Neck Management in Head Neck Management in Head and Neck Cancer:and Neck Cancer:

History and Current PracticeHistory and Current Practice

Laura Goguen, MDLaura Goguen, MDOtolaryngology Head and Neck SurgeryOtolaryngology Head and Neck Surgery

Dana Farber Cancer InstituteDana Farber Cancer InstituteBrigham and WomenBrigham and Women’’s Hospitals Hospital

BostonBoston

Current HNC StatsCurrent HNC Stats

Worldwide 6Worldwide 6thth most common cancermost common cancer1,21,2

Advanced stage, III or IV, in 66%Advanced stage, III or IV, in 66%11

Neck mets Neck mets Significant poor prognostic indicatorSignificant poor prognostic indicator

11Jemal 2009&2007, Jemal 2009&2007, 22Shiboski2005Shiboski2005

Chemoradiation Therapy for Chemoradiation Therapy for Advanced H&N CancerAdvanced H&N Cancer

Effective at controlling primary diseaseEffective at controlling primary disease““Organ PreservationOrgan Preservation””

Evolving confidence in its ability to treat Evolving confidence in its ability to treat neck diseaseneck disease1,2,31,2,3

11Rabalais2009; Rabalais2009; 22Ong2008; Ong2008; 33Wang2009Wang2009

Neck Management in HNC Neck Management in HNC OutlineOutline

HistoryHistoryNeck dissection classificationNeck dissection classificationCurrent PracticeCurrent Practice

ControversiesControversiesDFCI experienceDFCI experience

Neck management recommendationsNeck management recommendations

History Neck ManagementHistory Neck Management

460 BC: Hippocrates460 BC: Hippocrates““CarcinomaCarcinoma””

16001600--17001700’’s: s: Observation Observation -- Cancer spread local, regional Cancer spread local, regional and general circulationand general circulationTreatment Treatment -- topicals, bleeding, purging, topicals, bleeding, purging, cauterization & limited resectionscauterization & limited resectionsNeck mets = incurableNeck mets = incurable

18001800’’s: Dawn of Scientific Medicines: Dawn of Scientific Medicine

1838: Microscopic pathology, M1838: Microscopic pathology, Müüllerller1846: Anesthesia, William Morton1846: Anesthesia, William Morton1867: Antisepsis1867: Antisepsis

Morton & Warren, Ether Anesthesia Morton & Warren, Ether Anesthesia MGH, 1846MGH, 1846

George Crile, Neck DissectionGeorge Crile, Neck DissectionCleveland, 1906Cleveland, 19061,21,2

1Crile JAMA 19062Ferlito. Neck Dissection, 2010

Important Inventions/InnovationsImportant Inventions/Innovations

1898: Radiation Therapy, Marie Curie1898: Radiation Therapy, Marie Curie19181918--1939: Between WWI & WWII1939: Between WWI & WWII

Primary radiation for HNCPrimary radiation for HNC

Important Inventions/InnovationsImportant Inventions/Innovations

1938: Antibiotics, Alexander Fleming1938: Antibiotics, Alexander Fleming19401940--5050’’s:s:

Blood transfusionBlood transfusionImproved anesthesia, critical careImproved anesthesia, critical care

Hayes Martin, Radical Neck DissectionHayes Martin, Radical Neck Dissection11

DissectDissectLevels I Levels I –– VV

SacrificeSacrificeCNXICNXIIJIJSCMSCM

IndicationsIndicationsAll N+All N+

1Cancer,1951

Modified Radical Neck DissectionModified Radical Neck Dissection

1963 Suarez1963 Suarez11; 1966 ; 1966 BocaBoca22

DissectDissectLevels ILevels I--VV

Preserve Preserve ≥≥11CNXICNXIIJIJSCMSCM

11Rev Otorrinolaringol; Rev Otorrinolaringol; 22J Laryngol OtolJ Laryngol Otol

Modified Radical Neck DissectionModified Radical Neck Dissection

IndicationsIndicationsN+ neckN+ neck

Without invasion of SCM, IJV or CN 11Without invasion of SCM, IJV or CN 11

N0 neckN0 neckElective neck mgmtElective neck mgmt

Bilateral neck dissectionsBilateral neck dissections

Patterns of Nodal SpreadPatterns of Nodal Spread

1972: Lindberg1972: Lindberg11

2,044 CNDs2,044 CNDs1990: Shah1990: Shah22

1,100 CNDs1,100 CNDs

11Cancer; Cancer; 22Am J SurgAm J Surg

Neck LevelsNeck Levels

•Oral CavityI, II, III

•OP, Larynx, HPII, III, IV

Selective Neck DissectionSelective Neck Dissection

1988: Byers1988: Byers11

DissectDissectPreserve at least one neck levelsPreserve at least one neck levels

IndicationsIndicationsElectiveElective

Prophylactic, StagingProphylactic, StagingTherapeuticTherapeutic

N1, early N2N1, early N2

11Head&Neck SurgHead&Neck Surg

Selective Neck DissectionSelective Neck DissectionLevel I, II, IIILevel I, II, III

