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

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
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. 1986
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. 1986
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. Induction Chemotherapy
Laryngectomy and
Post-op XRT
~66% 5-year
survival
Laryngeal Cancer
Induction chemo
then XRT
Surgery as salvage
2/3 able to preserve
Larynx without surgery
Wolf et. Al.
VA Laryng. Ca Study

18. Neck Management in Induction ChemotherapyNo
surgery
6 died of uncontrolled
neck disease
18 Complete
Responders
37 patients with
N2 or N3 disease
19 Partial
Responders
Neck
Dissection
@12 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
Residual Disease
n=8(25%)
Residual Disease
n=17(39%)
McHam et. al. 2003

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
21 hemi-necks
(+) CT neck mass
(-) PET
42 hemi-necks
(-) CT neck mass
(-) PET
O B S E R V E
42 NED
21 NED

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

27. Yao et al 2005 (Iowa) NPV 100% Median f/u 26 months PET @ 12 weeks
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
1 persistent
disease
32 NED

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

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 2011 112 patients with N(+) SCCA
Definitive Radiotherapy +/- Chemotherapy
50 Patients with residual lymphadenopathy on CT scan

32. Porceddu et al 2011 50 Patients with residual adenopathy PET scan
41 Patients PET (-)
OBSERVATION ONLY
41 Patients NED

33. Porceddu et al 2011 50 Patients with residual adenopathy PET scan
41 Patients PET (-)
9 Patients PET (+)
OBSERVATION ONLY
Neck Dissection
6 Patients
Persistent
Tumor
3 Patients
NED
41 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.

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