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The impact of superselective and selective neck dissections after CRT on QoL
Commentary by Dr. Martin Chasen
Despite being the standard of care for patients with head and neck cancer, planned neck dissection may subject patients with pathologic complete response in the neck to the morbidity of surgery without any added benefit. The use of concurrent chemotherapy with radiation does significantly improve outcomes, therefore its use in the setting of oropharyngeal and laryngeal cancer has become a considered first line option. The increasing prevalence of HPV associated oropharyngeal cancer, which carries a better prognosis and response to treatment has also brought into question the use of surgery. In a pooled analysis of several Radiation Therapy Oncology Group studies, post-CRT neck dissection was a significant predictor of grade 3 or higher late toxicity. Today the aggressiveness of neck dissections performed after radiation is evolving from the use of modified radical to selective and superselective (removal of 1–2 neck levels – i.e. only those initially harboring disease) dissections. The impact of these limited post-CRT neck dissections on patient reported QoL is unknown, but may be useful to clinicians considering how to manage possible residual nodal disease after definitive chemoradiation. This Phase II trial was performed in patients with HPV/p16-positive squamous cell carcinoma of the oropharynx who had received deintensified chemoradiotherapy, followed by a superselective/selective neck dissection. Many patient reported QoL outcomes (EORTC QLQ-C30, EORTC H&N-35, EAT-10 and NDII) before CRT, before neck dissection, and at several time points after neck dissection were collected.
Results: There were 37 patients and 60% had N2b disease. 87% had a unilateral neck dissection. Twelve patients had 1–6 nodes removed and 18 patients had 13 or more nodes removed.
All patients had an initial decrement in QoL after CRT with return to baseline approximately 1.5 years after completion of CRT. Patients with 12 or more nodes dissected accounted for the acute QoL decline seen in most of the NDII items between the Pre-ND and Early Post-ND time points. These patients had recovered to almost Pre-ND function by the Late Post-ND time point.
Conclusion: Superselective and selective neck dissections may not adversely affect long term recovery of QoL after CRT, especially in patients with fewer nodes dissected.
Impact of post-chemoradiotherapy superselective/selective neck dissection on patient reported quality of life
Kyle Wang, Robert J. Amdur, William M. Mendenhall, Rebecca Green, Shannon Aumer, Trevor G. Hackman, Adam M. Zanation, Jose P. Zevallos, Samip N. Patel, Mark C. Weissler, Bhishamjit S. Chera
Volume 58, July 2016, Pages 21–26