Salvage Neck Dissection Research Articles

Efficacy of salvage neck dissection for isolated nodal recurrences in early carcinoma of oral tongue with watchful waiting management of initial N0 neck

Recent studies have shown that salvage treatment may be effective for early tongue carcinoma with nodal failures after watchful waiting policy. We wanted to assess the efficacy of salvage neck dissection. We conducted a retrospective review of all patients with pT1 and pT2 oral tongue cancer who underwent partial glossectomy without any neck surgery and determined the survival after salvage neck dissection in this group of patients. Seventy patients with N0 disease underwent partial glossectomy, 20 patients had development of isolated nodal failures after watchful waiting policy. Apart from the initial T classification, which found to have significant difference in 5-year disease specific survival rate (100% vs 46%, p = .023); other parameters including age, sex, tumor thickness, adjuvant radiotherapy and rN classification had shown no significance in affecting survival. Salvage neck dissection may not be effective for controlling isolated nodal recurrence in patients with oral tongue carcinoma with T2 disease.

Residual cervical lymphadenopathy after definitive treatment of nasopharyngeal carcinoma: fine needle aspiration cytology, computed tomography and histopathological findings

Patients with nasopharyngeal carcinoma may have residual cervical lymphadenopathy after definitive treatment of the primary tumour and regional cervical nodal disease. Whether such lymphadenopathy truly represents persistent disease is unclear. There are few published studies addressing this clinical problem. We retrospectively and systematically reviewed the clinical records of 12 patients with nasopharyngeal carcinoma who had presented to a tertiary academic hospital, over an 11-year period, with suspected persistent cervical nodal disease after definitive radiotherapy or concurrent chemoradiotherapy. Findings on fine needle aspiration cytology and computed tomography scanning were correlated with final histopathological results. The incidence of negative neck dissection was 41.7 per cent. The positive and negative predictive values of fine needle aspiration cytology in identifying disease were 100 and 42.9 per cent, respectively. Computed tomography scanning had a positive predictive value of 58.3 per cent in identifying disease. In patients treated definitively for nasopharyngeal carcinoma, residual cervical lymphadenopathy may not represent persistent disease. Head and neck surgeons involved in the management of these patients should bear in mind the current limitations of fine needle aspiration cytology and computed tomography in confirming the diagnosis pre-operatively. Salvage neck dissection may over-treat some of these patients.

Prospective Assessment of Patterns of Failure After High-Precision Definitive (Chemo)Radiation in Head-and-Neck Squamous Cell Carcinoma

To prospectively analyze patterns of failure in patients with head-and-neck squamous cell carcinoma treated with definitive high-precision radiotherapy with a focus on location of failure relative to target volume coverage. Sixty patients treated with three-dimensional conformal radiotherapy or intensity-modulated radiation therapy were included. Locoregional failure volume was defined on the planning data set at relapse, and dose received was analyzed by use of dose-volume histograms. Thirteen patients were deemed to have had locoregional failures, of which two did not have any viable tumor on salvage neck dissection, leaving eleven patients with proven persistent or recurrent locoregional disease. Of these, 9 patients had in-field failure, 1 marginal failure, and 1 both in-field and marginal failures. Overall, only 2 of 11 patients (18%) with relapse had any marginal failure. Of the 20 sites of locoregional failure, 15 (75%) were in-field and 5 (25%) marginal. Distant metastases were detected in 3 patients, whereas a second new primary developed in 3 others. With a median follow-up of 26 months (interquartile range, 18-31 months) for surviving patients, the 3-year local control, locoregional control, disease-free survival, and overall survival rates were 75.3%, 74%, 67.2%, and 60.5%, respectively. Locoregional relapse remains the predominant pattern of failure in head-and-neck squamous cell carcinoma treated with high-precision definitive radiotherapy with the majority of failures occurring "in-field" within the high-dose volume. Marginal failures can occur, particularly in the vicinity of the spared parotid gland. The therapeutic index of high-precision conformal radiotherapy is largely dependent on adequate selection and delineation of target volumes and organs at risk.

