The role of computed tomographic scans in the management of the N-positive neck in head and neck squamous cell carcinoma after chemoradiotherapy

OBJECTIVE: To determine the sensitivity and specificity of computed tomographic (CT) scanning in predicting residual cervical metastatic disease (N-positive neck) in patients undergoing curative radiotherapy and chemoradiotherapy for squamous cell carcinoma (SCC) of the upper aerodigestive tract. DESIGN: Retrospective case series (1995-2002) of patients undergoing radiotherapy and chemoradiotherapy for advanced head and neck SCC. METHODS: Study entry criteria included N-positive neck disease, a complete response to treatment at the primary tumor site, posttreatment CT scan, posttreatment neck dissection, and correlation of posttreatment CT scan with pathologic neck specimen. We calculated the sensitivity and specificity of the CT scan to predict the presence of residual cervical metastatic disease after curative radiotherapy and chemoradiotherapy. RESULTS: Forty-three patients (including 10 with bilateral N-positive necks) met the study criteria for analysis. Twenty (38%) of the 53 neck dissection specimens were positive for residual cervical metastatic disease. The sensitivity of the CT scan was 85%, while the specificity was only 24%. The positive predictive value of the CT scan was 40%. CONCLUSIONS: While the role of the posttreatment neck dissection remains controversial, the surgeon must rely on clinical examination and imaging studies. Our practice has been to perform planned staged neck dissections on all N2/N3 necks as well as N1 necks with an incomplete response to treatment. Based on our results, it appears that the CT scan technique lacks adequate sensitivity and specificity to reliably predict the presence of residual metastatic disease.