Combined Radiotherapy With Planned Neck Dissection for Small Head and Neck Cancers With Advanced Cervical Metastases

Abstract

Background: We have previously described our treatment algorithm for patients with small head and neck cancers with advanced cervical metastases (stage N2 or greater). Primary radiotherapy is given to the primary site and neck, followed 6 weeks later with endoscopy and biopsy of the primary site. If biopsy of the primary site is negative by frozen section, an immediate neck dissection is performed even when no clinical residual neck disease is present. Our initial review found that 36% of patients with a complete clinical response to radiotherapy had positive nodes on histological examination. Study Design: Retrospective. Methods: The medical records of 71 patients treated at UCLA Medical Center from 1986 to 1999 by this algorithm were reviewed. Results: After radiotherapy, 69 of 71 patients had a complete response at their primary site. Forty-two patients had a complete clinical response in the neck. Seventy-one neck dissections were performed. Overall, 31 of 71 neck dissections (44%) had positive nodes. Among the 42 patients with a complete response to radiotherapy, 13 (31%) had positive histological nodes. Among the 29 patients with a partial response to radiotherapy, 17 (59%) had positive nodes. Follow-up and incidence of neck recurrence are discussed. Conclusion: Planned neck dissection for advanced cervical metastases remains controversial for patients with a complete clinical response to radiotherapy. However, our results suggest that clinical assessment after radiotherapy cannot assure the absence of neck disease. Until there are reliable methods to distinguish which patients are truly free of neck disease, we believe the benefits of a planned neck dissection outweigh the low morbidity of this procedure.

Effectiveness of Superselective and Selective Neck Dissection for Advanced Nodal Metastases After Chemoradiation

“…However, it remains controversial whether to perform a planned neck dissection for patients with bulky disease (N2-N3) who have a clinical complete response to chemoradiation. 3 A few studies [4][5][6][7] suggest that clinical assessment (including posttreatment imaging) after radiotherapy or chemoradiotherapy cannot ensure the absence of neck disease. Wang et al 4 found that 31% of patients had pathological positive nodes following a complete clinical response.…”

Planned Neck Dissection before Combined Chemoradiation in Organ Preservation Protocol for N2-N3 of Supraglottic or Hypopharyngeal Carcinoma

“…Others recommend neck dissection for all N2 and N3 diseases regardless of the response to therapy [21,22] .…”

Do neck levels negative on initial CT need to be dissected after definitive radiation therapy with or without chemotherapy?

“…Although most withhold adjuvant neck dissection after a complete response for initially small disease burden in the neck, there is an ongoing debate regarding the management of N2 or N3 disease with many institutions performing neck dissection even if achieving a complete response to radiation with or without chemotherapy. 10,12,14,15,28,[33][34][35] Neck dissection is also routinely offered to nodal levels that have achieved a PR or a ''very good PR'' to radiation with or without chemotherapy due to at least a 15% to 25% risk of containing viable metastatic disease. [35][36][37] Recently, there has been an increased interest in the use of posttreatment FDG-PET scans to help determine whether viable tumor remains in the neck and thus warrants a neck dissection.…”

“…[1][2][3][4][5][6][7][8][9][10][11][12][13][14] Although some have used the posttreatment response based on CT imaging and/or fluorodeoxyglucose positron emission tomography (FDG-PET) scan to guide further therapy, others recommend routine neck dissection for initial bulky (>4.5 or 5 cm) nodal disease based on the poor negative predictive value (NPV) of a complete response in predicting pathologic outcomes. 10,12,15 Recently, neck dissection has been shown to be associated with an increase in late morbidity compared with radiation-based therapy alone. 16 Moreover, similar neck control rates for selective neck dissection (SND) compared to a more extensive complete neck dissection have been reported, calling into question the routine use of a comprehensive neck dissection.…”