Transcript Efficacy of modified radical or radical neck dissection

Efficacy of modified radical or radical
neck dissection for N1 compared to
selective neck dissection and
postoperative radiotherapy
A search of the evidence by Terence Harrison
RMH Clinical Librarian
Background
• Treatments are usually:
– Observation
– Radical or modified radical dissection (followed by
radiotherapy if necessary)
– Chemoradiotherapy
• Alternative, treatment via selective neck dissection
followed by radiotherapy
• Problem: selective neck dissection may not be adequate
and so require further surgery (e.g. by taking internal
jugular vein)
Evidence sources searched
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Cochrane
PubMed Clinical Queries
DARE
Clinical Evidence
Trip
SumSearch
ACP Journal Club
Bandolier
Results of search
• From the evidence-base, 26 papers of interest were
found
• Of these, five appear to be of relevance: one
examines lymph node yields, while the other four
focuses on the efficacy of SNDs
• I have made a basic critical appraisal of these five
papers: each are Level 4 evidence
Paper 1
Selective Neck Dissections For Squamous Carcinoma of the Upper Aerodigestive
Tract: Patterns of Regional Failure
by Robert M. Byers, et al
Head Neck. 1999 Sep;21(6):499-505.
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This retrospective study attempts to answer the question, What are the patterns of failure
when a selective neck dissection is chosen as part of a cancer operation and the neck is
staged pathologically N0, N1, or N2B? Five hundred seventeen neck dissections were
analyzed: suprahyoid (41), supraomohyoid (284), and anterolateral (192).
Regional recurrence in patients treated with a suprahyoid dissection was 43% with
pathologically positive nodes. The regional recurrence in the patients treated with a
supraomohyoid neck dissection was 1.9% with pathologically negative nodes, 35.7%
with path N1 without postoperative radiation therapy, and 5.6% with postoperative
radiation therapy. The neck staged pathologically N2B failed with and without
postoperative radiation, 8.3% and 14%, respectively. Thirteen percent of the
anterior/lateral neck dissections failed regionally. If multiple pathologically positive
nodes (N2B) were present, the regional failure with postoperative radiation was 30%
and 33.3% without postoperative radiation.
In summary, the results suggest that a SND is a satisfactory staging procedure and is a
definitive operation, but only if all the nodes are pathologically negative (otherwise,
postoperative radiation is advisable).
Paper 2
Results of Selective Neck Dissection in Management of the Node-Positive Neck
by Peter E Andersen, et al.
Arch Otolaryngol Head Neck Surg. 2002;128:1180-1184.
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The objective of this study was to determine the oncologic efficacy of selective node dissection in
patients with node-positive squamous carcinoma of the head and neck. It involved a ten-year
retrospective medical chart review of 106 previously untreated clinically and pathologically nodepositive patients undergoing 129 selective neck dissections and followed for a minimum of 2 years or
until patient death. For primary sites involving the oral cavity and oropharynx, a supraomohyoid neck
dissection removing nodal levels 1 to 3 was performed; for primary tumours on the larynx and
hypolarynx a lateral neck dissection involving removal of levels 2 to 5 was perform,ed. Patients were
considered for SND only in the setting or no previous treatment to the head and neck (only patients
with freely mobile metastatic disease in the neck were eligible .
Regional metastasis was clinically staged as N1 in 58 patients (54.7%), N2a in 5 (4.7%), N2b in 28
(26.4%), N2c in 14 (13.2%), and N3 in 1 (0.9%). Extracapsular extension of tumour was present in 36
patients (34.0%), and postoperative radiation therapy was administered to 76 patients (71.7%).
Overall, 9 patients experienced disease recurrence in the neck. Six of these recurrences were in the
side of the neck that had undergone selective neck dissection, for a regional control rate of 94.3%.
Authors conclude that SND should be applied only in patients without massive adenopathy. Evidence
of nodal fixation or obvious gross ECS, a history of neck surgery, and radiotherapy are believed to be
relative contraindications to this approach until further information is gathered. There are other
caveats. They assert that the results support the use of SND in carefully selected patients with
clinically node-positive squamous cell carcinoma of the head and neck region.
Paper 3
‘The effects of more conservative neck dissections and radiotherapy on nodal yields
from the neck.’
by Bhattacharyya N.
Arch Otolaryngol Head Neck Surg. 1998 Apr;124(4):412-6.
