Eur Arch Otorhinolaryngol DOI 10.1007/s00405-014-2893-x
Review Article
Is elective neck dissection indicated during salvage surgery for head and neck squamous cell carcinoma? Alvaro Sanabria · Carl E. Silver · Kerry D. Olsen · Jesus E. Medina · Marc Hamoir · Vinidh Paleri · Vanni Mondin · Alessandra Rinaldo · Juan P. Rodrigo · Carlos Suárez · Carsten C. Boedeker · Michael L. Hinni · Luiz P. Kowalski · Afshin Teymoortash · Jochen A. Werner · Robert P. Takes · Alfio Ferlito
Received: 30 October 2013 / Accepted: 14 January 2014 © Springer-Verlag Berlin Heidelberg 2014
Abstract Among patients with head and neck squamous cell carcinoma with a negative neck who are initially treated with (chemo)radiotherapy, a number of cases will recur locally without obvious neck recurrence. There is little information available as to the most efficacious management of the neck in these cases. We have reviewed the literature to see what conclusions can be drawn from previous reports. We conducted a bibliography search on MEDLINE and EMBASE databases. Studies published in the English language and those on squamous cell carcinoma of the oral This paper was written by members and invitees of the International Head and Neck Scientific Group (www.IHNSG.com). A. Sanabria Department of Surgery, Universidad de Antioquia, Hospital Pablo Tobón Uribe, Medellín, Colombia A. Sanabria Department of Surgery, Universidad de La Sabana, Chia, Colombia C. E. Silver Departments of Surgery and Otolaryngology, Head and Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA K. D. Olsen Department of Otorhinolaryngology, Mayo Clinic, Rochester, MN, USA J. E. Medina Department of Otorhinolaryngology, The University of Oklahoma Health Sciences Center, Oklahoma, OK, USA M. Hamoir Department of Head and Neck Surgery, Head and Neck Oncology Program, St. Luc University Hospital and Cancer Center, Brussels, Belgium
cavity, nasopharynx, oropharynx, larynx and hypopharynx were included. Data related to neck management were extracted from the articles. Twelve studies satisfied the inclusion criteria. Five studies reported only one treatment plan (either neck dissection or observation), while the others compared neck dissection to observation. The rate of occult metastases ranged from 3.4 to 12 %. The studies included a variable distribution of primary sites and stages of the recurrent primary tumors. The risk of occult neck node metastasis in a clinically rN0 patient correlated with tumor site and T stage. Observation of the neck can be suggested for patients with T1-2 glottic tumors, who recurred with less advanced tumors (rT1-2). For patients with more V. Paleri Department of Otolaryngology‑Head and Neck Surgery, Newcastle upon Tyne Foundation Hospitals NHS Trust, Newcastle upon Tyne, UK V. Mondin · A. Rinaldo · A. Ferlito ENT Clinic, University of Udine, Udine, Italy J. P. Rodrigo · C. Suárez Department of Otolaryngology, Hospital Universitario Central de Asturias, Oviedo, Spain J. P. Rodrigo · C. Suárez Instituto Universitario de Oncología del Principado de Asturias, Oviedo, Spain C. C. Boedeker Department of Otorhinolaryngology‑Head and Neck Surgery, Helios Hanseklinikum Stralsund, Stralsund, Germany M. L. Hinni Department of Otolaryngology‑Head and Neck Surgery, Mayo Clinic, Phoenix, AZ, USA
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advanced laryngeal recurrences or recurrence at other highrisk sites, neck dissection could be considered for the rN0 patient, particularly if the neck was not included in the previous radiation fields. Keywords Head and neck squamous cell carcinoma · Neck dissection · Chemoradiotherapy · Surgery · Salvage
Introduction Head and neck squamous cell carcinoma (HNSCC) is the seventh most frequent cause of death in the United States [1]. Most tumors are treated by surgery, radiotherapy, chemoradiotherapy or combinations of these modalities. Many current treatment protocols aim at “organ preservation” when possible, particularly with regard to the larynx. Although many patients present with advanced tumors with clinically evident neck metastasis, some are classified clinically as N0 (cN0). In some of these cases, prophylactic or “elective” neck dissection is not performed either because it is assumed that the tumor has a low risk of lymph node metastasis, or the neck will be treated by