title: Management of the "violated neck" in the era of chemoradiation.
abstract: OBJECTIVE
  To determine if patients who have undergone an open neck biopsy (a "violated" neck) have improved disease control and survival with completion neck dissection.
  
  
  METHODS
  Retrospective review of patients who underwent open cervical biopsy for diagnosis prior to definitive treatment between February 1997 and February 2010 at two academic tertiary referral centers.
  
  
  RESULTS
  Ninety-four patients met study criteria, with completion neck dissection performed in 53 patients (56%). The majority of patients (84%) had oropharyngeal tumors. Human papilloma virus (HPV) status was positive in 55 of 63 patients (87%). Chemotherapy was used more often in patients treated nonoperatively (88%) compared to patients who underwent neck dissection (49%; P < .001). Five-year disease-specific survival (DSS) was 84% for patients treated with neck dissection and 82% for nonoperative treatment (P = .5806), and disease-free survival (DFS) was 82% for patients treated with neck dissection and 70% for nonoperative treatment (P = .6047). Five-year DSS was 84% for patients with HPV-positive disease and 63% for HPV-negative disease (P = .0086), and DFS was 79% for HPV-positive disease and 50% for HPV-negative disease (P = .0004). Only advanced primary tumor (T3/T4) stage (hazard ratio [HR] = 8.8, P = .004) was associated with DSS, whereas advanced primary tumor stage (HR = 5.3, P = .008), N3 disease (HR = 5.6, P = .036), and HPV-positive disease (HR = 0.2, P = .032) were significant predictors of DFS, after controlling for all other variables.
  
  
  CONCLUSIONS
  In the era of chemoradiation, completion neck dissection following an open cervical biopsy does not appear to provide a survival advantage. A high proportion of HPV-positive oropharyngeal tumors may explain the favorable outcomes observed.
authors: Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland 21287, USA.
authors: Myriam
authors: M
authors: Loyo
authors: Jonas T
authors: JT
authors: Johnson
authors: William H
authors: WH
authors: Westra
authors: Simion I
authors: SI
authors: Chiosea
authors: Christine G
authors: CG
authors: Gourin
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001706:Biopsy; D002294:Carcinoma, Squamous Cell / Q000401:mortality / Q000473:pathology* / Q000628:therapy*; D059248:Chemoradiotherapy; D003131:Combined Modality Therapy; D018572:Disease-Free Survival; D005260:Female; D006801:Humans; D008207:Lymphatic Metastasis / Q000473:pathology; D008297:Male; D008875:Middle Aged; D037981:Neck Dissection; D009367:Neoplasm Staging; D009959:Oropharyngeal Neoplasms / Q000401:mortality / Q000473:pathology* / Q000628:therapy*; D030361:Papillomavirus Infections / Q000401:mortality / Q000473:pathology* / Q000628:therapy*; D016016:Proportional Hazards Models