Managment Of N+Neck

Management of the Neck (N 0 and N + ) Dr. A D’Cruz Tata Memorial Hospital

Cervical Metastasis ,[object Object],[object Object],[object Object],[object Object]

Management of the neck Surgery ,[object Object],[object Object],[object Object],[object Object]

1. Should the neck be addressed in a N0 neck? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

END v/s Observe ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],“ It must be shown that neck dissection performed for clinically palpable metastases (cN+) is less successful than a similar operation for involved but not palpable nodes (cN0 but pN+)”

N0 Current Management Policies – I Mathematical Models ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

N 0 Current Management Policies - II Historical evidence ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],N0 Current Management Policies - III Retrospective

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],N 0 Current Management Policies - IV Trials – Prospective

Tongue cancer Retrospective analysis (1997 – 2001) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Tumor characteristics Observe Operate T Stage T1 118(59%) 69(43.4%) T2 82(41%) 90(56.6%) Grade I 48(24%) 30(18.9%) II 132(66%) 109(68.6%) III 20(10%) 20(12.6%) PNI No 181(90.5%) 145(91.2%) Yes 19(9.5%) 14(8.8%) Thickness <=3 39(19.5%) 13(8.2%) 4-9 115(57.5%) 89(56%) >=10 37(18.5%) 52(32.7%) Cut margin +ve 7(3.5%) 4(2.5%) -ve 184(92%) 146(91.8%) close 9(4.5%) 9(5.7%)

Status at last follow -up ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Views on management of N0 neck Questionnaire ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

2. Extent of neck dissection (N0 neck) ,[object Object],[object Object],[object Object],[object Object],[object Object],- Lindberg, Byers, Shah

SOHD (Oral Cavity) Recurrences in dissected neck [Primary controlled; 2 YR follow up] ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Lateral Neck Dissection – Reccurences in dissected neck [Primary controlled; 2 YR follow up] ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Critical Assessment of SOHD 94 Patients / 107 SOHD’s Spiro Am J surgery 1998 94 Patients / 107 SOHD’s 24 Clinical N + 83 Clinical N - 26 Path +ve 17 Path +ve 64 Path -ve 4 (15%) Neck Fail 3 (5%) Neck Fail 5 (29%) Neck Fail

ORAL SCC T2 – T4 N0) RCT (148 patients) ,[object Object],[object Object],[object Object],[object Object],[object Object]

3. What should be the extent of dissection for the N + neck ,[object Object]

Management of the neck ,[object Object]

Management of the neck Bocca 1984 Laryngoscope 843 Cases Byers 1985 Am J Surg 967 Cases Anderson 1994 Am J Surg 366 Cases RND 63% 12% MRND 71% 8% p (NS) 5 year Survival Neck Failure MND = RND Same control  Less Morbid

Level V Metastases Overall 3 % Hypopharynx 7 % Oropharynx 6 % Oral Cavity 1 % Larynx 2 % Davidson et al, Am J Surg, Oct. 93. N = 1277

SND in N+ Neck Kowalski 1993 164 / 95 +ve Kolli 2000 69 / 39 +ve Traynor 1996 29 patients +ve Safe

Therapeutic Neck Dissection – 25 Yr Review ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],- K. Muzzafar, Laryngoscope: 2003

SND in N+ Neck Anderson (106 patients/ 129 necks) Oral Cavity 42 (39.6%) Oropharynx 37 (34.9%) Larynx 20 (18.9%) Hypopharynx 7 ( 6.6%) T0 1 (0.9%) T1 9 (8.5%) T2 28 (26.4%) T3 36 (34.0%) T4 32 (30.2%) Post Op RT 71.7% N1 58(54.7%) N2a 5(4.7%) N2b 28(26.4%) N2c 14(13.2%) N3 1(0.9%) ECS 30(34%) Regional failures 9 (5.7%) 6 within fields Archives 2002

SND in N+ Neck Medina & Byers ; Head & Neck 1989 114 patients node +ve - 91(79.8%) pathologic evidence of mets N1 / No ECS Surgery Only - 10% recc Multiple / ECS - 24% SX + RT - 15%

SND in N+ Neck ,[object Object],[object Object],[object Object],[object Object]

AHNS - Procedures Studied ,[object Object],[object Object],[object Object],[object Object]

Evidence-Based Review ,[object Object],[object Object],[object Object]

Results Expert opinion 5 D Case series (no control group) 4 C Case control studies 3 Cohort studies, Low quality RCT 2b B Meta-analysis of cohort studies 2a High quality RCT 1b A Meta-analysis of RCT’s 1a Study Design Level of Evidence Grade of Recommendation

4. Adjuvant treatment after neck dissection PROGNOSTIC IMPLICATIONS ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Level of Lymph nodes Lower nodes have worse prognosis Spiro Am J Surg 1974, Tulenko Am J Surg 1966, Mendelson 1976

RCT – Role of RT in management of Neck ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

POST OP RT ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],( Ang et al, 2001 ) RCT – 213 patients Low risk n = 31 Intermediate risk n = 31 High risk n = 151 NO ADJUVANT RT 57.6 Gy/ 6.5 weeks n = 76 63 Gy / 5 weeks n = 75 63 Gy / 7weeks

[object Object],[object Object],[object Object],[object Object],Ang et al, 2001 Results

Management of Neck - Single node, NO ECS ,[object Object],[object Object],[object Object],[object Object],Barkley Am j Surg 1972

