Efficacy of Targeted Chemoradiation and Planned Selective Neck Dissection to Control Bulky Nodal Disease in Advanced Head and Neck Cancer

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Abstract
RECURRENCE in the neck is a common reason for treatment failure in patients treated for head and neck cancer. Recurrence can develop in the untreated neck among patients with clinically negative nodal disease, or it can occur after failure to control the regional disease among patients with palpable neck nodes. In the latter case, recurrence is most likely when the neck nodes are large and/or multiple (N2-N3), often referred to as bulky nodal disease. These patients have traditionally been treated with combined-modality therapy in an attempt to achieve a higher rate of regional control.1 The usual approach has been to perform a neck dissection in patients with resectable disease and whose primary disease is to be treated surgically, followed by postoperative radiotherapy. When it is desirable to treat the primary disease with radiotherapy, the bulky nodal disease is removed surgically after completion of the radiation. For nodal disease lying outside the reduced field for the primary tumor, the total dose can be limited to 50 Gy if planned neck dissection is included. Otherwise, the nodal disease is treated with at least 60 Gy by means of electron beam therapy to boost the dose. Nodal disease lying within the reduced field covering the primary tumor will usually receive a total dose of 68 to 74 Gy. It has been traditionally accepted that the neck dissection performed in either setting must be comprehensive, with removal of all of the lymph node groups encompassed by level I to V.

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