A conservation approach to pharyngeal carcinoma with advanced neck disease: optimizing neck management

BACKGROUND: Surgical management of advanced neck disease remains controversial when a conservative approach based on radiotherapy is retained for primary tumors. The objective of this study was to evaluate retrospectively treatment results in pharyngeal cancers presenting with N2-N3 neck disease, using neck dissection followed by radical locoregional radiotherapy (RT) and to compare these results with those obtained in patients treated by radical RT alone. METHODS: From August 1991 to November 1996, 41 patients with carcinomas of the oro- or hypopharynx were staged as T1-T3 N2-N3 M0 (American Joint Committee on Cancer [AJCC] stage IV). Twenty-four patients were treated with neck dissection followed by RT (group 1) and 17 patients with radical RT (group 2) using a progressively accelerated concomitant boost schedule. Chemotherapy was delivered to 6 patients in group 1 and 8 in group 2 partially concomitantly with RT. RESULTS: Three-year actuarial locoregional control was 73% and 55% for groups 1 and 2, respectively (p = .52). The corresponding 3-year actuarial overall survival rates were 37% and 50% (p = .42). Severe postoperative complications were observed after neck dissection in four patients (16%). Acute toxicity during RT was similar in the two groups. Late toxicities were also similar, except for two patients in group 1 who developed severe laryngeal edema. CONCLUSIONS: Neck dissection followed by radical RT to the primary tumor and neck represents a valid treatment option in this subset of patients, allowing good control of advanced neck disease, while at the same time conserving pharyngolaryngeal function. However, for patients who are at high risk of severe postoperative complications, radical RT can be considered a worthy alternative, particularly for oropharyngeal carcinomas.