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Head and Neck Cancer Management of Isolated Nodal Recurrence after Head and Neck Cancer Treatment Velda Ling-yu Chow and Jimmy Yu-wai Chan 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 towards 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 tumour 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: 20 August 2013 Accepted: 16 November 2013 Citation: European Oncology & Haematology, 2013;9(2):90–2 Correspondence: Jimmy Yu-wai Chan, 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: chanjyw@gmail.com Head and neck cancer encompasses tumours 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 utilised 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. 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 should undergo neck dissection to eliminate 90 potential residual viable nodal tumour. 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 tumours. The best imaging modality for the assessment of tumour 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 tumour (30–40 %) in neck specimens from patients who had a radiological complete response. 10 Despite the potential ability of 18F-fluorodeoxyglucose positron emission tomography (18F-FDG PET) scan to distinguish viable tumour cells, current evidence show that it is not sensitive enough to allow early detection of residual tumour after CRT. Rogers et al. 11 performed © Touc h ME d ic a l ME d ia 2013