Need for Elective Treatment

Several studies have shown a diminished survival rate in patients with occult lymphatic metastasis. Tulenko et al.12 showed that the 5-year cure rate decrease from 79% in patients without any evidence of metastasis to 29% in those with occult disease detected on pathologic examination to 11% in those with clinically evident disease. Similarly, Alvi and Johnson13 showed that disease control rates decreased from 82% for patients without metastasis to 47% for those with occult metastasis and to 31% when extracapsular spread was present in lymph nodes containing occult metastasis. Accordingly, identification and treatment of patients with occult metastasis appear warranted.

However, because there is no statistical difference in regional control rates or survival between patients undergoing elective neck dissection for micrometastasis compared with those undergoing therapeutic neck dissection for N1 disease, extrapolation suggests that patients with NO necks can be followed until metastasis becomes clinically evident.3 Unfortunately, patients at risk of micrometastasis to the cervical lymphatics do not absolutely progress in an orderly fashion.3,9,14-17 A report by Anderson et al.14 showed that most patients initially observed with NO neck, have greater than N1 nodal involvement clinically at subsequent treatment, even under close follow-up (Fig. 3-1). In fact, most patients (77%) had metastatic disease greater than N1 or associated extracap-sular spread on pathologic analysis. In addition, in patients with NO necks, the rate of distant metastasis is higher in those who develop subsequent nodal recurrence (11%) as compared with patients who remain disease free (3%).7,8 This suggests early intervention is warranted in patients at high risk of occult nodal involvement.

Figure 3-1 (A) Clinical findings in patients failing in the neck after observation for NO neck. (B) Pathological findings in patients failing in the neck after observation for NO neck.

Theoretically, the early identification and treatment of patients with metastatic squamous cell carcinoma to regional cervical lymph nodes will have a favorable impact on survival, but prospective studies have failed to confirm this association. However, improved disease-free survival has been observed in both prospective and retrospective analysis. Kligerman et al.17 found that the disease-free survival increased from 49% to 72% with the addition of elective supraomohyoid neck dissection. Similarly, Fakih et al.16 also reported increased disease-free survival with the addition of elective neck treatment (67% vs 47%). In summary, elective neck dissection helps in prognostication, identifies cases requiring adjuvant treatment, and improves initial disease control rates.

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