Selective neck dissection following adjuvant therapy for advanced head and neck cancer

Abstract

In the past, surgeons believed that in order to eradicate regional disease, a radical or modified radical neck dissection was necessary. An evolution in surgical principles and the popularization of primary chemoradiation has raised the questions regarding the role of neck dissection and the extent of neck dissection following therapy. The aim of this study was to determine the efficacy of selective neck dissection (SND) for patients with N2 or N3 disease following treatment with primary radiation therapy or chemoradiation. A retrospective review of 58 patients with stage III or IV head and neck squamous cell carcinoma was conducted. The primary sites included base of tongue (n = 15), hypopharynx (n = 12), tonsil (n = 16), larynx (n = 11), and unknown primary (n = 4). Definitive treatment consisted of either concomitant chemoradiation (67.2%) or external beam radiation therapy (32.8%). In the monotherapy group, all patients received a total curative dose of 66 to 72 Gy in once-daily fractions of 180 to 200 cGy. The combined chemoradiation group received a similar radiation schedule and a 4-day continuous infusion of cisplatin (20 mg/m(2)/day) and 5-fluorouracil (1000 mg/m(2)/day). A planned SND of levels II to IV was performed on all the patients 3 to 6 weeks after completion of definitive medical therapy. Seventy neck dissections were performed on 58 patients with advanced neck disease following radiation or chemoradiation. The median time of follow-up was 34 months (range, 9-71 months) following the neck dissection. Pathologically, 22.4% (13/58) of the patients had viable tumor cells identified in the neck dissection specimen. Seventy-two percent of the patients are currently alive, and 28% died as a result of distant disease, local or regional recurrence, or other causes. Of patients who died from distant disease, 11% had pathological evidence of residual tumor cells identified in the neck dissection specimen. Of patients who died from local or regional disease, 50% had pathological evidence of residual tumor cells identified in the neck dissection specimen. The rate of regional recurrence following SND is similar to reported rates following modified/radical neck dissection. This suggests that SND provides an appropriate surgical option for advanced neck disease in select patients following adjuvant therapy.