Managment Of N+Neck

Management of the NeckManagement of the Neck(N(N00 and N and N++))

Dr. A D’Cruz Tata Memorial Hospital

Cervical Metastasis Cervical Metastasis

• Single most important prognostic factor

• 50% decrease in survival

• Paradigm shift in the management in last 20 years

• Treatment usually influenced by choice of treatment for

primary

Management of the neckManagement of the neckSurgerySurgery

Should the NShould the N0 0 neck be addressedneck be addressed

What should be the extent of dissection NWhat should be the extent of dissection N00

What should be the extent of dissection for the NWhat should be the extent of dissection for the N+ + neckneck

When & what adjuvant treatment is indicated after neck When & what adjuvant treatment is indicated after neck

dissectiondissection

1. Should the neck be addressed in a N0 neck?1. Should the neck be addressed in a N0 neck?

No debateNo debate

- T3,T4- T3,T4

- Cheek flap- Cheek flap

- Site- Site

Glottis (low risk)Glottis (low risk)

BOT, PFS, SGL (high risk)BOT, PFS, SGL (high risk)

DebateDebate

T1,T2 oral cavity, which T1,T2 oral cavity, which

can be treated per orallycan be treated per orally

END v/s ObserveEND v/s Observe

ENDEND

Trend towards better survival Trend towards better survival

Single surgerySingle surgery

? Diversion of lymphatics? Diversion of lymphatics

ObserveObserve

No compromise on survivalNo compromise on survival

Sx avoided in upto 80%Sx avoided in upto 80%

Low salvage ratesLow salvage rates

““It must be shown that neck dissection performed for clinically It must be shown that neck dissection performed for clinically

palpable metastases (cN+) is less successful than a similarpalpable metastases (cN+) is less successful than a similar

operation for involved but not palpable nodes (cN0 but pN+)”operation for involved but not palpable nodes (cN0 but pN+)”

Weiss et al

• A patient with a N0 neck status should be observed if the

probability of occult cervical metastasis is less than 20%

• If the probability is greater than 20%, treatment of

the neck is warranted (quality adjusted survival)

Arch Otolaryngol H & N Surg. 1994;120:699 -702

N0 Current Management Policies – IN0 Current Management Policies – IMathematical ModelsMathematical Models

NN00 Current Management Policies - II Current Management Policies - IIHistorical evidenceHistorical evidence

SiteSite % nodal metastases% nodal metastases

T1T1 T2T2 T3T3Oral tongueOral tongue 1414 3030 4747Floor of mouthFloor of mouth 1111 2929 4343RMTRMT 11.511.5 3737 5454

Lindberg et al, Byers et al, Shah et al.Lindberg et al, Byers et al, Shah et al.

Author (n)Author (n) DFSDFS OASOASHaddadinHaddadin - - p = 0.01p = 0.01**(137) (137)

LydiattLydiatt nsns nsns(156)(156)YuenYuen p < 0.05p < 0.05** - -(63) (63) Piedbois(1991)Piedbois(1991) -- p < 0.04p < 0.04(233)(233)

* in favour of elective neck dissection* in favour of elective neck dissection

N0 Current Management Policies - IIIN0 Current Management Policies - IIIRetrospectiveRetrospective

Author (n)Author (n) DFSDFS OASOAS

Vandenbrouck (1980)Vandenbrouck (1980) nsns nsns(75)

Fakih (1989)Fakih (1989) nsns nsns(70)(70)

Kligerman (1994)Kligerman (1994) p = 0.04p = 0.04** - -(67)(67)

* in favour of elective neck dissection* in favour of elective neck dissection

N0 Current Management Policies - IV Trials – Prospective

Tongue cancerTongue cancer Retrospective analysis (1997 – 2001)Retrospective analysis (1997 – 2001)

359 patients359 patients

ObserveObserve OperateOperate (200 patients)(200 patients) (159 patients)(159 patients)

SOHD (89) MND (70)SOHD (89) MND (70) Previously untreated ptsPreviously untreated pts Per oral excisions Per oral excisions

Observe Operate

Tumor characteristicsTumor characteristics

T Stage T1 118(59%) 69(43.4%) T2 82(41%) 90(56.6%)

Grade I 48(24%) 30(18.9%) II 132(66%) 109(68.6%) III 20(10%) 20(12.6%)