Salvage surgery after induction chemotherapy with paclitaxel/cisplatin and primary radiotherapy for advanced laryngeal and hypopharyngeal carcinomas

Induction chemotherapy followed by primary radiotherapy in responders is considered an alternative to surgery for advanced cancer of the larynx and hypopharynx (LHC). Comparison of therapeutic approaches is challenging and must respect oncological and functional outcome as well as quality of life during and after treatment. One aspect of primary radiochemotherapy is the option of salvage surgery in case of residual tumor. The outcome after salvage surgery following new organ-preserving strategies has to be examined. All patients undergoing induction chemotherapy with paclitaxel and cisplatin followed by radiotherapy from 01/96 to 07/05 were included. Salvage surgery was performed either for local recurrence or suspected persistent nodal disease. Complete tumor removal, perioperative morbidity, and overall survival were analyzed in a retrospective study. 28 out of 134 patients underwent salvage surgery after primary treatment with induction chemotherapy and radiotherapy for advanced LHC. 15 patients had laryngectomy (LE) with neck dissection (ND), while 1 patient had lasersurgical partial laryngeal resection with ND for local recurrences. Twelve patients had salvage ND for suspicion of persistent lymph node metastases. 73% of LE patients had major postoperative problems such as pharyngocutaneous fistulas. In 56% of the cases, tumor removal turned out to be microscopically incomplete. Eight out of 12 patients who underwent salvage ND because of suspicious lymph nodes (66%) were free of vital tumor. When metastatic disease was present in the neck (4/12), recurrences occurred in 75% during postoperative follow-up. Only 2 out of 20 patients undergoing surgery for histologically proven recurrence after radiochemotherapy (10%) are actually tumor-free and alive after a mean observation time of 43.9 months. Salvage surgery for local recurrence is associated with high morbidity and poor oncological and functional outcome. ND for suspicious persistent nodal disease after radiochemotherapy can be an over-treatment. In our patients, it was burdened with cervical recurrences and distant metastases in presence of histologically confirmed lymph node metastases. In the light of our results, unfavourable outcome after salvage surgery must be pointed out when initially informing patients about different therapeutic options for advanced LHC.

Effectiveness of salvage selective and modified radical neck dissection for regional pathologic lymphadenopathy after chemoradiation

The objective of this study was to evaluate the effectiveness and safety of our careful observational strategy and neck dissections and the accuracy of ultrasound-guided fine-needle aspiration cytology, and to determine the prognostic factors for outcome and regional control after primary chemoradiation. Diagnostic evaluation of the regional status after concurrent chemoradiation for advanced head and neck cancer remains difficult, and the indications for a salvage neck dissection and its extent are not clearly defined. In a series of 540 patients, there was suspicion of regional residual or recurrent disease after chemoradiation in 61 patients who underwent 68 salvage neck dissections and 68 patients who were considered unresectable. For the patients with salvage neck dissection, the accuracy of ultrasound-guided fine-needle aspiration cytology was determined. Disease control in the neck, disease-specific and overall survival, and parameters that may have prognostic value for the outcome were evaluated. Neck dissection specimens contained viable tumor in 26 (43%) patients. Of these, 13 had selective neck dissections and 13 modified radical neck dissections. Ultrasound-guided fine-needle aspiration cytology had a sensitivity of 80% and specificity of 42%. Nine patients developed a regional recurrence after salvage neck dissection (5 located in contralateral neck). Five-year regional control and overall survival rates were 79% and 36%, respectively. Significant prognostic factors for overall survival were surgical margins and "residual versus recurrent disease" in multivariate analysis. Considering the good regional control rate and the high rate of unnecessary neck dissections with a theoretical planned neck dissection strategy, we conclude that a careful observational strategy is worthwhile and safe. For the evaluation of radiation treatment response, ultrasound-guided fine-needle aspiration cytology has a low specificity.

