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Table 1. 
Pathological Node Status and Impact of Radiation Therapy*
Pathological Node Status and Impact of Radiation Therapy*
Table 2. 
Clinical Node Status*
Clinical Node Status*
1.
Farr  HWGoldfarb  PMFarr  CM Epidermoid carcinoma of the mouth and pharynx. Am J Surg. 1980;140563- 567Article
2.
Martin  H The treatment of cervical metastic cancer. Ann Surg. 1941;114972- 986Article
3.
Bocca  EA Conservative technique in radical neck dissection. Ann Otol Rhinol Laryngol. 1967;76975- 987
4.
Medina  JEByers  RM Supraomohyoid neck dissection: rationale, indications, and surgical technique. Head Neck. 1989;11111- 122Article
5.
Spiro  JDSpiro  RHShah  JP  et al.  Critical assessment of supraomohyoid neck dissection. Am J Surg. 1988;156286- 289Article
6.
Kowalski  LPMarrin  JWaksman  G Supraomohyoid neck dissection in the treatment of head and neck tumors. Arch Otolaryngol Head Neck Surg. 1993;119958- 963Article
7.
Byers  RM Modified neck dissection: a study of 967 cases from 1970 to 1980. Am J Surg. 1985;105414- 421Article
8.
Kerrebijn  JDFreeman  JLGullane  PJ Supraomohyoid neck dissection: is it diagnostic or therapeutic? Head Neck. 1999;2139- 41Article
9.
Traynor  SJCohen  JIEverts  EC  et al.  Selective neck dissection and the management of the node-positive neck. Am J Surg. 1996;172654- 657Article
10.
Sobin  LHed.Wittekind  Ced.(International Union Against Cancer [UICC]), TNM Classification of Malignant Tumours. 5th ed. Baltimore, Md Wiley-Liss1997;
11.
Andersen  PECambronero  EShah  JP  et al.  The extent of neck disease after regional failure during observation of the N0 neck. Am J Surg. 1996;172689- 691Article
12.
Pellitteri  PKRobbins  KTNeuman  T Expanded application of selective neck dissection with regard to nodal status. Head Neck. 1997;19260- 265Article
13.
Spiro  RHMorgan  GJShah  JP Supraomohyoid neck dissection. Am J Surg. 1996;172650- 653Article
14.
Vikram  BStrong  EWSpiro  RH  et al.  Failure in the neck following multi-modality treatment for advanced head and neck cancer. Head Neck. 1984;6724- 729Article
15.
Brazilian Head and Neck Cancer Study Group, Results of a prospective trial on elective modified radical classical vs supraomohyoid neck dissection in the management of oral squamous carcinoma. Am J Surg. 1998;176422- 427Article
Original Article
March 2000

The Role of Supraomohyoid Neck Dissection in Patients With Positive Nodes

Author Affiliations

From the Departments of Head and Neck Surgical Oncology (Drs Kolli, Datta, Hicks, and Loree) and Radiation Oncology (Dr Orner), Roswell Park Cancer Institute, Buffalo, NY.

Arch Otolaryngol Head Neck Surg. 2000;126(3):413-416. doi:10.1001/archotol.126.3.413
Abstract

Background  Supraomohyoid neck dissection (SOHND) is currently used as a staging procedure for patients with clinically negative nodes in the neck who are at increased risk (>20%) for metastatic disease.

Objective  To assess the potential role of SOHND in patients with clinically positive nodes at levels I, II, or III. We evaluated, in particular, whether selective neck dissection in patients with clinically positive nodes results in decreased regional control and/or diminished survival.

Patients and Methods  We retrospectively reviewed the charts of all patients who underwent SOHND from January 1, 1971, to December 31, 1997. The oral cavity and oropharynx represented the primary sites in the majority of the patients. Two-year follow-up information was available on all patients.

Results  During the study period, 69 patients underwent 84 SOHNDs. Of the 69 patients, there were 30 patients with clinically negative nodes and 39 patients with clinically positive nodes in the neck. The overall regional control rates were 88% vs 71% for pathologically negative vs positive nodes, respectively, with or without adjuvant radiation therapy. Adjuvant radiation therapy significantly improved regional control in patients with pathologically positive nodes but not in patients with N0 disease (P = .005). Similar results were noted in patients with both clinically and pathologically positive nodes.

Conclusions  Supraomohyoid neck dissection in patients with pathologically positive nodes in the neck is inadequate therapy for regional control without postoperative radiation therapy. However, in patients with pathologically positive nodes in the neck, SOHND with postoperative radiation therapy can achieve regional control comparable to that of comprehensive neck dissection and postoperative radiation therapy.

