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Head and Neck Cancer
Management of Isolated Nodal Recurrence After
Head and Neck Cancer Treatment
Velda Ling-yu Chow, MBBS(HK), MRCSEd 1 and Jimmy Yu-Wai Chan, MBBS(HK), MS(HK), MRCSEd, FCSHK, FHKAM (Surgery) 2
1. Resident; 2. Division Chief and Assistant Professor, Division of Head and Neck Surgery, Department of Surgery,
University of Hong Kong Li Ka Shing Faculty of Medicine, Queen Mary Hospital, Hong Kong SAR
Abstract The status of the regional cervical lymphatics is one of the most significant prognostic indicators in head and neck cancers. The traditional
treatment for cancers with cervical nodal metastasis has been surgical. With the global trend toward organ-preserving therapy, chemoradiation
has gained increasing popularity over primary surgical therapies for cancers in the head and neck region. The subsequent management of the
neck for those with residual or recurrent nodal metastasis, however, has become one of the most debated topics in the field of head and neck
oncology. This review addresses several important controversies, including the optimal assessment of the nodal response to chemoradiation, the
potential role and the oncological results of planned and salvage neck dissection after chemoradiation, and the type and extent of neck dissection
required in order to achieve the optimal balance between tumor control and surgical morbidities. Further clinical trials and ongoing researches
will help us to define the best therapeutic option in such circumstances.
Keywords Chemoradiation, recurrence, nodal metastasis, head and neck cancer
Disclosure: The authors have no conflicts of interest to declare.
Received: August 20, 2013 Accepted: November 16, 2013 Citation: Oncology & Hematology Review, 2014;10(1):10–2
Correspondence: Jimmy Yu-wai Chan, MBBS(HK), MS(HK), MRCSEd, FCSHK, FHKAM (Surgery), Division of Head and Neck Surgery, Department of Surgery, University of Hong
Kong Li Ka Shing Faculty of Medicine, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong SAR, China. E: firstname.lastname@example.org
Head and neck cancer encompasses tumors of different origins and histological
types. Over 90 % of them are squamous cell carcinomas arising from the
epithelium of the upper aerodigestive tract, extending from the nasal and
oral cavities, down to the larynx and hypopharynx. Among the various clinical
and pathological prognosticators, the presence of cervical nodal metastasis
is the most important factor that adversely affects survival after treatment.
Cancers with N0 classification on presentation usually have excellent cure
rates with either surgery or radiotherapy, while those with regional metastases
on presentation have significantly worse survival. Over the past decades,
treatment of the neck has received much attention and has become one of
the most debated topics in the field of head and neck oncology. Traditionally,
treatment of the neck in patients with clinically evident nodal metastasis has
been surgical. Nowadays, chemoradiation (CRT) has been utilized more and
more as the primary treatment, aiming at organ and function preservation.
Neck dissection for residual or recurrent nodal metastasis is associated with
increased incidence of potentially severe complications. 1 It exacerbates the
chronic effects of radiation, including subdermal fibrosis, neck stiffness, pain
and diminished shoulder mobility, and quality of life. 2 In this article, we will
address some of the current controversies in the surgical management of
isolated nodal recurrence after head and neck cancer treatment.
should undergo neck dissection to eliminate potential residual viable nodal
tumor. 3,4 It is also accepted that patients with complete response of N1 disease
do not require neck dissection. 5,6 The main controversy lies within the N2 to 3
disease group, whereby there is uncertainty as to how well clinical complete
response predicts the eradication of tumors. The best imaging modality for the
assessment of tumor response after CRT and the ideal timing to perform such
investigation remains under investigation. Ideally, the imaging should allow
a timely identification of patients who will benefit from post-irradiation neck
dissection while avoiding surgery in those with complete response.
Traditionally the response evaluation after CRT was performed by clinical
examination and computed tomography (CT) scan 6–8 weeks post
treatment. Some reports in the literature advocate that CT scan after CRT is
the imaging of choice. Clayman et al. 7 showed no recurrence in 29 observed
oropharyngeal cancer patients with negative CT scans after CRT. Similarly,
Corry et al. 8 reported no nodal relapse in 60 observed patients. Liauw et
al. 9 found one neck recurrence out of 32 patients with complete response
on CT scan after radiotherapy. However, the accuracy of CT assessment of
complete response was disappointing in some experiences, reporting high
rates of viable tumor (30–40 %) in neck specimens from patients who had a
radiological complete response. 10
Assessment of Nodal Response to Chemoradiation
Surgery after CRT should be reserved for patients with residual viable cancer.
There is general agreement that patients with less-than-complete response
10 Despite the potential ability of 18F-fluorodeoxyglucose positron emission
tomography (18F-FDG PET) scan to distinguish viable tumor cells, current
© Tou c h ME d ica l ME d ia 2014