Controversies in management of the neck in head and neck cancer

Abstract

As definitive external radiation and multimodality organ preservation strategies (eg, combined chemotherapy and radiation therapy ) improve, the role of surgery is being re-examined in the management of locally advanced head and neck cancer. Consensus regarding the use of neck dissections for complete responders and incomplete responders has yet to be achieved and the data are surprisingly controversial. A possible benefit from neck dissection after a complete response of the primary tumor after CCRT or definitive external radiation for advanced squamous cell carcinoma of the head and neck may only be anticipated in patients with persisting subclinical neck disease who have no other sites of disease. Some clinicians have even argued that the salvage rate for clinically detectable residual neck disease does not justify neck dissection. Randomized data addressing these questions and a trial addressing the accuracy of new imaging modalities, such as postchemotherapy and postradiation positron emission tomography scanning, across multiple institutions would be appropriate. As a department, we are aggressive in our treatment of isolated residual neck disease after CCRT or definitive external radiation and for patients initially diagnosed with N3 nodal disease. We are investigating the use of adjuvant neck brachytherapy at the time of neck dissection and we are pleased with our early results.

Interstitial high‐dose‐rate brachytherapy combined with cervical dissection on head and neck cancer

“…Randomized data addressing these questions and a trial addressing the accuracy of new imaging modalities, such as postchemotherapy and postradiation positron emission tomography scanning, across multiple institutions would be appropriate. 18 As a multidisciplinary department, we are aggressive in our treatment policy for isolated residual or recurrent neck disease, even after definitive EBRT.…”

PET-NECK: a multicentre randomised Phase III non-inferiority trial comparing a positron emission tomography–computerised tomography-guided watch-and-wait policy with planned neck dissection in the management of locally advanced (N2/N3) nodal metastases in patients with squamous cell head and neck cancer

“…The rationale is that, among patients who exhibit a clinical CR in the neck following CRT, the recurrence rate in the neck is low (< 10%), and similar to that (8%) in patients with pathologically negative neck following ND. 8,16 Other level 2/3 studies 9,17,18 have also found that ND in patients who show a CR to CRT does not confer any benefit in terms of improved survival or reduction in nodal recurrence compared with a watch-and-wait policy. Importantly, a large retrospective cohort study found that 43% of patients showed CR on CT, with a control rate of 92% at 5 years.…”

“…However, studies are small, mainly retrospective, single-centre studies. Many authorities on head and neck (H&N) cancer and literature reviews 7,8 have stressed the need for a multicentre randomised trial to obtain an answer to this important question.…”

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“…Some clinicians have even argued that the salvage rate for clinically detectable residual neck disease does not justify neck dissection being performed. Randomized trials addressing these questions, and a trial addressing the accuracy of new imaging modalities such as post chemotherapy and post radiation positron emission tomography scanning, across multiple institutions would be appropriate [50,51]. …”