Abstract
Purpose
The aim of this study was to define the role of neck dissection during surgery for patients who have received elective nodal irradiation in the course of treatment for a prior squamous cell carcinoma of the head and neck (SCCHN) and are subsequently diagnosed with a second primary SCCHN.
Materials and methods
We reviewed the medical records of 13 patients who received both definitive radiotherapy and elective nodal irradiation for T1-4 N0 M0 SCCHN of the oral cavity, oropharynx, hypopharynx, or larynx who then subsequently developed a metachronous T1-4 N0 M0 SCCHN primary at a new site. All second primary tumors were treated with surgery. Ten of the 13 patients also received an elective neck dissection (END) at that time: 7 unilateral and 3 bilateral. We report the outcomes for the patients in this series.
Results
One (8%) of 13 neck dissection specimens was positive in 1 (10%) of 10 patients. The 5-year outcomes were the following: local-regional control, 67%; local control, 77%; disease-free survival, 62%; overall survival, 38%; and cause-specific survival rate, 77%. Six patients experienced treatment-related complications of grade 2 or higher (per Common Terminology Criteria for Adverse Events, version 4). Complications occurred exclusively in patients who received an END.
Conclusions
The risk of occult nodal disease may be low enough to justify omitting an END for a second primary SCCHN in selected patients while maintaining treatment efficacy and reducing patient morbidity. Larger studies on this subject are needed to further address this question.
1
Introduction
The role of elective neck dissection (END) during resection of a second primary squamous cell carcinoma (SCCA) of the head and neck (SCCHN) in patients who have received elective nodal irradiation (ENI) for a previous SCCHN is ill defined. In this select group of patients, the risk of occult nodal disease may be low enough to omit END. Evidence shows that neck dissection in the treatment of SCCHN is significantly correlated with severe late toxicity . In addition, recent studies suggest that there may be no benefit in performing END during salvage surgery for locally recurrent SCCHN in patients who have previously received radiotherapy (RT), with or without ENI . Therefore, it is worthwhile to investigate the role of END in other selected patient populations.
The patients examined in this small retrospective cohort presented with N0 SCCHN and received definitive RT to the primary site of the cancer as well as ENI. They then experienced a metachronous second primary N0 SCCHN at a new site some time after their initial therapy and received surgery with or without END. We investigated the role of END in this setting by analyzing the pathologic results of neck dissection as well as actuarial outcomes of disease control and patient survival to quantify the risk of occult nodal disease. We also examined surgical complications in this setting.
2
Materials and methods
All patients included in this retrospective, institutional review board–approved outcome study were treated with definitive RT at the University of Florida for T1-4 N0 M0 SCCHN between 1976 and 1995. For the purposes of this study, SCCHN refers to SCCA of the oral cavity, oropharynx, hypopharynx, or larynx. Eligible patients met the following criteria: (1) definitive RT to the primary site and ENI, (2) clinically N0 metachronous second primary SCCHN, (3) no evidence of distant metastases, (4) curative-intent surgery for the second primary with or without END, and (5) minimum follow-up of 1 year after the surgery unless a coded event (ie, recurrence or death) occurred within the first year of follow-up.
Thirteen patients met the inclusion criteria. Table 1 illustrates the site, stage, time course, and treatment parameters for the first and second primary head and neck cancers. The mean age at initial diagnosis was 62 years (range, 46–69 years). The first primary SCCHN sites consisted of 6 cancers of the larynx and 7 cancers of the oropharynx. These cancers received external-beam RT to the primary site to a median total dose of 74.4 Gy (range, 60–76.8 Gy), with 2 patients (patients 5 and 7) receiving brachytherapy in addition to external-beam RT. The median overall treatment time for RT was 44 days (range, 42–58). The ENI was delivered to a median total dose of 40.5 Gy (range, 40.5–50 Gy). The dose fractionation schedules used for ENI were 50 Gy in 25 once-daily fractions or 40.5 Gy in 15 once-daily fractions. One patient (patient 8) received induction chemotherapy, 2 cycles of adjuvant fluorouracil, and cisplatin. The mean time until diagnosis of the second primary head and neck cancer was 5.9 years (range, 0.2–25.8 years). The second primary SCCHN sites included the following: larynx, 3 patients; hypopharynx, 2 patients; oropharynx, 1 patient; and oral cavity, 7 patients. Treatment for all of these cancers was definitive surgery. At surgery, 3 patients received a bilateral modified radical END, 7 patients received a unilateral modified radical END, and 3 patients received no END.
