Less may be more: nodal treatment in neck positive head neck cancer patients

Abstract

Ongoing debates about the need and extent of planned neck dissection (PND), and required nodal radiation doses volumes lead to this evaluation. Aim was to assess nodal control after definitive intensity modulated radiation therapy (IMRT ± systemic therapy) followed by PND in our head neck cancer cohort with advanced nodal disease. Between 01/2005 and 12/2013, 99 squamous cell cancer HNC patients with pre-therapeutic nodal metastasis ≥3 cm were treated with definitive IMRT followed by PND. In addition, outcome in 103 patients with nodal relapse after IMRT and observation only (no-PND cohort) were analyzed. Prior to PND, PET–CT, fine needle aspirations, ultrasound and palpation were assessed regarding its predictive value. Patterns of nodal relapse were assessed in patients with isolated neck failure after definitive IMRT alone. 70/99 (70 %) PND specimens showed histopathological complete response (hCR), which translated into statistically significantly superior survival compared with partial response (hPR) with 4-year overall survival, disease specific survival and nodal control rates of 90/83/96 vs 67/60/78 % (p = 0.002/0.001/0.003). 1/99 patient developed isolated subsequent nodal disease. 64/2147 removed nodes contained viable tumor (3 %). Predictive information of the performed diagnostic investigations was not reliable. 17/70 hCR patients showed true negative findings in available three to four investigations (0/29 hPR). 27/103 no-PND patients developed isolated neck disease (26 %) with successful salvage in 21/24 [88 %, or 21/27 (78 %)]. Nearly all failures occurred in the prior nodal gross tumor volume area. A more restrictive approach regarding PND and/or nodal IMRT dose-volumes may be justified.

Ultrasound in patients with treated head and neck carcinomas

“…The results of the present study were agreed with retrospective studies [ 2 , 10 ] but not agreed with a retrospective study. [ 14 ] The reasons for such contradictory results are the differences in the inclusion criteria. The study reported a very small amount of success of secondary treatment because of a heterogeneous group of patients with the diseased condition included in the study.…”

Prognostic role of extracapsular spread in planned neck dissection after chemoradiotherapy

“…The presence of viable tumoral cells in planned neck dissections after previous treatment with radiotherapy or chemoradiotherapy (pN+) has been associated to higher rates of local 1,16,21 and regional 2,11,13,14,19,20,26 failures, higher rates of appearance of distant metastases, 3,21,23,26 and poorer overall 11,12,15,18,22 and specific-disease survival. 5,9,10,14,17,20,21,[23][24][25][26] However, there is little information about the pathologicl characteristics of the positive neck metastases in relation to the prognosis of the disease. In a study carried out in 12 patients with N2-N3 tumors treated with radiotherapy or chemoradiotherapy and a planned neck dissection with positive lymph nodes, Lavertu et al 9 found that presence of ECS (n = 7) carried a worse prognosis, but because of the small number of patients the difference was not statistically significant (P = .09).…”

“…The presence of viable tumoral cells in planned neck dissections after previous treatment with radiotherapy or chemoradiotherapy (pN+) has been associated to higher rates of local and regional failures, higher rates of appearance of distant metastases, and poorer overall and specific‐disease survival . However, there is little information about the pathologicl characteristics of the positive neck metastases in relation to the prognosis of the disease.…”

“…Regardless of the strategy used in the management of the cervical lymph nodes after chemoradiotherapy, all the studies agree that in case of neck dissection, the persistence of viable cancer cells in the neck is associated with a significant decline in survival …”

“…7,8 Regardless of the strategy used in the management of the cervical lymph nodes after chemoradiotherapy, all the studies agree that in case of neck dissection, the persistence of viable cancer cells in the neck is associated with a significant decline in survival. [1][2][3]5,[9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26] Several studies 27,28 and meta-analyses 29,30 conclude that the presence of metastatic lymph nodes with ECS, defined as extension of the tumor outside the lymph node capsule, has a high prognostic capacity, justifying the inclusion of the ECS as a criterion in the pathologic classification of the 8th edition of the TNM classification. 31 The objective of the present study is to evaluate the prognostic significance of metastatic neck nodes with ECS in a cohort of patients treated with a planned neck dissection after an initial treatment with chemoradiotherapy.…”