elective radiotherapy. In this scenario, organ preservation treatments can often produce complete cure. However, in up to 50 % of cases treated with organ preserving regimens and, depending on the primary tumor site and stage [2, 3], the tumor recurs locally without clinically evident recurrence in the neck. In these cases, “salvage” treatment is necessary for control of the recurrence and to achieve cure and long-term survival. Although there are instances of salvage treatment based exclusively on chemoradiotherapy [4–6], most cases are treated by surgery. However, there is little evidence on how the (still) clinically negative neck (rN0) should be treated in these patients. Some authors [2, 7] suggest performing an elective neck dissection either because of the possibility of occult neck metastasis, or because complex
L. P. Kowalski Department Otorhinolaryngology‑Head and Neck Surgery, Centro de Tratamento e Pesquisa Hospital do Cancer A.C. Camargo, São Paulo, Brazil A. Teymoortash · J. A. Werner Department of Otolaryngology‑Head and Neck Surgery, Philipp University, Marburg, Germany R. P. Takes Department of Otolaryngology‑Head and Neck Surgery, Radboud University Medical Center, Nijmegen, The Netherlands A. Ferlito (*) ENT Clinic, University of Udine, Piazzale S. Maria della Misericordia, 33100 Udine, Italy e-mail:
[email protected] 13
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reconstruction involving free flaps will require exposing the cervical structures anyway—thus justifying an “incidental” neck dissection. Others suggest a “wait and see” [8–10] policy. However, if untreated occult metastasis becomes apparent during follow-up, the possibilities of subsequent salvage are poor. This fact must be weighed against the morbidity associated with dissection of a previously irradiated neck including compromised wound healing, nerve injuries, bleeding, lymphatic fistula and functional and esthetic consequences. In cases with pathologically negative nodes, it offers no benefit at all. The purpose of this systematic review is to identify the evidence base that supports or refutes the use of elective neck dissection in patients with HNSCC initially classified as N0 who present clinically with isolated local recurrence after initial treatment with radiation therapy, with and without chemotherapy.
Materials and methods We conducted a bibliography search on MEDLINE and EMBASE databases for studies published from January 1990 to September 2013 ((head and neck neoplasms [Mesh]) OR (head and neck cancer)) AND ((neck dissection [Mesh]) OR neck dissection)) AND ((chemoradiotherapy [Mesh]) OR (chemotherapy) OR (radiotherapy) OR (radiochemotherapy) OR (chemo radiotherapy)) AND ((salvage) OR (rescue)). An expanded search was used with each relevant article using Boolean operators. References were explored to identify other articles. We included only studies published in the English language and those diagnosed with squamous cell carcinoma of the oral cavity, nasopharynx, oropharynx, larynx and hypopharynx. Articles dealing with planned neck dissection after chemoradiotherapy were excluded from this analysis. Only data related to neck management were extracted from the articles; therefore, articles dealing only with salvage surgery for local recurrence without any information about neck dissection were excluded.
Results The primary search identified 73 articles. Only twelve of these studies satisfied the inclusion criteria (Fig. 1). Some studies were excluded due to lack of specific data about neck dissection on N0 tumors [11–20]. One study was excluded because its data were included in a newer one [21]. Twelve studies met the inclusion criteria. Five [2, 22–25] were case series that studied only one regimen (either neck dissection [22–25] or observation [2]), while the others
Eur Arch Otorhinolaryngol
Fig. 1 Search strategy
