1. Birga Terlunen-Traboldt ENT-Journal Club Need for Neck dissection after Radiochemotherapy? A study of the French GETTEC Group Vedrine P;Thariat J;Hitier M; Kaminsky M; et al. Need for Neck dissection after Radiochemotherapy? A study of the French GETTEC Group.The Laryngoscope, Head and Neck, 2008;118(10);1775-1780

2. Birga Terlunen-Traboldt Study design The study discusses the need for a neck dissection (ND) after a RCT for patients with unresectable cancer of the head and neck The study involved 103 patients with a tumor of oropharynx/hypopharynx or larynx tumor stage III or IV 7 patients have a stage of III and 96 of IV All patients were treated between 1996 and 2002 and had an unresectable primary tumor with node positiv disease (in ultrasound or CT scan) and no distant metastases Patient with distant metastases, induction therapy or without a complete response in the primary tumor after the RCT were excluded

3. Birga Terlunen-Traboldt Intention of the study It is the intention of the study to clarify if it is always necessary to perform a neck dissection after RCT when there are positive nodes before the treatment

4. Birga Terlunen-Traboldt Node stage of the patients The node stage of the 103 patients was as follows 14 had a N1 node stage, 69 a N2 and 20 a N3 All of them were treated with a radiotherapy to a median total dose of 70 Gy (45-70Gy) in the nodes and 70 Gy in the primary tumor A standard chemotherapy was included two to three cycles of platinum-based therapy with 5-FU

5. Birga Terlunen-Traboldt Response and no Response A mean time of 3 months after RCT the patient underwent a clinical examination and a CT-scan, afterwards the decision was taken if it is a matter of nodal response or no response A complete clinical and radiological disappearance was observed in the neck by 63 of the 103 patients (61%) 40 patients had a residual neck disease (39%) 28 (70%) of them underwent a neck dissection, the remaining 30% got a wachtfull follow-up by scary nodes or were unresectable or medically unfit for surgery

6. Birga Terlunen-Traboldt Performance of Neck dissection ND was performed with a mean delay of 4.2 month after RCT 14 of the 28 ND (50%) showed pathological evidence of viable tumor 10 of the 14 showed extracapsular spread

7. Birga Terlunen-Traboldt Complications Complications of ND after RCT were recorded in 4/28 cases; no greater wound healing problems or severe infectious were reported It might be possible that the complication rate by surgery after RCT increases after treatment So what is the best time for ND? The CT scan is done 3 months after RCT and the surgical window is after the acute dermatitis phase and before the onset of chronic post RCT- subcutaneous fibrogenesis

8. Birga Terlunen-Traboldt Conclusions Disease free survival and overall survival were similar between patients with a complete response in neck and no ND and patients with a neck dissection for residual neck disease in this study The feature of this study is to decide a neck dissection not from the tumor or nodes stage but from the completed nodal response, so by completed nodal response no ND should be necessary

9. Birga Terlunen-Traboldt Hypotheses This way is widely accepted worldwide for N1 disease but highly debated for N2-N3 neck disease, even after complete response The combined imaging of CT scan, ultrasound and PET-CT can increase the reliability of nodal response after RCT They should have divided the response patients in two groups one get also a ND and the other no other treatment then you can see in the follow up if the ND group get less positive nodes in the future or not