PNI No 181(90.5%) 145(91.2%) Yes 19(9.5%) 14(8.8%)

Thickness <=3 39(19.5%) 13(8.2%) 4-9 115(57.5%) 89(56%) >=10 37(18.5%) 52(32.7%)

Cut margin +ve 7(3.5%) 4(2.5%) -ve 184(92%) 146(91.8%) close 9(4.5%) 9(5.7%)

Status at last follow -upStatus at last follow -up

Observe Observe Operate Operate Disease free Disease free 131(65.5%) 131(65.5%) 117(73.6%)117(73.6%)Alive with DiseaseAlive with Disease 38(19%) 38(19%) 25(15.7%)25(15.7%)Died of DiseaseDied of Disease 8(4%) 8(4%) 5(3.1%) 5(3.1%)Died of other causeDied of other cause 6(3%) 6(3%) 1(0.6%) 1(0.6%)Lost to follow-upLost to follow-up 17(8.5%) 11(6.9%)17(8.5%) 11(6.9%)

Over All Survival

OASMNTH

96847260483624120

Cu

m S

urv

iva

l

1.1

1.0

.9

.8

.7

.6

.5

.4

.3

.2

.1

.0

operate

Observe

p=0.24

Views on management of N0 neck Views on management of N0 neck QuestionnaireQuestionnaire

Werning et al,Werning et al,

Random survey of 763 otolaryngologistsRandom survey of 763 otolaryngologists

To determine the variability of Mx of the N0 neckTo determine the variability of Mx of the N0 neck

13% 13% ObserveObserve

66%66% ENDEND

19%19% Radiotherapy to neckRadiotherapy to neck

Arch Otolaryngol Head Neck Surg 2003Arch Otolaryngol Head Neck Surg 2003

2. Extent of neck dissection (N0 neck)2. Extent of neck dissection (N0 neck)

Location:Location: Oral BOT Hypopharynx LarynxOral BOT Hypopharynx Larynx

Level of :Level of : I-IIII-III II-III II-III II-IV II-IV II-IV II-IV NeckNeck

SOHD SOHD ( I – III)( I – III) - - Oral cavityOral cavity Lateral neck Lateral neck (II – IV)(II – IV) - - Oropharynx, Larynx, Hypopharynx Oropharynx, Larynx, Hypopharynx

- Lindberg, Byers, Shah

SOHD (Oral Cavity) SOHD (Oral Cavity) Recurrences in dissected neck Recurrences in dissected neck

[Primary controlled; 2 YR follow up][Primary controlled; 2 YR follow up]

Path Path Surgery only Surgery only Sx + RT Sx + RTStagingStaging

MedinaMedina11 ByersByers2 2 MedinaMedina11 ByersByers22 N0N0 0 / 510 / 51 7/130(5%) 7/130(5%) 1/29(3.45%) 1/29(3.45%) 2/24(8%)2/24(8%)

N1N1 - - 1/10(10%) 1/10(10%) 1/31/3 0/80/8

MultipleMultiple 0 / 10 / 1 5/21(24%)5/21(24%) 2/16(12.5%)2/16(12.5%) 6/14(15%)6/14(15%)NodesNodes

11 Hawai 1991 , Hawai 1991 ,22 Head & Neck 11; 1989 Head & Neck 11; 1989

Lateral Neck Dissection – Reccurences in dissected neck Lateral Neck Dissection – Reccurences in dissected neck [Primary controlled; 2 YR follow up][Primary controlled; 2 YR follow up]

Path StagingPath Staging Surgery only Surgery only Sx + RT Sx + RT

MedinaMedina11 ByersByers2 2 MedinaMedina11 ByersByers22 N0N0 0 / 15(0)0 / 15(0) 10/130(8) 10/130(8) 1/19(5.2) 1/19(5.2) 1/126(1)1/126(1)

N1N1 - - 0/4(0) 0/4(0) 0/3(0)0/3(0) 0/17(0)0/17(0)

MultipleMultiple - - - - 00/6(0)/6(0) 3/20(15)3/20(15)NodesNodes

11 University of Oklahoma experience , University of Oklahoma experience ,22 Am J Surg 1986;150: 414-421 Am J Surg 1986;150: 414-421