Role of concurrent chemoradiotherapy in organ preservation for locally advanced head and neck cancer

e17044 Background: Optimal management for head and neck cancer is controversial. Standard of care has been surgery followed by radiotherapy, but is done with the risk of organ resection. The VA larynx study, EORTC 24891, and 91–11 US Intergroup trial have shown that chemoradiotherapy is comparable to surgery with radiotherapy in laryngeal cancers while preserving organ function. It is unclear, though, whether this could be accomplished in other tumor sites without sacrificing locoregional control and/or survival. Methods: We performed a retrospective chart review of patients who were treated at the Miami VA Medical Center with chemoradiotherapy for advanced staged head and neck cancers from 1996 to 2008. The majority of patients (84%) received 5FU and cisplatin. The choice of chemoradiotherapy was either determined by patients’ choice or their comorbidities, such as pulmonary disease and cardiac disease, precluded them from undergoing major surgery. Primary endpoints included death, relapse rates, and disease-free survival; secondary endpoints were toxicities associated with treatment and diminished organ function. Results: A total of 62 patients were included. Out of these patients, 52% had stage III disease and 50% had primary sites in the oropharynx; the remaining included larynx and hypopharynx. 20% of patients required salvage neck dissection. Complications included severe mucositis (69%), dysphagia (19% short term, 34% long term), hoarseness (13%), and dry mouth (24%). 27% had relapse of disease and median time for disease-free survival was 26 months. A total of 35 patients had died with a 2-year survival rate of 59.6%. Overall survival was best for laryngeal and oropharyngeal cancer (63 and 46 months, respectively) compared to hypopharyngeal cancer (22 months). Conclusions: Concurrent chemoradiotherapy is a valid option for treatment of locally advanced head and neck cancers especially for laryngeal and possibly oropharyngeal primaries with significant but tolerable toxicities. Although organ preservation is possible for the majority of patients with locally advanced head and neck cancer, however, the poor survival seen in hypopharyngeal cancer needs further investigation. No significant financial relationships to disclose.

Survival of patients with neck recurrence following radical neck dissection: Utility of a second neck dissection?

Treatment of neck recurrence following radical neck dissection is extremely difficult. Retrospective review of 699 radical neck dissections was performed. Recurrence rates, host, tumor, treatment factors, and survival were analyzed. One hundred nineteen patients who had undergone radical neck dissections had recurrence, 69 were considered candidates for salvage surgery. Factors that increased the risk of neck recurrence were neck node (N) status and no adjuvant radiotherapy. Factors associated with radical salvage treatment were young age, good general condition, and low recurrent N classification. Five-year survival for salvage neck dissection was 31%. Young patients and low T and N classification did well. Low recurrent N classification and salvage surgery were associated with good prognosis for recurrence. In our study, radical neck dissection has a regional failure rate of 20%, a third of recurrence cases were offered curative treatment. Of these, 31% were cured with salvage surgery.

Indikationen zur chirurgischen Therapie des Oropharynxkarzinoms

Therapy of oropharyngeal squamous cell cancer traditionally has been radiation-based, with surgery mainly in reserve. With increasing depth of local infiltration and volume of regional metastases the role of surgery in safeguarding curative chances increases. However, after failed chemoradiation of oropharynx cancer, few patients are cured by salvage surgery. Thus, primary surgery with postoperative radiotherapy may be contemplated if circumtances are favorable. The oropharynx can be approached by transoral, transmandibular or transcervical routes. Primary surgery is increasingly valuable when resultant morbidity is decreased as in the case of more elaborated transoral approaches. Classical approaches also have improved with increasing use of midline mandibulotomy, marginal mandibulectomy, reconstructive surgery, selective neck dissection (ND), and rehabilitation. Elective ND is restricted to levels I or II to III or IV, therapeutic ND is comprehensive (classic or modified radical depending on capsular integrity), and salvage ND is individualized. Surgery, most often followed by radiotherapy, in selected cases of oropharynx cancer is an interesting alternative to chemoradiation, and in advanced disease a facultative but essential part of multimodal therapy.

Results of salvage therapy after failure of initial treatment for advanced olfactory neuroblastoma