Supraomohyoid NDSupraomohyoid NDIndicationsIndications

OCOC

Selective Neck DissectionSelective Neck DissectionLevels II, III, IVLevels II, III, IV

Lateral ND Lateral ND IndicationsIndications

OPOPLarynxLarynxHPHP

History Neck Management History Neck Management RT &/or SurgeryRT &/or Surgery

1950 1950 –– 1980: 1980: Improvements in RT and surgeryImprovements in RT and surgeryStage I or II: Surgery or RTStage I or II: Surgery or RTStage III or IV: Surgery & RTStage III or IV: Surgery & RT

1986 Mendenhall1986 Mendenhall11

ND p RT = N1 PR & N2,N3ND p RT = N1 PR & N2,N311Int J Rad Onc Biol PhysInt J Rad Onc Biol Phys

Combined Modality TreatmentCombined Modality TreatmentAdvanced HNCAdvanced HNC

1991 VA Study1991 VA Study11: Induction CRT: Induction CRTAssess neck p 2Assess neck p 2ndnd cycle, ND @ 3mo for cycle, ND @ 3mo for PRPR

Presently: Induction or concurrent Presently: Induction or concurrent CRTCRT

Planned ND or Planned ND or ND for PRND for PR

11N Eng J MedN Eng J Med

Current Neck Management p CRTCurrent Neck Management p CRTControversiesControversies

1.1. Who should get ND?Who should get ND?Planned vs. PRPlanned vs. PR

2.2. Neck assessment Neck assessment CT, PET/CTCT, PET/CTOptimal timingOptimal timing

3.3. Neck dissection timing and morbidity Neck dissection timing and morbidity 4.4. Type of neck dissectionType of neck dissection

1. Who Should Get ND p CRT?1. Who Should Get ND p CRT?

Planned Planned –– all PR, all N2 & N3all PR, all N2 & N31,2,31,2,3

TraditionTraditionMendenhall p RT ND mgmtMendenhall p RT ND mgmtEarly trials lower dose neck RTEarly trials lower dose neck RT

Neck assessments inaccurateNeck assessments inaccurateEarly trials often relied on PE Early trials often relied on PE

Later neck salvage difficultLater neck salvage difficultStill consider for all N3?Still consider for all N3?

1.Lavertu 1997; 2.McHam 2003; 3.Brizel 20041.Lavertu 1997; 2.McHam 2003; 3.Brizel 2004

1. Who Should Get ND p CRT?1. Who Should Get ND p CRT?

Neck PR patients onlyNeck PR patients onlyAssessments accurateAssessments accurate1,2,3,41,2,3,4

No improved control/survival when CR No improved control/survival when CR neck undergoes NDneck undergoes ND1,21,2

ND morbidND morbid

1.Argiris 2004 2.Greven 2008 3.Lau 2008 4.Forest 20061.Argiris 2004 2.Greven 2008 3.Lau 2008 4.Forest 2006

1. Who Should Get ND p CRT?1. Who Should Get ND p CRT?DFCI ExperienceDFCI Experience

1993 Norris, Busse, Clark1993 Norris, Busse, Clark11

N+ CR p induction predicts neck response N+ CR p induction predicts neck response and ND may not be neededand ND may not be needed

2006 Goguen et al2006 Goguen et al22NPV 100% when PE, CT and PET all CRNPV 100% when PE, CT and PET all CRNo improvement survival with ND in CR ptNo improvement survival with ND in CR ptND not needed for CR ptsND not needed for CR pts

11Semin Surg Oncol; Semin Surg Oncol; 22Arch OtolaryngolArch Otolaryngol

2. Neck Assessment p CRT2. Neck Assessment p CRT

CT accuracyCT accuracy1,2,31,2,3

CT NPV 94CT NPV 94--97% at 497% at 4--12 wks12 wksNeck relapse 0Neck relapse 0--5%5%

PET/CT accuracyPET/CT accuracy44--99

PET or PET/CT NPV 97PET or PET/CT NPV 97--100% at 12100% at 12--16 wks16 wksNeck relapse 0Neck relapse 0--3%3%

11Yeung2008; Yeung2008; 22Forest2006; Forest2006; 33Liauw2006; Liauw2006; 44Rabalais2009; Rabalais2009; 55Ong2008; Ong2008; 66Wang2009; Wang2009; 77Nayak2007; Nayak2007; 88Porceddu2005; Porceddu2005; 99Yao2007Yao2007

2. Neck Assessment p CRT2. Neck Assessment p CRTDFCI ExperienceDFCI Experience

Study in progress:Study in progress:Neg CT predicts neg path at NDNeg CT predicts neg path at ND

NPV CT 95% (110 heminecks)NPV CT 95% (110 heminecks)N2 NPV 97% ( false neg 1/34; 85 N2)N2 NPV 97% ( false neg 1/34; 85 N2)N3 NPV 86% (false neg 1/7; 17 N3)N3 NPV 86% (false neg 1/7; 17 N3)

