Planned neck dissection as an adjunct to the management of patients with advanced neck disease treated with definitive radiotherapy: for some or for all?

Abstract

Management of patients with head and neck carcinoma and advanced nodal disease is controversial. The purpose of this analysis was to evaluate the efficacy and toxicity of definitive radiotherapy followed by planned neck dissection in patients with bulky neck disease. The records of 52 patients who were treated between 1989 and 1995 at the Peter MacCallum Cancer Institute with a planned neck dissection after radical radiotherapy were reviewed. All had advanced neck disease with one or more nodes >/=3 cm in maximum diameter, 94% being staged N2-3. The most common primary site was the oropharynx (56%). Sixty percent of patients had either T2 or T3 primaries and all were AJCC stage IV. Treatment consisted of high-dose radiotherapy to the primary and involved neck sites using various fractionation protocols followed by radical or modified radical neck dissection after confirmation of a complete response at the primary site. The median follow-up for living patients was 58 months (range 32-97). There were nine regional failures, of which three were outside the dissected neck, yielding a 5-year actuarial overall neck control rate of 83% and an in-field control rate of 88%. In-field control rates by neck stage were N1 3/3; N2 31/35; N3 11/13 and NX 1/1. There was only one in-field failure among 28 patients who had pathologically negative neck specimens compared with five in 24 patients with morphologic evidence of residual disease. Of the 24 patients with pathologically positive necks, 5 were long-term survivors and were probably cured by their surgery. Another 4 died of intercurrent disease without documented recurrence of their head and neck cancer. Ten patients recurred at their primary sites (5-year actuarial control 79%) and 8 developed distant metastases (5-year actuarial rate 20%). A total of 21 patients failed at one or more sites and none was salvaged. Five-year actuarial disease-free survival was 57% and overall survival 38%. Nine patients (17%) sustained significant complications following neck dissection. In patients with advanced neck disease who are treated primarily with radical radiotherapy, planned neck dissection provides excellent regional control and appears to cure a subset of patients. However, routine neck dissection adds significant morbidity to treatment and should ideally be avoided in those patients in whom surgery is either unnecessary (no residual tumor) or futile (unsalvageable disease recurrence outside the dissected neck). Based on our analysis and other recently reported series, we now recommend observing patients who have a complete response to high-dose radiotherapy (+/- chemotherapy). The ability of PET imaging to detect residual viable tumor in the head and neck or at distant sites is under investigation.