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PubMed1996

The extent of neck disease after regional failure during observation of the N0 neck.

BACKGROUND: The optimum management of the N0 neck remains controversial. When the neck is observed it is hoped that close follow-up will detect regional failure at an early stage. To test this hypothesis we examined patients undergoing therapeutic neck dissection for newly developed neck metastases during observation after treatment of the primary tumor. METHODS: A retrospective chart review of 47 patients undergoing neck dissection for regional failure after surgical treatment of the primary tumor and observation of the neck from 1987 to 1992 was performed. The median time to failure in the neck was 13 months. RESULTS: The clinical neck stage at the time of neck dissection was N1 in 37, N2A in 6, N2B in 1, and N3 in 3. However, pathologic staging revealed stages of N1 in 19, N2A in 5, N2B in 20, and N3 in 3. Extracapsular spread (ECS) was present in 23 patients (49%). Overall 36 patients (77%) had adverse pathologic findings (N greater than 1 or ECS). CONCLUSIONS: These data indicate that when observation is used for the neck at risk for metastasis, patients tend to fail with high stage disease in the neck. This supports the philosophy of elective treatment of the neck but cannot show whether elective treatment will improve survival.

Aged↗
PubMed1999

Management of functional bladder neck obstruction in women: use of alpha-blockers and pediatric resectoscope for bladder neck incision.

PURPOSE: Functional bladder neck obstruction has been definitively diagnosed in the last few years due to detailed synchronous pressure flow, electromyography and video urodynamics. Clean intermittent self-catheterization and bladder neck incision are the modalities of treatment. To our knowledge the role of alpha-blockers is not yet defined in women. A new technique was developed to perform bladder neck incision using a pediatric resectoscope. MATERIALS AND METHODS: A total of 24 women with obstructive voiding symptoms or retention were evaluated with video pressure flow electromyography, and diagnosed with functional bladder neck obstruction due to high pressure and low flow on silent electromyography and bladder neck appearance on fluoroscopy. Patients were initially treated with clean intermittent self-catheterization and alpha-blockers. Catheterization was stopped when post-void residual was less than 50 ml. and only alpha-blocker therapy was continued. Bladder neck incision was performed in patients who had a poor response to or side effects of alpha-blocker therapy, or when therapy was discontinued due to economic reasons. Clean intermittent self-catheterization was continued in patients who had a poor response to alpha-blockers or refused to undergo bladder neck incision. Bladder neck incision was performed in the initial 2 cases with an adult resectoscope using a Collin's knife and subsequently a pediatric resectoscope (13F). Uroflow and post-void residual measurements were performed in all cases. RESULTS: Of the 24 patients 12 (50%) showed improvement in symptoms, peak flow and post-void residual (p <0.01) with alpha-blocker therapy only. Of the 12 patients who had a poor response to alpha-blockers 6 underwent bladder neck incision subsequently and 6 remained on clean intermittent self-catheterization. All 8 patients treated with bladder neck incision, including 2 who had a good response but discontinued alpha-blocker therapy, had sustained improvement in post-void residual and peak flow (p <0.01) after a mean followup of 3.8 +/- 2.4 years. Grade 1 stress incontinence in 2 adult resectoscope cases responded to conservative treatment. None of the pediatric resectoscope cases had stress incontinence. CONCLUSIONS: Clean intermittent self-catheterization and alpha-blockers are the initial treatment options for functional bladder neck obstruction. The alpha-blockers were successful in 50% of our patients. Bladder neck incision should be offered judiciously with minimal risk of curable stress incontinence. The pediatric resectoscope is useful to make a well controlled incision safely in the female urethra.

Adrenergic alpha-Antagonists↗
PubMed2002

Functional neck dissection for the clinically negative neck: effectiveness and controversies.

