Can Adjuvant Neck Dissection be Deferred in Locally Advanced Head and Neck Cancer Patients with Complete Response to Definitive Chemoradiotherapy?
Carolyn Vachani, RN, MSN, AOCN
Abramson Cancer Center of the University of Pennsylvania
Last Modified: October 31, 2007
Patients with locally advanced squamous cell cancer of the head and neck are typically treated with a combination of chemotherapy and radiation therapy. This therapy can achieve a clinical complete response (CR), meaning an absence of tumor on CT/PET scans. It is what comes next that is controversial. At some centers, these patients then undergo a surgical neck dissection, which carries the risk of fibrosis (scarring), wound healing problems, lymphedema, pain syndromes, and nerve damage. Some centers (including the University of Maryland, who presented this study) only perform neck dissection in those who do not achieve a CR, choosing to follow closely those who did achieve a CR. This presentation is an analysis of the experience at University of Maryland Medical System.
The group consists of 120 patients: 92% had stage IV disease (N2 or N3 or T3 or T4), 75% had tumors in the oropharynx. They received radiation therapy with concurrent (given at the same time) chemotherapy, which included a platinum agent (cisplatin or carboplatin). They then had CT/PET scan and if CR was achieved, they were observed; if CR was not achieved, they underwent neck dissection.
Seventy-six percent of patients achieved CR and were assigned to observation. Of these, 3% developed recurrence in the head/neck. Eleven percent developed distant metastasis, which the authors feel would have occurred even with neck dissection.
The remainder of patients appeared to not achieve CR and underwent neck dissection. Pathologic examination of the neck specimen found that some did not have residual disease after all. Of those patients, 80% are alive without evidence of disease. The patients who did have tumor detected by pathology, 80% have experienced disease recurrence.
Neck dissection can result in significant problems for patients and avoidance of this procedure, if possible, is important. The authors conclude that the findings of this review support their policy of close observation. Given the low rate of neck recurrence in patients who achieved a CR (3%), this seems to be a reasonable approach.
Partially funded by an unrestricted educational grant from Bristol-Myers Squibb.