Vedrine Pierre-Olivier, Thariat Juliette, Hitier Martin, Janot François, Kaminsky Marie-Christine, Makeieff Marc, De Raucourt Dominique, Lapeyre Michel, Toussaint Bruno
Department of Otolaryngology-Head and Neck Surgery, Cannes Hospital, Cannes, France.
Laryngoscope. 2008 Oct;118(10):1775-80. doi: 10.1097/MLG.0b013e31817f192a.
BACKGROUND/HYPOTHESIS: The need for a neck dissection after radiochemotherapy (RCT) for patients with unresectable cancer of the head and neck remains questionable. We evaluated our strategy to perform a neck dissection in patients with a controlled primary tumor based on the response to RCT according to regional control, survival rates, and morbidity.
The French "Groupe d'Etude des Tumeurs de la Tête et du Cou" (GETTEC) group retrospectively performed a multicenter review. One hundred and three stage III (N = 7) or IV (N = 96) patients with unresectable primary tumors and node-positive disease and no distant metastases treated between 1996 and 2002. Tumors were considered unresectable or with poor surgical curability based on advanced stage, or patients were surgically unfit for medical reasons.
With a median follow-up of 30 months, the complete clinical and radiological nodal response rate was 61%. Among 39% (N = 40) of patients with residual neck disease, 70% (N = 28) underwent a neck dissection, whereas the remaining 30% either underwent watchful follow-up for probable scary nodes, or were deemed unresectable or medically unfit for surgery. Half of the neck dissection specimens showed pathological evidence of viable tumor. Grade 3 to 4 complications were recorded in four patients (14%) after neck dissection. Regional control was better for complete responders. Disease-free survival and overall survival were similar between patients with a complete response in the neck and no neck dissection, and patients with a neck dissection for residual neck disease.
The strategy to avoid a neck dissection is safe in patients with a complete response in the neck, regardless of initial nodal stage. In patients with residual neck disease, postRCT neck dissection can be performed with limited morbidity. Progress is warranted to optimize the pathological response in the nodes and to better assess ambiguous nodal responses with multi-modal imaging.
背景/假设：对于头颈部不可切除癌症患者，放化疗（RCT）后是否需要行颈部清扫术仍存在疑问。我们根据区域控制、生存率和发病率，评估了基于RCT反应对原发肿瘤得到控制的患者进行颈部清扫术的策略。
法国“头颈部肿瘤研究组”（GETTEC）进行了一项回顾性多中心研究。1996年至2002年间，103例III期（n = 7）或IV期（n = 96）原发肿瘤不可切除且有淋巴结转移且无远处转移的患者。根据晚期阶段，肿瘤被认为不可切除或手术治愈率低，或者患者因医学原因不适合手术。
中位随访30个月，颈部淋巴结的临床和影像学完全缓解率为61%。在39%（n = 40）颈部有残留病变的患者中，70%（n = 28）接受了颈部清扫术，而其余30%要么对可能可疑的淋巴结进行密切随访，要么被认为不可切除或因医学原因不适合手术。一半的颈部清扫标本显示有存活肿瘤的病理证据。颈部清扫术后4例患者（14%）记录到3至4级并发症。完全缓解者的区域控制更好。颈部完全缓解且未行颈部清扫术的患者与因颈部残留病变而行颈部清扫术的患者的无病生存率和总生存率相似。
对于颈部完全缓解的患者，无论初始淋巴结分期如何，避免行颈部清扫术的策略是安全的。对于颈部有残留病变的患者，RCT后颈部清扫术的发病率有限。有必要取得进展以优化淋巴结的病理反应，并通过多模态成像更好地评估不明确的淋巴结反应。