were case series comparing neck dissection with observation [7–10, 26–28]. A summary of findings is shown in Table 1 [2, 7–10, 22–28]. Study assessing observation Yuen et al. [2] in 1995 evaluated 167 patients with rT3-4 larynx tumors. In this group, 126 were classified as N0; of these, 26 % (33/126) were staged T3N0 and 74 % (93/126) as T4N0. All patients were treated with resection of the recurrence at the primary site without neck dissection. Neck recurrence was detected in 23/126 (18 %) patients after controlling the local recurrence. Interestingly, 19/126 (15 %) patients presented with distant metastasis without neck recurrence. Salvage surgery was feasible for only 5/23 (21 %) of the neck recurrences. The 5-year actuarial survival rate of N0 patients was 45 %. This is the only report on neck observation and has the highest rate of neck recurrence. These findings can be explained by selection, as the authors only included advanced recurrent tumors (rT3-4) with a higher number of T4N0 patients (>70 %), who have a higher risk of occult neck metastases. Studies assessing routine neck dissection Wax and Touma [22] in 1999 reported on 34 patients with laryngeal tumors, initially staged as N0, who were treated exclusively with radiotherapy and developed local recurrence. They were then treated with laryngectomy and neck dissection (30 bilateral and 4 unilateral). 28/34 (82 %)
patients had tumors staged as T1-2 before recurrence and 20/34 (59 %) had glottic tumors. Lymph node metastases were found in 6/34 (17 %) patients, mostly with supraglottic tumors (4/14 (28 %) vs. 2/20 (10 %) with glottic tumors). The presence of nodal metastasis was directly related to the stage of the disease (Table 2) [7, 22, 24–26]. There were no regional failures after neck dissection. Temam et al. [23] in 2005 reviewed 30 patients with HNSCC staged originally as N0 and treated with curative intent using radiotherapy with or without concurrent chemotherapy, who presented with local recurrence after primary treatment and were treated by local salvage surgery and elective neck dissection. In this cohort, 17/30 (57 %) patients had oropharyngeal tumors and 15/30 (50 %) had tumors staged as T4N0. Only 1/40 (2.5 %) of the neck dissection specimens contained occult metastasis. After salvage surgery, 15 patients recurred, but only 3 of the 15 (20 %) had nodal recurrence, always occurring concomitantly with a second local recurrence. Solares et al. [24] in 2005 reviewed 69 patients originally staged N0, treated with radiotherapy with or without chemotherapy, who developed local recurrence and underwent salvage surgery and neck dissection. 37/69 (53 %) patients had larynx tumors. 17/69 (24 %) patients had lymph node metastasis. 7/17 (41 %) had more than two positive nodes and 3/17 (17 %) had extracapsular invasion. Supraglottic tumors had the highest frequency of metastasis (55 %), followed by hypopharynx (43 %), oral/oropharynx (20 %) and glottic cancers (12 %). 28/69 (40 %) patients had a second recurrence. There were no neck recurrences when the primary site was controlled. All patients who had more than two positive nodes had recurrence either at the primary site or distant metastasis. Unfortunately, this study did not report the T stage at the first examination and at the time of recurrence. Amit et al. [25] in 2013 reported on 42 patients with laryngeal cancer treated with chemoradiotherapy to the central or the lateral compartment of the neck depending on the stage of the primary. All patients had a negative neck at the time of local recurrence and underwent a salvage laryngectomy with paratracheal node dissection and modified radical neck dissection (42 unilateral and 9 bilateral). Originally, 36/42 (85 %) patients were staged N0, 24/42 (57 %) were T1–T2. 26/42 (62 %) patients had glottic tumors. Occult nodal metastases were found in 8/42 (19 %) patients with no instances of contralateral lymph node metastases. The frequency of occult metastases in patients with T1-2N0 tumors was 14 vs. 22 % in T3-4 or N+ patients. The frequency in glottic tumors was 15 vs. 25 % in supraglottic tumors. The rate of occult metastasis in the above studies ranged from 3.3 to 24.6 %. Some comparisons can help explain the differences. Wax and Touma [22] and Amit et al. [25]
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2005 Larynx (Glottic 26, Supraglottic 11), oropharynx (15) hypopharynx (7), oral cavity (10) 2005 Larynx (Supraglottic 3), oropharynx (17) hypopharynx (4), oral cavity (6) 2005 Larynx (Glottic 41, Supraglottic 22)
Solares et al. [24].
Bohannon et al. [27].
0
0
63
71
27
3
2010 Larynx (Glottic 59, Supraglottic 12)
32
37
0
0
34
51
0
Non larynx
126
Larynx
Farrag et al. 2006 Larynx [26]. (Glottic 24, Supraglottic 8, subglottis 2)c
Yao et al. [7].
Temam et al. [23].
