Abstract
Simple SummaryA retrospective multicentric study of 322 patients with head and neck cancers of unknown primary (HNCUP) was performed testing the impact of neck dissection (ND) extent on nodal relapse, progression-free survival and survival. After 5 years, the incidence of nodal relapse was 13.4%, and progression-free survival (PFS) was 59.1%. In multivariate analysis after adjusting for nodal stage, the risk of nodal relapse or progression was reduced with lymphadenectomy, selective ND or radical/modified ND but survival rates were similar. Patients undergoing lymphadenectomy or ND had significantly better PFS and a lower nodal relapse incidence in the N1 + N2a group, but the improvement was not significant for the N2b or N2 + N3c patients. Severe toxicity rates exceeded 40% with radical ND. In HNCUP, ND improves PFS regardless of nodal stage but fails to improve survival. The magnitude of the benefit of ND did not appear to depend on ND extent and decreased with a more advanced nodal stage.Purpose: Management of head and neck cancers of unknown primary (HNCUP) combines neck dissection (ND) and radiotherapy, with or without chemotherapy. The prognostic value of ND has hardly been studied in HNCUP. Methods: A retrospective multicentric study assessed the impact of ND extent (adenectomy, selective ND, radical/radical-modified ND) on nodal relapse, progression-free survival (PFS) or survival, taking into account nodal stage. Results: 53 patients (16.5%) had no ND, 33 (10.2%) had lymphadenectomy, 116 (36.0%) underwent selective ND and 120 underwent radical/radical-modified ND (37.3%), 15 of which received radical ND (4.7%). With a 34-month median follow-up, the 3-year incidence of nodal relapse was 12.5% and progression-free survival (PFS) 69.1%. In multivariate analysis after adjusting for nodal stage, the risk of nodal relapse or progression was reduced with lymphadenectomy, selective or radical/modified ND, but survival rates were similar. Patients undergoing lymphadenectomy or ND had a better PFS and lowered nodal relapse incidence in the N1 + N2a group, but the improvement was not significant for the N2b or N2 + N3c patients. Severe toxicity rates exceeded 40% with radical ND. Conclusion: In HNCUP, ND improves PFS, regardless of nodal stage. The magnitude of the benefit of ND does not appear to depend on ND extent and decreases with a more advanced nodal stage.
Highlights
Optimal neck management for patients with head and neck cancer of unknown primary (HNCUP) is still controversial [1]
neck dissection (ND) extent was associated with clinical nodal stage (Table 1, p < 0.001)
Adapted neck management from lymphadenectomy alone, which might be considered as hyper-selective ND, to radical ND, is based on clinical nodal stage and patient-related factors
Summary
Optimal neck management for patients with head and neck cancer of unknown primary (HNCUP) is still controversial [1]. The American Association of Clinical Oncology (ASCO) guidelines and the US National Comprehensive Cancer Network (NCCN) recommend performing, for small-volume nodal disease, either definitive surgery or radiotherapy (with or without chemotherapy). ASCO and NCCN guidelines recommend limiting the treatment of small nodes to a single modality (surgery or radiotherapy). In the mother publication of the current study by Pflumio et al, of 350 patients, 74.5% had unilateral disease and more than two-thirds of them had bilateral irradiation. The main objective of the study was to address the role of nodal and mucosal irradiation with an original hypothesis that unilateral irradiation would be responsible for 15% more relapses than bilateral irradiation. We showed that the regional control rate and occurrence of mucosal primaries did not differ between patients who had unilateral irradiation and those who had bilateral irradiation, and that severe toxicities were more frequent after bilateral than unilateral irradiation.
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