Navigating treatment ambiguities in head and neck squamous cell carcinoma: A retrospective analysis of equivocal PET-CT findings and decision-making strategies following primary non-surgical treatment

Post-treatment positron emission tomography/computed tomography (PET-CT) scans for head and neck cancer are challenging due to radiation-induced inflammation, leading to equivocal results. The decision by the Leeds-Mid Yorkshire multidisciplinary team (MDT) to proceed with a targeted biopsy or a second PET-CT reflects the uncertainty of balancing timely intervention and potential delays in patient outcomes. A review of the Leeds-Mid Yorkshire radiology database identified 34 head and neck cancer patients with equivocal PET-CT results following chemoradiation between 2019 and 2023. This audit aims to inform the future clinical management of equivocal findings in head and neck squamous cell carcinoma (SCC). Among the 34 analysed cases, oropharyngeal cancer was the most common (n = 28, 70%). All PET-CT reports indicated partial metabolic response, leading to two main management strategies: a second PET-CT (n = 4, 12%) or other interventions (n = 30, 88%). Kaplan-Meier analysis indicated no difference in disease-specific survival between the second PET-CT group and other-interventions group (log rank = 0.758). Similarly, there was no significant difference in overall survival between patients in the two groups, as determined by the log-rank test (p = 0.498). Decision making in this patient cohort is complex and requires MDT input. Our analysis found no significant survival difference between second PET-CT scans and other intervention (for example, biopsy) pathways. We recommend that for primary and nodal sites, radiological reports should include qualitative and quantitative assessments, clear categorisation (negative, positive, or equivocal), and standardised uptake values (SUVmax).