Planned Neck Dissection after Concomitant Radiochemotherapy for Advanced Head and Neck Cancer

A Nomogram to Predict Nodal Response after Induction Chemotherapy for Hypopharyngeal Carcinoma

BACKGROUND

For hypopharyngeal carcinoma, metastatic neck nodes with a low response to induction chemotherapy (ICT) should not be managed with concomitant chemoradiotherapy (CCRT), and the prediction of chemosensitivity before ICT could prevent adverse events from occurring during chemotherapy. In this study, we developed a nomogram to predict the regional response to ICT.

METHODS

A total of 153 hypopharyngeal carcinoma patients with regional metastasis treated with ICT in our institution from January 2010 to September 2020 were retrospectively studied. According to ICT response evaluated by RECIST 1.1, patients were divided into chemo-insensitive (PR < 70%/SD/PD) (group 1) and chemosensitive (CR/PR ≥ 70%) (group 2) groups. Patients' clinical, image, and hematologic data before ICT were collected. The nomogram was built based on multivariate analysis and stepwise logistic regression and was evaluated from the aspects of discrimination and calibration.

RESULTS

A nomogram based on five critical predictors, namely, tumor differentiation degree, T classification, metastatic lymph node size, number of lymph node metastases, and cervical nodal necrosis, was developed. The areas under the curve (AUC) values were 0.76 and 0.70 after adjusting the results using bootstrap methods. The calibration curve showed relatively good agreement between the predicted and observed probabilities.

CONCLUSIONS

Our nomogram yielded good accuracy in predicting the regional ICT response and will be a useful tool to assist clinicians in decision making.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:849-855, 2023.

Correlation between PET-CT and ct in the staging after the treatment of head and neck squamous cell carcinoma

OBJECTIVE

The aim of this study is to find out if a single imaging test is enough to follow-up on an oncological post-treatment patient. In such a case, we would know which was more valuable after comparing the two, by CT or PET-CT.

METHODS

Between January 2012 and July 2018, we collected data from all patients with previous medical history who were treated with a head and neck squamous cell carcinoma in our hospital, through surgery or by using an organ preservation protocol which we had done. Patients were required to have a CT and a PET-CT performed in a maximum period of 30 days between techniques. We compared the post post-treatment stage given to each case by using only the physical examination (only the CT and the PET-CT), with the ones given by the Tumor Board. After treatment, we analysed the similarity through Cramer's V statistic test.

RESULTS

We performed a comparative analysis, obtaining a correlation of 0.426 between the stages given by the Tumor Board and the one assigned based on physical examination, without imaging techniques. By only using the computed tomography as an imaging method the correlation was 0.565, whereas with only the use of positron emission computed technology, it was estimated at 0.858. When we compared the statistical association between stages using exclusively one of the two imaging techniques, the correlation was 0.451.

CONCLUSION

Independent of the modality, we have demonstrated that in patients who have received previous treatment, there was a higher correlation in the stages with respect to the diagnostic method conducted by the Tumor Board using PET-CT as the sole image.

LEVEL OF EVIDENCE

Level 1.

The management of metastatic neck nodes following induction chemotherapy in N2/3 classification hypopharyngeal carcinoma

BACKGROUND

For patients with less chemosensitive neck nodes, poor prognosis after chemoradiotherapy (CRT) could be predicted and neck dissection is needed.

METHODS

Ninety-two N2/3 hypopharyngeal carcinoma patients were retrospectively studied. According to response after induction chemotherapy (ICT), patients were treated with neck dissection followed by concurrent CRT (CCRT) (group 1), surgery plus postoperative CRT (group 2), or CCRT for primary and regional sites (group 3).

RESULTS

Overall survival and disease-free survival rates of group 1 were significantly higher than group 2 (p = 0.038, p = 0.031) and group 3 (both p = 0.018). Regional control rate of group 1 was significantly higher than group 3 (p = 0.041). There were no significant differences between groups 1 and 2 regarding local and regional control (p = 0.746, p = 0.302).

CONCLUSIONS

Neck dissection followed by CCRT is the best choice for patients with responsive primary but nonresponsive nodes.

Salvage neck dissection for isolated neck recurrences in head and neck tumors: Intra and postoperative complications

BACKGROUND AND OBJECTIVES

The current evidence regarding complications after salvage neck dissection (ND) for isolated regional recurrences (IRRs) in head and neck cancers is poor. The aim of this study is to evaluate the incidence and differences in complication rates of salvage ND after primary surgery, radiotherapy, chemoradiotherapy, or combined treatments.

METHODS

This was a multicentric retrospective study on 64 patients who underwent salvage ND for IRR in three Italian institutes between 2008 and May 2020.

RESULTS

Complications were detected in 7 of the 34 patients (20.8%) and surgeons described difficult dissection in 20 patients (58.82%). Accidental vascular ligations or nervous injury during surgery were never detected. None of the variables analyzed were statistically significant in predicting the risk of complications, disease-free survival, or overall survival.

CONCLUSIONS

IRR represents a rare entity among total relapses. The incidence of complications after salvage ND for IRR is higher than after primary surgery but at an acceptable rate in experienced hands. However, an adequate balance between functional and oncological outcomes is mandatory.

Surgical site complications of post-chemoradiotherapy neck dissection: Urgent need for standard registration

Nowadays, a substantial number of head and neck cancer patients are treated by organ-preserving chemoradiation (CRT), with a possible increased risk of complications after planned or salvage neck dissections. We try to determine the risk pattern of surgical site complications (SSC) post-CRT.

Quantification of 18F-fluorodeoxyglucose uptake to detect residual nodal disease in locally advanced head and neck squamous cell carcinoma after chemoradiotherapy: results from the ECLYPS study

BACKGROUND

The Hopkins criteria were introduced for nodal response evaluation after therapy in head and neck cancer, but its superiority over quantification is not yet confirmed.

METHODS

SUV_{body weight} thresholds and lesion-to-background ratios were explored in a prospective multicenter study of standardized FDG-PET/CT 12 weeks after CRT in newly diagnosed locally advanced head and neck squamous cell carcinoma (LAHNSCC) patients (ECLYPS). Reference standard was histology, negative FDG-PET/CT at 12 months after treatment or ≥ 2 years of negative follow-up. Area under the receiver operator characteristics curves (AUROC) were estimated and obtained thresholds were validated in an independent cohort of HNSCC patients (n = 127).

