Effectiveness Neck Dissection Postoperative Radioterapy

7/24/2019 Effectiveness Neck Dissection Postoperative Radioterapy

1/4

Effectiveness of modified radical neckdissection and postoperative radiotherapy

Efficacitedun evidement cervical radical modifie en

association avec la radiotherapie postoperatoire

N. Zwetyengaa*, J.-C. Fricaina, H. Demeauxb, C. Deminierec, F. Siberchicota

aDepartment of Maxillofacial and Plastic Surgery, University hospital of Bordeaux,place Amelie-Raba-Leon, 33076 Bordeaux cedex, Franceb Department of Radiotherapy, Univer sity hospital of Bordeaux, hopital Saint-Andre,1, rue Jean- Burguet, 33076 Bordeaux cedex, FrancecDepartment of Anatomy, University hospital of Bordeaux, place Amelie-Raba-Leon,33076 Bordeaux cedex, France

Disponible en ligne sur

www.sciencedirect.com

Summary

Background and objective. The aim of this study was to evaluate

the effectiveness of a modified radical neck dissection with pre-

servation of non-lymphatic structures usually removed in advanced-

stage head and neck epidermoid carcinoma associated with post-

operative radiotherapy (PORT).

Methods.We analyzed retrospectively the files of 109 patients, pre-

senting with epidermoid carcinoma of the upper digestive/respiratory

tractstaged N2or N3,overa 6-yearperiod.Theratesof regionalcontrol,

mortality, and recurrence were analyzed and linked to the kind of

neck-dissection (usual radical neck dissection [RND], modified radical

neck dissection [MRND], selective neck-dissection [SND]) performed.

Results. Forty-three neck dissections were RND, 92 were MRND,

and21 were SND. PORT wasused inall cases.The mean follow-up was

57.3 months. The overall rate of regional control was93.6%(97.7% for

RND and 93.5% for MRND; p = 0.35). Patients having undergone

MRND hada betterprognosis andless recurrence then patients having

undergone RND (respectively p= 0.007, and p= 0.0004).

Discussion.MRND in association with PORT is an effective treat-

ment in patients with advanced headand neck epidermoidcarcinoma

staged N2 and N3.

2010 Elsevier Masson SAS. All rights reserved.

Keywords : Epidermoid carcinoma, Head and neck cancer, Neckdissection, Radiotherapy

Resume

Introduction.Le but de cette etude etait devaluer lefficacitedun

evidement cervical radical modifie preservant les structures non

lymphatiques habituellement resequees dans les stades cervicaux

avances des carcinomes epidermodes des voies aerodigestives

superieures en association avec la radiotherapie postoperatoire.

Patients et methodes.Les dossiers de 109 patients pris en c harge

pour un carcinome epidermode des voies aerodigestives superieu-

res sur une periode desix ans etclasses N 2 o u N 3 o n t eteanalyses de

manie`re retrospective. Le taux de remission regional, la mortaliteet

letauxderecidive ont eteanalyses et rapportes autype devidement

cervical (evidement cervical radical classique [ECR], evidement

cervical radical modifie [ECRM], evidement cervical selectif

[ECS]).

Resultats. Qurante-trois evidements etaient des ECR, 92 etaient

des ECRM et 21 etaient des ECS. La radiotherapie postoperatoire a

etesystematique. Le suivi moyen etait de 57,3 mois. Le pourcentage

global de remission cervicale a etede 93,6 % (97,7 % pour lECR et

93,5 % pour lECRM ; p= 0,35). Les patients ayant beneficie dun

ECRM avaient un meilleur pronostic vital et moins de recidives

compares aux patients ayant beneficiedun ECR classique (respec-

tivement p= 0,007 et p= 0,0004).Discussion. LECRM associe a` la radiotherapie postoperatoire est

un traitement efficace des carcinomes epidermodes des voies aero-

digestives superieures chez les patients classes N2 et N3.

2010 Elsevier Masson SAS. Tous droits reserves.

Mots cles : Carcinome epidermo de, Cancer de la tete et du cou,Evidement cervical, Radiotherapie

*Corresponding author.e-mail :[email protected](N. Zwetyenga).

