THE MANAGEMENT OF THE CLINICALLY POSITIVE NECK AS PART OF A LARYNX PRESERVATION APPROACH

Purpose: For patients with squamous cell carcinoma of the head and neck with palpable neck node metastases, the standard management of the neck usually involves neck dissection and postoperative neck irradiation. A strategy of larynx preservation with induction chemotherapy and radiation therapy has been utilized for patients with locally advanced resectable cancer of the larynx, hypopharynx, and oropharynx. For patients treated in this non-surgical manner for the primary site, the optimal management of the clinically positive neck has not been clarified. To determine whether response to induction chemotherapy could help to select patients in whom neck dissection could be omitted in favor of definitive radiation therapy alone, we have analyzed our prospective larynx preservation experience. Methods and Materials: Between 1983-1989, 80 patients were entered onto larynx preservation protocols involving 1-3 cycles of cisplatin based chemotherapy followed by radiation therapy with or without neck dissection. There were 54 patients with clinically positive necks prior to treatment, of whom 44% (24/54) had a complete response, and of whom 20% (11/54) had a partial response to chemotherapy in the neck. In 22 of these 35 patients with clinically positive necks who achieved a major neck response to chemotherapy, radiation therapy (median 66 Gy) was used as the only subsequent treatment of the neck. Results: At a median follow-up of 25 months (range 7-83 months), neck control for this subset is 91% (20/22). Neck failure occurred in 20% (1/5) of patients with a partial response to chemotherapy treated without neck dissection and 6% (1/17) of node positive with a complete response. Conclusion: These results suggest that patients with clinically palpable cervical nodal metastases who have a complete response to chemotherapy and receive high dose radiation therapy have excellent neck control and may not need neck dissection. Further experience will be required to confirm these preliminary data and to determine if patients who achieve a partial response in the neck after induction chemotherapy can be treated with radiation therapy without neck dissection.