Controversies in management of the neck in head and neck cancer

Opinion statement As definitive external radiation and multimodality organ preservation strategies (eg, combined chemotherapy and radiation therapy [CCRT]) improve, the role of surgery is being re-examined in the management of locally advanced head and neck cancer. Consensus regarding the use of neck dissections for complete responders and incomplete responders has yet to be achieved and the data are surprisingly controversial. A possible benefit from neck dissection after a complete response of the primary tumor after CCRT or definitive external radiation for advanced squamous cell carcinoma of the head and neck may only be anticipated in patients with persisting subclinical neck disease who have no other sites of disease. Some clinicians have even argued that the salvage rate for clinically detectable residual neck disease does not justify neck dissection. Randomized data addressing these questions and a trial addressing the accuracy of new imaging modalities, such as postchemotherapy and postradiation positron emission tomography scanning, across multiple institutions would be appropriate. As a department, we are aggressive in our treatment of isolated residual neck disease after CCRT or definitive external radiation and for patients initially diagnosed with N3 nodal disease. We are investigating the use of adjuvant neck brachytherapy at the time of neck dissection and we are pleased with our early results.     

Head and neck cancer

Tumors of the head and neck comprise an important neoplasia group, the incidence of which is increasing in many parts of the world. Recent advances in diagnostic and therapeutic techniques for these lesions have yielded novel molecular targets, uncovered signal pathway dominance, and advanced early cancer detection. Proteomics is a powerful tool for investigating the distribution of proteins and small molecules within biological systems through the analysis of different types of samples. The proteomic profiles of different types of cancer have been studied, and this has provided remarkable advances in cancer understanding. This review covers recent advances for head and neck cancer; it encompasses the risk factors, pathogenesis, proteomic tools that can help in understanding cancer, and new proteomic findings in this type of cancer. Cancer 2010. © 2010 American Cancer Society.     

头颈肿瘤功能性颈淋巴结清扫术的适应证及临床根治效果

背景与目的：功能性颈淋巴结清扫术自1967年Bocca提出后,在头颈外科临床中已被推广应用,但对其临床应用适应证及其临床根治效果,国内外头颈外科专家特有不同观点,本研究旨在探索功能性颈淋巴结清扫术临床应用适应证和临床根治效果。方法：对152例次功能性颈淋巴结清扫术病例,利用手术标本病理检查及随诊资料进行分析讨论。结果：152例次功能性颈清扫术,舌鳞癌20例次,喉鳞癌23例次,甲状腺乳头状癌96例次,滤泡状腺癌9例次,髓样癌4例次,舌,喉鳞癌N0,N1,N2病例术后5年复发率分别为12．5％,14．3％,40．0％和20％,16．7％,50．0％,甲状腺乳头状腺癌N1a,N1b病例术后5年复发率分别为：6．5％,7．1％。结论：功能性颈淋巴结清扫术适用于较早期及低度恶性的头颈肿瘤手术治疗,且可获得良好的临床根治效果。     

Head and neck cancer

In this review, the authors outline the epidemiology, genetic factors, treatment and outcomes of head and neck cancer.     

Head and neck dermoids

The clinical picture, associated anomalies and distribution in 95 cases of head and neck dermoids is described. Orbital and ocular dermoids formed the commonest site of head and neck dermoids. Mandibulofacial and external ear anomalies were frequently associated with dermoids due to failure of embryonic blood supply. Injection of radiopaque material into the dermoid can help in locating its pouches, and sinuses which can be responsible for the recurrences after their excision.     

Head and neck brachytherapy

Experience accumulated over several decades in the treatment of head and neck tumors by irradiation has demonstrated the need for a high tumor dose to achieve local control. With external beam irradiation alone, it is difficult to spare adjacent normal tissues, resulting in undesirable late effects on the salivary glands, mandible, and muscles of mastication. Interstitial implantation is ideally suited to deliver a high dose limited to the volume of the primary tumor, thus maximizing tumor control while minimizing complications. A large experience has been accumulated with low dose rate (LDR) brachytherapy in treatment of carcinoma of oral cavity, oropharynx, and nasopharynx. Recent analysis of large clinical series provided data indicating that modalities of LDR brachytherapy should be optimized in treating these tumors for increasing therapeutic ratio. LDR brachytherapy is now challenged by high dose rate (HDR) brachytherapy and pulsed dose rate (PDR) brachytherapy. Preliminary results obtained with these 2 last modalities will be discussed.     

头颈肿瘤颈淋巴结清扫的手术选择

作为治疗与预防头颈恶性肿瘤颈部淋巴结转移的首要方法,颈淋巴结清扫术经过一百多年的发展,已经日趋规范合理。但是,由于头颈恶性肿瘤的种种特殊性导致其颈部淋巴结转移有较大的不确定性,头颈外科医师在施行原发灶手术时,往往会面临是否需要行颈淋巴结清扫术、如何确定颈淋巴结清扫范围的困惑。根据常见头颈恶性肿瘤的颈淋巴结转移特性及手术对患者的创伤程度,梳理出当前较为规范的颈淋巴结清扫术术式,为头颈外科医师提供参考,有助于改善头颈恶性肿瘤颈部淋巴结治疗和预防的总体效果。     

Management of N0 neck in head and neck cancer: current controversies

Squamous cell carcinomas of the upper aerodigestive tract are characterized by a high frequency of lymphogenic metastatic spread. The neck should be included in the treatment concept because almost 25% of all patients develop occult lymph node metastases. The only exception are early carcinomas of the lower lip and the vocal cords. Since currently for high risk patients no prognostic markers or other factors for occult metastatic spread are available, treatment strategies have to include the exact knowledge of direction and extent of regional lymphatic drainage. Based on this prerequisite, concepts for selective cervical lymph node dissection in case of the clinical N0 situation were developed which may also be used for an individually optimized radiotherapy. Intensity modulated radiotherapy (IMRT) bears a high potential for an optimized irradiation in case of potential occult metastatic spread of carcinomas of the upper aerodigestive tract. Without compromising local control rates IMRT allows a considerable reduction of permanent xerostomia by sparing at least one major salivary gland. The significant scientific purpose for the N0 neck, however, will remain the identification of high-risk patients, e.g. by means of tissue and/or serum-related markers, which carry a high risk of local and distant metastases.     

The Indications and Clinical Curative Effects of Modified Neck Dissection in Head and Neck Cancers

OBJECTIVE Functional neck dissection was first described by Bocca and Pignataro in 1967. It has been used in clinical practice for years, but remains controversial among neck-surgery experts. This study was designed to evaluate indications and curative effects of functional-neck dissection (FND). METHODS One hundred and fifty-two cases which underwent FND were reviewed with an analysis of pathological specimens and follow-up datas. RESULTS The series of FND included 20 cases of tongue carcinoma, 23 cases of larynx carcinoma, 96 cases of thyroid papillary adenocarcinoma, 9 cases of follicular adenocarcinoma and 4 cases of medullary adenocarcinoma; the five-year recurrence rate for tongue carcinoma was 12.5%, 14.3%, 40.0% and for a larynx carcinoma was 20.0%, 16.7%, 50.0% in N0 stage, N1 stage, N2a stage, respectively. The 5-year recurrence rate of thyroid papillary adenocarcinoma was 6.5%, 7.1% in N1a, N1b, respectively. CONCLUSION Functional neck dissection is indicated in early and low malignant head and neck neoplasms and results in satisfactory curative effects.