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Purpose: To review the University of Iowa experience with intensity-modulated radiotherapy (IMRT) in the treatment of head-and-neck squamous cell carcinoma. Methods and Materials: From October 1999 to April 2004, 151 patients with head-and-neck squamous cell carcinoma were treated with IMRT for curative intent. One patient was lost to follow-up 2 months after treatment and therefore excluded from analysis. Of the remaining 150 patients, 99 were treated with definitive IMRT, and 51 received postoperative IMRT. Sites included were nasopharynx, 5; oropharynx, 56; larynx, 33; oral cavity, 29; hypopharynx, 8; nasal cavity/paranasal sinus, 8; and unknown primary, 11. None of the patients treated with postoperative IMRT received chemotherapy. Of 99 patients who had definitive IMRT, 68 patients received concurrent cisplatin-based chemotherapy. One patient received induction cisplatin-based chemotherapy, but no concurrent chemotherapy was given. Three clinical target volumes (CTV1, CTV2, and CTV3) were defined. The prescribed doses to CTV1, CTV2, and CTV3 in the definitive cohort were 70–74 Gy, 60 Gy, and 54 Gy, respectively. For high-risk postoperative IMRT, the prescribed doses to CTV1, CTV2, and CTV3 were 64–66 Gy, 60 Gy, and 54 Gy, respectively. For intermediate-risk postoperative IMRT, the prescribed doses to CTV1, CTV2, and CTV3 were 60 Gy, 60 Gy, and 54 Gy. Results: The median follow-up was 18 months (range, 2–60 months). All living patients were followed for at least 6 months. There were 11 local–regional failures: 7 local failures, 3 regional failures, and 1 failure both in the primary tumor and regional lymph node. There were 16 patients who failed distantly, either with distant metastasis or new lung primaries. The 2-year overall survival, local progression-free survival, locoregional progression-free survival, and distant disease-free survival rates were 85%, 94%, 92%, and 87%, respectively. The median time from treatment completion to local–regional recurrence was 4.7 months (range, 1.8 to 15.6 months). Only one marginal failure was noted in a patient who had extensive tonsil cancer with tumor extension into the orbit and cavernous sinus. Patients with oropharyngeal cancer did significantly better than patients with oral cavity and laryngeal cancer, with a 2-year local–regional control rate of 98%, compared with 78% for oral cavity cancer and 85% for laryngeal cancer (p = 0.005). There was no significant difference in local–regional control for patients who received postoperative radiation or definitive radiation (p = 0.339) and for patients who had chemotherapy or not (p = 0.402). Neither T stage nor N stage had a significant effect on local–regional control (p = 0.722 and 0.712, respectively). Conclusions: Our results have confirmed the effectiveness of IMRT in head-and-neck cancer. It offers excellent outcomes in local–regional control and overall survival. More studies are necessary to further improve the outcomes of laryngeal cancer as well as oral cavity cancer. [Copyright &y& Elsevier]

Purpose: [(18)F] fluorodeoxyglucose positron emission tomography (FDG PET) imaging has been shown to be valuable in early detection of persistent and recurrent head-and-neck cancer after treatment. Previous studies have reported its use in patients treated with conventional radiation. Many patients are now treated with intensity-modulated radiation treatment (IMRT). We evaluated the value of FDG PET in the assessment of treatment response and surveillance in head-and-neck cancer patients treated with IMRT. Methods and Materials: We performed a retrospective review of 85 head-and-neck cancer patients treated with IMRT at our institution between December 2000 and September 2003 who had FDG PET in their follow-up. Of these, 58 were treated with primary IMRT with or without chemotherapy, and 27 were treated with postoperative IMRT. Results: Sixty-four patients had negative initial FDG PET after treatment. Forty of them, who had 6 to 24 months of follow-up after the imaging study, had no evidence of local or regional recurrence, although three of them developed distant disease. Twenty-one patients had a positive initial FDG PET after treatment, with 11 positive at the primary site, 9 positive in the neck, and 3 positive distantly. Six of 11 patients with a positive FDG PET at the primary site were true positive, and 3 had salvage surgery. Eight of 9 patients positive in the neck had a salvage neck dissection. One had fine needle aspiration of the lymph node with positive cytology but refused surgery later. For patients with follow-up of 6 months and longer, only 1 of 45 patients with a negative initial FDG PET at the primary site developed a local recurrence. None of 49 patients with a negative initial FDG PET in the neck developed a regional recurrence. Two cases are presented in which abnormal FDG PET preceded laryngoscopy or computed tomography in detection of tumor recurrences. Conclusions: FDG PET is useful in the posttreatment management of head-and-neck cancer patients treated with IMRT. It is highly accurate in the detection of persistent and recurrent disease after treatment and allows salvage treatment to be initiated in a timely manner. It also provides prognostic information concerning the risk of recurrence after curative therapy. [ABSTRACT FROM AUTHOR]

Purpose: The role of neck dissection after radiation therapy ([RT] with or without chemotherapy) for regionally advanced head and neck cancer is controversial. As much as 50% of residual lymphadenopathy after radiation has no viable tumor cells present on histopathologic analysis. [18F] fluorodeoxyglucose positron emission tomography (FDG PET) imaging can detect metabolically active cancer. This study examines the ability of post–RT FDG PET imaging to predict the tumor status of residual lymphadenopathy after nonsurgical management of regionally advanced neck disease.Methods and material: From February 2000 to October 2002, 41 patients were treated definitively by radiation (with or without chemotherapy) and underwent FDG PET and computed tomography (CT) imaging after treatment to assess response. Patients with negative CT and FDG PET scans were observed and did not undergo neck dissection. Patients with radiographically persistent lymphadenopathy underwent either neck dissection or fine-needle aspiration of the lymph nodes using ultrasound guidance. The results of the FDG PET scans were correlated with the pathologic findings.Results: Twelve patients with persistent lymphadenopathy underwent either neck dissection or fine-needle aspiration. Four of the 12 were found to have viable residual tumor in the cervical lymph nodes. The pathology did not correlate with the size of the lymph nodes in the pre–RT or post–RT CT studies. However, the pathology correlated strongly with the post–RT FDG PET studies. All patients with a negative post–RT FDG PET or those with a maximum standardized uptake value (SUVmax) of less than 3.0 in the post–RT FDG PET were found to be free of residual viable tumor. Using an SUVmax of less than 3.0 as the criterion for a negative FDG PET study, the negative predictive value was 100% and the positive predictive value was 80%.Conclusions: A negative post–RT FDG PET scan is very predictive of negative pathology in neck dissection or fine-needle aspiration even with large residual lymphadenopathy. Therefore, if the post–RT FDG PET scan is negative, neck dissection might not be required for regional control. A prospective study with longer follow-up and greater patient numbers is needed to determine whether a policy of deferring neck dissection based on a negative FDG PET is supported. [Copyright &y& Elsevier]