Wax and Touma [22]
1995 Larynx (subsite not determined) 1999 Larynx (Glottic 20, Supraglottic 14)
Yuen et al. [2]
Primary tumor
Year
Authors
Table 1 Summary of studies results
Not reported
Not reported
Not reported
Local and neck
Local for T1-2 (14) and local +neck for T3-4(28) Not reported
Not reported
RT field
71
51
63
30
Neck dissection (34)/Wait and see policy(17) Neck dissection (38)/Wait and see policy(33)
Neck dissection (41)/Wait and see policy(22)
Neck dissection (30)
Neck dissection (69)
Neck dissection (34)
34
69
Wait and see policy
Neck treatment
126
N. patients
Comparison
Comparison
53.5
Comparison
65.1
66.7
Only one intervention
Only one intervention
Only one intervention Only one intervention
34
20
2c
23
7
32c
Unknown
Unknown
11
6
28
52
Unknown
Original T3-4N0
Unknown
Neck inter- Original vention T1-2N0
100
100
100
0
Proportion of dissection (%)
10
15
83
0
Unknown
35
7.9
3.4d
12.2
3.3
24.6
17.6
Early recur- % pN+ rencesb (%) (%)
52
Not reported
50–58
32
59.7
Not reported
45
Overall survival dissection group (%)
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104
18
45
26
426
Yirmibeso- 2013 Larynx (26), oral cavity glu et al. (7), oro[10]. pharynx (7), hypopharynx (4)
Total
Local and neck
Not reported
Local for T1-2 (14) and local +neck for T3-4(28) Not reported
Local and neck
RT field
Data reported for 29 patients classified as N0 before salvage surgery
d
Data for non-dissection group not reported
c
Hemi-necks
% of recurrences classified as rT1-2N0
b
a
Lee et al. [28].
2013 Larynx (Glottic 18, Supraglottic 11, subglotis 3, transglottic 9) and hypopharynx (4) 2013 Larynx (50), oral cavity (27), oropharynx (20) and hypopharynx (29)
104
4
Basheeth et al. [9].
Dagan et al. 2010 Larynx (34), [8]. oropharynx (21) hypopharynx (2) Amit et al. 2013 Larynx [25]. (Glottic 26, Supraglottic 16) 41
Non larynx
0
Larynx
42
Primary tumor
23
Year
34
Authors
Table 1 continued
44
149
45
42
57
N. patients
Neck dissection (30)/Wait and see policy(14)
Neck dissection (80)/Wait and see policy(74)a
Neck dissection (38)/Wait and see policy(7)
Neck dissection (40)/Wait and see policy(17) Neck dissection (42)
Neck treatment
Comparison
Comparison
68.2
Comparison
84.4
51.9
Only one intervention
100
289
20
129
157
24
25
19
18
24
26
34
Comparison
70.2
Original T3-4N0
23
Neck inter- Original vention T1-2N0
Proportion of dissection (%)
50
83.8
58
24
56
10.0
7.5
7.9
19.0
10.0
Early recur- % pN+ rencesb (%) (%)
55
71
70 % for unilateral and 45 % for bilateral
Not reported
45
Overall survival dissection group (%)
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Table 2 Relationship between pN + status and tumor site and stage
* Not statistically significant
Table 3 Comparison of neck dissection vs. observation in salvage laryngectomy
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Year
No of patients
Supraglottic (%) Glottic (%)
T1–T2 (%)
T3–T4 (%)
Wax and Touma [22] Solares et al. [24] Yao et al. [7] Farrag et al. [26]
1999 2005 2005 2006
34 37 41 32
28 55 20 25
10 12* 10 8*
17
23
12 20
20* 10*
Amit et al. [25]
2013
42
25
15
14
22
Authors
Year
Time
Neck dissection (%)
Observation (%)
p
40 33 48
0.87 0.49 0.46
56
0.20
Yao et al. [7]
2005
5 year
Bohannon et al. [27]
2010
2 year
(G) 58 (SG) 50 52
Dagan et al. [8]
2010
5 year
45
included early laryngeal tumors, 82 and 57 %, respectively. Solares et al. [24] included mainly (90 %) patients with non-laryngeal tumors. The studies that assessed only the larynx had similar rates of occult neck metastasis of 17.6 and 19 %, while studies that included other sites have a higher variation in the rate of metastasis. If only the larynx tumors included in the study by Solares et al. [24] are considered, the rate of occult metastasis is similar to other studies, 9/37 (24 %), although their proportion of supraglottic tumors is higher, and this could explain the high rate of neck metastasis. The low rate of occult metastasis in the Temam et al.’s [23] study is difficult to explain. Studies comparing observation with neck dissection Yao et al. [7] in 2005 reported on 63 cN0 patients with glottic and supraglottic tumors who had local recurrence after radiotherapy and were treated with laryngectomy and neck dissection. 22/63 (35 %) patients had glottic tumors and 52/63 (82 %) were classified as T1-2N0. 41 patients (31 with glottic and 10 with supraglottic recurrent tumors) underwent neck dissection, while the other 22 were observed based on surgeon’s preference. Occult metastasis was found in 5/41 (12 %) patients from the neck dissection group (10 % for glottic cancer and 20 % for supraglottic cancer). They also noted a higher rate of occult lymph node metastases when the recurrent tumors were advanced (Table 2). For glottic cancer, the authors were not able to find a statistically significant difference in 5-year overall survival between those who underwent neck dissection and those who did not (58 vs. 50 %) (Table 3) [7, 8, 27]: while survival was higher for patients with supraglottic tumors who underwent neck dissection (50 vs. 33 %), the difference was non-statistically significant. It should be pointed
