Accuracy of Response Assessment FDG PET-CT Post (Chemo)Radiotherapy in HPV Negative Oropharynx Squamous Cell Carcinoma

Simple Summary Oropharyngeal squamous cell carcinoma is often treated with (chemo)radiotherapy with curative intent. Human papilloma virus (HPV) is a key risk factor for the development of a majority of oropharynx cancers in many parts of the world. PET-CT is widely used as an accurate method of assessing response following (chemo)radiotherapy and most of the data supporting this is based upon HPV-related disease. Oropharynx squamous cell carcinoma that is not related to human papilloma virus has an inferior prognosis and there is little data regarding the accuracy of response assessment PET-CT after chemoradiotherapy. This study shows that a negative PET-CT after treatment for patients with HPV-negative oropharynx cancer has a high negative predictive value with treatment having been successsful; however if the PET-CT is equivocal there is a significant chance of disease being persistent. Background: Data on the accuracy of response assessment 2-[fluorine-18]-fluoro-2-deoxy-D-glucose (FDG) positron emission tomography-computed tomography (PET-CT) following (chemo)radiotherapy in patients with oropharynx squamous cell carcinoma (OPSCC) is predominantly based on HPV-positive disease. There is a paucity of data for HPV-negative disease, which has a less favourable prognosis. Methods: 96 patients treated with (chemo)radiotherapy for HPV-negative OPSCC with baseline and response assessment FDG PET-CT between 2013-2020, were analysed. PET-CT response was classified as negative, equivocal, or positive based on qualitative reporting. PET-CT response categories were analysed with reference to clinicopathological outcomes. Test characteristics were evaluated, comparing negative results to equivocal and positive results together. Post-test probabilities were calculated separately for positive and equivocal or negative results. Results: Median follow-up was 26 months. The negative predictive value of a negative scan was 93.7 and 93.2%, respectively, for primary tumour and nodal disease. For a negative scan, the post-test probability was 0.06 for primary and 0.07 for nodal disease. The post-test probability of an equivocal scan was 0.51 and 0.72 for primary and lymph node, respectively. The post-test probability of a positive scan approached 1. For patients with/without a negative scan, two-year overall survival and progression-free survival were 83% versus 30% and 79% versus 17% (p < 0.001), respectively. Conclusion: The NPV of a negative response assessment PET-CT in HPV-negative OPSCC is high, supporting a strategy of clinical monitoring. Contrasting with the published literature for HPV-positive OPSCC, an equivocal response scan was associated with a moderate rate of residual disease.