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Salvage Neck Dissection After Chemoradiation in Head and Neck IJHNS 10.5005/jp-journals-10001-1083 REVIEW ARTICLE Salvage Neck Dissection after Chemoradiation in Head and Neck Cancer: Practice and Pitfalls Salvage Neck Dissection after Chemoradiation in Head and Neck Cancer: Practice and Pitfalls Jaiprakash Agarwal, Sayan Kundu, Rahul Krishnatry, Tejpal Gupta, Vedang Murthy Ashwini Budrukkar, Sarbani Ghosh Laskar ABSTRACT that any node-positive disease at diagnosis can lead to 2 Locally advanced head and neck cancers are usually treated 5-year survival rates of less than 50%. Brizel et al with concurrent chemoradiation. The residual nodes after demonstrated a decreased rate of neck control by 35% in chemoradiation in such patients are a common scenario, but patients with N2 or greater regional disease who received the further investigation and treatment options in form of neck CRT without ND as compared to ND patients.3 When occult dissection are still not very clear. This review focuses on the current state of available evidence in literature for management metastases are present, overall survival drops to levels found of such patients and directs for the future development to fill the in patients who present with node-positive necks at lacunae. diagnosis, irrespective of the primary treatment modality 4 Keywords: Radiotherapy, Hypopharyngeal cancer, Oral cancer, employed. Failure in the neck after definitive neck Larynx, Chemoradiotherapy. treatment offers a distinctively poorer prognosis than local 5 How to cite this article: Agarwal J, Kundu S, Krishnatry R recurrences. In a tumor registry based study by Deschamps Gupta T, Murthy V, Budrukkar A, Laskar SG. Salvage Neck et al, out of 1291 patients of head and neck cancer treated Dissection after Chemoradiation in Head and Neck Cancer: between 1998 and 2007 there were 224 recurrences of which Practice and Pitfalls. Int J Head and Neck Surg 2012;3(1): 15-21. 47 isolated neck recurrences. Twenty-one percent of isolated neck recurrence patients had regional disease (N+) at initial Source of support: Nil presentation. Median survival and 5-year survival was 14.7 Conflict of interest: None declared months and 5% for isolated neck recurrences than 40.1 months and 15% for others.6 INTRODUCTION Concurrent chemoradiation therapy (CRT) is an accepted Role of Imaging in detecting primary treatment for locally advanced head and neck Residual/Recurrent Disease cancers. Although CRT often provides excellent local The ideal investigation to ascertain the residual disease and control, its efficacy in treating advanced regional disease decide for further treatment post-CRT is still not known. (nodes) remains controversial. Current CRT protocols There have been discrepancies between findings on imaging include treatment of nodal metastases in the neck, but there studies and the presence of pathologic residual carcinoma are a lot of discrepancies in recommendation for the residual in the neck adding dilemma to the decision of surgery vs nodes post-CRT. This includes the controversy of choice observation. The key reason for this difference in different of investigation, timing of assessment, type and timing of retrospective studies is not just in the final outcomes but neck dissection (ND) and case selection criteria. Also, there probably in the timing of these investigations.7,8 Timing is scanty information in literature regarding management has different meaning for different investigations, ranging of complete clinical response in patients of advanced from viability and clonogenic capacity of the tumor cells regional disease (N2 or N3). In this review, we present the still in those nodes (USS FNAC, PET) if done earlier than concise evidence to date in literature for surgical the time needed for regression, the morphological regression management of neck nodes in radically treated head and of these nodes (clinical, CT, USS or MRI), resolution of neck cancer patients with CRT. acute inflammation post-CRT (PET-CT), undue delay in surgery if we wait too long for investigations.9-11 Also an Neck Nodes are Important Prognostic important issue that becomes critical in most developing Factor affecting Survival countries is the availability and the cost. So there cannot be The primary justifications for posttreatment ND in radically the best investigation of choice suggested for all. treated CRT patients are; the 25% chance of residual neck What can be suggested at this juncture is a clinical disease, the challenge of accurate clinical follow-up in assessment at 8 weeks post-CRT, when the acute effects of patients with postradiotherapy neck fibrosis, and the poor treatment have subsided and before the chronic side-effects outcomes in salvage neck surgery.1 It has been reported set in. When physical examination of