Neoadjuvant immunotherapy is moving into the management of resectable locally advanced mucosal head and neck squamous cell carcinoma, and with it comes the tempting proposition that a good response should permit a smaller resection. This commentary sets out why that inference is not yet safe.
Two problems are named. Response assessment in this setting is unreliable - imaging and clinical examination after immunotherapy do not map cleanly onto residual viable tumour. And regression is heterogeneous: tumours do not shrink concentrically towards a centre, so a radiologically smaller mass may still contain viable disease scattered through the original footprint. A resection planned to the post-treatment volume can therefore leave tumour behind in tissue that looked clear.
This is a commentary rather than a study, so it produces no numbers to weigh, and it does not argue against neoadjuvant immunotherapy. It argues against response-adapted surgical de-escalation until prospective trials have shown where the margins should sit. Until then, plan the resection to the pre-treatment extent, discuss the distinction explicitly in the multidisciplinary meeting so that the radiological response is not silently read as a change to the surgical plan, and consent the patient on that basis.
- Plan resection margins to the pre-treatment tumour extent, not the post-treatment imaging.
- Record the pre-treatment mapping formally before immunotherapy starts, so it is available at operation.
- Say explicitly in the multidisciplinary meeting whether a good response is changing the surgical plan - and by default it should not.
- Treat pathological response assessment as research data at present, not as a surgical decision tool.
- Consent the patient for the operation the pre-treatment disease required.
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