CERVICAL LYMPH node metastasis is one of the most significant prognostic factors in patients with squamous cell carcinoma of the head and neck.1 Surgical options for management of the neck metastasis varies from classic radical neck dissection2 to modified radical neck dissection3 to selective neck dissection. The supraomohyoid neck dissection (SOHND) is commonly used as a staging procedure for patients with clinically N0 disease but who have an increased risk (>20%) for occult cervical metastases in squamous cell carcinoma of the oral cavity and oropharynx.4,5

There is controversy about the management of patients with lymph node metastasis identified during the pathological examination of the SOHND specimen. Several reports68 stated that SOHND was adequate therapy for patients with a single positive lymph node without extracapsular spread. The presence of multiple positive nodes or extracapsular extension is well recognized as an indication for adjuvant radiation therapy.7,9

The recent trend toward selective neck dissections with or without radiation therapy for patients with positive nodes in the neck led us to review our experience with SOHND in clinically negative and positive nodes. The aim of this study was to evaluate the efficacy and outcome of SOHND with or without adjuvant radiation therapy in the management of metastasis in squamous cell carcinoma of the head and neck.

PATIENTS AND METHODS

We identified 72 patients who underwent SOHND at Roswell Park Cancer Institute, Buffalo, NY, between January 1, 1971, and December 31, 1997. A chart review was performed to identify the demographics, clinicopathologic features, treatment modalities, and outcomes. All patients had follow-up information for a minimum of 2 years after the completion of treatment or until death.

Three patients were excluded from the analysis because comprehensive radical neck dissection was performed to treat contralateral neck disease. Of the 69 evaluable patients, there were 39 men and 30 women. The age range at diagnosis was 32 to 85 years (median, 62 years). The primary sites of disease in the 69 patients are shown below.

Clinical neck examination reports and TNM10 staging results were used to assess the pretreatment neck status. The clinical and pathological neck status in the 69 patients is shown below.

The initial neck surgery was unilateral SOHND in 43 patients and bilateral SOHND in 15 patients. Fourteen patients underwent SOHND on one side and a comprehensive radical neck dissection on the other side. As stated earlier, 3 patients in this group were excluded from the analysis because they had positive nodes only in the side where a comprehensive neck dissection was performed. The remaining 11 patients had positive nodes on the side where an SOHND was performed and pathologically negative nodes on the side where the comprehensive neck dissection was performed. The total number of evaluable SOHND results was 84.

Statistical analysis of the therapeutic outcome was performed using the Fisher exact test. Survival distributions were calculated using the Kaplan-Meier method, and the distributions were compared using the log-rank test. P < .05 was statistically significant.

RESULTS

Pathological reports were reviewed, and the node status in the neck was determined. All the patients had follow-up information for a minimum of 2 years or until they had regional recurrence or died (range, 3 months to 27 years). The pathological node stage is summarized in in the "Patients and Methods" section. Table 1 summarizes the impact of adjuvant radiation therapy on regional control, disease-specific mortality, and distant metastasis in relation to pathological stage in patients who received SOHND.

Of the 69 patients, 34 had pathological N0 disease. Of these 34 patients, 7 received postoperative radiation therapy for considerations at the primary site. Regional control in the neck was achieved in 30 (88%) of the 34 patients. Of the 4 patients with recurrent metastasis in the neck, 2 patients underwent prior radiation therapy. Of the 5 patients who died of disease, 2 underwent radiation therapy, and the only patient who developed distant metastasis underwent radiation therapy. The addition of adjuvant radiation therapy in the pathological N0 group did not have any impact on the regional failure rate (P = .16).

Of the 35 patients who had pathologically positive nodes, 20 received postoperative radiation therapy. Regional control in the neck was achieved in 25 (71%) of the 35 patients. Of the 10 patients with recurrent metastasis in the neck, 8 did not undergo adjuvant radiation therapy. Addition of adjuvant radiation therapy improved the regional control rates in patients with positive nodes after SOHND (P = .006). Of the 15 patients with pathological N1 disease, 5 patients received adjuvant radiation therapy. Of these 5 patients, there was only 1 patient (20%) with recurrent metastasis in the neck, whereas 4 (40%) of 10 patients who did not receive adjuvant radiation therapy had recurrent metastasis in the neck. However, this difference was not statistically significant (P = .35). Of the 20 patients with pathological N2 disease, 9 of whom had N2c disease, 15 received adjuvant radiation therapy. There was only 1 patient in this group with recurrent metastasis in the neck, whereas 4 of 5 patients who did not receive adjuvant radiation therapy had recurrent metastasis in the neck. The impact of adjuvant radiation therapy on regional control in patients with N2 disease was statistically significant (P = .005). There were no patients with clinical or pathological N3 disease in this study.

