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Selective Vs Modified Radical Neck Dissection and Postoperative Radiotherapy Vs Observation in the Treatment of Squamous Cell Carcinoma of the Oral Tongue

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Selective Vs Modified Radical Neck Dissection and Postoperative Radiotherapy Vs Observation in the Treatment of Squamous Cell Carcinoma of the Oral Tongue ORIGINAL ARTICLE Selective vs Modified Radical Neck Dissection and Postoperative Radiotherapy vs Observation in the Treatment of Squamous Cell Carcinoma of the Oral Tongue Bradley A. Schiff, MD; Dianna B. Roberts, PhD; Adel El-Naggar, MD, PhD; Adam S. Garden, MD; Jeffrey N. Myers, MD, PhD Objectives: To assess the role of selective neck dissec- Results: For clinically Nϩ patients, 5 of 45 treated with tion in patients with squamous cell carcinoma (SCC) of selective neck dissection and 1 of 19 treated with radi- the oral tongue with advanced nodal disease, and to as- cal or modified radical neck dissection had recurrences sess the role of postoperative radiotherapy in patients with in the ipsilateral neck. If only patients with significant SCC of the oral tongue with pathologically N1 necks. tumor burden on final pathological examination (clini- cally Nϩ/pathologically N2) are considered, 4 (25.0%) Design: Retrospective study of the medical records of of 16 patients undergoing selective neck dissection had all patients who underwent neck dissection for SCC of recurrences in the neck, while none of the 14 patients the oral tongue from January 1, 1980, to December 31, treated with radical or modified radical neck dissection 1995. Median follow-up was 5.7 years. had recurrences in the ipsilateral neck (P=.07). Of the 50 patients who had pathologically N1 disease, 25 re- Setting: The University of Texas M. D. Anderson Can- ceived postoperative radiotherapy and 25 did not. Of the cer Center, Houston, a tertiary care cancer hospital. latter, 2 had recurrences in the neck, while none of the 25 patients who received radiotherapy had recurrences Patients: A total of 220 patients with SCC of the oral in the neck (P=.24). tongue who received surgical treatment of both the pri- mary tumor and the neck and who had an identifiable Conclusions: Selective neck dissection may be suffi- type of neck dissection, no synchronous or metachro- cient for many Nϩ patients with SCC of the oral tongue, nous lesions, and no evidence of local recurrence. but some patients with extensive nodal disease may ben- efit from more aggressive treatment of the neck. Radio- Interventions: All patients underwent resection of the therapy may be beneficial for all of the node-positive pa- primary tumor and neck dissection. The extent of neck tients, but further studies are needed. Prospective, dissection was determined by surgeon preference. Some randomized clinical trials will be useful in further defin- patients received radiotherapy to the neck as well. ing the role of selective neck dissection in the clinically N2 neck and radiotherapy in the N1 neck for patients Main Outcome Measures: Clinical and pathological with SCC of the oral tongue. nodalstatus,typeofneckdissection,anduseofradiotherapy. The end points evaluated included the regional control rates. Arch Otolaryngol Head Neck Surg. 2005;131:874-878 HE TREATMENT OF THE NECK sternocleidomastoid muscle, and spinal ac- in oral cavity cancer has un- cessory nerve, based on an understand- dergone numerous changes ing of the fascial planes and lymphatic during the past 50 years. Author Affiliations: Radical neck dissection was CME course available at Departments of Head and Neck first described by Crile in 19061 and popu- T 2 Surgery (Drs Schiff, Roberts, larized by Martin et al, and it was the main www.archoto.com El-Naggar, and Myers), surgical treatment of cervical lymphade- Radiation Oncology nopathy secondary to squamous cell car- anatomy of the neck. Bocca and Pigna- (Dr Garden), and Pathology cinoma (SCC) until the last third of the taro4 subsequently presented this proce- (Dr El-Naggar), The University 20th century. The cosmetic and func- dure in the English-language literature, and of Texas M. D. Anderson Ballantyne5 pioneered its use in the United Cancer Center, Houston; and tional defects associated with radical neck Department of Otolaryngology, dissection prompted the search for less States. Modified radical neck dissection, Albert Einstein College of morbid alternatives. According to Ferlito which is often oncologically equivalent to Medicine, Montefiore Medical and Rinaldo,3 Suárez suggested a modi- radical neck dissection but with a signifi- Center, Bronx, NY (Dr Schiff). fied dissection preserving the jugular vein, cant improvement in postoperative mor- (REPRINTED) ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 131, OCT 2005 WWW.ARCHOTO.COM 874 ©2005 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/02/2021 bidity, gradually replaced radical neck dissection in the treatment of the neck for many patients with SCC of the Table 1. Total and Ipsilateral Regional Recurrence oral tongue. Detailed examination of lymphatic drain- in All Neck Dissections age patterns by Rouvierre