Critical Assessment of SOHDCritical Assessment of SOHD

94 Patients / 107 SOHD’s

24 Clinical N + 83 Clinical N -

26 Path +ve17 Path +ve 64 Path -ve

4 (15%) Neck Fail3 (5%) Neck Fail5 (29%) Neck Fail

94 Patients / 107 SOHD’s

Spiro Am J surgery 1998

ORAL SCC T2 – T4 N0)ORAL SCC T2 – T4 N0)RCT (148 patients)RCT (148 patients)

RecRec 5Yr Survival 5Yr Survival Comp Comp

MNDMND 1919 63%63% 41% 41%

SOHDSOHD 1616 67% 25%67% 25% p0.7150 p0.7150 p0.043 p0.043

Am J Surg 1998 Brazilian H & N groupAm J Surg 1998 Brazilian H & N group

3. 3. What should be the extent of dissection What should be the extent of dissection for the Nfor the N+ + neckneck

““IS SELECTIVE NECK DISSECTION A VALID PROCEDURE FOR N+ NECK?”IS SELECTIVE NECK DISSECTION A VALID PROCEDURE FOR N+ NECK?”

Management of the neckManagement of the neck

• Crile 1906, Martin 1950Crile 1906, Martin 1950

Management of the neckManagement of the neck

Bocca 1984 Laryngoscope 843 Cases

Byers 1985 Am J Surg 967 Cases

Anderson 1994 Am J Surg 366 Cases

RND 63% 12%

MRND 71% 8% p (NS)

5 year Survival Neck Failure

MND = RNDSame control • Less Morbid

Level V Metastases Level V Metastases

Overall 3 %

Hypopharynx 7 %

Oropharynx 6 %

Oral Cavity 1 %

Larynx 2 %

Davidson et al, Am J Surg, Oct. 93. N = 1277

SND in N+ NeckSND in N+ Neck

Kowalski 1993 164 / 95 +ve

Kolli 2000 69 / 39 +ve

Traynor 1996 29 patients +ve

Safe

Therapeutic Neck Dissection – 25 Yr ReviewTherapeutic Neck Dissection – 25 Yr Review

Median follow up – 4.3yrsMedian follow up – 4.3yrs

SNDSND MNDMND RNDRND(61)(61) (54)(54) (61)(61)

Regional ControlRegional Control 2(3.3%)2(3.3%) 3(5.6%)3(5.6%) 3(4.9%)3(4.9%)((p = NS)p = NS)

DFS at 2yrsDFS at 2yrs 80%80% 64%64% 64%64%ComparableComparable

- K. Muzzafar, Laryngoscope: 2003

SND in N+ NeckSND in N+ Neck

Anderson (106 patients/ 129 necks)

Oral Cavity 42 (39.6%)Oropharynx 37 (34.9%)Larynx 20 (18.9%)Hypopharynx 7 ( 6.6%)

T0 1 (0.9%)T1 9 (8.5%)T2 28 (26.4%)T3 36 (34.0%)T4 32 (30.2%)

Post Op RT 71.7%

N1 58(54.7%)N2a 5(4.7%)N2b 28(26.4%)N2c 14(13.2%)N3 1(0.9%)ECS 30(34%)

Regional failures 9 (5.7%) 6 within fields

Archives 2002

SND in N+ NeckSND in N+ Neck

Medina & Byers ; Head & Neck 1989

114 patients node +ve - 91(79.8%) pathologic evidence of mets

N1 / No ECS Surgery Only - 10% recc

Multiple / ECS - 24%

SX + RT - 15%

SND in N+ NeckSND in N+ Neck

1.1. Only in pts without massive adenopathyOnly in pts without massive adenopathy2.2. No nodal fixationNo nodal fixation3.3. Obvious gross ECSObvious gross ECS4.4. No prior neck surgery / RTNo prior neck surgery / RT

AHNS - Procedures StudiedAHNS - Procedures Studied

Selective neck dissectionSelective neck dissection Total thyroidectomyTotal thyroidectomy ParotidectomyParotidectomy Endoscopic laryngeal surgery Endoscopic laryngeal surgery

Evidence-Based ReviewEvidence-Based Review

Thorough, systematic review of literature Thorough, systematic review of literature

Each relevant paper reviewed by explicit Each relevant paper reviewed by explicit

guidelines and assigned a ‘level of evidence’guidelines and assigned a ‘level of evidence’

All papers compiled and topic is assigned ‘grade All papers compiled and topic is assigned ‘grade

of recommendation’ of recommendation’

