The Role of Post- Chemoradiotherapy Neck Dissection: Evidence for a Change in Paradigm Tung T. Trang, M.D. Director of Head and Neck Oncology Department

The Role of Post- Chemoradiotherapy Neck Dissection: Evidence for a

Change in ParadigmTung T. Trang, M.D.

Director of Head and Neck OncologyDepartment of Otolaryngology –Head and Neck

SurgeryMetroHealth Medical Center

Format

• History and Basics of Neck Dissection

• The old paradigm, neck dissection in:– Radiotherapy alone– Chemo-radiotherapy

• Evidence for a change in paradigm

George W. Crile

• First neck dissection

• 1906

• Saint Michael’s Hosp.

• Cleveland, OH

Bulky Neck Metastases

TTT TTT

Levels of Neck Dissection

Radical Neck Dissection

Myers et.al. TTT

Modified Radical Neck Dissection

Myers et.al. TTT

Selective (Bocca) Neck Dissection

Myers et.al. TTT

Format




Neck Dissection Following Definitive Radiation Therapy

• Mendenhall and Parsons et. al. - University of Florida

• Radiation only for head and neck cancers

• N0 and N1 neck disease had excellent control after radiation only without neck dissection

Mendenhall et. al. 1986

Parson et. al. 1989


• Factors that prognosticated worse neck control

– > 3cm neck nodes– Fixed nodes– Multiple nodes


Parson et. al. 1989


• For N2 or greater

• 49% failure rate due to uncontrolled neck disease without planned neck dissection.

• 25% failure rate due to uncontrolled neck disease with planned neck dissection.


Important Points From the Era of Radiation Only

• 1. N0 and N1 neck disease was sterilized with just radiation alone without neck dissection (or chemotherapy).

• 2. In patients with N2(+) disease, the addition of neck dissection significantly decreased the incidence of uncontrolled neck disease.

Format




Laryngeal Cancer

Laryngectomy and Post-op XRT

Induction chemo then XRTSurgery as salvage

~66% 5-year survival

2/3 able to preserve Larynx without surgery

Induction Chemotherapy

Wolf et. Al. VA Laryng. Ca Study

Neck Management in Induction Chemotherapy

37 patients with N2 or N3 disease

18 Complete Responders

19 Partial Responders

6 died of uncontrolled neck disease

Nosurgery

NeckDissection

@12 weeks

13 died of uncontrolled neck disease

Wolf et. al. 1992

Conclusions From VA Study

• Partial responders were more likely to have residual neck disease and need addition of neck dissection

• 12 weeks was (too?) long to wait for neck dissection after treatment as 13/19 died of disease despite neck dissection.

• 6/18 complete responders still died of neck disease…Neck dissection may still be needed in complete responders.

Wolf et. al. 1992

Paradigm of Planned Neck Dissection

109 patients with N2+ disease had concurrent chemoradiation

Complete Responders n=65

Partial Respondersn=44

Neck Dissection n=32

No Neck Dissection n=33

Neck Dissection n=44

McHam et. al. 2003

Residual Diseasen=8(25%)

Residual Diseasen=17(39%)

Planned Neck Dissection for N2(+) Disease

• Conclusions from this study:– Having a complete clinical response could not

predict a complete pathological response.– No difference in survival between neck

dissected and un-dissected patients.– Recommend planned neck dissection

because dying of uncontrolled neck disease is very morbid.

McHam et. al. 2003

Uncontrolled Neck Disease

• Chronic draining wound

• Uncontrolled Pain• Bleeding• Malodor• Social Isolation

TTT

Format




Role of PET scans: Yao et al 2005 (Iowa)

70 hemi-necks with N2 (+) disease

Concurrent ChemoradiationWith complete response at primary

42 hemi-necks(-) CT neck mass(-) PET

O B S E R V E

42 NED

Yao et al 2005 (Iowa)70 hemi-necks with N2 (+) disease



O B S E R V E

21 hemi-necks(+) CT neck mass(-) PET

42 NED 21 NED

Yao et al 2005 (Iowa)70 hemi-necks with N2 (+) disease



O B S E R V E

21 hemi-necks(+) CT neck mass(-) PET

7 hemi –necks(-) CT neck mass(+) PET

3 persistentdisease

4 NED42 NED 21 NED

Neck Dissection

Yao et al 2005 (Iowa)