and others6-9 showed levels I and II to be the main sites of drainage for SCC of the oral No. tongue, with levels IV and V playing a lesser role. Work Pathological No by Lindberg,7 Byers,10 andShahetal11 further eluci- Neck Stage Radiotherapy Radiotherapy Total dated the patterns of lymphatic drainage most common Total Regional Recurrences for SCC of the oral tongue, establishing the rationale for pN0 6/102 1/17 7/119 selective neck dissections of specific lymph node levels pN1 4/25 0/25 4/50 initially developed by Suárez.3,5 One particular selective pN2b 0/3 10/42 10/45 pN2c 0 1/6 1/6 neck dissection, that of levels I to III—also known as the Total, No. (%) 10/130 (7.7) 12/90 (13.3) 22/220 (10.0) supraomohyoid neck dissection12—has been com- monly used in the management of the clinically node- Ipsilateral Regional Recurrences pN0 4/102 1/17 5/119 negative neck in patients with SCC of the oral tongue. pN1 2/25 0/25 2/50 13 Many studies, including one performed prospectively, pN2b 0/3 5/42 5/45 have shown that the supraomohyoid neck dissection pro- pN2c 0 1/6 1/6 vides control rates similar to that of modified radical neck Total, No. (%) 6/130 (4.6) 7/90 (7.8) 13/220 (5.9) dissection for patients with N0 oral cavity SCC. The role of selective neck dissection in patients with clinically evident nodal disease (cNϩ) is more contro- versial. Medina and Byers12 suggested supraomohyoid neck dissection for patients with N0 disease and select METHODS patients with N1 disease, while Shah and Andersen14 rec- ommended supraomohyoid neck dissection for patients We reviewed the medical records of all patients treated at The with N0 disease, but modified radical neck dissection with University of Texas M. D. Anderson Cancer Center, Houston, sacrifice of the sternocleidomastoid muscle and the in- for SCC of the oral tongue from January 1, 1980, through ternal jugular vein for patients with nodal disease. More December 31, 1995. We identified 266 patients who underwent 15-17 surgery that included a neck dissection. Patients who had an un- recent articles have suggested that selective neck dis- specified type of neck dissection, had synchronous or metachro- section is adequate surgical treatment for certain pa- nous lesions, or experienced local recurrence were eliminated tients with N2 disease. However, no prospective clinical from the study. Of the 266 patients with SCC of the tongue, 220 studies exist to prove the efficacy of supraomohyoid neck met the foregoing criteria. dissection compared with modified radical neck dissec- The major variables examined were the clinical and pathologi- tion in patients with SCC of the oral tongue with node- cal nodal status, type of neck dissection received, and use of positive necks. radiotherapy. The end points evaluated included the regional con- The role of postoperative radiotherapy in treatment trol rates. Follow-up time was calculated from the patient’s of the neck in patients with SCC of the oral tongue also initial visit at M. D. Anderson Cancer Center for treatment of the continues to evolve. Studies by Meoz et al18 and Leborgne primary tumor until the date of last contact or death. The use of 19 preoperativeimagingwasdependentonsurgeonpreference.Ninety- et al show that radiotherapy is a viable modality for six (36.1%) of 266 patients underwent preoperative imaging. Ap- elective treatment of the neck. There is evidence that proximately 90% (86/96) of these patients were treated after 1990. postoperative radiotherapy to the neck improves locore- Differences in the proportions of patients who developed disease gional control,20 and adjuvant radiation is often used af- recurrences were tested by the Pearson ␹2 test. If there were 10 ter neck dissections for patients with significant nodal or fewer patients in a group, the 2-tailed Fisher exact test was used. disease. The criteria for neck radiation are not well es- The ␹2 tests were performed with the assistance of the Statistica tablished, and radiation can be given postoperatively on statistical software application (StatSoft, Tulsa, Okla). the basis of either characteristics of the primary tumor or pathological features of the neck dissection speci- RESULTS men. Radiotherapy is often given to patients with ad- vanced-stage disease, close or inadequate surgical mar- REGIONAL CONTROL RATES FOR PATIENTS gins, unfavorable histologic findings including TREATED WITH SELECTIVE NECK DISSECTION lymphovascular invasion or perineural spread, multiple AND MODIFIED RADICAL OR RADICAL or large lymph node metastasis, or the presence of ex- NECK DISSECTION tracapsular spread.14 The role of radiotherapy for the N1 neck without extracapsular spread, however, is not well We reviewed the records of the 220 patients with oral tongue established. cancer treated with resection of the primary tumor and neck Given the lack of information on the role of selective dissection with or without adjuvant treatment and found neck dissection in patients with SCC of the oral tongue with that 22 patients (10.0%) had recurrences in the neck alone advanced nodal disease, and the potential benefit of post- (Table 1).
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