Expert opinion5D

Case series (no control group)4C

Case control studies3

Cohort studies, Low quality RCT2bB

Meta-analysis of cohort studies2a

High quality RCT1bA

Meta-analysis of RCT’s1a

Study DesignLevel of Evidence

Grade of Recommendation

ResultsResults

4. Adjuvant treatment after neck dissection 4. Adjuvant treatment after neck dissection PROGNOSTIC IMPLICATIONSPROGNOSTIC IMPLICATIONS

Extracapsular spreadExtracapsular spread1.1. Johnson (Arch 1981) < 40% SurvivalJohnson (Arch 1981) < 40% Survival2.2. Steinhart 1994 – ECS 28% v/s NO ECS 70%Steinhart 1994 – ECS 28% v/s NO ECS 70%3.3. Carter (Am J Surg 1985) – Carter (Am J Surg 1985) –

““Macroscopic ECS worse than Microscopic”Macroscopic ECS worse than Microscopic”

Desmoplastic stromal patternDesmoplastic stromal pattern1.1. 284 Patients (no RT) – 7 fold increase in regional recurrences 284 Patients (no RT) – 7 fold increase in regional recurrences OLSEN (Archives 1994) OLSEN (Archives 1994)

Number of lymph nodesNumber of lymph nodes1.1. O’BRIEN ( Am J Surg 1986) - No. of nodes RecurrencesO’BRIEN ( Am J Surg 1986) - No. of nodes Recurrences2.2. KALNINS (Am J Surg 1977) KALNINS (Am J Surg 1977)

N0 75%, 1 node 49%, 3 nodes 30%, >3 13%N0 75%, 1 node 49%, 3 nodes 30%, >3 13%

Level of Lymph nodesLower nodes have worse prognosisLower nodes have worse prognosisSpiro Am J Surg 1974, Tulenko Am J Surg 1966, Mendelson 1976Spiro Am J Surg 1974, Tulenko Am J Surg 1966, Mendelson 1976

RCT – Role of RT in management of NeckRCT – Role of RT in management of Neck

Peters et alPeters et al (1993) (1993) RISK GROUPSRISK GROUPSRCTRCTN = 240N = 240 LOW RISK LOW RISK HIGH RISKHIGH RISK

DOSE ADOSE A DOSE B DOSE C DOSE B DOSE C52 – 54 Gy/ 6wks52 – 54 Gy/ 6wks 63Gy/ 7wks/35# 63Gy/ 7wks/35# 68.4Gy/7.5wks/35# 68.4Gy/7.5wks/35#Interim AnalysisInterim AnalysisHigher ReccHigher Recc

57.6Gy/ 6.5wks57.6Gy/ 6.5wks

CONCLUSIONS:CONCLUSIONS:l.l. A minimum of 57.6 Gy with boost of 63 Gy to sites of high risk and A minimum of 57.6 Gy with boost of 63 Gy to sites of high risk and

ECS, is essentialECS, is essentialm.m. Treatment should be started as soon as possibleTreatment should be started as soon as possiblen.n. Dose escalation above 63 Gy does not appear to improve Dose escalation above 63 Gy does not appear to improve

therapeutic ratiotherapeutic ratio

POST OP RT POST OP RT

RCT – 213 patients

Low riskn = 31

Intermediate riskn = 31

High riskn = 151

NO ADJUVANT RT 57.6 Gy/ 6.5 weeksn = 76

63 Gy / 5 weeksn = 75

63 Gy / 7weeks

RISK FACTORS:

•Oral cavity primary

•Margins close / positive

•Perineural invasion

∀≥ 2 positive lymph nodes

•Largest node > 3 cms

•Performance status ≥ 2 [WHO]

•Delay > 6 weeks

((Ang et al, 2001Ang et al, 2001))

Low risk / Intermediate risk had similar control & survivalLow risk / Intermediate risk had similar control & survival

They did better than high riskThey did better than high risk

High risk had a trend towards better control when RT was given over 5 weeksHigh risk had a trend towards better control when RT was given over 5 weeks

NO DATA about the ROLE FOR RT with A SINGLE NODENO DATA about the ROLE FOR RT with A SINGLE NODE

