Management of Isolated Nodal Recurrence After Head and Neck Cancer Treatment

Oncology & Hematology Review, 2014;10(1):10–2

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: August 20, 2013 Accepted November 16, 2013 Citation Oncology & Hematology Review, 2014;10(1):10–2
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 types. Over 90 % of them are squamous cell carcinomas arising the epithelium of the upper aerodigestive tract, extending from the 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- thancomplete response should undergo neck dissection to eliminate 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 PET scans 1 month after CRT and found that six of seven patients with a negative scan had residual cancer at neck dissection. Similarly, Gourin et al.12 and Greven et al.13 reported an unacceptably high proportion of patients who had residual nodal tumours despite a negative PET scan, which was performed 8 to 10 weeks and 1 month after concurrent chemoradiotherapy, respectively. When performed 10–15 weeks after treatment, however, some found a better correlation between the PET scan results and the pathological nodal status.14

Recent advances in magnetic resonance imaging (MRI) have provided further biological information: diffusion-weighted MRI is a non-invasive imaging technique that measures the differences in water mobility of different tissue microstructures. Water mobility is likely influenced by cell size, density and cellular membrane integrity and is quantified by means of the apparent diffusion coefficient. This coefficient in malignant lymph nodes is reduced because of the increased density of tumour cells.10 Vandecaveye et al.15 evaluated response in 29 patients 3 weeks after the completion of radiotherapy. Results showed positive predictive value of 70 % and negative predictive value of 96 % for adenopathy per neck side. He also reported a sensitivity of 76 % for diffusion-weighted MRI as opposed to 7 % for conventional MRI. Dynamic contrast-enhanced MRI is another promising imaging sequence that provides information regarding tumour blood flow and permeability.16 Reports indicate that this technique may be useful to predict both intra-tumour hypoxia and tumour response.

Role of Planned and Salvage Neck Dissection
The concept of planned neck dissection was first used in 1970s to indicate an elective neck dissection performed to a clinically undetectable disease.10 Many centres worldwide practise planned neck dissection after radiotherapy because historically the complete response rates for large volume nodal disease to radiotherapy alone was low and the outcome of subsequent salvage was poor. Mabanta et al. studied 51 patients with neck recurrence after primary radiotherapy for head and neck squamous cell carcinoma and he found that 35.3 % of the patients had unresectable disease.17 The 5-year regional control after neck dissection was 9 % and the overall absolute and cause-specific survival rates were 10 % at 5 years. With the global trend towards organ and function preservation, CRT is gradually gaining popularity over surgical treatment in the management of head and neck cancers. Advances in radiation delivery, such as intense-modulated radiotherapy and altered fractionation regimens, have led to development of concurrent CRT and, consequently, enhanced disease control. As a result, the role of planned neck dissection becomes less well-defined.10

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Keywords: Chemoradiation, recurrence, nodal metastasis, head and neck cancer