H&N Ca Patients With CR to CRT May Not Need Surgery

RANCHO MIRAGE, California—Patients with advanced head and neck cancer who have a clinical complete response (CCR) to chemoradiotherapy (CRT) are at low risk for recurrence in the neck, and most can be spared laryngectomy, Ramesh Rengan, MD, PhD, of the University of Pennsylvania, said at the 2007 Multidisciplinary Head and Neck Cancer Symposium (abstract 8).

"These patients were getting intensive chemoradiotherapy," Dr. Rengan told ONI in an interview. "If there was no evidence of disease in the neck, the question was whether patients could just be observed rather than continuing to surgery. The risk is, what if the neck is harboring disease that is not recognized? There are few salvage possibilities, so the stakes are very high."

This analysis included outcomes for 213 patients enrolled on larynx/organ preservation protocols. Of these, 190 patients were protocol-eligible and received all of their treatment at Memorial Sloan-Kettering Cancer Center. Forty-seven patients underwent immediate neck dissection and were dropped from the analysis, as was one patient who discontinued treatment. That left for analysis 142 treated patients, including 86 who were node positive. Median follow-up was 9 years.

Patients received one to three cycles of induction cisplatin followed by radiotherapy alone or with concomitant cisplatin-based chemotherapy. They were treated with 1.8 to 2.0 Gy/d of radiation with either conventional or a delayed accelerated fractionation, with concomitant boost schedule and a median dose of 70 Gy to the gross tumor volume.

10-Year Recurrence Rate

Dr. Rengan reported that clinical complete remissions in the neck were seen in 69 (80%) of the 86 node-positive patients. The 10-year incidence of neck failure in 65 node-positive patients with clinically negative necks after chemoradiotherapy was 14%. Median overall survival in patients with CCR was 12.2 years for N1 disease, 6.5 years for N2 disease, and 0.8 years for N3 disease. Seventeen patients had a less than complete response, and 14 went on to neck dissection, 10 with median overall survival of 1.4 years.

He said it would be reasonable to conclude that patients with advanced neck disease who have a CCR in the neck after chemoradiation can be spared a neck dissection, since long-term neck control is 85% or better. "This result depends on the response to induction chemotherapy," he stressed. "If the patient has a poor response, immediate laryngectomy and neck dissection are needed."

The question of how to determine whether a patient has no residual disease in the neck following chemoradiotherapy is crucial. Dr. Rengan said that functional imaging (PET scans or MRI spectroscopy) is under study as a means of identifying the 10% to 15% of patients who appear to have a complete response but are still harboring difficult-to-detect disease. He envisions a process that would begin with chemoradiotherapy for advanced head and neck cancer, include functional imaging of all apparent clinical complete responses, follow low-risk patients with observation only, and select out patients with latent neck disease for more aggressive treatment.