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Recurrent head and neck cancer forces one binary decision: salvageable, or systemic? The standard workup answers it with a chest CT. A 500-patient series from Tata Memorial suggests that's looking in the wrong place first, bone, not lung, was the commonest site of distant spread, and one patient in ten had metastases a neck and chest CT could not see.

Full description

Episode 22. Krishnakumar Thankappan reviews Prakash, Purandare and colleagues on FDG PET/CT for restaging recurrent head and neck carcinoma, published ahead of print in the Indian Journal of Nuclear Medicine on 17 August 2026.

Five hundred patients with histopathologically proven recurrent HNSCC, restaged with PET/CT between 2010 and 2018. Distant metastases were found in 28.8%. Ninety-eight patients had extrathoracic disease; 54, 10.8% of the cohort, had extrathoracic metastases with nothing in the chest at all, and management changed in every one of them.

The episode also takes the reported 100% sensitivity apart. Only 8 of those 54 cases had histopathological confirmation; the rest were adjudicated by follow-up imaging or by an MDT that had the PET in front of it. Plus what actually predicts distant spread on multivariate analysis, why SUVmax is useless for triage, and how a 2018 data cutoff changes what the finding now means.

Chapters

• 0:06 — Opening
• 0:37 — The clinical question
• 1:40 — Study design and cohort
• 2:28 — Results: 28.8%, and bone ahead of lung
• 4:06 — What this does not show
• 5:32 — Who to refer for PET/CT
• 6:53 — Limitations
• 7:35 — Bottom line

Numbers from the episode

144/500 (28.8%) with distant metastases · 54 (10.8%) extrathoracic only · skeletal 34% vs lung 30% · recurrent stage IV, OR 2.06 (1.29–3.29) · shorter DFI, OR 0.92 (0.87–0.98) · optimal DFI cut-off 10 months · SUVmax AUC 0.61

Paper

Prakash A, Purandare NC, Shah S, Puranik AD, Agrawal A, Pantvaidya G, et al. Utility of FDG PET/CT in Restaging and Detection of Distant Metastases in Recurrent Head and Neck Carcinoma. Indian J Nucl Med. doi: 10.25259/IJNM_71_2026

Music: "Podcast Intro / Opening Talk Show" by Alex Morgan (Pixabay).

Numbers from the episode

144/500 (28.8%) with distant metastases · 54 (10.8%) extrathoracic only · skeletal 34% vs lung 30% · recurrent stage IV, OR 2.06 (1.29–3.29) · shorter DFI, OR 0.92 (0.87–0.98) · optimal DFI cut-off 10 months · SUVmax AUC 0.61

Paper

Prakash A, Purandare NC, Shah S, Puranik AD, Agrawal A, Pantvaidya G, et al. Utility of FDG PET/CT in Restaging and Detection of Distant Metastases in Recurrent Head and Neck Carcinoma. Indian J Nucl Med. doi: 10.25259/IJNM_71_2026

Music: "Podcast Intro / Opening Talk Show" by Alex Morgan (Pixabay).

Superficial parotidectomy is the removal of parotid tissue lateral to the plane of the facial nerve. That definition sets the terms of the operation: it is not a gland excision that happens to involve a nerve, but a nerve dissection from which the gland is delivered as a consequence.

This episode is a companion to the step-by-step surgical video on the Head and Neck Cancers channel. The case is a pleomorphic adenoma of the lower pole of the right parotid. Rather than narrating the steps alone, the episode pauses at each stage to set out why the operation is constructed the way it is.

In this episode

• Why the capsule of a pleomorphic adenoma argues against enucleation, and what recurrent disease looks like when it returns
• The developmental reason the facial nerve lies within the parotid, and why there is no true anatomical superficial lobe
• The changing dissection plane across the field, and the subplatysmal-to-sub-SMAS trap in the anterior face
• Preserving the posterior branch of the great auricular nerve, and why patients notice it years later
• Two landmarks — the tragal pointer through the superior tunnel, the posterior belly of digastric through the inferior tunnel — and the failure mode of each
• The tympanomastoid suture and retrograde dissection as alternatives
• What the nerve stimulator is actually telling you, current spread, and why long-acting neuromuscular blockade removes a safety check before the incision
• Working between the landmarks: tunnelling, testing, nerve fishing, and the patience the stage demands
• The inferior kick, the bifurcation at the pes anserinus, and branching variability
• Why most postoperative weakness is traction and thermal injury rather than transection
• Frey syndrome, first bite syndrome, and what to counsel

Watch the operation

Superficial Parotidectomy — Step by Step: https://youtu.be/c_KYd-g1ZDw?si=lOZMFFygA2eoymCb 

Presented by

Dr. Krishnakumar Thankappan, Professor and Head, Department of Head and Neck Surgery and Oncology, Amrita Institute of Medical Sciences, Kochi, India.

This content is provided solely for professional surgical education. It does not replace supervised operative training, institutional protocols, or individual clinical judgement

Most units moved to weekly cisplatin years before the randomised evidence caught up. JCOG1008 gave us the interim answer in 2022. This month brings the five-year data — and a number that is easy to misread.