Single node ECS -Ve M D Anderson Data

POST OP CHEMORADS EORTC – NEJM 2004 ,[object Object],[object Object],[object Object],[object Object],[object Object],Curative post surgery 167 RT [66 Gy / 6.5 weeks] 167 CT / RT [100mg Cispat/m2 T3;T4;Node +ve &T1/T2 adverse factors

POST OP CHEMORADS RTOG (9501) – NEJM 2004 ,[object Object],[object Object],[object Object],[object Object],[object Object],Curative surgery 231 RT [60 – 66 Gy ] 228 RT + Cisplat [100mg/m2, Day 1,22,43]  2 nodes; ECS; +ve margins

Management of the neck RT / Chemo-Rads ,[object Object],[object Object],[object Object],[object Object]

2. Do we need chemo-rads for an N1 neck ,[object Object],Daily Fractionated RT = Chemo-rads 92% control at 3 years for <3cms node with daily RT * Mendelhall, Int J Radiation Onco 1986

3. How is an N2 / N3 node ideally managed with chemo-rads ,[object Object],[object Object],[object Object],[object Object],[object Object],Menderhall, In J. Rad Oncol 1984 (110 patients) McComs & Fletcher – Am J. Roentgenol 1957 Berkley & Fletcher – Am J. of Surgery 1972 RT + NECK DISSECTION

N2/N3 nodes: Planned Neck dissection ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],- Menderhall 1986, Peters 1996

CHEMORADIOTHERAPY:N2/N3 Node ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],STENSON et al, Archives 2000

CT RT – RCT (LAVERTU et al , Head Neck 1997) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],NO SIGNIFICANT COMPLICATIONS  NOT STATISTICALLY SIGNIFICANT

N2/N3 nodes Oro/laryngopharynx Early disease - RT Locally advanced - Chemorads/RT Sx+PORT Small Primary Large Neck Node - ? ? T4 T3 II T2 I T1 N3 N2 N1 N0

Node excision followed by RT ,[object Object],[object Object],[object Object],[object Object],[object Object]

SPLIT THERAPY - COMPARISON OF STUDIES WITH SURGERY FOLLOWED BY RT LR- Local Recurrence; RR- Regional Recurrence, OAS- Overall Survival; DFS- Disease free Survival DSS – Disease specific survival T/N criteria T1-2, N1-3 T1-3, N2-3 T1-3N2-3 T1-3N2-3 T1-2N2-3 T1-2N2-3 Survival statistics Median survival 19mths DSS at 2yrs-49% 5yr OAS-55% 3yrOAS-37%, DFS-60% 73% alive at 60mth 5yr OAS-60% 5yr DFS-59.4% RR 4% 15% 11% 8% Nil 13% LR 9% 28% 28% - 20% 7% No. of pts. 65 32 35 24 15 52 Trial Design Retrospective Retrospective/ Prospective Retrospective Retrospective Retrospective Retrospective Prospective Author/ Institute French Head And Neck Study group 2 Smeele Byers Allal Verschur TMH

4. Does an N2 / N3 node influence the choice of treatment of the primary Concurrent CTRT- 9303 RTOG ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],87(50) 86(50) 87(50) 38(22) 39(23) 32(18)

Management of the neck Surgery N Stage N 0 N 2 -3 Neck Treatment N 1 SND / Wait & Watch MND / RND SND / MND Histology of LN pN 2 – 3 ECS pN1 pNO Further Treatment ? RT RT / ? CT / RT None

Management of the neck * Except T1 glottis, Bracytherapy alone treating primaries RT CT / RT N 0 N 1 N 2 -3 N Stage Neck Treatment Histology of LN Elective neck * Irradiation Neck RT Neck RT No residual tumor on completion of treatment Observe Residual tumor on completion Neck dissection Imaging Neck dissection Residual tumor No residual tumor on completion Observe END 4 – 6 weeks

Management of Neck N 2b (Multiple levels) ,[object Object],[object Object],[object Object],[object Object],Mendenhall 1986, Int J Radiation Oncology

Cervical Metastasis Chemotherapy ,[object Object],[object Object],[object Object],[object Object],Responders 60 - 70 % survival Non responders 20 - 30% survival

Dagum - - - 58% 5yrs Actuarial Survival (48) Wang 9.8 9.8 - 67% DFS (71) Narayan 19.2 17.3 15.3 38% 5yrs OAS (52) SPLIT THERAPY - Comparison of results of studies with RT followed by Surgery LR RR DM Survival Statistics LR- Local Recurrence RR- Regional Recurrence DM- Distant Metastasis; OAS- Overall Survival

3. How is an N2 / N3 node ideally managed with chemo-rads Radio-curability proportional to volume of tumor Occult 4500 rad 1 cms 6000 ” 3 cms 7000 ” 6 cms 8000 ” McComs & Fletcher – Am J. Roentgenol 1957 Berkley & Fletcher – Am J. of Surgery 1972 RT + NECK DISSECTION

Patterns of recurrence ,[object Object],[object Object],[object Object],[object Object],[object Object]

Patterns of recurrence ,[object Object],[object Object],[object Object],[object Object],Recurrences-Nodal Stage Total recurrences = 94 N1 47(50%) N2a 14(14.9%) N2b 22(23.4%) N2c 4(4.3%) N3 7(7.4%) ECS 55(58.5%)

Adjuvant radiotherapy- Is it a confounding factor? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Managment Of N+Neck

Recomendados

Recomendados

Más contenido relacionado

La actualidad más candente

La actualidad más candente (20)

Destacado

Destacado (20)

Similar a Managment Of N+Neck

Similar a Managment Of N+Neck (20)

Más de fondas vakalis

Más de fondas vakalis (20)

Último

Último (20)

Managment Of N+Neck