Response of Neck Metastases to Chemoradiation§

Abstract

Objectives: To analyze the response of neck disease to treatment with primary chemoradiation. Methods: Retrospective review of patients with head and neck cancer treated with chemoradiation with curative intent at a Veterans hospital. Results: Thirty-four patients were identified who received concomitant chemotherapy and radiation: 7 patients with N1, 22 with N2, and 7 with N3 disease. 78% of patients had complete clinical and radiographic response of their neck disease following treatment. Eleven patients underwent neck dissection post treatment. 33% of the neck specimens had pathologically positive nodes. 81% of patients were alive without evidence of recurrent disease in the primary site or neck at last follow-up. Conclusions: The majority of HNSCC patients treated with chemoradiation have complete response in the neck. Patients with clinical and radiographic evidence of complete response in the neck may not require neck dissection, even with N2 or greater disease. INTRODUCTION Multiple treatment modalities have been used for the treatment of head and neck squamous cell carcinoma (HNSCC). Over the last fifteen years there has been a trend toward organ preservation protocols for HNSCC. Since the original studies on laryngeal preservation were published in 1991 [1], there has been a shift toward use of primary chemoradiation, with curative intent, for oropharyngeal and hypopharyngeal squamous cell carcinomas as well. Chemoradiation has been shown to give excellent locoregional control rates for HNSCC and is a reasonable alternative to surgery with postoperative radiation for selected tumors [2]. However, there continues to be ongoing discussion regarding the best management of advanced neck disease with this modality and the role of a planned neck dissection in this setting. Some authors advocate planned neck dissection following CRT for all patients with N2 or N3 disease pre-treatment, while others believe patients without clinical or radiographic evidence of neck disease do not necessarily need a neck dissection [3-8]. This study has two objectives: (1) to analyze the response of neck disease to treatment of HNSCC patients with primary chemoradiation (CRT); and (2) to determine whether a planned neck dissection should be done following chemoradiation in patients who had positive neck disease pre-treatment. *Address correspondence to this author at the Division of Head and Neck Surgery, David Geffen School of Medicine at UCLA, 10833 LeConte Avenue, CHS 62-132, Los Angeles, CA 90095-1624, USA; Tel: (310) 2683407; Fax: (310) 206-1393; E-mail: mbwang@ucla.edu Presented at the Annual Meeting of the American Academy of Otolaryngology-Head and Neck Surgery, Toronto, Canada, September 18-20, 2006. METHODS Institutional Review Board approval for this project was obtained. Medical records for 280 HNSCC patients were reviewed between March 2000 and January 2006 at the West Los Angeles VA Medical Center. Inclusion criteria included patients with advanced stage (stage III and IV) HNSCC who also had positive nodal disease (N1, N2, or N3) and were treated with primary chemoradiation. To be included these patients also must have completed a full course of conventional external beam radiation (over 5 to 7 weeks) and at least one concurrent dose of chemotherapy (Table 2). Exclusion criteria included squamous cell carcinoma of other areas of the head and neck including salivary glands, distant metastases at diagnosis, absence of cervical nodal disease, and any patients that did not complete radiation therapy or did not receive at least one dose of chemotherapy. A total of 36 subjects were identified and included in this study. RESULTS There were 36 HNSCC patients identified during this time period who were treated with primary CRT and had positive cervical adenopathy pre-treatment. Primary sites included the oral cavity, oropharynx, hypopharynx, and unknown primary. There were 35 males and 1 female. The age range was from 47 to 82 (median 62.5). There were 7 patients with N1 disease, 22 with N2 (3 with N2a, 13 with N2b, and 6 with N2c), and 7 with N3 nodal disease. Followup ranged from 2 to 66 months (median 22.5) (Table 1). Nearly all patients received a platinum-based chemotherapy regimen concomitant with their radiation (Table 2). Patients received one to three cycles of chemotherapy, with Response of Neck Metastases to Chemoradiation The Open Otorhinolaryngology Journal, 2008, Volume 2 47 Table 1. Patient Characteristics Characteristics Value Age, range (median), y 47-82, 62.5