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Overall survival
out, however, that patients who underwent neck dissection had more advanced recurrent tumors (rT3-4 19 % in the dissection group vs. 13 % in the observation group). Thus, it is possible that elective neck dissection may offer a survival advantage for patients with more advanced recurrent tumors. In fact, the authors recommend bilateral neck dissection at the time of laryngectomy for recurrent staged rT3-4N0 tumors and all patients with recurrent supraglottic cancers because of the higher rate of occult metastases. Farrag et al. [26] in 2006, reported on 51 patients with persistent/recurrent laryngeal cancer who were staged N0 after treatment with radiotherapy. Thirty-four patients underwent salvage laryngectomy with neck dissection and in 17 the neck was observed—the choice based on the surgeon’s discretion. 24 (70 %) patients who underwent neck dissection had glottic tumors and 32 (94 %) were classified as T1-2. The authors included three initially N+ patients and 5 recurrent N+ patients. The rate of metastasis to the cervical lymph nodes was 1/29 (3.4 %). Unfortunately there was no information about survival or the initial and recurrent T stage of the observation group patients. However, all 17 patients who underwent salvage surgery without neck dissection were staged N0 both before radiotherapy as well as pre-salvage surgery, and none developed neck disease in the follow-up period. Bohannon et al. [27] in 2010 reported on 71 patients with laryngeal tumors originally classified N0 who were treated with surgery or radiotherapy with or without chemotherapy, which recurred locally and were treated with salvage surgery. 59/71 (83 %) patients had glottic tumors and 34/71 (47 %) were classified T1-2. Thirty-eight patients (53 %) underwent neck dissection based on the surgeon’s discretion. There was a higher percentage of supraglottic tumors in the observation group (24.2 vs. 10.5 %). The rate
Eur Arch Otorhinolaryngol
of regional recurrence in the observation group was twice that of the dissection group (15 vs. 8 %), probably because of the higher number of supraglottic tumors in the “observation” group. Dagan et al. [8] in 2010 reported on 57 patients with T1-4N0 tumors who underwent radiotherapy to the local and regional basin and had a local recurrence without clinically apparent neck metastasis. All were treated with salvage surgery, 40 with neck dissection and 17 with neck observation. Glottic T1-2 cancer patients were excluded. The neck dissection group included more advanced recurrent tumors (rT3-4 52 vs. 24 %) as compared to the observation group. There were no statistically significant differences in overall survival or cancer-specific survival and an expectant policy was recommended for the N0 neck. However, this study has the drawbacks of a likely selection bias, a small sample size, and the predominance of advanced tumors in the neck dissection group. Yirmibesoglu et al. [10] in 2013 analyzed 44 patients with HNSCC originally classified as N0 who were treated with radiotherapy with or without to chemotherapy, and developed local recurrence. T1-2 glottic, nasopharynx, nasal cavity and paranasal sinus tumors were excluded. A neck dissection was performed in 30 patients based on the preferences of the surgeons. The observation group had more larynx tumors (79 vs. 50 %), more T3-4 primary tumors (65 vs. 50 %) and more negative margins (71 vs. 63 %). Positive nodes were found in 3 (10 %) patients who had neck dissection. There was no difference in survival between neck dissection and observation patients. Basheeth et al. [9] in 2013, reported on 45 patients with recurrent laryngeal and hypopharyngeal cancer classified as N0 who had received radiotherapy or chemoradiotherapy as primary treatment. They all underwent salvage larynge ctomy/pharyngolaryngectomy and 38 patients had elective neck dissection. The 7 patients in the observation group had more advanced initial primary tumors (71 vs. 37 %) and more advanced recurrent primary tumors (100 vs. 76 %). The most surprising result was the good survival of the observation group even though they had more advanced recurrent tumors. Of note, the incidence of major wound complications was significantly greater in patients undergoing bilateral neck dissection (67 %) than in patients undergoing unilateral or no neck dissection (30 %) (P = 0.03). Lee et al. [28] in 2013 reported on 149 patients with recurrent oral cavity, oropharynx, larynx and hypopharynx cancer who developed isolated local recurrence with an N0 neck, and were submitted to salvage surgery. 