Ang et al, 2001Ang et al, 2001

Results

Management of Neck - Single node, NO ECS

Rec.Rec. SURGERY SURGERY 11% 11% 5/475/47

SURGERY + PORTSURGERY + PORT 0% 0% 0/210/21[Retrospective][Retrospective]

Barkley Am j Surg 1972Barkley Am j Surg 1972

8/31

4/23

0/9

0/19

1/18

Total

0/3

0/4

0/2

4/25

6/109

Total RNDRND

XRT+XRT-

2/12

2/6

0/1

0/2

0/2

0/1

0/2

0

0/1

0/4

4/440/174/24N1ECS-

0/110/80/2N1ECS+

9.5%

23/243

8/34

4/27

7/127

Reg Rec

13/10010/143

13%6.9%

Regional Recurrence

6/190/2N2ECS+

2/170/2N2ECS-

1/166/105N0

SNDSNDpN Stage

Role of XRT

Single node ECS -Ve

M D Anderson Data

POST OP CHEMORADSPOST OP CHEMORADSEORTC – NEJM 2004EORTC – NEJM 2004

Curative post surgery

167RT [66 Gy / 6.5 weeks]

167CT / RT [100mg Cispat/m2

T3;T4;Node +ve&T1/T2 adverse factors

Median follow up 60 months

• Progression free survival 47% v/s 36% (p = 0.04)

• Overall survival 53% v/s 40% (p = 0.02)

• Locoregional recurrences 18% v/s 31% (p = 0.007)

• Toxicity [GR≥3] 41% v/s 21% (p = 0.001)

POST OP CHEMORADSPOST OP CHEMORADSRTOG (9501) – NEJM 2004RTOG (9501) – NEJM 2004

Curative surgery

231RT [60 – 66 Gy ]

228RT + Cisplat

[100mg/m2, Day 1,22,43]

≥ 2 nodes; ECS; +ve margins

Median follow up 60 months

• Locoregional control 82% v/s 72% (p = 0.01)

• Disease free survival better (p = 0.04)

• Overall survival similar (p = 0.19)

• Acute toxicity [GR≥3] 77% v/s 34% (p < 0.001)

Management of the neckManagement of the neckRT / Chemo-RadsRT / Chemo-Rads

1.1. Should the N0 neck be radiatedShould the N0 neck be radiated

2.2. Do we need chemo-rads for an N1 neckDo we need chemo-rads for an N1 neck

3.3. How is an N2 / N3 node ideally managed with How is an N2 / N3 node ideally managed with

chemo-radschemo-rads

4.4. Does an N2 / N3 node influence the choice of Does an N2 / N3 node influence the choice of

treatment of the primary treatment of the primary

2. Do we need chemo-rads for an N1 neck2. Do we need chemo-rads for an N1 neck

No proof that N1 node with T1 / T2 primary No proof that N1 node with T1 / T2 primary needs to be treated with chemo-rads needs to be treated with chemo-rads

Daily Fractionated RT = Chemo-rads

92% control at 3 years for <3cms node with daily RT *

Mendelhall, Int J Radiation Onco 1986

3. How is an N2 / N3 node ideally managed 3. How is an N2 / N3 node ideally managed with chemo-rads with chemo-rads

SIZESIZE CONTROLCONTROL

1.5 – 2.01.5 – 2.0 88% - 92%88% - 92%

2.5 – 3.02.5 – 3.0 74%74%

3.5 – 6.03.5 – 6.0 70%70%

>7.0>7.0 0%0%

Menderhall, Menderhall, In J. Rad Oncol 1984In J. Rad Oncol 1984(110 patients)(110 patients)

McComs & Fletcher – Am J. Roentgenol 1957

Berkley & Fletcher – Am J. of Surgery 1972RT + NECK

DISSECTION

N2/N3 nodes: Planned Neck dissectionN2/N3 nodes: Planned Neck dissection

ADVANTAGESADVANTAGES

30% of specimens have 30% of specimens have

occult metastasisoccult metastasis

Better regional control Better regional control

ratesrates

Poor salvage rates if Poor salvage rates if

picked up later (14-22%)picked up later (14-22%)

DISADVANTAGESDISADVANTAGES

Unnecessary surgery in Unnecessary surgery in

70% of cases70% of cases

Better imaging like PETBetter imaging like PET

Complication ratesComplication rates

- Menderhall 1986, Peters 1996

CHEMORADIOTHERAPY:N2/N3 NodeCHEMORADIOTHERAPY:N2/N3 Node

69 of 237 patients treated on CT/RT protocols69 of 237 patients treated on CT/RT protocols

