7.1 Does the Site of the Primary Tumor Influence the Type of Dissection (i.e., Functional vs. Radical)?

This question was frequently asked in the early days of functional neck dissection when the operation was not considered safe from the oncological standpoint. At that time, more aggressive neck treatment was advised for tumor sites behaving more aggressively (floor of the mouth, tongue, hypopharynx). Thus, radical neck dissection was preferred to a functional approach as a means to improve the outcome.

Nowadays we have learned to separate primary and neck. We are aware that some tumor locations have worse prognosis than others. Hypopharynx cancer is usually more aggressive than tumors of the larynx, but this will not be modified by using a different neck treatment than the one required for the clinical scenario. In other words, for an N0 neck on a patient with a piriform sinus tumor, radical neck dissection is not safer than functional neck dissection.

In head-and-neck cancer patients the neck must be treated according to its own status. The primary should not be used as a criterion for deciding the approach to the neck. The decision whether to use radical or functional neck dissection should be based only on the characteristics of the neck. However, once a functional approach has been selected, the type and extent of the dissection (complete or selective) should be determined by the location of the primary and the experience of the surgeon, as we have repeatedly emphasized in the previous pages.

7.2 Does the Number of Nodes Dictate the Type of Dissection?

This is another controversial issue concerning functional neck dissection. Again, most doubts in this respect come from the early days when functional neck dissection was considered insufficient. Although not unanimously recognized, the number of positive nodes in the neck dissection specimen may harbor prognostic information. However, the exact number of nodes defining the chances for a poor outcome varies in different studies. On the other hand, in some series, the number of nodes is not considered to be important from the prognostic standpoint. In any case, selection of the surgical approach to the neck should not be indicated by the number of nodes, but by the characteristics of every single node that has been detected in the patient’s neck.

Functional neck dissection can be performed in patients with nonpalpable and small palpable mobile nodes (usually smaller than 2.5 cm), the size being just a merely orienting factor. The operation is totally safe in patients with multiple nodes, as long as all nodes fulfill these criteria. In these cases, radical neck dissection will not be safer than a functional approach. Thus, it is not the number of nodes that is important, but their clinical characteristics.

7.3 Do You Always Use Postoperative Radiation Therapy after Functional Neck Dissection in _PN+ Patients?

We would very much like to have a conclusive answer to the question of postoperative radiotherapy for positive nodes, but unfortunately this is not the case. In fact, nobody has the answer to this question.

Postoperative radiotherapy has been recommended in a large variety of situations: for all patients with positive nodes; only for patients with more than a certain number of positive nodes—the number being as variable as the authors that propose this approach; only for patients with positive nodes showing extracapsular extension; and also, for a number of combinations of the above.

In our experience, postoperative radiotherapy does not improve regional control or survival in previously untreated patients with cancer of the larynx undergoing surgical treatment—all patients in this series had functional neck dissection as part of the initial treatment. Several aspects of the previous statement should be emphasized: (1) This series includes only patients with cancer of the larynx, a special subset of head-and-neck cancer patients with particular characteristics. Extension of this statement to other tumor locations requires further studies. (2) Patients included in this study were N0 patients with occult disease and patients with palpable mobile nodes smaller than 2.5 cm. (3) All patients in our series were treated with the same functional approach, removing all lymph node regions except level I. (4) The study was performed retrospectively with a historical control from the same institution. Although this may be considered a weak point of the study, it must be remembered that the great majority of studies trying to assess the usefulness of postoperative radiotherapy are retrospective studies.

With this in mind, we can affirm that postoperative radiotherapy did not improve the outcome of our patients (survival and regional control) in any situation. Patients with positive nodes did worse than those without nodes; and patients with extracapsular spread had an especially bad prognosis. However, this was not improved or modified by the addition of postoperative radiotherapy.

In conclusion, we do not routinely use postoperative radiotherapy in pN+ patients with cancer of the larynx treated with functional neck dissection. In contrast to “routine use,” we encourage an individualized approach to cancer patient management, evaluating all variables and selecting the best option for every single patient. We do not believe there is a “treatment of choice,” but rather consider that we have “choices of treatment” and try to fit the treatment to the patient and not the patient to the treatment.