Persistently enlarged, but PET negative cervical node post chemorads for H&N Cancer

[Mandelin Rain]

I occasionally run into this scenario where an initial 5cm cystic node shrinks to ~2cm and becomes PET negative at 12 weeks.

In the absence of other findings, I'm curious what everyone else is doing in this situation.

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[communitydoc13]

Watch it. You can repeat CT in 3 months. If continued regression or stability, I would follow clinically and use to justify annual scans at years 1 and 2.

If cystic, I'm thinking HPV positive disease? These nodes can be huge but not really represent a high burden of cancer cells.

The last 2 patients (over many years) that I sent for neck dissection for residual PET avid disease after chemorads had no viable tumor on neck dissection.

 

[thecarbonionangle]

Keep watching it

 

[temujim]

I occasionally run into this scenario where an initial 5cm cystic node shrinks to ~2cm and becomes PET negative at 12 weeks.

In the absence of other findings, I'm curious what everyone else is doing in this situation.

CT Neck with every follow up until resolved.

 

[evilbooyaa]

I favor continued imaging surveillance. If no residual PET avidity at 3 months, then would just do CT neck with contrast... like q3 month for at least 1 year.

I've had 2 patients who had this, both of them got needle biopsies which were negative so we monitored. Both at like 2-3 years out now with persistently necrotic, cystic node, no growth. HPV+ Ophx for both.

I pushed hard against even the thought of going straight to neck dissection. Fortunatley Med Onc wanted to just put a needle in it which I thought was at least a reasonable middle ground.

 

[dieABRdie]

I occasionally run into this scenario where an initial 5cm cystic node shrinks to ~2cm and becomes PET negative at 12 weeks.

In the absence of other findings, I'm curious what everyone else is doing in this situation.

Watch it... the first H&N patient I ever treated on my own had a 6cm node up front. Still 4cm at 3 months, but PET negative. I was freaking out (Like I'm supposed to know how to do this!); ENT wanted to take them for salvage. I convinced them to wait 3 more months.

6 months post treatment..... COMPLETELY GONE.

There's a retrospective review out there from 2019 that suggests p16+ lymph nodes can take 6 months to resolve.

 

[TheWallnerus]

watch

 

[Mandelin Rain]

I definitely agree with the consensus to watch. Sounds like CT q3mos is what most are doing.

 

[gmsquid]

Characteristics and kinetics of cervical lymph node regression after radiation therapy for human papillomavirus-associated oropharyngeal carcinoma: quantitative image analysis of post-radiotherapy response - PubMed

Our results showed a substantial decrease in nodal volume within the first 1-2 months following RT. These findings support our current nodal imaging paradigm, propose a quantitative methodology, and describe a reference dataset for further validation and comparison studies.

pubmed.ncbi.nlm.nih.gov

Watch

 

[madchemist89]

What are people doing in general imaging for head and neck? My problem is there doesn't seem to be data or consensus outside of the 3 month post treatment pet for definitive rt patients.

 

[TheWallnerus]

What are people doing in general imaging for head and neck? My problem is there doesn't seem to be data or consensus outside of the 3 month post treatment pet for definitive rt patients.

Personally I think we will have patient complaints/symptoms or physical exam findings concurrent or antecedent any imaging concerns for head and neck patients in long term followup. Would be difficult to prove surveillance imagiing PET works in a study. I have caught the rare zebra recurrence (retropharyngeal LN eg) with surveillance PET, but this is a once in a decade thing.

 

[kimplera]

What are people doing in general imaging for head and neck? My problem is there doesn't seem to be data or consensus outside of the 3 month post treatment pet for definitive rt patients.

i get a 12 week post treatment PET/CT (for definitive, CT alone for adjuvant), if all negative get CT chest at 1 yr and then just clinical followup. If PET and/or CT equivocal get repeat in 3 months until negative.
For sinus or nasopharynx usually get CT or MRI at each f/u to a year then less frequently.

agree with watching the above.

 

[evilbooyaa]

What are people doing in general imaging for head and neck? My problem is there doesn't seem to be data or consensus outside of the 3 month post treatment pet for definitive rt patients.

If no suspicious pet findings at 3 months I stop. If I'm getting the yearly CT chest then I may add on a neck.

If they have this sort of node on persistent imaging I consider q3 month CT for 1-2 years and then q6 month after until say year 3-4. No 'right' answer.

 

[thecarbonionangle]

I do imaging q3M, don't at me!

 

[RadOncDoc21]

It’s a free world and it’s your patients… do whatever you feel is right for them. Docs, specifically rad oncs need to be more acceptable to other approaches and practices. That’s my kumbaya message for the week.

 

[evilbooyaa]

I do imaging q3M, don't at me!

CT or PET?

CT neck q3 month until 2 years - whatever IMO

 

[thecarbonionangle]

CT or PET?

CT neck q3 month until 2 years - whatever IMO

PET CT about 3-4 months after finishing treatment. If completely negative go to CT neck contrast only and revert to PET if ever any findings that need further work up. A lot of these patients fit criteria for lung cancer screening so they will get a CT lung yearly. if they do not, and im worried, i might add a CT lung once or twice a year (heavy nodal borden with extension to lower neck/upper mediastinum). I do this for first two years then image Q6M or once a year thereafter.

 

[evilbooyaa]

Very reasonable - variation in practice but nothin' wrong w/ it