title: Who merits a neck dissection after definitive chemoradiotherapy for N2-N3 squamous cell head and neck cancer?
abstract: BACKGROUND
  The role of neck dissection (ND) after definitive chemoradiotherapy for squamous cell head and neck cancer is incompletely defined. We retrospectively reviewed 109 patients with N2-N3 disease treated with chemoradiotherapy to identify predictors of a clinical complete response in the neck (CCR-neck), pathologic complete response after ND (PCR-neck), and regional failure.
  
  
  METHODS
  All patients were given 4-day continuous infusions of 5-fluorouracil (1000 mg/m2/d) and cisplatin (20 mg/m2/d) during the first and fourth weeks of either once daily (n = 68) or twice daily (n = 41) radiation therapy. ND was considered for all patients after completion of chemoradiotherapy and was performed in 32 of the 65 patients achieving a CCR-neck after chemoradiotherapy and in all 44 patients with residual clinical evidence of neck disease. CCR-neck, PCR-neck, and regional failure were then correlated with potential predictors, including T, N, largest lymph node size (<3 cm, > or =3 cm), primary tumor site, and radiation fractionation schedule.
  
  
  RESULTS
  Achievement of a CCR-neck was predicted by N, N2 vs N3 (53 of 80 vs 12 of 29, p =.019) and by largest lymph node size, <3 cm vs > or =3 cm (19 of 25 vs 46 of 84, p =.06). Achievement of a PCR-neck could not be predicted by any clinical parameter. Regional failure occurred both in patients undergoing ND and those not dissected (5 of 76 vs 4 of 33, p =.33) and proved more likely only in the ND patients with residual positive pathology compared with those achieving a PCR-neck (5 of 25 vs 0 of 51, p <.001). Primary site was not a useful predictor of CCR-neck, PCR-neck, or regional failure. Most importantly, CCR-neck (vs <CCR-neck) did not predict either a PCR-neck (24 of 32 vs 27 of 44, p =.21) or regional failure (5 of 65 vs 4 of 44, p =.80).
  
  
  CONCLUSIONS
  After chemoradiotherapy, clinical parameters do not identify those patients with residual neck node disease or those at risk for regional failure, suggesting that ND be considered for all N2-N3 patients.
authors.affiliation: Department of Hematology and Medical Oncology, The Cleveland Clinic Foundation, 9500 Euclid Ave, Desk R 35, Cleveland, Ohio 44195, USA.
authors.forename: Scott A
authors.initials: SA
authors.lastname: McHam
authors.forename: David J
authors.initials: DJ
authors.lastname: Adelstein
authors.forename: Lisa A
authors.initials: LA
authors.lastname: Rybicki
authors.forename: Pierre
authors.initials: P
authors.lastname: Lavertu
authors.forename: Ramon M
authors.initials: RM
authors.lastname: Esclamado
authors.forename: Benjamin G
authors.initials: BG
authors.lastname: Wood
authors.forename: Marshall
authors.initials: M
authors.lastname: Strome
authors.forename: Marjorie A
authors.initials: MA
authors.lastname: Carroll
mesh_terms: D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use*; D017024:Chemotherapy, Adjuvant; D002945:Cisplatin / Q000008:administration & dosage; D005260:Female; D005472:Fluorouracil / Q000008:administration & dosage; D006258:Head and Neck Neoplasms / Q000188:drug therapy / Q000532:radiotherapy / Q000601:surgery / Q000628:therapy*; D006801:Humans; D007262:Infusions, Intravenous; D008207:Lymphatic Metastasis; D008297:Male; D037981:Neck Dissection / Q000379:methods; D018307:Neoplasms, Squamous Cell / Q000188:drug therapy / Q000532:radiotherapy / Q000601:surgery / Q000628:therapy*; D018714:Radiotherapy, Adjuvant; D012189:Retrospective Studies; D016896:Treatment Outcome
chemical_list: D002945:Cisplatin; D005472:Fluorouracil