Planned neck dissection as an adjunct to the management of patients with advanced neck disease treated with definitive radiotherapy: For some or for all?

Background. Management of patients with head and neck carcinoma and advance d nodal disease is controversial. The purpose of this analysis was to evalu ate the efficacy and toxicity of definitive radiotherapy followed by planne d neck dissection in patients with bulky neck disease. Materials and Methods. The records of 52 patients who were treated between 1989 and 1995 at the Peter MacCallum Cancer Institute with a planned neck d issection after radical radiotherapy were reviewed. All had advanced neck d isease with one or more nodes greater than or equal to 3 cm in maximum diam eter, 94% being staged N2-3. The most common primary site was the oropharyn x (56%). Sixty percent of patients had either T2 or T3 primaries and all we re AJCC stage IV. Treatment consisted of high-dose radiotherapy to the prim ary and involved neck sites using various fractionation protocols followed by radical or modified radical neck dissection after confirmation of a comp lete response at the primary site. The median follow-up for living patients was 58 months (range 32-97). Results. There were nine regional failures, of which three were outside the dissected neck, yielding a 5-year actuarial overall neck control rate of 8 3% and an in-field control rate of 88%. in-field control rates by neck stag e were N1 3/3; N2 31/35; N3 11/13 and NX 1/1. There was only one in-field f ailure among 28 patients who had pathologically negative neck specimens com pared with five in 24 patients with morphologic evidence of residual diseas e. Of the 24 patients with pathologically positive necks, 5 were long-term survivors and were probably cured by their surgery. Another 4 died of inter current disease without documented recurrence of their head and neck cancer . Ten patients recurred at their primary sites (5-year actuarial control 79 %) and 8 developed distant metastases (5-year actuarial rate 20%). A total of 21 patients failed at one or more sites and none was salvaged. Five-year actuarial disease-free survival was 57% and overall survival 38%. Nine pat ients (17%) sustained significant complications following neck dissection. Conclusions. In patients with advanced neck disease who are treated primari ly with radical radiotherapy, planned neck dissection provides excellent re gional control and appears to cure a subset of patients. However, routine n eck dissection adds significant morbidity to treatment and should ideally b e avoided in those patients in whom surgery is either unnecessary (no resid ual tumor) or futile (unsalvageable disease recurrence outside the dissecte d neck), Based on our analysis and other recently reported series, we now r ecommend observing patients who have a complete response to high-dose radio therapy (+/- chemotherapy). The ability of PET imaging to detect residual v iable tumor in the head and neck or at distant sites is under investigation . (C) 1999 John Wiley & Sons, Inc.