Management of the Neck in the Setting of Definitive Chemoradiation: Is There a Consensus? A GETTEC Study

Abstract

Omission of ND based on computed tomographic scan and positron emission tomography-based complete response to chemoradiation is the most common strategy for advanced nodal disease among centers. However, neck management strategies vary among institutions, and some institutions continue advocating systematic ND before irradiation. The new treatment options and the changing epidemiology, namely docetaxel-based induction chemotherapy and human papilloma virus-related head and neck squamous cell carcinoma having better response profiles and prognosis, are adding to the nonconsensual approach. The best therapeutic index in terms of neck management remains to be defined in this evolving context.

PET-NECK: a multicentre randomised Phase III non-inferiority trial comparing a positron emission tomography–computerised tomography-guided watch-and-wait policy with planned neck dissection in the management of locally advanced (N2/N3) nodal metastases in patients with squamous cell head and neck cancer

“…In other countries, a significant proportion of patients are still treated with planned ND. 5 Proponents of this management policy maintain that CRT does not eradicate large-volume nodal disease in a large proportion of patients (up to 50%), putting them at risk of recurrence. Some believe that for most of these patients, salvage by surgery will not be possible, 9 resulting in devastating consequences.…”

“…4 Since 2000, it appears that there has been a shift towards active surveillance guided by imaging, but there remains a significant proportion of patients being treated by planned routine ND. 5 Therefore, there continues to be lack of consensus regarding the best management for advanced nodal disease in patients receiving CRT.…”

Up-front neck dissection followed by definitive (chemo)-radiotherapy in head and neck squamous cell carcinoma: Rationale, complications, toxicity rates, and oncological outcomes – A systematic review

“…It is generally accepted that, due to the very low probability of nodal persistence and the morbidity associated with ND, any planned ND before or after (C)RT in organ-preservation protocols is usually not considered for cN0-1 disease [6,25,65,[76][77][78][79]. On the other edge of the spectrum, the risk of residual and viable tumor after CRT is substantial for cN2-3 disease and positively correlated to N stage and nodal size [28,[80][81][82].…”

“…Some advances include altered fractionation RT, intensity-modulated radiotherapy (IMRT), and combination of chemotherapy or non-cytotoxic molecular targeted agents with radiation [2][3][4][5]. Single modality approaches with surgery or RT alone is recommended for patients with early-stage tumors (UICC stages I-II), whereas combined modalities, like surgery followed by RT with or without concomitant chemotherapy are generally performed for loco-regionally advanced disease (UICC stages III-IV) [6][7][8]. In the past two decades, radical CRT has also become a widely accepted treatment alternative to primary surgery, with the advantage of organ-preservation in selected locally advanced HNSCC cases [3].…”

“…In attempt to decrease the risk of postoperative complications and to increase a better regional control, planned ND without surgery to the primary tumor before (C)RT in patients with advanced HNSCC has been employed in organ-preservation strategy. The so called up-front ND (UFND) is currently less known and performed [6], but confers the advantages of avoiding adjuvant surgery on a previously irradiated neck as well as the removal of hypoxic tissues and bulky nodal metastases, which may be less responsive to (C)RT and possibly associated to an increased risk of distant metastases [34][35][36]. Satisfying control and postoperative complication rates with UFND, along with minimal delay of definitive treatment, have been reported previously [31,[37][38][39][40][41][42].…”