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Long-term Neck Control Rates After Complete Response to Chemoradiation in Patients with Advanced Head and Neck Cancer

Reviewer: Charles Wood, MD
Abramson Cancer Center of the University of Pennsylvania
Ultima Vez Modificado: 13 de noviembre del 2006

Presenter: R. Rengan
Presenter's Affiliation: Memorial Sloan-Kettering Cancer Center
Type of Session: Scientific

Background

• The indications for planned neck dissection in patients with advanced head and neck cancer who achieve a complete response to chemoradiation are unclear
• This study sought to evaluate outcomes in advanced head and neck cancer patients enrolled into organ-sparing protocols at Memorial-Sloan Kettering Cancer Center (MSKCC)

Materials and Methods

• Between 1983 and 1996, 213 patients with head and neck cancer were entered into larynx/organ-sparing protocols consisting of induction cisplatin chemotherapy, followed by radiation with or without concurrent platinum chemotherapy
• 190 patients were protocol-eligible and completed treatment at MSKCC
  • Of these patients, the following were excluded:
    • 47 patients undergoing pre-radiotherapy neck dissection
    • 1 patient who declined to further radiotherapy after 18 Gy 
• 86 of the remaining 142 patients presented with node-positive disease and were included in this analysis
  • 29% (N=25) with N1
  • 62% (N=53) with N2
  • 9% (N=8) with N3
• Patients received a median dose of 70 Gy (range 44-72) to the gross tumor volume, in conventional 1.8-2 Gy daily fractions, or via a concomitant boost technique delivered over the latter part of the radiotherapy course
• Clinical response was determined via physical examination and imaging studies

Results

• The median follow-up duration for surviving patients was 9 years
• 69 patients (80%) achieved a clinical complete response (CCR)
  • N1: 92% (23/25)
  • N2: 79% (42/53)
  • N3: 50% (4/8)
• 4 patients underwent immediate neck dissection following completion of chemoradiation and were excluded from the neck failure (NF) analysis
• Of the remaining 65 patients, the 10-year actuarial NF incidence was 14%
  • N1: 13%
  • N2: 15%
  • N3: 0%
• The median overall of the patients within the NF analysis by nodal stage was as follows:
  • N1: 12.2 years
  • N2: 6.5 years
  • N3: 0.8 years
• 17 patients (20%) did not achieve a CCR
  • N1: 8% (2/25)
  • N2: 21% (11/53)
  • N3: 50% (4/8)
• 14/17 patients not achieving a CCR underwent neck dissection, with 10 (71%) having pathologically-involved nodes
• The median survival of patients not achieving a CCR was 1.4 years

Author's Conclusions

• The majority of patients with node-positive head and neck cancer achieving a CCR to chemoradiation demonstrate long-term disease control in the neck
• The utility of functional imaging in this patient subset remains largely undefined, and may prove valuable in identifying the 10-15% of patients who will ultimately experience a relapse in the neck

Clinical/Scientific Implications

The question of when to proceed with a post-chemoradiation neck dissection in patients with an excellent response to treatment remains largely unanswered. This study, though somewhat limited in size and retrospective, suggests that the majority of patients demonstrating a CCR to chemoradiation may be adequately managed without a neck dissection. Predicting those that will ultimately experience neck relapse, however, is a more difficult task, and, as suggested by the authors, an area in which functional imaging might prove valuable.