Alternatives for Therapy

An assessment of the risk of occult regional metastases is based on the site, stage, and pathologic characteristics of the primary tumor. Management of the NO neck is typically addressed when this risk is estimated to be >2O%.15,16 With the exception of early-stage glottic tumors and very small superficial lesions, most primary tumors of the upper aerodigestive tract staged NO probably warrant consideration of the neck.

Three management options exist for NO patients who are determined to be at significant risk of occult metastases. A program of clinical observation reserves neck dissection for patients who develop regional metastases subsequent to treatment of the primary tumor. Elective neck irradiation (ENI) delivers a tumoricidal dose of radiation to the cervical lymphatics. END is the third option.

The salvage rate for patients who develop regional metastases during a program of clinical observation is estimated to be 5O to 59% after multimodal therapy.16-18 Although a subset of truly pNO managed with observation will not receive unnecessary surgery, those in whom cervical metastases do develop will have a poor outcome.

If the decision is to treat the NO neck, radiation and surgery are options. For patients whose primary tumor is treated with irradiation, ENI is probably the treatment of choice. If the primary is treated surgically, one must decide whether to dissect or to radiate the neck.

As the regional recurrence rates after treatment of clinically NO patients are 2.O to 8.O% for ENI19'20 and 2.O to 11.O% for END, 21-24 other considerations are factored into the choice of treatment. Important differences include the length of time required for treatment, the comparative cost of treatments, and the increased morbidity associated with postirradiation surgery, if required.

If the primary tumor is resected, a policy of ENI will expose 6O to 7O% of patients to the sequelae of irradiation unnecessarily. Radiation is not a benign form of therapy. Possible effects include xerostomia, fibrosis, and contracture, which confound the physical examination. Atherosclerosis and radiation-induced malignancy are also reported.25,26 Patients who receive ENI will not get the prognostic information afforded by pathologic staging, and cervical irradiation will not be an option for recurrent or second primary disease.

The morbidity of neck dissection is an important factor in considering END. Compared with radical neck dissection, the routine use of selective procedures has decreased the impact of END on postoperative appearance and function. The main determinant of cost for END is surgical time; hospital stays are generally not lengthened if the primary tumor is resected.

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