Caution Regarding Elective Neck Dissection During Salvage Surgery

Is elective neck dissection the optimal management of the node-negative (N0) neck during salvage surgery after initial treatment with elective nodal irradiation (ENI)?

Background: When the neck is seeded at the time of squamous cell carcinoma recurrence, there is a likelihood of occult regional metastatic disease. While it is common practice to include an elective neck dissection as part of the salvage procedure, dissection after radiotherapy has been associated with decreased quality of life, increased operative time and the potential for increased complications.

Study Design: Retrospective patient chart review with comparison of toxicity and actuarial outcomes

Setting: University of Florida, Gainesville, Florida

Synopsis: Researchers reviewed the medical records of 57 patients who were treated with ENI from 1965 to 2006 for TI-4 N0 M0 squamous cell carcinoma of the oropharynx, hypopharynx or larynx, developed an isolated local recurrence and remained N0. Forty patients were salvaged with neck dissection and 17 with neck observation. In the dissected group, the five-year local-regional control rate was 75 percent for all patients, but neck dissection resulted in poorer outcomes compared with observation. In the dissected group, local control, regional control, cause-specific survival and overall survival rates were 71 percent, 87 percent, 60 percent and 45 percent respectively, compared to 82 percent, 94 percent, 92 percent and 56 percent respectively for the observed group. Toxicity was more likely with dissection, including a 5 percent rate of fatal complications, increased fistula formation, wound complications and longer postoperative hospital admission. Limitations to the study were that the patient population was highly selected and should not be generalized to other recurrent settings. The analysis, for example, involved patients treated over a 40-year period and included a significant treatment-selection bias. In addition, the patients salvaged with neck dissection were more likely to have advanced recurrences.

Bottom Line: Routine elective neck dissection should not be included during salvage surgery for locally recurrent head and neck squamous cell carcinoma if initial radiotherapy included ENI.

Citation: Dagan R, Morris CG, Kirwan JM, et al. Elective neck dissection during salvage surgery for locally recurrent head and neck squamous cell carcinoma after radiotherapy with elective nodal irradiation. Laryngoscope. 2010; 120(5):945-952.

—Reviewed by Sue Pondrom