Potential Effects of END

The most immediate benefit of END is that the information obtained from pathologic staging of the neck contents can be used to target those patients who may benefit from combination therapy. Selectively targeting patients who will benefit from adjuvant therapy reduces overall the morbidity and cost of treatment.

Whether END provides a therapeutic benefit is more controversial. Intuitively, it makes sense that removing microscopic metastases at the earliest opportunity would improve patient outcome. However, no prospective randomized studies have been conducted to compare the outcome of patients managed with END with patients treated with therapeutic neck dissection for metastases that occur during observation. Retrospective studies have demonstrated a possible survival benefit for patients treated with END.

Figure 1-1 compares the results of four studies15-18 that reported data comparing the survival rates of patients who were pN+ and who received END with the survival rates of patients who received therapeutic neck dissection for metastases that were clinically evident. These data suggest that survival is improved when patients receive END. Overall survival between studies cannot be compared because the two earlier studies included advanced lesions from many sites, whereas recent studies looked only at early oral cavity lesions. These retrospective studies suggest a therapeutic benefit for END, but they do not provide conclusive evidence that END in and of itself provides a survival advantage. To answer this question, prospective studies are required.

TABLE 1-2

Incidence of Occult Regional Metastases by Primary Site

TABLE 1-2

pN+ (%)

Primary Site

UPMC24

Byers et al.10

Shah29

Oral cavity

41

45

34

Oropharynx

36

39

31

Hypopharynx

36

56

17

Larynx (supraglottic/advanced glottic)

30

26

37

4 Pitman and Johnson

Figure 1-1 Patient survival with therapeutic neck dissection (TND) vs elective neck dissection (END) with pN+.
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