Olfactory neuroblastoma is a very aggressive tumour with high rates of locoregional recurrence and distant metastasis. Therefore, salvage therapy plays an important role in control of these neoplasms. In this study, we present our experience and treatment outcomes for salvage therapy in patients with recurrent olfactory neuroblastoma. We retrospectively analysed 17 patients treated for advanced olfactory neuroblastoma during the last 15 years. The disease-free 5-year survival rate was 48% in all patients and 42% in the 17 patients with recurrence or distant metastasis. Salvage therapy was performed in 6 of 8 patients with recurrence or metastasis and proved successful in 50% of them. In the patients with locoregional recurrence, the success rate of salvage radiotherapy plus neck dissection was superior to salvage chemotherapy alone. In addition, 17% of the patients with distant metastasis after initial treatment died after salvage therapy. In 15% of patients with a clinical stage N0 at initial diagnosis, nodal recurrence developed and was successfully treated with salvage therapy. Complete surgical resection, including craniofacial resection and postoperative radiotherapy without elective neck dissection, is the preferred approach in the treatment of advanced olfactory neuroblastoma. In locoregional recurrence, successful salvage therapy may include selective neck dissection and radiotherapy, but in cases of distant metastasis, the prognosis was poor.

Transoral Carbon Dioxide Laser Supraglottic Laryngectomy and Irradiation in Stage I, II, and III Squamous Cell Carcinoma of the Supraglottic Larynx

To evaluate feasibility, functional outcome, and disease control of endoscopic surgery and irradiation in patients with squamous cell carcinoma of the supraglottic larynx. Prospective, single-arm, phase 2 multi-institutional trial. Southwest Oncology Group trial S9709. Thirty-four patients diagnosed as having stage I, stage II, or selected stage III (T1-2N1M0) supraglottic laryngeal carcinoma enrolled from September 15, 1997, to December 1, 2001. Transoral supraglottic laryngectomy by carbon dioxide laser followed by planned postoperative radiotherapy. Three-year progression-free survival, proportion of patients requiring tracheostomy as a result of surgery, and time to adequate oral intake. All 34 patients underwent surgery without major protocol deviation. Thirty-two patients (94%) completed planned postoperative radiotherapy without major deviation. At the time of analysis, only 1 patient (3%) had documented local disease recurrence at the primary disease site and required salvage total laryngectomy, and 2 patients (6%) had documented regional recurrence and required salvage neck dissection. Estimated 3-year progression-free survival and overall survival were 79% and 88%, respectively. No subjects required tracheostomy as a direct consequence of endoscopic resection. Patients who required tracheostomy before endoscopic resection due to either obstructive tumor bulk or unfavorable anatomy that precluded safe intubation (4 patients [12%]) were all decannulated in the early postoperative period (<or=1 week). Of the 34 patients, 24 (71%) recovered adequate oral intake (no longer requiring supplemental intravenous fluids or tube feeding) in the early postoperative period (before hospital discharge) (median time, 2 days; range, 1-7 days), with an additional 7 patients (21%) achieving delayed recovery (2.7-9.8 months). Three patients (9%) remained dependent on a feeding tube at last documented follow-up. Transoral endoscopic carbon dioxide laser excision of supraglottic tumors combined with postoperative radiotherapy appears feasible in a multi-institutional setting, with reasonable disease control. Although timing was variable, most patients recovered adequate swallowing in the early postoperative period.

Superselective Neck Dissection After Chemoradiation&lt;subtitle&gt;Feasibility Based on Clinical and Pathologic Comparisons&lt;/subtitle&gt;

To determine whether superselective neck dissection (removal of 2 or less contiguous neck levels) is effective salvage surgery for patients with residual single-level adenopathy after concomitant intra-arterial cisplatin and radiotherapy. Analysis of prospectively collected data. The study group comprised 177 patients (239 heminecks) with N+ disease. Intra-arterial treatment with cisplatin (150 mg/m2) on days 1, 8, 15, and 22 and radiation therapy (2 Gy/d) 5 times per week for 7 weeks. Comparisons were made between neck-level-specific disease at restaging and pathologic disease after neck dissection. Tumor sites included oropharynx (n = 81), hypopharynx (39), larynx (n=27), oral cavity (n = 19), and other (n = 11). Response of nodal disease based on clinical evaluation was as follows: complete response, 89 patients (50%); partial response, 81 patients (46%); progressive disease, 4 patients (2%); and unevaluable, 3 patients (2%). Of the 89 patients whose necks were restaged as a partial response, 73 had clinical evidence of residual adenopathy involving only 1 neck level. Within this subset, 54 patients (57 heminecks) subsequently underwent a salvage neck dissection, for which comparisons were made between the restaging evidence of residual adenopathy and the pathologic findings that were specific for each neck level. Only 2 of the 54 patients had evidence of pathologic disease extending beyond the single neck level: one had disease in a contiguous neck level, and the other had disease in a noncontiguous level. The use of superselective neck dissection with removal of only 2 contiguous neck levels would have encompassed known disease in all but 1 patient. Superselective neck dissection is feasible after this specific chemoradiation protocol has been administered to patients with persistent nodal disease that is confined to 1 level.