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A retrospective review of a case series. Consecutive sample and analysis of 108 NDs
for patients with cancer of the head and neck: 42 RNDs, 39 MRNDs, 18 FNDs, 19
SOHNDs. The study focused on lymph node yields of types of dissections (for occult
positive nodes) and relationship to N-stage and preop-radiotherapy.
Author’s conclusions:
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The tNY differs among types of neck dissection, with the RND and MRND
yielding more nodes than the SOHND, and the MRND yielding more than the
FND. Recovery rates: MRND 26.3 nodes, RND 21.8, FND 16.1, SOHND 9.9.
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The rate of pNY is not statistically different among different types of neck
dissections.
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(Preoperative) radiotherapy achieves a significant reduction in the nodal content
of the neck. After radiotherapy, however, a significant number of lymph nodes
will still remain in the neck.
Note: Selection bias: e.g. N0 receives RND, N2 receives SOHND
Paper 4
‘Selective neck dissection for node-positive necks in patients with head and neck
squamous cell carcinoma: a word of caution.’
by Santos AB, Cernea CR, Inoue M, Ferraz AR.
Arch Otolaryngol Head Neck Surg. 2006 Jan;132(1):79-81
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The aim of this retrospective case series study was to evaluate the regional recurrence
(RR) rate in a consecutive series of patients with node-positive head and neck
squamous cell carcinoma (N HNSCC) who underwent SND.
The authors analysed the charts of 191 consecutive patients who underwent 256 neck
dissections at a single institution from 1999 to 2002. The vast majority of the patients
underwent RND. Twenty-eight patients underwent at least 1 therapeutic SND. One
hundred ninety-one patients with N+ HNSCC underwent 256 neck dissections
(NDs) between 1999 and 2002. Of these, 17 had unilateral SNDs and 11 had
bilateral NDs (6 patients, bilateral SND; 5 patients, radical ND and SND).
Results: There were 4 RRs (11.8%) among 34 patients who underwent SND, and
2 RRs (40%) among 5 patients who underwent radical ND.
Authors’ conclusion: that SND may be indicated in very carefully selected cases of N+
HNSCC, but that caution should be exercised in patients with an advanced T stage and/or
with multiple clinically positive neck nodes, even when postoperative radiotherapy is
used.
Paper 5
‘Selective neck dissection for the treatment of neck metastasis from squamous cell
carcinoma of the head and neck’
by Chepeha DB, et al.
Laryngoscope. 2002;112(3):434-8.
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This is a retrospective study, the objective of which was to determine the proportion of patients
disease free in the neck, with the primary site controlled, who had been treated with a selective neck
dissection (SND) for squamous cell carcinoma (SCCa) of the upper aerodigestive tract and who had
cervical metastasis less than 3 cm. A group of 52 patients who had 58 selective neck dissections for
cervical metastases from SCCa of the upper aerodigestive tract were identified, then followed for a
minimum of two years. All patients in this study were described by the authors as “pathologically Npositive”, but only half were considered clinically N-positive.
Of the 94% of the patients who had been treated with an SND for SCC a of the upper aerodigestive
tract and cervical metastasis, less than 3 cm remained disease free in the neck with the primary site
controlled.
Authors state: “The results compare favourably to a large cohort of patients who were treated with
MRND and had comparable cervical disease and identical indications for postoperative radiation
therapy”. Also: “With similar indications for radiation therapy, the regional control rate in this cohort
is comparable to control rates obtained with modified radical neck dissection”. Also: “The similarity
of regional control rates between patients who have been treated with an SND versus an
MRND with comparable indications for radiotherapy adds strength to the hypothesis that
sparing level V in patients with cervical metastasis may be oncologically safe”.
Study problems: Authors agree that follow-up studies prospective studies need to be carried out on a
clinically N-positive population to know the efficacy of SND in an “intent to treat” model.
Other papers of interest
(Note: shown in red if available in full-text)
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Byers RM, Wolf PF, Ballantyne AJ. Rationale for elective modified neck dissection.
Head Neck Surg. 1988;10:160-167.
de Campora E, et al. Clinical experiences with surgical therapy of cervical metastases
from head and neck cancer. Eur Arch Otorhinolaryngol. 1994;251(6):335-41.
