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In Reply:

Department of Maxillofacial Plastic Surgery, Johann Wolfgang Goethe-University Medical School, Frankfurt am Main, Germany

I very much appreciate the comments of Dr Pohar who clearly argues from a radiation-oncologist's point of view.

I cannot agree with his assertion that, "Many if not most centers use radiation therapy and/or chemotherapy rather than surgery as the initial therapy in patients with oropharyngeal cancers." First, the main portion of the patients evaluated in the discussed article¹ suffered from oral cavity cancer. Second, according to the DÖSAK tumor registry (Giessen University Medical School, Giessen, Germany), approximately 81% of primary cancers of the lip, the oral cavity, and the oropharynx are treated with surgery as first-line therapy in the German-speaking countries (Germany, Austria, and Switzerland), and only 10% are initially treated with radiation.² Third, regarding oncologic treatment of oral cavity and oropharyngeal cancer, the German consensus of head and neck surgeons and radiation-oncologists ³ states for oral cavity cancer that "alternatively to an operation, a T1 tumor in the dorsal segment of the mobile tongue may be referred to interstitial brachytherapy. In case of clinical suspicion of lymph node metastases as well as in case of category T2, the necessary combination of brachytherapy and percutaneous radiotherapy leads to higher complication rates and shall be carried out only in case of contraindications to an operation"; and for oropharyngeal cancer that "alternatively to an operation (on presentation of contraindications to an operation), a primary single radiotherapy may be pondered for the stages I and II (T1N0 and T2N0)." For advanced tumor stages of both sites, the consensus recommends chemoradiotherapy "alternatively." Primary radiologic treatment for the neck is not designated. Therefore, surgery has to be regarded as the initial treatment of choice by us. We know, however, that primary irradiation may be successful in some patients, and also in the clinical N0 neck; we nevertheless are mindful of the fact that well known and acknowledged survival statistics are based on surgical treatment whereas there is no prospective randomized study comparing the two modalities with respect to tumor control and functional assessment. Furthermore, we, and surely many other head and neck oncologists, see a problem in primary irradiation when it comes to a local recurrence.

It is true that positron emission tomography (PET) and computed tomography (CT) did not have significant differences concerning the sensitivity, specificity, accuracy, or positive or negative predictive value, which was an assessment based on the final histologic results. However, the consequences for the patients can be very different. For example, let's consider a T2 tumor in the lateral floor of the mouth without midline involvement. When PET demonstrates a spot in the ipsilateral neck, our decision would be ipsilateral modified radical neck dissection. When CT demonstrates suspicious lymph nodes with borderline findings on both neck sides, a surgeon will tend to prefer resection on both neck sides. Granted that if a single metastatic node was found in the pathohistologic examination, the specificity of both diagnostic techniques would have been the same because "it was counted as a correct positive finding when at least one pathologic lymph node was found in the preoperative examination as well as histologically" —but what a difference for the patient! PET will always be more practical in interpretation as compared with CT—a spot is a spot, and it has been interpreted as a positive node by us, irrespective of the standard uptake value. CT evaluation has many more uncertainties.

Finally, we doubt that triple endoscopy, CT scanning, and physical exam are less straining and less costly for both the patients and the society. A large portion of distant metastases and synchronous second primaries are detected by PET, which cannot be detected by the mentioned tools. In fact, skeletal scintigraphy and abdominothoracic CT have to be added to the mentioned tools resulting in even higher costs. These findings by PET completely change the regimen necessary for the respective patients. However, our main goal pursued in our article was to demonstrate the possibility of reducing the rate of elective neck dissections in oral and oropharyngeal cancer patients with a combination of imaging techniques and sentinel node biopsy. The emphasis lies on the usage of sentinel node biopsy. If other groups are able to demonstrate this using CT and sentinel node biopsy, we will be content. The future, however, belongs to a combination of morphologic and functional diagnostics.

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 and oropharyngeal cancer. J Clin Oncol 22:3973-3980, 2004[Abstract/Free Full Text]

2. Reicherts M, Hassek S, Kainz M, et al: Gießen: Zentralregister des Deutsch-Österreichisch-Schweizerischen Arbeitskreises für Tumoren im Kiefer- und Gesichtsbereich, 2000

3. Bootz F, Howaldt HP (eds): Karzinome des oberenAerodigestivtraktes. Interdisziplinäre kurzgefasste Leitlinien der Deutschen Krebsgesellschaft und ihrer Arbeitsgemeinschaften, der Deutschen Gesellschaft für Hals-Nasen-Ohren- Heilkunde, Kopf- und Halschirurgie und der Deutschen Gesellschaft für Mund-, Kiefer- und Gesichtschirurgie. Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF) online Web site. http://leitlinien.net/

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Related Correspondence

• Positron Emission Tomography Paradigm Fuzzier Than Reported
  Surjeet Pohar
  JCO 2005 23: 4803-4804 [Full Text]

This Article Full Text (PDF) Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Alert me to new issues of the journal Save to my personal folders Download to citation manager Rights & Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Kovács, A. F. Search for Related Content PubMed Articles by Kovács, A. F. Related Articles Related Correspondence Social Bookmarking                            What's this?