RESULTS

In ECLYPS, 124 patients were available for quantification. With a median follow-up of 20.4 months, 23 (18.5%) nodal neck recurrences were observed. A SUV₇₀ threshold of 2.2 (AUROC = 0.89; sensitivity = 79.7%; specificity = 80.8%) was identified as optimal metric to identify nodal recurrence within 1 year after therapy. For lesion-to-background ratios, an SUV₅₀/SUV_liver threshold of 0.96 (AUROC = 0.89; sensitivity = 79.7%; specificity = 82.8%) had the best performance. Compared with Hopkins criteria (AUROC = 0.81), SUV₇₀ and SUV₅₀/SUV_liver provided a borderline significant (p = 0.040 and p = 0.094, respectively) improvement. Validation of thresholds yielded similar AUROC values (SUV₇₀ = 0.93, SUV₅₀/SUV_liver = 0.95), and were comparable to the Hopkins score (AUROC = 0.91; not statistically significant).

CONCLUSION

FDG quantification detects nodal relapse in LAHNSCC patients. When using EARL standardized PET acquisitions and reconstruction, absolute SUV metrics (SUV₇₀ threshold 2.2) prove robust, yet ratios (SUV₅₀/SUV_liver, threshold 0.96) may be more useful in routine clinical care. In this setting, the diagnostic value of quantification is comparable to the Hopkins criteria.

TRIAL REGISTRATION

US National Library for Medicine, NCT01179360. Registered 11 August 2010, https://clinicaltrials.gov/ct2/show/NCT01179360.

The different role of PD-L1 in head and neck squamous cell carcinomas: A meta-analysis

Programmed cell death-ligands 1 (PD-L1) is a promising immune target for tumor immunotherapy. We conducted this meta-analysis to investigate association between PD-L1 expression and clinicopathological characteristics of head and neck squamous cell carcinomas (HNSCC). Electronic databases were searched for eligible studies. Hazard ratio (HR) with 95 % confidence interval (CI) were extracted to assess the relationship between PD-L1 expression and overall survival (OS) and disease-free survival (DFS) of patients. Odds ratio (OR) with 95 %CI were applied to assess the association between PD-L1 expression and clinicopathological features. A total of 1729 patients were identified for this meta-analysis. PD-L1 expression was higher in female patients in HNSCC (OR = 0.58, 95 %CI:0.44-0.76). In oral squamous cell carcinoma (OSCC), female(OR = 0.56, 95 %CI: 0.41-0.77)and lower grade(OR = 0.48, 95 %CI: 0.24-0.93)were associated with the higher PD-L1 level. There was no significant association between OS and PD-L1 in OSCC patients (HR = 0.89, 95 %CI: 0.37-2.14). In oropharyngeal squamous cell carcinoma (OPSCC), PD-L1 was overexpressed in younger patients (OR = 0.43, 95 %CI: 0.21-0.86), higher tumor grade (OR = 2.46, 95 %CI: 1.38-4.37)and positive HPV status (OR = 2.09, 95 %CI:1.42-3.07). No significant correlation was detected between PD-L1 expression and OS in OPSCC patients (HR = 0.78, 95 %CI: 0.57-1.06). However, the higher PD-L1 expression in tumor cells indicated a better DFS of OPSCC (HR = 0.34, 95 %CI: 0.18-0.67). This meta-analysis demonstrated that PD-L1 overexpression in HNSCC associated with female patients. However, no significant difference was observed in OS or DFS, except the DFS in OPSCC.

Prognostic role of extracapsular spread in planned neck dissection after chemoradiotherapy

BACKGROUND

The purpose of this study is to evaluate the prognostic significance of nodes with extracapsular spread (ECS) in patients treated with a planned neck dissection after chemoradiotherapy.

METHODS

We carried out a retrospective study of 109 cN+ patients who achieved a complete response in the primary location after chemoradiotherapy and treated with a planned neck dissection.

RESULTS

The 5-year disease-specific survival for patients without residual metastatic nodes in the neck dissection (pN0, n = 69) was 75.7% (95% CI: 64.4%-87.0%). For patients with metastatic nodes without ECS (pN+/ECS-negative, n = 17), the corresponding figure was 74.0% (95% CI: 48.2%-99.8%), and for patients with metastatic neck nodes with ECS (pN+/ECS-positive, n = 23) it was 8.7% (95% CI: 0.0%-24.3%) (P = .0001).

CONCLUSION

The presence of ECS in the pathologic study of the planned neck dissections carried out after chemoradiotherapy in patients with human papillomavirus-negative (HPV-negative) head and neck squamous cell carcinoma (SCC) allows identification of a group of patients with a high risk of failure.

18F-FDG-PET/CT for the detection of disease in patients with head and neck cancer treated with radiotherapy

Objective

The aim of this study is to evaluate the diagnostic performance of FDG-PET/CT for the detection of residual disease after (chemo)radiotherapy in patients with head and neck squamous cell carcinoma (HNSCC) and to evaluate the prognostic value of the FDG-PET/CT findings.

Methods

Patients with HNSCC who underwent FDG-PET/CT after (chemo)radiotherapy were studied retrospectively.

Results

104 FDG-PET/CT-scans were performed at a median of 13.2 weeks post-treatment (5.4–19.0 weeks). The diagnostic performance was time dependent with decreasing sensitivity and slightly increasing specificity over time. Sensitivity, specificity, PPV and NPV at 9 months after imaging were 91%, 87%, 77% and 95%, respectively. In a logistic regression model, the odds of a correct FDG-PET/CT increased with 33% every additional week after end of therapy (p = 0.01) and accuracy plateaued after 11 weeks (97%; p<0.001). A complete response on FDG-PET/CT was associated with an overall survival benefit (50.7 versus 10.3 months; p<0.001). Residual disease on FDG-PET/CT increased the risk of death 8-fold (p<0.001).

Conclusion

FDG-PET/CT is able to detect residual disease after (chemo)radiotherapy, with an optimal time point for scanning between 11–12 weeks after therapy. However, a reevaluation is probably necessary 10–12 months after the FDG-PET/CT to detect late recurrences. In addition, FDG-PET/CT can guide decisions about neck dissection and identifies patients with poor prognosis.