This study was performed to evaluate the effectiveness of functional neck dissection in controlling metastasis to the clinically negative (cN0) neck, focusing on recurrences in the pathologically negative (pN0) neck and the role of extracapsular spread in the cN0 neck. A series of 172 patients (253 dissected fields) treated for cN0 laryngeal or hypopharyngeal cancer with a 5-year minimum follow-up is presented. Occult metastasis was observed in 30% of the patients. Extracapsular spread was present in 39% of the positive nodes. The neck recurrence rate was 5.2%. Surgical specimens from cases of neck recurrence in pN0 necks were reevaluated for micrometastasis by immunostaining with antibody for cytokeratins. The immunohistochemical findings were positive in 1 of 4 cases. Functional neck dissection provides good neck control and survival rates for the cN0 neck. The accurate prognostic significance of extracapsular spread in cN0 necks is still unknown. Micrometastasis alone may be insufficient to explain recurrences in pN0 necks.

Adult↗
PubMed1997

Effectiveness of selective neck dissection for management of the clinically negative neck.

OBJECTIVE: To determine the effectiveness of selective neck dissection for management of the clinically negative neck in head and neck squamous cell carcinoma. DESIGN: A retrospective comparison of patients treated electively with selective neck dissection and comprehensive neck dissection. SETTING: Academic tertiary referral center. PATIENTS: Patients with clinically negative necks and previously untreated head and neck squamous cell carcinoma. INTERVENTION: Elective neck dissection, surgical treatment of the primary lesion, and postoperative radiotherapy as indicated. OUTCOME MEASURES: Regional recurrence, distant metastasis, and disease-free survival. RESULTS: Selective neck dissection was as effective as comprehensive procedures for staging the clinically negative neck. Occult metastases had a statistically significant effect on patient outcome as measured by distant metastasis. CONCLUSION: Elective neck dissection provides invaluable staging information, which guides the decision for adjuvant therapy.

Adult↗
PubMed2004

The role of computed tomographic scans in the management of the N-positive neck in head and neck squamous cell carcinoma after chemoradiotherapy.

OBJECTIVE: To determine the sensitivity and specificity of computed tomographic (CT) scanning in predicting residual cervical metastatic disease (N-positive neck) in patients undergoing curative radiotherapy and chemoradiotherapy for squamous cell carcinoma (SCC) of the upper aerodigestive tract. DESIGN: Retrospective case series (1995-2002) of patients undergoing radiotherapy and chemoradiotherapy for advanced head and neck SCC. METHODS: Study entry criteria included N-positive neck disease, a complete response to treatment at the primary tumor site, posttreatment CT scan, posttreatment neck dissection, and correlation of posttreatment CT scan with pathologic neck specimen. We calculated the sensitivity and specificity of the CT scan to predict the presence of residual cervical metastatic disease after curative radiotherapy and chemoradiotherapy. RESULTS: Forty-three patients (including 10 with bilateral N-positive necks) met the study criteria for analysis. Twenty (38%) of the 53 neck dissection specimens were positive for residual cervical metastatic disease. The sensitivity of the CT scan was 85%, while the specificity was only 24%. The positive predictive value of the CT scan was 40%. CONCLUSIONS: While the role of the posttreatment neck dissection remains controversial, the surgeon must rely on clinical examination and imaging studies. Our practice has been to perform planned staged neck dissections on all N2/N3 necks as well as N1 necks with an incomplete response to treatment. Based on our results, it appears that the CT scan technique lacks adequate sensitivity and specificity to reliably predict the presence of residual metastatic disease.

Adult↗
PubMed2006

Role of neck dissection following concurrent chemoradiation for advanced head and neck carcinoma.

BACKGROUND: Our primary objective was to determine the role of neck dissection following concomitant chemoradiation (CRT) for advanced stage III-IV head and neck squamous cell carcinoma (HNSCC). METHODS: One hundred eighty-four patients with HNSCC treated with CRT were included. One hundred twenty-three patients reached a regional complete response (CR) after CRT and no neck dissection was performed. Forty-five patients among the 58 who reached a regional partial response (PR) underwent a neck dissection. RESULTS: Overall, regional CR rate after CRT was 68%. Patients who reached a regional CR (no neck dissection) had an overall neck recurrence rate of 5%. Patients with regional PR who underwent a neck dissection had a 7% neck recurrence rate. CONCLUSIONS: Patients with regional CR not followed by a neck dissection have a low rate of neck recurrence. Systematic neck dissection is not mandatory for patients with nodes less than 6 cm reaching a regional CR. For patients with nodes larger than 6 cm, no firm recommendation can be given because of the small number of patients in this series. If the regional response is incomplete, cervical dissection is warranted.