The role of interstitial brachytherapy with salvage surgery for the management of recurrent head and neck cancers

The role of interstitial brachytherapy (IBT) in the salvage surgical management of regional lymphatic metastases for head and neck cancer has not been defined to date. To further explore its therapeutic benefit in the management of head and neck squamous cell carcinoma, the authors reviewed their experience utilizing IBT at the M. D. Anderson Cancer Center. A retrospective chart review of all patients who were received IBT for cervical recurrences of head and neck cancer was undertaken. Twenty-two patients were identified; all patients underwent neck dissection and intraoperative placement of afterloading catheters as part of the salvage treatment. Soft tissue reconstruction was performed when necessary. The duration and dosage of salvage brachytherapy was reviewed, and the overall disease-free survival rates were determined. All patients had been treated with external beam radiation therapy prior to recurrence, with an average dose of 65 grays (Gy), and 46% of patients had undergone prior neck dissection. The median time to regional recurrence after definitive treatment was 30 months. Soft tissue coverage of the surgical bed with a muscle flap, most commonly a pectoralis major flap, was performed in 19 of 22 patients. The median IBT dose was 60 Gy over a total duration of 4 days. Postoperative complications were few, and there were no perioperative deaths. Recurrences in the reirradiated necks occurred in 27% of patients. Regional recurrences are common after multimodality treatment for head and neck cancer and are challenging to manage. Although its role has not been defined clearly, salvage neck dissection with IBT is beneficial in the management of recurrent lymphatic metastases of upper aerodigestive tract carcinomas.

Isolated neck recurrence after definitive radiotherapy for node‐positive head and neck cancer: Salvage in the dissected or undissected neck

The role of salvage neck dissection for isolated regional recurrences after definitive radiotherapy (RT) is ill-defined. Five-hundred fifty patients were treated with RT for lymph node-positive head and neck cancer. RT consisted of a median dose of 74.4 Gy. Chemotherapy was administered in 133 patients (24%). Patients were followed for neck failure after planned neck dissection (n = 341) or observation (n = 209). Salvage therapy was offered to those with isolated neck recurrences. There were 54 (10%) failures in the neck at a median 3.7 months after RT (range, 0 to 17 months). Thirteen patients had isolated recurrences after receiving definitive RT with (n = 11) or without (n = 2) neck dissection. Nine patients underwent attempted surgical salvage with or without re-irradiation and 4 were successfully salvaged without major complications. Patients with neck failure after definitive therapy usually have poor outcomes, but salvage attempts may be successful in selected patients with an isolated neck recurrence.

Role of Surgical Salvage for Regional Recurrence in Laryngeal Cancer

The aims of this study were to analyze the pattern of regional recurrence in laryngeal cancer, evaluate the role of surgical salvage, and identify factors affecting salvage outcome. Retrospective analysis was conducted on medical records from a 16-year period. Of 463 patients diagnosed with laryngeal cancer, 25 patients with regional recurrence managed with salvage neck dissection were identified and subject to study. Isolated local recurrences and all distant metastases were excluded. All patients were male with a median age of 61 years. The overall rate of regional recurrence was 5.4%. Median time to regional recurrence was 13 months. Isolated regional recurrence occurred in 76% of cases, whereas locoregional recurrence occurred in 24%. A 5-year survival rate for patients undergoing neck dissection as salvage management was 61.2%. Patients with recurrence in the contralateral neck were definitely associated with poor prognosis. Although standard statistical significance was not met, trends for poorer salvage result were identified in patients with a history of local recurrence before regional recurrence, recurrence in a previously dissected neck, and recurred node size of 3 cm or above. Our study shows that salvage neck dissection for regional recurrence in laryngeal cancer is an acceptable approach. Surgical eradication of disease should be warranted whenever possible. Prudent planning of management is mandatory in the presence of history of local recurrence before regional recurrence, previously dissected neck, large size of recurrent node, and contralateral neck recurrence.