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

BACKGROUND

Planned neck dissection (ND) after radical chemoradiotherapy (CRT) for locally advanced nodal metastases in patients with head and neck squamous cell carcinoma (HNSCC) remains controversial. Thirty per cent of ND specimens show histological evidence of tumour. Consequently, a significant proportion of clinicians still practise planned ND. Fludeoxyglucose positron emission tomography (PET)-computerised tomography (CT) scanning demonstrated high negative predictive values for persistent nodal disease, providing a possible alternative paradigm to ND. Evidence is sparse and drawn mainly from retrospective single-institution studies, illustrating the need for a prospective randomised controlled trial.

OBJECTIVES

To determine the efficacy and cost-effectiveness of PET-CT-guided surveillance, compared with planned ND, in a multicentre, prospective, randomised setting.

DESIGN

A pragmatic randomised non-inferiority trial comparing PET-CT-guided watch-and-wait policy with the current planned ND policy in HNSCC patients with locally advanced nodal metastases and treated with radical CRT. Patients were randomised in a 1 : 1 ratio. Primary outcomes were overall survival (OS) and cost-effectiveness [incremental cost per incremental quality-adjusted life-year (QALY)]. Cost-effectiveness was assessed over the trial period using individual patient data, and over a lifetime horizon using a decision-analytic model. Secondary outcomes were recurrence in the neck, complication rates and quality of life. The recruitment of 560 patients was planned to detect non-inferior OS in the intervention arm with a 90% power and a type I error of 5%, with non-inferiority defined as having a hazard ratio (HR) of no higher than 1.50. An intention-to-treat analysis was performed by Cox's proportional hazards model.

SETTINGS

Thirty-seven head and neck cancer-treating centres (43 NHS hospitals) throughout the UK.

PARTICIPANTS

Patients with locally advanced nodal metastases of oropharynx, hypopharynx, larynx, oral or occult HNSCC receiving CRT and fit for ND were recruited.

INTERVENTION

Patients randomised to planned ND before or after CRT (control), or CRT followed by fludeoxyglucose PET-CT 10-12 weeks post CRT with ND only if PET-CT showed incomplete or equivocal response of nodal disease (intervention). Balanced by centre, planned ND timing, CRT schedule, disease site and the tumour, node, metastasis stage.

RESULTS

In total, 564 patients were recruited (ND arm, n = 282; and surveillance arm, n = 282; 17% N2a, 61% N2b, 18% N2c and 3% N3). Eighty-four per cent had oropharyngeal cancer. Seventy-five per cent of tested cases were p16 positive. The median time to follow-up was 36 months. The HR for OS was 0.92 [95% confidence interval (CI) 0.65 to 1.32], indicating non-inferiority. The upper limit of the non-inferiority HR margin of 1.50, which was informed by patient advisors to the project, lies at the 99.6 percentile of this estimate (p = 0.004). There were no differences in this result by p16 status. There were 54 NDs performed in the surveillance arm, with 22 surgical complications, and 221 NDs in the ND arm, with 85 complications. Quality-of-life scores were slightly better in the surveillance arm. Compared with planned ND, PET-CT surveillance produced an incremental net health benefit of 0.16 QALYs (95% CI 0.03 to 0.28 QALYs) over the trial period and 0.21 QALYs (95% CI -0.41 to 0.85 QALYs) over the modelled lifetime horizon.

LIMITATIONS

Pragmatic randomised controlled trial with a 36-month median follow-up.

CONCLUSIONS

PET-CT-guided active surveillance showed similar survival outcomes to ND but resulted in considerably fewer NDs, fewer complications and lower costs, supporting its use in routine practice.

FUTURE WORK

PET-CT surveillance is cost-effective in the short term, and long-term cost-effectiveness could be addressed in future work.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN13735240.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 17. See the NIHR Journals Library website for further project information.

Management of the lymph node-positive neck in the patient with human papillomavirus-associated oropharyngeal cancer

BACKGROUND

The goal of the current study was to assess the rates of recurrence in the neck for patients with lymph node-positive human papillomavirus-associated cancer of the oropharynx who were treated with definitive radiotherapy (with or without chemotherapy).

METHODS

This is a single-institution retrospective study. Methodology included database search, and statistical testing including frequency analysis, Kaplan-Meier tests, and comparative tests including chi-square, logistic regression, and log-rank.

RESULTS

The cohort consisted of 401 patients with lymph node-positive disease who underwent radiotherapy between January 2006 and June 2012. A total of 388 patients had computed tomography restaging, and 251 had positron emission tomography and/or ultrasound as a component of their postradiation staging. Eighty patients (20%) underwent neck dissection, and 21 patients (26%) had a positive specimen. The rate of neck dissection increased with increasing lymph node stage, and was lower in patients who had positron emission tomography scans or ultrasound in addition to computed tomography restaging. The median follow-up was 30 months. The 2-year actuarial neck recurrence rate was 7% and 5%, respectively, in all patients and those with local control. Lymph node recurrence rates were greater in current smokers (P = .008). There was no difference in lymph node recurrence rates noted between patients who did and those who did not undergo a neck dissection (P = .4) CONCLUSIONS: A treatment strategy of (chemo)radiation with neck dissection performed based on response resulted in high rates of regional disease control in patients with human papillomavirus-associated oropharyngeal cancer.

Tolerance and toxicity of primary radiation therapy in the management of seropositive HIV patients with squamous cell carcinoma of the head and neck

OBJECTIVES/HYPOTHESIS

To report tolerance and toxicity of radiotherapy (RT) with or without chemotherapy in HIV seropositive patients with squamous cell carcinoma of the head and neck (SCCHN).

METHODS

This is a single institution retrospective study of 73 HIV seropositive patients with SCCHN treated from January 1997 through 2010. Stages I, II, III, and IV were 8%, 10%, 24%, and 58%, respectively. The median age at RT, HIV diagnosis. and the duration of HIV seropositive were 51 (32-72), 34 (25-50), and 11 (6-20) years, respectively. Patients were treated definitively with RT alone (35%) or concurrent chemo-RT (65%). Median dose of 70 Gy (66-70) was delivered to the gross disease. Median duration of treatment was 52 (49-64) days. Fifty patients (70%) were on HAART.