Adult↗
PubMedDate not supplied

Incisional or excisional neck-node biopsy before definitive radiotherapy, alone or followed by neck dissection.

An analysis of 508 patients (660 heminecks) with head and neck squamous cell carcinoma and clinically positive neck nodes who were treated with radiotherapy alone to the primary lesion (with or without a neck dissection) was conducted to determine if open neck-node biopsy before definitive treatment adversely affected the probability of control of neck disease, the risk of distant metastasis, or the cause-specific survival rate. The prognostic factors analyzed included biopsy status of the neck, N stage, neck treatment, node mobility, node location, T stage, primary site, and control of disease above the clavicles. Sixty-six patients who had undergone an open neck-node biopsy before definitive radiotherapy were compared with a control group of 442 patients who did not undergo a neck-node biopsy; no detrimental effect of the biopsy on neck control, distant metastasis, or cause-specific survival was demonstrated. We conclude that the potential adverse effect of violating the neck before definitive treatment cannot be demonstrated if radiotherapy is the next step in the patient's management.

Biopsy↗
PubMed2006

"Watch-and-see" policy for the clinically positive neck in head and neck cancer treated with chemoradiotherapy.

BACKGROUND: Chemoradiotherapy (CRT) is becoming more widely used for head and neck cancer. However, there are conflicting theories regarding the best management options for patients with advanced nodal disease. METHODS: From 1990 to 1999, we treated 96 patients with N1-N2 neck disease by concomitant CRT for organ preservation, using weekly carboplatin or a low daily dose of cisplatin, followed by a "watch-and-see" policy for the neck. In the present study, we retrospectively analyzed the treatment outcome in 63 of these patients who received definitive CRT for primary and neck diseases and were monitored for neck disease for more than 2 years. RESULTS: In 12 of the 22 (55%) N1 patients, CRT successfully controlled the neck disease. CRT was successful in 18 of the 41 (44%) patients with N2 disease. In 6 (60%) of 10 patients with residual or recurrent N1 disease, salvage surgery was successful. Of the 23 patients with residual or recurrent N2 disease, salvage surgery was successful in 8 patients (35%). The group of patients who showed a clinical complete response (CCR) to CRT had an overall survival rate of 62.4% (33 patients), whereas for those with a less than complete response (<CCR), the figure was 13.3% (30 patients; P < 0.001). Among the <CCR-neck group, patients who underwent neck dissection (ND) as well (n = 20) did not have a significantly better overall survival than those who did not undergo ND (n = 10; P = 0.069). CONCLUSION: We propose a treatment plan for neck disease that involves observing the neck closely following CRT. ND should be planned only when there is evidence that neck disease exists.

Antineoplastic Agents↗
PubMed1998

Management of the clinically positive neck in organ preservation for advanced head and neck cancer.

BACKGROUND: To investigate clinicopathologic predictive criteria for the optimal management of neck metastases in patients with advanced head and neck cancers treated with combined chemoradiotherapy. METHODS: Prospective study, 48 patients. Mean length follow-up, 23 months. RESULTS: Neck stage predicted neck response to chemoradiotherapy; N3 necks showed more partial responses (P = 0.04), and N1 necks showed more complete responses (P = 0.12). Primary tumor site strongly predicted the pathologic response found on neck dissection in patients with a clinical partial response (cPR) following chemoradiotherapy. There was no difference in survival between patients with a clinical complete response (cCR) after chemoradiotherapy, and patients with a pathologic complete response (pCR) after neck dissection (P = 0.20); however, when grouped together, these patients survived longer than did patients with a pPR at neck dissection (P = 0.06). CONCLUSIONS: Clinical response to induction chemotherapy is a poor predictor of ultimate neck control. Induction chemotherapy followed by chemoradiotherapy, and planned neck dissection for patients with persistent cervical lymphadenopathy, provides good regional control.

Adult↗
PubMed1999

Comparison of the sensitivity of lateral neck radiographs and computed tomography scanning in pediatric deep-neck infections.