2. Neck Assessment p CRT2. Neck Assessment p CRTTimingTiming

Early PET/CT inaccurateEarly PET/CT inaccurate1,21,2

False positiveFalse positiveTreatment related inflammationTreatment related inflammationCancer cells in evolution toward deathCancer cells in evolution toward death

False negativeFalse negativeSmall pockets of residual cancer, need to Small pockets of residual cancer, need to repopulate further to be detectablerepopulate further to be detectable

PET/CT more accurate at 3mo p PET/CT more accurate at 3mo p CRTCRT1,2,3,4,5,61,2,3,4,5,6

11Porceddu; Porceddu; 22Yao2007; Yao2007; 33Rabalais2009; Rabalais2009; 44Ong2008; Ong2008; 55Wang2009; Wang2009; 66Nayak2007Nayak2007

3. Neck Dissection Timing and 3. Neck Dissection Timing and MorbidityMorbidity

Timing ConflictTiming ConflictPET/CT at 3 monthsPET/CT at 3 months““Safe Surgical WindowSafe Surgical Window”” 44--12 weeks p 12 weeks p CRTCRT1,2,31,2,3

After acute CRT toxicities resolvedAfter acute CRT toxicities resolvedBefore radiation related fibrosisBefore radiation related fibrosis

11Grabenbauer2003; Grabenbauer2003; 22Vedrine2008; Vedrine2008; 33Stenson2000Stenson2000

3. ND Timing and Morbidity 3. ND Timing and Morbidity DFCI ExperienceDFCI Experience

Study in progress:Study in progress:Can ND be safely delayed until Can ND be safely delayed until ≥≥12 12 wks?wks?

Are complications increased?Are complications increased?Does regional control or survival Does regional control or survival decrease?decrease?

ND Complications p CRTND Complications p CRT

0.320.325%5%13%13%SystemicSystemic

0.480.485%5%10%10%AirwayAirway

0.560.5611%11%16%16%Minor Minor WoundWound

0.150.153%3%12%12%Major Major WoundWound

PP--ValueValue≥≥12Week 12Week ND (38pts)ND (38pts)

<12Week <12Week ND (67pts)ND (67pts)

ND ND ≥≥ 12 Weeks p CRT12 Weeks p CRT

No increased complicationsNo increased complicationsNo diminished regional control or survivalNo diminished regional control or survival

4. Type of ND p CRT4. Type of ND p CRT

CNDCNDRND or MRNDRND or MRND

SNDSND1,2,3,4,5,61,2,3,4,5,6

Based on primary, pre & post CRT Based on primary, pre & post CRT imagingimaging

Superselective ND, RobbinsSuperselective ND, Robbins44

≤≤2 neck levels2 neck levelsPlanned ND or PR neck @ only one level Planned ND or PR neck @ only one level by imagingby imaging

11Yeung2008; Yeung2008; 22Rao2008; Rao2008; 33Doweck2003; Doweck2003; 44Robbins 2005; Robbins 2005; 55vanderPutten2009 vanderPutten2009 66Mukhija2009Mukhija2009

4. Type of Neck Dissection4. Type of Neck DissectionDFCI ExperienceDFCI Experience

Study in progress:Study in progress:CT as roadmap for designing SND or CT as roadmap for designing SND or SSNDSSND

NPV per neck level I NPV per neck level I –– V = 96 V = 96 -- 100%100%

Ability of More Limited Neck Surgery to Capture Neck Disease

CT PR ≤ 2 positive levels, 67 heminecksSND captures 94%

SSND 91%

CT PR 1 positive level, 55 heminecksSND captures 95%

SSND 93%

CT PR 1 positive LN, 52 heminecksLN biopsy captures 90%

4. Type of ND DFCI Experience4. Type of ND DFCI Experience

CT Roadmap for Neck Surgery after CRTCT Roadmap for Neck Surgery after CRTCT PR CT PR >> 2 neck levels or ECS2 neck levels or ECS

CNDCND

CT PR 1 neck levelCT PR 1 neck levelSND SND

LN biopsy alone not safeLN biopsy alone not safe

ConclusionConclusion

Recommendations Recommendations Neck Management p CRTNeck Management p CRT

CRT highly effective at treating CRT highly effective at treating neck metsneck mets1,2,31,2,3

CT and PET/CT 12 weeks p CRTCT and PET/CT 12 weeks p CRTSafe to perform ND Safe to perform ND ≥≥12 weeks12 weeks

1.Rabalais 2009 2.Ong2008 3.Wang20091.Rabalais 2009 2.Ong2008 3.Wang2009

Recommendations Recommendations Neck Management p CRTNeck Management p CRT

Neck CR Neck CR ObservationObservationRepeat PET/CT at 6mo p CRTRepeat PET/CT at 6mo p CRT

Neck PR Neck PR –– NDNDLimited disease Limited disease -- SNDSND

Usually levels II, III, IVUsually levels II, III, IV

>2 levels or ECS >2 levels or ECS -- CNDCND