Clarke LK. Pathways for head and neck surgery: a patient-education tool. Clinical
Journal of Oncology Nursing, 2002;6(2): 78-82
Cohen J, Stock M, Andersen P, Everts E; Critical pathways for head and neck surgery:
development and implementation (Provisional record). Archives of Otolaryngology Head and Neck Surgery, 1997; 123(1):11-14
Ferlito A, et al. Neck dissection: past, present and future? J Laryngol Otol. 2006
Feb;120(2):87-92. Epub 2005 Nov 25. Review.
Ferlito A, et al. Neck dissection: then and now. Auris Nasus Larynx. 2006;33(4):36574.
Other papers of interest (continued)
(Note: shown in red if available in full-text)
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Hintz B, et al. Randomized study of control of the primary tumor and survival using
preoperative radiation, radiation alone, or surgery alone in head and neck carcinomas. J
Surg Oncol. 1979;12(1):75-85.
Leemans C.R. et al. The efficacy of comprehensive neck dissection with or without
postoperative radiotherapy in nodal metastases of squamous cell carcinoma of the upper
respiratory and digestive tracts. Larynoscope, 1990;100:1194-1198.
Mendenhall W M, Million R R, Cassisi NJ. Squamous cell carcinoma of the head and
neck treated with radiation therapy: the role of neck dissection for clinically positive
neck nodes. Int. J Radiat Oncol Biol Phys. 1986;12:733-740
Mendenhall WM, et al. Squamous Cell Carcinoma of the Head and Neck Treated With
Irradiation: Management of the Neck. Semin Radiat Oncol. 1992 Jul;2(3):163-170.
Muzaffar K. Therapeutic selective neck dissection: a 25-year review. Laryngoscope.
2003;113(9):1460-5.
Other papers of interest (continued)
(Note: shown in red if available in full-text)
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Narayan K, et al. Planned neck dissection as an adjunct to the management of patients
with advanced neck disease treated with definitive radiotherapy: for some or for all?
Head Neck. 1999 Oct;21(7):606-13.
Schiff BA, et al. Arch Otolaryngol Head Neck Surg. 2005; 131(10):874-8. Selective vs
modified radical neck dissection and postoperative radiotherapy vs observation in the
treatment of squamous cell carcinoma of the oral tongue.
Traynor SJ, Cohen JI, Gray J, Andersen PE, Everts EC. Selective neck dissection and the
management of the node-positive neck. Am J Surg. 1996;172:654-657.
Wu GH, et al. Indication and clinical radical effect of functional neck dissection for head
and neck neoplasm, Ai Zheng. 2002 Jun;21(6):654-7.
Other papers of interest (continued)
(Note: none readily available in full-text)
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Bocca, E. Functional results of radical bilateral dissection of the neck. Arch Ital Otol
Rinol Laringol. 1953;64(Suppl. 14):331-6.
Bocca E. Functional problems connected with bilateral radical neck dissection. J
Laryngol Otol. 1953 Sep;67(9):567-77.
Bocca E, Pignataro O. A conservation technique in radical neck dissection. Ann Otol
Rhinol Laryngol. 1967 Dec;76(5):975-87.
Bocca E. Conservative neck dissection. Laryngoscope. 1975 Sep;85(9):1511-5.
Bocca E, Pignataro O, Sasaki CT. Functional neck dissection. A description of operative
technique. Arch Otolaryngol. 1980 Sep;106(9):524-7.
Bocca E. Ethical problems in tumors of the head and neck. Acta Otorhinolaryngol Ital.
1992 Nov-Dec;12(6):613-4.
Synopsis of the 5 papers examined
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In a 1999 retrospective study the authors argued that SND is a satisfactory staging
procedure, but only if all the nodes are pathologically negative - otherwise,
postoperative radiation is advisable.
In a 2002 retrospective study the authors concluded that SND should only be used for
N+ selectively and with caveats (see paper for details).
A 1998 retrospective review of a case series argued that radiotherapy achieves a
significant reduction in the nodal content of the neck – however, a significant number of
lymph nodes would still remain in the neck
Another retrospective study, published in 2006, found that SND may be indicated in
very carefully selected cases of N+ HNSCC but that caution should definitely be
exercised
In a 2002 retrospective study where half the patients were clinically N-positive, of the
94% of the patients who had been treated with an SND for SCCa of the upper
aerodigestive tract and cervical metastasis, less than 3 cm remained disease free in the
neck with the primary site controlled.
None of the above studies provided an adequate comparison of MRND or RND for N1
compared to SND and postoperative radiotherapy. Clearly more studies – especially
comparative studies - are needed