“On the one hand you don’t want to give radiation to a young woman, on the other you’ve got an indication for post-operative adjuvant radiotherapy, that is, a positive node. If you think selective neck dissection is therapeutic then you don’t have to do anything. But there’s no compelling evidence in the literature that that’s correct,” he said.
Explore This IssueApril 2006
The panelists agreed that in this sort of patient, more needs to be known about the node and whether there has been extranodal spread. Dr. Shaha advised going back to pathology and getting more details about the tumor and whether there was spread.
If the patient had three positive nodes, then this is a high-risk case. In this variation of the case, panelists agreed on the use of chemoradiation, even with its risks and side effects. “The patient will get an incremental benefit of about 8% if they get chemo with the radiation. I think they should get chemoradiation,” said Dr. Johnson. Treatment of high-risk cases is also supported by two papers from the May 2005 edition of the New England Journal of Medicine.
A Branchial Cyst and Tumor
Dr. Shaha then presented more cases for discussion. One was of a 56-year-old male who presented with a right neck mass and was initially referred as having a branchial cyst. However, closer examination of CT scans revealed that below the cyst was a 4 cm by 4 cm tumor at the base of the tongue. A substantial portion consisted of cyst material.
Again, panelists agreed that chemoradiation is an effective way to treat cases like this. As Dr. Johnson noted, “Chemoradiation is needed under any circumstances. I’m reasonably confident that chemoradiation without surgery will cure this patient. I don’t know why we bother them with surgery,” he said.
During my training the standard was to do a tonsillectomy and neck resection, and if the nodes were positive then post-operative radiation therapy. Now, about 90% of our patients will get chemoradiation therapy.” – —Ashok Shaha, MD
This approach is a major paradigm shift, and is something that likely still confuses most clinicians, said Dr. Shaha.
Interestingly, there are centers in Europe and the US in which tongue base tumors are treated endoscopically with laser excision, Dr. Johnson said. “Most of the patients I see require chemoradiation, primarily to control cervical adenopathy. It is unclear if the surgery enhances local control or if equal results could be achieved with chemoradiation alone.”