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Managment Of N+Neck
1. Management of the Neck (N 0 and N + ) Dr. A D’Cruz Tata Memorial Hospital
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11. Tumor characteristics Observe Operate T Stage T1 118(59%) 69(43.4%) T2 82(41%) 90(56.6%) Grade I 48(24%) 30(18.9%) II 132(66%) 109(68.6%) III 20(10%) 20(12.6%) PNI No 181(90.5%) 145(91.2%) Yes 19(9.5%) 14(8.8%) Thickness <=3 39(19.5%) 13(8.2%) 4-9 115(57.5%) 89(56%) >=10 37(18.5%) 52(32.7%) Cut margin +ve 7(3.5%) 4(2.5%) -ve 184(92%) 146(91.8%) close 9(4.5%) 9(5.7%)
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17. Critical Assessment of SOHD 94 Patients / 107 SOHD’s Spiro Am J surgery 1998 94 Patients / 107 SOHD’s 24 Clinical N + 83 Clinical N - 26 Path +ve 17 Path +ve 64 Path -ve 4 (15%) Neck Fail 3 (5%) Neck Fail 5 (29%) Neck Fail
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21. Management of the neck Bocca 1984 Laryngoscope 843 Cases Byers 1985 Am J Surg 967 Cases Anderson 1994 Am J Surg 366 Cases RND 63% 12% MRND 71% 8% p (NS) 5 year Survival Neck Failure MND = RND Same control Less Morbid
22. Level V Metastases Overall 3 % Hypopharynx 7 % Oropharynx 6 % Oral Cavity 1 % Larynx 2 % Davidson et al, Am J Surg, Oct. 93. N = 1277
26. SND in N+ Neck Medina & Byers ; Head & Neck 1989 114 patients node +ve - 91(79.8%) pathologic evidence of mets N1 / No ECS Surgery Only - 10% recc Multiple / ECS - 24% SX + RT - 15%
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30. Results Expert opinion 5 D Case series (no control group) 4 C Case control studies 3 Cohort studies, Low quality RCT 2b B Meta-analysis of cohort studies 2a High quality RCT 1b A Meta-analysis of RCT’s 1a Study Design Level of Evidence Grade of Recommendation
45. N2/N3 nodes Oro/laryngopharynx Early disease - RT Locally advanced - Chemorads/RT Sx+PORT Small Primary Large Neck Node - ? ? T4 T3 II T2 I T1 N3 N2 N1 N0
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47. SPLIT THERAPY - COMPARISON OF STUDIES WITH SURGERY FOLLOWED BY RT LR- Local Recurrence; RR- Regional Recurrence, OAS- Overall Survival; DFS- Disease free Survival DSS – Disease specific survival T/N criteria T1-2, N1-3 T1-3, N2-3 T1-3N2-3 T1-3N2-3 T1-2N2-3 T1-2N2-3 Survival statistics Median survival 19mths DSS at 2yrs-49% 5yr OAS-55% 3yrOAS-37%, DFS-60% 73% alive at 60mth 5yr OAS-60% 5yr DFS-59.4% RR 4% 15% 11% 8% Nil 13% LR 9% 28% 28% - 20% 7% No. of pts. 65 32 35 24 15 52 Trial Design Retrospective Retrospective/ Prospective Retrospective Retrospective Retrospective Retrospective Prospective Author/ Institute French Head And Neck Study group 2 Smeele Byers Allal Verschur TMH
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49. Management of the neck Surgery N Stage N 0 N 2 -3 Neck Treatment N 1 SND / Wait & Watch MND / RND SND / MND Histology of LN pN 2 – 3 ECS pN1 pNO Further Treatment ? RT RT / ? CT / RT None
50. Management of the neck * Except T1 glottis, Bracytherapy alone treating primaries RT CT / RT N 0 N 1 N 2 -3 N Stage Neck Treatment Histology of LN Elective neck * Irradiation Neck RT Neck RT No residual tumor on completion of treatment Observe Residual tumor on completion Neck dissection Imaging Neck dissection Residual tumor No residual tumor on completion Observe END 4 – 6 weeks
54. Dagum - - - 58% 5yrs Actuarial Survival (48) Wang 9.8 9.8 - 67% DFS (71) Narayan 19.2 17.3 15.3 38% 5yrs OAS (52) SPLIT THERAPY - Comparison of results of studies with RT followed by Surgery LR RR DM Survival Statistics LR- Local Recurrence RR- Regional Recurrence DM- Distant Metastasis; OAS- Overall Survival
55. 3. How is an N2 / N3 node ideally managed with chemo-rads Radio-curability proportional to volume of tumor Occult 4500 rad 1 cms 6000 ” 3 cms 7000 ” 6 cms 8000 ” McComs & Fletcher – Am J. Roentgenol 1957 Berkley & Fletcher – Am J. of Surgery 1972 RT + NECK DISSECTION
56. Management of the neck Surgery N Stage N 0 N 2 -3 Neck Treatment N 1 SND / Wait & Watch MND / RND SND / MND Histology of LN pN 2 – 3 ECS pN1 pNO Further Treatment ? RT RT / ? CT / RT None
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