Department of Otolaryngology-Head and Neck Surgery, Department of Surgical Oncology, Princess Margaret Cancer Centre-University Health Network, University of Toronto, Canada.
Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Canada.
Oral Oncol. 2021 Mar;114:105165. doi: 10.1016/j.oraloncology.2020.105165. Epub 2021 Jan 30.
Management of the neck in oropharyngeal carcinoma varies due to a lack of clarity of patterns of lymphatic drainage and concern of failure in the contralateral neck. With recent advances in transoral surgical techniques, surgical management has become increasingly prevalent as the primary treatment modality. We compare international practice patterns between surgical and radiation oncologists.
A survey of neck management practice patterns was developed and pilot tested by 6 experts. The survey comprised items eliciting the nature of clinical practice, as well as patterns of neck management depending on extent of nodal disease and location and extent of primary site disease. Proportions of surgical and radiation oncologists treating the neck bilaterally were compared using the chi-squared statistic.
Two-hundred and twenty-two responses were received from 172 surgical oncologists, 44 radiation oncologists, 3 medical oncologists, and 3 non-oncologists from 32 different countries. For tongue base cancers within 1 cm of midline (67% vs. 100%, p < 0.001), and for tonsil cancers with extension to the medial 1/3 of the soft palate (65% vs. 100%, p < 0.001) or tongue base (77% vs. 100%, p < 0.001), surgical oncologists were less likely to treat the neck bilaterally. For isolated tonsil fossa cancers with no nodal disease, both surgical and radiation oncologists were similarly likely to treat unilaterally (99% vs. 97%, p = NS). However, with increasing nodal burden, radiation oncologists were more likely to treat bilaterally for scenarios with a single node < 3 cm (15% vs. 2%, p < 0.001), a single node with extranodal extension (41% vs. 18%, p < 0.001), multiple positive nodes (55% vs. 23% p < 0.001), and node(s) > 6 cm (86% vs. 33%, p < 0.001). For tumors with midline extension, even with a negative PET in the contralateral neck, the majority of surgical and radiation oncologists would still treat the neck bilaterally (53% and 84% respectively).
The present study demonstrates significant practice pattern variability for management of the neck in patients with lateralized oropharyngeal carcinoma. Surgical oncologists are less likely to treat the neck bilaterally, regardless of tumor location or nodal burden. Even in the absence of disease in the contralateral neck on imaging, them majority of practitioners are likely to treat bilaterally when the disease approaches midline.
由于对淋巴引流模式缺乏清晰认识以及对对侧颈部失败的担忧，口咽癌颈部的管理方式存在差异。随着经口外科手术技术的进步，作为主要治疗方式，手术治疗的应用越来越普遍。我们比较了手术和放射肿瘤学家之间的国际实践模式。
我们开发了一项关于颈部管理实践模式的调查，并由 6 名专家进行了试点测试。该调查包括了有关临床实践性质以及根据淋巴结疾病的范围、原发部位疾病的位置和范围进行颈部管理的项目。使用卡方检验比较了治疗双侧颈部的手术和放射肿瘤学家的比例。
我们从 32 个不同国家的 172 名外科肿瘤学家、44 名放射肿瘤学家、3 名内科肿瘤学家和 3 名非肿瘤学家那里收到了 222 份回复。对于中线 1cm 以内的舌根癌（67%比 100%，p<0.001）和中线内侧 1/3 软腭受累的扁桃体癌（65%比 100%，p<0.001）或舌根癌（77%比 100%，p<0.001），外科肿瘤学家不太可能双侧治疗颈部。对于无淋巴结疾病的孤立扁桃体窝癌，手术和放射肿瘤学家同样倾向于单侧治疗（99%比 97%，p=NS）。然而，随着淋巴结负担的增加，放射肿瘤学家更倾向于双侧治疗以下情况：单个淋巴结<3cm（15%比 2%，p<0.001）、单个淋巴结有外淋巴结延伸（41%比 18%，p<0.001）、多个阳性淋巴结（55%比 23%，p<0.001）和淋巴结>6cm（86%比 33%，p<0.001）。对于中线延伸的肿瘤，即使对侧颈部的 PET 检查为阴性，大多数手术和放射肿瘤学家仍将双侧治疗颈部（分别为 53%和 84%）。
本研究表明，对于侧发性口咽癌患者的颈部管理，存在显著的实践模式差异。无论肿瘤位置或淋巴结负担如何，外科肿瘤学家都不太可能双侧治疗颈部。即使在影像学上对侧颈部没有疾病，当疾病接近中线时，大多数医生可能仍会双侧治疗。
