Is Elective Treatment Preferable to Observation and Therapeutic Neck Dissection

The value of elective treatment of the neck is not universally accepted. The notion of watching the neck and treating it only when metastases become clinically apparent is allegedly supported by two prospective randomized studies.28,29 In both studies, the survival of patients with cancer of the oral cavity who underwent "elective" neck dissection was not significantly better than the survival of patients who underwent a therapeutic neck dissection. Unfortunately, these studies have not resolved the controversy. In fact, they have been criticized because the number of patients studied was insufficient to arrive at a conclusive opinion.

The efficacy of elective treatment of the neck in patients with larynx cancer has been recently compared to that of therapeutic neck dissection at the time metastases become clinically apparent in an interesting retrospective study by Gallo et al.30 From a population of 1808 patients with cancer of the larynx treated at the University of Florence, two groups of patients were selected for comparison. The first group of 76 patients had clinically an N0 neck, underwent elective neck dissection, and had histologically positive nodes. The second group consisted of 96 patients who were initially staged N0 but who subsequently developed lymph node metastases and underwent therapeutic neck dissection. Postoperative radiation to the neck was given to 11% of the patients in the first group and to 20.8% in the second group (P = 0.178). The criteria used to determine when patients were selected for one group or the other were not established a priori. However, Gallo and colleagues state that patients were "usually" selected to undergo elective neck dissection when they had an advanced tumor (T3-T4); had a fat, short, or muscular neck that was not easy to evaluate clinically; had a low educational level; and poor follow-up was anticipated. In this study, there was not a statistically significant difference between the two groups of patients in overall determinant and actuarial survival rates, with a minimum follow-up of 5 years. This is surprising because patients who underwent delayed therapeutic neck dissection had a significantly higher incidence of distant metastases, multiple positive nodes, and extracapsular tumor spread.30 Other retrospective studies have found that elective neck dissection decreases the neck recurrence rates significantly in patients treated for N0 supra-glottic carcinoma.31

Self-examination by the patient and reliable follow-up evaluation are essential for watchful waiting to succeed in the management of the N0 neck. Unfortunately, a significant number of the patients who do not undergo elective neck dissection cannot be salvaged later, when they present with palpable metastases, because the disease is too far advanced.29 In a review of 122 patients with T3-T4 N0 cancers of the larynx who were treated by total laryngectomy and observation of the neck at the University of Hong Kong, 36% of the patients who later presented with palpable metastases had inoperable disease, amenable to palliative treatment only. Furthermore, of the patients who were operable, 42% eventually died of a neck recurrence. These observations, in combination with the idiosyncrasies of character and social background of many patients with larynx cancer, lead most head and neck surgeons to treat the neck electively, even though the impact of this decision on patient survival remains controversial.

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