OBJECTIVE: To compare the sensitivity of lateral neck films and computed tomography (CT) scanning with contrast in evaluating children with a high index of suspicion for a deep-neck infection, either retropharyngeal, parapharyngeal, or combined based in clinical presentation. STUDY DESIGN: A retrospective chart review of children presenting to the Children's Hospital of Buffalo, New York, with the diagnosis of a deep-neck infection between January 1991 and November 1997 was conducted. In total, 57 children were included in the study, ranging in age from 12 to 119 months (1-10 y). METHODS: Charts were reviewed for presenting signs, symptoms, and laboratory values and included only those children with the presence of fever, limited neck range of motion, a lateral neck mass, dysphagia, and a leukocyte count greater than 15,000 cells/mm3. Results of lateral neck radiographs and CT scanning with contrast were evaluated and compared when available. RESULTS: Lateral neck radiographs were found to have a sensitivity of 83% for determining the presence of a pediatric deep-neck infection, whereas CT scanning with contrast had a sensitivity of 100. CONCLUSION: Lateral neck radiographs were found to offer no benefit in the workup of children strongly suspected of having a deep-neck infection based on clinical presentation. Despite the higher cost, CT scanning with contrast is the recommended radiologic test in such cases. This single study allows the determination of size, type, and location of the infectious process and is invaluable in treatment planning for pediatric patients with infection in deep-neck spaces.

Cellulitis↗
PubMed1991

Standardizing neck dissection terminology. Official report of the Academy's Committee for Head and Neck Surgery and Oncology.

The emergence of the multitude of modified techniques for neck dissection procedure has resulted in a nomenclature system that is nonuniform. To eliminate potential misinterpretation, overlap, and lack of standardization, the Academy's Committee for Head and Neck Surgery and Oncology, with input from the Education Committee of the American Society of Head and Neck Surgery, has developed a classification system for these procedures. This has now been adopted by the American Academy of Otolaryngology-Head and Neck Surgery. The classification is based on the following concepts: (1) radical neck dissection is the fundamental procedure with which all other neck dissections are compared, (2) modified radical neck dissection denotes preservation of one or more nonlymphatic structure(s), (3) selective neck dissection denotes preservation of one or more group(s) of lymph nodes, and (4) extended radical neck dissection denotes removal of one or more additional lymphatic and/or nonlymphatic structure(s). Adherence to the principles of this classification system to describe neck dissection techniques should provide an improved method of communication. Furthermore, the system provides a rational framework on which subsequent terminology can be added.

Head and Neck Neoplasms↗
PubMed1999

The role of neck dissection in head and neck mucosal squamous cancer.

The most clinically useful system of classification of neck lymph nodes is grouping into levels I-V. Anatomical, clinical and pathological studies demonstrate that although generally lymphatic flow is from above downwards, level I is often bypassed and level V is seldom involved. Neck dissection is classified into radical, modified radical, selective and extended radical neck dissections. Recent studies demonstrate that elective neck dissection is beneficial to the outcome of oral cancer patients, but not necessarily to laryngeal and pharyngeal cancer patients. Modified radical neck dissection is as effective as radical neck dissection when performed in the elective situation. Selective neck dissection in the form of supra-omohyoid neck dissection is useful as a staging procedure. Modified radical neck dissection is acceptable for the N1 neck provided postoperative radiotherapy is given.

Carcinoma, Squamous Cell↗
PubMed2003

Neck level-specific nodal metastases in oropharyngeal cancer: is there a role for selective neck dissection after definitive radiation therapy?

