Lymph Node-Positive Head and Neck Cancer Treated With Primary Radiotherapy: Can Treatment Response Determine the Extent of Neck Dissection?

Extent of neck dissection required after concurrent chemoradiation for stage IV head and neck squamous cell carcinoma

“…Sewall et al 38 demonstrated equivalent results after comprehensive and selective neck dissection with respect to regional control and survival-a finding that has been supported recently by others. 21,32 The current study confirms the effectiveness of SND and SSND, when surgically possible, in this patient population. Despite the tendency to perform more aggressive neck dissection in patients with greater pretreatment nodal stage, our data suggest that residual neck disease is found almost exclusively in the originally positive levels, or the next distal level, and that dissection of clinically involved nodal regions plus 1 adjacent nodal level would appear sufficient.…”

“…Yeung et al 21 examined the ability of CT assessment of treatment response to guide neck dissection after definitive radiotherapy (AE chemotherapy). The CT scan had a !95% negative predictive value (NPV) at each level of the neck posttreatment, even when adjacent levels were pathologically involved.…”

“…6,13 However, this practice has not been universally adopted, as the result of reservations about operating in an irradiated neck, because multiple studies have confirmed an increased risk of complications in such a setting. [17][18][19][20] In an attempt to avoid these complications in patients whose neck disease was controlled with CCRT, some institutions have begun to rely on posttreatment imaging studies, such as CT, 21 positron emission tomography (PET), 22 or PET-CT, 23,24 to guide neck treatment. Others have found imaging studies to be inconsistent predictors of pathologic response with unacceptably high false-negative rates.…”

“…[29][30][31] Recently, some authors have demonstrated equivalent control rates with SND compared with comprehensive neck dissection, sparing the patient both function and morbidity. 21,32 The extent of neck dissection necessary in the pretreatment Nþ neck treated with initial CCRT has not yet been completely defined.…”

Neck dissection after radiochemotherapy in patients with locoregionally advanced head and neck cancer

“…A trend toward higher subjective morbidity of grade 3 and 4: pain (24 vs. 17%), dysphagia (48 vs. 35%) and hoarseness (20 vs. 9%), was evident in patients with ND [13]. Recently Yeung et al, from Florida, found that the 5-year neck control rate in patients with a radiological CR who did not undergo a ND and were followed was 100%, and there was a 5% risk of leaving behind disease in the neck if the ND was limited to the levels of residual adenopathy as determined by post-RT CT. A CR rate was defined as the absence of any lymph nodes greater than 1.5 cm in the greatest axial dimension and lymph nodes with any focal lucency, focal enhancement or focal calcifications [14]. The major advantage is the reduction in morbidity: neck fibrosis, shoulder pain, shoulder disfunction; especially if the spinal accessory nerve is damaged or sacrificed.…”