35% of neck specimens pathologically positive35% of neck specimens pathologically positive

26% total complications26% total complications

10% wound complications10% wound complications

CONCLUSIONS:CONCLUSIONS:

FeasibleFeasible

Acceptable complication ratesAcceptable complication rates

May be overtreatment in 65-70% of patientsMay be overtreatment in 65-70% of patients

STENSON et al, Archives 2000STENSON et al, Archives 2000

CT RT – RCT CT RT – RCT (LAVERTU et al(LAVERTU et al,, Head Neck 1997)Head Neck 1997)

2 cycles Cisplat + 5 FU + RT2 cycles Cisplat + 5 FU + RT

Assessed at 50 – 55 GyAssessed at 50 – 55 Gy

Non respondersNon responders RespondersRespondersProgressive diseaseProgressive disease

65 – 72 Gy65 – 72 GySURGERYSURGERY

Persistent Persistent CRCR PlannedPlannedadenopathyadenopathy No dissectionNo dissection dissectiondissection (17) (17) 3/12 relapsed3/12 relapsed (35) (35)

8/17+ve – 1 relapsed8/17+ve – 1 relapsed (25%) (25%) 4/18+ve4/18+ve

no relapsedno relapsed

NO SIGNIFICANT COMPLICATIONS • NOT STATISTICALLY SIGNIFICANT

T4

T3

IIT2 IT1

N3N2N1N0

N2/N3 nodes Oro/laryngopharynx

Early diseaseEarly disease - RT- RTLocally advanced Locally advanced - Chemorads/RT - Chemorads/RT

Sx+PORTSx+PORTSmall Primary Large Neck Node Small Primary Large Neck Node - ?- ?

?

Node excision followed by RTNode excision followed by RT

T1/T2 lesions of the PFS, Oropharynx, SGLT1/T2 lesions of the PFS, Oropharynx, SGL N2/N3 operable adenopathyN2/N3 operable adenopathy

SchemaSchemaAppropriate nodal debulkingAppropriate nodal debulking

Radical RT to neck and primaryRadical RT to neck and primary(66-70Gy;7 wks)(66-70Gy;7 wks)

T/N criteria

T1-2,N1-3

T1-3, N2-3

T1-3N2-3

T1-3N2-3

T1-2N2-3

T1-2N2-3

Survival statistics

Median survival 19mths

DSS at 2yrs-49%5yr OAS-55%3yrOAS-37%,

DFS-60%73% alive at 60mth

5yr OAS-60%5yr DFS-59.4%

RR

4%

15%

11%

8%

Nil

13%

LR

9%

28%

28%

-

20%

7%

No. of pts.

65

32

35

24

15

52

Trial Design

Retrospective Retrospective/Prospective

Retrospective

Retrospective

Retrospective

Retrospective

Prospective

Author/Institute

French Head And Neck Study group2

Smeele

Byers

Allal

Verschur

TMH

SPLIT THERAPY - COMPARISON OF STUDIES WITH SURGERY FOLLOWED BY RT

LR- Local Recurrence;RR- Regional Recurrence,OAS- Overall Survival;DFS- Disease free SurvivalDSS – Disease specific survival

4. Does an N2 / N3 node influence the choice of treatment of the primary4. Does an N2 / N3 node influence the choice of treatment of the primary Concurrent CTRT- 9303 RTOGConcurrent CTRT- 9303 RTOG

N Stage Cisplat+5FUN Stage Cisplat+5FU RT-Concurrent RT-Concurrent RT aloneRT alone -RT -RT [N=173][N=173] Cisplat Cisplat [N=172][N=172] [N=173][N=173]

N0N0 87(50)87(50) 86(50) 86(50) 87(50)87(50)N1N1 38(22)38(22) 39(23) 39(23) 32(18)32(18)

N2aN2a 02(01)02(01) 07(04) 07(04) 03(02)03(02)N2bN2b 17(10) 13(08)17(10) 13(08) 13(8) 13(8) N2cN2c 26(05)26(05) 23(13) 23(13) 36(21)36(21)

N3N3 03(02)03(02) 04(02) 04(02) 02(01) 02(01)

87(50) 86(50) 87(50)

