Controversies in management of the neck in head and neck cancer

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.