Clinical investigation
Necessity for adjuvant neck dissection in setting of concurrent chemoradiation for advanced head-and-neck cancer

Presented at the 44th Annual Meeting of the American Society for Therapeutic Radiology and Oncology, October 6–10, 2002, New Orleans, LA.
https://doi.org/10.1016/j.ijrobp.2003.09.004Get rights and content

Abstract

Purpose

Neck dissection has traditionally played an important role in the treatment of patients with squamous cell carcinoma of the head and neck who present with regionally advanced neck disease (N2-N3). Radiotherapy and concurrent chemotherapy improves overall survival in advanced head-and-neck cancer compared with radiotherapy alone. The necessity for postchemoradiation neck dissection is controversial. The intent of this report was to define the value of neck dissection in this patient population better.

Methods and materials

Patients with locally advanced squamous carcinoma of the head and neck who also presented with nodal disease and underwent hyperfractionated radiotherapy and concurrent cisplatin/5-fluorouracil chemotherapy constituted the study population. Adjuvant modified neck dissection (MND) was planned 6 to 8 weeks after completion of chemoradiation in those patients who had a biopsy-proven pathologically complete response at the primary tumor site, irrespective of the clinical/radiographic neck response. A cohort of patients underwent electrode assessment of tumor oxygenation. Pathologic findings from the MND were used to compute the negative and positive predictive values and overall accuracy of the clinical/radiographic response (cCR). Regional control, failure-free survival, and survival were compared according to whether patients actually underwent MND.

Results

A total of 154 patients received concurrent chemoradiation. Of these, 108 presented with nodal disease: N1, n = 30; and N2-N3, n = 78. MND was performed in 65 (60%) of 108 patients, including 13 (43%) of 30 with Stage N1 and 52 (66%) of 78 with Stage N2-N3. For N1 patients, the negative predictive value of a cCR, positive predictive value of less than a cCR, and the overall accuracy for clinical response was 92%, 100%, and 92%, respectively. For N2-N3 patients, the corresponding values were 74%, 44%, and 60%. Patients with poorly oxygenated tumors were more likely to have residual disease at MND. The median follow-up was 4 years. The 4-year disease-free survival rate was 70% for N1 patients, irrespective of the clinical response or whether MND was performed. The 4-year disease-free survival rate was 75% for N2-N3 patients who had a cCR and underwent MND vs. 53% for patients who had a cCR but did not undergo MND (p = 0.08). The 4-year overall survival rate was 77% vs. 50% for these two groups of patients (p = 0.04).

Conclusion

The clinical and pathologic responses in the neck correlated poorly with one another for patients with N2-N3 neck disease undergoing concurrent chemoradiation for advanced head-and-neck cancer. MND still appears to confer a disease-free survival and overall survival advantage with acceptably low morbidity. Tumor oxygenation assessment may be useful in selecting patients who are especially prone to have residual disease. Better tools need to be developed to determine prospectively whether this procedure is required for individual patients.

Introduction

Neck dissection has traditionally played an important role in the treatment of patients with squamous cell carcinoma of the head and neck who present with regionally advanced neck disease (N2-N3). This strategy evolved in the early 1970s from the recognition that the rate of ipsilateral neck recurrence was lower in those patients who received combined radiotherapy (RT) and surgery compared with either of those modalities alone (1). Modified fractionation regimens were initially adopted in the 1980s and facilitated the delivery of more efficacious, higher doses of RT. Despite this more intensive approach, the regional control rates remained greater with the incorporation of neck dissection into the treatment plan (2).

The emergence of RT and concurrent chemotherapy regimens in the 1990s led to additional improvements in treatment efficacy. A meta-analysis of >8000 patients treated on randomized trials through 1993 demonstrated an 8% absolute survival benefit for concurrent therapy over RT alone for patients with advanced disease (3). Many of the trials included in that analysis used regimens of RT and/or chemotherapy now known to be substandard. Several randomized trials with a cumulative enrollment of >1500 patients, all of which used state of the art RT and chemotherapy regimens, have been published since 1993. Each of these trials has demonstrated absolute improvement of approximately 20% in both locoregional control and overall survival 4, 5, 6, 7, 8, 9, 10, 11.

The necessity for neck dissection after concurrent chemoradiation is controversial 12, 13. Some have suggested that it is either superfluous or ineffective in this setting and should be abandoned (14). The rationale for this line of argument is that a clinical/radiographic complete response (CR) in the neck indicates total disease eradication and that additional surgery will not reduce the risk of regional recurrence; rather, it will only increase morbidity. The other contention of this viewpoint is that neck dissections are ineffective for patients with advanced disease because improvements in regional control do not reduce the propensity for distant failure and thus do not improve survival. Others assert that clinical parameters do not identify those who do not need the procedure.

This report constitutes the first analysis of the efficacy of neck dissection for patients with advanced neck disease receiving concurrent chemoradiation at Duke University Medical Center. Published data specifically addressing the role of neck dissection after concurrent chemoradiation are sparse 12, 13, 15, 16. An evaluation of the previously published data on this topic is also presented. Our overall intent was to define the value of neck dissection in this patient population better.

Section snippets

Methods and materials

Patients with locally advanced squamous carcinoma of the head and neck who also presented with nodal disease and underwent hyperfractionated RT and concurrent cisplatin/5-fluorouracil chemotherapy constituted the study population. This treatment program has been used at Duke University Medical Center since 1990. The details of this regimen have been previously published (9).

Adjuvant modified neck dissection (MND) was planned 6 to 8 weeks after completion of chemoradiation in those patients who

Results

Between 1990 and 2000, 154 patients received concurrent chemoradiation. Of these, 108 presented with nodal disease: 30 with N1, 62 with N2 (N2a, 23; N2b, 20; and N2c, 19), and 16 with N3. MND was performed in 65 (60%) of 108 patients, including 13 (43%) of 30 with N1, 43 (69%) of 62 with N2, and 9 (56%) of 16 with N3. Eighty-three percent of these patients presented with a T3-T4 primary. The primary tumor location was the oropharynx in 64%, larynx in 16%, hypopharynx in 13%, and oral cavity in

Discussion

The results of this study showed a therapeutic benefit associated with the incorporation of adjuvant MND into the treatment program for patients with N2-N3 neck disease and undergoing a course of concurrent chemoradiation. Patients who had a cCR in the neck and who did not have subsequent neck dissection had worse disease-free and overall survival than those patients who underwent neck dissection, irrespective of the clinical neck response in the latter group. This observation suggests that

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