50/149 (33 %) of the patients had larynx tumors [35/50 (70 %) glottic tumors], 47/149 (31 %) had oral cavity tumors, 27/47 (57 %) tongue tumors, 23/149 (15 %) oropharynx tumors, and 29/149 (19 %) had hypopharynx tumors. There were 74 hemi-necks in the observation group and 80 in
the neck dissection group. The dissection group had more hemi-necks treated initially with chemoradiotherapy (21 vs. 8), fewer hemi-necks treated with exclusive radiotherapy (5 vs. 18) and more advanced recurrences (44 vs. 22). 19 patients developed a regional recurrence [10/19 (52 %) in the observation group vs. 9/19 (47 %) in the dissection group]. Occult lymph node metastasis was found in 6/80 (7.5 %) of the dissected hemi-necks. In a multivariate analysis, the authors found a relationship between neck dissection and better regional control and cause-specific survival. The study included a large number of N+ patients at the initial classification and at the time of recurrence.
Discussion The presented review revealed that the overall rate of occult lymph node metastases in patients undergoing salvage surgery for recurrent tumors ranged from 3.4 to 12 %. The variability can be explained by the variable distribution of primary sites and the recurrent primary tumor stage in the studies. Also some studies included mainly laryngeal tumors [7, 9, 26, 27, 29], while others included various subsites [8, 10]. This difference does not entirely explain the heterogeneity of results (7.5–12 % in the larynx group vs. 3.4–10 % from other subsites). Some studies included primarily tumors in early stages [7, 26, 29], while others included more advanced tumors [8–10, 27]. A few studies described mostly advanced recurrences [26, 27] while others early recurrences, with a clear difference in the rate of occult metastasis (3.4–7.9 % in the advanced group vs. 7.5–12.2 % in the early group). This finding is counterintuitive, as one would expect to find fewer occult metastases in early rather than in advanced primary recurrences. This may be explained by the fact that early laryngeal primary recurrences usually occurred in tumors treated with a smaller radiation field to the central neck, leaving the lateral nodes untreated and increasing the risk of occult metastasis. The one study with better methodology [27] showed that neck dissection decreased the risk of regional recurrence by almost 50 %, which confirms the beneficial effect of neck dissection. The risk of occult neck nodes metastasis in a clinically N0 tumor depends on the tumor site and T classification stage [3]. There is a general agreement regarding elective treatment of the necks when the characteristics of the primary tumor (T stage, site of the primary tumor, tumor thickness, etc.), predict the likelihood of occult metastasis to be more than 20 % [30]. For example, in oral cancer, it is accepted that a tumor with more than 4 mm of depth of invasion has a 25 % risk of metastasis. This rate can increase to almost 40 % if the tumor is located in the oropharynx or has deeper penetration [31–34]. In these cases,
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elective neck dissection in conjunction with the resection of the primary tumor has yielded good results. On the other hand, there is no consensus regarding management of the N0 neck in patients with local recurrence. Some authors suggest neck dissection en bloc with the recurrent primary tumor based on the premise that the biologic behavior of the recurrent tumor implies a higher risk of lymph node metastasis, that the initial (chemo)radiotherapy may have left residual microscopic tumor in the neck or both. In addition, complex (free flap) reconstruction may be necessary after resection of the local recurrence requiring entering the neck for exposure and dissection of vessels; in such cases, most surgeons prefer to extend the procedure to some form of neck dissection. Finally, the success of a second salvage surgery in the neck after a regional recurrence is usually poor. Other authors suggest a “wait and see” policy based on the risk of nerve and vessels injuries and on the lack of evidence showing the superiority of neck dissection as a strategy to avoid regional recurrence or impact