RESULTS

RT± chemotherapy induced acute toxicity was: median weight loss 20 pounds (6-40), 100% developed dysgeusia and xerostomia (grades 1-3). Acute mucositis and dysphagia/odynophagia grades ≤ 2 and 3 were 83% and 17%, respectively. Treatment breaks in excess of 10, 7, and 3 days were found in 5%, 13%, and 15% of patients, respectively. With a median follow-up of 4 years (2-12) the RT ±chemotherapy induced late dysphagia and xerostomia grades >2 were 26% and 23% of patients, respectively.

CONCLUSION

Our data show that primary RT ±chemotherapy for HIV seropositive SCCHN is less tolerated compared to the historical data for SCCHN without HIV.

LEVEL OF EVIDENCE

2b.

Planned neck dissection following radiation treatment for head and neck malignancy

Introduction. Optimal therapy for patients with metastatic neck disease remains controversial. Neck dissection following radiotherapy has traditionally been used to improve locoregional control. Methods. A retrospective review of 28 patients with node-positive head and neck malignancy treated with planned neck dissection following radiotherapy between January 2002 and December 2005 was performed to assess treatment outcomes. Results. Median interval to neck dissection was 9.6 weeks with a median number of 21 + 9 lymph nodes per specimen. Ten of 31 (32%) neck dissection specimens demonstrated evidence of residual carcinoma. Overall survival at two years was 85%; five-year overall survival was 65%. Concurrent chemotherapy did not impact the presence of residual neck disease. Conclusion. Based on the frequency of residual malignancy in the neck of patients treated with primary radiotherapy, a planned, postradiotherapy neck dissection should be strongly advocated for all patients with advanced-stage neck disease.

Is neck dissection necessary after induction plus concurrent chemoradiotherapy in complete responder head and neck cancer patients with pretherapy advanced nodal disease?

BACKGROUND

The aim of the present study was to assess, in the setting of a single-institution prospective clinical trial, the necessity of planned neck dissection (PND) in physically and radiologically complete responders with pretherapy advanced nodal disease.

METHODS

Between January 2000 and July 2007 a total of 139 patients were enrolled to receive a regimen of platinum-based multidrug induction-concurrent chemoradiotherapy (IC/CCRT). A total of 75 of the enrolled patients with advanced nodal disease were included in this retrospective study. Between 8 and 12 weeks from the end of treatment, the response to IC/CCRT was evaluated by fiber-optic endoscopy and head and neck contrast-enhanced computed tomography or magnetic resonance imaging.

RESULTS

The complete clinical response (cCR) rate was 68%. Among the 51 patients who achieved locoregional cCR at the end of CCRT, 8 underwent PND according to the study recommendation. Of the 43 patients with cCR who did not undergo PND, 2 patients (4.7%) experienced isolated regional recurrences with the 5-year regional control being 82%. Patients with cCR did not have a significantly lower regional control compared with patients with cCR who underwent ND (P=.962). Pathological evidence of residual disease was found in 81% of the patients with less than cCR who underwent ND.

CONCLUSIONS

In physically and radiologically complete responders to IC/CCRT, a PND appears not justified. Conversely, PND should be performed in patients clinically suspected of having residual disease in the neck, as a significant proportion have viable tumor cell in post CCRT ND.

Hyperfractionated radiotherapy with concurrent cisplatin/5-Fluorouracil for locoregional advanced head and neck cancer: analysis of 105 consecutive patients

Objective. We reviewed a cohort of patients with previously untreated locoregional advanced head and neck squamous cell carcinoma (HNSCC) who received a uniform chemoradiotherapy regimen. Methods. Retrospective review was performed of 105 patients with stage III or IV HNSCC treated at Greater Baltimore Medical Center from 2000 to 2007. Radiation included 125 cGy twice daily for a total 70 Gy to the primary site. Chemotherapy consisted of cisplatin (12 mg/m²/h) daily for five days and 5-fluorouracil (600 mg/m²/20 h) daily for five days, given with weeks one and six of radiation. All but seven patients with N2 or greater disease received planned neck dissection after chemoradiotherapy. Primary outcomes were overall survival (OS), locoregional control (LRC), and disease-free survival (DFS). Results. Median followup of surviving patients was 57.6 months. Five-year OS was 60%, LRC was 68%, and DFS was 56%. Predictors of increased mortality included age ≥55, female gender, hypopharyngeal primary, and T3/T4 stage. Twelve patients developed locoregional recurrences, and 16 patients developed distant metastases. Eighteen second primary malignancies were diagnosed in 17 patients. Conclusions. The CRT regimen resulted in favorable outcomes. However, locoregional and distant recurrences cause significant mortality and highlight the need for more effective therapies to prevent and manage these events.

Current practice in management of the neck after chemoradiotherapy for patients with locally advanced oropharyngeal squamous cell carcinoma

Patients whose necks respond completely to chemoradiation are unlikely to have residual viable tumour, which questions the need for planned neck dissection. Partial responders often need further assessment. Positron emission tomography/computed tomography (PET/CT) is becoming the standard method of assessing the response of both the primary site and neck to chemoradiation. There is debate, however, about the timing of assessment, the best imaging technique, and the extent of neck dissection, and emerging evidence supports more selective procedures with their attendant reductions in morbidity. Various trials have tried to settle these controversies, but we hypothesised that current practice varies across the United Kingdom (UK), so we set out to establish what it is. A total of 219 questionnaires were sent to head and neck surgeons of varying disciplines and their oncology counterparts, which outlined a clinical picture of a patient with persistent nodal disease after chemoradiotherapy, and requested information about the respondents' preferred choice and timing of investigations in addition to the type of neck dissection, if indicated. There were noticeable variations in practice, with a tendency towards personal choice rather than a multidisciplinary approach. Although there were some items of broad agreement, there was disparity about the timing of imaging and operation. There is inconsistency in the management of the neck in these patients in the UK, which may reflect an absence of guidelines and paucity of evidence-based information. We need to unify practice to improve the care of patients.

Up-front neck dissection followed by concurrent chemoradiation in patients with regionally advanced head and neck cancer

BACKGROUND

The appropriate management of the neck in patients with regionally advanced head and neck cancer remains controversial. The purpose of this study was to retrospectively analyze our institutional experience with up-front neck dissection followed by definitive chemoradiotherapy.