| Patient no. | Age at presentation (y) | Primary site | Primary stage | Primary site dose (Gy) | ENI dose (Gy) | Time to second primary (y) | Second primary site | Second primary stage | Surgical procedure | Neck dissection |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 46.1 | IHE | T2N0 | 70 | 50 | 25.8 | SHE | T2N0 | Partial laryngectomy | Bilateral |
| 2 | 56.9 | FVC | T2N0 | 76 | 40.5 | 6.7 | Glottic | T4N0 | Laryngectomy | – |
| 3 | 64.7 | Tonsil | T1N0 | 66 | 40.5 | 6.3 | Pyriform sinus | T2N0 | Partial laryngectomy | Right |
| 4 | 66.2 | Glottic | T3N0 | 74.4 | 40.5 | 7.8 | Pyriform sinus | T3N0 | Laryngectomy | Bilateral |
| 5 | 64.2 | Soft palate | T1N0 | 60 | 40.5 | 1.7 | Oral tongue | T2N0 | Glossectomy | Right |
| 6 | 54.5 | AEF | T3N0 | 64 | 40.5 | 3.9 | Oral tongue | T1N0 | Partial glossectomy | |
| 7 | 69.0 | Tonsil | T3N0 | 64 | 50 | 3.9 | Oral tongue | T1N0 | Partial glossectomy | Right |
| 8 | 64.1 | BOT | T3N0 | 76.8 | 40.5 | 0.8 | Retromolar trigone | T1N0 | Partial mandibulectomy | Left |
| 9 | 68.4 | Tonsil | T3N0 | 74.4 | 40.5 | 8.7 | FOM/AR | T4N0 | Composite resection | Right |
| 10 | 61.8 | Soft palate | T2N0 | 76.8 | 40.5 | 6.9 | Oral tongue | T2N0 | Hemiglossectomy | Left |
| 11 | 55.6 | Soft palate | T2N0 | 65 | 40.5 | 0.2 | FOM | T1N0 | Local excision | – |
| 12 | 66.5 | FVC | T2N0 | 74.4 | 50 | 3.6 | AEF | T2N0 | Laryngectomy | Bilateral |
| 13 | 64.6 | Epiglottis, FVC | T3N0 | 74.4 | 50 | 0.5 | BOT | T1N0 | Partial glossectomy | Right |
The pathology reports were reviewed to evaluate the rate of occult positive lymph nodes. We quantified how many lymph nodes were dissected and to what extent, if any, cancer was present in regional lymph nodes at the time of surgery. Surgical margins for the resection of the second primary tumor were also evaluated. Discharge summaries and postoperative clinic notes were reviewed to assess the length of hospitalization after surgery and to identify complications related to the surgery.
The oncologic outcomes evaluated were second primary site local recurrence, defined as the date of biopsy-proven SCCHN at the same site, and regional recurrence, defined as the date of biopsy or radiographically proven disease in lymph nodes. Regional recurrence was further classified as “in-field” or “out-of-field” relative to the previously irradiated field based on comparison of radiographic studies at the time of nodal failure to the original treatment fields. Other outcomes evaluated were disease-free survival, defined as any recurrence; overall survival; and cause-specific survival, defined as any death while disease was present or due to a treatment complication. No patients in this series were lost to follow-up.
JMP software was used for statistical analysis (SAS Institute, Cary, NC). The Kaplan-Meier product limit method provided estimates of local control, regional control, freedom from distant metastases, overall survival, and cause-specific survival .
2
Materials and methods
All patients included in this retrospective, institutional review board–approved outcome study were treated with definitive RT at the University of Florida for T1-4 N0 M0 SCCHN between 1976 and 1995. For the purposes of this study, SCCHN refers to SCCA of the oral cavity, oropharynx, hypopharynx, or larynx. Eligible patients met the following criteria: (1) definitive RT to the primary site and ENI, (2) clinically N0 metachronous second primary SCCHN, (3) no evidence of distant metastases, (4) curative-intent surgery for the second primary with or without END, and (5) minimum follow-up of 1 year after the surgery unless a coded event (ie, recurrence or death) occurred within the first year of follow-up.
Thirteen patients met the inclusion criteria. Table 1 illustrates the site, stage, time course, and treatment parameters for the first and second primary head and neck cancers. The mean age at initial diagnosis was 62 years (range, 46–69 years). The first primary SCCHN sites consisted of 6 cancers of the larynx and 7 cancers of the oropharynx. These cancers received external-beam RT to the primary site to a median total dose of 74.4 Gy (range, 60–76.8 Gy), with 2 patients (patients 5 and 7) receiving brachytherapy in addition to external-beam RT. The median overall treatment time for RT was 44 days (range, 42–58). The ENI was delivered to a median total dose of 40.5 Gy (range, 40.5–50 Gy). The dose fractionation schedules used for ENI were 50 Gy in 25 once-daily fractions or 40.5 Gy in 15 once-daily fractions. One patient (patient 8) received induction chemotherapy, 2 cycles of adjuvant fluorouracil, and cisplatin. The mean time until diagnosis of the second primary head and neck cancer was 5.9 years (range, 0.2–25.8 years). The second primary SCCHN sites included the following: larynx, 3 patients; hypopharynx, 2 patients; oropharynx, 1 patient; and oral cavity, 7 patients. Treatment for all of these cancers was definitive surgery. At surgery, 3 patients received a bilateral modified radical END, 7 patients received a unilateral modified radical END, and 3 patients received no END.