In this episode:

• Why the trial was designed as a noninferiority study, and what the 1.32 margin was chosen to preserve
• The five-year efficacy results across overall survival, relapse-free survival and local control
• Why "not worse" and "better" are different claims — and why the confidence intervals matter more than the gap between the curves
• The baseline imbalances that randomisation did not stratify for
• Dose intensity as the likely explanation for why this trial and the Indian phase III trial disagree
• Late toxicity, nutrition support–free survival, and the two treatment-related deaths

Key numbers:

261 patients randomised, 132 to 3-weekly cisplatin 100 mg/m² and 129 to weekly 40 mg/m². At a median follow-up of 5.6 years, five-year overall survival was 58.7% versus 71.2%, stratified HR 0.76 (95% CI 0.52–1.12) — noninferiority confirmed. Five-year relapse-free survival 53.0% versus 64.3% (HR 0.81), local relapse-free survival 57.2% versus 68.8% (HR 0.79). Adjusting for T stage, N stage and primary site moved the hazard ratio to 0.88 (95% CI 0.60–1.29). Estimated dose intensity was 33.6 versus 29.3 mg/m² per week. No late adverse event differed by 10% or more between the arms.

Paper discussed:

Tahara M, Kiyota N, Kodaira T, et al. Long-Term Follow-Up of JCOG1008, a Randomized Phase II/III Trial of Chemoradiotherapy Comparing 3-Weekly Cisplatin With Weekly Cisplatin in Postoperative Head and Neck Cancer. J Clin Oncol. Published online June 26, 2026. doi:10.1200/JCO-25-01708

Trial registration: jRCTs031180135

Links:

Summary: hnoncology-journalclub.netlify.app
Video channel: youtube.com/@headandneckcancers

The first phase 3 trial of BRAF/MEK inhibition in radioactive iodine-refractory, BRAF V600E-positive differentiated thyroid cancer, and the results are decisive.

In this global, double-blind trial (153 patients, 42 sites, 11 countries), previously treated patients who had progressed on one or two VEGFR-targeted therapies were randomised 2:1 to dabrafenib plus trametinib or placebo. Dabrafenib plus trametinib more than tripled median progression-free survival , 12.8 vs 3.7 months (HR 0.38, 95% CI 0.25–0.57; p<0.0001), and produced a 57% response rate against 4% on placebo. Interim overall survival favoured the combination but was not yet significant (HR 0.66; p=0.083), immature and confounded by crossover. Pyrexia (48%) and anaemia (45%) were the most common adverse events, with no new safety signals.

We work through what this means for second-line practice, why BRAF genotyping now carries a clear therapeutic consequence, and the limitations, half the cohort from mainland China, and no head-to-head against cabozantinib.

Paper: Gao M, Park YJ, et al. Efficacy and safety of dabrafenib plus trametinib in adults with differentiated thyroid cancer: a randomised, double-blind, placebo-controlled, phase 3 trial. The Lancet Oncology, 13 July 2026.

 https://doi.org/10.1016/S1470-2045(26)00133-6

Can a $180-a-year regimen close the access gap in advanced head and neck cancer?

In this episode we cover METRO PLUS (Kapoor et al., JCO Global Oncology 2026), a single-center, open-label, phase III trial from Varanasi testing whether adding triple oral metronomic chemotherapy — erlotinib, celecoxib, and weekly methotrexate — to paclitaxel-carboplatin improves survival in platinum-sensitive, unresectable advanced HNSCC.

238 patients, randomized 1:1, in a young, oral-cavity-predominant cohort. The combination doubled median overall survival (10 v 5 months; HR 0.54) and progression-free survival (6 v 2 months; HR 0.38), lifted the 6-month OS rate to 68.6% versus 36.5%, and did all of this without increasing grade 3-5 toxicity. Quality of life favored the combination across multiple domains.

Paper: https://doi.org/10.1200/GO-25-00721

Audio companion to our surgical video on the Sistrunk procedure for thyroglossal duct cyst. Embryology, why simple excision recurs, and a concise step-by-step of the operation — incision, subplatysmal flaps, strap separation, central hyoid skeletonisation and resection, en bloc specimen delivery, and layered closure. Watch the dissection: https://www.youtube.com/watch?v=cki1r1fIAw8

A 23-study, 751-patient meta-analysis asks a practical question: when you give neoadjuvant immunotherapy before surgery in resectable head and neck cancer, does adding chemotherapy actually help?

Baratz and colleagues (Mayo Clinic, JAMA Otolaryngology–Head & Neck Surgery, March 2026) pooled the prospective phase 1 and 2 data across three regimens — chemoimmunotherapy, single-agent immunotherapy, and dual-agent immunotherapy — in mostly HPV-negative, locally advanced disease.

What we cover:

• The headline response gap: major-plus-complete pathologic response of 66% with chemoimmunotherapy vs 18% dual-agent vs 6% single-agent
• Complete pathologic response (~38% vs 5% vs 3%) and why radiographic complete responses appeared only in the chemoimmunotherapy arm
• The counterintuitive safety finding — more grade 3–5 events with single-agent immunotherapy (29%) than chemoimmunotherapy (17%) — and why the authors won't draw conclusions from it
• The crucial caveat: these are pooled single-arm trials, not a randomized head-to-head
• Who the likely target population is for a future phase 3 trial: HPV-negative, T3/T4 oral cavity disease

Bottom line: A large, consistent signal that neoadjuvant chemoimmunotherapy outperforms immunotherapy alone on pathologic response — strong enough to justify a phase 3 comparison, not strong enough to settle it.

Source paper
Baratz HQ, Hidalgo C, Price DL, et al. Neoadjuvant Immunotherapy and Chemoimmunotherapy Regimens in Head and Neck Cancer: A Systematic Review and Meta-Analysis. JAMA Otolaryngol Head Neck Surg. Published online March 12, 2026. doi:10.1001/jamaoto.2026.0080
https://doi.org/10.1001/jamaoto.2026.0080

More episodes: hnoncology-journalclub.netlify.app