METHODS

Fifty-five patients with radiographic evidence of large or necrotic lymph nodes underwent up-front neck dissection followed by definitive chemoradiation.

RESULTS

The 5-year overall survival (OS) and progression-free survival (PFS) rates were estimated at 71.3% and 64.7%, respectively. There were 2 failures in the dissected neck, for a control rate of 96.7%. There were 7 locoregional failures and 12 distant failures, for locoregional and distant control rates of 87.3% and 78.2%, respectively.

CONCLUSION

Up-front neck dissection followed by chemoradiotherapy resulted in excellent locoregional control, OS, and PFS. Utilization of this strategy should be considered in carefully selected patients with regionally advanced head and neck cancer. © 2012 Wiley Periodicals, Inc. Head Neck, 2012.

A cost-effectiveness analysis of positron emission tomography-computed tomography surveillance versus up-front neck dissection for management of the neck for N2 disease after chemoradiotherapy

OBJECTIVES/HYPOTHESIS

To study the cost effectiveness of positron emission tomography-computerized tomography (PET-CT) scanning in the management of the neck after chemoradiotherapy (CRT).

STUDY DESIGN

Cost effectiveness and decision analysis model.

METHODS

A cost-effectiveness analysis comparing up-front neck dissection to serial PET-CT imaging in a hypothetical clinical scenario of debate. A patient with an oropharygeal cancer with pretreatment N2 disease having a complete response was considered. Standardized costs were obtained using national databases. A literature review in PubMed was performed to obtain information on incidence, probabilities, and range for various clinical events in the algorithm.

RESULTS

PET-CT strategy costs an average of $14,492 per patient. Neck dissection had a 0.6% greater efficacy in controlling neck disease with a $22,433 incremental cost.

CONCLUSIONS

Our results strongly support the use of PET-CT imaging as the more cost-effective strategy for surveillance of neck after completion of definitive CRT compared to up-front neck dissection.

A planned neck dissection is not necessary in all patients with N2-3 head-and-neck cancer after sequential chemoradiotherapy

PURPOSE

To assess the role of a planned neck dissection (PND) after sequential chemoradiotherapy for patients with head-and-neck cancer with N2-N3 nodal disease.

METHODS AND MATERIALS

We reviewed 90 patients with N2-N3 head-and-neck squamous cell carcinoma treated between 1991 and 2001 on two sequential chemoradiotherapy protocols. All patients received induction and concurrent chemotherapy with cisplatin and 5-fluorocuracil, with or without tirapazamine. Patients with less than a clinical complete response (cCR) in the neck proceeded to a PND after chemoradiation. The primary endpoint was nodal response. Clinical outcomes and patterns of failure were analyzed.

RESULTS

The median follow-up durations for living and all patients were 8.3 years (range, 1.5-16.3 year) and 5.4 years (range, 0.6-16.3 years), respectively. Of the 48 patients with nodal cCR whose necks were observed, 5 patients had neck failures as a component of their recurrence [neck and primary (n = 2); neck, primary, and distant (n = 1); neck only (n = 1); neck and distant (n = 1)]. Therefore, PND may have benefited only 2 patients (4%) [neck only failure (n = 1); neck and distant failure (n = 1)]. The pathologic complete response (pCR) rate for those with a clinical partial response (cPR) undergoing PND (n = 30) was 53%. The 5-year neck control rates after cCR, cPR→pCR, and cPR→pPR were 90%, 93%, and 78%, respectively (p = 0.36). The 5-year disease-free survival rates for the cCR, cPR→pCR, and cPR→pPR groups were 53%, 75%, and 42%, respectively (p = 0.04).

CONCLUSION

In our series, patients with N2-N3 neck disease achieving a cCR in the neck, PND would have benefited only 4% and, therefore, is not recommended. Patients with a cPR should be treated with PND. Residual tumor in the PND specimens was associated with poor outcomes; therefore, aggressive therapy is recommended. Studies using novel imaging modalities are needed to better assess treatment response.

Metabolic tumour volume. Prognostic value in locally advanced squamous cell carcinoma of the head and neck

PURPOSE

Evaluate the predictive and prognostic value of semi-quantitative FDG-PET variables derived from pretreatment FDG-PET images in patients suffering from locally advanced squamous cell carcinoma of the head and neck (SCCHN), treated by means of concomitant radiochemotherapy.

PATIENTS, METHODS

40 patients with newly diagnosed SCCHN that were treated with concomitant radiochemotherapy underwent FDG-PET/CT for treatment planning; 18 patients had neck dissection prior to their baseline scan and to receiving radiochemotherapy. FDG-PET images were used to calculate metabolic tumour volumes using region growing and a threshold of 50% (MTV50) of primary lesions and involved lymph nodes as well as the mean and maximum standard uptake value (SUVmean and SUVmax) of the primary tumours.

RESULTS

Neither SUVmean nor SUVmax values of the primary tumour were significantly different between responders and non-responders whereas MTV50 values of the primary tumour proved significantly higher in non-responders. SUVmean, SUVmax and MTV50 of the primary tumour were not predictive for overall or disease free survival. Contrariwise, dichotomized summed MTV50 values (cut-off≥31 cm3) of the primary tumour and involved lymph nodes in patients that didn't have neck dissection prior to radiochemotherapy were predictive for disease free and overall survival in both univariate and multivariate analysis (p≤0.05).

CONCLUSION

Summed MTV50 values of both the primary tumour and involved lymph nodes provided independent prognostic information on disease free and overall survival.

[Complications and clinical outcome of salvage surgery after concurrent chemoradiotherapy for advanced head and neck squamous cell carcinoma]

Concurrent chemoradiotherapy (CCRT) is increasingly used in organ preservation for head and neck squamous cell carcinoma (HNSCC), with surgery as second-line treatment for salvaging locoregional failure. The significance of post-CCRT salvage surgery, however, remains to be established. We report complications and clinical outcome in 34 salvage surgeries on 30 subjects with advanced HNSCC treated by docetaxel and cisplatin concurrent with conventional radiotherapy. Postoperative complications occurred in 9 (30%) subjects and 10 (29%) surgeries. There was no significant difference in complication incidence between salvage surgeries for persistent disease (7 of 19 cases, 37%) and those for recurrent disease (3 of 15 cases, 20%). Complication incidence in isolated neck dissection (6 of 21 cases, 29%) did not differ significantly from that in primary site resection (4 of 13 cases, 31%). Most frequent complications were dysphagia and skin flap necrosis, occurring in 5 subjects each. Three with dysphagia underwent percutaneous endoscopic gastrostomy, and two with skin flap necrosis led to pharyngocutaneous fistula, requiring pectoralis major myocutaneous flap repair. No carotid artery rupture or chyle fistula occurred. Overall 3-year survival after salvage surgery was 74% for persistent disease, and 87% for recurrent disease. Although post-CCRT salvage surgery harbors high risk of complication, it renders good survival and is recommendable for all whose disease is operable.