Supraomohyoid neck dissection was performed in 26 patients with clinical evidence of neck disease whose results showed pathologically positive nodes. Of the 26 patients, 14 received adjuvant radiation therapy; only 1 of these patients developed recurrent metastasis in the neck. Of the 12 patients who did not receive adjuvant radiation therapy, there were 6 patients (50%) with recurrent metastasis in the neck (P = .02). In this subgroup, there were 9 patients with pathological N1 disease and 17 with pathological N2 disease. Adjuvant radiation therapy did not significantly affect the regional failure in patients with pathological N1 disease (P = .58), whereas it had a significant impact on regional failure in patients with N2 disease. Of 5 patients with N2 disease who did not receive radiation therapy, there were 4 with recurrent metastasis in the neck. (P = .01). Adjuvant radiation therapy did not influence disease-specific mortality rates or distant metastasis rates in any of the groups. These results are summarized in Table 2.

Local control was achieved in 59 of the 69 patients. Of the 34 patients with pathological N0 disease, 4 had local failure. None of these patients had recurrent metastasis in the neck. Adjuvant radiation was used in 2 of 4 patients. Of these 4 patients, 2 died of disease, while the other 2 died of other causes. Of the 6 patients with local recurrence in the pathologically positive node group (n = 35), 4 underwent adjuvant radiation therapy, and 3 had regional control. Of these patients, 4 died of disease, 1 died of other causes, and 1 underwent successful salvage therapy. The patient who underwent local salvage therapy with surgery and survived did not have regional metastasis and received adjuvant radiation therapy. Of the 34 patients with pathological N0 disease, 1 developed lung cancer and 2 patients had second primary tumors during the follow-up period. In the group with metastases, 2 lung cancers and 2 second primary tumors were identified.

The overall 2-year and 5-year survival rates for patients with pathological N0 disease were 78% and 64%, respectively. For the patients with positive nodes, these rates were 79% and 60%, respectively. Adjuvant radiation therapy did not improve overall survival in the latter group. However, the patients with N0 disease who received radiation therapy for advanced primary tumors (T3 or T4) did poorly. The 5-year survival rate in this subset was 19% compared with 78% for the patients with N0 disease who did not receive radiation therapy (P = .004, log-rank test).

COMMENT

Supraomohyoid neck dissection is well recognized as a staging technique in patients with clinically negative nodes in the neck in the management of squamous cell carcinoma of the oral cavity and oropharynx.4,5 The diagnostic yield of SOHND in staging clinical N0 disease appears to be superior to clinical evaluation or radiological imaging modalities. For the management of the clinical N0 neck, a wait-and-see approach is an option. However, a recent report by Andersen et al11 showed that when cervical metastasis develops in observed patients it is at a higher neck stage and the patients have worse outcomes. The role of SOHND in patients with clinically positive nodes in the neck remains unclear.

In our study, the overall regional control rates achieved with SOHND in patients with pathologically negative vs positive nodes in the neck were 88% vs 71%, respectively. Supraomohyoid neck dissection appears to be adequate therapy for regional control in patients with pathological N0 disease. It has recently been reported that in selected cases it may be adequate therapy for pathological N1 disease (Kowalski et al,6 Byers,7 and Kerrebijn et al8). Although the difference was not statistically significant in our study, 4 (40%) of 10 patients with N1 disease had recurrent metastasis in the neck after surgery without adjuvant radiation therapy. Based on our data, we are hesitant to advocate surgery alone in patients with pathological N1 disease.

In patients with pathological N2 disease, SOHND alone was inadequate therapy. However, regional control can be achieved in these patients with the addition of adjuvant radiation therapy. Traynor et al9 and Pellitteri et al12 reported similar control rates in patients with positive nodes in the neck with adjuvant radiation therapy. Adjuvant radiation therapy did not affect disease-specific survival or the incidence of distant metastasis in any of these patients. The largest study in this area is by Spiro et al,13 who described 287 patients and 320 SOHNDs. They reported that SOHND with radiation therapy was highly effective in controlling neck metastasis in carefully selected patients with limited disease in the upper part of the neck.

Traditionally, SOHND is indicated as a staging procedure only in patients with clinically negative nodes in the neck at risk for occult metastasis. We had 26 patients with clinically positive nodes in the neck who underwent SOHND, and the results showed that they also had pathologically positive nodes. In this group, SOHND alone was inadequate therapy. Postoperative radiation therapy improved regional control in necks with pathologically positive nodes. However, the increase in regional control with adjuvant radiation therapy was statistically significant only in patients with N2 disease (Table 2).