Salvage neck dissections in oral and oropharyngeal squamous cell carcinoma: histological features in relation to disease category

The histological findings in a series of 37 salvage neck dissections from patients who had an oral or oropharyngeal squamous cell carcinoma managed initially by primary surgery with or without neck dissection, and without postoperative radiotherapy, are described. None of the cases had an intraoral relapse. Pathological stage N2 or N3 disease was seen in 87% of the 15 salvage dissections from ‘wait and watch’ necks, 100% of the 10 salvage dissections of contralateral necks and 50% of the 12 salvage dissections of operated necks. The typical ‘inverted-cone’ pattern of metastasis was seen in 87% of ‘wait and watch’ necks. Skip or non-contiguous metastases to level III/IV accounted for relapse in 30% of the contralateral and 66% of the operated necks. The median time interval between original surgery and the salvage neck dissection was 15 months (range 1–48 months). In at least 15% of cases, the short time interval coupled with the histopathological features suggested that the metastatic disease suddenly became more rapidly progressive following removal of the primary tumour.

P211 Salvage Neck Dissection in the Era of Combined Treatment Techniques for Head and Neck Cancer

P211 Salvage Neck Dissection in the Era of Combined Treatment Techniques for Head and Neck Cancer

The Role of Positron Emission Tomography Scans in the Management of the N‐Positive Neck in Head and Neck Squamous Cell Carcinoma After Chemoradiotherapy

The objective of this study was to determine the sensitivity, specificity, and predictive value of 18-fluorodeoxyglucose positron emission tomography (PET) in predicting residual cervical metastatic disease in patients with N-positive necks undergoing curative radiotherapy and chemoradiotherapy for squamous cell carcinoma (SCC) of the upper aerodigestive tract. The authors studied a prospective case series of patients (2003-2005) of patients undergoing radiotherapy and chemoradiotherapy for advanced head and neck SSC. Study entry criteria included N-positive neck disease, a complete response to treatment at the primary tumor site, posttreatment PET scan (8-12 weeks after completion of treatment), followed by salvage neck dissection. The posttreatment PET scan neck findings were correlated to the salvage neck dissection pathology report. The sensitivity, specificity, and predictive values of the PET scan to predict residual cervical metastatic disease after curative chemoradiotherapy were calculated. Twenty-one neck dissections (pretreatment N1 = 5, N2a = 2, N2b = 8, N3 = 6) were entered into the protocol. Four (19.0%) of the 21 neck specimens were positive for residual cervical metastatic disease, whereas the remaining 17 (80.9%) specimens demonstrated no residual carcinoma. The overall sensitivity and specificity were 75.0% and 64.7%, respectively. The positive predictive value was 33% and the negative predictive value was 91.7%. Although the role of posttreatment neck dissection remains controversial, the surgeon must rely on clinical examination and imaging studies. Our practice has been to perform planned staged neck dissections on all N2 and N3 necks, as well as N1 necks with an incomplete response to treatment. Based on this small prospective study, it appears that PET imaging lacks adequate sensitivity and specificity to reliably predict the presence of residual cervical metastatic disease after completion of chemoradiotherapy. With a negative predictive value of 91.7%, however, a negative PET scan appears to be a reliable predictor of the absence of residual tumor.

PET-CT vs contrast-enhanced CT: What is the role for each after chemoradiation for advanced oropharyngeal cancer?