Phase I/II study of oncolytic HSV GM-CSF in combination with radiotherapy and cisplatin in untreated stage III/IV squamous cell cancer of the head and neck

PURPOSE

This study sought to define the recommended dose of JS1/34.5-/47-/GM-CSF, an oncolytic herpes simplex type-1 virus (HSV-1) encoding human granulocyte-macrophage colony-stimulating factor (GM-CSF), for future studies in combination with chemoradiotherapy in patients with squamous cell cancer of the head and neck (SCCHN).

EXPERIMENTAL DESIGN

Patients with stage III/IVA/IVB SCCHN received chemoradiotherapy (70 Gy/35 fractions with concomitant cisplatin 100 mg/m(2) on days 1, 22, and 43) and dose-escalating (10(6), 10(6), 10(6), 10(6) pfu/mL for cohort 1; 10(6), 10(7), 10(7), 10(7) for cohort 2; 10(6), 10(8), 10(8), 10(8) for cohort 3) JS1/34.5-/47-/GM-CSF by intratumoral injection on days 1, 22, 43, and 64. Patients underwent neck dissection 6 to 10 weeks later. Primary end points were safety and recommended dose/schedule for future study. Secondary end points included antitumor activity (radiologic, pathologic). Relapse rates and survival were also monitored.

RESULTS

Seventeen patients were treated without delays to chemoradiotherapy or dose-limiting toxicity. Fourteen patients (82.3%) showed tumor response by Response Evaluation Criteria in Solid Tumors, and pathologic complete remission was confirmed in 93% of patients at neck dissection. HSV was detected in injected and adjacent uninjected tumors at levels higher than the input dose, indicating viral replication. All patients were seropositive at the end of treatment. No patient developed locoregional recurrence, and disease-specific survival was 82.4% at a median follow-up of 29 months (range, 19-40 months).

CONCLUSIONS

JS1/34.5-/47-/GM-CSF combined with cisplatin-based chemoradiotherapy is well tolerated in patients with SCCHN. The recommended phase II dose is 10(6), 10(8), 10(8), 10(8). Locoregional control was achieved in all patients, with a 76.5% relapse-free rate so far. Further study of this approach is warranted in locally advanced SCCHN.

Cesium implant for tongue carcinoma with a thickness of 1.5 cm or more: cases successfully treated with a Modified Manchester System

PURPOSE

Deciding on treatment carcinoma of the tongue when the tumor has a thickness of 1.5 cm or more is difficult. Surgery often requires wide resection and re-construction, leading to considerable functional impairment. A cesium implant is an attractive option, but according to the Manchester System, a two plane implant is needed.

MATERIALS AND METHODS

According to the textbook, a tumor is sandwiched between the needles, which are implanted at the edge of the tumor. This may cause an unnecessarily high dose to the outer surface of the tongue, which sometimes leads to a persistent ulcer. To avoid this complication, we invented a modified implantation method, and applied the method to five consecutive patients.

RESULTS

With a minimum follow-up of 2 years, all primary tumors in 5 consecutive patients have been controlled. No complications occurred in soft tissue of the tongue or in the mandible.

CONCLUSION

Our modified Manchester System was feasible and effective for tumors that has a thickness of 1.5 cm or more.

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

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.

Selective Versus Comprehensive Neck Dissection after Chemoradiation for Advanced Oropharyngeal Squamous Cell Carcinoma

OBJECTIVE: To determine whether a comprehensive neck dissection (CND) or a selective neck dissection (SND) is indicated as planned post–primary chemoradiation treatment (CRT) for patients with advanced oropharyngeal squamous cell carcinoma (OPSCC).

STUDY DESIGN: Case series with chart review.

SETTING: A community teaching hospital.

SUBJECTS: Patients with advanced OPSCC who received a uniform CRT protocol at Greater Baltimore Medical Center (GBMC).

METHODS: Medical records of patients treated with primary CRT for locoregionally advanced OPSCC at GBMC between 2001 and 2007 were reviewed. All patients received 7000 to 7500, 6000, and 5000 cGy to primary disease sites, involved cervical lymphatics, and uninvolved cervical and supraclavicular lymphatics, respectively, with concomitant cisplatin (12 mg/m 2 /1 h) and 5-fluorouracil (600 mg/m 2 /20 h) given on days one through five and 29 through 33.

RESULTS: Seventy-six patients received CRT, and 41 met the criteria for neck dissection. Forty-eight neck dissections were performed (34 unilateral and 7 bilateral), of which 23 (48%) were CNDs and 25 (52%) were SNDs. Residual carcinoma was found in six (26%) of the CND and five (20%) of the SND heminecks. The CND group had six (26%) complications, whereas the SND group had two (8%).

CONCLUSION: The high rate of residual disease demonstrated in this study supports the need for post-CRT neck dissection. Although complication rates were not significantly different between the two groups, the trend in this study indicates that SND results in less morbidity. The presumed reduced morbidity and equivalent regional control rate suggest that SND is an appropriate surgical option for OPSCC patients after primary CRT.

Revisiting the role of positron-emission tomography/computed tomography in determining the need for planned neck dissection following chemoradiation for advanced head and neck cancer

OBJECTIVES/HYPOTHESIS

Planned neck dissection following chemoradiation (CR) has been advocated in patients with head and neck squamous cell cancer (HNSCC) with advanced nodal disease and a clinical complete response to CR because of the potential for residual occult nodal disease. The utility of positron-emission tomography/computed tomography (PET-CT) in identifying occult nodal disease in this scenario is controversial.