PURPOSE: To determine the extent of the required neck dissection for patients with persistent lymphadenopathy after definitive radiation therapy for oropharyngeal cancer. If feasible, a conservative approach using selective neck dissection would likely minimize the extent of neck fibrosis and other adverse sequelae. METHODS: Analysis of pretreatment and posttreatment radiologic scans and pathology reports of 76 patients with oropharyngeal carcinoma (35 tonsil; 41 base of tongue), who had radiologic evidence of persistent nodal disease for level-specific involvement. Patients were treated with twice-daily fractionations of external-beam radiation therapy (median dose, 76.8 Gy to the primary tumor) and planned neck dissection (levels I-V) for bulky nodes (N2-3) or salvage neck dissection for N1 disease. RESULTS: The distribution of clinical nodal disease by neck level on the basis of pretreatment and posttreatment radiologic scans indicated levels II and III to be most commonly involved. The false-negative rate for the restaging radiologic scans for each neck level was as follows: level I, 0%; level II, 8%; level III, 6%; level IV, 5%; and level V, 1.5%. Of the eight hemi-necks found to contain positive pathologic nodes in a neck level judged to be negative on the basis of restaging scans, five of the patients subsequently had disease recurrence in the primary site. Patients who had evidence of residual neck disease had a significantly lower rate of locoregional control (77% vs 100%, p =.0005). CONCLUSIONS: The extent of neck dissection for patients with nodal disease associated with oropharyngeal cancer treated with radiation therapy should include levels II-IV. It is reasonable to spare levels I and V in patients without radiologic and clinical evidence of positive nodes in levels I and V.

Adult↗
PubMed2002

The use of sentinel node biopsy to upstage the clinically N0 neck in head and neck cancer.

OBJECTIVE: To investigate the possible role of sentinel node biopsy (SNB) alone to upstage the clinically N0 neck in patients with oral and oropharyngeal squamous cell carcinoma. DESIGN: Prospective clinical study. SETTING: Head and neck referral center. PATIENTS: Patients with primary untreated oral and/or oropharyngeal squamous cell carcinoma accessible to injection and with clinically N0 necks were enrolled in the study. INTERVENTION: An SNB was performed after radiocolloid and blue dye injection. Preoperative lymphoscintigraphy and the perioperative use of a gamma probe identified radioactive sentinel nodes and visualization of blue-stained lymphatics identified blue sentinel nodes. If the sentinel node was found negative, there was no further treatment to the neck. If the sentinel node tested positive, a therapeutic neck dissection was performed. All patients underwent regular follow-up at the outpatient clinic to identify possible recurrence. MAIN OUTCOME MEASURES: Upstaging of the clinically N0 neck by SNB and development of subsequent disease in SNB-negative necks. RESULTS: An SNB was performed on 57 clinically N0 necks in 48 patients. Sentinel nodes were harvested in 43 (90%) of 48 patients. Fifteen (35%) of 43 patients were upstaged by SNB and 28 (65%) of 43 were staged SNB negative. There was a mean follow-up of 18 months. One patient developed subsequent disease after having been staged negative with SNB. The overall sensitivity of the procedure using the full pathologic protocol was 94% (15/16). CONCLUSIONS: Sentinel node biopsy can be used to upstage the N0 neck in patients with early subclinical nodal disease. However, before it becomes the standard of care in head and neck squamous cell carcinoma, longer follow-up observational trials are needed.

Adult↗
PubMed1994

Primary head and neck cancer. Histopathologic predictors of recurrence after neck dissection in patients with lymph node involvement.

OBJECTIVE: Retrospectively analyze several histopathologic variables that may predict neck recurrence after neck dissection. DESIGN: From 1970 through 1980, 284 patients with pathologically confirmed metastatic squamous cell carcinoma underwent neck dissection and received no adjuvant therapy. Kaplan-Meier evaluation estimated a 74% 2-year neck recurrence-free rate. After adjusting for the standard covariates of age, gender, neck stage, and tumor grade, we also controlled for the time-dependent covariates of primary recurrence, occurrence in the side of the neck not operated on, or development of new head and neck primary disease. SETTING: A large referral-based practice. RESULTS: The number of lymph nodes involved, invasion of vascular/lymphatic space, invasion of soft tissue, and desmoplastic lymph node pattern adversely affect neck recurrence. A desmoplastic stromal pattern was associated with almost a sevenfold increased risk of neck recurrence. To our knowledge, this finding has not been reported previously. CONCLUSION: Histopathologic evaluation of metastatically involved cervical nodes can identify patients with head and neck cancer who are at high risk for recurrence.

Adult↗
PubMed2005

Oncologic effectiveness of selective neck dissection in the N0 irradiated neck.