Supraomohyoid neck dissection alone appears to be adequate therapy for those patients with pathological N0 disease. The addition of radiation therapy to SOHND improves regional control in patients with pathological N2 disease. In our review, insufficient numbers of patients with N1 disease did not allow adequate statistical power of analysis. There is, however, a trend toward improved regional control in patients with pathological N1 disease using adjuvant radiation therapy in addition to surgery.

Our results indicate that SOHND alone is inadequate treatment for patients with pathologically confirmed clinically positive nodes. Adjuvant radiation therapy in these patients improves regional control and should be used in this setting. Our study, however, does not address the issue of whether SOHND with radiation therapy for patients with clinically positive disease is equivalent to comprehensive neck dissection with adjuvant radiation therapy. Our regional control rate for patients who underwent SOHND and radiation therapy to treat clinically and pathologically positive nodes (13 [93%] of 14) compares favorably with the control rate for patients who underwent comprehensive dissection and radiation therapy described in the literature. Vikram et al14 reported a regional control rate of 87% in patients with N2 neck disease treated with comprehensive neck dissection and adjuvant radiation therapy.

A recent prospective trial reported by the Brazilian Head and Neck Cancer Study Group15 compared SOHND with comprehensive neck dissection in patients with clinically negative nodes. In that study, the regional control and overall 5-year actuarial survival rates were 87.5% and 67.0% for the SOHND group vs 89.5% and 63.0% for the comprehensive neck dissection group, respectively. The differences were not statistically significant. However, given the poor results in the absence of radiation therapy (6 [50%] of 12 patients with regional recurrence in our study), SOHND alone is not adequate therapy for patients with clinically and pathologically positive nodes. Postoperative radiation therapy should be used in this setting to achieve adequate regional control.

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Article Information

Accepted for publication January 3, 2000.

Presented at the annual meeting of the American Head and Neck Society, Palm Desert, Calif, April 27, 1999.

Reprints: Thom R. Loree, MD, Roswell Park Cancer Institute, Elm and Carlton streets, Buffalo, NY 14261.

References
1.
Farr  HWGoldfarb  PMFarr  CM Epidermoid carcinoma of the mouth and pharynx. Am J Surg. 1980;140563- 567Article
2.
Martin  H The treatment of cervical metastic cancer. Ann Surg. 1941;114972- 986Article
3.
Bocca  EA Conservative technique in radical neck dissection. Ann Otol Rhinol Laryngol. 1967;76975- 987
4.
Medina  JEByers  RM Supraomohyoid neck dissection: rationale, indications, and surgical technique. Head Neck. 1989;11111- 122Article
5.
Spiro  JDSpiro  RHShah  JP  et al.  Critical assessment of supraomohyoid neck dissection. Am J Surg. 1988;156286- 289Article
6.
Kowalski  LPMarrin  JWaksman  G Supraomohyoid neck dissection in the treatment of head and neck tumors. Arch Otolaryngol Head Neck Surg. 1993;119958- 963Article
7.
Byers  RM Modified neck dissection: a study of 967 cases from 1970 to 1980. Am J Surg. 1985;105414- 421Article
8.
Kerrebijn  JDFreeman  JLGullane  PJ Supraomohyoid neck dissection: is it diagnostic or therapeutic? Head Neck. 1999;2139- 41Article
9.
Traynor  SJCohen  JIEverts  EC  et al.  Selective neck dissection and the management of the node-positive neck. Am J Surg. 1996;172654- 657Article
10.
Sobin  LHed.Wittekind  Ced.(International Union Against Cancer [UICC]), TNM Classification of Malignant Tumours. 5th ed. Baltimore, Md Wiley-Liss1997;
11.
Andersen  PECambronero  EShah  JP  et al.  The extent of neck disease after regional failure during observation of the N0 neck. Am J Surg. 1996;172689- 691Article
12.
Pellitteri  PKRobbins  KTNeuman  T Expanded application of selective neck dissection with regard to nodal status. Head Neck. 1997;19260- 265Article
13.
Spiro  RHMorgan  GJShah  JP Supraomohyoid neck dissection. Am J Surg. 1996;172650- 653Article
14.
Vikram  BStrong  EWSpiro  RH  et al.  Failure in the neck following multi-modality treatment for advanced head and neck cancer. Head Neck. 1984;6724- 729Article
15.
Brazilian Head and Neck Cancer Study Group, Results of a prospective trial on elective modified radical classical vs supraomohyoid neck dissection in the management of oral squamous carcinoma. Am J Surg. 1998;176422- 427Article
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