METHODS

The medical records of all patients treated with CR for advanced HNSCC with N2 or N3 disease from December 2003 to June 2007 were reviewed. Patients with a complete clinical response were included if PET-CT performed 8 to 11 weeks after CR showed no distant disease and they underwent planned neck dissection.

RESULTS

Thirty-two patients met study criteria. PET-CT was positive for residual nodal disease in 20 patients (63%). Pathology revealed carcinoma in 10 patients (31%): six of 20 patients with positive PET-CT scans (30%) and four of 12 patients with negative PET-CT scans (33%). The sensitivity and specificity of PET-CT was 60% and 36%. Regional recurrence developed in two patients (6%) who were not successfully salvaged.

CONCLUSIONS

PET-CT performed 8 to 11 weeks after CR does not reliably predict the need for planned post-treatment neck dissection in patients with a complete clinical response following CR. Regional recurrence rates are comparable to those reported for patients observed with PET-CT, suggesting no advantage for planned neck dissection, and salvage rates were poor. These data suggest that delaying the timing of PET-CT, with surgery reserved for positive findings, is a reasonable alternative to planned neck dissection to avoid unnecessary surgery.

Cost-effectiveness of CT and PET-CT for determining the need for adjuvant neck dissection in locally advanced head and neck cancer

BACKGROUND

Patients with node-positive head and neck squamous cell carcinomas (HNC) have a significant risk of residual disease (RD) in the neck after treatment, despite optimal chemoradiotherapy (CRT). Adjuvant neck dissection (ND) after CRT has been considered standard treatment, but its morbidity has led investigators to consider using post-CRT imaging to determine the need for surgery. We analyzed the cost-effectiveness of computed tomography (CT) and positron emission tomography-computed tomography (PET-CT) as predictors of the need for ND compared with ND for all patients.

MATERIALS AND METHODS

We developed a Markov model to describe health states in the 5 years after CRT for HNC in a 50-year-old man. We compared three strategies: dissect all patients, dissect patients with RD on CT, and dissect patients with RD on PET-CT. Probabilistic sensitivity analyses were carried out to model uncertainty in PET-CT performance, up-front and salvage dissection costs, and patient utilities.

RESULTS

ND only for patients with RD on PET-CT was the dominant strategy over a wide range of realistic and exaggerated assumptions. Probabilistic sensitivity analyses confirmed that the PET-CT strategy was almost certainly cost-effective at a societal willingness-to-pay threshold of $500,000/quality-adjusted life year.

CONCLUSION

Adjuvant ND reserved for patients with RD on PET-CT is the dominant and cost-effective strategy.

Outcome with neck dissection after chemoradiation for N3 head-and-neck squamous cell carcinoma

PURPOSE

To evaluate the role of neck dissection (ND) after chemoradiation therapy (CRT) for head and neck squamous cell carcinoma (HNSCC) with N3 disease.

METHODS AND MATERIALS

From March 1998 to September 2006, 70 patients with HNSCC and N3 neck disease were treated with concomitant CRT as primary therapy. Response to treatment was assessed using clinical examination and computed tomography 6 to 8 weeks posttreatment. Neck dissection was not routinely performed and considered for those with less than complete response. Of the patients, 26 (37.1%) achieved clinical complete response (cCR) after CRT. A total of 31 (44.3%) underwent ND after partial response (cPR-ND). Thirteen patients (29.5%) did not achieve cCR and did not undergo ND for the following reasons: incomplete response/progression at primary site, refusal/contraindication to surgery, metastatic progression, or death. These patients were excluded from the analysis. Outcomes were computed using Kaplan-Meier curves and were compared with log rank tests.

RESULTS

Comparing the cCR and cPR-ND groups at 2 years, the disease-free survival was respectively 62.7% and 84.9% (p = 0.048); overall survival was 63.0% and 79.4% (p = 0.26), regional relapse-free survival was 87.8% and 96.0% (p = 0.21); and distant disease-free survival was 67.1% and 92.6% (p = 0.059). In the cPR-ND group, 71.0% had no pathologic evidence of disease (PPV of 29.0%).

CONCLUSIONS

Patients with N3 disease achieving regional cPR and primary cCR who underwent ND seemed to have better outcomes than patients achieving global cCR without ND. Clinical assessment with computed tomography is not adequate for evaluating response to treatment. Because of the inherent limitations of our study, further confirmatory studies are warranted.

[Neck dissection following chemoradiation for node positive head and neck carcinomas]

The optimal timing and extent of neck dissection in the context of chemoradiation for head and neck cancer remains controversial. For some institutions, it is uncertain whether neck dissection should still be performed upfront especially for cystic nodes. For others, neck dissection can be performed after chemoradiation and can be omitted for N1 disease as long as a complete response to chemoradiation is obtained. The question is debated for N2 and N3 disease even after a complete response as the correlation between radiological and clinical assessment and pathology may not be reliable. Response rates are greater than or equal to 60% and isolated neck failures are less than or equal to 10% with current chemoradiation protocols. Some therefore consider that systematic upfront or planned neck dissection would lead to greater than or equal to 50% unnecessary neck dissections for N2-N3 disease. Positron-emission tomography (PET) scanning to assess treatment response and have shown a very high negative predictive value of greater than or equal to 95% when using a standard uptake value of 3 for patients with a negative PET at four months after the completion of therapy. These data may support the practice of observing PET-negative necks. More evidence-based data are awaited to assess the need for neck dissection on PET. Selective neck dissection based on radiological assessment and peroperative findings and not exclusively on initial nodal stage may help to limit morbidity and to improve the quality of life without increasing the risk of neck failure. Adjuvant regional radiation boosts might be discussed on an individual basis for aggressive residual nodal disease with extracapsular spread and uncertain margins but evidence is missing. Medical treatments aiming at reducing the metastatic risk especially for N3 disease are to be evaluated.

The role of CT and ¹⁸F-FDG PET in managing the neck in node-positive head and neck cancer after chemoradiotherapy

CONCLUSION

Patients showing a complete response on computed tomography (CT) can be spared from neck dissection.

OBJECTIVE

To determine whether CT or fluorine-18-fluorodeoxyglucose positron emission tomography ((18)F-FDG PET) is superior in the evaluation of persistent nodal disease after chemoradiotherapy in patients with node-positive head and neck squamous cell carcinoma (HNSCC).

