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Original Investigation |

Exploration for an Algorithm for Deintensification to Exclude the Retropharyngeal Site From Advanced Oropharyngeal Squamous Cell Carcinoma Treatment

Matthew E. Spector, MD1; Steven B. Chinn, MD, MPH1; Emily Bellile, MS2; K. Kelly Gallagher, MD3; Stephen Y. Kang, MD1; Jeffrey S. Moyer, MD1; Mark E. Prince, MD1; Gregory T. Wolf, MD1; Carol R. Bradford, MD1; Jonathan B. McHugh, MD4; Thomas E. Carey, PhD1; Francis P. Worden, MD5; Avraham Eisbruch, MD6; Mohannad Ibrahim, MD7; Douglas B. Chepeha, MD, MSPH1,8
[+] Author Affiliations
1Department of Otolaryngology, University of Michigan, Ann Arbor
2Department of Biostatistics, University of Michigan, Ann Arbor
3Department of Otolaryngology, Baylor College of Medicine, Houston, Texas
4Department of Pathology, University of Michigan, Ann Arbor
5Department of Medical Oncology, University of Michigan, Ann Arbor
6Department of Radiation Oncology, University of Michigan, Ann Arbor
7Department of Radiology, University of Michigan, Ann Arbor
8Department of Otolaryngology, University of Toronto, Toronto, Ontario, Canada
JAMA Otolaryngol Head Neck Surg. 2016;142(4):313-318. doi:10.1001/jamaoto.2015.3602.
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Importance  Understanding the drainage patterns to the retropharyngeal lymph nodes is an important consideration in oropharyngeal squamous cell carcinoma (OPSCC) because treatment of these nodes is related to increased morbidity. Prediction of these drainage patterns could not only help minimize treatment morbidity but also prevent failures in at-risk patients as deintensification trials are under way for this disease.

Objective  To evaluate the prevalence of pathologic retropharyngeal adenopathy (RPA) in OPSCC relative to involvement of the oropharyngeal subsite, number of metastatic neck nodes, T classification, and N classification.

Design, Setting, and Participants  We performed a retrospective review from January 1, 2003, through December 31, 2010, at an academic referral center of 205 previously untreated patients with pathologically confirmed, advanced-stage (III, IV) OPSCC. Data analysis was performed from January 1, 2013, through June 30, 2015.

Exposure  Concurrent chemoradiotherapy.

Main Outcomes and Measures  Radiologic evidence of pathologic RPA was tabulated and related to involvement of the oropharyngeal subsite, number of metastatic neck nodes, T classification, and N classification.

Results  Of the 205 previously untreated patients (183 men; mean age, 56.1 years), pathologic RPA was identified in 37 (18.0%) of the 205 patients. Pathologic retropharyngeal lymph nodes were found in 12 (13.5%) of 89 patients with base of tongue cancers, 24 (22.0%) of 109 patients with tonsil cancers, and 1 (14.3%) of 7 patients with other oropharyngeal subsite cancers. Increasing prevalence of RPA was positively correlated with closer proximity to the posterior tonsillar pillar. A multivariable logistic regression model using the oropharyngeal subsite, involvement of the posterior tonsillar pillar, number of metastatic neck nodes, T classification, and N classification revealed that the number of metastatic neck nodes was statistically significant (odds ratio, 1.44; 95% CI, 1.20-1.71; P < .001).

Conclusions and Relevance  The prevalence of pathologic RPA in this cohort was 18.0%, and patients with multiple nodes had the highest risk of pathologic RPA, followed by involvement of the posterior tonsillar pillar. However, these data suggest that there is no clear algorithm that can be used for deintensification to exclude the retropharyngeal site from the treatment volume using extent of disease gathered from pretreatment imaging for patients with advanced-stage OPSCC.

Figures in this Article

Figures

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Figure 1.
Computed Tomograph Showing an Example of Pathologic Retropharyngeal Adenopathy

Axial computed tomographic scan showing a right cystic retropharyngeal lymph node obliterating the parapharyngeal space and abutting the internal carotid artery.

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Figure 2.
Proportion of Patients With Pathologic Retropharyngeal Adenopathy (RPA) Stratified by the 2013 American Joint Committee on Cancer Subsite, T Classification, N Classification, and Involvement of the Posterior Tonsillar Pillar

Other includes posterior pharyngeal wall (1 patient), soft palate (3 patients), and glossotonsillar sulcus (3 patients). All patients with a retropharyngeal lymph node met the computed tomographic criteria or had fludeoxyglucose-avid nodes.

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Figure 3.
Proportion of Patients With Pathologic Retropharyngeal Adenopathy (RPA) Stratified by the Number of Metastatic Neck Nodes

The prevalence of pathologic RPA increases when stratified by the total number of metastatic neck nodes (P < .001). Of the 37 patients with pathologic RPA, there were 35 patients who had other lymph node involvement.

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