The role of cervical lymphadenectomy after aggressive concomitant chemoradiotherapy - The feasibility of selective neck dissection

Objectives: To evaluate the necessity, technical feasibility, and complicat ion rate of neck dissection performed on patients with head and neck cancer after 5 cycles of concomitant chemoradiotherapy (CRT) and to justify a sel ective neck dissection (SND) approach and define the optimal timing of post -CRT neck dissection. Design and Setting: Retrospective analysis in an academic university medica l center. Patients: Sixty-nine eligible patients with advanced (stage III and IV) hea d and neck cancer who have undergone 1 of 4 CRT protocols. Patients ranged in age from 36 to 75 years, and surgical procedures were performed over a 4 -year period. Follow-up ranged from 6 to 64 months. Intervention: Neck dissection (most commonly unilateral SND) performed with in 5 to 17 weeks after CRT completion. Main Outcome Measures: Complication rate and incidence of positive patholog y (viable cancer) in pathologic neck dissection specimens. Results: Seven (10%) of 69 patients developed wound healing complications, 4 (6%) of whom required surgical intervention for ultimate closure. There w ere no wound infections. Other complications occurred in 11 (16%) of 69 pat ients and included need for tracheotomy, nerve transection and paresis, and permanent hypocalcemia. Twenty-four (35%) of 69 patients revealed microsco pic residual disease. Ten (50%) of 20 patients with N3 neck disease had pos itive pathology, whereas 14 (36%) of 39 patients with N2 disease had viable carcinoma in the dissection specimen (P=.09 by chi(2) analysis). There was no significant relation between radiologic complete response or partial re sponse and residual microscopic cancer. In 1 patient, disease recurred in t he neck after dissection. Mean follow-up time was 30.3 months. Conclusions: (1) Neck dissection for patients with N2 or greater neck disea se after CRT is necessary to eradicate residual disease. (2) The complicati on rate of SND after CRT with hyperfractionated radiotherapy is low. (3) SN Ds are technically feasible when performed within the "window" between the acute and chronic CRT injury (4-12 weeks). (4) SNDs, rather than more radic al procedures, appear to be therapeutically appropriate in this group of pa tients because of the low incidence of disease recurrence in the neck.