Recu le :24 septembre 2008

Acceptele :18 janvier 2010Disponible en ligne6 mars 2010

Original article

59

0035-1768/$ - see front matter 2010 Elsevier Masson SAS. All rights reserved.10.1016/j.stomax.2010.01.001 Rev Stomatol Chir Maxillofac 2010;111:59-62
mailto:[email protected]://dx.doi.org/10.1016/j.stomax.2010.01.001http://dx.doi.org/10.1016/j.stomax.2010.01.001mailto:[email protected]


2/4

Introduction

Supraomohyoid neck dissection is an efficient and safe

method for patients presenting with carcinoma of the upper

digestive tract staged N0 according to UICC. [1,2]. Most

patients with head and neck squamous cell carcinoma present

with neck metastases. Cervical node involvement is the most

significant prognostic factor in those patients [3]. This empha-sizes the exceptional importance of neck dissection. It has

been clearly established that postoperative radiotherapy

(PORT) improves both neck control and survival in such

patients[4,5]. The rational use of modified radical neck dis-

section (MRND) in conjunction with PORT seems to be an

effective neck treatment regardless of the primary site and

stage of the disease[6,7]. In advanced-stage cervical diseases,

classical radical neck dissection (RND) usually spares the

spinal accessory nerve (SAN) only[8,9]. Removing the sterno-

cleidomastoid muscle (SCM) induces esthetic and functional

sequels. Exeresis of the internal jugular vein (IJV) prevents

microsurgical reconstruction.

In 1988, we decided to operate advanced head and neck

epidermoid carcinoma by MRND, whenever it was technically

feasible, with preservation of non-lymphatic structures (SAN,

SCM, and IJV) associated to PORT.

The aim of our study was to confirm the effectiveness of this

treatment in a homogeneous group of patients undergoing

the same protocol.

Patients and method

The files of 1076 patients were analyzed retrospectively. The

patients were all treated in our institution, between January1999 and December 2005, for histologically proven squamous

cell carcinoma of the oral cavity, oropharynx, hypopharynx,

and larynx. One hundred and nine patients were staged N2 or

N3 and underwent RND or MRND. Unidentified primary

tumors, previous treatment, pre-operative chemotherapy or

radiotherapy, and incomplete PORT were exclusion criteria.

Ninety-eight male patients (89.9%) and 11 female patients

(10.1%) were included. The mean age was 57.4 years, ranging

from 17 to 87 years. The primary cancer sites were the oral

cavity in 31 cases (28.4%), the oropharynx in 43 cases (39.5%),

the hypopharynx in 24 cases (22%), and the larynx in 11 cases

(10.1%). Tumors were retrospectively staged according to

UICC. (table I). Seventy-nine patients were staged N2

(72.5%) and 30 staged N3 (27.5%). No patient presented with

metastases at the first consultation.

RND consisted in a complete lymphadenectomy with removal

of the SAN, the IJV, and the SCM. MRND consisted in a

complete lymphadenectomy with preservation of the SAN,

the IJV, and SCM. Selective neck dissection (SND) consisted in

the removal of node levels I, II, and III. The submental (level IA)

and submandibular triangle (level IB) were also removed in all

patients presenting with oral cavity tumors. Bilateral neck

dissections were performed whenever the primary tumor site

was on the median line or overlapped it, in cases of stage N2c,

and systematically for the apex and the base of the tongue. A

total of 156 neck dissections were performed: 43 RND, 92

MRND, and 21 SND. The neck dissection was bilateral in 47

patients (43.1%). All patients underwent PORT (mean dose:

59.4 Gy) since all of them were N+. The tumoral site andbilateral neck were irradiated at 50 Gy. A boost up to 65 Gy

was used in neck areas with extra-capsular spread and in

incomplete resection tumor site. PORT was initiated within 4

weeks after surgery even in case of incomplete healing.