• Median f/u 26 months

• PET @ 12 weeks

• NPV 100%• SUV > 3.0 were positive

• PPV only 43%

Nayak et al 2007 (Pittsburgh)43 patients with N2 (+) disease


33 patients(-) PET

O B S E R V E

32 NED 1 persistentdisease

Nayak et al 2007 (Pittsburgh)43 patients with N2 (+) disease


33 patients(-) PET

O B S E R V E

10 patients(+) PET

7 persistentdisease

3 NED32 NED 1 persistentdisease

Neck Dissection

Nayak et al 2007 (Pittsburgh)

• Median f/u 18.1 months• PET @ 8 weeks

• NPV 97%• SUV > 3.0 were positive• PPV only 70%

• Other recent unpublished data agree with high NPV of PET in this setting.

Porceddu et al 2011

Porceddu et al 201150 Patients with residual adenopathy

PET scan

41 Patients PET (-)

OBSERVATION ONLY

41 Patients NED

Porceddu et al 201150 Patients with residual adenopathy

PET scan

41 Patients PET (-) 9 Patients PET (+)

OBSERVATION ONLY

41 Patients NED

Neck Dissection

6 Patients Persistent Tumor

3 PatientsNED

Porceddu et al 2011

• Conclusions– NPV of PET 100%– PET better than physical exam or CT scan for

follow-up after definitive Radiotherapy +/- Chemotherapy.

Extent of Neck Dissections

• 69 patients with N2(+) disease• All had post treatment selective neck

dissections.• Only 1 patient recurred in the neck after

selective neck dissection.• Selective neck dissections are oncologically safe

in the post chemoradiation setting.• Selective neck dissection confers less morbidity

than (modified) radical neck dissection.

Stenson, 2000

Conclusions

• The SUV of a hyper-metabolic focus is an important variable to report on PET readings and has prognostic value.

Conclusions


• When negative, CT/PET done after definitive chemoradiation accurately predicts negative neck nodal status.

Conclusions



• We should consider routine use of CT/PET after definitive chemoradiation to guide therapy of neck nodes.

Conclusions



• We should consider routine use of CT/PET after definitive chemoradiation to guide therapy of neck nodes.

• Selective neck dissections may be enough to control disease in place of modified radical neck dissections.

Bibliography• Bocca etal. Functional neck dissection: evaluation and review of 843 cases. Laryngoscope 94:942, 1984

• McHam SA, Adelstein DJ, Rybicki LA, Lavertu P, Esclamado RM, Wood BG, Strome M, Carroll MA. Who merits a neck dissection after definitive chemoradiotherpy for N2-N3 squamous cell head and neck cancer? Head & Neck 2003;25:791-798.

• Mendenhall WM, Million RR 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 Radiation Oncology Biol. Phys. 1986;12:733-740.

• Mendenhall WM, Parsons JT, Stringer SP, Cassisi NJ, Million RR. Squamous cell carcinoma of the head and neck treated with irradiation: management of the neck. Seminars in Radiation Oncology 1992;2:163-170.

• Myers et.al. Operative Otolaryngology. W.B. Sauders Company. 1997 pp. 687-88.

• Nayak et al Laryngoscope 117(12):2129-34, 2007.

• Parsons JT, Mendenhall WM, Cassisi NJ, Stringer SP, Million RR. Neck dissection after twice-a-day radiotherapy: morbidity and recurrence rates. Head & Neck 1989;11:400-404.

• Porceddu SV et.al. Results of a prospective study of PET-directed management of residual nodal abnormalities in node-postive head and neck cancer after definitive radiotherapy with or without systemic therapy. Head and Neck 2011;33:1675-1682.

• Stenson et al. The Role of Cervical Lymphadenectomy After Aggressive Concomitant Chemoradiotherapy: The Feasibility of Selective Neck Dissection. Archives of Otolaryngology -- Head & Neck Surgery. 126(8):950-956, August 2000.

• Wolf GT, Fisher SG Effectiveness of salvage neck dissection for advanced regional metastases when induction chemotherapy and radiation are used for organ preservation. Laryngoscope 1992;102:934-939. Yao et al Int. J of Rad Onc, biol and phys. 63(4):991-9, 2005.

• Yao et al Int. J of Rad Onc, biol and phys. 63(4):991-9, 2005.

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The Role of Post- Chemoradiotherapy Neck Dissection: Evidence for a Change in Paradigm Tung T. Trang, M.D. Director of Head and Neck Oncology Department