THE MANAGEMENT OF THE CLINICALLY POSITIVE NECK AS PART OF A LARYNX PRESERVATION APPROACH

Purpose: For patients with squamous cell carcinoma of the head and nec k with palpable neck node metastases, the standard management of the n eck usually involves neck dissection and postoperative neck irradiatio n. A strategy of larynx preservation with induction chemotherapy and r adiation therapy has been utilized for patients with locally advanced resectable cancer of the larynx, hypopharynx, and oropharynx. For pati ents treated in this non-surgical manner for the primary site, the opt imal management of the clinically positive neck has not been clarified . To determine whether response to induction chemotherapy could help t o select patients in whom neck dissection could be omitted in favor of definitive radiation therapy alone, we have analyzed our prospective larynx preservation experience. Methods and Materials: Between 1983-19 89, 80 patients were entered onto larynx preservation protocols involv ing 1-3 cycles of cisplatin based chemotherapy followed by radiation t herapy with or without neck dissection. There were 54 patients with cl inically positive necks prior to treatment, of whom 44% (24/54) had a complete response, and of whom 20% (11/54) had a partial response to c hemotherapy in the neck. In 22 of these 35 patients with clinically po sitive necks who achieved a major neck response to chemotherapy, radia tion therapy (median 66 Gy) was used as the only subsequent treatment of the neck. Results: At a median follow-up of 25 months (range 7-83 m onths), neck control for this subset is 91% (20/22). Neck failure occu rred in 20% (1/5) of patients with a partial response to chemotherapy treated without neck dissection and 6% (1/17) of node positive with a complete response. Conclusion: These results suggest that patients wit h clinically palpable cervical nodal metastases who have a complete re sponse to chemotherapy and receive high dose radiation therapy have ex cellent neck control and may not need neck dissection. Further experie nce will be required to confirm these preliminary data and to determin e if patients who achieve a partial response in the neck after inducti on chemotherapy can be treated with radiation therapy without neck dis section.