Need for Neck Dissection After Radiochemotherapy? A Study of the French GETTEC Group

Védrine, Pierre-Olivier; Thariat, Juliette; Hitier, Martin; Janot, F.; Kaminsky, Marie‐Christine; Makeïeff, M.; Raucourt, D. De; Lapeyre, M.; Toussaint, B.

doi:10.1097/mlg.0b013e31817f192a

Cited by 41 publications

(19 citation statements)

References 18 publications

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“…While neck dissections are relatively safe surgical procedures, they do potentially add to the morbidity of chemoradiation. 34,35 Our large series provides addition evidence 27,36 that planned neck dissections are not required in all node positive patients undergoing chemoradiation.…”

Section: Discussionmentioning

confidence: 85%

Prediction of Neck Dissection Requirement After Definitive Radiotherapy for Head-and-Neck Squamous Cell Carcinoma

Thariat

Ang

Allen

et al. 2012

International Journal of Radiation Oncology*Biology*Physics

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BACKGROUND This analysis was undertaken to assess the need for planned neck dissection in patients with a complete response (CR) of involved nodes after irradiation, and to determine the benefit of a neck dissection in those with less than CR by tumor site. METHODS Our cohort included 880 patients with T1-4, N1-3M0 squamous cell carcinoma of the oropharynx, larynx or hypopharynx who received treatment between 1994 and 2004. Survival curves were calculated by the Kaplan-Meier Method, comparisons of rates with the log-rank test and prognostic factors by Cox analyses. RESULTS Nodal CR occurred in 377 (43%) patients of whom 365 patients did not undergo nodal dissection. The 5-year actuarial regional control rate of patients with CR was 92%. Two hundred sixty-eight of the remaining patients (53%) underwent neck dissections. The 5-year actuarial regional control rate for patients without a CR was 84%. Those who had a neck dissection fared better with 5-year actuarial regional control rates of 90% and 76% for those operated and those not operated (p <.001). Variables associated with poorer regional control rates included higher T and N stage, non-oropharynx cancers, non-CR, both clinical and pathological. CONCLUSIONS With 92% 5-year neck control rate without neck dissection after CR, there is little justification for systematic neck dissection. The addition of a neck dissection resulted in higher neck control after partial response though patients with viable tumor on pathology specimens had poorer outcomes. The identification of that subgroup that benefits from additional treatment remains a challenge.

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Section: Discussionmentioning

confidence: 85%

Prediction of Neck Dissection Requirement After Definitive Radiotherapy for Head-and-Neck Squamous Cell Carcinoma

Thariat

Ang

Allen

et al. 2012

International Journal of Radiation Oncology*Biology*Physics

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“…Several studies support the policy of omitting planned neck dissections in patients who obtain a complete response to radio(chemo)therapy [10-14]. However, these studies used various definitions of "complete response" of the neck.…”

Section: Discussionmentioning

confidence: 99%

Neck control after definitive radiochemotherapy without planned neck dissection in node-positive head and neck cancers

et al. 2012

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Background: The purpose of this study was to evaluate neck control outcomes after definitive radiochemotherapy without planned neck dissection in node-positive head and neck cancer. Methods: We retrospectively reviewed medical records of fifty patients with node-positive head and neck cancer who received definitive radiochemotherapy. Twelve patients subsequently underwent neck dissection for suspicious recurrent or persistent disease. A median dose of 70 Gy (range 60-70.6) was delivered to involved nodes. Response evaluation was performed at a median of 5 weeks after completion of radiotherapy. Results: Neck failure was observed in 11 patients and the 3-year regional control (RC) rate was 77.1%. Neck dissection was performed in 10 of the 11 patients; seven of these cases were successfully salvaged, and the ultimate rate of neck control was 92%. The remaining two patients who received neck dissection had negative pathologic results. On univariate analysis, initial nodal size > 2 cm, a less-than-complete response at the primary site, post-radiotherapy nodal size > 1.5 cm, and post-radiotherapy nodal necrosis were associated with RC. On multivariate analysis, less-than-complete primary site response and post-radiotherapy nodal necrosis were identified as independent prognostic factors for RC. Conclusions: The neck failure rate after definitive radiochemotherapy without planned neck dissection was 22%. Two-thirds of these were successfully salvaged with neck dissection and the ultimate neck control rate was 92%. Our results suggest that planned neck dissection might not be necessary in patients with complete response of primary site, no evidence of residual lesion > 1.5 cm, or no necrotic lymph nodes at the 1-2 months follow-up evaluation after radiotherapy.

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“…These retrospective studies show low regional failure rates in the order of 0% to 8%. 14,48,[51][52][53][54]56,57,60 There are very few prospective studies on this topic. In the small pilot study of Koch et al, 38 the number of PNDs was very limited and was proved to be of uncertain value.…”

Section: Retrospective and Prospective Studiesmentioning

confidence: 99%

Planned neck dissection for patients with complete response to chemoradiotherapy: A concept approaching obsolescence

et al. 2009

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The question of efficacy of "planned" neck dissection following complete response to chemoradiation of head and neck cancer is discussed. There is general agreement that preemptive neck dissection in patients who present initially with low volume (N1) neck disease is not necessary. However, routine performance of planned neck dissection for patients who present initially with high volume (> or =N2) disease remains controversial. The authors reviewed a large number of studies reported in the recent literature and discuss how they affect this debate.Twenty-four of the reviewed studies indicate a benefit in regional control obtained by "planned" neck dissection among patients who had bulky neck disease pretreatment. All these studies are retrospective, they do not assess treatment response prior to surgery, although they do show very good regional control rates. Twenty-six studies demonstrate no benefit from "planned" neck dissection after complete clinical response. The reasons for these different conclusions include the development of more effective chemoradiation regimens which have improved the initial locoregional control rates of patients undergoing primary chemoradiation treatment, and improvements in diagnostic technology which have increased ability to detect low volume persistent tumor in the post treatment period. When neck dissection is necessary for persistent or recurrent disease, recent studies have shown that selective or superselective neck dissection may produce results therapeutically equivalent to those obtained with more extensive procedures, with less morbidity.There is now a large body of evidence, based on long-term clinical outcomes, that patients who have achieved a complete clinical (including radiologic) response to chemoradiation have a low rate of isolated neck failure, and the continued use of planned neck dissection for these patients cannot be justified.

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Need for Neck Dissection After Radiochemotherapy? A Study of the French GETTEC Group

Cited by 41 publications

References 18 publications

Prediction of Neck Dissection Requirement After Definitive Radiotherapy for Head-and-Neck Squamous Cell Carcinoma

Prediction of Neck Dissection Requirement After Definitive Radiotherapy for Head-and-Neck Squamous Cell Carcinoma

Neck control after definitive radiochemotherapy without planned neck dissection in node-positive head and neck cancers

Planned neck dissection for patients with complete response to chemoradiotherapy: A concept approaching obsolescence

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