PATIENTS AND METHODS

Study entry criteria included node-positive HNSCC treated with definitive chemoradiotherapy, a local complete response, and post-treatment CT and (18)F-FDG PET studies 7 weeks after chemoradiotherapy. Forty-eight patients with 60 node-positive necks were eligible. Nodes larger than 1 cm, or with central necrosis on CT, or any visually hypermetabolic nodes on (18)F-FDG PET were considered positive. Regardless of PET findings, necks with positive CT were subjected to neck dissection, whereas those with negative CT were observed without neck dissection.

RESULTS

Twenty-two necks showed positive CT, 20 and 2 of which underwent neck dissection and fine needle aspiration cytology, respectively, resulting in pathologic evidence of persistent nodal disease in 13 necks. Five of 38 necks with negative CT developed regional recurrence. Diagnostic accuracy was equivalent between CT and (18)F-FDG PET. There was no difference in 3-year cause-specific survival between patients with positive and negative CT (79% and 81%, respectively).

PET monitoring of therapy response in head and neck squamous cell carcinoma

In the Western world, more than 90% of head and neck cancers are head and neck squamous cell carcinomas (HNSCCs). The most appropriate treatment approach for HNSCC varies with the disease stage and disease site in the head and neck. Concurrent chemoradiotherapy has become a widely used means for the definitive treatment of locoregionally advanced HNSCC. Although this multimodality treatment provides higher response rates than radiotherapy alone, the detection of residual viable tumor after the end of therapy remains an important issue and is one of the major applications of (18)F-FDG PET. Studies have shown that negative (18)F-FDG PET or PET/CT results after concurrent chemoradiotherapy have a high negative predictive value (>95%), whereas the positive predictive value is only about 50%. However, when applied properly, FDG PET/CT can exclude residual disease in most patients, particularly patients with residual enlarged lymph nodes who would otherwise undergo neck dissection. In contrast to other malignancies, data are limited on the utility of (18)F-FDG PET for monitoring the response to induction chemotherapy in HNSCC or for assessing treatment response early during the course of definitive chemoradiotherapy. The proliferation marker (18)F-3'-deoxy-3'fluorothymidine is currently under study for this purpose. Beyond standard chemotherapy, newer treatment regimens in HNSCC take advantage of our improved understanding of tumor biology. Two molecules important in the progression of HNSCC are the epidermal growth factor receptor and the vascular endothelial growth factor (VEGF) and its receptor VEGF-R. Drugs attacking these molecules are now under study for HNSCC. PET probes have been developed for imaging the presence of these molecules in HNSCC and their inhibition by specific drug interaction; the relevance of these probes for response assessment in HNSCC will be discussed. Hypoxia is a common phenomenon in HNSCC and renders cancers resistant to chemo- and radiotherapy. Imaging and quantification of hypoxia with PET probes is under study and may become a prerequisite for overcoming chemo- and radioresistance using radiosensitizing drugs or hypoxia-directed irradiation techniques and for monitoring the response to these techniques in selected groups of patients. Although (18)F-FDG PET/CT will remain the major clinical tool for monitoring treatment in HNSCC, other PET probes may have a role in identifying patients who are likely to benefit from treatment strategies that include biologic agents such as epidermal growth factor receptor inhibitors or VEGF inhibitors.

Controversies in surgical management of the node-positive neck after chemoradiation

The addition of chemotherapy to radiation in the treatment of advanced-staged head and neck cancer has improved local-regional control and increased complete clinical and pathologic response rates in the neck. However, for those patients with residual neck disease on a posttreatment computed tomography (CT) scan, there remains significant controversy as to how to further assess the neck for the presence of a viable tumor and when to perform a neck dissection. Recently, investigators from Australia have assembled level I evidence to support the use of positron-emission tomography (PET) scanning to assess treatment response and have shown a very high negative predictive value for patients with a negative PET at 12 weeks after the completion of therapy. These data support the practice of observing PET-negative necks and intervening with neck dissection in PET-positive necks. However, not all investigators, practitioners, and patients are comfortable with delaying intervention for such a long time interval after treatment. The authors favor assessment of the neck with a CT scan at 6 weeks after the completion of chemoradiotherapy and recommend neck dissection for patients with radiographic residual disease at this time point. One rationale is that 6 weeks is an optimal window for operative intervention after acute treatment effects have subsided and before extensive fibrosis and scarring, which translates to less morbidity for the patient who is treated surgically. Another rationale is that those who develop regional recurrence can be hard to salvage surgically, and waiting an additional 6 weeks could allow for the expansion of resistant clones. The significance of this is unclear, however, because patients with residual disease are at a higher risk for local and distant as well as regional failure. Thus, further prospective studies of the role of postchemoradiotherapy PET scanning and neck dissection are needed.

Role and extent of neck dissection for persistent nodal disease following chemo-radiotherapy for locally advanced head and neck cancer: how much is enough?

PURPOSE

Neck dissection (ND) is routinely performed for persistent nodal disease after definitive chemo-radiotherapy (CRT) for locally advanced head and neck cancer. This study analyzes the role and extent of ND necessary after CRT based on pathologic outcome.

PATIENTS AND METHODS

The study is based on 42 patients undergoing 48 ND's for persistent nodal disease after CRT. Patients were treated to a median radiation dose of 70.4 Gy at 1.8-2 Gy per fraction concurrently with platinum based chemotherapy. Patients with documented residual disease in neck, based on clinical or radiological examination underwent ND at a median interval of 59 days after completion of CRT.

RESULTS

Of the 42 patients undergoing ND, 11 (26%) had positive findings on pathologic evaluation. The clinical and treatment characteristics were similar for node negative and positive patients. The involved nodal level(s) were always confined within the clinically documented persistent disease. The median percentage of positive nodes to total nodes removed was 10%. Almost 50% of positive nodes removed had only microscopic or minute viable cancer pathologically. The outcome was better for pathologically node negative patients in comparison to node positive patients.

CONCLUSION

The results of this study suggest that standard ND appears to be an excessive treatment for persistent nodal disease after CRT. Limited ND or even gross nodal resection confined to involved nodal level(s) as identified clinically or radiologically should be tested in a prospective randomized trial for reducing treatment related morbidity while maintaining excellent loco-regional control.