The aim of our study was to assess the utility of positron emission tomography (PET) and 2 fluoro-2-deoxy-D-glucose coupled with neck CT compared with contrast-enhanced CT in predicting persistent cancer either at the primary site or cervical lymphatics in patients with oropharyngeal cancer treated with concurrent chemoradiation Thirty consecutive patients underwent clinical examination, PET-CT, and contrast-enhanced CT to assess response after the completion of the treatment. The outcome variable was positive tissue diagnosis or negative disease at 6 months. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were calculated for the primary site as well as cervical disease. Contrast-enhanced CT alone showed the best accuracy in detecting disease at the primary site after treatment (85.7%). Accuracy in evaluating residual tumor in the cervical lymphatics for contrast-enhanced CT and PET-CT was 59.3% and 74.1%, respectively. For evaluating the neck, PET-CT and contrast-enhanced CT demonstrated 100% NPV, but the PPV was 36.3% and 26.6%, respectively. In this preliminary study, PET-CT seems to be superior to contrast-enhanced CT in predicting persistent disease in the neck after chemoradiation for oropharyngeal or unknown primary cancer, but not at the primary site. However, the possibility of a false-positive result in the neck remains high, and thus overtreatment may result. Even more concerning are the false-negative results. Larger, prospective studies will be important in defining the role of PET-CT in obviating the need for salvage neck dissections after chemoradiation.

Does clinical and radiological response predict complete tumor control in N2–N3 squamous cell head and neck cancer after non-operative management of the neck?

Conclusion: A complete clinical and radiological response observed following chemotherapy and radiotherapy is not predictive of the absence of residual disease. Moreover, salvage neck surgery does not always seem to be an effective strategy. Consequently, early neck dissection should be advised for patients with complete clinical and radiological response (CCRR) after chemoradiotherapy for tumors with N2–N3 disease. Background: We retrospectively reviewed the outcome of 28 patients with N2–N3 disease treated initially with chemotherapy and radiotherapy. Patients and methods: A neck dissection was performed for all patients with residual disease in the neck. Results: A CCRR in the neck was achieved in 25 of 28 patients. The remaining three patients with residual neck mass underwent a salvage neck dissection: the pathological examination confirmed the persistence of tumoral disease. No regional failure was observed in these three patients. In 25 patients considered to have CCRR in the neck, 5 patients (20%) developed regional recurrence. Successful salvage approach was not possible for any of these patients.

Phase I study of concurrent chemoradiotherapy (CRT) with S-1 and cisplatin (CDDP) in patients (pts) with unresectable locally advanced squamous cell carcinoma of head and neck (SCCHN)

5575 Background: An oral drug, S-1, composed of tegafur, 5-chloro-2, 4-dihydroxypyrimidine, and oxonic acid in a 1:0.4:1 molar ratio has shown high activity for head and neck cancer with a response rate of 34%. The aim of this study was to determine the maximum tolerated dose (MTD) of S-1 in combination with CDDP and radiotherapy. Methods: Eligibility: histologically proven SCCHN with unresectable locally advanced lesions, PS 0–1, age ≤ 75, adequate organ functions, and no prior chemotherapy. Chemotherapy consisted of administration of S-1 twice daily on days 1–14 at escalating doses of 40, 60, and 80 mg/m2/day, and 2-hour infusions of CDDP at 20 mg/m2/day on days 8–11, repeated twice with a 5-week interval. Once daily radiotherapy of 70 Gy in 35 fractions was given concurrently starting on day 1. Two additional cycles of S-1 and CDDP were planned 4 weeks after the completion of CRT. Dose-limiting toxicities were defined as neutropenic fever lasting for 4 days, grade (gr) 4 thrombocytopenia, and gr 3 non-hematological toxicities except mucositis, dysphagia, anorexia, nausea, vomiting, and infection due to mucositis. Results: Seventeen pts were enrolled. One pt did not receive CRT because of disease progression. Gr 2–3 stomatitis, dysphagia, neutropenia, dermatitis and xerostomia were the most frequently observed adverse events. The MTD was reached at 80 mg/m2/day of S-1, with 2 of 6 pts experiencing neutropenic fever lasting for 4 days. Of 7 pts treated at 60 mg/m2/day of S-1, one pt developed gr 3 diarrhea, and another developed neutropenic fever lasting for 2 weeks. For the latter, a diagnosis of myelodysplastic syndrome was made based on bone marrow analyses. Of the 16 pts treated with CRT, 12 experienced a complete response (CR) according to RECIST. Two additional pts who had residual neck lymph node metastasis underwent salvage neck dissection and pathological CR was confirmed. Conclusions: S-1 at 60 mg/m2/day for 14 days and CDDP at 20 mg/m2/day for 4 days are recommended for CRT. Although data are preliminary, the CR rate was very promising, and this approach warrants further investigation. No significant financial relationships to disclose.