long-term prognosis. The literature review presented here supports performing elective neck dissection in conjunction with salvage laryngectomy. The rate of occult metastases in the neck dissection specimens, was between 17.6 and 19 % for patients with larynx cancer. In studies where the neck was observed and nodal metastases occurred subsequently, the surgical salvage rate was only 21 %. Studies comparing elective neck dissection with observation of the neck suggest that elective dissection is not beneficial in terms of survival (Table 3). However, comparisons should be interpreted with caution. Most studies proposed dissection for patients with more advanced primary or recurrent tumor stage and observation for less advanced recurrences. In patients with early recurrence, observation is a reasonable option, and the results reflect that. As the risk of occult metastasis in advanced recurrent tumors is high, neck dissection will reveal more occult metastasis, and affect the prognosis of the patient. Neck dissection is both a staging and therapeutic maneuver. Neck dissection will remove the tumor burden from the neck, as reflected in an extended disease-free survival closer to that of early tumors with necks observed. The other important factor is the heterogeneity of the studied tumors. Some reports focused only on laryngeal tumors, while others included oropharyngeal, oral cavity or hypopharyngeal tumors. The number of patients with these tumor sites can impact the rate of neck metastasis. Even for laryngeal tumor studies, the proportion of glottic and supraglottic tumors can produce different conclusions. Other important factors related to the initial therapy should be considered. The first one is the original radiotherapy field. For most glottic tumors, the field of radiotherapy is limited to the central neck. However, for others such as supraglottic or oropharyngeal tumors, the field
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usually includes both the central and lateral neck (unilateral or bilateral based on the tumor site). Unfortunately, information about this difference is rarely reported in the studies, and makes it impossible to explore the effect of this factor on the rate of occult metastasis. Another factor that can alter the decision regarding treatment of the neck is the staging and site of the primary tumor. The behavior of identical T stages is dependent on the site of the tumor. A T4 oropharynx or oral cavity cancer is more likely to metastasize than a T4 laryngeal cancer. Finally, with the development of better imaging, the classification of N0 patients has changed over time. More advanced radiographic staging using ultrasound-guided aspiration cytology, sentinel node biopsy, CT, MRI and PET-CT, can detect neck metastases that in previous years could not be found [35]. Thus, the definition of clinical N0 at the present time is more accurate and selective than it was in the past if radiographic criteria are added to clinical findings. The diagnostic techniques used for staging the neck were often not reported in the cited studies.
Conclusions After reviewing these studies, some inferences may be drawn. We suggest that observation policy for the neck could be used for patients with glottic tumors classified originally as early tumors (T1-2) and who recurred with less advanced tumors (rT1-2). For more advanced laryngeal tumor recurrences (rT3-4), the suggestion is that elective neck dissection could be considered with bilateral neck dissections for supraglottic tumors particularly if previous radiation fields did not include the lateral neck. For tumors located at other sites, it is difficult to offer a recommendation, but clinical judgment can guide therapy. Elective neck dissection should also be strongly considered in patients with oropharyngeal, oral cavity, and hypopharyngeal rT2-4 tumors. The final decision rests with the surgeon who must also consider the status of the soft tissues of the neck. In some cases, the degree of postradiation fibrosis is such that performing a neck dissection is not advisable. Hopefully, future diagnostic modalities will have enhanced accuracy in finding or excluding occult metastasis. References 1. Davies L, Welch HG (2006) Epidemiology of head and neck cancer in the United States. Otolaryngol Head Neck Surg 135:451–457 2. Yuen AP, Wei WI, Ho CM (1995) Results of surgical salvage for radiation failures of laryngeal carcinoma. Otolaryngol Head Neck Surg 112:405–409 3. Bataini JP (1993) Radiotherapy in N0 head and neck cancer patients. Eur Arch Otorhinolaryngol 250:442–445
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