For each cervical specimen, the number of nodes, number and

location of positive nodes, and number and location of extra-

capsular spreads were recorded.

All patient data was recorded on a computer file (MED-

LOGTM). Survival and recurrence probability were analyzed

with the Statistical Package for the Social Sciences (SPSSTM,

Chicago) according to neck stage (N2 or N3), histological

findings, and surgical procedure (RND or MRND). Neck recur-

rence was defined as a lymph node metastasis histologicallyidentical to the primary tumor, without any new head and

neck tumor, and at least 6 months after the first treatment.

The probability of survival or non-recurrence was estimated

by the Kaplan-Meier methodconsidering the period between

the first and the last consultation, or death. The log-rank test

and Fisher exact test were used to assess statistical signifi-

cance and considered significant ifpwas inferior or equal to

0.05.

Results

The mean number of nodes removed per side was 27.3 (1446)

in RND and 26.2 (1245) in MNRD. Eighty-three patients (76.1%)

had extracapsular spread.

At the time of the study,50 patients were still alive (45.9%), 48

of these were free of recurrence, 57 had died (52.3%), and two

were lost to follow-up (1.8%). The overall 2- and 5-year survival

rates were 57.9% and 39.4% respectively. The site of recur-

rences was local in 12 cases (11.0%), local with metastases in

three cases (2.8%), neck in four cases (3.7%), neck and metas-

tases in three cases (2.8%), and metastases in 27 cases (24.8%).

N. Zwetyenga et al. Rev Stomatol Chir Maxillofac 2010;111:59-62

Table ITumor staging according to the TNM system.

N\T Tx T1 T2 T3 T4 Total

N2a 1 4 8 13 10 36N2b 1 5 5 11 5 27N2c 3 4 9 16N3 1 7 7 9 6 30

Total 3 16 23 37 30 109

TNM: Tumour node metastasis.

60


3/4

The probability for 2- and 5-year non-recurrence was 50.5%

and 41.0% respectively. The mean delay for recurrence was

10.5 months.

Patients who underwent MRND had a more favorable

prognosis than those who had RND, at 5 years (respectively

48% and 39% of probability of survival; p= 0.007) (fig. 1).

Patients who had MRND had less recurrence than those who

had RND, at 5 years (respectively 57% and 22% of probabilities

of non-recurrence; p= 0.0004) (fig. 2). The site and nodal

status had no impact on survival and treatment failure.

At the end of the study, seven patients (6.4%) presented with

cervical lymph node metastases with no evidence of tumor

recurrence(table II). 97.7% of patients having undergone RND

(42/43) and 93.5% MRND (86/92) did not present with cervical

lymph node metastases (Fisher exact test;p = 0.35).

The overall rate of patients without cervical lymph node

metastases was 94.5% if the patient presenting with a

contralateral neck recurrence without neck dissection in this

area was included.

The mean follow-up was 57.3 months (minimum: 2 years).

Effectiveness of modified radical neck dissection and postoperative radiotherapy

Figure 1. Probability of survival according to the type of neck dissection (p= 0.007).

Figure 2. Probability of non-recurrence according to the type of neck dissection (p= 0.0004).

61


4/4

Discussion

This study confirmed the effectiveness of MRND in advanced

neck disease.

The standard surgical treatment of lymph node cervical

metastases in head and neck epidermoid carcinoma is RND.

It was first described by Crile and popularized by Martin et al.

[10,11]. Removing the SAN and SCM induces significant esthe-

tic and functional morbidity. PORT decreases morbidity in

neck dissection and offers acceptable control of the disease.

Sparing a non-lymphatic structure, especially the SAN, is

advised[8,9]. Removal of the IJV prevents any microsurgical

reconstruction. MRND is acceptable when feasible, for

patients staged N2, even N2+, or N3 [12]. MRND does not

compromise oncologic safety, and may be converted to RND if

necessary.

The 2 and 5 year survival rate is satisfactory for patients

staged IV (TNM) with extra-capsular node spread in 76.1%.

MRND decreases the pejorative aspect of extra-capsular

spread in terms of survival and recurrence; it also allowsfor a better quality of life.