the neck shows no International Journal of Head and Neck Surgery, January-April 2012;3(1):15-21 15 Jaiprakash Agarwal et al cervical adenopathy, for initial N1 and N2 disease described by Crile in 1906. It is a safe and reliable method observation with close follow-up may be suitable. When of addressing the lymph nodes. Although RND is an the findings at clinical examination are ambiguous, or if excellent technique, it is nonetheless associated with N3 node was present and there is clinical complete response substantial morbidity. The Committee of Head and Neck is present; PET-CT (12 weeks), CT or MRI (8-12 weeks), Surgery and Oncology and the American Academy of USS neck can be planned in order of preference. If clinically Otolaryngology/Head and Neck Surgery have revised the suspected residual node after chemoradiation then its better terminology and classification of neck dissection.20 to go ahead with planned ND. The investigations like CT, Radical neck dissection (RND): Resection of cervical lymph MRI, PET-CT or USS can help in identifying the involved nodes from all five levels along with sternocleidomastoid 12,13 levels of the neck to decide for extent of ND. muscle (SCM), internal jugular vein (IJV) and spinal accessory nerve (SAN). Is Planned ND Necessary after Initial CRT? Modified radical neck dissection (MRND): Modification of An early ND after residual disease in post-CRT (4-12 weeks) RND with preservation of one or more nonlymphatic has shown several distinct advantages of improved regional structures. control and survival. But the benefit of surgery in patients with a complete clinical response after CRT has been Selective neck dissection (SND): Modification of RND with difficult to show; also most retrospective single-institution preservation of one or more lymph node groups, which are reviews are limited by inadequate statistical power to detect removed in RND. 14,15 a survival advantage for this subset of patients. Another Extended radical neck dissection (ERND): Removal of facet which has been rarely discussed is that the presence additional lymph nodes (occipital or parotid nodes) or of pathologic residual carcinoma in the ND specimen has nonlymphatic structures relative to a RND. been associated with an increased risk of local and regional In a review by the Committee of Head and Neck Surgery recurrence as well as distant failure. and Oncology and the American Academy of Otolaryn- The morbidity of a potentially unneeded procedure gology/Head and Neck Surgery, the committee noted that cannot be ignored because if there is no residual disease there was a worldwide desire to maintain their previous present these patients can be easily followed-up avoiding classification but felt that minor modifications had to be surgery. But if wrong patient is selected for observation it amended to keep with the current philosophy of cervical can lead to persistence or progression of disease in the neck nodal metastases.21 As such, modified radical neck necessitating salvage ND, which has been associated with dissection (MRND) was divided into: an increased frequency and severity of postsurgical i. MRND type I: Resection of SCM, IJV and all five levels complications. A ‘window’ between acute and chronic CRT of cervical lymph nodes (preservation of SAN) injury 4 to 12 weeks after radiation has been described to ii. MRND type II: Resection of SCM and all five levels 19 minimize the surgery-related complications. of cervical lymph nodes (preservation of SAN and IJV) At this juncture, it is important to revisit the frequency iii. MRND type III: Resection of all five levels of cervical of pathologic residual carcinoma in ND specimens which lymph nodes (preservation of SAN , IJV and SCM). ranges from 20 and 68% and is affected by many factors Similarly, selective neck dissection (SND) was also including pretreatment nodal stage and bulk, radiation dose divided according to the levels of lymph node dissected: and technique, the use of chemotherapy, the timing and i. Supraomohyoid neck dissection (SOHND): Resection extent of ND, and most importantly clinical response to CRT of all lymph node levels from I to III. or patient selection.16-19 Most authors prefer the planned ii. Lateral neck dissection (LND): Resection of all lymph dissection in all patients with evidence of clinical or node levels from II to IV. radiological evidence of residual disease in neck, while iii. Posterolateral neck dissection (PLND): Resection of prophylactic ND after complete response is done in N3 and all lymph node levels from II to V. rarely for N2 or N1 disease. Usually patients with complete The gold standard procedure used till date for treatment response both clinically and radiologically are preferred for of residual or recurrent cervical lymph nodes following CRT
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