Less may be more: nodal treatment in neck positive head neck cancer patients.
Ongoing debates about the need and extent of planned neck dissection (PND), and required nodal radiation doses volumes lead to this evaluation. Aim was to assess nodal control after definitive intensity modulated radiation therapy (IMRT ± systemic therapy) followed by PND in our head neck cancer cohort with advanced nodal disease. Between 01/2005 and 12/2013, 99 squamous cell cancer HNC patients with pre-therapeutic nodal metastasis ≥3 cm were treated with definitive IMRT followed by PND. In addition, outcome in 103 patients with nodal relapse after IMRT and observation only (no-PND cohort) were analyzed. Prior to PND, PET-CT, fine needle aspirations, ultrasound and palpation were assessed regarding its predictive value. Patterns of nodal relapse were assessed in patients with isolated neck failure after definitive IMRT alone. 70/99 (70 %) PND specimens showed histopathological complete response (hCR), which translated into statistically significantly superior survival compared with partial response (hPR) with 4-year overall survival, disease specific survival and nodal control rates of 90/83/96 vs 67/60/78 % (p = 0.002/0.001/0.003). 1/99 patient developed isolated subsequent nodal disease. 64/2147 removed nodes contained viable tumor (3 %). Predictive information of the performed diagnostic investigations was not reliable. 17/70 hCR patients showed true negative findings in available three to four investigations (0/29 hPR). 27/103 no-PND patients developed isolated neck disease (26 %) with successful salvage in 21/24 [88 %, or 21/27 (78 %)]. Nearly all failures occurred in the prior nodal gross tumor volume area. A more restrictive approach regarding PND and/or nodal IMRT dose-volumes may be justified.
Department of Radiation Oncology, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland. gabriela.studer@usz.ch.
Gabriela
G
Studer
Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Zurich, Zurich, Switzerland.
Gerhard F
GF
Huber
Department of Radiation Oncology, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.
Edna
E
Holz
Department of Radiation Oncology, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.
Christoph
C
Glanzmann
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use; D002294:Carcinoma, Squamous Cell / Q000188:drug therapy / Q000401:mortality / Q000532:radiotherapy* / Q000601:surgery*; D003131:Combined Modality Therapy / Q000379:methods; D005260:Female; D006258:Head and Neck Neoplasms / Q000188:drug therapy / Q000401:mortality / Q000532:radiotherapy* / Q000601:surgery*; D006801:Humans; D015182:Lymphatic Irradiation; D008207:Lymphatic Metastasis; D008297:Male; D008875:Middle Aged; D037981:Neck Dissection; D009364:Neoplasm Recurrence, Local / Q000188:drug therapy / Q000401:mortality / Q000532:radiotherapy* / Q000601:surgery*; D050397:Radiotherapy, Intensity-Modulated; D016879:Salvage Therapy
Elective nodal volume and radiation; Isolated nodal failure; Nodal IMRT; PND; Planned neck dissection