Surgical resection is necessary to maximize tumor control in function-preserving, aggressive chemoradiation protocols for advanced squamous cancer ofthe head and neck (stage III and IV)

Background: The role of surgery in aggressive chemoradiation protocols for advanced head and neck cancer has been questioned because of the quoted hig h clinical response rates in many series. Methods:, The role of surgical resection was examined in an aggressive neoa djuvant protocol of weekly paclitaxel, carboplatin, and radiation for stage HI and IV with completion of radiation to 72 Gy if biopsy at the primary s ite was negative after administration of 45 Gy. Of 43 patients enrolled, 38 completed the protocol. The clinical response was 100% (including IS compl ete and 20 partial responses). Results. The complete pathologic response (negative primary site biopsy at 45 Gy) was 25 of 38 (66%). Of patients who presented with N1 to N3 nodes, n eck dissection revealed residual nodal metastases in 22%. Surgical resectio n of the primary site was required in 13 patients, including 5 with larynx cancer and 2 with base of tongue cancers. Four patients had resection with reconstruction for advanced mandible floor of mouth cancer, and one had res ection of nasal-maxillary cancer. Functional resection was performed in 9 o f 12 patients. The median progression free and overall survival was 64% and 68%, respectively, at median follow-up of 50 months. Nine patients develop ed recurrence (three local and six distant). There were no failures in the neck. Salvage surgery was performed in one patient with local and one with distant disease. Conclusions: Surgical resection is an essential component of aggressive che moradiation protocols to ensure tumor control at the primary site and in th e neck.