38(22) 39(23) 32(18)

Surgery

N Stage N 0 N 2 -3

Neck Treatment

N 1

SND / Wait & Watch

MND / RNDSND / MND

Histology of LN pN 2 – 3ECS

pN1pNO

Further Treatment ? RTRT / ? CT / RT

None

Management of the neck

Management of the neck

* Except T1 glottis, Bracytherapy alone treating primaries

RT CT / RT

N 0 N 1N 2 -3

N Stage

Neck Treatment

Histology of LN

Elective neck *Irradiation

Neck RT Neck RT

No residualtumor on

completion oftreatment

Observe

Residualtumor on

completion

Neck dissection

Imaging

Neck dissection

Residualtumor

No residualtumor on completion

Observe END4 – 6 weeks

Management of Neck Management of Neck NN2b2b (Multiple levels) (Multiple levels)

Failures with multiple nodesFailures with multiple nodes

RT + neck betterRT + neck better

< 6cms 50Gy + Neck< 6cms 50Gy + Neck

> 6cms 60Gy + neck> 6cms 60Gy + neck

Mendenhall 1986, Int J Radiation Oncology

Cervical MetastasisCervical MetastasisChemotherapyChemotherapy

• Debatable role VA trial (N2 / N3) [ 46 / 166 patients ]

• 61% did not receive a ‘CR’

• 33% unresectable at salvage surgery

Responders 60 - 70 % survival

Non responders 20 - 30% survival

Dagum - - - 58% 5yrs Actuarial Survival(48)

Wang 9.8 9.8 - 67% DFS(71)

Narayan 19.2 17.3 15.3 38% 5yrs OAS(52)

SPLIT THERAPY - Comparison of results of studies with RT followed by Surgery

LR RR DM Survival Statistics

LR- Local RecurrenceRR- Regional RecurrenceDM- Distant Metastasis;OAS- Overall Survival

3. How is an N2 / N3 node ideally managed 3. How is an N2 / N3 node ideally managed with chemo-rads with chemo-rads

Radio-curability proportional to volume of tumor

Occult 4500 rad 1 cms 6000 ”3 cms 7000 ”6 cms 8000 ”

McComs & Fletcher – Am J. Roentgenol 1957

Berkley & Fletcher – Am J. of Surgery 1972

RT + NECK DISSECTION

Surgery

N Stage N 0 N 2 -3

Neck Treatment

N 1

SND / Wait & Watch

MND / RNDSND / MND

Histology of LN pN 2 – 3ECS

pN1pNO

Further Treatment ? RT RT / ? CT / RTNone

Management of the neck

Patterns of recurrencePatterns of recurrence

SiteSite ObserveObserve Operate Operate

PrimaryPrimary 9(4.5%) 9(4.5%) 18(11.3%)18(11.3%)NeckNeck 94(47%) 94(47%) 9(5.7%) 9(5.7%)Neck+primaryNeck+primary 3(1.5%) 3(1.5%) 1(0.6%) 1(0.6%)2nd Primary2nd Primary 1(0.5%) 1(0.5%) 2(1.3%) 2(1.3%)

Patterns of recurrencePatterns of recurrence

59.5% recurrences 59.5% recurrences - Within 6 months- Within 6 months Median time to recurrence Median time to recurrence - 6.18 months- 6.18 months

ObserveObserveIpsilateral – 91, Contralateral – 1, Bilateral – 2 Ipsilateral – 91, Contralateral – 1, Bilateral – 2

Recurrences-Nodal StageRecurrences-Nodal Stage

Total recurrences = 94Total recurrences = 94

N1N1 47(50%) 47(50%)

N2aN2a 14(14.9%) 14(14.9%)

N2bN2b 22(23.4%) 22(23.4%)

N2cN2c 4(4.3%) 4(4.3%)

N3N3 7(7.4%) 7(7.4%)

ECSECS 55(58.5%)55(58.5%)

Adjuvant radiotherapy- Is it a confounding factor?Adjuvant radiotherapy- Is it a confounding factor?

ObserveObserve OperateOperate21/20021/200 55/159 55/159

C/M +ve C/M +ve 3 3 5 5

Poor diffPoor diff 6 6 12 12

PNIPNI 7 7 6 6

T sizeT size 5 5 12 12

+ve nodes+ve nodes - - 20 20

over all survival in months

96847260483624120

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