Conflict of interest statement

The authors have not declared any conflict of interest.

References

[1] Sobin LH, Wittekind CH, editors. UICC/TNM classification ofmalignant tumours. 6th ed., New York: John Wiley; 2003.

[2] Majoufre C, Faucher A, Laroche C, De Bonfils C, Siberchicot F,Renaud-Salis JL, et al. Supraomohyoid neck dissection in cancerof the oral cavity. Am J Surg 1999;178:737.

[3] OBrien CJ, Smith JW, Soong SJ, Urist MM, Maddox WA. Neckdissection with and without radiotherapy: prognostic factors,patterns of recurrence, and survival. Am J Surg 1986;152:45663.

[4] Leemans CR, Tiwari R, van der Waal I, Karim AB, Nauta JJ, Snow

GB. The efficacy of comprehensive neck dissection with orwithout postoperative radiotherapy in nodal metastases ofsquamous cell carcinoma of the upper respiratory and diges-tive tracts. Laryngoscope 1990;100:11948.

[5] Huang DT, Johnson CR, Schmidt-Ullrich R, Grimes M. Post-operative radiotherapy in headand neck carcinoma withlymphnode extension and/or positive resection margins: a compara-tive study. Int J Radiat Oncol Biol Phys 1992;23:73742.

[6] Pearlman NW,Johnson FB,KennaughRC. Modified radical neckdissection and postoperative radiotherapy in squamous cellhead and neck cancer. Am J Surg 1985;150:48890.

[7] Andersen PE, Shah JP, Cambronero E, Spiro RH. The role ofcomprehensive neck dissection with preservation of the spinalaccessory nerve in the clinically positive neck. Am J Surg 1994;168:499502.

[8] Saunders Jr JR, Hirata RM, Jaques DA. Considering the spinalaccessory nerve in head and neck surgery. Am J Surg 1985;150:4914.

[9] Pinsolle V, Michelet V, Majoufre C, Caix P, Siberchicot F, PinsolleJ. Branche externe du nerf spinal et evidements ganglionnairescervicaux. Rev Stomatol Chir Maxillofac 1997;98:13842.

[10] Crile G. Excision of cancer of the head and neck. With specialreference to the plan of dissection based on one hundred andthirty-two operations. JAMA 1906;47:17806.

[11] Martin H, Del Valle B, Ehrlich H, Cahan WG. Neck dissection.Cancer 1951;4:44199.

[12] Richards BL, Spiro JD. Controlling advanced neck disease: effi-cacy of neck dissection and radiotherapy. Laryngoscope 2000;110:11247.

N. Zwetyenga et al. Rev Stomatol Chir Maxillofac 2010;111:59-62

Table IIData for patients with cervical recurrence.

Number ofpatients

ClinicalTNM

Tumor site Type of neckdissection

Nodeshistologicalstatus

Dose ofPORT(Grays)

Time ofrecurrence(months)

Site ofrecurrence

Metastases Status -Follow-up(in months)

1 T3N3 Floor of mouth RND/SND 11C/3C+ 65 7 Ipsilateral Pulmonary DFD - 122 T3N2c Base of tongue MRND/MRND 29C/7C+ 65 7 Ipsilateral DFD - 233 T4N2c Inferior gum MRND/MRND 12C/4C+ 65 8 Ipsilateral DFD - 21

4 T4N2a Base of tongue MRND/SND 8C

/3C+ 65 8 Bilateral DFD - 95 T3N2b Oral mucosa MRND 8C/2C+ 65 9 Ipsilateral AWD - 286 T3N3 Oral tongue MRND 14C/2C+ 66 9 Controlateral Cutaneous DFD - 127 T2N2c Tonsillar pillar MRND 9C/2C+ 65 12 Ipsilateral Pulmonary DFD - 16

PORT: postoperative radiotherapy; C+: positive nodes with extracapsular spread; DFD: died from the disease; AWD: alive without disease.

62

Documents

Effectiveness Neck Dissection Postoperative Radioterapy