare (less than 3%). This experience is supported by the accepted radiobiologic concept that the small amounts of tumor that are present in roughly one third of the patients with N0 disease can be controlled by a lower nontoxic dose of radiation. PET, SNB, and limited neck dissections bring unnecessary risks and financial burdens to these patients.

In Table 2 of the Kovacs et al article, when comparing the utility of PET versus CT it becomes evident that there are no significant differences between the sensitivity, specificity, accuracy, and positive or negative predictive values of PET and CT in the patients studied.

Our data³ from the State University of New York Upstate Medical University (Syracuse, NY) on 52 patients with head and neck cancer show similar sensitivity, specificity, and accuracy rates when comparing patients staged with PET plus clinical findings to patients staged by CT plus clinical findings.

In conclusion, triple endoscopy, CT scanning, and physical exam should remain the standard staging method for OOSCC patients. Patients with N0 neck disease do not need a PET scan, a sentinel node biopsy, or a neck dissection if they have received radiation therapy.

Author's Disclosures of Potential Conflicts of Interest

The author indicated no potential conflicts of interest.

REFERENCES

1. Kovács AF, Döbert N, Gaa J, et al: Positron emission tomography in combination with sentinel node biopsy reduces the rate of elective neck dissections in the treatment of oral or oropharyngeal cancer. J Clin Oncol 22:3973-3980, 2004[Abstract/Free Full Text]

2. Fletcher GH: Head and Neck: Neck Nodes, in Textbook of Radiotherapy (ed 3). Philadelphia, PA, Lea and Febiger, 1980, pp 250-253

3. Pohar S, Brown R, Hsu J, et al: How does PET imaging change the management of patients with head and neck cancer? Radiother Oncol 173:S295, 2004 (suppl 1)[CrossRef]

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Related Reply

• In Reply:
  Adorján F. Kovács
  JCO 2005 23: 4804-4805 [Full Text]

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