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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.

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Presentation on theme: "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."— Presentation transcript:

1 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 of Otolaryngology –Head and Neck Surgery MetroHealth Medical Center

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4 Format History and Basics of Neck Dissection The old paradigm, neck dissection in: –Radiotherapy alone –Chemo-radiotherapy Evidence for a change in paradigm

5 George W. Crile First neck dissection 1906 Saint Michael’s Hosp. Cleveland, OH

6 Bulky Neck Metastases TTT

7 Levels of Neck Dissection

8 Radical Neck Dissection Myers et.al. TTT

9 Modified Radical Neck Dissection Myers et.al. TTT

10 Selective (Bocca) Neck Dissection Myers et.al. TTT

11 Format History and Basics of Neck Dissection The old paradigm, neck dissection in: –Radiotherapy alone –Chemo-radiotherapy Evidence for a change in paradigm

12 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 Parson et. al. 1989

13 Neck Dissection Following Definitive Radiation Therapy Factors that prognosticated worse neck control –> 3cm neck nodes –Fixed nodes –Multiple nodes Mendenhall et. al Parson et. al. 1989

14 Neck Dissection Following Definitive Radiation Therapy 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. Mendenhall et. al. 1986

15 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.

16 Format History and Basics of Neck Dissection The old paradigm, neck dissection in: –Radiotherapy alone –Chemo-radiotherapy Evidence for a change in paradigm

17 Laryngeal Cancer Laryngectomy and Post-op XRT Induction chemo then XRT Surgery as salvage ~66% 5-year survival 2/3 able to preserve Larynx without surgery Induction Chemotherapy Wolf et. Al. VA Laryng. Ca Study

18 Neck Management in Induction Chemotherapy 37 patients with N2 or N3 disease 18 Complete Responders 19 Partial Responders 6 died of uncontrolled neck disease No surgery Neck weeks 13 died of uncontrolled neck disease Wolf et. al. 1992

19 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

20 Paradigm of Planned Neck Dissection 109 patients with N2+ disease had concurrent chemoradiation Complete Responders n=65 Partial Responders n=44 Neck Dissection n=32 No Neck Dissection n=33 Neck Dissection n=44 McHam et. al Residual Disease n=8(25%) Residual Disease n=17(39%)

21 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

22 Uncontrolled Neck Disease Chronic draining wound Uncontrolled Pain Bleeding Malodor Social Isolation TTT

23 Format History and Basics of Neck Dissection The old paradigm, neck dissection in: –Radiotherapy alone –Chemo-radiotherapy Evidence for a change in paradigm

24 Role of PET scans: Yao et al 2005 (Iowa) 70 hemi-necks with N2 (+) disease Concurrent Chemoradiation With complete response at primary 42 hemi-necks (-) CT neck mass (-) PET O B S E R V E 42 NED

25 Yao et al 2005 (Iowa) 70 hemi-necks with N2 (+) disease Concurrent Chemoradiation With complete response at primary 42 hemi-necks (-) CT neck mass (-) PET O B S E R V E 21 hemi-necks (+) CT neck mass (-) PET 42 NED21 NED

26 Yao et al 2005 (Iowa) 70 hemi-necks with N2 (+) disease Concurrent Chemoradiation With complete response at primary 42 hemi-necks (-) CT neck mass (-) PET O B S E R V E 21 hemi-necks (+) CT neck mass (-) PET 7 hemi –necks (-) CT neck mass (+) PET 3 persistent disease 4 NED42 NED21 NED Neck Dissection

27 Yao et al 2005 (Iowa) Median f/u 26 months 12 weeks NPV 100% SUV > 3.0 were positive PPV only 43%

28 Nayak et al 2007 (Pittsburgh) 43 patients with N2 (+) disease Concurrent Chemoradiation With complete response at primary 33 patients (-) PET O B S E R V E 32 NED 1 persistent disease

29 Nayak et al 2007 (Pittsburgh) 43 patients with N2 (+) disease Concurrent Chemoradiation With complete response at primary 33 patients (-) PET O B S E R V E 10 patients (+) PET 7 persistent disease 3 NED32 NED 1 persistent disease Neck Dissection

30 Nayak et al 2007 (Pittsburgh) Median f/u 18.1 months 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.

31 Porceddu et al patients with N(+) SCCA Definitive Radiotherapy +/- Chemotherapy 50 Patients with residual lymphadenopathy on CT scan

32 Porceddu et al Patients with residual adenopathy PET scan 41 Patients PET (-) OBSERVATION ONLY 41 Patients NED

33 Porceddu et al Patients with residual adenopathy PET scan 41 Patients PET (-)9 Patients PET (+) OBSERVATION ONLY 41 Patients NED Neck Dissection 6 Patients Persistent Tumor 3 Patients NED

34 Porceddu et al 2011 Conclusions –NPV of PET 100% –PET better than physical exam or CT scan for follow-up after definitive Radiotherapy +/- Chemotherapy.

35 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

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

37 Conclusions The SUV of a hyper-metabolic focus is an important variable to report on PET readings and has prognostic value. When negative, CT/PET done after definitive chemoradiation accurately predicts negative neck nodal status.

38 Conclusions The SUV of a hyper-metabolic focus is an important variable to report on PET readings and has prognostic value. When negative, CT/PET done after definitive chemoradiation accurately predicts negative neck nodal status. We should consider routine use of CT/PET after definitive chemoradiation to guide therapy of neck nodes.

39 Conclusions The SUV of a hyper-metabolic focus is an important variable to report on PET readings and has prognostic value. When negative, CT/PET done after definitive chemoradiation accurately predicts negative neck nodal status. 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.

40 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: 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: 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: Myers et.al. Operative Otolaryngology. W.B. Sauders Company pp Nayak et al Laryngoscope 117(12): , 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: 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: 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): , August 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: Yao et al Int. J of Rad Onc, biol and phys. 63(4):991-9, Yao et al Int. J of Rad Onc, biol and phys. 63(4):991-9, 2005.


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