Treatment results on advanced neck metastasis (N3) from head and neck squamous carcinoma.

OBJECTIVE: To analyze the long-term results of patients with N3 neck metastasis from squamous carcinoma of the head and neck. STUDY DESIGN: This study is based on the analysis of a retrospective cohort of 224 previously untreated patients with squamous cell carcinoma of the head and neck and lymph node metastasis sized greater than 6 cm (N3) who were evaluated from 1981 to 1996. RESULTS: Fifty-four patients (24.1%) underwent neck dissection, 137 underwent radiotherapy alone (61.2%), and 33 received only supportive care (14.7%). Control of the neck metastasis was achieved in 46 cases among the treated ones (24.1%), varying from 51.9% for the patients who underwent surgery to 13.1% for radiotherapy alone ( P < 0.001). Exclusive distant metastasis occurred in 37.0% of the cases who had control of the neck disease. The 3-year overall survival rates were 17.9% for patients who underwent surgery and 7.0% for radiotherapy alone ( P = 0.003). The multivariate analysis showed as independent predictive factors the treatment approach ( P < 0.001) and tumor site ( P = 0.016). CONCLUSIONS: This study confirms the poor prognosis of patients with N3 neck disease, mainly when treated by radiotherapy alone. A radical neck dissection associated with adjuvant radiotherapy is indicated whenever feasible. Because of the high rate of distant metastasis, protocols including adjuvant chemotherapy should be investigated.

Postoperative complications after en bloc salvage surgery for head and neck cancer.

OBJECTIVE: To analyze the frequency of and risk factors for postoperative complications after en bloc salvage surgery for head and neck cancer. DESIGN: Retrospective cohort study. SETTING: Patients were evaluated from February 7, 1990, to November 17, 1999, in a tertiary cancer center hospital. PATIENTS: Consecutive sample of 124 patients from the hospital database. Only patients with recurrent head and neck squamous cell carcinoma undergoing en bloc salvage resection were eligible for the study. MAIN OUTCOME MEASURES: We analyzed the frequency of and risk factors for complications after salvage surgery. RESULTS: The tumor location was the lip in 6 patients, oral cavity in 55, oropharynx in 31, larynx in 24, and hypopharynx in 8. Previous treatment was surgery alone in 20 patients, radiotherapy alone in 68, surgery and radiotherapy in 21, and radiotherapy and chemotherapy in 14. An additional patient received chemotherapy alone before salvage surgery. The clinical stage of the recurrent tumor was I or II in 23 patients and III or IV in 101 patients. Postoperative complications occurred in 66 patients (53.2%). Fifty-three patients (42.7%) had minor complications, and 23 patients (18.5%) had major ones. There were 4 postoperative deaths (3.2%). The major factor associated with the overall occurrence of postoperative complications was the clinical stage of the recurrent tumor (P =.02). The occurrence of minor complications correlated with the previously treated site, with complications occurring more often in patients undergoing locoregional vs local treatment (P =.04). Major complications were associated with the time between initial treatment and salvage surgery (P =.05). CONCLUSIONS: Salvage surgery can be performed with acceptable rates of postoperative complications. The clinical stage of the recurrent tumor and the previous site treated were the 2 major factors associated with the occurrence of postoperative complications.

Distribution of metastatic lymph nodes in oropharyngeal carcinoma and its implications for the elective treatment of the neck.

OBJECTIVES: To analyze the distribution of lymph node metastases in patients with oropharyngeal squamous cell carcinoma and improve the rationale for elective treatment of the neck. DESIGN AND SETTING: Retrospective cohort study of patients evaluated from 1990 to 1998 in a tertiary cancer care center. PATIENTS: The 81 consecutive patients who were identified from the hospital database. Patients were eligible for the study if they had a previously untreated squamous cell carcinoma of the oropharynx and histopathologically diagnosed lymph node metastases without a second primary tumor treated by an en bloc resection. MAIN OUTCOME MEASURES: We analyzed the anatomic distribution of lymph node metastases. RESULTS: The clinical neck cancer stages were N0 in 22 cases, N1 in 22, N2a in 8, N2b in 14, N2c in 4, and N3 in 11. The most common sites for the metastases detected clinically as well as histopathologically were at levels II and III. Histologically, level I alone was involved in 5 cases and level IV alone was involved in none. Sixteen patients with N0 neck cancer stage underwent a radical neck dissection. There were 2 cases of metastases at level I and no level IV involvement. CONCLUSIONS: Pathological lymph nodes in oropharyngeal squamous cell carcinoma are more frequent at level I than at level IV. This finding suggests that elective neck dissection for patients with oropharyngeal carcinoma should be a supraomohyoid neck dissection (levels I, II, and III) rather than a lateral neck dissection (levels II, III, and IV).