BACKGROUND: The incidence and patterns of nodal spread in previously irradiated N0 necks are not well defined. Therefore, the safety and efficacy of selective neck dissection (SND) in this patient population is not well established. In a previous report from our institution, SND in irradiated patients with recurrent disease at the primary site but clinically negative necks resulted in excellent tumor control in the neck. The objective of this study is to validate our initial observations in a larger sample of patients with longer follow-up. METHODS: A retrospective chart analysis of patients previously treated with primary radiation therapy or chemoradiotherapy for squamous cell carcinoma (SCC) of the head and neck between January 1997 and June 2003 was performed. Patients with recurrent or persistent disease at the primary site or a second primary head and neck SCC, with no clinical or radiologic disease in the neck, who underwent surgical salvage with resection of the primary site along with a site-specific SND were analyzed. Patients who remained disease free at the primary site were analyzed for regional control after SND. RESULTS: Sixty-nine patients underwent a total of 96 site-specific SNDs. The mean age was 64.1 years (range, 39-91 years). There was histologically positive nodal disease in 17 of 69 patients (25%), and 22 of 96 necks (23%). Fifty-three patients had at least a 12-month follow-up. The mean follow-up was 23.3 months (range, 1-96 months). Of the patients with 1-year of follow-up, six patients died from recurrence at the primary site, and nine died from distant metastasis. There were no cases of neck recurrence with the primary site controlled. All patients who had more than two positive nodes had recurrence either at the primary site or distant metastasis. CONCLUSIONS: Our results confirm that the patterns of lymphatic spread are not affected by radiation. We conclude that SND is oncologically safe in the management of the N0 irradiated neck and that the finding of more than two positive nodes predicts a poor outcome.

Adult↗
PubMedDate not supplied

Squamous cell carcinoma of the head and neck treated with radiotherapy: does planned neck dissection reduce the change for successful surgical management of subsequent local recurrence?

For patients with squamous cell carcinoma of the head and neck whose primary lesion is managed with radiotherapy, radiotherapy alone or in combination with neck dissection may be used to treat clinically positive neck nodes. Although these two treatment options produce similar control rates for small mobile nodes, it is our impression that radiotherapy plus neck dissection is the preferred treatment for more advanced neck disease. The question that arises is whether the addition of a neck dissection after radiotherapy will decrease the likelihood of successful surgical management of a subsequent recurrence at the primary site. In an effort to answer this question, the records of 227 patients with squamous cell carcinoma of the head and neck were reviewed. All patients had clinically positive neck nodes and were treated with radiotherapy alone to the primary lesion. There was no apparent difference in the rate of disease control at the primary site or in the ability to manage patients successfully who developed a local recurrence when comparing patients initially treated with radiotherapy alone to those managed by radiotherapy and neck dissection. We conclude that postradiotherapy neck dissection does not decrease the likelihood of successfully managing a recurrence at the primary site.

Carcinoma, Squamous Cell↗
PubMed2004

Controversies in management of the neck in head and neck cancer.

As definitive external radiation and multimodality organ preservation strategies (eg, combined chemotherapy and radiation therapy ) improve, the role of surgery is being re-examined in the management of locally advanced head and neck cancer. Consensus regarding the use of neck dissections for complete responders and incomplete responders has yet to be achieved and the data are surprisingly controversial. A possible benefit from neck dissection after a complete response of the primary tumor after CCRT or definitive external radiation for advanced squamous cell carcinoma of the head and neck may only be anticipated in patients with persisting subclinical neck disease who have no other sites of disease. Some clinicians have even argued that the salvage rate for clinically detectable residual neck disease does not justify neck dissection. Randomized data addressing these questions and a trial addressing the accuracy of new imaging modalities, such as postchemotherapy and postradiation positron emission tomography scanning, across multiple institutions would be appropriate. As a department, we are aggressive in our treatment of isolated residual neck disease after CCRT or definitive external radiation and for patients initially diagnosed with N3 nodal disease. We are investigating the use of adjuvant neck brachytherapy at the time of neck dissection and we are pleased with our early results.

Antineoplastic Agents↗